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TRAVIS AIR FORCE BASE, Calif. – Within moments of being moved from the operating room to the cardiovascular intensive care unit, the 62-year-old heart bypass patient bolted upright into a sitting position clasping his chest.
Surgical patients sometimes experience incision pain, but 1st Lt. Jacob Bohanan, 60th Medical Group at Travis, sensed this was something else. Bohanan quickly checked the electrocardiogram reading and realized there was definitely something wrong. The patient was rushed to the catheterization laboratory where doctors at the David Grant USAF Medical Center discovered that one of the vessels had kinked. Minutes later, the patient was back in surgery for the repair.
“A kinked vessel is rare, but the mortality rate is about 90 percent, especially if you don’t act quickly,” said Capt. Susanna Pruangkarn, 60th MDG cardiothoracic ICU nurse. “I credit Lieutenant Bohanan for not passing this off as increased pain that the patient needed more pain medication for.”
Because of Bohanan, the patient was released from the hospital a week later with no complications, said Pruangkarn.
Cardiothoracic intensive care nurses are adept at noting subtle changes in a patient’s hemodynamics that could lead to serious complications. They also need quick reflexes to spot and prevent potential problems and the ability to remain calm in stressful situations. That’s one reason the David Grant USAF Medical Center is sending its CTICU nurses to the University of California Davis Medical Center in Sacramento, California, for additional training.
Bohanan, who is currently deployed, completed a three-week orientation at UC Davis about a month before the incident with the heart patient. He knew the patient was in trouble because he had witnessed a similar incident at UC Davis.
“CTICU nurses at UC Davis complete a six-month orientation,” said Pruangkarn, former lead for the CTICU orientation program. “We don’t have that amount of time so we send our nurses to UC Davis for three weeks and then train them on three to five (patients) to complete their orientation.
“Our heart nurses have to be extremely motivated to study on their own. That’s why they are hand-picked,” said Pruangkarn. “We want someone with extremely good judgment.”
CTICU nurses from DGMC have been training at UC Davis since 2010, which is the same year DGMC opened its heart, lung and vascular center. Heart surgeries were discontinued in 2016 when the cardiothoracic surgeon deployed and seven qualified CTICU nurses left the military or were reassigned. Candidates for surgery were referred to other hospitals.
DGMC has partnerships with a number of medical centers and hospitals in Northern California that allow the two new cardiothoracic surgeons who arrived in 2017 – as well as specialty care providers – to maintain their war readiness skills. But when the surgeons operate on their patients in a civilian facility, they are supported by that hospital’s staff.
In the interim, the CTICU nurses at DGMC conduct weekly in-house training and receive additional hands-on training at UC Davis.
“This is awesome training for our heart nurses and its good for readiness as the CT patient is typically the most unstable on the unit,” said Pruangkarn. “The nurses are pulling from all their assessment skills, from CT and ICU training. Those come into play when you’re downrange managing a critically ill patient.
Because heart surgery patients are so unstable, they require constant monitoring.
“You’re monitoring things that you would not necessarily monitor in other patients, like swans – a pulmonary artery catheter used to monitor blood flow and pressures in the heart, which tells us the kinds of IV medications the patient will need,” she said. “We don’t do hearts downrange but we do use swans on septic patients to monitor cardiac output.
“A nurse with swan training can help train nurses downrange who are not used to performing the procedure or know how to interpret the numbers. Having managed very critical patients stateside prepares us to manage critical patients downrange.”
The first six hours after surgery are the most critical time for heart patients and the most demanding time for the nurses.
“We are in charge of maintaining normal vital signs, titrating medications, monitoring oxygen intake and, hopefully, getting the breathing tube out quickly so (the patient) can recover normally as from most surgeries,” said 2nd Lt. Max Lyon, 60th MDG CTICU nurse. “The goal is six hours. They won’t be perfect at hour seven, but we try to get them back to baseline – getting out of bed and walking again.”
Lyon was a nurse at the University of Washington Medical Center in Seattle, Washington, before joining the Air Force in 2018. He completed his orientation with UC Davis in March, working with nurses who have 10 to 20 years of experience.
“A lot of teaching is recognizing what’s normal and not normal and how to intervene,” he said. “We are learning to use the equipment properly and, ultimately, how to respond to something like cardiac arrest. You see the repetition and you see sicker patients and experience sicker patients in a safe manner.”
Heath Rogers has been a registered nurse at UC Davis seven years. His goal is to allow DGMC nurses as much hands-on patient care as they are comfortable with or that the situation allows.
“To some degree, I teach,” said Rogers. “Sometimes just a little because (the DGMC nurses) are experienced. We cover some of the hows and whys – why are you using that medication and not this one? They know so much already, but every hospital is different.”
DGMC has 55 ICU nurses, but only 10 are CTICU nurses. One of the six active duty nurses is always on call so they will continue to cycle through UC Davis for refresher training twice a year.
“You don’t want to be struggling and looking things up,” said Lyon. “You need repetition so you gain muscle memory when treating trauma patients.”
The training agreement also benefits UC Davis, according to Kevin Floyd, CTICU nurse manager.
“DGMC nurses bring in a different perspective because they are from all across the country and that is so helpful. We learn how things are done elsewhere,” he said. “Besides being helpful, they are respectful of what we need.”
As an example, Floyd said when a patients suffered cardiac arrest, the military nurses answered calls from other patients on the ICU.
“They are limited on what they can do, but they would come grab a nurse,” he said. “The relationship we have with the Air Force is just so amazing.”
Last year, DGMC amended its agreement with UC Davis to allow its medical technicians to shadow the nurses since they work as a team at DGMC.
“Our techs record the cardiac output and indexes, chest tube output, urine output, blood sugars and they are an extra set of eyes,” said Pruangkarn. “We are also constantly dialoging with them, which makes them stronger.
“At UC Davis, they are learning skills that can help us here and (will help) when they are downrange managing critical patients.”
With the success of the CTICU nurses’ orientation program, DGMC and UC Davis are working toward two other agreements for burn and trauma training so active duty members have that experience when they deploy.
| Date Taken: | 09.01.2019 |
| Date Posted: | 09.20.2019 18:23 |
| Story ID: | 342801 |
| Location: | TRAVIS AFB, CALIFORNIA, US |
| Web Views: | 145 |
| Downloads: | 0 |
This work, Cardiothoracic ICU nurses train at UC Davis, by Merrie Schilterlowe, identified by DVIDS, must comply with the restrictions shown on https://www.dvidshub.net/about/copyright.
