10/09/25 ICU-Junior Support/Leadership/Conflict

Two things to reflect on today.

I was doing ACCESS role today, and one of the nurse I supervised is a transition phase 3 nurse.

The patient has encephalitis and was intubated til this morning, the Dr assess him and the patient obey all commands, so they want to give a go to extubate him. 

After the extubation, the patient was initially coping ok with HFNP 50L and 50%, but by the afternoon, I noticed the patient is quite tachypnea up to 40-50, SaO2 hasn't changed much, ABG hasn't changed much, but something is just not feeling quite right, so I flag with the doctor. 

The doctor said to encourage Triflow and sit the patient right up, we did but it's not very effective, anyway we just keep monitoring the patient as the Dr suggested. 

By 6.30pm, the ABG was getting worse with PO2 trending down and PCO2 trending up, so we flagged with the Dr again. 

Just when we were discussing with the Dr, the patient suddenly dropped SaO2 to 88% and looks purple, we quickly called the Dr to r/v and put HFNP up to 100%, 60L. 

The patient's symptoms resolved but he also stated he is feeling hard to breathe, the Dr r/v him and believe there's some upper airway secretion that the patient can't clear it off. So I suggested to called the on-call physio as patient has very ineffective cough. After the physio treatment the patient gets slightly better.

I think I should have be more vigilant with the patient situation as the transition nurse may not have enough experience to pick up early signs of respiratory distress.

Second thing is that when I was helping the other nurse doing tubey round, the patient was not ventilated very well, I gave some propofol bolus, and let the nurse know the patient is not ventilated too well. 

The nurse acknowledged it but I feel that she didn't take it serious enough, she was spending too much time to turn the patient and making laugh with the patient's loose bowel situation. 

I felt it was not appropriate and so I became a bit firm and let the nurse know that the patient is not stable, we need to finish the turn quickly. 

I believe the nurse and the wardies can acknowledge my voice tone change and realise the seriousness, so we were able to finish the turn without causing further issues.

I believe I did the right thing by having a more firm/authority leadership style at the time to ensure the patient safety is maintained.

Overall it was a good learning day.