Moving Too Slowly in Emergent Situations

  1. 0
    I have worked in ICU for several months now. While I know I still have a lot to learn, I am beginning to feel confident in the more routine aspects of ICU work. Except....

    I don't feel like I move fast enough in truly emergent situations.

    I can think of two examples. The first had already coded on night shift (I took over care on day shift). He was already maxed on on several pressors, but I had to add several more. I had multiple teams of doctors (critical care, surgery, hematology, etc.) writing multiple orders for new meds, tests, IV boluses, etc. I took the patient to CT (made one of the critical care docs come too because the patient was so unstable). Multiple docs attempted to get an A-line, but all were unsuccessful. I was NEVER was able to pick up a blood pressure or an 02 sat on the monitor, so I had to check the BP manually with a Doppler every so often. I expressed to the other nurses (who helped me tremendously) that I did not feel that I was taking adequate care of the patient. They would reply, "Don't worry about it, you're doing all you can do, he's going to code again anyway." At the end of the day, the patient DID code again, and we were unable to recussitate. I looked back over my orders, and I found several medications I had not given, lab tests not ordered, and FFP that I had not given. (Side note: at that time we did not have a secretary to put in orders, so the RNs were responsible for faxing orders to pharmacy/entering their own labs)

    The second patient came from surgery, and we coded her several minutes after she had arrived (very sick patient prior to surgery, prognosis not good, unable to get a BP or A-line access while in the OR). Similar story to the first--several new orders, pharmacy needing clarification for post-op orders, new labs and medications. There was a post-op antibiotic that needed clarification (I never clarified it, it was never given). The doc gave me a verbal order for a new medication (never wrote the order, never gave the med). We coded this patient several times throughout the day. I gave blood and FFP. Again, the BP monitor and sat monitor never picked up. Again, the patient coded at the end of the day and we were unable to recussitate her.

    While I don't argue that both patients were very sick and as the other nurses said, "Going to code again anyway," I feel like if I hadn't missed the FFP on the first patient, or maybe given more FFP or PRBCs or the new medication to the second patient, I could have stabilized them and at least given them a chance for survival. I feel that I cared for the patient to the best of my ability, but I don't feel like I did a good or even adequate job. I know that I need to take care of these types of patients to gain experience for "the next time" I have one. However, I feel guilty because I feel like I am failing the patient and I should just ask a more experienced RN to take over. I feel like I am struggling just to maintain the patient, and I miss critical orders and medications.

    Has anyone else experienced this as a new ICU RN? Any advice from experienced RNs?

    Laurenboog

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  2. 12 Comments...

  3. 4
    Sounds like a problem with the system, not with you.

    In my ICU, all orders are entered onto our electronic system by the doctor requesting them, and show up instantly on our bedside computer.
    Similarly, lab tests are ordered the same way, but in addition our doctors go a step further and bring us the pathology request form, as well as verbally telling us what they're requesting, why, and if we need to do it now, or when we next draw bloods.

    Sounds like your system needs improving, and any fault is with it, not with you.

    I'm sure you did the absolute best you could, it sounds like it.
    CrabbyPatty, CCL RN, katmarieRN, and 1 other like this.
  4. 2
    Don't beat your self up over it. If you're unable to get an SpO2 or ABG's, or even a real blood pressure, then you're really fighting a loosing battle, it was their time to go. Pat yourself on the back for doing the best you could on that day, and move on.

    Hopefully, they didn't have you pick up another patient right away once you cleaned up that disaster!
    sunnycalifRN and CrabbyPatty like this.
  5. 1
    I doubt the blood products would have actually saved the patient anyways and think about how long it takes for the blood products to be typed and cross matched and prepared--the patient might have coded by then anyways.

    In the future, ask a less busy RN to enter your orders and make it a priority to write down and review orders ASAP so you dont forget critical elements.
    VivaLasViejas likes this.
  6. 1
    I agree, these patients are on the way out no matter what you do. Getting the extra FFPs or Blood in are the least of your problems with these patients. Your seasoned co-workers were telling you not to worry about it and were right on the money with that advice.
    CCL RN likes this.
  7. 1
    I would have made a big stink about transporting a pt who is maxed out on pressors to CT. I mean a really big stink. Too unstable.

    Otherwise, what could you do? Sounds like a system set up for failure...
    CrabbyPatty likes this.
  8. 0
    Quote from ShaunES
    Sounds like a problem with the system, not with you.

    In my ICU, all orders are entered onto our electronic system by the doctor requesting them, and show up instantly on our bedside computer.
    Similarly, lab tests are ordered the same way, but in addition our doctors go a step further and bring us the pathology request form, as well as verbally telling us what they're requesting, why, and if we need to do it now, or when we next draw bloods.

    Sounds like your system needs improving, and any fault is with it, not with you.

    I'm sure you did the absolute best you could, it sounds like it.

    Wow, can I come work with you?????? My ICU experience (almost 3 years now) is just like the OP's!!!
  9. 0
    Quote from Biffbradford
    Don't beat your self up over it. If you're unable to get an SpO2 or ABG's, or even a real blood pressure, then you're really fighting a loosing battle, it was their time to go. Pat yourself on the back for doing the best you could on that day, and move on.

    Hopefully, they didn't have you pick up another patient right away once you cleaned up that disaster!

    I recently had one of those situations at work and my 2nd patient kept having psuedo seizures every time things would get really bad with my critical patient!!!

    When my poor patient was moments away from coding, I called the family in (they were in the waiting room) and explained what we were going to have to do to the patient in a few minutes (Code him, chest compressions, probably broken ribs, etc) because his heart was giving out and he was on so many pressors already and we lost his A-line pressure...the monitor was showing he had an MI. The poor wife made him a DNR and he died within 5 minutes, but not before my other patient decides to have another pseudo-seizure!!! UGH!!!!!

    What a day!

    Would have gone much more smoothly if I had the support system I needed to care for him, but he still would have died. He was so very sick.
  10. 0
    Quote from CCL RN
    I would have made a big stink about transporting a pt who is maxed out on pressors to CT. I mean a really big stink. Too unstable.

    Otherwise, what could you do? Sounds like a system set up for failure...

    I completely agree with you about the patient being too unstable for CT. The reason I went was because the surgeons ordered the CT d/t massive abd. distension, and the pt. was doing so poorly anyway....I just figured that the pt. would definately die if the CT scan was not done but if the CT showed a "fixable" problem, perhaps the surgeons would attempt surgery (assuming they would take the risk of operating).

    No one was pressuring me to take the patient, I just was hoping the CT would give the team some information to work off of. At that point, this patient was very sick but the team had not been able to pinpoint the cause of the situation.
  11. 0
    Quote from LaurenBoog
    I completely agree with you about the patient being too unstable for CT. The reason I went was because the surgeons ordered the CT d/t massive abd. distension, and the pt. was doing so poorly anyway....I just figured that the pt. would definately die if the CT scan was not done but if the CT showed a "fixable" problem, perhaps the surgeons would attempt surgery (assuming they would take the risk of operating).

    No one was pressuring me to take the patient, I just was hoping the CT would give the team some information to work off of. At that point, this patient was very sick but the team had not been able to pinpoint the cause of the situation.
    I hear you, and that's fair. If you can squeeze a CT trip into that busy day, then I don't think you are moving too slowly
    Sounds like you are doing the best you can. Cut yourself some slack!


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