Ugh, those "I'm so stupid" momentsRegister Today!
- by TheCoppertop Sep 28, '12I've been an ED nurse for 5 years and just moved to a new state, a new job. I'm as confident as I can be after 5 years, I definitely don't know it all but I can hold my own.
Yesterday, my 2nd week off orientation I had a critical care room with 2 bad pts plus I was responsible for a medical bed until the 1pm nurse arrived. It was 12:30 and in the med bed I got a meth smoker, not taking her meds, already had a few CVAs, she was a mess.
Blubbering about how I wasn't allowed to stick her as she always gets IVs in her neck from the doc, they know her there. So when the doc came in I told him this and he ordered an ultrasound guided IV. He gave her hell about her pressure and not taking her MANY bp meds, he seemed really freaked about her shape and kept having me cycle her BP. Her BP was 250/150 range, repeatedly. She was a mess.
So the ultrasound nurse, an ER nurse, came and set to work, I gave this pt the ordered ntg, sl clonidine po (made her chew 0.3) and had to get ATBs on board on my septic pt so I ran to do that while that nurse got the IV and blood. I was in my critical room when the doc (I don't know) called me out of the room and asked me if I had Meth lady.
I said yes and he said all gruffy "put her in trendelenberg and set up an EJ". Nice, the ultrasound nurse struck out on her fried veins and didn't tell me, just left. So I put her in trendelenburg and set up the EJ. Her pressure spiked even HIGHER, her face was all red, she was moaning, and after about 10 min the *doubt* set in. "Omg, we put *hypotensive* pts in this position! Crap, did he say reverse trendelenburg because of her pressure? Her damn heads gonna blow off! He's gonna walk in here and flip! And if she strokes out it'll be my fault!"
A good 10 min went by and I got nervous, put her in reverse. So he walked in and YELLED at me, "THATS NOT TRENDELENBURG! Put the patient in trendelenburg, thats her head LOWER and I'll be back!" He huffed out and I felt this -->. big.
Fortunately then my med bed relief nurse walked in and I was able to apologetically hand the whole mess to her. It really shook me for the day though, I was afraid of having the patient in that position, in her condition for a good period of time when she obviously worsened in trendelenburg. I didn't know the doc isn't very experienced and wanted her neck veins extra full (he tried and couldn't get it, made u/s come back). What a mess.
Even when you're confident in what you're doing you can still have these "I'm so stupid" shaken moments, right? I wish I could just accept that I did the right thing due to her worsening but the doubt I had is what bugs me. i hate it when docs flip out like that and huff off before you can say "she got worse while waiting!" Anyone else?Last edit by Joe V on Oct 3, '12 : Reason: spacing
- Sep 28, '12 by AP0525In some cases, let docs yell and act stupid. You did the right thing by not leaving her in trendelenberg if she felt worse. With a pressure that high, he should have just been able to lay her flat and stick. I'm pretty sure she probably had some JVD going on.
- Sep 28, '12 by Career ChangesI don't see that you did anything wrong, other than maybe leave her in trend too long. It seems your thought process was spot on.
- Sep 28, '12 by artsmomScary doc! IMO, always protect your patient and license first. Someone's Bp is threw the roof and he wants her in trendelenburg for an extended period of time?? You did the right thing, prudent nursing sometimes involves questioning a doctor's orders. And while this is irrelevant to your story- maybe that woman needs a portacath.
- Sep 28, '12 by sserrnSometimes we have to be the thinkers. You did fine.
- Sep 28, '12 by brainkandy87This whole situation just blows my brains out. Does your facility not let RN's do EJ's and/or US PIV's independently (our ER docs "check" us off on skills such as EJ, US, etc)? I love my ER docs and the great procedures they do, but I'd never want a doc to put in a PIV over a nurse. How often do they do PIV's compared to us? But I do know every facility is different with policy concerning RN's and EJ's. I think you might've avoided a lot of the yelling had you not trendelenburg'd her until he was walking in the door (it doesn't take that long for those veins to distend once the head is dropped) and you would've had a lot less worry about her BP.
Anyway, it happens. Docs get mad and yell, even the nice ones. No matter how many years you do this, you'll always end up doing something that makes you feel stupid. We are just human.
- Sep 29, '12 by iluvivtYou did fine..you were the one assessing the patient at the time and you made the best decision for the patient. It is also uncomfortable to stay in that position for too long for most people. I am certain I would have told the MD my rational the minute he got irritated that the pt was not in the position he had requested.
Maybe it's because I am an IV nurse BUT I listen to the patient but do not always just do what they think is best. I always look for myself and can find veins even on the worst of the worst. Once in a blue moon I will use the US but I have put PIVs in for twenty plus years without it so I rarely need it. The point is always take a a look yourself and apply warmth to any potential sites on the difficult to start patients.
- Sep 29, '12 by TheCoppertopThanks to all who replied! I know I did the right thing for the patient and I do feel better about it now. I'm at a L1 Trauma center and I'm surprised RNs cant do EJs, I've done quite a few at my previous jobs! I'm in that new job "prove myself" period and it sucks how something like this can knock you miles back down the ladder! The doc strode off before I could say anything and that irked me too. Its weird here, the docs have little offices with closed doors and we're supposed to relay issues to supervisors (charge nurses) and they in turn go speak to the docs. Like "Psst, hey supe! can you go enter the sanctum and tell the doc that my patient just went pulseless? k thanks!"Its bizarre to me, had this happened at any other place I've worked I knew the docs well enough to say heyyyy hotshot, this is what happened! Not here! I'm here for the Trauma experience but after a few years I will go back to a mid-size hospital where I can communicate. Its tough being a nameless face amongst 80+ nurses. I pride myself on being a careful and trusted nurse. I'm already doing well, kicked off orientation 4 weeks early because I got it, and assigned to critical rooms straight off. I don't say much but when my previous docs heard me say something was wrong, they trusted me and hopped to it.