[nursesandra]

Hi guys,

I just wanted to post a situation that happened to me so that I could get some feedback.
The other day I had a pt. who was quite young and was diagnosed with terminal liver cancer, he had only a few months to live. The pt's new wife was at the bedside 24hrs and she had her own psychiatric problems, was saying that if the pt. died she would kill herself too.
The pt. had just had a bilary drain inserted, and I was caring for him. His vital signs were stable and after the MD's rounded in the morning and told him that there was nothing they could do for him (the pt. was in denial about the diagnosis), he started having a panic attack.
He was shaking and was hyperventilating, he was tachycardic and hypertensive. I gave him some O2 by Nasal prongs, gave him some relaxation techniques to do, and I told the medical student what had happened (all of the MD's were in the OR).
The pt. then calmed down, and was visiting with some family members throughout the day. When the family members were leaving ,they mentioned dying to him, and he started having another panic attack. By this point he had ATIVAN ordered, so I gave him an ativan and some Gravol IV, I checked his vitals and he was tachy, hypertensive, breathing very quickly except this time he was febrile. I paged the MD but he was busy in the OR, he said to page the medical student. I did this, the medical student came and said to keep monitoring the pt. The pt. eventually calmed down, but he was still febrile and tachycardic, and his breathing was horrible. I felt like there was something else wrong too, so I ordered some bloodcultures/chestxray/urine c+s, but the doctor still wasn't coming so I paged him again, no reply, I paged the medical student and told him that the pt. was still breathing rapidly and was wheezing. The med. student said he was coming with the resident to assess the pt.and to read the chest xray. By this point it was the end of my shift, and when i gave my report to the next nurse she was mad at me saying "He's probably septic from the Bilary drain insertion!".
I left the floor feeling like I had missed something, that I should have been more persistent in contacting the MD's, as it started out as a panic attack, but it later became something more serious.
I'm often left wondering sometimes when I should call the MD, as they often get mad if you call them for something that isn't an emergency.

Any feedback? Thanks!

[JentheRN05]

I think you did the right thing contacting the doctor and being persistent. He probably does have an infection. But until you get the results back you/Dr. won't know. How long ago was the insertion?

[nursesandra]

Originally Posted by JentheRN05

I think you did the right thing contacting the doctor and being persistent. He probably does have an infection. But until you get the results back you/Dr. won't know. How long ago was the insertion?

The insertion was done the day before (1 day old). After I left Dr. ended up ordering antibiotics anyways (prophylactic) and the pt. had a pleural effusion (as seen on the chest xray) that had already been there for about 2 months . A couple of days later they ended up inserting a chest tube.

[sirI]

Hmmmmm....sudden onset? No previous hx? Did he have any chest discomfort?

Cannot r/o PE with superimposed anxiety/panic attack??

I think your persistence is admirable. (applause!!)

[sirI]

I was posting and missed your recent report. Makes sense that there was something else going on.

Good job!!

[SarasotaRN2b]

Originally Posted by nursesandra

By this point it was the end of my shift, and when i gave my report to the next nurse she was mad at me saying "He's probably septic from the Bilary drain insertion!".
I left the floor feeling like I had missed something, that I should have been more persistent in contacting the MD's, as it started out as a panic attack, but it later became something more serious.
I'm often left wondering sometimes when I should call the MD, as they often get mad if you call them for something that isn't an emergency.

Any feedback? Thanks!

First, it looks like you did everything you could. Second, I think the night nurse has no right to be mad at you. If she had cared for this patient, the night before she would have been aware of the insertion and should have suggested the possibility of sepsis occurring.

Considering this very sad case, you did what you could to help your patient.