Been having a string of really bad patients....

  1. I'm a new graduate that just got off orientation, so now I'm on my own, and I've been having a run of really bad patients. They start out fine at the beginning of my shift, but towards the end, they wind up intubated, comatose, and/or requiring surgery of some sort. The first patient was a patient that received tpa. I admitted him, his wife at his side, and I started doing my assessment. Everything was looking fine, and I told the wife, when she asked me when he was going to be able to go home, that I thought he would be able to go home pretty soon, by the end of the week at most. Vital signs were stable, the patient was awake and alert x3, and the only abnormal sign that I saw upon assessment was a big hemotoma where they had tried to place a peripheral iv. Otherwise, everything was normal, and I thought things would be pretty easy. A couple hours into my shift, the patient starts c/o of n/v and a headache. I thought maybe it was the nitroglycerine and so I told him that that was a frequent symptom of ntg. Then, he told me that he was having a really bad headache, and then threw up all over the bed. His eyes floated to the back of his head, and I went and got help from one of the more experienced nurses and I called the doctor. One of the interns, as soon as he came into the room, said the patient was stroking out, and we wound up coding the patient, intubating the patient, and placing him on pressors to maintain bp.

    A week later, I had a patient that was admitted for cerebellar stroke. It was obvious that she was having muscular deficits, but she was able to talk and was aao x2, had to reorient to time. Pupils were equal and briskly reactive, right side was slightly weaker than the left. Otherwise neuroassessment was normal. Vital signs were normal. Patient was on a NRBM for O2 support. Then throughout my shift (I work night shift, btw), the patient began to get lethargic. I thought maybe she was just tired and sleeping, but still I told the on-call MICU doctor whenever he came by that the patient was getting more lethargic. He said to keep watching her. Towards the end of my shift, the patient got really combative, trying to get out of bed. I paged the MICU intern, and he said restrain her, which I did. All throughout, I was performing neuroassessments q15 minutes. Finally, I saw that her right pupil was slightly more dilated than the left. I pgd the MICU intern again, and he said he was coming to take a look, but it took him a while, and all the time the patient was confused and kept trying pull her lines off and pull her NRBM off and being very difficult to manage, despite restraints. Finally the MICU intern and resident came by, they looked her and called for the neuro on-call, and he suggested we take her straight to CT stat, but by this time the patient was so agitated and confused that there would be no way that she would lay still for the CT. The MICU resident said I could use propofol, 30 mg IV, so I gave it to her, which made her quiet, but on the way, her O2 sat fell to 40, and we almosted coded her down in CT. Fortunately, the ED shockrooms were right next door, and we wound up intubating her there. I got a lot of heat from the ER nurses for giving 30 mgs of propofol to an unintubated pt. Even the RT down in ED wound up writing on the big board "30 MGS PROPOFOL + UNINTUBATED PT = INTUBATED PT". Finally, we get the pt to CT. Neurosurgery comes by, looks at the pics, and they zoom her off to surgery, and I'm standing there by myself in this big hallway in front of O.R.

    Then just last night, a week after all that, I get another patient. He's got a massive cancer/infection of the face. ENT comes by and does a biopsy of it. The man starts oozing a small amt of blood from his soft palate. They told me that this would be normal and just just watch it. If it starts to bleed a lot, pg them or the MICU intern. Well, all throughout my shift, everything is okay. I suction the pt frequently to get rid of the blood in his mouth. (FYI: the patient is a 60 y/o BM, retarded, who's' been taken care of by his family all his life. the pt is mostly stuporous, but does respond to pain, with severe contractions of the bilat LE's and UE's--think your basic nursing home pt.). Anyway, I'm working a 16-hour shift this night, and halfway through, I decide to give this guy up because he's giving me a bad vibe--his breathing is raspy, his O2 sat is erratic (because he doesn't sit still????), and his mouth is still oozing blood (8 hrs after the biopsy). I've told the on-call MICU intern, and he says just watch it because this is to be expected because he's been oozing blood from that area for a while now anyway because of his coagulopathy due to his infection/cancer (????). Anyway, as soon as I give report to the on-coming nurse, the patient starts to desat, his breathing is labored, and we pg the on-call MICU intern and resident. They come by soon, and then the call the on-call anesthesia because by now the pt's o2 sat is 80 and his breathing is really bad. Turns out that it takes us almost an hour to intubate the patient because his anatomy is so twisted. Surgery had to be called to intubate the patient because anesthesia couldn't make any sense of it. When surgery came by, he put his hand in the patient's mouth and pulled a clot about as big as his palm out, and finally they intubated the patient.

    I'm so tired. On top of all this, the nursing assistants have been giving me a lot of heat. They act like they're my boss, and they say that it's time for pt hygiene now or never. the charge nurse/supervisor doesn't do anything about this, and lets these nursing assistants get away with anything because all during the shift, the nursing assistants are helping the charge nurse do whatever needs to be done.

    Sorry for the long thread. I don't know what I'm doing wrong. I feel like i'm slowly sinking in quick sand, but I don't know how to get out. The other nurses are teasing me and calling me the angel of death. it makes me sick each time i hear that. i feel like crawling into a big black hole.

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  2. 16 Comments

  3. by   teeituptom
    Hiya

    Know the feeling. Last night had a 4 room assignment. One pt having an MI, another in CHF, another with asthma. The fourth was a young adult c/o of Chiggers. Ans as he yelled and screamed that the doctor was taking to long. I just had to smile at him... Rather than say what I was thinking.
    iVE HAD PERIODS WHEN i SEEMED TO ATTRACT ALL THE WORST PTS IN THE ER, NO MATTER WHAT MY ASSIGNMENT WAS.
  4. by   MandyInMS
    I'm so sorry you're having a bad time right now Ghetto...don't feel all alone though..it happens to every nurse..sounds to me like you have done very well considering you JUST got off orientation...seems like we all have a run of bad pts from time to time, sorry your 'run' has happened so soon.We had a male RN not long ago who had the same luck...for like 4 shifts in a row he had a pt to pass away..of course he did nothing wrong/it was their time to go...we joked around with him a little bit, but only to 'lighten' the mood..telling him things happen in 3's and why he havta be diff and make it 4's..we also told him it has happened to us ALL..he was feeling much like you describe..It's NOT you hun, things 'just happen' that we have no control over sometimes...as long as you do your best for your pts and learn along the way you can leave with a clear conscience...keep your chin up As far as the NA's "bossing" you...nip that in the bud or you'll regret it later...been there done that..I'm sure you probably just want to 'get along' with everybody..but, you have to make your position known from the start and stick by it..in a honest and respectful way of course.. I read in another post "Stand UP or be stood upon" your comments made me think of that...best of luck to you...hang in thereeeee! (((hugzzzzz)))
  5. by   VickyRN
    So sorry, Ghetto. Patients today are much, much sicker than they used to be. There are patients who are routinely admitted to med-surg units who just five years ago would have been in the unit!!! Don't be too hard on yourself--emotionally, such experiences are very hard. You did your professional best. Ignore the teasing. Stick it out for at least 6 months. Things tend to run in cycles for some unknown reason. You WILL have your nights when everything is haywire--everybody in the hospital is coding, your L & D is overflowing, the ER is full of very sick patients. Then other nights are just as smooth as glass. I remember when I was doing OB in a community hospital. Was new to OB and "helping out" the more experienced OB nurse--had two HORRIBLE deliveries back-to-back in ONE night. Never saw anything like it again the whole remaining 3 years I was at this hospital. As for the "bossy" NA's--this is something that can make you totally miserable if not properly dealt with. Discuss this situation ASAP with your supervisor.
    Last edit by VickyRN on May 24, '03
  6. by   P_RN
    Sheesh just off orientation and you got slammed. I'm so sorry.It does get better, but there will still be some who crump no matter what.

    Only one suggestion. When you call a doc with concerns TELL him to come check the patient now. As in "You need to come here now."

    If he says no....then "offer" to call his chief or even the attending doc. Present your case over the phone with facts and vitals, but don't let them push you around.
  7. by   whipping girl in 07
    Originally posted by Ghetto Supersta
    The first patient was a patient that received tpa... A couple hours into my shift, the patient starts c/o of n/v and a headache. I thought maybe it was the nitroglycerine and so I told him that that was a frequent symptom of ntg. Then, he told me that he was having a really bad headache, and then threw up all over the bed. His eyes floated to the back of his head, and I went and got help from one of the more experienced nurses and I called the doctor. One of the interns, as soon as he came into the room, said the patient was stroking out, and we wound up coding the patient, intubating the patient, and placing him on pressors to maintain bp.

    A week later, I had a patient that was admitted for cerebellar stroke...The MICU resident said I could use propofol, 30 mg IV, so I gave it to her, which made her quiet, but on the way, her O2 sat fell to 40, and we almosted coded her down in CT. Fortunately, the ED shockrooms were right next door, and we wound up intubating her there. I got a lot of heat from the ER nurses for giving 30 mgs of propofol to an unintubated pt. Even the RT down in ED wound up writing on the big board "30 MGS PROPOFOL + UNINTUBATED PT = INTUBATED PT". Finally, we get the pt to CT. Neurosurgery comes by, looks at the pics, and they zoom her off to surgery, and I'm standing there by myself in this big hallway in front of O.R.

    I'm so tired. On top of all this, the nursing assistants have been giving me a lot of heat. They act like they're my boss, and they say that it's time for pt hygiene now or never. the charge nurse/supervisor doesn't do anything about this, and lets these nursing assistants get away with anything because all during the shift, the nursing assistants are helping the charge nurse do whatever needs to be done.


    Ghetto, I think you're being a little too hard on yourself. First of all, you work in ICU, correct? The first thing you need to get in your mind at the beginning of the shift is that anyone of those patients could code at any time, that's why they're in ICU. Even the ones that look stable, even the ones that have been fine for three days and have orders to move to the floor in the AM. Sometimes the ones that crap out do not look like they are going to until they do. You always have expect the unexpected.

    As for the patients you mentioned, they all sounded like they needed to be in ICU and it sounds like you did what you were supposed to do. Personally, I hate tpa; it's really scary stuff and someone can stroke out from it without much warning. The nurse who precepted me on nights last year has had several patients do badly after receiving tpa, even though the chance of a hemorrhagic stroke is supposed to be less than one percent. About a month after I got out of orientation, I took care of a patient who received Retavase for a MI. She was being transferred from an outlying hospital, and the ER doctor there decided to give it to her even though it was contraindicated because of her uncontrolled BP (220/130). They gave the first dose and the paramedics gave the second dose in route. Initially she was stable when I received her, but as I gave her drugs to try to get her BP down (Tridil at 100mcg/min wasn't even touching it!), her HR started dropping and she was also vagaling every time she would vomit. Her pupils were equal and reactive, she was AAOx3 and had no headache, her only complaint was n&v. I had to put a foley in her and start two new IVs and she did not bleed at all. She was on heparin but her ptt at 3am was sub-therapeutic. Finally after two half doses of inapsine, she went to sleep. I checked on her at six and she was arousable. By eight AM, when the day nurse went in to assess her, her pupils were blown and she was unresponsive. She had had a massive cerebral hemorrhage with virtually no warning. Of course, she died. My manager came to me and fussed, but she knew that I had done everything I could have done.

    As for the patient you gave the propofol to, I can honestly say I have never given propofol to a patient who was not intubated (unless he was about to be intubated) but other nurses I work with have without problems. 30mg is not that much (3cc, right?) and it wears off quickly. If she was getting that combative (think hypoxemia) despite the NRB mask, it sounds like she may have needed to be intubated anyway. Also, if the respiratory depression was drug-induced, some Narcan or Romazicon should have turned her straight around. However, in the future, you may want to suggest the drugs you want to give (hey doc, you want to give her some Versed or Ativan to transport her?). Also, it is against our hospital policy for nurses to push propofol (only CRNAs or MDs can push it, but we can maintain propofol gtts). As for the RT who felt the need to express his/her feelings on the big board in the ER, what an idiot. I'm not convinced that 3cc of propofol would knock out someone's respiratory drive completely unless there were other drugs on board or the patient was really small. The ER nurses and RT were giving you a hard time because you're new, and a resounding "Bite me!" would probably have been an appropriate response.

    The third patient was an accident waiting to happen and that's why he was in ICU. You didn't do anything wrong and he probably should have been intubated to begin with to protect his airway.

    As for the CNAs, you'd better set them straight ASAP, although it is better to do hygiene on your patients early when you have help than later when you don't. If they have several nurses to help and they are offering to help you NOW, do your best to accomodate (unless you have an unstable patient or something else that's keeping you from doing it now). Early in my nursing career I became the queen of the 4am bath and usually ended up with no one to help with the turn or I'd put someone else behind on their work so they could assist me. My co-workers got to the point where they WOULDN'T help me if I started late. I learned to get it done early, and now I often do a bath before visiting and before I open my notes, especially if both of my patients are AAO and I don't want to wake them up in the middle of the night.

    Good luck to you, and don't worry, pretty soon someone else will get to claim the title of Angel of Death...we trade crowns frequently in my unit.:chuckle

    Sincerely,
    Queen of the Fecal Bag
  8. by   shelml
    I here yah girlfriend. We all get them. Sometime it feels like it by the end of every shift...Smile...It's good you commented on this. It allows comparison & repeats connections nurses have dealing with pt care. I'm about a yr out of school started in 4/1 ratio day Tele Unit then winded up stepping back to 6/1 ratio M/S unit on nights. I constantly remind myself how much I enjoy being a nurse. In TX, relocating to NC. In what state are you located? Good Luck
  9. by   ERNurse752
    My very first night shift in the ER, still on orientation "technically," and I had two of my pts die...of course, one came in as a cardiac arrest, and one came in as a near resp. arrest who progressed to cardiac arrest very quickly...but I was also dubbed Angel of Death. Also Nurse Nightmare...

    Every time (even now, 1 1/2 years later!) I walk into a room with a critical pt, I am likely to get told to get out! But it's all in fun, and I didn't, and still don't, let it bother me.

    But I can see where it would bother you, especially since people aren't very supportive of you, it seems.

    You're new...there is no way you can know everything, and it sounds like you did everything you were supposed to do.

    p_rn gave some good advice about telling the doc he/she needs to come in NOW, or call someone else.

    You might already know about it, but a good site that someone on here runs is www.icufaqs.org
    Lots of good information...kind of like an online ICU orientation.

    Don't be so hard on yourself, and good luck with the future...keep up the good work!
  10. by   karenG
    oh thats so tough...........

    we have a saying here that all things come in threes! My first ward- when I was 19, back in the dim and distant past, was terminal care! I thought I was the angel of death- had 3 deaths on my first day and I was convinced it was my fault!! In all we had 21 deaths while I was there and I can remember all their names!!! it is hard......

    you take care of yourself......

    Karen
  11. by   cab631
    17 years in ICU and I see people in your shoes everyday. Talk to your supervisor about the problem with the CNAs. But look at how your prioritize your time. Maybe you can rearrange your work pattern a little. In my unit we started baths at 0400 and you just went in and just started doing your thing. We'd each get everything ready, make a roll of sheets and lifters and then call someone to hold and help turn. It ususally didn't take anyone away from their patient for more than 5 or 10 minutes, max. And then it would be my turn to help whoever helped me. Even if you don't like that person, you can help turn. We have to wake them all up at 0400 for labs and the A&O ones we wake up at 0500 for CXRs. So why not bathe them then? Of course, we do "buffing and puffing" some before visiting hours when the shift first starts, but the real baths came in the early am. See if there's someone you can buddy up with and help each other out. And if you develop a reputation for being the first one to jump in and help others out without being asked, they'll soon recognize that, and they will gladly help you. It takes time. Hang in there. And when SH#@ starts rolling downhill, take notes and learn.
  12. by   Agnus
    You stated you are on nights and it is near the end of your shift when these things happen. It is to be expected. It seems related in some way to the cercadian rythm. Statistically most codes and deaths occure between 4 am and 9 am. It is a time when our metabolism is in a dangerous flux. (Remember how the DM will have a drop in their glucose level at 4 am?)

    It is in appropriate and cruel to refer to you as the angle of death. Rest assured though they would not be teasing you if they thought there was any truth to this. Still it is cruel. I am not sure how to ask them not to do this. They are not thinking or they would not do it if they realized how this was effecting you.

    You have some extreemly sick patients it is the nature of things that these will be ones who go bad on us.

    As for the CNA you need to have a talk with her. It is your place to do so. Contrary to what many believe the correct answer to the interview question "what do you do when you have a conflict with a co worker?" is not "take it to the supervisor." The answer the interviewer wants to hear is, "I prefer to handle conflicts myself. So I discuss it with the co-worker and work it out."
    Your boss is not there to settle petty squables. She would much rather you solve your own problem with the CNA. In fact managers are generrally advised to stay out of these things and to alow you to settle it yourself even when you do bring it to her.

    Demonstrate your maturity and LEADERSHIP take the bull by the horns and deal with this person.
    Last edit by Agnus on May 25, '03
  13. by   Hellllllo Nurse
    I've been a nurse for ten years and worked numerous places. At every job, there are CNAs who act like they are the boss. I know it's hard, but stand up to them. If your manager does not support you in this, then that is not a place you want to work. Nursing is tough, and keeps on getting tougher. I've been in your shoes and I know how it feels. You have my support.
  14. by   BadBird
    Sounds like a normal shift to me. What concerns me is why is a new graduate RN working at 16 hr. shift? I think you need to slow it down a bit before you burn out.

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