"A BP of 70/30 is normal"
- 1May 21, '08 by TigerGalLESo I had a patient today that came back from dialysis with a pressure of 70/30 and a temp of 103.1. After calling a rapid response and paging the MD. The MD had the nerve to tell me that a BP of 70/30 was normal for that patient!!! I'm sorry but that BP isn't even enough to keep his access patent!! And the pt told me his BP runs 130/80 normally. The doctor told me to give some Tylenol and give a dose of vanco... No fluid... no transfer to the unit... no nothing!!!!! So after the rapid response that got me NO WHERE.... The MD finally came and saw the pt an hour later and after 2L of NS he was still 70/40.... Then 5 hours after the initial rapid response was called.... OH now he wants to transfer... Well there is no ICU bed now!! There was a bed then.. but not now... Thanks a lot doc... yea b/c i didn't have 5 other patients......... GRRRRR...
This is the same patient that right after the rapid response stood up on the side of the bed and told me to get the hell out of his room or he was going to throw me through the ******* window.... How he could even stand up with that BP i'll never know.... what a jerk... man my day sucked....
- 0May 21, '08 by gal220RNTigger:
Feel good about the fact you did the right thing in escalating the care and forcing the issue with this idiot doc. If you have rapid response, you should be able to take the issue higher until you get the response you felt appropriate.
Some days just suck. Go home and either take a run around the block or drink a beer. I can't guarantee tommorrow will be better, but you will be better prepared to deal with whatever comes your way, including incompetent stubborn docs.
Press on, Friend!
- 1May 21, '08 by suzanne4Do hope that you notified your manager as well as the administrative supervisor about this incident.
But one thing in your favor is that the RRT was called and they responded and all of their calles get critiqued as well. So things will fall back on this physician by administration as well, or it should.
You completely did the correct thing here, not the physician and shame on him for not trusting you from the beginning.
70/30 is not a normal blood pressure unless you are small peds patient, and most would be started on a neosynephrine drip if there was no change after the fluid boluses were given.
- 0May 21, '08 by TigerGalLEYea I quoted the doc.... and quoted the pt stating what his normal BP was.... I charted so much on him.. Trust me I covered my butt...
And actually heelgal I drank 2 beers.. Haha... It is just frustrating when you have to give 1 on 1 care to a pt when you have 6 pts total...
The odd thing is... this doc has never acted like this before. I was really taken aback.. An ER nurse had to come up and monitor his levophed drip since we can't do that on the floor. He is a sick man.. and a mean man... Oh well I can only do so much...
- 4May 21, '08 by happybunny1970Yes, I agree. I work in Acute Hemo, and we neither access patients below 80 systolic nor return them below that... very rare to return one below 90. However, there are a handful of patients who are absolutely asymptomatic with systolics in the 70s... that's just where their 'normal' is (strange as it seems, and they make me nervous as hell). We take VS Q15min throughout treatments, and pay attention when the pressures start creeping down, but do not generally treat it unless a) it is in the 80s and/or b)they are symptomatic (lightheaded, cramping, decreased responsiveness, change in mental status, etc.) We are taught "treat the patient, not the number."
I also agree that our Nephrologists would not have bolused the patient with 2L NS... shoot, that's probably all the fluid they got off during the treatment, and now it's been put right back on -- far too quickly! --, threatening them with fluid overload and wet lungs, plus whatever other fluids they take in over the next 2 days until their next treatment. Which means the next treatment we have to try for MORE fluid, which will cause a more unstable blood pressure.
My suggestion would have been Albumin 25-50g given slowly, or Mannitol, which would encourage fluids to shift from the tissues into the vascular system. Had the patient been symptomatic, I would suggest reviewing the "dry weight" (ultrafiltration goal) because it may need to be changed due to change in actual body composition.
What we generally see in Dialysis is patients coming in with high blood pressures, which are gradually lowered throughout the treatment as we pull off fluid. After a period of time (hours after the treatment, when the person's fluids have shifted from the tissues to the vascular system quite normally on their own), you'll see the blood pressure rise again. Simple osmosis, nothing more, which is why the Albumin or Mannitol often work.
Sounds like there was an unfortunate breakdown in communication here...