hi, i've been reading the "dangerous nurse" posts, and all i can do is wonder about myself sometimes.
long post:
assigned to an elderly woman, who looked terrible when i first went in to assess her. multiple serious issues, her nephrologist and attending came in, both saw how she was, both agreed she wasn't doing well, attending called her son and told him the poor prognosis. intensivist came in to see her, saw her mottled feet, poor mental status, i told him about the plan, he alluded that he would be back later to assess her.
later that morning, this patient was slowly deteriorating in mental status, and becoming more hypotensive. i called the intensivist, told him about the blood pressure, he ordered a different vasopressor. i asked for an a-line, he said he would be over, and that "if she needs an a-line, that's what we'll do."
i didn't tell him about the mental status, i hadn't even thought about it at this point. mostly because it wasn't that great to begin with, and i was more concerned about her bp.
waited, and waited for this intensivist, meanwhile checking the bp every 10 minutes by cuff, it was staying up with the new pressor, but the patient was looking worse. her respiratory rate started increasing, about 24-32, becoming more labored.
finally the bp was dropping, and not picking back up, i maxxed out the new drip, and called the intensivist again. he came over, took one look at her, said: "she looks a lot worse than this morning, doesn't she?" (with a condescending sneer, of course) attempted an a-line, not successful, talked to the family, who agreed to let her go with comfort care measures. she passed on my shift.
now that i look back, i know i should have told the intensivist: "you need to get here now, she's not looking good." i only told him about the occasionally dropping bp, that's all i was thinking about.
i talked it over with my manager, who said i did fine, of course. i really think the standards are too low for nurses on my floor, management seems to have a tolerant attitude towards incompetence.
the thing is, i don't think i'd be smart enough to do the right thing the next time this happened. i don't have a system in place for this, i use sbar for communicating with doctors, but it doesn't seem to be good enough with icu patients. sometimes everything's so subtle, you need to be clairvoyant just to get through your shift.
here's the thought that keeps nagging me: "a good icu nurse would have seen clearly what was going on, and got that intensivist over immediately." this patient wouldn't have made it anyway, but what if this happened with someone who could survive?
