how quickly someone can go downhill.

  1. Always listen to your gut.

    I had a patient who I'd had the previous night, and he had been complaining about not getting much sleep. I got him comfy, got him in a recliner, gave him some coffee and a blanket, he slept, had a ok night. That AM before leaving, I was running a little behind, and he gave me a hard time, saying "hey, you're supposed to be home by now!".
    When I came back that night, he was ok, his wife was there nd she was going home. He was being moved to a private room, and I checked his 02 while walking, it was good.
    The cardiologist wanted him to get some IV fluid due to a low bp during the day, and a little dizziness. I hooked him up, and over a hour he got a 100 mls. He called me because he was feeling short of breath, and his lungs sounded a little tight. I spoke with his doc and his cardiologist, got 40 of Lasix, gave him that, and told myself I'd be back in 10 minutes.
    I came in, and he had just called me.
    He was GREY, and sats of 88. Called the rapid response, got some help, he kept saying he was going to pass out, we got him back to bed, called the docs.....etc. etc. gave him another 40 of lasix, got him to the ICU. We hooked him up to the ICU monitor, he coded right away. got him back, coded again(shocked twice). I was there for 2.5 hours while we coded him 5 times, got him to the cath lab, and he coded 2 more times. Ultimately died on the cath lab table.
    Figured out he had another MI(he had been admitted with one, and had a balloon pump with a regrafting 4 days prior).
    I know I did everything I could, but it still upsets me. I've been taking care of patients for 5 years and have never had anyone code like this before. Just putting this out there. I hope his family finds peace.
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  2. 30 Comments

  3. by   usalsfyre
    You did nothing wrong, and quick recognition of status change is important.

    Lasix was a poor choice for an acute event, but it wasn't your call.
  4. by   9livesRN
    It sucks, but it's real life, had one like that that brought his own recliner in, not to mention the weeping legs with theribke limp edema that just bubble and burst like a vulcano!
  5. by   highlandlass1592
    Quote from usalsfyre
    You did nothing wrong, and quick recognition of status change is important.

    Lasix was a poor choice for an acute event, but it wasn't your call.
    Why would you say to this nurse Lasix was a poor choice? Based on the information they shared, how would they have known this was an acute event?? I just don't get that...
  6. by   highlandlass1592
    Quote from locolorenzo22
    Always listen to your gut.

    I had a patient who I'd had the previous night, and he had been complaining about not getting much sleep. I got him comfy, got him in a recliner, gave him some coffee and a blanket, he slept, had a ok night. That AM before leaving, I was running a little behind, and he gave me a hard time, saying "hey, you're supposed to be home by now!".
    When I came back that night, he was ok, his wife was there nd she was going home. He was being moved to a private room, and I checked his 02 while walking, it was good.
    The cardiologist wanted him to get some IV fluid due to a low bp during the day, and a little dizziness. I hooked him up, and over a hour he got a 100 mls. He called me because he was feeling short of breath, and his lungs sounded a little tight. I spoke with his doc and his cardiologist, got 40 of Lasix, gave him that, and told myself I'd be back in 10 minutes.
    I came in, and he had just called me.
    He was GREY, and sats of 88. Called the rapid response, got some help, he kept saying he was going to pass out, we got him back to bed, called the docs.....etc. etc. gave him another 40 of lasix, got him to the ICU. We hooked him up to the ICU monitor, he coded right away. got him back, coded again(shocked twice). I was there for 2.5 hours while we coded him 5 times, got him to the cath lab, and he coded 2 more times. Ultimately died on the cath lab table.
    Figured out he had another MI(he had been admitted with one, and had a balloon pump with a regrafting 4 days prior).
    I know I did everything I could, but it still upsets me. I've been taking care of patients for 5 years and have never had anyone code like this before. Just putting this out there. I hope his family finds peace.
    This is a no-win situation, unfortunately. I've learned that lesson the hard way, many years ago...listen to my instincts. I may not always know what's going on but I can tell when we've got a problem...and if I have to push the issue I will.

    It's hard to lose a patient, standing there and not knowing what's going on to be able to try to fix it. I lost a dear patient I was close to a little over two years ago...one of the hardest codes of my life. She kept telling me "I'm dying, don't let me die..." and I worked my butt off to try to prevent it. That one will haunt me till the day I die...I've lost patients before, it's a part of critical care nursing..but for her to keep calling my name over and over, asking me to stop her from dying...wow.

    I honestly can't tell you that you'll get over this..but you will find a way to deal with it.
  7. by   usalsfyre
    Quote from usalsfyre
    You did nothing wrong, and quick recognition of status change is important.

    Lasix was a poor choice for an acute event, but it wasn't your call.
    New onset of SOB is an acute event. As this was a patient with previous cardiac hx and had trouble noctournal orthopnea the night before it was a fairly safe bet to assume it was cardiac in nature.

    Lasix, despite what all of us were taught years ago, has no place in the acute management of heart failure. Many of these patients end up actually dehydrated. Pre and afterload reducing agents are much more useful. Bring on the BiPap, NTG and ACE Inhibitors.
  8. by   highlandlass1592
    Quote from usalsfyre
    New onset of SOB is an acute event. As this was a patient with previous cardiac hx and had trouble noctournal orthopnea the night before it was a fairly safe bet to assume it was cardiac in nature.

    Lasix, despite what all of us were taught years ago, has no place in the acute management of heart failure. Many of these patients end up actually dehydrated. Pre and afterload reducing agents are much more useful. Bring on the BiPap, NTG and ACE Inhibitors.
    Actually, this patient had gotten fluid earlier so depending upon an in-depth lung assessment (which the only information given here was "tight") as well as a cardiac assessment, Lasix definitely may have been indicated. And some form of diuretic therapy IS indicated in heart failure management, especially exacerbation which might be caused by right heart failure. Diuretic therapy is driven by kidney function, better to be a bit dry than wet.

    And re: orthopnea, that was not listed when the symptoms were discussed, what was stated was " he had been complaining about not getting much sleep". As this pt was post-op for CABG, that is not an uncommon complaint.

    Your post jumped to some conclusions that weren't supported by information presented by OP. And as this patient went into an acute situation rather quickly, NTG and ACE inhibitors wouldn't have been indicated, IV inotropes would have been indicated as well as the possible use of Milrinone if the patient stabilized, which unfortunately didn't happen. IMHO the OP was looking for support regarding a situation which deteriorated rather rapidly...not a lecture on presumed heart failure management.
  9. by   jahra
    I am so sorry for the family. When things change that fast, difficult to cope
    with that news.

    Please get the support you need for yourself, even with experience we
    all encounter situations in which we question ourselves.
    Find your support system and work through your feelings.
    You used your gut feelings and kudos to you for all your work in the care of this patient.

    In regard to armchair quarterbacking, I personally feel in a thread like
    this, members should send directly comments to the OP after asking if that discussion
    would like to take place.

    I think we should be sensitive to the fact this is a very recent event and
    ask the OP if they would like the suggestions on how the MDs etc could/
    should have managed the situation on the thread itself .

    We do not have all the facts of the case...................
  10. by   emmanewgrad
    Quote from highlandlass1592
    This is a no-win situation, unfortunately. I've learned that lesson the hard way, many years ago...listen to my instincts. I may not always know what's going on but I can tell when we've got a problem...and if I have to push the issue I will.

    It's hard to lose a patient, standing there and not knowing what's going on to be able to try to fix it. I lost a dear patient I was close to a little over two years ago...one of the hardest codes of my life. She kept telling me "I'm dying, don't let me die..." and I worked my butt off to try to prevent it. That one will haunt me till the day I die...I've lost patients before, it's a part of critical care nursing..but for her to keep calling my name over and over, asking me to stop her from dying...wow.

    I honestly can't tell you that you'll get over this..but you will find a way to deal with it.
    I'm sorry you have endured this in your life, she knows you tried your best.
  11. by   Been there,done that
    This isn't the time to even think about YOUR shoulda .. coulda. wouldas.
    The patient was a fragile cardiac client.We do not have a crystal ball.

    I had a patient that was hospitalized for 6 weeks, dressed and ready to go home... died in the bathroom, getting ready to leave.
    God calls us when he calls us. We are only his servant in our efforts to provide care... it was your patients time.
  12. by   Biffbradford
    Interesting that he had another MI. I know that the OP can't answer to that, but it's quite unfortunate. May I ask how old the pt was?
  13. by   usalsfyre
    Quote from Been there,done that
    This isn't the time to even think about YOUR shoulda .. coulda. wouldas.
    The patient was a fragile cardiac client.We do not have a crystal ball.
    When exactly is the time then? We don't have a crystal ball on any patient and chalking it up to a "fragile cardiac case" is a cop-out. Learning happens immediately post event. If your not learning from these events, than your letting your patient population down. The time to ponder the fragility of the human condition and put these events away emotionally is with a couple of days off and the hobby and/or adult beverage of your choice. Looking back at what you could have done better is how you keep this event from happening again. I think the OP did a fine job working with what she had. Next time, there might be another way to go about it though.
  14. by   Zaphod
    Kind of doubt it was another mi. If he just had cabg he could have restenosed but not as likely. Could have been a fatal arrhythmia especially if he had a rca infarct to begin with which would exlain the low bp. I've had a pt in cv post cabg sit in a chair walk arround and almost getting ready to get discharged get into vfib out of the blue. The surgeon oppened the chest and everything was patent. It has been haunting me as he was in his 40s

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