Seeing red

[VickyRN, MSN, DNP, RN]

Please help me sort this all out if you can. Came on my usual night shift Tuesday @ cardiac step down unit in a level one trauma university teaching hospital. Had a patient who had been on the floor for several hours. This was a 70-year old gentleman who had been fairly healthy and who had presented to an outlying hospital with an active MI. He was rushed by ambulance to us and sent immediately to the cath lab for interventions (PTCA/stent, etc). While in the cath lab, on the table, with cath in progress, another pt presents to ED in more emergent state. So they stop the cath on my patient (no interventions yet--LAD occluded), send him up to the floor with sheath in place, to do the cath on the other pt. Well, time dragged on, the cath lab was very busy, and my pt was lost in the shuffle. The brilliant doctors decide to wait until morning to finish the job on this pt. Mind you, he is actively infarcting and they are aware it is his LAD. Apparently the doc's didn't want to incovenience the cath lab by calling in the after-hours crew to finish the job on this patient. Just wait till morning!!! The residents seemed clueless and were writing their usual frequent, confusing and contradictory orders. Kept me in a tizzy most of the night so couldn't think enough to see the big picture. It took NTG @ 100mcg's to control his pain; had heparin and integrilin going also. VSS all during the night, thank God, but was having frequent nausea with emesis. Doctors aware. First set cardiac enzymes @ 1930 showed troponin of 7! Residents and fellow aware. @ 3AM MB's 120 range and troponin 32!!! Still didn't want to do anything. Charge nurse also aware. Everyone knows that time is muscle when actively infarcting. This patient would have been much better off if he had opted to stay at the outlying hospital and they had TPA's him there! His family was so sweet and trusting. As soon as dayshift came on, one of the head doctors rushed him down to the cath lab first case. Have not been back, so don't know how the gentleman fared.

[ERNurse752, RN]

That's awful!

Whatever happened to "Time is heart muscle?" That's pretty scary to think that they would do that to someone. I could see taking the more emergent case first, but they could've just kept the guy in the cath lab until the emergency case was done, and then finished up on him, instead of sitting on him all night. I mean, it was pretty obvious that all his enzymes were shooting straight up, and he wasn't getting any relief withough massive NTG. Did they share any rationale with you for why they weren't acting on the information they had?

You'll have to keep us posted on what happened to him.

[mustangsheba]

"Finish what you are doing, do it well, and then move on." That's the criteria I was taught. The time it would have taken to finish your patient (assuming the other patient is receiving intermediate medical intervention) would have made a world of difference to pt. No. 1 and very little to pt. No. 2. I can't imagine defending in a legal case letting him wait until morning to finish his procedure. I am lucky. The charge nurses I have worked with would be on the phone to the HO's till they figure it out. Bottom line: It is not okay to wait until morning because it's inconvenient to call in staff.

[prmenrs, RN]

I would've been on the phone to the Nursing Manager and the Medical Director of the Unit, no matter what time it was. What you described was so far from appropriate, I can't think of the right word!!

An Incident Report would be a good idea to alert management to the fact that they may have a lawsuit on their hands if something happens to this poor guy. And write up a narrative account of the whole thing to keep for yourself, and copy to your nurse-manager.

Phew! Bad night!

[deespoohbear]

Make sure you cover your A**!! This sounds like a lawsuit just waiting to happen. That patient and family must have been awfully sweet and patient to allow that to happen. Of course, if they didn't have anyone in the family who had a medical background it may have been difficult for them to comprehend the whole situation. The OT they would have had to pay the cath lab staff would be substantially lower than a lawsuit payout. My guess is the doctor had something else planned for the evening and didn't want to be held up at the hospital. Since when have doctors cared about calling in staff after hours? I'm sure we have all seen or heard about the emergency gallbladder at 3 a.m!!! Most of the doctors I know could care less about what kind of life the staff may have outside of the facility. Most of them think the world revolves around them on their own personal time schedule!! :rolleyes:

[VickyRN, MSN, DNP, RN]

At work tonight. The pt managed to survive his hospital stay so far. They finished the cath the next morning, first case and stented the marginal branch to his LAD. Has been a bit confused the past few nights--other than that, doing fine and plan is to D/C him home in AM. Can't tell you how relieved I am that he is doing well. This was the first time I ever encountered something this bizarre happening at our hospital in the whole 15 months I've been here--cath interrupted without intervention and pt sent to floor to await finishing the job the next day. Usually the care here is EXCELLENT and above reproach. Believe you me, if I ever encounter this again, it'll be the last time it happens around here!!!

[Jenny P]

It is things like this that make you wonder why teaching hospitals are supposed to be so much better than non-teaching ones. I'm sure we can all tell stories about trying to save the patient from the residents. Unfortuneately, this patient lost myocardium because of the nurse being run ragged. Why do nurses have to think for the doctors in cases like this? It's too bad that no one did use TPA on this gentleman. Healingtouch, take care of youself.