Vent and Anger

  1. OK, I'm calm now after a few days of venting of management and coworkers. But I'm still upset.

    It's a very confusing story and for confidentiality's sake I'll be vague.

    We were taking care of a gyn patient with an infection. We have gyn residents and they were her primary. She spiked a fever, they ordered a chest xray as part of her work up. It showed pneumonia. They say call her medical doc witht he cxr results.

    They also order an ABG. Here's where nursing and RT mess up. Through a series of mishaps the ABG takes 3 hours to do.

    Shift changes, on comes myself. I get the ABG results on my time and they don't look good. Not "we need to vent the patient" but the was hypoxic. I immediately call the medical doc, we get a pulmonary and infectious disease consult. The ladies temp is now 104 and she's breathing 44. But she is complaining of now SOB, I'm in the room with the patient and here comes the gyn residents. They know I've called ina pulmonologist because they arrive while I'm on the phone with him. They see the patient and all they order is a continuous pulse ox.

    The pulmonologist comes in and says her Xray is worse than just pneumonia and we transfer the patient to critical care for further monitoring.

    The pulmonologist later complains to the gyn residents how they are mismanaging the infection, that they need to I&D her immediately, that she is septic and they are throwing her into ARDS.....too much info I know.

    I'm now out of the picuture. The supervisor shows me a blistering report from the Gyn residents, how we had a critical patient, how were ignoriing her, how were weren't promptly reporting her condition, how we were falsifying records and saying she was breathing 18 (her day shift respirations) and completely made us look dangerous and imcompetent.

    I was livid to say the least. Particularly since they were in the room, and if she was so critical why didn't they order an ICU bed at that time????

    I feel completely confident in how I handled the situation once I had the blood gases. Yes, we're going to have to eat the fact we delayed treatment because of the blood gas incident. But as soon as I had the gases I responded with the appropriate docs: medical and pulmonary.

    I'm getting mad all over again. I of course wrote my version of the story, correcting their several "misconceptions" which to me were borderline lies. They obviously were upset that a pulmonolgist said they were killing their patient and had to blame nursing.....grrr.

    I know I've lost most of you by now, thanks so much for listening.

    Yes, our documentation is immaculate and we will prevail in the end.
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  2. 20 Comments

  3. by   itsme
    Sounds like the residents were trying to cover there own asses by blaming nursing. Figures. Well one day they will learn that any medical facility can not run without nurses and they will learn to depend on us! Sorry you had a bad night.
  4. by   passing thru
    Anytime a patient is breathing more than 36 times a minute, even without any other symptom, intervene!
    Don't wait for any tests.
    Call the docs.
    Most people will crash within an eight hour shift with respirations of 32-36 or more . Respiratory arrest. Yes, sinus rhythm ...but they stop breathing.
    I've seen nurses actually stand at the bedside watching patients on a monitor and not recognize a crisis, watching and commenting that "the heart rate is sinus rhythm," and although concerned that the respiratory rate was 40-50, continue to focus on "everything will be allright because she is in sinus rhythm."
    I have been in the room with those nurses when they say that and still standing & looking at the patient when the patient suffers a respiratory arrest. The nurses are always puzzled. ?

    They simply cannot and do not make the distinction between a cardiac arrest and a respiratory arrest.

    You simply can't breathe that fast for 8 hours & longer without O2 support and will require ventilator support. (Exhaustion)
    If I come on and find a patient breathing 40 times a minute....
    they are "working"....it doesn't matter which doc, who or what,

    I start calling everybody, docs, supervisors, all docs, ICU to get a bed available....because it is simply a matter of time.
    I tell the docs , this patient HAS to transer to ICU.

    If the patient is in any kind of distress, it is only going to go downhill from there.
    Last edit by passing thru on Jul 15, '03
  5. by   Tweety
    Originally posted by passing thru
    Anytime a patient is breathing more than 36 times a minute, even without any other symptom, intervene!
    Don't wait for any tests.
    Call the docs.
    Most people will crash within an eight hour shift with respirations of 32-36 or more . Respiratory arrest. Yes, sinus rhythm ...but they stop breathing.
    I've seen nurses actually stand at the bedside watching patients on a monitor and not recognize a crisis, watching and commenting that "the heart rate is sinus rhythm," and although concerned that the respiratory rate was 40-50, continue to focus on "everything will be allright because she is in sinus rhythm."
    I have been in the room with those nurses when they say that and still standing & looking at the patient when the patient suffers a respiratory arrest. The nurses are always puzzled. ?

    They simply cannot and do not make the distinction between a cardiac arrest and a respiratory arrest.

    You simply can't breathe that fast for 8 hours & longer without O2 support and will require ventilator support. (Exhaustion)
    If I come on and find a patient breathing 40 times a minute....
    they are "working"....it doesn't matter which doc, who or what,

    I start calling everybody, docs, supervisors, all docs, ICU to get a bed available....because it is simply a matter of time.
    I tell the docs , this patient HAS to transer to ICU.

    If the patient is in any kind of distress, it is only going to go downhill from there.
    Thanks for responding Wanda. We WERE intervening. That's the whole point. While they were ordering a pulse ox machine, I was on the phone with two docs.

    Being a med-surg nurse for many years, I usually can tell when a patient is going to crash, and one can't sustain 40 breaths of minute for long. I agree with you there.

    But also there is a point sometimes where if you give the antibiodics, tylenol, etc. A patient responds. I think this is what they were thinking, and I've seen many a patient get well who during the acute phase of their illness breathed 40. But sustained over an 8 hour shift? No, they can't breath that fast for long. The problem being unbeknownst to us the Xray was worse than radiolgist reported. He reported pneumonia on the left side, which isn't always a life-threatening emergency. The pulmonologist who came in said ARDS, it was then we had to move her to the unit.

    It was then then docs were told the cause was probably her untreated abcess, it was then gyn decided the nurses were the one's mismanaging her. Not true, as soon as I saw the patient, I was intervening.

    Edited to add: What does whether or not a patient is in resp. distress have to do with whether a patient is in sinus or not??? That's scarey.

    Also, when we got to the unit and I check on the patient later she was doing o.k. The critical care nurse said she didn't see where the patient was critical. That's the problem with our hospital and the shortage of critical care beds and critical care nurses a patient actually has to be in respirator failure, rather than have the potential for failure to be considered critical. We have to be unsafely particular sometimes who we send to the unit, because someone who really needs the bed won't have one when needed.
    Last edit by Tweety on Jul 15, '03
  6. by   altomga
    okay, I hope I read your post right.....

    You came on and had to clean up a mishap from the previous shift?? Is that correct??

    It makes me soooooooo MAD when the docs do not get the concept of "I just got here and I will get to it!!!!!!!" I can not do anything about the other shift not completing their work so go yell at the wall

    This sorta thing happened on my floor last night....a pt was transferred to us from a general floor and had NOW labs ordered at 1620.....okay now it is around 2000 and we get the pt....noted that labs were done and were getting ready to do them...
    The resident comes up "sorta" fuming that the labs weren't done and wanted to know why!!!

    Okay, in the end he did apologize and said he did not mean to direct his frustration at us,

    Anyway, sounded like you did the right thing and the doc's were just trying to cover the A$$
  7. by   Rapheal
    You did a good job. Nursing gets blamed for so much, and it is a shame that your nursing supervisor did not give a blistering response to that "blistering report".

    And why does your hospital have to be unsafely particular about who gets an ICU bed? An actual patient needs to be treated before worrying about a potential patient. If another patient comes in or has a change of status to critical, then isn't transferring to another hospital with the ICU bed an option? Or am I just being naive?
  8. by   jnette
    Originally posted by itsme
    Sounds like the residents were trying to cover there own asses by blaming nursing. Figures. Well one day they will learn that any medical facility can not run without nurses and they will learn to depend on us! Sorry you had a bad night.
    Really ! I understand your frustration, Tweety, and feel for ya ! :kiss And I agree with Raphael : "You did a good job. Nursing gets blamed for so much, and it is a shame that your nursing supervisor did not give a blistering response to that 'blistering report'."

    Just know that you know that you KNOW you did all you could in a timely manner and that you did your very best. Ther rest is on them. Take comfort and solace in that and be proud of your self. Hugs to you. And glad the pt. made out ok in the end.

    Sure does sound like a major case of blame displacement, tho'.

    Sux, huh?
  9. by   MelRN13
    Tweety, you're an awesome nurse and you did the right thing. Sometimes residents make me sooooooo .
  10. by   LoisJean
    Hey, Tweetie...do I got this right? She's a gyn patient; she has an infection; ABGs are ordered but are 'delayed' 3 hours because of some mishap? Never mind the mishap. You order up a pulmonary consult (yes, I read the resp rate and temp), the gyn dudes show up and all they do is order up pulse o2s? So this went from gyn to rt to medical to radiology to pulmonary and you get the heat for bad practice?! Where the *h* do you work? And for 8 HOURS this woman is basically left to suffer without treatment!? Go, figure, buddy. It's the 'Dr. Peter Principle: Lots of doctor wannabes elevated to the highest levels of their incompetence.

    Question: what would happen to you if you went eyeball to eyeball with one of those jerky gyns and gave them a small piece of your incensed mind? You know, like one on one in the alley behind the hospital?

    I've read alot of your posts. You are a good and competent nurse and I'd wager that most of your co-workers are, too.

    How's the lady, by the way?

    Peace,
    Lois Jean
  11. by   Tweety
    Originally posted by altomga
    okay, I hope I read your post right.....

    You came on and had to clean up a mishap from the previous shift?? Is that correct??

    It makes me soooooooo MAD when the docs do not get the concept of "I just got here and I will get to it!!!!!!!" I can not do anything about the other shift not completing their work so go yell at the wall

    This sorta thing happened on my floor last night....a pt was transferred to us from a general floor and had NOW labs ordered at 1620.....okay now it is around 2000 and we get the pt....noted that labs were done and were getting ready to do them...
    The resident comes up "sorta" fuming that the labs weren't done and wanted to know why!!!

    Okay, in the end he did apologize and said he did not mean to direct his frustration at us,

    Anyway, sounded like you did the right thing and the doc's were just trying to cover the A$$

    Yep, we're going to have to accept we delayed treatment 3 hours while waiting on the ABG. In addition to that they made other accusations which were very incorrect. Especially our lack of response after we got the ABG results back.

    They just got their feelings hurt because both the medical MD and the pulmonologist accused them of mismanaging her infection. The route of her problems. She was full of puss "down there" and the pulmonologist made them do a bedside I&D late in the night, which made them look bad. Again, I think they are blame shifting here.
  12. by   SmilingBluEyes
    tweety....nothing to add above the others except

    remember sjoe's tagline

    you are doing a great job; dont' take the blame lying down.
  13. by   Tweety
    Originally posted by Rapheal
    You did a good job. Nursing gets blamed for so much, and it is a shame that your nursing supervisor did not give a blistering response to that "blistering report".

    And why does your hospital have to be unsafely particular about who gets an ICU bed? An actual patient needs to be treated before worrying about a potential patient. If another patient comes in or has a change of status to critical, then isn't transferring to another hospital with the ICU bed an option? Or am I just being naive?
    What I meant was, there was a point that my patient was a "potential" critical patient. She wasn't on the verge of being intubated, perhaps she could have been managed on the floor with agressive medical treatment (before we knew she had ARDS, when we thought it was pneumonia and before we knew that she was full of puss which the pulmonologist noted on his exam.)

    Our beds are so tight to send someone to critical care with a "potential" to crash sometimes isn't good enough to get them a bed. Our unit beds are for the very seriously ill and trauma patients, mostly who are vented.

    But basically if a doc orders critical care, they get it. But it gets scarey when you call the supervisor for a critical care bed and get told either they don't have it, or there isn't a nurse. Or if a nurse has to have a tripled assignment to take your patient, it had better be a seriously ill patient. It's worse during our busy season here in Florida in the Winter.
  14. by   Tweety
    Originally posted by LoisJean


    Question: what would happen to you if you went eyeball to eyeball with one of those jerky gyns and gave them a small piece of your incensed mind? You know, like one on one in the alley behind the hospital?

    I've read alot of your posts. You are a good and competent nurse and I'd wager that most of your co-workers are, too.

    How's the lady, by the way?

    Peace,
    Lois Jean
    I'm off for three days, but the lady was doing, especially since the pulmonologist was agressive in demanding her infection be drained.

    Thanks for the nice compliment.

    I'm hoping after management gets our reports that they put us face to face. I'm still expecting at least to have my say. My manager got an earful on Sunday morning though.

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