Need advice and reassurance on a bad situation.

markjrn · Jun 9, 2005

I should have called the doctor at 0430.

I agree.

About a half hour later

I'm sure you were busy, but I would never go for that long without assessing a patient in that condition.

I hope you did plenty of charting. Sometimes it's just tough learning through the school of hard knocks.

markjrn · Jun 9, 2005

Our ER docs are not required and will not respond to calls like that. They come for codes, and a select few of them will re-intubate someone or start a central line. This is because they are not responsible for any patient except those in ER and codes. I really don't think they would even give us orders in a crisis (non-code) situation even if the attending does not respond. It's kind of the same as grabbing a doctor out of the hall and asking him to take care of a patient. Our only other option is to call the chief of staff/medical director.

I've never had an ER doc help me in a crunch either - it's not their patient, and they don't want to get involved.

I work in ICU where there is always a doc present, but when I worked the floor, if a doc didn't respond to pages, etc, I just worked the chain of command - Charge, House Super, etc. They often would address the MD problem while I was taking care of my patients.

military girl · Jul 9, 2005

Just to join the bandwagon, don't beat yourself up over what happened. Easier said than done, I know.

As a new nurse, I know that there are so many questions. You find that you may find yourself over thinking lots of stuff. I had my bad situation last year, and I still think about it. And I feel that if I had intervened sooner, the out come would be better.

Life does go on, and one day, you will be the "experienced" nurse. Be the voice of wisdom and guidance for the new nurse that will be soon coming along.

BeenThereDoneThat74, MSN, RN · Jul 9, 2005

What other resources do you have- a charge nurse, house supervisor, educator? Any of these people could have given you more advice, or convinced you to take it further.

Are we talking about residents here? I work in teaching hospitals, where often times the resident is unable to make that kind of decision. They don't like to bother their seniors (for fear that they don't know how to handle it on their own). Our fellows are not in house at night, so the senior has to page the fellow if they can't handle it (which they are very hesitant to do). But you have to put the ball in their court. Unfortunately, documenting Dr. Jones aware may not cut it in a court of law.

As a new grad, you may not feel comfortable going over their heads (it took me a while to feel comfortable in that too). But taking up the nursing chain of command is not going over their heads. Of course, a supportive floor staff always helps too. When you get to know the docs you work with, you eill realize who is competent and who is not. if the resident on call is a flake, that's a problem. We've called the attendings at home. Fortunately one of our attendings has given us carte blanch to do that. She knows we know our patients better than the residents, and will never get mad at us. Of course, they are not all like this.

You knew that BP was low, but I just can't imagine that another nurse did not agree with you. Your gut feeling was right. Just because you are new, doesn't mean you can't analyze the situation appropriately. It's all in your presentation. Don't ever be 'sorry to bother' the doc. Confidently give them your assessment findings. And if the pt. is only oriented to person, he may not be able to tell you exactly how he feels. If his baseline is confused, it may be hard to see further deterioration (ie. inceased mental status changes).

It will get better. You cn't come out of school knowing everything.

mattsmom81 · Jul 9, 2005

Hey, no one said they were "required", just that sometimes they come around to look at the chart before the actual code, and see us fighting with the doc for orders that are obviously needed. sometimes they will get on the phone themselves, give their own orders, or call the code a while before we actually have one so the patient gets taken care of. Usually they appreciate a heads up anyway if we expect someone is goig down the tubes.

Exactly. You work in the kind of place I'm used to! Not every ICU is lucky enough to have a doctor handy, nor is every hospital a teaching hospital with residents and fellows. Hospitals like ours generally expect the ER doc to handle codes unless the attending just happens to be there. So, in MY ICU and many others, I bet, calling the ER doc for a heads up is very acceptable; even appreciated by the ER staff.

Personally I prefer this kind of hospital over a big teaching hospital, because all the interns, residents, etc are just too confusing to keep up with..LOL!

heartICU · Jul 9, 2005

Here's the story...
At 2330 I picked up 2 pts. on my m/s floor giving me 8 total. My pt. b. after assessment showed these abnormals: BP 60/30, R 28, P 89 apical and irregular, peripheral pulses weak but palpable. Pt. denied any s/s of hypotension, pain, discomfort, nausea. His mentation was normal for him; he's only ever been oriented to self, but will respond appropriately to most other questions. He was repeatedly trying to get oob without assist. Pt skin turgor was poor, he had mottling at the knees, abdominal sounds were very hypoactive. I reviewed the chart and noted that the bp was the only change in pt. condition since the 13th. I called the MD who increased iv fluids, and at that time i asked to provide the pt. with 1:1 supervision because I did not want restraints and we had an extra cna that night. This pt. repeatedly was climbing out of bed and pulling on lines. He said ok. So I completed the orders. I reassessed the pt. again at 0200- he was the same, and at 0430. At 0430, he was noted to have no output, and his lung sounds were becoming coorifice at expiration. I had and experienced Rn come in to assess him, to be certain I was not missing anything and to verify my assessment accuracy, as I was concerned. I'm a new grad as of Dec. I tought I'd call the MD. I asked the experienced nurse If I should call the Md with these changes, and because the pt. condition had not improved. She asked me what I thought the doc would do. I replied that the only thing left was to transfer him, but I'd feel better. She sid to try and wait until 0500. The pt. was responsive at this time. He is 84 years old and a full code, by the way. The doc walked in at 0500, and quickly walked in a pt. room to see a new admit. I had to see my other pts. , so I wrote a note with my concerns and put it on top of the pt. chart, and put the chart on top of the new admit chart, and went to see the other pts. About a half hour later, the cna who had been with the pt. runs in the room I was in and states the MD wants to see me now. I go into b.'s room, and he's on the verge of a code. His color is gray, and he's agonal breathing. I start bolusing him and transfer him to ICU where he codes within 30 minutes of transfer. Now the Md is pissed. I am upset. What should I have done differently? Please be kind, I cried the whole way home. I should have called the doctor at 0430. Thanks, Anna

A good rule of thumb to follow - and one that can always protect you - is that if you call the MD with a problem, and s/he orders something (fluid, meds, etc) and this particular intervention does not help the problem, you need to call again. If it was a problem you needed to call about to begin with, and it hasn't improved despite intervention, you need to call again. Keep calling until you get an intervention that works. That is the rationale I always used when I was unsure if I should call or not. Good luck to you.

fifi9857 · Jul 10, 2005

Here's the story...
At 2330 I picked up 2 pts. on my m/s floor giving me 8 total. My pt. b. after assessment showed these abnormals: BP 60/30, R 28, P 89 apical and irregular, peripheral pulses weak but palpable. Pt. denied any s/s of hypotension, pain, discomfort, nausea. His mentation was normal for him; he's only ever been oriented to self, but will respond appropriately to most other questions. He was repeatedly trying to get oob without assist. Pt skin turgor was poor, he had mottling at the knees, abdominal sounds were very hypoactive. I reviewed the chart and noted that the bp was the only change in pt. condition since the 13th. I called the MD who increased iv fluids, and at that time i asked to provide the pt. with 1:1 supervision because I did not want restraints and we had an extra cna that night. This pt. repeatedly was climbing out of bed and pulling on lines. He said ok. So I completed the orders. I reassessed the pt. again at 0200- he was the same, and at 0430. At 0430, he was noted to have no output, and his lung sounds were becoming coorifice at expiration. I had and experienced Rn come in to assess him, to be certain I was not missing anything and to verify my assessment accuracy, as I was concerned. I'm a new grad as of Dec. I tought I'd call the MD. I asked the experienced nurse If I should call the Md with these changes, and because the pt. condition had not improved. She asked me what I thought the doc would do. I replied that the only thing left was to transfer him, but I'd feel better. She sid to try and wait until 0500. The pt. was responsive at this time. He is 84 years old and a full code, by the way. The doc walked in at 0500, and quickly walked in a pt. room to see a new admit. I had to see my other pts. , so I wrote a note with my concerns and put it on top of the pt. chart, and put the chart on top of the new admit chart, and went to see the other pts. About a half hour later, the cna who had been with the pt. runs in the room I was in and states the MD wants to see me now. I go into b.'s room, and he's on the verge of a code. His color is gray, and he's agonal breathing. I start bolusing him and transfer him to ICU where he codes within 30 minutes of transfer. Now the Md is pissed. I am upset. What should I have done differently? Please be kind, I cried the whole way home. I should have called the doctor at 0430. Thanks, Anna

First of all, YOU ARE A GOOD NURSE. All any nurse manager/nursing supervisor/charge nurse can ask is that you know your patient--you may not know what is wrong, but you know something is not right. Trust your instincts. It is hard as a new nurse to have enough self confidence to make those calls in the middle of the night. If a patient is going bad, several nurses on the floor should go in to help assess--even when the primary nurse is the most experienced. I know that is not always possible, but it should be a priority. Each nurse will think of something different. Your charge nurse should be shot or at least reported for very poor judgement. I am charge nurse on 3rd shift on a 36 bed medical unit and my first priority is the patient. I like for the primary nurse to call the doctor first, after some instruction--for experience--but if the answer is not what I think should be done, I will call the MD, identify myself as the charge nurse, give my assessment and say something such as "I am not comfortable caring for this patient on my unit because..". In your situation, I would have took one look, had the crash cart put outside the room, got an experienced nurse in the room with the primary nurse and while waiting on the Md to call ME back, would have already gotten availabilty of a critical care bed. I am sorry that it did not happen that way and hope that situation does not occur again, but if it does, trust your instincts, get a good nurse in there with you (which may not be the most experienced nurse) for reassurance, and call the doctor. That is what they get paid the big bucks for!

barefootlady, ADN, RN · Jul 12, 2005

Midnight RN,

I can only say you did a really good job being a new nurse and having such a big load. You hang in there, be the patient advocate, keep learning, follow your gut feelings, document, document, document. I hope if I am sick, I have a astute nurse like you caring for me.

pie123 · Jul 12, 2005

As a new grad I had a child almost arrest on me and the doc slept at home. I was saved because the supervisor knew that something wasn't quite right, but I didn't know what to do:(. I put it that plainly to her and to the doc. So don't worry if you don't know what to do- but keep bugging the people that DO know, and don't be afraid to call other units for a second set of eyes.

This makes me feel much better that there is someone who admits to not knowing what to do. I always get the feeling that if this is said, others will look at you & think, "Gosh! She doesn't know what to do. I wouldn't want her as my nurse." Thanks again.

DG5 · Jul 12, 2005

MidnightRN, you are obviously an RN who chose nursing because you CARE. A caring nurse will be an observant nurse and you were obviously doing your best to observe and chart everything that you could. Its a pity the more experienced nurse took you off guard with your gut feel. Sometimes involving another colleague can make the decision more complicated rather than more simplified! But as a new grad, I would have done EXACTLY what you did. How can we improve on our practice if things like this didn't happen to us? Just carry on being the caring nurse you are, and you will find that your skills as a patient advocate will surprise you. What a great discussion.