How would you respond to this doctor? - page 2

by Parsifal

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Caring for a septic lady in her 30's alongside a young-ish new ER doctor. Patient very sick with multi-organ involvement. Just intubated, central-lined, vasopressors, etc. Was given two amps bicarb prior to/during intubation... Read More


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    Quote from Parsifal
    Caring for a septic lady in her 30's alongside a young-ish new ER doctor. Patient very sick with multi-organ involvement. Just intubated, central-lined, vasopressors, etc.

    Was given two amps bicarb prior to/during intubation (unable to obtain ABG's prior to intubation d/t poor perfusion/pulses etc., but bicarb/CO2 by chemistries was 9)

    30 minutes after intubation ABG's show a pH of 7.0. Bicarb of 13. Base Excess of -15.

    I approach the doctor...

    Me: " Hey did you see the ABG's?? You want me to give any more bicarb?.."

    Doctor: "...No...(waving his hand at the results rather off-handedly) ..this is all metabolic...bicarb wont cure anything..."

    Ummm. How would you respond to this? (true story...true conversation...true hand gesturing)
    That's crazy!
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    Wow. What a tool. I would first start off by hovering over the physician and doing so until he makes eye contact. I would clear my throat and repeat the bicarb level and pH. To be honest, you have to assert yourself in certain situations. By backing off, you are NOT being the patient's advocate. You might take a little heat, but who cares, someone's life is on the line. Push the BIcarb, get a drip called into the pharmacy, and prepare the electrolyte shifts.

    ICU_Dude
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    "Can I give her a couple amps while you decide what to do? I'm really concerned that she can't wait with that pH."

    Give him an out, with the expectation that he'll consult someone or come up with an order, but buy some time for your patient.
    corky1272RN likes this.
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    We all agree that bicarbonate is just a bandaid for this but an additional few amps wouldn't have hurt. Just curious, did he bother hyperventilating the patient or is that just meaningless too? How many liters did the patient receive? Stat antibiotics? what was the lactate? In the icu I work in the patient must be delivered to us within 15 minutes after a central line is placed. It's just unsafe we have a lot more monitoring and intensivists.
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    Doctor: "...No...(waving his hand at the results rather off-handedly) ..this is all metabolic...bicarb wont cure anything..."
    Me....Uhm, since we both agree it's METABOLIC ACIDOSIS it's the bicarb she needs......or we can always discuss this with the attending"
  6. 0
    Quote from prep8611
    We all agree that bicarbonate is just a bandaid for this but an additional few amps wouldn't have hurt. Just curious, did he bother hyperventilating the patient or is that just meaningless too? How many liters did the patient receive? Stat antibiotics? what was the lactate? In the icu I work in the patient must be delivered to us within 15 minutes after a central line is placed. It's just unsafe we have a lot more monitoring and intensivists.
    That is a great policy.....a majority of ED especially at night.....the ED doc is the go to man.....there are probably more facilities that don't have those resources than those that do.
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    Quote from Esme12
    That is a great policy.....a majority of ED especially at night.....the ED doc is the go to man.....there are probably more facilities that don't have those resources than those that do.
    Ya our intensivists follow the surviving sepsis protocol to a T. We are a community hospital but we still use vigileo monitoring and what not.Im still interested in knowing what the patient's source of sepsis was. Bicarbonate isn't really the answer past a few amps, its only going prevent the patient from coding in the ER which I guess is the goal of the ER. That gas is just not compatible with life. I wish I had more information to know what was going on.... Either way the pt could use a few more amps just for pressor management alone. Septic patients really just dont belong in the ER, too much work for a swamped ER nurse.


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