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- by Parsifal Oct 17, '12Caring 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)
- Oct 17, '12 by netglow"Well no, no it won't "cure" her silly-head..." Heh.
But that kind of answer isn't nice (unless the doc is a you know what). I'd try to carefully help the process because remember it's scary when someone is dying and they are only 30 to boot.
- Oct 17, '12 by juan de la cruzI would agree with the above by following up with a statement such as "what do you think we should do in the mean time?" and "would you let me know as soon as you find out?". As a nurse practitioner in the ICU who works in a hospital with a huge training mission (translation: residents and fellows everywhere), I do notice that residents get defensive when nurses ask questions about clinical management they feel are their responsibility. Residents are still learning and many of their decisions have to be discussed with a fellow or a supervising attending physician. I'm sure this resident is aware that something has to be done regarding that ABG though he minimized the gravity of the situation by being flippant. In his mind, he is likely processing and organizing his thoughts and will present the situation to a senior physician so that a plan can be arrived at. Truly, depending on your facility there are options other than bicarb. If he doesn't act on it in a timely manner and you feel that patient care is being compromised, do not hesitate to bug him again. Once he comes up with a plan, do not be shy to ask what the rationale is.
- Oct 20, '12 by ICURN87Wow, I would think that bicarb is the answer here. Then probably put her on a bicarb drip. You know, I've heard some things at my hospital about avoiding bicarb IV push unless it's a code blue situation. It doesn't make sense to me. For this patient, she sounds so acidotic that she's HEADED for a code. I say push the damn bicarb already! Just my 2 cents.
- Oct 23, '12 by hodgieRNtotally agree!
- Jan 17 by FinkI would probably say way too much to the hand waving little doc and be in a world of trouble. However, as a patient advocate, if it would help get his attention and get him focused on the patient and their problem, I would!
- Jan 17 by dah dohI would probably ask "then what would you like to do with the patient?" (That's the politically correct version)...
- Jan 18 by SRNA4UI agree with IndiCRNA. Get that pt to the ICU immediately. It seems in the ICU are opinions are valued a lot more from the residents there than from what you are receiving from the ER resident. At times, we have residents that come to us and ask us what drug we think we should give, especially on night shift. I like those moments. Then at times, I have had to go over a residents head straight to the attending to get what I needed because the pt was going down the tubes. Often times, our staff intensivists or our staff anesthesiologists, who also run the SICU will tell us to come to them if we feel like we're not getting things we need since we know many of the residents are new and we've been in the ICU in a while.