Another night in Hooterville....<sigh>

  1. Not knowing whether to laugh or cry...elderly gentleman...end stage COPD...admitted 4 days ago...2 days after admission a fellow nurse observed pt had not voided in 2 days...MD had also ordered labs on admission that verified renal failure...BUN 111... Creatnine 9.8... K 6.97.....pt had evidently been in renal failure for a while, ya know (my first night at work this week, day 3 of admission).....he was alert and oriented ...blood pressure was decent, averaging 160 systolic, 80's diastolic...O2 at 3L/m/nc.... respiratory rate 24 bpm...SaO2 96%...no respiratory distress...sinus rhythm, peaked T wave (well, DUH !!!...K level critical, MD aware but not really attending to matters at hand {catching my drift here???}......)....orders given to rehydrate pt with IVF 1/2 NS @ 150 cc/hr.... auscultating breath sounds q 2 hours just in case rales developed...diminished bilaterally throughout, but otherwise, essentially clear....
    Day shift, yesterday, MD comes in and orders Kayexelate 15 grams retention enemas q 6 hours with 2 hours post enema K levels being drawn...first K level was 6.25, second K level was 6.8...following second retention enema, his respiratory rate increased to 28 bpm...SaO2 by pulse ox was 86% !!!!! ABG drawn...pH - 8.1/ PO2 88/ C02 60....orders given for NaHCO3 1 amp IV q 6 hours x 6 doses... decreased IV fluid rate to 25 cc/hr...no repeat ABG' s ordered so how the heck are we supposed to know effectiveness of treatment???
    O2 delivery changed to Venturi mask @ 40 %...pulse ox stayed
    in range of 93- 95% for the duration of yester-DAY...last night, pt minimally responsive...Sao2 in same range for my initial assement...MD makes night appearance with a consulted nephrologist and they decided to " watch pt for a couple of days before attempting dialysis"... at 2348, he desaturated to 74%..B/P hit the bottom at 84/ 36...
    respiratory rate 40 bpm...sinus rhythm, T wave taller than QRS, K level at that point was 6.9 ...MD called...he said " the pulse ox is malfunctioning, the ABG yesterday revealed 'a much better O2 saturation' (refer to above values, please !!!) and the value was low because the pts hand was below his heart level " No new orders recieved...NONE...NADA...continue present treatment orders and then he added " I will see him in the morning"...
    Well, alrighty then...made nursing supervisor aware of situation and she said " well, just keep an eye on him"...moved crash cart to hallway directly outside his room...proceeded to make pt comfortable...HOB to 90 degrees ...elevated arms on pillows by his side...to " heart level "...SaO2 remained an average of 80-88%...
    Eventually, the gentleman's respiratory rate decreased to an acceptable rate of 24 bpm...SaO2 by that "malfunctioning pulse ox" increased to 93% by 0500...B/P at that time was 118/50...
    the last K level post retention enema was 6.8...lab personnel called MD ( while I was giving report to dayshift charge nurse)...
    MD calls unit and gives STAT order for 10 units regular insulin IV, an amp of NaHCo3 IV, and an amp of D 50 IV...changes order for retention enemas to q 4 hours...
    Sooooooooooooooo.......after the above orders were carried out and more documentation was done, I gathered my belongings, heading to the time clock and was almost knocked down by that *$%(@!!! MD running to bedside of above pt , already screeching verbal orders of STAT this, STAT that...I was significantly unimpressed with his " sudden concern" for this gentleman...
    ...I had done 1:1 all night with this poor soul...documenting the inaction of the MD...and snickering about the malfunctioning pulse ox that was accurate for the other pts, but was so wrong for this critically ill man...
    Since I have been awake, my thoughts have been all consuming regarding the pt's welfare...I am between tearful laughter and RAGE regarding the lack of medical attention he recieved last night... ... thought about calling in with " illness and fatigue" because I am " sick and tired "' of that MD ignoring the obvious and neglecting HIS duties until he "decides" to go into his STAT code mode...I can imagine the disrespectful comments he made regarding my care of the pt last night...but that's OK...my documentation of HIS inattentiveness will " clean his clock"...he does NOT read nurse's notes, regards them as frivolous paperwork for the nurses, by the nurses...
    <SIGH>
    I appreciate your patience with my VENTILATION posting...I know you understand my frustration and the dread I feel for the upcoming night on the telemetry unit from HELL...will update tomorrow if I survive tonight with one iota of lucidity.....
    Last edit by suzannasue on Sep 30, '02
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  2. 7 Comments

  3. by   midwestRN
    I'm sorry you had to go through that night. Reminds me to always watch my own family if they are in the hospital. In my opinion, your supervisor should have stood up and took action, and called whoever it is that is above her unless the pt had discussed dialysis and other options with the Dr and decided against it. If that was the case, all who take care of him should be notified.
  4. by   BadBird
    OMG, that poor patient, I totally understand your frustration, I left a hospital where I was working agency due to the inaction on the part of the residents, I thought my license was at stake everytime I walked through the doors. Now I am much happier and work with some awsome Dr's.
  5. by   patadney
    That poor soul should have been dialyzed or made DNR as soon as the Kaexylate didn"t work! I have been called in to do dialysis on a pt with a K of 9 who was down to 6.9 by the tiem I got there.Of course he was a chronic dialysis pt. I hope that neprologist got written up.
  6. by   Beetlejuice
    What a terrible experience. Nurses are partners with physicians not subordinates. We treat the patient's response to illness; physicians treat the illness. If that patient is not responding to the docs treatment, it's our job as nurses to point that out and yes, be so bold as to make treatment recommendations/suggestions. Be the patient advocate. That doc has a boss...next time run it up the chain. Wake people up. Your nursing supervisor ought to be fired.

    I'm not suggesting you get rude or aggressive. Just be assertive. Get the doc to set more refined "call" parameters. From reading your thread, you sound very intelligent. This is your strength. Don't be intimidated by docs.

    I am not scolding you. This is a learning experience.

    cheers,
  7. by   canoehead
    I agree that the first night of neglect should have sent calls of the chain of command. The supervisor was either incompetent or cared more about whether she annoyed the doc than whether the pt died, should be fired (but of course she won't). I don't think there is any way you can be in trouble, but want to gently encourage you to beat the drum hard for your patients no matter what the doc says. Sometimes the worst thing you can do for your patient is to follow the rules. Call the doc with each set of vital signs, Q15min if need be, or the head of the dept if that doc doesn't respond. If the sup isn't listening, or making calls herself call her supervisor at home.

    I've had docs get up and come in just to shut me up also had pts transferred for the same reason. You have to KNOW you are right and be prepared to not back down even for an instant. When the chart goes for review by the ICU committee though are you going to be the nurse that followed orders, or the one who saved the patient's and the doc's ass? And the next time...he will listen.
  8. by   RNConnieF
    Thank God for on time, accurate documentation, with any luck the DON will review the case and see that the MD SU#*S and the only reason the pt. is still alive it that nursing, in the form of YOU, provided him with care beyond what the non thinking MD ordered. Next time, if your professional judgment is screaming that the MD is off base, the the Chief Of Staff out of bed at 300 AM, you'll be surprised how fast the attending will be at the bedside (may be with a stick up the butt from the Chief). NO MD should be allowed to abandon a pt as this one did. When in doubt, go to your Nursing Co-Ordinator first THEN get the Chief of Staff out of bed. Works every time. Don't doubt your assessment and judgment.
  9. by   l.rae
    l will never undestand why he didn't get the D-50/insulin/NaHC03 cocktail to start with...works well...it's what we do first in the ER..........sometimes MD stands for ''mighty dumb''.....LR

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