What would you do?

sapphire18 · Jan 30, 2012

With sats like that bypass NC and go straight to NRB. That first abg should have gotten him intubated, or at least in icu, immediately. And yes fluid boluses and drips are definitely warrented with BPs like that...I 100% agree with your thinking. ICU right away, why play around in IMCU?? That was a clearly CRITICAL patient in my opinion. Not sure what you should do at this point but talk to the nurse manager? That is very sad considering how young the patient was.

CrunchRN, ADN, RN · Jan 30, 2012

Why wouldn't they have gone directly to ICU? Makes no sense.

elfinM · Jan 30, 2012

Thank you. I would never be one to say that I know it all, or that I am perfect, but I would like to think that some things do click. Your comment makes me feel like maybe I do know a little more than I give myself credit for. Thanks!

elfinM · Jan 30, 2012

That was my questions also CrunchRN. I would think you would want a charge RN to have the ability to see a bigger picture. Just a bit of fyi- Nurse manager asked the RN, who has a ASN-(as do I) to be the new charge RN. He took the position away from our Previous charge RN who has 30+ years, BSN and PCCN and gets multiple request from previous patients for her to stop by and see them. I am not sure if this is a place I want to stay at.

MomRN0913 · Jan 30, 2012

I see a direct transfer to the ICU. Intubated on the spot. Pressors or bolus right on board.

Where was the doc? A Doc doesn't respond to your version of an RRT?

Guttercat, ASN, RN · Jan 30, 2012

This recently took place in front of me, (not in my care) and involved a charge RN. It has really bothered me and I wanted to see what you all thought.
Male, 57, suspected MI day before. Had vomited some dark emesis previous day. You walk in and his sats are 77% on room air. You place 2L o2 by nc and pt doesn't tolerate, so you change him to a non rebreather at 15L o2. Ok so far, pt states "I just want to stop breathing". Blood pressure is 58/0, Abgs are obtained and the tube is very dark, almost black. ABG comes back ph 7.2, lactic acid 8 (granted not a good number to start with). The Rn of this pt has called md and order for IMCU bed obtained. I walked in and the pt is turning blue in the face, and I inquire about called a CAT call (our rapid response team, I am thinking intubation as blue is not a good sign.) Charge RN says "We already have an Imcu bed and we have everyone we would need here. Lets get going". The charge Rn, new grad Rn and Precepting Rn and respiratory tech are at the bedside. They grap the respiratory box off of crash cart and go to imcu. (I am thinking I want a better airway than this and how about some drips to address the BP).
The end of story is patient was placed in imcu and after 20 minutes transferred to icu and intubated. By this time he has a bp of 48/0 and ph 6.8 lacitic acid of 12. (this was over 1 1/2 hours. From floor to icu) Pt ended up not making it. I am disgusted that the Charge RN was told by the Manager that nothing else could be done, she did a good job. I am thinking she should have got more help, so that drips could have been started earlier and maybe have given him a chance. I feel for this patient and family. Do you think I am being too critical here or is there room for improvement. I have been doing this for over 6 years, would like to think I can see trouble. Turns out pt never had an MI, miscommunication between shift RN's!

^^^How not to do it^^^

I would've called RRT the second he went from RA to NRB.

Sounds he was crumping fast... like a big, fat PE.

What a cluster.

Sorry you had to witness this.

catlover5 · Jan 31, 2012

I had a pt recently that had a big drop in bp, another nurse came so I could have another set of eyes, we called a rapid response and while the team was in there with the house supervisor, I was on the phone with the dr who was covering for the pt's usual dr.....the dr is saying to send pt to the units and I repeat that out loud to everyone present. The house supervisor quickly says NO, pt is staying here, this dr just wants to avoid dealing with it since it isn't dr's pt...... ?????? Man was I scared through the rest of the shift! The only person to check in with me on that pt was a nurse who was on the RR team. Charge or house supervisor never asked a thing about the pt. Where I used to work, the charge had 2-3 pts during a shift (they don't here) and would always check with a nurse throughout the shift if there was any issue with a pt. Our house supervisors would too. We worked as a team and if we had a float from another unit, everyone, especially the charge, would be so helpful with that nurse. Nursing makes me very uncomfortable in this state (Fl). So very different than Indiana.....

dabearrn · Jan 31, 2012

CAT call would have been the right call. Intubate him on the floor, and then move him to your CC unit.

If he gets better you can take the tube out. If not, then intubation proved to be the right call. Either way, the pt is secured.

Yeah, sounds like a PE.

Ivanna_Nurse, BSN, RN · Jan 31, 2012

Agreed with the pe and calling rapid on the spot. You did what you could- maybe there could be a debriefing for this case, to talk it over?? Ivanna

Esme12, ASN, BSN, RN · Jan 31, 2012

You have had other issues with this floor/manager in the past. I'm not so sure this floor is a good fit for you. Your O2 sat should not be higher than your B/P. :eek: Pallor, dark emesis, lowB/P, EKG changes screams GI bleed what was the HCT/HgB. I would have called a rapid response and placed the patient on 100% O2, largebore IV's and gone directly to ICU. Stepdown? was the patient a DNR or something? Wow.

I am not sure with a changed intervention would have changed this patients outcome for something ominous was going on but taking this route didn't increase his changes any...that is for sure.

**NickiLaughs, ADN, BSN, RN** · Jan 31, 2012

Yeah, Intubate, Bolus and grab some gtts. Don't be hard on yourself, ultimately we're not in charge, which gets frustrating and disheartening at times when we see patients not getting what they need.