Anyone had a "moment" recently?

highlandlass1592, BSN, RN · Dec 4, 2008

Hello all,
So let me start out by saying I have had a rough month. My G-Pa died, and I had exp. surg, where I got a new diagnosis. So I have been a little stressed to say the least, I don't feel as though I am stressed to the max either.
I was at work the other day and had to take my patient (positive for cocaine and ETOH on admission) to CT because when they took him earlier his IV blew. No problem. The patient was actually very pleasent, young, and completely rational. A while later results were called back....PE's in R atrium, pulm artery, fluid around ascending aorta, poss thrombus in kidney, and a few other minor (gallstones, liver disease, etc). I immediately started paging teaching for orders, consults-(Please consult an intesivist). I got the heparin gtt, notified everyone, and made sure he was doing ok. It really threw me after I started thinking about it. I know not to "expect" anything, but I thought I'd be doing the ativan DT protocol thing-worst maybe intubating diprivan-then this.
It really got me. I found myself watching him like a hawk. I was terrified he was going to code any minute. It is so stupid but I really got worked up about it. One of the other nurses was like "take a flippin' xanax-relax" I just had about 30 mins where I was really freaked out. I think maybe because I am used to "doing" something i.e. intubating, coding, calling a surgeon, putting a line or NG in. There was nothing else to do but watch. Anyone else ever had a "moment" like this with a patient??:stoneI feel bad because, I am usually calm, very analytical, and deliberate in my care. Thanks for taking the time to read this. CAT

Heck yeah I've had that happen. Look, it happens to everyone. And sometimes we just a get a feeling something is going to happen. We get those feelings for a reason and we tend to be hypervigilent. Sometimes, the stress of life can really add to the stress on our job. And it makes us even more hypervigilent if that is possible. :banghead: It just starts a cycle.

Take some time for yourself, recover from your shift. Take a bubble bath, have some wine, whatever you need to do for you to be able to relax and recharge. And then go into work the next time you're scheduled and know you'll have a better night. You had a lot on your plate and sounds like you just hit your boiling point for stress. Hugs to you.

Indy, LPN, LVN · Dec 5, 2008

Yeah, the first patient I got who had a saddle embolus over the opening to his left and right pulmonary artery. ER brought me a little ole dude on room air and no monitor, who was greenish with a 72% O2 sat and very restless.

Admitting dx was PE and please start heparin, which was not hung in ER 'cause they didn't want to use their pump. That woulda been okay had he been transferred to me IMMEDIATELY and on oxygen, not an hour later on room air. (insert a lot of bad words here.)

Then after I've got the resp. therapist in, told her where to find the thing she was yelling about, yelled at her to shut up and help me, got his assessment done, (quick one) monitoring set up, and grabbed the chart to see what I was missing, I see the x ray report. Not "pulmonary embolus." No, "saddle embolus to left and right pulmonary artery" and a host of other crap along with bilat. pneumonia. Did I mention pt was drunk as a monkey?

Yeah, so I had the thrill go up and down my spine sort of like a religious experience. I made some kinda little noise that had my coworker looking at me funny. Then I showed her the report and she said whatever bad words I had not already said. Thing was, the new doc in ER had called the cardiologist for admit orders, and I was not entirely sure he told him exactly what the report said. I proceeded to get the cardiologist on the phone (he was not in town and was in the middle of an important religious thing.) and ask, hey did you know this is __________ and read him the report. He said, "no, I didn't know that's what it was" and was back in town and in the patient's room within an hour.

Now this story did not have a good ending. But just so you know, no you are not alone feeling that "holy crap" freakout feeling, and thinking your patient's gonna just go any minute. Cardiologist looked at the patient, said "call me if he becomes unstable." I looked at him like he was on drugs or something and said, "he hasn't been stable yet." Ah well, that was probably hypervigilance speaking and the doc was aware of that. I did have to bug him for something to keep the pt from coughing. This little dude got us so upset because we didn't even have a general surgeon, let alone cardiothoracic surgery in our facilty. Hello transfer?

Mommy_of_3_in_AL..RN · Dec 5, 2008

My moment. Young patient..my age..ruptured AVM. Essentially dead on arrival, but was intubated with minimal pulse and BP. Brought to unit, where the whole gamut of tests to determine brain death were performed. She was definitely, without a doubt, brain dead. BP very unstable. Placed on 4 drips. Within one day, arrested (still brought back), and full blown renal failure. Drips maxed out per protocol. Family, being very religious, refused to end ventilator support because the pastor had convinced them that there would be a miricle in three days. Day 3 comes. Still no said miracle. This sounds bad, and maybe even a little cold, but she at this point was beyond gone. VERY cold and stiff. Pupils fixed and dilated at 9 mm. I felt so bad for the famliy because of their sudden loss, but at the same time, was mad becuase i can not conceive of myself alowing a family member to go through that rather than pass away when it was time. Outcome: the patients brain herniated, her pressures bottomed out, monitor showed wide QRS complexes, but was still not a DNR since we were waiting on a miracle. Patient was coded. Pressure increased slightly, defibrillated, and asystole. She died in a much more stressful and barbaric manner than if they had let her go to begin with.

PLease do not think that i do not beleive miracles happen, becuase they do. I have seen them. But i am also enough of a realist to know when there is nothing left to do. No hope. It just upsets me to see sometimes, and still assist a family in holding out such far fetched hope.

VivaRN · Dec 6, 2008

My moment occurred after going from ICU to the floor. In the ICU I was used to being very independent, ie if I thought my patient needed a breathing tx I gave it and got orders later.

Well now I had 7 pts and one was an elderly Asian man who did not speak English, very quiet, who had been stable all day. Until I went in to assess and noticed he was wheezing and having some mucous. I listened to his lungs and heard wheezes. Not distress, but increased work of breathing; it was enough to make me nervous since the floor did not have monitors and I wasn't sure he would call for help. Sat 96% on RA. Was it the start of pneumonia? asthma? something worse? My first impulse was ALBUTEROL.

I went to just do it and realized that was not the culture on the floor. So I politely called the MD and told him the story, can I give him a breathing tx, and the MD said NO. I was like, excuse me? The MD said as long as his sat was ok he was ok. I disagreed. Hello, airway! He could crash in there and no one would know, and why don't we prevent something like that? I argued (I mean "advocated") and finally got my way. Then I called the RT and asked him to come give it ASAP. The RT agreed with my assessment, which made me feel better about being so anxious with the MD.

Talk about hypervigilance. I reassessed until the end of my shift and gave report to the oncoming nurse to check him frequently. I think she thought I was a little nuts, but you never know - in the bustle of the floor a quiet thing like him could be overlooked. In hindsight I was probably overreacting but I had a strong feeling about it.

I would rather be hypervigilant than not vigilant enough and miss something. I think that is probably true of most of us.

MaryAnn_RN · Dec 6, 2008

Ever noticed that when an alarm goes everyone listens up really intently?

*LadyNurse* · Dec 12, 2008

ahhh...those moments....

I happened to have one last night.

The patient was a new admission during the day for DKA. 30 y/o WM

Pt has a blood glucose greater than 900. History was scetchy per parents

(bipolar--doesn't take meds, undx dm, fatty liver...)

He was admitted to us...pt confused, lethargic, would follow simple commands. Insulin gtt in progress q2 bmp with mg and phos levels, q4 abgs

(ph 6.8 bicarb 4)

During the beginning of my shift the patient's RR could be best described as being Kussmalls. He had a hight rate in the mid 30s (trying to blow off).

I was immediatey concerned with his ability to maintain his airway. I spent the majority of the night speaking with the hospitalists on the case about him.

Now I know that in some cases intubation is not indicated unless the patient is obtunded and cannot protect his airway, but I'm telling you...I had THE FEELING.

This guy was circuling the drain, QUICK.

I spent the first 2 hours of my shift at his bedside and trying to plead my case with he mds.

The pts bp was dropping (73 systolic) levophed started,bicarb pushed,

fluid bolus in progress.

I finally conviced once of the mds to come in and take a LOOK at this guy. He procedes to tell me that although his RR had become more shallow...he was fine and did not need intubated at this time (2105)

at 2115 We were coding my pt.

He was initally in a nsr 90s...he started to brady to 40-50s...then pea.

he was intubated, code successful. He is still very sick, but he was alive when I left (In our unit, we take it 12 hours at a time :wink2:)

Moral:

Trust your instincts...they are what gives us our moments.

Magsulfate, BSN, RN · Dec 13, 2008

Here's my little story from last week... Maybe not as dramatic and complicated as you guys, but freaked me out just the same.

Old lady, new trach, possible chronic vent patient was going along, doing fine and had been weaned down to CPAP a few days before. Well, I'm sitting outside the door and I hear the vent going off. I go in there and look,,, everything is connected, her chest is rising and falling... just a little fast, but not too bad. I look at HER and she is looking bad. Bad color, eyes rolled up in her head. I look at vitals,, vitals good.....

Then I look away for 5 seconds to get the resp tech, at this point I just think she needs a little suctioning. When I look back, she's bradycardic at 20! HOLYCOW!

SO, we start bagging her and give atropine. A minute later she's waking up with this crazy suprised look on her face, like what the heck happened!!!!

Anyway, the rest of the day, I argued with resp tech about weening her back to cpap,, LEAVE HER ON ACMV whle I'm here! jeeezeeeeeeee!! call the doc, I dont care, you're not putting her back on cpap with me here!! lol btw, she's fine now. I mean still chronic vent, but no long term anoxic injury or anything.

RNperdiem, RN · Dec 14, 2008

Stories like these are one of the reasons I am in ICU.

It would not be uncommon on the med-surg floor to have a patient you had that bad feeling about.

Of course they were all full codes.

Of course there was nothing obvious to call the doctor about- yet.

Of course the floor patients had no monitoring to alarm when they went bradycardic or hypoxic.

The 5 other patients still had their needs.

When the patient's vital signs would start on a downward slide, the doctors would seem to take forever to answer my page and require some convincing that the problems are real.

I know about those situations; they are exhausting.