had an AWFUL night

Sounds to me like you did just fine. We've all had those shifts before! I wouldn't take to heart (pun intended) what the cardio said about you being overwhelmed. When you have multiple pts nose-diving at the same time, take the help when you can.

I would consider writing up the incident with ER sending you the unstable CP with no work-up. Also, in the future, I would suggest calling the rapid response so you get immediate help. Our ICU covers the RR & pretty much takes over, initiating the protocol orders & then following up with the MD.

I've been there where I tried to manage a pt report of CP on the floor by myself...never again (not if I think it may be truly cardiac related). It was also the same night I started the shift with a RR, a death about an hr before the cp complaint (comfort measures, so expected), & a stable asymptomatic CP with a critical troponin near the end of shift.

The best thing to do now is to get it all out (like you did in your post), think about what went right, what went wrong, what you will change or improve on next time...and then let it go!

when i left, both were still live and rerlatively stable, why do i feel so crappy and like failure???

Ah, probably because you were handed a cluster**** of an assignment? A rule out MI patient with severe chest pain who had no troponins drawn??? That is incredibly substandard care. He should not have been transferred in the first place, much less to a regular floor. It sounds like you handled the woman taking her own meds appropriately, given the circumstances.

For both patients, I personally probably would have called a rapid response due to the situations you've described, but at the hospital where I worked med/surg, we had a pretty low threshold for calling (this was encouraged). Possibly where you work it's more frowned upon? I would at least have involved my charge nurse earlier for help.

At any rate, I'm sorry you had such a bad night, and I hope your next shift is better. It sounds like you did a good job with the hand you were dealt. That'll teach you to pick up OT!

Sooooo... I had a long reply but now it's not showing? Try again.

Sounds to me like you did just fine. We've all had those shifts! Don't worry too much about the cardio thinking you were overwhelmed. When you have multiple pts nose-diving at the same time, take help where you can get it.

I would consider writing an incident report for ER sending up an unstable pt with no work-up. Also, in the future, an immediate rapid response would probably be your best action when presented with a symptomatic CP pt. Even the hypotensive & sedated pt would qualify for RR (although I'd probably do as you did, & see what I could do myself). By calling the RR, you get more eyes on the pt & protocol orders to implement without going back & forth with the MD.

I've tried to manage a pt report of CP during a shift by myself...never again (unless I don't feel it to be truly cardiac related)! It was ona similar night as yours where I started the shift with calling RR on a different pt at 2300, had an expected DNR death at 0015, pt reported cp at about 0130, & morning labs revealed another observation pt for CP had a critical troponin (although aymptomatic).

What you do now is get it all out (like you did in your post), think about what you did right, what you would change or improve...& then let it go.

It always feels awful when people don't recognize your awesomeness.

You were doing everything right with the patient who looked like he was having a MI - getting EKGs, getting labs, calling the physician. You were on your game. It blows that the cardiologist found some imaginary fault with you - and in reality, that fault was probably that he was a hot shot cardiologist and one of the ones where you have to earn his trust before he wants you touching his patients and wasn't anything to do with you at all. I would have been a little miserable after that shift, too.

I am sorry you had to deal with that. I work on a telemetry floor in florida and deal with this a lot on our floor- just trying to get my one year of experience and move to another city with more options- out hospital is still all paper charting AND a plethora of useless staff- hope your shifts get better- sounds like you handled it beautifully!

All I can say is at my hospital, that chest pain would have gone straight to our unit - CCU/CVICU step down that takes everything from heart caths to VADs and transplants. Seriously, no troponins drawn by ED? He would have come up with 2 sets run, an echo to assess EF, a nitro drip at the least and been npo for a potentially emergent trip to the cath lab. Actually, he may have never left the ED depending on his 12 lead and enzymes. Might have gone straight to the lab. If for some reason they tried to send him to a med bed, the charge for whatever floor they tried to turf him to would have delivered him to our unit herself/himself, no ifs ands or buts.

I'm sorry you've had to deal with all that. Sounds like a feces fest. The narcan patient? You did the right thing absolutely. You kept the patient safe. You're not an addictions counselor. You can advise and educate, but you're not a rehab unit. You kept your patient safe and involved the right resources.

Speaking of, Don't forget to use your resources. Use that rapid response, your charge, your buddy, or your helper nurse. Let them know as soon as things start to go south; give them an update on the fact that you're seriously tied up and are going to need assistance.

Not saying you did anything wrong at all, just to keep in mind when/if something else presents itself. Hang in there and get some rest! I had a mega RRT last night too along with an additional very unstable patient. I'm ready for a bit of rest and I'm sure you are too!!

To me.....sounds like you were amazing. PS I would be "freaking out"

Perspective.

You needed and should have gotten support from your charge. The cardiologist needed and should have made should there was enough support and coverage for her patient.

You feel wimpy because you left nothing on the field and you're exhausted but you rocked it last night.

Instead of feeling like a failure, feel like an essential part of getting sick folks thru a rough night that could have gone a whole lot more sideways if not for you. Allow yourself to feel fantastic about that. Then eat some chocolate and go to bed.

Sometimes doctors make these comments because they dont want to believe the patient needs a higher level of care and deal with the transfer. The charge nurse told him everything you did, so onviously you were not mistaken with you "freakingout"-ness but in fact correct!

good lord, sounds like a typical day for me. Im so sorry you had to deal with that.

Id be very angry at the first patient- we dont have time for games like that

Sounds like you dealt with it all ok. Sorry about the doc misunderstanding your concerns.

ughhh.

and we do this job ,again, why?????

It sounds like you did an amazing job and you are a great nurse. When I worked med surg, and spent all my time with 2 out of my 5 patients, I felt like a sub par nurse too. It's just a natural feeling when you are a good caring nurse. Sometimes we don't give ourselves enough credit.

Yikes! What a crappy night! I feel tired just reading about your shift (and this is not a dig at your writing style!). It's true: we all have assignments like this at some time or another. Once in a while you get a perfect storm of unstable patients. But that really sucks that you didn't get the support that you deserved/needed. Reward yourself with something after all of your hard work- you deserve it!

One thing I would maybe bring up to your manager is the lack of support. Were you able to communicate with your charge nurse about your hypotensive patient and your emerg patient? Did she pitch in to help? What were your other colleagues doing? These questions might help your manager address problems such as workload (i.e. was everyone else very thinly stretched) and workplace culture (i.e. everyone for themselves).

As others have suggested, don't be afraid to use your rapid response team earlier next time (unless your hospital has strict initiation criteria- which hopefully it doesn't). They are my favourite resource and can help push for patients to be moved to a more appropriate setting, initiate orders, offer recommendations, and provide support.

The only other thing I would comment on would be possibly delegating more tasks to your colleagues. Is there someone else who could have obtained your cardiac pt's trop/BW? Is there someone who could have tended to your stable pts (i.e. hanging meds, answering call bells) while you dealt closely with your unstable pts?

Again, you really did an amazing job! And hope your days off are relaxing.