Can somebody please explain what happened in my clinicals yesterday? (Long)

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Hi All,

I am a student nurse doing my OB rotation. My teacher assigned me a postpartum c/s patient to take care of. I was with her from the moment she woke up in recovery until the end of my shift. This young lady is 16 y/o, just had her first child, and the c/s was due to fetal distress. They had her on morphine, pitocin and mag. sulfate. Everything was going fine until around 12:30 pm. As I was assessing her fundus, I noticed that she had blood stains from her incision site. The blood had stained her gown and one of her sheets. I called the RN and asked her to look at it. She did. The blood was not bright red and it had made a small stain on her dressing. The RN instructed me to mark the dressing and assess the site in about an hour to see if the stain had gotten any bigger. In an hour, my teacher comes in to look at the site. The stain did not get bigger on top of the dressing, however there was blood coming from the bottom of the dressing. This was only happening in one spot. My teacher went to go and get some 4 x 4 to reinforce the dressing. When she came back with the 4x4 we went to go and put it on pt.however the pt. is now bleeding from 3 different spots from the incision and the blood is running like a steady stream. My teacher tells me to put pressure on the bleeding while she goes and gets the nurse. Both my teacher and the nurse walks in a couple of seconds later and the nurse assess the situation and says that we need to get a doctor to look at it. There happens to be a doctor (we will call her dr.1) already on the floor checking on another pt. so they have her come in to take a look. By that time, my patient has soaked through several 4 x 4. Dr. 1 looks at the site and continues to put pressure on the incision. At first she says that sometimes incisions bleed, but it is nothing to be concerned about. Then she states that she doesn't want to remove the dressing because is probably tamponading the blood. However, as the pt. continues to soak through the 4 x 4 she realizes that she is probably going to have to remove the dressing and look at the incision. Dr. 1 removes the dressing. The bleeding has stopped, and she inspects the staples and the incision. She decides that it is not necessary to reopen the pt. so she begins to put on another dressing. As she does this, my pt. starts to bleed again. Dr. 1 asks us to call Dr. 2. A few minutes later Dr. 2 arrives. Dr. 2 assess the situation, and at first she feels that everything is OK, but upon further investigation she states that they should probably remove the staples. The nurse asks Dr. 2 to please take the pt. to the OR and sew her up there and then take her to the ICU floor for further evaluation since ICU has a 1 to 1 nurse/pt. ratio and she is short staffed and does not have the personnel to watch the pt. around the clock. Dr. 2 does not agree to this. Instead, Dr. 2 makes out a laundry list of things for the nurse to get for her and states that she is going to remove the pt.'s staples and sew her back up in the room. Due to the fact that the postpartum floor is not setup for this type of procedure, it takes the nurses a long time to come back with the stuff. In the mean time, Dr.1 decides to inject Lidocain around the incision site to numb the area. She tries to break off the neck of the ampule bottle, but she breaks it in such a way there are little pieces of glass everywhere and jagged edges on the bottle. Then she inverts the bottle to withdraw the medicine with her needle and the medicine spills all over the place. Dr. 2 starts to remove the staples. As she is removing one of the staples, blood starts to squart out. She starts to apply pressure, and the blood stops. She continues on with the removal of the staples and once that task is complete she reaches into my pt. (with clean gloves, not sterile gloves) and starts removing blood clots. Now both doctors realize that this procedure has turned out to be more extensive than what they thought, and they call for Dr. 3. Dr. 3 comes in and takes over the procedure. She cleans the pt. out, irrigate her, and sew up the bleeder, then she packs my pt. with a saline soaked gauze and tells her that she will need to go to the OR tomorrow and be sewn up. She then puts on another dressing and leaves. My pt. is wondering why they would just leave this hole in her and not sew or staple her back up. Her mom is concerned about her daughter is catching an infection. The Dr. says that the pt. will be fine and they leave. I visited my pt. today and at 4 p.m. she still had not been sewn up. When the mom asked why, the nurse replied that the doctors were doing C-sections and they would see her daughter before the night was out. She also replied that they now have all the supplies the doctor would need to sew up her daughter on the floor so that the Dr. could perform the procedure in the room. When I checked my pt. she was still having drainage from the incision site, and it was soaking through her gown.

This is my question, is this normal? Should the doctors have ever perfomed a procedure such as that in an unsterile environment? Isn't my pt. at an increased risk for infection? If so, shouldn't somebody be administering some type of antibiotic? Also, how long can she be kept open like is? I know that she has a dressing on, but there is a reason why the doctors either stitch up or sew up your outer skin layer. Please explain this to me. I am really trying to understand because on the outside looking in, this seemed like unsafe health care.

Thank you,

Debra

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I am a student also, so this is my guess. We do wound care as clean, not sterile, so maybe they looked at it as a wound, although it seems a little more involved than that. I don't know about the anitbiotics but maybe she received some prophylaxis during surgery so they consider her to be covered.

I have also seen some procedures done at bedside (insertion of intra-ventricular drain!??!!) that I would have never guessed could be done there.

If nothing else, for the patient's peace of mind she should have been taken care of quickly vs. a couple of days later. And how about the effect of the delay on her healing and pain control?

Were they residents? Not to be offensive but I have seen some crazy stuff go down when residents have gotten creative.

It seems like c/s patients are sometimes treated shabbily compared to other surgical patients. It also seems like the doctors are not very compassionate. Anyone, including a 16 year old new mother, deserves to have things explained properly to them.

Thank goodness for nurses :)

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Specializes in Vents, Telemetry, Home Care, Home infusion.

I would have expected OR to check for post partum hemorrhage ---think they got in over their heads. IV antibiotics should have been ordered prophylacticly....at least that's what I see on OB homecare referrals my agency gets....not my specialty.

Oh Smiling....

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

This is a mess ----they got in WAY OVER THEIR HEADS.I agree with Karen. What should have happened, is OR prepped/Team readied and patient whisked there for evaluation and PROPER treatment. There are so many things wrong with this scenario, I can't even enumerate them. It's obvious the people involved had no real clue what to do next.....

Figuring out WHERE the bleeding was coming from,yes, a priority.

I am also curious.....

What were her vital signs? You state she "squirted" blood, (not just oozed)----and someone reached in with (NONSTERILE!) gloves and "removed clots".....

this screams "trouble" right there!!!! Did her vital signs ever change? Did develop a fever?

And yes, you are right; infection is a huge risk here. I wonder if they ever did tx with antibiotics, given this situation, or at least order CBC and blood cultures?

I have to say the way it would have worked on my unit, is the primary doctor (the one who did the csection----or the physician on-call if after hours) would be up, surveying the situation, and correcting things in our OR prior to leaving the patient this way..... I can't speak for this institution, but it just appears to me there too many "cooks spoiling the brew" here---meaning too many doctors who did not know what they were doing messing around in there. While SOME wounds are re-opened and packed with sterile curlex, and left without re-stitching or stapling, this is usually later in the game, when wound healing is in jeopardy and they have signs of infection or dehiscence going on. This situation clearly is different.

I have to say, at best, it appears you witnessed some very disorganized care---at worst, serious neglect.

Finally, did you have a post-clinical conference to discuss the situation with your instructors? I wonder what they had to say, what their impressions were, since they actually witnessed this.....I was not there; you and your instructors were. This should really be discussed among you. Very serious situation going on there.

Situation is horrible, all around. So sorry. If you have more questions, or specifics to add, please let us know. Will keep checking.

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Forgot to give you KUDOS on your observations.....well on the way to putting the pieces together to make a fine nurse.

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I hope that you learned from the BEST thing (and the WORST thing) from this scenario.

The BEST thing: a nurse identified that this patient should be taken to the OR to explore this wound. The floor nurses were not prepared with staff, equipment or resources. In the event of a problem, they are up the proverbial "creek without a paddle".

The WORST thing: it does not seem the nurse was very assertive about sending the patient to the OR. If the doctors would not listen to her, she should have called the supervisor or NM and be persistent. Advocate for the patient's safety and welfare. Recognize the problem: Do something about it. IMHO ;)

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

I agree with Karen, Kudos to you and your desire to learn from the situation and work for the best for your patient. Seems to me they did treat her badly, but like I said, I was not there. Please, do discuss this with your instructors as soon as you can. There is a LOT to learn from this very unfortunate situation.

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How about calling the nurse manager or supervisor to get the pt. to the OR? I think they would have in the end, saved time and been safer by just taking the pt. to the OR. I agree it does sound like a case of "creative" residents. YOU did make some goood observations! Good for you!!!

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Holy Pete, my first thought with the Mag and all was possible DIC... So glad that wasn't it.

Horrible situation and I am so sorry you had to experience it.

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Specializes in Trauma.

That's bad. I am a nursing student also, but I think it sounds just like what everyone said. They got in over their heads. I have a question about this though.

If ever I am put in this situation in my career and I am sure it will happen unfortunately. Can I pull the doctor aside and tell him that this patient needs to go to the OR and demand something other than what they were doing? As an RN, I am the advocate for the patient. So, is this within my rights or would it be considered out of line? I mean, I understand they are suppose to know more than me, but if I don't feel right about something and something looks "wrong" to me, is it in my right to suggest or demand something else?

Because this one doctor said no, they were not going to the OR and you the nurse thinks that is a bad choice, can you go above their head on that?

Thanks:)

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Specializes in Maternal - Child Health.
That's bad. I am a nursing student also, but I think it sounds just like what everyone said. They got in over their heads. I have a question about this though.

If ever I am put in this situation in my career and I am sure it will happen unfortunately. Can I pull the doctor aside and tell him that this patient needs to go to the OR and demand something other than what they were doing? As an RN, I am the advocate for the patient. So, is this within my rights or would it be considered out of line? I mean, I understand they are suppose to know more than me, but if I don't feel right about something and something looks "wrong" to me, is it in my right to suggest or demand something else?

Because this one doctor said no, they were not going to the OR and you the nurse thinks that is a bad choice, can you go above their head on that?

Thanks:)

Good question, bean!

It is not only within your rights to insist on apropriate care for your patient, it is your legal, moral and ethical obligation to do so. Failure to properly advocate for your patient can land you in front of your BON as well as in a courtroom!

The first course of action is to speak to the doctor privately. If that doesn't yield satisfactory results, then you must call the nursing supervisor. Your next avenue is the attending (if you are dealing with a resident) or the chief of the medical specialty (in this case the chief of OB).

You sound like you will be an excellent patient advocate. You can be my nurse any time!

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Specializes in NICU.
That's bad. I am a nursing student also, but I think it sounds just like what everyone said. They got in over their heads. I have a question about this though.

If ever I am put in this situation in my career and I am sure it will happen unfortunately. Can I pull the doctor aside and tell him that this patient needs to go to the OR and demand something other than what they were doing? As an RN, I am the advocate for the patient. So, is this within my rights or would it be considered out of line? I mean, I understand they are suppose to know more than me, but if I don't feel right about something and something looks "wrong" to me, is it in my right to suggest or demand something else?

Because this one doctor said no, they were not going to the OR and you the nurse thinks that is a bad choice, can you go above their head on that?

Thanks:)

You go through the chain of command.

Student or orientee - should go to preceptor

Staff nurse - should go to charge nurse

Charge nurse - should go to nurse manager or on-call nursing supervisor if it's an off-shift - AND charge nurse should call another attending physician

Don't skip that chain of command - it's there to help you!

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