Could I have done anything else?

[MDMBSNRN]

I was working in ICU the other night (technically as a float nurse, although I was given a patient assignment), and was receiving a patient from the ED. He was in his late 70s (78, I believe), and resided in a skilled nursing facility. The patient had a past history of HTN, hyperlipidemia, dementia, CHF, renal failure, MI X 3, CABG X 2, two cardiac stents, and DM. Apparently, he had been in the dining room at lunch, had become cyanotic and hypoxic, and was rushed to the ED with sats in the 70s.

The patient was placed on BiPAP, a CXR was done, and labs were obtained. The blood gas, of course, wasn't great. The patient was in respiratory acidosis with a pH of 7.1 and CO2 in the 60s. CXR revealed a left lower lobe infiltrate. Initial troponin (drawn at approximately 1330) was 0.142. The patient received a one time dose of Levaquin in the ED, but the admitting physician decided not to continue antibiotics in ICU because she felt that his WBC of 8.2 wasn't indicative of infection.

When the patient arrived to ICU (at approximately 1946), his troponin had increased to 2.44. The ED had noted evidence of a lateral infarct on his EKG, but could not determine the age of said infarct. Vitals were stable, and he was in normal sinus rhythm. After a few hours, however, his BP began to steadily trend down. It got to as low as 90/37 before stabilizing. Heart rate also began decreasing (although I feel that this occurred as the BiPAP was optimized, his gas improved, work of breathing eased, and he became less anxious).

I inquired with both the ED and the charge nurse about the acutely elevated troponin in someone with such a cardiac history. I also asked about whether it would be prudent to start antibiotic therapy on an elderly patient with a known infiltrate on CXR. I asked the charge nurse three to four times about whether or not the physician needed to be called. No one else on the unit acted like it was a big deal, but I was greatly concerned.

The patient denied chest pain, however he did have advanced dementia. I don't know that this was reliable information. I was pulled to another unit at 0400, however, I did see his 0600 labs. By 0600, WBC had increased to 18.2, potassium was elevated at 5.5, creatinine and BUN had both further increased (although he had a history of renal failure, and was dehydrated). Troponin had increased again to 2.568. The blood gas was much better, and had almost returned to normal, but that was the only thing that looked decent.

I realize that CHF and pneumonia can elevate the troponin. However, the BNP was 73, and the infiltrate noted on CXR wasn't especially large. I know that a PE can also elevate the troponin, however this patient showed no signs of a PE. I feel like the troponin was truly an indication of cardiac damage, and that treatment did not reflect this.

I just wonder if I, personally, could have done anything else, or if maybe I made too much of a big deal out of his condition. No one else in ICU seemed concerned with anything, and I felt like my concerns were very minimized by staff. Did I blow this out of the water, or was I justified? And what would you more experienced nurses have done if you were in my position?

[Loo17]

The only thing I personally would have done differently than you is that I would have called the admitting doctor myself and then documented such. If the doctor had no additional orders I would chart "critical troponin reprted to xx MD at this time, no new orders. "Vs change of ___ reported to xx MD, no new orders." Etc. I work in the ED not ICU. If you are ever concerned the best thing to do is to talk to the doctor and ask for an explanation if you don't understand why. Most doctors will appreciate your questioning if you do so in a polite manner to improve your knowledge and if they don't oh well, don't let it stop you from asking.

[MDMBSNRN]

I just remembered one detail after reading your reply. The admitting doctor had been made aware of the increased troponin by the ED (the jump from 0.14 to over 2), and she stated that she felt it was due to "the difference between oxygen supply and demand occurring with hypoxia, but could also be an MI given the infarct of indeterminate age on EKG." No new orders were given at that time, and the patient was transported to ICU. The admitting physician suggested monitoring in ICU and followup if necessary.

I completely agree with what you said, and I am usually the first one to call the doctor myself. In ICU, however, this independence isn't encouraged. The charge nurse is the one to call the doctor 99% of the time, and if he/she doesn't feel that this is necessary, it is not taken well when a nurse takes his/her own initiative. This isn't an excuse on my part by any means, and I now regret that I didn't at least call and speak with the physician myself to communicate my concerns.

Had I not been pulled to another unit, I would have certainly called at 0600 when the rest of the labs came back. I just feel like the patient did not receive the best care, and that the troponin was treated way too lightly. I also didn't agree with not starting an antibiotic on the patient, despite the fact that his WBC count hadn't become acutely elevated at the time.

[calivianya, BSN, RN]

That is a BIG jump in troponin!

Are there policies in place for calling critical labs? That second troponin would have been a critical result at my facility. Lab would have called the critical to me and I would have had to call a physician within one hour of lab documenting that they spoke to me, or I would have been in hot water. If your facility does not have his policy in place, I'd make a suggestion that it would be a good idea. It really protects you, and if the MD gives you grief about calling in the middle of the night over one elevated lab, you have the defense of it being facility policy and they will know that you don't have a choice but to call.

Any time troponin jumps like that, I'd call. I would also grab another EKG and take a really good look at it - when the ED said infarct, did they just see Q waves, or did they see current ST elevation/depression? Q waves are previous MIs, dead tissue, but current elevation/depression is a problem happening right now. Even if there was no elevation/depression on the first EKG, if you've had a big jump in troponin, I'd say it would be worth getting another EKG so you can take a good look at it and see if there were changes in ST elevation since the first one. Then, you have really good stuff to call into the physician. "Hi, this is Nurse X, patient Smith now has a critical troponin and there is new ST segment elevation in leads X and X compared to his EKG obtained upon arrival..."

I probably would have called in the BP dropping, too. 90/37 is a MAP of 54.6, roughly. Anything under 65 is not perfusing the end organs, so the patient is setting up for some possible kidney damage at the least, and it sounds like he didn't have a ton of kidney function to spare. I would not necessarily call the first low BP, but if it is dropping consistently, that's another story. Looking at that diastolic of 37 specifically, I'd be thinking about coronary artery perfusion. Knowing that the heart perfuses during diastole, and that the troponin is already elevated, I'd be concerned about the heart getting enough oxygen to continue functioning properly.

One more random thought - you won't necessarily see chest pain in diabetics with MIs. They are set up for silent MIs - that same neuropathy they famously have in their legs can prevent them from having chest pain, too. A lack of chest pain in a diabetic with an elevated troponin does not rule out an MI.

You did right asking your coworkers what they would do, but I feel like they led you astray. Your instincts were good. Trust yourself a little more - if you feel like something is wrong, it probably is. I firmly believe in the virtue of butt-covering. I don't want to be held responsible for anything potentially wrong with a patient, and if I have passed changes on to the physician and he/she decides to do nothing, my butt is covered. I know plenty of ICU nurses who will only call if something is really seriously wrong, and it sounds like those are the type you worked with that night. However, it's pretty easy for someone else to be nonchalant about changes in the patient, but if you are the primary nurse, the primary butt on the potential fire is yours.

I probably call things in too often, but I'd rather be that person than the person that doesn't call often enough, you know?

[MDMBSNRN]

Calivianya, first and foremost thank you for your great information and wonderful reply! There is a policy for critical labs, and that first huge jump in troponin occurred while the patient was still in the ED. The ED did communicate this to the physician per the policy, and she came back in and saw the patient again. This was when she gave the rationale that an oxygen supply demand imbalance was causing the elevation (most likely) but AMI couldn't be ruled out. The patient was not substantially hypoxic for long, and I don't really buy the whole supply versus demand idea, but I am not confident enough at this point to say that it is totally incorrect.

I know that Q waves were present on the EKG, and I believe that depression was also noted (if my memory serves me correctly). While the patient was in NSR, the ST segment did look somewhat elevated to me on the monitor (personal opinion), and I felt as though the ST segment elevated further once the BP began dropping, but this was a slight change, and I may have been overreacting. While it certainly wasn't the classic "tombstones," or anything dramatic, the rhythm just didn't look quite right to me.

I inquired about a repeat EKG just to see if there had been any changes. Both the ICU charge nurse, other ICU staff, and respiratory stated that they did not feel that this was needed. And the physician ha written in her admission note that she did not plan to repeat an EKG until in the morning. I do not feel that this was prudent, and I certainly wanted to obtain another EKG to look for any recent and significant changes.

Another problem with that shift was that we had 9 patients with 3 nurses and no monitor tech. There was a charge nurse and two staff nurses. I had four patients that night, including this patient. The acuity was high, and we really needed additional help. This isn't an excuse either, but the department was chaotic, we had two who were extremely critical, and I think this patient got lost in the grand scheme of the unit. Both myself and the charge nurse called the ADON and requested extra help, made him aware of the situations at hand, and tried to get additional staff called in. Needless to say, this did not happen.

Also of note, as the BP dropped, I saw that the patient was having PVCs, and these began occurring more frequently. This also concerned me, as I know that this can be a sign of a heart that is inadequately perfused, or of irritable cardiac tissue (not to mention electrolyte imbalances and other causes). There were never any runs, and I saw a couplet at most. I did eventually bolus the patient with 500 ml of normal saline per policy because I was worried about cardiac oxygenation and organ perfusion. This brought his BP up to 104/55, and it appeared to hover around the 100s/50s to 90s/40s for the rest of the night. After the fluid bolus, and some adjustments to the BiPAP, the PVCs began to slowly dissipate. I alerted the charge nurse to this as well, and this didn't seem to be of concern either.

I felt like there was a real issue at hand, and that it needed to be addressed, but the way the other nurses acted made me feel like I was on the wrong track. I know that they all have way more experience than me, and I don't want to disrespect that knowledge. However, I really felt like more needed to be done for the patient.

[Loo17]

It is interesting to hear how that unit runs, nurses have no autonomy! I cant imagine having to run everything past the charge nurse.

Where I work we order repeat EKG's under protocol orders all the time and never have to go through the charge nurse in order to contact a doctor. I don't think I could work under those conditions.

When the troponin came in critical a second time in the ICU I would think the doctor would need to again be contacted regarding the critical value and that at the very least an EKG would need to be repeated. I am also surprised that given this patients extensive history that there was not an old EKG the doctor could use for comparison. I work for a teaching hospital so I am not sure if that is why my facility seems to operate so much differently than yours. We document every significant VS or mental status change and critical value in a form in the eMAR and have to include the time the MD was notified, their name, and either "no new orders" or "see new orders". Its a good way to cover ourselves as well as document we did something. We could never write we consulted a nurse or supervisor in place of the provider. As an outsider it sounds dangerous. If a patient declined would the doctor be pointing blame at the nurse saying they should have called? Would the patient or family?

I have certainly consulted nurses about my patients and been given advice that I shouldn't worry or don't call the doctor or just advice that didnt feel right. Always trust your gut, its your name on the chart not whomever you are working with. The worst that can happen is another nurses feelings get hurt that you didn't take their advice or the doctor gets snappy that you bothered them. They will get over it.

[MDMBSNRN]

That form in the eMAR sounds like a great idea. I wish that we had that. We resort to writing a nursing note that we called the doctor, and whether we received new orders. I think that the form in the eMAR would be a great resource. Unfortunately, nurses are losing more and more autonomy at this hospital. We can no longer hold any medications without calling the doctor. For instance, if a patient's blood glucose is 40 and you need to hold insulin, you cannot simply hold based on nursing judgement. Management told us that we had no nursing judgement, and that it was outside of our scope to make those decisions. Everyone is more on edge now when making decisions.

I certainly don't enjoy the charge nurse being such a central figure, as I do not feel that we are allowed to make independent decisions at full capacity. Having to consult charge about so many issues becomes tiresome, yet you get jumped on if you make your own decisions and call the doctor independently. I've been run over by that train repeatedly.

[Loo17]

That form in the eMAR sounds like a great idea. I wish that we had that. We resort to writing a nursing note that we called the doctor, and whether we received new orders. I think that the form in the eMAR would be a great resource. Unfortunately, nurses are losing more and more autonomy at this hospital. We can no longer hold any medications without calling the doctor. For instance, if a patient's blood glucose is 40 and you need to hold insulin, you cannot simply hold based on nursing judgement. Management told us that we had no nursing judgement, and that it was outside of our scope to make those decisions. Everyone is more on edge now when making decisions.

I certainly don't enjoy the charge nurse being such a central figure, as I do not feel that we are allowed to make independent decisions at full capacity. Having to consult charge about so many issues becomes tiresome, yet you get jumped on if you make your own decisions and call the doctor independently. I've been run over by that train repeatedly.

That is horrible. I hope you are able to find greener pastures one day soon! Good luck!

[MDMBSNRN]

I interview at Centennial Medical Center in Nashville, TN in a few weeks for an ICU position. I'm praying hard that I get the job there, as this hospital is getting worse by the day.

[MunoRN, RN]

That form in the eMAR sounds like a great idea. I wish that we had that. We resort to writing a nursing note that we called the doctor, and whether we received new orders. I think that the form in the eMAR would be a great resource. Unfortunately, nurses are losing more and more autonomy at this hospital. We can no longer hold any medications without calling the doctor. For instance, if a patient's blood glucose is 40 and you need to hold insulin, you cannot simply hold based on nursing judgement. Management told us that we had no nursing judgement, and that it was outside of our scope to make those decisions. Everyone is more on edge now when making decisions.

I certainly don't enjoy the charge nurse being such a central figure, as I do not feel that we are allowed to make independent decisions at full capacity. Having to consult charge about so many issues becomes tiresome, yet you get jumped on if you make your own decisions and call the doctor independently. I've been run over by that train repeatedly.

If based on your nursing judgement, which isn't defined by your employer, a medication should be held then the expectation of every single BON in the country is that you hold the medication. You can certainly be required to notify the provider of your decision, but your decision cannot be overridden by the provider or your employer. I doubt any BON would hesitate to pull your license if you did something against good nursing judgement because you were told to by a physician or manager.

[MunoRN, RN]

An important thing to remember about troponins, even the most sensitive ones, is that they are delayed. A cardiac event/ishchemia will not be immediately reflected in the troponin level, it takes typically about 8 hours. So if a patient had an event prior to arrival in the ER, and then the troponin drawn after being in the ER for two hours is sharply positive, that doesn't in any way suggest a change from when they first arrived in the ER and there really is no point in doing another 12 lead at that point, since the 12 lead done on arrival already reflects what the 2 hour troponin shows. I would expect the 12 lead would show old infarcts, so if there are no signs of a new, treatable infarct then it would be inappropriate to take the patient to the cath lab for instance which would only exacerbate the renal failure you already mentioned. The Physician was attributing the troponin increase to demand ischemia, which is actually quite common.

[MDMBSNRN]

MunoRN, good point about the troponins, and the time it takes from cardiac injury to elevation. I had heard an elevated troponin blamed on demand ischemia before, but I have never seen it so acutely elevated in those instances. Also, the patient was immediately given oxygen at the SNF, and was transported to the ED within 30 minutes of the initial event, where he was immediately placed on BiPAP. I know that his blood gas was significantly altered, with a pH of 7.1 something (I don't remember the exact value), and a sharply elevated CO2. I just wasn't sure how elevated a troponin could become from demand ischemia.