CPAP, a talk with my charge, and an unhelpful RT

[x3divine]

Okay, so I'm a new grad nurse resident at the cardiac ICU who is off orientation and on night shift. Last night, my charge nurse pulls me aside and tells me that the RT (respiratory therapist) feels that I am not a safe nurse because I didn't know how to turn on and off the CPAP machine.

This lady RT, mind you, is not the nicest lady around and I feel that I already had a bad rapport with her from a different night where she did not want to be bothered (texting on her phone) by me asking her questions about my patient and asking her to run my ABGs - her job! (different story). SO basically, my OSA patient absolutely required CPAP at night and I had the RT put her on the machine. I saw the patient was de-satting to 87 with it on, so I decided to fiddle with the machine to see if I could add some oxygen with the mask, and ended up turning it off. I was not familiar with the home device CPAPs, so I immediately tried to call the RT to help me turn it back on. She came back in the room and basically scolded me, "did you turn this off?" I said, yes, on accident because the patient was desatting and I wanted to see if I can add oxygen."

I asked her how to work the machine, but she just ignored me, put on oxygen with the mask, and left the room. I then get called in by my charge nurse and she asked me about the situation. I explained, and then I was told by a different (more seasoned) nurse (who I'm assuming heard the news) that I could've killed the patient because I kept the mask on when the machine was off. Mind you, the machine was off for no more than 30 seconds. She said that the patient could have suffocated and told me to not to it again.

I was so scared and shaken, because it was the first time I've encountered anything like that especially with another person saying that I was not a safe nurse because I didn't know that I turned the CPAP off. The next night, a different RT was on and he was one of the more helpful ones, and I immediately asked him about the machine. He told me that even if the machine stopped working, the patient would not suffocate because there are exhalation ports on the mask, etc.

In the whole situation, they asked me questions, but there wasn't much feedback except for the "possibly killing your patient" part, so I literally left that shift confused, and very down-hearted.

Nevertheless, my patient survived and no harm was done in the end. My questions are:

- what are your thoughts about the situation

- do I need to make an incident report

- what could I have done about the situation

[Rose_Queen, BSN, MSN, RN]

No one should be messing with equipment they are not familiar with! That was your first mistake. You should have asked for the RT's help before touching anything. Yes, an incident report should have been completed and included the fact that you were trying to use equipment that you weren't trained to use. In the future, never touch equipment you don't know- ask for help first instead of after something has gone wrong.

[NICU Guy, BSN, RN]

I then get called in by my charge nurse and she asked me about the situation. I explained, and then I was told by a different (more seasoned) nurse (who I'm assuming heard the news) that I could've killed the patient because I kept the mask on when the machine was off. Mind you, the machine was off for no more than 30 seconds. She said that the patient could have suffocated and told me to not to it again.

I was so scared and shaken, because it was the first time I've encountered anything like that especially with another person saying that I was not a safe nurse because I didn't know that I turned the CPAP off. The next night, a different RT was on and he was one of the more helpful ones, and I immediately asked him about the machine. He told me that even if the machine stopped working, the patient would not suffocate because there are exhalation ports on the mask, etc.

I worked as a Registered Sleep Technologist for 14 yrs prior to going into nursing. Thousands, if not millions of people wear CPAP at home. What if the power goes out in the middle of the night? Do all these people die in their sleep? No, they either wake up to realize that it turned off or when the power is restored most home machines will auto start and the patient never realized the power was off (except for the flashing clocks). Many power outages last longer than 30 seconds and the person survives.

[Spidey's mom, ADN, BSN, RN]

I think this could have been handled better. We all make mistakes, especially when we are new at something. I've been a nurse for 19 years and in a new situation, still could make a mistake.

Yes, I'd do the incident report and just state facts.

And yes, I'd be careful about things for which I had no training.

But this stuff happens and it is an opportunity to learn.

[CCU BSN RN]

1. Thoughts on the situation: As stated above, in general don't get involved with equipment you are unfamiliar with. Also, you're going to need RT, so even if this lady is an ice queen, you need to find a way off of her **** list. I don't know how to do this, I'm terrible at interpersonal conflict, but I do know you need to find a way to resolve it.

2. You should probably fill out an incident to CYA but I probably wouldn't unless my charge or manager directly told me to, to be perfectly honest.

3. In the future, it's fine to take someone off CPAP and pop them on a cannula or venti mask or whatever while you're waiting for RT to show up if you don't feel comfortable fiddling with their CPAP or if you accidentally turn it off. That at least shows you're meeting the patient's needs while futzing with equipment. We've all messed with equipment we're not trained on when it's something like a home CPAP. The patient isn't going to suffocate with the machine off but they will desaturate further, something you were trying to prevent in the first place. Also, future thoughts, grab another RN with more experience or your charge RN to help you mess with it. By sheer exposure they probably know how to add oxygen. Usually just a little port by the mask on a home machine, but is sometimes further down the tubing or directly on the machine itself. Usually adding oxygen to a home CPAP is physically hooking up oxygen tubing to the machine. Sounds like you hoped you could turn up the FiO2 like a vent/hospital BiPap. Would be nice but not usually an option on home machines, just FYI.

[psu_213, BSN, RN]

At my facility, no staff member is allowed to adjust the settings or silence an alarm on a piece of equipment unless said staff member has been trained on and is legally allowed to work with that equipment. For example, a PCT cannot adjust nor silence an IV pump. In my facility, nurses are not trained on how to adjust, put on, take off, etc. BiPAP and CPAP, therefore nurses are not allowed to adjust those pieces of equipment--only RT can do that (many nurses do adjust BiPAP and that is their neck on the line if something goes wrong). In my facility, if something were to bad were to happen to pt. on CPAP/BiPAP and it was due to a nurse "fiddling" with the machine, that nurse could be in some deep doo-doo.

In your situation, it sounds like the RT and 'they' (some sort of review board?) handled it poorly--it does not do a lot of good to simply tell someone "you could have killed them," especially when it is not really true (or a massive stretching of the truth). I don't really think an incident report does a whole lot to help the situation, and, as someone else already said, try and "make up" with this RT with whom you have had issues.

[Been there,done that, ASN, RN]

We've ALL "fiddled" a new situation. In a perfect world, you would have an RT that would have helped you in the first place.

Your "fellow" nurse needed to butt out and also needs some CPAP education. NO way was the CPAP being turned off for a short period of time going to "suffocate" the patient.

You do not need to fill out an incident report, you were in the process of learning the machine when the RT from hades interrupted you. I unplugged a vent once, it was off for 30 seconds ... big deal.

I would discuss the difference in the RT's support with your manage. Ask what "exactly" should you expect of RT.

Good luck, sounds like a rough unit.

[Rose_Queen, BSN, MSN, RN]

We've ALL "fiddled" a new situation. In a perfect world, you would have an RT that would have helped you in the first place.

Your "fellow" nurse needed to butt out and also needs some CPAP education. NO way was the CPAP being turned off for a short period of time going to "suffocate" the patient.

You do not need to fill out an incident report, you were in the process of learning the machine when the RT from hades interrupted you. I unplugged a vent once, it was off for 30 seconds ... big deal.

I would discuss the difference in the RT's support with your manage. Ask what "exactly" should you expect of RT.

Good luck, sounds like a rough unit.

How does fiddling with equipment in which one has zero training and no one else in the room "learning the machine"? And yes, absolutely to the incident report- a piece of equipment was turned off unintentionally. User error is still an indication for an incident report to point out the failure of the system in having trained individuals touching the CPAP.

[Been there,done that, ASN, RN]

How does fiddling with equipment in which one has zero training and no one else in the room "learning the machine"? And yes, absolutely to the incident report- a piece of equipment was turned off unintentionally. User error is still an indication for an incident report to point out the failure of the system in having trained individuals touching the CPAP.

Per OP "I was not familiar with the home device CPAPs, so I immediately tried to call the RT to help me turn it back on. " OP was prudent in her action.. RT was at fault, not the OP. RT needed to intervene per the nurses's request .. and teach in this situation. Instead, RT chose to throw OP under a bus, rather than assist her.

All it would take would be 2 minutes of instruction.. the OP would have been taught by a team member and the patient would have the O2 they needed.

[Rose_Queen, BSN, MSN, RN]

Per OP "I was not familiar with the home device CPAPs, so I immediately tried to call the RT to help me turn it back on. " OP was prudent in her action.. RT was at fault, not the OP. RT needed to intervene per the nurses's request .. and teach in this situation. Instead, RT chose to throw OP under a bus, rather than assist her.

All it would take would be 2 minutes of instruction.. the OP would have been taught by a team member and the patient would have the O2 they needed.

But she needed the RT's help to turn it back on because she tried fiddling with it herself first. Second paragraph clearly states that is the case.

[Kooky Korky, BSN, RN]

No one should be messing with equipment they are not familiar with! That was your first mistake. You should have asked for the RT's help before touching anything. Yes, an incident report should have been completed and included the fact that you were trying to use equipment that you weren't trained to use. In the future, never touch equipment you don't know- ask for help first instead of after something has gone wrong.

She says she asked for help, but the RT was not responsive. OP should have gone to her Charge Nurse or put the pt on 02 until help arrived re: the CPAP or ???

This is a newer nurse who feared because the pt was desatting and the RT was unhelpful.

I hope she can find a way to deal with this RT, who probably has a miserable life and brings her woes to work with her and should have been fired long ago.

If somebody wants an incident report, they will tell the nurse to write one. I'd include the RT's behaviors in it.

[Rose_Queen, BSN, MSN, RN]

She says she asked for help, but the RT was not responsive. OP should have gone to her Charge Nurse or put the pt on 02 until help arrived re: the CPAP or ???

This is a newer nurse who feared because the pt was desatting and the RT was unhelpful.

I hope she can find a way to deal with this RT, who probably has a miserable life and brings her woes to work with her and should have been fired long ago.

If somebody wants an incident report, they will tell the nurse to write one. I'd include the RT's behaviors in it.

From the OP: I saw the patient was de-satting to 87 with it on, so I decided to fiddle with the machine to see if I could add some oxygen with the mask, and ended up turning it off. I was not familiar with the home device CPAPs, so I immediately tried to call the RT to help me turn it back on.

She did not ask for help until after she fiddled with the machine and accidentally turned it off. It wasn't an unresponsive RT issue to begin- it was OP not asking for help until after she made the situation worse.