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Discussion

Feel like I did something wrong

I work on an elderly care medical ward.

My patient was fine in the morning, admitted with AKI and deranged electrolytes.

Then after lunch he projectile vomited and desaturated, needing 2L of o2.

I was very worried he had aspirated, request chest physiotherapist review him and medical team.

Both were not  very concerned, felt he could self clear the secretions, to monitor overnight if worsened then would be for chest xray and antibiotics.

His work of breathing was increased and I was just worried about him. His heart rate was up to 116bpm, I asked the doctor if I should do ECG, she advised recheck in 1 hour.

Patient was also due IV magnesium which was delayed as had just came up from pharmacy and I was preparing to give.

After 1 hour, patient was agitated, desaturated to 88% on 2L o2 and HR was up to 185bpm.

I put patient on 15L/100% o2 and 3 lead heart monitor. Rhythm looked abnormal so I put out peri arrest call.

Peri arrest team treated patient with IV beta blocker, HR came down to 125bpm and rhythm became regular. O2 was weaned back to 2L.

I can't get over feeling I didn't care for the patient properly. I feel I should have just done an ECG instead of relying on doctor to agree with doing one. I also feel I should have chased pharmacy for the magnesium earlier in day or borrowed from another ward, but sometimes pharmacy get frustrated with you continually calling them to chase meds. The patient was stable when I left, HR still high but considered safe  to stay on ward. 

I feel I failed and I felt the crash team blamed me although they didn't say anything.

Our staffing has been bad and I'm worried maybe I was too tired from previous shift To focus properly.

Do you think I caused this deterioration

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    From your account, it looks to me that your actions were appropriate. You alerted providers to changes in condition; you likely have no control about the times pharmacy delivers meds. Reflection is useful about what you might have done differently, but don't use it to beat yourself up.

    Your patient was ill, you assessed and intervened as best you could. A debrief with your crash team would be more helpful than trying to read read minds about blame. You did not cause this deterioration.

    Just out of curiosity, was your patient's magnesium low? And even if you had gotten it sooner, to my recollection, it is infused over an hour, so it may or may not have helped. 

     

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    I think you did all the right things. Unless that magnesium was dangerously low, I don't think this was what caused things to go wrong.

    Any combination of pain, agitation, atrial fib, pre-existing lung problems, fluid overload, and possibly aspiration can create the scenario you describe.

    The fact that the crash team was able to wean down the oxygen and stabilize the patient without too much effort makes me suspect that they didn't blame you at all. In fact, they were probably glad to get called before the patient condition deteriorated further. 

     

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