Had a rough shift...need some input please!

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Specializes in Emergency.

Hey all,

I haven't started a new thread in a while, but had a tough one last shift.

Got in at 3pm, got report. Great, only 5 pts to start, 4 who were doing fine, and one new admit who had just arrived to the floor (all new admit stuff done, just need to go say hello, assess and monitor). This new pt came from the ED, had been there most of the day. Hx: Hypothyroid, back surgery, foot surgery, had SVT 5 years ago and was cardioverted. Presented for SVT, cardioverted in ED (under sedation). In ED got lots (don't remember how much) of morphins and ativan and some cardio meds. Pt stable, admitted to our floor on tele. HR at start of shift 78, SR. VS good. Pt is a walkie-talkie. Young 41yo F. Husband at bedside. Go in, say Hi, do assessment. Pt appears relaxed, and normal. Have meds and scheduled cardiac enzymes to draw. first two sets WNL. Scheduled for 2DE with bubble for next day. Pt eats dinner, still OK, meds given, still fine. Not 10 minutes later, called to room for pt. Tele calls at same time...HR 180-190 sustained, pt hyperventilating, tells me she has CP and pressure, convinced she is dying. Call ClinII to room (I'm new grad...need help!). Ask for NA to get VS and EKG. Try to talk to pt who is so far into panic that I can get no response other than "Somebody help me!" Unable to get EKG or VS since pt is so tense and shaking. We look at orders...NO IV meds ordered for anxiety or pain, etc. Page MD on call TWICE with no response. Meanwhile, husband and sister (who just showed up) are yelling at us to DO SOMETHING! OK, so I get right up close to her and try to talk her down (Seen this before (my mom has a panic disorder)). No help. We start SL nitro in the hopes that it will ease the chest pain/pressure. Gave 2 doses, but had to hold third as BP was 99/80. Finally get MD on phone who gives orders for IV Digoxin and Ativan (2mg IV), call cardiology, and transfer to PCU where he will see pt. WHAT!!! We really could use you at the bedside now doc! Could you please grace us with your presence? It will take us a while to get her to PCU. Call cardio, they call back and give us prn lopressor orders and amiodarone bolus/drip orders AND take her to ICU. Ok great, can do, but she is still in a severe state of panic...can we do more sedatives??? No orders for sedation received. OK, pts bp now 228/110 and pulse at 187. Pt is diaphoretic, hyperventilating, and crying for help. Finally first MD paged shows up, and asks for a paper bag. Pardon my french but ***!!!!???? I realize that in mild or moderate panic, this can help, but we are WAY beyond that! Ok get orders for 10mg valium IV. Give it. Pt still panicky. MD talks to family who we have finally gotten out of the room. Comes in. Pt says that she is going to die, and is scared and crying and cannot stop hyperventillating. Get orders for 10 more mg of valium. Ask my TL to get itafter checking vitals to make sure she is ok for additional dose. She is concerned about giving so much valium, but at this point, pt is stillso panicked I don't think it's an issue. After all they give pts way more than this at times. After a total of 20mg valium iv and fluids, and bolus of amio, pt finally is calm and rational again. She insists that she is not having a panic attack b/c the cardiologist in the ed cardioverted her. OK, whatever you want to believe os OK with me, I know that b/c she panicked it made the situation much harder to deal with. Started amio drip, and transferred her to ICU for close observation.

Now, I am not unsympathetic to panic attacks having had a mom who had them and having had a couple myself over the years, but this was a tough one to handle for a newbie nurse. In spite of her high b/p's and pulse, I knew she was probably not going to die on us, and what she really needed was heavy sedation and possibly some psych meds in the future to prevent serious panic attacks from occuring. Her family swore she had never had any issues like this before. I spent 3 1/2 hours in the room trying to talk her down and felt like I had been there for 24 hours. I needed valium after that (just kidding!). Are there other things I could have done? She was in such a state that she would not listen to me whan I tried to help her breathe, etc. I think the family being there made it worse, but we couldn't get them out of the room. Any advice in how to handle this in the future? I just kept trying to reassure her that she was not dying and that I would stay with her and make sure she would be OK. Could I have done more?

Thanks,

Amy

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Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.

Was the pt getting O2?

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Specializes in ER.

She had a life threatening heart rhythm and thought she might die so she was frightened, as we all would be. Possibly as a new grad you were a bit anxious too, and that may have added to her panic. Her Family definitely did. Without orders clearly you needed someone at the desk getting them, and someone at the bedside ready to cardiovert if she showed the slightest sign of being unstable. You probably put on a non rebreather for 100% O2, and pacer pads to cardiovert, and as you do all that in a calm voice you tell her that her heart is racing, and it's natural to be scared, her body is going to start pumping out adrenaline, but she needs to help you by being as relaxed as possible, and you are getting meds to help her with that.

The doc not giving decent orders after the first phone call would tempt me to call a code, or rapid response, whatever you have that will come to the bedside quickly and stabilize her immediately. Failing that, with the first low BP you can call her unstable and cardiovert. But I can't imagine any new grad that could or should make that kind of decision.

Please understand that she didn't need psych meds or valium (though it probably didn't hurt her). She needed a stable heart rhythm, and perfusion to her brain, and surroundings that wuld make her confident that everything was under control. Her family needed a firm hand- "you are welcome to stay but only if you can STAY CALM and help her relax, otherwise you need to step outside." No screaming, no freaking out, or they need to leave to get control.

If you have orders for nitro, and a life threatening rhythm, don't wait on vitals or an EKG to give it. And if the doc doesn't respond to a 911 page after about thirty seconds go into ACLS protocols or call a code. Check your policies, they should allow ACLS certified RN's to give meds according to protocols in an emergency, while someone else contacts the doc.

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That situation meets the criteria for a rapid response team call per my facilities criteria. RT and an experienced ICU nurse answer the call, who then call an ICU fellow if the situation warrants it.

No new grad needs to be in that situation. The pt needed to be cardioverted.

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Specializes in Telemetry.

Wow, sounds like a scary situation for you but it also sounds like you handled it very well.

In my opinion, this patient should have been started on a beta blocker and an antianxiety med before leaving the ER. Enzymes, thyroid, echo, and stress test will rule out any physical/physiological causes for the panic attacks. Which came first, the chicken or the egg? Is it primarily a panic attack increasing the HR or is there some underlying abnormality that is causing the panic attack that is thereby causing the HR to go up? I had a pt once that was discharged, dressed and ready to go home when he suffered a panic attack with feelings of doom and increased HR. EKG showed he was infarcting right then and there!! I've also had pts that the cause was purely psychological.

My advice... in situations where you are unsure (and yes you will always have these situations no matter how many years of experience you have), always get help. Get coworkers, charge nurse, supervisor, doctor, rapid response team, code team, etc etc.

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Specializes in Emergency.

Hey all,

Thanks for your replies! As soon as I went into the pts room, I knew it was beyond my limited knowledge. Luckily we have phones that we carry with us and the ClinII number is always the same. As soon as I walked in and saw what was happening, I called her and she was right there to help me through it. In the state she was in it was hard to tell which came first the SVT or the panic. She was in such a severe state of panic that no matter what I did, nothing helped. I tried so hard to get her to breathe with me to calm herself, but to no avail. I know I am a new nurse, but having been raised by a mom who has a diagnosed panic disorder, I knew it was no joke for her. I just sat down on the bed and held her hand and told her she was going to be OK. Yes she had some high BPs and heart rates, but I felt very confident that she was not in any danger, and that her panic over her high heart rate was just adding to her problem. Especially after two doses of sl nitro. My TL and two other RNs got me through this, but I was more worried for the pt since I know firsthand how scary chest pain can be. It may not have been orthodox, but I sat right down on the bed with her, held her hand and just tried to get her to focus on my voice and that I was not going to let anything bad happen to her if I could help it ( I know we are not supposed to say that but it was what she needed to hear). I refused to leave her even when my TL wanted me to pull the meds that were ordered over the phone, but I really couldnt leave since she was so irrational at this point. I requested the other nurses to pull the meds for me and bring them to the room so that I could not leave her. I felt like her only link to sanity so no way was I leaving the room.After the MD filnally got there, and 20mg of valium and amiodarone bolus she finally began to calm down. FYI, We had called our MRT (Medical Response Team a while ago and they were there, but the attitude was "Its a panic attack, what are we supposed to do?" Hello??? I'm sorry, but isn't panic disorder a legitimate disease? Not to vent, but I consider any time the pt feels scared and convinced they are dying to be a medical emergency and not necessarily just another person in need of a psych eval. Is it any less scary to that pt who has rarely had a problem than to the pt who has been given two months to survive no matter their history? Why do we as nurse and the drs go to they're just a psych pt, drug seeking, addict, and ignore the valid panic a pt can experience when they never had a significant problem before?

This particular pt is still in ICU. Tell me there isn't a real problem there.

Amy

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Specializes in Cardiac Telemetry/PCU, SNF.

You did a great job with the tools you had...those tools were a little lacking though (no thanks to the docs). Luckily in my facility we have both a rapid response team and a code team. You call for it and they show up quick, get the situation under control. Sounds like that wasn't available to you so saying "call RRT" is kind of a moot point. First thing I would have done though was pop O2 on her and maybe even start pursed lip breathing. Grabbed a 12-Lead and set of VS, just to make sure nothing besides the SVT was going on...then called for RRT.

Take it as a learning situation as well. Learn what to ask the docs for in a situation like this and don't sit there waiting for orders, go "Dr. X, I need Ativian, and Amio for this..." it's hard, but seeing situations like this will teach you to respond in a pro-active rather than reactive manner.

Cheers,

Tom

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Specializes in Travel Nursing, ICU, tele, etc.

I would have called a code. Nobody would EVER have faulted you for calling a code for a pt with a pulse over 180. To hold her hand for 3 1/2 hours is totally insufficient. You did NOT get the back-up and support you needed in that situation. It truly irritates me that you had to put up with those bullcrap orders! Are you kidding me?? That much Valium? Of course the patient was panicking, she felt like she was dying because she was on her way. A heart can't pump like that for long. I'm surprised she lasted as long as she did. You were put in a VERY unfair situation. I would write up the Cardiologist and then find out why there is such an aversion to Codes in your institution. Never put your patients through that kind of ordeal again, I don't care who is telling you it is OK.

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Specializes in Cardiothoracic Transplant Telemetry.

As someone who has experienced SVT with rates of 180, I can tell you that it is truly frightening, and that you do not need a underlying panic disorder to freak out and think that you are dying.

This was a young patient whose heart is racing and who has chest pain. What she needed was meds to bring the rate down. Adenosine or Diltiazem would have done the trick, and once you had orders to take her to the PCU or ICU she should have been rolling down the hall! No way should this patient have been at that rate for four hours.

None of this was your fault, and I am glad that you did not leave the patient, but the priority should have been treating the rate and rhythm, not the anxiety. Get the rate down, and the patient will feel calmer.

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Specializes in Emergency.

Hey all,

Thanks again for your replies. We DID call a MRT on her, and we did start her on O2 immediately, but it was a very frustrating situation to deal with.

FYI, She came back to our unit two days later from ICU, and guess what? Turns out she had been treated with I131 in the past for hyperthyroid. Somehow, her thyroid started working again, and she was taking thyroid supplements on top of it, and her regular doc missed it. Her panic attacks were a result of the overabundance of thyroid hormone in her system. I got to care for her when she returned to us, and it was great to talk to her and see that she was doing well. She was very happy to see me and thanked me for staying with her through that really bad panic attack. We had orders for her for IV Ativan q6, and she did have a minor panic attack on my shift, but I was able to get orders for more frequent IV Ativan if needed, and she was fine after a few minutes of me sitting with her and giving her meds. I felt so bad for her because she was expressing how embarrassed she was, and that she felt like a burden to us, but I was able to reassure her that while her feelings were normal, it wasn't her fault and it wasn't "mental". I related to her my experience with my mother (severe panic attacks), and myself (have had a few in my life), and how terrifying they were to me, but that people who have not experienced a panic attack have a hard time understanding what it's like. She was a really great patient, and I was glad to have been able to care for her and see her get better. She got discharged yesterday, and I hope she continues to do well.

What was really frustrating for me the first time was that I knew that she really needed a Dr. to show up and reassure her she was going to be OK and give the right orders for the situation, and that took a long time to happen. When we call for the Medical Response Team, there is not usually an MD unless we have to call a code, and the general attitude when they showed up was not very helpful in the situation, because they felt it was a psych case, not medical. I really felt like I did nothing to help, but this pt told me when I took care of her later that the fact that I refused to leave the room, and even sat right down on the bed with her and held her hand and hugged her made all the difference in the world at that moment. I would still like to know if there is a good way to get a pt in severe panic mode to focus and listen to your instructions...

Amy

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Specializes in Cardiology.

it appear to me that you are looking at a panic attack as being the culprit here. like others have said, she was having a tachy arrhythmia and the panic that ensued was a reaction to that situation. read up on the thyroid and arrhythmias. learn from this situation:

http://www.mayoclinic.com/health/hyperthyroidism/ds00344/dsection=2

http://www.mayoclinic.com/health/hyperthyroidism/ds00344/dsection=6

http://jcem.endojournals.org/cgi/content/full/87/3/968

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Specializes in IM/Critical Care/Cardiology.

Hi Amy,

Aside from her obvious need for treatment I just wanted to tell to you your dedication for compassionate nursing is very impressive. Good job, and I hope you never have to deal with a situation like that for the length of time you did again. How were you afterwards? Spent I'm sure.

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