This pt had been on the unit for a few days. Had been on tinza and asa since admission to the unit.
Start of shift, first day with him. He was c/o mild chest pain and bit of sob. A bit diaphoretic too. His SpO2 were fine but I cranked up the O2 a bit anyway. Paged the resident.
Came in within 5 min and assessed the pt. Came out and told me he sounded crackly and that pt pain has subsided. Ordered 1 time dose of IV Lasix. NOTHING else. I was expecting maybe a nitro spray or chest xray or whatever.
I came in next day...found out pt had a full code late in the night shift and passed away. Code team notes stated probably PE attack.
I don't know...been almost a week and been thinking this death could have been avoided.
I always recommend discussing issues with the resident. Often if you tell them what you THINK needs to be done, they are more than willing to do it, plus you get insight why they did (or did not) do a test. I've learned a lot from PGY1s. That being said, don't be afraid to call above them, and be sure to tell them you're going to do exactly that. I'll use the phrase "I guess I'll have to call the next resident, thanks."
They suddenly become very interested in what you might have to say.
Fair warning though, be willing to swallow any pride if you're wrong. It's tough working in the University hospital setting, but overall it will make you a better nurse, and it will make them better doctors. I'll swallow my pride as long as I feel I'm advocating for the patient.
I would leave nursing before I ever worked at a place where my boss, or my boss's boss was a physician.
To each his own, but these docs are the nicest men and women I've ever worked for, and absolutely one of the best jobs I've had. We have NONE of the crap going on that I read about daily here. No horrible ratios, no bullying, lateral violence, forced overtime, etc. Docs are always respectful to the nurses. They usually leave most of the management details to the DON. This situation was rather unique.
This pt had been on the unit for a few days. Had been on tinza and asa since admission to the unit.
Start of shift, first day with him. He was c/o mild chest pain and bit of sob. A bit diaphoretic too. His SpO2 were fine but I cranked up the O2 a bit anyway. Paged the resident.
Came in within 5 min and assessed the pt. Came out and told me he sounded crackly and that pt pain has subsided. Ordered 1 time dose of IV Lasix. NOTHING else. I was expecting maybe a nitro spray or chest xray or whatever.
I came in next day...found out pt had a full code late in the night shift and passed away. Code team notes stated probably PE attack.
I don't know...been almost a week and been thinking this death could have been avoided.
Before continuing to read your post, I first read your assessment and considered what I would have been thinking and what I would have done. I immediately suspected PE so I thought, OK, check for that and r/o MI.
So I read on. I'm a *relatively* new nurse and was dead on. I hope this resident learned from this and goes on to be a wonderful doctor. But, wow. What a mess up.
On the flip side, I've missed the dumbest things myself a few ti.es, so I don't judge too harshly. As long as the provider learns and continues to grow.
Sometimes we have issues with residents that are on rotations that are non-ER residents. Sometimes the new ER residents can be a bit of a headache (such as not putting orders in but expecting fluids to be hung and then telling a tech that fluids need to be running. No ****, patient had legit orthostatics for once which by the way, would be nice if you put the order in for orthostatics so they can bill for it even though I did it on my own). Another example is a teenage patient who passed out and the family medicine resident ordered almost nothing besides bmp, cbc, and drug screen. I kept on asking for more info and had to point out that the orthostatics were once + for once (kid had been working out a lot more due to wrestling and basketball season overlapping).
One non-ER resident was a pain because he didn't ask how to order stuff or if there was more stuff to order. Like one time the attending was like "yep, the orders look fairly complete" to the resident even though half the orders I harassed him to order. The other non-ER resident was okay because he asked questions. He didn't throw in random orders such as throwing an x-ray in as a nursing order and then argue about whether the x-ray was ordered correctly (it won't ever cross over). He did have trouble with legit ICU patients that he probably should have let the attending or NPs see due to how sick they were and he kept on adding orders on so a nurse would have to go back in 3 times because there were new orders within 10 minutes of each other.
Before continuing to read your post, I first read your assessment and considered what I would have been thinking and what I would have done. I immediately suspected PE so I thought, OK, check for that and r/o MI.
So I read on. I'm a *relatively* new nurse and was dead on. I hope this resident learned from this and goes on to be a wonderful doctor. But, wow. What a mess up.
On the flip side, I've missed the dumbest things myself a few ti.es, so I don't judge too harshly. As long as the provider learns and continues to grow.
So take this same patient that had CP and was dyspneic on the floor and the resident hear's crackles in the lungs and gave 40IV lasix and they got better? Seems like problem would be solved and everyone would rejoice.
Now lets say the same patient had CP and was dyspneic. Lasix didn't help and the patient coded and died and the autopsy shows PE. Pretty easy to diagnose huh? Diagnoses are really easy in retrospect. Now how many would have ordered a d-dimer? How many send this patient to CT? Also how many get a d-dimer that is negative and still send this patient to CT? You should all just send this patient to CT; forget the dimer if you really think PE.
I run "rapid response" for one of the hospitals I work at. The D-dimer is the Houdini of medicine. Everyone thinks a negative D-dimer rules out PE; it does not. Again a negative D-dimer DOES NOT rule out PE. Read the research. If someone has been in the hospital >1 night a d-dimer means nothing, other than false hope. In hospitalized patients if you are concerned about PE a CT is the ONLY choice.
If I have a patient that is dyspneic and I find another reason for the dyspnea I stop looking at PE. This will haunt me sooner or later as my CHF exacerbation, Asthma exacerbation, acute bronchitis, pulmonary hypertensive, anxiety hyperventilation, Sleep apnea, viral URI, pneumonia, drug seeker, pneumothorax, cystic fibrosis, pleural effusion, sarcoid, or COPD'er will eventually also have a PE. I can't get CT's on them all. It seems like this resident found another reason (or made it up) to explain the dyspnea and acted on it and it burned them. Seriously though we can't get a CT on every patient with dyspnea or chest pain so we pick our battles. Sometimes we are wrong.
Also as an ER doc you know how many times my ears have been ringing PE or maybe could be, or I cannot say it is not PE? Probably 500 times. How many times have I picked up a PE between 3 years of residency and 2 years of being an attending? 15: 15 freaking times. I have CT'd or d-dimer'd 500 people to pick up 15 PE's. Thats crazy.
So take this same patient that had CP and was dyspneic on the floor and the resident hear's crackles in the lungs and gave 40IV lasix and they got better? Seems like problem would be solved and everyone would rejoice.
Now lets say the same patient had CP and was dyspneic. Lasix didn't help and the patient coded and died and the autopsy shows PE. Pretty easy to diagnose huh? Diagnoses are really easy in retrospect. Now how many would have ordered a d-dimer? How many send this patient to CT? Also how many get a d-dimer that is negative and still send this patient to CT? You should all just send this patient to CT; forget the dimer if you really think PE.
I run "rapid response" for one of the hospitals I work at. The D-dimer is the Houdini of medicine. Everyone thinks a negative D-dimer rules out PE; it does not. Again a negative D-dimer DOES NOT rule out PE. Read the research. If someone has been in the hospital >1 night a d-dimer means nothing, other than false hope. In hospitalized patients if you are concerned about PE a CT is the ONLY choice.
If I have a patient that is dyspneic and I find another reason for the dyspnea I stop looking at PE. This will haunt me sooner or later as my CHF exacerbation, Asthma exacerbation, acute bronchitis, pulmonary hypertensive, anxiety hyperventilation, Sleep apnea, viral URI, pneumonia, drug seeker, pneumothorax, cystic fibrosis, pleural effusion, sarcoid, or COPD'er will eventually also have a PE. I can't get CT's on them all. It seems like this resident found another reason (or made it up) to explain the dyspnea and acted on it and it burned them. Seriously though we can't get a CT on every patient with dyspnea or chest pain so we pick our battles. Sometimes we are wrong.
I'm confused as to why you quoted me in your ramblings.
Anywho, ordering Lasix is fine, but the resident should have ruled out other causes as well. I'm not saying mistakes aren't expected. In fact I made the disclaimer that I have made the dumbest mistakes myself.
Still confused about your rambling on about d-dimers in response to my post.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
S
Now lets say the same patient had CP and was dyspneic. Lasix didn't help and the patient coded and died and the autopsy shows PE. Pretty easy to diagnose huh? Diagnoses are really easy in retrospect. Now how many would have ordered a d-dimer? How many send this patient to CT? .
I have been a full time RRT RN for 5 years now. I know a PE when I see it. Obviously CT is in order to confirm. Our RRT RNS can order a STAT chest CT to R/O PE on our own per protocol. We don't need a provider to agree with us that it may be a PE. If I think it's a PE then I order the chest CT.
D-dimer? What for?
On a typical RRT response call the first the physician will know that I suspect their patient is havinga PE is when the patient is already in CT or just after. Those physicians who are in house will know much sooner and may decide for themselves to CT.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Also as an ER doc you know how many times my ears have been ringing PE or maybe could be, or I cannot say it is not PE? Probably 500 times. How many times have I picked up a PE between 3 years of residency and 2 years of being an attending? 15: 15 freaking times. I have CT'd or d-dimer'd 500 people to pick up 15 PE's. Thats crazy.
I assume these patients just came in off the street? Our RRT team has higher success finding PE, but we are dealing with patients already in the hospital
Also as an ER doc you know how many times my ears have been ringing PE or maybe could be, or I cannot say it is not PE? Probably 500 times. How many times have I picked up a PE between 3 years of residency and 2 years of being an attending? 15: 15 freaking times. I have CT'd or d-dimer'd 500 people to pick up 15 PE's. Thats crazy.
You know the value of d-dimer in ddx of PE is relative low, I'm assuming. So many other things can be a source of elevated d-dimer that on my floor, a d-dimer is rarely even batted an eye at.
In just my (nearly 2 yr) experience alone I've dealt with 3 new-onset PEs and too numerous to count adm dx spontaneous PE. You must have a fairly healthy population to start with.
Recently had a resident ask me how I knew the pt's HR was irregular if the pt wasn't on tele. It was a good thing I was talking to him over the phone - my eyes rolled so hard they popped out and had to be taped back in. (It's a nifty thing you doctors have called a stethoscope.)
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Recently had a resident ask me how I knew the pt's HR was irregular if the pt wasn't on tele. It was a good thing I was talking to him over the phone - my eyes rolled so hard they popped out and had to be taped back in. (It's a nifty thing you doctors have called a stethoscope.)
If don't happen to have your "doctor's stethoscope " handy you can also (and i can hear the resident gasp in horror about now), you know, TOUCH your patient and detect an irregular heart beat by palpating a pulse.
Putting hands on a patient seems to have gone out of style for everyone but nurses, but you can learn a lot.
I'm confused as to why you quoted me in your ramblings.
Anywho, ordering Lasix is fine, but the resident should have ruled out other causes as well. I'm not saying mistakes aren't expected. In fact I made the disclaimer that I have made the dumbest mistakes myself.
Still confused about your rambling on about d-dimers in response to my post.
I quoted you because you said you immediately thought PE and many have posed the idea of a d-dimer. My thoughts are that if you have been in the hospital you should never rule out PE by d-dimer. The research has shown that there is a false negative rate of 7-10% for high probability via wells criteria. In my opinion every hospitalized patient is high risk via Wells. Still for every chest pain starting in or out of hospital we cannot rule out every diagnoses by tests. Occasionally we have to use our brains. For every chest pain I see (3-4/day on my job) I cannot order a CT PE and CT aortic dissection for every single one. Sometimes I have to say that I don't think it is a PE or Dissection. Over the next 20 years I will be wrong. At some point someone will die from a PE or a Dissection and I will have missed it. I refuse to order a CT on every single chest pain that walks in the door to prevent that 1.
missmollie, ADN, BSN, RN
869 Posts
I always recommend discussing issues with the resident. Often if you tell them what you THINK needs to be done, they are more than willing to do it, plus you get insight why they did (or did not) do a test. I've learned a lot from PGY1s. That being said, don't be afraid to call above them, and be sure to tell them you're going to do exactly that. I'll use the phrase "I guess I'll have to call the next resident, thanks."
They suddenly become very interested in what you might have to say.
Fair warning though, be willing to swallow any pride if you're wrong. It's tough working in the University hospital setting, but overall it will make you a better nurse, and it will make them better doctors. I'll swallow my pride as long as I feel I'm advocating for the patient.