Help Please!!!

MAISY, RN-ER, BSN, RN · Dec 12, 2007

Patient comes to ER in respiratory distress(F, 88, AA)-walked in, ends up intubated and on vent.

When I receive report next day, patient is vented, in CHF, pneumonia and possibly septic-heading to ICU when a bed opens.

Family at bedside in AM-broach DNR discussion. Family told by ICU resident(new) she'll be okay-NO DNR on file. Meanwhile, losing lines-can't get any blood for tests from patient. Request central line.

Several hours later....(what took so long?)

ICU attendings(2) come with resident-after several attempts and kits (2 hours)to insert in subclavian, finally they listen to me and place in femoral. My disapproval apparent, very pissed I allowed it to go on as long as it did! Everyone disappears.

Go into room to clean disaster and patient after multiple insertion attempts-all physicians take off. Patient pale-heart rate dropping,goes into junctional rhythm....CODE. Remember no DNR.

What happened? Pneumo of course...what a surprise after she was used as a practice dummy. Given meds, shocked, chest tube, cpr, cracked ribs...

new phone call to family. Patient heart in a varied rhthym-pupils fixed and dilated. "Nobody's home" Family give consent over the phone, on way for DNR signature. Now after "saving" her, I get to give morphine bolus, morphine drip, remove vent and tube, and care for her until last breaths.

My issues....

Allowing resident to continue attempting access...I should've made a stink regardless of her two attendings on site-they should've known better.

Allowing resident to give the family hope for recovery, instead of making sure DNR paperwork was initiated and signed.

Having to code a patient due to not having DNR paperwork-a frail person who we injured "to save" for a poor outcome anyway. Always a dilemma for me. *will have dnr on my chest!

Removing that vent, and giving that morphine bolus to ease discomfort and air hunger. The drip did not go for very long before expiration. This was the right thing, but waited a very long time. My patient suffered and didn't need to.

I am not sure if this story was helpful for your paper. If you need more specifics please let me know. If I had my way, I'd always let people know all of the facts, and encourage them to take living wills and dnr very seriously. There is nothing worse than being the nurse at the end. Even though I'd feel bad if any patient died, I feel worse when it happens like this story.

Maisy;)

jpswife · Dec 13, 2007

Thanks for such a fast response, Maisy! I appreciate it! And I welcome anyone else to add. This will help me a lot!

Weeping Willow · Dec 13, 2007

Should we concern ourselves about the comfort of a person receiving the death penalty? That is, when someone is getting a lethal injection and the meds used to kill cause paralysis of resp muscles, therefore no breathing, and the prisoner can't speak and beg for help, should we care? Should we kill prisoners more humanely?

Weeping Willow · Dec 13, 2007

In the case Maisy cited above, I want to say that it just isn't possible to prevent all pain for all patients. Life is filled with pain. Not her fault.

Weeping Willow · Dec 13, 2007

Patient comes to ER in respiratory distress(F, 88, AA)-walked in, ends up intubated and on vent.
When I receive report next day, patient is vented, in CHF, pneumonia and possibly septic-heading to ICU when a bed opens.
Family at bedside in AM-broach DNR discussion. Family told by ICU resident(new) she'll be okay-NO DNR on file. Meanwhile, losing lines-can't get any blood for tests from patient. Request central line.
Several hours later....(what took so long?)
ICU attendings(2) come with resident-after several attempts and kits (2 hours)to insert in subclavian, finally they listen to me and place in femoral. My disapproval apparent, very pissed I allowed it to go on as long as it did! Everyone disappears.
Go into room to clean disaster and patient after multiple insertion attempts-all physicians take off. Patient pale-heart rate dropping,goes into junctional rhythm....CODE. Remember no DNR.
What happened? Pneumo of course...what a surprise after she was used as a practice dummy. Given meds, shocked, chest tube, cpr, cracked ribs...
new phone call to family. Patient heart in a varied rhthym-pupils fixed and dilated. "Nobody's home" Family give consent over the phone, on way for DNR signature. Now after "saving" her, I get to give morphine bolus, morphine drip, remove vent and tube, and care for her until last breaths.
My issues....
Allowing resident to continue attempting access...I should've made a stink regardless of her two attendings on site-they should've known better.
Allowing resident to give the family hope for recovery, instead of making sure DNR paperwork was initiated and signed.
Having to code a patient due to not having DNR paperwork-a frail person who we injured "to save" for a poor outcome anyway. Always a dilemma for me. *will have dnr on my chest!
Removing that vent, and giving that morphine bolus to ease discomfort and air hunger. The drip did not go for very long before expiration. This was the right thing, but waited a very long time. My patient suffered and didn't need to.
I am not sure if this story was helpful for your paper. If you need more specifics please let me know. If I had my way, I'd always let people know all of the facts, and encourage them to take living wills and dnr very seriously. There is nothing worse than being the nurse at the end. Even though I'd feel bad if any patient died, I feel worse when it happens like this story.
Maisy;)

2 hours' of sticking her? They caused a pneumothorax? Sounds like malpractice to me, Maisy, although I don't know how you could have prevented their torture, short of throwing yourself between her and them. Unless you're good with magic words that would have made students less student-like, teachers less teacher-like. Sadly, sadly, this is how they learn.

Weeping Willow · Dec 13, 2007

When patient signs consent for a particular surgeon to operate, should that surgeon turn the case over to the Resident? I know the consent specifies that the surgeon can bring in assistants as needed but I doubt it says he can allow said other parties to do the whole case while he supervises. That is not, IMHO, assisting, it is teaching.

jpswife · Dec 13, 2007

Oh, wow, thanks!!! Willow, that is great!

MAISY, RN-ER, BSN, RN · Dec 13, 2007

Interesting thought Willow, I believe consent covers surgery but does not specify who will be doing it. I will check tomorrow to be sure on our sheets.

I do believe I could have prevented the marathon that went on with that central line insertion. As I handed in fresh kits, they kept closing the curtain....both attendings were cursing and sweating when the last kit was requested. At that point, I stated I didn't understand why they were struggling when a femoral line would take two minutes. Then and only then did they pop that line in.

Since that time, I had another occasion with the same attending but different resident and another central line. I didn't fool around. I advised the patient it probably would be faster and have less risk as a femoral triple lumen. Of course, the resident was unhappy...wanted to try a svc. NOT AGAIN! Not my patient! There is no good reason to risk a pneumo, this is especially true of slightly built people.

While I believe in learning, I also believe if the attending is unable to do something due to a patient's physiology....they should be smart enough to try something different or admit they can't do it, and try an alternative. That's how residents truly learn and become safer doctors.

As far as the death penalty, I remember watching a move when I was a kid called "I want to live!" it made a huge impression on me. IMHO I do believe in the death penalty, and think that convicted killers who are without a doubt killers should be executed, however, I don't believe they should suffer....we must maintain our humanity, even when they chose not to. They should be unconscious when executed.

Maisy;)

suespets · Dec 13, 2007

hey maisey ,i thought i was the only one to remember that movie(susan hayward) don't remember much about it, but i remember it really impressed me. i keep meaning to see if i could get it on dvd. whattaya think?