Hitting a wall

[BodhiHeart]

I had a patient on 100% heated high flow that became confused, then repeatedly had intermittent periods of desaturation. The blood gas showed hypoxemia. The patient was proned then several hours a repeat blood gas showed some improvement so the patient was not intubated. The night residents were honest about wanting to avoid intubation, but were in contact with an attending MD. The patient’s pulse oximetry reading continued to intermittently desaturate below 88% throughout the shift. I was drawing blood one time from the patient and another nurse came up to me afterwards and told me the patient was desaturating in the 70s. It could have been from a tourniquet, who knows. Every 15 -30 minutes another nurse would tell me he was desaturating and I felt like many nurses thought I was not watching my patient or informing the MD, but the MDs were aware of the situation. Any advice or insights for this type of situation? I left feeling defeated.

[amoLucia]

My guess - people were just trying to be helpful and to know that you were on top of everything.

Give them the benefit of the doubt, afterall, they were interested in the pt's welfare, just as you.

You could just appreciatively nod & acknowledge their intentions by saying, "thank you for watching out for my pt and me. But I just spoke with Dr X and he knows about the fluctuations and what we're doing. TY".

[PaSSiNGaS, MSN]

Tell them you are handling the situation and to focus on their own patients.

[frozenmedic]

Not sure if this occurred here, but consider lowering your alarm parameters to whatever you and the physician feel is appropriate given the patient's clinical context. Alarm fatigue is real, and low numbers without beeps will likely attract less attention from your coworkers.

[Susie2310]

Why didn't the residents want to intubate?

[frozenmedic]

19 hours ago, Susie2310 said:

Why didn't the residents want to intubate?

I'm assuming this was a COVID patient, based on the significant reluctance to intubate in the setting of profound hypoxia. As we have learned more about this disease, one of the consistent trends is that intubated patients have horrible outcomes, somewhere between 20%-60% of patients actually survive to extubation. Patients who are able to be limped through the worst part of their disease and are never intubated have much better survival. This includes techniques like "awake proning" for patients on BiPAP or HFNC.

Obviously I didn't care for the actual patient in question, but another trend with COVID patients is profound hypoxia out of proportion to the patient's overall appearance....ie these patients are hypoxic with sats sometimes as low as the 40s% (yes really!) but are alert, have only mild to moderate distress, and minimal symptoms of end organ damage. In these cases the temptation is to intubate to make the numbers look better, but again, this drastically increases the patient's mortality.

[Chazzie_Made_It, ADN]

On 8/7/2020 at 5:06 PM, amoLucia said:

My guess - people were just trying to be helpful and to know that you were on top of everything.

Give them the benefit of the doubt, afterall, they were interested in the pt's welfare, just as you.

You could just appreciatively nod & acknowledge their intentions by saying, "thank you for watching out for my pt and me. But I just spoke with Dr X and he knows about the fluctuations and what we're doing. TY".

This is exactly what I am thinking. I'm often in a patients room and will have the tele tech call me in the room and notify me that the pt is desating. Or I will have another RN come in to tell me. I also do the same. The bottom line is, if I, or another nurse, needs help I want them to know I am there and am aware of the situation and available to help. Likewise, I'm glad to know others are looking out for my pt too. I hate to come out of a room and then have so and so tell me your pts sats are in the 70s and then I have to go back in. This is team work.

[CrunchRN, ADN, RN]

On 8/11/2020 at 2:39 PM, frozenmedic said:

I'm assuming this was a COVID patient, based on the significant reluctance to intubate in the setting of profound hypoxia. As we have learned more about this disease, one of the consistent trends is that intubated patients have horrible outcomes, somewhere between 20%-60% of patients actually survive to extubation. Patients who are able to be limped through the worst part of their disease and are never intubated have much better survival. This includes techniques like "awake proning" for patients on BiPAP or HFNC.

Obviously I didn't care for the actual patient in question, but another trend with COVID patients is profound hypoxia out of proportion to the patient's overall appearance....ie these patients are hypoxic with sats sometimes as low as the 40s% (yes really!) but are alert, have only mild to moderate distress, and minimal symptoms of end organ damage. In these cases the temptation is to intubate to make the numbers look better, but again, this drastically increases the patient's mortality.

Thank you for that up to date info.

[amoLucia]

Ditto for the info.