I'm not sure how I should feel about this???

Nurses General Nursing

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I'm so tired after doing 14 hours today...but, I can't get this off my mind and this is the perfect place to get some feedback...so I'll try to be as brief as possible. This was my first day back at work after being off for two days; however, I haven't been on my floor for over a week because over the weekend I was floated to another floor. So, first day back at work, on my floor, I get report on a pt who looked fine a week ago...chronic trach, weaning off the vent, been off for many weeks, on a trach collar, some confusion, always on the callbell, etc. I get report...taped from the off-going shift that she has "4+ BLE, very anxious overnight, given Haldol, Ativan and Benadryl, RT increased her FiO2 to 100%...but, I don't know why, the order is only for 70%, I think she has an EKG ordered but can't find the order...pt in same condition yesterday, but MD wrote in progress note that pt is stable." I first ask RT about her ?EKG...he says "She had an ECHO last night and it is showing Right atrial/vent enlargement with pulm. htn." Seems to correlate with the edema...feel that it is significant. Then the CNA tells me that she is cyanotic. I go in to assess...she is cyanotic, worst edema I have ever seen, O2 sats are in 70s to 80s. RT goes back in...we monitor her for awhile. MD arrives...ECHO on chart, he SEES pt himself, writes orders and leaves. I check the chart, the only new orders were for coumadin and a PRN lotion for her back and that she is essentially stable. I thought WHAT??? Did you even look at this pt??? I asked him if he saw her ECHO results? Did he want to treat that?!? He says "no, this is long standing...meds would only help long term...she has been this way for awhile." I know he saw her so, I thought "OK...he knows her, I haven't seen her for a week...OK?!? Pt starts asking for a drink. She can only have PO if she is capped...she is cyanotic without the cap...I'll kill her if I cap her. I call RT, they tell me to cap her for brief periods, let her sip, then remove cap. I held her off for a few hours...but kept thinking how is she going get nutrition if I withhold PO intake...I didn't know what to do...she kept asking...finally I gave in and sent the CNA for coffee. At the same time, RT comes to reassess...can't get an O2 sat at all, they call for me and my sup...who flips out because pt is in the condition she is...tells me to notify the MD...I explain I have already discussed this with him...he is completely aware of current situation...I explain that she has been this way for a few days...she says "I don't think so" but then admits she hasn't listened to her taped report from the offgoing shift (This is at 2:30 in the afternoon...we start at 7:00am!!! How does a sup do her job if she hasn't listened to her report???) she insists that I need to be "proactive" especially because pt is a full code and if we aren't treating the Right heart enlargement what is the sense of putting her through a code. So, on that, I call. The DR. flips out...he thinks I questioning his judgement, tells me that if I am concerned about her NEW change of condition I should call the House MD...I explain that she has been cyanotic since this AM...this is not a NEW change of condition. He tells me that he is "to stop focusing on the ECHO results" and that he is "seeing pts and I have no right to call him..." and then tells me that he is "ending this conversation" and refuses to discuss her code status. Well, her ABGs were in the toilet, she ended up having her trach changed, going back on the vent...and sent to the ICU per the covering MD's orders. I then sat down with my sup...and we listened to report together at 4:00pm...she still had yet to listen to report herself...we discover that this pt had in fact been this way since Monday...nothing has been done, as MD has continued to write she is stable...but no one has had the sense to question it. So, this mess fell into my lap today and I was so PO'd!!! Everyone said to chart, chart, chart everything. So, I did. Now, I'm worried that all my charting is really going to rub someone the wrong...especially the attending MD. I feel like what I did was right but, I feel in so many ways this situation was so wrong. I don't know what to do next...I've gone to the sup...should I go to the DON? I'm exhausted but, I just can't sleep because of this. Thank you to anyone who has gotten this far in reading this...and even more thank yous to anyone who has any words of wisdom to impart

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Definitely write this up, whether you submit it or not. If you don't submit it, keep it for your own records and don't tell anyone you have it.

I think you should submit it. This is a scary situation.....if he thought this pt was stable, what does he consider UNstable???? So many people messed up on this woman: her doc for not seeing what he should have seen, and the nurses for not jumping up and down on his head until something was done. Since he is not writing appropriate orders, the matter should have been taken to the chief of staff by the supe.

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Specializes in ICU, Agency, Travel, Pediatric Home Care, LTAC, Su.

I would definately write it up and follow up on it. Take it as high up on the chain of command as you have to. It will PO a lot of people, but something needs to be done. This is a dangerous situation and it needs to be addressed. I agree to keep a copy of everything yourself, but mention it to NO ONE. If able, I would even be tempted to keep a copy of your nursing notes in case someone tries to change them.

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I am currently in nursing school. Your words brought tears to my eyes. It is so touching that we care the way we do. You are willing to jepordize your livelyhood for a stranger (pt). Only the best of the best would do this. Not even the MD. Who else is there to fight for her? God Bless you and thank you for being one of "Us".

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Chart your hiney off and do an incident report. You may save another patient from this kind of non treatment.

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Specializes in ICU, Research, Corrections.

Man alive, sister (or brother, as the case may be):angryfire You should be losing NO SLEEP over this one. The doctor should be. IMO this is almost criminal negligence! I would also be slightly miffed with my coworkers for letting this pt go on like this.

How many signs does the dumb Dr need that this pt needs help? If she wants to lay in bed and die, she can do that at home. She is cyanotic with 4+ pitting edema and the doc thinks that's OK? You just don't put someone on 100% O2 with no plan to fix the problem. Is this a resident at a teaching hospital? I guess I would have at least asked for a cardiology and pulmonary consult. You could have called a rapid response if your hospital has a team.

I agree with the other advice on keeping documentation. Keep everything. Kudos for you for being a patient advocate. Who cares if your charting does not please the doctor? You don't work for him or report to him, you are responsible for the pt.

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Thank you so much to all of you for taking the time to read this...and thank you so much more to all of you who responded, and for some of your encouraging words. I feel so much better this AM after clearing my head and getting some sleep.

What scares me however, about my charting is that everything is computerized where I work, so my charting was done in the computer under the pt's notes and that is where I charted every detail of the incident. If anyone chooses to read the notes about the incident...they can. I'm sure the MD will be looking for notes about the incident this AM, as he apparently called the floor as the pt was being tx'd to the ICU. The secretary, who was very aware of what went on, told me he sounded very surprized and nervous that her condition warranted such drastic measures.

So, I do feel nervous that he is going to be PO'd and wonder how far he will go to cover himself. But, in many ways I just feel so disappointed in myself for knowing that this pt wasn't OK...and that if RT had not come back to reassess when they did, that I would have given in by giving her a drink. I didn't trust myself and my abilities and if RT had not come back in when they did, it really scares me to think about what may have happened. I owe RT a TON of credit on this one.

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Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.
The secretary, who was very aware of what went on, told me he sounded very surprized and nervous that her condition warranted such drastic measures.

So, I do feel nervous that he is going to be PO'd and wonder how far he will go to cover himself.

And this, my dear, is why you fill out an incident report ASAP. Discreetly print out a copy for yourself, and send copies to your manager and the chief medical officer.

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I would definately write it up and follow up on it. Take it as high up on the chain of command as you have to. It will PO a lot of people, but something needs to be done. This is a dangerous situation and it needs to be addressed. I agree to keep a copy of everything yourself, but mention it to NO ONE. If able, I would even be tempted to keep a copy of your nursing notes in case someone tries to change them.

I also agree. Fill out an incident report, make copies of it, and make copies of you nurses notes. Things have a way of "dissapearing", when the "you know what" hits the fan.

Lindarn, RN, BSN, CCRN

Spokane, Washington

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Specializes in L & D; Postpartum.

Defintely lots of charting and incident report. And who cares if the MD gets PO'd. Sounds like the red flag should be waving regarding his care anyway. If he/she tries to get in your face about it, do not have that conversation without someone there as an observer. What you don't want is a he said-she said thing. Good luck and way to advocate for your patient.

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We didn't mean don't tell anyone you documented it, we meant don't tell anyone you kept a copy!! Who cares who reads it, everyone needs to read what happened to fail this pt! The doc is not the only one who should be nervous, what about the other nursing staff who "cared" for her before you came back??

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Specializes in ER, Occupational Health, Cardiology.
But, in many ways I just feel so disappointed in myself for knowing that this pt wasn't OK...and that if RT had not come back to reassess when they did, that I would have given in by giving her a drink. I didn't trust myself and my abilities and if RT had not come back in when they did, it really scares me to think about what may have happened. I owe RT a TON of credit on this one.

It sounds to me as though your training and gut instinct told you from report on that this pt was in trouble and needed far more help than she was getting. It also sounds as though you did all of the things that you should have.

What kind of rep does this MD have? He sounds like some kind of a nut! I've dealt with a few MDs that were total jerks, but they usually backtracked to the pt and reviewed things again out of anger, and hoping to prove me wrong. The one time that didn't work, the MD's pt died. However, the Nursing Sup and I had already moved the pt to ICU. He was admitted for new onset diabetes w/a BS >800! I worked on a Cardiac Telemetry floor as an LPN then. The pt kept deteriorating through the late afternoon and early evening, and I called the MD 5 times. He told me to stop bothering him. The House Sup got an EKG and it showed the man was having an MI. We transferred him to ICU at 8 p.m. and by the time I went off at 2300, he had expired. That was also the night that I learned NOT to tell a pt that I wouldn't let them die, which I had said that night to a very sweet, very frightened gentleman. From then on, I said that I would do everything that I could not to let that happen.:o

I would really be interested to hear how this all plays out.

Congratulations to you, and continue to be an advocate for your pts, no matter how many foundations you have to shake!;)

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