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

[Lisky90]

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

[MA Nurse]

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.

It's fine that you charted everything to CYA! Don;t worry about what that Dr. thinks, your license was on the line, and you needed to document it all...it's ok!! Good job!!

[Daytonite, BSN, RN]

As long as you thoroughly documented in your nursing notes all that you did as well as all the calls you made to this patient's doctor and all the calls to your supervisor, the chart will be your proof of your performance. Yes, it was a harrowing experience. You did your job. I know you feel emotionally drained over it. About the only other thing I can see for you to do is to call or send a written memo to the chief of the service of this patient's attending physician and tell him what happened and referencing the patient's medical record number. Your supervisor may have already done this, however. This way the chart will come up for physician peer review, if there isn't a mechanism for it to happen already. This is a situation where the medical staff needs to step in and take care of their own problem. It is not up to the nurses other than to make sure that the doctors in charge of the other doctors know about the situation. Then, you've done all you can do. You happened to run up against a doctor who was incompetent and saved his orifice proving once again that we all work together as a team. It's up to his colleague doctors to be made aware of it and take it from there. Go home. Do something to relax. Tomorrow is another day.