Input on crazy situation...

Published

Have to get some feedback about the crazy situation I was dragged into tonight. I'll give you the background and I would love to hear what you guys think (BTW, I am a new nurse, I graduated in May and work in a smaller L&D department in a medium size hospital. We don't do real high risk or under 34 weeks when we can help it). We had a patient come in with complaints of ctx, not feeling well, she was 33 weeks with little prenatal care. She is a Type 1 diabetic poorly controlled. Patient was put on monitor and has fetal heart tones in the 60s that won't come up for a few minutes. A scalp lead was placed and she was given Terbutaline. Cervix is thick and closed. Blood glucose was then found to be 658! At this point we have 2 OBs present (both right out of school) and 3 family practice residents (who seemed to know more than the OBs about DKA, diabetics, etc.). Now fetal heart tones are back up but she is having recurrent late decels with decreased variability. The OB obviously does not know what to do, is wasting time, and is not listening to the advice of the residents who deal with DKA and are suggesting an insulin pump to stabilize patient and then a c-section. Other OB finally starts making decisions and orders an insulin pump and fluid with 40 of potassium. Thats when I left (THANK GOD I don't work night

shift!!!!!!!!!!). So, I will let you know the outcome when I find out, but what do you

think of this situation? Input? Thoughts? The resident who is very good in my opinion

was distraught, kept shaking his head and said the OB wasn't listening. At one point she

was discussing some plan of action and all three residents said "no, that would kill her,

she would have severe cerebral edema." And I am thinking to myself 'what the h is

going on?' This patient is obviously beyond our scope of practice. And I feel like I

don't remember hardly anything about DKA, insulin drips, etc! Scarey!

Up Vote Up Vote ×
Specializes in NICU, High-Risk L&D, IBCLC.
A scalp lead was placed and she was given Terbutaline. Cervix is thick and closed.

Am I missing something? If you are talking about a fetal scalp electrode, I'm not really sure how you can place it when the cervix is thick and closed......

Up Vote Up Vote ×
Specializes in ER.

Fix the mom first, and then see how the baby is- everytime.

They don't know how to treat DKA...sheesh.

Up Vote Up Vote ×
Specializes in med-surg, OB/GYN, pediatrics, geriatrics.

Crazy Situation:

Yes, this seems to qualify as one! You've called it correctly. As a nurse, your responsibility is for your patient(s). It appears that no one is running the show. Make sure that your shift chrge nurse on the unit is made aware of the situation revolving around your patient and her care. She will take over any nursing decisions/discussion surrounding the situation, including notification of *her* supervisor. You concentrate on providing the best nursing care you can for the mom and baby. This also includes charting accurately and as often as the situation warrants; there will be a lot of "who did what and when..." way after this woman actually delivers her baby. So you are responsible for recording vital signs for each, mom and baby in chronological order No opinions are needed. Just the facts, ma'am. Do *your* job. The players in this unfortunate melodrama are peripheral to how you do your job. Go and hang out with mom, provide support if she is uncomfortable (per your L&D policy such as warm packs to her lower back, etc. Check the vital signs as often as you feel it is needed to give the MD actual input on how mom's doing

(while he twiddles his thumbs and decides what to do). Be sure to address your charting to include the baby's vitals as often as you think it's needed. If your protocol says every 15 minutes, take the FHR at least that often, describing any patterns, variations, etc. It sounds like the baby is on a monitor; be sure to initial the strip as per protocolas well as mom's or baby's position; just include and document everything pertinent. Ask your charge nurse if you do not know where to put addendum charting. This charting is for your protection as well as the mom's, e.g., you, as the assigned nurse, did everything properly and recorded it as well. Also, it may end up being the only legible and continual notes on the patient!

You'll feel anxious fifty ways over when/if you get caught up in one of these scenarios. Remember to think of what and who your concern is.

Always utilize your charge nurse or one who has years of experience to talk it out for later cases. And don't let these doctors rattle you. If they want a report on the patient, give them the chart pleasantly; try not to discuss it too much or give an opinion. That will come in time.

You sound able and smart-use your skills wisely:-) Good luck and compassion will serve you well.

Franny

10+ L&D/Level 4 ICU.

Up Vote Up Vote ×

Beccazrn- Your right, she didn't have an internal-- I don't know why I was thinking this... Maybe because they called me in and I wasn't quite awake yet.

Franny- Excellent advice! Problem is that there was no charge nurse! We only have a charge nurse (the manager) during the day. Isn't that awful. In fact, the nurse there with the most experience in L&D had been there a year (I've only been a nurse for 4 months). And both of the OBs had just finished their schooling within this past year! Its just a nightmare!

I do agree with fixing the mom first, but it was like no one knew what they were doing. I understand what my "job" is as the nurse, but I'm curious to know what the docs should have been doing? Just because I like to understand how things work, not just carry out orders.

Up Vote Up Vote ×
Specializes in L&D.

Where I work, if FHT's were down that low (depending on how long), she probably would have been a stat c/s. She would have been started ASAP on an insulin drip as well. There would have been no fussing and messing around, hemming and hawing about how to treat her. Then again, I do work with an awesome group of docs.

Up Vote Up Vote ×
Specializes in L&D.
Beccazrn- Your right, she didn't have an internal-- I don't know why I was thinking this... Maybe because they called me in and I wasn't quite awake yet.

Franny- Excellent advice! Problem is that there was no charge nurse! We only have a charge nurse (the manager) during the day. Isn't that awful. In fact, the nurse there with the most experience in L&D had been there a year (I've only been a nurse for 4 months). And both of the OBs had just finished their schooling within this past year! Its just a nightmare!

I do agree with fixing the mom first, but it was like no one knew what they were doing. I understand what my "job" is as the nurse, but I'm curious to know what the docs should have been doing? Just because I like to understand how things work, not just carry out orders.

And the's OB's were Attendings? Ugh! So... how did everything turn out?

Up Vote Up Vote ×

I haven't heard yet because it was the end of my shift, but I will find out tomorrow when I go in to work and I will update the thread. I am definitely going to bring this up at a round-table type discussion thing coming up because there were just soooooooo many miscommunications and misunderstandings.

Up Vote Up Vote ×

That's a pretty scary situation, especially because the doctor could easily look up how to manage DKA on the internet. This is the 21st century.

The patient may not even need a c/s; the late decels could well be from the profound hypovolemia that is a hallmark of DKA.

Up Vote Up Vote ×
Specializes in Maternal - Child Health.

A 33-weeker IDM with mom's diabetes very poorly controlled is likely to be born with significant respiratory distress. Given that this is a low-risk hospital, I hope that the hospital to which the baby would likely be transferred for NICU care was consulted prior to a hurried C-section!

Up Vote Up Vote ×
Specializes in L&D.

Initiate your chain of command immediatly in this type of situation!!! If you didn't have a charge nurse on duty (shudder) call the House Superviser &/or the L&D head nurse (you do have her home number, right?). This is a patient who you would want to transfer out as soon as possible. You could suggest the MD (or residents) call the Perinatologist on call at your usual transport hospital to ask his advice on management/stabilization before transport.

It's a good idea to bring this up at your round table discussion. Everyone can learn from discussing this kind of situation: "This is what happened, this is what we did, this is what I wish we had done, other suggestions as to how this could have been handled differently?"

Up Vote Up Vote ×

Nurse Nora- Excellent advice. I did just have a meeting with the head of nursing and mentioned the situation (we don't have ANY interdisciplinary round tables-- my suggestion was to start one). Anyway the place is a nightmare.

The patient finally got an insulin drip and the correct fluid resus. and was then sent home the next day! I can't believe it, but I guess the baby looked better after the treatment. I'm sure she won't be coming back to our hospital (probably a good idea on her part).

Up Vote Up Vote ×
+ Join the Discussion