Intubation tube dislodged, RN blames PCT

[LonghornChic, BSN]

I am shadowing a couple of units as a nursing student this summer, with one of them being the ICU. This was my third and last day in this particular unit. I was shadowing an RN who had just completed her ICU residency but had been in med-surge for 2 years prior.

A little background: morbidly obese (550 lb) patient intubated due to ARDS (was initially admitted for a post op infection). This pt. also had multiple skin integrity issues that were beginning to develop as a result of the current situation and obesity. As is common with many ICU patients, there were multiple lines and tubes attached to him. Drains, suctions, ventilator, monitors, etc.

The nurse asked for assistance in turning the patient to the side. 2 PCT's (patient care techs) and myself (the student) arrived to assist. She decided that we would use the lift to turn him and asked one of the PCT's to position himself at the head of the bed (the side the pt.s face would be facing), me to hold the legs on the same side as the first PCT, and the other PCT to stand opposite to put pillows underneath once the pt turned. The RN would be controlling the lift and would not have a visual of the patient after the lift started. No further instructions were given.

The patient was hooked up to the lift and everyone ready. The RN adjusted some of the tubes so that they wouldn't interfere too much during the procedure. Once the lift began rising, the tubes caught on to the top of the lift sheet and the PCT (at the HOB) mentioned to the RN that the tubes were getting tugged by the sheet. The RN adjusted them a bit more and kept operating the lift. I was starting to get concerned because I could begin to see a lot of secretions coming out of the patients mouth and his 02 sat had gone down to 82%.

The RN also noticed the declining 02 sat and stopped the lift. She came around to the other side, asked the first PCT to move, and started suctioning the patient. She was started saying something like "this damn thing is probably out" and proceeded to push the intubation tube further in. Seeing that the RN was struggling, the first PCT's asked her if she'd like for him to call RT or extra help. She mumbled something under her breath and continued working on this patient. I could tell she was flustered. The PCT finished lowering the lift and then took it upon himself to ask the charge to come help (she was right across the room).

RT was called in and a whole bunch of commotion started as they were trying to re-intubate and stabilize the patient.

After all of this, I spoke to the PCT's involved in the situation. Apparently, the RN stated that the first PCT neglected to notify her of the dislodging tube as he had a better visual from his angle and an incident report was being initiated. I am not sure of all the details, just that an incident report would be started.

As a nursing student, I am am a little confused as to what the PCT's role in all this is supposed to be. I do not believe it was in the PCT's scope to assess the patients status during the process but it is that of the RN's. I also sort of sympathize with the RN because she was still new to the unit and was probably terrified with this situation (I am nut sure of what the culture is in this unit but it seems pretty tight knit) and should of probably had help from more experienced staff for this more complex case.

Any thoughts?

[DoeRN]

So it's the PCT's fault because he told the RN that the tubes were getting caught in the sheet? Yeah she's CYA.

[iluvivt, BSN, RN]

This is ALL on the RN. It is the responsibility of the RN to direct any assistive personal providing any patient care to his or her assigned patient. She failed to do so! Perhaps she did not realize just how easily an ET tube can come out if it is pulled on and not secured well. I have seen patient sit up an literally give a big cough and out it came!

[dishes, BSN, RN]

Incident reports are done to determine how to prevent an event from happening again in the future, not to lay blame.

[emtpbill, ASN, RN, EMT-P]

Highest level provider is responsible. Especially something like advanced airway maintenance .

[OlivetheRN, ADN, BSN, RN]

If it were me, I would have been at the head of the bed keeping eyes on the airway, etc, and let someone else run the lift, since as someone else pointed out, it would fall on me if the airway were to become dislodged.

[dishes, BSN, RN]

When working with mixed staffing levels, the person with the most knowledge is in charge. The one in charge should stand in position where they have a full view of the patient. In the future, the PCT should operate the lift under the direction of a RN, as the RN stands at the head of the bed and monitors the patient's airway and tubes.

[LadyFree28, BSN, LPN, RN]

If it were me, I would have been at the head of the bed keeping eyes on the airway, etc, and let someone else run the lift, since as someone else pointed out, it would fall on me if the airway were to become dislodged.

Agree.

I would want to make sure that the airway wouldn't be compromised , and let the PCT handle the lift.

She made a rookie mistake; and instead of owning up to it, decided to shift the blame.

[NurseGirl525, ASN, RN]

It's up to the RN, not the PCT. If an incident report is completed, they will let her know. Incident reports are not to punish. They are to see how the situation could have been handled better.

Things like this happen. It can be difficult to maneuver with all those tubes that are happening in an ICU. Sometimes, no matter how much slack you give, things get caught. They just do.

When these things happen, you learn how to do better next time. But in the end, it falls on the RN.