Just venting frustration...

[jbp0529]

Ok, so the other night we had this patient who was s/p lung biopsy for cancer, who had a prolonged stay in our unit, on the vented for several weeks, planned for trach sometime in the future, who over the course of her stay developed sepsis and most recently ARDS (diffuse infiltrates on her CXR's). When we came on at 7 pm, the day shift told us that after she got back from a road trip to CT or where ever, that she dropped her sats from the 90's to the 80's to eventually the 60's. ABG's were awful, and the sat on the gas correlated with our sat on the monitor. BP currently stable though. At shift change, they were in the room with the MD hand bagging her to try to get her sats up, and this only brought it up to the low 70's. Needless to say, she was very sick.

So when the primary team left for the day, the on call intern and resident were left to manage her care. From dealing with them in the past on other patients, I knew they weren't too bright, especially the resident. Getting orders from him is like pulling teeth. The RT's suggested we try her on APRV ventilation. The resident who is totally unsure of himself and is awful at making decisions, "didnt want to just yet", but yeck... her sats were in the 70's !! The RT ended up doing it anyway, while he took an hour to decide what he wants to do. Her sats came up from the low 70's to the high 70's on APRV.

So several more hours go by and nothing changes. We (the nurses) and the RT approach the resident and ask him what to try next. He basically said he didnt know, but was comfortable leaving the pt where she was, with sats in the 70's - until morning!! We were like, "oh hell no," and suggested putting her on high frequency ventilation (HFOV), and possibly getting her a pronating bed (she was hemodynamically stable at this point). The respiratory therapist told him that its better to put her on oscillator sooner, rather than later, and he needs to decide. He was like "well I dont know, let me call my fellow for advice"- his answer to everything in life. About 4 hours later, with continued paging and updating, still no word on the high frequency, and came to find out he hadn't even called his fellow!!!! Geez!!

By this point we called the fellow ourselves, and the Respiratory Supervisor was now involved. We all updated the fellow and he said he'd talk to the resident. 2 more hours later, we find out they talked, but the resident wasnt "comfortable" using the high frequency vent bc he didnt know how to manage it. And he was visibly getting upset bc we kept "bothering" him with this, and called the fellow. UGH . By this point its nearing morning, and now her BP is starting to fall, sats are now in the low 70's, high 60's. ABG continues to look awful, with PO2's in the 30-40's. Her lungs sound completely wet (rales all the way up), and he orders fluid boluses for us. We are like, "how about some pressors instead??", he didn't want to do that. Finally ended up having to wake up the attending to tell him what's going on, and he says he will talk to the resident and will be in shortly. Of course, no word back from the idiot resident. Now its close to 6 am, and we were praying to God that someone with some sense would be here soon.

I feel like we did all we could, and used every available option as far as notifying people, but it it was so frustrating that nothing was done. All we could do was document very carefully, and the RT supervisor even made an entry in the MD progress notes stating "doctor so-and-so continually updated on pt's status, and low SpO2. Dr so-and-so, fellow, also notified. HFOV remains available to patient pending MD order." I'm sure this will make the resident angery, but who cares, we had to cover our butts.

Thanks for listening to my gripe. Sorry it was so long.

[chris_at_lucas_RN, RN]

Good for you.

So what if the resident gets angry--let's all hope he goes into dermatology.

And good for your patient too. I'm sure her little roadtrip to CT or wherever was something she wanted to do. There are consequences for everything, and hers was a decline in her condition. But at least she didn't sit home like a hothouse flower afraid to continue living her life.

Other than to be empathic, I don't know what else to say. Sounds like the situation from hell.

You documented really, really well, right? This lady and/or her family have wonderful grounds for a malpractice suit against the resident, the fellow, the attending, and right on up the chain of "responsibility."

[Hoozdo, ADN]

Sounds like you need a policy on how to escalate problems with a patient over an intern and resident. Can you ever call the attending? Have you discussed this with your nursing manager?

This resident and intern were not providing safe and timely care. It is up to you to advocate......personally I would make a LOT of noise over the outcome of this patient. Hopefully, you can prevent this happening to another patient.

[jbp0529]

Sounds like you need a policy on how to escalate problems with a patient over an intern and resident. Can you ever call the attending? Have you discussed this with your nursing manager? .

Funny thing was, we did end up calling the attending in the wee hours of the morning. But it didnt seem to help bc he just said he would page the problematic resident. It seemed like everyone we tried to call wasn't taking our situation seriously.

I haven't been at work since the night all this happened. I dont know how the patient did during the day shift, or if anything was ever done.

[cardsRN]

i shouldn't get started on this topic, but here i go...

it is politics plain and simple. the on call staff is afraid to jeopardize their position or lose face by making the wrong call, therefore they do nothing. it is less risky to just not change the plan of care. as a result of this thinking, they do not respond to changes in patient condition.

it is almost like they do not see the patient as a real person or care at all what happens to them, all they care about is being able to tell the primary team "no changes" in the AM. it is almost sociopathic the apparent disregard for humanity. i have a theory that md's training esp surgeons is partially to blame for the removal of humanity from our md's. one shred of compassion and appropriate response to our patients' condition is all we ask for. all we can do is go up the chain. notify nursing supervisors, call the fellow, call the attending. but we all know the attendings could not care less after the pt leaves OR. they are done with them, they are not interesting anymore.

guess i have some feelings here. i hope your pt is ok, OP.

[meandragonbrett]

Just passin` the buck and nobody wants to take responsibility. Unfortunately, it happens all too often.

[SICU Queen]

That is why, as of last week, I no longer work in bedside care at a teaching hospital.

Everyone (residents and fellows) is too afraid of jeopardizing themselves and the patients pay the price for it while the nurses are made to feel like irritants for demanding action in a timely manner.

[Dinith88]

That is why, as of last week, I no longer work in bedside care at a teaching hospital.

Everyone (residents and fellows) is too afraid of jeopardizing themselves and the patients pay the price for it while the nurses are made to feel like irritants for demanding action in a timely manner.

It's funny, but working at big 'teaching centers' has its own unique set of problems for the nurses. Dealing with all the "junior 'baby' doctors" can cause serious headaches. It may be just my opinion, but when someone spouts off about working at a 'major teaching center' i'm not impressed. They should be called 'major doctor-teaching centers' because that is the focus. The juniors do alot of the stuff nurses would routinely do at a community-based setting...relegating the nurses to med-pushing, charting, technicians. And have you ever experienced a code at one of these places? The room gets crammed full of baby-docs all jockying for something to do...the nurses routinely just sit back. (i admit i've not worked midnights in a teaching center so it may be different)

...but...this is just my experience. I'm much happier working with 'grown-up docs' and having more autonomy. I'd not go back.