Need advice and reassurance on a bad situation.

bluesky, BSN, RN · May 16, 2005

Here's the story...
At 2330 I picked up 2 pts. on my m/s floor giving me 8 total. My pt. b. after assessment showed these abnormals: BP 60/30, R 28, P 89 apical and irregular, peripheral pulses weak but palpable. Pt. denied any s/s of hypotension, pain, discomfort, nausea. His mentation was normal for him; he's only ever been oriented to self, but will respond appropriately to most other questions. He was repeatedly trying to get oob without assist. Pt skin turgor was poor, he had mottling at the knees, abdominal sounds were very hypoactive. I reviewed the chart and noted that the bp was the only change in pt. condition since the 13th. I called the MD who increased iv fluids, and at that time i asked to provide the pt. with 1:1 supervision because I did not want restraints and we had an extra cna that night. This pt. repeatedly was climbing out of bed and pulling on lines. He said ok. So I completed the orders. I reassessed the pt. again at 0200- he was the same, and at 0430. At 0430, he was noted to have no output, and his lung sounds were becoming coorifice at expiration. I had and experienced Rn come in to assess him, to be certain I was not missing anything and to verify my assessment accuracy, as I was concerned. I'm a new grad as of Dec. I tought I'd call the MD. I asked the experienced nurse If I should call the Md with these changes, and because the pt. condition had not improved. She asked me what I thought the doc would do. I replied that the only thing left was to transfer him, but I'd feel better. She sid to try and wait until 0500. The pt. was responsive at this time. He is 84 years old and a full code, by the way. The doc walked in at 0500, and quickly walked in a pt. room to see a new admit. I had to see my other pts. , so I wrote a note with my concerns and put it on top of the pt. chart, and put the chart on top of the new admit chart, and went to see the other pts. About a half hour later, the cna who had been with the pt. runs in the room I was in and states the MD wants to see me now. I go into b.'s room, and he's on the verge of a code. His color is gray, and he's agonal breathing. I start bolusing him and transfer him to ICU where he codes within 30 minutes of transfer. Now the Md is pissed. I am upset. What should I have done differently? Please be kind, I cried the whole way home. I should have called the doctor at 0430. Thanks, Anna

First of all I want to say how sorry I am you had this experience. That attending should be shot! I am an ICU nurse so it is difficult for me to even fathom having more than 2 pts! To be completely honest, I probably would have insisted that the doc come see the pt the first time. Otherwise, I would have called the nursing supervisor and gotten the hospital involved as this was an unsafe situation. The BP and mottling alone is a complete red light but it's obvious that you knew that but none of the more experienced people that you consulted advised the urgency necessary for the situation. It is in your interest to document who and when you consulted both the doc and the nurse. I once was in a similar situation where a pt of mine had a silent MI and ended up dead. This was about 3 months after I graduated. The doctor called a multidisciplinary meeting and tried to pawn it off on me but he couldn't because I faithfully showed how I had contacted them on multiple occasions (when u/o crashed, when levo needs went up) and there were no other outward signs of MI (chest pain, EKG changes, etc) AND my charge nurse backed me up on all the unanswered phone calls that night. In the end, the intensivist had to admit that he had told the resident to do cardiac enzymes but there had been a communication breakdown between the two and the resident had ordered them on the wrong patient. As we were walking away, one of my colleagues said she overheard the attending say I was going to be an excellent nurse some day. I still think maybe I should have been more aggressive but everyone but the supervisor had gotten involved and no-one could get the attending that night. Weird. This pt was 65 or so.

Long Term Care Columnist / Guide · May 16, 2005

First of all, do NOT beat up on yourself for what happened. You were placed in an unsafe situation in the beginning---8 patients, one of whom was obviously VERY unstable---and then basically left high and dry by the 'experienced' nurse, who played 20 Questions with you and then advised you to wait to call the MD again.

Secondly, you are a new nurse, and you did almost everything right---you kept assessing and reassessing the patient, you kept the MD informed, and you asked someone with more experience for help. The only thing you didn't do was listen to your gut instincts........you listened to the other nurse instead, and unfortunately the outcome was bad. It probably would have been bad no matter what you did or didn't do, but that's not the point........the point is, you didn't act on your own intuition, and that is something that's almost universal among new grads. They tend to defer to nurses with more experience because they don't yet feel confident in their own skills or trust their instincts.

THAT is the ONLY thing you did 'wrong', in my opinion, and I don't know know very many new nurses who wouldn't have gone along with what the 'older' nurse advised, myself included. Of course, I know better now that I've got 8 years under my belt and made the same type of mistake a time or two; plus, I've learned that my very first obligation is to protect the patient, not the doctor, the family, the other staff, or anyone else for that matter. And I couldn't care less if a doctor doesn't like being called 15 times a night......that's why they get paid the big bucks, and if I get an earful, big deal.......I just let it run off my back and move on to the next task.

Likewise, you are not there to make sure the MD gets his or her full night's sleep, you're there to take care of your patient. Your instincts in this case were right on, and while I suspect you wouldn't have been able to save this patient even with a timely transfer to the ICU---you received him in a highly unstable condition to begin with---this is a huge learning opportunity for you. Examine it, talk it over with your manager, a mentor, or another nurse whom you like and whose judgment you trust, and learn from it........then move on. These experiences, as painful as they are, happen to EVERYONE, and they offer us a chance to grow even as we agonize over the "coulda/shoulda/woulda's".

Be gentle with yourself.

I wish you peace. :)

midnightRN · May 16, 2005

Thanks. I don't trust my instincts enough. I also charted everything. I wish I'd been a better pt. advocate. I can promise I will be next time. Sincerely, Anna

Tweety, BSN, RN · May 16, 2005

I worked nights for the last 14 years, and we do pick and choose witch situations warrant a call in the middle of the night. Like you and the others I agree you should have called earlier. If the BP was 60/30 at 11:30 and you got orders, I would have called the MD after may 30 minutes or an hour if he hasn't responded. Critical BPs like that need close attention. I don't mind giving a fluid bolus and giving an honest try, but after a short time of an hour or so, it's time to move from med-surg to to critical care. 4:30 or 5:00 was too long to wait, the patient may have needed pressors, or other treatments that required a transfer ealier. It was just his time and probably no matter what anyone did, he was going to crash.

You're new, you're learning, the experienced RN made a poor decision IMO. But in the end it's your license too. It's very important to document when you use your resources, however. This includes collaboration with experienced nurses and charge nurses, pharmacists, etc.

Give yourself a break, we all live and learn. You did a good job and you care.

Long Term Care Columnist / Guide · May 16, 2005

Thanks. I don't trust my instincts enough. I also charted everything. I wish I'd been a better pt. advocate. I can promise I will be next time. Sincerely, Anna

Good for you, for documenting everything you did! Too many nurses leave out critical details, or neglect to chart at all......and we all were taught from day one in nursing school--- "If it wasn't documented, it wasn't done".

As for being a better patient advocate, I'm confident that you will be. In time, and with experience, you'll learn to trust your instincts; for now, take comfort in the knowledge that you will never, ever make the same mistake again. You'll make others, to be sure---we all do---but this is one you'll never repeat because you are obviously a caring and competent professional, and good nurses always take note of such a situation, evaluate it, and then apply what they've learned. :)

pricklypear · May 16, 2005

... you are not there to make sure the MD gets his or her full night's sleep, you're there to take care of your patient.

This is so true! I think another thing to think about in this situation is the unchanged condition of your patient. Just because a patient doesn't get any worse doesn't mean everything is ok. When you intervene with fluids (or whatever) you expect some kind of improvement. If you don't get it, something else needs to be done. From your description of the situation, you picked up on the most important signs. DO trust your instincts, they're obviously right on!

Also, nurses have been sued for NOT going the the next level when they don't get anywhere with the primary doctor. Remember, (forgive me if I sound somewhat cynical) it's your word against theirs when it comes to phone conversations and even documentation of those conversations. They can always say "If the nurse had told me THAT it would have been different" even if you did tell them THAT 18 times.

I'll repeat mjlrn97, don't beat yourself up. Chalk it up to a valuable learning experience. Believe me, we've all had them. Mine was on the symptoms of CO2 narcosis!! I'll never miss that again.

meownsmile, BSN, RN · May 17, 2005

Sometimes there isnt much you can do when you walk into a situation like this, was the family there. You inherited that problem and sorry you had to feel the brunt of that situation. It does happen though, and you know now. And i agree,, dont beat yourself up for something you needed help with and didnt get. Just be a little more aggressive with it next time, especially if they are a full code.

I have also noticed that docs dont like notes left for them, they think they need face to face communications. I have seen them completely ignore notes left on the front of charts and not address it at all.

Onlyhuman · Jun 7, 2005

Also, nurses have been sued for NOT going the the next level when they don't get anywhere with the primary doctor.

So, how do you go to the next level? Do you go to the next level when a doctor doesn't give you the orders you need or when the doctor still hasn't return your page?

**canoehead, BSN, RN** · Jun 7, 2005

First off I would have done the exact same thing as you when I was a new grad. Now you have the confidence in your guts to push the issue a bit more next time.

Any blood pressure below, say 80 systolic means the kidneys aren't getting perfused, and the brain and heart are taking a hit too. If the BP is between 70-80 and the doc insists on not doing anything besides a fluid bolus I would insist on parameters as to when he DOES want to be called, put the pt on Q5min vitals with an auto cuff and actively look for reasons to call him back. Write any parameters as an order

If he says "don't call me back for an hour" write it. If he says "don't take any more vital signs until ..." write it. Of course, you won't be doing it as these are all nursing judgements and he can only order minimums on nursing interventions. You will continue to chart vitals and call with changes, but when someone looks back at the chart they will see how responsive the doc was, and how you continued to advocate for your patient. Remember that. For a doc you like just say "Do you want me to write that as an order?" and they will realize what they just said- sometimes they become more attentive when you remind them this is all going to be available for the family to see someday.

I would draw the blood and do and EKG (also RN interventions) but let the lab know we do not have an order...yet... Some lab techs will go ahead if they know the score and give some results verbally, but most if not all will hold the blood for a short time if you say you are "getting the doc in here, and we'll have orders momentarily" By this time you have said clearly "I am requesting that you come in to assess this patient because (list your findings)" Plus you know that the kicker is that the pt is losing vital organs as we speak with a BP of 60, so you have NO GUILT about pushing the doc and the charge nurse.

In our small hospital I am lucky enough to know everyone, and I would call the ICU, tell them we would have a transfer within a few hours, or as soon as the doc could be convinced. Fluid boluses 250cc at a time I would be OK with giving myself (I know it's not an RN thing) and would be careful to chart lung sounds after every 250cc. I would argue that RNs can initiate ACLS interventions, esp if BP below 75 systolic. However, if the patient needed meds emergently I would call above the doc, or, more sneakily, call whoever would have to come and run the code and let them know we had a real sickie- just a heads up- and sometimes they will wander by and give a few orders, or call the attending themselves, just to avoid the code situation.

You can also call your supervisor (you should call your supervisor) or an ICU nurse and have them assess the patient. Have a nurse to nurse consult, and then you are on stronger ground, tell the doc that "xxx from ICU has come over to give me some help and he/she thinks....." You may get a better response when the MD talks with someone with a different approach, or with more credentials. That means you were right, maybe next time he/she will listen carefully when you express a concern. We all go through that newbie testing period. :)

Pushing your charge as a new grad is very difficult, but if you say "I am just not comfortable waiting to see how this turns out. If he gets worse we won't have any time to pull him back, so he needs to be assessed before that happens." Also let her know that as a new grad you need her support, and also a little more time leeway with a sick patient than someone else might. You are erring on the side of caution.

As a new grad I had a child almost arrest on me and the doc slept at home. I was saved because the supervisor knew that something wasn't quite right, but I didn't know what to do:(. I put it that plainly to her and to the doc. I also wrote down the hourly calls to the doc, and his orders, so when his boss came in all that happened was plain. So don't worry if you don't know what to do- but keep bugging the people that DO know, and don't be afraid to call other units for a second set of eyes.

**canoehead, BSN, RN** · Jun 7, 2005

If the doc doesn't return pages all bets are off, call their boss, or the head doc if you have to. How many pages you wait on really depends on how sick the patient is.

pricklypear · Jun 7, 2005

So, how do you go to the next level? Do you go to the next level when a doctor doesn't give you the orders you need or when the doctor still hasn't return your page?

We have called the medical director in the past if a doc is not responding or is not responding appropriately. Or, if the patient has consulting doctors, you could call them and explain the situation. Of course, it has to be an appropriate consulting doc who will be receptive to the situation.

I wish I could remember where I read it, but there was an article about a nurse who followed the patient's primary doc's orders exactly - even though she felt it wasn't enough - and was sued later because of a bad outcome. Basically, they said she had an obligation to seek higher authority in a situation like that.