Need advice and reassurance on a bad situation.

[midnightRN]

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

[barefootlady, ADN, RN]

Great post Canoehead. Sometimes when everyone is busy(???), I take the vitals, know there will be no change for the better and then call one of the ER doctors. I tell them patient has taken a turn for the worse since I last spoke to the attending, super is aware, and patients needs help now. I have only had a problem once, super called ER and doctor was there within 10 minutes. Patient did expire, after transfer to ICU, but at least, I did my job and know patient was not ignored even if attending was busy.

[pricklypear]

Great post Canoehead. Sometimes when everyone is busy(???), I take the vitals, know there will be no change for the better and then call one of the ER doctors. I tell them patient has taken a turn for the worse since I last spoke to the attending, super is aware, and patients needs help now. I have only had a problem once, super called ER and doctor was there within 10 minutes. Patient did expire, after transfer to ICU, but at least, I did my job and know patient was not ignored even if attending was busy.

Our ER docs are not required and will not respond to calls like that. They come for codes, and a select few of them will re-intubate someone or start a central line. This is because they are not responsible for any patient except those in ER and codes. I really don't think they would even give us orders in a crisis (non-code) situation even if the attending does not respond. It's kind of the same as grabbing a doctor out of the hall and asking him to take care of a patient. Our only other option is to call the chief of staff/medical director.

[mattsmom81]

Oh boy....I had a similar situation as a new grad. But I was never able to reach the doc! I charted each attempt to reach him, and got my charge nurse and supervisor involved. Finally we moved the patient to ICU without talking to the attending. He finally called me back after we had moved the patient.

He was pissed...because he got caught. He made a big brouhaha and tried to get me fired because I charted in my last entry "Dr H. finally returned call and call transfered to ICU nurses". He made a big deal about the 'finally' ...LOL!

I agree with everybody else...trust your instincts, call and recall those docs... and keep involving everyone you can...the more the merrier when a patient is going bad.

[canoehead, BSN, RN]

Hey, no one said they were "required", just that sometimes they come around to look at the chart before the actual code, and see us fighting with the doc for orders that are obviously needed. sometimes they will get on the phone themselves, give their own orders, or call the code a while before we actually have one so the patient gets taken care of. Usually they appreciate a heads up anyway if we expect someone is goig down the tubes.

[pricklypear]

Hey, no one said they were "required", just that sometimes they come around to look at the chart before the actual code, and see us fighting with the doc for orders that are obviously needed. sometimes they will get on the phone themselves, give their own orders, or call the code a while before we actually have one so the patient gets taken care of. Usually they appreciate a heads up anyway if we expect someone is goig down the tubes.

You have WAY nicer ER docs than we do! Some of ours are OK, but some don't really care what's "good for the patient" unless it's an ER pt. One in particular sometimes doesn't even show up at codes. There have been times we've had the patient intubated and back before he waltzes in the door!

[meownsmile, BSN, RN]

Our ER docs wont come except for code situations. If i got no response from a page, which i have had happen,, first thing i do is call house supervisor and keep documenting. I document every 10 minutes after i page until i get a return call and get orders. If time keeps running and no calls, i have the supervisor call him. They usually will respond to them calling their home phone. They may be torked off for a while,, but they get over it.

[hollyster]

You have WAY nicer ER docs than we do! Some of ours are OK, but some don't really care what's "good for the patient" unless it's an ER pt. One in particular sometimes doesn't even show up at codes. There have been times we've had the patient intubated and back before he waltzes in the door!

Our ER docs do not even come to codes unless they are on the first floor period.

If the doc you were trying to reach does not respond,and there are o other docs on the case, call another doc in the group,if he is in a group practice, let them know pts condition and of the repeated attempts to notify the primary.

You great by documenting everything. If you ever had to testify the statement of "finally returned call" will show your fustration due to the docs inaction. Maybe the doc will think twice before he blows off phone calls.

[pricklypear]

Our ER docs do not even come to codes unless they are on the first floor period.

.

Who does respond to the code if the patient isn't on the first floor??

[mattsmom81]

I agree about notifying the ER about a patient circling the drain... and know I've been fortunate to work with some great ER docs! Sure makes a difference. :)

Sometimes the ER doc will come and take a look ahead of time, and even intervene til we can reach the attending....depending on how busy he is and what kind of terms he is on with the attending doc.

[hollyster]

Who does respond to the code if the patient isn't on the first floor??

CCU nurses,RT and during the day one of the intensivest. At night the one house md.

We usually wind up with quite a few mds who happen to be on the floor.

[mommatrauma, RN]

A few things here...and I'm addressing a few different issues brought up within a few posts, not just the O.P. Our ER physicians, will absolutely in no way get involved with a patient that has already left our department. Whether it be a code or otherwise. It can very much be a liability issue, because they will not be following up with the patients aftercare following an intervention they order...and if something more should happen to the patient ie patient crashes, or has a poor outcome, it can be detrimental to them...and they have enough of their own patients they also need to worry about..Documentation is a very good thing...but you have to keep out your opinion or other words that may look like its kind of a name calling note..ie "finally" called back...yes, I understand you were very frustrated by this point that the MD finally called back, but it can lessen your credibility when you put words in like that...trust me, if you document 50 times that the MD was paged and on the 50th page he called back...you get your point acrossed...when you put "finally" in there, it starts looking like you are taking up issue with the MD calling back on the 50th time...in which the patient records are not the place for this, no matter how true...As for the pressure of 80. Initially giving a fluid bolus is not an unreasonable first attempt to improve the BP, it however should not have been continued without a re-eval by the MD for an improvement, and at which time no improvement was made, then the patient should have been started on pressors...Also, I might have reassesed the patient alot more often given the BP significance...ie before 0200...With a pressure like that, probably more like every 15 minutes or so at the most, until the patient was either stabalized or transferred out...The other issue is why was the patient hypotensive...BP drops are usually a late sign of some other issues, ie sepsis, PE, dehydration, etc, etc....and the problem is that if they were some of the issues, the patient could have masked other symptoms because of meds they were on, ie not tachycardic b/c on a beta blocker....the OP also said there were no s/s of hypotension, however a thready pulse is definitely indicative of that...the mottling of the skin definitely sounds ominous... Also, the fact that the patient sounded more agitated by constantly trying to climb out of bed and pulling at lines definitely sounds like it could have been because the patients brain was being poorly perfused...Also as for sending off bloodwork and doing an EKG...not sure what you would look for w/bloodwork in the newly hypotensive patient that would have given you an answer quick enough to be helpful at that point... unless the patient was bleeding out before your eyes...The EKG..ok, I can see...look for EKG changes in relation to MI, irregular heart beat, poss PE...but again if you can't get the MD in to see the patient in the first place all the EKGs in the world with noone to interpret them does nothing for the patient...I think given that you were a new nurse, you did what you could, you recognized a change, you called the MD, you did your best with the interventions you could within your scope of practice...you followed up with your interventions and continually made the MD aware of the current situation...The MD definitely dropped the ball here, unfortunately for the patient...It is very frustrating when you try to take the best care of your patients you know how and you have to deal with laziness and incompetence in the meantime...You were a patient advocate, even if the patient's outcome isn't what we would have liked, you still went to bat for the patient when he needed you the most....As you get more experienced, your skills and confidence will improve, and you will trust your judgement enough that you will know when to be more assertive in the name of the patient...Keep up the good work!

[willdgate]

I am a nursing student, so I could be wrong, but i go with intution, and I would have bothered the doctor and would not have cared how mad he gotten, because in the end things come back on the other person.