Nurses, do drop in! *VENT*

[AutumnLeavesRN]

Hello all, I don't post much but felt compelled to post after last night's debacle. Well I will try to explain this in the safest way possible and nurses do chime in and let's discuss this please.

Ok I have been a registered nurse for about 2.5 years.....May will be 3 years. I work on an ICU step-down floor. I had a patient come in with respiratory failure. Admission po2 35, CO2 73. Should have gone to ICU but that's another can of worms. Anyway....she was hypoxic,anxious and fighting the bipap all the way up to the floor. I got into a slight tussle with the patient, not in a harmful way but her lips were turning BLUE and she was trying to throw the bipap mask off. Long story short I had to give her Ativan to calm her....a smidgen dose half an mg which was just enough for her. She calmed down, remained on her bipap, and started to rest.

The RT comes in to give a neb and notes her breathing rate....ok. She had ativan because she was physically fighting me and her family on wearing the mask. The RT says "can we get her some narcan because she's not waking up" 10 mins after administering ATIVAN. I told her she didn't have a narcotic so no....she is fine. She was arousable but drowsy. She decides that since the patient's sats went from 40s to 80s she doesn't like that or any of the orders the MD put in so she runs some unordered ABG's. I say ok...that's your decision. At this point the O2 was set at 80% on the machine.

The RT then wants me to call the MD. My first THOUGHT is " you have a license like I do, YOU call the doctor they are your ABG's". But I agree to a certain degree because 80% wasn't getting her past 85% o2 sat so we get new settings from the MD. Now 100% O2 and surprisingly she did not fight but it did make her more drowsy. Ok so here is where the line was crossed.......

The RT, not ME, but the RT goes in my patient's room and tells the patient and the patient's husband that if she is refusing to be intubated if it came to that then she would die. It took me an hour to calm all the 6-7 family members down that came there afterward crying. I had to clarify that if the medical interventions that were currently in place for her failed and she began to deteriorate then we'd need to discuss with the chaplain and physician what kind of interventions, if any, we would need to do IF IT CAME TO THAT and she is refusing intubation. The RT tried to make it seem like she was going to die like.....right then. I had to put into words that they could understand. At one point we were both at the patient's side and she was saying all these things and I was trying to get her to shut up as she was talking over me. Even answering questions like "well if she goes on the vent, it could be long term or she could get better no one knows".

I charted everything...her name, position, and all she discussed with the patient. Not once did she mention discussing their decision or concerns with an MD. I had to clarify this with my own patient and the family. Outside of the patient's room I asked her if she would let me talk with the family about healthcare decisions such as advanced directives. She told the HS she felt she didn't overstep her role and that it needed to be discussed and it was discussed WHEN I ADMITTED HER. It's one of the admission requirements lol. I could not react the way I wanted to but I was able to put the family at some ease. No to give them false hope but to at least let them know all that we are doing and doing it aggressively with continuous bipap, IV steroids around the clock, and neb treatments q4. Was I wrong or should I have been more aggressive???

Nurses please, I would love to hear your input on this please!! Can we discuss this?

[ProgressiveActivist, BSN, RN]

You did fine.

I am going to assume that the pt has severe COPD. An Sp02 of 88-90 with a paC02 of 50 may be where she lives. Increasing the Fi02 to 100% was probably unnecessary.

How was the follow up ABG?

You need to discuss this RTs disruptive and insensitive behavior and lack of clinical judgement your manager asap.

The pt did not need narcan or multiple unordered blood gases or a lot of tension in that room. Although the patient was tenuous what she needed was ventilation and rest, not a room full of distraught family.

[AutumnLeavesRN]

Oh goodness yes.....severe COPD and still, STILL smokes 2+ packs a day per 3 family members reports. I told the HS and she has zero backbone. I will discuss this with my nurse manager on my next rotation. Because we had a code on the floor, I put this situation to the back and focused my concern on the patient in the code so when I saw the nurse manager this morning I didn't bring it up but I most definitely will when I see her. And many of the RTs there when they don't see an O2 sat of >90% on a patient like her, they will up the O2% on the bipap and then beg us to call the MD!

[Been there,done that, ASN, RN]

This scenario should not have progressed to a contest between RT and nursing.

What did the doctor at the bedside order?

[ProgressiveActivist, BSN, RN]

You work with some incompetent RTs. Protect your patient. Get parameters from the MD for the Sp02 for these bipap patients. This is usually written as titrate Fi02 for Sp02>88% or whatever

Ask if he wants to tweak the inspiratory and expiratory pressures if the patient is hypoxic. Assess for resp rate or Ftot on the vent and work of breathing. Do mouth care with moisturizer every two hours to prevent mucus plugs.

Do not let these clowns practice medicine without

a license, or manipulate you into doing their work.

If that patient develops a pneumothorax the first words out their mouths will be the nurse said it was what you wanted.

RTs are responsible to notify the physician of any

critical value on an ABG not you. Its their machine and their job to call for orders to change the settings. That's pure

laziness. Know their policies so that you can stand your

ground and say no.

Feel free to say I dont ask you to call my labs don't ask me to

call yours.

I hate to think of what these RTs do with a ventilator.

[ED Nurse, RN]

Did you actually hear the conversation between RT and family or did you just go by what the family told you?

If a pt is unsure if they want to be intubated, or can't say, then I always go with advanced directives- families get hysterical in these situations and usually end up doing more harm than good. They know what the pts wishes are but panic in critical situations. If I don't have advanced directives in hand, or a POA with proof of such, then we have to do everything to save the pt.

I have found that with pts who are anxious bc of the bipap, that instead of Ativan, a smidge of morphine works wonders.

[TU RN, DNP, CRNA]

I think the MD should've been brought on to discuss the direction of the treatment and code status before the RT. Maybe the patient needed another ABG anyway to see how the BiPAP was working.. considering the admission gas was pretty bad. Depending on what that "unordered gas" resulted as, the RT might have been justified in thinking intubation. Who knows if the lady's somnolence was a result of the touch of Ativan you gave her or an advanced stage in her failure. Either way the RT's rude behavior towards you is unacceptable and you're right in reporting them.

BiPAP is great and all, but if the patient is looking like how you say despite it - they need to be tubed. If the family/patient are refusing intubation, they need to sign a legal "Do Not Intubate" document. People really need to get educated and get their affairs in order man... especially these folks who just take a dump on their health. I feel like asking them sometimes "what did you expect was gonna happen?"

[ProgressiveActivist, BSN, RN]

"Hello doctor, (give update and numbers)The reason Im calling is that Ms X's family is upset. They have some concerns since RT Renee was in there talking about intubation. Her son wants to speak with you."

I would absolutely make that call the next time this RT agitates the family of a patient who is

turning around.

If the MD comes in to evaluate and talk to the

family, even better. I would let him know privately that there was no need for this RT to get dramatic.

I know you had a code but you need to use your resources and be assertive. That means telling it like it is.

[nrseduk8ter]

Does your facility have a variance reporting system? If so, I would use it! When a variance is reported, it goes to ALL the higher ups (risk management, quality, your management, administration, etc.). This person sounds dangerous!

[VANurse2010]

That patient needed to be intubated and sent to ICU.

[thenightnurse456]

1. This patient needed to be in ICU

2. The RT is out of line on everything.

3. A MD needed to review this patient and have a discussion with the family and patient regarding intubation, DNR etc.

[AutumnLeavesRN]

It wasn't a contest per say but it does sound that way. She way saying one thing and I had to clarify to the family what those things meant. The MD had seen this patient long before she got up to the floor and was the one who ordered the bipap settings. I told the RT the reason the bipap settings were adjusted was because the patient fought 100% down in ER so the doc lowered them. It wasn't really a contest but it ends up being 'RT there for umpteen years' vs. 'RN there for 2.5 years' because I have seen them try this on other nurses who actually let them speak on their patients' behalf but I wasn't going to do that. I called the doc no doubt but that was all I was going to do and only because I agreed on the lower ipap, epap, and rate settings. 80% O2 was ok for a COPD pt like her in my eyes but this RT just got all hysterical when her sats weren't progressing past 85% on 80% oxygen.