Platelet level 10 and pulling art lines

Nurses General Nursing

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I need some feedback. I recently had a patient who had stents put in. She has an art line and her platelet level has fallen to 10. The cardiologists wouldn't order platelets for her when I asked and finally they called in a hematologist, who did have us give platelets. They went up and then down, more platelets were given, up and then down again. The patient had an episode of severe confusion. I called the cardiologist (primary) and he wasn't there. They gave me his partner who ordered a CAT scan and said he would come see her. The confusion went away. The doctor came in and said that she was just fine and he was ticked but controlled. I told him that she IS fine right now but was severly confused and that with a platelet level of 10, I felt that he needed to be notified in case she had a bleed. He said that was correct and that he still wanted a cat scan. Later he came back and it hadn't been done yet and I asked if he still wanted it and he said yes. I go to lunch, come back and my manager rips me apart for getting the original cardiologist mad, exagerating the problem and making the patient have uneeded tests. She does this in front of everyone. Apparently the doc had complained about me. Then he comes back in and told me that I am creating problems for this patient who came in for something simple and now is having all kinds of problems. I just bit my tongue and walked away. Then to top the whole mess off, he came back again and yelled at me for taking heparin out of the art line flush, for not pulling the lines yet, and for holding plavix and aspirin. The patient had a platelet level of 26 and the hematologist had written those orders. I explained that to him and he yelled that HE wasn't the one who had to come back and take care of the patient when she clots. He then goes in and tells the family that he disagress with the hematologist and that he would definitely do things differently. He leaves and the family comes out and is upset because of this discussion and they had seen him yell at me, which mades them feel bad too. I then spent 30min trying to convince them that this dr conflict will be sorted out and that we would watch out for the patient. I wonder what you all think about this whole mess and if there is anything I should do now or have differently. Would you have called about the confusion? Would you pull lines at 26? Thanks for taking time to read this and give comments.

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Wow, you are an AWESOME nurse!!! You did a great job. Of course, I would have called that dingbat (MD) on the confusion; how on God's green earth could you not have? With a platelet count that low, how could you not suspect stroke or bleed? What an idiot this MD is! I think your manager is even worse for not defending in front of this so-called MD. I'd be furious!:angryfire I hope you charted your little heart out on this one, 'cause you know that I you hadn't called the MD and something would have happened, he would have blamed it all on YOU! I hope a recovery nurse can give you feedback on pulling lines at 26, 'cause I'm not sure. But this guy just seems like an *ss*hole all the way around! Keep up the good work!!!!!!

I need some feedback. I recently had a patient who had stents put in. She has an art line and her platelet level has fallen to 10. The cardiologists wouldn't order platelets for her when I asked and finally they called in a hematologist, who did have us give platelets. They went up and then down, more platelets were given, up and then down again. The patient had an episode of severe confusion. I called the cardiologist (primary) and he wasn't there. They gave me his partner who ordered a CAT scan and said he would come see her. The confusion went away. The doctor came in and said that she was just fine and he was ticked but controlled. I told him that she IS fine right now but was severly confused and that with a platelet level of 10, I felt that he needed to be notified in case she had a bleed. He said that was correct and that he still wanted a cat scan. Later he came back and it hadn't been done yet and I asked if he still wanted it and he said yes. I go to lunch, come back and my manager rips me apart for getting the original cardiologist mad, exagerating the problem and making the patient have uneeded tests. She does this in front of everyone. Apparently the doc had complained about me. Then he comes back in and told me that I am creating problems for this patient who came in for something simple and now is having all kinds of problems. I just bit my tongue and walked away. Then to top the whole mess off, he came back again and yelled at me for taking heparin out of the art line flush, for not pulling the lines yet, and for holding plavix and aspirin. The patient had a platelet level of 26 and the hematologist had written those orders. I explained that to him and he yelled that HE wasn't the one who had to come back and take care of the patient when she clots. He then goes in and tells the family that he disagress with the hematologist and that he would definitely do things differently. He leaves and the family comes out and is upset because of this discussion and they had seen him yell at me, which mades them feel bad too. I then spent 30min trying to convince them that this dr conflict will be sorted out and that we would watch out for the patient. I wonder what you all think about this whole mess and if there is anything I should do now or have differently. Would you have called about the confusion? Would you pull lines at 26? Thanks for taking time to read this and give comments.
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Well I would have done exactly what you did...so I guess we're both problem nurses. :rolleyes:

Without knowing this lady's full hx, I might also be tempted to place an article on HIT in that cardiologists mailbox since he seems unfamiliar with this phenom.

The hematologist will be MY expert guide when blood clotting factors go out of whack...and I would also defer decisions to him regarding pulling of lines, etc.

As usual, nurses get to deal with the brunt of dysfunction on the doc's part. He was very unprofessional IMHO. YOU did great IMHO.

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I think you did all the right things. Your supervisor is a jerk for not backing you and for not knowing the whole story most likely. I hope you just charted your pants off. That will back you up in the end. I would seriously think about having a chat w/your manager about verbal humiliation in public. HR won't like that much, oh nooooo.You just keep it up. I would hope MY nurse would do such a great job!

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Specializes in Critical Care/ICU.
Would you have called about the confusion?
Absolutely

Would you pull lines at 26?
Nope.

True story...I once had a patient with a high INR. This was in the month of July...the month that we get an all new group of eager residents. The know-it-all newbie that night wanted me to pull an art line from this patient's groin. I flat out refused backed up by my rationale that I would be standing there for at least 30 minutes applying pressure and frankly, I didn't have time for that and this patient was pretty sick and very busy. I said if you want it out, you pull it and stay here to hold pressure. He wanted the line out so bad that he agreed to it. He said he was already spending a lot of time in the room anyway because the patient was so sick.

I completely understand why he wanted the line out...we were thinking that this may have been a source of sepsis. But still...

This was at about 1 in the morning. He didn't leave the room until about 2:30. He actually sat there (on a chair offered by me) holding pressure to this lady's groin as I buzzed around the room doing my thing titrating drips, suctioning, giving blood, etc. I actually felt sorry for him after a while and got him a blanket. I got to know him pretty well that night but he never tried to give an order like that one again.

You did an excellent job LolaRN--especially for changing the bag that had the heparin in it! I agree with a previous poster who said that this patient needs to be checked for Heparin Induced Thrombocytopenia (HIT).

Then he comes back in and told me that I am creating problems for this patient who came in for something simple and now is having all kinds of problems.
Well DUH doc. Why do you think we have people sign those informed consents?! Problems happen.

This is a great article from the American Journal of Respiratory and Critical Medicine:

Thrombocytopenic Disorders in Critically Ill Patients

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