I had a patient with a bad diabetic wound ulcer on her foot and was also on dialysis. Ortho-wound was consulted and he planned to do surgery that same day (like he has for every patient I have ever had him consulted for) and the patient was also suppose to get dialysis in the morning. Her BP was normally in the 90's but that morning SBP was 80 and she was asymptomatic. I called the hospitalist first because nephro had yet to see her and half the time the specialists are like "I haven't seen this patient yet." Well hospitalist says to call nephro and I do and he says since she is asymptomatic he will wait to see her before doing any orders.
I call dialysis to let them know and tell them I will call once the doc comes - well 45 minutes later they are taking her down because doctor decided he will see her there. They give her albumin but BP drops to 40 after 5 minutes of dialysis even though not taking any fluids off. Doc says send her back up and will try tomorrow and his note says the hypotension is probably due to the food wound. The wound nurse told the surgeon about the BP so I let pre-op know about her BP and that the surgeon is aware and they say they will let anesthesiology know.
Patient comes back up to me about 3 hours later (she got a US of her leg done too). I took her off the 3L of O2 since she said she only wears that when getting dialysis and she was 97% on RA. She was alert and oriented but nauseated and had 2 bouts of emesis in addition to the two she had earlier in the day. Zofran wasn't cutting it so I gave her IM phenergan which ended up sedating her. When pre-op called for report I let them know that. Hospitalist was a little concerned about her breathing and so ordered STAT ABG where she was found to be slightly metabolic acidosis. After this time the PCT got her vitals and they were all stable - BP had actually come up to 115 and although her O2 was 93% I put her on 1L due to the sedation.
Well I get back from lunch and the hospitalist calls to say he and nephrology talked and decided she needed to be dialyzed and so told me to "call a rapid and use that to get her to ICU" so he didn't have to have a doc-to-doc with the intensivist and get her a bed that way. I told him they were actually taking her to pre-op (apparently he didn't realize she was doing surgery - I never know when these doctors bother to talk to each other) and I asked if he wanted me to cancel it. He said no but for her to go to ICU after. I call pre-op and tell them patient needs to go to ICU after.
I then get a call from pre-op saying patient had BP in the 60's and was not stable and their anesthesiologist was pissed. Watching their notes they wrote they said how she was consistently in the 60's, had to be given a shot of epi. They stated patient was completely unarousable and put her on a NRB (not sure about that one because all their charting had her in a 93-97 range and they only put it on for a short period). They then put in a note she was put on pressors for BP. And then they kept her down there for quite awhile. I called ICU to give report over 1.5 hrs after pre-op had a bed since no one called me and she was still down in pre-op.
Ultimately I feel bad because it looks like I ignored this patient but I felt like I kept pre-op abreast of what was happening. I let the doctors know about BP of which neither one of them were concerned. She had a very high WBC coming into the hospital (she was a sepsis diagnosis) from the previous night but all her vitals were WNL except the BP and I felt the mentation was directly attributable to a medication that I have seen zonk people out. When giving ICU report he says sometimes the transporting of a patient can be what makes the decline suddenly happen - which might be why her BP tanked even more on way to pre-op.
But I hate thinking a) I failed my patient and b) another unit/nurse thinks I just screwed them over.
