Priorities Can Kill: When Passing the Buck Gets Dangerous

Nursing is 24/7, right? So what if you don’t get to a task before the shift is over? Is it really necessary to push a doctor towards action (and thus annoy them to the bone)? It’s not like anyone suffered from lack of action… Or maybe you’re wrong.

Priorities Can Kill: When Passing the Buck Gets Dangerous

I couldn't breathe. My chest was aching with a fierceness that made me want to pass out. There was a pounding echoing in my ears so loud that I could hear my heart coupled with irregular breathing. Where did I screw up?! Inside my head I could hear my own voice screaming. What did I do?! I wanted to be sick. WHAT HAPPENED?!

The morning rushed before my eyes in a blur. The checklist started: Report was normal, I had read his labs, the initial assessment was benign-- why would things change so drastically and so fast?! I then remembered a nursing school professor tell me once that the smaller the patient, the faster you run. Unfortunately, this patient was a full-grown adult male and in a matter of 15 minutes he went from talking to me about what he wanted for lunch to unresponsive and gasping for air. What did I miss?!

I did the only thing I could think of... Call the rapid response team, STAT page the doctor and then pray that my patient could hold on long enough for another brain and set of skills to arrive on the scene.

My hands shook as I spiked a bag of saline to bolus a blood pressure that was steadily and rapidly circling the drain. His mean arterial pressure reading should have rang, whistled and had its own blinking emergency lights. When I looked up from our vitals machine the CNA was staring at me completely horrified. She began to edge closer to the code blue button. "Stop!" I forced out. "He has a pulse and he's breathing. Not yet." My words sounded foreign. Not yet?

Standing in the doorway I quickly read through his labs again. Everything was in the red but not critically red.

Then I saw it.

The big ugly culprit.

"Oh no. No, no, no, no."

His bicarbonate level leaped from the screen, almost lost among the metabolic panel electrolytes that are often reported with an oddly brainless faithfulness... The level was TWO days old. Each previous reading had literally been flirting with metabolic acidosis. And yet, there was no critical flag attached, no page to the doctor charted, no addressing of the situation what-so-ever (not even brought up in report or noted that it has been called to the nurse from the appropriate lab source). This critical value had slipped through the hands of doctors, nurses, and the laboratory team before now.

I looked over and watched the accessory breathing on my patient's chest. If I didn't do something now this man will be leaving this World today and at any minute. Responsibility crashed down with a vengeance as my mind rushed into the hyper-speed fueled by fight or flight. It really was life or death now.

Rapid response arrived with a flurry of orders. My resolve grew stronger at the site of my fellow nurse with her familiar rosy cheeks and flustered hair. We started hanging drip after drip. A fourth and fifth bolus, Trendelenburg positioning and then the big guns. 'I NEED DOPAMINE NOW!'

Somehow the dopamine was calculated, spiked, hung and started while we were simultaneously checking blood pressure, EKG changes, mean arterial pressure, capillary refill, placing oxygenation via a non-rebreather mask, calling the doctor (who wasn't answering the numerous STAT pages placed) and calling the Intensivist for a bed in the ICU. We begged for intervention without our hospitalist's orders, the ICU doctor had to be the one to make the call.

When the transfer order was placed in the system, I had the urge to go, go, GO! With minimal staff, we rushed my patient's bed down the corridor and burst into the intensive care unit. The hospitalist I had been paging all morning was left in our dust, looking utterly dumbfounded. I felt my blood boil at the sight of her standing there. I wondered what was so important in her day that she couldn't answer multiple STAT pages. I had to shake my head to release the past with my ill feelings because the present was ever pressing and malicious.

A scene unlike any I'd ever experienced emanated before my patient's bed as we rounded into his new room. It seemed as if the ENTIRE ICU was waiting there for us. My throat tightened and I wanted to weep. Knowing that regardless of the situation fighting to kill the man in my care, the culmination of what had been done and what was to be done could all be the things needed to save him.

The next moments unfolded like a dance. A fine waltz where everyone knew their turn, where they were going and knew the next steps needed to be. In a matter of minutes, multiple other IV sites were placed, a tube was in my patient's throat, a ventilator had been set, and all seemed relatively calm and controlled. My head was spinning after blurting out report over the rush, the waltz, which had come to an abrupt halt. Each individual in that room had listened to the details of my care that morning. Few questions were asked, some eyes were wide with disbelief and then, it was over. My role in this man's life was over.

I watched the milky bag of Propofol dripping through my patient's line and almost fell into a safe-guarded trance as the room fell silent, faint beeping echoing in the back of my mind. I slowly collected the tubes and tanks, linens and bed to return to my unit. My fight and my advocating were over. It was only now I felt as though I could breathe. The urgent need to continue praying for the man I had been talking to only hours before pressed down like rushing water. The phrase, "I hope he lives, please live, I hope he lives," played over and over in my head like a broken record.

Please, let it be so.

Upon returning to my unit, I addressed the physician that had successfully missed every call and page from me that morning. My mind has blocked the probable but likely inappropriate chiding and urgent requesting of more prompt response and attention concerning patient needs and emergencies in the future. At some point, I recall sitting down to write a S.A.F.E. report about the lab value that was missed and never acted upon or further investigated.

A week or so later I was getting off the elevator from the cafeteria. A woman exited that I recognized. It was my patient's sister. Fear gripped me for I knew what to ask and what I needed and wanted to hear. I stood tall and asked the dreaded question, "Is he still here? In the ICU?" She smiled a big smile. 'He's been off the ventilator for days. He's sitting up, talking to everyone, even eating and walking. He's going to make it out of here.' With that, she turned and headed on her way with a reassuring nod.

I stepped into the elevator and crumpled, nodding, as if in another trance. He's okay, you're okay, he's okay, you're okay. I wept for the few seconds I had to myself before getting out of that elevator to finish my shift.

In honor of a life that was almost taken by medical mistakes and a lack of action, I challenge all of you to remember that your role as a nurse is heavy and great. But, it is your duty to investigate, to ask questions and push to be the biggest and best patient advocate at all times. It is a great responsibility to have this on your shoulders, but without everyone working together for the greater good, we have the chance to do harm, cause pain and even hasten the end of a precious life.

Edited by tnbutterfly

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Jacqueline.Damm

About Jacqueline.Damm

Molded and formed by a drive to live up to her own expectations, Jacquie ultimately thrives on creativity. Dreams, testing her limits, and traveling all fuel the fire, thus leading to adventures of the past and yet to be: http://misadventuresofanurse.blogspot.com/

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you sound like supernurse, and to remember all those details, I applaud you! I hate to say this, but I'm glad to see more and more hospitalists LOSING their jobs, they are as useless as TITS ON A BOAR HOG! ANd I applaud you for your quick action, your accurate assessment, and getting all the help you needed for your patient in a timely fashion. You walked into a nightmare, and saw daylight. I'm seeing our doctors here more and more going to see their own patients in the hospital. I know hospitalists seemed like a good idea at the time, but like so many other things that do, right down the toilet.

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This is an excellent post considering some of the recent ones discussing whether one bothers to use a stethoscope, do an assessment, etc. Something as simple as one lab value can give the team a heads up on impending doom. We are all human and make mistakes. Sometimes our mistakes kill. I'm glad all turned out well for your patient. It sounds like you did everything you could to save their life.

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Specializes in Critical Care.

While the CO2 level might have been missed, I doubt that explains what happened with your patient. When a person is in acidosis they will become lethargic, even unresponsive and potentially stop breathing if not addressed, but that is usually a gradual process. The dramatic crisis your patient had most likely was a PE, flash pulmonary edema, ARDS or even an MI. You did the right thing by using the emergency response team. They are there for an extra level of support, with an ICU RN, protocol orders that can be initiated before you can get ahold of the Dr so the patient can be stabilized without coding. Even if you knew what was going on you would still need them to get the patient intubated and transferred to ICU before they coded. Ask the ICU nurses what actually happened they probably have an answer after all the tests and treatment in the ICU and you will probably find you did nothing wrong and the acidosis level you are worried about wasn't the primary reason for the patient's distress.

Things to do to expand your knowledge is take ACLS, attend a critical care conference, get certified in your specialty. Time and experience itself will increase your knowledge base and expertise so you will have a better idea what to do and suspect the next time this might happen. ACLS is very beneficial to increasing comfort level, knowledge and skill re acute situations, what to do, what meds and treatment are in order. These are just some ideas to increase your comfort level for the future. A silent prayer is always good too like you did. It certainly can't hurt!

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Specializes in psychiatric.

Propofol can be hung in bags?

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Specializes in Med/Surg, Onc., Palliative/Hospice, CPU.

Thank you annabelle123456 and xoemmyloex! I had a great time writing this article, and to be quite frank, it's an important story to share. I learned so much that day. Brainstormin' -they hang propofol drips in the ICU to keep a patient under sedation while intubated and on the vent. Brandy1017, thank you for your comment. I'm so glad you mentioned what you did. I am ACLS certified, but so much happened that day that I didn't understand. This is what I left out in my story... The rapid response nurse came back after my patient was settled in the ICU. She made a point to come and debrief the situation (I LOVE this about codes and rapid response situations). What we learned as we sat there at the computer and read through this man's chart was that he had kidney issues, COPD, heart disease, diabetes, and many other comorbidities. The CO2 level was the last trigger, the last straw so to speak, in a long line of health issues that led to the cascade of his metabolic acidosis. Long story short, all of the issues this man suffered from caused his body to compensate for a VERY long time. By the time I saw him, his body was deteriorating to the point that the compensation was spent and his resolve had grown too tired to fight. His medical history showed kidney disease that warranted hemodialysis, but he was on the cusp (so much that no physician was ready to dialyze him yet). Interestingly enough, dialysis would have been a GREAT (long-term) resolution to his kidney issues. I remember the nephrologist walking out of his room at one point saying "I can't touch him yet, he's too unstable. We need to get him better and able to withstand dialysis." So, here we were at a crossroads. Another moral of this tale, be ready to learn. My debriefing was the BEST thing to happen in the immediate aftermath of this rapid response. It's amazing to know how much there is to learn, that the curve is great, and that every day has something new, a stone yet to be turned. Thank you ALL for reading my article and supplying your fantastic comments. This circumstance is one that has led to a cascade of opened doors that I've applied to many situations since. It wasn't until I had a moment to sit down and take time to fully understand the extent of what I was working with that I truly grew from this patient's ordeal. Thank you, all of you! Happy New Year.

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Specializes in Psych, Substance Abuse.

Well written article. Thanks for sharing.

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Wouldn't it be appropriate to call an actual. Code Blue in This situation vs just a rapid response or am I in the wrong on this?

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Specializes in PDN; Burn; Phone triage.
Brainstormin' -they hang propofol drips in the ICU to keep a patient under sedation while intubated and on the vent.

The poster was being snarky. Propofol comes in bottles.

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Specializes in Pediatrics, Emergency, Trauma.

Things change in an instant...or sometimes it is an imperfect storm.

A great reminder to why the major issues can't be ignored and that advocacy and investigating IS a huge part and art of what we do...if no one else is checking, who will?

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I know this is a side topic, but propofol can be placed in a bag by pharmacy if the mL/hr is a high rate where you have to change the bottle frequently. If it's put in a bag, it's only good for 6 hours vs the 12 hours from the glass bottle (I think those numbers are correct. We tend to use fentanyl and versed drips with or without vec depending on the situation).

To to the original poster, it sounds like you did everything right! Thank you for sharing :)

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Why would call a rapid response versus a code blue? You said the lab was checked for two days,who is responsible for making sure checking the C02 lab ( was the doctor supposed to order it, was the nurses supposed to call and ask the doctor to order it ). Was anyone written up or receive a verbal warning for this or was it nobody's fault? What could have been done differently in this situation to prevent it, if anything?

When you hung those bags of bolus fluids , did you have an order or is this a protocol on your unit ?

FYI : I don't have RN experience yet so I'm not sure what to expect in this type of situation.

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