Sepsis....I called it!

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Specializes in Cardiac Telemetry, ED.

The other night I had a patient that had me worried from the moment I got report. He was a young guy with a history of COPD, MI, smoking and ETOH, admitted for pneumonia.

Clinical picture, his pressures were fine, in the 130s systolic. Respiratory rate was 24-28, sustaining sats in the 90s on 2L NC. BUT he was tachy, in the one fourties sustained, febrile at 39C, his lactate was elevated, bowel tones hypoactive and poor appetite, and he was anxious.

Blood cultures were still out, but I knew this guy was septic and headed down a bad path. I called the MD with my assessment findings of elevated body temp and tachycardia, gave pressure and RR, and the MD said he only wants to know if the blood pressure drops and the patient has respiratory distress. No specific parameters. He gave me an order for APAP "if it will make you feel better".

I went to my charge nurse and told him my concerns, the doc's response, and asked if he would come take a look at the patient himself, which he did. CN tells me just to keep watching; that he doesn't want the patient to look any worse than he does, and when he starts to sustain a RR in the 30s, it's time to do something.

So, I watched. And waited. I knew. It wasn't til the end of my shift that things started to turn (of course!!!!).

The pressures had started to trend down even though the patient was getting fluids at 200mL/hr (lowest systolic was 118), HR was sustained in the 140s despite 2g of IV mag. Temp was holding steady at 39. UOP was low. Work of respiration increasing, but still not "distress". I called respiratory to come take a look and give me their opinion. This guy, IMO, was textbook septic shock-SIRS-ARDS-MODS material. Still not time to call the doc, but getting closer.....

So, in report, I passed it on. Had no choice, it was time to go, the patient was starting to turn but hadn't turned yet. I told the oncoming nurse "You need to watch this guy like a hawk. He *will* be going sour.".

I come in today and find out, oh....he was transferred up to ICU in the night. SURPRISE!

I was just dying to look up his chart on the computer to find out what specifically had happened, but I restrained myself. HIPAA, after all.

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Specializes in ICU.

Good for you!!

Personally I think ALL doctors should spend some time in ICU - just to see what Septic shock is all about.

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Specializes in Cardiac Telemetry, ED.

I don't want to dis on the doc. I think he's pretty sharp, actually, and I think he had the exact same thoughts as me. He was doing everything I know of that he could do...the patient had respiratory care orders, was getting antibiotics and a lot of fluids...I think it was just a waiting game really. We can't send him to ICU until it's warranted, and by admitting him to our unit, the doc knew the patient would be monitored closely since we have tele and are used to some pretty sick patients. I just wish he would have communicated some more specific parameters, and I was dismayed at his attitude about the APAP. It really surprised me that he didn't think it would be of much value and it would have been nice for him to tell me why. Part of the problem is me, in that I'm lacking in a certain amount of confidence in dealing with doctors because of my inexperience.

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Specializes in Med-Surg.

Good job. Sepsis is a big killer and usually people crash before we recognize and treat it.

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The other night I had a patient that had me worried from the moment I got report. He was a young guy with a history of COPD, MI, smoking and ETOH, admitted for pneumonia.

Clinical picture, his pressures were fine, in the 130s systolic. Respiratory rate was 24-28, sustaining sats in the 90s on 2L NC. BUT he was tachy, in the one fourties sustained, febrile at 39C, his lactate was elevated, bowel tones hypoactive and poor appetite, and he was anxious.

Blood cultures were still out, but I knew this guy was septic and headed down a bad path. I called the MD with my assessment findings of elevated body temp and tachycardia, gave pressure and RR, and the MD said he only wants to know if the blood pressure drops and the patient has respiratory distress. No specific parameters. He gave me an order for APAP "if it will make you feel better".

I went to my charge nurse and told him my concerns, the doc's response, and asked if he would come take a look at the patient himself, which he did. CN tells me just to keep watching; that he doesn't want the patient to look any worse than he does, and when he starts to sustain a RR in the 30s, it's time to do something.

So, I watched. And waited. I knew. It wasn't til the end of my shift that things started to turn (of course!!!!).

The pressures had started to trend down even though the patient was getting fluids at 200mL/hr (lowest systolic was 118), HR was sustained in the 140s despite 2g of IV mag. Temp was holding steady at 39. UOP was low. Work of respiration increasing, but still not "distress". I called respiratory to come take a look and give me their opinion. This guy, IMO, was textbook septic shock-SIRS-ARDS-MODS material. Still not time to call the doc, but getting closer.....

So, in report, I passed it on. Had no choice, it was time to go, the patient was starting to turn but hadn't turned yet. I told the oncoming nurse "You need to watch this guy like a hawk. He *will* be going sour.".

I come in today and find out, oh....he was transferred up to ICU in the night. SURPRISE!

I was just dying to look up his chart on the computer to find out what specifically had happened, but I restrained myself. HIPAA, after all.

Does HIPAA really prevent you from seeing what happened? I would think it would be very valuable learning experience for you to know exactly where those s/s's. It's not just curiousity.

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Specializes in Advanced Practice, surgery.

Not sure of the legalities in the US but if this had been one of my patients in the UK I would take a little wander up to the ICU and see how he is doing myself.

Our ICU's are very helpful and tend to keep the ward staff informed of how thier patients are progressing

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Not sure of the legalities in the US but if this had been one of my patients in the UK I would take a little wander up to the ICU and see how he is doing myself.

Our ICU's are very helpful and tend to keep the ward staff informed of how thier patients are progressing

Once they are out of our care, we no longer have a 'need to know'.
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Specializes in CMSRN.

I agree that it could be found to be a possible violation. However if this could educate you and others regarding sepsis then that is considered valid. Students share info amongst each other for that very fact.

I would not look it up but I would take a walk to ICU. Ask your manager and present it as education and see what they think. No harm in asking.

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Specializes in LTC, FP office, Med/Surg, ICU, Dialysis.
I agree that it could be found to be a possible violation. However if this could educate you and others regarding sepsis then that is considered valid. Students share info amongst each other for that very fact.

I would not look it up but I would take a walk to ICU. Ask your manager and present it as education and see what they think. No harm in asking.

Good job for being vigilant!

I agree. It's crazy that you can't follow up on your patient's status due to HIPAA. It's not that you're snooping just to feed your curiousity or to prove somebody's fault, one need to know for educational purposes. But if you really legitimately want to know (for educational means), I'm sure there are ways to obtain the info ;) .

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Specializes in Med/Surg.

When a pt is transferred off our unit , we no longer have computer access to them. By HIPAA we no longer have a need to know and our computer will not "bring up" the chart for any pt that is not assigned to our unit. "They"(you know who they are") really don't want us to look up any pt that we haven't been assigned ,once we clock in and enter our assigned pt's on our status board ,those are the only ones we have "a need" to know. Only way to see how someone is doing ,call the unit and hope for a nurse you know or go see the pt if you have time.

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Specializes in Advanced Practice, surgery.
Once they are out of our care, we no longer have a 'need to know'.

Wow that's really tough especially if the patients will be coming back to you post ICU. The one thing that I do like is checking up on my patients to see how they are doing.

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Specializes in Cardiac Telemetry, ED.

Yes, once we are no longer assigned to that patient, the "need to know" does not exist. At our facility, we can look up any patient in the hospital, which is nice if you're getting a patient up from ED. Once they're in the computer system, you can look up their labs and diagnostics before they even get up to the floor.

Anyway, I'm off for a couple of days. Maybe he'll come back to our unit when he's doing better. I'll be able to look up what happened then, if I am assigned to care for him.

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