Share your story: "I hate it when I'm right!"

kstockdaleRN · Aug 10, 2006

Along these same lines - all you new students out there -

When you start nursing, you generally don'thave that "gut" feeling yet - BUT if you patient says "somethings wrong" or "don't let me die" PAY ATTENTION. They are always right.:)

goats'r'us, ASN, RN · Aug 10, 2006

and it's always the day from hell, right? as you read this story, i want you to imagine it happening with 2 fire alarms, about 14 other patients, 3 discharges and 2 patients returning from theatre.

mine's partly a 'something wrong with this patient', but also a 'something's sketchy about this co-worker'.

came for a pm shift, got handover and allocation. each of our wings was staffed by 2 people on a pm shift, and i was up one with a fairly new en (i shall call her...betty). at the start of the shift we'd decided we'd split the wing and take half each, and i stressed to her (since she was new-ish), if you need help, come and find me, and i'll do the same. i was a grad at the time, but i figured i ranked higher than her, so should make myself available if she needed help.

not long into the shift, i was at the desk and the phone rang. answered it and spoke to the worried wife of one of betty's patients, calling because when she'd been in earlier, he'd seemed vague, and he had barely eaten or drank all day. he was a day 2 tkr, and betty wasn't around to take the call, so i grabbed his notes to see what the am people had said, and reassured her that it was fairly common for post-op people to be confused, especially since they'd had to take down his pca that morning as he was knocking himself for six with his 5mg morph boluses (what, i ask, whas the anaesthetist thinking??). i gave her my word that we were aware he was confused and that we were keeping an extra eye on him and would go encourage him with his tea.

after that call, thought it prudent to discuss it with betty. found her in his room, discharging another patient, and looked in on this man, who was at that point talking on the phone with the handset upside down. righted the phone, had a few words to him, and came to the conclusion that something was amis.

spoke to betty, and decided we would share this man so that we could both watch him. told her i was going to speak to the nurse in charge, and asked betty to do vitals on him.

had a chat to the ic, citing 'something' being not right, confusion, and said 'it's probably just the morphine, but i'd hate for him to be having a heart attack or something'. she remembered that the guy was a mouth breather, and they'd had trouble with his sats post-op, so asked about his spo2, and recommended a mask rather than the usual nasal prongs.

went up to his room, and asked betty about his sats, and she said she was just about to check them. noted that he was on nasal prongs, so swapped him over to a mask and left betty to it.

went back to the desk and thought i should document his wife's concerns and my observations, and betty came and joined me a few minutes later. just as she sat down, i had an epiphany.. they'd removed his idc that morning, and i wasn't sure if he's passed urine since. sent betty up to check his bottle, and heard, a moment later, a worried voice calling me. entered the room to find the man standing, unaided, in the middle of his room, on his fresh new knee, looking lost. could get no sense from him, and he'd removed his mask. replaced the mask, and set about trying to encourage him to sit down, but to no avail. eventually said to betty, go grab 'j' (nurse in charge), i want her opinion.. it's probably just hypoxia, but i'd hate it to be a heart attack or something.

when 'j' cane up, she asked about his vitals, and betty said they were ok, so she set about trying to get him into bed (or a chair). he was now being paranoid too, and we started thinking about etoh withdrawal.

i got called away (it was now about 8pm and old ladies were asking to be settled for bed), but ran into 'j' in the hallway, who said that the man was back in bed but was now c/o chest pain, so she was calling the hmo.

betty was already getting the ecg machine, so i grabbed the obs machine and busied myself. it was then that i discovered what the odd feeling about betty was... the little turd hadn't done his vitals! :angryfire i went to record them and the previous ones were marked as 10am (it was almost 9pm). please remember that this is a post-op patient who, by protocol, should have q4hr obs.

obs were ok, sats a little low, set them to go off q5min, just in case. hmo arrived and couldnt decide between etoh and pe, so acted for both - a valium and some scans. very luckily, the patient was much calmer by then (probably a mixture of the oxygen and just being overwhelmed by the action surrounding him).

i took him to ct, while betty settled the wing, and due to a fire alarm, didn't get back to the ward till nearly 10, just as the physician arrived to check him out. left him to it and went to see if the results of his bloods had arrived. phone rang, and it was pathology, saying 'we just faxed some very urgent results'. pulled them off the machine and glanced at them, and my guts hit the floor.. 'troponin' followed by a very big number.

5 minutes later i was taking him to icu with a massive anterior infarct, thinking 'dammit, i said i didn't want it to be a heart attack!'

happily, i had 2 days off after that, and when i got back to the ward he was back in our post-op care room, looking a distinctly better colour.

i hate it when i'm right, i would have preferred post-op confusion/dehydration/etoh withdrawal/anything else (except maybe pe) that we considered

as a side note, i also learned not to take anyone's word that they'd done something i asked them to do. was livid that obs weren't done, as it made it look like i didn't know what to do when something was amis.

crikey! that was a long story, sorry if i blathered

picuman, BSN, RN · Aug 10, 2006

Had a unresponsive man ETOH who I knew needed the ER doc to look at. But his comment was that it was just another drunk. I insisted that the man was UNRESPONSIVE you know NO GAG REFLEX. The ER doc continued to neglect my patient. When he finally did come over and cram a tongue blade into the patients throat which caused him to vomit and aspirate. Now the ER doc wanted to intubate my drunk man. He did apologize after, but, the patient ended up with aspiration pneumonia.

Medic/Nurse, BSN, RN · Aug 10, 2006

Had my share! I often kinda HATE it when I'm right and have to take on the fight, because that has usually meant a bad (although accurate ) diagnosis for a patient. Not all have happy endings.

A few that stand out -

Young man (almost like a brother) MVC with sternal injury, in local hospital - being observed, 24 hours in he is just looking WORSE. Low gain ECG tracing, ST changes, narrowed pulse pressures and (Ta Da!!!) JVD - hmmmm, could this be cardiac tamponade??? Cardiologist wanted to argue, but I am pretty good at standing my ground and I'd whipped mom up to a "near frenzy" - so he said "we will get a CAT scan and end this nonsense" (Still not sure why the CT vs. US - but I stopped arguing at that point).

Well, IMAGINE my surprise when I was summoned for emergency transport to tertiary care 200 miles away! (They tapped 80ml from the pericardial space!) Pt did just great! Cardiologist is now a fan! I still think he is a bit of an idiot??

Another -

40ish cousin (very stoic) atypical chest pain: pt pale, clammy, borderline sinus tach with nonspecific ST - got some relief with NTG (pressure did not hold for a lot of it) morphine minimally helpful. Took him to local ED - the ED doctor dismissed the possibility of chest pain and went with GB disease (pt thin, not vomiting, etc) - I advised this doctor of the STRONG family history (Pt dad ~ my great uncle~ died at 50 AMI, all the men had heart disease) and that I feel this is was, although atypical, a cardiac cause - ED doc dismissed me - no monitor, markers, EKG !

Well, imagine the grief my family felt when 12 hours later when my cousin clutched his chest, asked his wife for a drink of water and then DIED on the medical floor. (The GB was just fine on autopsy.) The ED doc should have already been retired, this sealed the deal! Too LATE!

ALL about PE'S (Pulmonary embolisms)

I know the rage in clinical practice right now is CT Chest Angio of any chest pain (if on BCP's, travel, smoking history, immobility, etc) to r/o PE. I have NEVER had the CT turn up a surprise PE!

ALL clinically significant PE's share common presentations:

1. Short of Breath

2. Chest pain generally, can increase with inspiration - not always reliable

3. Oxygen saturation is always lower than expected. Usually 88 - 92% if compensating well.

4. High Heart Rate!

All these 25 year old CP's, that smoke on BCP's that have HR 75, SaO2 100% on RA - DO NOT HAVE PE'S! But, lets radiate 'em anyway - you never know. :) Just a little rant...

UM Review RN, ASN, RN · Aug 10, 2006

ALL about PE'S (Pulmonary embolisms)
I know the rage in clinical practice right now is CT Chest Angio of any chest pain (if on BCP's, travel, smoking history, immobility, etc) to r/o PE. I have NEVER had the CT turn up a surprise PE!
ALL clinically significant PE's share common presentations:
1. Short of Breath
2. Chest pain generally, can increase with inspiration - not always reliable
3. Oxygen saturation is always lower than expected. Usually 88 - 92% if compensating well.
4. High Heart Rate!
All these 25 year old CP's, that smoke on BCP's that have HR 75, SaO2 100% on RA - DO NOT HAVE PE'S! But, lets radiate 'em anyway - you never know. :) Just a little rant...

I have to disagree here. I've had patients with PEs that had only vague s/s. One strapping young fellow came in for treatment of CP and had an occasional dry cough, full breath sounds, satting >95% on Room air, but they did a D-Dimer in the ER anyhow, and surprise, surprise! the fella came up >1000 and the CT angio showed multiple PEs.

There were a couple of patients who freaked me out like that, so now I take no chances. After all, what're the consequences of doing a CT angio and someone's negative? Nothing. But to miss someone who's positive?

Very very bad. I haven't seen many successful Codes with patients who had missed PEs.

prmenrs, RN · Aug 10, 2006

This one is funny:

Friday mornings, the ophthamologist comes to do eye exams (for Retinopathy of Prematurity). Every baby scheduled for one gets a big picture of an eye attached to his/her bed, about an hour before the eye doc plans on being there, he would call and tell us to "drop them"--give the dilating eye drops.

We had a really nice, funny eye attending @ the time and he came into the small nursery I was in to set up to do the selected victims, I mean pts. He puts his head light thing on, goes to plug it in, light doesn't turn on, he tries another plug, same thing. Meanwhile, he's looking up @ me (he's down on the floor looking for outlets), saying, "it's not working, I can't get it to turn on", kinda panicky like his $$$$$$ light is maybe broken.

And then I noticed something--the plug has 2 ends, one to the outlet, the other to some plug on the light. So I pointed @ the other end, "does THAT go anywhere??"

He stopped and looked @ me again and said, "I'm never going to live this down am I?" "Absolutely not, Dr. G!!" :devil: :lol2: