*Sigh* another vent. My poor pt died. Long...

[Bumashes, MSN, APRN, NP]

I am blessed by the fact that about 90% of the drs I work around in my hospital are very open to a nurse's ideas and assessments. However, sometimes it just doesn't happen. So here's one for all you neuro nurses to cringe over...

I work on a med/surg/tele/onc floor. Very busy of course. One of my pts was a recent hemorrhagic stroke victim on day #2 in the hospital. In her early 80's and purportedly one of those who still chopped-her-own-wood type ladies until this happened. Upon first assessment, she was alert and oriented x1. She could hold her own cup and swallow her liquids and pills just fine. She could speak clearly and had no sensory or motor deficits. She couldn't properly identify objects, though. When asked what a pen was, she said a dishwasher. Cute. Pupils were definitely off. The right one was dilated and did not react. The left was dilated and reacted sluggishly. Anyway, so I was thinking this little lady was pretty lucky comparatively. This was 0700...

At 1300, the family called me to the room b/c the pt was red-faced and sweating. She had a mild fever at 99, and she was only hot around her face and chest/neck area. So I gave her a cool rag wipe down, turned down her room temp some, and gave the rag to the daughter who said she'd keep changing it up. Checked VS. Stable, but BP was elevated. It had been 145/84 in the am, and was now 185/92. Gave her a small dose of PRN clonidine. Instructed daughter to watch her closely, and I would try to be in every 15 minutes ( on med/surg no less!) One hr went by. The sweating stopped, her face stayed red and hot, the temp resolved, the BP was still high, but not as bad, but... I just had a premonition something bad was about to go down. Next check finds Glascow of 12, and pupillary reactions slightly changed. The right still remained dilated and nonreactive, but the left, which was still dilated, would start to constrict and then dilate again, whereas before it had just sluggishly constricted. I was calling and asking for advice from the neuro floor when the neurosurgeon arrived on scene to do his rounds finally. This is 1500.

*Sigh* He's one of the 10%. Actually, he falls into a different category b/c not only does he not listen to you, but he tries to demean you and be as rude as possible. Yay. Anyway, I don't care. I can be a ***** with the best of them when it comes to my pts. So I inform him of the goings on and he politely seems to listen. Then, when he makes no response, I take a hint and go check my other pts. He isn't big on discussing plans with us "underlings." So when I return, I look at his order. "Place 10 MD order sheets and 10 Progress Note sheets in chart immediately. Now." Whatta idiot.

So I keep watching my lady... At 1600, I have a Glascow of 9 and pupils are fixed and dilated. I call the neuro people up again and they give me advice on not moving the pt if possible and to keep her HOB up and all those ICP things that I vaguely remember from nursing school.

By 1700, I'm worried. The pt's daughter is worried. Glascow of 3. No responses from pt to auditory, tactile, or painful stimuli. Pupils are pinpoint and nonreactive. No corneal reflex. No nothing except she's still breathing on her own. I call Mr Talkative and inform him of the changes. He says "That's all I need to know." *Click* Wonderful. I'm ******. The daughter can sense how ****** I am even though I try to be calm and reserved. I understand that surgical intervention isn't exactly the best option for an 80 y/o lady, but you know what? It's not up to him! This lady was very active prior to this. It's not like she was just a couch potato waiting to die. She had quality of life. Something to live for. Her husband was at the bedside for a while and kept asking me what's wrong, why's she sleep so much, when can she come home?...

At 1800, the dr calls back and says, "Well, I guess we could do another CT scan on her." Yay! So I sent her off to the CT scanner while I tried to catch up on everything I'd missed during the day while worrying over her. I was there late as a matter of fact. I didn't leave until 2030. So I saw the results. They weren't what I expected. The scan showed no significant changes to the bleed. BUT I KNOW WHAT I SAW!!! I watched this lady go from almost normal to almost nothing over the course of a few hours. I knew I was right. CT scans aren't perfect, but they're all we've got sometimes. However, everyone's heard of "Don't watch the monitor, watch the pt." This was one of those times, I knew.

I was off the next day, but my coworker called and told me that she had gotten the pt for the day. The pt had recovered some function overnight (Glascow of 8) but had gotten rapidly worse over the morning. The dr hadn't wanted to send her to the ICU, but he did eventually. She went back down to a Glascow 3 on the floor and then went to the ICU. Then, the dr spoke to the family and convinced them to make her a DNR. She died 2 hrs later at 1400... Poor little lady.

Whew. Thanks for letting me vent guys. I needed that. I've been carrying it around for a few days now.

[Reminisce]

This might be a dumb question to most of you who are nurses already, keep in mind I am 18 and curious, is there a lot of death in the ICU? is ICU where the majority of the death happens?

[Penelope_Pitstop, BSN, RN]

*Hugs*

CVA patients are complicated. I work on the stroke overflow floor and I will say this...give me an ischemic stroke over a hemorrhagic stroke ANY DAY.

The bleeders, at least in my institution, tend to be sent to the ICU or at least IICU for the first day or so because of their unpredictability. A lot of times, what you're describing does happen, especially with the elderly.

You did all of the right things, that's why we do our neuro checks so frequently.

We recently became a certified stroke center, and we actually have a "stroke alert" team. I think that's made a huge difference. Without those resources, though, you're a bit stuck.

What freaks me out about the bleeders vs. the occluders is this: in an ischemic stroke, a high BP isn't really a "bad" thing, because it's telling us "hey! The brain is being perfused! There is a potential for penumbra recovery!" whereas with the hemorrhagic CVA, we're afraid that more bleeding is happening with a high BP, but we want to maintain perfusion all the same!

You fought the good fight. And tomorrow, you'll fight it again.

[Penelope_Pitstop, BSN, RN]

This might be a dumb question to most of you who are nurses already, keep in mind I am 18 and curious, is there a lot of death in the ICU? is ICU where the majority of the death happens?

I don't know where the majority of death happens. It depends on the patient population and the institution. The ICU patients are the sickest, so they are technically the most likely to die. However, some patients are terminally ill but are not in ICUs because ICU treatment isn't indicated.

I'd say hospice has the highest percentage of patient demise. But that's a different subject altogether!

[TheCommuter, BSN, RN]

is ICU where the majority of the death happens?

Hospice is the nursing specialty where the majority of patient deaths take place. After all, hospice patients are very sick, have terminal prognoses, and are typically given less than six months to live.

[ICURNEm]

Roughly 1/3 of ICU patients die, 1/3 have lasting effects from their illness and 1/3 make a complete recovery.

[Davey Do]

Bumashes:

I will chime in with CamaroNurse (C'mon, CN, I'll say it with you now) "You did all of the right things". You did what you could.

In reading your post, I noted that it was factual, succinct, and pretty darn good documentation.

You put principles above personalities. When the doc was not playing well with others, you kept your focus where it needed to be: on your patient, her care and treatment, and her family.

Venting is a good catharsis and helps to get our brain back in balance. Singing helps, too. So, recognize your good work and start singing your own praises.

The best to you.

[casi, ASN, RN]

If you have the option to call a rapid response do it. Better to get a team that will listen to you than get a butt of a doctor on the phone.

[Bumashes, MSN, APRN, NP]

Thanks for the support guys. I just really had to get it off my mind and over to others who can relate. And you can be darn sure that my charting was even more in depth and thorough, complete with calls and notifications and quotes of what I told the dr and what he responded with. I am most upset b/c this dr seems to like to play God. If you're above a certain age, he is not the dr you should see b/c your life will hold no value to him. Seen it before and will see it again with him. *Sigh* I've cried my tears and said my prayers for my little lady. Thanks again y'all.

[NurseCard, ADN]

You did a good job. Kudos to you. Sounds like in this ladies case, there probably wasn't a lot that could have been done for her; the bleed may not have been fixable in any way. However, the doctor could have been more... I don't know, sometimes I wish that not only would doctors be more sensitive, but I wish that they would be nice enough to explain things, and in a nice way too, not in a "You should know this, idiot" kind of way. No, I SHOULDN'T know certain things, *idiot*, I didn't go to medical school!

But anyway, I HAVE known doctors that would take the time to explain certain disease processes to a nurse like me =), and I am forever grateful.

Oh, wanted to add something... there's a doctor where I work that likes to write the same kind of orders... "Please place patient stickers in chart". Mmmm, kay. "Reminder, patient is to have meds dosed at 9am." Mmmm, okay, where's the ORIGINAL order to dose those meds at 9am instead of 7??? And why the reminders?? What really makes you think we aren't following your original orders???

[CNL2B]

I am obviously not a medical provider but I will give you my two cents.

Regardless of age, this lady should have been transferred to an ICU after it was determined that she was in the middle of a hemorrhagic CVA and was hypertensive. Hypertension is only going to put pressure on those poor little cerebral vessels and extend her bleed/CVA. This could have have possibly prevented her mortality in this situation -- obviously none of us have or could read the CT, and she may have had significant deficits upon recovery, but she may have recovered. This lady needed aggressive B/P management, probably with a Nipride drip or something similar. She also needed management if her blood happened to be thinned, and rapidly (you didn't mention this, don't know if that was the case.)

At my hospital, the floor nurses have a rapid response team that they call for a variety of issues --> one of them being acute neuro changes. They then institute what is called a "stroke protocol" and do a whole lot of interventions within an hour, including a repeat CT scan, WITHOUT the input of the provider. They are responsible during this process for calling the provider then and arranging appropriate care, generally which means transferring the patient to the ICU.

No, the lady may not have been a surgical candidate (I don't know, another one of those things nurses don't get to decide, and rightly so.) However, before a doctor decides he can just sit on significant neuro changes (sorry, perhaps I should have said "monitor" instead of "sit on", right?) he needs to have a discussion with the family as far as how aggressive they want to get with treatment. If he hadn't done that (e.g., she hadn't been made a DNR), she should have been treated more aggressively. And, really, what does that mean? A transfer to an ICU bed for closer monitoring, probably an arterial line, and an IV infusion of antihypertensives. We aren't talking about doing anything crazy or revolutionary here. From what I've seen, that's the standard of care.

I would call this situation borderline negligent on the part of the physician, which if I am not mistaken, falls into the malpractice category. Does your NM know this happened? The whole situation and the assessment and treatment initiation times should be reviewed closely to see what could be done better. Yes, this lady was old, but it sounds like she was in good health previously. Pretty atrocious, if you ask me. I'd be furious if that was my family member.

[passion4people]

Bumashes.......You are still fairly a new nurse,but you are the kind of nurse I would want taking care of me and my loved ones. Know that you were attentive to your patient and did what you were called to do. I believe the family had comfort in knowing that they had a caring and competent nurse caring for their loved one. Having to experience the loss of my brother the same way, it does make a difference. God Bless.........