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Time to vent - my apologies in advance.

Med-Surg   (8,479 Views | 37 Replies)

Levitas has 5 years experience as a BSN, RN.

5,585 Profile Views; 185 Posts

Okay, let me begin by stating that I do not like to complain about my assignment at work. I just don't. I feel like we're here to help people, and my preference of patient should never determine my attitude while taking care of people who need me.

That being said, I had an interesting night at work the other day. (Sorry for the long rant.)

I've observed that a number of my co-workers aren't keen to the idea of having a patient who needs blood transfused. I get it, it can be time consuming. In the ICU, where you might have 2-3 patients, it's almost more manageable than on the Med/Surg floor where you've anywhere from 4-8 patients.

Myself? I actually don't mind transfusing, at all. But there are certain... things that absolutely irk me, and here's one of them...

I get into work, told by the day nurse that I'm getting an immediate admission from the ED, and that the patient will need 2 units PRBC's, no problem, really. This patient had a hemoglobin of 5.2, mildly symptomatic in the ED, mind you.

The patient hits the floor about 20 minutes into shift. No blood band on the patient, no problem, I proceed to complete my admission otherwise, and decide to pass meds to all other patients until Lab is finished cross/matching their blood.

An hour and a half goes by... I call down to Lab, just to check on the status.

"I don't see any order for a cross/match." Lab says.

You have got to be kidding me... This patient had been in the ED since Noon that day. Her labs were completed, and reported to the ED by 1430 that afternoon... The patient hit my floor at 1950. 5 hours...

5 hours without anyone, Doctor, Nurse, anyone making mention to the Lab that we needed a cross/match. It's one thing if the ED was swamped, and couldn't get the blood started, I can understand that, but to not even pick up the phone, and get the cross/match?? Seriously?

I immediately call the ED, and the nurse who brought the patient up tells me, "I didn't really get report on the pt., I was asked by the day nurse to transfer the patient up.

I asked, "Were you aware that this patient has a Hgb of 5.2?"

They state, "Day nurse told me it was low, but I didn't know how low."

Me, "May I speak with the nurse who had the patient?"

ED, "They're gone for the day. The doctor too."

Sigh.

I call the attending, and get the order myself. Call down to the Lab, and ask if they can get this one done, stat, due to how long the patient has already been waiting. Fortunately, they did. However, the patient's blood had antibodies.... Ergh.

The blood wasn't available until 0330, and they were febrile, so I had to wait another hour (post acetaminophen) before starting transfusing at 0500. What a mess.

And I can see how this would have ended, especially if the patient continued to be symptomatic. The cross-hairs would have been on my forehead... Nuh uh, ain't happenin'. I absolutely hate doing it, but I reported this incident. To the supervisor, the clinical leader (on my floor, and the ED), as I refuse to be bait for someone else' negligence.

Had I been the one on the phone to get the report (remember, the day nurse had already gotten report, and just handed it off to me when I came in), I would have resolved this before the patient hit the floor. But it was a cascade of mishaps, just waiting for me when I walked into the door.

The cherry on top? I ended up with another admission at 0530, almost at end of shift, and that patient came up with an infiltrated IV, haha (I laughed at the time too).

Really though, you guys don't think I was in the wrong for being upset, do you? Or that I reported the incident? I mean, that patient could have been seriously injured due to this oversight. I've got to protect myself as much as the patient, yes?

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292 Posts; 5,508 Profile Views

You were correct to report this because there is a problem in the system that must be corrected. A lab value that low needs to trigger a process that leads to the problem being taken care of.

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Momma1RN has 6 years experience as a BSN, RN.

214 Posts; 6,439 Profile Views

I would have filled out an incident report as well. You did the right thing.

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tokmom has 30 years experience as a BSN, RN and specializes in Certified Med/Surg tele, and other stuff.

4,568 Posts; 48,765 Profile Views

You did an amazing job and yes, I would have written up the debacle too. Not for retribution, but for tracking a possible flaw in the system.

Your ED resembles mine. The ED nurses believe they are the bomb, yet don't use their critical thinking skills that pertain to the pts diagnosis!!

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Momma1RN has 6 years experience as a BSN, RN.

214 Posts; 6,439 Profile Views

You did an amazing job and yes, I would have written up the debacle too. Not for retribution, but for tracking a possible flaw in the system.

Your ED resembles mine. The ED nurses believe they are the bomb, yet don't use their critical thinking skills that pertain to the pts diagnosis!!

Sometimes I don't understand what goes on in the ED. Had a patient sent up once, for SOB. "lungs are clear!" Got up to the floor and within 30 minutes she had coded (probable PE). Her lungs were NOT clear. Sigh.

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1 Article; 1,068 Posts; 24,937 Profile Views

Agreed, you did the right thing; for your patient and for yourself.

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CardiacKittyRN has 1 years experience and specializes in Cardiac.

144 Posts; 3,406 Profile Views

You have ever right to be mad!! I agree it's a systems flaw. I personally think ED should have a certain amount of time from when they received an order to when it must be carried out. At my facility, that lab would be considered a "critical value" and per policy must be paged and addressed within 45 minutes. I wonder sometimes what goes on down there as well.. I know they are busy and its a different beast, but a floor nurse would know.. Needs blood, stat type and screen, page the doctor & get the ball rolling.. It's sad that a lot of the time their focus is just move em on .. Either out or up, what happens next isn't their problem.

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That Guy has 6 years experience as a BSN, RN, EMT-B and specializes in Emergency/Cath Lab.

3,421 Posts; 33,326 Profile Views

Sometimes I don't understand what goes on in the ED. Had a patient sent up once, for SOB. "lungs are clear!" Got up to the floor and within 30 minutes she had coded (probable PE). Her lungs were NOT clear. Sigh.

Then come on down and spend a few days with us and see that people with PE can have clear lung sounds.

In patients with recognized pulmonary embolism, the incidence of physical signs has been reported as follows:

  • Tachypnea (respiratory rate >16/min) - 96%

  • Rales - 58%

  • Accentuated second heart sound - 53%

  • Tachycardia (heart rate >100/min) - 44%

  • Fever (temperature >37.8°C) - 43%

  • Diaphoresis - 36%

  • S3 or S4 gallop - 34%

  • Clinical signs and symptoms suggesting thrombophlebitis - 32%

  • Lower extremity edema - 24%

  • Cardiac murmur - 23%

  • Cyanosis - 19%


    Not only that, but it is weird to me with that low of a Hgb, pt being symptomatic, that they weren't transfused in the ED. We can do it MUCH faster than you guys can ( not a dig on you guys at all just how we are allowed to do things ). I would report it to to hopefully help find a flaw in what was going on. Who knows, maybe the admitting doc said to just get them to the floor.

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31 Posts; 1,518 Profile Views

As an ED RN, I'm really enjoying all the over-generalization and ED nurse bashing. We could start bashing you guys as well, but lets keep it civil.

For the record, I'm curious as to why they weren't transfused in the ED and if it had been my patient I probably would have at least started the first unit. Then again, I don't know what else was going on with the patient or in the ED at that time. What exactly do you mean by mildly symptomatic?

Also, as others have pointed out you can in fact have clear L/S w/ a PE. What was the rest of this patient's presentation?

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

6 Followers; 4 Articles; 20,908 Posts; 149,564 Profile Views

Just to note....I had a PE recently and I had clear lungs.

I think the ED should have transfused...i would need more information but that should not have been left alone.

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SwansonRN has 2 years experience.

465 Posts; 9,713 Profile Views

Well nice job getting the job done, at least! You can go home thinking that you definitely left the patient better than you found them, which is always a good feeling.

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tokmom has 30 years experience as a BSN, RN and specializes in Certified Med/Surg tele, and other stuff.

4,568 Posts; 48,765 Profile Views

As an ED RN, I'm really enjoying all the over-generalization and ED nurse bashing. We could start bashing you guys as well, but lets keep it civil.

For the record, I'm curious as to why they weren't transfused in the ED and if it had been my patient I probably would have at least started the first unit. Then again, I don't know what else was going on with the patient or in the ED at that time. What exactly do you mean by mildly symptomatic?

Also, as others have pointed out you can in fact have clear L/S w/ a PE. What was the rest of this patient's presentation?

Not bashing, but at the very least a type and cross should have been ordered along with the other labs.

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