I had a patients family member who was a doctor come up to me during my shift and stated that they just came to visit her dad and he is not recognizing anyone. The patient did not have dementia, and about thirty minutes earlier I went in and was having a joking conversation with this alert and oriented man. I was concerned so I came in asked him the usual questions, took vitals on him, and all he could tell me was his name, could not keep a conversation. His o2 sat was 81% on 2.5L which it was 95% earlier, and I cannot remember his exact pressure now but it was in the 90's. I work on a rehab unit so we don't have any monitors or anything like that but the pt had been transferred the day before just an hour after newly diagnosed afib. So I knew the 81% might just be are pulse ox reading incorrectly because of his afib. I called the doctor telling him that I was concerned about him not really able to talk to me or recognize his family. The only change in his assessment I could find was his confusion and vitals. The first thing my rehab doctor said to me was well, is the oxygen turned on? After trying to explain the changes in the pt, the doctor cut me off and said ok I get it. The doctor ordered some tests, I called our statcare docs to let them know and our rehab doctor came up in a few minutes. He spoke with the family and assessed the patient. He didn't cancel any of the tests after his assessment. He called the statcare doctors and he sounded concerned on the phone as well when speaking to them. About ten minutes later those doctors came up and sometime between when the rehab doctor came in and assessed them and when they did, the patient became a little more with it and he was speaking clearly. His ABG's came back and were fine and the statcare doctors basically said he was ok. After those doctors left my rehab doctor came to me and said, did you actually see any change in his assessment or did you just call me because of his oxygen sat (he said this in a stern manner). I simply responded yes. But at this point I was confused because obviously he saw a change in him otherwise he would have cancelled the tests after he saw him, and I had been slightly ticked that he asked me earlier if the oxygen was actually turned on because I felt like it was sort of an insult d/t past experiences with this doctor. So about 30 seconds of pondering why would he be so stern and ask me that like I just base things on numbers and not actually my mind I decided to tell the doctor how I felt. I said you know dr. _________ I was not going to say anything but I think you should know that I feel a bit disrespected that you would ask me that in the manner you did and for that matter I feel like you are implying things about my intelligence by asking questions like well was the oxygen turned on. I said it and felt good that I said it because I didn't want to feel walked all over like I had on repeated instances with this man. He said in response no I am insulted that your insulted by asking you that. Your problem is that you take things way to personally. I bit my lip because I felt like maybe he was right. My question to you all is if you had a doctor that repeatedly said things that you felt made you feel like he thought you were not even stupid but lacking any common sense, would you have told them? If so, how should I have said it. I am just very sad because I feel so belittled all the time by the rehab doctors that I work with that I really felt I needed to stick up for myself. Maybe it was a bad example for the doctor that day of how I feel belittled but there seems like there are so many instances that I had to say something. I don't get questions like that from the other statcare doctors I work with, just the rehab doctors. I know he said that I take things personally, and I know I do at times which I don't know how to fix but I know it wasn't just me that felt disresspected by these doctors. I've had many nurses that I work with meintion that when they worked other med-surg floors their opinion was more valued and on our floor it is like we are treated as just pill pushers with no mind of our own. I guess I just want some advice or maybe someone to say feel better cuz right now I feel like crap. It's days like this I start thinking I am just stupid and I am that nurse has no common sense. It gets to the point where I feel like maybe I should rethink my career...like I should go be a bagger at the local supermarket. It really effects my self esteem and I wish it didn't. Any advice? Also, I know this is probably gonna be asked at some point but I've only been a nurse for two and a half years. Thanks for the vent.
When I was a newer nurse one of our surgical residents had come to the floor to do a consult on my pt. We were discussing the pt. when the doc answered his phone. I only heard his end of the conversation but it went like this.
Low O2 sats? does the pt. look like he is having trouble breathing? Well is his resp rate or heart rate increased? Does he appear anxious or is he saying he can't breath? He's not? O.k. how many times did you check the pulse ox? Once? check it again, ill wait. Still reading low but pt. is fine? Did you try another finger? No? ok ill wait. Still reading low but the pt. appears to be fine...hmmm did you try another pulse ox machine? No? ok ill wait..............that fixed the problem? ok bye.
Since overhearing that I NEVER take it personally when a doc asks me is the tubing connected to the wall....to the pt.....prongs in nose? They ask those kinds of questions from experience!! I also never feel bad when I call with what I think is a stupid question because I now know they have heard much worse!!!!
"So I knew the 81% might just be are pulse ox reading incorrectly because of his afib"
Why does afib throw off pulse ox? I understand the basic patho of Afib (ie, atria "quivering" instead of a coordinated contraction sending blood to the ventricles), does it just throw off pulse ox b/c the heart beats come irregularly? And if so, wouldn't it 'resolve' if you just left the pulse ox on and watched it for a minute or so?
Right but, in the case of cellular death it's not so much "throwing off" the pulse ox as genuinely lowering it, no? I guess I read it as Afib can make pulse ox artificially low... if the afib is bad enough that it drops cardiac output to a point you generally aren't oxygenating well enough, I would think that requires intervention.
Anyhow, I guess I still don't understand why you wouldn't be concerned about an O2 sat of 81 in an Afib pt unless it jumped back up pretty much in the minute or two I was looking at it concerned and/or proved to be an equipment problem.
If someone is in AF the pulse oximeter will not always pick up an accurate 02 saturation because of the irregular heartbeat. But the changes in mental status show that he may have been hypoxic secondary to a million and one possibilities and needed a call to the doctor. It may have been a TIA obviously. I wouldn't have worried about the doctors attitude so much.
I have cared for patients in AF whose pulse ox readings have been low, despite the machine being in place for awhile. Yet ABGs are fine.
Hey Ratherbe, I'm an NP and I work for a surgical team at an acute care facility. I get calls like that all the time. The questions the doc asked you were not so much about him not trusting your judgment, but about the fact that HIS senior or attending will ask HIM those questions and he cannot answer "of course the patient's oxygen was on, the nurse wouldn't have called me if it wasn't". Never take questions like that personally. He might not be able to be there at that moment to assess the patient, so he needs your basic assessment to help him make a plan--which includes knowing the O2 is on and how much. As far as him questioning you after the fact--honestly, to me it sounds like he was feeling defensive or had been given a hard time by his senior or something. He also wasn't feeling confident about his assessment skills (since he SAW the patient when he wasn't doing well, then doubted you later on). That's unfortunate. But don't let him get to you.
The point is, you made a good call. At the end of the day, your patient needed to be evaluated and worked up. It doesn't sound like he was doing so hot, and I'd watch him really close after that.
Sugarcoma, RN
410 Posts
When I was a newer nurse one of our surgical residents had come to the floor to do a consult on my pt. We were discussing the pt. when the doc answered his phone. I only heard his end of the conversation but it went like this.
Low O2 sats? does the pt. look like he is having trouble breathing? Well is his resp rate or heart rate increased? Does he appear anxious or is he saying he can't breath? He's not? O.k. how many times did you check the pulse ox? Once? check it again, ill wait. Still reading low but pt. is fine? Did you try another finger? No? ok ill wait. Still reading low but the pt. appears to be fine...hmmm did you try another pulse ox machine? No? ok ill wait..............that fixed the problem? ok bye.
Since overhearing that I NEVER take it personally when a doc asks me is the tubing connected to the wall....to the pt.....prongs in nose? They ask those kinds of questions from experience!! I also never feel bad when I call with what I think is a stupid question because I now know they have heard much worse!!!!