Toxic environment? Story time...

[BeatsPerMinute, BSN, RN]

Case: 68yr old F with Hx of emphysema, HTN, COPD, smoker for many years (quit 1 year ago) presented to the ED mid morning c/o severe abd pain "she had never felt before." Abd was rigid and distended. She was extremely agitated, in distress, placed on NC 3LPM, was assisted to commode, had BM, continued to c/o severe pain. Wheezing, SOB, and tachycardia, hypotension also noted. 3 Liters NS bolus given. BPs normalized. Fent IVP given for pain. Chest/Abd CT results done and showed clear lungs and concern for ileus in bowels. 

Early afternoon (per ED) the patient appeared to have been "calming down." ... But then later it was realized she was minimally resopnsive. Labs drawn. Lytes "okay-ish" but ABG showed ph was 6.8 , CO 83. Patient put on NRBM, Bipap prepped then skipped for intubation. 

ED calls me to give report. The patient codes, so ED nurse hangs up and will call me back. Upon call back, I go to the ICU attending so he can listen to the conversation. One round of CPR and Epi x 1 IVP given. Heart restarted. Patient not following commands. ICU attending tells ED nurse over phone to get a head CT. Then looks at me and asks me to prep for TTM, sedation, pressors, fluids, A-line and CVC insertion. I get everything together and tell charge what the plan is and ask her who will cover my patient. She says she doesnt know yet. 

Patient arrives. Charge nurse appears angry, glaring at the ED nurses, and presses them for details what happened & why CT was skipped. Per ED, "patient started moving. we called ICU MD, and he okay'd that we come straight up here... on the way up tho the blood pressures stopped reading." Charge acknowledges that the patient is moving some.

My alarm bells go off. As charge continues to press ED nurses for more details, I step in, check patient, check monitor. Patient legs are dusky, and rigid. Not following commands. Crap. I look at monitor: heart rhythm abnormal but everyone near arguing and not paying attention. I try stimulating the patient, nothing. I interrupt the chatter between charge and ED nurses: "Can anyone feel a pulse?!" Everyone freezes. Pulse thready. "Then lets get her off the stretcher on onto the bed, NOW." 

I flag the ICU attending. Code cart brought over. I tell one nurse to get her onto our bedside monitor while I get defib pads connected to our defib monitor. Moments later, pulse lost, patient asystole. I jump onto chest to start compressions. People rush in and I tell them "patient lost pulse again - brady down to asystole at X time." Heart quickly restarted after 30 secs. 

Charge nurse states "look she's moving around again, OK, she's going to be fine. Hey there! (to patient) its OK, please keep your arms straight."  Patient arms were flexing towards her core.

I ask my charge nurse who is going to cover my other patient. Charge looks like me like I'm an idiot, rolls eyes, sighs, and ignores me. She believed patient was fine because the patient was moving around.

I think to myself: "You really think that a patient that has coded twice, just intubated, with cold dusky skin, badly distended abd w/ ileus, uncertain BP readings, not following commands, just intubated, with rigid LE's and now rigid upper extremities flexing to the core is FINE?!" Stunned, walk away, ready to move on to next steps. It took every ounce of self control and restraint to keep my emotions in check and focus on the patient and issue at hand.

I set the BP cycling on monitor to auto check every 2 minutes. BPs not read-able for multiple cycles. Eventually, we get 60s/40s. Unit pharmacist (amazing human) recognizes the severity of the situation. He preps fluids, Levo, and threw in orders for me. ICU attending returns with PA, and he says, "pressors and fluids are going - EXCELLENT"

Ultrasound machine and supplies all ready to go - I assisted ICU MD and PA to get the CVC in first. Charge is standing there, just watching. I place an Aline kit + pressure bag on table next to her and directly hand her fluids. Charge nurse, with a passive aggressive, condescending, sarcastic tone asks me:  "what do you want with this? is this for the A line or fluids?" Done with the attitude and caring about tact at this point, I give her a very serious look, assertively and calmly say: "Fluids are already going, so please get the Aline ready while we get this CVC in because Aline will be next" 

By the end of the shift, patient had coded several more times. Each time I took charge of situation and ran the code. Backboard check. Pressors check. Everyone knew their roles. I communicated any VS changes, meds given, interventions with times to person doing the code documenting, ensured after each set of chest compressions, a back up person to take over was ready. Minimal interruptions. Went about as good as it could have gone. Charge nurse gave up on controlling situation and just left which honestly was more helpful. 

Patient ended up receiving numerous amounts of EPI and Bicarb IVPs, Bicarb gtt initiated, and ended up maxed on Levophed, Vasopressin, Epinephrine, Dopamine, and Phenylephrine.

The kicker: At no point could I leave the room for over 3 hours. Patient declared dead just before shift change. However, the charge nurse never made any assignment changes. While all this was going on, I was still technically responsible for my second patient I hadn't seen or, assessed, in hours. 

[JBMmom, MSN, NP]

I think that, unfortunately, this situation is not all that uncommon. Hopefully the rest of your coworkers aren't as thick as your charge nurse and others were checking in on your other patient. It would have been tragic if something happened to that patient while you were in the room with the new patient, but I think we often play the odds and hope that it won't happen. I know in my unit if you already have the sickest patient you're not likely to be the one open to admit, in case a scenario like you described happens. Sounds like you did your best with a very ill patient. 

[HiddenAngels]

And wow! I knew you story was going to end this way! I just knew it! . I was just afraid you were going to say your second patient coded … I was reading and waiting… and waiting…But thank God.!  . These are those times when I think Angels are really there helping us.

[BeenThere2012, ASN, RN]

I can hardly believe your charge was that inept?   How in the world was she given that role with her obviously incompetent knowledge and horrible attitude.   What a nightmare.  She is actually dangerous if she can’t even acknowledge what was going on with that patient, not to mention the support you needed and HER responsibility to make sure your other patient was covered.  
As charge in a PICU, I always jumped in to help with unstable patients and could have seen at a glance what needed to be done, not to mention at least do what what asked of me in the moment when a bedside nurse had all the details.  
THIS, is horrible!  I don’t know how you can even stand to work with her again.  Very sad ?

[Been there,done that, ASN, RN]

Charge needs to be reported to admin. She is dangerous.  Your fellow nurses will back you up that your other patient was not reassigned.