Vent - Still frustrated about this situation, what would you have done?

[ChocoholicRN]

I apologize in advance if this is long, but I want everyone to get the full picture before giving any input. Here goes:

I work on a med-surg floor and the only time we get vented patients is if they are DNR/comfort care. One night I had gotten report from the ED nurse about a vented patient I would be getting. She gave me an excellent report and I knew exactly what to expect when this patient arrived. We don't normally keep vents on our floor but the ICU is right next door so it's not hard to get a vent. Here is the beginning of the tricky part-the patient was on a sedative drip (don't want to give away too many details) in the ED that we can't have on the floor, but was to be switched to a new drip upon arrival which we can have but the ED can't (I don't get it either). So I told the nurse before sending the patient up, give him and IV push of something to hold him over till we got his drip set up on the floor. She did just that and then called to say she was sending up the patient and had called respiratory to set up the vent on our floor.

Well, the patient arrives and I'm finishing up with another patient but got to this guys room within minutes of his arrival. I know I had told the charge nurse and another RN about this patient but apparently everyone was shocked when he arrived. Now things get really sticky. I should have told the ED nurse to not send the patient up till the vent was ready here, but there was miscommunication. When she gave me report, I thought she said she was calling a resp. therapist to come up with the patient on the vent. Apparently she had said she was calling the resp. therapist to set up the vent by us and would be here when the patient arrived. Miscommunication happens and not always at the best times. The vent had not even arrived yet and the IV push that the ED nurse gave wasn't doing much. The patient was starting to wake up and fight the ET tube. Luckily his HHA was by his side to hold his hand and the MD was in control of the ambu bag. Still a bad situation since I still needed a few minutes to get his new drip set up. As soon as I finished up with this other patient and arrived to this guys room, all the other nurses vanished. They got the patient settled in bed and that was it, they were done helping. One nurse (a traveler, not even a regular staff nurse!!) who I get along with very well helped set up suction and get stat meds to sedate the patient. It's not like they were called to other rooms, they left to go sit by the nurses station. This whole time he was awake, fighting the tube, reaching to pull it out, and overall anxious. I still needed to set up the drip, the maintenence fluids, check his vitals, and keep him calm. If the HHA wasn't there he would have yanked out the ET tube. Now, given that the other nurses were in the room when he arrived and had seen the situation you would think they would offer to help and I wouldn't have to ask. Apparently, thats not true. The charge nurse was standing by the entrance to the room with her arms crossed, just watching what was happening while the travel nurse helped out. Another nurse was calling the pharmacy to yell at them to put the stat order through to Pyxis, something the travel nurse had already done and we didn't need 2 people yelling at the pharmacist.

Eventually I got the patient settled and after 3 hours he was finally sedated and comfortable enough where he was not awake, breathing over the vent or trying to pull out the tube. I had also been told in report that the patient had 2 sacral ulcers (not big ones, maybe stage 2) as reported by the HHA and the dressings were done daily at 10am. The ED nurse had not looked at the ulcers. I normally do a full skin assessment with every admission, but it took so long to get this patient sedated so the ulcers were not my main concern. I rarely have patients with vents and usually don't have to turn them much (just enough to get a pillow under one side, haven't had any with pressure ulcers) and was scared to turn this patient too much. I didn't want to dislodge the ET tube or disturb him or wake him after finally getting him comfortable. We learn in nursing school, A-B-C:airway, breathing, circulation. I got those covered, it was a frantic 3 hours, I was not about to possibly wake him up.

I spoke to my manager in the morning, told her the above situation and explained that I felt no one was really helping me except the travel nurse. She told me I should have asked for help and I can't completely blame everyone else. She knows me as a nurse and I do ask for help. But in obvious situations like what I just described where it is emergent and I'm already frantic, I didn't think I would have to ask all these experienced nurses for help, they would see what's going on and ask if I needed anything. True, no one is a mind reader, but would you really just sit back and watch this when you could at least offer your assistance? Any other floor I've worked on the staff has offered help or asked if I needed anything, and in much less critical situations too. I'm just baffled that I got the blame for this. Should I really have to ask for help when I'm trying to set up a drip and prevent this guy from yanking out his ET tube? Was I really wrong here? She also said I still should have assessed his skin, which I don't totally disagree with but as I explained it took so long to get him calm and sedated and I'm not used to turning patients who are vented. Please give me any feedback you have, this has been bothering me. Thanks!!

[Flare, ASN, BSN]

It's very easy for your manger to say that no noe offered help because you didn't ask. Flimsy in my opinion, but i suppose she does have a point. Nursing is a team sport, and lots of times the other team players aren't thinking beyond their own patient load. So lesson learned there - just speak up next time - especially if you see someone standing there staring at you - ask them if they could get you "XYZ" . I'm always one to ask if someone needs help. I'm also not to proud to ask for a quick hand. You were behind the 8-ball by having to establish things that should have been ready for the patient when he came up. I understand that the ED wants to clear the space, but you can't accept a patient like that until you have the vent and the drip ready. Next time tell the ED nurse that you will call as soon as the vent is ready for him to come up.

[RosesrReder, BSN, MSN, RN]

I would be saddened at the lack of support from my co-workers. Every floor or place I have worked you don't even have to ask and usually our pt load is keeps us busting at the seams. I do agree that next time ask for help and make get them oficially involved. As for your charge nurse, I can't believe she was just there standing with her hands crossed. All the wonderful charge nurses I have worked with get down and dirty with you. Minimally, what they could do is help gather supplies to the bedside and answer call bells to the rest of your pt's while you are tied up with the vent. True, you should not even have to ask despite their own assignments. If it is obvious then a helping hand or two should be there to help. Today for me........tomorrow might be you. Good luck!

[RNandRRT]

The only thing that I can imagine is that they were completely out of their comfort level. Not every nurse is composed of DNA meant to inspire taking care of ICU level patients. I have seen non-ICU nurses with no ICU experience get scared when they are informed their next admission is a non-vented trach patient s/p 10 years ago. For those of us with years of experience under our belt taking care of artificial airways it's nothing. Then on top of that, a ventilator? LOL

In this situation, I would venture to say, they were intimidated by the situation and didn't want to get involved. At least one possible explanation. Not necessarily true.

[kcochrane]

In that situation where it was apparent you needed help, you should not have had to ask. When I'm not busy I ask if people need help and/or I can see where there is a need for help and step in. I could also see if everyone was busy themselves, but if they were sitting around, that was just wrong. Although I am not surprised, not everyone is a team player. Kudos to that travel nurse.

[PostOpPrincess, BSN, RN]

Hindsight.

Love when people give you advice when they are not in the middle of everything.

You did what you could in your comfort level.

Next time, let the drip stay on UNTIL you can convert to your drip or have the ER nurse continue to titrate.

There really was no need for the patient to be crazy like that--it could've easily been an easier transition for everyone, but most particularly for the patient. Sometimes we stick to protocols because WE HAVE TO, not thinking of the end result...an agitated patient.

But that comes with experience and exposure to such situations.

You did your best....assess what you could've done better, and move on. You will know for next time...because there will be a next time.

[tokmom, BSN, RN]

I'd be a bit miffed too. I swear, you described my former place of employment. You could be knee deep in doo-doo and nobody would offer to help.

[nursemike, ASN, RN]

I agree, you really shouldn't have had to ask, but at least next time you'll know. I just finished posting on another thread that when I do charge, I've been taught I am accountable for every patient on the floor. So I'd suggest you start by telling your charge: "I need more help." Then s/he can't say you didn't ask. I suppose you could even note in the chart that assistance was requested. But, yeah, would these other nurses walk past a room and see a patient lying on the floor, bleeding, and say, "That's not my patient?"

If I understood the first part of your post, the patient was on comfort measures? And people are fretting over decubs? Really? Even if the patient is expected to recover, I agree that the ABCs are your first priority, and if his discharge plan is celestial, why torment him with dressing changes? Once he's sedated enough, I suppose clean dressings might increase his comfort, but in the short term, I doubt he really cared.

RN and RRT probably had a point about the other nurses' comfort zones, and it probably is on you to call out for what you need, much like running a code. Which is not easy. When you're going a mile a minute, it's hard to think about what to ask for. I work on a floor where other nurses regularly ask if you need help even with routine assignments, and even when you could use some help, it's hard to think what to ask for. (I usually say, "Yeah, thanks, could you chart my assessments for me?" But there have been times when one patient was crashing that others have seen that my other patients got their meds and whatever else they needed.) I guess I'm saying that we could both stand to take some time when things aren't crazy to consider what things we'll ask for when they are.

[luvRNs, BSN, MSN, RN]

So sorry about your harrowing experience ! A few things come to mind. This was a high risk hand-off, due to the vent AND the sedation. The need for clarity is essential because of that. Did the ED nurse need to call you to confirm you were ready prior to transfer, or did you need to call her and let her know you were ready? Someone needed to clarify at the outset who was responsible for the vent. If an RT was responsible for setting up the vent to begin with, where were they in this communication process? There should have been a hand-off there. Staff-charge nurse communication also appears to be a problem area.The difference in sedation is another issue.

As someone said, it is easy to "monday morning quarterback", but in this case an analysis of the systems in place by those involved is often helpful. What is really important is to identify the SYSTEMS failures that prevented the patient from receiving optimal care, and to attempt to prevent them from happening again. No pain, no gain

[caliotter3]

This sounds 100% exactly how things would have gone down (if the circumstances were the same) in the long term care facilities I worked in when I started out. Your description brought back old memories. The patient could die many times over before the other nurses would lift a finger, whether you asked for help or not. Learn to expect this and be more willing to speak up and say the obvious from here on out. That is the only advice I can give you.

[RNforLongTime]

Seems to me that the charge nurse saw what was going on and didn't offer any help. In my mind, that's a pretty bad charge nurse!

And this newly intubated pt should've been in the ICU NOT on a floor. I worked at a hospital that took STABLE TRACHED vent patients on the floor and when I did have a vent, I had two less patients than the other nurses. Any newly intubated pt with an ETT belongs in the ICU!

[EmBeMap]

Reading this post kind of made me cringe for you. Im confused why did you accept report on a non-dnr vented pt on a medsurg unit. what was the admitting doc thinking. icu nurses who are trained dealing with vents and multiple drips in most scenarios only get two patients. What kind of patient load did you have that night? 4-5 pts of different accuities? Second, where was the ER tech / nurse accompanying this patient during transfer? SOP in every hospital i have been in says a vented pt is an RN x 2 or a nurse and an er tech. this is for multiple reasons. er rn can check out sedatives to give iv push for issues like you stated. we have had people come out of sedation even while on drips and rn does iv push of paralytics and ups bolus of sedative to enable safe transfer. how did transport personell insure this patients safety? you were faced with a tough situation, if my charge nurse confirmed we were taking this pt. (you should have questioned them upon receiving report to cover your butt) then i would have demanded nicely that er rn accompany patient with drug box. if your unit handles the odd circumstances regularly i would start looking for a new job before you miss the next one and you lose your license. Hospital protocols are hard to change (i have been on the bad end trying to improve pt safety).

I would suggest calling house supervisor and full documenting the situatuion as it occured and hope the pts hha doesnt complain. You were the last to receive the patient and even though most of the issues werent your fault you will catch the fall out.

On a more positive note, i have been in your exact situation as a tech handing off the same type of patient to an ICU nurse and i can tell you i have went and gotten the vent myself because i was almost sure it wasnt being handled (i was right) and because it was the same vent and i ran into a resp tech who i drafted to set it back up. pt came out ok. just remember you worked hard for your license dont let hospital bully you into unsafe pt practices because 99% of the time if something goes wrong they wont defend you.