Was I overreacting?(long)

[newlywedRN]

Hi all, I am a long time reader but a first time poster but I have a question and would love some advice. I just graduated in May and have been working in a childrens hospital for 4 months now on a heme/onc and med-surg overflow floor. A few nights ago I was taking care of 6 mo old s/p BMT with an Upper Respitory Infection. When I came on the baby was breathing b/w 60-84 bpm, lungs sounded crackly and diminished, he was retracting, nasal flaring and occasionally grunting, HR 145-160, on 1L O2, all other vitals were fine at the moment. Within 30 mins of that first assessment his sats dropped to 85% and he desperatly needed suctioning, after suctioning he would bounce back up to sat at 92%-97%. I called respiritory and the doc and let him know and increased his O2 to 2L. He continued to drop his sats(82-87% at any given moment) about every 30min-1hr and needed suctioning that frequetly also. I again called the doc and let my charge nurse know about the situation and that I needed help with my other 3 pt's b/c this little guy was taking up a huge amount of time. The doc FINALLY came up to assess the pt and ordered a VBG, I can not remember the results but the doc relayed them to me as "crappy" and stated "If he were in charge this baby would be in the ICU but his senior thinks he is fine". After a two more O2 sat dips I called the doc again and he called his senior to come check on the baby. Another VBG was drawn and it came back worse. (by this time I am 3 hours into my shift and very frustrated) I called our STAT/rapid response team to take a look at the kid. He told me that he would keep an eye on him and to let me know if he gets worse but his hands were tied b/c the docs were comfortable with the current situation. They finally ran bicarb on this boy and his VBG improved but he was still breathing 80's and working very hard. I continued to update everyone(doc's, respiritory, stat team, charge nurse) on this situation and nothing was really happening, but I was scared to leave this little guy alone b/c he was doing so horrible, PLUS he was on reverse isolation so everytime you entered the room you had to glove, mask, gown before you could get to him while he was satting 80's. (He ended up in the unit the next afternoon after he almost needed to be intubated on the floor)My questions are...Am I wrong in thinking this was an ICU pt who needed much closer attention and monitoring right at that moment? What would you have done as the nurse who had used up all thier resources? Was it the right decision to leave this little guy on the floor to burn himself out breathing 80's and dropping his sats or should SOMEONE have intervened sooner? OR am I just overreacting??I am so new so all of this is a bit confusing for me. I feel like I could not help this little guy no matter what I did....Advice?Thanks in advance, Kerri

[FireStarterRN, BSN, RN]

You sound like you were on top of the situation and did all the correct things.

[jjjoy, LPN]

How open is your nurse manager to staff feedback? Some hospitals tend to take a "suck it up" attitude and others are more willing to look into the system and see if there's a real problem there (such as a doc who regularly leaves critical patients on the regular unit or a gap in the chain of command you can turn to in cases where you feel patient safety is at risk). I hope you work at a place like the latter. In that case, you NM would want to hear about the problem you had and explore with you whether or not there might have been a better solution. Unfortunately, many places are like the former so if you get a cold reception to your inquiries, know that it's not because you are "overreacting." If indeed it wasn't that critical a situation, you need to know that and there should be a reasonable explanation for you. If you don't get the kind of feedback you need at work, though, hopefully some folks here with knowledge in that area can help you learn from this experience.

[SakredStrega]

I can't really answer your questions, but I did want to say that you seem to be an excellent nurse. If I had a sick baby, I'd want someone like you taking care of them.:)

[al7139, ASN, RN]

Hi,

I am not a peds nurse, but I am a new grad. One thing my preceptors have taught me is to trust your gut. If it don't feel right to you, it aint. Any pt on my unit (cardiac/telemetry) that is going south, or just "don't seem right" to me, and I am talking to my team leader and their doc...I don't care what time it is. Just because I am a new grad, doesn't mean I can't recognize when a pt is in trouble. I will bug the heck out of their docs until I get what I need to help the pt. Most times, the docs and other nurses are great and agree with my assessment of the situation. Occasionally, I will have to deal with a doc who has that superiority (he knows better than I, even though he is home in bed while I am busting my hump trying to keep the pt breathing!) thing, or a nurse who treats me like I fell off the truck yesterday (OK mabye I did, but I still can tell the difference between a stable vs. a pt in trouble!). I have learned so far that sometimes I have to be ruthless, relentless, and annoying to get what I want (thank God not all the time) with some docs. And, if it's a resident who is scared of their mentor, thats even worse. I ask if they would rather transfer their pt to an acute care unit or tell their mentor the pt died overnight...Works every time!

So, in answer to your question, no you were NOT wrong in your assessment of the situation...The docs senior was wrong in not listening to you and trusting your judgement as a nurse. There is a reason we go to school for so long and have so much responsibility in pt care...the docs need to remember that we are not "menial labor", but highly trained professionals just like them (and sometimes even more so!). Hang in there! You were definitely in the right!

Amy

[nursemary9, BSN, RN]

Hi

I am not a Peds Nurse; I am a Hem/Onc RN who has worked on a Bone Marrow Transplant Unit.

I. personally, don't feel like you over-reacted at all; I think you were right on top of the situation. It sounds like that was a really scarey shift.

It also sounds like the baby should have been transferred sooner.

I think you did an amazing job & to think that you are a new grad, you really held your own.

You should be proud of yourself for the way you handled this situation--I'm not sure how many new grads would have been up to this.

Keep it up!!

[canoehead, BSN, RN]

You did a great job.

I would have called the attending directly and requested he respond to the bedside to do his own assessment, and documented the request. Very few docs will refuse if you directly tell them you need them NOW and at the bedside.

[sharona97, BSN, RN]

Having worked in peds for awhile, learned real quick to stay on top of those sick babies. You did great, utilized your staff, stuck to your gut, and recognized a real sick baby!

Have you asked at work for any feedback?

Good Job,

Sharona

[BBFRN, BSN, PhD]

The rapid response team should've had the authority to transfer the pt without a Dr.'s order or approval. You might want to ask that this be addressed. That would have fixed the problem in your case.

[General E. Speaking, RN, RN]

I would have been worried too. Resp rate that fast could lead to exhaustion and resp failure. You sound like an awesome caring nurse. Hats off to you!

[Tangerine Lipgloss]

I've been in that situation before. (more than once).

One day I went right into the ICU and asked the attending to come in and assess the child. This was after going up the chain of command on the floor with no satisfaction.

Attending came right in, saw immediately what was happening, ordered what I needed, I gave it to the patient with no change. He was rolled into ICU and intubated 20 mins later.

Sometimes you have to be very assertive. You were on top of the patient and took very good care of him.

[nurse grace RN, BSN]

No you were not overreacting , you were on top of things because you are an excellent nurse!!! I agree that the rapid response team should have transferred the patient. You followed your gut and stuck to your assessment against those docs ( not easy to do as a new grad). I am proud of you and you should be of yourself. Assertiveness is often necessary with residents because they are often afraid of their seniors and won't make a change without their guidance. I would have done exactly as you did. Your manager should tell you what a great job you did. Continue to do the excellent job that you are doing!:welcome: