Was I right, wrong, or am I going crazy

[nursingaround1]

This happened in a new hospital halfway between london and bristol, in about 2004. I had got tired of all the agency work in A&E in London, so signed up for a 3 month contract in a general surgical ward working nights.

I had some bad experiences straight away - as in no handover on my first shift, and I confronted the hardened battle axe of a nurse who was finishing the day shift as she was about to leave the ward. She told me that all the patients were fine - and left.

But that's another story, but suffice to say, I stuck with the place for two months, and things only got worse, and I had to quit. But one incident happened, and I felt that I was the only one in the hospital who could see this problem, and to this day I still think I'm in the right, although I do have some doubt now. So here's the scenario.

Mrs Smith had cellulitis of her left calf (it wasn't her real diagnosis as I can't remember, but I do remember she did not have a particularly serious problem). Anyway, I'd been giving her the evening IV AB,s and got to know her well as she loved to chat. She was one of the more lively patients in her 6 bedded bay.

Anyway, I turn up to work (I think about 2000hrs) and I am told by the charge nurse that Mrs Smith is 'unconscious.'

I'm thinking, okay, what happened, where is she now? I'm then told she is still in the bay at the end of the ward, unconscious. I can't believe my ears. An unconscious patient, regardless of cause = unprotected airway. It all goes back to ABC. I tell the charge nurse that this can't be right, but he then explains that she's had a CT, been seen by her consultant, been seen by the medical team, and been seen by the neurological team, and they cannot find a cause, and all scans are normal.

I am told that there is nothing to do, but to leave her there.

You may not believe this, but neither could I.

I explain that this is crazy. We have an otherwise healthy 60yr old woman with an unprotected airway, at the end of the ward. The charge nurse gets a bit angry, and tells me if I'm that worried, I can spend the night at her bedside, but that's up to me, and I still have 11 other patients for the night. All I wanted was for her to be somewhere where she could be observed, as a simple aspiration and she's gone. An otherwise healthy woman could be dead in a matter of minutes. She's on no kind of monitoring, absolutely nothing.

What should I do? I contemplated walking out. I contemplated complaining to the duty nurse supervisor, but found out she was ok with this as well. I stayed for the shift.

I managed to go past her room about every 15-20 minutes - pathetic really, but the best I could manage, and every time i tried to wake her.

At about 0300hrs I tried waking her, and she woke up, asked what time it was, and seemed completely fine.

You probably won't believe this, but this is exactly how it happened. I've never seen someone suddenly go unconscious for no apparent reason, and suddenly wake up hours later absolutely fine.

I called the house surgeon and told him about her, and he was like 'why did you bother calling me?' and I told him that it was a bloody miracle she was still alive, and that he might want to assess her while she's still conscious, because who knows what could happen. He agreed to come down and do an assessment.

Anyway, I worked there a little bit longer before an even worse event forced me to quit, but I'm curious what you think. Should she have been in a monitored unit? Should she even have been intubated? Was I over reacting?

I always felt I was in the right on this one, but it seems I was the only one in the hospital who felt that way.

[OrganizedChaos, LVN]

No, I don't think intubation needed either. I simply thought unconscious, risk of aspiration and death. Kept it really simple.

What if that had happened on my shift, the agency nurses shift? They would have noted my objections and asked why I didn't act upon them.

In some ways documenting my concerns almost makes it worse for me, but at the end of the day, in a court, they would all ask, why you did nothing.

And yes, the nurse did leave with no handover. The place actually had a handover system where they record the report and you listen to it. But the nurse who had my patients was 'old fashioned' they said and refused to leave a recording, and preferred to handover in person. She didn't do either.

So yes, I started a shift with no handover. I nearly left then.

As for all the people telling me to check her 'ABG's' and other stuff, all I can say is, who do you think you are and why would you even go there? Keep it simple, and realise there is a patient with an unprotected airway who could aspirate and die. Simple as that.

You really think of worst case scenarios, don't you? Good lord. Why would they go there with checking her ABGs, why are *you* going there with this unnecessary post? Her vital signs where WNL, tests came back fine. Why would she aspirate? Aspirate on what? What reasoning did you have to think she would since all the tests showed otherwise.

So to answer your question, you're wrong & crazy.

[nursingaround1]

You really think of worst case scenarios, don't you? Good lord. Why would they go there with checking her ABGs, why are *you* going there with this unnecessary post? Her vital signs where WNL, tests came back fine. Why would she aspirate? Aspirate on what? What reasoning did you have to think she would since all the tests showed otherwise.

So to answer your question, you're wrong & crazy.

Then we will have to disagree. But then I do have to wonder how much experience you have had in the broader nursing field and how many different places you have worked.

And yes, you should always consider worst case scenario.

[OrganizedChaos, LVN]

Then we will have to disagree. But then I do have to wonder how much experience you have had in the broader nursing field and how many different places you have worked.

And yes, you should always consider worst case scenario.

Well look at my profile if you are interested. I would consider worst case scenario if her vitals, labs & tests suggested it. Otherwise her "unconsciousness" could be explained. I do it every night for 8-9 hours.

[nursingaround1]

You really think of worst case scenarios, don't you? Good lord. Why would they go there with checking her ABGs, why are *you* going there with this unnecessary post? Her vital signs where WNL, tests came back fine. Why would she aspirate? Aspirate on what? What reasoning did you have to think she would since all the tests showed otherwise.

So to answer your question, you're wrong & crazy.

As for Abg, I don't know who brought that up, but such thoughts never crossed my mind.

As for why she would aspirated that doesn't even matter why, the question you should be asking is why not.any unprotected airway is at risk of this and it must always be considered.

I'm sorry but you are wrong and your thinking is not sound.

[OrganizedChaos, LVN]

As for Abg, I don't know who brought that up, but such thoughts never crossed my mind.

As for why she would aspirated that doesn't even matter why, the question you should be asking is why not.any unprotected airway is at risk of this and it must always be considered.

I'm sorry but you are wrong and your thinking is not sound.

So me & all the other nurses are wrong? As well as the other nurses & doctors you worked with. No, you are, clearly.

You said the patient fell asleep at 2000 & you woke her up at 0300, you realize that's 7 hours of sleep, right? That's a normal amount of sleep? I normally can sleep for 8-9 hours, more if I'm exhausted.

But my thinking is perfectly sound. You told me her vitals & labs were WNL, there is no reason to protect her airway if she is maintaining it on her own. You keep saying she could aspirate, she was swallowing her salvia on her own. Her airway was not unprotected, unless there is more to your story.

So do we all need to protect our airways when we sleep now?

[SubSippi]

No, I don't think intubation needed either. I simply thought unconscious, risk of aspiration and death. Kept it really simple.

What if that had happened on my shift, the agency nurses shift? They would have noted my objections and asked why I didn't act upon them.

In some ways documenting my concerns almost makes it worse for me, but at the end of the day, in a court, they would all ask, why you did nothing.

And yes, the nurse did leave with no handover. The place actually had a handover system where they record the report and you listen to it. But the nurse who had my patients was 'old fashioned' they said and refused to leave a recording, and preferred to handover in person. She didn't do either.

So yes, I started a shift with no handover. I nearly left then.

As for all the people telling me to check her 'ABG's' and other stuff, all I can say is, who do you think you are and why would you even go there? Keep it simple, and realise there is a patient with an unprotected airway who could aspirate and die. Simple as that.

Did you see what Esme said? If her gag reflex is present, then the patient is capable of protecting her airway regardless of her level of consciousness. You don't just intubate someone prophylactially because they're not awake. If what you're suggesting went into effect we would be tubing all of our patients before they went to bed.

[nursingaround1]

So me & all the other nurses are wrong? As well as the other nurses & doctors you worked with. No, you are, clearly.

You said the patient fell asleep at 2000 & you woke her up at 0300, you realize that's 7 hours of sleep, right? That's a normal amount of sleep? I normally can sleep for 8-9 hours, more if I'm exhausted.

But my thinking is perfectly sound. You told me her vitals & labs were WNL, there is no reason to protect her airway if she is maintaining it on her own. You keep saying she could aspirate, she was swallowing her salvia on her own. Her airway was not unprotected, unless there is more to your story.

So do we all need to protect our airways when we sleep now?

What part have you not bothered to read. She had been unconscious since sometime during the day - she'd been reviewed by medical teams, had a scan and other tests - no one could wake her, and her tests were normal. I never said she fell asleep at 2000hrs. I said I came onto work then, and was told my patient was unconscious, and they didn't know why. As for this deep sleep you keep talking about, perhaps you think all the other doctors who said she was unconscious instead of asleep are wrong as well? By saying Im wrong because I disagree with the observation of my patient with my colleagues, you're wrong as well, as you suggest she's simply asleep, when they all say she's unconscious, even the neurological team.

It sounds to me you're so desperate to attack every decision I make, that you attack without reason, and don't even bother to read the whole post - at least you'd assume so judging by the gaps in your statements.

[nursingaround1]

Did you see what Esme said? If her gag reflex is present, then the patient is capable of protecting her airway regardless of her level of consciousness. You don't just intubate someone prophylactially because they're not awake. If what you're suggesting went into effect we would be tubing all of our patients before they went to bed.

As I said, I never thought intubation an option.

I am concerned that a patient in this state was left without observation, at the end of a ward, with no nurse easily able to keep in line of sight.

[pixiestudent2]

What makes you think she wasn't sleeping?

Honest question.

Did you actually assess her?

Unconscious is such a vague word.

[blondy2061h, MSN, RN]

Did she get ANY sedating medications? I've seen patients that are extremely sensitive to even very low doses of opiates or anxiolytics. Coupled with exhaustion already this could easily account for her symptoms.

[pixiestudent2]

To answer your question, you do seem crazy. You don't seem to like the people on allnurses. You post ridiculous situations and you don't like the responses you get. But you keep coming back again, and again, and again.

You know what Einstein said about insanity.....

[nursingaround1]

What makes you think she wasn't sleeping?

Honest question.

Did you actually assess her?

Unconscious is such a vague word.

She's had 3 teams of doctors look at her: the surgical team who she was admitted under, the medical team and the neurological team - and they said she was unconscious. If a neurologist says someone is unconscious, and they 're even so convinced that they feel the need to scan her, then I guess she's unconscious.