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Discussion

What would you do?

This recently took place in front of me, (not in my care) and involved a charge RN. It has really bothered me and I wanted to see what you all thought.

Male, 57, suspected MI day before. Had vomited some dark emesis previous day. You walk in and his sats are 77% on room air. You place 2L o2 by nc and pt doesn't tolerate, so you change him to a non rebreather at 15L o2. Ok so far, pt states "I just want to stop breathing". Blood pressure is 58/0, Abgs are obtained and the tube is very dark, almost black. ABG comes back ph 7.2, lactic acid 8 (granted not a good number to start with). The Rn of this pt has called md and order for IMCU bed obtained. I walked in and the pt is turning blue in the face, and I inquire about called a CAT call (our rapid response team, I am thinking intubation as blue is not a good sign.) Charge RN says "We already have an Imcu bed and we have everyone we would need here. Lets get going". The charge Rn, new grad Rn and Precepting Rn and respiratory tech are at the bedside. They grap the respiratory box off of crash cart and go to imcu. (I am thinking I want a better airway than this and how about some drips to address the BP).

The end of story is patient was placed in imcu and after 20 minutes transferred to icu and intubated. By this time he has a bp of 48/0 and ph 6.8 lacitic acid of 12. (this was over 1 1/2 hours. From floor to icu) Pt ended up not making it. I am disgusted that the Charge RN was told by the Manager that nothing else could be done, she did a good job. I am thinking she should have got more help, so that drips could have been started earlier and maybe have given him a chance. I feel for this patient and family. Do you think I am being too critical here or is there room for improvement. I have been doing this for over 6 years, would like to think I can see trouble. Turns out pt never had an MI, miscommunication between shift RN's!

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    Intermediate care is the incorrect bed assignment and the 1.5 hour delay is absurd.

    That jumped out at me too. The pt should have been out of there pronto, the 1.5 hour delay is insane. It was obvious to anyone with a pulse the pt is doing badly, get them off the floor, the faster the better. That's what we do on our floor.

    I also agree with calling your CAT team. The motto of our team is "if you're concerned, so are we." Call 'em, worst that can happen is you get yelled at. Pt probably wouldn't have made it, but you can sleep a little easier at night.

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    Here is an update. I could not have called the RRT as they were already packing up and getting ready to leave the floor when I saw the pt turning several shades of blue. If I had been there earlier I would have called the RRT as I do NOT care about popularity. I have since talked with a trusted co-worker and have spoken with my boss. He says that what happened was done correctly and that he would stand by what they chose to do. I explained what I would have done and he said "that was another way to handle it". It is my understanding that this is going to be reviewed by the ICU due to the way it all happened. I will always do what is in the best interest of the patient, as my job is to protect the patient, not make friends. I do thank all of you for your thoughts and I wish I could have changed the outcome, but I don't think that was possible. I will keep you updated as to what happens. Thank you all again for all your viewpoints, it helps to see it in a different ways.

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    I agree with everyone's comments. I think what went wrong is not the fact that RRT was not called, but that the pt was not transferred immediately to ICU. Perhaps the RN who contacted the MD did not accurately describe the situation...? I just can't imagine a physician transferring a patient who couldn't breathe and had a BP of 50/0 to an intermediate unit.

    When a patient dies, a sense of guilt or "wanting to do more" tend to tug at our hearts, whether we are just bystanders or someone who directly handles that patient's care. A death of a patient impact us in so many ways and it especially has a great impact on the people who provided the care. I believe the charge nurse and the RN both want what's best for the patient. Having RRT at bedside may or may not change the outcome of the situation. I think it's best to provide support for your coworkers, as I'm sure everyone involved is walking away with some kind of lesson to help them become a better nurse.

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