What Would you Have Done?

[tsgarman, RN]

I am putting this out there for anyone to answer.

I had started a new PRN job in small ICU and it was my 3rd day of orientation when things in my opinion had gone wrong. On this particular night I had one very stable pt. who q now and then would take of his 100% NRB mask and desat, as long as you put it back on he was fine. Later in the night we were going to be getting an acute MI from ER. Well since I was new I did not figure I would be getting this pt. since I am still learning the ropes. The Rn in charge decided this would be a good time to learn how to do an admit. I thought about it and thought she was right. So I take him, besides my other pt. was fine. As I am getting report over the phone on this pt.my new admit my guy c the NRB has taken it off and is yelling for help and the pt. I am getting report on over the phone is rolling through the door at the same time. I am beside myself because the other 2 RN's are busy c mixing a gtt and there is no one to help my guy or take this other pt. I ask the other Rn on the phone why this pt is here when I am still getting report on him? Her reply "I did not think he would get there that quick." Yeah right! ER is just next door! Finally one of other RN's go into help my other pt. while I get off the phone to admit this MI. I don't even have the chart on this new pt because the Er Rn was still charting in it. So I had no idea what his orders were. Well this new pt. is fairly stable on amio, and integrilin gtts. VSS. As the night goes on my new pt. starts to c/o sweats and being hot. I ask if he is having any pain and he says no. I take his temp it was fine I check his SBP. It reads 60's. I decide to lay him down and retake it. Now it reads 50's. I then decide to switch arms and retake it again. Still 50's. I talk to one of the Rn's to see what we could do. She says sit on it awhile he did have 25mg lopressor in the ER, and he was A & O. So I thought OK. So I sit on it and watch q 15 minutes. It never increases. By this time I am thinking about calling the doc and getting some dopamine because his HR has dropped into the 50's. The RN says give him a fluid bolus I do and it still does not go up. I am ready to hang the dopamine now and call doc later. Well after about an hour of his pressure being in the 50's and his HR dropping the Rn decides we need to hang the dopamine. Low and behold his SBP is now in the 120's after a few minutes and his HR increases.

So should I have listened to this RN or should I have done what my gut told me and call the doc and hang the dopamine a lot sooner then we did.

Just a side note. I also work in a 32 bed ICU and we would of hung the dopamine and called the doc. I really hope this pt. doesn't end up having renal problems because of this.

[Tweety, BSN, RN]

When the dodo hit's the fan, you have an RN license, you can't say "well so and so told me to do this.........". (I'm a bit unclear, was it your 3rd day "off" orientation, or 3rd day on orientation with a preceptor.)

Nonetheless, in my opinion 50s is too low of a BP to manage without MD input. I would have called the MD, stating "he just got lopressor, he's obviously perfusing his vital organs as evidenced by the fact he's a&o, etc" then got the MDs input. Patients with low bp's crash so fast and suddenly it could have had a bad outcome. Let the MD decide "wait and hour, give the fluid, if he's not better then start the dopamine".

Always follow your gut instincts. You did good to get your fellow RNs input, but you're the one with a license as well.

[canoehead, BSN, RN]

If you were still on orientation you were kind of stuck with your preceptor's decision. But I agree with you that a SBP of 50 warrants a call to the doc, and sooner than as hour later.

[caroladybelle, BSN, RN]

Tell the preceptor that you are not comfortable with that BP and Call the MD.

It is your license to care for.

[tsgarman, RN]

It was my 3rd day on orientation, if that is what you want to call it. I was pretty much just thrown out there to fend for myself. You are all right I should have called the doc, it is my license on the line here. When I think about it I did not even know how to page the doc. My preceptor had not even showed me how to do that. I know it is still my license and I should have pressed the issue. I am smarter than that. I chalk this up to a lesson learned and one that will never be repeated.

You will be glad to know that I have decided to quit this postion, because I am just not comfortable with how things are done there. I worked to hard to get this license I am not going to screw it up by listening to incompetent RN's.

[laurasc]

You will be glad to know that I have decided to quit this postion, because I am just not comfortable with how things are done there. I worked to hard to get this license I am not going to screw it up by listening to incompetent RN's.

That's exactly what I was thinking as I read your post. No job, especially one that gives a new nurse that kind of orientation is worth the risk.

[DOCS RN]

Call the MD and have the dopamine ready as well as a bag of IVF for a bolus. Your would have been right to follow your gut.

[traumaRUs, MSN, APRN]

Less than 3 days of orientation!! Yikes! You are right to skedaddle right on out of there!

[MandyInMS]

I agree with the others...follow your gut and CYA :)