What Would You Do?

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Scenario:

0540 86y/o F admitted to acute psych ward for Maj. Dep calls to desk, states "I just don't feel right". Skin warm, pink, dry. Vitals 132/80-98.3-86-24-89% RA. Lungs with crackles throughout. Alert and oriented x3.

0542: Covering doctor paged, orders to send to ER for evaluation recieved.

0543: ER notified, instructed to send pt down in "whatever's most comfortable" (stretcher, wheelchair, etc)

0544: Returned to pt's room to find a decreased LOC, VSS. Color pale. Turns heads and looks at you when you speak. (Here's where I got a bad feeling- we packaged her up in the cardiac chair and sent her to the ER). Made a stop at the nurse's station- I wanted O2 on her, but beceause we're a psych ward, we don't stock O2 supplies.

0545: CNA takes concious pt to ER. ER notified of pt's change in status.

0546: Resp. arrest called.

This pt's BNP was over 1800. She's now intubated in the ICU.

I, on the other hand, was berated by the Nurse Mgr. in the ER as well as the supervisor for not calling a code and following the patient to the ER. Our psych ward is 5-7 minutes away from the rest of the floors, and at night, it's only staffed with 1 RN and 1 CNA. If I'd left the floor, I could've been charged with abandonment. I felt it necessary to get this patient to the ER where she could get a higher level of care than I could provide with limited resources.

What do you all think? I'm a bit discouraged- I was told that I have "poor judgement" and I'll be spoken to by legal tomorrow.

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Boy, she went downill fast! That had to be very scary. What was their suggestion on how to get here there?? You can't leave the floor "empty". The only possiblity was getting a nurse from the ER to come up and transport but that would have taken longer... Hmmmmm... I'm trying to think about what they really expected you to do???

I agree that a code "could' have been called, but you said her vitals were stable....

I don't know. I'm sorry you're being hammered for this. :o I would really like to know their ideas of what "they would have done" though. Please update us.

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Oh let them blow it out their XXX, you did the right thing.

Anybody else probably wouldn't have even sent her to the ER. Do they really not have anything else to do.....I mean, you sent her to ER and there was no o2 to put on her, what else was there to do? Makes a heckava lot more sense to get her to the ER instead of trying to work on her in a psyche unit without o2 supplies..that's IF you had known she was gonna code, which I'M SURE THESE GENIUSES would've been instantly able to tell...give me a break.

Speaking of which: if you got her @ 0540 and she CODED six minutes later, why the heck was she sent to the psyche unit, ANYWAY??? Why didn't the ER geniuses keep her down there? Could it be they're trying to cover their own behinds by blaming you? Hmmmm.....I think so. :rolleyes:

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Oh let them blow it out their XXX, you did the right thing.

Anybody else probably wouldn't have even sent her to the ER. Do they really not have anything else to do.....I mean, you sent her to ER and there was no o2 to put on her, what else was there to do? Makes a heckava lot more sense to get her to the ER instead of trying to work on her in a psyche unit without o2 supplies..that's IF you had known she was gonna code, which I'M SURE THESE GENIUSES would've been instantly able to tell...give me a break.

Speaking of which: if you got her @ 0540 and she CODED six minutes later, why the heck was she sent to the psyche unit, ANYWAY??? Why didn't the ER geniuses keep her down there? Could it be they're trying to cover their own behinds by blaming you? Hmmmm.....I think so. :rolleyes:

*Oops- I guess I made a typo- she'd been admitted a few days ago for major depression...sorry. :( But she had NO co-morbids! And I'd done my RN assessment on her earlier that night and she had clear lungs and no peripheral edema- she was FINE. Never have I EVER seen anyone circle the drain so quickly!

They said that I needed remediation as well- I graduated in May, and worked in an ICU for 5 months, then went to post-Katrina Mississppi- and I've been an aide for three years before. i KNOW what a code looks like- gr. This woman was NOT coding on my floor!

THey said..."I know it's easy to push off a bad patient on someone else, but use your head next time." :uhoh3:

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Well, you work on a psyche unit.

Was she having labs for BNP REGULARLY???

I mean...come on, it's up to the doctor to order labs, if she wasn't even being treated for CHF why should you have suspected it, okay, her O2 sat was 89 w/crackles but hadn't she been on room air?

You said there was no o2 on the unit to even put on her, I think they are just giving you a bunch of B.S., you got her off the unit as soon as you thought she needed a higher level of care; there was no reason to think she was going to code that fast regardless of what they say.......don't let them make you feel inadequate you did the right thing.

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Specializes in Utilization Management.

I feel like had you called a Code it would've taken that long to get a crash cart to the patient.

I've seen CHF kill in minutes like that. I think you did the best you could with the resources you had available. Your key word when you talk to TPTB will be "resources" because you had neither the staff nor the equipment to deal with this medical emergency.

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Your key word when you talk to TPTB will be "resources" because you had neither the staff nor the equipment to deal with this medical emergency.

Ditto that.

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Specializes in Telemetry, ICU, Resource Pool, Dialysis.

Wow. I'm really sorry that happened to you, and that you are being treated so badly by your employer. They put you in a crappy situation. I don't work psych, never have, but why aren't there emergency supplies in, or near your unit??? You should have access to (at the very least) IV supplies, fluids, and O2. Just because it's a "psych" unit doesn't mean the potential for an emergency does not exist!

What is your protocol for medical emergencies?

I think you did the right thing. #1, a concious, breathing person (no matter how bad off) is not coding. #2, if you had no supplies on the unit, what would be the point of keeping her there and calling a code? #3, did your manager REALLY expect you to leave the unit???

If it makes you feel any better, it sounds like she went into flash pulmonary edema. That happens so fast it'll make your head spin. Your manager was probably wrongly assuming that the condition she was in when she got to ER had been brewing for several hours. She could have left you unit concious and alert, in some distress, but been unresponsive by the time she got to ER. This is a really good opportunity for you to point out the need for a crash cart with O2 supplies on the unit. That way, you can call a code next time, and the code team and you will have supplies. They left you with no resources, and no choice in the matter - and now are going to let you take the fall for it. I hope you documented well.

(((((Keep your chin up, and good luck - you did the right thing.)))))

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Specializes in NICU, ER, OR.

As you stated it, you did the right thing. I'm thinking that they *think* she coded while she was with you, but instead of calling a code, you had the cna take her down.make sure you clarify yourself to them....sorry this happened........let us know how you make out?

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Specializes in ICU, step down, dialysis.

This is exactly what I'm wondering too...is there a policy on how you treat psych patients who need to go to ER? If so, does it require a RN/LPN to escort them down? Do you have a float nurse/rapid response team or even a house supervisor in your hospital you could have called to help you out and to escort the patient to the ER for you? I believe she needed a nurse with her to go down, but maybe your hospital doesn't have float nurses/RRT's. I don't believe though that you personally should have went down with her, you should have had someone there to help you out.

Not sure why they insist you had called a code, unless something like this is also routinely done at your hospital for patients circling the drain or unstable.

I hope the OP doesn't take my questions the wrong way...I'm not trying to dog you out or anything...very interesting scenario. Just curious about what your particular hospital policies are and what kind of resources you have there.

What is your protocol for medical emergencies?

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If your unit doesnt have oxygen I am betting that it doesnt have any other emergency resuscitation equipment. As someone else said look at your policy and procedure. If you do call a code does the ER or nursing supervisor bring a crash cart? If they dont then I can see no point in calling a code. I guess you can call a code and everyone can just stand and look at each other with no equipment.

You are perfectly correct in that you cannot leave the floor. Especially a psychiatric unit. What happens if someone becomes violent and harms a patient or themselves while you are gone? Ask legal that question and how they would explain to the family that the 1 nurse was 5-7 minutes away in the ER. I would also contact the state board of nursing for further clarification.

I think you are right and I wouldnt back down. Be civil, have your thoughts organized and I would press this issue to the Chief Nursing Officer. It does sound like the patient had flash pulmonary edema which strikes extremely fast. You had assessed the patient, called the doctor and had the patient to the ER in 6 minutes, I dont know how faster you could have been.

You were not "pushing" a bad patient off. You were following doctors orders and transferring the patient to the appropriate level of care.

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In a situation like this, it's not as if you have all kinds of time to mull the situation over. Sure, you could have weighed all the options and examined it from all sides, plus you caould have looked up all the policy and procedures on how to handle a situation like this, but DUH!!! HELLO! IT'S CALLED CRITICAL THINKING, and thank God you have it!! Seconds count in a situation like this, and you did the right thing. I would document everything to a tee on this. I certainly would make NO apology for your actions and say you would do the same thing if the situation arose again!! :yeah:

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