This is not the first time I received a pt with such a scenario fromt the ED.
Doctor asks us to take pt ASAP, since pt is possibly septic and he's had to personally hang fluids in ED because the nurse there seems to be "too busy". I work step-down, all pts on cardiac monitor, we do alines, drips.., but to a point- I have 4 pt's. Doctor assures us pt does not require ICU care. I call for report at 1700. Pt had been in ER since 1300 but only received 1 L out of 2L fluids ordered. Oh, only one IV access, so fluids where stopped while zosyn infused. I get last set of vitals (that the nurse "just" took) HR 98, SBP 110, 100%spo2 on RA... The nurse than asks me if I can come get the pt. Um, I assume care once the pt gets to my floor. Since when do floor nurses have the leisure to come get their pt's.?? She than asks me if the pt should come on cardiac monitor. I explain that we're a monitored floor, so probably yes, but it is her judgement call- I havent assessed the pt yet!
20min later, I look up, escort dropped off pt on a stretcher, no RN or MD or monitor. Pt looks pale, obviously very sick. Get my charge, get him into bed, hook him up to all fancy monitors. My first set of vitals: HR 130, BP 72/49, Spo2 98% on RA. 2 L bolus, insert another access BP does not increase. Pt is obviously septic, febrile, c/o of SOB, dyspnea. Poor clinical picture. Now running fluids wide open in both 18 G IV's. Finally, MD agrees to come see pt. I insert foley, set up Aline and CVP monitoring, MD inserts Aline and Central line. Pt is dyspneic, desatting to 80's by now on 6L NC. Albumin seems to help a little. For some reason, (maybe ICU nurses can explain here) glucose is 40.
3 hrs later, after 5-6L (not sure, just kept on hanging bags), Albumin, foley, central line, aline, 100% NRB, 50% dextrose for glucose level, ABG, full set of labs sent, Neo drip set up to ready to start, and much more, now mildly confused pt is rushed over to ICU. (I had 3 other pt's that I simply ignored this whole time)
HERE'S MY QUESTION:
This is not the first time that in report from ER I got a perfect set of vitals that totally doesnt correlate with the vitals I get on pt arrival. Did this pt's BP drop from 110 to 70 and HR increased from 98 to 130's in 30 minutes??? Yes, septic shock happens fast, but when I see this happening to ER pt's often, should I start thinking that nurse in out ER are doing s/t wrong? What else can explain this.
Second, do our ER nurses only see crashing pt's as sick? ER Nurses need to be educated that in suspected septic pt's, fluids must be started STAT, even if BP is ok. In early stage of septic shock BP often looks fine do to endotoxin effect on the CO. When the BP drops thats when its usually too late.
The above pt, in his late 30's didnt make it. Went into MODS... I truly regret not calling for report earlier (shouldnt have done so much teaching with my discharge pt earlier....)
