Monday, September 24, 2007

These big clumps of hair? Oh, they're nothing.

Take a tetraplegic. (That's the Medical Term for "quadriplegic", now fallen out of vogue because everybody knows what it means.) Give that tetraplegic person a rollicking urinary tract infection, dehydrate them significantly, add some weird heartbeats to the mix, and give her something called autonomic dysreflexia, which means "Nothing works right after you break your neck."

Admit that person to my floor with a blood pressure of 60 over 20. For those of you non-medical types, 100 over 70 or so is considered normal. 60/20 is a sign that something is wrong. Make sure her oxygen saturation level is somewhere in the high 70's (again, not good in a big way), and see that she's running a fever of 104.9 F.

Did I mention she's not producing urine? At all?

All the time I was running my twelve liters of fluid into her, to bring her to a grand total of nineteen liters of fluid, I was fighting with the attending who'd admitted her to our floor. She should've gone to the ICU straight off.

*** *** *** *** ***

Take a person with a significant medical history, including multiple cardiac catheterizations, liver problems, and several heart attacks. Put them through a very minor--as in out-fucking-patient, for God's sake--surgery. Make sure they lose something like 3 liters of blood during that surgery. (No, I'm not exaggerating. You can't make shit like this up.) Lose her once during the surgery and bring her back to life.

Send her to the post-op unit for four hours while you run five liters of blood into her. Make sure you're running huge amounts of IV fluid at the same time. Warm her up, dose her on fast-acting narcotic pain medication, and send her up to my floor.

The whole time she was there, from the time she arrived until I sent her to the ICU after she coded (too much fluid, most of it going to the lungs), I was fighting with the attending who sent her to us. She should've gone to the unit straight off.

*** *** *** *** ***

Here's a nice little old man who's recovering from a nasty bout of pneumonia. He's not dehydrated, his electrolytes are fine, and he's not feverish. But for some reason, he keeps throwing these bizarre heart rhythms on the monitor. They don't look good, and they're starting to look worse.

For eight hours, from the time he showed up to us until he coded and was pronounced dead, one of my coworkers fought the attending who sent him to us. He should've...but you get the idea.

*** *** *** *** ***

This is why I love the neurosurgeons I work with. If I say, "Hey. Something is Not Right here," they'll snap to and take a look at the patient, even if all I have to go on is a gut instinct.

And it's also why I hate every other service pretty much all of the time. The first patient had been admitted the night before, and all three nurses who had worked with him had agitated to send him to the unit. There's such a thing as having too much going on to be well cared-for by a nurse who has five or six other patients to manage.

The second patient was transferred to us over the objections of the manager of the post-op unit. The third came in okay, but should've been sent to the unit the minute he started manifesting tombstone T's. There are drips we can't run and tricks we can't pull on the floor that they can in the ICU.

I do not know what to do. In both the cases that were my patients, I worked my way up the chain of command, finally culminating in repeated phone discussions with the attending physicians. I kept everybody updated, shoved my other patients off on other nurses and the charge nurse, and chewed new assholes right and left for every resident I could reach. Every nurse I spoke with about those two patients, from the clinical manager to the ICU charge nurse, asked the same question right off: "Why is this patient not in the unit?"

Yet the attendings, either through sheer laziness or disrespect for nurses (the first, I suspect, in the latter case; the second reason in the first case), ignored that my hair was on fire and their patient was tanking. The residents went along with the attendings, with the added joy of being snarky to boot.

I can handle almost anything within reason. Nearly losing two patients in two weeks is hard, especially since one of them will have a lifelong anoxic brain injury courtesy of her stupid surgeon. The nurse who cared for the poor, sweet little man who died is a wreck--she's two years out of school, technically excellent, and usually unflappable.

I do not know what to do. I have excellent working relationships with the attendings and all but one of the residents. The brain surgeons routinely ask that I take care of their patients, because they trust me to flip a lid if something goes wrong. Yet in two cases, *something* stopped two experienced physicians from taking me seriously enough to listen to me when I said a patient was more than we could handle and was *getting worse*.

The first woman was, thank God, fine. The second will be easily amused for the rest of her life. The third patient is dead.

I know it's not just me, since Other Nurse had the same issues with stonewalling...but still. What could I have done differently? How do doctors like to be presented with things like this? I gave 'em detailed, succinct reports on their patients, but that wasn't enough...

This has been keeping me up nights.


woolywoman said...

Do you have a union? A nurse practice committee? Arisk managment dept? Those are the places I go. Sorry it sucks. You did what you could. It still totally sucks.

Judy said...

Sometimes doing everything right isn't enough. But you knew that already.

kati b said...

This is one of the scariest ideas to me as a student nurse - that let's just say I know my stuff, and I accurately assess a situation and I hit the big blue button. Not because I'm scared, but because it's warranted, but then noone comes? What then?

(I know that people will come when I hit the ACTUAL big blue button - we all heard the stories of the student who hit the code button because she walked into her patient's room and they were coughing so hard that they couldn't catch their breath. Still conscious, a floor full of staff nurses and a clinical instructor floating around somewhere, but she freaked and hit the button.)

Dr. Alice said...

I wish I had a decent answer for you. All I can tell you is that any doctor who shows such a clear lack of clinical judgement (especially documented by multiple nurses) should be reported. Though I agree, talking to administration first would be a good idea. You want to make sure they'll have your back.

shrimplate said...

Sometimes I find that it's helpful to take hostages and provide a list of demands. It's amazing how quickly people respond when there's a gun to a resident's head. Even faster on a consulting physician.

You've "got hand" on those docs, and I trust you will tread lightly and make the most of it. You'll be doing all of us a big favor.

Jo said...

Thanks, all. I think I'll start with one of my go-to, trusted folks, a clinical educator, and go from there. She's my main resource when things aren't going quite right.

Shrimpy, "got hand"? You're too up-to-date for me. Translate, please?

Umm Izzy said...

Does your hospital have a Rapid Response Team?
Our RRT can override the attending and consultants, and get them to the unit themselves, if they meet certain criteria.
At that point, the Critical Care Docs take over.

shrimplate said...

"You've got hand" is Seinfeldese for when somebody owes you one.

GingerJar said...

Can we say Rapid Response Team...I didn't even know for sure we had one at my hospital...till I called the Resource nurse and told her to come now my patient was *this* close to coding....

I had ER Doc, RT, and a roomful of helping patient survived and went to ICU.

Mountain Nursee said...

Complete an incident report and send to risk management
Also say on said incident report(s) you were told by the families that they are intending to sue (doesnt matter if they did or didnt say that)Put a copy of the incident report(s) into the CEO mailbox in a plain brown envelope with his name and 'personal" on it. Deny all knowledge of how it got there if questioned.