Tuesday, June 1, 2010

So Pissed!

I know sometimes doctors make bad decisions. But the same thing happened *twice* in the last week, and I don't want to have to deal with this nonsense!

So on Thursday I get a transfer from our Ortho floor around 1600, right at beginning of shift. The guy had had a fall, broke his tibia, nothing too exciting. He was coming to us for more monitoring, as he'd been having trouble breathing. Now, we can't do anything extra for shortness of breath that they can't do on the regular floor. All we can do is keep continuous watch on his EKG and pulse ox.

So he gets to me, and he's not lookin' too good. Breathing pretty hard, and asks for the bed to be sat all the way up, plus an extra pillow behind his back. I call RT immediately to get him a treatment, because I can hear his wheezing without a stethoscope. I call the doctor, and he decides he's probably fluid overloaded and orders 80mg of Lasix IV, along with a drip.

I'm thinking he's gonna wear out soon enough, with how hard he's breathing. He really should be on a BiPAP, which can't be done on our unit. But we decide to give the Lasix a chance to kick in. One hour later, there's only 75mL of urine in the catheter bag. Not a good sign...

Somehow in the course of all this, the appropriate people for an RRT show up. Not sure how, cuz I didn't call them lol. All of a sudden, orders are popping up all over the place. So we work on getting an ABG and one doctor decides we need to draw labs for starting a heparin drip, because the dyspnea could be caused by a PE which is a known post-op risk.

Before I know it, around 1745, he's headed downstairs to Stepdown. He eventually ended up intubated in ICU for a night. We knew from the moment he got to our floor, that he would end up leaving us very quickly. Why didn't the doctors see it?

Then today, I get report on a patient coming from the Oncology/Medical floor across the hall from us. Came in with pneumonia awhile back, spent some time in ICU, then stepdown, then to the normal floor. Over 90 years old. Family is insane, calling one of our sweetest doctors "the grim reaper" because she brought up the topic of palliative care and hospice. Patient is, of course, full code, and the son cannot be persuaded to change his mind, and becomes hostile at the suggestion.

The nurse giving me report said that the patient looks *bad* and that she will probably end up going to stepdown or ICU in the near future. The RRT nurse who showed up at 330 wrote in her note "Recommend pt go to stepdown." But no, the docs send her to our floor. Where all we can do is watch her struggle for every breath. Even after I tell my manager and he calls the appropriate people.

So she shows up on our floor around 2030, wearing a non-rebreather mask. She's satting 100%, but her RR is 32 and she's using all her strength to keep going. She's able to nod yes/no, and can say maybe 1-2 words. But she's exhausted. I'm thinking "why the hell is she here?"

I call the doc, and stress that she doesn't look good and that maybe she should go to stepdown. The doc says that they are trying to avoid another ICU stay, and she wants to try her here first. She promises a visit in about 45 minutes.

The docs show up, and immediately order an ABG, and put in a transfer request to stepdown. And I'm thinking "Why do you keep wasting my time, and jeopardizing the patient's safety?!"

I give report, and by 2230 she's headed downstairs while I frantically try to get all my charting and notes done by end of shift.

Dear Doctors,

Telemetry is not a magical unit. There are a couple extra heart medications we can give. And we can monitor EKGs and pulse-ox continuously. But in terms of breathing, we are incredibly limited. We can only use CPAP, which doesn't help someone seriously struggling to breath. All we can do is watch and wait and hope things don't get worse.

Therefore, I have a request to make of you. Please. Listen to us. If a nurse suggests that a patient is better suited to another unit, it's not just us trying to get out of taking another patient. We want our patients to be in the safest place.

If you are planning a transfer to higher level of care, and you are debating between two different levels, please, please, please, send the patient to the higher level. Worst case is that they get too much care. People can always be downgraded if they get better. But if a patient is sent to the lower level of care of the two, valuable time is wasted, putting the patient at risk.

I don't want to have to do go through this scenario again. Listen to your nurses, and err on the side of caution. That's all I'm asking.



UPDATE: Within 24 hours after showing up on our unit, the elderly patient transferred from Stepdown to ICU, then was put on comfort care and transferred *back* to 330 where she passed away peacefully. If only they'd just let her *stay* there in the first place...

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