when doctors don't know

i am filled with wrath (surprise, surprise) at the actions of a shockingly ignorant resident.

the patient: cool and clammy, oriented to self only when she had previously been pretty normal. had the creepy blank look that happens when the lights are on, but nobody's home that usually accompanies some kind of stat situation/code.

the problem: ? fluid overload vs. narcotic overdose vs. repeat hemopneumo after chest tube pulled vs. sepsis vs. just about ANYTHING.

the other problem: the resident. a small stubborn man who had been giving us problems all week. wouldn't listen to me when i told him cipro was 500 mg BID, but instead pulled out his iphone and pointed at the screen that told him the med was once a day. this is never a good sign.

the events: resident orders labs and ABGs. patient's extremities are cool, the veins are clamped down, and there's no blood. people are trying to draw her legs, RT is poking her and can't get an arterial sample, and all sorts of other problems. she looked bad, and i told the resident so. he kept saying it was "just fluid overload" and "just too much narcotic", but wouldn't give me any orders for meds. i tried talking with him several times, and each time he shut me down. i was growing more and more concerned about the patient, and as a result my temper grew shorter and shorter. i pulled some narcan to reverse narcotics and began to draw it up. by the time i had it mixed up, he finally decided to give it. i gave the drug, and nothing happened. he was still at the computer in the room, going on and on about narcotic overdose and how she couldn't clear medications. "HER CREATININE IS FINE, WHY CAN'T SHE CLEAR NARCOTICS?!?!?!" was what he got from me. at this point our problem was clearly NOT narcotics, as the narcan did next to nothing. we moved on to lasix to help with fluid overload, and then i nearly got into a shouting match with said resident when he wouldn't let me put in a foley to monitor her fluid status. he was going on and on about UTI, which i felt was next to irrelevant considering the circumstances. i finally couldn't take it anymore, which let to me letting my wrath out with voice raised and a hand on each hip, telling him exactly how sick i thought this woman was and that he was essentially doing nothing for her.

the labs came back. the chief resident came down. the PCO2 was critical: aka the patient was retaining carbon dioxide and it was making her sick. the decision was made to go to the ICU.

i told the chief resident a thing or two, including "i want to kill that resident, seriously, i'm gonna strangle him right here". then we called our manager and home and told her that. then i wrote him up.

these are the things that happen when doctors don't know. i'm not sure why that resident wasn't concerned about the patient's condition. i don't know why he wouldn't take suggestion, why he ignored my repeated voicing of concerns, why he had a blatant disregard for all nursing judgement.

all i know is the sick feeling that i get in my chest when i know something is wrong with a patient. the cold fist of fear that sits there and will not be ignored. there is patient advocacy, which is something nurses do on a daily basis. and then there is something else: some sort of 'momma bear' instinct that kicks in when something is truly WRONG and will not go away until the wrong is righted. it's a feeling that will make you kick and scream until you are heard, will help you claw through anything that gets in the way of getting what you believe is right for your patient. suddenly you don't care about how crazy you are coming off, if the doctor likes you as a person, or if you will have a reputation as a crazy vigilante nurse from now on. the only way to feel better is to get your patient what they need.

we got an ICU bed and the fist in my chest loosened. the patient went upstairs without incident, she was delivered to a place where they could give her what i couldn't and the sense of relief was immediate.

it's scary, when doctors don't know. thank god nurses do.