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.

this post: not for the faint of heart.

i have never before watched someone lose so much blood from rectal bleeding as i did tonight. 725ccs in 3 hours, 3/4 of a graduated cylinder of frank blood with clots. terrifying and shocking.

the problem lies in the treatment, which is wait and see, or as i like to think of it- record and stalk. every drop of blood, every cc of urine, all the vitals. watching the labs, watching the heart rate and blood pressure like a nurse nazi, that is the plan. unfortunately, i feel that i know the outcome of this, and it makes me anxious.

this man will tank. drop like a rock. be fine until he isn't fine and we're scrambling to bolus and transfuse and get in there to find the bleeding and stop it. there will be an urgent ICU transfer, or a trip down to the OR with an ambu bag in one hand and a pressure bag in the other.

***

i could not take the feelings of impending doom, so i do what i often do and call the night nurse from home so i can sleep in peace. as he has now lost about 900ccs of blood, the patient is going to the ICU. soon he will be covered in a bajillion monitors that will not let him slip into hypovolemic shock unnoticed.

and with that, i can relax. and add massive rectal bleeding to the list of crazy/weird/gross things that i've come across.

so i'm crabby, what of it?

things that irritated me today:

the transporter who tried to tell me that i didn't need a sheet under my patient to pull her across to the bed. he got a nice death glare and a steely "YES i do".

the nursing student who i overheard telling her classmates that "acute care is not her thing" and that she wants to do "as little patient care as possible". oh good, just what the profession needs, another administrator. another rule maker. another person who sits around and decides what hoops the people who actually DO THE WORK have to jump through.

the meeting that we had to sit through this afternoon, aka the monthly list of our sins. to recap: there are too many falls, too many 1:1 sitter cases, it's too loud, the hospital is not clean enough, and by the way the state is coming at any minute be prepared for an attack at any turn!! uplifting as always.

the fact that we are now being called into the manager's office to defend ourselves against accusations made by a patient who is known to have dementia and frequently rants on the topic of chickens. seriously? as much as i would love to lock you in a closet, or whatever the hell you're telling people that i did to you, i (unfortunately) still have a moral core that prevents me from doing so.


these are the things that i do not have time for.

full moon.

in 4 days we have had 3 rapid responses. 2 emergent transfers to the ICU. 1 unstable ED admit who rolled up drenched in blood, hypotensive after 5 liters of fluids. 1 very sick GSW patient with more tubes than holes to put them in. 1 patient who wanted to die so bad he nearly clawed off an extremity. 1 patient who almost passed out in the bathroom. A little old man who tried to punch us for putting an oxygen mask on. A different little old man who tried to hit the OT with his walker for making him get out of bed. the insanity is endless.

today i literally climbed in the shower with a patient to wash her hair. rivers of bloody water swirled around my feet as I combed out chunks of her scalp that were loose in her hair. then i helped scoop up a patient who passed out in the hall. ran back and forth for a half hour putting him on the monitor, bolusing, starting a heparin drip, trying to locate a doctor who had been a doctor for longer than 8 months to help us, etc. after we sent him to the ICU, I walked my patient who just happens to be one of our residents. after I dropped him off in his room, one of my coworkers approached me and asked me why I was walking arm and arm in the hall with Dr.___. this, people, is how rumors get started.

the night is over, and i'm {finally} off to bed.

until next time, moon.