negligence

now i'm sure we all know by now that i have a lot of emotions.  but i think that this patient situation made me the maddest that i have ever been about something at work.

so we get this admit called up...85 year old with diagnosis of kidney stone.  "stable" they say in report.  the admit went to my work bff and i went about my business.

that is, until, i see an elderly man being rolled down the hall with a nonrebreather bobbing above his face.  i can see from half way down the hall that his eyes are rolled back in his head, and by the time i got within a few yards of him i could hear him gasping for air.

"how long has he been like this?!?!", i asked transport.  he looked at me like i was crazy.  "he's like this since ED".

this particular transporter has a bit of a language barrier issue, and clearly all he was concerned about was trying to get the patient into a bed.  i'm frantically calling for work bff, and the code cart, and the stat team, and our friendly transporter is putting down the side rail to slide the patient across.

"YOU DO NOT PUT HIM IN THAT BED."

i was absolutely livid.  LIVID.  how DARE the ED nurse send up this patient?  how DARE she not tell us how sick he is in report?  and how DARE she let a transporter who has no clue what's going on take this man halfway across the hospital on 15 liters on a nonrebreather with agonal resps?

so we stat-teamed him right there on the cart.  of course we had no admission orders, so no one could determine what team was taking care of the patient (this was before we had computer charting).  the nurse had gotten verbally that the patient was a DNR, but we had no orders to that effect and no signed paperwork.  we put a nasal trumpet in, and after that didn't work, started bagging him.  we drew ABGs.

his pH was 7.19.  he was pretty close to being dead.

it turned out that the "stable" patient with a kidney stone was actually wildly septic and had been completely unresponsive since he got to the hospital 4 hours earlier.  he had required a nasal trumpet airway in the ED, but his nurse in the ED apparently took it out, put him on max O2 via a nonrebreather, and sent him on his way without a word of warning to the floor nurse.

he arrived to the floor at 2140.  he was transferred to the medical ICU at 2205.  

the ED nurse sent the patient to us to die.

hey, i get it.  he was really old and a DNR and beyond fluids and antibiotics (which they gave him) there wasn't much else to do.  the ED is no place for palliative care.  the trauma unit is also no place for palliative care, but i can work with you if you let me know what's going on.  the patient is 85, has dementia at baseline, is wheelchair bound, and lives in a nursing home.  if he's a DNR and these are his wishes, there are worse ways to go than fast from urosepsis.

however, i think that a warning would have been more than appropriate.  a clarification of his code status and documentation of it also would have been nice.

upon arrival to the MICU, he was immediately intubated and his family revoked his DNR status.  he was in the ICU for several days before he coded and died.

this happened three and a half years ago.  i was cleaning out my work binder today and dug up my notes on the patient.  at the time, i think i printed out some information and gave it to my manager to look into.  as far as i know, nothing ever came of it.

now i might sit down in front of my computer and night and rip into people on the blog to vent, but i am pretty forgiving at work.  i have never written up another nurse, and i don't think that people should get in trouble for innocent mistakes.  i'm a big believer in "well, you'll never do that again".  learn and move on.

but this was no innocent mistake.  you don't put 15 liters of oxygen on someone who you think is stable.  if you think your patient is unstable, you don't send him to the floor alone.  if you know the patient is sick, tell me.  if you don't know that your patient is sick and they are completely obtunded and unresponsive with agonal breathing, YOU SHOULD.

there is NO excuse for this.  that ED nurse, whoever she was, was negligent in her care of this patient.  plain and simple.  i've never seen anything so blatantly incompetent before, and i haven't seen it since.

i hope she knows what she did was wrong, and i hope that she learned from it.  i hope she hasn't forgotten this patient.  i know that i won't.






***disclaimer:  this is an incident involving one nurse from my hospital's ED.  it does not mean that i think that all ED nurses are this way (because i don't).  while i've had some negative experiences with our ED nurses that i've blogged about,  these experiences are the exception and not the rule.***