I got paged in the afternoon for a patient who was scheduled to be discharged.
Nurse: We just need a prescription for oxygen for her. Social work said they could get it filled.
Me: Wait, does she normally use oxygen? Who usually prescribes it for her?
Nurse: No she doesn't use home oxygen, but she's been on oxygen ever since she got here. The husband is really anxious to take her home, so do you mind coming in to write for it?
Me: So she's never been on oxygen before and all of a sudden she can't get off it?
Nurse: We tried taking her off and her oxygen saturation dropped into the 70s.
Me: Ummm...I'm not comfortable discharging her like that. If she's never had this problem and all of a sudden ,since surgery, she has this problem, I don't think I can discharge her in good conscience. I mean, that needs to be worked up because it's not normal.
Nurse: Well the husband is yelling at me--
Me: I'll be there in 15 minutes and I'll talk to him.
The husband was a jerk, but I explained that I really didn't want the patient to leave with an oxygen tank since I had no way of regulating that. I mean, then I wouldn't know how much she was using or how often, those things are flammable as hell, and really, I think it's a bad idea to not work that up completely. They both yelled at me, but I said that I was going to ask internal med to look at her and determine why she needed oxygen. If they said everything was great but she needed some oxygen, then fine, I'd gladly write them a script. but if they said something was wrong, we'd have to try and fix it. The husband yelled at me again, but they were both OK with it in the end after I explained that I really didn't want her to go home, have some sort of fall or stroke or something terrible, and have to come back.
About 2 hours later the nurse paged me that the patient was being moved to the ICU because she had suddenly developed chest pain, increased shortness of breath, and crazy high cardiac enzymes.
I seriously started shaking and it took me a little while to calm down. I'm really glad I didn't send her home.
Well done! If you ever need confirmation that you chose the right path in life, this is pretty darned good.ReplyDelete
Wait, you mean you were actually *considering* sending her home with a new O2 requirement??? I mean, I know you're in ortho, but I figured most of you forgot basic medicine after you became attendings, not before....ReplyDelete
you are not just sarcastic, you forgot how to be politeDelete
Into the 70s? Egad. The nurse may have been an idiot. In the ED we get really concerned if a patient comes in with a sat anywhere below 90.ReplyDelete
My initial snarky comment is, "Yes, yes, clearly nurses know what is best for the patients while doctors have no clue" (a paraphrase of what I've seen written in comments on medically-related NYT articles). But in all fairness that nurse probably isn't the brightest and I'd like to think most nurses would actually be concerned about a new O2 requirement with sats dipping to 70s. There are dummies in every field. But it highlights the lack of comprehensive medical training nurses receive. Most of their training is done on-the-job and the good nurses rise to the occasion, while the others endanger patient safety.ReplyDelete
Any nurse certainly has enough training to recognize this problem, even fresh out of school. It doesn't take much "comprehensive medical training" to know the normal range for vital signs.Delete
A story about one incompetent is not a good reason to generalize about all nurses. There are incompetent screwups in every profession, including physicians.
I'm not defending any consideration (however brief) of sending home a patient clearly unfit for discharge. But this is a great example of the all-too-common RN trying to convince interns/residents to modify the plan-of-care in totally inappropriate and sometimes unsafe ways. Nurses have a lot of experience on the floor, so they have a lot of perfectly appropriate advice. But they also have a more patient-centered focus (a highlight of the nursing field) that in some cases directly conflicts with necessary medical care. New interns are not ideally prepared to separate the appropriate advice from well-intended bad advice but ultimately they and their supervising physicians are responsible for any outcome.ReplyDelete
This is really true.Delete
Of course! This one incompetent nurse is clearly an example that we should use to generalize about all nurses everywhere. That is surely an appropriate and valid extrapolation from this anecdote.Delete
That is basically the opposite of pretzel is saying. He/she is saying that in general nurses provide EXCELLENT recommendations and interns/residents should listen to them. However sometimes nurses are wrong, and as an intern it can be hard to tell the difference, especially when they are very insistent.Delete
As a medicine resident, I really have to say... you seriously didn't notice that your patient was on O2 in the morning and hence might not be ready for discharge? Don't you guys round at least in a cursory way? And you had to consult medicine to investigate low sats in the early post-op period? I would be on the phone immediately with radiology to get the CTPA.ReplyDelete
I don't *really* mean to be snarky, but come on... the worst part is that if the patient had gone home and returned to emerg with a PE she'd get consulted to medicine since ortho would refuse re-admission.
You probably haven't worked (as a resident) on a surgical service. Many people go to the floor from PACU on oxygen (NC) and are weaned by protocol to room air. Sometimes the patient is operated on late afternoon/evening, on oxygen overnight and seen the next morning before the oxygen may be completely weaned. The decision to discharge from a surgical standpoint may be made and the expectation that the patient can be weaned to RA prior to discharge is completely normal.Delete
+1 to pretzel's comment.
+1 for pretzel's comment.ReplyDelete
Whats the difference b.w nursing and medicine, explained with brevity.
As a nurse, I can't begin to understand the mindframe from which THAT nurse was working --unless she was a new nurse or one of those just truly clueless people.ReplyDelete
I get offended, though, when people don't realize how much education a nurse has (at least a nurse with a BSN). I took organic and biochemistry, anatomy and physiology, genetics, microbiology, patho, pharmacology, and research classes all before getting into nursing school. We do learn a lot of what we need to know in the job site, but isn't that true with doctors--they really learn a lot of what they will use on a daily basis once they are in residency?
As a nurse, I beg you not to lump the vast majority of us in with that nurse!
Don't worry, I do not lump. But a negative outcome could get me sued, so I especially have to watch out for the relatively few incompetent nurses as well as the well-intended-but-bad advice that anyone (even "good" nurses and physicians) can give.Delete
Also I think it's important to recognize that basic science training, however rigorous, does not have much bearing on a nurse's clinical acumen. If you did well in those courses then I trust you are capable of intelligent thought, which is a precursor to good nursing and doctoring.
I dated a RN during his community college-based nursing training. He was (per IQ testing) of below-average intelligence (tho' had a very good heart and excellent work ethic). He had a lot of trouble understanding basic physiology and had failed a semester of chemistry which he retook and passed. However, he was quite a bit smarter than many of his classmates, most of whom also made it through the program. There is a lot of money in training new nurses and many people get in who are really not qualified.
It strikes me as really unfair that both the excellent nurses and subpar ones both get to call themselves RNs.
I'm actually surprised that you didn't get paged earlier with the sats into the 70s. Considering as a resident I frequently got paged with normal vital signs, you think an abnormal one would have warranted some communication.ReplyDelete
But good for you, to not let this patient go home!
You are right, Katherine - the nurse should have recognized much earlier that this patient had something going on causing her to drop her sats to the 70s and should have initiated an evaluation. (Methinks the nurse was too anxious to get rid of the obnoxious patient and husband.)ReplyDelete
Pretzel, you are right on, too. An astute nurse who observes, assesses, and reports on the subtle signs that patients exhibit before they crash is invaluable to a patient and the physician, but how's the doc to know who to trust?
As a nurse with about a gazillion years of critical care experience, as a patient on several occasions, and as the mother of a daughter who has had numerous encounters with the health care system (including 15 surgeries before she turned 30), I am very concerned about the ability of some nurses to integrate their scientific learning and apply it to a patient.
The level of intellectual curiosity among nurses today (again, in general) is distressingly absent, even among the nurses in the Mecca of Modern Medicine where I work. No one ever seems to ask themselves WHY any more.
Take for example, a patient with a history of sleep apnea, who is freshly post-op on PCA, who the nurse leaves flat on her back and doesn't check for hours. Is anyone surprised that the patient stopped breathing and that the respiratory arrest went unnoticed until it was too late?
When my daughter had open heart surgery, I asked the surgical ICU nurse why my daughter was on a continuous infusion of insulin. "To control her blood sugars." Yeah, okay. Let me try this - I explained my background to the nurse, including the fact that I had worked in that very same SICU some years back. So, I get that insulin controls blood sugar, but since my daughter was not a diabetic, why was SHE receiving it? "Because the doctor ordered it to control her blood sugar." Are you kidding me? This conversation continued in its circuitous manner until I put a call in to her surgeon. He told me that research had shown that if they keep a patient's blood sugar artificially low, there is a lesser incidence of sternal infections. This is a very simple concept but apparently, this nurse never asked the question.
Or the nurse who said she needed an order for a CXR after placing a naso-gastric tube. "Um, did you aspirate stomach contents when you placed it? Yes. The NGT is being used for decompression, not feeding, correct? Yes. Then why do you need a CXR for placement? Because, the Nurse Manager said we should." What will the CXR tell you that you do not already know? Silence.
Is the patient getting anxious and a little confused? I have known nurses to call for a sedation order without checking the patient's VS and oxygen saturation first.
Nor do nurses ever touch patients any more, and if they do, it is through a layer of latex. A nurse today cannot assess the character of a pulse because heart rate is measured (by the aid) with the O2 sat monitor. Has the pulse become irregular? No one knows. I've seen nurses who can start an IV without recognizing that the patient's skin has become cold and clammy.
Is the patient congested? Call Respiratory Therapy for everything - chest PT, suctioning, nebulizer treatment. The nurse is completely hands-off.
I do apologize for tearing off on a lengthy rant, but this is a very touchy subject for me and for other wonderfully intelligent, high-quality nurses who are saddened by what we see. TCG
+1 to everything Anonymous/TCG said above. Sadly, if my favorite experienced nurses are to be believed, a more modern-day Anon/TCG would have forgone nursing school for medical school. I myself considered nursing but was advised to go to medical school given my good grades in biochemistry. I think I could have become an intellectually curious and competent nurse, tho' I'm not sure my back would have survived. Also don't know if it's possible to be a truly happy nurse OR doctor these days, excepting those with perennially sunny outlooks. The overall healthcare climate is pretty abysmal.Delete
I am an aspiring medical student and I love reading your blog! It is so funny and a joy to read. I hope to continue my blog through my medical training like you do :)ReplyDelete