Monday, September 18, 2006

Learning Lesson(s)

Ahh, back to the beginning of another week.  Still feels odd to be off on a Sunday & Monday.  In fact, I didn't even know what day it was today!  So much for me being alert & oriented.  :)

I put in 4 days straight.  It wasn't too bad until the last night because we had no tech & 5 patients each.  It's just too hard because the majority of our patients are older & more needy.  Between patient care and paperwork...we are exhausted.  Not enough time in a 12 hr shift when we don't have a tech to take care of the patient's basic needs. 

I did receive a patient Friday night around midnight being admitted with a DVT (blood clots) in her left arm.  She was started on a Heparin drip in the ER.  When I went to check out her labs before getting report, I noticed they were still pending.  I thought it was odd that they were admitting a patient without knowing the majority of her lab values, but I assumed (lesson #1 - don't ever assume) that they must know she is stable & therefore ready for transport to our floor.  So I get report & am told she's diabetic & that they didn't have time to do an accuchek in the ER (how long does it take for an accuchek?  60 seconds?).  I said I'd check it when she got to the floor (lesson #2 - insist they do it prior to transport while the pt is still in the ER). 

Before the patient even makes it to the floor, I get a call from lab saying her stat PTT is 166.  That is extremely high for someone on Heparin, much less someone that was just started on Heparin & supposedly that is the baseline.  Next call from lab...the patient's blood glucose is 606.  Ugh...this is like deja vu from a couple of weeks ago in which the blood sugar went ignored.  She gets to the floor & I immediately turn off her Heparin drip and place a call to the doctor...who of course is not the same doctor that admitted her just an hour earlier.  I get the doctor on call who knows nothing about this patient.  The patient has an insulin pump & the admitting doctor had marked "no"on the medication reconciliation form to her using it.  I have no idea why as usually when a person has a pump, they are pretty good at regulating themselves.  Why she didn't ask for an accucheck in the ER, I don't know, but regardless, it wasn't her responsibility.  It should have been checked in triage or at the very least, by the time she got a bed in the ER. 

Anyways, so now I'm on the phone with the doctor who is asking me why the other doctor marked no to her using her own insulin pump.  As if I'm psychic or just know everything.  I tell him I don't know, that it's simply marked no without any explanation.  His next question was "What did the patient have to eat today?"  Huh?  Who cares....her blood sugar is 606 at this moment.  I tell him I didn't know, that I hadn't asked her (who asks that anyways?)  His reply "You really should have the answers to my questions."  Oh how I wanted to hit him upside the head with the phone...grrr.  So he tells me to give her some insulin now, change the sliding scale and don't recheck her blood sugar for 6 hours.  Nice...such quality care I swear!  He's ready to hang up & I'm like "Wait a minute, she's also on a Heparin drip & her PTT at this moment is 166."  So he says hold it for 2 hours & repeat the PTT...if it's greater than 80, hold for another 2 hours or if it's less than 80, start at 15 units/kg/hr.  What a strange order!  Turns out the PTT drawn wasn't a was drawn after the patient got a Heparin bolus....grrrrrr, the ER nurse started the patient on Heparin prior to getting a baseline PTT or CBC even though the protocol clearly states it at the top of the page.  Luckily the patient was tolerating both conditions rather well.....very lucky for the ER.

I talked to my clinical leader & asked if I should write up an incident report.  She was saying no, that she'd talk to the ER clinical leader about it.  She did call her & it was the same general excuse "we're really busy down here."  Which is fine, I understand that...but compromising a patient is wrong, I don't care how busy you are or what department you work in.  What would have happened if I had allowed the PTT to go unnoticed/untreated as well as the extremely high blood sugar?  I would expect to get in trouble for it as well as the hospital has to be made aware that if the nurses & doctors are that busy that critical lab values are being ignored, then it's time to do something about it rather than end up with a lawsuit &/or the guilt of harming a patient.

I had her again the next night, blood sugar still a little high, but in the 300's-400's...working it's way down & she was managing it with her pump now.  Her Heparin was therapeutic at 8 pm, so I put in an order for the next PTT 6 hours later or 2 am...fully expecting I'd have a result by the latest 2:45 (lesson #3 - don't expect anyone other than yourself to stick to time lines).  The lab didn't draw it until 3:05 - so much for timed studies.  I check the computer around's not even been received in the lab yet.  What the hell?  4:00 comes & goes, I finally decide to take a lunch break only to have someone come in the break room & say "Lab called, they say your PTT is greater than 200, do you want the test repeated stat just to be sure that is correct?"  It's now 4:30 am.  I say "yes, of course" because how could it be therapeutic to now suddenly over 200?  So again, I expect that STAT means quickly (lesson #4 - my definition of STAT is not the same as others).  It's now 5:00 & no lab tech in sight.  I call the lab dept & she doesn't know anything, they are short-staffed (shocking) & says she'll try to page the lab tech.  At that point I give up depending on others & turned off the Heparin drip just to be safe even though I knew it would probably throw off the lab result as it only takes an hour or two for Heparin to get out of the system.  Lab finally calls me at 6:05 to tell me the PTT was I'm glad I did turn it off. 

I was internally debating about whether to write up incident reports.  Looking back, I definitely should have...because how is the hospital supposed to know this stuff is going on if it's not reported in writing to the higher ups?  How are any changes going to be made if they don't even know it's a problem?  So that's lesson #5 - report, report, report even if it means someone else might get in trouble. 

I had a really sweet patient that was very complimentary towards me.  He was asking me how long until I turn  I told him I'm nearly twice that age.  He thought I was lying.  Ahhh, so glad I look younger than my 

I am playing volleyball tonight...yay.  Haven't done that in nearly 2 years.  My hospital called again last night desperate for help because they were short-staffed.  I hope the administration sees that relying on agency nurses to fill in the gaps because they readjusted the staff nurses schedules isn't working out the way they had planned.  I plan to go back to Sun, Mon & Tuesday nights after this schedule is over (beginning of November).  I've heard everyone else that they asked to work weekends fussed & bitched & got out of it.  So it's basically me & mostly all agency & travel nurses.  I like the travelers though...because at least they are around for a few months (or longer) & you get to know them.  Agency...ehhh, not my favorite - they don't know anything about the hospital because they don't get an orientation.  So a lot of it is helping them figure out all that they need during the shift.



tendernoggle said...

WOW!  You have had a stressful week!
So glad to hear that you are going to get to play volley ball again! It has been a long time hasn't it?
God bless,

am4039 said...

20 how cute, lol. Sounds like a rather interesting week. I think nurses are great and help the doctors out a lot who get so much money. Happy that patient is ok.