D&D

My room is comfortably small with rubber lining the walls

and there's someone always calling my name

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D&D
janelemon
Work is starting to wear on my raw nerves at times, but I'm pretty much stuck there for now since I don't have the seniority or specialized training to go somewhere else and not take a $20-30k pay cut. For example:

Yesterday, I cared for a patient after she had been sedated to have a broken ankle set (closed reduction of a displaced fracture of the tibia and fibula). I was assigned to the observation area of the ER, and she was transferred to my area from the orthopedic procedure room to recover. There was a complication during the sedation in that her IV infiltrated when the ketamine (sedative) was infusing. This means that the IV slipped out of the vein and the medication went into the tissues of her arm instead. The effect of ketamine when not administered intravenously is difficult to determine, so the physicians decided to wait a few minutes to see if it took effect. It did not, so they placed a new IV and re-dosed the ketamine. Her ankle was successfully set and casted, and she was brought to me still sedated. It took her much longer than usual to wake up from the sedation since the dose that went into her arm started to take effect as well. I closely monitored her, and when she started to wake up, she complained several times of nausea and dizziness, which is a very common side effect from the ketamine. Our standard of care is that we give IV fluids for hydration and an anti-nausea medication (almost always Zofran). I went to the resident caring for this patient, who was in the middle of his very first shift of his very first pediatric rotation (why they start new pediatrics residents in the emergency department is FAR beyond my comprehension, but whatever). He assessed the patient, determined that she did not appear dehydrated, and insisted that she did not need IV fluids. I reminded him that this was our standard (we do this in most cases), and asked why we wouldn't want to administer this intervention. It certainly couldn't hurt, and a little hydration makes everyone feel better. Also, this patient had not had anything to eat or drink for about eight hours at this point and if she didn't appear dehydrated then, she was going to soon. He told me that he just didn't think she needed anything, that he was not going to order anything, and that I should just encourage her to drink fluids. He walked away.

When the patient was awake enough, I attempted to get our out of bed to a wheelchair. Lying flat she was fine, and sitting or standing she reported feeling so dizzy that her vision started to tunnel. Her blood pressure measurably dropped when she was upright. This is called orthostasis, and the most common cause is dehydration. I put her back to bed, and again summoned the resident. The patient was pale and looked uncomfortable and was complaining of thirst. The resident took her pulse and told me that she did not need any supplemental hydration because her heart rate was not appreciably high. Again he insisted that she just drink water or juice and try to get out of bed when she was feeling better. I wanted to wring his scrawny neck.

I was tempted to just start IV fluids on my own and then insist he write an order, but I didn't. Something like that, even if it's standard of care, could cost me my job and possibly my nursing license.

An hour later, the patient was not feeling better, her pain was getting out of control, and her parents were at their wit's end. I called the resident back, and the parents got on his case...it turns out that they were both paramedics and agreed with my suggestion for IV fluids, but didn't want to cause a fuss when the resident kept refusing, but then questioned the resident as to why he never ordered fluids. The resident got the attending physician (who supervises all of the training physicians in the ER) to see the patient. The attending was in the room for all of 30 seconds, came out, and said, "I think she would improve with some IV fluids." The resident not only agreed, but told the attending that he was thinking the same thing and told me he'd write an order.

WHAT A PRICK. I HATE that some doctors completely dismiss the opinions and suggestions of nurses, but will not hesitate when given suggestions by other doctors. (And to be fair, it's not all, or even most, doctors who do this. Most of my colleagues respect our opinions, appreciate suggestions, and will provide rationales for their plans of treatment...and quite often will let us dictate our own orders, especially for things like pain medication and IV hydration.) I went through a LOT of training to be where I am, and I work very hard to make sure my patients get the best care possible. If nurses weren't supposed to advocate for their patients, hospitals would hire trained monkeys instead.

I am pissed that some nitwit first-year resident got under my skin like this. If this happens again, I'm going straight to the attending. This is frowned upon and viewed as bad politics, but I think good patient care trumps all.

I feel like I failed this patient in not being more assertive with this resident. I have years more clinical experience than he does, and know empirically that a 20cc/kg fluid bolus perks everyone up. Fuck, we sometimes put in IVs and give fluids when patients complain of vomiting once, even as they sit there cramming mcdonalds into their gullets (and clearly do not need any intervention at all...but some physicians are of the mentality of "they're in the hospital, we must do something"). I want to write a letter of apology to the patient and her parents for not pushing harder to make her feel better sooner, but that's certainly forbidden, as it makes the hosptial seem at fault for something and can get me personally and the hosptial into all kinds of legal trouble (and would probably cost me my job). I'm going to learn from this, and be a better nurse from now on.

I meant to catch up with this resident after he ordered the fluids and have a polite discussion with him as to why he did not agree with me until the attending came along, but his shift ended and he signed that patient off to another resident, who was more than happy to write orders for whatever medications I requested to get the patient's pain under control. What a relief.

In the end, the patient went home, but hours after she should have. The average recovery time after a ketamine sedation is about 90 minutes. Hers was close to 7 hours. Even accounting for the extra dose of ketamine she received when her IV infiltrated, this was too much. The obstacle to her discharge was her dizziness and nausea and inability to sit upright in a wheelchair, never mind stand. She perked right up after a fluid bolus and a healthy dose of zofran, and went home an hour or so after this was completed. If I had pushed the resident harder to order those fucking IV fluids, or engaged in bad politics and spoke directly to the attending, her ER stay would have been cut in half. I did apologize to the patient and her parents for the course of treatment being so rough, and made sure I was very thorough in my discharge teaching and planning, including referring them to case management, who will call them on Monday to make sure everything is going okay. The parents thanked me, told me that they overheard me asking the resident for a fluid order several times and heard him refuse, and they thought I did the best I could. They told me that they couldn't have asked for a better nurse, and that the physician was kind of a dope (their words). I was flattered, but I still feel guilty for not doing a better job in speeding along this patient's recovery.

I actually feel better having written all of this down and having admitted my error in all of this. I'm hoping that it will stop haunting me. I'm glad for a couple days off before my next shift so I can get some sleep and try to purge this from my conscience.

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Ugh. That really sucks. Hon, it sounds like you really did try to do your best for the patient (which was clearly noticed by her parents) while dealing with a real jackass intern. I've heard about the internal politics between nurses and doctors... hopefully this twit will learn better because you were right and he was wrong, and it should be about quality patient care, not about anyone's ego.

Moron.

Thank you for agreeing with me. :) The internal politics in medicine are astounding, and medical dramas only begin to capture them.

Is there any way you could have talked to the attending physician in a place where you could have known you would have been out of earshot of anyone else?

The bad politics come from speaking to the attending physician when I disagree with the resident's plan instead of working it out with the resident. It doesn't matter who overhears the conversation.

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