27 August 2010

Friday Flashback - Death of a thousand little cuts

I walked in to work for the morning shift a few weeks ago, staffing the "flex pod" of the ER -- an area of acute care, monitored beds which we open from 10AM-2AM. There was, predictably, a row of patients lined up waiting for me to see them, as the charge nurses love to stack the pod before the doc even arrives. There were, however, no nurses in sight. I signed on to the computer and skimmed through the complaints to see what my morning was going to look like: two chest pains, one shortness of breath, one generalized weakness, one abdominal pain/vomiting. Not too bad; par for the course.

The tech wandered over and dropped the above ECG on my desk, from the generalized weakness patient. Any medical students out there, or readers who remember my previous post, The Wrong Juice, might recognize the wide QRS complexes and peaked T-waves as being highly suspicious for Hyperkalemia, a dangerous elevation of the potassium level in the blood. Elevated potassium will also cause muscle weakness, and is well-known for causing sudden death. It's one of those medical emergencies that make ER docs smile, because it's real, it's dangerous, it's dramatic, and we can fix it. A quick review of this patient's chart showed no history of kidney disease or any reason for elevated potassium, but the ECG changes were decidedly new. So I leaped into action.

Or I would have, except that there were STILL no nurses anywhere to be found. Where the hell were they? I went and briefly said "hi" to the patient and did a cursory history, noted that he did not have so much as an IV line started, and then went looking for a nurse. Finally, one strolled in, carrying her cup of coffee and chatting with the unit clerk; apparently they had gone off to the coffee stand while waiting for me to arrive.

I pounced on her: "The guy in bed D has a really abnormal ECG and I think he might be hyperkalemic, so let's get a line in him and an iStat ASAP."

She looked at me with a blank expression, "Oh, OK. I'll get right on it." And she turned back to the clerk to finish their conversation.

"No, I need you to do this NOW. This guy may well code on us if we don't get cracking!"

Visibly annoyed at my rudeness, she put down her coffee, rolled her eyes to the clerk, and shuffled off to the IV cart. Satisfied that she was on it, I wen on to see the waiting chest pain patient, with the instruction that she was to bring me the iStat as soon as it was back. Ten minutes later, I was finishing up with the chest painer who sounded like he might have unstable angina, and I came back to the nursing station to see the nurse sitting there drinking her coffee and continuing to gossip! "Where's the result on D?" I asked.

Nonchalantly, she replied "Oh, he was a hard stick and I couldn't get it, so I asked Betty to try."

I glanced in the room: there was nobody there. "So where the hell is Betty?"

"I don't know. She said she would be right over."

"Go get her right now and get an line in him!" With a sense of growing anxiety I went in to see the next chest painer, who had a history of several past heart attacks. I rushed through the H&P and came out to see the first nurse and Betty sitting there chatting amiably. "Well, do we have a line?"

"Oh, yes," Betty responded in a voice that made clear that she thought I was silly for being so worked up over such a little thing. She had been around for 30 years and thought all the doctors were like children, to be placated, but of no real importance. "But," she went on, "I got the line but it didn't draw, so I called for the lab to come draw the blood." She turned back to her conversation.

"Aaarrrgh! Get me a needle and I'll draw the damn blood myself!"

"Oh, don't be silly. Lab'll be here any minute." As I rooted through the drawer looking for a needle, I noticed the pulse ox on my next patient, who was short of breath, was 88%. Crap. Gotta prioritize. So I went to see that patient, hoping against hope that there might be SOMEBODY on shift today who would do their job. When I came out, the nurses had not moved, but they did confirm that the blood had been drawn.

"Where are the results?"

"I dunno. Maybe in the lab?"

Ultimately I had to personally walk down to the lab (not far, fortunately) to determine that yes, indeed, the patient's potassium was >9 (normal 3.5-4.5). On my way back I stopped by the charge nurse to discuss with her the fact that I had a very sick patient and the staff did not seem to share my sense of urgency. She promised to kick-start them, and fortunately, I had the patient treated and off to stat dialysis soon enough.

But the rest of the day was no different. Note that during this whole time the nurses weren't exactly jumping on the other patients, either. Getting anything done was like pulling teeth. I hate to rag on nurses, since without them I get nothing done, and many a good nurse has saved my ass. But good lord it's infuriating when you are stuck with the "B" team.

[Addendum: as Gruntdoc pointed out, criticizing nurses can be dangerous to your health, so note it's just the "B Team" that makes me crazy.  And there are docs on the "B Team," too.]

Originally Posted 14 December 2007


  1. What's your opinion on giving docs access to the pyxis for situations like this?

  2. Just goes to show you how vital every member of the team is. I applaud your efforts to find a needle for a blood draw. Most doctors I know can't even work the monitors and would rather spend 15 minutes finding a tech or a nurse than spend five minutes and do it themselves.

  3. So if the patient had coded and died, would the hospital have investigated and found it was failure to provide prompt care that was the cause of the death? Seems like the nurse who refused to act promptly put the hospital at risk, as well as the patient.

  4. The problem is that for every true life-threatening situation, there are 19 where the doctor or patient in question throws a fit over nothing.

    I am a nurse in labor and delivery and we have plenty of doctor tantrums over not getting the midnight induction's enema done quickly enough. I joke with the pharmacy about needing "stat Cervidil," a medication that is inserted vaginally and then left in place for 12 hours to soften the cervix, usually while the patient sleeps soundly.

    We consider an epidural for a patient in labor an emergency procedure and regularly call the lab to ask that the CBC we just sent be put on immediately because the anesthesiologist wants to check platelet levels. Perhaps the sample the lab would have processed first would have been someone who was actually ill, rather than choosing to undergo an elective procedure.

    Last night we were running a patient down the hall for a stat c/sec (APGAR's 9/9 as usual, because electronic fetal heart tracings are diagnostic of absolutely nothing), when a father stepped out in the hall and stood in front of her bed to ask for a pillow for himself, and then wanted to speak to a supervisor because the 2 nurses pushing the bed "verbally abused" him.

    In most cases, a complaint about nurses turning up the Pitocin too slowly or not getting the induction into their room at the time of their reservation will lead to the offender being informed that "Dr. So-and-so's panties are in a bunch again."

  5. B Team? Sounds more like you got stuck with F Troop.

  6. The Hyperkalemia could have referred to my dad's recent ER visit. It's good to know that sick patients and family members aren't the only ones frustrated with the process. But it belies the greater question... Will staffing improve with healthcare reform? Seems like bureaucracy will increase, and with it those less than optimal players. It's worse when they schedule them all together...

  7. If these nurses routinely neglect sick patients like this the way to take care of the problem is to document it in writing.

    Unless each incident is specifically documented in detail in writing nothing will be done.

    Its difficult to do it, because when you do, you make an enemy. But unless its done nothing will change. Document it and either they will get the message and change their ways. Or enough incidents, usually 4 or 5 good documented incidents and they're out the door.

    Management can do nothing with vague complaints. Be specific. Document times etc.

  8. Reminds me of the day I looked at an EKG and saw those same changes and in looking through the out patient records found the last K+ was 7.7--a month ago, with NO intervention. All meds ordered STAT but then I went to do a paracentesis and emerged an hour later after draining 5 liters. Checked the first patient--no meds given. When I asked the nurse she said, "Oh, I couldn't give those meds without the labs back. Don't worry, I checked with the charge nurse and she said it was okay to wait." I made a request that next time meds are held she check with me rather than another nurse. K+ then popped up at 8.7. Is hyperkalemia and its potential to be lethal not emphasized in nursing school?

  9. Just fyi, I linked to this post. Probably should have asked first--my bad if I violated blogging etiquette. In any case, good stuff.

  10. "Is hyperkalemia and its potential to be lethal not emphasized in nursing school?"

    It's lethality is mentioned, along with the lethality of a whole lot of other things that aren't really lethal. It's easy to graduate nursing school thinking that anything you do is going to kill a patient.

    Obviously, that doesn't work, and nurses are forced to learn everything on the job. Unfortunately, that means that nurses are going to end with not-very-accurate information based on anecdote. Consider your story: the take-away from that is that the charge nurse who said, "It'll be fine" was validated, because it was fine, and will say it again, the next time a similar situation comes up.


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