It's been an interesting week, to put it mildly. Before I became interested in the wonderful field of nursing, I had absolutely no idea what these poor souls did. When visiting friends or family in the hospital, I never suspected how much crap nurses dealt with on a daily basis.
Sometimes it's the patient that can drive you damn near batty, but more often than not, it's the people you have to deal everyday. Patients in my unit (PACU) are often sedated with pain medications, sedatives, etc., plus they are transferred to another department within 30 minutes to an hour (if they're stable of course.) Too bad that we can't give our co-workers something to pipe them down too!
Case in point...
CRNA brings a patient in to recovery S/P I&D of infected elbow. Patient has oral airway on arrival to PACU. Respirations of about 6 per minute, SpO2 of 79-93% with jaw thrust maneuver and 10 LPM via face tent. Unresponsive, was reversed at the end of the case. I get report, (while holding his jaw, naturally), and what kind of pain med did he get 30 minutes earlier while in the OR under anesthesia? Why 20 milligrams of morphine....all at once. CRNA *attempts* to leave. Oh no, I don't think so. Insert a nasal airway, opt for a larger OAW, attempt to stimulate. SpO2 is up to 82-92% (still holding that jaw.) CRNA tries to leave. I don't think so.
After about 10 minutes of this, I finally get the guy to give him some Narcan. So he gives 40 micrograms. Mr. Elbow's respirations pick up to around 12, still has OAW and NAW intact. SpO2 92-96% on 10 LPM via face tent. Okay, you can leave now.
Mr. Elbow is arousable now. OAW and NAW discontinued. Respirations deep and even, decent O2 sats, wean his O2 to 2 LPM via nasal cannula. He continues to be somnolent and has one of the worst cases of obstructive sleep apnea I've ever seen, sats are up and down. So, I end up giving him 40 mcg of Narcan times 2. He finally wakes up, (while maintaining more than adequate analgesia), and I can get him off to the floor. And yes, I give a detailed report to the receiving nurse about the entire incident, and caution against the possibility of re-narcotizing.
Two hours later, I get a phone call from the charge nurse where Mr. Elbow has been sent to spend a lovely overnight vacation in paradise. Same problem, though not as severe as it was in PACU. Even though I am not obligated to follow up as this is no longer my patient according to hospital policy, I go upstairs and do it anyway (after all, it is my license.) When asked about his apnea, wife tells me that he sleeps like that all the time, never even thought about a sleep study. The charge nurse has already contacted the surgeon and was unsuccessful at getting an order for Narcan.
My only option is to contact the anesthesiologist on call. Great. I'm sure he'll want to hear this in the middle of the night. Luckily, he's a pretty good old boy. Tell him the story and he asks me if I gave pain meds in PACU (why hell no.) Gives me an order for Narcan IM, continuous pulse oximetry (I've already got it on Mr. Elbow), O2 (got that on too), no IV pain meds (he had dilaudid ordered) and respiratory rate checks every hour. Then he wants an incident report on the CRNA due to the morphine given in OR. (He'll love me for that, I can assure you.)
Anyway, the floor nurses are happy now, they've got the orders they needed. My nursing license is happy now because it's safe for the moment. The anesthesiologist is happy, his patient had a good outcome (even thanked me for going up there to check it out...that's unusual in itself.) Elbow's wife tells me this morning that Elbow's brother informed them today that their father had OSA so bad that he had a UPPP (trimming of soft tissue in the throat.) Imagine that. Elbow was discharge with an order for a sleep study.
There are some great CRNA's out there that are a pleasure to work with, don't get me wrong. But every bowl of cherries has it's pits. Another one brought me a 17 year old with an O2 sat of 17%, get the bag out. (You could see her neon blue lips when she rolled through the door from the OR.) That's a whole 'nother story.
3 comments:
That CRNA should be written up. As a CRNA with over 20 years of practice, I've never had to leave a patient with the PACU staff with an oral airway in, period. Our staff prides itself on leaving a patient that could survive on their own (in case the PACU nurse isn't as competent as you). This individual does not represent the majority of excellent nurse anesthesia practitioners.
One heck of a story. I am a nursing student and have a lot to learn...thanks for sharing. I too did not know all that nursing entails before this experience. I am doing my senior practicum clinical in an ICU and I am learning a ton and nurses do have to put up with a lot of crap!
Yow. I'm not a nurse, far from it, but just want to say, if I were you're patient, I'd certainly appreciate the follow up that you did, beyond the call of duty. Kudos to you for your kindness and humanity.
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