Saturday, July 26, 2008

When Day Shift tries to kill your patient...

Had a pt about a month ago that I'd had before, anuric, on dialysis 5+ years, admitted for chest pain and rule out PE; frequent flier, but nice. PE was ruled out that morning at 9 am, looked like she had just got dehydrated. So, I come strolling in for night sift, and take a look at her and think, "something's wrong." The lady that had been pleasant, A/O x4 is now awake, but lethargic, and just looked off. Her heparin drip was possibly infiltrated, and day shift had tried to restick and restart, but couldn't get a vein.

So, I decided to take a quick set of vitals, check the chart to figure out why she was on a heparin drip and call the doc.It all went to crap from there. BP 66/33. Stat APTT > 250! Did day shift notice the pt had blood oozing from her subclavian old temp dialysis port, the ABG stick site, and every other stick she'd had this admission? No, they tried to restart the heparin and they hadn't gotten the first APTT back on the pt. Their response to "where's the APTT?" is "lab couldn't stick her." Hello, blue port on the cath, did you call the doc to get an ok to use for blood draw?! Nope, and this is the bad part, they would have restarted the heparin if they could have gotten a vein!

When Lab came around, I aksed them, "WTF do yo mean you couldn't get a blood draw?" and they said no one had called them and told them the pt was back from dialysis to take the APTT...so this lady had unknown amount of heparin, with no APTT for at least 8 hours...Doc orders FFP, 150cc bolus and a stat coag after the FFP goes in; I also called ICU and told them to hold a bed, I've got one that's probably coming their way. I got her naked and looked for every possible bleeding site, noting location and amount. Thank God 3 of my patients were walkie-talkies, and my charge started doing the care/feeding of my quad with a trach across the hall.

I'm checking on this woman every 15 minutes, and suddenly she's got blood running over her shoulder and down her chest, and dripping steadily everywhere else. We put a another pressure dressing on top of the first, and call the doc again. We get hespan 250, and her BP, which had come up to 96/71, starts falling like a rock. I roll her over and one of the RN's says "Holy XXXX!" because blood is pooling under the pt. Surgeon on call says to push protamine -- I told him about her pressures and her anuria, and he said push the protamine, we've got to reverse that heparin since she's got no kidney function to do it. I do the protamine, plus the rest of the bag of hespan, and open up a bag of NS trying to get her BP out of the toilet, and I'm yelling for the secretary to call the lab and get an emergency type/cross match for 1 unit of PRBC plus another FFP. Her BP goes down to 58/31. At this point, every RN (except 1, plus 2 LPNs to look after the other 35 pts) on the floor is in the room, we've got the doc on the phone, Pt then develops chest pain. nitro x2, morphine and xanax, no relief, we take her to ICU, and I left wondering if she'd be alive when I came back on shift.

The patient did survive this situation, and went home a week later. The same nurse who'd hung the heparin on my patient had a heparin drip on another patient the next day, and with the same results. But, hey, she's an RN so it's all good.

1 comment:

Julie Davis said...

Holy moly! Best example - there are only a few people who can handle such situations! Glad you're one of them - one who keeps their cool, too! All the best! Cheers, Julie