Monday, September 8, 2008

Learning curve continues

A patient had had an outpatient laproscopic surgery, and the next day didn't feel well so they came to us. He kept de-satting to 80% when not on a non-rebreather, although denied any chest pain or any other problems except feeling unwell. Sutures were intact, belly soft. A VQ scan showed a high probability of a PE. So we gave some anti-coagulants, and kept an eye on him. I was on the night shift, had "fluffed and puffed him" for a few hours sleep.

A few hours later I went in to do bloodwork and take vitals, and I knew in my gut something wasn't right. He woke up, but didn't talk to me, just kind of stared despite me asking simple questions. Now at first I thought, ok, he hasn't slept all night, was exhausted with trying to breathe. Earlier in the month I had a patient who was slow to rouse and answer questions (5-7 minutes) and I had summoned the other nurse and let the team know, all for probably nothing as she ended up being fine. I felt a bit stupid after that, because I probably just overwhelmed her and she was sleepy.

The monitor looked fine, saturation was fine, and BP was ok. I started to take his blood, he pulled back and said "ow". Ok, then he's fine, I told myself.

Anyway this patient had terrible veins so I asked another nurse to come in to draw the blood instead. The patient was still not responding well, and looked like he was having a hard time speaking. That's when I realized that he wasn't sleepy, that perhaps something else was going on. Total time was about 3 minutes which wouldnt' have mattered, but still I felt like an idiot, not going with my gut in the first place. Neurologically he was not really responding well, had expressive aphagia, and did not follow commands. However he did move all limbs.

Blood sugar was normal (something we always check with decreased LOC), and we called the team. They came and assessed him, and by the time they were done it was change of shift.

Apparently he had a stroke sometime in the night while sleeping.

I thought many times about my actions throughout the night, and I don't think there was anything I could have done differently that would have made a difference in the outcome. This patient was not a candidate for tPA which would be affected by time, and despite a small amount of hesitation and unsurity, I assessed the patient appropriately and notified the team.

Although I'm sad that this patient did not do well, it was a great learning experience.

I learned that I still need to pay attention to the subtle things. Another nurse thought she saw a slight difference in pupil size, which another nurse confirmed. After numerous attempts, I couldn't see it. I have been looking at pupil sizes for over 8 years, have I missed things? What else have I been missing?

Perhaps because its ingrained in me that I'm not supposed to stare, that I don't look hard enough at people. Perhaps I'm not actively looking for things in order that I miss things. I think I need to examine this, and really focus on it. Some days I'm thinking I might be ok at this stuff, but other times I feel like an idiot.

**note: "fluff and puff" is a term I learned just recently which means you get them settled into bed, provide and straighten out their blankets, pillows etc, so they can sleep.

**Ok so the picture is an obvious difference in pupils. I'd be able to see that 5 feet away.

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