I had a patient recently that had an interesting hospital course of action. To the nurses, it was clear what was going on. The residents and MD disagreed – and did not share this information with the nurses.
This patient, who was an octogenarian, was Covid-19 positive. She was admitted for altered mental status and decreased blood pressures. Her D-Dimer was high. Now for those of you working with Covid patients, it is not unusual to see high D-dimers. Those patients are treated with high dose Lovenox to prevent clotting. Altered mental status and low blood pressure is also common in the elderly when sepsis occurs.
This patient was only getting standard subQ heparin Q8, and they had started her on midodrine for her low blood pressures. She was out on the medical-surgical floor when the staff out there decided her O2 saturation level on a non-rebreather was too low and she needed to come to the critical care unit. I accepted the patient as a STAT transfer, and once she came to me, I realized that everyone was freaking out.
Her O2 was 100% on the non-rebreather. Her blood pressures, taken hourly, were all in the 105-115 range systolic and 65-75 diastolic. She wasn’t short of breath. She was alert and oriented, and was quick to tell us that she didn’t live with her daughter, but that her daughter lived with HER. We all got a chuckle over that.
We got her settled, put her on continuous monitoring, and watched. Nothing happened. She remained stable. I was thrilled to have a completely stable “critical” patient. The next day, I noticed that her oxygen went down to the 80s. I went into the room and found her with her oxygen off talking on the phone. The mask kept bumping into the receiver while she talked so she just slid it down out of the way. I replaced the mask and she recovered, but true to many Covid-19 patients, it took quite a few minutes to get back to the 99-100% range I had been seeing. Mystery solved. This is most likely why she was so low out on the med-surg floor. They probably didn’t wait that 10 minutes to see how she did before checking her oxygenation status. I called cardiopulmonary told what I witnessed and we switched her over to a high-flow nasal cannula so she could talk on the phone without the mask bumping – she did great. Again, O2 saturation was perfect in the 95-100% range, and never once did I notice any tachypnea. The patient was happier as well.
Later on that day, the ultrasound team came in to check her legs for DVT. I never got to read that report as we had several critical goings on in the unit at the end of the day that took precedence. It turned out she did have a small DVT in her lower leg. It wasn’t until I was giving report that it happened.
I received a phone call from a local hospital stating they had received the transfer of my patient and was calling to give me a bed assignment.
WHAT.
THE.
HECK.
I called the resident, explained that I was in the middle of giving report to the oncoming staff and that I had no idea that shipping this lady out was on the table and WHY ON EARTH WAS SHE EVEN GOING OUT ANYWAYS??
He came over to explain. The physician team felt she had a submassive pulmonary embolism and needed immediate transfer.
She had no chest CT done.
She was not on a heparin drip that indicated this concern.
She was not short of breath in any way.
She had no clinical indication whatsoever that this was going on. This was just a sweet old lady in bed who took her oxygen mask off to talk on the phone.
I was highly frustrated. The MD team could have taken 2 minutes out of their day to TALK TO THE NURSING/CARDIOPLUMONARY staff to see how she was doing. Or I don’t know, how about updating us?
Physicians of the world: talk to your nurses.
The Nurses' Lounge 