Anon, RN writes:
I’m trained as an ICU nurse but lately I’ve been picking up these shifts in an outpatient pain treatment clinic. It hasn’t been an easy thing to get out of that critical care mindset. In critical care you stick with the ABC’s (airway/breathing/circulation). In clinic nursing the first question after the procedure is, “Does my patient have a ride home?”
So I’m working there the other day. Pretty much twiddling my thumbs all day and bored out of my mind because there’s really not much to do except take vital signs and fill out intake forms. But then one of the clerks grabbed me.
“There’s a patient in the bathroom that needs assistance.”
Indeed there was. I found a patient who needed me to help her out of a little situation, let’s just say. So I got her cleaned up and brought her in to the room where she would have her procedure done. I slapped a pulse ox on. Her oxygen saturation was about 70%. With a very good waveform.
Thankfully my critical care mindset kicked right back in. Step one, get her on some oxygen. Step 2, find out what the hell is going on.
Turns out she’s a COPD’er (Chronic Obstructive Pulmonary Disorder – like emphysema) who uses oxygen at home, normally 3 liters. She told me sometimes she just doesn’t bother with the 02 if she’s making a quick trip somewhere. I asked her what about today? This is a little more than a quick trip. She said she ran out of oxygen, and they should be delivering it while she was out.
I got her down to 3 liters and her oxygen sats kind of waivered between 82-88%, which is fine for someone with COPD.
She was completely stable so the doc did the procedure at the bedside. Which was all for the best because at that point she was really in quite a lot of pain.
I asked the charge nurse what we should do about discharging her. This is where the story gets really crazy.
“She only needs to be close to her baseline, in order to be discharged.”
“Yes, but her baseline is that she is on home oxygen, which she didn’t bring today and her 02 sats are in the 70′s without it.”
“It’s okay. We’ve discharged her with 02 sats in the 70′s before.”
I explained to the charge nurse that it’s not okay to discharge someone with 02 sats in the 70′s. Especially if they “forgot” their oxygen that day. It was at that point that I decided I really had no use for this “charge nurse,” and tried to come up with an answer on my own. First I tried to find out if the patient’s son could go to her house and get one of the tanks that was being dropped off. No dice. He had no money for a cab ride and we couldn’t even confirm really that the oxygen had been delivered. I tried to find out if there were any kind of social worker around that might be able to identify some resources for the patient, maybe give her a loaner tank to take home. Again, no dice. So the only other plan was to take this patient to the ER.
We arranged for a transport person to come, and I went to find a portable oxygen tank for her. The charge nurse asked the transport person if he could return the oxygen tank to the clinic. “No, I can’t,” he said. Then the charge nurse said, “Well you can’t take it, then. If it leaves our floor it will never come back.”
At this point I decided I would transport her to the ER (it was the next building over) so I could bring the precious oxygen tank back to the clinic. Also, the patient was getting a little somnolent, which is never a good sign when you are worried about hypoxemia/hypercarbia, so I figured it would be best if a nurse accompanied her. So I took her to the ER, and got her safely checked in.
When I got back to the clinic there was some talk about how we can avoid this in the future, blah blah blah, we never should have done the procedure on her, yadda yadda yadda, and the conclusion was that if she turned up at the clinic again with out her oxygen tank, we should just turn her away.
How about some patient teaching?
How about some communication with her PCP to find out why she thinks it’s okay to go anywhere without oxygen?
How about a better EMR system so we could “flag” her and alert her other providers that she needs better education?
If anyone thinks we are even close to fixing healthcare, well. I’ve got some land down in Florida you might be interested in.