What to do if your patient has a low sat

Dear RNs:

So your patient suddenly has low sats.  Do the following before calling the doctor:

1. Check the connections
2. Check the flowmeter (is it on?)
3. Assess the patient
4. Call respiratory therapy. 

Follow these three simple steps and your RT will love you.

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To call the Dr. or not to call, that is the dilemma

Here's something you will come across from time to time if you work nights. Of course as all RTs may have noticed by now, there often seems to be no rhyme or reason to "some" doctor orders, nor consistency to how a doctor will respond to a request to change the order.

Consider the following example:

The patient is a 75 YO non-COPD post operative patient with a registered SpO2 of 88% at 3-o-clock in the morning. Mind you, I did say three a.m. The patient is in no respiratory distress, and has no respiratory history. Otherwise, his vitals are normal. The order is for 2lpm. What do you do?

1. Call the doctor and wake him up
2. Increase the oxygen to 3lpm and have the RN call the doctor in the morning
3. Ignore the spo2 and pretend you didn't see it as the patients SpO2 probably always drops while he is sleeping
4. Since the SpO2 has an accuracy of plus/minus two, assume actual reading is 90%

Okay, what's your guess?

Day #1: This night the RT decides to use his common decides "b" is the best solution. The patient is stable and no harm done. If the patient's SpO2 was at a critical level, then a call to the doctor would be warranted, but not in this case.

The next day when the RT arrived at work he was lectured by said doctor who said, "Why do I write orders if you're not going to follow them?"

Day #2: Different patient but same information; different doctor, but this doctor is the spouse of the doctor in the scenario above. What does he do now?

Using the same choices above, since the RT now knows option #2 is not good, he decides to go with option #1 and wake up the doctor. The doctor says, "Why the hell are you waking me up at 3 in the morning to tell me this?"

"Um," says the RT, "Because yesterday, same scenario, your husband told me that I have to call before I increase oxygen to get an order."

"Oh," she says, "Well, then increase it to 3lpm and leave it at that."

"Well, then can we..."

Click. The doctor was no longer available.

"...get an order for protocol just in case... oh, what the heck.

So, what is the best thing to do in a scenario like this? Well, based on my experience, you're damned if you do and damned if you don't, so you might as well wake the doctor up and let her lecture you about how idiotic you are.

Thus, RN Cave Rule #72:

If you think you better call the doctor you better call him. If you think the doctor might yell at your and tell you you are an idiot because he doesn't want to be irritated in the middle of the night, call him anyway.

RN Cave Rule #62

I've been posting RT Cave Rules on this blog as I think of them, but there are some RN Cave Rules I've alluded to from time to time that involve us RTs. One of them is RN Cave Rule #62,

RN Cave Rule #62: Whenever there is a stinky, dirty, disgusting, puky, gross, obscene, unruly patient, RT must be somehow involved in the care of that patient. Tell me you don't know what I'm talking about.

I thought of this tonight because I was called down to ER to do a routine EKG. As I walked into ER I immediately was hit with this rancid smell. It was one that I was familiar with unfortunately, as it was the smell of a human who hadn't taken a bath in a loooonnggg time.

I had this feeling in the pit of my stomach that it was in that patient's room where I was headed. And, lo and behold, I was right.

He was a young, gruff guy with tattoos covering his body, and was in his mid-30s, but his clothes were filthy dirty. His hands were callous, dry, rough and dirt filled like those of a mechanics. His boots sat at the side of the ER cot, and his filthy socks loosely dangled on his feet.

Last night I walked into a room of a patient whose skin appeared to be falling off, and she had little white flecks in her thinning hair. Why she needed an EKG I have no idea, but I had to touch her up close, and I didn't want to. But, because it's part of my job, I had no choice.

Yes I wore gloves.

I told you guys once about the time I walked into ER and was slammed with the most God-awful smell ever. I walked past a room with several nurses and knew the smell was from there. And, I thought, since that man smells that bad, somehow, some way the nurses will make it so that I have to go in there.

And I was right.

This man had his legs wrapped a month earlier for whatever reason by his doctor, and the wrappings were supposed to be changed every day. But this homeless man never did anything, and there were maggots in there. Maggots I tell you.

There is nothing worse than rotting human skin. Nothing.

But if someone comes in that way, an RT is automatically indicated. It's king of a well-if-I-have-to-take-care-of-this-gross-patient-you-should-too rule.

Same is true on the patient floors. We once had a patient who had gangrene, and man if that rotting skin doesn't stink up the whole floor, and there's nothing you can do about it. But, even though the patient is breathing fine, the doctor just has to order nebs.

Why, the patient stinks, thus in accordance with RN Cave Rule #62, we have to get RT involved

Is the patient in isolation? Well, then they too need to be on nebs.

Fair is fair, I suppose. But I hate this RN Cave Rule.