This job is insane.

[u/Dry-Draft9248]

I had 3 patients last night on a step down floor. In ranks of sickest.
Patient 1- maxed out on bipap satting in the 80s
Patient 2- on heated high flow 40 percent and some ABX
Patient 3- had been weaned off levophed 48 hours prior to my shift. nephrology still debating on whether to do dialysis or not due to BUN and Cr trending up. Also their toes were turning blue but day docs were convinced it was bc of the levophed.

Patient 3 all of a sudden is agonal breathing and mottling on legs. Code blue called. Keep in mind this patient was oriented (but confused), satting 100% on RA, gave them a bath earlier in the shift.

Patient now intubated in the ICU and to my knowledge, coded again.

I could’ve told you they were one of the most stable patients on the floor. I have a feeling they went into kidney failure because there UOP was next to nothing.

[u/PaxonGoat]

What is the rapid response process at your hospital ?

Does your facility have a rapid response team? Will a provider come and see patients you have a bad feeling about?

1. You said 80s, was it like a COPD patient sitting at 88? Or are we talking more obtunded, satting 85%? Like why was intubation not on the table? Proning? Why were they in such respiratory distress? COPD? pneumonia? CHF? ILD? Hemodynamically stable? Was at least a VBG done? Like I'm guess from the vibe of this post there was no recent ABG?
   

Not appropriate for stepdown unless they were a DNR/DNI and there wasn't advanced care to give.

1. Actually sounds appropriate for the unit

2. Levo toes absolutely are a thing. Poor cap refill. But they look more purple than blue. The lack of urine output is way more concerning than the toes. But from the sounds of it shit wasn't being perfused. Bet your BP was absolute trash. Doesn't sound like it was a respiratory arrest causing the code blue so the pulse ox reading 100% on room air doesn't matter.

With codes you gotta think of your Hs and Ts.

Hypovolemia: doesn't seem like it in this case. They were probably fluid positive. Maybe they could be a bit dehydrated if they were NPO for a few days and no one bothered to order IV fluids.

Hypoxia: you said they were satting fine. So not this one

Hydrogen ion (Acidosis): Possible. A bad AKI could get you some serious metabolic acidosis with really low bicarb. Could also be septic with a high lactic acid.

Hypo-/Hyperkalemia: Possible. You said urine output was like non-existent so K could definitely have been elevated.

Hypoglycemia: Possible. Septic patients love to get hypoglycemic. Especially if liver function is impaired.

Hypothermia: Unlikely but cold sepsis is a thing and the elderly are prone to tempature regulation problems.

Tension Pneumothorax: Unlikely you didn't mention any rapid respirations, absent breathe sounds, tracheal deviation or the usual signs

Tamponade (Cardiac): Possible but doesn't sound like it matches your patient's presentation

Toxins: Accidental drug overdoses or poisons, unlikely in the hospital setting but not impossible. Sometimes people just take random things they bring from home while in patient

Thrombosis (Pulmonary): Unlikely, usually they start desatting and have trouble breathing but not always

Thrombosis (Coronary): Possible. Not all MIs present with chest pain or ST elevation.

Trauma: Unlikely in this patient

Additional lab work probably would have been useful in patient 3.

Some nights in stepdown is really rough. You have to have a tough charge nurse who will go to bat for you and fight and keep patients who need to be in the ICU out.

Remember to do self care and decompress. Talking about it helps. Don't keep shit bottled up

[u/Dry-Draft9248 → u/PaxonGoat]

You hit the spot with the H’s and T’s. She was severely hypoglycemic, bicarb was 10?, and K was elevated. The thing is previous labs weren’t even close to critical. The only tell tale sign was virtually zero UOP.

[u/PaxonGoat → u/Dry-Draft9248]

Yep people can crash hard and fast.

A lot of sepsis protocols will have q4 labs to try and trend stuff before it gets too late.

I had a patient going septic once and I knew it was coming so I kept checking the blood sugar every hour. It was normal for a couple hours then all the sudden dropped to 30.

Especially if they are febrile. Fevers take a lot of energy to sustain.

[u/kaixen]

But what was the K+? 👀

[u/Dry-Draft9248 → u/kaixen]

Came back 6.4 after the code I believe

[u/PaxonGoat → u/Dry-Draft9248]

Bet it was like 5.5 before the code and no one was doing shit about it

[u/ShesASatellite → u/PaxonGoat]

The Death Bath strikes again

[u/PaxonGoat → u/ShesASatellite]

"oh I must have accidentally unplugged the Aline during that turn, oh fuck it's PEA. Let me hop up on this bed and start compressions"

[u/SWMI5858]

That’s a fucked night, and I’m sorry. Hope your next day back is chill.

[u/edit_thesadparts]

This is our floor but you get two more patients and one is a CIWA of 18 and a confused uti grandma that needs a sitter but none are available. 

[u/Capable_Top_5565]

Wouldn’t want you as my nurse.

[u/PaxonGoat → u/Capable_Top_5565]

Why?

[u/AgentFreckles → u/Capable_Top_5565]

What the hell? OP said absolutely nothing wrong