If It Isn't Charted...It Never...

...happened.

I generally regale you, my faithful readers, with stories of my wild successes. Usually I play the distinguished (if not a little crusty) hero with some great over-arching theme to impart upon the nursing masses.

Not today.

Today I was called into the office for a closed door conference with the unit educator and the unit manager. The door closing behind you is pretty much a fateful sign. You're not escaping without some pound of flesh taken in payment.

All this over a shift that was an ass-kicking from the start. Two very sick patients--one in severe septic shock, and the other most likely in the same situation. One was on hemodialysis, the other on CVVHD. A handful in and of itself, but across the pod lay a 180 kg woman who was to be taken for a CABG. Only the night shift nurse had pulled the PCI sheath, held pressure for 4 minutes flat, determined the patient wasn't bleeding externally from the site, and called it a day. It wasn't much later that the patient developed a football sized hematoma. That grew to be basketball sized while her pressures cratered from the shock of it all. Not hard to do when your ejection fraction is <15%.

Meanwhile that patient's nurse was chasing herself silly trying to get her other patient transferred to the floor because the first case of the day needed to go into that bed for staffing reasons. As in, we didn't have staff to take that case. When she left to transfer her patient, I was tasked with watching her other patient's hematoma grow.

I was left to doppler distal pulses and set up a C-clamp to hold pressure on the femoral artery to prevent the hematoma from growing any bigger. All the while maintaining some semblance of hemodynamic stability. I had just turned the patient's levophed up to our unit's max dose to maintain a pressure in the 60s (nothing like squeezing a dry tank, right!?!) when my patient on hemodialysis bottomed her pressures in response to the fluid draw. So away I went to titrate some pressors to maintain a MAP above the renal injury threshold. Just as I was about to get her settled, my CVVHD patient clotted her filter. And it was while I was attempting to rinse back the 200+ mls of blood in the machine that the anesthesiologist and anesthesia tech appeared to take hematoma lady to the OR.

It was a dangerous situation. Did I mention my charge nurse was off the floor kissing Joint Commission ass with the manager--we were being recertified for LVADs you see.

I had no help.

I spent the rest of the shift trying to catch up on my charting while taking care of two still very sick patients. Towards the end of the shift one of my patients began breathing at a rate greater than 50. She was intubated, but not sedated, and pressure support CPAP-ing. (Recipe for disaster really since we were not about to extubate her...)

My calls to physician essentially fell on deaf ears. I received orders to increase the pressure support, but nothing else. I complied, and at shift change the patient wasn't doing much better.

In my rush to get home to take over care of my children from the babysitter, I neglected to chart my communications with the physician. (And somehow went an entire shift without charting vent settings!? Facepalm! WTF??)

And the night shift nurse took exception to the hot mess I handed her and promptly tossed me under the bus.

Fade to employee conference. I sat in my seat while my manager and educator talked down to me, asked me loaded questions in the most condescending tone they could muster, and basically held my nuts to fire...

Because I screwed up and didn't document.

So in the meantime, I've been banished to "the garden" to take care of chronic patients.

There are so many things wrong with the way I was treated that even now I get tears of frustration thinking about it.

BUT.

Kids, remember this.

If it isn't charted.

It. Never. Happened.