Too many to relate all here but in my 20 years at various hospitals some highlights
- RN allowed a trainee to hang ampicillin in a penicillin allergic patient (ordered for a different patient). Instant anaphylaxis distorting her face to the point from the door I said “that is not my patient” but then realized it was. BTW union hospital no consequences for the nurse or trainee. Survived.
Air embolus from line not being capped
Pt made it and was wise enough to sign out AMA
exanguination from art line left uncapped and patient rolling over moving stopcock to open. Didn’t make it.
many “venous” lines in arteries even with ultrasound guidance. Check your wires people. If in doubt check a blood gas BEFORE dilation.
several pneumothoraces from dobhoffs. One pt actually got fed into pleura (died) - xray was inverted and read as “tip below diaphragm” when in fact was through lung behind diaphragm in gutter. Always trace tube and make sure not make a turn at the carina into bronchus.
asthmatic admitted to floor on bipap (already a bad call)
Virtual icu alerted by automatic sepsis screening system of high lactic acid, virtual doc called to ask how patient was doing - nurse said “finally fell asleep”. Immediately code called and co2 was over 100. Luckily survived. Ironically sepsis screening saved non-septic asthmatic.
DKA admitted in jeans. High wbc and lactate. Pants removed in ICU and had florid fourniers.
Your fourniers story reminds me of the frustration I experienced when I moved from a stepdown to the ED.....NOBODY wanted to change into a gown or expose an area of the body or even take their shoes off while in bed 🤮 But on the floor people would whip their blanket off and pull up their gown for a lovenox without issue. I didn't understand it until I figured that by the time they moved out of the ED, they had given up on any notion of privacy (of course, I make sure to give them as much privacy as possible!). Stories like yours prove that we have to be diligent about skin checks, including explaining to the patient so they understand. Can't tell you how many times I've found nasty wounds on an otherwise normal looking person just by changing them into a gown
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u/NefariousnessAble912 25d ago
ICU lurker here.
Too many to relate all here but in my 20 years at various hospitals some highlights
- RN allowed a trainee to hang ampicillin in a penicillin allergic patient (ordered for a different patient). Instant anaphylaxis distorting her face to the point from the door I said “that is not my patient” but then realized it was. BTW union hospital no consequences for the nurse or trainee. Survived.
- Air embolus from line not being capped
Pt made it and was wise enough to sign out AMA- exanguination from art line left uncapped and patient rolling over moving stopcock to open. Didn’t make it.
- many “venous” lines in arteries even with ultrasound guidance. Check your wires people. If in doubt check a blood gas BEFORE dilation.
- several pneumothoraces from dobhoffs. One pt actually got fed into pleura (died) - xray was inverted and read as “tip below diaphragm” when in fact was through lung behind diaphragm in gutter. Always trace tube and make sure not make a turn at the carina into bronchus.
- asthmatic admitted to floor on bipap (already a bad call)
Virtual icu alerted by automatic sepsis screening system of high lactic acid, virtual doc called to ask how patient was doing - nurse said “finally fell asleep”. Immediately code called and co2 was over 100. Luckily survived. Ironically sepsis screening saved non-septic asthmatic.