Just a little update about what's been going on.... this is a copy of the letter I just sent our hospital's CEO:
On Wednesday, February 11, 2009, at approximately 4:15 p.m., I received an urgent call from my father, stating that my mother had fallen on their tile floor on her right hip. When EMS arrived we insisted to have them take her to ********* Hospital. After several hours in the ER, our worst fear was confirmed, her hip was broken, explained to us as being a compression fracture of the long part of the femur into the head of the femur, and a partial hip replacement would be needed. She was transferred to room ** for surgery the following day. We were told that Dr. Michael Cantrell (ortho trauma surgeon) would be doing her surgery Thursday afternoon.
I arrived back at the hospital a few hours later early Thursday morning. I was very impressed with the NP's for Anesthesia, Angie, and the Ortho Trauma Surgeon's NP, Cindy. Both were very professional, explained everything in detail to my parents, and answered all questions we had relating to the surgery. It was explained to us, since mother was being followed by internist Dr. Bobby Johnson, the Trauma surgeons wanted medical clearance for her prior to surgery, but as soon as he gave the OK, they would proceed with the surgery that day.
Mother was in excruciating pain, IV pain meds were ordered by Dr. Cantrell for every 3 hours. Her pain was well controlled for 2 ½ hours up to 4 hours, but when it returned, it returned with a vengeance. There was normally a 30-40 minute delay in response time for pain medication by our nurse, *****; this was very frustrating for us. At that time, we did not know the frequency the pain meds were ordered, ***** would not come in mother's room to let us know it was too early to receive more medication, I would wind up finding another nurse, Peggy, in the hall, who would also have to give mother her medicine.
As we continued to wait for surgery, on 3 occasions, I asked ***** why Dr. Johnson had not been in yet, or called, to clear mom for surgery. Each time, ***** would state that, “They left him a message.” I asked her on the 3rd occasion if she had called back to make sure he actually got the message, she reported we had to just wait on him to call them back. At 2:15, I called Dr. Johnson's office and left a message with the receptionist that we were waiting on medical clearance, asked her if a message had been given to Dr. Johnson regarding this, and she was unaware of any messages regarding my mother, but took our room phone number. At 3:45 p.m. I talked to Dr. Johnson's clinic nurse, who put me on hold, spoke with Dr. Johnson, and apologized for any delay, but denied knowing he needed to give mother clearance for surgery. Dr. Johnson was in our room within an hour or so, but unfortunately surgery had to be put off until Friday.
By the end of the afternoon, when it became evident that mother's pain would not be controlled with PRN injections and delayed administration, I asked ***** what could be done regarding inadequate pain control, especially since surgery had been delayed, she just said that she could only give the pain medication every 3 hours. She did not offer to contact the physician (Dr. Cantrell) regarding the inadequate pain control. I made contact with the Ortho's NP regarding inadequate pain control and was told that they would go ahead and start a PCA pump since she would need one for surgery. Mother called for pain medication around 5 pm and ***** did respond to say that Dr. Cantrell had ordered her a PCA pump and mother could wait for that. At that time, I asked her to please give my mother her pain medication (it was due) as we had no idea what time the PCA pump meds would get to the floor or be set up. A few minutes later, I found Peggy and she gave mother her medication.
Her 7p-7a nurse, ****, entered her room sometime after 7pm, and asked mother how her surgery went today and if she had been using her PCA pump. Mother explained to her that she didn't have surgery yet and she was still waiting on her PCA pump. She said she must have gotten the wrong information during report, asked mother a few questions and left the room. I found the whole incident disconcerting and strange, and was also concerned that **** never laid a stethoscope on my mother. By this time my mother was 2 days out from her last BM, and was now requiring oxygen, but **** never auscultated her lungs, heart, or abdomen. A day-shift nurse, Peggy, then entered the room and set up mother's PCA pump. (Peggy was also orienting another nurse, Tim, that day, and was extremely busy attending to mother who was actually assigned to *****.)
After the PCA pump was set up, mother's pain was well controlled, and only had to “hit the button” once during the night. The next day, ***** was assigned to my mother again; surgery was completed by Dr. Howard Miller (Cantrell's partner) that afternoon.
Mother was brought back to her room from recovery about 4:15 pm. The PACU nurse told me and ***** that we needed to let Dr. Johnson know that mom would need to be evaluated for sleep apnea, and she definitely needed to stay on her oxygen because she couldn't keep her sats up without it. A spot check showed that her sat was 93 on 2 liters O2.
Mother returned from surgery with “foot pumps,” an immobilizer on her right leg, and NO TED hose on her left. I asked ***** for a TED hose (anti-embolism stockings) for her left leg, she said she would get one. She returned with no TED hose, but took mother's vital signs, her BP was 111/45. I was very alarmed (mother's diastolic is usually high 80's and 90's while ON BP medication, and she hadn't had any in 2 days). I asked her 3 times for TED hose over the next 2 hours. I was very afraid of thromboembolism and mother is at high risk for that. We continued to give mother sips of water, anything we could think of to help her blood pressure, thinking it might be related to fluid loss during surgery. Frustrated, after my 3rd request for TED hose , I sat down on the other side of mother's bed and noticed very little urine output in her foley, and an IV bag clamped, not infusing, and laid on top of an 02 flowmeter. At that point, I went out to the nurse's station, ***** was talking on a cell phone in the charting area. I asked another nurse, Peggy, what rate IV fluid my mother's post-op fluids should be running at (should have been 50 ml/hr) and said I would be waiting by the tube system until a TED hose dropped for my mother and would somebody please go in and start my mother's post-op fluids, as I was very concerned with her low blood pressure, little urine output, and risk for embolism. I received a pair of TED hose from the secretary around 1830 (the misogram attached showed it had been requested at 1812, 2 hours after I asked for it) and placed one on my mother's left leg since an immobilizer was in place on her right leg, and her post-op IV fluids (Lactated Ringers) were started shortly before 1900 (almost 3 hours after she got back to her room). Her IV pump showed that 64 ml of LR had infused (at 50 ml/hr) at 2000.
Shortly after 8pm, ****, came in, asked a few questions, and again, never placed a stethoscope on mother. A short time later, mother started having uncontrollable tremors (very likely could have been post anesthesia shakes) with increased confusion, nausea, pale, and bluish around her lips. I called the nurse, told them what symptoms she was having and also requested her O2 sats and blood sugar to be checked. A short time later, **** and another nurse arrived with Zofran for nausea, checked her blood sugar (slightly high, but unremarkable) and did a spot check on her O2, which was 86%. The other nurse increased her O2 to 4L to get her sats to stay above 92. I asked for a pulse oximeter to be left on my mother, stating that I did not feel comfortable with her being on that high amount of oxygen without monitoring it. **** stated they never use pulse oximeters on their floor, I asked who the house supervisor was that night, and the other nurse said they could call respiratory to get a pulse ox put in the room.
Mother continued to have periods of dropping her sats to high 80's - low 90's, shaking, and shallow breathing. Sometime after all that, **** brought in an incentive spirometer and said we'd need to get mother to do it every few hours. Being elderly and high risk for post-op pneumonia, she should have been given an incentive spirometer immediately post-op. Still never once did **** lay a stethoscope on my mother. My father stayed with my mother that night, she did have one episode of apnea during the night with a desat to 86 that corrected when my father aroused my mother.
I arrived the following day, mother was still needing 4L O2 to maintain sats above 92, temp was elevated >100 to 101 and being treated with/relieved temporarily by tylenol, and a Chest X-Ray was done late afternoon. Joy, Physical Therapist, came late afternoon, and after looking at mother, she explained with her high temperature, need for so much O2, and weakness she would not proceed with helping her walk, but was able to help mother sit on the side of the bed. We were very impressed with Joy's professionalism and caring approach to mom. Mother's BP continued to run very low for her, with diastolics in the high 40's low 50's.
I knew that mother's home meds included high blood pressure medication, as well as a fluid pill, and both of those could further lower her low blood pressure. Mother asked the oncoming 7p-7a nurse, ****, if they were giving her blood pressure and fluid medicine. **** responded with, “well, I don't know, but if they are, they give it to you in the morning.” I then asked if she could look to see what medications were being given to mother, she responded with, “I guess I could look in the computer, but if they give her that, it is in the morning, we don't do it on this shift.” I then say, “I am very concerned with mother's low blood pressure that is not normal for her. Will you please look and see if blood pressure medication and fluid pills are ordered and being given to her? Her blood pressure can't get much lower without being life threatening and if she is being given medication to lower it, it needs to be brought to the doctor's attention.” She told us that we could ask the day-shift in the morning.
Elderly patients with bone fractures, large bone surgery, and immobility are at increased risk for life threatening complications of thromboembolism, fat embolism, and pneumonia. The potential for these complications is greatly reduced by (1) anti-embolism stockings, (2) appropriate fluid management, and (3) use of an incentive spirometer. Had I not been a nurse, I would not be aware of these things. Knowing that failure to utilize these interventions can actually set a patient up to have a blood clot, stroke, fatal embolism, or pneumonia (not to mention delayed healing) is extremely upsetting to our family. WE HAD TO ASK FOR THESE THINGS to be done for our mother repeatedly, even while we knew they should have been instituted immediately. Even after asking, we encountered a delay. This is not acceptable, and hopefully, mother is not already developing life-threatening complications. It will be several days (up to months) before we will know, and her physical therapy has already been delayed.
I would like to share the good news as of treatment of mother's anemia and low blood pressure. At 0230 Sunday morning, a hemoglobin and hematocrit was drawn. Apparently that early morning test showed anemia, and at 1500, a unit of blood was started on mother, and by 1800, mother was looking much better and was able to have her O2 turned down to 2 liters. My father is staying with mother tonight, and we have a different 7p-7a nurse, I can't remember her name, but she knew what medications mother was being prescribed and reported that her blood pressure medication had been decreased by 50% for tomorrow's dose."
1 comment:
Harriette! What a horrible ordeal for your family. I hope your mom is better today and that the nursing care is better as well. I can't imagine having to deal with such incompetence! I will keep your family in my prayers.
Sherry
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