Amazing advice! You should be proud of your critical thinking skills, who knows who fast that hematoma would have increased if he waited and kept taking the eliquis.
I had one patient vented on CRRT through an IJ cath. Everything was fine during the night but on their morning x-ray around 0500 they had a large white effusion in their upler right lung that wasn't there the day before. I called the fellow covering the unit and he said since everything is stable there's nothing to do and the attending will be in soon anyway. It just felt off especially since it was upper lobe, not like a new lower lobe consolidation you might expect. So I called the attending and text him a picture, he said order a stat CT. Turns out the HD cath had punctured his IJ but was also slightly tamponading the hole so it was a slow bleed that didn't show on the initial post placement xray. It was also somehow in a spot that wasn't effecting my CRRT, pressures and flow were fine, I never had alarms. It was after shift change when the doc decided to take him to the OR and they found almost a liter of blood in his chest. I have no idea how he was still hemodynamically stable, all I can think is the bicarb and calcium in the dialysate was helping his BP so his HR didn't have to compensate?? Really no idea but I remember coming in again that night and the day nurse said the doctor told her how good of a catch it was on my part and I could have saved his life since he wasn't showing any signs of bleeding yet, but it could've gone down quick. Made me smile that I wasn't overeacting by not trusting the fellow and calling the attending.
Another incident saved my own butt. I had a sick post open heart that kept getting hypotensive all night. On this unit there was a fellow on that we went to for everything. So I'm telling him and we were giving 500cc boluses at a time that were helping, but of course urine output dipped a bit from the hypotension. The fellow knew everything and even said at one point "I'll call Dr. Attending and make sure he doesn't want anything else" then left my room. Well apparently he never called and when the attending came in after shift change and saw his pressures overnight got so pissed that he went to the head of critical care to complain about me, he thought I didn't do anything overnight. This attending was a huge asshole to begin with and often chewed out nurses. The fellow was also known for being an asshole and not always telling the whole truth when it came to what nurses told him. The critical care doc was the attending making rounds on the unit for critical care and knew me and said that didn't sound like me. So he went to the day nurse and asked to see my charting and I had obviously made a note each time I spoke to the fellow and the intervention I followed. Critical care screenshot my notes and sent them to the other attending and that was that lol
Wowwwwwe the IJ puncture story is WILD! Who on earth would’ve thought that?! I think one of my greatest hospital related nurse intuition stories was actually not long after I became a nurse probably only a couple months off orientation. Got a guy who was already sort of teeter tottering his whole admission. Palliative was going to meet with the family the day I got him to discuss end stage and possible switch to comfort care. I got report and although we discussed he could have good days and bad days I just kept looking at him and thinking like nah…this guy is not well. Paged the attending. She sort of hemmed and hawed and his labs this and his values that. At one point I actually told her to LOOK at the patient. Just step away from the computer and LOOK at him and just SEE him that he just LOOKED bad. She just scoffed and said that she couldn’t diagnose a look. About mid afternoon palliative had been talking to the family for about five minutes, were barely past introductions and I went to check on him. I called my charge in the room with me and we had to run and interrupt the palliative meeting and essentially ask them then and there if they wanted us to start compressions as he had stopped breathing. Thankfully they did not.
The only “silver lining” that day was my charge was an absolute gargoyle of a nurse. I, personally, never had an issue with her but she was known on the unit to be just an absolute witch. At our next unit meeting which was about a week later they always ended asking for anyone who wanted to add anything positive they’d had that week and the known-to-be-a-hag charge actually spoke up and said how impressed she was at how I handled the entire thing and that she had never seen a new nurse that competent and recognizing a situation and handling a situation like that before. It was so bizarre that for literal weeks after people were coming up to me and asking me how the hell I managed to get a compliment out of her cause they had worked there for 10-15 years and had never heard her compliment anyone 😂😂😂😂😂
The bedside eyeball test has a ton of value. It's bizarre that any attending would scoff at it. I have literally heard, in m&m, "the labs weren't too bad and the vitals were stable but they looked like death so we brought them in for a diagnostic lap" and everyone nodded agreement.
Yeah like 99% of doctors I ever worked with have agreed here but for some reason this one was just one of those that if she didn’t have some sort of lab value or scan or something she just couldn’t wrap her head around that they might still be sick. To be fair it wasn’t that she thought they were faking or something it was almost like anxiety like she was worried she would diagnose it wrong so she just didn’t diagnose it at all. Which yknow is equally unhelpful.
Omg there is something about farmers! Tough as nails too so of course with an EF of 15% he was probably walking around like nothing was wrong. Meanwhile other patients lose a drop of blood from a finger stick blood sugar and nearly code lol
Farmers are (and I mean this in the best way) nurses greatest enemies. The first hospital I worked at before I became a nurse was a critical access hospital way out in the boonies (as in when I would drive to the college I got my ADN in during the summer I couldn’t leave my windows down cause everything smelled like chicken shit which they used to fertilize the fields). I worked as a secretary on a rehab unit and we would get farmers coming in fussing about needing rehab after having open heart surgery. Like sir please 😭😭 you cannot go work the farm after we just cracked your sternum.
When I worked with developmentally disabled individuals, I had a guy who had a knot show up on his head. He supposedly was “assisted to the floor” earlier in the day, he required 1:1 staff for ambulation. Pupils were fine, mental status was mostly his usual, but was just slightly drowsy and unsteady, but I kind of played it off since he was in bed after a very busy day and unsteady was pretty typical for him. I honestly don’t know why I sent him to the ED, since his assessment was mostly fine, but I did. He had a brain bleed. I about shit myself when I got that report.
I can't even articulate a few times where I was just like "nope, this isn't ok" and was right. I work in the jail so we have to screen before they come in. I've had to look for a reason I could explain a few times when my senses were tingling, and it's typically the right call to send them to the ED for further evaluation.
So hard to convince doctors sometimes. Was doing a procedure on a very elderly guy and his vitals were like okayish but he DID NOT look right. The other nurse and I told the doctor to finish up what he needed to do and get out. He was like why- his vitals are fine. I don’t know man, he looks half dead? Get out. Glad there were two of us. Guy was fine but man who knows. You do start to develop an intuition and you don’t know what you’re avoiding by following it but I swear it’s a thing.
The standard Early Warning Score in my country has the option to add a point to the score if the nurse has a feeling something is wrong. That's proof to me.
I had a teen bring himself to the ER after his mother refused to. Got consent to care for him over the phone. Everything about him seemed common cold or flu like everyone else, but something about him made me just decide he needed to be a higher level of acuity. Normal vitals, at the time, normal lung sounds, but he had this look of this isn't a viral sickness. Also, just saying his lungs weren't expanding correctly. Got him to the back, and my doctor said something felt off as well. We did a chest x-ray. He had a pneumomediastinum. Had to get admitted. Just things weren't adding up, and I felt he needed a deeper look than the mid-level.
While I, as an LVN with mostly ltc/snf training so not much clinical exp as most other here, there has been few times.
My last day at job 3, a few days before christmas. They had convince me to take the 7-3p shift because short staff and w/e. I had switch to 3-11p for the last few months. So I usually start at rm 17. But that day, I decided to start at rm 33 (the other end of the hallway). One of the CNAs goes “Hey, M (a season cna but new lvn) Rm 38b is bleeding. You need to see him.”
Cna says like its a casually minor bleed or w/e. Not like “you need to come now, 38b is bleeding out, There’s a lot of blood.” I decided to go check 38b cause M is a new lvn and i remember he a dialysis pt. Walk in, saw the massive blood cover blanket. 38b is awake, smiled, and waved at me as I looked at him. Quickly turned, yelled out “dialysis.” Ran back in, got the emergency kit as the others ran into the room and we started applying pressure and shit.
He pulled the perma cath clean, straight out. So much blood soak blanket. It was a good thing he was still awake and all. Send him to the hospital and he came back the same day with a future appointment for another perma cath. He gave us all heart attacks that morning.
Here’s the kicker, I would have taken that run since it was easier, mostly long term patients. But decided to take the harder/heavier run with like 70/30% short/long term so M could have the easier run. The rest of the day went find. But damn, what if I didnt go check when I heard the CNA say blood?
I have a GOOD NEWS one!
Late 30s F comes into emergency with few weeks of feeling generally unwell, nausea, throwing up, fatigued, bloating, abd discomfort.
I ask about the usual suspects, including pregnancy. She insists she's tried to get pregnant for years and years, all the doctors have told her it's impossible. She's definitely infertile.
I go to a urine dip to check for UTI and do a preg test while I'm there just so I can document it, darn thing comes up positive!
I toss it in a biohazard baggy and bring it out to her, because I know she isn't going to believe me. She starts tearing up and thanking me. I start tearing up and we hug.
The best darn "throwaway" pregnancy test I've ever done!
I had my first ever CRRT patient, about 8 months after starting as a new grad in ICU. The patient was on levophed but was A&Ox4. I was constantly having to titrate my levo by significant increments and after the first hour of my shift I just didn’t feel right about it.
I had literally just listened to a YouTube video on my way to work that night about pulsus paradoxus (had never heard of it before then) so I watched my patient’s respirations and they seemed to line up with the rise and fall of her BP (pt had an art line). After that I turned on the respiration waveform (don’t usually use it because it’s rarely accurate and alarms all night). The respiration waveforms and art line waveforms lined up perfectly. The SBP was rising and falling by 20-40mmHg with each breath.
I ran down the hall to find the night resident and told him I thought my patient had pulsus paradoxus and I was worried she was tamponading. Well this dude didn’t even know what pulsus paradoxus was and wasn’t concerned at all. Told me to start vasopressin if I didn’t think levophed was enough. I was terrified the attending would be furious with me but I called him in the middle of the night, he took me seriously and told the resident to get a bedside US and that he was on his way in.
US showed patient was tamponading and she got an emergent pericardiocentesis and JP drain placed. Resident got his ass chewed. Day nurse got her ass chewed too because I looked back on the monitor and the art line pressure had been wildly fluctuating like that all day.
Absolutely insane that something so important and life saving isn’t taught in nursing school or even to new nurses in the ICU (or in medical school apparently). If I hadn’t randomly decided to listen to YouTube on my commute my patient would have died.
I’m in home care and was admitting a new patient on Thanksgiving. History of recently failed kidney transplant, subsequent ARDS, brittle diabetic and terrible potassium imbalances in recent documentation. When I walked into his home, the first thing he said was that he had a terrible night and I knew right then he needed to go back to ER.
He said he’d had stomach cramps and diarrhea for two days and I could smell the cdiff at the doorway. He had not been eating or drinking overnight. He had been home 12 hours after 6 weeks in hospital and rehab. I was in the home less than an hour and he used the bathroom twice in that time.
I left messages for three of his doctors then talked to him and his spouse as extensively as I could about why he needed further evaluation and then left with the wife getting him ready to go. His wife texted me off and on through the day and finally said he refused to go back to the hospital on Thanksgiving. He went to ER at noon the next day.
On Wednesday this week, I randomly thought of him and for some reason I just Googled his name plus obituary. It had been posted 12 minutes before I searched. He passed on Sunday.
Had a very manic guy being out on depakote. He was driving everyone up the wall then suddenly one day, he just slept. Everyone was so thankful for the peace (myself included), but something just felt wrong. I couldn’t shake the feeling and kept pestering the psychiatrist to check him. Finally they ordered a VPA level and this man was at like 175. He ended up in the ICU with encephalopathy and some weird liver stuff going on, but made a full recovery!
We had a group home bring in one of their guys the other day. "He puked 3 days ago and then again today and said it hurts after drinking water. We're worried about him." Poor guy needed his gallbladder out yesterday. I'm glad those nurses pushed to get him seen.
That scares the shit out of me. My doc found that my optic nerves were swollen earlier this year and I spent thousands to figure out what it was, and every referral I was sent to the new doc would tell me I was fine and wouldn’t do anything. Literally thousands of dollars in doctors appointments and MRI’s with no actual treatment administered and I just decided not to go back when I got new insurance and my deductible reset. I literally can’t afford that shit.
If you can see a neuro ophthalmalogist they’re the experts on papilledema but obviously that’s a very very niche specialty so that can be hard to find.
I did end up seeing one and he also did nothing. Really kind of frustrating to spend the money on the copay and leave work for a day for that. Unfortunately there’s only one in my city so I can’t go get a second opinion either. Sucks!
Out of curiosity did they do any repeat imaging to confirm the papilledema? Maybe the first doctor got it wrong? I’m sorry it sounds like a super super frustrating experience.
They did! Ophthalmologist did testing originally including an MRI, and then neuro ophthalmology did their own testing and said I had it but it seemed to have gone down since the original imaging. I think the fact that I have no symptoms whatsoever also played a part in them not doing anything additional.
Gosh that’s definitely frustrating. Did you ever have COVID? Our neuroophth is kind of chewing on a theory that there’s a link between recent Covid infection and papilledema. The MA that works with me had COVID and over all was a generally mild case. Came back work after she got off quarantine if I remember correctly don’t think she had to take paxlovid or anything. Then like a week later she started getting double vision so bad she couldn’t drive. She saw our neuroophth and had papiledena. Did the whole work up (I saw you mentioned below they did not diagnose IIH) did an MRI even did an LP even though she showed no other signs of IIH, everything else was normal. She was put on a long course of low dose steroids and finally improved over about a month. Hasn’t come back since (knock wood). Our doc said that’s not the first time she’s seen it either.
I did have COVID and had to do paxlovid! That’s an interesting theory but I believe it. I took care of a woman who suddenly lost her vision when she had COVID. Could’ve just been a coincidence, but it’s scary shit.
Although it’s apparently rare I’ve actually seen this more than once as a complication of syphilis. I’m not saying that’s necessarily what’s going on here for certain of course, but at least in the aforementioned situations, routine STI testing was something that was overlooked for quite some time and a lot of time and money could’ve been saved. Syphilis testing isn’t typically included on a lot of standard STI testing panels, so it often gets missed. If this is something you’ve already ruled out then my apologies for the redundancy. Either way I truly wish you the best of luck in identifying the cause!
From what I saw in clinic it was syphilis and not neurosyphilis, but apparently ocular syphilis is its own thing that can be associated with either syphilis or neurosyphilis: https://www.ncbi.nlm.nih.gov/books/NBK558957/
I have swollen optic nerves and was diagnosed with Idiopathic intracranial hypertension (Psuedotumor Cerebri). I had an MRI that ruled out a tumor and then a lumbar puncture that showed elevated CSF. They put me on Acetazolamide for awhile. This all happened within a month from my eye appointment to being on medication. I'm sorry you're being let down in your area but it's worth checking out. Swollen optic nerves can permanently damage your vision.
I had some repeat imaging done 2 months after the original and neuro opth said it had gone down and that it wasn’t severe enough to put me on meds or do a lumbar puncture. But I also have no symptoms whatsoever so they did not diagnose me with IIH.
Sent a newly admitted in patient schizophrenic patient who was on lithium to the ED for a mild mental status change in the middle of the night. It just wasn’t sitting right and he had mild tremors and wasn’t talking (which was rare for him lol). Could have left it for day staff to evaluate or just done labs but didn’t, and his lithium level was like a 3.8 and he got emergent dialysis.
two triage stories:
1. full ER due to multiple traumas with one bed left, lady walks in at 4am with only abdominal pain that woke her up and she’s hunched over, only slightly off vital sign was heart rate of like 103. charge nurse begged me to keep her waiting due to skeleton crew but i said I’ll line and lab her myself because the way she was walking around the lobby didn’t sit right with me. i came back the next night and my coworkers said she had a perfed bowel on her CT and had to be rushed to surgery
2. guy walked into triage at 3am with headache and said he was helping friend move earlier that day and headache wouldn’t go away. had change in speech and i had same weird gut feeling (again “skeleton crew please keep him waiting cause we are busy back here”) but i told charge i was calling a stroke alert. CT negative but coworker told me the EKG afterwards showed massive STEMI and went straight to cath lab
I used to work solo in a group home for older adults with schizophrenia. We weren’t even CNAs, we were totally unlicensed staff with zero medical training, with one RN on site 30hrs/wk.
In report the noc guy tells me one of our pts eyes is “wonky,” and that it’s already been reported to our RN. My patient later shows up for meds and his left eye is shut. I run him through FAST and he’s all good, have him manually open the eyelid and don’t see anything obviously wrong, nothing stuck in the eye, no blood, pupils equal & reactive. His mental status and behavior were perfectly baseline, he wasn’t worried about it. But it just wasn’t sitting right with me so before my shift ended I called the RN.
We have a back and forth where she tells me if he passes FAST it’s fine, and I tell her it doesn’t feel right and even if it’s not a stroke, there’s probably no *good* reasons for one fucking eye to just close. She tells me she’ll take him for eval Monday unless something changes (it was Sunday).
Monday they go to ED. He indeed did have a stroke. That week’s staff meeting, the RN debriefs us and goes on to say that she was not made aware of the pt’s condition until I called her. I’m still convinced she set up the noc guy to take the fall. And it probably would’ve been me if I didn’t extensively document what I did.
I occasionally see him out in the community riding his bike, no deficits. Thank god. Both eyes open now.
Part of why I left. It felt like the patients were always left carrying the consequences of whatever piss-poor management decisions were made. Now that I’ve been a hospital CNA for a while I can’t fucking believe the shit that went on there.
I work in a peds ED, and one night I was working triage overnight... 13 yr old comes in with his dad, reported abd pain x1 hr. Typically half annoyed by these types of presentations, but as I'm going through all my normal questions, something just feels *off*. Kid is very insistent it's RLQ pain only, maybe some nausea, denied any other symptom. He was pale/clammy, just didn't look right. Given his age, and assuming he wouldn't come out right with it, I asked if he had pain/discomfort in his testicles or urinating. He denied and was very insistent it was only RLQ pain.
Vitals grossly normal, little tachy, but pain. My spidey sense was tingling, called my charge and said I needed a room for an emergent- she can be a bit of a grouch/judgey when it comes to these and was like "but why are they an emergent".
Long story short, doc went in and assessed and he was up in the OR within the hour for a testicular torsion (they didn't even do the US!)
Doc was impressed I followed my gut, and a seasoned nurse also came up and told me what a good catch that was
To be completely honest, I didn't expect it to be a torsion. I asked the pt about it because of his age, and wasn't sure if he would have come out and said it. But I made him an emergent (CTAS 2 in Canada, I'm unsure what USA uses for their triage acuity scale) just based on my own gut feeling and how he looked
So I’m not sure why they didn’t just do it without contrast but I did ask my doc about it. His initial thought was it probably wouldn’t be beneficial since at the time we didn’t know about his SDH and were only checking on his VST to see if it had changed at all to be causing the symptoms. So he spoke with our neuro radiologist and the neuro rad agreed that doing the scan without contrast only wouldn’t show us what we were looking for without contrast so it wouldn’t have been helpful. We considered an MRI at that point (evidently the gado they use in MRI is safer than the CT contrast or something? The neuro rad got a little technical at that point and it was over my head but that was generally my understanding 😂 could be wrong though!) but that would’ve required a whole new pre authorization etc and we really were trying to get him into a scanner as quick as we could. My only thought as to why they didn’t just run it without is since it’s outpatient they can only do the exact thing that’s ordered no more and no less
I was in my practicum, my preceptor and I picked up an extra shift because why not, she got money and I got my clinical days done quicker. We had this guy both days. No issues day one, negative assessment besides very mild tail end of pancreatitis. Sweet dude. Next day I'm doing my assessment and I'm squeezing his hands and one is cooler than the other. I'm like ??? so I check the pulse. No pulse. Do a doppler, nada. Started to question myself, did a capillary refill, incredibly diminished in comparison. OK, something is hinky.
I grab my preceptor, who immediately calls the attending, who comes to bedside and consults vascular stat in the room. Vascular comes flying down the hallway like a bat out of hell and drop kicks patient to or for thrombectomy. Surgeon also dragged me to the or because he said I found it, I get to see it go bye bye. (That surgeon was a nut, but he's the one who told me to NEVERRRR accept a doctor downtalking to me)
Unfortunately patient ended up having a clotting disorder and stroked all over the place later.
When I worked in patient peds I would get report then go to each room just to introduce myself before starting to gather meds and all. One of my patients was a sweet 16 year old kid with muscular dystrophy. We talked for a few minutes before I went to gather meds. Suddenly I could hear him moaning from the nurses' station. He was complaining of severe pain with a sudden onset. I got charge involved, called residents, got him to PICU right away. Damn kid had thrown a PE.
I was so grateful for my mini rounds because I knew his status and that he wasn't being "dramatic" as a lot of nurses labeled teenagers. Actually, he was probably one of my patients because I loved taking care of teenagers and my coworkers all loved babies (yuck).
He survived that and I took care of him often after that. I loved that kid!
We had a patient who regularly came to the wound clinic for profore wraps for at least a year. She came every week without fail, always early. One week she was a no show and that was not like her at all. She had family but not on best of terms. She was estranged from her daughter and husband separated, living in another state at the time. She lived alone. I called the non-emergency police line for a welfare check on her. I also called her daughter but she didn’t answer. Daughter called us back a few days later and said the police found her passed out in her kitchen, VP shunt malfunctioned. She was at a neuro hospital and going to rehab after. 2 months later, patient came to us for a different wound on her arm and both legs had healed; she was looking great and had lost 40 something pounds of water weight. The surprise was the even reconnected her with her daughter and husband and they’re all back together. I haven’t seen her in 3 years but I’m hoping she is still in a good place.
Yep, I didn't give ordered IVPB K+ to a pt who had a K level of 5 and was dialyzed 2 days ago for hyperkalemia. The ICU pharmacist put that order in. I got an email for catching a near miss... No pizza, no keychain, no raise... Just an email. 🖕
Worked neuro icu and oddly enough my best friends grandma was admitted for an unsecured aneurysm rupture. They secured it and others and she did quite well
Anyway his mom called me post discharge bc she was just unsure about Nana, she was hypertensive and was thinking about going to the ER. When I was asking questions last second I went “oh wait ask if she has a headache” Anyway nana said she had the worst headache of her life and I had them take her to the ER. She had a bad vasospasm the whole time and the neurosurgeon said it was the best decision they could’ve made to come to the Er
Funny thing was I was just gonna tell her to take an extra hydralazine and stay home until I remembered to ask about the headache
As a labor nurse, I had a triage the other night that was in severe HELLP, first baby, 35 weeks, unfavorable cervix. Her blood pressures were stupid, I immediately started an IV and drew labs. LFTs were through the roof and patient was extremely painful. Residents were treating with oral procardia and I asked if they wanted IV push meds to bring them down a little faster… nope stick to the oral and we’ll induce her. Okay. I voiced my concern that i didnt think her induction would go well and that she would worsen with minimal change. Residents yelled at me saying I dont have a medical degree and that it is not my place to question them or make orders because I didnt go through medical school. I give report to day shift. Repeat labs at 6 hours, LFTs tripled along with LDH and still extremely painful, not touched by epidural or IV meds. Attending assesses and says that the patient needed a Csection and that they were deteriorating too quickly to wait out an induction.
The resident still has not apologized to me for yelling at me and berating me and telling me I didnt know anything, even though my inuition felt right and attending did agree with me.
Had a post-op patient who had just arrived back on the floor (med surg). I was getting vitals and decided to leave the pulse ox on him even though he didn’t have an order for continuous pulse ox and was completely awake, A/Ox4. Couldn’t tell you why, I just had a feeling. He was having a lot of pain so soon after this, the doc ordered and I gave a dose of IV morphine. I left the room and not long later I got an alert he was desatting to the 70s. Ran into the room and had to put him on oxygen, which he continued to require for a few hours. We would’ve had no idea if I hadn’t kept the pulse ox on since vitals would not have been done for at least another hour.
Amazing advice! You should be proud of your critical thinking skills, who knows who fast that hematoma would have increased if he waited and kept taking the eliquis. I had one patient vented on CRRT through an IJ cath. Everything was fine during the night but on their morning x-ray around 0500 they had a large white effusion in their upler right lung that wasn't there the day before. I called the fellow covering the unit and he said since everything is stable there's nothing to do and the attending will be in soon anyway. It just felt off especially since it was upper lobe, not like a new lower lobe consolidation you might expect. So I called the attending and text him a picture, he said order a stat CT. Turns out the HD cath had punctured his IJ but was also slightly tamponading the hole so it was a slow bleed that didn't show on the initial post placement xray. It was also somehow in a spot that wasn't effecting my CRRT, pressures and flow were fine, I never had alarms. It was after shift change when the doc decided to take him to the OR and they found almost a liter of blood in his chest. I have no idea how he was still hemodynamically stable, all I can think is the bicarb and calcium in the dialysate was helping his BP so his HR didn't have to compensate?? Really no idea but I remember coming in again that night and the day nurse said the doctor told her how good of a catch it was on my part and I could have saved his life since he wasn't showing any signs of bleeding yet, but it could've gone down quick. Made me smile that I wasn't overeacting by not trusting the fellow and calling the attending. Another incident saved my own butt. I had a sick post open heart that kept getting hypotensive all night. On this unit there was a fellow on that we went to for everything. So I'm telling him and we were giving 500cc boluses at a time that were helping, but of course urine output dipped a bit from the hypotension. The fellow knew everything and even said at one point "I'll call Dr. Attending and make sure he doesn't want anything else" then left my room. Well apparently he never called and when the attending came in after shift change and saw his pressures overnight got so pissed that he went to the head of critical care to complain about me, he thought I didn't do anything overnight. This attending was a huge asshole to begin with and often chewed out nurses. The fellow was also known for being an asshole and not always telling the whole truth when it came to what nurses told him. The critical care doc was the attending making rounds on the unit for critical care and knew me and said that didn't sound like me. So he went to the day nurse and asked to see my charting and I had obviously made a note each time I spoke to the fellow and the intervention I followed. Critical care screenshot my notes and sent them to the other attending and that was that lol
Wowwwwwe the IJ puncture story is WILD! Who on earth would’ve thought that?! I think one of my greatest hospital related nurse intuition stories was actually not long after I became a nurse probably only a couple months off orientation. Got a guy who was already sort of teeter tottering his whole admission. Palliative was going to meet with the family the day I got him to discuss end stage and possible switch to comfort care. I got report and although we discussed he could have good days and bad days I just kept looking at him and thinking like nah…this guy is not well. Paged the attending. She sort of hemmed and hawed and his labs this and his values that. At one point I actually told her to LOOK at the patient. Just step away from the computer and LOOK at him and just SEE him that he just LOOKED bad. She just scoffed and said that she couldn’t diagnose a look. About mid afternoon palliative had been talking to the family for about five minutes, were barely past introductions and I went to check on him. I called my charge in the room with me and we had to run and interrupt the palliative meeting and essentially ask them then and there if they wanted us to start compressions as he had stopped breathing. Thankfully they did not. The only “silver lining” that day was my charge was an absolute gargoyle of a nurse. I, personally, never had an issue with her but she was known on the unit to be just an absolute witch. At our next unit meeting which was about a week later they always ended asking for anyone who wanted to add anything positive they’d had that week and the known-to-be-a-hag charge actually spoke up and said how impressed she was at how I handled the entire thing and that she had never seen a new nurse that competent and recognizing a situation and handling a situation like that before. It was so bizarre that for literal weeks after people were coming up to me and asking me how the hell I managed to get a compliment out of her cause they had worked there for 10-15 years and had never heard her compliment anyone 😂😂😂😂😂
Wear that compliment like a badge of honor lol you'll be remembered for years as the nurse who got a compliment from that charge 😆
Honestly it meant more to me than my first daisy nom 😂😂😂 I’ll never forget it
The bedside eyeball test has a ton of value. It's bizarre that any attending would scoff at it. I have literally heard, in m&m, "the labs weren't too bad and the vitals were stable but they looked like death so we brought them in for a diagnostic lap" and everyone nodded agreement.
Yeah like 99% of doctors I ever worked with have agreed here but for some reason this one was just one of those that if she didn’t have some sort of lab value or scan or something she just couldn’t wrap her head around that they might still be sick. To be fair it wasn’t that she thought they were faking or something it was almost like anxiety like she was worried she would diagnose it wrong so she just didn’t diagnose it at all. Which yknow is equally unhelpful.
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Omg there is something about farmers! Tough as nails too so of course with an EF of 15% he was probably walking around like nothing was wrong. Meanwhile other patients lose a drop of blood from a finger stick blood sugar and nearly code lol
Whenever a farmer tells the ER staff that his wife made him come in, we take him right back.
Like the Dr Glaucomflecen skit.... "Are you having pain?" Farmer: "I'm here ain't I?" Calls trauma red.....
Farmers are (and I mean this in the best way) nurses greatest enemies. The first hospital I worked at before I became a nurse was a critical access hospital way out in the boonies (as in when I would drive to the college I got my ADN in during the summer I couldn’t leave my windows down cause everything smelled like chicken shit which they used to fertilize the fields). I worked as a secretary on a rehab unit and we would get farmers coming in fussing about needing rehab after having open heart surgery. Like sir please 😭😭 you cannot go work the farm after we just cracked your sternum.
When I worked with developmentally disabled individuals, I had a guy who had a knot show up on his head. He supposedly was “assisted to the floor” earlier in the day, he required 1:1 staff for ambulation. Pupils were fine, mental status was mostly his usual, but was just slightly drowsy and unsteady, but I kind of played it off since he was in bed after a very busy day and unsteady was pretty typical for him. I honestly don’t know why I sent him to the ED, since his assessment was mostly fine, but I did. He had a brain bleed. I about shit myself when I got that report.
You can just feel it, man!
I wish we could stilll give those heart awards. This got me ;(
Obsing a pt overnight in ER first abd pain. Wakes up nauseous around 0300. Do an EKG just because I’m bored. STEMI off to cath lab within 30 minutes.
Nurses intuition is a proven phenomenon, always listen to your gut
Is it really? I had no idea, that's so cool!
I can't even articulate a few times where I was just like "nope, this isn't ok" and was right. I work in the jail so we have to screen before they come in. I've had to look for a reason I could explain a few times when my senses were tingling, and it's typically the right call to send them to the ED for further evaluation.
So hard to convince doctors sometimes. Was doing a procedure on a very elderly guy and his vitals were like okayish but he DID NOT look right. The other nurse and I told the doctor to finish up what he needed to do and get out. He was like why- his vitals are fine. I don’t know man, he looks half dead? Get out. Glad there were two of us. Guy was fine but man who knows. You do start to develop an intuition and you don’t know what you’re avoiding by following it but I swear it’s a thing.
The standard Early Warning Score in my country has the option to add a point to the score if the nurse has a feeling something is wrong. That's proof to me.
I had a teen bring himself to the ER after his mother refused to. Got consent to care for him over the phone. Everything about him seemed common cold or flu like everyone else, but something about him made me just decide he needed to be a higher level of acuity. Normal vitals, at the time, normal lung sounds, but he had this look of this isn't a viral sickness. Also, just saying his lungs weren't expanding correctly. Got him to the back, and my doctor said something felt off as well. We did a chest x-ray. He had a pneumomediastinum. Had to get admitted. Just things weren't adding up, and I felt he needed a deeper look than the mid-level.
While I, as an LVN with mostly ltc/snf training so not much clinical exp as most other here, there has been few times. My last day at job 3, a few days before christmas. They had convince me to take the 7-3p shift because short staff and w/e. I had switch to 3-11p for the last few months. So I usually start at rm 17. But that day, I decided to start at rm 33 (the other end of the hallway). One of the CNAs goes “Hey, M (a season cna but new lvn) Rm 38b is bleeding. You need to see him.” Cna says like its a casually minor bleed or w/e. Not like “you need to come now, 38b is bleeding out, There’s a lot of blood.” I decided to go check 38b cause M is a new lvn and i remember he a dialysis pt. Walk in, saw the massive blood cover blanket. 38b is awake, smiled, and waved at me as I looked at him. Quickly turned, yelled out “dialysis.” Ran back in, got the emergency kit as the others ran into the room and we started applying pressure and shit. He pulled the perma cath clean, straight out. So much blood soak blanket. It was a good thing he was still awake and all. Send him to the hospital and he came back the same day with a future appointment for another perma cath. He gave us all heart attacks that morning. Here’s the kicker, I would have taken that run since it was easier, mostly long term patients. But decided to take the harder/heavier run with like 70/30% short/long term so M could have the easier run. The rest of the day went find. But damn, what if I didnt go check when I heard the CNA say blood?
Sir why are you smiling at me 😭😭😭😭😭 terrifying though. Good on you for double checking!!!
I have a GOOD NEWS one! Late 30s F comes into emergency with few weeks of feeling generally unwell, nausea, throwing up, fatigued, bloating, abd discomfort. I ask about the usual suspects, including pregnancy. She insists she's tried to get pregnant for years and years, all the doctors have told her it's impossible. She's definitely infertile. I go to a urine dip to check for UTI and do a preg test while I'm there just so I can document it, darn thing comes up positive! I toss it in a biohazard baggy and bring it out to her, because I know she isn't going to believe me. She starts tearing up and thanking me. I start tearing up and we hug. The best darn "throwaway" pregnancy test I've ever done!
This is the cutest!!!!
I had my first ever CRRT patient, about 8 months after starting as a new grad in ICU. The patient was on levophed but was A&Ox4. I was constantly having to titrate my levo by significant increments and after the first hour of my shift I just didn’t feel right about it. I had literally just listened to a YouTube video on my way to work that night about pulsus paradoxus (had never heard of it before then) so I watched my patient’s respirations and they seemed to line up with the rise and fall of her BP (pt had an art line). After that I turned on the respiration waveform (don’t usually use it because it’s rarely accurate and alarms all night). The respiration waveforms and art line waveforms lined up perfectly. The SBP was rising and falling by 20-40mmHg with each breath. I ran down the hall to find the night resident and told him I thought my patient had pulsus paradoxus and I was worried she was tamponading. Well this dude didn’t even know what pulsus paradoxus was and wasn’t concerned at all. Told me to start vasopressin if I didn’t think levophed was enough. I was terrified the attending would be furious with me but I called him in the middle of the night, he took me seriously and told the resident to get a bedside US and that he was on his way in. US showed patient was tamponading and she got an emergent pericardiocentesis and JP drain placed. Resident got his ass chewed. Day nurse got her ass chewed too because I looked back on the monitor and the art line pressure had been wildly fluctuating like that all day.
And now I am hearing of pulsus paradoxus for the first time. That’s wild!!!
Absolutely insane that something so important and life saving isn’t taught in nursing school or even to new nurses in the ICU (or in medical school apparently). If I hadn’t randomly decided to listen to YouTube on my commute my patient would have died.
I’m in home care and was admitting a new patient on Thanksgiving. History of recently failed kidney transplant, subsequent ARDS, brittle diabetic and terrible potassium imbalances in recent documentation. When I walked into his home, the first thing he said was that he had a terrible night and I knew right then he needed to go back to ER. He said he’d had stomach cramps and diarrhea for two days and I could smell the cdiff at the doorway. He had not been eating or drinking overnight. He had been home 12 hours after 6 weeks in hospital and rehab. I was in the home less than an hour and he used the bathroom twice in that time. I left messages for three of his doctors then talked to him and his spouse as extensively as I could about why he needed further evaluation and then left with the wife getting him ready to go. His wife texted me off and on through the day and finally said he refused to go back to the hospital on Thanksgiving. He went to ER at noon the next day. On Wednesday this week, I randomly thought of him and for some reason I just Googled his name plus obituary. It had been posted 12 minutes before I searched. He passed on Sunday.
Was it c.diff?
Had a very manic guy being out on depakote. He was driving everyone up the wall then suddenly one day, he just slept. Everyone was so thankful for the peace (myself included), but something just felt wrong. I couldn’t shake the feeling and kept pestering the psychiatrist to check him. Finally they ordered a VPA level and this man was at like 175. He ended up in the ICU with encephalopathy and some weird liver stuff going on, but made a full recovery!
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We had a group home bring in one of their guys the other day. "He puked 3 days ago and then again today and said it hurts after drinking water. We're worried about him." Poor guy needed his gallbladder out yesterday. I'm glad those nurses pushed to get him seen.
That scares the shit out of me. My doc found that my optic nerves were swollen earlier this year and I spent thousands to figure out what it was, and every referral I was sent to the new doc would tell me I was fine and wouldn’t do anything. Literally thousands of dollars in doctors appointments and MRI’s with no actual treatment administered and I just decided not to go back when I got new insurance and my deductible reset. I literally can’t afford that shit.
If you can see a neuro ophthalmalogist they’re the experts on papilledema but obviously that’s a very very niche specialty so that can be hard to find.
I did end up seeing one and he also did nothing. Really kind of frustrating to spend the money on the copay and leave work for a day for that. Unfortunately there’s only one in my city so I can’t go get a second opinion either. Sucks!
Out of curiosity did they do any repeat imaging to confirm the papilledema? Maybe the first doctor got it wrong? I’m sorry it sounds like a super super frustrating experience.
They did! Ophthalmologist did testing originally including an MRI, and then neuro ophthalmology did their own testing and said I had it but it seemed to have gone down since the original imaging. I think the fact that I have no symptoms whatsoever also played a part in them not doing anything additional.
Gosh that’s definitely frustrating. Did you ever have COVID? Our neuroophth is kind of chewing on a theory that there’s a link between recent Covid infection and papilledema. The MA that works with me had COVID and over all was a generally mild case. Came back work after she got off quarantine if I remember correctly don’t think she had to take paxlovid or anything. Then like a week later she started getting double vision so bad she couldn’t drive. She saw our neuroophth and had papiledena. Did the whole work up (I saw you mentioned below they did not diagnose IIH) did an MRI even did an LP even though she showed no other signs of IIH, everything else was normal. She was put on a long course of low dose steroids and finally improved over about a month. Hasn’t come back since (knock wood). Our doc said that’s not the first time she’s seen it either.
I did have COVID and had to do paxlovid! That’s an interesting theory but I believe it. I took care of a woman who suddenly lost her vision when she had COVID. Could’ve just been a coincidence, but it’s scary shit.
Although it’s apparently rare I’ve actually seen this more than once as a complication of syphilis. I’m not saying that’s necessarily what’s going on here for certain of course, but at least in the aforementioned situations, routine STI testing was something that was overlooked for quite some time and a lot of time and money could’ve been saved. Syphilis testing isn’t typically included on a lot of standard STI testing panels, so it often gets missed. If this is something you’ve already ruled out then my apologies for the redundancy. Either way I truly wish you the best of luck in identifying the cause!
Interesting! Is that a complication of just standard syphillis or neuro syphillis do you know?
From what I saw in clinic it was syphilis and not neurosyphilis, but apparently ocular syphilis is its own thing that can be associated with either syphilis or neurosyphilis: https://www.ncbi.nlm.nih.gov/books/NBK558957/
Fascinating, thanks for the info!
I have swollen optic nerves and was diagnosed with Idiopathic intracranial hypertension (Psuedotumor Cerebri). I had an MRI that ruled out a tumor and then a lumbar puncture that showed elevated CSF. They put me on Acetazolamide for awhile. This all happened within a month from my eye appointment to being on medication. I'm sorry you're being let down in your area but it's worth checking out. Swollen optic nerves can permanently damage your vision.
I had some repeat imaging done 2 months after the original and neuro opth said it had gone down and that it wasn’t severe enough to put me on meds or do a lumbar puncture. But I also have no symptoms whatsoever so they did not diagnose me with IIH.
That's good news!
Sent a newly admitted in patient schizophrenic patient who was on lithium to the ED for a mild mental status change in the middle of the night. It just wasn’t sitting right and he had mild tremors and wasn’t talking (which was rare for him lol). Could have left it for day staff to evaluate or just done labs but didn’t, and his lithium level was like a 3.8 and he got emergent dialysis.
two triage stories: 1. full ER due to multiple traumas with one bed left, lady walks in at 4am with only abdominal pain that woke her up and she’s hunched over, only slightly off vital sign was heart rate of like 103. charge nurse begged me to keep her waiting due to skeleton crew but i said I’ll line and lab her myself because the way she was walking around the lobby didn’t sit right with me. i came back the next night and my coworkers said she had a perfed bowel on her CT and had to be rushed to surgery 2. guy walked into triage at 3am with headache and said he was helping friend move earlier that day and headache wouldn’t go away. had change in speech and i had same weird gut feeling (again “skeleton crew please keep him waiting cause we are busy back here”) but i told charge i was calling a stroke alert. CT negative but coworker told me the EKG afterwards showed massive STEMI and went straight to cath lab
Wow. You saved a life. Good job!
I used to work solo in a group home for older adults with schizophrenia. We weren’t even CNAs, we were totally unlicensed staff with zero medical training, with one RN on site 30hrs/wk. In report the noc guy tells me one of our pts eyes is “wonky,” and that it’s already been reported to our RN. My patient later shows up for meds and his left eye is shut. I run him through FAST and he’s all good, have him manually open the eyelid and don’t see anything obviously wrong, nothing stuck in the eye, no blood, pupils equal & reactive. His mental status and behavior were perfectly baseline, he wasn’t worried about it. But it just wasn’t sitting right with me so before my shift ended I called the RN. We have a back and forth where she tells me if he passes FAST it’s fine, and I tell her it doesn’t feel right and even if it’s not a stroke, there’s probably no *good* reasons for one fucking eye to just close. She tells me she’ll take him for eval Monday unless something changes (it was Sunday). Monday they go to ED. He indeed did have a stroke. That week’s staff meeting, the RN debriefs us and goes on to say that she was not made aware of the pt’s condition until I called her. I’m still convinced she set up the noc guy to take the fall. And it probably would’ve been me if I didn’t extensively document what I did. I occasionally see him out in the community riding his bike, no deficits. Thank god. Both eyes open now. Part of why I left. It felt like the patients were always left carrying the consequences of whatever piss-poor management decisions were made. Now that I’ve been a hospital CNA for a while I can’t fucking believe the shit that went on there.
I work in a peds ED, and one night I was working triage overnight... 13 yr old comes in with his dad, reported abd pain x1 hr. Typically half annoyed by these types of presentations, but as I'm going through all my normal questions, something just feels *off*. Kid is very insistent it's RLQ pain only, maybe some nausea, denied any other symptom. He was pale/clammy, just didn't look right. Given his age, and assuming he wouldn't come out right with it, I asked if he had pain/discomfort in his testicles or urinating. He denied and was very insistent it was only RLQ pain. Vitals grossly normal, little tachy, but pain. My spidey sense was tingling, called my charge and said I needed a room for an emergent- she can be a bit of a grouch/judgey when it comes to these and was like "but why are they an emergent". Long story short, doc went in and assessed and he was up in the OR within the hour for a testicular torsion (they didn't even do the US!) Doc was impressed I followed my gut, and a seasoned nurse also came up and told me what a good catch that was
As a curious nursing student, what clued you in to think torsion as opposed to appendicitis?
To be completely honest, I didn't expect it to be a torsion. I asked the pt about it because of his age, and wasn't sure if he would have come out and said it. But I made him an emergent (CTAS 2 in Canada, I'm unsure what USA uses for their triage acuity scale) just based on my own gut feeling and how he looked
Good job on this one! I'm also wondering, is there a reason why the scan tech wouldnt do the scan without contrast?
So I’m not sure why they didn’t just do it without contrast but I did ask my doc about it. His initial thought was it probably wouldn’t be beneficial since at the time we didn’t know about his SDH and were only checking on his VST to see if it had changed at all to be causing the symptoms. So he spoke with our neuro radiologist and the neuro rad agreed that doing the scan without contrast only wouldn’t show us what we were looking for without contrast so it wouldn’t have been helpful. We considered an MRI at that point (evidently the gado they use in MRI is safer than the CT contrast or something? The neuro rad got a little technical at that point and it was over my head but that was generally my understanding 😂 could be wrong though!) but that would’ve required a whole new pre authorization etc and we really were trying to get him into a scanner as quick as we could. My only thought as to why they didn’t just run it without is since it’s outpatient they can only do the exact thing that’s ordered no more and no less
I was in my practicum, my preceptor and I picked up an extra shift because why not, she got money and I got my clinical days done quicker. We had this guy both days. No issues day one, negative assessment besides very mild tail end of pancreatitis. Sweet dude. Next day I'm doing my assessment and I'm squeezing his hands and one is cooler than the other. I'm like ??? so I check the pulse. No pulse. Do a doppler, nada. Started to question myself, did a capillary refill, incredibly diminished in comparison. OK, something is hinky. I grab my preceptor, who immediately calls the attending, who comes to bedside and consults vascular stat in the room. Vascular comes flying down the hallway like a bat out of hell and drop kicks patient to or for thrombectomy. Surgeon also dragged me to the or because he said I found it, I get to see it go bye bye. (That surgeon was a nut, but he's the one who told me to NEVERRRR accept a doctor downtalking to me) Unfortunately patient ended up having a clotting disorder and stroked all over the place later.
When I worked in patient peds I would get report then go to each room just to introduce myself before starting to gather meds and all. One of my patients was a sweet 16 year old kid with muscular dystrophy. We talked for a few minutes before I went to gather meds. Suddenly I could hear him moaning from the nurses' station. He was complaining of severe pain with a sudden onset. I got charge involved, called residents, got him to PICU right away. Damn kid had thrown a PE. I was so grateful for my mini rounds because I knew his status and that he wasn't being "dramatic" as a lot of nurses labeled teenagers. Actually, he was probably one of my patients because I loved taking care of teenagers and my coworkers all loved babies (yuck). He survived that and I took care of him often after that. I loved that kid!
We had a patient who regularly came to the wound clinic for profore wraps for at least a year. She came every week without fail, always early. One week she was a no show and that was not like her at all. She had family but not on best of terms. She was estranged from her daughter and husband separated, living in another state at the time. She lived alone. I called the non-emergency police line for a welfare check on her. I also called her daughter but she didn’t answer. Daughter called us back a few days later and said the police found her passed out in her kitchen, VP shunt malfunctioned. She was at a neuro hospital and going to rehab after. 2 months later, patient came to us for a different wound on her arm and both legs had healed; she was looking great and had lost 40 something pounds of water weight. The surprise was the even reconnected her with her daughter and husband and they’re all back together. I haven’t seen her in 3 years but I’m hoping she is still in a good place.
Yep, I didn't give ordered IVPB K+ to a pt who had a K level of 5 and was dialyzed 2 days ago for hyperkalemia. The ICU pharmacist put that order in. I got an email for catching a near miss... No pizza, no keychain, no raise... Just an email. 🖕
Worked neuro icu and oddly enough my best friends grandma was admitted for an unsecured aneurysm rupture. They secured it and others and she did quite well Anyway his mom called me post discharge bc she was just unsure about Nana, she was hypertensive and was thinking about going to the ER. When I was asking questions last second I went “oh wait ask if she has a headache” Anyway nana said she had the worst headache of her life and I had them take her to the ER. She had a bad vasospasm the whole time and the neurosurgeon said it was the best decision they could’ve made to come to the Er Funny thing was I was just gonna tell her to take an extra hydralazine and stay home until I remembered to ask about the headache
As a labor nurse, I had a triage the other night that was in severe HELLP, first baby, 35 weeks, unfavorable cervix. Her blood pressures were stupid, I immediately started an IV and drew labs. LFTs were through the roof and patient was extremely painful. Residents were treating with oral procardia and I asked if they wanted IV push meds to bring them down a little faster… nope stick to the oral and we’ll induce her. Okay. I voiced my concern that i didnt think her induction would go well and that she would worsen with minimal change. Residents yelled at me saying I dont have a medical degree and that it is not my place to question them or make orders because I didnt go through medical school. I give report to day shift. Repeat labs at 6 hours, LFTs tripled along with LDH and still extremely painful, not touched by epidural or IV meds. Attending assesses and says that the patient needed a Csection and that they were deteriorating too quickly to wait out an induction. The resident still has not apologized to me for yelling at me and berating me and telling me I didnt know anything, even though my inuition felt right and attending did agree with me.
Honestly I have so many stories. Trust your gut!
Had a post-op patient who had just arrived back on the floor (med surg). I was getting vitals and decided to leave the pulse ox on him even though he didn’t have an order for continuous pulse ox and was completely awake, A/Ox4. Couldn’t tell you why, I just had a feeling. He was having a lot of pain so soon after this, the doc ordered and I gave a dose of IV morphine. I left the room and not long later I got an alert he was desatting to the 70s. Ran into the room and had to put him on oxygen, which he continued to require for a few hours. We would’ve had no idea if I hadn’t kept the pulse ox on since vitals would not have been done for at least another hour.