Medical Scenario #7

Disclaimer :

These are hypothetical situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients. 

SCENARIO: 

You are a respiratory therapist working in the Neonatal Intensive Care Unit (NICU). A NICU nurse walks by and tells you the physician came by and said to increase the PIP from 20 cmH20 to 23 cmH20, on a 26-week-old baby who is intubated. She states that there was a “bad” blood gas. This is not your patient and the RT who has been caring for this baby the last 3 shifts is in the breakroom eating lunch. You are covering for the other RT while they eat. This is the physician's first day back on after having 7 days off. 

VITAL SIGNS: 

• Heart Rate (HR): 120 bpm 

• Respiratory Rate (RR): 90 breaths per minute 

• SpO2: 90% 

• Fio2 40% 

& DISCUSS:  What should you do at this time? 

ANSWER:  

As a respiratory therapist (RT) working in the Neonatal Intensive Care Unit (NICU), facing a situation where a physician instructs you to adjust the settings on a ventilator for a patient not under your direct care, especially when the primary RT is momentarily unavailable, requires careful consideration and adherence to best practices in patient care and communication.

Here’s an appropriate course of action in such a scenario: 

Verify the Order: 

• Clarify and Confirm: First, clarify the order with the physician to ensure there's no misunderstanding regarding the ventilator settings adjustment. It’s important to confirm the change verbally and understand the clinical rationale behind it, especially considering the physician's recent return and potential unfamiliarity with the patient's current status. 

• Check Patient’s Medical Records: Quickly review the patient’s medical records or electronic health information for any recent notes, orders, or care plans that might support or contradict the requested change. This may provide immediate context for the physician’s order and any recent clinical developments. Look to see what the last few blood gases have been. 

ACTION:  

You verified the order with the physician and looked in the EMR. The order has already been placed by the doctor. 

SITUATION:  

The doctor is wondering why the changes have not been made yet and tells you to make the change immediately. 

& DISCUSS:  What should you do at this time? 

ANSWER: 

Consult with the Primary RT 

Attempt to Consult the Primary RT: It’s crucial to attempt to briefly consult with the RT who has been closely monitoring the patient over the past shifts. They possess direct, recent knowledge of the patient's condition, responses to current settings, and any specific considerations or care plans discussed with the medical team. This is the physician's first day back and he might not be as informed as the RT since they have been in direct care with the patient for the last 3 days. 

Assess the Urgency 

• Determine Urgency:  Assess the clinical urgency of adjusting the PIP (Peak Inspiratory Pressure) settings. If the baby’s current respiratory status indicates immediate distress or if there’s a clear, immediate clinical justification for the increase, this might necessitate more prompt action. 

• Safety First:  Ensure any action taken is within the scope of your professional practice and aligns with NICU protocols for ventilator management and adjustments. Safety and well-being of the neonate are paramount. 

ACTION:  

You see that the CO2 on the blood gas is slightly elevated at 53 mmHg and the baby seems to have normal WOB. The PH is 7.31. 

& DISCUSS:  What should you do at this time? 

ANSWER: 

You walk down the hallway and speak with the RT on break. It’s a good thing too! The RT explains they tried going up on the PIP the previous shift and the baby had not tolerated this increase in pressure. The RT also notified you that the lungs were already hyperexpanded to 11 ribs with a flattened diaphragm. If you would have made the change without communicating with the patient’s RT, this may have caused harm to the patient, even though the physician ordered this. 

& DISCUSS:  What should you do at this time? 

ANSWER: 

You notify the physician of your findings and pull up the CXR. The physician thanks you and agrees that increasing the PIP may not be the best option at this time. He notices there is quite a bit of fluid in the lungs and orders a dose of Lasix. Eventually this corrects the situation with the elevated CO2. 

Key Takeaways: 

1. Verification and Documentation are Crucial: 

Always verify orders, especially those related to critical care settings like ventilator adjustments. This includes confirming the order with the physician and reviewing the patient's medical records for recent notes, orders, or care plans. Documentation of orders and clinical findings in the electronic medical record (EMR) is essential for continuity of care. 

2. Communication and Teamwork Matter: 

Effective communication within the healthcare team is paramount. This scenario emphasizes the importance of consulting with the primary RT who has direct, recent knowledge of the patient's condition and care history. Their insights can provide crucial context that might not be immediately apparent to others, including physicians, especially if they've been away from the unit. 

3. Clinical Judgment and Patient Safety: 

Assessing the urgency of medical interventions and balancing them against the potential risks is a critical skill. In this scenario, even though the physician ordered an increase in PIP based on a single parameter (elevated CO2), the RT's understanding of the patient's overall condition and history of intolerance to increased PIP prevented potential harm. Patient safety always takes precedence, and interventions should be tailored to the individual patient's tolerance and condition. 

4. Collaboration with Physicians: 

RTs should feel empowered to share their observations and concerns with physicians, offering a collaborative approach to patient care. In this case, the RT’s input led the physician to reconsider the initial order in favor of an alternative treatment that addressed the underlying issue without risking harm to the patient. 

5. Critical Thinking and Advocacy: 

RTs play a vital role in advocating for the best interest of their patients. This includes being willing to engage in discussions with physicians about care decisions and presenting relevant clinical information, such as the patient's previous response to treatment and current chest x-ray (CXR) findings, to guide appropriate care plans. 

6. Continuous Learning and Adaptability: 

The NICU environment is dynamic, with each patient presenting unique challenges. RTs must continuously learn from each case and be adaptable, using both their clinical training and experiences from previous cases to inform care decisions. 

7. Professional Responsibility: 

RTs have a professional responsibility to act within the scope of their practice, adhere to hospital protocols, and prioritize the well-being of their patients. This includes making difficult decisions about when to follow orders as given and when to seek further clarification or propose alternative approaches based on clinical judgment and patient-specific considerations. 

This scenario underlines the importance of a multidisciplinary approach to patient care in the NICU, where the expertise of each team member is valued and critical to achieving the best possible outcomes for neonates. 

Disclaimer:

Always follow your hospital's policies, procedures, and guidelines. Your hospital may have specific guidelines that you must follow. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on actual patients.