A 23-month-old toddler was severely dehydrated
after vomiting due to gastric outlet obstruction. She had metabolic
alkalosis (pH = 7.58), and her last peripheral IV site had been
lost. The nurse caring for her that day was expert, had worked on
that unit for years, and had helped write unit and hospital
pediatric policies. One of these policies limited the number of IV
sticks in children, so the nurse requested that anesthesiology
attempt femoral access.
When the anesthesiologist arrived with an
assistant, they took the patient to a treatment room for sedation
before attempting to establish a femoral IV site. The nurse
informed them that hospital policy prohibited sedation in the unit
without monitoring. When her comments were ignored, she went to
alert the charge nurse and obtain a copy of the policy.
In the meantime, propofol was administered
without monitoring. Upon her return, the nurse observed that the
child was apneic and again requested monitoring. The
anesthesiologist replied that it wasn't necessary, applied a
painful stimulus, and noted that spontaneous respiration resumed.
He proceeded to prepare for the femoral stick, but the nurse
noticed that he did not use sterile technique and he contaminated
the needle. At this point, the nurse attempted to stop the
procedure, and the verbal exchange became heated. The
anesthesiologist threw the needle on the floor and walked toward
the door. The nurse firmly requested that he stay and monitor the
patient while she was still sedated.
The child was apneic briefly but recovered
without incident. The anesthesiologist did eventually insert a
peripheral IV and the re-hydration therapy resumed.
The situation was "saved" by the patient's nurse,
who in the midst of a very difficult encounter with a physician,
repeatedly made firm requests for adherence to policies designed
for safety. Despite her many years of experience, this nurse was
emotionally distressed by the event.
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