My Post-Op Bleeder and a Resident's Reality Check

I have a lot of respect for doctors, both residents and attendings. I especially respect the ones who recognize the fact nurses can have valuable insights on their patients since we spend significant time face-to-face with the patients, implement their treatment plans, and do most of the hands-on stuff. We are very familiar with our patient's baseline, needs, preferences, history, etc. In my experience, most doctors recognize and utilize that, and even express appreciation directly. I always love getting messages from a doctor thanking me for giving their patient excellent care throughout my shift.

However, there's always at least one that dismisses and looks down on nurses, forgetting that we see their patient a lot more than they do. This story is about a patient who almost crashed because one such resident dismissed my insights about the patient's baseline changes. My goal isn't to shame anyone, so I will, of course, include no names or identifiable info. But there's definitely a lesson to be learned from this story, and I hope one was.

My patient was post-op, some kind of vascular surgery in one of her legs. Pain was poorly controlled. She was always reporting severe pain, but her vitals mostly didn't reflect it. Typically, severe pain can make your blood pressure, heart rate, and respiratory rate increase. When she was in pain, her vitals remained stable. I don't know why, that's just how she was. As her bedside nurse, I knew this very well about her, and I therefore recognized that changes in vital signs should be carefully investigated.

She called me in to report new difficulty breathing. I checked her oxygen and found her oxygen levels to be very low, requiring a significant amount of supplemental oxygen. Even with oxygen flow maxed out, her levels remained borderline in the low 90s (typically we want 93% or above). I also noticed her heart rate had significantly increased. Her baseline was in the 80s, but she was now in the 130s and above. Finally, her blood pressure was dropping a little. All of these signs can mean multiple things, but in a freshly post-op patient, my first concern was that she was bleeding internally.

I called the overnight resident, a young new-grad I hadn't met before. She arrived at the bedside to assess the patient. From the moment she arrived, she practically ignored me, which I thought was odd. Didn't she want to know how the patient normally is? What meds she had recently? When this started? If the pulses in her leg were present? Usually, when the patient is in crisis, the doctor finds the bedside nurse and bombards her with questions about background and situation so they can make an educated decision about treatment. Ignoring the nurse was a new approach for me...

I tried to speak up to explain what had been happening. The doctor didn't look at me, just assessed the surgical site on the patient. I mentioned the change in her vitals, pointing out the significant increase in heart rate. Still without looking at me, she replied very shortly in a very unmistakeably condescending tone.

"Well yeah, she's gonna have a high heart rate. She's in pain." If that was said matter-of-factly as an opinion, I wouldn't have minded. But the way she said it was almost mocking, like I was an idiot for pointing out the increased heart rate in the first place. It's hard to explain in writing, but it was unmistakably condescending and dismissive. I calmly replied.

"I mean, I've seen her vitals when she's in pain, and she does not typically get tachycardic. This is abnormal for her." The resident ignored me. I don't remember what happened between that point and transferring the patient to the ICU, but I know that it turned out the patient was indeed bleeding internally and developing a hematoma. I believe they ended up doing emergency surgery and she recovered fine, but I did not miss the opportunity to find that resident's senior and provide constructive feedback about the resident's behavior.

Moral of the story: Nurses see their patients a lot more than their doctors, which is nobody's fault. That's just how it is. But that also means nurses may have valuable insights about patients that doctors may need for decisions about care. This is an important way for doctors and nurses to work together as a team. I hope that resident learned something that day, but based on interactions I've had with her since, I sort of doubt it... Oh well.