On to markings

 Received a pt a little bit ago, he had gone to our sister hospital for a cardiac catheterization.

They attempted to do a radial approach and was unsuccessful so they did the approach through the femoral artery. Now, one of the known complications is nicking the artery and causing bleeding. This poor soul was one of the unlucky few who experienced this and ended up with a retroperitoneal bleed - essentially, where they nicked had bled into his abdomen, creating a large blood clot when it stabilized.

It's obviously a medical emergency because your belly is a LARGE area and you can bleed into it quite quickly so the nurses that were there were laying all their body weight onto the poor gent in attempts to save his life.

Unfortunately, they didn't think it prudent enough to both to tell the poor gent that they were trying to save his life by doing just this. Now, do remember that this action is EXTREMELY painful to the pt. So of course this pt was fighting the poor nurses trying to save his life. I'm sure they could have saved some of the grief that they were receiving by just simply teaching the guy a few things!

So when I got him he was bruised, but not overly so. As soon as I received him on shift I examined his groin, how much bruising he had to the area and his abdomen for any subtle or blatant bruising, as well as his lower back because it can show up there as well. All things to keep an eye on. Stupid me though didn't mark the borders of his bruising (more on why that's important in a just a min) but just made a mental note of where and how much bruising was there in the area. I also checked out what was going on with his dressings to make sure that they were dry and intact, or whether there was any previous or active bleeding (femoral and radial areas). Both were as they should be, clean, dry and intact.

So off my pt goes to sleepy town and in the morning when I wake him for blood work, he tells me that his belly really hurts. I asked him if he needed to void, he told me no but I told him that he needed to attempt to void anyways. So off he goes, does just that and questions why he had to pee so much when he didn't feel the urge to go. So some education time later, I told him I needed to see his nether region to check out the bruising and whether there was any swelling. One of my red flags went up because I noted that his mons pubis (where all your hair is above you lady/gent bits) was more swollen than at the start of the shift and another flag went up when I saw that his bruising had extended in towards his mister bits. 

I asked if his pain had changed since voiding, thankfully he indicated that it had lessened but was still present. I went an looked to see whether my CBC was back and examine what his Hgb (red blood cells) were and how much things had changed.

From my pt returning and having his Hgb checked at ~1000hrs it was 127 then at 1600hrs it was 121 but when I got the result at 0600hrs it was 108 - so in almost 24hrs it had dropped 19points - significant! 

Off I went to tell my charge nurse all this and ensure that i was doing the right thing by getting a hold of the physician... she agreed and off I went to call him.

I advised the Dr of all of the above and asked what they wanted done.... I got complete silence. I understood that I likely woke the Dr up but still expected something more. So I asked whether he wanted me to just monitor it or do something more extensive. I was told to monitor it. I asked how normal the spreading of the bruising was... I was told that gravity would naturally spread the bruising down the leg and into the groin and nether bits, but that marking is prudent. I advised that I had done this prior to calling. Then I got silence again. I was expecting more from this Dr, some sort of direction to take. I asked if he wanted me to repeat the CBC, say like 6hrs later.... I got a "ya, sure". Ok, I guess I'll take it. The good thing was that at least I could document it all. I did my part in all this.

Marking my pt was quite interesting, having to get down and dirty really.... getting handsy with his bits and pieces so that I could mark where the boundaries of the bruising were. He was a sport though and took it all in stride.... "oh I wish this could have happened when I was a 19 yr old!" HA! 

Unfortunately, when I came back 12 hrs later, he was transferred out to give the bed to someone who was sicker so I don't have any notion as to how things ended. wahwahwah. C'est la vie, such is the life of a ER/ICU nurse.... we don't always get to know the outcome of our pts after they head out of our area.