Yep, that's me, Standing on the corner in Winslow Arizona...we stopped there on our trip back from Oklahoma in November. We had stopped in Winslow before but never went to the corner. It was a nice day...a little cool then but they have been getting snow lately, it's up in the high country. Just one of those places you have to stop and see.
So, here's the scenario. 56 year old hispanic male comes in post op from ortho surgery after trauma, lets say he was hit by a car, it was a right femur fracture. He gets 2 units of blood post op. He codes at about 1am and doesn't make it. No real medical history to speak of. The first unit of blood was hung at about 1330. The second not until 1900. His iv infiltrated at some point in the afternoon and that's why it took so long for the second unit to go in. A couple of side notes...the same tubing was used for both units of blood. The tourniquet was accidentally left on his arm for over an hour. There was still a pulse in the arm. So, what do you think killed him...and what was the worst nursing error. What would you do if these were your nurses? or your family member?
first do NO HARM
4 comments:
Hey I would first think a fat emboli from the femur fracture. Although the rest seems like a tragic series of errors.
I was thinking that too but, if it wasn't a femur, let's say it was a humerus, would you think the same?
My guess is leaving the tourniquet on for an hour. Even though he still had a distal pulse, it might have increased vascular resistance to the point of causing distributive shock. Also, considering virchow's triad, a combination of the IV access, tourniquet and altered coagulation might have contributed to thrombus formation.
and if it was a member of my family...I would be looking to throttle somebody....just for forgetting their patient as well as their job.
Post a Comment