Day-two laparotomy patient at 02:00 on a district ward
Mr A., 58, is on his second night after emergency laparotomy for a perforated peptic ulcer in a district hospital. At 02:10 the enrolled nurse reports: pulse 124, BP 94/56, respirations 28, temperature 38.6 °C, SpO2 92% on room air, urine 40 mL in the last three hours via catheter, abdomen distended and tender, wound dry, and he keeps asking where he is. He has received 3 L of crystalloid since 18:00 and his last analgesia was four hours ago. The doctor on call covers three wards; when telephoned he says "give paracetamol, chart vitals and call me in the morning". There are 22 other patients and one enrolled nurse on the ward. No ICU, no blood gas analyser, and the hospital ambulance is unavailable until 07:00.
1. Interpret the observations. What is your working explanation, what else must you actively exclude, and why is this not simply 'pain' or 'needs more fluid'?
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Working explanation: evolving sepsis, probably intra-abdominal (anastomotic leak or residual contamination).
Reasoning chain:
- He meets all three qSOFA criteria: respiratory rate ≥22, systolic BP ≤100, and altered mentation. Any two of three signals high risk of poor outcome; three is a red flag that must trigger escalation now, not in the morning.
- Fever 38.6 °C plus tachycardia, tachypnoea and new confusion point to infection with organ dysfunction. Post-operative day 2 is the classic window for a leak.
- Hypovolaemia/haemorrhage must be excluded: falling urine output with a distended abdomen could be bleeding or third-space loss. Check drain output, wound, mucous membranes, capillary refill, and if possible haemoglobin.
- Fluid overload alone does not fit: 3 L is a lot, but he is tachycardic and has had almost no urine; overload would more typically give basal crackles, raised JVP and a falling rather than rising respiratory rate from pain.
- Also exclude atelectasis/pneumonia (listen to chest, encourage coughing), and opioid effect (pupils, respiratory pattern) - but opioids do not cause fever of 38.6 °C.
The safest position is to treat him as deteriorating and potentially septic until proven otherwise, because untreated sepsis after laparotomy kills faster than over-treatment does.
2. The doctor repeats his instruction and hangs up. Set out, step by step, what you do in the next 60 minutes - including what you say, whom you call, and what you write.
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1. Do not let the refusal end the escalation. A junior doctor's decision does not remove my accountability for a deteriorating patient.
- Call back using SBAR, specifically: "Mr A. is qSOFA-positive at 02:10, I am concerned he has an intra-abdominal leak and I need you to review him tonight. If you are not coming, please give me your clinical plan and I will document it."
- If still refused, escalate up the chain: nurse in charge/on-duty supervisor, then the medical superintendent or the most senior doctor on call, then the ward matron. Use the phone list if available.
2. Document contemporaneously. Time of each call, who was spoken to, the verbatim advice, the observations that prompted it, and the escalation. An undocumented escalation did not happen.
3. Do not abandon monitoring. Continue 15–30 minute vital signs, hourly (or more frequent) urine measurement, SpO2, conscious level, fluid balance, and pain score.
4. Stay within scope. I may position, oxygenate if hypoxic, keep him warm, take blood cultures if the facility permits and an order exists, and prepare IV access. I should not prescribe antibiotics or unilaterally change fluid rates - but I must request both in the SBAR and record the answer.
5. Prepare for transfer. The ambulance is not available before 07:00, so work on stabilisation and on the earliest possible referral plan now, in case he deteriorates further before dawn.
3. If no doctor attends and the patient becomes more hypotensive at 04:00, what is the defensible nursing action, and how do you balance 'act in the patient's interest' against 'work within your scope of practice'?
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Defensible action: treat as an emergency, resuscitate within nursing scope, and physically escalate the referral.
Concretely:
- Call a code/emergency bell, bring the nurse in charge to the bedside so the decision is shared and witnessed.
- Airway and breathing: sit up or position for comfort, give oxygen to keep SpO2 ≥94%, monitor continuously.
- Circulation: ensure two large-bore IV lines, take blood for grouping/crossmatch and FBC if laboratory staff can be reached, keep the patient warm, measure urine hourly, record a strict fluid balance.
- Re-contact the doctor as a deterioration call, not a repeat of the same call, and state clearly: "Systolic is now X, he is no longer responding normally - I am formally requesting review or transfer."
- Notify the nurse manager/matron and, under the facility's escalation policy, the medical superintendent at home. Telephone the referral hospital to warn them.
- Record everything, including that instructions were refused.
The balance: scope of practice limits prescribing and procedures, not the duty to recognise deterioration, escalate, and provide basic resuscitation. Where an order is needed and cannot be obtained, the correct action is to obtain it through the chain of command - while continuing to keep the patient alive - not to do nothing because the first doctor said no.