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RN refusing to perform a written order

Discussion in 'General Residency Issues' started by Frozen, Feb 20, 2011.

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  1. Frozen

    Frozen

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    So a situation came up that I was curious about how physicians(resident or otherwise) handled or if it has happened to you.

    A nurse was uncomfortable administering an ordered medication because she believed it was too dangerous (patient was in ICU with lots going on with him). She flat out refused to administer said meds....

    I don't want to delve into too many specifics, this is not the apppropriate place for that, but have you had this sort of thing happen and how do you deal with it in a professionall manner?
  2. Arcan57

    Arcan57 Junior Member

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    Make sure the med and dose are correct, ask the nurse what her concern is regarding the med, try and address the concern with the nurse. If it's an emergent situation, I'll push the med myself. If it's not emergent, I'll get the charge nurse/nursing supervisor involved.

    Assuming that the nurse was motivated by fear of harming the patient, and not sticking it to a doc she doesn't like, yelling at her or belittling her opinion is an almost certain write-up.
  3. Groove

    Groove Member

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    Don't have anything to add that Arcan didn't address, but if you're a med student or even an intern for that matter, just get used to nurses that are unfamiliar with you, questioning your orders. Try to handle it in an appropriate manner but aggressively or abrasively trying to coerce them into following out said orders is most definitely destined to backfire on you. Keep in mind that you have a lot to learn from most of these nurses, as a student and also as a resident sometimes. Some of the experience of the ICU nurses was invaluable to me as an intern. Most have been doing their job for a long time and have a lot of tips and knowledge to share. My first day as a resident was on call that night in a NSICU full of 20 sick neuro patients. Thank God for the nurses that night. Try to act professional and don't be condescending if they don't understand your thought process. Escalate the matter if not carrying out the order would cause pt harm...obviously, but make damn sure your order is the correct one. Run it by your upper level first if you can. Gaining the confidence of the nurses is just something you're going to have to deal with and takes time, and nurses unfortunately as a resident/med student can make your life a living hell if they don't like you or think you're a bad physician, so watch how you behave.

    Oh yea, one last piece of advice. Chocolate. I brought a couple of those mixed bags of chocolate during each ICU rotation and would put one on each nursing desk. Instant superstar. They loved me after that. Even never questioned that one hair brained order as an intern to give 3g of Mag to a renal dialysis pt to "correct his Mg" in the middle of the night. Had never heard any of the renal fellows actually yell until the following day. Learned quickly from that one.
    Last edited: Feb 20, 2011
  4. Frozen

    Frozen

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    Thanks for sound advice.

    Point of clarification: this was an interaction between an attending and float nurse, I was just a spectator waiting for my resident.

    I'm not sure what took place for interactions, just that the particular nurse swapped patients afterward with another RN.
  5. MrBurns10

    MrBurns10 Excellent, Smithers Moderator Emeritus

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    I think you've gotten good advice here. This happened to my team once. An ESRD patient vomited blood during HD, then had more hematemesis and melena upon arrival to the ED. Her Hgb 10, but she had only become symptomatic like 20 minutes before arrival. We wrote to transfuse 2 units, and the ICU nurse refused to do it. She then paged every member of our team to verify the order, and when she didn't get the answer she wanted, she proceeded to call his PCP complaining that we wanted to transfuse a hemodialysis patient with a Hgb of 10 who "wasn't actively bleeding" (clearly not true). And this was despite my upper level trying to explain to her why we wanted to transfuse. Anyway, long story still long, the nurse's supervisor was told about the event and the nurse apologized the next day.

    I think the most important thing is to try and calmly find out why a nurse doesn't want to perform an order and explain your reasoning. If the RN still won't do it, find someone who will or do it yourself, and then speak to their supervisor if you deem it appropriate to do so.
  6. Ronin2258

    Ronin2258 Prometheus Unbound

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    Had one before, went all the way to the pharmacist, and a bit shy of the administration, until I was proven right.

    Had a carotid patient admitted to the telemetry unit that required 100mg of regular metoprolol twice a day, per his medication list he kept on him. Not believing it myself, I ran through the primary doctor's electronic medication reconciliation, (part of the regional health system, and he was in our network,) and found it to be correct. Wrote the order, and it should have been a done deal.

    Nurse refused the order, thinking I made a mistake of reading a computer readout from a dictation on the dosage. :rolleyes: They swore it had to be metoprolol SR at that amount, and charge nurse of the unit and the pharmacist both gave me a chewing, with the threat of reprimand, despite the evidence I had that stated otherwise. Seniors backed me, fortunately, and I refused to lose my cool or be hostile about it, standing by my guns and the evidence that was in permanent record. Nevertheless, I was overridden by bureaucracy and it was given as SR.

    Unknown to the nursing or pharmacy, the primary doc put him on that schedule of regular metoprolol because SR didn't give him enough control. They gave the SR in the morning, as he had enough beta blocker during surgery to last him through the night. The SR dose didn't touch his blood pressure, with systolic in the 160's-170's. heart rate never dropped below 100. Mind you, nursing was panicking because he was setting off his telemetry warnings until one thing happened.

    I re-instated the correct dosage of regular metoprolol.

    Within an hour or so after the correct dose was given, the patient's systolic was 100's-120s, with pulse of 70's-80's for the rest of his time on telemetry. Seniors got a good chuckle the junior resident (me) showed up this particular charge nurse, and this ward, both were a pain in their semperini.

    Never got an apology from the charge nurse or pharmacy *shrug*. They dropped the threat of reprimand. Though no one ever questioned my orders on that unit again. I made an addendum to the online med list to clarify the metoprolol was regular, immediate release to prevent future muck ups.

    Learning points:
    1. Make sure you got the right order, and make sure you can back it up.
    2. Be nice, despite their threats, yelling and screaming. You as the physician have to be the voice of reason and the calming influence when things hit the fan.
    3. Realize that both sides are looking after the best interests of the patient. We have the backing of our knowledge base and critical thinking. Nursing has their protocols in place to keep them from hurting the patient. I have fortunately not encountered apathetic nurses.
    Last edited: Feb 20, 2011
  7. filter07

    filter07

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    So why did this patient get blood? It's not clear to me based on this story...
  8. Smurfette

    Smurfette smurfalicious Administrator SDN Senior Moderator

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    The patient had an UGI bleed (hematemesis and melena). It can take a few hours for the cbc (hgb) level to reflect the blood loss....so if the patient had been symptomatic for a short period of time, the hgb reading of 10 was not reflective of the acute blood loss. In order to 'keep up' with the blood loss (this patient is actively bleeding until proven otherwise), you need to give the blood now, and should not wait until you get a lower hgb level to transfuse.
  9. MrBurns10

    MrBurns10 Excellent, Smithers Moderator Emeritus

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    Yeah, see Smurfette's explanation.
  10. Impromptu

    Impromptu ASA Member

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    I like the responses given above, especially about always being professional. Ensure that you have written the right order. Everyone should feel empowered to speak up without retribution if they have a concern, more mistakes will be caught that way. Find out the nurses concern and evaulate it. A whole lot of good will can be gained from showing someone that you value their input. Document your reasoning. Believe that everyone at the hospital is covering their own behinds and will gladly place the blame on you, so have that reasoning documented. If you still wish to proceed with your medical plan and the nurse still refuses, talk with the supervisor (not in a punitive manner, but in a way to get the patient the proper care).

    If that doesn't help use the incident reports. Again, not as punitive, but so that systemic problems can be found and addressed.
  11. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I know I'm a cynic but I've been working in hospitals for a long time now and in administration for awhile too. Once things get to the incident reporting stage they get punitive, by definition. Hospital administrations are primarily interested in two things once an incident report happens, covering themselves and avoiding spending extra money.

    I've been through dozens of these issues where we all know there are systems issues and someone finally steps in it. The primary response is always to scapegoat one of the individuals involved. The second is to create an "action plan" that can be presented to the Joint Commission if they ever get wind of what happened. By doing those things they avoid doing any of the expensive things that would really help such as increasing staffing or buying new infrastructure.

    The other thing about incident reports is that you've definitely taken the situation out of the constructive arena. Once pen hits paper everyone has to circle the wagons and fight for their lives. Oddly enough I've found that you can take a problem up the chain to the highest levels and it can all stay friendly but once there's documentation it starts to look more like a trial than a discussion.
  12. MattD

    MattD Curmudgeon

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    I second the question :) By 'symptomatic' do you mean the pt had only started vomiting blood 20 minutes before arrival, or by 'symptomatic' do you mean actual physiologic responses to an acute blood loss anemia? Was there any quantification whatsoever of the pt's actual blood loss? Tachycardia? hypotension? narrowed pulse pressure? failure to respond to fluid challenge? If not and if the patient wasn't just hemorrhaging blood from their GI tract I think I'd have given fluids and admitted to an ICU for close monitoring and serial CBCs, and worked up the bleed. CRIT, TRICC, and their progeny are pretty convincing that blood transfusion should not be utilized simply to 'top off the tank'... of course, different places have different philosophies and all that...

    Now of course if the pt was symptomatically anemic and/or hemorrhaging, I'm less likely to question ;-)
  13. proman

    proman Member Moderator

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    Almost all studies evaluating blood transfusion in the ICU exclude patients actively bleeding (certainly TRIC and CRIT did). I don't think their results can be extrapolated to an actively bleeding patient (melana + hematemesis). The ESRD also limits how much crystalloid can be safely given too.
  14. Rendar5

    Rendar5

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    only thing to add is that if a nurse isn't comfortable taking responsibility for a particular order, even after an explanation of the way, if it's a one-time thing you can offer to do it yourself (i.e., push a certain med, set up a drip).
  15. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I have no idea how to set up a drip or work a pump. Any attempt on my part to try to do so would end badly so that wouldn't be an option for me.

    Just for the sake of discussion though let me ask a question: Is it appropriate for a nurse to refuse an order after it has been verified and all questions and concerns addressed? If the order is correct (i.e. med, dose, route, etc. are all good) and concerns have been listened to and rationals explained and the order has been given or confirmed by an authoritative member of the medical team (e.g. the attending) and the nurse refuses isn't the nurse practicing medicine?

    Questioning for the sake of accuracy is one thing. Refusing because the nurse disagrees with the treatment plan is really a different issue.

    For the sake of not going off on a tangent let's assume we're not talking about ethical issues like withdrawal of care or abortions, etc.
  16. shopsteward

    shopsteward

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    I don't think this is quite "practising medicine", as it is unlikely that the nurse is doing anything which would require a doctor's qualifications and licence. It would also be hard to argue that the nurse was practising medicine if qualified doctors were present at the time. But refusal by the nurse seems likely to be a breach of the nurse's terms and conditions of employment (ie it is a breach of the employment requirement on that person to work as a nurse at that time and place). It's possible it could also be a breach of the professional obligations of the nurse, depending on what qualifications and licences the nurse holds.

    I tend to think, having seen a good many workplace disputes, that most of them start through a lack of ordinary good manners - which isn't about etiquette, but is about 1) being ordinarily polite, 2) sharing sufficient information, and at the right times, and 3) making people feel they've had the chance to make their point and have had it taken into consideration.
  17. dilated

    dilated Fought Law; Law Won

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    No, it's generally more about the fact that some nurses (primarily ICU) genuinely believe they know more medicine than the residents. At some institutions nursing has a disproportionate amount of power and pulls this, at other places you never see it. It is inevitably based on "I've seen X number of patients with something similar and we did Y and this is not Y or we did Z and had a bad result and this is Z". However, they have no formal medical training in the things you're arguing with them about, so they just get defensive and dig in if you give them a list of medical reasoning.

    If they're telling me about something nursing related then I accept it. If it's something inappropriate but non-critical ("I don't want to give him more mag") I just sigh and don't bother. If it's something important ("he doesn't need pressors") then you're going to have to bludgeon them with your seniors and the charge nurse and they'll hate you but whatever, you'll get through it.

    Another trick is telling them that they're welcome to refuse the order, but they will be writing a note documenting that they refused a written medical order and why. That usually dissolves some of the more ridiculous objections.
  18. MrBurns10

    MrBurns10 Excellent, Smithers Moderator Emeritus

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    haha, to be honest I don't remember the case in detail as this occurred in July. But I do remember that her Hgb that was drawn pre-transfusion, a couple hours after her initial CBC on arrival to the ED, was around 7.0. So the patient must have presented such that it was obvious she needed transfusing even before her Hgb reflected it.

    The issue I had with the nurse wasn't just that she refused an order (from every medical member of our team) but that she had the audacity to call the patient's PCP and lie to him to get the answer she wanted. I am doing my intern year at a predominantly private hospital and we are one of the only two teaching services in the hospital. So, sometimes we don't get the same level of respect that the private physicians do...and that includes our attendings.
  19. MattD

    MattD Curmudgeon

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    True, and hence my caveat about active hemorrhage. I'd certainly have a patient presenting like this typed and crossed regardless, with an expectation of transfusing if the H/H continued dropping and/or pt became symptomatic. I think it's an interesting question though, what are people's individual transfusion 'triggers'? How much witnessed hematemesis or melena is required for you to assume an ongoing active hemorrhage necessitating transfusion vs observation? Any thoughts folks?????????
  20. gutonc

    gutonc No Meat, No Treat Administrator SDN Senior Moderator

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    I don't go with any sort of volume of horking up blood (mostly since nobody is very good about quantifying such things...any amount of blood that you are hacking up is too damn much and might as well be 5L if it's a teaspoon).

    Excepting my leukemia/BMT patients (who we just routinely transfuse to keep Hgb >8 regardless of sxs or cause, since we know it will a long time before they can keep it up on their own), my trigger is primarily active bleeding with symptoms of any sort. If I need volume to keep their BP up and keep them from being orthostatic, it might as well be blood.
  21. Janedoedoctor

    Janedoedoctor

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    First step, make absolutely sure that the indication for the med, dosing and route of administration are in order.

    Second step: ask nurse what his/her concern is and reassure them

    Third step: call attending. There are some nurses out there who will be obstructive on purpose but they are rare. Usually, when an experienced ICU nurse refuses to carry out an order, the problem is with the order and not with the nurse. And even if your order is correct, would you really want to run the risk of having a complication with the med and have documentation of the nurses' concerns about your order in the chart, without the attending being involved?
  22. HooahDOc

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    At least your nurses are acknowledging orders even exist. Without providing too many details, multiple times I have had nurses "forget" to do labs or give meds. Orders put into the system aren't even acknowledged until 6-7 hours later. I have even had nurses blatantly LIE about a patient getting prbc. This particular person came in with a Hgb of 6 and active UGIB. The upper-level medicine resident saw the pt in the ED, wrote the initial orders and everything for transfusion. I called to ensure the units were running. The first time I was told they were, "on their way from the blood bank". 15 minutes later I call back and am told, "there was something wrong with them so they were sent back and new ones are on their way". 15 minutes later I go up to the ward and see no blood there. I ask what is going on, and am informed that between the ED and ward the consent was lost so I had to fill out another one before they could get any units from the blood bank. :eek:

    This isn't a case of nurses trying to stick it to me, because they generally respected me (in fact they were surprised at the end of the rotation to learn I was a psych intern) and I treated them well. Until near the end of the month, then I became a bit more of an ass. I wasted at least 1-2 hours a day calling the floors and reminding them to actually draw labs or do things I had asked them to do and for which orders were in the system.

    Unfortunately, this is the "culture" of where I am and it has been this way for years.
  23. proman

    proman Member Moderator

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    Very hard question (and will probably get lost in this thread). I don't think the concept of a transfusion trigger is appropriate. Our experience with patients who refuse blood shows that what we are comfortable with is much different than what the body actually needs. The American Society of Anesthesiologists has a policy statement that most people with a hemoglobin <7 need a transfusion and those >10 don't. I think that's a reasonable approach. I think it's worthwhile to really consider the markers of oxygen delivery more than the what the absolute hemoglobin number is. Of course, it's easy for me to say because I am in a cardiac OR with a PA catheter and continuous SvO2 other invasive monitoring.

    Regardless, we need to start considering a blood transfusion as a tissue transplant and the consequences of a transplant are significant. In addition, I think preoperative patients, when appropriate, need to have the red cell mass optimized.
  24. Impromptu

    Impromptu ASA Member

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    This thread got me talking with aa friend who is also an anesthesia resident and he told me of a recent experience with a nurse refusing an order. He was called to the MICU for an intubation of a patient with sudden decreased mental status for airway protection. When he got there he asked the veteran nurse to please get the suction, the intubation kit, and induction medicines. She said she didn't think the patient needed to be intubated and would not assist in any way in the intubation. Her concern was that his mental status wasn't altered enough to warrant intubation. It put my friend in an awkward position.

    Ideally, I think that the MICU resident should have resolved the concerns before calling the anesthesia resident.
  25. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    What? That's called "practicing medicine without a license" --> fired.
  26. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I disagree. If the physician in authority (i.e. the attending) has made a medical decision and the order is correct and all questions have been answered and the nurse refuses to implement the order then that nurse is overruling the physician. That's practicing medicine. I agree with your points about employment obligation but I think it's also practicing medicine.
  27. shopsteward

    shopsteward

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    A nurse who refused to give a medication could put that refusal on the patient's record. But even if they did so, medically speaking the physician's decision would still stand in respect of the patient's treatment, and could still be implemented in relation to that patient either by the physician (subject to the points made above as to the practicality of this) or by another nurse. So I don't think a simple refusal, which is the premise of this thread, would be practising medicine.

    The position could change if the nurse, rather than just refusing to act, actively does something which is in contradiction of the physician's orders, such as giving a different dose/form of medication to the one ordered. In that case, the "practising medicine" case could be made out. Even in this case I still think the other disciplinary routes are the more likely.

    If a case of refusing to act related to an emergency ("this exact medicine now or there will be harm to the patient") and there were no-one present other than the nurse able to administer the medicine in a timely manner, the "practising medicine" case would be an interesting one to argue on either side.
  28. AmoryBlaine

    AmoryBlaine the last tycoon

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    I think an interesting question here for you (an attending) is what do you do in this situation to CYA?

    You don't want to start a chart war with an RN (this could not under any circumstances go well) but at the same time you need to make it clear that this was your plan (the treating physician) and it was not carried out because an RN refused to do it.

    You know nurses are cool and all, I'll spare you the "I love RNs" crap, but ones that make trouble are toxic as all hell. Even in residency I've had some bad situations come up because RNs disagreed with plans and it is a lose-lose situation for the docs and the pts.
  29. Flopotomist

    Flopotomist I love the Chicago USPS

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    I think in the majority of cases, nurses who do this are not just being spiteful, they honestly believe that they are protecting the patient - and that is a good thing that should be encouraged as an extra layer of safety. When I have had these situations, I always start my response with a sincere "thank you for sharing your concerns - what specifically is it that you are worried about?"

    This gives a starting point for a dialogue wherein you can explain your rationale, helps educate the nurse, and may help you identify if you have actually made an error and the nurse was right (in which case another thank you is in order).

    PLUS, taking this approach for the small, non-emergent things helps establish rapport with the nurses so that during the big emergent times, the nurse will have an increased level of respect for you.
  30. anonperson

    anonperson

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    Please. Some nurses think they know more than physicians, generally residents. It's annoying and somehow they believe xx years of NURSING experience somehow means they have a detailed grasp on medically/surgically managing a patient because of blindly following some pathway/algorithm.

    A good nurse is invaluable. But part of that is making sure a nurse knows their role. I don't mean that to be derogatory but I see it all too often with nurses insisting on doing something a certain way because that's the way it was done in the past or by a certain attending even if studies point to the opposite.

    Main thing to remember is nurses can be incredibly passive aggressive and petty. They can act like petulant teenagers so you have to throw them a bone every once in awhile on decisions that don't affect patient outcomes so they can feel somewhat important.

    Also...
    If I hear one more nurse proclaim themselves as a "patient advocate" I'm going to punch a wall. Somehow they've convinced everyone that if it weren't for them, attendings/residents would be murdering patients left and right. Completely insulting. What I want to know is where is that same nurse when it's time to take care of a critically ill patient when it happens to overlap during their signout...

    Just ranting due to delirium from being on call 24+ hrs.
  31. AmoryBlaine

    AmoryBlaine the last tycoon

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    I totally agree. Ask your average floor RN if she wants to stay and be a patient advocate 2 hours past her shift without pay, let alone overtime. Or if she wants to perform patient advocacy right through her one hour protected lunch break.
  32. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I would write the order at least twice. In the chart I would document "I have reordered [the therapy] and I have informed nurse [name] of the order." I would leave it at that in the chart. If you get into documenting the process you're going through to get the problem straightened out it can bite you later because the plaintiff's lawyer will always say that whatever you did was not enough (i.e. "You shouldn't have left it with the nurse manager of that floor, you should have gone all the way to the CEO.")

    I would review the nursing notes for land mines that they might have put in there. If they did write something inappropriate I would bring that immediately to the attention of their manager or risk.

    Remember that we're only talking about the extreme situation where nursing is refusing a correct order after an explanation of the medical reasoning and necessity.
  33. NYRN

    NYRN

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    I agree with DocB on all his points, especially about involving incident reports. I don't think I have ever filled out an incident report on an MD, even if we have a disagreement or heated discussion. I believe that we can handle things between us, and involving suits of both the nursing and medicine type who haven't touched a patient in 20 years doesn't help matters at all.

    If I have believe an order is incorrect, I will run it by the resident who ordered it. 99.9% of the time, either the order is changed to make it right, or he/she stands by the order and explains why this order is appropriate for the patient, and everyone is happy. If I still think this order might be wrong, I will ask the attending. If the attending stands by the order, than its cool. I will also call the pharmacy and speak to them regarding the med and see if they feel the med dose is appropriate. I can't recall ever having an issue with an attending order other than sometimes with the way the computers work, sometimes they order the med on the wrong patient, the patient mentions an allergy long after they have been triaged and its not in the record, or if there is an issue with administration like the patient has a PEG and they are ordering a med that cannot be crushed. We have a policy now that all pediatric orders must be verified with an attending before we are allowed to give them because there were so many mistakes being made.

    In the cases where a nurse outright refuses an order from an attending and all checks have been made that the order is not an error or inappropriate, he/she should be reprimanded. In the case with the patient who was ordered a blood transfusion and the nurse refused to give it because she thought the H+H was high enough, she is totally in the wrong. That is a medical decision, and her saying that she wouldn't give it because the hgb is 10 is beyond her scope of practice. That is practicing medicine.

    There should also NEVER be a chart war between nurses and physicians. Derogatory notes should NEVER be written about each other, because the hospital can face liability for it. We had a rotating resident write a nasty note in the chart about a nurse, and he was nearly fired from residency. The hospital is all about its bottom line, if they think you opened them up to a huge lawsuit, they will not be happy with you and if they believe you will cost them more money that you are making them, you are gone. I mean "you" in a general sense, and it goes for both nurses and physicians.
  34. FutureInternist

    FutureInternist

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    :thumbup::thumbup:
  35. Trifling Jester

    Trifling Jester Senior Member

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    Just call the house supervisor. Let them handle it.

    -The Trifling Jester
  36. Socrates25

    Socrates25

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    Let me tell you about my plan to stick it to the man.

    I had a newborn baby on the unit who was LGA (large for gestational age) and IDM (infant of a diabetic mother). These kids need blood sugar checks due to risk of hypoglycemia from sudden withdrawal of cord blood sugar with lingering insulin in the bloodstream. It's routine protocol.

    Nurse flat out refused. I asked her why. She said "this baby is not LGA." I said you are obviously wrong, plot her out on the growth curve, her weight is 4300g which is > 95th percentile for her gestation. Furthermore, her mother is a diabetic putting this baby at high risk for hypoglycemia. Nurse said "I dont draw blood sugars on kids unless they are jittery." I escalated to the charge nurse who also refused to draw it, stating that "the baby is sleeping and we dont do heelsticks on sleeping babies unless there is a problem." I said you're damn straight there's gonna be a problem when this baby's sugars go down to the 20s and she starts seizing. I dont give a damn if she's jittery or not, draw the damn blood sugar!

    At this point I'm paging the attending, but he's not responding for some reason (I wouldnt hear back from him for a good 3 hours after which everything had already transpired).

    I went down to the L&D room and talked to the mom/dad of the baby, assuming that the reason the nurse didnt want to do the heelstick was because the parents didnt want their baby stuck with a needle. But no, the parents were fine with it. They had no idea that I had ordered the baby's blood sugar to be checked.

    I then proceeded to do the heelstick myself. The baby's first blood sugar was 35 so I ordered a D20 bolus. Nurse refused to get a PIV on the baby so I did it myself and set up the pump/tubing by myself.

    I then told the mother/father that the nurse was incompetent and that she was putting the baby at risk. I further told the mom/dad that if the baby had problems from blood sugar due to this nurse's incompetence that she should sue the nurse and the hospital for everything they can get.

    I then wrote a note in the chart about the nurse's refusal to follow orders and my advice to the parents to sue the hospital.

    I got written up (which was expunged from my record after 6 months, my program director and program chair had my back) and both the bedside nurse and the charge nurse got their asses fired AND had licenses revoked by the state nursing board. I have never been so happy about getting "in trouble" in my life.

    Bitches got served.
  37. NYRN

    NYRN

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    The nurses were in the wrong, no disputing that, but you and your attending are very lucky that neither of you got into trouble. They could have easily punished all of you if the baby had a bad outcome, and do you really think that the lawyers involved would have sued only the nurses? At least in this case it worked out in your favor, but it could have easily and more likely, could have gone the other way. I saw a resident write less inflammatory things about a nurse in the chart and he nearly got fired months before graduating residency. The hospital is out for the hospital, not for you, not for the nurse. If getting rid of all of you is in their best interest, they WILL do it.
  38. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I'm amazed you didn't get fired for saying that. I suspect that didn't make it to administration which is lucky for you. Had it come to light that you had recommended to the parents of an active patient that they sue the hospital you'd likely never set foot in that hospital again.
  39. Arch Guillotti

    Arch Guillotti Senior Member Administrator SDN Senior Moderator Lifetime Donor

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    Assuming this story is true, I think you are a fool for handling things the way you did and are lucky that you didn't get fired. Talking to the parents in that manner and throwing others under the bus on the chart would almost certainly put risk management in a tailspin.


  40. NYRN

    NYRN

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    :thumbup: Risk management would have a field day with this resident, that is if his attending didn't rip him a new one first.

    You know, the more I think of it, I think you are right. I'm calling BS on this one. The fact that the resident got the PIV on baby, and then supposedly set up an IV tubing and pump?? :laugh:

    D50 is given in a large 50 mL ampule anyway not on a pump, and you don't give D50 to a neonate anyway, you would give D25 or even D12.5%.

    I also doubt that 2 nurses had their licenses revoked for refusing a fingerstick unless the baby died. It takes more than a pissed off physician to make that happen.
  41. oldbearprofessor

    oldbearprofessor MIT strong Administrator SDN Senior Moderator SDN Advisor

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    Actually, you don't usually give D50, D25,D20 or D12.5. You give 2 mL/kg of D10 in an asymptomatic infant such as this (see Uptodate for a good chart on this) and then start a glucose infusion. Boluses without then starting an infusion are not a good idea. Via a peripheral IV, usually we don't go above D12.5 for an infusion except in an extreme emergency. Beyond that would need central access which is easily obtained via the UVC in the first hours of life.

    Of course, the best answer is that you take the sleeping baby with a glucose of 35 and give it to the mother to breast-feed, or if she has chosen to not breast-feed, give it a bottle of infant formula. Then recheck and go from there.

    http://pediatrics.aappublications.org/cgi/content/full/127/3/575/F1

    I don't believe a word of the story, but that's irrelevant. Just wanted to put in a plug for feeding babies and the correct guidelines.
  42. Arch Guillotti

    Arch Guillotti Senior Member Administrator SDN Senior Moderator Lifetime Donor

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    Despite the fact that we may agree on an issue, it really is very poor form for a nurse to come on this site and mock a physician.

    Especially when it is clear that your knowledge of the treatment required in this scenario is poor.
  43. Llenroc

    Llenroc Bandidos Motorcycle Club

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    99% of the time, nothing comes of these "incident reports". The administrators get flooded with thousands of them each day, so it's a boy cried wolf phenomenon. At most you might get chewed out by an program director, but even that's usually after 4-5 of these things have accumulated against you.

    Unless you did something medically inappropriate or just blatantly unprofessional (violent, swearing, etc.), you've got little to worry about.
  44. dragonfly99

    dragonfly99

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    In the ideal world, perhaps. But it ain't necessarily so...you can generalize based only on your particular experience in your particular program.
  45. NYRN

    NYRN

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    I'm well aware that you would give PO to an asymptomatic baby, that should go without saying. We have in department pharmacists, and they go over ACLS and other emergency drugs with us on a regular basis, and I have never heard of or seen anyone go and push D50% on a child that young especially if they are asymptomatic. Is that what you would have done?

    I see that you find it more important to stick with another physician than to do the right thing. I wasn't even defending the nurses in the situation, I was just saying that this is poor advice for this "resident" to give to med students and premeds, and that doing so is very dangerous both the the resident him/herself and the attending responsible for him/her. I know in real life that if this actually happened, this resident would have been fired if the parents actually did file a suit, and good luck to that resident ever placing elsewhere ever again. I hope that you as an attending never have a resident that does this to you, because you will be the one facing the lawyers, at risk management dealing with this, and will have the settlement paid out against your malpractice insurance.

    I called BS on this one because I have yet to see a physician, other than an anesthesiologist/intensivist, who knows how to set up an IV pump, tubing and run a drip, certainly not a medicine/peds resident. I also find it hard to believe that this resident got off scott free from putting the hospital in a position of liability as bad as he did.
  46. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    I think Arch's point was that you stated that the poster in question was wrong, provided what you felt was the right answer which was wrong (see the post from OBP - a neonatologist for the correct answer).

    Thus, while you are correct that it is highly doubtful that this story is true (for many reasons, not the least of which is the hanging of the D whatever and running it through a pump), by mocking him and providing the wrong answer yourself, you come off looking bad.

    I think you have *totally* misread Arch's comment. He AGREES with you that the story is most likely bogus and that the management was wrong. He disagrees with your approach (mocking the physician and then giving the wrong advice).

    You are preaching to the choir. I have yet to see *anyone* here who believes the story posted by socrates25. It is indeed very bad form to tell a patient's family that another member of the health care team is incompetent and that they should sue.
  47. oldbearprofessor

    oldbearprofessor MIT strong Administrator SDN Senior Moderator SDN Advisor

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    ACLS? For a newborn? Besides, the original post indicated that he'd given D20, not D50. Please read the post from Socrates25 more carefully. Of course it needs to be said that feeding the baby is the first step as many believe that all newborns with a glucose < 40-50 need an emergent IV bolus.

    BTW, although it is certainly true that few physicians are capable of setting up an IV infusion, some of us actually can start peripheral IVs and would be capable of giving, without nursing assistance, the 2 mL/kg of D10 that would be given per protocol if the oral feeding was unsuccessful. Furthermore, although few in number, there are physicians (including residents) who based on previous training know how to set up one of those fancy new IV pumps. Regardless, I still don't believe any of the story. Newborn nurseries uniformly in my experience have established protocols for management of LGA/IDM babies. The drawing of an initial glucose per such protocol is not usually, if ever, physician-driven (i.e. needing a specific discussion, as opposed to following physician reviewed nursery protocols) and is never controversial.
    Last edited: Mar 13, 2011
  48. NYRN

    NYRN

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    I think we are misunderstanding each other here. If we are talking about a baby that is 100% asymptomatic, and there is no reason why the baby cannot breast/bottle feed, than the baby should be fed first before IV lines and such are started. I didn't bring that up because that goes without saying. Socrates said that he took the fingerstick, and upon getting the reading, placed a PIV, pushed D50 and started a drip. OBP also said that he does not push D50 in a neonate, which is exactly what I said in my response. I never said anything about the dosing of a drip, all I said was that I doubt he started it himself. He is presenting the idea that the baby needs treatment this instant because he/she is in danger. IF that is the situation, than I don't know how its "wrong advice" to push glucose. He made it out like although the baby is asymptomatic, that he wanted treatment given now, and PO was not an option or a thought in his mind.

    I respect Arch, I think he does give sound advice on here. I just don't have any problem with him. If calling someone on their BS (Socrates or anyone else for that matter) is the same as mocking a physician, than so be it. How do we know he is even a physician anyway? Sure doesn't sound like it to me. Besides, others called him out on it just the same as I did. If its OK for everyone but not for me, than that is why I got the idea that Arch was sticking with the MD's even if they were wrong. If I misunderstood, than I apologize.

    Nobody who actually works in a hospital setting would believe that, but there are impressionable premeds and med students on here who don't know any better. My #1 concern during this whole thread was not what people thought of me, but was that the people going into or just starting medicine don't pick up bad behaviors such as this. If they are being told that this behavior is OK, than they won't know any better when they get into trouble for it. This type of situation where the nurse outright refuses anything after a discussion to relieve any concerns, almost never happens. No I'm not a physician yet, but everyone in the health care setting is responsible for teaching and guiding the future doctors we work with, and I do whatever I can to help them out and teach them.
  49. NYRN

    NYRN

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    Typing while doing something else, didn't mean ACLS, I meant NALS. I could have sworn he wrote D50, who knows he could have edited his post too. Those who think that an emergent bolus should be given before PO when there is no contraindication to feeding, are those who aren't experienced. That is why I didn't even bother to mention it. There are some docs that know how to use an IV pump, but there aren't many, we aren't disagreeing on that. My whole point was lost in all the attacking. The point I was trying to make was that what he did was BS, and that pushing D50 or even D20 as a first intervention and telling the parents to sue was wrong. That is all I said.
  50. KidDr

    KidDr Senior Member

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    "Calling someone one their BS" is not the same as mocking a physician, and it's not what Arch pointed out. Whether or not this story is true (like you and others, I certainly doubt it), I think the main issue people have is that in your initial response is sounded like you were mocking the idea that a physician would know how to start an IV on an infant, and set up the tubing and IV pump. As OBP and others have pointed out, some physicians (even residents) know how to do this, and it's disrespectful to put up a laughing smiley face in reference to the idea that a physician could possibly have these skills. That's all.
    Last edited: Mar 13, 2011

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