RN refusing to perform a written order

[Winged Scapula]

I could have sworn he wrote D50, who knows he could have edited his post too.

No editing because:

1) it would be visible *at least to a member of the Mod staff*
2) he would have had to edit it in the posts where he/she is quoted

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[oldbearprofessor]

No editing because:

1) it would be visible *at least to a member of the Mod staff*
2) he would have had to edit it in the posts where he/she is quoted

I also saw his post before NYRN posted and it said D20, not D50. Also, although not necessarily the top expert on newborn care, he did at least indicate that he did a heelstick whereas twice you've (NYRN) indicated that it was a fingerstick (posts 40 and 48 in this thread). Have you (NYRN) ever done or seen a fingerstick done on a newborn? I know this is a small wording issue, but, we are talking to trainees here and we want to be accurate.

 

[fab4fan]

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.

With all due respect, I think you need to stop defending yourself. You're starting to look ridiculous.

 

[Winged Scapula]

I also saw his post before NYRN posted and it said D20, not D50. Also, although not necessarily the top expert on newborn care, he did at least indicate that he did a heelstick whereas twice you've indicated that it was a fingerstick (posts 40 and 48 in this thread). Have you ever done or seen a fingerstick done on a newborn?

Hey now...quoting me. Who you talking to OBP?

 

[oldbearprofessor]

Hey now...quoting me. Who you talking to OBP?

Sorry, already fixed the attribution as best I could. But of course, I am curious if YOU ever have done a "fingerstick" or started an IV drip on a newborn without nursing help?. I have, but not in the last 15 or so years.....

 

[Winged Scapula]

Sorry, already fixed the attribution as best I could. But of course, I am curious if YOU ever have done a "fingerstick" or started an IV drip on a newborn without nursing help?. I have, but not in the last 15 or so years.....

Fingerstick on a NB? Nope.

Placed a UA/central line and started a drip on a newborn without nursing help? Yep. Well, they got the supplies but I did it myself. They "wouldn't let" us start regular ol' IVs but if the PICU/NICU attendings or fellows weren't available, we would occasionally start central access.

It has been awhile though.

 

[NYRN]

FS is how we document any blood sugar taken with a glucometer. The computer doesn't have an option for heelstick, and if we write our notes we just write FS, the docs know what we are talking about. I'm used to writing it that way, I am aware that its actually a heelstick.

This discussion is getting out of hand. The whole point was to warn the future doctors that this behavior is wrong, and will get you into deep doo-doo. Believe it or not, I do care about the education of our future physicians, and I don't want them to learn bad behavior and get themselves into trouble. If I didn't care I would just sit by, say nothing and watch them hang themselves with their own rope. In real life, this type of hypothetical situation where nurses outright refuse anything after a discussion addressing all concerns, and involving charge nurses is so rare, that it may not ever come up for these future docs in practice.

 

[Buzz Me]

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.

Really? At the county hospital here, I've set up IV pumps and run everything from NS boluses to Levophed, heparin, insulin, amiodarone and epinephrine. Not great at placing IVs in newborns/babsies but have done the former a couple times (umbilical vessels) on Peds Surg, while have used the wrist or ankle veins in the latter while on Burns.

Hardest part about setting up an IV pump, IMHO, is getting all the air out of the line first (to avoid the "downstream occlusion" warning beep) and then entering the patient's weight. Scrolling through to find the drug isn't tough, nor are the concentration calculations (but then again I was an engineering major).

 

[Socrates25]

If you want to call me a liar, go ahead. Going into residency I never would have believed such a thing would happen either.

For the record, the baby was asymptomatic (e.g. not jittery with normal physical exam) but the mother did state that she only had 1 very small feeding where he only took about 1/4oz and wasnt interested in the bottle on a 2nd attempt. Could I have given it more time and told the mom to try to feed her again? Sure. But the mom was concerned/frustrated and thats BEFORE I told her about the nurses's incompetence, so I opted for the more aggressive route given her demeanor. She had great looking veins that I anticipated I would have no trouble getting so I opted to do it all in one setting after her blood sugar came back on the low side.

As for IVs, residents do more than half of all venipuncture/IVs on peds patients in our hospital, from birth to 18 years old. So we're all pretty good at it. We have piss poor ancillary staff. Now the nurses usually do set up all the tubing and I had only recently learned how to do that from other nurses. I think it was only my 3rd time setting it up and I had a nurse friend from a different part of the hospital come down to double check it.

As for "you should sue this hospital" I guess the legal eagles never found out, as the risk dept never dragged me to their oak table conference room. Call me foolish or lucky or whatever. There was no clause in my residency contract that requires me to never speak ill of staff/hospital or advise a lawsuit. Could they have fired me? Perhaps. Its a moot point now and I was so pissed at the time that if they had fired me I probably would have teamed up with the mother of the patient to get a nasty TV expose on the news about how a nurse at the hospital put a baby at risk and now they are covering it up by firing the resident. I'd love to see the risk management team's response. I picture a bunch of stiffs in suits saying "no comment" and hiding from the cameras.

Regardless of the ethics/legal exposure of advising someone to sue the hospital, it was DEFINITELY ethical to tell the patient that the nurse was incompetent/negligent just the same as I would if my attending was a surgeon who was clearly drunk trying to operate on a patient. There's a huge problem in this country of docs refusing to rat out the "bad seeds" in our profession.

 

[Socrates25]

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.

Say what you will about the lawsuit thing, but its absurd to think that we have no responsibility to point out bad actors in the system. The nurse was CLEARLY WRONG for refusing to do the heelstick and the baby was at a potential risk because of it.

 

[Socrates25]

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.

You're right it did take more than a pissed off physician to make it happen. I had to prove that they had NO GOOD JUSTIFICATION for ignoring the order and that the ignoring of the order put a baby at risk of a bad outcome. I also had to get written statements from my attending, 2 other peds attendings, and a couple of nurse administrators to assert that the nurses were in fact wrong.

This wasnt a gray area where both sides have a good argument depending on your perspective.

 

[Socrates25]

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.

How are you guys diagnosing LGA? Are your L&D nurses plotting the weight vs gestation on the normogram, because as far as I know, thats the most legitimate way to do it and thats what we use. I will say that our L&D nurses do NOT plot normograms.

That means there is some interpretation involved since you have to plot them on a graph, so I disagree that diagnosing LGA is "never" controversial. I will agree that the vast majority of the time it is not/shouldnt be controversial.

I know some hospitals use the cookie cutter protocol of only babies > 4000g are LGA but that brings me back to the original question. If its a nursing driving protocol then the nurses either have to plot these babies on a normogram or they are going to miss some babies who are really LGA who dont meet their rigid criteria.

 

[oldbearprofessor]

I had a newborn baby on the unit who was LGA (large for gestational age) and IDM (infant of a diabetic mother).
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.

How are you guys diagnosing LGA? Are your L&D nurses plotting the weight vs gestation on the normogram, because as far as I know, thats the most legitimate way to do it and thats what we use. I will say that our L&D nurses do NOT plot normograms.

That means there is some interpretation involved since you have to plot them on a graph, so I disagree that diagnosing LGA is "never" controversial. I will agree that the vast majority of the time it is not/shouldnt be controversial.

I know some hospitals use the cookie cutter protocol of only babies > 4000g are LGA but that brings me back to the original question. If its a nursing driving protocol then the nurses either have to plot these babies on a normogram or they are going to miss some babies who are really LGA who dont meet their rigid criteria.

We use the Lubchenko curves. Neither they nor the Olsen curves have a 95%ile line by the way. As a real aside, using the newer Olsen curves, 4300 grams in a 40 week baby would not be above the 90%ile for a male and just barely over it for a female.