Weird PCA Orders

[SleepIsGood]

I sat back and read all the posts here. I'm trying to approach this with a pretty objective mind here. The topic was initially about PCA orders, which I thought was quite interesting. In fact after reading the thread I tried out some of the PCAs that were discussed here. But another issue popped up and that is nursing/pharmacy ignoring physician orders.

Most of this is politics here. Jet is a great guy,etc and so are some of the other online attendings here. However, as you guys can clearly see there are pharmacists and other nurses (without naming who they are) that seem to be kissing some major butt on here with comments like, "so and so's sage advice,etc".

In the real world, that's exactly how nurses and pharmacists,etc get into the minds of the medical directors and unit directors of hospitals. They flatter, flatter, and flatter even more. Unfortunately, the flattering often works. It's unfortunate, but it happens. As for leaving the ego at the door comment made by someone here. Well it's not an issue of an 'ego' which is the spin that nurses,docs that are in cohoots with nurses, and anxillary staff want you to believe. I'll give you an example. IF there's an infection that's going around in the unit/hosp that the same team is caring for, why is it that the physician is perceived to not be washing their hands,etc (this was actually claimed by nurses against a resident I know)? Who is to say that it wasn't a nurse or phlebotomist that wasnt washing their hands and 'spread' the bug to other pts? The culture of medicine unfortunately has docs being the center of the evil. The sad part is that some attending physicians, influenced by other paraprofessionals, concede that it is truly the doctor's fault. In my opinion their spine is often lacking. See here's how the attending see's it. The attending will be at set hospital for X number of years. They typically do not want to stick their neck out and back up a resident because of the backlash they will receive. To them, what's the point, the resident is there for 3-4 yrs and then out. What they dont realize is that they too were a resident once.

Bottom line, orders are just that, orders. As cloud, and volatile indicated, they should be followed. If there is a problem then that nurse/pharmacist needs to speak DIRECTLY with the ordering physician. I will agree that pharmacists know about drugs and what drugs are good against certain organisms (usually in vitro). However, we dont treat bugs we treat patients and that's why we went to medical school and that's why physician orders should be followed. Now granted, if a physician writes for arsenic in an IV, that's a little overboard, but I have yet to see a doctor write for that.

Bottom line SDN1977, et al. Again I do not understand why you come on here to argue political topics. I think your insertions on here only indicate your passive-aggressiveness against physicians/resident physicians. I sit here while typing and contemplate what your true motive is. This discussion has almost NOTHING to do with medications now. Secondly, this isnt a multidisciplinary forum, last I checked it did say Anesthesiology on it.

The global issue that this thread should demonstrate to readers is how paraprofs are now more than ever more likely to disobey orders written by physicians. Stick up for what you wrote as long as it's not completely ridiculous. If ppl do not follow them, report them. Write incident reports! Dont chicken out because you dont want to be seen as a 'bad guy'. These individuals have no problem disobeying your orders, then you shouldnt have any problem reporting them. Sorry but I have to call a spade a spade.

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[The_Sensei]

...Stick up for what you wrote as long as it's not completely ridiculous. If ppl do not follow them, report them. Write incident reports! Dont chicken out because you dont want to be seen as a 'bad guy'. These individuals have no problem disobeying your orders, then you shouldnt have any problem reporting them. Sorry but I have to call a spade a spade.

Amen, brother!

 

[Dr. J?]

Bottom line SDN1977, et al. Again I do not understand why you come on here to argue political topics. I think your insertions on here only indicate your passive-aggressiveness against physicians/resident physicians. I sit here while typing and contemplate what your true motive is. This discussion has almost NOTHING to do with medications now. Secondly, this isnt a multidisciplinary forum, last I checked it did say Anesthesiology on it.

SIG, this is chicken sh it. SDN1977, has been respectful and informative with her posts. Your issues with paraprofessionals shouldn't be taken out on her.

 

[jwk]

Now granted, if a physician writes for arsenic in an IV, that's a little overboard, but I have yet to see a doctor write for that.

Bottom line SDN1977, et al. Again I do not understand why you come on here to argue political topics. I think your insertions on here only indicate your passive-aggressiveness against physicians/resident physicians. I sit here while typing and contemplate what your true motive is. This discussion has almost NOTHING to do with medications now. Secondly, this isnt a multidisciplinary forum, last I checked it did say Anesthesiology on it.

The global issue that this thread should demonstrate to readers is how paraprofs are now more than ever more likely to disobey orders written by physicians. Stick up for what you wrote as long as it's not completely ridiculous. If ppl do not follow them, report them. Write incident reports! Dont chicken out because you dont want to be seen as a 'bad guy'. These individuals have no problem disobeying your orders, then you shouldnt have any problem reporting them. Sorry but I have to call a spade a spade.

Random thoughts...

SIG, you admit that SOME orders should be questioned (arsenic). Which ones should be questioned, which should not? Where is the line drawn?

SDN has made some superb contributions in this forum, including this thread. As I keep saying, the voice of experience... Oh, and SDN wasn't the one who moved the thread in a different direction - that started with Volatile and Noyac in posts #5 and #7.

Funny - anesthesiology is about as multidisciplinary a specialty as you can get. Pharmacology and physiology, plenty of surgery, medicine, peds, and OB, and a smattering of psych on occasion. And that's why there is a private anesthesiology forum - just for the docs.

I see and hear of very very few nurses or others outright disobeying an order. SDN, a voice of experience, has given a number of excellent reasons why orders might be questioned, or on occasion changed. You see this as a challenge to your authority - others might just see it as an ego run amok in a system that is being designed with an increasing number of checks and balances to make sure errors don't happen, a system that as a resident, you have little exposure to - so far.

Tens of thousands of patients die every year from medication errors. Some of those errors are by nurses (maalox in a central line), some by physicians (my own internist gave me samples of the wrong medication last week) and some by pharmacists (pulling the wrong antibiotic out of the refrigerator in the OR satellite pharmacy). I count it as a positive thing that someone, ANYONE, would question an order that they don't understand or appears to be incorrect, with the end result intended to be for the patient's benefit, not the ego of the prescriber.

 

[VolatileAgent]

You see this as a challenge to your authority - others might just see it as an ego run amok in a system that is being designed with an increasing number of checks and balances to make sure errors don't happen, a system that as a resident, you have little exposure to - so far.

just call me.

such a system, where utilized, is designed to improve communication, reduce errors and speed delivery of care. it is not designed to empower people to make decisions where they are not necessarily authorized to do so. and, my initial response was to something implicit in jet's OP that caught my attention, and that i've seen a few times - once with devastating consequences - and nothing more. i have a real problem with someone not carrying out an order and then not contacting me about it, for whatever reason and whomever is doing it. not only has that person (potentially) jeopardized patient care, they've also robbed me of an opportunity for a teaching/learning experience.

is that so hard to understand?

 

[VolatileAgent]

okay, i'm on a roll here... here's something else that actually happened to me on a unit rotation sometime back. here's the story.

i go to pre-round on a patient in the ICU and, as i grab the chart and the bedside, the nurse says to me, "you need to put in an order for restraints." now, i'd been on call the night before and i asked her, "why is the patient in restraints?"

she immediately gets this disgusted look on her face and says back to me very nastily and sarcastically with the 'duh' expression on her face, "because he was all over the place and was going to injure himself!"

so, i asked her, "well, why didn't you call me?" (which she hadn't, of course.)

this was her response, i kid you not: "ugggh... look, i've got a bunch of other stuff to do. i've got a really sick patient in my other bed. can you just put the order in?"

my head nearly blew off of my shoulders. trying to keep my cool and stay calm, i explained to her that there are a lot of reasons why a patient can become agitated and that such a patient needs to be evaluated, not simply put in restraints - especially if it is a change in their baseline status, which this was. i refused to put the order in and told her supervisor.

know what happened in the end? nothing.

i have a real problem with things like this. and, i'm sure most residents who participate in this forum can relay similar (if not the exact same) story. restraints are not a "standing order" in our institution, and i definitely would not have backed-up this nurse if she'd been reported to the licensing board and/or sued. that's just a fact.

it is critical that we work as a team. everyone who is empowered to impact patient care has to remember that. i do expect to be questioned about a potentially confusing (or wrong) order or perhaps about what i might have been thinking when i make certain "non-obvious" decisions, but i have to be involved in the discussion.

sorry to hijack this thread, but this is not why i got into medicine. i understand that people do what they think is the right thing to do, but then why do we even need doctors? is this the way the system should be run?

getting back to jet's original post (perhaps he oversimplified or understated what really happened), but this nurse had no right to refuse to hang the PCA order without consulting the originally prescribing physician. again, maybe she did.

otherwise, we will continue to progress towards operating in a system that exists solely to execute institutional protocols based on standardization. the physician will continue to get more and more marginalized, eventually being seen as nothing more than another technician in the healthcare food chain.

if that happens, forget about going to med school or just drop out now, students. you'll be better served becoming a nurse practitioner or a PA. you'll eventually make just as much money, only be expected to work shifts, and have a lot less malpractice exposure. as it stands now, do you think a jury knows or understands or cares about hospital protocols? you think that's gonna save your ass in court? HA!

sadly, this thread may have turned into an accidental insight to the attitudes that are creeping into the healthcare administration machine, and a harbinger of what lays ahead as we progress in our careers as physicians... no one will be empowered to make decisions anymore, and even if they do let you try to fly "outside the box" from time to time some committee with no direct contact with that patient will decide whether or not that decision gets implemented - orders will only be suggestions, nurses can do what they want with or without you, and you will exist only to be responsible when sued by the patient after something out of your immediate control goes wrong.

 

[SleepIsGood]

Random thoughts...

SIG, you admit that SOME orders should be questioned (arsenic). Which ones should be questioned, which should not? Where is the line drawn?

SDN has made some superb contributions in this forum, including this thread. As I keep saying, the voice of experience... Oh, and SDN wasn't the one who moved the thread in a different direction - that started with Volatile and Noyac in posts #5 and #7.

Funny - anesthesiology is about as multidisciplinary a specialty as you can get. Pharmacology and physiology, plenty of surgery, medicine, peds, and OB, and a smattering of psych on occasion. And that's why there is a private anesthesiology forum - just for the docs.

I see and hear of very very few nurses or others outright disobeying an order. SDN, a voice of experience, has given a number of excellent reasons why orders might be questioned, or on occasion changed. You see this as a challenge to your authority - others might just see it as an ego run amok in a system that is being designed with an increasing number of checks and balances to make sure errors don't happen, a system that as a resident, you have little exposure to - so far.

Tens of thousands of patients die every year from medication errors. Some of those errors are by nurses (maalox in a central line), some by physicians (my own internist gave me samples of the wrong medication last week) and some by pharmacists (pulling the wrong antibiotic out of the refrigerator in the OR satellite pharmacy). I count it as a positive thing that someone, ANYONE, would question an order that they don't understand or appears to be incorrect, with the end result intended to be for the patient's benefit, not the ego of the prescriber.

Hey man

Point well taken. Please stray away from using lines that essentially say, "it's better for the pt". Too often I see random statements made by nonphysicians that end in this phrase, which is usually a tactic used to throw sand in the eyes of the reader.

Having said that, I understand that mistakes are made and things happen. My personal experience with pharmacists in real life has been great. If they think something needs to be changed, they call me first. They discuss with me what they're thinking. I then choose to agree or disagree. For the record JWK, I'm not trying to insult you in any way, it's just a discussion. However, the original argument stemmed from an ?OB nurse friend of Jet's flat out refusing to perform an order written by another physician. If it was a significant issue or a 'mistake' that nurse should have spoken directly with the physician that ordered the drug. Then try to understand why he/she made that order. Perhaps there was something unique to the pt's disease process that warranted the physician writing said medication. The point of this is that the nurse shouldnt have refused the order and then go home and call Jet to flaunt what she did (ie refuse a doc's order).

Dude, I know you've been in hospitals alot. You cant convince me that you dont see MANY nurses/paraprofs on a daily basis that perceive they know better than the doc. It's a total power trip for them to deny a physician's order. It's a form of what they call in psych "passive aggressiveness". I see it done to other residents on a daily basis. Who's ego issue are we talking about then?

One of these days the nurse/pharmacist is going to refuse a drug which the pt REALLY needs (but doesnt realize they need) and compromise pt care. Luckily, I always check the MARs and mk sure the drug that I ordered was actually given. However, if I am too busy I sort of trust that my order was carried out. What if it wasnt and I didnt realize it. That my friend is potential for compromised pt care.

Having said that. This isnt meant to undermine paraprofs. They have a place. As I stated earlier, docs treat patients, not diseases and bugs. If one desires to treat pts become a doctor. Simple.

 

[Annette]

How do you know the nurse wasn't disicplined? I've worked at a couple of places were discipline is kept strictly confidential. So, even if you are the one making the complaint, and the discipline doesn't include an apology, you will never know what happened.

I think we all agree that orders that are questioned should be run by the ordering physician, not just blown off. In the example you cite, the nurse was wrong- you should have been called. Maybe she didn't know, or just didn't want to deal with it. There will be lazy and ignorant people where ever you work. It is a fact of life.

If you don't like the theraputic interchanges, volunteer for the P+T committee.

 

[SleepIsGood]

sadly, this thread may have turned into an accidental insight to the attitudes that are creeping into the healthcare administration machine, and a harbinger of what lays ahead as we progress in our careers as physicians... no one will be empowered to make decisions anymore, and even if they do let you try to fly "outside the box" from time to time some committee with no direct contact with that patient will decide whether or not that decision gets implemented - orders will only be suggestions, nurses can do what they want with or without you, and you will exist only to be responsible when sued by the patient after something out of your immediate control goes wrong.

LOL. yo Volatile. I think you're the guy that always discredits the private forum, for which I should be pist at you, however, you bring up a great point.

I think medicine in general is becoming restricted by nonPhysicians implementing protocols and as you stated creating "boxes" in which physicians can practice within. It's red tape man. Plain and simple. The problem is that physicians are shying away from administrative jobs. And for good reason---less pay and more work at times. Docs can clear 150k easily. Nurses and other paraprofs take on more adminstrative jobs nowadays because 150K is nearly a doubling of their yearly income. This thread essentially shows the need for more of us to get involved with administrative roles and actually CREATING policy. Or else, we will be bound by the red tape that others impose upon us.

 

[toughlife]

Hey man

Point well taken. Please stray away from using lines that essentially say, "it's better for the pt". Too often I see random statements made by nonphysicians that end in this phrase, which is usually a tactic used to throw sand in the eyes of the reader.

Having said that, I understand that mistakes are made and things happen. My personal experience with pharmacists in real life has been great. If they think something needs to be changed, they call me first. They discuss with me what they're thinking. I then choose to agree or disagree. For the record JWK, I'm not trying to insult you in any way, it's just a discussion. However, the original argument stemmed from an ?OB nurse friend of Jet's flat out refusing to perform an order written by another physician. If it was a significant issue or a 'mistake' that nurse should have spoken directly with the physician that ordered the drug. Then try to understand why he/she made that order. Perhaps there was something unique to the pt's disease process that warranted the physician writing said medication. The point of this is that the nurse shouldnt have refused the order and then go home and call Jet to flaunt what she did (ie refuse a doc's order).

Dude, I know you've been in hospitals alot. You cant convince me that you dont see MANY nurses/paraprofs on a daily basis that perceive they know better than the doc. It's a total power trip for them to deny a physician's order. It's a form of what they call in psych "passive aggressiveness". I see it done to other residents on a daily basis. Who's ego issue are we talking about then?

One of these days the nurse/pharmacist is going to refuse a drug which the pt REALLY needs (but doesnt realize they need) and compromise pt care. Luckily, I always check the MARs and mk sure the drug that I ordered was actually given. However, if I am too busy I sort of trust that my order was carried out. What if it wasnt and I didnt realize it. That my friend is potential for compromised pt care.

Having said that. This isnt meant to undermine paraprofs. They have a place. As I stated earlier, docs treat patients, not diseases and bugs. If one desires to treat pts become a doctor. Simple.

That already happened to me and I went straight to their supervising attending. I have actually questioned many of their "orders" (more like verbal orders from their attendings) and have forced them to change them after putting doubt in their head about their decisions.

 

[Noyac]

Random thoughts...

SIG, you admit that SOME orders should be questioned (arsenic). Which ones should be questioned, which should not? Where is the line drawn?

SDN has made some superb contributions in this forum, including this thread. As I keep saying, the voice of experience... Oh, and SDN wasn't the one who moved the thread in a different direction - that started with Volatile and Noyac in posts #5 and #7.

Funny - anesthesiology is about as multidisciplinary a specialty as you can get. Pharmacology and physiology, plenty of surgery, medicine, peds, and OB, and a smattering of psych on occasion. And that's why there is a private anesthesiology forum - just for the docs.

I see and hear of very very few nurses or others outright disobeying an order. SDN, a voice of experience, has given a number of excellent reasons why orders might be questioned, or on occasion changed. You see this as a challenge to your authority - others might just see it as an ego run amok in a system that is being designed with an increasing number of checks and balances to make sure errors don't happen, a system that as a resident, you have little exposure to - so far.

Tens of thousands of patients die every year from medication errors. Some of those errors are by nurses (maalox in a central line), some by physicians (my own internist gave me samples of the wrong medication last week) and some by pharmacists (pulling the wrong antibiotic out of the refrigerator in the OR satellite pharmacy). I count it as a positive thing that someone, ANYONE, would question an order that they don't understand or appears to be incorrect, with the end result intended to be for the patient's benefit, not the ego of the prescriber.

Yes JWK, I may be responsible for taking this thread into a different direction. But as you can tell, it is an issue. Paraprofessions can not be expected to keep up with the literature of every specialty out there. And to refuse an order without calling the ordering physician is WRONG in every sense of the word. This is not a power trip for physicians b/c who would write a harmful order intentionally just to test the system? You guys can state that JACHO mandates this and that, but we all know what it is like dealing with JACHO. A lot of good comes from JACHO but so does a lot of crap and red tape that interferes with good patient care.
So Volatile and I may have changed the direction of this thread but our statements seem to be raising some issues.

 

[sdn1977]

Yes JWK, I may be responsible for taking this thread into a different direction. But as you can tell, it is an issue. Paraprofessions can not be expected to keep up with the literature of every specialty out there. And to refuse an order without calling the ordering physician is WRONG in every sense of the word. This is not a power trip for physicians b/c who would write a harmful order intentionally just to test the system? You guys can state that JACHO mandates this and that, but we all know what it is like dealing with JACHO. A lot of good comes from JACHO but so does a lot of crap and red tape that interferes with good patient care.
So Volatile and I may have changed the direction of this thread but our statements seem to be raising some issues.

Noyac - you and I have communicated privately over this, but you still insist there was no communication with the nurse and the prescribing physcians over the refusal to hang the pca (who knows....the pharmacist may have refusesd to mix it - could have happened & the nurse took the flak). There is not enough information presented in the post for this much angst. There is just too much supposition & anecdotcal evidence of nurses & pharmacists failing to do thus & such then grabbing onto the greater implications in their threat to healthcare. The nurse may have communicated her inability to follow thru with the order & received a different order - we don't know that. All we know is she did not hang this pca.I still claim, she used Jet's opinion as a respected colleague perhaps to develop an understanding - he has yet to chime in on that. Pehaps there is a reason why????

This nurse may have called the ordering physician. What makes you think she didn't? It doesn't make sense she didn't call to get other pain orders - think about it - Jet was not the pts physician & he was at another hospital & this occurred days later. Jet's post made no indication that situation occured (perhaps I missed it). And...I cannot stress enough....IF YOU ARE A RESIDENT......& YOU ARE OFF CALL, THERE IS NO WAY I CAN REACH YOU! I TRIED 3 OF YOU TODAY (SUNDAY) FOR DISCHARGE ORDERS & YOU WERE OFF CALL - SOMEONE ELSE CHANGED YOUR ORDER. IF YOU WANT TO BE CALLED - BE AVAIALBLE! YOU WON'T EVEN SEE THE CHANGE BECAUSE THE CHART IS NOW IN MEDICAL RECORDS & THE VERBAL ORDER HAS BEEN FLAGGED FOR SIGNATURE BY A DIFFERENT RESIDENT! (I'm speaking generally of residents....not just anesthesia residents - remember we have many, many, many residents!)

The point is not in "who would write an order just to test the system". It is why write an order which cannot be carried out if you knew your hospital policies on pca orders (which, I will grant you...a resident may not know in August, but certainly an attending does & know the methods to circumvent them.)?

Ok....whomever suggested I get off my soapbox - I'm off (& I haven't seen one of those in years!) & whomever suggested this is an Anesthesiology forum - get over it - I've got the ketamine....you want it - you work with me & the policies I have in place. I don't care what you did in your old facility. I cannot speak for other departments....but..tell me a specific order your pharmacy has deliberately ignored (with all the appropriate reasonings.....Crcl/BUN/drug level, etc..) I've given you pharmaceutical reasons why this one might be turned down, but none of it is significant to you. You may not agree, but there it is & supported by the P&T, your Chief of Service, the Executive Committee & the Chief of Staff...can't get much higher than that. Again....you learn to work with the system or make yourself crazy fighting it. Your choice!

It is actually too very bad this thread disintegrated into a bashing session. This might have been an educational thread for all of us on the ways, situations & doses in which to use ketamine in a pca.....it got sidetracked. Thank you again Noyac & Volatile - you've made your point! But...did you get your ketamine in your pca

Now...if you need to reach the pharmacy....you can just look down....we are at the bottom of the pedestal you are all standing on!

 

[VolatileAgent]

Thank you again Noyac & Volatile - you've made your point! But...did you get your ketamine in your pca

Now...if you need to reach the pharmacy....you can just look down....we are at the bottom of the pedestal you are all standing on!

no, apparently we haven't because you've completely missed the point.

we're talking about a direct patient-care decision that has been interfered with - it doesn't matter exactly why it was interfered with (policy, logic checks, etc.). and it was "refused" by someone who should not have the authority to refuse it without clarification.

fact is, this kind of thing happens a lot. a lot of times, it gets clarified. but, many times this can impact patient care, even temporally (eg, the order was right but got delayed because someone was "empowered" to question it in spite of the fact that the only reason it wasn't carried out in the first place is because they were "educationally challenged", etc.).

in jet's particular case, it was not a case of an unclear or even potentially wrong order. it was a nurse refusing to do something because she was unfamiliar with it. okay, fine. call the prescribing physician at the time it happened, not a crony. if the order was interefered with at an institutional level because of some bureaucractic bull****, that's something completely different. if the patient suffered from that decision, then the hospital is opening itself to liability - pure and simple. and, i'm sure that's something they're trying to avoid, not engender, right?

this is one of the many problems with medicine, and its growing. too many lawyers and lawsuits, ultimately, dictating patient care policy. too many administrators and hospital bureaucrats who have no direct contact with the patient mandating patient care. too few nurses and paraprofs to fill the hugely underemployed healthcare job market, so they feel immune to any possible repercussions of indolent and/or insubordinate actions.

who ultimately suffers from all of this? the patient. and, all of this with a continued ineffective and misguided "cost-containment" paradigm while the demographic wave of aging baby-boomers is poised to crush us all.

 

[The_Sensei]

Now...if you need to reach the pharmacy....you can just look down....we are at the bottom of the pedestal you are all standing on!

As well we should

 

[Noyac]

Noyac - you and I have communicated privately over this, but you still insist there was no communication with the nurse and the prescribing physcians over the refusal to hang the pca (who knows....the pharmacist may have refusesd to mix it - could have happened & the nurse took the flak). There is not enough information presented in the post for this much angst. There is just too much supposition & anecdotcal evidence of nurses & pharmacists failing to do thus & such then grabbing onto the greater implications in their threat to healthcare. The nurse may have communicated her inability to follow thru with the order & received a different order - we don't know that. All we know is she did not hang this pca.I still claim, she used Jet's opinion as a respected colleague perhaps to develop an understanding - he has yet to chime in on that. Pehaps there is a reason why????

This nurse may have called the ordering physician. What makes you think she didn't? It doesn't make sense she didn't call to get other pain orders - think about it - Jet was not the pts physician & he was at another hospital & this occurred days later. Jet's post made no indication that situation occured (perhaps I missed it). And...I cannot stress enough....IF YOU ARE A RESIDENT......& YOU ARE OFF CALL, THERE IS NO WAY I CAN REACH YOU! I TRIED 3 OF YOU TODAY (SUNDAY) FOR DISCHARGE ORDERS & YOU WERE OFF CALL - SOMEONE ELSE CHANGED YOUR ORDER. IF YOU WANT TO BE CALLED - BE AVAIALBLE! YOU WON'T EVEN SEE THE CHANGE BECAUSE THE CHART IS NOW IN MEDICAL RECORDS & THE VERBAL ORDER HAS BEEN FLAGGED FOR SIGNATURE BY A DIFFERENT RESIDENT! (I'm speaking generally of residents....not just anesthesia residents - remember we have many, many, many residents!)

The point is not in "who would write an order just to test the system". It is why write an order which cannot be carried out if you knew your hospital policies on pca orders (which, I will grant you...a resident may not know in August, but certainly an attending does & know the methods to circumvent them.)?

Ok....whomever suggested I get off my soapbox - I'm off (& I haven't seen one of those in years!) & whomever suggested this is an Anesthesiology forum - get over it - I've got the ketamine....you want it - you work with me & the policies I have in place. I don't care what you did in your old facility. I cannot speak for other departments....but..tell me a specific order your pharmacy has deliberately ignored (with all the appropriate reasonings.....Crcl/BUN/drug level, etc..) I've given you pharmaceutical reasons why this one might be turned down, but none of it is significant to you. You may not agree, but there it is & supported by the P&T, your Chief of Service, the Executive Committee & the Chief of Staff...can't get much higher than that. Again....you learn to work with the system or make yourself crazy fighting it. Your choice!

It is actually too very bad this thread disintegrated into a bashing session. This might have been an educational thread for all of us on the ways, situations & doses in which to use ketamine in a pca.....it got sidetracked. Thank you again Noyac & Volatile - you've made your point! But...did you get your ketamine in your pca

Now...if you need to reach the pharmacy....you can just look down....we are at the bottom of the pedestal you are all standing on!

Ok, so how do we know the ordering physician hadn't already arranged the ketamine/fentanyl pca with pharmacy? and now the nurse is refusing the order b/c she is unfamiliar with it. Are we to only write orders that nurses are familiar with?
Look, I am as tired ofthis thread as you are. But the comments you have made recently are uncharacteristic of your past here. All i said was that she should have spoken with the ordering physician who could have educated her instead of refusing and then asking another physician at some other hospital. If she respects Jet so much, would she have refused this order if he had written it? I doubt it.

 

[lvspro]

Yo
It amazes me that any of the para's on here have the balls to keep arguing their point. Since the issue... not the orders, but the circumstances surrounding it, seem to be getting lost in the trees, I will reiterate it, and state the issue that MD/DO's have with all of this...

If you have a problem with the order, call me!!! When you outright refuse an order, and then ask you other "buddies" to validate your decision, you are not a "member" of the team anymore, but the coach, which, is not your job... its the MD/DO's.

 

[dhb]

This might have been an educational thread for all of us on the ways, situations & doses in which to use ketamine in a pca

I would actually like to know more about this

 

[SleepIsGood]

....
whomever suggested this is an Anesthesiology forum - get over it - I've got the ketamine....you want it - you work with me & the policies I have in place. I don't care what you did in your old facility. I :

The true SDN1977 comes out....so now you're taunting the fact that you have the meds and we should bow down to you for it?

Sorry, not how it works. Atleast not how it's supposed to work. Again, as I stated in another post. It's true you know a lot about drugs and how they work in vitro. However, we dont treat bugs and petri dishes ma'am, we treat patients. The day you go to med school and learn about patient care, we'll play by your rules. Again I ponder. What is a pharmacist doing in an Anesthesiology forum other than attempt to stir things up? How about bugging the IM folks about how you have access to all the digoxin and wont give it up w/o them having to bow down to you. Or perhaps you want to bug the surgeons about how they should get their pt's glcs levels <200?

All the MD/DO's in here. Read the lines that SDN1977 has written above. She wants us to abide by the rules she has in place. Clearly this may be what is happening with medicine now. Unfortunately, us youngin's are coming into this mess because those above us played the hand they were dealt and were passive. More and more turff is being lost by Docs and gained by aggressive paraprofs.

This should be a kick in the bottom for all of us reading this post. We can all be passive, then we'll wake up one day and be taking orders from a nurse/pharmacist. Furthermore, this nurse/pharmacist will be making equal $$. Our choice as to what will happen in the future. DOCTORS, become active in your hospital !! Later

 

[Arch Guillotti]

The true SDN1977 comes out....so now you're taunting the fact that you have the meds and we should bow down to you for it?

Again I ponder. What is a pharmacist doing in an Anesthesiology forum other than attempt to stir things up?

Dude let it go for chrissakes. Her posts are some of the best and most informative in this group.

 

[Mike MacKinnon]

Noyac

If you were joking it was NOT obvious, but you are now BACKPEDDLING and that IS obvious. You simply decided to do it after your own peers looked down upon you nurse bashing.

Im my career ive saved many a med student, resident and attending from testifying before the "MAN".

If all nurses just "Followed Orders" (which BTW none have to if not comfortable with them) the death rate at the start of med students internship and start of residencies would be much higher than the 4% increase it now sees.

In fact, an RN has a legal obligation to refuse any order they are not comfortable performing.

HOWEVER. When i have not liked an order i DEFINITLY call the person who ordered it and discuss. This has almost always lead to a equitable compromise. If the call didnt make me feel better i inform them of that and chart it then call the attending or the director of medicine.

So some of what I wrote (suggestion sheet not order sheet) was written tongue in cheek. It was mostly meant to be funny and I'm sorry of some of you guys didn't get it.

As I stated above. She needs to talk to the doctor that ordered it. If the policies don't allow it then the doc needs to work on educating the policy makers. This is unfortunate for some things but it is how it is.

Come on everyone, RELAX.

 

[VolatileAgent]

Im my career ive saved many a med student, resident and attending from testifying before the "MAN".

If all nurses just "Followed Orders" (which BTW none have to if not comfortable with them) the death rate at the start of med students internship and start of residencies would be much higher than the 4% increase it now sees.

this is flat-out horsesh*t!!! i challenge you to prove this, you egomaniac. and, with legitimate, linkable sources, not your "personal experience" or "what you heard."

In fact, an RN has a legal obligation to refuse any order they are not comfortable performing.

you are very confused about what your role actually is, and are apparently desperately in need of retraining. and if you actually carried this attitude in the hospital - in our institution - you would very quickly be out of a job, at least in the critical care areas where i work... actually, sadly you might not be.

(folks, you just got an insider's view of the entire problem with the "new system" right here. misinformed and still simultaneously thinking he/she is the one who's actually in charge.)

 

[jwk]

Can this thread deteriorate any more?

 

[Noyac]

Noyac

If you were joking it was NOT obvious, but you are now BACKPEDDLING and that IS obvious. You simply decided to do it after your own peers looked down upon you nurse bashing.

Im my career ive saved many a med student, resident and attending from testifying before the "MAN".

If all nurses just "Followed Orders" (which BTW none have to if not comfortable with them) the death rate at the start of med students internship and start of residencies would be much higher than the 4% increase it now sees.

In fact, an RN has a legal obligation to refuse any order they are not comfortable performing.

HOWEVER. When i have not liked an order i DEFINITLY call the person who ordered it and discuss. This has almost always lead to a equitable compromise. If the call didnt make me feel better i inform them of that and chart it then call the attending or the director of medicine.

If "suggestion sheet" as opposed to "order sheet" is not an obvious joke to you then I can't help you.

As far as backpeddling, I don't think so. The only person that disagreed with me that I respect was SDN and she and I have talked privately about this topic. I doubt that she feels that I was backpeddling.

During this entire debate, I have stated exactly what you just stated. Call the ordering Doc. Man are you confused.