Verbal order-Denied by resident

[Traumamama02]

Wednesday morning I came into work and took report on a patient in airborne isolation r/o TB, a laundry list of co-morbidities, mild respiratory distress, vitals not to bad in the moment but I'm sure you can see where this is going.... yup straight to RSI hell with a chaotic attending and a hot shot resident.

Long story short, as the RT was preparing her equipment, I was preparing mine, setting my monitor parameters, etc, etc. The resident walks in to the room with a spiked and primed bottle of propofol and clearly says 'here ya go, it's already for you', and hangs it on an IV pole. I clarify the starting dose with him and he gives me a verbal order for 30 µg/kg/min. Attending walks in the room. Then I clarify what RSI drugs he wants; 20mg Etomidate and 120mg of succ.

Fast forward, the patient is intubated, Sp02 is crap, abg is crap, blood pressure has been crap prior to me assuming care but the current trend for 2 hours has been adequate with resuscitation efforts, pt is waking up within seconds post securing the tube, RT is suctioning and simultaneously, I pipe up and start a conversation about starting the propofol at a lower dose than the resident had ordered and adding an analgesic, fentanyl, to accommodate propofol (which as we all know propofol has hypotensive side effects and no analgesic properties). My rationale being that I can keep the prop at a fairly low rate, keep the blood pressure adequate and the patient can be more comfortable and less likely to wake up with PTSD.

Attending shuts my idea down and states that propofol has analgesic properties and she'd rather use Versed and fentanyl bc versed does not have a profound effect on blood pressure as propofol... lol...wait it gets better...so keep in mind that now is not the time to educate a physician and what not because the patient is fighting the vent and circling the drain respiratory wise and I've got to move this patient out of isolation and into the Critical Care area of the ER; according to infectious disease it's OK to do that because now the patient is a 'closed circuit' ... I know I know ... ***, right.

Back to RT suctioning... The attending requests her to stop suctioning so we can cycle blood pressure and get an accurate reading before we start the propofol bc this man needs sedation now and we need him calm and I have the propofol hanging in front of me, and a verbal order from the resident and a discussion with the attending about changing sedation gtts and it's obviously not in the best interest to leave the pt put in an order for a titration gtt that I didn't even get details for or wait for the doc to do it and then call pharmacy and have them validate it so I can get it out and blah blah blah...

So the nurse I give bedside report (who should be helping me bc she has no pts) to can bridge the gtt to the new sedation orders. in my mind this keeps the patient safe and the tube is less likely to come out, exposing the dept, plus I have 3 other neglected patients ...I need to hand off this one and now ... so b/p is 125/88, sp02 is 86%, attending sees the b/p and walks out. The understanding is that this is an adequate blood pressure to start the propofol, so I start the propofol at 10 mcg/kg/min instead of 30; I followed pharm protocol bc frankly 30 is to much to start with this guy...anyway I titrate by 5mcg q 5 to 20mcg and everyone is ready in the assigned area, patients is chill, last bp is 110/70-ish and we go, fentanyl is overridable in the pyxis, versed is not ..let's get that fent going ... and hand off is complete.

Now I'm charting and the charge tell me to save it and come talk to him now.. I comply, the director is there waiting .. the conversation starts with, 'did you hang propofol without an order?' 2 docs say you did and there are writing you up bc the pt decompensated and is now on 5 mcg of levophed, (5 people!!!)and the prop is still hanging and now at 40!!! Resident dictates he never gave any orders for propofol... when I asked the nurse that took over for me how long it took her to bridge him off the propofol, she said she didn't because propofol is used so often that she didn't bother looking at the orders and just continued to use it...

Resident is lying!!!! And I'm blown away at all of it!!!

Bring on the question and comments please!!!

[Traumamama02]

I got a clarification order (for start dose and max.. the titration is pharm protocol) right before induction so I'd know how to proceed once the tube was conformed and they leave .. turns out attending didn't like my idea so she made this a huge deal when clearly I had orders and had the patient safely in the forefront of my mind... I'd never do anything without an order and I would never disrespect or challenge a clinician...

I appreciate the feedback, I wanted it whether I liked it or not , I asked to hear the opinions of my brothers and sisters in nursing... I appreciate you all.

[Lunah, MSN, RN]

Got the print out from the Pyxis btw :)

Do your physicians have access to the Pyxis?

[Julius Seizure]

This sounds like a weird situation with terrible communication all around.

Hopefully everybody in the department learned something about communication - this situation sounds like it was a mess!

[TriciaJ, RN]

Maybe critical care is different, but in many hospitals verbal orders are not allowed. Phone orders are one thing, but if the physician is physically on the premises, then he/she needs to write the order.

This is not the first time I've heard of a verbal order being denied retroactively and a nurse being thrown under the bus. Probably the rationale behind the no-verbal-orders rule.

[hawaiicarl, BSN, RN]

When we have a resident, or attending, with a history of denying verbal orders we just blackball them from verbal orders. Obviously administration always backs up the physicians, so we get together, and as a group refuse to take any verbal orders from the resident, once the staff doc hears nurses refuse to take verbal orders from a resident they quickly realize what is going on. We had an attending that used to do this too, same thing .... Hey guys Doc SoAndSo burned me on a verbal order saying they did not give it, form this point on no verbal orders. Hospital policy with CPOE always backs up this action as verbal orders are only supposed to be accepted during emergency situations, and physicians are required to have at least %80 order entry to show compliance.

Cheers

[beckster]

Whoa - my first thought is that this resident is using propofol. Why did he get you the propofol and spike the bottle? Simply to be "helpful? If he removed it from Pyxis or whatever he created a digital trail. And, he just shot himself in the foot by alienating nursing staff. He should know better; by the time one gets to residency one learns that a good relationship with staff is paramount. He'll never get an uninterrupted hour of sleep again when he's on call!

[BSN16]

ok...sounds like to me that the resident initially ordered propofol (and got you the order) and then changed their mind to versed/fent combo because of blood pressure issues. which why would you have to educate them on this combination and its effects of resp issues and how long it takes to kick in?

so it sounds like you moved this patient with a medication that was d/c'd or never wanted. and instead of waiting for the versed gtt you just moved them anyway? Honestly i agree with the physicians in this case, all though their behavior was a little bizarre it sounds like they didnt want propofol

[canoehead, BSN, RN]

From what you wrote, I thought the resident initially wanted propofol, but the attending came in and stated he wanted fentanyl/versed, essentially overriding the resident's order. It sounded like propofol should not have been started, but I didn't "hear" them give a dose for anything else either.

[offlabel]

Sounds generally like a general lack of understanding of sedation, analgesia, mechanical ventilation and hemodynamic management. Sorry you were in the middle of all of that. What a circus.

[softrbreeze]

Is there no video that can be accessed to back up your story? (Of the resident BRINGING the propofol, I mean).

[CardiacDork, MSN, RN]

Traumamama, I do believe that this is a multifaceted issue. I am not sure how your medication system works there as far what drips are readily available and override-able. So please, know that I am speaking from my experience.

1) It sounds kind of silly but you really want to try and restrain your patient immediately before intubation. It's a life saver. Trust me!

2) I would have began the propofol right after intubation at a low dose, after all the propofol is usually written to titrate, and if not I would have discussed this with the resident.

3) When the attending asked for versed and fentanyl, I would have told the attending right there and then

A)I can start fentanyl NOW because I can override the Pyxis

B) I cannot start versed now because I cannot override the Pyxis.

This WILL prompt him to make the logical decision to allow you to keep the propofol until you have the versed, if he still doesn't get it then you can something like:

C) So do you want to wing it with just Fentanyl and see what happens? or keep him on a. low dose of propofol until we get the versed?

3) I would have paged and called the resident until he put in four orders:

A) Fentanyl to titrate to a specific RASS/CPOT score less than 3, 4, or 5 .

B) Versed to titrate to a specific RASS

C) Propofol to titrate to. certain RASS

D) Nursing other "OK to keep propofol as form of sedation until arrival of versed from pharmacy etc. at which time propofol can be switched over to versed".

I would have called his cell phone, paged him, called his home, and maybe his mom too. Seriously.

Also I would documented all the interactions very clearly.

[ComeTogether, LPN]

When the attending "shot down" your idea of hanging the propofol at a lower rate and said she'd rather use versed and fentanyl, she was saying d/c propofol and start versed and fentanyl.

I am unfamiliar with this type of setting, but I wouldn't think you would use both propofol AND versed, but if so then I think the attending needed to clarify and in addition you needed to ask for clarification.

I think everyone should take the heat on this one and the resident should seriously learn a lesson for lying to cover his rear.