Should I be blame for this?

[ARRR10]

I work nights at a hospital and I had a patient who was having issues with his blood pressure. There were orders by his surgeon to give labetolol if systolic is >150 and diastolic >90 and to give HCTZ daily. Throughout my shift, my pt's BP stays around the 130s/60s and the only issue he had for me throughout the night is a critical H and H drawn from his CBC- I called the hospitalist (who was being consulted) concerning the low critical H and H- no further orders. I learned today from one of my coworkers that the surgeon was angry that he wasn't paged about the high blood pressures and he wanted to know the nurse that took care of his pt that night (which was me). I had one of my coworkers double check the BPs the night I had him- his VS appeared to be stable; however, prior to working my shift and the night before he had a BP-150's/90's (this was taken during days) and another one 180's/90's. Our unit prints out rounds report showing all documentations (VS, I&O's, etc.) backtracked 24 hours. So, I'm all stressed out about the situation, but I don't see what I did wrong. Do you guys think I should be blame for this?

[Orange Tree]

I wouldn't page a physician about a SBP of 180, earlier in the day, that had been resolved by the time I arrived. That's just nutty.

[danegerous, BSN, RN]

My general rule of thumb is: When in doubt, page the doc

However, I wouldn't be paging him with someone else's lab results. How am I to know he wasn't made aware (that's more a question for report).

However (again) an elevated BP (even slightly) can be indicative of something important, especially when coupled with a low H&H. Now, if this patient is a fresh post-op, that brings even more into play.

Was the doc that ordered the labetolol the surgeon? If not, those paramenters are invalid and irrelevant. I know we have very particular surgeons that want to be called with any variance from baseline. Often times I think it's dumb, but then I call and they tell me why it's not. Or, at the very least, you ell them and they say nothing, but you're covered. That does two things, 1) let's the doc know that you're proactive and actually watching the patient (they think we don't a lot of the time). And 2) it allows you to document and CYA.

If you had called and said, "Hey, Dr. John, I just wanted to let you know that Mr. Smith's H&H came back. His HgB is 6.4, Hct is 20, BP is 134/62. He seems the same as far as mental status, but I just wanted to let you know, do you want me to get a few units of pRBCs ready?"

Now the doc knows you know your stuff. That element is totally off the table now (which is what sounded like was the issue when he was ******). Also, now you're letting him know of your other assessment values and giving him the ball. Doctors never like to be out of control, especially surgeons!

So, no, you weren't wrong. I think there may have been a slightly different way to attack the situation, though. At my hospital, if the issue is blood and they're a surgical, I call the surgeon. If it's a NSTEMI, call the cardiologist, etc. I only call the house doc when the others don't answer or no one else is assigned. I use them as a sort of emergency back up doctor.

I hope this makes sense.

PS - doctors will always show anger to the nurse in front of them, even if it's really directed at the nurse from yesterday. That's jsut the way it is. If he says something, be bold. Don't pass the buck, but let him know that you assessed the data, and the patient, and neither warranted a call. Then he will at least respect you as an independent thinker.

[ARRR10]

What does "cya" and "NSTEMI" mean? also, yeah the labetolol parameters were ordered by the surgeon and the labs were ordered by the hospitalist. Apparently there were conflicting issues going on between the docs about the pt's diagnosis. Thanks for the replies!!!

[TheEmmyRN]

NSTEMI- means Non ST Elevation MI - a heart attack that doesn't show ST elevation on a 12 lead EKG. Only part of the coronary artery is blocked.

CYA- I always though it meant "cover your A@@" Ha Ha Ha!

[HollyHobby]

I cannot imagine why the surgeon would be angry at you for not calling about the BP. First, the BP was fine on your shift. Did he really expect you to call normal BPs to him? At night?

Second, since the surgeon wrote the labetolol order, he was obviously aware of the BP issues. Once a doctor writes a PRN order like that, you generally don't call to tell him about having to use the PRN order unless of course the BP (or whatever) was totally out of line from the previous values OR the doc specifically wants you to call. Otherwise there would be no point in writing a PRN order at all; you'd just call every time you needed labetolol and he'd give you a one-time order every time. That's just silliness.

For a surgical patient like yours, I would probably have called that critical hemoglobin to the surgeon. Even though the hospitalist wrote the lab orders and even though you called the hospitalist with the result, I'd still call the surgeon too.

Sometimes it all depends on what doctor you're dealing with, what time it is, whether or not that doc is in a good mood, and the phase of the moon. It is better to be safe and call, but again, it never would have occurred to me to call about that blood pressure. I would have called the hemoglobin and mentioned the BP trend at that time, but I wouldn't have called the BP alone.

Surgeons tend to be control freaks. Often, even though they consult the hospitalist to manage the care, they can't stand to not be in control of everything. Sometimes, a doctor gets a bug up his behind and wants someone to blame for it. In the future, with this particular doc, you should call pretty much anything abnormal to him. No doubt he'll be mad about that, but you'll be covered.