[RN75]

I am new to cardiac unit and orienting. Had a patient scheduled for CABG the next morning at 0830. Stents were placed a few days earlier and Plavix was ordered by MD. Plavix was a new med for this patient. A dose was given 48 hours prior to CABG by one nurse and I gave a dose at 1000 am the morning BEFORE (the day before) his surgery. The preop order was not checked off to stop Plavix. Today, I was called into my managers office asking me about giving the Plavix because the patient had to be taken back to be reopened due to postoperative bleeding and oozing. He also had other arteries that were blocked which required additional surgery.

I've done research online and read differing opinions about giving Plavix before surgery. Some say to stop this med 5 days preop, some say 48 hours preop, due to risk of hemorrhage. Other studies conclude Plavix is not a serious reason for postoperative bleeding as there are multiple reasons a patient could bleed out.

I was interviewed by my manager today and am told she is considering firing me because I gave the Plavix and should have known better considering I am a seasoned nurse. To a point I agree with her, but in other ways I do not because its been a few years since Ive worked in a hospital setting and she knew that before hiring me and also because I think its harsh to fire me by pinpointing the reason the patient had postoperative bleeding is because I gave Plavix that should have been held. To say I am completely the reason enough to warrant termination makes me feel like walking on pins and needles with absolutely no wiggle room taking the full brunt of this patients postoperative complication. I am not a heart nurse, though I have floated many times to the cardiac floors and was being oriented. Believe it or not I am a very good nurse and have 12 years Med Surg under my belt, precepted student nurses, trained new employees, etc. I feel like their fall guy to make the patients family happy by telling them they fired me as to put the spotlight on me for this patients complication. If its my fault then I will take responsibility for it. So please - anyone out there experienced in Cardiac Nursing, I would seriously appreciate your honest opinion and input. Do you think this warrants being terminated or is Administration CYA's?

I love nursing, but honestly, I am really depressed right now. I have been thinking of leaving this profession because of the demands of nurse/patient ratios, poor organization on floors, yet requiring nurses to be nearly infallible. Im just really discouraged right now.

[suanna]

A seasoned cardiac nurses probably wolud have questioned if the order to give plavix had been left active by mistake. The fault however isn't yours, it's the physicians. It is the surgeons' responsibility to review and stop any potentialy harmful pre-op meds. I have little doubt that the plavix contributed to the patients post-op bleeding. Those of us who work post CABG shudder to hear adout a patient who has had Plavix in the last week before surgery. Our standing otrders for CABG pre-op care include a list of meds that the doctor wants stopped and when- he just has to check the box. Expecting the nurses to read the docs mind is unrealistic. What if the patients stents were unadequate for the vessels, or the other blockages were in high grade lesions 80-90% blocked. If your patient was depending on a stent to provide collateral circulation to his LAD or dom RCA I an see continuing the Plavix- but more likely stopping it and starting a heparin drip. When I get the right to make those decisions about my patients I want a much bigger pay check. It sounds like you could be benificial if formulating an action plan to help avoid this problem in the future. Helping find a soultion to the problem would go a long way to proving you are a nurse they want on the unit.

[jmgrn65]

I agree with the op that the physician should have ordered it stopped if he wanted. The entire burden shouldn't be on you. Some Nurses would have questioned it, other not so experience nurses would not have.The physician needs to take responsibility for not stopping it. You don't /can't write orders.

[nurse gracie]

I agree with the other posters. The physician is responsible for writing orders to stop/hold medications. I don't believe they should be blaming you at all. Good luck, I too am in a bind at work and have considering leaving the profession. I will say a prayer for you that all works out OK.

[RN75]

Originally Posted by suanna

I have little doubt that the plavix contributed to the patients post-op bleeding. Those of us who work post CABG shudder to hear adout a patient who has had Plavix in the last week before surgery.

Does this mean you think the Plavix did cause or just contribute to the problem?? Since Plavix has to do with anti-platelet coagulation, shouldn't the doctor check the platelet count before surgery? If the platelet count was okay, then how could Plavix caused the problem?

Originally Posted by suanna

Expecting the nurses to read the docs mind is unrealistic. What if the patients stents were unadequate for the vessels, or the other blockages were in high grade lesions 80-90% blocked. If your patient was depending on a stent to provide collateral circulation to his LAD or dom RCA I can see continuing the Plavix- but more likely stopping it and starting a heparin drip. When I get the right to make those decisions about my patients I want a much bigger pay check.

That's a very good point I will point out when the manager calls me on Monday with her decision to keep me or not.

Originally Posted by suanna

It sounds like you could be benificial if formulating an action plan to help avoid this problem in the future. Helping find a soultion to the problem would go a long way to proving you are a nurse they want on the unit.

This is good advice, however, after pondering this all day and half the night, I don't think I want to work for this hospital. I think the manager is using me as a scapegoat and I don't want to work for people like that. I am disappointed in her but it hasn't been the first time I've been the sacrificial lamb. They took this patient back to surgery to find out why he was bleeding and in the process found other blocked arteries they did not catch the first time around. How do I know the surgeon didn't tie off a vessel correctly or left a foreign body in his chest? Who knows why the patient was oozing? Maybe it was the heart- lung machine which are heparinized and someone put too much heparin in? I just think its harsh and over-reacting to fire me because I should have known better not to give Plavix. Its like you and others here already said, I'm not the doctor and can't make that call to discontinue a med or not! The patient just had stents put in and I told him he was getting plavix to keep his blood flowing and not throwing a clot. When to stop these meds is not my call yet Nursing Administration says I am to blame and they would fire me today if they had to, but will think about it over the weekend.

Whatever her decision, I have made mine. I don't want to work for someone who will fire me like that for this reason. I think she is over-reacting to cover their own butts. That way they can tell the patient and his family they fired an incompetent nurse and hope to avoid potential litigation. Thats just my gut feeling.

Thanks for helping me out with this. The ironic thing about this, is the last nurse I worked with told me I was a good nurse and will definitely be an asset at this hospital. She's worked there 17 years.

[Zookeeper3]

Think of it this way;

-pt. has chest pain, EMS gives ASA
-ER doc gives thrombolytics (doesn't work...)
-cath lab doc drops an IABP, gives integrillin and plavix... then for a multitude of reasons the pt. is rushed for a CABG. All in a few hours.

point is that patients are given many anticoags and invasive proceedures happen and bleeding does or doesn't occur.

Many hearts are simply oozy, we use Amicar to help reverse it. Some hearts have leaky grafts and you wish they would go back... some pour and they reenter the chest.

I promise you that there were many things that could have been done to help reverse simple plavix. Could that have added to a bad situation.. possibly. But hearts do ooze, leak and pour it is not uncommon.

surgeons with bad outcome statistics can be known to peruse the chart in attempts to fingerpoint. So do managers on power trips. The political arena in cardiothoracic is mind numbing and exhausting.

Feel comfortable that you did not harm this person.

[Angie O'Plasty, RN]

Originally Posted by Zookeeper3

Feel comfortable that you did not harm this person.

Is your manager suggesting that Plavix is the only anticoag that this patient got? Because in scapegoating you, it sure sounds like it. Is it possible that she's not a nurse? Or that she doesn't know what goes on during a CABG?

I agree, due to her attitude and treatment of you, this is not a good place to work.

[RN75]

Originally Posted by Angie O'Plasty, RN

Is your manager suggesting that Plavix is the only anticoag that this patient got? Because in scapegoating you, it sure sounds like it. Is it possible that she's not a nurse? Or that she doesn't know what goes on during a CABG?

I agree, due to her attitude and treatment of you, this is not a good place to work.

Yes, my manager is a RN and she said I could have killed this patient by giving him the Plavix the day before his surgery. He also got Plavix the day before which another nurse gave since it was ordered daily. I took care of the patient during orientation. He was waiting to have surgery the next morning at 0830. I did not preop him because that would have been done by the night nurse around 6 am the next day.

I am a staff nurse caring for patients who come in on tele awaiting surgery, heart caths, stents, whatever the case may be. The doctor signed the preop order but failed to check holding the Plavix. Maybe I should have known to call and question giving Plavix since he was going to surgery the next day, at least thats what my manager would say as I did not use good critical thinking in this case. In my mind, I am protecting the patient by giving the Plavix as to prevent him from throwing a clot before surgery. Its my understanding the heart-lung machine is heparized, but I have no knowledge of what goes on during a CABG except they stop the heart and the patient is put on the heart-lung machine.

She's pinning the patients negative outcome on me and I don't appreciate it. I may not be a seasoned cardiac nurse, but I am a conscientious one who cares deeply for my patients. I take pride in my work. Now here she comes along and handles this situation like this saying shes going to think it over this weekend whether to fire me or not. I fully expect her to fire me on Monday. I have never been fired in my life, especially for something like this, nor had disciplinary problems whatsoever in 12 years of Med-Surg Nursing.

I seriously think this is the straw that broke the camels back for me in nursing. I think the prudent thing for me to do if she decides she wants to keep me employed is to decline that and tell her why, then move on. I can see yet another incident like this happening where the nurse gets blamed for the negative outcome of the patients surgery or hospital stay. If I am responsible then okay....but after studying CABG and Plavix, as well as talking to other peers who would tell me like it is, I think I am being scapegoated for the doctor. I have lost all respect for this hospital who claims all this integrity, blah, blah, blah. The bottom line is they need the surgeon cause he brings in the money so lets protect him at all cost. Me? I'm the new kid on the block having been oriented for 2 weeks; so lets fire this imcompetent RN in order to mitigate possible litigation if something goes wrong even more; which I understand the patient isn't doing well after they went back in discovering even more problems that had nothing to do with bleeding.

I've had enough of nursing. I think Im gonna sell Mary Kay. Anyone up for some personal pampering?

Seriously, I was really depressed yesterday and didn't sleep very well at all last night because of this. I've got an attitude adjustment cause I know what's really going on here. As long as the cause for this patients problems were not because of me, I feel a lot better. I just don't appreciate my manager doing this to me knowing full well what really happened.

If someone comes on here and tells me the Plavix did it, then okay I'm open for correction.

[NurseCherlove]

RN75,

I am so sorry this happened to you - hospital politics is such crap! I totally think they are trying to scapegoat you for many reasons.

To begin with, what about all of the other nurses who gave plavix for the past week - are they getting fired? They are just as culpable since it is generally accepted that plavix should be stopped at least 5 days before a major invasive surgery like CABG.

Also, what about the preop nurse. She is supposed to review this kind of stuff before the patient has the chance to end up on the table. Will she be fired?

And then obviously, the MD who, like another poster said, maybe should have ordered a heparin gtt and ordered to hold the plavix if there was an imminent concern over the blockages.

Even if you go in there on Monday and the manager says she is "only gonna write you up" or something, I would resign anyway just like you are planning.

Best of luck to you!

Also, thank you for helping me to make a decision I've been struggling with - either staying at the hospital or taking a new job at a cardio office.

[RCHRTRN]

RN75,
I have a unique perspective on this situation. I am a CCU RN who left CVOR due to family health reasons.
As stated previously, you should not be expected to read a surgeon's mind. However, I know from my experience with CV surgeons, nothing is ever his/her fault.
The policy of our CV surgeon is no elective procedure is performed unless the patient has been off Plavix for at least 5 days. (We learned this the hard way.)
During my time in surgery, the circulating nurse, CRNA, and the perfusionist checked the patient's medication reconciliation in the surgical holding area to determine if the patient had been on anticoagulants. If the patient had been on Plavix within five days of surgery, a call was placed to the surgeon to make sure he/she was aware.
I was the CV coordinator during my last year in surgery and I checked each patient's chart the day before to determine if the patient had been on Plavix and if so, was a platelet inhibition test conducted.
At my hospital, all patients on anticoagulants have a brightly colored label placed on the front of their chart that lists the anticoagulants and the time of last dose. (Your hospital may wish to consider something similar.)