[AliRae]

I've been caring for an infant on PD recently. He's deteriorated to the point of intubation. Has been intubated since Sunday, hadn't required any sedation until yesterday, when he was coughing gagging, head-thrashing. I sent someone to ask the resident to come over and see the kid. 10 minutes later he showed up, took one glance at the kid and said he wouldn't order anything. I explained that the kid was intubated, lined within an inch of his life, getting PD cycles every hour and BOUND to be uncomfortable. He walked away from me.

Next time the kid woke up, I called him in again. He told me he'd order something the NEXT time it happened. Fine. I explained that the kid had gotten really hypotensive with morphine, suggested a benzo and asked for a very small dose. He again walked away.

I finally just called him over and asked him to write the order so we didn't have to risk our tube by finding him the next time the kid woke up. He looked at me and said "NO!" in a tone I wouldn't even use with a dog, and turned to walk away again. Honestly, my head nurse was sitting with her back to him, and I thought her jaw was going to hit the floor.

I said to him (quite firmly, I must say) "Excuse me, but that was extremely rude and you can NOT talk to me or any other human like that. Don't just say no to me without giving me some kind of rationale behind your answer." He hemmed and hawed and finally wrote the order.

Sorry that was long, but here's my question- my extern was sitting there and heard the whole thing. She thought I was rude to the resident and shouldn't have reacted so strongly. Was I out of line? Maybe it's just me, but it felt more like advocating for my patient than being rude to a doc. Was it crazy to push for some sedation/analgesia for such a sick baby? And should I have let his rudeness slide and taken it as "just a part of the job"? How could I have handled this better?! I'm finally becoming secure enough in myself to be assertive, but I keep thinking I somehow missed the mark on this one.

[jamonit]

No! i was told on my last job that it's part of our job to stand up for ourselves...in other words, if a doctor/resident is rude, it is within our rights to say something about it, in a tactful manner. it sounds like you handled it the same way that i would have. now that you've stood up for yourself, just keep your interactions strictly professional with said resident. your extern may have been taken aback, as she most likely felt uncomfortable being in the confrontation. on the other hand, remember--you are your patients' advocates...you are the voice for that little baby and you did the right thing.

from this point forward, don't tolerate rudeness or attitude. teach your extern the same thing. in my opinion, the only way to build a mutual respect between nurses and doctors is to start laying clear boundaries about professional conduct. horizontal harrassment or any sort of harrassment should not be tolerated.

good luck with everything!

[JaneyW]

You were perfect. That resident learned a couple of lessons, I'm sure. Don't beat yourself up. The resident was rude, you were assertive.

[traumaRUs]

Not even a bit out of line. Its more than standing up for yourself, its standing up for your PATIENT - the whole reason our profession exists. You should totally be proud of yourself and your extern should have this explained that you were standing up for your patient's right to pain relief and sedation. Nothing at all wrong with that.

You are to be commended.

[Jolie]

If a resident is intimidated by your advocating for a helpless infant, that is his problem, not yours. You were absolutely right to advocate for this child and stand up for yourself when you were mistreated by the resident.

The only thing I would add is that when I am not getting an acceptable response from a resident (not receiving a necessary order, or resident fails to give a rationale for refusing such an order), I suggest to the resident that s/he and I call the attending together to obtain a satisfactory resolution for the patient.

[AliRae]

Originally Posted by Jolie

I suggest to the resident that s/he and I call the attending together to obtain a satisfactory resolution for the patient.

I like that idea a lot. Our attendings and residents are always on the floor with us so we can just walk into their office with questions. I could always say, "Would you like to go speak with Dr. Attending or do you want me to run over there?" Kind of a non-threatening way to let the resident take responsibility but letting him know I will if he won't.

[AliRae]

Originally Posted by traumaRUs

your extern should have this explained that you were standing up for your patient's right to pain relief and sedation. Nothing at all wrong with that.

The funny part about all of this is that I had literally JUST finished talking to my extern about respect for the nursing profession and how, if we want it, we're the ones who are going to have to demand it. I'm just a rather happy-go-lucky person, so I don't think she was ready for my tough side to come out like that.

[janfrn]

I agree with everybody else AliRae. Good job!! I prefer the direct approach myself.
You handled yourself well and your extern should be taking notes.

But there are times when a little passive-aggression works well too. I witnessed a perfect example of how it works the other night. We'd admitted a teenager who was thought to be intoxicated and had been found unconscious in an alley. He was a big boy and he started waking up soon after he arrived. The resident on that night (anaesthesia... gotta love 'em) personally started a propofol infusion and was running it at anaesthetic doses. Then he had to put in an art line because the kid was hypotense and we'd need to monitor his gases. There were three of us in the room and all three of us questioned the propofol, and asked if we should give him a fluid bolus, since he had been peeing quite well and now wasn't. We all got blown off. So when the orders were being worked through and we found out he wanted a tox screen sent, I made a show of going to look up the correct collection methods in a book at the desk a few feet from where he was sitting. One of the others came up a minute later and asked me what we needed to do. Then she said loudly, "Well, it might take us an hour or two to get that 10 mL of urine, since all he's got now is sludge. Might even have to change the foley." He muttered something about "500 mL saline bolus over 1/2 an hour" and went back to what he was doing. Paula leaned over and said, "Excuse me... did you say something?" "Well, he might be dry, alcohol is a diuretic, you know." Ya think? The propofol was decreased to our unit standard and the kid had a pressure again. I later saw this resident doing a neuro exam on the obviously obtunded kid... don't think he made out too well.

Don't y'all hate July?!

[AliRae]

Originally Posted by janfrn

Don't y'all hate July?!

Amen, sister.

Although, in our case, we've been lucky. The resident in my story is a third year, so we already know not to expect anything good from him. As for the newbie second year? She's showing him up big-time, and we all love her.

Oh, and my personal favourite duh moment? Surgery minions all gathered around the room of a splenic lac/renal hematoma with falling H/H. Top dog asks why the kid is febrile. Second in command, totally cocky, shoots back "Has a foley ... UTI." Top dog glares, looks around the circle and gets no answer. I quietly said "blood in the belly," and if looks could kill, I'd be in the morgue. That second in command then went over to the computer and ordered a U/A, just for the heck of it! I told him I wasn't going to send it, and referred him to the results of the one I had sent 3 hours earlier. =)

[janfrn]

Originally Posted by AliRae

That second in command then went over to the computer and ordered a U/A, just for the heck of it! I told him I wasn't going to send it, and referred him to the results of the one I had sent 3 hours earlier. =)

BEAUTY!!