Send In The Clowns

fedupnurse · May 20, 2002

l.rae,

I have been an ICU nurse in a teaching hospital for 10 glorious years. Ya ready???

A few years ago we had this one new 1st year medical resident who thought he was all that and then some. SO it is July 1 and we had a DNR in the unit. She was vented. The patient died so I called him to come and pronounce the patient. He siad I've never done that. I said no $hit Sherlock it's July 1st. You haven't done anything you are about to do. Get on up here and I'll walk you thru it. 2 hours later!!!!! he walks in to the unit and we go into the room. She is purple, on a monitor still (Policy) and due to his slow pace rigomortis has definetly started in. She is also still on the vent. He says to me "how do I know if she is really dead?" I said "She's blue, flat line and STIFF! So listen to her chest for the absence of any sounds and then say dead. He goes to put his stethescope on her chest and the vent gives her a breath. He jumps so high he practically wen tthru the ceiling! He said "SHE'S ALIVE! What kind of game are you trying to play?" I said see that garden hose sticking out of her mouth? Yeah. See that tube connected to it? Yeah. Follow that tube to that gigantic piece of equipment called a ventilator and you will see that is what is breathing for her. He refused to pronounce her. I said you won't make it till next July. Sure enough he got canned about halfway thru the year.

Really nice resident named Brent. July 1st. Beeper goes off indicating a code. He stands there in front of me with this terrified look on his face. I said is it that you don't know where to go or you don't know what to do? He said both. I said we will have no problem with you my friend. He was one of the best residents we ever had.

It doesn't end on July 1st though. I had a 1st year last night that wanted us to hang Norcuron but no sedation because his pressure was too low. I said no way. Won't do it. No sedation in drip form, no paralytic in drip form either. She said how about 1 of Ativan q 6. I said how bout we end this converstion before someone gets hurt.

I could go on for hours....

July 1st is the scariest day of the year. And you all thpught it was Halloween!!!! Silly's!

CseMgr1, ASN, RN · May 20, 2002

I know it all too well. Years ago, when I was a nursing student doing my clinical rotation at a major teaching hospital, I looked on as an intern struggled to insert a foley catheter into a woman....who had defacated in the bed. He dropped the catheter into the feces...and not giving it a second thought, picked up the soiled catheter and stuck it in. If I had been observed doing that by my clinical instructor, I would have been rheemed, steamed and dry-cleaned.....before being sent home, with a "U" in clinical. I just wonder if that poor woman wound up dying with a massive urosepsis.....

mattcastens · May 20, 2002

I haven't had a whole lot of problems with the residents. It's been the attendings in Family Practice that I always have a beef with.

I am of the very strong opinion that family practitioners should only step foot in critical care for social visits and updates -- not for any sort of management.

I was recovering a very tricky double valve replacement about a year ago. The FP and brand new resident came in to see how things were going. In our unit (as I think in most) the cardiac surgeon is the primary for all things until he signs off on the case -- no matter how much the other docs might protest.

The FP obviously wanted to make an impression on the newbie, so he came in, looked pensively at the monitor and said, "Hmmm. Filling pressures look a bit high. Let's give him 40 of Lasix."

I refused.

He was obviously not expecting that, and his ego was hurt in front of the baby. He started to try to bully me.

I said, "Look -- I don't know where you learned your cardiac surgery, but I've just spent the last two hours working with fluids and pressors to get the wedge right where it can do some good. The man has an ejection fraction of only 30%, so there's NO WAY I'm going to start drying him out after all the work I've done. You can do one of two things: you can give the Lasix yourself and face the consequences, or you can go out to the desk and talk to Dr. S____ [the surgeon] about it."

He gave me a nasty look and stormed out of the room. I heard some angry mumbling and then Dr. S. say, "WHAT?? Are you out of your mind??" Then he called in, "Matt? Does he need Lasix?"

I responded, "No, Mark, he does not." [We're on a first-name basis with our surgeons.]

That was the end of that. The resident looked bug-eyed that 1) I refused an order, and 2) I knew more than his mentor. The FP only speaks to me minimally now. Fine with me.

fedupnurse · May 20, 2002

This past August a second year resident was "running" a code. The patient had coded on the floor x2 before being sent to the unit. He then proceeded to code x2 again in the unit. Due to there being nothing but new nurses on that night I went to that side of the unit to see if I could help. The assitant nurse manager was doing notes. I said how did he code on the floor (meaning brady or tachy). A first year said brady every time. I said he's already over his max on atropine then. The second year said that's per code. I said it's per 24 hours as per the director of the ACLS program here. I wouldn't give it if I were anyone in this room. The manager said nothing only answering the amount of time since his last atropine when the stupid second year asked. I said "I'm outta here" and went back to my side of the unit. After wards Mr. Arrogant know it not comes up to me with daggars in his eyes and tells me that I am not allowed in anymore codes. I said to hime "YOU do not set nursing policy in this or any other nursing unit. You need to retake ACLS because if that was a viable patient that atropine OD YOU ordered x4 codes would have been a sentinel event meaning you would have KILLED that man and I would have been the first one to call the State DOH, the family and the State Board of Medical Examiners on your sorry butt. The part that upset me was that the manager took his side! "He's the doctor". I didn't even argue with her, just wrote up a QU and contacted the head of the residency program and the director of ACLS and told my unit manager. Nothing was done. Now if a nurse had given too much atropine.....

I also recently had a 3rd year medical resident keep a patient in the ER who had a BP of 50 by doppler while she sent 3 other patients up. I got this woman up to the unit and continued to increase her Levophed as she was maxed out on Dopamine. I did a gas without an order because I knew this womans pH was not compatible with life or to allow the pressors to work. Her pH was 7.0 and her bicarb was 8. I said how many amps of bicarb to you wnat me to push. Her answer: "She's not acutely shocky, so let's just add one amp to her IV fluid." I said you terrify me and called the attending and got a real order. She graduates next month and will be out there on her own. When I find out where she will be practicing I will send out fair warning!!!

zumalong · May 20, 2002

Over the years I have seen some doozy residents. We have 1st year surgical residents on our unit. Most of the residents in uro and neuro have already gone through the first 3-4 years so aren't too bad.

The worst case I remember seeing was this cocky arrogant jerk who always had to have the last word. We were in a code situation he comes in with his 'book'. He says Im running this code. Then he proceeds to open his book and look up which drug he should be ordering. I ran out-grabbed a third year from general surgery (who we had raised just fine) and brought him to code. Then I took mr book man out of the room and sent him to find his blankie.

Oh my--could I go on!!! When I was first a nurse a surgical resident was irrigating a foley. He told me to get him a 50 cc syringe. I brought in a 60 cc. He screamed at me (in front of patient mind you) that I was stupid and couldn't I follow simple directions?? I left the room so angry I began to cry (I hate when that happens) I realized that he was a jerk and it wasn't worth it to get upset. So I calmed down and when he left the room--I went up to him with every size syringe I could find. I dropped them in his lap and walked away. I think he survived 3 or 4 more months.

In our hospital most of the surgical ICU's have done away with residents because of so many mistakes. We had a nurse who was a new grad--her patient was 86 yrs old with terminal prostate CA. His K+ was 2.8 and he was having some arrythmias. This nurse called a 1st year resident who got all excited about her first potential code. She told the nurse to give him 40meq IVP stat. The worst part was that a experienced nurse drew it up for her. The med was given--the patient coded and died. The resident got a slap on the wrist and sent to animal research for 2 years. The nurse was suspended. 10 years later--the case went to civil court (state let her off with mandatory inservicing for all staff).

The most infuriating part is that we nurses always get the blame. I was a new LPN at the time and learned a very important lesson--to always know what I'm giving and how I am giving it. Residents--can't live with them, could die with them.

CseMgr1, ASN, RN · May 20, 2002

I work for a major insurance company as a nurse case manager...and we have our share of rude and arrogant doctors, too. They make medical decisions about our clients' needs, based on Political judgement (not standards of care, mind you), and you don't DARE challenge them.....!

gypsigirl · May 20, 2002

These last post scared me crapless.....what can a new nurse do to protect herself? If your new and you don't know that the doctor's orders are stupid and you follow them are you liable?

VickyRN, MSN, DNP, RN · May 20, 2002

YES

l.rae · May 20, 2002

gypsigirl...yesyesyesyesyes! with my 22 yrs exp...i'm still scared crapless every july. i'm hoping these posts keep coming, not just for entertainment, but enlightenment too. imho...knowing what you don't know is just as important (if not more) than knowing what you do know. fedupnurse is right on with his story about the 1st yr. res. brent who admitted "i don't know." this has been my litmus test for residents...the ones who ask questions and leave their ego at home are almost always the best ones...but still question everything! if they are worth their salt...they will thank you!.....keep the faith...keep the good avice coming.....thanks lr

PediRN · May 20, 2002

Originally posted by gypsigirl
These last post scared me crapless.....what can a new nurse do to protect herself? If your new and you don't know that the doctor's orders are stupid and you follow them are you liable?

Hey Gypsigirl,

You always have to check every single dose of medication a doctor orders; you are the last stop between the medication and the patient. If you administer the wrong medication (or dose, time, etc), YOU are liable, period. This does not only go for new docs, everyone makes mistakes, even the veterans. Be very careful, ALWAYS ask someone if you're not sure. If a doc writes an order that you know is wrong, refuse to give it. If s/he gives you a hard time, let your nurse manager know. We do NOT have to follow their orders if they are wrong!!

fedupnurse · May 21, 2002

Yes you are responsible. When you get (if you haven't already) your RN job try to find a mentor you can bounce things off of. We get stupid orders every day. You must get to know the meds you routinely deal with in whatever specialty you have and also know labs you need to know before giving the meds. Don't be fooled by attendings. They write stupid orders too!!!!! Ask your colleagues who is trustworthy and who isn't.

Best of luck.