Where does my responsibility lie? MD at crisis ignores request for orders!!!

[GalRN]

I got in the middle of a nasty issue last night at work and am at a loss. I'm sure that this has happened to many out there and would like to know what you have had to do, or would do next time...

I am a psych traveler but this subject is universal- all specialties have these situations I'm sure. I feel like I was more concerned about my fellow nurses reactions as far as job security, but I didn't need to be- they back the travelers up the same as staff.

OK, we had a serious crisis- needed an MD order ASAP and could not really intervene without one. The situation was a psych nurse nightmare. Brief background- I had a patient who I had put on 1:1 about an hour before (he had scratched his arm open with a toothbrush). That part of the unit was saturated with manipulative behavior and I figured that he wanted to let me know that he was there, psychotic, and not to be ignored. He got what he needed/wanted- he wanted and got his 1:1.

I was in the med room when I heard a scuffle, a few shouts, and someone yell to call security. I ran out and found that he'd grabbed the tech's pen from her hand (he was quick!) and had it to his throat, threatening to stab it in and dig around until he hit something and bleed out. About a dozen security showed upand hung back while the staff attempted de escalation. This was not a situation that was getting better if there was just talk. This guy needed some meds in him and it really didn't matter how he got them, although without a struggle was the hope.

His attending MD was actually on the unit at the time, and I interrupted his visit with another pt (something I don't do unless it's really emergent). I knocked, stuck my head in and said "Dr, we have a crisis out here that needs your immediate attention!" I stepped back expecting him to come out or at least respond. He had seen all of the security come onto the unit. I was actually expecting to get yelled at if he was being a real jerk.... but.... nothing. He was talking to the patient as if I hadn't just even been there. The patient was done and came out a second later. I opened the door and said "Dr (name), you're patient (insert name) has a pen to his throuat and is threatening to kill himself. You NEED to come out here!" then, "Are you coming, or should I just get him some meds? IM injection? He has no prns, as we discussed earlier." The patient had nothing in the way of an antipsychotic, and I'd given him the whopping 0.25mg of ativan earlier that was ordered. The doctor was aware but had not addressed it..

So he- get this- picked up the phone and STARTED DICTATING HIS NOTE!!!

I had a patient about to try to kill himself, staff that couldn't move near him unless he made a move to do worse, and desperately needed to get some meds into him. (He had command hallucinations a few years ago- I was assuming he was again). Obviously he could have severely injured himself, the staff, or both and it was getting worse the longer he stood there. He needed meds. The doctor HAD to do his job. There was no way around it. I opened the office door again and stated the same thing again, louder then stood there and kept eye contact. He stared at me and dictated a little faster. The rest of the staff not with the pt stood behind me and glared at him, just so he would know that they were not happy and that I was serious. He dictated. Finally I held up the syringes in my hand (I'd drawn the standard cocktail when I heard the noise from the med room), and shouted "Haldol 10, Ativan 2, Cogentin 2. IM stat! If you have an issue with that it'll still take about 2 minutes from here to the patient's butt!". Then I went and ended up using it as a chemical restraint as the pt refused. The pen was taken the same time and he was released. He was in a room with not much else in it and the staff was not blocking his way out. He was staying in of his own volition and did not need a mechanical restraint. After a while he calmed down and we were able to keep him distracted until he got drowsier and was in bed, with a one to one staff in a stripped room.

Obviously the MD behavior was so far from OK that I'm not able to find the words... I am so upset. Getting yelled at is bad, but the issue is that the patient did not get the treatment that he needed right away. This MD has done thing like this in the past and I found after that one of the new younger nurses had grabbed the phone from his hand and hung it up about 6 months ago. This was his version of "putting the nurse in her place". I didn't know what to do, as I'd never seen this happen before and wasn't sure how to address it. Didn't have time to call the staff ed person at home either.

What happens on your unit when/if this situation comes up? What would you have done?

BTW, I wrote it as a telephone order and he signed it after I left that night- never saw the pt though.

[SlightlyMental_RN]

Wow...I can not believe the attitude and behavior that that MD demonstrated. Personally, I wouldn't have administered the injection, but used a show of force w/physical restraints. As NurseCard mentioned, you can always get an order for the restraints at a later time. I just wouldn't have given the shot without an order, as that's practicing out of my scope of practice, no matter how much an a*@h^%$ the MD was being. Sorry this happened to you.

[lindarn]

I would definitely bring it up to the med director. If it were you that was as careless, you know they would not let it go. Just because he is a Dr does'nt mean he has free rain to be careless and reckless. Good luck and let us know how it goes.

I would go further than that. I would report him to administration, the Board of Medicine, and if you really want to be a b@!! buster, make and appointment with the senior partner of the law firm who defends the hospital. Read him/her the riot act, and fill him in on Dr. so and so's antics. Point out how he puts the hospital in jeapardy, and that you make copies of the incident report that you wrote on him. And furthermore, you are keeping it if and when Dr. @$$Hole ever gets sued.

I would think that the law firm would set the hospital straight about how unprofessional conduct like that can cost the hospital $$$$$. JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Spokane, Washington

[wooh, BSN, RN]

Agree with reporting him. I'd make sure to keep it factual though, no references to it being because of gender, what country he's from, anything like that. Just "pt did x, I did y, doc did z, I did a, doc did b..."

And make sure to mention the threat to staff, administrators hate workers comp claims.

[aura_of_laura]

Hmm... I'm not sure I see what all the fuss is about. It sounds like a difference of opinion, that you saw a crisis, and the MD did not. To me, the situation doesn't sound all that much like a crisis - the guy had a pen, not a scalpel, and despite one's best intentions it's tough to kill one's self that way. It's part of being a psych nurse and/or tech to know how to handle those types of situations - the doc shouldn't have to be there (in fact, in my experience, they usually get in the way because they aren't trained in crisis intervention). When a patient is attention seeking that badly, I would not pull the doc away from another patient to intervene.

Standing orders for PRN psych orders are illegal in many states. I would never administer a med without an MD order, even if I know what they would order 99% of the time.

I'm afraid I side with the doc on this one.

[leslie :-D]

Hmm... I'm not sure I see what all the fuss is about. It sounds like a difference of opinion, that you saw a crisis, and the MD did not. To me, the situation doesn't sound all that much like a crisis - the guy had a pen, not a scalpel, and despite one's best intentions it's tough to kill one's self that way.

you are mistaken, aol.

pens are lethal objects, when used with force and intent.

The mighty pen

Self-Defense Weapons | Ultimate Defense System

Teen Stabbed With Pen Dies From Wounds - Sacramento News Story - KCRA Sacramento

leslie

[aura_of_laura]

you are mistaken, aol.

pens are lethal objects, when used with force and intent.

The mighty pen

Self-Defense Weapons | Ultimate Defense System

Teen Stabbed With Pen Dies From Wounds - Sacramento News Story - KCRA Sacramento

leslie

I agree that they can be lethal, but anything can be lethal. Heck, a rubber band can be lethal - it doesn't mean we treat it on par with possession of a gun. This is part of psych... I've handled patients with pens, screws, toothbrush-shivs, broken formica plate pieces - it's what we're trained to do. And when the situation is deemed too dangerous to staff, we are trained to leave that patient alone and remove ourselves from the situation. The worst that can happen is that he would have attempted to hurt himself with the pen (unlikely), and maybe do some damage (unlikelier) - he's in a hospital, what better place to be when you need stitches? And being that he "scratched his arm with a toothbrush," he appears to be attention-seeking more than suicidal. I had a patient last week insert a toothbrush the whole way into his arm - if someone is serious about wanting to hurt themself, they won't make little scratches on the skin. Psych Nursing 101.

What could the doctor have done to remove the pen from the patient's hand? Nada. He could have ordered medication for afterwards, but that's not really an issue of safety. This was an issue of deescalation, and I don't understand what the doc could have done to make that patient hand over the pen.

I'll admit I could be reading this situation wrong, but chances are I'm not. I think we need to disband the lynch mob - people are calling for his license, for goodness sake! Over this! Perhaps better crisis training all around is in order, MD included, but I wouldn't hang someone for this.

[Batman25]

Write it up, make administration aware, report him to Board, and definitely make the attorney aware. Sometimes the lawyers/Risk Management are the best to stop this behavior the fastest. This could lead to a potential lawsuit and appealing to the greed of the facility could get the quickest action. The time for the doc to be a control freak and an egomaciac isn't when a patient is in extreme distress. He should have stopped dictating notes and gotten you the meds needed at once. And while I'm glad he signed the order you could have put yourself at risk. Don't do that in the future.

[GalRN]

To clarify- This patient was known to the facility, and although I had not been his nurse, I had been lucky enough to read his admit and d/c notes, as well as the previous restraint records. He was one of the few pts I have met who was attention seeking and psychotic (not in a micropsychotic process way). He had been upset that another pt, who he thought was engaged to him, did not want to stop playing Uno to discuss the God machine that they were creating together. He had been off of his meds for a while (Magellen decided to stop covering the ones that worked for him). His psychotic belief was that he was already God or Satan, he would cease to be God and become Satan forever if he couldn't finish the machine, which he could only create with a female God counterpart. He also had mentioned necrophilia and witches in his mouth- but that didn't appear to be the cause of this episode.

The abrasion that he caused with the toothbrush was manipulative behavior, to get the other patient to notice him.... the tech assigned to his 1:1 knew him and was the one de escalating him as I tried to get the order. They could have taken him down and put him in restraints, but in the past he had gotten worse after a restraint and stopped working with the staff to stay safe. However- there was a bed ready and restraints were being set up while the de escalation was attempted. If his hand had even twitched there were enough ppl to forcibly prevent him from hurting himself.

It had been written repeatedly over many hospitalizations that the best way to deal with him in a standoff was with meds. He had stated during his debriefing after a prior restraint that he felt it would not have been necessary to restraint him physically if he had been given meds in time. He had always been helped with the cocktail given. Zydis, other injected meds, and everything except for Haldol had given him severe akathisia. The other effective antipsychotics (the ones that help him) are not available in a fast acting injectable form. Yes, I drew up the meds knowing that I had no order and possibly the MD would have chosen others if he had decided to choose at all, but I had only a few seconds and drew them up and decided to have them on hand- it would've taken more time if I'd gotten the MD to order them and then gone back. Had he rx'd something else I would have gotten it. I had no problem wasting the meds in the syringes I had if the MD thought something else was better.

The med was given, and written up as a chemical restraint simply b/c he would not take po form. He had asked for it earlier but had no rx.

I wholeheartedly agree that if I was in charge I would've done things differently- but the supervisor was there and clearly didn't want to just grab him and get the pen right away. It wouldn't have helped to talk it out in the middle of this. We discussed it later. He would prefer to de escalate with enough staff ready in case of a struggle. I'd be more comfortable justing grabbing the pen and and the patient but if he's there when the crisis starts and he takes charge I'm not going to question it in front of the patient.

This is a facility that swears all the pts are voluntary- they really think that, yet this guy was there. It's one of the issues the medical director is meeting with people to get written guidelines on. She is realistic and hopefully she'll force a policy to be documented soon. She hasn't had a chance- she just took over.

In the meantime- the tech was doing a really good job de escalating while I was trying to get the order. The rest of the staff was letting her have a go at it (usually I see 5 ppl talking to the pt at once). She actually was able to bring his attn to the choice of whether to return the pen, and how he could not create any machine if he was dead. She asked him if he'd be willing to take a med po and he'd said no. I did not ask, so I assumed that he would have said no to the injection. In other specialties you could say it was not a restraint and assumed implied consent, but it's kind of sketchy, I think. I basically told him I had meds for him and that I'd need to inject them. He was put in a hold for that and not given a chance to say yes, really- he may have consented but frankly it was quicker to get the meds into him given his record of clearing up once meds were on board.

It is the policy of the hospital to medicate and only use the restraints as a way to keep someone from moving while being injected, and to allow time for the meds to work. The laws in various states are different, and I try to work within the tightest I've seen in an emergency b/c I would rather impinge less on someone's freedom from being tied to a bed than to have less meds. It's my experience that once that OOC, the pt cannot pull it together without meds and try to physically restrain someone until they kick in only. In the state I come from the pt can only be physically restrained for that time and once calm all restraints have to come off at once.

I have worked in settings where it was common to have much more violent pts and have restrained ppl very quickly when necessary, then gotten meds.

In this case we couldn't have gotten an order elsewhere. This MD does not allow others to cover for him. Has to be called at home for any orders. It sucks. It has gotten to the point where ppl have waited 2 hrs for a call back from him. There is one other MD like this. The 3 other attendings share a practice and are always available with rotating coverage. This is a situation I walked into and it's not going to be hashed out now just b/c I am here. I have brought it up and the medical director is doing her best. She is one of the reachable ones, and said that in the future I can call her in a crisis regardless of who the MD is- she's got a pager and has always called back right away for her own pts. She can over rule the others now if she sees fit and I don't anticipate this happening again b/c I'll page her in front of him. He is in trouble- only b/c I sought her out and spoke to her. It is documented that the med was held up b/c of MD taking forever- and it's in the paperwork that he was there. I put it so I'm covered but unless asked there won't be a huge issue made on paper. The director has the info, and she'll deal with him- she's ****** and did call management.

It sucks to be the newbie- especially when you want to stay employed- tough balance when advocating for the pt AND trying to keep your job....