Where does my responsibility lie? MD at crisis ignores request for orders!!! - page 2

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... Read More

  1. 5
    Wow!!!!!!! I am at a loss.... you are right, that is definately a nightmare situation for a psych nurse, to be sure.

    At every place that I have worked, it was perfectly okay, in a dire emergency situation such as this, to initiate mechanical restraint and THEN get the order from the doctor, but to go ahead and give medication before the doctor gives the order for it? Unless there is some facility wide medication protocol in place for such a situation...

    If this patient was able to be restrained enough to be given the shot, surely he could have been restrained enough to get the pen away from him and get him on the ground or get him to the bed and into the restraints.

    I mean, it was an emergency situation and you certainly did what you felt like you had to in order to keep the patient and everyone else safe. I don't think I would have done what you did though; if I had enough staff to hold the guy down to give him a shot, well, WITHOUT the order for the shot, I would have went ahead and had his butt carted off to the seclusion room. Then, without the pen in hand, if he proceeded to smash his head against the wall as hard as possible, I guess we would have had to proceed to 5 point restraints.

    Again, the MD was a complete and total ass and you did what you felt was necessary, and I commend you for that. But, in most places you can't give medication without an order but you can initiate mechanical restraint and THEN get the order. If this guy later suffered some kind of nerve damage from the shot, allergic reaction, anything, it's not the doctor's butt, it's yours.

    I wouldn't want to be in that situation.
    sharpeimom, lindarn, TDCHIM, and 2 others like this.

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  2. 1
    Quote from classicdame
    turn him in to the medical board in that state - total negligence. I hope you documented well.
    if nothing else, do this...definitely.
    there is absolutely no excuse for this dr's behavior.
    he was negligent, abandoned a pt in crisis, with an unacceptable delay of care.
    if the med'l board gets enough of these concerns, he will be penalized.

    i also agree about putting him in mechanical restraints..this qualified as an emergency.

    sharpeimom likes this.
  3. 1
    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.
    MUUGUZI likes this.
  4. 1
    Quote from nurse12b
    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
    netglow likes this.
  5. 3
    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.
    sharpeimom, netglow, and leslie :-D like this.
  6. 0
    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.
  7. 8
    Quote from 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.
    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

  8. 1
    Quote from leslie :-D
    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.
    SlightlyMental_RN likes this.
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    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.
    sharpeimom likes this.
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    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....

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