how to deal with this intensivist

[fiveofpeep]

Hey Everyone,

We all had a horrible week. Acuity is extremely high, we dont have enough nurses. Everyone is burned out and overworked.

On my last day of many consecutive days in a row I missed that my patient should have been on a type of respiratory modality overnight. It was a new order given at change of shift, but I had the patient the night before and she was already on it the night before, so I didnt really think about notifying RT. I didnt catch this until the following morning. I immediately told the charge nurse and head nurse and called the doctor.

I said it was all my fault. I know I read the order. I just was so exhausted that I missed the fact that RT never started the treatment. The patient was respiratory-sound so I didnt have any respiratory distress or desatting to jog my memory.

This is my first really big mistake and I feel horrible, but Im also putting it in perspective, that I need to move on and learn from this. I think there were two major factors to my mistake:

1) being exhausted and overworked

2) getting orders at the beginning of my shift when I will review them quickly because I am stressed and busy

So anyways, I call the doctor and he doesnt yell. He just continues to hang up one me. Even when I had to call him later about another patient who was in 10/10 pain, he continued to hang up on me. I was almost brought to tears when this guy kept hanging up on me while my patient who had major abdominal surgery is suffering because a doctor is mad at me about a totally different patient. I charted all of this and told the charge nurse. Luckily this all happened before change of shift, so the oncoming nurse was able to deal with the client's pain and get orders where I could not.

I feel like Im in a bind having this Dr. be so mad at me. He is our intensivist and guides the overall care for most of our patients. I call him at least once a shift and he charts on our unit. I dont know how to deal with him now.

What if when I come in to work again he continues to ignore me? How will I ever get any orders for my patients? What if he comes on the unit and acts like nothing happened? Or even worse, what if he sees me on the unit and chastises me further?

Thanks for the advice.

[Hoozdo, ADN]

Well, if your pt did not have respiratory distress, satting fine, and had an

acceptable ABG - then he did not need any more than NC. What was the

order for? Bipap, CPAP? Or was he vented and needed to switch to another

mode for the night?

As far as working too many days in a row - learn to say no once in awhile

for your own sake. I know the money is tempting, but not at the expense

of your own health. One of my favorite sayings is, "Nurse Thyself". You are

number one, not your employer. Let them hire more nurses.

As far as the intensivist, that is unacceptable. He is putting your patients

at risk with his childish behavior. It depends on your personality on how you

want to fix this. I would not leave things as they are.

Personally, I would just say to him I don't appreciate you hanging up on me.

You put my patient's at risk. Depending on his answer, things could be

straightened out, or you are going to have to go to management for guidance.

[CNL2B]

I think you should go to management with the concerns you have with this intensivist. It is NEVER acceptable to hang up on another caregiver on the phone. It is NEVER acceptable to not listen to nursing concerns about patient that he is covering. This is an attitude that needs to be broken, and quickly.

The issue with the respiratory order (CPAP/BiPAP?) - IMO, it is absolutely the RT's responsibility to be checking their orders and doing their own work independently. They have a license too. If you have an RT that covers your unit and isn't floated 15 other places, this should be an expectation. This is one of my pet peeves, actually -- I have worked places where RT is great and they do everything, and I have worked places where you have to call them for every little thing. (I'm also a little confused in that it was a new order but the patient was on it the night before -- what's up with that?) Is it your responsibility to notify RT for these kinds of orders? Is it something the clerk could have done, but missed? Did RT not see the patient for the entire shift anyway? Were they supposed to be following the patient? I would talk to management as well about the RT role and what the expectations are. Yeah, maybe you dropped the ball (maybe....not 100% sure on that, especially since the patient was fine) but RT should have picked it up and ran with it.

Being overworked and exhausted does no one any good. Man, I feel for you. I have seen this kind of crap go on and on 100+ times at a number of facilities. I wouldn't pin this on you, actually -- your system is a crappy system -- obviously it failed here. I hate it that this kind of stuff gets pinned on nursing all the time -- and actually, you pinned it on yourself!

Let me give you a piece of my very best advice. Ready? Here it is: DO NOT TAKE FULL RESPONSIBILITY FOR SYSTEM ERRORS. Learn to recognize yourself as simply being a piece of the problem, and don't personalize it. This was you in this instance, but it easily could have been one of your coworkers. This involved other departments and other caregivers. If you keep on pinning this all on yourself, you are opening yourself up for disciplinary action for issues that aren't entirely yours. Don't do that.

Did you do an incident report on this? I feel that it warrants that, since an ordered treatment went 8-12 hours without getting implemented -- if we missed 8-12 hours of an antibiotic, we'd have to write it up. I see this as being a similar scenario. Hopefully you did, and somebody that can actually do something about it will examine the situation and try to fix how things operate around there (I wouldn't hold my breath, though, unless you have some managers that are really good at/like operations.)

Anyway, that's my two cents.

[fiveofpeep]

well I took responsibility because as a new grad I was having trouble with criticism and I learned over time that what they expect from you is to basically throw yourself under the bus and offer no excuses, because no excuse is good enough to validate making a mistake. so that is what I did. I do think respiratory was partly at fault but as the nurse, being the overall manager of care I should have noticed it wasnt done.

The manager is aware of the whole ignoring thing, but I dont think he will do anything about it. Im just worried about how the md will be when I come in to work next.

thanks everyone for the advice and support. Ill let you know how it goes when I see him. I figure I will apologize and then see if he also apologizes and if he doesnt I will say I didnt appreciate you hanging up on me. My patient was in pain as a result of your actions.

[blueheaven]

I cannot emphasize this enough, WRITE it up. Advice given above was very well stated and right on the money...thanks CNL2B

Did you do an incident report on this? I feel that it warrants that, since an ordered treatment went 8-12 hours without getting implemented -- if we missed 8-12 hours of an antibiotic, we'd have to write it up. I see this as being a similar scenario.

Yes, the fact the treatment went 8-12 hours needs to be written up. The doctor's behavior also needs to be addressed in the report.

[GoldenFire5]

Could you have called the surgeon and asked for pain management orders? If not, you could ladder up the medical chain of command. Call the MD house officer, say I've called this MD twice, he's hung up on me, I need pain management for this pt. And then also talk to the intensivist the next time you see him.

[fiveofpeep]

I did write an incident report

I didnt feel right calling the surgeon because the intensivist made the narc drip nontitratable so we could start weaning off the vent and I didnt want to supersede him. the pt could at least have had some prn morphine for break thru pain or something though.

[fiveofpeep]

yeah and I would have liked to go up the chain of command further, but I handed my patient off before that was possible. I really impressed upon the nurse how worried I was about the pt's pain so I hope she took it seriously.

The charge nurse didnt have my back (she is a day shifter who I think is kinda out to get me, always criticizing, very cold, never supportive, very stand offish) so I didnt feel comfortable going up the chain of command anyways.

I know that if I would have had that patient for longer I would have had to go up the chain of command eventually because it was simply unacceptable for that patient to be in that kind of pain for so long.

[meandragonbrett]

so I didnt feel comfortable going up the chain of command anyways.

Sometimes in the ICU, you unfortunately have to do things that make you uncomfortable.

Don't apologize to the intensivist. Grow a pair and ask him "Hey, why did you hang up on me repeatedly last night? That was unprofessional and it won't be tolerated"

[CABGx4, ASN, BSN, MSN, CRNA]

Ultimately, that was RT's responsibility. The doc should have communicated that order with them, if it was a big change he wanted. Now he's acting like a baby towards you?? Sounds like a real d0uchebag.

That's like when consents aren't on the chart and they look at you like "where's the consents?" I say "hey I'm not the doctor & it is THEIR responsibility to get them." I will do what I can but my job is not to follow you around and make sure your job gets done correctly. We (all nurses) have enough crap to take care of!

[GoldenFire5]

I didnt feel right calling the surgeon because the intensivist made the narc drip nontitratable so we could start weaning off the vent and I didnt want to supersede him. the pt could at least have had some prn morphine for break thru pain or something though.

It would have been OK to describe the vent weaning goals to the surgeon or the house medical officer. At best, they could have acknowledged the weaning goals and still given you pain orders. Or, they could have called the intensivist and told him to manage his case appropriately and call you back.

If you are charting that your patient is in pain, you called for orders and the MD hung up on you repeatedly, then you still need to call someone else for orders, I think. It's not good for the patient to let it go, and it wouldn't hold up in court.

It's not the same as an MD listening to what you have to say, acknowledging the situation and saying the current orders are fine as is.

[fiveofpeep]

oh rest assured, I most certainly would have called someone higher up the chain if I had stayed later, but this all happened right before I was handing my patient off to another nurse for the rest of the day and I knew he would take her calls and I couldnt stay later because I was already helping out with overtime and reached the max hours.

thanks for the advice. I do agree I should have done more to get this under control if I had had more time.