Standing up to my charge nurse prevented a mistake

[002rn05]

so, my pt suddenly developed chest pain, SOB, and extreme dizziness right at the start of shift and I immediately went to my charge to notify her that I'd be calling the MD. I received orders for a stat EKG and troponin level. Unfortunately this pt only had access through a Midline in the subclavian, and due to the patients stage V renal failure, was pitting 4 edema without a vein in site. Per policy we are not allowed to draw blood from midlines. I requested an order for a foot draw, but the draw was unsuccessful.

My charge, in front of everyone at the nurses station, grabbed my patients chart and started to demand that I draw from the midline because according to her it was intact a PICC. I knew that I should not draw from the line as I had been reported by the previous shift NOT to, and I also knew that the line was in fact a midline... But she continued. She raised her voice for all to hear demanding to know why I wouldn't draw and stating over and over that I have an ORDER to draw (which was really the radiologist sign off saying I could "use" the line but never stated I could draw from it.)

I politely told her I was not comfortable with drawing from the line since I had been told not to and that I would need confirmation to draw. She was infuriated. I knew somewhere there had to be more clarification documented so I searched through his/her chart and found the MDs order NOT to draw. I was so proud of myself for doing what I knew was right, but now I fear my charge is reckless and as a new nurse feel out of sorts with everything that happened.

Has anyone else experienced this type of hierarchal bullying? What did you do? Especially as a new nurse I feel like I've lost my leader.

[Anna Flaxis, BSN, RN]

It's true, we don't really know the whole story, and we never will. We can only make a best guess as to what really happened by taking the information provided at face value.

Some facilities are behind the times, so I can see a "midline" terminating in the subclavian being placed, and a "do not draw" order being written based upon habit/superstition/this is how I was taught mentality.

The OP didn't say the charge "yelled" or "screamed", but that she "raised her voice". We don't really know what that means because we were not there.

I do know that many people are elevated into leadership positions, not because of their superior leadership skills, but because they are willing to do the job. It is a trap for any new nurse to place their leader upon a pedestal. I remember as a new nurse being led down the garden path by those that I trusted to have more knowledge and skill than myself, and I learned long ago to trust myself.

Again, the simplest solution, based upon the info we have, would have been for the charge nurse to call the provider and get a one time order to draw. This would have both served the patient and the newer nurse, who would have learned by example.

ETA: FWIW, I don't see this as "heirarchical bullying", but rather, an exchange that went sideways, with both parties having some accountability for that.

[nurseprnRN, BSN, RN]

Think of it this way,

When you pull on a large syringe, it has much more "power to suck" thus much greater negative pressure occurs in the syringe, which usually results in a collapsed catheter and a failed draw.

On injection Larger syringes generate LESS pressure.

You can do 2 quick experiments to reassure you of the involved physics.

1) Take a 2cc syringe full of water (no needle) and a 60cc syringe full of water (no needle). Aim them at the ceiling in the break room one at a time and quick like a bunny push as hard as you can. Which one hits the ceiling the easiest, indicating that the water is being expelled at the higher pressure?

2) Take those same syringes and put their snouts in a basin of water. Pull hard, counting 1-2-3 (if you get that far). Which one pulls up the most water the fastest, indicating the highest degree of suction?

I'm not going to tell you the answers, but I hope someone will actually do it and report back.

I just looooove evidence-based practice :)

[iluvivt, BSN, RN]

Read what IVRUS wrote.....correct as usual. I was getting dizzy until someone came along and clarified the terminology. Nursing includes weighing the risks versus the benefit in many situations. I absolutely would not have hesitated drawing from the midline if someone could not easily get blood from a standard venipuncture draw. I have that on our midline policy too because I put it there but I was careful in my wording and I said "avoid performing blood draws from this type of peripheral line". A midline is considered a peripheral access type. The avoidance of blood draws is for many reasons...its dwell time is usually extended when blood draws are avoided...you really do not want to Tpa midlines and if blood draws are performed you increase risk of thrombotic occlusion plus a few other reasons.

So the benefit of getting the blood outweighs the risk to the patient in this situation IMO. I understand you had an order not to draw so I would have called for an order for a one time draw or if need be allow it if needed.I would have also evaluated the patients IV needs to make certain the ML was the most appropriate type of VAD especially in light of the patient's sudden change in condition. We have what we call an" IV nurse consult" and anyone can order it and we can then look at the entire situation and asses the vasculature (with US if needed) and make a recommendation for the most appropriate VAD.

Too bad the charge nurse could not be civil and explain the rational of her thinking or find someone who could! I disagree with her tactics...not very conducive to team work. She should have listened to your concerns...checked the policy and the order..and then you could have made a plan to get the blood ASAP. Sounds like she was stressed or a bit panicked.

By the way midlines are made in many Fr.sizes similair to PICC Fr sizes and most will draw just as well as similar PICC sizes. A PICC should never be trimmed to be a midline. If a PICC can not ne advanced and the choice then becomes to place a ML..then a ML kit should be used. Making a PICC a ML would be an off label use and puts you in a legal bind and many are power injectable an labeled as such and may be used for that purpose (not good) . If you find that situation make plans to get a more suitable access. I have seen it done.... we are aware and take remedial action as soon as we can change it.

[SwansonRN]

Sorry this question may have been answered before, but how is your unit taking any labs on this patient at all? During dialysis? It seems scary to me that this patient has end stage renal disease and there is no way to routinely check lytes at the very least. I hope this situation was a wake up call to the people taking care of this patient. Glad everything turned out okay. Also, the covering provider probably should have came and tried with an ultrasound or do an art stick. Seems lazy.

[iluvivt, BSN, RN]

Pts with ESRD generally should have a tunneled or percutaneousely placed CVC via the IJ if a CVC is needed. Sometimes if it does not matter ( ie.comfort care) we get an approval for a PICC .A PIV is a good option as well but even then you should avoid certain veins. such as the cephalic.Place in the dominant arm and save non dominant for fistula/graft. If desperate to use non dominant stay low heR the hands lower back of FA .