PT. advocacy- Was I out of line?

  1. I really need your help here guys- pt. came in c/o srom. Nitrazine was +, no doubt. Orders to pit her were received, vag cx obtained. At the end of the day the doc on call for the weekend came in, did an ultrasound and vag exam and said pt. was not ruptured. No fern test was done. Pit was cut off, pt watched all night then sent home. The next day (48 hrs after ?srom) pt came bak with c/o leaking fluid, temp of 100.7 night before. Temp now was 97.9, pulse 130's. FHT's 160/170 with decrease variablity but reactive at times. Doc got cbc which show white count had double from 2 days before and was now 27,000. Vag culture for 2 days before was + for group B. She was nitrazined and neg. She is also 41 weeks and 3cm dilated.
    Doc on call wrote prescription for antibiotics and gave orders to d/c to home. At my facility 2 Rn's must sign the strip before the pt is d/c'd. This pt belong to my charge nurse and I would not sign the strip because I did not think she should go home.
    The partner of the doc on call was notified of the situation by my charge nurse. He ended up taking over care for this pt. Well the doc on call let me have it. Among all the things he said to me was that I should resign and I did not belong in L&D. You can only imagine all the other things he said to me as he stomped around shouting and pointing his finger.
    Anyways- The pt was induced and followed by the on call doc's partner. Was I out of line? I felt like I was being an advocate for the pt and her baby. I just could not live with myself if she had gone home and came back with a dead baby. Please give me your opinions. Thanks, LDRN
    Last edit by LDRN697 on Jun 25, '01
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  2. 19 Comments

  3. by   canoehead
    first off, stomping shouting and finger pointing is wrong, especially if it occurred in front of anyone else. this doc should be reported,as you were taking a stand for the patient, not trying to get your entertainment by keeping him in patients.

    you know, i would agree with you. there was obviously something cooking with a increased wbc and fever, and the most likely cause would be rom. i think it certainly warrants staying in house on a moniter and abx. (i wonder what the diff showed). if i was the doc i would be inclined not to wait around though, let's induce and get the show on the road, especially with fetal tachycardia. i agree that there was no way in good conscience to sign off on the strip.

    however, i assume the doc, if he felt strongly enough to shout at you could have just dc'ed her anyway without nursing permission, so obviously he had his own doubts. can you tell us what the outcome was? perhaps the chart could be flagged for review, and this md and you could get the benefit of other professional opinions after the fact. certainly it would allow you to feel confident in that the next time you disagreed with him your opinion would have to be taken seriously, even if he disagrees.
  4. by   HazeK
    What is our #1 responsibility as nurses?
    Safe patient care/advocacy for the welfare of our patients!

    Of course you were appropriate!!!
    You go, Girl!
  5. by   nanamac
    I sure don't think you were out of line. You would have been the one who had to answer the attorneys questions as to WHY she went home etc. I would have done the same thing. Unfortunatly sometimes part of our job is to save our patients from the docs. You made a good choice!
  6. by   kitty=^..^=cat
    i think you should let your risk manager know about the situation. s/he can initiate a chart review and make sure that this physician isn't causing other risk/liability exposures in his practice.
  7. by   MollyJ
    I'm not an L & D nurse at all, but I have friends who work in the area.

    What strikes me here is that the non-on call partner was willing to get involved and assume the care. That by itself was a significant endorsement of the nurse(s) bringing the situation to his/her attention. As for the howling associated with the bruised ego: it isn't going to help his/her case any when this goes before the reviewing committee (and I'd bet a box of donut holes that it is headed there).

    Most advocacy is not attended by accolades [at least in the short term] and I think advocacy should be done as respectfully as possible (and I am not even trying to imply you didn't) so that the erring professional has room to back down but some of them will NOT be smart enough to do so. If that was your sis in the bed, what would you have wanted the nurses to do for her? I assume the answer would be, "what I did," so for the moment you have to be happy knowing that you did the right thing even if the doctor of record won't be nominating you for nurse of the year. It is hard to think about these things when some powerful doc is screaming at you and telling you that you're not fit to call yourself RN. Your peers here do not reflect that back to you.

    Be strong. You did good.
  8. by   fiestynurse
    It is the policy at your facility that two RNs must sign the strip before a patient is discharged. This doesn't mean the nurses are suppose to blindly sign it without using their professional judgement. That's a great policy and it is for situations just like the one you have discribed above. So what! if the doctor doesn't like it. Let him have his little trantrum! He knew that if he discharged the mother against that hospital policy, it would be his butt on the line and his butt alone.
    Way to go!! You are an awesome L&D nurse for standing-up for your patient and probably saving her life and her baby's. I have experienced mothers coming in septic and near death because a doctor would not hospitalize them or diagnosed them over the phone. Those moms end up with a stat c-sect and mom in the ICU and baby in the NICU, if they make it. What kind of idiot doctor is this? I would definitely write-up an incident report and let the risk manager know that you want a peer review of some kind. Follow-up on it!
  9. by   jamistlc
    originally posted by kitty=^..^=cat
    i think you should let your risk manager know about the situation. s/he can initiate a chart review and make sure that this physician isn't causing other risk/liability exposures in his practice.

    yes! yes! yes!

    you did your job and duty for your client!
    i am a bit confused in this time where evryone sues or any rationale, why would the md put themselves at risk like this?

    you were corect and if you have a similar situation it is your duty to do the samething again! we are the clients advocate it is our responsibility to do these things. even if it means we are yelled at... (bs). it was wrong for this md to yell at you in front of everyone (apparently this was the case). very unprofessional, you were the professional in this scenerio!
  10. by   mother/babyRN
    You were absolutely not out of line! Not only because you stood up for the patient, but because had anything happened, and you had been intimidated into doing what you felt was not appropriate, YOU could have been held liable if a lawsuit ensued...Remember, if there is an event that leads to a lawsuit, nursing experts will be called...In the case you describe, you could have been found negligent had anything happened and a lawsuit been filed. We are not only patient advocates, we are responsible for delivering the minimal standard of care in our field. You are cognizant in your field, and the resident who chastized you is a bully. In most hospitals, there are harrassment policies that prohibit someone attempting to intimidate you in any way, whether emotionally or sexually..Often , it is under the sexual harrassment policy. As for your patient, she is lucky to have you....If you read into nursing law, you will see that you are responsible for advocating the patient EVEN if it means you go over the doctors head to do it...Just because you contact a supervisor, it doesn't necessarily end there. You may find checking into case law an EYE opening experience. They pretty much find against the nurse for everthing. It doesn't matter if her intent was good, staffing was bad, or the doctor (as in this case), was an idiot. You may approach him separately and tell him you thought his actions were inappropriate and at the very least , unprofessional. If you don't get backed by your nurse manager, consider filing an official complaint. Any action against you is also against the law...In the meantime, pat yourself on the back for doing absolutely the right thing!
  11. by   MickeymomRN
    Just curious, was a fern done the second time she came in? Results? How could she be nitr - after being + the first night? We know that there could be false positives. That's why we do ferning with all our r/o srom pts. Was she contracting? WBC's do go up during labor. How many weeks was she? Was her entire strip nonreactive? No accels at all?
    I applaud your standing up in the best interest of the patient. I have seen so often the patient's suffer b/c the nurse is too busy or too intimidated by the doctor. So what if the doctor doesn't want to be woken up during the night. Why the h*** did he get into OB after doing residency and knowing that babies come whenever and that complications cannot wait til morning for evaluation. How long have you been in OB? Have you worked with this doctor before? Does he have a reputation for yelling like this and acting like a child? What was the outcome? Interested to hear your answers.
  12. by   WildBill
    Way To Go LDRN697
    I have lived your experience. I lost a baby to the same situation and I knew something was wrong but I wasn't sure what it was.
    I carried my child full term, was going to be induced that week because I had passed the due date. I phoned my physician the night before to report things had changed and was told to come in as scheduled the next day unless labor started. Our child was stillborn on the day before my husband's bithday. This was a planned pregnancy, my 2nd child, and we had followed every step carefully.
    My point is, if there is a doubt, you should react. There is nothing worse than burying your child. The physician's nurse retired from his office shortly and the physician practically moved in with us. I know he has very deep regrets and I really don't hold him responsible. I feel that I dropped the ball and should have been more aggressive. I am now a nurse. I know that pts. look to the MD and the nurse to look out for their interests. Until you have actually lived a situation, you don't understand it. You may think you do, but you don't. I wouldn't care how mad that doctor got, you had a huge part in saving the life of that child. The parents and the doctor may not realize that, but I do. You should be very proud of yourself.
  13. by   OC_An Khe
    Your actions were absolutely correct. I would also definitly follow up with risk management and HR with regards the MD's behavior.
  14. by   mother/babyRN
    One of the most difficult things I have ever had to do as a nurse ( and it has, unfortunatly, occurred several times), is put my job on the line, go in to a room, close the door and outright beg a patient and his or her family to demand appropriate treatment or a transfer. It is scary. Your heart rate and stress level increase. Confrontation with people/staff who totally disagree can be terrifying. In the end, if I had the life of a patient on one hand, and my job and some unpleasant backlash from superiors on the other, I know I could go home to my family and sleep well knowing I did all I could coupling my education with life skills and those feelings which come with experience, to save them, fully prepared to take the heat if I was incorrect. Thats why we are all here isn't it? To care for and advocate for the people we take care of? I ask patients to remember that I (and the docs) work for them....To someone who "doesn't want to bother me", I remind them I am there of my own choosing , and then ask, "You'd do the same for me if you could, wouldn't you?"
    It is only human to question yourself, but you will learn to trust your instincts. In doing so, so will the professionals you work with and for. Someone who is as insecure as the resident you describe has issues of their own. I would be proud to work with you....

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