Being Pulled into the Office for calling CAT

[ryuunohime]

Hey guys,

I've been a member of this board for a long long time. Some background on me: 6.5 years of nursing, started as a CNA, worked as an LPN and now I'm an RN on a Med/Surg floor for the past 1.5 years.

Last week, I had a patient who was on remote tele and was an older gal with various co-morbidities including obesity, diabetes, CAD and recent CVA with minimal residuals. I had this lady for a total of 5 days and my doctor assigned to her was a internal medicine resident who doesn't have the best reputation.

The first day I get this patient, her pulse is in the 30 to 40 range, the tele is picking up 3 to 5 second bouts of asystole and her BP is 200ish/90 ish. The patient is lethargic and gray, and is very difficult to wake up.

I immediately page the doctor. No response for about 15 minutes. Meanwhile I have my CNA and myself in the room doing vitals, trying to wake up the patient, ect. I page the MD again and calls me, says he's aware of the situation and plans to make rounds on her in about 30 minutes or so. I tell him I feel he needs to be here sooner than that, he blows me off and says he will come when he's doing rounds. I page my charge nurse, tell her the situation, and she tells me to call the CAT. Which is Cricical Assessment Team Nurse, or the charge nurse up in ICU. The CAT nurse comes down, assesses my patient and agrees that the patient should be up in ICU on a drip. He pages the doctor. He gets no response.

2 HOURS LATER the doctor finally shows up, declares the patient to be fine, her BP is now around 160/80 and she is much more awake and looks to be in better color. He orders an oral BP medication and consults with cardiology, and the patient ends up getting a pacemaker. Meanwhile he and his attending physician scold me on the floor, and insinuate I don't know how to properly take vital signs. Apparently my charge nurse or the ICU nurse don't know how to take a blood pressure either.

Yesterday I get a call from my Clinical Coordinator that I need to have a meeting with her and the Unit Manager, and that its "Going to take too long to pull me off the floor so we need you to come in on your day off."

Nurses, did I do something wrong here? Did I rush things, or am I justified in initiating a CAT response? Thanks for the replies, this has been eating me up.

[FloatRN19]

I probably would not have stopped paging the doctor and documented with quotes his refusal to see the patient in a timely manor. And then pages his supervisor or attending and apologize for calling them, but said resident isn't responding.

[smf0903]

Nope, if I were in your shoes and had a questionable picture of the patient and the doc "refused" to come see said patient I'd call a rapid response. We've done it before (we had a peach of a hospitalist for a while who would rather sleep than answer pages...or come to rapids or codes for that matter, but I digress...) I'd rather err on the side of caution than have my patient take a nosedive down the proverbial drain.

I hope you documented the interactions with the doc as well. Good luck to you!

[Sour Lemon]

Yesterday I get a call from my Clinical Coordinator that I need to have a meeting with her and the Unit Manager, and that its "Going to take too long to pull me off the floor so we need you to come in on your day off."

Ridiculous! I would make sure who to find out would come in and take over the care of a patient during any similar event in the future- the clinical coordinator or the unit manager. If neither of them were willing to put their own *** on the line, then I'd keep handling things the way I saw fit.

[Been there,done that, ASN, RN]

" I page my charge nurse, tell her the situation, and she tells me to call the CAT."

You could be being called out because you did not respond fast enough. Where I come from... gray people with "bouts"of asystole.. earn a code response.

What ever it is, you are under no obligation to go in on your day off.

[RNNPICU, BSN, RN]

It sounds like you assessed and intervened appropriately. The reason you may be called in is not due to your assessment and escalation but for the physicians failure to escalate. There may be some history if this MD not escalating or responding appropriately and your unit is gathering evidence. If you have the Charge RN and the ICU Charge RN assessing and sending the pt to the ICU, the pt needs ICU.

It could also be that you should have responded quicker. Hard to get from a forum how long it took before help arrived. What is your chain of command can you independently call a CAT or do you talk to Charge first?

[Susie2310]

My thoughts are that no, you didn't rush things. The patient was having a symptomatic arrhythmia and was not perfusing properly with severe bradycardia, 3-5 second periods of asystole, elevated blood pressure, grey skin color, and altered level of consciousness (lethargy, difficult to arouse). You were right to recognize this situation needed urgent action as it could have led to cardiac arrest. Without knowing what the heart rhythm was it sounds to me as though the patient may have been experiencing a serious heart block, and the cardiologist put a pacemaker in.

I don't understand why the physician thought you didn't know how to take vital signs. You identified a very slow heart rhythm and a high blood pressure, if I understand correctly, and the cardiologist put a pacemaker in.

My only questions are whether you could have called the CAT or a rapid response directly and then notified the charge nurse and physician? This would have brought help more quickly. Obviously I don't know what the procedure is for summoning a critical assessment/rapid response in your facility. Have you taken ACLS? If not, this would be helpful. Also, I was wondering what happened to the patient during the time after they were seen by the CAT nurse who received no response on paging the doctor. What is your chain of command for obtaining urgently needed medical assistance for a patient if the physician is not responding?

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

At my hospital, if the nurses are even in doubt about the physical stability of our patients, we are obligated to call the MET (medical emergency team)team first and inform (not ask) the doctor what we did and why, then and RRT (gets RT and lead resident involved with the MET team) if needed...anything to prevent a CODE.

[brownbook]

Hopefully it is the doctor whose actions will be reviewed. You did nothing wrong.

[mrsboots87]

Sounds like the doctor tried to save face for being late by attempting to throw you u see the bus. They could be calling you in for any number of reasons. Go in confident that you did the right thing because beside asking about calling a CAT instead of just doing it, you did everything right. And if policy is to involve the charge before calling a CAT then even that was fine. Your patient was not in good shape and had very real potential to decline rapidly.

[WKShadowNP, DNP, APRN]

Hopefully it is the doctor whose actions will be reviewed. You did nothing wrong.

I agree. It sounds more like an RCA and not "you're in trouble"kind of meeting. I've had to go through those but they give no indication prior, leaving you in a worried state until it's said and done. Good luck!

[ryuunohime]

So I got done with the meeting and I left in tears. It was a laundry list of things I should have done. I didn't check a blood sugar. This event happened at 8ish in the morning and the last BG check on the patient was at 6, which was 123 and there was no insulin given.

Also I apparently told the CAT nurse that the patient needed IV push medications and to be on a drip up in the ICU. I did no such thing as I have zero experience with these meds. I also got told I over reacted, as both the nurse before me and the doctor thought the patient was stable.

Anyway, it was a good old fashioned ass chewing and I'm sitting here drinking wine and questioning my entire career choice. Yay Nursing!

Some days I very much regret taking out so much student debt to get so much abuse. This sucks because just yesterday I got the Daisy Award and I was being paraded around like I was an example to nurses everywhere, and today I'm dog ****.

Sorry for the pity party guys.