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.

[guest52816]

I completely agree with the posts that say you did nothing wrong. In my opinion, you did exactly what you are trained to do. Feel good about your choice regarding this patient. And follow the advice of the others who have told you to leave such an unsafe and unsupportive environment.

Congratulations on the Daisy award. You did the right thing.

[Libby1987]

Gray and lethargic? I would have called a RR (or 911 in my setting) before I called an MD who was not immediately available. And I would have owned it, that would have been very easy and defensible to stand behind. I would have looked my manager straight on, without malice, and said, "I called RR because the patient was gray and difficult to arouse at that moment in time." Substantiated with pacemaker indicated and placed. What response could they really have at that point?

But don't feel bad about yourself or the industry. Learn from it, grow from it, build your confidence.

[bgxyrnf, MSN, RN]

It's probaly because you didn't respond fast enough. That should have been a code response IMMEDIATELY. I'm an RT, so not really sure how you all do it on the RN side, but if I go into assess a patient who's bradycardic (especially to the 30s) and not responding, I'm pulling the code alarm.

IF they tell you that you are wrong for calling the CAT, I would stand up and politely tell them that you will work where they don't advocate killing people, hand them your badge and leave.

From my perspective in the ED, I wouldn't call a code because the patient has pulses and is not in a lethal rhythm.

A rapid response is the appropriate action while someone is putting on the pacer pads and ensuring sufficient IV access.

[Susie2310]

From my perspective in the ED, I wouldn't call a code because the patient has pulses and is not in a lethal rhythm.

A rapid response is the appropriate action while someone is putting on the pacer pads and ensuring sufficient IV access.

Just sharing my thoughts, not being argumentative. The patient had an irregular pulse with 3-5 second periods of asystole, and was symptomatic with inadequate perfusion: severe bradycardia, grey skin, altered level of consciousness, difficult to arouse, lethargic, (and the cardiologist put a pacemaker in). It sounds to me as though they were in danger of arresting. I think calling a code would have been the right action, but in my earlier post I said rapid response because the OP works in med-surg and I didn't know whether he/she is supposed to call a rapid response or a code for this situation, and it sounded from their post that they were supposed to call a CAT/rapid response.

[JerseyTomatoMDCrab, BSN]

The day nurses have to fear punitive action for calling rapid responses on declining patients is a day I am very scared to see. This is nonsense.

[MrChicagoRN, RN]

We had a doc complain when the night nurse called an RRT at 2am. He said he had talked to the floor around 11pm and felt he was being "undermined."

We told him that patients' conditions can change radically over a few hours, and the nurse who was there felt the RRT was necessary, so she called it.

RN had our full support, from both managers & the institution, and we told her so. Second guessing and scolding the nurse creates a punitive environment, and adversely affects patient care.

Who knows, maybe they were investigating so they could discuss the MDs lack of a timely response. It happens.

Good job to the OP.

[Susie2310]

We had a doc complain when the night nurse called an RRT at 2am. He said he had talked to the floor around 11pm and felt he was being "undermined."

We told him that patients' conditions can change radically over a few hours, and the nurse who was there felt the RRT was necessary, so she called it.

Off topic, but I have been told by a primary care physician: "It's unlikely to change" in response to my reply to the EKG tech that I knew otherwise when they told me that my family member's 12 lead EKG rhythm was "unlikely to change." My family member had a cardiac history.

[chacha82, ADN, BSN]

I think you did everything right...the MD scolding you is seriously lucky that patient is still alive. I would have called a rapid response as well.

[TriciaJ, RN]

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.

We've all been there. I now have an incredible capacity to second-guess myself which is not helpful. It's not even clear at this point whether you over-reacted or under-reacted, depending on whom you ask!

Here's the takeaway: You identified that your patient was in trouble and summoned help. The doctor was a douche so you did a work-around. And your patient is now fine. Thanks to you, whether you get any credit or not. So now the only thought in your head should be "You're welcome, jerks!"

[Apples&Oranges]

Sounds like you work in a community, rather than an academic teaching hospital. In a city hospital RNs, PCTs, unit secretaries, hell, housekeepers are encouraged to call a rapid response if the resources to deal with a change in condition are not RIGHT THERE.

One of the few positive things I have to say about my previous unit director was the he emphasized at EVERY staff meeting, EVERY review: No one will EVER be reprimanded for calling a RRT. EVER. It is always better to call and realized you didn't need the extra support than to hem and haw, second guessing yourself until it becomes a full blown code.

You know you did the right thing. We ALL know you did the right thing. EBP has shown over...and over...and over...that facilities which institute AND USE rapid response teams (as opposed to just code teams) have exponentially better patient outcomes, not just in critical care settings, but on medical units, obs units and even in the cafeteria.

I am not one to throw around the "look for another job" card as easily as many do here, that's rarely the answer, but in this case... you may want to look for a more progressive environment. One that values critical thinking and proactive action by nurses.

[blondy2061h, MSN, RN]

It's completely inappropriate to question the nurse who was at the Bessie's decision to call a rapid response. Who cares what the physician or the previous nurse says? They weren't there. Clearly it was decided that this patient did need cardiac intervention if they went on to get a pacemaker. This place has a dangerous culture if this is how things are done. Our rapid responses are always taken seriously, and I've been to many for patients far more stable than that.

Bessie is bedside. That's what I get for typing on my phone!

[bgxyrnf, MSN, RN]

Just sharing my thoughts, not being argumentative. The patient had an irregular pulse with 3-5 second periods of asystole, and was symptomatic with inadequate perfusion: severe bradycardia, grey skin, altered level of consciousness, difficult to arouse, lethargic, (and the cardiologist put a pacemaker in). It sounds to me as though they were in danger of arresting. I think calling a code would have been the right action.

No need to be on eggshells. Discussion and debate are not argumentative, they're simply all of us sharing our views and opinions based on our judgments and experiences.

The patient was clearly in a dangerous situation and in need of immediate intervention... in my world, that's a rapid response. A code is for an asystolic patient on whom we're initiating the appropriate ACLS algorithm.

Keep in mind that I have no experience working the floor; my only experience is in the ED and the ICU.