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.
Specializes in Pedi; Geriatrics; office; Pedi home care..
No, you did not. It sounds to like you followed proper protcol. You paged the doctor; (who in my opinion) blew your concerns off twice (no response = #1; he responded with "I'll be there in 30 minutes = #2). You asked your charge nurse to check your patient & got her opinion. Your charge nurse told you to call for CAT. She is your supervisor; she told you to call for CAT. The CAT nurse responded; did her assessment; and, recommended ICU.
Hopefully your notes reflect all of this; and, that the doctor got there 2 hours after initial contact.
Get written statements from your cage nurse and the CAT nurse and take them with you.
It's doctors like the one you described who are arrogant;
have the attitude "I am a doctor; you are just a nurse (aka - you are an underling; and, therefore are not knowledgeable); can be the biggest PIAS and trouble makers for nurses. (40 + years of experience as a nurse has shown and taught me this.)
This patient would have been an ERT (or whatever you want to call it) at my hospital and would have very quickly progressed down the ACLS pathway to pacing for symptomatic bradycardia. This comes from both progressive care/Stepdown and ED and it should apply to any floor in any hospital as its ACLS.
As for the reprimand, your manager can make or break your job. Unfortunately, I think I'd be looking for another job myself after this event. Also, we have event reporting that we can bring the situation to light for upper management so you may be able to report this upward for review. Enough complaints about this one doctor and they'll get the message.
If your manager doesn't back you up on this very clear cut case, I would look around for a new manager. I only tell people on allnurses to get another job about once every five years...and this is a situation where I would move on.
Just FYI, even if you hadn't found all those alarming things in your assessment, AND had you charge and the rapid response nurse agreeing that the patient was sick, you'd still be right in calling a rapid response. You felt your patient needed help, you asked for it. Someday you'll just have a gut feeling, and following through on it will save someones life.
Specializes in ER, ICU/CCU, Open Heart OR Recovery, Etc.
Take your own private notes during this meeting if you decide to go. Also write your own account of what happened for your personal records. Do you have malpractice insurance?
You need to find a new job. You're workplace does not support safe practice and people WILL die; it is a matter of when and no doubt the nurse will be held accountable for not escalating. If this was my workplace you would have been pulled over the coals for not acting fast enough... 2 hours before the pt saw a DR is unacceptable. At my hospital vitals like that would meet rapid response meaning ICU DR (not nurse) needs to review within 10mins. It does not matter that they were stable prior to your shift or when the DR arrived. In that moment it needed to be escalated. Find a hospital that supports you.
" 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.
Exactly that and I hope you are getting paid if you go in!
Without going into too many details, I've personally seen cases where rapid responses were called after patients hadn't been doing well for some time and the patient died shortly after ICU transfer. It's hard to say if earlier transfer would have made a difference.
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.
D and D are not always welcome by some people here. Sharing, views, opinions, judgments, experiences - same thing.
OP - you did the right thing. Do not feel obligated to go in on your day off ever again. I know you were scared and wanted to get it over with and see how bad things were, but they should be paying you for your time, at the very least. They likely won't volunteer to do that. Hopefully, you clocked in and out or filled out whatever form of time sheet you had to fill out to get paid.
Like the nurse who agreed to a blood alcohol test on her time off - people, what are we thinking?
I am glad your patient is well. I hope that doctor realizes he screwed up and I hope he and your manager and anyone else involved in this serious lack of good judgment and this bullying fall under an elephant or something like that. LOL
BTW, you were damned if you did and damned if you didn't, you know. You were "wrong" for what you did and you'd have been wrong if you'd accepted the "doctor's" order to wait for him to Round and the pt had gone downhill. No way could you win in a case like this with a manager who won't back up your correct decision to intervene with a CAT.
Your Clinical Coordinator & Unit Manager & "the nurse before you" were not there at the time you were assessing the patient, were they? And, didn't your charge nurse tell you to call the CAT? And wasn't it the CAT that agreed that the patient needed to be in the ICU? The status of a patient can change in the blink of an eye. A heart rate of 30-40 is a problem. A blood pressure of 200/90 can be a problem. Runs of systole with difficulty arousing a patient are DEFINITELY a problem!!!
And, DIDN'T THE PATIENT HAVE A PACEMAKER PUT IN???? So, apparently it was not related to blood sugar.
If you let the patient because the doctor felt the patient was stable, and the patient died, you would have been called in the office too.
You should have asked them what they would have done in the same situation. And, what is the big deal about calling the CAT anyway? The ICU nurse came down to assess the patient as a second opinion. It's not like you called 911 and the paramedics came.
I find that a big problem in hospitals now is that there are too many "clinical coordinators", "nurse managers", "charge nurses"---and although they all sit on their asses and perform zero patient care, they have a hell of a lot of say about the care being rendered by the nurses actually doing the work. Where were they at 8 in the morning when your patient's heart rate was 30? Oh yeah---they probably don't come in until 9am, and they leave at 5pm. Silly me.
Additionally---I would never have gone in on my day off, unless I was going to get paid overtime for it. The issue was a work issue, not a personal one, and should be dealt with on work time. Otherwise, they could have done it over the phone while you were sitting on your couch in your pajamas, drinking coffee. If they felt it was going to take too much time, then it was their responsibility to shorten it so you wouldn't be off the floor for too long.
Were you "written up", or just chewed out? If it were me, and I was just "chewed out" over a situation like this, I would have actually asked for a formal write up---because then I would have written that I paged the resident twice because he didn't answer the first time, that the patient was having runs of systole and was difficult to arouse with a general heart rate of 30, that the patient ended up having a pacemaker put in and that you were verbally reprimanded by the resident and attending physician. I would have written that you followed the chain of command---the chain of command that has to be followed when the Unit Manager & Clinical Coordinator aren't there because they work 9-5. I also would have written how many nurses were working that day, how many patients each nurse was taking care of at that time. I would want that entire episode to be documented someplace----in your employee file is a good a place as any. If your spineless Unit Manager and Clinical Coordinator are unwilling to do it, then their "chewing out" was a bunch of crap. It was just something they did because the doctor's probably bullied them to do it. They don't deserve to be in those supervisory positions if they don't support their nurses in situations like this.
Kysam
14 Posts
The manager and clinical coordinator should have supported you. That's a shame