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.
Seriously, please move this event up the chain of command. Tell the whole thing: patient condition, MD response, what was done, how long it took, pt outcome, and (very important) the meeting that resulted. Move it up to the DON and CNO (Director of Nursing and Chief Nursing Officer, in case your facility calls them something else). They can't fix what they don't know is broken, and this is very broken.
I'm sorry you were treated this way. I'm so sorry you left in tears. You cared enough to escalate in the face of doctoral indifference, and that's a sign of a great nurse.
And I second (third, ...hundredth?) the notion to get the hell out of that manager's herd. Maybe not a different facility is needed, but competent and supportive administrators are vital for a nurse, and you clearly don't have them on the floor you're on now.
Unit managers who don't support their nurses' decisions to call rapid response teams (CATs, STAT teams, etc) are spineless and a danger to both their staff and the patients in their unit. Start keeping an eye out for a new position.
This. I am so sorry you had this experience. Besides, if the pt was having a questionable hr/rhythm, how was a blood sugar check a top priority before calling a rapid response? Yes it's something that should be eventually checked, but not the first thing in that situation.
I'm curious: For the people working on the wards, what's the difference between a code blue and a rapid response?
Semantics, mostly.
At one place the theory was that an RRT call was to prevent respiratory/cardiac arrest for a patient in distress, and a code blue was active respiratory/cardiac arrest.
At my most recent inpatient position, we were actively encouraged to call the ICU charge assigned code blue team for the shift as a second pair of eyes on the situation if we were unsure about our patient in any way. Not calling a code, just consulting with the code team. It didn't have a specific name. To punish a nurse for ensuring a patient is safely cared for is disturbing and destructive.
The MET or CAT or whatever team that you called (it's RRT - rapid response- at my hosp) should have been the ones to check a blood glucose if it had not been done already and the MD could also have ordered that. Sometimes in the heat of the moment you don't always think of everything. But that is how we nurses learn things over the years... though we should not be scolded for it like you were! You will probably never forget to check a glucose after your supv's actions. However, I don't think a low glucose would have caused the elevated BP and low HR. Your instincts were right to call for help no matter what anyone else says! Your patients and your license are what you have to protect! My advice next time a patient is deteriorating and definitely when symptomatic like that, call the CAT. Don't call the MD first, nor your supv. As someone else also mentioned, ACLS is a great way to be more comfortable with emergent situations. And that definitely was emergent. In fact, if your patient had gotten any worse at all, it would have probably ended up being a code situation. I'm curious as to what may have "brought her back"? Usually with low heart rate, you'll see a low BP. Anyway, you probably saved her life. No nurse should be treated the way you were treated. Don't listen to anyone who would scold you over not thinking of everything when you did the most important thing... You recognized a critical situation and YOU called for help and probably saved her life. Also, I agree that you should write an account of what you did and what was said at the time by the MD and the supv. and what was said in the meeting and give to the higher-ups.
I agree with all the responses and I have to say this. The manager that called you in to the office to reprimand you for not checking a blood sugar is an absolute idiot and should not be a manager. You likely saved the patient and yet you're being told that a CAT (RR) should not have been called and why on earth did you not check a blood sugar? Do you know what it sounds like? It sounds like the manager is so task-oriented that she's like a robot (patient sick ALOC, must check blood sugar). Yeah that's a "task" that you could have performed but you were critically thinking also and hypoglycemia is not usually to blame for symptomatic bradycardia with long pauses. I'm sorry you went through this. I actually agree with the poster who said you should take this up the chain of command. I'm sure you may find some reasonable, smart nurses who will see the idiocy of this nurse manager's action.
I hope you documented, documented, and documented some more!! You absolutely did the right thing. You assessed your patient (the part about the previous shift thought she was stable-- have they ever heard of "rapid change in condition??) and you did what you felt was in her best interest. You notified your supervisor and she told you to call the team.
Sounds to me like you are being used as a wheel chock for the bus you are being thrown under!! The doctor was WRONG in not coming to check his patient and dumped the blame... you being the "lowest" on the totem pole got the brunt of it. NEVER ignore your "gut" when you feel something is not right.... fight until you get someone that will listen/do something.
I agree with the idea that you might be happier in a different environment that encourages nurses to act on their patient's behalf...
Seriously, please move this event up the chain of command. Tell the whole thing: patient condition, MD response, what was done, how long it took, pt outcome, and (very important) the meeting that resulted. Move it up to the DON and CNO (Director of Nursing and Chief Nursing Officer, in case your facility calls them something else). They can't fix what they don't know is broken, and this is very broken.
I'm sorry you were treated this way. I'm so sorry you left in tears. You cared enough to escalate in the face of doctoral indifference, and that's a sign of a great nurse.
And I second (third, ...hundredth?) the notion to get the hell out of that manager's herd. Maybe not a different facility is needed, but competent and supportive administrators are vital for a nurse, and you clearly don't have them on the floor you're on now.
Respect, my friend.
I was going to post something similar to this. If you feel that you were reprimanded (verbally or otherwise) for your actions in the care of this patient, then you absolutely should move it up the chain of command. At my hospital, I would file a grievance with HR if I felt that I was not being heard by management. A letter to the DON can be very effective.
If there was something else that you should have done or they felt would have been a better action in the care of this patient, then this should have been a learning opportunity. Unfortunately, those who suggest you find a new job, know this type of environment too well. It is toxic and could end your career (either by their lack of support of and passion to belittle nurses leading to you holding blame, or making poor decisions in the future, or by your own burn out). The best thing I ever did was leave my first nursing position. I was scared to leave and start out new all over again, but now I work for a much better hospital where RRTs are encouraged to be called by anyone and nursing mistakes are taken seriously enough to find ways of preventing the same mistake in the future through research and education. I also am not one to push the "find a new job" advice that seems very popular on all nursing forums. But I truly feel that everyone on here that has advised you make the change, really cares about you and has your best interest. This story strikes a cord with every nurse (or other healthcare worker) that felt they did the best they could with what they had, just to get crapped on by management, administrators, coworkers, providers, or whoever after the fact, yet none of these people were available during the event to be of any help.
RRTs were looked down upon at my first nursing job. In fact, if you wanted to get the resident bedside quickly but they were not listening, you could tell them "then I will be calling an RRT" and they will magically appear at bedside in mere moments. At my current job, they had to do a lot of education to get it out of the doctors' heads that "it looks bad" to have an RRT called for their patients. An RRT is NOT bad practice, and it does not indicate that a provider should have done something else. It shows that there was a change in patient status that needs to be addressed ASAP. Our RRT is staffed 24 hours/day by RNs that were hired specifically for RRT. They continue to follow patients that RRTs are called for throughout their stay. They go from floor to floor just to check on the the staff, see if they have any questions or concerns about anyone in their care.
The reason I wrote all this is because if you do choose to go up the chain of command, you should not just take a complaint, you should always have a suggestion for improvement. This will let them know that you are not just some miserable employee who can't take criticism, but you are actually an invested nurse who cares about the future of your hospital and are willing to be part of improvement.
Is it possible that they want you to go in to discuss the actions or rather inaction of the Doctor? I might have called a rapid response sooner than you did, but policies vary from facility to facility. Our rapid response nurses can make the decision to take to ICU and we have an in-house intensivist 24/7. Believe me, I know what a blessing that is. The inaction of the Doctor in this situation was potentially life threatening. if you documented well, they don't have a leg to stand on making you the fall guy in this instance. They should be grateful that you did not blow this off. You went through the chain of command as you should. I don't see that you did anything wrong
Your third paragraph by itself indicates a patient whose MEWS score alone would warrant immediate transfer to a higher level of care. If they are after you, it is totally wrong on their part. When you speak with the coordinator describe the patient's appearance just as you did with us. Go in to the meeting confident in your assessment skills and your judgement. Simply state that what you were seeing indicated an unstable patient (it did) and that you were concerned that she would further deteriorate. Good luck.
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.
oh wow. I am so sorry this happened to you. You are a good nurse who intervened appropriately. We all know that the nurse before us can have a stable patient and we get one going down the tubes. There is a reason people are in the hospital. They're sick. The patient had a pacemaker placed so obviously there were problems with her rhythm of sufficient concern to warrant that. It's part of my hospital's rapid response protocol to get a blood sugar but given the cardiac rhythm, the change in mentation and the gray appearance, a cardiac cause resulting in hypo-perfusion would have been my first thought too. I hope you don't let this discourage you or prevent you from intervening again in a similar situation. The patient always comes first. Again, I'm so sorry this happened to you.
I got reprimanded when I was a GN for calling an oncologists office at Pharmacy's request because they wanted to confirm a dosage on a med for an 8 year old hemophiliac patient. The child was in ICU and I was a newbie and scared to death as it was, even with my preceptor. The office nurse confirmed the dose, than about an hour later the doc called in a rage, wondering who was questioning his orders. The manager pulled me in and asked me why I had done that and scolded me. I did have the presence of mind to say that I thought confirming something like was a GOOD thing, not something to get in trouble for. To be fair, this manager was all right for the most part..maybe not the best one I ever had, because she was still caught up in the usual culture of 'the doctor is always right'. She went on to do different things and we became friends and coworkers later, but I really resented that at the time.
" 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.
That's what I thought -- that was definitely a code situation.
Also, WTH with having you go in on your day off???
Specializes in Pulmonary & Cardiothoracic Critical Care.
Understood.
For me, a code means CPR. Everything else is aimed at not having to call a code and includes everything up to and including intubation, cardiac drips, and an emergent transvenous pacer at the bedside.
I'm curious: For the people working on the wards, what's the difference between a code blue and a rapid response?
In some institutions floor nurses are trained to call code blue for actual or impending cardiac arrest. The difference between the two teams responses is very little. In the institution I work for calling a code blue instead of a RRT will get you a pharmacist but all other team members are the same.
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Thomgirl
6 Posts
Seriously, please move this event up the chain of command. Tell the whole thing: patient condition, MD response, what was done, how long it took, pt outcome, and (very important) the meeting that resulted. Move it up to the DON and CNO (Director of Nursing and Chief Nursing Officer, in case your facility calls them something else). They can't fix what they don't know is broken, and this is very broken.
I'm sorry you were treated this way. I'm so sorry you left in tears. You cared enough to escalate in the face of doctoral indifference, and that's a sign of a great nurse.
And I second (third, ...hundredth?) the notion to get the hell out of that manager's herd. Maybe not a different facility is needed, but competent and supportive administrators are vital for a nurse, and you clearly don't have them on the floor you're on now.
Respect, my friend.