calling the md at night when charge disagrees

[fiveofpeep]

Hey Friends

Im looking for some advice. The other night I had a patient who abruptly had a change in their respiratory status and suddenly became tachypneic and had increasing hr. I wanted to call the md because I knew something was up and I asserted this multiple times to the charge nurse, who kept stating that it was too late at night to call and I should wait. The patient ended up decompensating (and wouldnt you after 3hrs of working to breathe?) and had to be intubated shortly after I left. I feel like it's my fault because I should have some how asserted myself differently to the charge nurse, but on the other hand, I also need to be respectful of the charge nurse who has more experience.

How can I respectfully go against the recommendation of the charge nurse next time? I feel like I made my point multiple times each hour that I wanted to call and I was worried she was worsening. I understand that in most cases, I should trust the charge nurse, but what about those times (like this time) when you just know that something is up with your patient? How can I do better next time? I definitely still need to ask before I call, but how can I get around it if they say no and I really really feel like I need to call?

Thanks :)

[Orange Tree]

...tell her you were trying to order a pizza, but accidentally dialed the wrong number?

I'm glad our charge nurse doesn't have to approve phone calls- that's nutty. Do you have a rapid response team where you work? I think I actually would have called them first.

[mustlovepoodles, RN]

Do you actually have to get the charge nurse's approval or are you just afraid of ticking her off? Somehow, I think that if this sort of situation ever ended up in court the jury wouldn't be impressed and they sure as heck wouldn't be going after her. They'd be going after you. I'm not trying to admonish you at all. You're a new nurse without the buttload of experience that some of us old dogs have. But clearly you were concerned and had concrete evidence to back yourself up. What's the worst thing that could happen if you called? The doctor blows it off and gets mad because you woke him up? The charge shoots you dirty looks or even yells at you? Would that really be so awful?

Next time you have a situation like this, of course tell your charge nurse and get her input. But if you continue to be concerned it is incumbent upon you to call the doctor. Don't "keep telling her" you're worried--step up. And if it's against the rules to go against your charge, I'd go over her head. Surely you have a house supervisor. Call her! Better yet, get her to go with you to assess your patient. Two heads are better than one. Sure, your charge is going to be hacked,but so what?

Okay, now just get on with it. You can't go back and change things. In all likelihood your patient would have ended up on a vent anyway. Just determine to stand on your own nursing judgement. ABCs, my dear...

[NC Girl BSN]

I think when your back is up against the wall, the next time call the MD. I know how it is being new and unsure of your judgement and you look to someone with experience to help out. Sadly, this was not the case this time. I know the next time will be totally different and you will trust your own judgement more. You are a good nurse! Every situation will be a learning experience and the more you have them, the better you will become.

[ellbartto]

The person most familiar with the patient's condition and current trend is the nurse assigned to that patient. While the charge nurse is briefed by the outgoing charge, it's not possible for them to possess the intricate details that one obtains by spending time with the patient and providing that direct care. If your intuition suggests something is amiss, then you're acting as the patient's advocate. Don't second guess yourself and accept responses like: "Oh, he'll probably just get upset for calling unless...this or that is happening." The best way to learn a physician's thresholds is to discuss it with them during an actual event. You must learn for yourself when they WANT to be called, and when you feel they NEED to be called.

[rn/writer, RN]

Considering the choice of outcomes (getting chewed out vs. having the patient crash) I would rather be wrong for calling than for not calling.

That little voice that comes from your gut is there for a reason. Learn from this.

You must learn for yourself when they WANT to be called, and when you feel they NEED to be called.

Well stated.

[Music in My Heart]

If it's your patient then it's your responsibility to notify the physician whenever your clinical judgment determines that it's time. If something bad happens, it's your butt on the line... and you are the primary advocate for your patient.

Do you really have to get approval before you call?

I let the lead know before I call just in case they want to speak to the doc, too, but that's just as a courtesy.

[Penelope_Pitstop, BSN, RN]

I actually do it the other way around...FIRST I call the doctor, THEN I fill in the charge. "Oh, BTW, Mr. Toadbowel is fixin' to crump on me. Just a heads-up. Don't worry, I already called Dr. Foulsmell. Waiting on callback." Or, I don't even tell the charge until I get the callback.

I don't know how charge nurses are picked in your facility/department, but where I work, some rather green nurses are chosen. Would I go to them for advice? Not in a million years. First of all, I became a nurse before they even applied to nursing school. (Why am I never charge? Good question, but not one for today). Second of all, some people are good at staffing situations, making shift assignments, that kind of thing, but aren't good at clinical judgement calls.

You're new, so it may take you a while to tell which charges are which. Some nurses are very resourceful, helpful and knowledgeable but aren't charge. Why? Sometimes these nurses are just so strong on the floor, management doesn't want to take them away from a full assignment. Or sometimes these nurses plain don't want to be charge. However, you'll figure out who these nurses are (because they will check on you, will offer help without grumbling, that kind of thing). These ones are the ones to seek out!

And you are NOT, by any stretch of the imagination, going over the charge nurse's head by calling the doctor.

[fiveofpeep]

thanks for all the responses everyone.

yeah Im sure the pt would have ended up on the vent anyways. and I think the main reason I didnt call was because I did trust the charge's judgment over my own. It is not a rule to get approval but it's the way we do it around here unofficially and Im only two weeks off orientation so I do not have much experience.

Im not really looking to be told that Im wrong, because I agree that I was. Thats why Im asking for help. I know that this is a valuable lesson for me to learn to trust my own judgment and have faith in myself, but what I need to know is how I can approach the situation differently next time. And she saw the patient and assessed the pt so I figured she knew with her extra experience. But you're right, I should have just done it. I know I will call the md next time, but I mean how can I verbalize it respectfully? In this unit culture, it wont be acceptable for me to just call the md. All the nurses, new and old, talk with the charge about it before the call. I see it happen all the time. Im just more looking for how I can deal with this interaction better.

Im thinking next time that Ill just say, "I know it might not seem like a reason to call to you, but I feel like I need to call regardless to cover myself."

[fiveofpeep]

oh and PS...I really dont mind calling the doc. Im not afraid to and I know that's why they get paid the big bucks so calling is okay with me. Its more that Im looking for a way to breech the issue next time.

seriously, just to call at 6 I had to twist the charge's arm because she was ready to have me just pass it on to the next shift! It's hard because you want to trust others and get help from them, but I almost feel like I lost trust because I followed advice that didnt work out for my patient.

You are all right. Next time I just need to call regardless if Im really feeling that feeling. I do feel much more confident in my judgment after this situation, but now I need to gain some confidence in following it through and dealing with the politics.

[Music in My Heart]

One comment: I have been regularly engaging the docs in conversation about when they'd like to be notified. After all, the relationship is between them and me and they are the ones who know what they want.

[BBQvegan]

I am just nearing the end of my first year as a nurse. This is a tough job, and we have to keep our priorities in order. Like another poster said, "ABCs, my dear"! The situation = the patient cannot breathe well. Were O2 sats dropping? Was there a change in breath sounds? Did you try other things first, such as increasing O2 per nasal cannula? When that wasn't working, did you try a venti mask? Did the patient have a prn respiratory treatment? Do you have respiratory therapists on hand that you can call? If these interventions are not successful, you MUST call the MD, or initiate a rapid response. I can't imagine that it would be essential you get approval from a charge nurse to call an MD. It is YOUR patient, and YOUR responsibility to keep that patient safe.