Change in fellows and residents...safety

[m0ckingbird]

I work in a teaching hospital and every month or so our fellows and residents change.  However, the fellows we have this time scare me, and I'm afraid that something is going to go wrong.  I have been in the cardiac ICU for one year.  I worked three years in CT stepdown before that.  I have been charge on both units, and I'm a new charge in CICU.  I work with advanced devices, but some of them are still new for me like impellas and balloon pumps.  I can give many of our newer doctors ideas and advice to help patients such as drips, sedation and weaning ventilators.  But, there are other areas I'm not trained in such as acting as a CVAD nurse.  We usually have a CVAD nurse we call to the unit for line placement.  We are very understaffed now, and yesterday there was no CVAD nurse in the hospital.  I had a patient with possible bacteremia and they wanted to remove a femoral iHD line that had been in for 2 days and place a new iHD in his right jugular.  They came to tell me that the CVAD nurse was unavailable, so I should assist them.  I don't normally do that.  I set up the room and got the checklist.  My charge nurse handed me an iHD  trialysis line and I brought it to the room.  I felt rushed and I gathered equipment quickly.  I reminded them to wash their hands and asked them if they scrubbed the site for 2 minutes.  I had them do a time out.  I felt like I was doing all the things that should be done.  The patient was scared and I gave him fentanyl and ativan to relax him.  He spoke Spanish and we had a translator on a phone.  The doctors started to place the line and then dilated the jugular vein.  Then they pulled out the iHD cath and said "this looks long, how far should I put it in?"  I'm thinking- how the hell should I know you are the doctor.  Then they said he seems to be having a lot of bleeding.  I realized then they had never asked me to stop the heparin drip.    I told them about the heparin and I stopped it with a verbal.  I felt awful that I should have reminded them about the drip and not let them start a procedure yet.  I was rushing to do something new and it slipped my mind. I started to get very scared that this was taking a turn.  I called the CVAD nurse repeatedly and got an answer eventually from an ICU transport nurse who was busy but covering and I asked their question about insertion and catheter length and they told me it was the wrong length.  This was for a femoral line.  I called the more experienced CN IV for help and we started calling other units that carry a 15cm line.  I started to feel panicky that the doctors didn't know the right catheters or steps.  They were working very slowly and had made two attempts to find the IJ.  They didn't look adept at the procedure.  I called the attending and said I think he needs to come.  A few physicians showed up and started watching them.  We got a new line to them.  Then the physicians had to tell the fellow and resident each step to do this correctly.  They looked like they didn't know what they were doing completely.  I pulled heparin locks, but they kept asking me what strength was needed.  They had the pharmacists try to figure out the strength and they said they didn't know.  I talked to several nurses on the unit and then chose the heparin strength.  Still no written orders for this and doctors asking me what strength to use.  This whole situation was terrifying me and I felt like it was all out of order.  We finished the procedure and I tried to take a break at 3 p.m. and they were like, let's pull out the other iHD line.  I told them the other doctor just had me restart the heparin and I needed to eat lunch and see my other patient.  They waited for me to come back and tell them when I was ready.  But I was really on edge and I felt like I didn't trust them.

The more experienced physicians stayed on the unit for a few more hours while they tried to place lines in other rooms and took twice as long as it should take in patients that were decompensating.  I repeatedly asked for orders to match the verbals they gave me in which they had me override medications to adequately sedate the patient ativan and fentanyl. All these steps put me in liability and risk and it's become very routine on our unit.  We're always rushed and told to get things now, they will write orders later.  Our heparin drip, I was told later, should be discontinued when paused per joint commission and then reordered.  

I just don't know what to do.  I have this terrible fear that something will go wrong and the nurses are having to babysit the doctors.  But, I know I don't know enough to do that in every circumstance.

 

[offlabel]

Post was way too long for me to read the whole thing but if there is an issue, call the resident's or fellow's attending...this isn't your deal.