Chemical code vs full code

[grnvillechick]

Hi everyone !!! I have come across a most frustrating issue at work..and I was wanting your input so I can properly deal with this ---

I had 74 yr old pt...dx was brain stem CVA with very poor prognosis...on a T piece, not vent at this point...family of 9 children and one very sweet and very passive spouse. The family could not come to grips with the reality of this pt's state and could only agree to a Chemical Code...No CPR--no Defibrillation...attempts by our hospitals' chaplain to get a DNR were futile. The day I had this pt, the family yet again declined DNR offers.

8 hours into my 12 hour shift--with a very critical pt trying to crash on me all day..my brain stem CVA pt becomes bradycardic --30's and junctional..and agonal resps. In the unit at the time was a first level resident of the medical teaching program ...who rushed into the room and immediately started to yell out typical code rhetoric--get the cart---place the backboard,etc---I told him this pt was a chemical code only--he yelled at me and said " I do full codes only..." and despite 2 other nurses trying to verbally stop him ( one was the nurse manager) --he began CPR. I called his upper classman resident(who was in charge of him) and when he arrived, he followed suite and now we had 2 docs doing CPR..the very thing this fammily did not want..the very last thing this poor pt needed. Finally the pt's Pulmonologist came and stopped the code and told them off in a hurry. He then got mad at the nurses for " not getting the DNR like I told you !" he never approached the family for it himself of course.

No record of CPR was put in the code sheet. No mention of the CPR was told to the family. With my nurse manager there agreeing to all of it, I had no choice but to go along with it. Yet it still bothers me. The family was lead by the chaplain and I had very little chance to console them because---

In the meantime..I am still dealing with my crashing pt...who happened to be the pt of the resdient who initiated the CPR and wasn't listening to us. While I was taking off orders and preparing for my pt to go to the cath lab, this guy walked into my room at some point and shut off the Dopamine ...he never told me, couldn't remember exactly how long the pt was off..and pooh poohed the idea of titration--it was at 15 mcgs at the time he shut it off.

My question is , considering how dangerous this guy was on 2 occassions on 2 different pts....shouldn't I write him up???? my nurse manager witnessed it all...but she is burned out and leaving in a few weeks, so what does she care. How should I handle this idiot in the future...as it stands right now, I think I would like to refuse care of pts assigned to him...but that isn't the solution . Funny thing is that I LIKED this one before that day.

he seemed to listen and work with the nurses...but apparently he is in the GOD mode now..they all get there at some point. so HELP ME!!!!!!!

[SICU Queen]

Jeez... what an a$$hole... I'd write it all up, at least to cover your own butt. AND, I'd be telling him in NO uncertain terms NOT to touch ANY of your equipment at the bedside. If he wants something done, he can WRITE AN ORDER for it and you'll happily take care of it... I threw a CV surgeon out of one of my rooms once for messing with my stuff...

As far as the chemical code vs. full code, you need to inform Mr. Pulmonologist that it is NOT the nurse's duty to obtain a DNR, in fact, we can't write one without an MD order where I work, and I'm sure that's the way it is everywhere else...

AND, I'd also find out what the policy is regarding residents who don't follow code status.

This kind of crap is what makes me wish I wasn't a nurse.

[grnvillechick]

whew !! you mean I isn't crazy??? Your southern cousin!!!

[P_RN, ADN, RN]

Write it ALL up. Incident reports are for "internal quality control" and your legal department may NEED some advance info about this clown.

[traumaRUs, MSN, APRN]

Yes, an incident report (maybe two) needs to be completed. Also, if you didn't document that CPR was done, you need to amend the chart now. You can't not chart something that was done to a pt, just because it wasn't suposed to be done. This poor pt and their poor family.

Was this a med student? Resident? You can always go over their head to the attending too.

[Jenny P]

Here in Minnesota, nurses don't get the DNR from Families; the docs are the ones that HAVE to do it! We can't even write a telephone order for a DNR; the docs MUST WRITE both a note about talking with the family and the actual DNR order. This is a fairly new law here, and I forget if it was Medicare initiated or if it is a state law; so if I were you, I'd check it out. It cuts out the chance that a doc will "blame" us for either writing or not writing DNR on the chart as he "ordered" (what- a doctor might lie to save his a$$?).

BTW, you should write out 2 different incident reports because this was 2 different incidents even if it was at the same time. I'd also notify the residents' attending, and the medical director of your hospital.

I learned the hard way (when a CV surgeon messed with my gtts.) to always check my gtts. after a doc was in the room and a pt. starts crashing. The doc usually has done something they shouldn't have (and didn't tell me!) when the pt. crashes soon after the doc leaves the unit and is unavailable.

[canoehead, BSN, RN]

Absolutely write him up, he'll do it again and the pt may not be so lucky.

I would also want to talk with the attending about the residents difficulty with a chemical code. If the order is written that way they need to take it up with the orderer, not just go out on their own without discussing it with the family.

[Jenny P]

I just thought of another reason that some first level resident might code a pt.-- I've seen this once and reported the guy-- THEY WANT THE PRACTICE OF DOING A CODE!!!! :eek: They may not CARE what the outcome is, they just want the practice to "check it off their list" of experiences! Usually these idiots only do this to pts. who are terminal; may be homeless or don't have families.

[MHN]

? could this be classified as a medical assault .

Definate lack of inservice for resident medical staff between different codes

[misti_z]

Two incidents reports are definitely called for....both occurence are ridiculous.

[CEN35]

well he was very inappropriate. if somebody does not write him up, or do something to put a leash on him........it will happen again.

technically our hospital is not a teaching hospital. however, many of our others are, and do have residents. in agreement with the other hospitals, we have a limited number of medical, and surgical residents in our hospital.

my experience has been limited with residents.

some are great! sometimes though, you have to just put your foot down! you need to let them have it! i have had a few tossed already.

i'm not a mean or bad person, but if they are doing something they shouldn't and/or not sure of what they are doing........it comes to a halt.

they could end up hurting someone, or doing the wrong thing one day.

me :)

[grnvillechick]

here is the update----

the resisent found me at the beginning of my shift ..and told me he needed to talk with me. He later found me that day..and apologized profusely about his actions. He told me he had just lost a pt he worked very hard on before coming to the unit..and wasn't really emot stable. I listened to him...and told him I understood he was having a bad day, but it still did not make things right. He promised to never touch another drip..and we both went and made a request to the ethics committee to review Chemical code orders...to see if it could be eliminated as it apparently causes much confusion house wide.

I am still going to watch him like a hawk as will the others...and feel at least in some small way things are being addressed...and yes, I did write up all up !!! thanks so much for the input..I appreciate it !!!