Did this ever happen to you?

Honestly, if you aren't getting orders you believe are appropriate from one MD, and the patient has other MD's following her, you could call them. You were good in your assessment skills, but as a green nurse sometimes it's hard to trust your instincts enough to push for what you know should be done.

In this case I would have called neurosurgery regarding the patient. Sometimes it's hard to know who you are supposed to call in certain situations, I think that's one of the hardest things to figure out with patients.

Just chalk it up to a learning experience. :)

You knew something needed done, now so you called the neurosurgeon but then you didn't complete the order you obtained. The order did not need to be approved by the fellow, you should have just done the ct scan.

So I've been working in an ICU for about 5 months. So still very green. I had a patient who had a ischemic stroke but was stable. No interventions at this time. I did neuro checks on her q1 hour just incase. Around 4am she started to be a bit more confused and sleepy. Nothing too crazy still oriented to person place and time and motor intact. I was conserned though because she had been fine all night and this was a change as far as I was conserned. I let the ICU fellow know and he came to the bedside and assessed the patient. He said he wasn't concerned. But to keep him updated. 5 am patient is still confused and a bit more lethargic. I let the fellow know he said he wasn't concerned but would bring it up with the day team. I didn't like this answer so I called and woke up the neuro attending. He said repeat CT scan would be his recommendation. It turned out I should have called neuro surgery (my fault I admit). But I'm sure the recommendation would the same. I reconsulted with the ICU fellow and he said he would tell day shift to do a CT scan. This is around 530-600. So 7AM rolls around and pt is increasing lethargic and neuro surgery comes by and asked why I hadn't gotten a ct scan if my patient had a change in MS. I said I tired but the fellow didn't order it and wasn't concerned. neuro surgery was ******. I feel like crap right now because I knew something was wrong but wasnt able to get something done. Also in the future how do I prevent MDs from not listening to me!!!!!!!??? I wrote in my note all my attempts to get the doctor to order a CT scan...does this cover me? I can't force a doctor to order anything and I can't just take the patient to CT scan without an order. Fmylife is how I'm feeling right now. All and any input is appreciated.

In the future, follow the chain of command of your facility. I gather you work in a teaching hospital...get used to getting "funny" responses from residents (especially around June/July:no:)...if something does not sound right, bounce it with a trusted peer or your nurse in charge...if still if does not sound right, call the attending.

Thanks for all the feedback. Certainly learning something new everyday.

Growing "nursing balls" is hard to do....I think mine are just now descending ***** :-) I think we've all done things like that on different levels simply because we weren't courageous enough or didn't want to step on toes, but dangit, sometimes you just have to. It's just hard to know and have the confidence in yourself especially when you're new.

Job sucks, doesn't it?

Welcome to critical care nursing. It's is your primary job description to take the blame for Fellows that don't follow thier patients, consults that don't consult with anyone. You will have interns/residents and med students who are "just there to learn" so you are responsible for providing the most complex and specialized medical education. Heaven help you if you miss-read the mind of whatever attending thought you should be practicing medicine for him this week, and did or didn't order the appropriate tests, labs, or x-rays in his name.

Wake someone up: boy-you really don't know what you are doing- Don't you know "that's why the fellows and residents are on call for this service...yada..yada..yada."

Took a bad order from a resident or fellow " Don't you know to call an attending when the staff in training are making an error in judgenment" Of course it's your job to decide what constitutes an error in judgement/treatmwent with 20/20 forsight.

I don't know a solution to your problem. Just keep in mind, being a patient advocate you can only do so much. At some point you have to decide you made every reasonable effort to provide for the patients safety, and you cannot be held to blame when the staff in charge of thier medical care don't care. If in doubt- notify your supervisor of your concerns, and let them sort out who the weakest link in the chain of care/command is. DON'T let anyone tell you "that is what your job is as the patients advocate" as a way of making you responsible for all the ills that will befall a patient in a critical care area. I'm always willing to take the blame for something I did- but I am most willing to redirect any effort to make the RN the "hospitalist" for every decision about every condition the patient has. More that once I have pointed out the "RN" on my badge and told the ranting attending to take it up with the "Doctor" that made the decision he has issue with. I have nursing care to provide.

Yes, something similar to this did happen involving residents. I learned from that to climb up the physician chain of command when I think something needs to be immediately addressed with a patient. Later, I had an incident with a staff pulmonary doc involving his very sick pt. who's pleural effusion got so bad that it was causing the pt. to be severely compromised. This happened on night shift. I called this pt's primary pulm. doc. several times to try to get him there to do something; he kept blowing me off. I climbed up over his head. He did eventually get there. By this time and this pt's SPO2 was in the low 80's for some time, etc. etc. Right when he puts the chest tube in, the SPO2 inc. to the 90's. He was so mad about coming in a 0200 in the morning but I didn't care. I think he thought he got some vengeance on me though since he tells me the Pleur-Evac was not necessary and to not set it up because it would not be necessary. It went all over the floor and bed. But, I didn't mind this either since the pt. was ok.