Did I handle this incorrectly?

[swirlygirl]

I recently had a situation at work that I feel was handled correctly, but was told that the House MD and the critical care intensivist thought I handled badly. What would you guys have done differently? Little background - I work nights on a post-op/telemetry floor with an average of 6-7 patients. Recently we've been having patients that are admitted to our floor from the ICU that are unstable and are transferred back to the ICU within hours.

I had a 64 year old male patient 4 days post-op from a lap hemicolectomy. He had a normal recovery and was to be discharged the next day. Vitals were stable all night. Heartrate in the 80's. At around 3:30am his heartrate jumped to 165. He was asymptomatic except for c/o lightheadedness and dizziness. I called a rapid response and had the patient assessed by the house MD. EKG showed a new onset of atrial flutter. Patient was given one dose of adenosine, then given Cardizem 10mg IV push and started on a Cardizem drip at 10mg/hr. Patient remained on our floor. After 1 hour pt's heartrate hadn't changed so I called the House MD again and got an order to give another Cardizem 10mg IV push and increase patient's drip to 15mg/hr. After about another 45 minutes the patient's heartrate was still 160. Paged house MD, got no answer, so I called another rapid response. (House MD has to respond to this call). When House MD arrives, he orders a third Cardizem 10mg and increases patients drip to 20mg/hr. In the meantime, I also called the patient's attending physician. Attending physician wants patient transferred down to ICU immediately and also orders cardiology consult. House MD then makes a comment to me that "If you're going to call a rapid response on the patient every 5 minutes I guess we'll have to take him downstairs." Critical care intensivist is in the room telling the House MD that I overreacted and didn't want to wait for the Cardizem to work. (This was overheard by our CNA.) I did give the Cardizem time to work, it just didn't! We are not a cardiac unit, and the patient was symptomatic.

I feel like the only thing I could have done differently was call the attending physician sooner to get the patient transferred. When I went back to work a few days later, I found out that the patient had spent 3 days in the ICU on a Cardizem drip prior to being transferred back to our floor, then discharged. Sorry this is so long, I'm just frustrated by the whole situation.

[canoehead, BSN, RN]

You waited an hour after the cardizem, when did he think it was going to kick in? MAYBE I would have paged the house MD again before rapid response, but maybe not (if he has ignored any pages in the past I'd have done exactly what you did).

I have also gotten the "well I'll have to transfer to ICU to stop you from paging me" speech. PUH leeeze, my patient got emergent transfer to the city within an hour after we got labs back that I "made" him draw. I've also gotten a doc stating a patient was perfectly fine twice in 30 minutes, and after he walked out of the room the patient arrested. If you know something is wrong you are probably right.

FYI for all the new docs out there- when an experienced nurse keeps saying something is wrong 90% of the time there really is something very wrong. Same goes for parents about their kids- and this law will save your butt at least once a year. Even if you can't find anything this is the time to document extensively and make sure your senior knows the RN/parent is nervous.

[swirlygirl]

you waited an hour after the cardizem, when did he think it was going to kick in? maybe i would have paged the house md again before rapid response, but maybe not (if he has ignored any pages in the past i'd have done exactly what you did).

i have also gotten the "well i'll have to transfer to icu to stop you from paging me" speech. puh leeeze, my patient got emergent transfer to the city within an hour after we got labs back that i "made" him draw. i've also gotten a doc stating a patient was perfectly fine twice in 30 minutes, and after he walked out of the room the patient arrested. if you know something is wrong you are probably right.

fyi for all the new docs out there- when an experienced nurse keeps saying something is wrong 90% of the time there really is something very wrong. same goes for parents about their kids- and this law will save your butt at least once a year. even if you can't find anything this is the time to document extensively and make sure your senior knows the rn/parent is nervous.

thanks for the quick response!! i did page him again, but he didn't answer his page. that's why i called the second rapid response.

[classicdame, MSN, EdD]

sounds like they did not want to be bothered. You only have to worry about your license and they will not care if you lose it. I think you did right.

[systoly]

The intensivist had a golden opportunity to teach and positively impact not only the care of this patient, but also future care, when he was in the room with you, but he chose not to. And that is where the situation was handled badly.

[Tait, MSN, RN]

You did fine, the patient is safe and back home :)

FYI on our floor we can't do ANY titration of medications except for reducing Nitro/Cardi down, but not up. (Well aside from Heparin). If dosing gets sketchy they go straight to the unit to straighten it out.

He needed to shut his pie hole :)

Tait

[Orca, ADN, ASN, RN]

We had a patient on my mental health unit once who was being followed by a cardiologist, who said he would follow the patient for any medical needs. Unusual, I thought, but okay. One day the patient began drifting in and out of consciousness while sitting in the chair. I paged the cardiologist. No reply. I kept repeating the page, with no response. Finally I called the psychiatrist and told him what was going on, and he ordered various labs (CBC, chem panel, etc.). Finally, almost three hours after the initial page, Dr. Cardio called the unit and told the LPN who answered the phone that we needed to stop paging him "unless the patient is lying dead in the floor." I told her to hand me the phone. I told Dr. Cardio, "If you don't do something you probably won't have to wait much longer for that. Thanks to the psychiatrist, we just found out that your patient has a blood ammonia level that is incompatible with life." Suddenly Dr. Cardio got much friendlier and gave me appropriate orders. He apologized the next day.

Given a choice, I had much rather be accused of doing too much than too little in situations like this. I see no issue with what you did.

[Goldenhare]

You were correct to do what you did! And the facts you found out about the pt after the fact PROVES that! If you hadn't done what you did and something had happened to the pt, the house officer still would be complaining. You could have called the attending earlier, but the way I look at it, it could have happened that while you were chasing down the attending, the pt's condition could have gotten worse.

[qt2168]

I personally think you did a great job. One hour is definitly long enough for cardizem to take effect. That doctor just did not want to be troubled. You were a great advocate!

[MedSurgeMess]

It kills me that doctors act like this.....they are making big $$$$ to protect patient life. Many are good and care, and many others couldn't care less, and it shows in their demeanor. You did the right thing, and your patient is grateful for it! Great job and thanks for caring.

[SFRN]

You DID EVERYTHING you were supposed to do. Don't feel bad. I think the comment made by the House MD was unprofessional and inappropriate but that's how some behave. Remember sometimes you gotta pat yourself on the back cause aint NO one else going to.

[Straydandelion]

Given a choice, I had much rather be accused of doing too much than too little.

The BEST answer to any situation comes the day after with hind-sight, ultimately however I always follow the above philosophy.