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.

[BluegrassRN]

If you can encounter this doc in the next couple of days, confront him. Say "My aide overheard you saying that I handled the situation with X improperly. What would you have liked me to do differently?" If he mumbles or stutters around, or gets angry, just say "I'm serious. I want to do the right thing, and I am always trying to improve my practice. I *WELCOME* your input, and I want you to help me be a better nurse. Tell me what you would have preferred I do, so that I can do that when a similar situation arises."

Jerks don't like to be called on being jerks. Nice guys who behaved poorly feel awful, and will usually apologize and treat you better the next time. Nice guys who were (somewhat) justified in their behavior will apologize and then discuss what their reasoning was for saying what they said. Make sense?

End the conversation with "I appreciate your explanation. Please, if you *ever* feel I am not handling something in the appropriate manner, PLEASE tell me directly and as soon as possible, so I can learn and improve."

I've had a variation of this conversation with a couple of docs. I try to listen to what they have to say, and then sometimes I justify my actions--particularly if someone else was telling me to do something, or if the doc was at fault. Like if he says page me first and you say "Well, actually I DID, but I didn't get a response." But be careful when you do this--you don't want to seem defensive. It's a fine line between showing that there was a thought process and you had great justification in doing what you did, and seeming defensive and not really open to suggestions for improvement.

Personally, I'm not sure I would have called a rapid response team for that--I'm not sure, though, and it seems that rapid response means something different in different facilities. Moot point, though, because if the doc wanted a cardizem drip, I would have had to send the pt to step-down or ICU, since we don't titrate any drip except insulin and heparin on our floor.

Having been burned by this sort of situation myself, I now always ask for parameters when I'm calling about rhythm, BP, heart rate, etc. Next time you encounter this situation, when you get the initial orders, you'll know to ask "Can you give me some parameters? Do you want to bolus again after an hour if he hasn't converted, or should I just call you?" Really, that's probably the only thing that you could have done differently.

[blondy2061h, MSN, RN]

Sounds like you did a great job! Titrating cardiac drips with a 7 patient assignment is a LOT!

[sicushells, RN]

Some people are never going to be happy with the care you give. They can always find something they would have done differently. Sometimes they're right, sometimes it's an ego trip. You have to learn from the first and shrug off the second.

It sounds like what you did was totally appropriate. Also, I LOVE BluegrassRN's idea. That sounds perfect!

[rita359]

You did what you should have done and more for a med surg tele floor. After all these patients are supposed to be stable. This patient was not stable and should have been moved to a unit much sooner. I think the dr just doesn't have a clue what the workload for 7 patients is. Put this behind you.