Did I do the right thing? *long*

Posted
by nursesaideBen nursesaideBen Member

Specializes in Medical Telemetry, LTC,AlF, Skilled care.

This past weekend I had an oncology patient who was a full code. In the early morning hours about 0500 I was getting qshift VS and this patient's heartrate was 41. I looked at his chart and he was typically running in the 50's. B/P was normal. Patient denied, SOB, dyspnea, dizziness, palpitations, and CP. I spoke with my charge nurse and we decided to put him on tele to keep an eye on him. Well, it wasn't long until he started dipping down into the 30's and staying there. I called the attending which was his Oncologist and he ordered 1mg Atropine IV, I administered the drug and his heart rate came up into the 60's but by the time I was giving report to the dayshift nurse he was starting to dip down into the low 40's again. That day he had a cardiology consult, the cardiologist ordered a BNP and cardiac enzymes. That night I recieved report, labs hadn't come in yet and he was maintaining a HR of about 40. A couple hours into the shift his heart rate was averaging 25, labs came back his BNP was 970, suggesting CHF, and his enzymes were normal. Patient again was asymtomatic, B/p WNL etc. I paged his attending and notified him of the situation, he was going to order Atropine again, I told him it had been minimally effective last time so he told me to page the cardiologist. I did so, and he became very agitated with me stating, "He's asymptomatic, so I don't know what you want me to do." I stressed to him once again what his HR was, what his BNP was, that he was a Full code, etc. Finally he told me to call the oncologist to see if we could transfer him to PCU and the oncologist agreed. We immedidately transferred him he had a scheduled 2100 of Oxycodone which I did NOT administer because my charge nurse and I both felt it could cause his HR to drop even more. Once he was transferred I get a call from the PCU nurse, chewing me out for not giving this 2100, stating "He has cancer and is in pain he NEEDS his pain medicine, I don't understand why you didn't give it to him." I explained to her why, she continued to rant, until I cut her off and told her he was her patient now she could do what she wanted. Of course I didn't want him to be in pain but at the same time I didn't want to kill him either, was I in the right?

EmmaG, RN

2,999 Posts

I don't think it's so much an issue of it contributing to his bradycardia as it could cause vasodilation, hypotension and reduced cardiac output...which was already compromised with such a low heart rate. He was somehow compensating for the low rate as his BP was WNL. Oxycontin can cause histamine release which can lead to vasodilation; if that were to have happened, he'd have been in big trouble.

My take on it, anywho.

walk6miles

walk6miles

Specializes in ICU of all kinds, CVICU, Cath Lab, ER.. 2 Articles; 308 Posts

I am at a loss as to why the cardiologist didn't come in and place a temporary pacemaker..... is he of the mindset that cancer = death sentence? Without knowing more details, it sounds like he is condeming the patient to death because he has cancer. The patient made himself a full code so he must be willing to fight the fight.

You were absolutely right!! It is hard to do the right thing some time...

God bless!

EmmaG, RN

2,999 Posts

Yeah, the cardiologist was being an ass.

MadisonsMomRN

MadisonsMomRN, BSN, RN

Specializes in Addictions, Corrections, QA/Education. 377 Posts

I would have held it too. Keeping him breathing is a priority over pain. Not saying pain management isnt important but we gotta keep him alive... especially since he's a full code.

I totally agree with the previous poster!

I think you made the right call!

nursesaideBen

nursesaideBen

Specializes in Medical Telemetry, LTC,AlF, Skilled care. 250 Posts

I am at a loss as to why the cardiologist didn't come in and place a temporary pacemaker..... is he of the mindset that cancer = death sentence? Without knowing more details, it sounds like he is condeming the patient to death because he has cancer. The patient made himself a full code so he must be willing to fight the fight.

You were absolutely right!! It is hard to do the right thing some time...

God bless!

This cardiologist is about to retire, some of the nurses have told me that he's adopted an "I don't want to be bothered" type of attitude.

nursesaideBen

nursesaideBen

Specializes in Medical Telemetry, LTC,AlF, Skilled care. 250 Posts

Thanks for all your support guys! I've been brooding over this all week.

walk6miles

walk6miles

Specializes in ICU of all kinds, CVICU, Cath Lab, ER.. 2 Articles; 308 Posts

Indeed, he has adopted a lousy attitude; perhaps the State Board of Licensing should review his attitude.

I like to say that some physicians take the "hypocritic" oath!!!!

loricatus

loricatus

Specializes in ED, ICU, PACU. 1,446 Posts

You used sound nursing judgement to make the decision to hold the meds. As an OP said, your priority was breathing (ABCs always come first). The nurse that complained either did not have the foresight to see the consequences of giving the oxycodone, or didn't want to take the responsibility for what would happen if she gave it. The only thing I see that you could have done differently was to give the choice to the patient (informed choice, of course). I doubt that the patient would have chosen the pain meds being a full code & obviously a fighter; but, you never know for sure.

EmmaG, RN

2,999 Posts

This cardiologist is about to retire, some of the nurses have told me that he's adopted an "I don't want to be bothered" type of attitude.

Then he needs to be reported to the medical chief.

nursesaideBen

nursesaideBen

Specializes in Medical Telemetry, LTC,AlF, Skilled care. 250 Posts

Then he needs to be reported to the medical chief.

That'd be nice except that the company I work for doesn't believe in discipling physicians and buys into the whole MD=God mentality.

jjjoy

jjjoy, LPN

2,801 Posts

I can't tell you whether or not your choice was *right* but you did what you thought was in the patient's best interest given that you can't know everything and based on sound reasoning. Your charge nurse backed you up.

I never understand why people chew out others for honest mistakes and I understand it even less when they chew out others when no mistake was made (eg docs who get angry when you call to clarify their poorly written order!).

My best guess is that the person is frustrated with the situation not with the individual. They find themselves having to deal with something they wish would just go away and the person who put them in that situation, whether truly responsible for it or not is an easy target for their frustration.

It sounds like you tried to explain your side so that you could understand the situation and learn from it and the nurse wasn't willing to engage in constructive discussion. So unfortunate! Who knows, maybe SHE'D been chewed out for a similar thing, wasn't given any clear explanations either, and was now 'passing it on.' Gee, thanks!

I hope you do find out what's the best course of action in such situations and let us know!!!

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