Didn't follow doctor's orders

Published

Last time I was at work I had a CNA call me at the station as she was doing vitals and she said my patient had an o2 sat of 60% on 4l of o2. I brought a nonrebreather mask with me when I went into the room and put it on the patient. The patient appeared to be OK otherwise- she stated she felt fine and was not having any increased SOB. She was sleeping at the time her vitals were taken she she wasn't up and about. Her o2 sat increased to 96% and her HR decreased from 111 to 104 with the oxygen. I called her doctor. He asked me how she was otherwise and I told him her resp rate, that she felt fine otherwise and was not having any SOB. He told me to put the nasal cannula back on at 4L and to "leave her alone". I tried that- I put her back on the 4L and her sat droped to 80's before I tried a venti mask at 50% and the best I got was 85% so I put her back on the nonrebreather again. (I checked her previous o2 sats for other shifts and had previously been satting at about 90% on 4L). That's pretty much the end of story here. The nurse that took over was kind of freaking out about myself and the doctor not being in agreement so I asked my charge nurse who agreed with me, She asked the next shift's charge nurse who also agreed with me. Any opinions?

If a COPD'er is having trouble with sats, we titrate o2 based on ABGs; what's the use of keeping them above 90% o2 sat when they are retaining so much co2 that they are passing out (as I have seen before, but only in hospice patients)? Our MDs usually want COPD pts to be between 88-92% on O2. Sometimes lower, but if that is the case, they need to write the order for that.

Given the situation, I think you did the right thing, ESPECIALLY when you brought in RT. I think I would have attempted to get some parameters from the doc (so, what parameters do you want to give me for her o2 sats?--and then document if he REFUSES to give them) and get ABGs. Like someone else noted, the pulse oximeters are not always the most accurate, particularly if the pt has some peripheral circulation issues or heart arrhythmias. In an ideal world, that's what I would have done. In terms of the reality of the demands of floor nursing, I think you did what you could.

If this is a chronic problem, though, especially with a certain physician or group of physicians, it needs to be addressed, either through your department manager, or risk management. If a doc isn't reponding to requests for clarification and parameters of treatment, he's negligent. Period. Sometimes implementing an across the board standard, with the physician having to specify if he wants care that is specialized to that individual patient, is the best way IMHO to get these lazy or incompetent docs to treat their patients appropriately.

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Specializes in Almost everywhere.
ahh. with COPDers you have to look at their baseline sats. Some live quite comfortably in the 80s.

And I have put COPDers on nonrebreathers with the MD's blessing. You have to weight the benefits vs risks.

:yeahthat: Baseline sats...something to ponder. I would be looking at a parameter..like okay Doc what are we to be shooting for here with this patient? 88%??? 90%??? And what else can I do for this pt to make her comfortable? NRB....got to do what you gots to do!!!

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As someone has already mentioned you have to look at their baseline, some COPD patients do live comfortably with sats in the 80's. It is important to know if they are CO2 retainers before you crank the O2 up-to much O2 could cause a COPDer to go into respitory failure.

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Specializes in Almost everywhere.
If a COPD'er is having trouble with sats, we titrate o2 based on ABGs; what's the use of keeping them above 90% o2 sat when they are retaining so much co2 that they are passing out (as I have seen before, but only in hospice patients)? Our MDs usually want COPD pts to be between 88-92% on O2. Sometimes lower, but if that is the case, they need to write the order for that.

Given the situation, I think you did the right thing, ESPECIALLY when you brought in RT. I think I would have attempted to get some parameters from the doc (so, what parameters do you want to give me for her o2 sats?--and then document if he REFUSES to give them) and get ABGs. Like someone else noted, the pulse oximeters are not always the most accurate, particularly if the pt has some peripheral circulation issues or heart arrhythmias. In an ideal world, that's what I would have done. In terms of the reality of the demands of floor nursing, I think you did what you could.

If this is a chronic problem, though, especially with a certain physician or group of physicians, it needs to be addressed, either through your department manager, or risk management. If a doc isn't reponding to requests for clarification and parameters of treatment, he's negligent. Period. Sometimes implementing an across the board standard, with the physician having to specify if he wants care that is specialized to that individual patient, is the best way IMHO to get these lazy or incompetent docs to treat their patients appropriately.

:yeahthat: :yeahthat: :w00t: :w00t:

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Specializes in Trauma ICU, MICU/SICU.

I disagree with leaving a pt on a non-rebreather. This is very dangerous esp for a COPD'r. A non-rebreather means they are reabreathing NO CO2. And since they are not getting any CO2 eventually, they may go into resp arrest.

If you can't keep pt's sats up on aerosol mask than it is time to consider the plan for this pt. Intubation, bi-pap, etc. I believe that you, resp, and the doc needed to discuss the plan. Was pt. DNR?

Policy at our hosp is 1 hour for non-rebreather. To leave a pt. on non-rebreather longer, you would need to monitor CO2 either with a CO2 monitor or via ABG.

My question is why did you go it alone? Why didn't you re-consult with the doc, when sats were not at a safe level. Was he a resident? Is there a doc above him to consult with if you were not satisfied with his response/assessment? What did the nursing sup have to say? Had your patient developed a PE? My concern is WHY your pt was no longer able to maintain sats. I was in a very similar sit with a pt. about a week ago and if I had to do it all over again, I would have called the attending. I did not and it turned out the pt. had b/l PE's which I suspected PE from the get go and was shot down.

Nursing is tough though esp. on night shift when you have to decide what to do when you don't think the docs are doing the right thing where your pt is concerned. But, non-rebreather all night long does not sound like a safe choice to me.

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Specializes in Critical Care.

You shouldn't just walk away from low sats. But, if you disregarded the doc's input from the last call you are obligated to call him back.

If he continues to disagree with you and order otherwise, you are perfectly within your rights to demand that he come in and evaluate his pt - even at 3am.

And if he refuses: you use your chain of command. Your supervisor has the right and obligation to call HIS chief of Staff to settle an issue. No chief of staff is going to side with a doctor that claims he's much too tired to go evaluate his pt in an emergency situation.

I'm not disagreeing with WHAT you did, but how you didn't cover yourself. IF ANYTHING HAD HAPPENED TO THAT PT, the doctor would have pinned it on you. And here you are, without a life-jacket. A full blown investigation that involves you disregarding a doc order is a license jeopardy situation for you.

Your license is more important then that docs tired disregard of your assessments.

If a doc doesn't listen to you: MAKE HIM LISTEN. You have lots of resources to do just that, but it requires assertiveness.

~faith,

Timothy.

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Specializes in Trauma ICU, MICU/SICU.
You shouldn't just walk away from low sats. But, if you disregarded the doc's input from the last call you are obligated to call him back.

If he continues to disagree with you and order otherwise, you are perfectly within your rights to demand that he come in and evaluate his pt - even at 3am.

And if he refuses: you use your chain of command. Your supervisor has the right and obligation to call HIS chief of Staff to settle an issue. No chief of staff is going to side with a doctor that claims he's much too tired to go evaluate his pt in an emergency situation.

I'm not disagreeing with WHAT you did, but how you didn't cover yourself. IF ANYTHING HAD HAPPENED TO THAT PT, the doctor would have pinned it on you. And here you are, without a life-jacket. A full blown investigation that involves you disregarding a doc order is a license jeopardy situation for you.

Your license is more important then that docs tired disregard of your assessments.

If a doc doesn't listen to you: MAKE HIM LISTEN. You have lots of resources to do just that, but it requires assertiveness.

~faith,

Timothy.

Well said Timothy! You said a lot of what I was thinking, but much better. your post screams of the experience I'm getting, but don't quite have yet.

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Hi! This happened a bit ago but I was surprised to see the post up again. I agree though about getting the Cheif of Staff involved... I will definately do that next time. I can't tell you how ready I am now to "go there" after getting cr&p orders, and sometimes, no orders, from doctors when I call them at night and they are mad about it. And I always call for good reasons in the middle of the night... I wait until 6:30-7:30 for the things that can wait.

If you're wondering about what happened... the morning nurse checked her o2 sat on a nasal cannula and at first it was still low enough and she needed the nonrebreather but maybe 2 hours later she was back on the nasal cannula with decent sats. Someone was asking why I did it alone... but I did consult with respiratory, charge nurse, and the doctor... it's just that the doctor specifically said no ABG's and to put her back on the NC AND LEAVE HER ALONE. No, he was not a resident. It was an attending and there were no consults so it was just him. I discussed the situation with respiratory and the night charge and day charge and they all agreed with leaving the nonrebreather on. Next time I will consult with the nursing supervisor who can get me the number for the cheif of staff.

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Specializes in Critical Care.

True story:

3 am Admit: Temp 102 w/ immunocompromised HX, hx of Chronic pain.

No antipyretics, no antibiotics, no infection work-up, no routine meds.

I call the doc:

"What!"

"I'm calling about Mr. X."

"Well, DON'T!" - Click.

He hung up on me.

I called right back:

"WHAT!"

"I'm calling about Mr. X"

"Didn't I just tell you not to call me about him?!"

"Yes, you did."

"Then why did you CALL!!"

"Because, I need some orders."

"THEY'LL WAIT TILL MORNING!!!" - click.

So, I called him right back:

"What's it gonna take to get you to stop calling me?!"

"Orders."

"What do you want!!"

"Specifically, blood cx, urine C&S, antibiotic, morning xray and cbc/chem7, antipyretic, and something for pain."

"Fine!" - click.

So, I called right back.

"What!" (at this point, I am leaving the expletives out.

"Well, I need orders."

"DIDN'T YOU JUST WRITE YOUR OWN ORDERS!!!!"

"No, I gave you categories of orders, you have to fill in the specifics."

At that point, he actually gave me orders, said something rude, and hung up.

And you know what: I really, truly ENJOYED this exchange. Know why? He had to keep answering my page because the last time he blew me off, the chief of staff came in and did his job for him in the middle of the night. That tends to ruffle feathers. It's OK to ruffle MINE, but not his boss'.

BTW - EVERYBODY on several units knew that if they had to call this doc in the middle of the night to come and get me, because I ENJOYED waking him up. Not vindictively, but as needed.

~faith,

Timothy.

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Specializes in Trauma ICU, MICU/SICU.
Not vindictively, but as needed.

:lol2:

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