EKG order

[cepr4]

Hi, so I'm a new nurse and had a question about EKG's and orders. So I had a patient that was having chest pain and SOB. VSS. Still put her on 2l NC to be safe, even though her o2 was good just because she was having short of breath and gave two tablets of nitro. I stat paged out to the doctor and got no answer. At this point I grabbed a more experience nurse and he told me to get an EKG. The EKG showed AJR, so I paged again and messaged the cardiology doctor this time too, who told me to get an EKG, but the internal med doc needed to put the order in. Basically I got the EKG before an actual order was in since the doctor was taking so long to respond to my STAT page. Once an order was put in, I got another EKG that showed NSR with 1st AV block. Long story short I had rapid team come up to look at the patient and the rapid doctor came and looked at both EKG's. But the rapid team told me I could lose my license for getting the first EKG without an actual order. Has anyone heard of this? I totally understand grabbing an EKG for no reason, but I was just getting it proactively before the doctor put the actual order in since I knew it was gonna put in, and the cardiologist also said too. Feeling a little discouraged because I didn't know this and wonder what other things I could do in hopes to proactive and help my patient could actually get me in trouble. 

[Hannahbanana, BSN, MSN]

floydnightingale said:

time to look for a new job, there's enough work out there to not have to tolerate a toxic or threatening atmosphere and every day you work there your license is at risk due to administrative incompetence, if there's a bad outcome they will not hesitate to throw you under the bus

Well, I do try to remember not to ascribe to malice that which could be laid to ignorance. The hoary old "Lose your license" trope just refuses to die. It's as common anywhere there are nurses as exam gloves and washcloths. 

[FiremedicMike, RN, EMT-P]

delrionurse said:

Aren't they all orders per protocol and not self-initiated? In many places providers are aware of orders per protocol and the nurse enters them in. 

Sure I suppose that's accurate, but I'd also say those are common sense protocols that shouldn't need to exist.  I'm guessing based on how that incident went at the OP's hospital, those common sense protocols not only aren't in play, but there is no ability to critically think and act on what's right.

 

[emtpbill, ASN, RN, EMT-P]

  I can see you possibly losing your license if you, per se, started grabbing and pushing Morphine or antiarrythmic (sp) drugs before a doctor could look at the patient and put ordrers in, either verbal or written.

 

    You'll be fine. Many times I have put orders in for radiology or lab orders before the doctor saw the patient. Working the ER I have gotten to know what doctors want as far as diagnostic tests.  If you need guidance and cannot get a doctor to respond timely then just kick it up to the charge nurse for advice. But if your gut tells you otherwise then I would listen to my gut instinct.  If its in the patients immediate best interest and you can justify what you did (within scope of practice) then I would be hard pressed to find anyone that would go against you.

[FolksBtrippin, BSN, RN]

Whoever said that is either stupid, untrustworthy or both. Unfortunately there are plenty of them in healthcare. As long as you aren't completely surrounded by them and your boss isn't one, it's okay to ignore that person and keep on going. And as others have said it is utter nonsense that you would lose your license for that. 

I wouldn't quit over this but I would put that person on watch. People who continually act that way need to be corrected.

[ForeverYoung018]

There are many cases in which we do things and obtain an order later. For instance, if we go in and find a patient hypoxic, we aren't going to wait for an order to apply O2. We would apply the O2, see if sats come up, and then notify doctor and get an order. This is ridiculous and you will not lose your license. In the future, if the doctor isn't responding, just call a Rapid Response. I have done that multiple times when I don't get a response in a timely manner. I am grateful that our Rapid Response nurses are phenomenal and always have the floor nurse's backs with stuff like this. 

[Tweety, BSN, RN]

Any reasonably intelligent nurse will do an EKG on a patient experiencing chest pain.  Any reasonable doctor is going to order an EKG.  

When I have a patient in chest pain I don't wait for the doctor to call me back.  Been doing that for 32 years and haven't lost my license yet.  I start doing the EKG while someone is calling the doctor.  Often by the time the MD calls back I have the EKG in hand and can report what it says.  These days I have to put the order in right away so it will download from the EKG machine into the electronic chart.  100% of the time the docs are fine with this.  Never had a doctor say "no I don't want an EKG and I'm going to report you to the Board of Nursing".

The RRT was being a drama queen.  But the point being you should always cover yourself with an order.

 

[offlabel]

Invite the RR team member to write you up and be sure to copy the cardiologist and the medical director of the RR team. 

[Candy999]

what do you mean you had no order? You had a verbal order from a cardiologist. That is not your problem that the house doc did not respond on time to the emergency. You did what the prudent nurse would do and you caused no harm. ECG and trop always ordered for a pt with a chest pain. You did not do anything stupid. And it is not invasive.

Did the rapid come in because the pt started to feel worse or because the house doc asked them and the pt was doing fine?

 

There are some people in the healthcare that try to make new grad feel bad about themselves and RRT staff is often one of those people. Because RRT are always old, seasoned nurses. Do not feel bad you did not do anything bad. 

[Nurse Beth, MSN]

But what's essential for you to know is your facility's policies regarding obtaining an EKG, lactate, or ABG under certain situations.

Contact your educator and ask for the source. Read it yourself.

Otherwise, it is just someone else's opinion, which does not protect you. It's incredible how many nurses will pass on misinformation as fact and how many nurses are willing to accept it.

I always ensured I knew the rules before breaking them with a defensible, safety-based rationale.

[Mary R]

mrphil79 said:

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The thing I'm surprised you didn't get jumped on for was involving a cardiologist - unless you had standing orders for that, it's a decision that should be up to the hospitalist. Accelerated junctional and 1st degree blocks aren't butt puckering rhythms that warrant a page to cardiology unless you have a specific order to notify of any rhythm changes - and you'll quickly learn that the readings on the tops of EKGs are wrong a good 30-50% of the time. Honestly there's not a single rhythm that would cause me as the nurse to involve a cardiologist without a specific order in place - from NSR to 3rd degree to asystole, I'm dealing with the hospitalist on the floors and the ER doc if I'm in the ER. It's THEIR job to consult other docs. 
Definitely get the EKGs - but leave the cards consult to the hospitalist in the future. "

I didn't think she was consulting cardiology but instead paging a cardiologist already consulted. If cards has seen my patient my hospitalists are going to ask why I am not paging them with any CP, arrhythmia, etc concerns. I go to the hospitalist secondary when cards doesn't get around to calling me back in a timely manner. 

[jenOK9]

No you could not lose your license.  Sometimes people say things like that to make you look or feel insecure because they are insecure and like to be a big deal.  You did a great job.  Did you talk to your nurse manager about this?  The only thing I would have done differently is to contact the charge nurse or house supervisor and bring them in so they are responsible, too, since the md wasn't reachable.

[nomad_2888]

Better safe than sorry with that EKG prep.

Now, about that nitro situation – if 2 doses were administered, why not a 3rd? Did the nitro relieve the chest pain? Did you update the doc on the chest pain relief along with the supplemental oxygen? A 12 lead EKG is typically initiated for any change in rhythm...Also if the patient is SOB, giving oxygen to be safe is...no bueno. Too much oxygen can cause just as much damage, especially for early ARDs.

When unsure, call RRT! Keep the charge nurse in the loop if the doc's MIA. Don't feel discouraged for advocating for the patient.

Soft heart, and a steel spine ❤️