We are standing at the counter of the nurse's station in the ER when I tell Dr. Hanson that his patient in 18 is asking for pain medication.
"There's nothing wrong with her," he retorts. "She's just full of BS."
"If there's nothing wrong with her, and she's just full of BS, why are doing $8,000 worth of tests?" I ask bluntly. "Maybe we should give her some pain medication just in case."
When Dr. Hanson slides back into the doc box to order some morphine, another nurse who had overheard the exchange nudges my arm to get my attention. She half whispers, "I like the way that went down." I hadn't given the exchange a second thought while it was happening, but, based on her comment, it occurs to me that I'd just done something she would have found hard to do. It may be easier for me to confront doctors because I'm older than a lot of them and worked here longer than most of them. Also, in the ER, we are used to working alongside different classes of providers, interacting on a casual level that might feel uncomfortable to nurses in other departments. Admittedly, I am writing from an ER perspective. But, even if you are relatively young, new, or intimidated for any other reason, there are three times nurses must be assertive enough to speak up.
First...
First, we need to confront providers when their orders don't make sense or demonstrate a clear mismatch to a patient's individual situation. In the era of point and click, entire panels of orders are quickly entered. Sometimes the entire set is intended for another patient. Or maybe the doctor fails to remove a fluid bolus from a panel ordered on a potentially septic patient who is also showing signs of acute CHF. Maybe a provider orders an x-ray on the wrong hip, or omits a Digoxin level on a patient with symptoms of toxicity, or orders antibiotics without ordering the usual blood cultures. These simple, potential, or even obvious oversights are easy to confront because we're "just checking" without questioning judgment. It's an easy question: "Hey, I just wanted to double check. Do you want any blood cultures before we start the Rocephin?"
Second...
The second level is a slightly harder conversation. But when there appears to be clear judgment error, we still need to ask. For example, an 87-year-old with multiple system failures comes in via EMS. He is crashing, and we intubate him on arrival. The workup shows he needs immediate surgery to remove a large intra-abdominal abscess. But, when the family shows up, we learn that the patient has an Advance Directive and doesn't want any heroic measures. He probably would have refused intubation if he had been alert enough to express himself. The surgeon evaluates the patient and states that he will not survive the surgery. The family decides to have him extubated and go to comfort measures only. The daughter specifically asks, "But you won't do anything to make him die quicker, will you?" Dr. Stone assures her that we will not.
Dr. Stone and the surgeon spend several more minutes discussing the case with the family while the respiratory therapist removes the ET tube, and the patient starts breathing on his own again. As Dr. Stone walks away, he says, "We can restart Fentanyl drip." The Fentanyl drip was held along with the Diprivan due to low blood pressure prior to the decision to extubate the patient. It was running at 300 mics/hour. I ask Dr. Stone, "Are you sure you want to restart it? You just told the daughter we wouldn't do anything proactive to cause his death." He replies that it will be okay and turns to walk away. I just questioned his judgment, and he confirmed his intention.
Third...
Now we hit level three. It gets more challenging when we have already questioned a doctor's judgment once, but he persists in following a course we cannot condone. Continuing the case above, I follow the doctor toward the doc box. I'm not belligerent, but I can't let this go. "Dr. Stone, at the very least I'm going to need you to enter a new order, and I'll have to chart we had this conversation just in case we all end up in court together trying to explain why we ran Fentanyl at a rate that stopped this guy from breathing right after you assured the daughter we wouldn't do anything to hasten his death." He stops on a dime, whirls back toward me, slaps himself on the forehead, and says, "I forgot we just extubated him. Good catch." They can be very good. They are not gods. Sometimes the third level is essential.
If we get to level three, a second or third opinion may help bolster courage before going back for the decisive confrontation. For example, there is an order for a bolus of Integrilin which is well over the standard protocol dose. I question the doctor, and he confirms the dose. But he is looking at an x-ray, and I have a feeling I don't have his full attention. I double check the order in the computer, pull the medication from the Pyxis, and turn to another seasoned RN in the med room. I hold up the bottles and show her that the order for the bolus alone grossly exceeds the volume in the large bottle for the total infusion. We look at each other and say in unison, "No way." Emboldened by her confirmation, I go back to the doctor with both bottles in my hands. I get his complete attention and show him the bottles, explaining the usual dose compared to his current order. He checks again and finds that he is off by two decimal places, accidentally ordering 100 times his intended dose. Oops.
A friend gave me a t-shirt years ago. It is threadbare now, and the slogan is hardly readable. But it has generated some interesting comments and stories through the years: "Be kind to nurses. We keep doctors from accidentally killing you." It's true. We are it. We are the patient's final defense in the delivery of most healthcare, and we must have the courage to confront other providers on whatever level is necessary to make sure we all get it right.
