I Need Advice - MD Not Signing Order - page 2

Hey everyone. I'm a RN working in a PACU. At my facility, CRNAs do the cases and there is one float MD that is there as a resource. We have "protocols" to give meds for pain/nausea without needing to... Read More

  1. by   caliotter3
    Quote from Andrew, RN
    I'm on call Saturday and Sunday for 12 hours each day. This is so screwed up. I'm wondering if they're going to take this away from me too. I'm wondering if I still have a job.

    People keep things from this doctor all the time because he is overboard.
    When dealing with an overboard doctor or other staff member, it is best to CYA all the way. If things go ok for you, in the future, never do anything with this doctor that is not to the T the way it should be. Assume nothing with him, always put it in writing and get his signature or a TO from him before proceeding.
  2. by   It'sMe, RN, BBA, MBA
    Andrew, keep your head up and hang in there. This sounds more like "killing the messenger" than anything else. Your career is important so don't let their poor planning and practice ruin your career. Help fix it and you will turn from "heel" into "hero." We all are pulling for you!
  3. by   Virgo_RN
    I agree with the above. Your facility needs to have written protocols and order sets in place, and for whatever reason, you are being called out on something that has been common practice for a long long time.
  4. by   Chapis
    Where can I find your Orientation Woes Thread?
  5. by   wtbcrna
    Quote from Andrew, RN
    Hey everyone. I'm a RN working in a PACU. At my facility, CRNAs do the cases and there is one float MD that is there as a resource. We have "protocols" to give meds for pain/nausea without needing to call the doctor. The doctor then signs the order some time later, often not seeing the patient ever.

    Here's my problem. I had a patient that just had a very painful ankle surgery. The surgeon wrote for a dilaudid PCA. I called the pain nurse to come and set it up. In the mean time, the patient was hurting at a "12 out of 10" and their vital signs/facial expressions reflected this. The pain nurse told me it would take her a while to get there and that I could give the patient some dilaudid IVP. Nothing wrong with that, we do it all the time. Basically, we are giving the patient their loading dose that the pain service nurse would be giving anyway once they get the PCA set up.

    So, I give her 1mg IVP. Waited 5 minutes, gave another 1mg. The patient's pain went down and I left it at that. I wrote my order for it. The patient had a good outcome and had pain relief. This was earlier in the week.

    Fastforward to today. I get called into my charge RN's office. The anesthesiologist is refusing to sign this order. I got sent home and they are going to talk to the pain service nurse later today when she comes in at 3 pm. I'm not sure if I'm going to have a job and it's up to "how far" the doctor wants to take this.

    Basically, I was going by our protocols and giving the patient a medication in a manner consistent with its guidelines. I don't know what to do.

    I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.

    This sucks. =(
    No offense intended, but I wouldn't have signed an order like that either and I would rarely if ever order that much dilaudid in such a short period of time. Basically every milligram of diluadid is equal to 8mg of morphine and it takes approximately 10minutes for each dose to take full effect, especially full respiratory depression.
    Do you normally give 16mg of morphine over 5minutes time in your PACU and do your protocols actually specifically state to give that much dilaudid over such a short period of time? Pushing that much dilaudid that quick is dangerous in opioid naive patient.

    I am not trying to give you a hard time, but I just think that was a very dangerous thing to do.
  6. by   Koyaanisqatsi-RN
    Quote from wtbcrna
    No offense intended, but I wouldn't have signed an order like that either and I would rarely if ever order that much dilaudid in such a short period of time. Basically every milligram of diluadid is equal to 8mg of morphine and it takes approximately 10minutes for each dose to take full effect, especially full respiratory depression.
    Do you normally give 16mg of morphine over 5minutes time in your PACU and do your protocols actually specifically state to give that much dilaudid over such a short period of time? Pushing that much dilaudid that quick is dangerous in opioid naive patient.

    I am not trying to give you a hard time, but I just think that was a very dangerous thing to do.
    Yeah, it seems to me this is likely going to be what the MD is upset about.
  7. by   azhiker96
    In my PACU we need an order for every med (except in rescue situations;O2, narcan, etc). In those cases we still try to get a doc asap and then write verbal orders as needed.

    We have a pre-printed PACU orders sheet to make it easier for a doc to check the boxes and fill in the numbers. Most of our docs use that sheet which has places for PRN tx for pain, nausea, hyper/hypo tension, O2, and testing. The docs who don't use that sheet get paged more often than those who do use it. Sometimes the doctors want to be paged so they know if the patient is anything more than a boring recovery. Good luck buddy! Always cover yourself with an order and charting.
  8. by   Batman24
    Hopefully the pain nurse will be able to clear up the confusion. I would however use this as a learning experience and not do it again until protocols are in writing to protect yourself from here on out.

    If this doctor is known to be a problem all the more reason to do nothing without written orders to cover yourself. I have a feeling this will pass after they talk to pain nurse but still use it as a way to change your ways from here on out so you don't become a scapegoat again in the future.
  9. by   Andrew, RN
    Pain nurse is saying that she gave me an order to medicate the patient, not necessarily a dilaudid order.

    They took away my weekend call and told me to stay home on Monday. They're going to meet with me on Tuesday. I want to sit down and talk with this doctor so we can figure out what the problem is and what we can do about it.
  10. by   Batman24
    I'm sorry this happened to you. Sounds like you are being a scapegoat here. I would start looking for a new job today. Pls don't let this scare you away from nursing. You will find your fit and sometimes that takes time. Consider this a good learning experience. Wishing you the best.
    Last edit by Batman24 on Apr 17, '09
  11. by   sjt9721
    Quote from Andrew, RN
    Pain nurse is saying that she gave me an order to medicate the patient, not necessarily a dilaudid order.

    They took away my weekend call and told me to stay home on Monday. They're going to meet with me on Tuesday. I want to sit down and talk with this doctor so we can figure out what the problem is and what we can do about it.
    I'm going to type this as gently as I can...

    Is the pain nurse qualified to "give an order" to another nurse? I've made the assumption that she's not advanced practice. Perhaps she can write an order based on her department's written protocols, but that doesn't qualify her as someone you can legally take a verbal order from.

    Without written protocols, you did practice medicine without a license. You gave a drug without a written or verbal order from a physician (or other qualified provider).

    I realize what the practice "has always been" and that "everyone does it" and that "it's understood". Many moons ago I did this same type of thing because that's what the seasoned nurses around me told me to do. I was (we all were) lucky that it never bit us in the butt.

    This is a (hard) lesson for you regarding your scope of practice and protection of your license. I do hope that things work out for you.
  12. by   BittyBabyGrower
    I'm sorry this happened to you. When writing a verbal/telephone order, make sure you document who you spoke to and read back what they said to you. Also, does your hospital have issues with sliding orders such as 1mg-5mg q10-20 minutes? This can be construed, sometimes, as medical management. We can no longer have such orders where I work, it has to be a specific dose, unless it is written in a preprinted titration protocol, such as most ICU settings have. He may be having an issue with the fact that you did not start at the lower dose and interval, instead you jumped to the higher dose and interval. JMHO.
  13. by   RN1982
    Playing Satan's advocate but if you didn't have written orders from the doc, but medicated the patient anyways, that can be construed as "practicing outside your scope". Also, I would like you to clarify with us, the role of the pain nurse. Is she an advanced practive RN? Does she have the authority to prescribe narcotics without a physcian's go-ahead? In the future, I suggest not medicating a patient without a signed order from the physician no matter often the practice is to medicate the patient, get a signed order later. It's your license, protect it.

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