I Need Advice - MD Not Signing Order - page 4

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   VICEDRN
    Dear Andrew-

    I will let the other comments from experienced nurses stand without further comment because I am student.

    I actually thought it might help though if I let you know that nursing is not the only profession where this kind of stuff goes on. I am a former paralegal and I gotta good story for you.

    An associate attorney asked me to prep some subpoenas for trial. I ordered the subpoenas, filled them out and served them according to the directions he had given me which I had written down as we spoke. When the partner was preparing the boxes for packing for trial, he asked the associate where was the subpoena for such and such entity. The associate didn't have one and he blamed me for the entire incident.

    I almost lost my job. No matter what happened, I refused to back down but it didn't matter. After that, I told the associate that he would need to communicate to me all requests in writing via email so that we wouldn't "miscommunicate" again. Of course, he didn't want to do this, called me stupid in so many words and etc. I could on and on with similar stories. I have been threatened with my job sooo many times over stuff like this. Trust me on this!

    Inside, I was boiling that I had to use the politically correct speak "miscommunicated." Inside, I couldn't wait to leave work as a paralegal. The only thing I can say is that since then I have learned to go inward with it. I learned that I know what I know, that I just need to accept that his lies are his problem and his ego is not my problem but also that I am not in control of what happens to me in these situations. Maybe it rides out like someone else already said or maybe it doesn't. I have learned to over-communicate and smile when people act like I am stupid for doing so.

    Leaving nursing isn't the answer because it happens everywhere. Good luck.
  2. by   wtbcrna
    Quote from Andrew, RN
    Some of this advice is helpful, some of it isn't. Thanks anyway for those who have commented.

    Here's some facts. The hospital is not JCAHO so their standards don't apply here.

    The pain nurse is a RN, not AP. They write orders all the time that later get signed by the anesthesiologist, just like I do, only they write much more... PO opioids, sleep aids, toradol, etc etc.

    In the given situation, I have done nothing wrong. The patient had pain, I treated it using a drug that they were prescribed to get. It's a gray area I am in. Perhaps if I had given fentanyl (a drug the anesthesiologist seems to be more comfortable with) instead I would not be in this mess and the doctor would have signed the order, but I gave dilaudid because that is the drug the patient was to receive via PCA.

    The pain nurses often times when setting up the PCAs will give a loading dose starting with 2mg and redose 1-2mg at a time. I've seen them give 4-6 before. Every patient is different and requires a different dose for dilaudid. To the person that says "OMG it's 8 times more potent than morphine blah blah blah"... It's 2-8 times more potent, depending on the patient.

    I gave 1mg, repeated it, then stopped. There was no harm done to the patient. Nothing bad happened. They're just singling me out. I gave a normal loading dose that the pain service nurse would have given. She was sitting around in the breakroom instead of being at the bedside treating the patient's pain. So I did.

    This is what I hate about nursing. Infinite responsibility and no real power to do anything.
    You know your post really worries me that you think there is nothing wrong with your dosing of this patient. Here is dosage recommendation from Lexi-Comp's Drug Guide (which is used by the American Pharmacists Association): Dilaudid-IV: Initial: 0.2-0.6mg every 2-3hrs for opiate naive patients. Now from the Anesthesia Drugs Handbook by Sota Omoigui (which is still one of the most popular drug references for anesthesia providers) recommends: Slow IV: 0.5mg-2mg (0.01-0.04mg/kg) every 4-6hrs. I am not sure how you can justify giving a dosage that goes against pretty much all drug references and think it is ok....mistakes happen and we learn from them, but thinking it is ok to dose patients like this without realizing that these are high doses of opioid doses stacked one on top of each other before even maximum respiratory depressant effect has set in is bad judgement in the very least.

    All this other stuff that your talking about is extraneous information. The simple fact with your current state of denial thinking that this type of dosing is ok to use on patients just because they are in pain is going to cause a patient serious harm or death.

    I could care less what another nurse does, and neither should you when it comes to something like this. This is you doing something that is not recommended and you can't defend it. By the way Dilaudid is 5-8x more potent than morphine depending on the reference. Do I need provide those references also? Try anything by Stoelting to start....

    To start why don't you put aside the scapegoat attitude and set up meeting with the anesthesiologist and have him/her explain to you their aversion to signing your order, because if I am so wrong then why is MDA not willing to sign the order?
  3. by   litbitblack
    Well Im sorry I disagree with some of you. If you have an order for a pca dilaudid and you give a loading dose it is still part of the original pca dose. WHY is it any different. The pt is getting pain med as ordered he is just getting his loading dose before the actual pca is started. Now if there are standing pca dilaudid orders that do not have an ordered loading dose then there would be a problem. I probably would have ordered per pca orders to the order that you wrote. The doc is being like that because he knows he can. I would personally talk to him and explain your thinking. Maybe he is thinking totally off the wall about the whole thing. And if hes not then I would call him about everything lol. Even tylenol unless there is a standing to cover you. We had some ortho docs who wanted us to handle stuff before we called them. When i first started working on that unit i had to get to know who wanted what. WEll after awhile this particular doc wouldn't even cover an order for an h&h on a post op that had a low bp (which is what we normally did). He flat out refused to sign this other nurses order for lab. He wanted to be the decision maker. LOL....which is totally fine with me if you don't trust my nursing judgement...i will call you 30 times a day if required lol. Hang in there. If there was a pca standing order for that bolus then I think you did nothing wrong. And to save yourself and your license then I would call him for everything you don't have a sig for and if you have a question about anything. Its your license and they get paid the big bucks so CAll HIM!!!! let us know what happens.
  4. by   Virgo_RN
    Quote from wtbcrna
    You know your post really worries me that you think there is nothing wrong with your dosing of this patient. Here is dosage recommendation from Lexi-Comp's Drug Guide (which is used by the American Pharmacists Association): Dilaudid-IV: Initial: 0.2-0.6mg every 2-3hrs for opiate naive patients. Now from the Anesthesia Drugs Handbook by Sota Omoigui (which is still one of the most popular drug references for anesthesia providers) recommends: Slow IV: 0.5mg-2mg (0.01-0.04mg/kg) every 4-6hrs. I am not sure how you can justify giving a dosage that goes against pretty much all drug references and think it is ok....mistakes happen and we learn from them, but thinking it is ok to dose patients like this without realizing that these are high doses of opioid doses stacked one on top of each other before even maximum respiratory depressant effect has set in is bad judgement in the very least.
    "IV Medications" by Gahart states:

    "0.5 to 1 mg every 3 hours as needed. May increase up to 4 mg every 4-6 hours if pain is severe."

    The OP gave the patient 2mg for 12/10 pain. This falls within the guidelines published by both Gahart and Omoigui.
  5. by   BradleyRN
    Quote from Andrew, RN
    I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.
    I would not have given more than 1mg in your situation, as the pt's ability to tolerate the drug must first be assessed. I do not believe that you made a "huge mistake" by giving 2mg though. The error i find is in an order that could potentially allow 4mg over 20 minutes. If i had given 1mg twice 5 minutes apart, then i would have just written: Dilaudid 2mg X 1 dose now. Since you only gave 2mg, what was the point in writing for more than that? Offer to rewrite the order to a dosage a little more fitting for a pt who may have never received the drug previously. Explain that 2mg would have been the loading dose anyway, and acknowledge that you should have written "MAX of 2mg" instead of 4. :spin:
  6. by   wtbcrna
    I am trying to teach you something since I write PACU orders everyday and you don't!

    1. You have not stated the body habitus of your patient, and along those lines if they were obese would you even know if they had Pickwickian syndrome. Would you even be able to recognize it? Do you even know what that is, because I you probably have had patients with it...

    2. The reference I stated was based on mg/kg. Did you take that into account? You gave no indictation that you did. Did volume of distribution even come into your mind? Those doses are over several hours and meant to be worked in with maximum respiratory depressant effect set in and then another dose given.

    3. You have not stated the exact type of surgery, the ASA level of your patient, what opioids were given during surgery, if any blocks/local were given or not. Did you consider that extreme pain after ankle surgery might be early signs that something is wrong?

    4. Was this an opioid naive patient or a chronic pain patient, if it is chronic pain patient then you are probably actually quite right in your dosing execpt for the time between dosing. Again you gave no indication that this wasn't an opioid naive patient.

    5. Did you send this patient to a unit that has constant pulse oximetry monitoring? Did you consider that respiratory effects might increase later after the pain decreased? Does the patient have OSA diagnosed or undiagnosed? Were they snoring in the PACU (that could give you indication)?

    6. How about since you came up with this plan on your own based on what you normally see in your PACU did you consider that there might have better alternatives? How about Toradol, an alpha-2 agonist, a rescue lower ext. block (which may or may not be done very often at your institute), and then just the normal nursing measures repositioning etc (which I assumed that you had already done).

    7. Now getting back to this 12 out of 10 pain.....That is not an objective scale. Patients can rate their pain like that and be comforted with two motrin or 160mg Oxycontin TID plus breakthrough oxy IR 10-15mg every 4hr prn (that was my personal highest dose opioid dependent patient) and have had the same procedure.

    8. Instead of considering me a troll you may want to think about all these questions that I just posted and if you can reasonably justify all your answers then I think most reasonable MDAs would probably sign your order or they might still be a jerk no matter what you do.

    Again I am telling you this as someone that provides anesthesia everyday, and I would have problem with my PACU nurses giving that much narcotic over such a short period of time without consulting with me.

    The other thing with this if you give such large doses of narcotics up front you have no idea what kind of doses the patient actually needs to make them comfortable (it should be the smallest dose possible to eliminate as many side effects as you can), and then you take a patient like this the start out on large doses of opioids continue them through the post op stay and the surgeon thinks they need large doses of opioids to go home on. Then these patients go home on large doses of narcotics. These patients then have up-regulation of their opioid receptors and develop opioid induced hyperalgesia.

    You obviously care about your patients or you wouldn't have went out of your way to make them comfortable, but there is a lot of other things that come into play.

    I have made errors in nursing, and I learned from them and moved on. I also hated many of the things that you are talking about and decided being an APN was the best route for me. Throw away your career in nursing or learn from it and move on it is totally up to you.
    Last edit by madwife2002 on Apr 18, '09 : Reason: quoted from deleted post
  7. by   madwife2002
    I suggest you ask what management feels you have done wrong and what can you do to rectify the mistake or problem!!! Go with cap in hand because how you handle this could make or break your career.

    You feel you have done nothing wrong but obviously somebody does, so you want to difuse the situation not aggrevate.
    Listen to what they have to say, try to keep emotion out of it, then present the facts. Try not to be defensive
  8. by   netglow
    Quote from Virgo_RN
    "IV Medications" by Gahart states:

    "0.5 to 1 mg every 3 hours as needed. May increase up to 4 mg every 4-6 hours if pain is severe."

    The OP gave the patient 2mg for 12/10 pain. This falls within the guidelines published by both Gahart and Omoigui.
    This is correct.

    Follow Vito's direction... this is the best way to organize your mind. You are a fighter, like me :heartbeat. Blow off some steam... prepare, but don't let anyone get an idea of where you see fault, no more discussing. When you formally meet this is your deal, if things look like you are going to be thrown under the bus, you question the doc, the pain nurse, your boss on the lack of protocol (have your documentation typed and dated, but don't let it leave your hands). You control the direction of that meeting. It means being calm, cold and calculated, clear, and concise in your questioning/response.
  9. by   Virgo_RN
    wtbcrna, it's not that you aren't raising valid points. The issue here is one of context. This is a new nurse who is working in a facility in which nurses writing these types of orders without an MD's order is the norm, and Andrew, RN, is taking the fall for it. This is something that has become an unofficial "protocol" where he works, and the new nurse who is doing what he has been trained to do by the experienced nurses who have come before him is the one being hung out to dry. Of course the anesthesiologist's concerns are valid (that he does not want to sign an order he did not give), but what we're really looking at here is a problem brought on by the facility's lack of written protocols, and Andrew, RN, the newbie, is caught in the crossfire. I agree it's a dangerous practice and needs to stop, but I don't agree that Andrew, RN, should bear this responsibility on his shoulders when this is a practice that has been in place and has been allowed to continue long before he ever set foot in that place.
  10. by   It'sMe, RN, BBA, MBA
    Quote from Andrew, RN
    Some of this advice is helpful, some of it isn't. Thanks anyway for those who have commented.

    Here's some facts. The hospital is not JCAHO so their standards don't apply here.

    The pain nurse is a RN, not AP. They write orders all the time that later get signed by the anesthesiologist, just like I do, only they write much more... PO opioids, sleep aids, toradol, etc etc.

    In the given situation, I have done nothing wrong. The patient had pain, I treated it using a drug that they were prescribed to get. It's a gray area I am in. Perhaps if I had given fentanyl (a drug the anesthesiologist seems to be more comfortable with) instead I would not be in this mess and the doctor would have signed the order, but I gave dilaudid because that is the drug the patient was to receive via PCA.

    The pain nurses often times when setting up the PCAs will give a loading dose starting with 2mg and redose 1-2mg at a time. I've seen them give 4-6 before. Every patient is different and requires a different dose for dilaudid. To the person that says "OMG it's 8 times more potent than morphine blah blah blah"... It's 2-8 times more potent, depending on the patient.

    I gave 1mg, repeated it, then stopped. There was no harm done to the patient. Nothing bad happened. They're just singling me out. I gave a normal loading dose that the pain service nurse would have given. She was sitting around in the breakroom instead of being at the bedside treating the patient's pain. So I did.

    This is what I hate about nursing. Infinite responsibility and no real power to do anything.
    Keep your chin up young man! This is a hospital and nursing administration problem. Forget JACHO, you have a state Department of Health (or whatever your state hospital licensing agency is in your state) and if I was your nurse manager and the DON I would be on top of this like white on rice! If there is even a hint of non-written standing orders being used the state department can come in and shut down your surgical services! Do you know how scared the Hospital Administrator would be of that possibility? He/She would have an immediate ulcer and have to go to another hospital and have it repaired! Surgical services, especially day surgery, is the lifeblood of the hospitals right now. The decrease is having an adverse impact.

    You need to be supported by your NM and DON in this situation. Your DON better have a heck of a relationship with the CMO. The CMO needs to go to this MDA and tell him to get over it, resolve it and help write standing orders to cover this in the future. JACHO or not pain relief is one of the number one sentinental events that MEDICARE and MEDICAID are looking at and they pay 70% of the bills. You tried to do right and they simply need to move on and fix the things that need to be fixed. You are the good guy in this and not the heel and you need to hold your head up and help fix the problem. Good luck!
  11. by   Andrew, RN
    Hopefully I will get to keep my job and help them change their policies so they can be doing things the right way.

    One of my friends got hired at this PACU the same time I did. She has 20+ years of Emergency Room and PACU. Here's what she had to say about this when I told her:

    i heard absolutely nothing!! Be sure to bring pain service into the mix. They order things and don't tell you or don't explain what they want when we are not familiar with the "way things are done" it really makes you feel like they enjoy not telling you what the rules are. i mostly get that feeling from one person. she seems to think that the way they do things is the way it is done everywhere. They do things way different than what i was used to. we used a lot of dilaudid, and not in pca's. (at the other hospital we worked at) plus we could give a bolus from a pca without waiting for the pain person to return to the department. we are not oriented to the machines, they don't tell us what they are giving, and when you ask they act like you are retarded for asking. they tie our hands to treat our patients the way we want to. I think I would get patients out faster and more comfortable to give morphine then fentanyl. if they have dilaudid in the pca, then the best thing to do is not mix drugs. the time i like to mix is give morphine up to 10 then give a tiny dose of fentanyl. i mean tiny. stephanie uses that and it works great. you end up wasting 3/4 of the fentanyl, but only use one morphine and they are comfortable. also we gave smaller doses of morphine quicker. one mg every 2-3 minutes. 5 mg is a lot for some people, 10 doesnt faze others. ask them for more clarification of what is expected. also ask what way to document pain team ordering medications and if you should write the order from them, since they give it. (they write it from the float because they are not physicians.) i really did not hear a thing... keep me updated and i will keep my ears open and not let them know i heard from you
    Last edit by NRSKarenRN on Apr 19, '09
  12. by   wtbcrna
    Quote from Virgo_RN
    wtbcrna, it's not that you aren't raising valid points. The issue here is one of context. This is a new nurse who is working in a facility in which nurses writing these types of orders without an MD's order is the norm, and Andrew, RN, is taking the fall for it. This is something that has become an unofficial "protocol" where he works, and the new nurse who is doing what he has been trained to do by the experienced nurses who have come before him is the one being hung out to dry. Of course the anesthesiologist's concerns are valid (that he does not want to sign an order he did not give), but what we're really looking at here is a problem brought on by the facility's lack of written protocols, and Andrew, RN, the newbie, is caught in the crossfire. I agree it's a dangerous practice and needs to stop, but I don't agree that Andrew, RN, should bear this responsibility on his shoulders when this is a practice that has been in place and has been allowed to continue long before he ever set foot in that place.
    Actually, you make my point for me quite eloquently, if you don't have written protocols and you don't have the training/advanced practice license then you shouldn't trust the MD or APN to come to the same conclusion that you have. It is your license that you have to protect just as it is that MDs license that they are protecting.

    Don't get me wrong either just because I don't agree with AndrewRN giving the meds in that dosage over that amount of time doesn't mean I would advocate to have him fired or even written up. I personally would just explain why this isn't a safe practice, no matter what the other RNs at that facility do, and as long as similar situation didn't occur again I wouldn't worry about it. I wouldn't want to work at facility like that one either.

    This should just be treated as a learning experience nothing more nothing less.
  13. by   Andrew, RN
    This MD isn't trying to protect his license. He's being passive-aggressive and overboard.

    The dosage I gave of this drug in this situation was safe. I've never had one of my patients respiratory arrest. I've never had to give narcan or reverse one of my patients because of something I have done. I've had to bag patients and reverse patients because of CRNAs that gave elderly patients and/or patients with impaired liver metabolism/kidney function too much opioids.

    The issue here is the facility and the way they go about "business as usual". I'll be in touch with a lawyer and my state board of nursing soon.

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