MD was angry I questioned him.

[ella2990]

Almost time for shift change, I admitted a very young male who was very confused but pleasant. Hooked him on tele and noticed his heart rate was very irregular it would be as low as 50s to SR to as high as 120s-150s at rest. EKG was done and was uremarkable. No cardiology consult was put in the order. No H&P was documented since he was very out of it when brought to the ED the night before. BMP was also unremarkable except for k of 3.0 and ammonia level of 48umol (which in our hospital is considered critical value). Looked at the ED documentation and pt was given 4 doses of Latulose and no repeat ammonia level was done and also no documented repletion of K was done. I tried paging the doctor who admitted the pt but I already know he won't be calling me back since it was already past 1900 and I also called the on call MD for that night but I know I won't be hearing any call back anytime soon. So the best I could do at that time was document all my findings and my attempt on calling both the hospitalist and the on call. I also told the night nurse to page the on call again if she doesn't get any call back within the hour.

I came back the next day, and the nurse reported to me that his heart rate went as low as the 30s and his lactulose level was still 48 after giving one dose last night. K was also still at 3.0.

I text paged the MD of the situation. No call back after 30 mins. I call paged the MD 2x since I thought that it was critical that the MD be notified of the pt's heart rate dropping to the 30s.

MD finally called me back and told me that he will be discharging the pt today to the psych facility and almost hung up on me as soon as he finished his sentence. I told the MD of what happened last night and that his K and ammonia are still abnormal. He told me he's not at all concerned about it. At first I thought I was imagining things. I mean yes I only have 2 years of nursing experience vs. how ever many years he's been practicing, and the thought of questioning him I thought was insane! But it still bugged the crap out of me. At that time I was very nervous and braced myself for whatever's about to happen. I repeated myself and told him that maybe his heart rate was all over the place because his K was low. He said "well he can just get K supplement at the psych facility", I told him, I don't think the pt was safe to be DC with such erratic heart rate and maybe the pt will benefit for a cardiology consult. I also told him maybe his high ammonia is contributing to him having altered mental status. I can already tell he was very pissed and annoyed. He told me well go ahead and and put the consult in but want him DC today!

To make my story short. Cardiologist saw the pt and told me that the pt was not safe to be discharged and was glad I insisted on consulting him. Turned out the pt was in junctional bradycardia and that if the pt was DC'ed at the psych facility, there was a big change he'd code and be sent back here or the ICU.

My question now is, why was the primary physician angry at me? I feel like I did the right thing. I did not disrespect him or was aggressive in anyway.

[FolksBtrippin, BSN, RN]

You did your job well. You were right, and he was wrong. Sometimes people get mad about that.

That patient could have died. Most psych facilities are not equipped to give K or deal with irregular heart rate. I work in psych and our patients have to be medically cleared first.

[CardiacDork, MSN, RN]

You are a TRUE patient advocate. Hats off to you!

[KatieMI, BSN, MSN, RN]

You did what you should do. Just for the future reference: HIGH potassium causes bradycardia (that's how IV shot execution works), not low potassium. Potassium of 3 is usually not low enough to cause alarming changes in heart rate/rhythm).

New heart rate/rhythm alteration in patient from mental health => drugs he/she is taking + aggravating factors (most commonly, dehydration) (it should be ONE of your first differentials, not the only one). Know doses and times; if primary care refuses to deal with it (which they commonly do, as most of primary hospitalists do not have mental health experience), call the doctor who manages these meds.

And, yeah, get this jerk out of your mind.

[JKL33]

ella2990,

Like a previous commenter, I really enjoyed reading this! I love how you wrote about bracing yourself for whatever was about to happen - that's the same thing I used to do when I knew something wasn't right. I'd say to myself, "what's the worst that can happen?" Well, s/he will yell at me or sigh or get snarky. Big deal. I'll take that any day over not doing what is right for the patient. The more you do it, the more comfortable it becomes.

I'm surprised anyone would've been able to acquire a psych bed for this gentleman anyway. In the ED, we can't get one if the patient has sneezed twice while in the department...okay that's an exaggeration (and I understand why it's important)...but this guy would not have gotten a bed.

Very good work! Kudos to you.

[LovingLife123]

You did what you should do. Just for the future reference: HIGH potassium causes bradycardia (that's how IV shot execution works), not low potassium. Potassium of 3 is usually not low enough to cause alarming changes in heart rate/rhythm).

New heart rate/rhythm alteration in patient from mental health => drugs he/she is taking + aggravating factors (most commonly, dehydration) (it should be ONE of your first differentials, not the only one). Know doses and times; if primary care refuses to deal with it (which they commonly do, as most of primary hospitalists do not have mental health experience), call the doctor who manages these meds.

And, yeah, get this jerk out of your mind.

I have to disagree with you that a potassium of 3.0 does not cause irregular rhythms. I see it all the time with a K level of higher than 3. They start with throwing a few PVCs then it escalates to an irregular rhythm if it goes untreated. Not saying that was the cause here as the cardiologist confirmed another issue, but most certainly a level that low can cause issues. It's why in the ICU unit I'm on we treat under 4.0. We are aggressive enough to try and head of issues.

[NurseKatie08, MSN]

OP, great job advocating for your patient! Also, let me just add that Lactulose can also end up causing low K due to losses in the stool. I am a liver transplant nurse and very very familiar with giving Lactulose for hepatic encephalopathy (which I'm imagining this is why this patient was getting it). We honestly don't even measure ammonia levels...mental status is what really tells you if the Lactulose is working. Good job! Considering psych usually requires medical stability, this person definitely was not stable to transfer!

[kataraang, BSN]

Great job on advocating for the patient! You acted responsibly and professionally. The patient got the care he needed, and perhaps his life was even saved. I know you know this but never allow someone's reaction or demeanor deter you from the right decision. But multiple pages to multiple people going unanswered...this is an organizational problem. I feel that should be addressed to find out a) problem with paging system or b) people ignoring/disregarding pages.

If I had a patient with heart rate dipping into the 30s, and a doctor didn't reply ASAP I'd be calling a rapid response. Or grabbing any available doctor regardless of specialty into the room.

[Nurse Beth, MSN]

You are awesome!

Strategies I've found to work when provider d/cs patient inappropriately:

"Doctor, the B/P is 89/45"

"I'm not concerned. Re-check it and discharge him!"

"OK, what parameters for B/P do you want used for discharge?"

A version of this works every time. Here's another:

"Would you like an EKG or can I take that as an order to discharge without an EKG?"

Also is there a chain of command at your facility for when providers do not respond?

[Ruby Vee, BSN]

If the physicians aren't occaisionally "yelling" at you from time-to-time, you probably aren't doing your job as a patient advocate.

No, seriously -- well done for standing up for your patient. A lot of nurses cave under the pressure, something that serves no one, including the jerk of a physician who wasn't doing his job. Like Beth, I've found that asking for specific orders works well. "If a K+ of 3.0 is OK, when would you like to be notified?" "Should I do an ECG for that bradycardia, or are you giving me a verbal order NOT to do one?" It won't make the jerk any happier to have it phrased that way, but I wouldn't worry about what the jerk thinks of you. The cardiologist and your other colleagues know you did the right thing, and had the backbone to stand up to the primary physician. Well done!

[KatieMI, BSN, MSN, RN]

If the physicians aren't occaisionally "yelling" at you from time-to-time, you probably aren't doing your job as a patient advocate.

This should be printed, nicely framed and hung over every nursing station.

[Esme12, ASN, BSN, RN]

If I had a dime for every time I annoyed a physician....I would be rich!

Well done! You advocated for your patient and prevented an untoward outcome

[quazar]

So proud of you. You may "only" have 2 years of nursing under your belt, but your spine is already rock solid. You did GREAT.