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.

[MiladyMalarkey, ASN, BSN]

Sounds like you advocated for your patient to me, to the patients benefit!

[Helen Crump]

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.

Who cares why he was mad? Your job is to take care of the patient, not soothe MD egos. You did a fantastic job, keep doing what your doing. Dr. Jerk will get over it.

[Kooky Korky, BSN, RN]

The only thing I'd have done differently (in addition to all that you did) is I'd have called my Supervisor/Manager and made that person aware that this doctor wasn't returning your calls and that the pt's labs and cardiac status were off.

She could have probably reached the doctor or, if not, could have involved the Chief

of the service, who would have, hopefully, dealt properly with the situation and looked into why the first doctor was ignoring you.

Even if the manager/sup had done nothing, you would have been off the hook.

I hope you documented every single attempt to reach the doctor.

I would also ask this doctor sometime soon what was up with his not wanting to deal with the low K+ and the high ammonia. Very nicely, of course.

Approach him in the manner of someone who wants to learn and realizes that he is the teacher and you appreciate his time and sharing of his knowledge.

At the very least, the doctor should have answered your pages and should have explained why he was not concerned about the lab values and why he was choosing not to treat them at that time, maybe should have given you parameters for when to call him.

just curious - what did the night nurse do about this patient?

[3ringnursing, BSN]

Nice work nurse! A job well done.

I have more than 23 years nursing experience, and I still get the pissed off on call doctor attitude from some when my requests clash with their thoughts.

Why? Who knows ... the moon is full, they had a fight with their significant other, or they are merely not listening to what you are saying - take your pick. All you can do is steel your resolve and be a champion for the patient. That my friend is your primary job description, and you did it well - fabo in fact.

It won't change as you accumulate nursing years under your belt. Some on call providers will still try to bulldoze through whatever you are saying as a tactic to decrease phone time interaction - much to the patient's cost if you allow it.

Just keep doing what you've been doing - you have had it right all along. It's the hospitalist that needs a wake up call. He/she could have killed that young man if not for your Intervention. That is a big kudos to you and your problem solving skills. God bless you and every nurse like you!

[RNGummy40]

Dear ella2990, BSN, RN,

You did your job! There may have been may factors why the MD was upset with you, BUT who really cares?

If the physician was concerned about psychiatric boarding, then do his job, and assess his patient! He needs to complete an H&P for starters! When do psychiatric facilities accept patients without an H&P? The patient was confused and had an elevated lactose level, that not an excuse! Any nurse can perform an assessment on a patient confused (whether or not the patient is violent).

The untreated medical concerns the physician initially refused to address, would prevent any psychiatric facility from treating the patient. I have not worked with any psychiatrist or psychiatric nurse practitioner who would throw caution to the wind and prescribe anti-psychotic with the rhythm abnormalities the patient presented with! Psychiatric facilities and hospitals in general are trying to prevent QTC prolongation when administering anti psychotics and your patient did not seem appropriate to treat. In addition the potassium and lactate levels, would just complicate treatment.

From reading your post, I wonder if your facility has an ASAP team? At my facility, that patient would have been ASAP'd. That doctor would have had to answer to the House Supervisor, Unit Manager, the Critical Care Nurse, and Respiratory Therapist, oh and SOCIAL WORK!!!

NOW, looking back at the discharge plan the MD had in mind. Lets hypothesize, and say you did allow the patient to discharge with not interventions, complete assessments documents, but abnormalities documented. Who would be the nurse signing off on the discharge? Who would be the social worker? Who would be the Doctor? If the patient coded in transport, if you could get a psychiatric facility to accept, even after giving a nurses to nurse, who would be responsible?

You deserve a significant acknowledgement of the great work you did and if your facility has a anonymous reporting system, you should be reporting what that doctor did.

[Here.I.Stand, BSN, RN]

My question now is, why was the primary physician angry at me?[/Quote]

I would be willing to bed that the primary MD got a good shellacking by the cardiologist. His ego is wounded, so he lashes out at someone other than himself.

In any case, you were right and did an AMAZING job advocating for that patient! You may have saved his life.

[dkrnusa, BSN]

Great Job!! I would really enjoy working along side you!!

[djh123]

I think you did great. On a much less critical level, I argued once on the phone with a NP about some new orders for one of my residents. She got cranky and I quit trying to argue with her, but the deal was, she had literally never seen this resident, while I'd worked with her for at least a couple of years if not longer. It's been a while since that happened, but I'm pretty sure at least one of her new orders proved to be a bad choice after a while.

[RNikkiF]

You did the right thing. You trusted your instincts. Don't lose a wink of sleep about why the doctor was mad. He was probably embarrassed because you caught something he missed... Most docs would thank you. Sounds like you got a diva. Rest easy and keep on trusting that gut. He'll be a little quicker to trust you next time since you showed some cajones!!

[dimpledRN]

You did the right thing and that patient was lucky to have you advocating for him!!

[Jules81, BSN, RN]

From a patient/family point of view thank you for being dilligent! In 2013 my mother went to the ER three days in a row the week of Christmas and was discharged each time with constipation. Pain kept getting worse but they kept dismissing her. On Christmas Eve she went in with fever, distended stomach, and pain so severe she was physically unable to get out of the car. Her colon ended up rupturing and she became septic and nearly died. No one at the hospital advocated for her and when my father questioned the discharge the third day the nurse just shrugged and said if the doctor thought there was something wrong he wouldn't be discharging her. Mom spent 22 days in ICU, additional 10 days in the stepdown unit, and went home with a colostomy and was unable to care for herself and required help for several months. She ended up with a colostomy reversal but has several lasting medical conditions as a result of the ordeal. Long story short, NEVER EVER be sorry for questioning if you feel like something is wrong. You could be saving someone's life. Physicans are not God. They are not all knowing and do have bad days. Know that you did the right thing no matter how many years experience you have vs. the physican. If he's mad it may be because he knows he made a mistake or it could be because he was in a crappy mood but a bad call is a bad call. You made the right one.

[Charity, RN, APRN]

You did the right thing. Just can't take it personally, as some people can never "be wrong." At my teaching hospital, we don't hesitate to follow the chain of command. In the past, it has had to be taken to the doctor's department head, and even to a hospital administrator!