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Have you encountered useless residents?

Posted
by seks seks Member

This pt had been on the unit for a few days. Had been on tinza and asa since admission to the unit.

Start of shift, first day with him. He was c/o mild chest pain and bit of sob. A bit diaphoretic too. His SpO2 were fine but I cranked up the O2 a bit anyway. Paged the resident.

Came in within 5 min and assessed the pt. Came out and told me he sounded crackly and that pt pain has subsided. Ordered 1 time dose of IV Lasix. NOTHING else. I was expecting maybe a nitro spray or chest xray or whatever.

I came in next day...found out pt had a full code late in the night shift and passed away. Code team notes stated probably PE attack.

I don't know...been almost a week and been thinking this death could have been avoided.

VANurse2010

Has 6 years experience.

I don't consider that useless as much as the mistake of an inexperienced doctor. I'm not blaming you, either, but in the future if you continue to have concerns you should consider escalating over the resident.

Lol don't get me started

AJJKRN

Specializes in Medical-Surgical/Float Pool/Stepdown. Has 6+ years experience.

I don't consider that useless as much as the mistake of an inexperienced doctor. I'm not blaming you, either, but in the future if you continue to have concerns you should consider escalating over the resident.

Adding to VANurse2010's suggestions, I have found that telling a resident what you want helps advocate for the Pt and then you guys can get to learn together. It wouldn't have hurt to have done some serial trop's and maybe a D-dimer, which the resident may have been open to if suggested, or even asked for the CXR if you felt it was needed. Collaboration is key to excellent Pt care.

blondy2061h, MSN, RN

Specializes in Oncology. Has 15 years experience.

I'm curious how long you've been a nurse. It sounds a bit like you expected the resident to totally take care of whatever was up with the patient. Often times with residents, you need to nudge them toward what you need, and stay on top of them if the patient isn't improving. I'm not judging you at all, but I'm moderately experienced, and remember my novice days well and see myself from those years in this post.

RNperdiem, RN

Has 14 years experience.

I only ever had this kind of problem when dealing with the dreaded overnight "cross-covering" resident. These docs don't really know the patient that well since they are covering other services, and unless the patient is going downhill fast, they tend to "band-aid" over problems overnight until the regular doctors take over. Frustrating at times.

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 10 years experience.

Chest pain, SOB, diaphoresis...on an unmonitored floor at my workplace, it would have been a rapid response. On a monitored floor, nurse immediately gets an EKG per protocol and trops x 3 will be drawn.

What were the VS? How long have you been a nurse? If you are a newer nurse, what did your more experienced colleagues say? If you're an experienced nurse, why didn't you advocate for the patient and get that EKG and the trops? What was the bigger picture of the patient? Was the VTE risk score high? Was there any reason to think the patient might have been developing a PE? His presentation was more ACS than PE in my opinion, but you haven't given the bigger picture, so I can't say with 100% certainty.

I have my issues with the interns at times, but they are usually open to collaboration as long as we nurses don't treat them like know-nothing morons.

There's a charge nurse on one of the floors I usually work on for which the extent of her nursing interventions is "I told the doctor." She sucks as a charge, and she sucks as a nurse. Sometimes, you need to push harder to get the patient the basic treatment his/her presentation is calling for.

Been there,done that, ASN, RN

Has 33 years experience.

With ANY change of condition, when you request ANY physician assessment..if you feel the orders were not appropriate/adequate... you MUST advocate.

If this means further communication with the resident , or going above their head.. so be it.

Obtain the orders you expect. Enlist the aid of more experienced nurses, nursing supervision, or call the attending at home.

Pulmonary embolism is a catch all for unexplained demise.

Yes, this death MAY have been avoided.

vintagemother, ADN, CNA, LVN, RN

Specializes in Med-Surg, Psych, Geri, LTC, Tele.

I'm curious how long you've been a nurse. It sounds a bit like you expected the resident to totally take care of whatever was up with the patient. Often times with residents, you need to nudge them toward what you need, and stay on top of them if the patient isn't improving. I'm not judging you at all, but I'm moderately experienced, and remember my novice days well and see myself from those years in this post.

I was thinking along these lines, too. In my nursing practice, I learned to ask for what I want. I was fortunate to deal with mostly one doctor for most of my pts. He would give me what I asked for in most cases. The fact of the matter is, we nurses are on the front lines and see the pt more than the MDs do.

Interestingly, I've not seen my coworkers or instructors ask for specific orders.

VANurse2010

Has 6 years experience.

I was thinking along these lines, too. In my nursing practice, I learned to ask for what I want. I was fortunate to deal with mostly one doctor for most of my pts. He would give me what I asked for in most cases. The fact of the matter is, we nurses are on the front lines and see the pt more than the MDs do.

Interestingly, I've not seen my coworkers or instructors ask for specific orders.

It depends on the culture of the unit/hospital. In teaching hospitals, which the OP is obviously working in, I feel like asking for orders and offering suggestions to interns and residents is expected. At community hospitals where you're mostly or exclusively dealing with attendings, asking for specific orders may or may not fly, depending on the physician, service, and what's being asked for. Suffice it to say, though, there is a difference in tolerance of nursing assertiveness between the two.

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 10 years experience.

It depends on the culture of the unit/hospital. In teaching hospitals, which the OP is obviously working in, I feel like asking for orders and offering suggestions to interns and residents is expected. At community hospitals where you're mostly or exclusively dealing with attendings, asking for specific orders may or may not fly, depending on the physician, service, and what's being asked for. Suffice it to say, though, there is a difference in tolerance of nursing assertiveness between the two.

I have worked in both, and I concur with the differences in expectations between a teaching and nonteaching hospital.

Know what your acute CP protocol is. Along with what the protocol is to accurately monitor the tinza. If the patient was on antithrombotics, then I am not sure how he died of a PE.....but this is not my area, just curious.

You can only go forward from here. The first time a patient c/o of CP, is when the protocol is instituted. Which includes all of the interventions as noted by PP. Plus, PT, PTT, PTINR, D-Dimer....all those thing that may or may not be part of anti-coagulation protocols.

And acute CP with everything you describe would have been a RR. And any anti-coagulation for PE intervention/prevention is closely monitored for effectiveness or lack thereof.

I would assume that you reported off to another nurse the CP events and interventions. 24 hour gig. But I would be clearer on advising the MD that you have started the CP protocol, the r/o PE protocol when you call them. That way, they can add to it as test results come back in.

Again, you can only go forward from here.

I don't consider that useless as much as the mistake of an inexperienced doctor. I'm not blaming you, either, but in the future if you continue to have concerns you should consider escalating over the resident.

Yes....do not be intimidated by doctors. Advocate for your patient.

I always make suggestions that I feel are needed, like when I call the MD I will tell them about the pt and what's going on and then ask "Would you like to order a chest X-ray/Do you want to increase their Lasix?/Do you think we should DC "X" med d/t them being put on "X" med?

Just a few examples. I'm finally feeling more confident in my ability to advocate for my patients.

PMFB-RN, BSN, RN

Specializes in burn ICU, SICU, ER, Traum Rapid Response. Has 16 years experience.

Yes, frequently. Most are simply inexperienced and lack confidence. The vast majority go on to become competent physicians. Mostly they are not too dangerous if they keep their ego in check and are willing to listen to their nurses and willing to ask for help from their staff and senior residents.

A minority are simply stupid people and don't comprehend when they are in trouble, or (even worse) have a personality that won't allow them to listen to you because you are a nurse and also won't allow them to call for help.

PMFB-RN, BSN, RN

Specializes in burn ICU, SICU, ER, Traum Rapid Response. Has 16 years experience.

Yes....do not be intimidated by doctors. Advocate for your patient.

This is great advice. I take it a step further and set out to intimidate those doctors who have shown themselves to be dangerous to my patients.

One of the great things about working in one place for a while is the development of relationships between me and attending physicians. If you are a dangerous resident I will not hesitate to call your attending (who is probably a fishing buddy of mine) and get you straitened out. Residents know that when I call them and alert them to a problem with a patient that they had better address it effectively, or if over their heads, call their senior or attending for help. If they don't I will. They know that and it shows.

I don't expect them to know everything. I do expect them to do their best, listen to good advice from the nurses, and call for help when needed.

BeachsideRN, ASN

Specializes in NICU, Trauma, Oncology. Has 7 years experience.

Residents don't know what they don't know yet.