help cardiac nurses!

A seasoned cardiac nurses probably wolud have questioned if the order to give plavix had been left active by mistake. The fault however isn't yours, it's the physicians. It is the surgeons' responsibility to review and stop any potentialy harmful pre-op meds. I have little doubt that the plavix contributed to the patients post-op bleeding. Those of us who work post CABG shudder to hear adout a patient who has had Plavix in the last week before surgery. Our standing otrders for CABG pre-op care include a list of meds that the doctor wants stopped and when- he just has to check the box. Expecting the nurses to read the docs mind is unrealistic. What if the patients stents were unadequate for the vessels, or the other blockages were in high grade lesions 80-90% blocked. If your patient was depending on a stent to provide collateral circulation to his LAD or dom RCA I an see continuing the Plavix- but more likely stopping it and starting a heparin drip. When I get the right to make those decisions about my patients I want a much bigger pay check. It sounds like you could be benificial if formulating an action plan to help avoid this problem in the future. Helping find a soultion to the problem would go a long way to proving you are a nurse they want on the unit.

I agree with the op that the physician should have ordered it stopped if he wanted. The entire burden shouldn't be on you. Some Nurses would have questioned it, other not so experience nurses would not have.The physician needs to take responsibility for not stopping it. You don't /can't write orders.

I agree with the other posters. The physician is responsible for writing orders to stop/hold medications. I don't believe they should be blaming you at all. Good luck, I too am in a bind at work and have considering leaving the profession. I will say a prayer for you that all works out OK.

I have little doubt that the plavix contributed to the patients post-op bleeding. Those of us who work post CABG shudder to hear adout a patient who has had Plavix in the last week before surgery.

Does this mean you think the Plavix did cause or just contribute to the problem?? Since Plavix has to do with anti-platelet coagulation, shouldn't the doctor check the platelet count before surgery? If the platelet count was okay, then how could Plavix caused the problem?

Expecting the nurses to read the docs mind is unrealistic. What if the patients stents were unadequate for the vessels, or the other blockages were in high grade lesions 80-90% blocked. If your patient was depending on a stent to provide collateral circulation to his LAD or dom RCA I can see continuing the Plavix- but more likely stopping it and starting a heparin drip. When I get the right to make those decisions about my patients I want a much bigger pay check.

That's a very good point I will point out when the manager calls me on Monday with her decision to keep me or not.

It sounds like you could be benificial if formulating an action plan to help avoid this problem in the future. Helping find a soultion to the problem would go a long way to proving you are a nurse they want on the unit.

This is good advice, however, after pondering this all day and half the night, I don't think I want to work for this hospital. I think the manager is using me as a scapegoat and I don't want to work for people like that. I am disappointed in her but it hasn't been the first time I've been the sacrificial lamb. They took this patient back to surgery to find out why he was bleeding and in the process found other blocked arteries they did not catch the first time around. How do I know the surgeon didn't tie off a vessel correctly or left a foreign body in his chest? Who knows why the patient was oozing? Maybe it was the heart- lung machine which are heparinized and someone put too much heparin in? I just think its harsh and over-reacting to fire me because I should have known better not to give Plavix. Its like you and others here already said, I'm not the doctor and can't make that call to discontinue a med or not! The patient just had stents put in and I told him he was getting plavix to keep his blood flowing and not throwing a clot. When to stop these meds is not my call yet Nursing Administration says I am to blame and they would fire me today if they had to, but will think about it over the weekend.

Whatever her decision, I have made mine. I don't want to work for someone who will fire me like that for this reason. I think she is over-reacting to cover their own butts. That way they can tell the patient and his family they fired an incompetent nurse and hope to avoid potential litigation. Thats just my gut feeling.

Thanks for helping me out with this. The ironic thing about this, is the last nurse I worked with told me I was a good nurse and will definitely be an asset at this hospital. She's worked there 17 years.

Think of it this way;

-pt. has chest pain, EMS gives ASA

-ER doc gives thrombolytics (doesn't work...)

-cath lab doc drops an IABP, gives integrillin and plavix... then for a multitude of reasons the pt. is rushed for a CABG. All in a few hours.

point is that patients are given many anticoags and invasive proceedures happen and bleeding does or doesn't occur.

Many hearts are simply oozy, we use Amicar to help reverse it. Some hearts have leaky grafts and you wish they would go back... some pour and they reenter the chest.

I promise you that there were many things that could have been done to help reverse simple plavix. Could that have added to a bad situation.. possibly. But hearts do ooze, leak and pour it is not uncommon.

surgeons with bad outcome statistics can be known to peruse the chart in attempts to fingerpoint. So do managers on power trips. The political arena in cardiothoracic is mind numbing and exhausting.

Feel comfortable that you did not harm this person.

Feel comfortable that you did not harm this person.

Is your manager suggesting that Plavix is the only anticoag that this patient got? Because in scapegoating you, it sure sounds like it. Is it possible that she's not a nurse? Or that she doesn't know what goes on during a CABG?

I agree, due to her attitude and treatment of you, this is not a good place to work.

Is your manager suggesting that Plavix is the only anticoag that this patient got? Because in scapegoating you, it sure sounds like it. Is it possible that she's not a nurse? Or that she doesn't know what goes on during a CABG?

I agree, due to her attitude and treatment of you, this is not a good place to work.

Yes, my manager is a RN and she said I could have killed this patient by giving him the Plavix the day before his surgery. He also got Plavix the day before which another nurse gave since it was ordered daily. I took care of the patient during orientation. He was waiting to have surgery the next morning at 0830. I did not preop him because that would have been done by the night nurse around 6 am the next day.

I am a staff nurse caring for patients who come in on tele awaiting surgery, heart caths, stents, whatever the case may be. The doctor signed the preop order but failed to check holding the Plavix. Maybe I should have known to call and question giving Plavix since he was going to surgery the next day, at least thats what my manager would say as I did not use good critical thinking in this case. In my mind, I am protecting the patient by giving the Plavix as to prevent him from throwing a clot before surgery. Its my understanding the heart-lung machine is heparized, but I have no knowledge of what goes on during a CABG except they stop the heart and the patient is put on the heart-lung machine.

She's pinning the patients negative outcome on me and I don't appreciate it. I may not be a seasoned cardiac nurse, but I am a conscientious one who cares deeply for my patients. I take pride in my work. Now here she comes along and handles this situation like this saying shes going to think it over this weekend whether to fire me or not. I fully expect her to fire me on Monday. I have never been fired in my life, especially for something like this, nor had disciplinary problems whatsoever in 12 years of Med-Surg Nursing.

I seriously think this is the straw that broke the camels back for me in nursing. I think the prudent thing for me to do if she decides she wants to keep me employed is to decline that and tell her why, then move on. I can see yet another incident like this happening where the nurse gets blamed for the negative outcome of the patients surgery or hospital stay. If I am responsible then okay....but after studying CABG and Plavix, as well as talking to other peers who would tell me like it is, I think I am being scapegoated for the doctor. I have lost all respect for this hospital who claims all this integrity, blah, blah, blah. The bottom line is they need the surgeon cause he brings in the money so lets protect him at all cost. Me? I'm the new kid on the block having been oriented for 2 weeks; so lets fire this imcompetent RN in order to mitigate possible litigation if something goes wrong even more; which I understand the patient isn't doing well after they went back in discovering even more problems that had nothing to do with bleeding.

I've had enough of nursing. I think Im gonna sell Mary Kay. Anyone up for some personal pampering?

Seriously, I was really depressed yesterday and didn't sleep very well at all last night because of this. I've got an attitude adjustment cause I know what's really going on here. As long as the cause for this patients problems were not because of me, I feel a lot better. I just don't appreciate my manager doing this to me knowing full well what really happened.

If someone comes on here and tells me the Plavix did it, then okay I'm open for correction.

RN75,

I am so sorry this happened to you - hospital politics is such crap! I totally think they are trying to scapegoat you for many reasons.

To begin with, what about all of the other nurses who gave plavix for the past week - are they getting fired? They are just as culpable since it is generally accepted that plavix should be stopped at least 5 days before a major invasive surgery like CABG.

Also, what about the preop nurse. She is supposed to review this kind of stuff before the patient has the chance to end up on the table. Will she be fired?

And then obviously, the MD who, like another poster said, maybe should have ordered a heparin gtt and ordered to hold the plavix if there was an imminent concern over the blockages.

Even if you go in there on Monday and the manager says she is "only gonna write you up" or something, I would resign anyway just like you are planning.

Best of luck to you!

Also, thank you for helping me to make a decision I've been struggling with - either staying at the hospital or taking a new job at a cardio office.

RN75,

I have a unique perspective on this situation. I am a CCU RN who left CVOR due to family health reasons.

As stated previously, you should not be expected to read a surgeon's mind. However, I know from my experience with CV surgeons, nothing is ever his/her fault.

The policy of our CV surgeon is no elective procedure is performed unless the patient has been off Plavix for at least 5 days. (We learned this the hard way.)

During my time in surgery, the circulating nurse, CRNA, and the perfusionist checked the patient's medication reconciliation in the surgical holding area to determine if the patient had been on anticoagulants. If the patient had been on Plavix within five days of surgery, a call was placed to the surgeon to make sure he/she was aware.

I was the CV coordinator during my last year in surgery and I checked each patient's chart the day before to determine if the patient had been on Plavix and if so, was a platelet inhibition test conducted.

At my hospital, all patients on anticoagulants have a brightly colored label placed on the front of their chart that lists the anticoagulants and the time of last dose. (Your hospital may wish to consider something similar.)

RN75,

As stated previously, you should not be expected to read a surgeon's mind. However, I know from my experience with CV surgeons, nothing is ever his/her fault.

The policy of our CV surgeon is no elective procedure is performed unless the patient has been off Plavix for at least 5 days. (We learned this the hard way.)

During my time in surgery, the circulating nurse, CRNA, and the perfusionist checked the patient's medication reconciliation in the surgical holding area to determine if the patient had been on anticoagulants. If the patient had been on Plavix within five days of surgery, a call was placed to the surgeon to make sure he/she was aware.

I was the CV coordinator during my last year in surgery and I checked each patient's chart the day before to determine if the patient had been on Plavix and if so, was a platelet inhibition test conducted.

At my hospital, all patients on anticoagulants have a brightly colored label placed on the front of their chart that lists the anticoagulants and the time of last dose. (Your hospital may wish to consider something similar.)

:yeahthat:

Normal procedure at my hospital is to hold the plavix and start the pt on a heparin gtt if anticoagulation is necessary to prevent coronary stents from occluding. However, holding the plavix is not a call that a new cardiac nurse would be expected to make without an order.

Even if your nurse manager does not fire you, I would seriously consider resigning. She sounds very punitive, and unwilling to stand up for her staff. There is a learning curve in each specialty and she sounds like she is not willing to support you while you gain the experience you need to question these types of situations in the future.

Does this mean you think the Plavix did cause or just contribute to the problem?? Since Plavix has to do with anti-platelet coagulation, shouldn't the doctor check the platelet count before surgery? If the platelet count was okay, then how could Plavix caused the problem?

That's a very good point I will point out when the manager calls me on Monday with her decision to keep me or not.

This is good advice, however, after pondering this all day and half the night, I don't think I want to work for this hospital. I think the manager is using me as a scapegoat and I don't want to work for people like that. I am disappointed in her but it hasn't been the first time I've been the sacrificial lamb. They took this patient back to surgery to find out why he was bleeding and in the process found other blocked arteries they did not catch the first time around. How do I know the surgeon didn't tie off a vessel correctly or left a foreign body in his chest? Who knows why the patient was oozing? Maybe it was the heart- lung machine which are heparinized and someone put too much heparin in? I just think its harsh and over-reacting to fire me because I should have known better not to give Plavix. Its like you and others here already said, I'm not the doctor and can't make that call to discontinue a med or not! The patient just had stents put in and I told him he was getting plavix to keep his blood flowing and not throwing a clot. When to stop these meds is not my call yet Nursing Administration says I am to blame and they would fire me today if they had to, but will think about it over the weekend.

Whatever her decision, I have made mine. I don't want to work for someone who will fire me like that for this reason. I think she is over-reacting to cover their own butts. That way they can tell the patient and his family they fired an incompetent nurse and hope to avoid potential litigation. Thats just my gut feeling.

Thanks for helping me out with this. The ironic thing about this, is the last nurse I worked with told me I was a good nurse and will definitely be an asset at this hospital. She's worked there 17 years.

I just wanted to say that I think you're making a smart decision by leaving. Your manager sounds horrible. You might consider turning in your letter of resignation before she has the chance to fire you.

I just wanted to say that I think you're making a smart decision by leaving. Your manager sounds horrible. You might consider turning in your letter of resignation before she has the chance to fire you.

I did hand the manager my letter of resignation. She said she would put it my file but that their decision was to "let me go" with a no rehire status. The first time we discussed this (before they decided) her demeanor was not as harsh informing me that if they did decide to terminate me it wouldn't affect my job reference. But when I went in to meet with her and another ICU Nurse Director, I think it was more of a power trip they were on. I told them both it was punitive and harsh to fire me for something like this. Usually an incident report is filed and likely some disciplinary action; but not getting fired over ONE isolated med error! I have never been fired in my life over 12 years in my nursing career so sitting there in that office resisting shame and intimidation was very difficult. I listened carefully to their rationale and finally spoke up telling her "I am good nurse. Just because I made a mistake doesn't make me a bad nurse. The PCM angrily replied, "Well WE think you are!" To that I looked her straight in the eye and calmly answered, "That's your opinion... but it's not mine, all the patients I've cared for over 12 years, or all the previous managers I worked with." I think me standing up for myself made her even more angry because that's when she said, "Well, it doesn't matter because you will never work for this facility or any affiliated facility in this area again because we are not recommending you for rehire!"

I just let it go and told her that there are many other nurses working there that should be sitting in this chair than me, namely one who was verbally and physically abusing an Alzheimer's patient by screaming at him and manhandling him because he didn't understand what was going on and had soiled the bed and was being noncompliant. And I asked her what is she going to do about the Pharmacist who made the mistake of putting the Plavix on the Mar, or the nurses who preopp'd this patient before surgery, or the nurse that gave him a dose the day before me? She said that was none of my business.

The point to me is I gave them my letter of resignation and had it ready to give to them before this meeting. Even if they would have decided not to terminate me, I would have resigned. After a week of orienting there, I got bad vibes that one wrong move and I will be out of there. I have never felt this way about a place.

When I left, I went straight to the hospital I use to work and ran into an old nurse friend who had no idea I had just went through this being told I wasn't a good nurse. She asked how I was and where I was working but I didn't tell her what had just happened 30 minutes ago. She said I should come back to work there, because I was such a good nurse and was good at what I did. I am back working where I belong with nurses and people in charge who treat people the way they want to be treated.

BTW: Plavix acts in that it inhibits platelets causing them not to work like they are supposed to. It doesn't decrease the number, it only makes them act stupid over the life of the platelet which is approximately 7-10 days. This is why we should stop Plavix 5-7 days before a scheduled surgical procedure. According to the nurse manager, they claimed I was the only one who gave Plavix 75 mg the day before surgery because the pharmacist made the mistake. I clearly saw it given on the MAR the day before and the computerized med cart! They are lying.

Thanks everyone for your help. Its wonderful knowing we can come here and get the help and knowledge of our peers when we need it.