HR in 40s. Doc insisting on dig IV

[General E. Speaking, RN]

One of the nurses on my unit had a pt (due to be discharged) but had a short run of SVT. We called the cardiologist to update. At the time the HR was in the 70s. He ordered dig 0.25mg IV X 3 doses Q4hrs apart.

After the first dose, the HR dropped to and stayed in the low 50s occasionally dropping to the hi 40s. No more dysrhythmias noted. She came to me and told me that she wasn't going to give the second dose. I agreed but told her to call the doc just to update.

He became very irritated (new doc to us) and kept insisting that she give the doses as prescribed. She even ask him what if the HR drops to the 30s by the time the last dose is due? What then? He told her I SAID TO GIVE ALL THE DOSES OF DIG.

I wish I had been the one to call him. I would have loved to tell him, "No sir, I will not give that dose. The HR is too low. I am calling you to update you on the patient's condition. Thank you." And hung up (gently...not rudely:D)

We didn't give the doses and HR stayed in 40-50s all night. I was in a meeting when that doctor came to round. It will be interesting to see what kinds of interactions we are going to have in the future with this cardiologist. If crap like this continues, we will have to have a little chat.

[rn-jane]

One of the nurses on my unit had a pt (due to be discharged) but had a short run of SVT. We called the cardiologist to update. At the time the HR was in the 70s. He ordered dig 0.25mg IV X 3 doses Q4hrs apart.

After the first dose, the HR dropped to and stayed in the low 50s occasionally dropping to the hi 40s. No more dysrhythmias noted. She came to me and told me that she wasn't going to give the second dose. I agreed but told her to call the doc just to update.

He became very irritated (new doc to us) and kept insisting that she give the doses as prescribed. She even ask him what if the HR drops to the 30s by the time the last dose is due? What then? He told her I SAID TO GIVE ALL THE DOSES OF DIG.

I wish I had been the one to call him. I would have loved to tell him, "No sir, I will not give that dose. The HR is too low. I am calling you to update you on the patient's condition. Thank you." And hung up (gently...not rudely:D)

We didn't give the doses and HR stayed in 40-50s all night. I was in a meeting when that doctor came to round. It will be interesting to see what kinds of interactions we are going to have in the future with this cardiologist. If crap like this continues, we will have to have a little chat.

I say good nursing judgement. As for the doctor I think you need to speak with your nurse manager next staff meeting for this to be brought up and discussed with the doctor. There are parameters that must then be written by the cardiologist in the order. Cya. We have a cardiologist that does something similar with amiodarone and once he realized he had to write the parameters they became more realistic since it would be his butt and not ours that would be in a sling if something happened.:redbeathe.

[deenasao]

i thought i'd copy and past the facebook conversation i had about this post:

ok. question for you. we're having a discussion on a nursing message board and i want to know your opinion. one of the posters is a crna, so i'm curious if your take is the same as hers [since you are also a nurse anesthetist].

patient is due to be discharged but has a short run of svt. hr in the 70s. cardiologist orders digoxin 0.25mg iv x 3 doses q4hrs. after the first dose, the hr dropped to and stayed in the low 50s, occasionally dropping to the hi 40s. no more dysrhythmias noted. the cardiologist is called and he still insists that the digoxin be given.

what to do?

we all agree that the doc should institute hr parameters. ask for an explanation for his order.

this is where the debate ensues. the two opinions are:

"don't give it. the risks outweigh the benefits. if the hr started to rise the dig could have been given. if it dropped you would have a real problem on your hands."

"give it because the cardiologists explanation will be: 'a lot of times patients will have an exaggerated response initially to a med and then level off quickly'."

so... what's your opinion?

i would not give it! if we give another dose, i think the heart rate will drop even further. most svts are short run any way and the pt probably already has been living with it for quite some time and probably asymptomatic. i really never given dig quite that much so im not sure if it will level off.. but to cover our rn license, i wouldnt give it bcuz the heart rate is already in high 40's and baseline is probably 70-80s, im guessing. oh sorry, i guess hr was mentioned to be the 70s. any ways i don't know what the crna said, but 70s is still w/n range its not like the hr is >100. if the patient has it again, i would probably have the patient do valsava manuevers to break the svt. of course, anesthesia is different from the actual nursing environment since we just give meds and we dont need orders for what we give.

[wtbcrna, MSN, DNP, CRNA]

i thought i'd copy and past the facebook conversation i had about this post:

ok. question for you. we're having a discussion on a nursing message board and i want to know your opinion. one of the posters is a crna, so i'm curious if your take is the same as hers [since you are also a nurse anesthetist].

patient is due to be discharged but has a short run of svt. hr in the 70s. cardiologist orders digoxin 0.25mg iv x 3 doses q4hrs. after the first dose, the hr dropped to and stayed in the low 50s, occasionally dropping to the hi 40s. no more dysrhythmias noted. the cardiologist is called and he still insists that the digoxin be given.

what to do?

we all agree that the doc should institute hr parameters. ask for an explanation for his order.

this is where the debate ensues. the two opinions are:

"don't give it. the risks outweigh the benefits. if the hr started to rise the dig could have been given. if it dropped you would have a real problem on your hands."

"give it because the cardiologists explanation will be: 'a lot of times patients will have an exaggerated response initially to a med and then level off quickly'."

so... what's your opinion?

i would not give it! if we give another dose, i think the heart rate will drop even further. most svts are short run any way and the pt probably already has been living with it for quite some time and probably asymptomatic. i really never given dig quite that much so im not sure if it will level off.. but to cover our rn license, i wouldnt give it bcuz the heart rate is already in high 40's and baseline is probably 70-80s, im guessing. oh sorry, i guess hr was mentioned to be the 70s. any ways i don't know what the crna said, but 70s is still w/n range its not like the hr is >100. if the patient has it again, i would probably have the patient do valsava manuevers to break the svt. of course, anesthesia is different from the actual nursing environment since we just give meds and we dont need orders for what we give.

each to their own....i would probably not have given before i was apn either, but as an apn now i would continue to give the loading dose after i discussed the case with cardiologist.

[fiveofpeep]

If the md wrote parameters and it was within the parameters I might have been more apt to give it, given that patient was asymptomatic, but I would probably be asking everyone on the unit if they agreed first and still have had misgivings. I dont know...this is a tough one.

BTW, our cardio is sarcastically referred to as "God" around my religious hospital for his high self reverence.

[deenasao]

lol :)

[General E. Speaking, RN, RN]

Thanks for the responses. BTW, the nurse did ask him if he would like to give parameters. He flatly refused. I still feel like we did the right thing.

[HouTx, BSN, MSN, EdD]

Big time KUDOS to the OP!

If you are ever involved in a malpractice case, this is what your actions will be compared to... always good to ask yourself what a 'reasonable and prudent' nurse would do under those circumstances. And the OP is a perfect example. I know that it's often easier just to do as you're told, but you have to ask yourself if it passes the 'red face' test... would you be able to justify your actions to a jury or the patient's family without shame?

Of course it varies by state, but here in TX, nurses have a legally defined "duty to patient" that cannot be superseded by the physician. This includes a duty to question and refuse (if appropriate) orders that are not within acceptable standards. If a discussion with the physician does not work, then we are expected to initiate the established chain of command.

[wtbcrna, MSN, DNP, CRNA]

Thanks for the responses. BTW, the nurse did ask him if he would like to give parameters. He flatly refused. I still feel like we did the right thing.

Good for you guys. The guy sounds like a real jerk.

[deenasao]

Big time KUDOS to the OP!

If you are ever involved in a malpractice case, this is what your actions will be compared to... always good to ask yourself what a 'reasonable and prudent' nurse would do under those circumstances. And the OP is a perfect example. I know that it's often easier just to do as you're told, but you have to ask yourself if it passes the 'red face' test... would you be able to justify your actions to a jury or the patient's family without shame?

Of course it varies by state, but here in TX, nurses have a legally defined "duty to patient" that cannot be superseded by the physician. This includes a duty to question and refuse (if appropriate) orders that are not within acceptable standards. If a discussion with the physician does not work, then we are expected to initiate the established chain of command.

I think this is what it comes down to. Well said. I love that expression "red face test". I've never heard that one. That's great.

[netglow, ASN, RN]

Somewhere on this site I posted about an experience I had as a student.

My RN had told me to go ask parameters for meds for a pt who experienced an "event" earlier that morning. She told me that this cardiologist was a problem and I needed experience in how to deal. He refused to answer my question x 3. He just sat there with arms crossed, scooched way down in his chair, with a smirk on his face, just staring at me. I got tired of this fast and remember glancing at his jacket and embroidered name/specialty and mumbling something about how I would just go and get the NP, and she would be able to handle it. Well he hopped up and said that would not be necessary. I then got my parameters.

Hey, what ever works. I intend to keep this trick at hand for future needs!!