I Need Advice - MD Not Signing Order

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Specializes in Pyschiatry/Behavioral (Inpatient).

Hey everyone. I'm a RN working in a PACU. At my facility, CRNAs do the cases and there is one float MD that is there as a resource. We have "protocols" to give meds for pain/nausea without needing to call the doctor. The doctor then signs the order some time later, often not seeing the patient ever.

Here's my problem. I had a patient that just had a very painful ankle surgery. The surgeon wrote for a dilaudid PCA. I called the pain nurse to come and set it up. In the mean time, the patient was hurting at a "12 out of 10" and their vital signs/facial expressions reflected this. The pain nurse told me it would take her a while to get there and that I could give the patient some dilaudid IVP. Nothing wrong with that, we do it all the time. Basically, we are giving the patient their loading dose that the pain service nurse would be giving anyway once they get the PCA set up.

So, I give her 1mg IVP. Waited 5 minutes, gave another 1mg. The patient's pain went down and I left it at that. I wrote my order for it. The patient had a good outcome and had pain relief. This was earlier in the week.

Fastforward to today. I get called into my charge RN's office. The anesthesiologist is refusing to sign this order. I got sent home and they are going to talk to the pain service nurse later today when she comes in at 3 pm. I'm not sure if I'm going to have a job and it's up to "how far" the doctor wants to take this.

Basically, I was going by our protocols and giving the patient a medication in a manner consistent with its guidelines. I don't know what to do.

I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.

This sucks. =(

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Is there a policy written up for this in your facility? Pull the policy and see what it says. That is what your facility will go by. Sorry this is happening to you.

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I don't know what to say. If you were only doing what is routinely done around there, I don't see the problem. Hope you survive this.

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Specializes in Pyschiatry/Behavioral (Inpatient).

There is no official policy in writing. It's all one big gray area. They were going to write a policy but the MD in charge of that has been gone due to health problems.

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Specializes in Pyschiatry/Behavioral (Inpatient).

I'm about to give up on being a nurse, this is my second job at a totally new hospital (the first one really screwed me over if you care to read my Orientation Woes thread)

I can't handle this. I feel like I should just go into a different field if everything I do can never be right.

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Did they indicate why the doctor refuses to sign? The only thing I see in what you wrote is to add "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg for pain until PCA begun. Program PCA for no loading dose" or something similiar.. but on a unit used to this type of order it may not be necessary.

They were going to write a policy but the MD in charge of that has been gone due to health problems.

It seems to me this is more a facillity problem and shouldn't blame you...let us know what the pain nurse says.. I am hoping she ALSO co-signed the order since this was due to her not being able to get to the patient right away.

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Specializes in Utilization Management.
I'm about to give up on being a nurse, this is my second job at a totally new hospital (the first one really screwed me over if you care to read my Orientation Woes thread)

I can't handle this. I feel like I should just go into a different field if everything I do can never be right.

Take a deep breath, Andrew. This too shall pass. ***((hugs))

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Specializes in Pyschiatry/Behavioral (Inpatient).

My manager is telling me the reason he won't sign it is because I "didn't talk to him first about it".

Which makes no sense. We give fentanyl, we give morphine, we give antiemetics without talking to him. Why would dilaudid be any different? There were no problems that he needed to be contacted with.

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Specializes in Cardiac Telemetry, ED.

It may have something to do with the way the order was written. I might have added "per PCA protocol, as ordered by Dr. X", or something to that effect, indicating that what you were doing was consisted with the protocol ordered by the MD. I'd also have made sure there was a copy of the protocol order set in the chart, assuming you use these. It does sound like the doctor is splitting hairs to cover his own behind. I hope the outcome is good for you, because it doesn't sound like you did anything technically wrong.

Edited to add: Just saw your post above....if he ordered the protocol, then you don't need to talk to him first. That's what protocols are for. Is Dilaudid on the protocol? I can see if he didn't order the protocol, or if Dilaudid is not on the protocol, how this would be a no-no.

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I am betting the MD is saying that you were "practicing medicine without a license." Sounds more like a misunderstanding between the pain nurse and the MD, with you caught in the middle. It is one of those "gray areas." 99.99% chance that it will blow over after the MD gets over his ego and the charge nurse talks with the pain nurse about the situation. Hang in there.

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Specializes in Pyschiatry/Behavioral (Inpatient).

I'm on call Saturday and Sunday for 12 hours each day. This is so screwed up. I'm wondering if they're going to take this away from me too. I'm wondering if I still have a job.

People keep things from this doctor all the time because he is overboard.

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Specializes in Pyschiatry/Behavioral (Inpatient).
I am betting the MD is saying that you were "practicing medicine without a license." Sounds more like a misunderstanding between the pain nurse and the MD, with you caught in the middle. It is one of those "gray areas." 99.99% chance that it will blow over after the MD gets over his ego and the charge nurse talks with the pain nurse about the situation. Hang in there.

This is what I'm hoping for.

This department needs better order sheets and more things in writing than what they have now. There are no protocols in writing, it is just an understood thing that you can give certain drugs in certain situations. I've never felt comfortable with it. The other nurses I work with have been there for 20+ years so they're used to doing things "the way they've always been done" even though they aren't exactly the most legal way. I always have to ask people "What do you normally do in this situation?"

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