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.
Another issue is why can the "pain nurse" be the only one to set up a PCA. Our PACU nurses set up their own PCA's all the time and floor nurses set them up all the time. Waiting for pain med because only one certain nurse can set up the PCA pump seem cruel to the patient's needing pain med. Maybe this is also something positive that can come out of this. The root problems is that the "pain nurse " was unavailable and that is why there are these ambiguous , non written protocol orders.
Well, Andrew, initiations are for a new member to prove they're up to all that membership is about. You just had a lollapaluza of one, and it's only natural that you went into "shoulda, woulda, coulda", as a result.
You're 22 years old, a newby, and scared out of proportion regarding your future in or out of a career that imposes incredible pressure. Personalities are everything in our profession, which you learned the hard way. Labeling a physician as passive aggressive won't help the situation, only aggravate it.
From your last post, it seems your take has changed somewhat, possibly due to the amount of time and rhetoric that has gone on. The fact is, the matter is now out of your hands. You need to wait patiently (or not) for a verdict, and then look at the consequences of that decision.
As someone with almost half a century of nursing experience (none of it in current PACU circumstances), I have the luxury of objectivity and knowledge of disciplinary actions in which I've participated. This forum is the best thing I've known for reconciliation of actions previously known and some unencountered. The input of many very experienced nurses represents vast experience and knowledge. I hope you'll look up the "about me" tabs of each contributor, and thank them for sharing and taking their time to present their thoughts based on their experience, knowledge and research, about your situation. They have judged you as they would themselves, yet still offered much support to you. Value that!
This is no time to be "faint of heart", and you know that. It is time to take some "medicine" that you may think isn't yours. You've shared with us your "flight" response - which we've all experienced, too. It would be wise to have some time out after getting this behind you, to have your equilibrium back, talk to the instructors at your school of nursing if you wish (just if you think it might make you more clear about the transition from book learning to practise).
I wish you well, and applaud the concern you've shown to ameliorate the excrutiating pain of your patient - at your own expense.
This MD isn't trying to protect his license. He's being passive-aggressive and overboard.
The dosage I gave of this drug in this situation was safe. I've never had one of my patients respiratory arrest. I've never had to give narcan or reverse one of my patients because of something I have done. I've had to bag patients and reverse patients because of CRNAs that gave elderly patients and/or patients with impaired liver metabolism/kidney function too much opioids.
The issue here is the facility and the way they go about "business as usual". I'll be in touch with a lawyer and my state board of nursing soon.
From what I can gather from the CRNA's post, the physician isn't signing off on the order because he didn't order it. On top of that, you pushed a potentially dangerous amount of dilaudid and there is no way in heck any provider with an ounce of sense in his/her brain is going to put his/her initials on that, especially when he/she didn't even do it.
Look, you basically practiced medicine, went outside the scope of your practice, and you got caught. Everyone else on your floor was doing it too, and the physicians and other providers we even encouraging it. But you have to take responsibilty here. You were lucky that nothing happened to the patient, because if he had gone into respiratory distress, if he had even (god forbid) died, it would have been your fault, and yours alone. Do you really want that on your head? You made a mistake, accept it, learn from it and move on.
Yes, the physician ordered a PCA for dilaudid. But if you can't just make up the dosage based on what you think is appropriate and expect the providers to a-okay it the next day based on the fact that you didn't kill the patient.
From what I can gather from the CRNA's post, the physician isn't signing off on the order because he didn't order it. On top of that, you pushed a potentially dangerous amount of dilaudid and there is no way in heck any provider with an ounce of sense in his/her brain is going to put his/her initials on that, especially when he/she didn't even do it.
Look, you basically practiced medicine, went outside the scope of your practice, and you got caught. Everyone else on your floor was doing it too, and the physicians and other providers we even encouraging it. But you have to take responsibilty here. You were lucky that nothing happened to the patient, because if he had gone into respiratory distress, if he had even (god forbid) died, it would have been your fault, and yours alone. Do you really want that on your head? You made a mistake, accept it, learn from it and move on.
Yes, the physician ordered a PCA for dilaudid. But if you can't just make up the dosage based on what you think is appropriate and expect the providers to a-okay it the next day based on the fact that you didn't kill the patient.
Just so there is no misunderstandings I am senior military SRNA and will graduate in December. My screen name stands for Want To Be CRNA. Not that it changes anything, but as someone had pointed out AndrewRN had noted this problem for a long time, and still managed to be caught up in it even after his post in December:
"Dec 10, 2008 08:12 PM
PACU Ordersby Andrew, RN
Registered User
Age: 22
Received 40 Kudos from 25 posts Join Date: Jul 2008
I'm working in a PACU. We use CRNAs and there is a float doctor that we call if we have a problem with patients/need further orders.
The RNs write orders without officially getting an order. Routinely, this is 1-5 mg Morphine IVP q 7 min for a max of 20 mg for inpatients and Fentanyl 25 mcg IVP q 5 mins for a max of 100 mcg for outpatients. Same with antiemetics and other drugs routinely used in a PACU.
The RNs write in whatever they're giving and then sign the order "R+V by Dr. Anesthesiologist." The doctor will never see the patient or sign the order unless there is a problem.
I asked if this is a standing order/protocol/whatever and they said "No, this is just the way we've always done it"
I have a problem with saying I got an order verbally from a doctor and charting as such, when I did not. I told the nurses in this unit "What would prevent me from writing in whatever I want like a blank check?" and they responded with "Your ethics as a nurse"
I'm not a doctor/PA/NP, I have no prescriptive authority. So, how can they do this? "
Another issue is why can the "pain nurse" be the only one to set up a PCA. Our PACU nurses set up their own PCA's all the time and floor nurses set them up all the time. Waiting for pain med because only one certain nurse can set up the PCA pump seem cruel to the patient's needing pain med. Maybe this is also something positive that can come out of this. The root problems is that the "pain nurse " was unavailable and that is why there are these ambiguous , non written protocol orders.
I am a little unclear on this also since when working ortho, we all knew how to set up a PCA..perhaps PCA's should be known by all for just such situations?
If you have a physician that won't sign orders....throw it back on THAT physician.
The next time that this happens, call the physician, and when he says at 3:00 a.m. when you call, "Can't you just write it up and I'll sign it when I come in tomorrow".
Just say, "Dr. Smith, I would be happy to, but the last time I did that you refused to sign the order and that got me called to my boss's office. In order to protect the patient as well as my license, you need to either e-mail or fax the order over, or come in."
Don't punish them all because of what one idiot did.
Where I work they suspend the privileges of physicians that don't come in to sign their orders and they are not permitted to work until they sign off on them.
I don't think the problem was the signing of the order, I think it had more to do with the actual order itself. It seems that the doc wouldn't sign the order because he didn't order it in the first place.
Another issue is why can the "pain nurse" be the only one to set up a PCA. Our PACU nurses set up their own PCA's all the time and floor nurses set them up all the time. Waiting for pain med because only one certain nurse can set up the PCA pump seem cruel to the patient's needing pain med. Maybe this is also something positive that can come out of this. The root problems is that the "pain nurse " was unavailable and that is why there are these ambiguous , non written protocol orders.
This is exactly how things work at the facility. They don't train me or expect me to set up PCAs. Only the pain service nurses do that. Big emphasis on the "ambiguous non-written protocol orders". That is how my PACU works. It's very messed up.
To elaborate more: They have one float MD that is available as a resource for every patient in the OR/PACU. The CRNAs do the anesthetic. The patient goes to PACU. If the patient goes home, they get fentanyl, if they are admitted, they get morphine. There is no standing order, this is just "the way they've always done it." So, the PACU RN gives morphine or fentanyl to the patient, then fills out an order sheet saying how much was given. The float MD then signs the sheet days/weeks later, often times never seeing the patient. They are only in the loop if there is a problem.
I made a thread about the legality of this practice about 6 months ago when I first started working there.
Edit: Oh, looks like someone found that and quoted it here... alright. Yeah, I've had issues with working at this PACU since the beginning, I brought it up over and over again but I just kept getting "that's the way we've always done it" I didn't want to be a trouble maker so I just went with the flow. Now it's coming back on me.
So, hopefully on Monday/Tuesday I'll go in and clear up this whole mess. I'm going to make sure I meet with the director of surgery, head of anesthesia, someone from HR, my boss, and the doctor. I'm not taking this sitting down.
And to all those whining that I "gave too much dilaudid". Over and over, I am telling you that I did not. I'm not going into details on the patient but they needed that 2mg and could tolerate it. It's my clinical judgment. If it was some 150 year old Civil War veteran that weighs 80 pounds, no way would they get anywhere close to that. I've never had any of my patients respiratory arrest or have ANY problems because of meds I've given. Plenty of times I've had to bag people/reverse them because a CRNA gave them too much opioids. Stop criticizing how much dilaudid I gave, that horse is dead so stop beating it. You all made your point, it isn't an amount YOU would have given. I understand that. It's a dose I gave and I felt totally comfortable giving it to that patient.
Even though I'm a new RN, I've had 4 years of previous PACU experience as an aide, so I've seen and learned a lot from that. No, it's not the same thing as being an RN but I got to see plenty of mistakes RNs and MDs made and learned from that.
This is exactly how things work at the facility. They don't train me or expect me to set up PCAs. Only the pain service nurses do that. Big emphasis on the "ambiguous non-written protocol orders". That is how my PACU works. It's very messed up.
To elaborate more: They have one float MD that is available as a resource for every patient in the OR/PACU. The CRNAs do the anesthetic. The patient goes to PACU. If the patient goes home, they get fentanyl, if they are admitted, they get morphine. There is no standing order, this is just "the way they've always done it." So, the PACU RN gives morphine or fentanyl to the patient, then fills out an order sheet saying how much was given. The float MD then signs the sheet days/weeks later, often times never seeing the patient. They are only in the loop if there is a problem.
I made a thread about the legality of this practice about 6 months ago when I first started working there.
Edit: Oh, looks like someone found that and quoted it here... alright. Yeah, I've had issues with working at this PACU since the beginning, I brought it up over and over again but I just kept getting "that's the way we've always done it" I didn't want to be a trouble maker so I just went with the flow. Now it's coming back on me.
So, hopefully on Monday/Tuesday I'll go in and clear up this whole mess. I'm going to make sure I meet with the director of surgery, head of anesthesia, someone from HR, my boss, and the doctor. I'm not taking this sitting down.
And to all those whining that I "gave too much dilaudid". Over and over, I am telling you that I did not. I'm not going into details on the patient but they needed that 2mg and could tolerate it. It's my clinical judgment. If it was some 150 year old Civil War veteran that weighs 80 pounds, no way would they get anywhere close to that. I've never had any of my patients respiratory arrest or have ANY problems because of meds I've given. Plenty of times I've had to bag people/reverse them because a CRNA gave them too much opioids. Stop criticizing how much dilaudid I gave, that horse is dead so stop beating it. You all made your point, it isn't an amount YOU would have given. I understand that. It's a dose I gave and I felt totally comfortable giving it to that patient.
Even though I'm a new RN, I've had 4 years of previous PACU experience as an aide, so I've seen and learned a lot from that. No, it's not the same thing as being an RN but I got to see plenty of mistakes RNs and MDs made and learned from that.
I am glad your vast experience has taught you that that was the right amount of opioids to give since I haven't ever had to give that much Dilaudid that quick and I have very high satisifaction from my patients waking up we will just have to take your word on it. Just a word of advice you need to wait at least 10minutes between doses of Morphine or Dilaudid to see the full respiratory depressant effect.
You probably don't want to hear this either, but you cannot justify your actions by saying so and so always does it this way and if you come into the meeting like this with that kind of "I know it all and I did nothing wrong attitude" you are going to probably force management to fire you.
Also, from my experiences with management they have probably all gotten together, pulled their facts together, and in the majority of cases already determined what they are going to do to you.
Andrew - the RN's are the ones deciding how much narcotics to give? Is this under a written protocol? If not, you are practicing medicine w/o a license!
RNKPCE
1,170 Posts
Another issue is why can the "pain nurse" be the only one to set up a PCA. Our PACU nurses set up their own PCA's all the time and floor nurses set them up all the time. Waiting for pain med because only one certain nurse can set up the PCA pump seem cruel to the patient's needing pain med. Maybe this is also something positive that can come out of this. The root problems is that the "pain nurse " was unavailable and that is why there are these ambiguous , non written protocol orders.