Sometimes I just don't think doctors take the time to think about the patient at all. Without specific details I just want to mention a recent situation that just breaks my heart.
A patient was debrided at the bedside. Very large abdominal wounds, with wound vacs. Initially he offered to let the RN bolus her off the PCA, but I heard afterwards he even changed his mind about that. (All the nurse could do was stand there at the bedside and help the patient hit the button as often as she could.)
The screams coming from the room were wrenching and sad, though she only cried out loud enough for us to hear twice in the THIRTY minutes he was physically debriding her.
It absolutely broke and enraged my heart. She deserved a fat dose of dilaudid and a shot of versed...at least.
Tait
PS. As always, please feel free to share your stories on the subject.
Specializes in ICU, Intermediate Care, Progressive Care.
So, back to the original scenario: You are this woman's nurse. And, for argument's sake, let's say she isn't oriented: elderly, turner, feeder, bed-ridden with dementia. This is all hypothetical by the way. The doc comes in at shift change in the morning and orders you to prepare the patient for debridement, time is short, and he's not going to write orders for IV Diluadid or anything else. "She can have what's already in her PCA," he barks, and you know her PCA drugs aren't going to shield her from the pain of the procedure. All sarcasm aside, what would you honestly do in a situation like this? One of the nurses in this thread mentioned she stood between the PA and the patient...
I'm not a nursing student yet, but here's my .
My gut reaction to this question is that I would have to say something or step in, I think. Especially in the hypothetical situation of the patient being completely unable to advocate for him or herself. I couldn't stand there and listen/watch a patient clearly suffering when it's avoidable.
It's one thing to deal with a Dr. who won't prescribe adequate pain management in general, but for such an invasive and painful procedure, it's really bordering on torture. We don't do C-sections without anesthesiology... women balk at giving birth naturally without painkillers, even though that's something our bodies are designed to do... hell, you get local anesthetics at the dentist! There's no reason the Dr. couldn't do SOMETHING for this patient. Just because he is in a hurry is NO excuse to sacrifice patient comfort and dignity. I understand there is an inherent amount of pain to most if not all medical procedures, but there's no reason to exacerbate or ignore the pain when we could so easily avoid it by waiting half an hour.
I was under the impression that the patient in question was unable to advocate for herself. I imagine most oriented patients would decline an invasive procedue without proper medication. I was under the impression that the patient wasn't completely oriented. I don't know, I could be wrong.
As far as a letter writing campaign: obviously, I wouldn't be writing letters while I was standing in the room with the doctor obviously. I guess I should have indicated that in my previous post but it's one of those things I expected people to clue into. So let me explicate it more clearly: I would only write letters after the event happened.
So, back to the original scenario: You are this woman's nurse. And, for argument's sake, let's say she isn't oriented: elderly, turner, feeder, bed-ridden with dementia. This is all hypothetical by the way. The doc comes in at shift change in the morning and orders you to prepare the patient for debridement, time is short, and he's not going to write orders for IV Diluadid or anything else. "She can have what's already in her PCA," he barks, and you know her PCA drugs aren't going to shield her from the pain of the procedure. All sarcasm aside, what would you honestly do in a situation like this? One of the nurses in this thread mentioned she stood between the PA and the patient...
If the patient had a PCA, then they had to be pretty alert and oriented, because PCAs aren't prescribed for people who aren't aware enough to use them properly. In my opinion, in this particular situation, the nurse did the right thing by staying with the patient and offering some amount of comfort and worrying about going up the chain or command (which definitely should happen) later. It doesn't sound like this doc was going to wait around for the nurse to be there to do the procedure, and probably would have kept going even IF concerns had been voiced at the bedside. The last thing this patient needed at this point was a nurse and doctor arguing, or getting physically confrontational while the doc (most likely) proceded to do said procedure anyway.
I also agree that patient's can usually be thier own best advocates, and the best thing we can do is educate them about how to advocate for themselves. After all, we can't refuse treatment for our patients or request a new doctor for them, they CAN do that for themselves though, and we need to make sure they know that.
This post actually made me think of a very similar situation when I first started working. A doc did a debridement, or something similar (wasn't my patient) at the bedside. Apparently, this doc was "old school" and notorious for this type of thing, and nursing staff had been complaining for years about him, to no avail. Someone mentioned to this particulat patient, after this incident, that they needed to make it known how unhappy they were with his care. The patinet refused to see him again, went to the hospitals customer service department, etc. I'm not sure what the outcome was, exactly, but I know there were ramnifications for the doc. In today's customer service obsessed healthcare industry, the patients have far more pull then we do in a lot of situations.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
Most of the time you need to be an experienced nurse before even contemplating interrupting a doctor who is in the process of a procedure that causes pain to the patient who isn't premedicated properly. You can do a lot more damage if you attempt to physically restrain a doctor or even put a hand between you and that doctor if you don't understand what he or she is doing.
Unfortunately, there are things done in the course of our work, that despite our best pharmaceutical efforts, still hurt like a s*n-uv-a-b*tch, and if you are not a nurse how do you know which those are?
It appears that what 2ndwind observed was a situation that comes up fairly often, especially in teaching hospitals, when a person becomes overwhelmed with frustration at their inability to successfully do something like intubate, start an IV, an LP or the like and continues to try long after they should have sought assistance. Each situation is different.
Tait and her co-workers did the right thing after one of these episodes occur, a review of the episode with strategies laid down to avoid or prevent that particular event from happening again. When we point out that perhaps non-nurses shouldn't be accusing nurses of lacking in advocacy, it isn't to be mean. It simply points out that your frame of reference at that point isn't enough to make that judgement.
Same story every day. Nurses who don't turn, nurses who give patients their benadryl, phenergan, and morphine together on tolerant patients to knock them out and make them shut up. I was a patient once. Had to pee and got tossed a urinal. Sorry lady, but I'm not so good at the catching when my neck is in a collar.
My point is, you need to say some people are jerks and aren't compassionate, not doctors or aides or nurses. Many nurses think we have a monopoly on patient advocacy and caring, and we shouldn't perpetuate it.
Specializes in multispecialty ICU, SICU including CV.
They did PICC lines in the arm and the neck without painkillers (not sure if this is standard procedure or not but she said it was painful and they said they couldn't give her anything), dressing and woundvac changes without any kind of anesthesia, and in one circumstance when she had a bowel impaction, the doctor came in, put on a glove, didn't even use lube, shoved his finger into her rectum, and left--all without saying a word or any kind of courtesy/explanation/etc.
FYI PICCs and central lines are routinely inserted with LOCAL anesthesia -- usually systemic pain medication is not needed. The need for sedation should be assessed on every patient having any kind of invasive procedure done. Some need it, some don't. Even on my obtunded patients, I make the doc do a local. There is no excuse not to -- the lidocaine is right there in the central line kit (and in most hospitals, this is the case now -- all packaged together.)
Woundvacs or other deep dressings I would say about 90% of the time should be premedicated with narcotics. I have run across a few patients here and there that seem to have minimal sensation in their wound bed, but that is generally rare. Sometimes these patients need sedation, too.
The bowel impaction thing -- lovely bedside manner. It is pretty shocking what some nurses/MDs will do to their patients without thinking about medicating them. Some of the things people have posted on in this thread I wouldn't do to my dog, much less a human being. Ugh.
Just a little more info re my post. I did my arm grabbing prior to the PA's gearing up for yet another attempt -- not while an attempt was in progress (nursel56, you were right on). Looking back, I would have still stopped him, the danger to the patient was too great. I guess I could have left the room, and gone for help first, but, well, the situation made me decide I could not leave the patient and the PA for even a minute in fear of what would go on because I was no longer there to see it...
I am not an advocate of lawsuits, but by golly if I EVER had a family member go through anything like that (or myself), I'd be dialing a lawyer from the bedside....I've seen an old school surgeon insert a chest tube in a patient without any anesthetic at all. I've also been the nurse who had to do a wet to dry dressing change on a drug addict who was only given 1 hydrocodone prior to the change. That was all the doctor would order for him and the DON backed him up, as did the rest of the hospital......
Same surgeon did a c-section on me with my first baby, before I knew enough to stay away from him (before I was a nurse), and it turned out well...interestingly enough he gave me a PCA and ample take home hydrocodone and was very concerned about my pain level. Go figure.
Specializes in Clinical Research, Outpt Women's Health.
I would have asked the pt if she wanted us to stop until she could have adequate pain medication. If she said yes I would have stopped and insisted that the physician stopped also. Even if it got me fired that is the stand I would have taken. There have to be limits.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
Just a little more info re my post. I did my arm grabbing prior to the PA's gearing up for yet another attempt -- not while an attempt was in progress (nursel56, you were right on). Looking back, I would have still stopped him, the danger to the patient was too great. I guess I could have left the room, and gone for help first, but, well, the situation made me decide I could not leave the patient and the PA for even a minute in fear of what would go on because I was no longer there to see it...
There are times when you have to intervene, and even if I was a student in a situation like that, I couldn't have let it continue without saying something. Most of the time they'll stop with a small reality check. It's a pretty disturbing trait when a person gets their ego in the way of what's best for the patient, and a tendency his attending should know about if he didn't already.
:yeah:
bewitched
132 Posts
I'm not a nursing student yet, but here's my
.
My gut reaction to this question is that I would have to say something or step in, I think. Especially in the hypothetical situation of the patient being completely unable to advocate for him or herself. I couldn't stand there and listen/watch a patient clearly suffering when it's avoidable.
It's one thing to deal with a Dr. who won't prescribe adequate pain management in general, but for such an invasive and painful procedure, it's really bordering on torture. We don't do C-sections without anesthesiology... women balk at giving birth naturally without painkillers, even though that's something our bodies are designed to do... hell, you get local anesthetics at the dentist! There's no reason the Dr. couldn't do SOMETHING for this patient. Just because he is in a hurry is NO excuse to sacrifice patient comfort and dignity. I understand there is an inherent amount of pain to most if not all medical procedures, but there's no reason to exacerbate or ignore the pain when we could so easily avoid it by waiting half an hour.