Issues with a doc...(long)

[registerednut1221]

I have been at my facility for almost 2 years. We have a a regular doc every other week and on his off week, we have different docs roatate. Each time we get a new doc we get the usual bombardment of new labs, CXRs, med changes, etc. It's not fun, but expected and you do what you have to do. I understand that they have to cover themselves. I keep my mouth shut about crazy orders like c-diff x3 on a patient that has had a grand total of one BM in 3 days. I keep my mouth shut when the docs order expensive tests that require our patients to be transported to a different facility (which we will never be reimbursed for because is was frivilous to begin with). I smile and proceed without complaint when a doc re-orders the exact same labs that were run less than an hour earlier (that they would have realized were already done if they had bothered to check the exsisting orders/progress notes before writing new orders---they don't see the results in the computer yet and just ASSUME no one has checked the K+ today on a patient that had a k+ of 3.2 yesterday and is getting 40 mg iv lasix q 8 hours). I have learned to adapt to our zebra chasers and, to be honest, I usually gain a great deal of knowledge from these experiences. I do, however, have a problem with a doc not reading the progress notes/nurses notes before they decide to completely change a patient's medications. This weekend a new doc did just this on a patient that I have been taking care of for weeks. He wasn't there less than 4 days ago when another doc tried the exact same thing and my pt's (who is in a-fib) heart rate shot up to and was sustained at 180, bp was nothing/nothing, she ended up having a mild MI and, to be honest, we nearly lost her before we got her back under control. When I got these new ordes, I VERY RESPECTFULLY asked him a few questions and recapped the incident we had just a few days prior. He very respectfully asked me to follow the orders as written. I told him I was concerned about inducing the same cardiac instability I had seen with her before and had only wanted to mention it. So after he had discontinued cardizem, added iv lasix and doubled the lopressor on my patient I monitored her very closely. @ 1200 her heart rate had increased from 70s-80's to 105 and her BP had dropped to a whopping 73/55 it was now time for me to go give this lady 50mg of lopressor and 400 mg cordarone. I VERY RESPECTFULLY notified this doctor that I would holding her scheduled dose of lopressor due to BP issues. He wasn't very happy about this. I all but pleaded with him that I felt we had had an unstable patient, gotten her stable and were now pushing her back towards instability. He informed me that we needed to "challenge" this patient. I told him I was concerned that she wasn't physically strong enough at this point to be "challenged". He then proceeded to tell me that the previous dr's orders were "asinine" and that we (nursing staff) were the reason that we did not have a full time doc at our facility because we "challenge" the docs too much. At this point I told him "I am going to open this door" (referring to the door to his office that was seperating us from the rest of the staff). After opening the door and holding it open with my hip, I told him that the staff here was growing weary of different docs coming through every other week and completely changing the plan of care on all the patients at our facility. At this point he got very loud and I walked out to the nurses station (so I would have witnesses to our conversation and it would not turn it to a he said/she said). he followed me and very loudly, while pointing his finger at my face as if to make his point more clear, and told me that we had to get "some things straight". He referred to an incident that had transpired more than 3 months ago and said that this "was not the first time we (he and I ) had had 'issues'" I reminded him that although it was me that he had taken his frustrations out on at that time, i was not even that particular patient's nurse and it was another nurse he had truly had 'issues' with. He then said to me "No, it was you and, on that, I am crystal clear." (all the while point his finger and getting in my space.) He told me that if I were capable of taking care of everything, then maybe I should be the one writing the orders. I told him I was only trying to protect my patient. Some how my protecting my patient comment turned into a 'lack of respect' issue for him. He continued to yell at me for a minute or two and then stormed back to his office and wrote a new albumin order on my patient. When I left my shift last night, my patient had a bp of 63/44 and was minimally responsive (all reported and charted). I just don't understand what happened. I have been at this same facility for almost 2 years and have dealt with 100's of docs. I have never had an issue with any other doc and this is my second episode with this one. I have written everything up and plan on taking it to my nurse manager. I don't want to look like a trouble maker, but at the same time, I truly am trying to protect my patient. I understand that in the end the doc always wins, but I cannot just sit back and let him do this to me and my patient every time he rotates through our facility.

Any advice?

[RN1989]

Call the state medical board and report him for acting in a dangerous manner. Be prepared to write out a sworn statement and have it notarized.

[bigsyis]

Congratulations on your critical thinking and patient advocacy. You didn't mention your CN or Supervisor-were they around, and did they help you? This guy sounds like an insecure, royal bu++, and I am glad to hear how you handled him.

[nurse grace RN, BSN]

You did a great job advocating for your patient. He sounds like a real a**hole. He was probably last in his class in med school. By all means report him to everyone who will listen!

[angel Ann]

You did the right job by protecting your patient.docs arent the ones present to look after the patients for 24 hours, so your justification is based on your observations,knowledge and your confidence to know whats best for her/him.It seems that the doc you are referring to doesnt listen nor considering what the nurses are reporting and just willed himself to make unrealistic orders.I wonder if he made a better explanation for his orders to at least justify himself as a knowledgeable doctor rather than pointing his finger at your face.For as long as you showed a respectful communication with him, you are in the right position.That doc is just insecure:yelclap:

[teeituptom, BSN, RN]

I truthfully dont have issues with MDs

I just train them

[Altra, BSN, RN]

I agree with previous posters that this should have been immediately referred to your charge nurse and the house supervisor, and then discussed with your manager at the earliest opportunity.

I do wonder though, why you have been reluctant to point out labs already drawn, tests that require transport, important info in progress notes, etc. He sounds like a lazy ass.

[jojotoo, RN]

First of all, the doc does not "always win" if by that you mean that his orders are going to be carried out come he** or highwater. Clinically you were correct in holding the Lopressor and notifying the MD. Hopefully your documentaion reflected that. At the first drop in BP, I would have probably told the doc that if it drops any further that I would be notifying the patient's family regarding a change in the patient's condition. That might have given him something to think about.

And MLOS has an excellent point about notifying the charge nurse, the house sup, doing whatever you can to take this up the chain of command. All this needs to be documented in the chart - but in a very neutral way. It's CYA time.

It's OK to document: "Awaiting Potassium result drawn at 3PM. Spoke with Dr. xyz.

Per MD order - redraw Potassium now/ stat." Very neutral. Very factual. After a few of these, whomever does your chart review (UR) will be having a converstion with this MD.

As far as being a troublemaker - I hope to God (literally pray) that I or my loved ones will have a "troublemaker" taking care of me.

[leslie :-D]

i agree about remaining neutral when documenting EVERYTHING, including the comment he made about the other doctor's assinine orders, and nurses being the reason there hadn't been a full time doc.

he's creating a hostile work environment.

but it is critical for others to know you were against these n.o's....via documentation, as well as sharing all w/your cn, nm.

keep your cool, do not argue w/him but continue to express concerns about the well being of your pts and any inappropriate orders.

any conversation should ideally be witnessed/heard by others.

sounds like you're on top of everything.

great job.

leslie

[teeituptom, BSN, RN]

i agree about remaining neutral when documenting EVERYTHING, including the comment he made about the other doctor's assinine orders, and nurses being the reason there hadn't been a full time doc.

he's creating a hostile work environment.

but it is critical for others to know you were against these n.o's....via documentation, as well as sharing all w/your cn, nm.

keep your cool, do not argue w/him but continue to express concerns about the well being of your pts and any inappropriate orders.

any conversation should ideally be witnessed/heard by others.

sounds like you're on top of everything.

great job.

leslie

I like patting those doctors on the head, and telling them to chill.

[registerednut1221]

I agree with previous posters that this should have been immediately referred to your charge nurse and the house supervisor, and then discussed with your manager at the earliest opportunity.

I do wonder though, why you have been reluctant to point out labs already drawn, tests that require transport, important info in progress notes, etc. He sounds like a lazy ass.

My charge nurse was notified and actually stepped in to help with the situation and charted some of her own observations in this patient's chart. My nurse manager was not present at the time, but I will be speaking with her Tuesday morning. I also haven't been reluctant to point out the obvious to the docs. When they ask for a lab that has already been drawn I do tell them that "it was drawn at 0630" (or whenever) and "it just hasn't had time to result yet." For tests that require transport, I will tell them that the patient will need to be transferred to this facility or that one (depending on the test) because we don't do that particular procedure here. I don't question the order, I just let them know that it cannot be done here. Some of them will say "Oh, I didn't realize that. Let me cancel the order." but then there are some that get a little defensive about it, but I just chart that dr ordered this test that requires transport to this facility; md notified of required transport; transport arrangements to be made at dr's request.

[jojotoo, RN]

My charge nurse was notified and actually stepped in to help with the situation and charted some of her own observations in this patient's chart. My nurse manager was not present at the time, but I will be speaking with her Tuesday morning. I also haven't been reluctant to point out the obvious to the docs. When they ask for a lab that has already been drawn I do tell them that "it was drawn at 0630" (or whenever) and "it just hasn't had time to result yet." For tests that require transport, I will tell them that the patient will need to be transferred to this facility or that one (depending on the test) because we don't do that particular procedure here. I don't question the order, I just let them know that it cannot be done here. Some of them will say "Oh, I didn't realize that. Let me cancel the order." but then there are some that get a little defensive about it, but I just chart that dr ordered this test that requires transport to this facility; md notified of required transport; transport arrangements to be made at dr's request.

Excellent charting. And Leslie is right - the phrase "hostile work environment" would be a good one to work into the conversation with your manager when discussing the MD's behavior.