maybe I wasn't being nice.....

[hearthelper]

So, maybe I wasn't being nice to my fellow coworkers, but common on we need to be a little more intelligent about our decisions. I work in ICU and had transferred my pt out of the unit to the Med/Surg floor when about 2 hours of her leaving she went into SVT with a HR around 200 (which I could see the second she went into it b/c we watch the telemetry for the hospital in ICU.) So, I watched the monitor for about 3-5 minutes (the telemetry tech notified them as soon as the pt went into SVT) hoping that they were going to turn her around but instead they called a rapid response. So, I went straight to the room to find 4 nurses standing around the pt, who was asymptomatic and stable. They did have the crash cart in the room, the BP machine on pt but the most important thing that no one had done was to notify the DOCTOR so you can get some orders for some meds, or I guess we could all just stand around her until crapped out on us!! At this point the pt had a HR of 200 for 10-15 minutes. I called the MD got orders and we converted the pt. Afterwards, one of the nurses overheard me being critical of their response to the pt and I know I should not have done that and I do feel bad for cracking jokes about them. This is a typical expected reaction on the med/surg floor and it happens too often. We are all nurses and all been taught the same principal things for ACLS response to a pt in SVT and they did act appropriately with a majority of the event but why wouldn't you call the MD as soon as you know your pt is in SVT??

[ChristaRN]

Just a couple thoughts based on my personal experience with rapid response teams, both Peds and adult. In my current life as a peds nurse we are fortunate to have a pediatric hospitalist in the hospital 24/7 so things work pretty smoothly 9/10 times. The hospitalist, usually a resident as well, a PICU nurse, respiratory therapist, nursing supervisor, Clinical Resource Specialist and chaplain will all respond. The child is usually transferred to PICU within minutes (the only delays I have seen were when the PICU was full and they had to transfer the most appropriate patient they could to us simultanously with us trying to get our patient to them). This system works pretty well. Now rewind back 4 years to my days as a med-surg nurse in a smaller hospital. If we were to call a rapid response team we would be met by a Family Practice Resident (the only physicians in the hospital at all times who were given permission to make emergent decision for patients who were or were not theirs), critical care nurse, nursing supervisor and lab tech (this was at night, I'm sure way more people showed up during the day). Our responsibilities once the RR was called was to get the code cart, place the patient on the monitor connected to the code cart (which the DOC OR CRITICAL CARE NURSE would interpret), get vitals, place O2 if needed and stay with the patient and of course start a code if things deteriorated to that point. The rapid response team would arrive in literally 2 minutes or less. Of course many times before a rapid response was called I may have had an idea that things were heading South with a patient and have been in touch with the doc but once I called a rapid response I didn't call the doc again until things were being taken care of by the rapid response team. At that facility it was policy that the decision would be made by the Resident and Critical Care nurse as to whether the issue could be handled right on the floor or if the patient needed to be moved to a higher level of care. We would move the patient STAT per the recommendation of the resident and CC nurse and from there the communication via phone to the patient's Doc would be initiated by the Resident or the CC RN. My rationale for that is that (1) many of the interventions needed may not be legally possible on a M/S floor and (2) if a M/S nurse isn't familliar with what's happening to their patient (which is totally understandable) then they may also be unfamilliar with orders the doc might give which can increase the likelihood of transcription errors or med errors stemming from confusing verbal orders. Often times after the inital STAT orders were obtained the patient's physician would ask to speak to the floor nurse to get a more detailed account of what happened with the patient. I will be starting next month in PICU, my first critical care job but I don't think CC experience makes one a better nurse. The skill set required of med-surg level nurses is wide and in some ways I think catching a problem early can be very difficult when you have so many patients and no monitors/bells and whistles to help you.

[quiet_one]

medsurg nurses at my facility are not required to have ACLS certification! BLS yes, but the advanced stuff is done by the code team 99% of the time at my hospital (even though I am a medsurg nurse that is ACLS certified).

Also rapid response would not have been called if these nurses knew exactly what to do (this is not a routine problem for them), rapid response usually arrives within a two minutes at my facility, so during that time I generally find myself trying to get vitals, crash cart and fully assess the situation and when the patient is in capable hands I page the MD.

And yes medsurg nurses 'all too often' do not know exactly what to do when a rapid response is called...when that changes there will not be rapid responses!

[caroladybelle, BSN, RN]

If there's a code cart where you work, you should probably know what's in it, what it's for and how to use it. Period.

As to the hospital not providing the class: boo-hoo. I took ACLS and PALS on my own time. I needed it and the hospital courses did not jive with my schedule.

Again, it's pretty simple: If there's a code cart where you work, know what's in it and how to use it.

(And by the way, it's not just ICU that uses code carts. We use them in the ER and sometime we have 6-8 patients. Also, you need to know a bit more than ACLS to work in the ICU. Seriously, if learning ACLS is too much for a nurse, then, well, I don't even know what to say. ACLS isn't difficult.)

Condescending much?

Pretty much every place that I did medsurg, the nurses did indeed know what was in the code cart, and what's its for.

As to having the legal wherewithall to give the meds or intubate the pt, that belongs to the code team.

If you read the OP, there is no indication that the nurses did not know what was in the code cart. In my post, there was no mention of nurses not needing to know the contents of the code - knowing the makeup of the code cart is standard. Especially since they are used everywhere in the hospital - I don't believe anyone posted that they were used ONLY in the ICUs.

And as I work in CC, I do know ACLS, along with cardioverting pts on a regular basis., and CRRT/CVVHD.

But I don't expect MedSurg to need to know it.

And for some very smart people, ACLS is indeed difficult. Just as I deal routinely with some ER/ICU nurses that don't know chemo, accessing portacaths safely, chemo precautions, or DIC, parameters for transfusing/holding transfusions on pts in acute leukostasis, or how to manage a post ARAC or High Dose IL-2 pt in crisis. And I can explain it to them, to no avail - often they can't "get it".

All of us have specialties that come with certain requirements and responsibilities. It would be lovely if we all knew "Everything". But none of us do.

[Flying ICU RN]

All of us have specialties that come with certain requirements and responsibilities. It would be lovely if we all knew "Everything". But none of us do.

That statement just about wraps it up in a nutshell.

You know, I've taken care of many a complex patient, but what is necessary for me to know well are the technical aspects of the job, not the underlying reasons for them. I'm not even so concerned with diagnosis and history as I am current condition.

I can initiate a timely intervention on anyone for any reason, that's what counts for a nurse.

[Flying ICU RN]

I can't, even as an icu RN, push any drug without an order. .

Check policies, atropine should be a first line grab and push drug.

[caroladybelle, BSN, RN]

That statement just about wraps it up in a nutshell.

You know, I've taken care of many a complex patient, but what is necessary for me to know well are the technical aspects of the job, not the underlying reasons for them. I'm not even so concerned with diagnosis and history as I am current condition.

I can initiate a timely intervention on anyone for any reason, that's what counts for a nurse.

A problem though, is that a timely intervention can sometimes do more harm than good, if you do not assess the history

I have seen CC nurses pour fluid boluses into pts that have gotten large doses of ARAC, that have low pressures. These pts have serious capillary leak, and it will clobber their lungs, but not do squat for the BP. I have seen ER give PRBCs to pts with borderline HCT, and WBCs of over 100K, and mild SOB, crackles in the lungs. The CXR will be starting to white out. The blood viscosity will be like molasses. The PRBCs invariably worsen the pts condition, SOB and heighten risk of embolization.

The simple answer that looks right often can be very wrong and worsen the situation.

I've had pts that were acutely neutropenic, with mild temp, sit in the ER for hours, not get ABX started until they hit the floor. This delay easily can kill them. Any temp > 100.4 in a neutropenic pt is an emergency - they should not produce any fever at all with low WBCs, unless seriously infected. But if you don't know their history or diagnosis, you might not spot that.

[Flying ICU RN]

I have seen CC nurses pour fluid boluses into pts that have gotten large doses of ARAC, that have low pressures. These pts have serious capillary leak, and it will clobber their lungs, but not do squat for the BP

Perhaps so. But were they doing these massive boluses at the direction of a physician, or independently? This ARAC, is an anti leukemia drug is it? Who would be giving this and how far in the past?, is it a chemo drug?

I can give neither large boluses of fluid nor start titratable gtts without the direction of the MD. I can, and do, anticipate and prepare for either, but I cannot independently initiate either.

Patient advocacy is all well and good, but what you describe in my view, is a medical analysis outside of my purview. At some point, I must stay on my side of the fence.

[PatricksRNMommy]

Perhaps so. But were they doing these massive boluses at the direction of a physician, or independently? This ARAC, is an anti leukemia drug is it? Who would be giving this and how far in the past?, is it a chemo drug?

I can give neither large boluses of fluid nor start titratable gtts without the direction of the MD. I can, and do, anticipate and prepare for either, but I cannot independently initiate either.

Patient advocacy is all well and good, but what you describe in my view, is a medical analysis outside of my purview. At some point, I must stay on my side of the fence.

We all have our areas of expertise... I work on PCU/Tele/Stroke floor so if a patient on med/surg is on a cardiac med or has a cardiac history that they are not knowledgable about or they think a doctor's orders might be questionable , they will often call me. If I have a question about a chemo med or radiation treatment or a difficult to access infusaport, I call the oncology floor. Question about taking care of a dialysis patient, their access, or labs.... I call the renal floor. Newer cardiac drips that I'm unfamiliar with.... CVICU. We all need to respect eachother's strengths and weaknesses and use eachother's expertise for the benefit of our patients. You may not know to question a doctor's order to give large fluid boluses to this patient receiving ARAC (and neither would I... and maybe neither would the doctor himself) but ultimately, even if you are following a doctor's order, your actions could cause the deterioration of the patient. If the ER doc doesn't want to consult the patient's oncologist, maybe you could call an oncology nurse that you trust and get her take on the situation so you could be better prepared to take care of your patient. If the patient "drowns" in all that fluid, do you think it's only the doc who's going to take the heat? How many patients do you think we have all saved by questioning an order?

[Flying ICU RN]

If the patient "drowns" in all that fluid, do you think it's only the doc who's going to take the heat?

If everyone stands around and lets the pulmonary edema continue to develop without attempting reversal, yes of course, serious heat would come my way.

I don't know,.. I see way too many nurses at all levels of care, worry way too much about too much stuff to the point of paralyzing themselves into an inability to act timely, and appropriately. I call it the "Deer in the Headlights Syndrome." In my view, a line does have to be drawn in the sand somewhere. I suppose it's up to the individual to determine where that line should be.

[HamsterRN, ADN, RN]

The point I was trying to make in my original post was the first thing that any Nurse (med/surg, lpn, rn, icu) should do if there is a change in the status of your pt the MD should be notified. I can't, even as an icu RN, push any drug without an order. All I expected the nurses to do would be to get the ball moving so we could help the pt sooner instead of waiting for the MD to call back and give his orders. I don't expect the Med/Surg RNs to run a code just know to send somebody to call the doc. This wasn't a dump as stated in a previous post. The pt had never been in SVT before and was pretty stable from a cardiac standpoint. She had a hx of afib. There are some interesting post in response to my original post and have enjoyed interacting with allnurses.

Does your Rapid Response Nurse have the ability to initiate ACLS (and push drugs) without an MD order? If not, that sort of defeats the purpose of many of the ACLS algorithms which is to avoid waiting for the Doc to return a page to treat the patient.

Our Rapid Response team does not include an MD, the MD is always notified but it is usually more of an FYI than a request for orders.

[Fribblet]

Condescending much?

Nope. It's a statement of fact. Every nurse should know the basics.

Pretty much every place that I did medsurg, the nurses did indeed know what was in the code cart, and what's its for.

Good, then they are practically ACLS certified.

As to having the legal wherewithall to give the meds or intubate the pt, that belongs to the code team.

If you're ACLS certified, you're a allowed to initiate first line responses. ACLS does not teach, nor give the authority to, the nurse to intubate. Not sure which class you took....

If you read the OP, there is no indication that the nurses did not know what was in the code cart. In my post, there was no mention of nurses not needing to know the contents of the code - knowing the makeup of the code cart is standard. Especially since they are used everywhere in the hospital - I don't believe anyone posted that they were used ONLY in the ICUs.

If you read my post, I mention that I was speaking "off topic." You mentioned specifically in your post that med/surg nurses have multiple patients while ICU nurses only have 2. My point was that it does not matter where you work, or what your patient load is, ACLS, imo, should be a requirement, PALS if you work with children.

And as I work in CC, I do know ACLS, along with cardioverting pts on a regular basis., and CRRT/CVVHD.

But I don't expect MedSurg to need to know it.

I'm saying I do. I know it's not a requirement (at some hospitals it is), but what I'm saying is that I think it SHOULD be. And, incidentally, many hospitals agree and are requiring that ALL nurses be ACLS certified.

And for some very smart people, ACLS is indeed difficult. Just as I deal routinely with some ER/ICU nurses that don't know chemo, accessing portacaths safely, chemo precautions, or DIC, parameters for transfusing/holding transfusions on pts in acute leukostasis, or how to manage a post ARAC or High Dose IL-2 pt in crisis. And I can explain it to them, to no avail - often they can't "get it".

ACLS is an extension of BLS. What you described above is highly specialized. ACLS really isn't hard. You need to know the deadly rhythms and what to shock and a few drugs.

All of us have specialties that come with certain requirements and responsibilities. It would be lovely if we all knew "Everything". But none of us do.

I'm not asking for everyone to know everything. I'm asking that nurses know the basics of how to treat someone who is crashing. If expecting nurses to know what to do to save a life is asking too much, then, I don't even know what to say.

[DayOhioRn]

Nope. It's a statement of fact. Every nurse should know the basics.

Good, then they are practically ACLS certified.

If you're ACLS certified, you're a allowed to initiate first line responses. ACLS does not teach, nor give the authority to, the nurse to intubate. Not sure which class you took....

If you read my post, I mention that I was speaking "off topic." You mentioned specifically in your post that med/surg nurses have multiple patients while ICU nurses only have 2. My point was that it does not matter where you work, or what your patient load is, ACLS, imo, should be a requirement, PALS if you work with children.

I'm saying I do. I know it's not a requirement (at some hospitals it is), but what I'm saying is that I think it SHOULD be. And, incidentally, many hospitals agree and are requiring that ALL nurses be ACLS certified.

ACLS is an extension of BLS. What you described above is highly specialized. ACLS really isn't hard. You need to know the deadly rhythms and what to shock and a few drugs.

I'm not asking for everyone to know everything. I'm asking that nurses know the basics of how to treat someone who is crashing. If expecting nurses to know what to do to save a life is asking too much, then, I don't even know what to say.

As a step down unit nurse, and one who has taught a code cart class, I have to ask....why not pull the ACLS Algorithm off the Code Cart???? At my facility , I am fortunate that someone had the smart idea to attach the ACLS algorithms to all the code carts, and to make it a policy. l On every PEDS cart the algorithm is chained to the side of the cart and on every Adult cart the ACLS protocol is chained to the side of the cart. If you get nervous and forget, you have a large laminated chart to assist you.

I too believe that every Med-Surg nurse should have a general idea what is going to happen in a code. ACLS certification is a good start. I don't buy the "some nurses are not that smart" excuse, or the my facility doesn't pay excuse. I sure helps you from having that deer in the headlights look. I keep wondering, what about the facilities that DON'T have a rapid response team? What then? Theses women were right to call the team, and while the patient was stable, the could have pulled up a history, taken vitals and prepared the patient for the team, and called a physician. I understand that some Med-surg floors cannot push meds , but standing around is not the answer either. So I ask the Med-Surg nurses out there, call your MD, the RRT and get vitals, including a blood sugar, know your last pertinent labs and patient history including the events that lead up to the incident if possible, and be prepared to share what you DO know! It helps! By the same token, the nurses in the RRT need to LISTEN and be prepared to give suggestions without prejudging the med-surg nurse who has the patient. They are often looking to you for guidance, and there is absolutely no justifiable reason to criticize someone who has called for your help.

As for the OP making fun of these women, she acknowledges she was in the wrong, as she missed an opportunity to educate these women on what is expected of them when a patient goes into SVT, and that is a shame. A learning opportunity all around I should say, and it looks like it was missed.