MD was angry I questioned him.

[ella2990]

Almost time for shift change, I admitted a very young male who was very confused but pleasant. Hooked him on tele and noticed his heart rate was very irregular it would be as low as 50s to SR to as high as 120s-150s at rest. EKG was done and was uremarkable. No cardiology consult was put in the order. No H&P was documented since he was very out of it when brought to the ED the night before. BMP was also unremarkable except for k of 3.0 and ammonia level of 48umol (which in our hospital is considered critical value). Looked at the ED documentation and pt was given 4 doses of Latulose and no repeat ammonia level was done and also no documented repletion of K was done. I tried paging the doctor who admitted the pt but I already know he won't be calling me back since it was already past 1900 and I also called the on call MD for that night but I know I won't be hearing any call back anytime soon. So the best I could do at that time was document all my findings and my attempt on calling both the hospitalist and the on call. I also told the night nurse to page the on call again if she doesn't get any call back within the hour.

I came back the next day, and the nurse reported to me that his heart rate went as low as the 30s and his lactulose level was still 48 after giving one dose last night. K was also still at 3.0.

I text paged the MD of the situation. No call back after 30 mins. I call paged the MD 2x since I thought that it was critical that the MD be notified of the pt's heart rate dropping to the 30s.

MD finally called me back and told me that he will be discharging the pt today to the psych facility and almost hung up on me as soon as he finished his sentence. I told the MD of what happened last night and that his K and ammonia are still abnormal. He told me he's not at all concerned about it. At first I thought I was imagining things. I mean yes I only have 2 years of nursing experience vs. how ever many years he's been practicing, and the thought of questioning him I thought was insane! But it still bugged the crap out of me. At that time I was very nervous and braced myself for whatever's about to happen. I repeated myself and told him that maybe his heart rate was all over the place because his K was low. He said "well he can just get K supplement at the psych facility", I told him, I don't think the pt was safe to be DC with such erratic heart rate and maybe the pt will benefit for a cardiology consult. I also told him maybe his high ammonia is contributing to him having altered mental status. I can already tell he was very pissed and annoyed. He told me well go ahead and and put the consult in but want him DC today!

To make my story short. Cardiologist saw the pt and told me that the pt was not safe to be discharged and was glad I insisted on consulting him. Turned out the pt was in junctional bradycardia and that if the pt was DC'ed at the psych facility, there was a big change he'd code and be sent back here or the ICU.

My question now is, why was the primary physician angry at me? I feel like I did the right thing. I did not disrespect him or was aggressive in anyway.

[Rose_Queen, BSN, MSN, RN]

Doctors are just like other people in other professions: some are jerks. Sounds like this is one of them. Know you did the right thing for your patient and just let it roll off your back.

[Wuzzie]

Sounds like he wanted to turf the "undesirable" psych patient ASAP. Look at it this way, now that cardiologist thinks you're a rock star nurse AND you made a difference in a patient's life so win-win for you. The other guy...meh. Now you know how good a doctor he is...not. So tell me, which one's opinion matters to you more?

[TriciaJ, RN]

He wasn't mad at you because you did anything wrong; he was mad at you because you made him do something. He was going to turf the patient and make him someone else's problem. That doctor would have been the one in the hot seat when the unstable patient coded and died on psych. So he owes you gratitude and an apology. Neither of which you are likely to get. You won't get any lifesaving awards for saving this patient's life; you'll have to make do with personal satisfaction.

When you're a nurse, you don't have to do something wrong to get yelled at. You will get yelled at for doing the right thing, too. You'll get used to it. Meanwhile, please accept my kudos for being a conscientious and assertive nurse.

[cardiacfreak, ADN]

It's all about being a patient advocate. Good job for standing up to the doctor when you knew your patient needed more treatment.

[Boomer MS, RN]

Almost time for shift change, I admitted a very young male who was very confused but pleasant. Hooked him on tele and noticed his heart rate was very irregular it would be as low as 50s to SR to as high as 120s-150s at rest. EKG was done and was uremarkable. No cardiology consult was put in the order. No H&P was documented since he was very out of it when brought to the ED the night before. BMP was also unremarkable except for k of 3.0 and ammonia level of 48umol (which in our hospital is considered critical value). Looked at the ED documentation and pt was given 4 doses of Latulose and no repeat ammonia level was done and also no documented repletion of K was done. I tried paging the doctor who admitted the pt but I already know he won't be calling me back since it was already past 1900 and I also called the on call MD for that night but I know I won't be hearing any call back anytime soon. So the best I could do at that time was document all my findings and my attempt on calling both the hospitalist and the on call. I also told the night nurse to page the on call again if she doesn't get any call back within the hour.

I came back the next day, and the nurse reported to me that his heart rate went as low as the 30s and his lactulose level was still 48 after giving one dose last night. K was also still at 3.0.

I text paged the MD of the situation. No call back after 30 mins. I call paged the MD 2x since I thought that it was critical that the MD be notified of the pt's heart rate dropping to the 30s.

MD finally called me back and told me that he will be discharging the pt today to the psych facility and almost hung up on me as soon as he finished his sentence. I told the MD of what happened last night and that his K and ammonia are still abnormal. He told me he's not at all concerned about it. At first I thought I was imagining things. I mean yes I only have 2 years of nursing experience vs. how ever many years he's been practicing, and the thought of questioning him I thought was insane! But it still bugged the crap out of me. At that time I was very nervous and braced myself for whatever's about to happen. I repeated myself and told him that maybe his heart rate was all over the place because his K was low. He said "well he can just get K supplement at the psych facility", I told him, I don't think the pt was safe to be DC with such erratic heart rate and maybe the pt will benefit for a cardiology consult. I also told him maybe his high ammonia is contributing to him having altered mental status. I can already tell he was very pissed and annoyed. He told me well go ahead and and put the consult in but want him DC today!

To make my story short. Cardiologist saw the pt and told me that the pt was not safe to be discharged and was glad I insisted on consulting him. Turned out the pt was in junctional bradycardia and that if the pt was DC'ed at the psych facility, there was a big change he'd code and be sent back here or the ICU.

My question now is, why was the primary physician angry at me? I feel like I did the right thing. I did not disrespect him or was aggressive in anyway.

I just read this, and it was a pleasure to do so. Well done and congratulations to you for advocating for your patient. As others have said, try to let the MD's response roll off your back and realize what you did was the best for the patient. Maddening what happened but part of the reality of nursing at times.

[ella2990]

Doctors are just like other people in other professions: some are jerks. Sounds like this is one of them.

Funny you mentioned that, while he was busy ignoring my text page, I caught him walking towards the stairwell and called his name, he kept walking away, and I had to run to catch up! When I did, he kept climbing down and ignoring me as I was clarifying one of the meds he prescribed to the pt WHILE trying to catch up with him to have a face to face conversation. -___- let me tell you I was out of breath by the time I went back to the nurses station..

[Wuzzie]

So he owes you gratitude and an apology. Neither of which you are likely to get. You won't get any lifesaving awards for saving this patient's life; you'll have to make do with personal satisfaction.

Really good point and one to emphasize for you younglings. Personal satisfaction is a big part of your being happy in this career. Because, lets face it, nurses are the first to be thrown under the bus and the last to be congratulated. So celebrate your achievements small and large. Even if the party is only in your head. Don't expect others to do it for you because it just isn't going to happen. And continue to be a strong advocate for your patients even if you have to do it in anonymity. I promise you an amazing thing will happen. Little by little you will earn the respect of the people who really matter: your co-workers, smart caring doctors, colleagues outside of your unit, nursing students who will follow your example and your patients. In the words of Rachel Platten "Like a small boat in the ocean setting big waves into motion" you WILL make a difference.

[mmc51264, BSN, MSN, RN]

I have gotten to the point where if a resident ignores my requests for advice or a situation that I think is important, and I usually don't page unless it is necessary (we have a text paging system). I just ask them if they are too busy, should I page the attending? They forget or haven't figured out that the nurses have been there longer than them and usually know the attendings and have decent relationships with them.

They are more afraid of them than the nurses. I had an endocrine fellow giving us a hard time about some orders that were not written clearly. When she came up with the attending, who is my physician and she hugged me, hows the family, etc, the fellow certainly changed her attitude toward me.

You did the right thing advocating for your patient.

[mmc51264, BSN, MSN, RN]

Also, I have found out that sometimes if they are rude to you, they are rude to other nurses and the patients. Because I work in a teaching hospital, our attendings are very protective of the nurses and if it gets back that a resident or fellow is rude, they are the ones that get reamed a new one.

[Purple_roses]

Who cares if the primary physician is mad at you? The way I see it, we are all colleagues. He isn't your boss. He's calling the shots, but you're assessing and implementing, and your input is vital to patient advocacy. You absolutely did the right thing in an awkward situation!

For the record, when I say "who cares if the physician is mad at you"---well, I'm still trying to ingrain that in my brain as well. I don't mean that we should go around being rude or anything like that, but just that providers are not gods. We shouldn't feel weird about discussing patient health with a doctor.

[audreysmagic, RN]

Sounds like he wanted to turf the "undesirable" psych patient ASAP. Look at it this way, now that cardiologist thinks you're a rock star nurse AND you made a difference in a patient's life so win-win for you. The other guy...meh. Now you know how good a doctor he is...not. So tell me, which one's opinion matters to you more?

That was my first thought. I see so, so many times in reviewing the records of psych patients that are being transferred where the doctors are signing off just to get them off the floor. I had a patient once with a very high CPK where the doctor said, "It's trending down, I'm not doing a repeat; he's clear for psych." We are a freestanding facility so my medical consultant put his foot down and told them he would not be accepting this patient until CPK was below the level he wanted to see...when I called back to check on the latest CPK levels the next day, patient was off the stepdown floor and in ICU. A lot of doctors immediately decide no patient with any psych or substance abuse issues is capable of having any medical concerns and want to turf them ASAP. It's so frustrating to me. You did the right thing, OP!