MD's orders

[BA_anthropology]

..and I don't mean the official type. I mean the type that gets you into FIGHTS!

Today, I was so studiously administering 80mg Lasix IV push over 8 minutes, and the patient's doctor walked in the room and told me to "just push it," in regards to the last 30mg (in 3mL), because he needed to assess the patient.

Now, I'm a nursing student. I can't even take REAL verbal orders from a doctor at this point, let alone administer something incorrectly because the doctor told me to. Whaaaat was going on here? I don't know if "just pushing" Lasix IV is something nurses do regularly, but I was pretty taken off guard by such a suggestion. What about deafness?? What about irritating the veins??

He added, "we don't do that in the real world." And he said, "real world," like my administering lasix was the behavior of those in of la-la land, but specifically meaning that people don't actually follow a 10mg/min for Lasix IV. This is probably true to some extent, and if he's done that a million times and nothing bad happened, that's his b'ness, but I certainly wasn't going to take any chances.

My mind kind of blanked and I tried to explain, "I'm actually a nursing student and I can't take verbal orders, sooooo sorry." (as though this was *that* type of order).

He continued to get agitated and repeated, "Just push it!! Just push it!!" I didn't know what to say or do, but I knew I wasn't just going to push something incorrectly and hurt the patient. Again told me that this isn't how things work in the real world, in a really mean and frustrated tone.

I just told him, "I can push it over 2 minutes." (We'd already been arguing for one minute and 1 mL at that point).

Oh boy, was he MAAAAAAAD.

And just and added note to the story, this all occurred in front of the patient's family as well as the patient. The family later thanked me and expressed that they were frustrated that he'd been so impatient, and didn't know anything about what was going on with the patient.

After I gave the Lasix, the doctor listened to the patient's lungs from her back side, which was EASILY accessible to him the entire time and left...so I was pretty confused as to the purpose of our whole beef.

Anyway, the point of this huge post, aside from venting is: in hindsight, the best thing to do would probably have been to stop administering the med and continue after he assessed the patient, right? I would have been open to that as a compromise, but I didn't even think of it at the time. I mean, this is about the 3rd time I've ever given it, and the first time I was ever pushed around by a doctor.

Any thoughts on how you've handled similar "orders," as experienced nurses?

[blondy2061h, MSN, RN]

I would have handed him the syringe and walked out.

[BA_anthropology]

I would have handed him the syringe and walked out.

Oooo! That would have been good.

But, can we do that? As in, is that allowed if we've pulled it from the pyxis and initiated it?

[FancypantsRN]

I have never had that happen. Good for you for not getting intimidated and iv slamming lasix. Yes, hindsight- next time I would just finish after the doc leaves (if they are that impatient). Nice job handling it.

[blondy2061h, MSN, RN]

Oooo! That would have been good.

But, can we do that? As in, is that allowed if we've pulled it from the pyxis and initiated it?

MDs are allowed to push drugs we got from the Pyxis. There are drugs that the MD only is allowed to push, and they can't get in the Pyxis. Same goes from some drugs respiratory gives at my facility. However, it is poor practice for anyone to give a drug they didn't draw up. Doesn't sound like this guy has much regard for doing things by the book, though.

[ChristineN, BSN, RN]

He might think nurses don't give it that slow in the "real world," but this one does. I still follow the "10mg of Lasix per min" rule that I learned in nursing school. I am not going to bottom out my pt's BP just to pull off a little fluid.

[LouisVRN, RN]

I probably would have asked if I could step to the side to allow him to assess the patient. Or told the patient I would continue pushing the medication after the assessment. i would definitely not allow a doctor to "boss" me into doing something incorrectly. Nor would I take "Just push it already" as a verbal order, more just a sign of irritation however I would not have engaged in a verbal dispute with a doctor in front of a patient, unless the doctor was somehow going to put the patient into immediate harm. I believe it is things like this that make patients and families distrust the entire healthcare team.

[Orange Tree]

It sounds like you handled it well. I don't think you need any help :)

[BA_anthropology]

I probably would have asked if I could step to the side to allow him to assess the patient. Or told the patient I would continue pushing the medication after the assessment. i would definitely not allow a doctor to "boss" me into doing something incorrectly. Nor would I take "Just push it already" as a verbal order, more just a sign of irritation however I would not have engaged in a verbal dispute with a doctor in front of a patient, unless the doctor was somehow going to put the patient into immediate harm. I believe it is things like this that make patients and families distrust the entire healthcare team.

Agreed! I actually tried REALLY hard to think of what I should say and do to make sure the patient felt safe with both the doctor and myself. Including just stating that it wasn't how I'd learned to do it, etc. I was just kind of dumbfounded!

[netglow, ASN, RN]

What a brat he was. I will tell you this. 9 times out of 10 the family and patient will immediately notice when you hold fast to safety first, and especially if an MD throws a fit and you are calm and insistent. Some wierd stuff happened similarly to me when I was a student. When the "tantrum" was over and the MD left the room, I just continued on with what I was doing, and turned and gave the patient a wink and a smile. That's all that I needed to do.

[kellyc034]

He was out of line. You did the right thing in NOT pushing it fast.

Kelly

[Laurie52]

He might think nurses don't give it that slow in the "real world," but this one does. I still follow the "10mg of Lasix per min" rule that I learned in nursing school. I am not going to bottom out my pt's BP just to pull off a little fluid.

The main reason that furosamide is given slowly (and I still follow the old 4 mg/min rule) is more related to the tinnitus and ototoxicity associated with more rapid infusion.