Need Your Opinion About Medical Emergency

[intellica]

I am a nurse clinician, and have been a nurse for 26 years. I have worked at my current place of employment for over 17 years and currently hold the position of head nurse. It is in a community setting with a pediatric clientele. Recently we had a medical emergency (code blue), the client in question was having a seizure and had turned blue. There was no doctor on site, so it became my job to "run the code". (I.e direct the other nurses how best to help this patient)

Near the end of the code, one of the LPN's (formerly called, nursing assistants, but they are now called licensed practical nurses), starts contradicting one of my directives, and our manager (an occupational therapist), agrees with her and implements her directive.

Let's call the LPN Sandy and the Manager, Eva (not their real names)

The clients seizure had ended, but his oxygen levels were low and his heart rate was fast. I needed to monitor him while we waited for an ambulance. I had asked a bystander to please move out the way, as she was blocking my view of the patients face (the bystander was consoling the client).

Sandy the LPN disagreed with me and stated that the bystander should retake her position, and my manager Eva agreed and told the bystander to resume her position which consequently prevented me from seeing the patients face (an important source of clinical information). In addition, it prevented the patient from entering the "postictal state" which is a kind of a sleeping phase that happens at the end of a seizure (the bystander was stimulating him, singing to him, etc). In addition it added an extra voice to the cacophony of voices that were asking questions, commenting, etc. I am hearing impaired and wear hearing aids, so the more voices there is the more difficult it is to hear.

The ambulance came and took the child to the hospital. Afterwards, I met with the team of LPN's who had intervened with the child, because one of them was shaken and needed reassurance.

After I reassured her, Sandy says (in front of the nursing team) "I really did not like when you asked the bystander to leave"

I responded that this was best practice and also institutional policy. She continued however to argue back and forth with me about my decision (which she ultimately overridden). She then proceeded to tell me she did not like that I was telling people what to do, she began imitating me "get me the stethoscope! get me the defibrillator!" She felt I was too bossy and she did not like my tone of voice.

I was hurt and embarrassed. I  told my manager how I felt. My manager states she did nothing wrong because "everyone is allowed to have an opinion".

[intellica]

Nurse Beth, thank you for this comment, as I was attempting to distinuish our different roles. I would like to add that I was not just upset because she countermanded me. After the code, in an informal debriefing, she confronted me for running the code, which is absolutely my role!  She did this infront of the nursing team. Team work during medical emergencies is tantamount in terms of importance, and there is a certain level of profesionalism that is difficult to maintain when emotions are high. The children that frequent my school suffer important co- morbidities and are incredibly fragile, I am open to the fact my  emotions my have been evident in my voice, but I don't' thinik I deserved to be attacked, directily after. Imagine, doing this to someone running a code in a hospital, 

[Wuzzie]

intellica said:

After the code, in an informal debriefing, she confronted me for running the code, which is absolutely my role!  She did this infront of the nursing team.

This is evidence of the power struggle I mentioned earlier. This needs to be addressed immediately.

[Nurse Beth, MSN]

intellica said:

Nurse Beth, thank you for this comment, as I was attempting to distinuish our different roles. I would like to add that I was not just upset because she countermanded me. After the code, in an informal debriefing, she confronted me for running the code, which is absolutely my role!  She did this infront of the nursing team. Team work during medical emergencies is tantamount in terms of importance, and there is a certain level of profesionalism that is difficult to maintain when emotions are high. The children that frequent my school suffer important co- morbidities and are incredibly fragile, I am open to the fact my  emotions my have been evident in my voice, but I don't' thinik I deserved to be attacked, directily after. Imagine, doing this to someone running a code in a hospital, 

You are welcome, @intellica ? ! I feel your response. Try to step back and plan how you will handle it if you are rechallenged in public.

I'm sure you'll make the right choice.

[londonflo]

intellica said:

The clients seizure had ended, but his oxygen levels were low and his heart rate was fast. I needed to monitor him while we waited for an ambulance. I had asked a bystander to please move out the way, as she was blocking my view of the patients face (the bystander was consoling the client).

Assessment is the priority here. Not a teacher, OT or anyone else. Everything you did was correct from start to finish. 

[londonflo]

intellica said:

as I was attempting to distinuish our different roles.

 

 The physical situation (assessment)  of the patient is the most important at this time. Airway, breathing, heart rate. Impact your discussion that the students  have many physical important co- morbidities. Are the teacher and OT CPR certified? Is someone in a post-ictal state available to personal support? 

You may have found a job that does not respect your education, experience and leadership.  You may have found the Achilles heel in this job. 

Quote

As an expression meaning "area of weakness, vulnerable spot," the use of "Achilles' heel" dates only to 1840, with implied use in Samuel Taylor Coleridge's "Ireland, that vulnerable heel of the British Achilles!" from 1810 (Oxford English Dictionary).[12]

 

Not your Achilles heel but theirs. Why do I think that all the disciplines are saying to the parents "I saved him/her! But I am so glad YOU saved the child through the seizure.

Afterall the patient was going there for professional nursing health care ..the primary diagnosis to have these services is physical care delivered with ancillary service/...OT, Teaching can be delivered out patient or at school. . 

[Kohai2, BSN]

Sounds like you need to move up the chain of command here and there needs to be more education in this setting. 

1. Whoever is running the code is RUNNING THE CODE. That's it. Period. If the manager isn't running the code, their opinion doesn't matter at that moment. Same for the LPN. You can't sing someone out of a seizure so I'm not sure why anyone would object to the teacher not being able to be in the kid's face singing. That is not a relevant medical intervention at this time, therefore it takes a backseat to you being able to monitor the child's respiratory status.
 

2. You have a documented disability and the workplace has agreed to make reasonable accommodations—not singing during a code or in the immediate aftermath seems reasonable to me. I'm not even hearing impaired and that sounds like an idiotic thing—extra noise during a stressful situation. No. 
 

3. Have a chat with the LPN that during a code, she should not be taking things Personally, take them Professionally. People die because of assumptions like 'oh I assumed someone would have a stethoscope' so it's good you said what was needed. Closed loop communication is the standard and if someone isn't regularly running codes they aren't likely to sound as calm as the AHA videos. It's OK to be scared. Your voice will very likely reflect that. 
 

Overall, I'd be looking for some serious changes or a new job. You're the top medical person there so if the *** hits the fan and a kid dies, whose feet will they lay the blame at? Yours. Not the OT manager. Not the LPN. You. 

[MarkMyWords]

This sounds like a misunderstanding over the word "leave". You might have said 'please move aside for a minute'.  Females more than men are sensitive to tone of voice, in my non-medical life experience.  And it is hard to control that.

You were right but with the wrong way of saying it.

 

[londonflo]

MarkMyWords said:

'please move aside for a minute'.

 Let's discuss aside for a minute. Every minutes counts for assessment, it is continuous That is why we call it "continuous nursing monitoring"

 

 

[lvntrail, LPN]

 I'm confused as to why it became your role to 'run the code'. If the LPN  ( sounds like there was more than one present?) the OT or even the teacher were already managing their student/ patient did they need you to step in? Does the student's care plan or your facility protocol state the RN will take over care?  The reason school based nurses defer to EMS is not because they are necessarily more capable or ' higher' than us but because they have equipment we do not ( they add value to the care). Were you able to give a level of care the LPN or OT  or even teacher could not? ( In the actual event- not scope) Was there need of you taking over care?  Your team definitely needs a post- event review to clear the air and confirm steps for next time. I agree there is a power struggle and part of the issue is you do not seem to respect other professional staff or the dynamics of a team. You have been publicly disrespectful to fellow nurses and to the teacher. Even in your explanation you list CNA with nurses- perhaps you ment CRNA...If there is any chance staff saw your Reddit you will have a hard time overcoming the nursing assistant comment or having referred to the teacher ( who is likely very invested in the child) as a bystander. The explanation that it was to make it clear for the general public is odd since you used nurse clinician for yourself, a very unclear term. I hope you will go back to Reddit and try to undo some of the damage done the role of LPN by correcting your comment. Since you are a RN and have years of experience at this facility,  you are perhaps the best one on your team to set the example of humility, growth and teamwork moving forward. 

 

 

[londonflo]

MarkMyWords said:

You might have said 'please move aside for a minute'.

OK, please step aside until we get him stabilized and into the ambulance to the hospital. He needs a calm environment  NO external stimuli, no singing. no talking... a environment  of calm calm and silence. 

If the manager/director does not let you convene how to deal with a resident when having the seizure, I would suggest a program on:

1) reasons for seizures in your patient population.

2) roles of every person ( professional, occupational and others). Dialogue such as this;

1. We so appreciate that other disciplines. You have a tremendous contribution to a resident's life. However there are aspects of a patient's physical body..that contribute to interruptions in their functioning that cannot be addressed by other disciplines in a PHYSICAL Life threating episode.
2. My role: I am there to perform continuous monitoring of the patients every day and in a crisis such as VS, oxygen perfusion, respiratory competence , tissue perfusion. I monitor this via the medically accepted assessment techniques of capillary perfusion besides the heart rate and visual direct assessment (face, nailbeds etc), vital signs, respiratory rate, neurological signs, and the quality and rate of respirations.  . I provide comparison data to help with those who will provide further care. I cannot be obstructed in my assessment responsibilities. If I ask you to get out of the way, I have  reason that is in the assessment, physical recovery and most of all in the best interests of the patient. I am sure you will agree this is our goal.
3.  Your Role:  I acknowledge these important disciplines  (OT, ST, Teachers etc.) have a tremendous effect on a quality of life for the patient and their families in the "here and now and future oriented". However during a physical episode of the body that entails neurologic and cardiac support, the physical well being of our patient is of the upmost priority
4.  Comforting the patient, as always, is very important. But additional stimuli is not beneficial during the seizure and post ictal phase. It is in the best interests in the outcome of the patient to ask the registered professional nurse (who is responsible for the patient during a seizure or any other critical incident) when soothing measures can be applied. Yes, those are important but need to be given when most beneficial and timely.
5. It is important to talk to any worker, in any role who has interacted with this precious life. What are they feeling now?

 

[Kohai2, BSN]

Reply to Lvntrail:
In healthcare settings the person with the highest credentials relevant to ACLS or PALS is the one running the code because they need to make decisions about which meds to give and when. The OP said that they're the head nurse at their facility. If there's no physician around, they're the one running the code.
 

Your point of actual event vs. scope makes no sense. The scope of practice matters immensely in the actual event of a seizure or any medical emergency. The LVN won't be pushing IV lorazepam in most states. The OT can't give meds at all. So yeah, the RN can provide services those two cannot. 
 

"Publicly disrespectful to staff" by telling the teacher to move? By telling someone to grab a stethoscope and a defibrillator? No, that's called giving direct communication in a crisis and it's what you're supposed to do. In the Medical Emergency that was described, the teacher absolutely was a bystander. Had that been in a hospital she would have been in the corner not leaning over the patient blocking view of the airway. You don't think parents watching their kids code are invested or care? Of course they do but they aren't going to be standing around participating because they aren't medical professionals. 

[intellica]

Reply to lvntrail, LPN

The EMS was not there yet. If I am present, it is my obligation to run the code because where I am from, law 90  dictates that the LPN's cannot evaluate. One must have the capacity to evaluate to run a code.  I was the only one present who  legally can run a code.  I had a deontological obligation to do so and I did. 

The LPN in question and I enjoyed (what I thought) was an excellent working relationship. Which was why I was taken aback by her reaction.

The teacher was invested in the client, but I needed to see his face. The teacher and I also have a lovely working relationship that goes back 15 years.

I came to all nurses for help. I posted one unintended slight to LPN's in my original post, I have clarified and apologized. Your comment is judgmental, harsh and disrespectful  towards me. I came for help and advice. LPNS ARE NURSES, THEY ARE NEEDED AND IMPORTANT!!  I can take constructive feedback but this is ridiculous! You accuse me of lying and doing detriment to the LPN practie, you  accuse me of lying when I explain why I elaborated on the LPN defination!! when I respect the HELL out of my team??!! I will no longer be acknowledging any disrespeectful or judgmental comments. Nurse bullying is a problem in our community and it is hard to learn from our mistakes when people LIKE YOU get nasty afterward!! and I do not accept it!! SHAME on you!