Over riding a resident?

[beeble]

I was wondering what your opinions are on this.

I worked nights. A pt had mild chestpain a few days after surgery (sternal incision).They had d/c'd pain meds d/t AMS. Inthe a.m. (0600) he c/o of this pain,'soreness'. The brand new resident was there. She then ordered a stat portable CXR, stat trops, and stat EKG.

Guess who would have to do the labs and EKG? The normal staff for these things would arrive at 0700.

I tried to talk to her that he stated this was the same pain he has been having and that it was normal soreness. She stated that"I followed him yesterday and he didnt c/o this'. I stated maybe you were focused on his AMS yesterday. She insisted they be done. 0600 is a crunch time. I didnt feel these things were truly 'stat'.

I paged her and she didnt call back. I then paged her senior who modified her orders to 'routine', meaning they would be done this a.m. when regular staff were here (not STAT).

Then she called back, I told her I had talked to her denior, and he modofied them. She then said I should have talked to her first and "How would I like it if she went to MY supervisor?.....

I didnt go to the senior with a complaint but a legitimate patient care issue.

What do you think?

[Laboratorian]

I was wondering what your opinions are on this.

I worked nights. A pt had mild chestpain a few days after surgery (sternal incision).They had d/c'd pain meds d/t AMS. Inthe a.m. (0600) he c/o of this pain,'soreness'. The brand new resident was there. She then ordered a stat portable CXR, stat trops, and stat EKG.

Guess who would have to do the labs and EKG? The normal staff for these things would arrive at 0700.

I tried to talk to her that he stated this was the same pain he has been having and that it was normal soreness. She stated that"I followed him yesterday and he didnt c/o this'. I stated maybe you were focused on his AMS yesterday. She insisted they be done. 0600 is a crunch time. I didnt feel these things were truly 'stat'.

I paged her and she didnt call back. I then paged her senior who modified her orders to 'routine', meaning they would be done this a.m. when regular staff were here (not STAT).

Then she called back, I told her I had talked to her denior, and he modofied them. She then said I should have talked to her first and "How would I like it if she went to MY supervisor?.....

I didnt go to the senior with a complaint but a legitimate patient care issue.

What do you think?

I hate commenting on nurse things but I want to make sure I'm reading this clearly...

The reason you sought out an override was because it was 0600 and you were ready to go?

Is this really a valid reason?

[beeble]

The patient was not in distress, and regular people would be coming at 0700. I have 6 patients. This was NOT stat.

[chloecatrn]

Chest pain is something I don't play with. Labs take, maybe, 10 minutes? And the EKG is another 10? If this guy had an MI, and you were the reason that the troponins and EKG were pushed an hour, that would suck. I swear, I have a story for everything, but I've seen badness happen in far less than an hour with chest "discomfort" that the patient had been experiencing for over 24 hours. No way would I have let that go.

ETA: Oh, and I'd apologize to both residents... the intern for going over her head to the senior, and the senior for getting him involved in your power struggle with the intern. Going up the chain of command because it's 6 am and you don't want to do labs and an EKG is really crappy.

[evolvingrn, BSN, RN]

I understand your frustration....and im a night shifter so i know how 6 am can be with 6- 8 pts... so i definately get your pt that if its not an emergency its inappropriate. but i can certainly understand her frustration too... im sure that is embarassing for her to get overided. and in her perspective it didn't hurt anything to do it stat it could only help to have that info, she probably didn't realize the dynamics of an order at that time would mean for the rest of your pts.Kwim?

[HiHoCherry-O]

I would have completed the orders. You never know when it will be something more than "just soreness."

Not to mention 7-8 is crunch time as well; getting report, prioritizing patients, new orders coming through, family members calling, breakfast, meds etc, you get the idea.

[LouisVRN, RN]

I completely disagree with you. You never know when chest pain is serious and that's why at most places there is a chest pain protocol. At our facility it is required that you page the doctor twice waiting 15 minutes between before going up the chain of command, and this is for emergent issues. Questioning whether the orders were REALLY STAT or not is not your job. The provider feels they need to be done STAT, she already stated this when it sounds like you questioned her.

I also agree with the poster that said that the oncoming shift is usually very busy as well and that these orders could have been pushed back more so because of this, even if your have ancillary departments on site to do these.

IMHO you owe this doc an apology for going over their head.

[caroladybelle, BSN, RN]

I don't play with chest pain, and the nature of the complaint, yes, I would have done it stat, regardless of the time or inconvenience.

The pt was postop with a sternal incision......this could be surgical pain or a lot of other things and it is better to be on the safe side. And bluntly, chances are the attending is going to want that data first thing in the AM...whether that is inconvenient for the nurse or not. And whether you have 6 patients or not or the "regular" people are coming in an hour.

A lot of ugly stuff can happen in an hour....and many pts minimize issues.

And I really don't think that the resident was out of line to expect that care, even with it 0600 AM, and the nurse with 6 patients. If a case comes up in court, that won't hold up as an adequate reason either.

Yes, it can be frustrating, but we have to err on the side of safety for the patient.

[wee_oneRN]

Maybe the tests were unnecessary, but not dangerous for the patient. If the resident had ordered something you felt was dangerous or unethical I would understand taking the steps you took. However, you just didn't agree with the orders. You really should apologize as already stated above.

Think about this the next time you have a hunch and want the physician to order a test based on your personal assessment skills. Haven't you ever had an MD order a test just because of your judgment? I always appreciate the physicians who respect my clinical skills enough to order a lab/xray even though they may not feel it is needed based on their assessment. What will you do now to convince this resident to trust your judgment when you went out of your way to make it clear that you don't trust theirs?

[perfectbluebuildings, BSN, RN]

It seems to me that you wanted the orders changed simply for your own convenience, not for any reason related to the patient, and for that reason you went over the resident's head to change the orders? How long did all that paging take? During the time you were using for that, you would easily have had the time to call radiology come up for the CXR (no work at all on your part), and still obtain the labs and EKG yourself.

I realize you are saying that the patient did not seem that sick to you, but come on, chest pain in a recent cardiac post-op? It is better to be safe than sorry. I agree that you owe these physicians an apology.

And I do work nights on a floor, and I do know how busy 6AM is, but that doesn't matter. As previous posters have said, the patient's health and safety come first. So you might end up leaving a little late... So what?

And to go from another angle/devils advocate, if you didn't think these symptoms needed immediate physician attention, why'd you page the physician in the first place? Just so you could say you had to cover yourself, and then pass any work to someone else?

I'm probably getting out of hand here, but this just seems like plain-out laziness and I'd be ticked off too if I were that resident.

[ShaunES]

An ECG takes 30 seconds, and pulling bloods takes 2 minutes.

I don't understand why you would spend time trying to get the order changed when you could have done in the time you spent complaining!

[Batman25]

I would never take a chance with chest pain. In the amount of time you took to make calls and have the order changed you could have completed the tests.