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?

[GilaRRT]

The doc made a good call, you were wrong to question these specific orders.

[steelydanfan]

All of the above posters have stated my position clearly; you were wrong, you owe the resident an apology, and I hope you are never my nurse.

[NurseCard, ADN]

Sorry, got to agree with everyone else. I too understand your frustration as much as anyone, but doing those tests certainly wouldn't have hurt the patient. I could see if it were something that you felt would cause the patient undue distress, because in that case you would be trying to advocate for your patient. But, these were simple tests that could have been done in a few minutes.

I really do understand your frustration though; I try to stay away from MedSurge because I lack the patience to deal with situations such as these. Perhaps you may want to try a different specialty than the one you are currently in?

[steelydanfan]

Sorry, got to agree with everyone else. I too understand your frustration as much as anyone, but doing those tests certainly wouldn't have hurt the patient. I could see if it were something that you felt would cause the patient undue distress, because in that case you would be trying to advocate for your patient. But, these were simple tests that could have been done in a few minutes.

I really do understand your frustration though; I try to stay away from MedSurge because I lack the patience to deal with situations such as these. Perhaps you may want to try a different specialty than the one you are currently in?

What does Med-Surg have to do with this? This nurse could have called on the crisis team if she felt THAT stressed. Yeah. maybe she did not have the ability to do a quick EKG on her own, but the resources were near at hand, if she wanted to bother.

[LouisVRN, RN]

I have to say here, with everyone saying how it wouldn't hurt the patient, I think you could have played performing these actions in a light that would have benefited the patient. Saying "I know you stated the pain feels like the same pain you've been having but resident ______ and I just want to do some tests to make sure that we're treating everything that we need to" That said with a reassuring smile makes pts :)

[carolmaccas66, BSN, RN]

I've only done a nursing student clinical in a cardiology/renal ward, but I have cared for patients who came in with chest pain etc in general med/surg wards.

I think this is a tricky situation. I know most registrars/Drs would order an ECG/EKG stat, trops etc. I would do an ECG even without a Drs say so just to cover myself and the patient, and of course report any changes.

This Dr was probably maybe a bit worried and trying to cover themselves and the hospital legally - I know I always think in a legal sense cos there's just too much that can go wrong. But yes 0600 is a really tricky time to get anything done. And yes she is annoyed you went over her head BUT if the Dr didn't answer their pager that is their problem not yours.

I would just tell the senior nurse you are on with and let them handle it - it is their call, not yours in the end. We keep being told nurses are supposed to be independent practitioners but then when we do try to be independent, we get told we are 'jumped up' and 'we're not Drs' (we know that thank you doctor!) - this problem goes much deeper I think - you usurped her authority. Seems like we aren't seen as independent and we will always have this nurse/Dr clash in certain cases.

I would also chart his pain from 1-10 (1 no pain, 10 worse pain for the patient ever) every 15 minutes or so and see if it gets worse or not - maybe that would help? I'm not a cardiology nurse so am unsure as to how much pain he was in, but I would at least do an ECG and compare it to other ones if he/she had any and get bloods done.

ADD: meant to say i would also do 15 minute obs and document, & doing other tests as well to see re any changes, etc.

[highlandlass1592, BSN, RN]

I definitely don't want to beat you up, I think others are trying to do that and I personally don't think that's called for. However, your post does raise some concerns. This is a patient population I deal with so I feel comfortable sharing some thoughts.

You don't mention what type of surgery this patient had (valve, cabg, aneurysm) but you may want to consider that if that EKG shows changes from pre-op, you may be dealing a variety of issues: pericarditis, new onset ischemia, the possibility of grafts going down (in CABG pt's), leaking anuerysm, possiblity of slow tamponade. Any of these things could be going on which is why, I"m guessing, the resident ordered the testing they did. And that was what I would have done as well. I'm not sure about where you work but where I work, we are seeing much sicker patients who have many complications so something like sternal pain must be investigated.

Now, just a thought: I understand about the narcs being on hold. If you had truly thought this was a pain issue, did you try to present it as such to the resident? Saying something like: "This pt's incisional pain is not being controlled by tylenol, could we try something like toradol since the narcs are on hold?" May have gotten you something for the incisional pain..and your problems would have been solved.

I can't endorse your idea of delaying care due to end of shift issues. Unfortunately, these things happen. This is what we signed up for and what we are supposed to do...take care of our patients. I can't ask a patient to stop coding because I'd like to go to lunch...sounds silly doesn't it? But the paraellel to what you are relating is quite relevant..sometims pt's require care at inopportune times...but that is the job we've chosen.

[carolmaccas66, BSN, RN]

As to staying back on a shift, I can't count the number of times I haven't left on time - there is always some drama or something I maybe 4got to do, and no, many times I haven't been paid for overtime. I was told once 'nurses just have to stay back when patient issues arise, it's part of the job'.

[nurse2033, MSN, RN]

I assume you mean "overriding"... lol

[Flipper911]

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?

So what happens if the trops were elevated and she had some ST changes on her EKG? The time you spend calling the resident and then her senior you could have drawn the labs at least and had the EKG at bedside. These are not very involved processes and I probably would have just followed through with the orders. Because even if you have a 1% chance of being wrong it is too much.

[RN1982]

You were wrong, the resident was right. You should have just drawn the labs. I think you were putting them off so you wouldn't have to do them because it was 6am. Sorry, I call it how I see it. In the time you spent calling to "override" the intern, you could have performed the ordered tests. The patient could have been having true chest pain but instead you wasted time.

[JulieCVICURN, BSN, RN]

I definitely don't think that it being almost time for shift change is a legit excuse. Nursing is a 24 hour a day job. I don't know if you guys help each other on your unit, but if you do (like we do in my unit) you even could have had the oncoming nurse help you with some of the stuff before report. Whenever I have to wait on report from someone because they're busy with the patient they're handing off to me, I help them finish what they're doing. It beats sitting around doing nothing, and I get to know the patient faster that way.