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?

[HamsterRN, ADN, RN]

I agree that we shouldn't question orders to avoid work, but we should question them when they put other patients at risk or when they waste resources without any justification, and I'm surprised with how emphatically we've argued that we should follow these orders without questioning them. While it's true you don't take CP lightly, you do need to evaluate it properly before going all gung ho, and a patient with what sounds like recent open heart who is having sternal soreness is not concerning for ACS without any other abnormal findings, and with recent OHS, troponins are completely worthless. The CXR and EKG won't hurt if you don't have other patients, but if you do have other patients then those patients are going to receive less care, which is fine if there is a reason for the extra time you are giving another patient but there is not a justifiable reason to jeopardize the care of other patients in this case based on the description given.

If I called one of our OHS surgeons saying one of his patients was complaining that his sternum was sore, I'd get hung up on and probably banned from taking hearts indefinitely.

[BabyLady, BSN, RN]

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

If it was you hurting, would you want someone to take care of it now, or wait untill you are "in distress" before giving you any relief.

This is why the Joint Commission states over and over again, that pain is under-treated.

No way would I have questioned an order based on the time of day it was given when the primary reason was to put it off on the next shift.

[RN1982]

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

Seems to me you cared more about yourself than you did your patient. It is really concerning for me to read that you are more concerned about the regular staff coming in at 7a.m. to complete orders that should have remained STAT orders to begin with. I don't think you truly understand how fast a person having an AMI can decompensate. You are lucky that the patient wasn't in any "distress", had they been, it would have been your license on the chopping block. Perhaps you will think better of it next time, I hope you do.

[carolmaccas66, BSN, RN]

That makes me think when I was a 3rd year student RN on a renal/cardiology ward, I was talking to a patient, walked away from him, and less than 2 minutes later he had bradyed down to 20 bpm! The senior RN who found him yelled 'Get the Clinical Nurse (yelled his name) now!'. He called the MET team and about 20 doctors & anaesthetists (I kid you not) ran in to attend this patient, plus all us nurses as well. I was superfluous so I went to attend to other patients, but it scared me to think if no-one had noticed this patient (the ward was insanely busy at the time), he could have very well died. It really hit home how unstable these patients are, and that the threat of death is very close to these types of patients in our hospitals. He had not c/o any chest pain, etc either. He seemed fine to my perhaps untrained eyes. He had no dysrhythmias at the time either.

He was an unstable diabetic which of course didn't help.

To me, any c/o chest pain would now send alarm bells ringing in my head and that patient would be treated as a priority. If you have 6 other patients and they are stable, they can wait till the other staff come on, or you call for help.

My limited experience only.

[platon20]

I agree that we shouldn't question orders to avoid work, but we should question them when they put other patients at risk or when they waste resources without any justification, and I'm surprised with how emphatically we've argued that we should follow these orders without questioning them.

I agree with #1, not with #2. There are 2 occassions where a nurse should question a doctor's orders: 1) when its unsafe; 2) when its an obvious oversight or duplicate order. The scenario described by the OP fits neither of those scenarios. Its not like the resident ordered a heparin drip for musculoskeletal chest pain. THAT is an unsafe order and needs to be questioned. Doing stat troponins, CXR, EKG DOES NOT HARM THE PATIENT AND IS A VALUABLE DIAGNOSTIC WORKUP, therefore it should have been done, as ordered.

While it's true you don't take CP lightly, you do need to evaluate it properly before going all gung ho, and a patient with what sounds like recent open heart who is having sternal soreness is not concerning for ACS without any other abnormal findings, and with recent OHS, troponins are completely worthless.

You are ABSOLUTELY wrong here, and it illustrates the trouble that nurses have when they think they can replace the thinking of doctors. While its true that chest pain should be evaluated in person by a doctor, there are studies showing that musculoskeletal chest pain vs ischemic chest pain in post-op patients cant be distinguished very well by most patients. Therefore they deserve a basic workup. As for troponins being "worthless" in OHS cases, again you are absolutely WRONG on this point. Of course they are going to have elevated troponins, but the TREND in troponin rise is critical. Lets say you have a pre-op heart patient with troponin of 200. Post-op, it rises to 500 due to myocardial injury from the procedure. Then, it will commonly start to drop off slowly, maybe 2 days post-op its down to 250. Then the patient c/o chest pain on POD #3 and the troponin level is back up to 400. Are you honestly going to sit there and ignore the troponin level because you say its "useless" in OHS cases? Thats absolutely wrong logic, if post-op troponins rise at hte same time the pt is c/o chest pain, then you have to assume that they are having an ischemic event post-op that needs to be managed. Again, to say that troponins serve no role in the post-op care of OHS patients is ridiculous. Thats something that DOCTORS, not NURSES, are trained to address and you are wrong for thinking you have the knowledge base to make that decision.

The CXR and EKG won't hurt if you don't have other patients, but if you do have other patients then those patients are going to receive less care, which is fine if there is a reason for the extra time you are giving another patient but there is not a justifiable reason to jeopardize the care of other patients in this case based on the description given.

Thats no justification for ignoring the order. If you are getting swamped by critically ill patients and cant keep up with them all, then its your responsibility to notify the charge nurse and have somebody else help you out. You cant in good conscience say "I'm too busy with my other patients to deal with this patient who could be having a life-changing ischemic event."