Really, Doctor?!

Nurses General Nursing

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So I had my first code called on my my patient last night. Without going into a lot of details, a strike code was called but basically the patient had too much pain medication (she was on Q2H dilaudid).

Her doctor previously rounded before shift change, saw she was very lethargic & had pin-point pupils. Didn't order anything but changed a few other things.

When shift change came we did bedside report & she was acting different from her usual self so a code was called. When I called the doctor he was upset that the shift coordinator wanted to transfer her to the ICU & ordered Narcan.

*I* was pissed because HE saw her & could've order Narcan when he SAW her! I saw the doctor today & he said not to call a code. It took all of me not to say anything back at him.

The patient wasn't transferred, the Narcan helped her & she is fine today.

Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

It sounds like this patient was semi alert? If she had adequate respiratory effort and was able to protect her own airway, just give the narcotics time to wear off, and skip the transfer and the Narcan!

Annie

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Specializes in Psychiatric and emergency nursing.
1) Chill down about what?

2) I don't understand what you're saying here.

3) Yes, that is a good point. Thank you.

4) I was not the one who called the stroke code, it was the night shift nurse. I thought it would've been more appropriate to call a code white since it was a change in status.

5) I just don't understand why the doctor was upset why we called a code (regardless of what it was) when he had just saw her & saw her condition. I'm going to protect the patient & do what is best for them. It was at shift change & even during the day it's not easy to get ahold of a doctor. Why would I call the patient's doctor when there is a HUGE change that could be life altering?

In my facility, if a stroke is suspected (which sounds more in line with the acute confusion, unilateral weakness and slurred speech), we call a stroke alert as opposed to a regular rapid response, which on the floors gets us an ER physician, an ACLS trained nurse, a pharmacist, and lab. It helps to define exactly what kind of personnel we need to respond to the call.

Generally, while an overdose on opiates can cause pin-point pupils, lethargy, confusion, and possibly slurred speech, the addition of unilateral weakness would have pointed towards a stroke, especially since it sounds like she may have been post-op with Q2H hydromorphone around the clock? As far as the physician being upset it was called, I would rather call it and be wrong than the other way around.

I agree with all the others in that if the opiates had been overdone a bit, as long as she was maintaining airway and perfusing appropriately (HR, O2% measurements, BP), you could have simply withheld the following dose and assessed for improvement, or you could have asked the doctor for an order of Narcan; no transfer to ICU necessary. Although, if she did have a stroke, that may have presented a need for transfer to Neuro ICU or a neuro floor, depending on the findings of the CT, necessary treatments, etc.

While I'm not giving the doctor a full pass here, they often have many patients, and we are often their eyes and ears regarding acute changes in a patient.

I think what KatieMI was trying to say was the nurse vs. physician mentality has to stop. While a physician may possess more education, a nurse with years of experience can often see trouble coming a mile away, and the physician relies on us to be able to assess acute changes, and request orders if it's something the physician missed, or forgot to write an order for; they are only human, after all. Physicians and nurses MUST work together as a cohesive team to provide optimal care to the patient and maximize positive outcomes.

By the by, the ONLY time I have ever flat out told a physician that "it was his license to do with as he pleased" was when a physician wanted to push immediate Alteplase on an elderly patient with a stroke and a fall. Patient was still well within window of treatment time, and the physician had not yet received CT scan results or gone over risks/benefits with the available family... that's a no from me, good sir.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
It sounds like this patient was semi alert? If she had adequate respiratory effort and was able to protect her own airway, just give the narcotics time to wear off, and skip the transfer and the Narcan!

Annie

She was semi alert but not herself. She couldn't answer any questions, not coherent & rambling. She also had signs of a stroke which I did not see all throughout my shift. It was the shift coordinator who decided on the transfer.

I still don't understand why the doctor wouldn't want to give Narcan when he saw her then. He also asked me if I gave Toradol to the patient. Why would I give any pain reliever to the patient? I know Toradol is an NSAID, not a narcotic or opioid but she clearly wasn't in any pain. Why would I give anything that would have a chance to depress her breathing or respirations any further?

It had been 3 hours since her last dose of 1.5mL of Dilaudid & the patient wasn't even close to coming out until we Narcanned said patient.

The doctor called upon a trauma resident from the ER to come up & check on the patient. He did & he even noticed a slight droop to the L side of the patient's face. The Narcan had worked by then & the patient was awake & alert.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
In my facility, if a stroke is suspected (which sounds more in line with the acute confusion, unilateral weakness and slurred speech), we call a stroke alert as opposed to a regular rapid response, which on the floors gets us an ER physician, an ACLS trained nurse, a pharmacist, and lab. It helps to define exactly what kind of personnel we need to respond to the call.

Generally, while an overdose on opiates can cause pin-point pupils, lethargy, confusion, and possibly slurred speech, the addition of unilateral weakness would have pointed towards a stroke, especially since it sounds like she may have been post-op with Q2H hydromorphone around the clock? As far as the physician being upset it was called, I would rather call it and be wrong than the other way around.

I agree with all the others in that if the opiates had been overdone a bit, as long as she was maintaining airway and perfusing appropriately (HR, O2% measurements, BP), you could have simply withheld the following dose and assessed for improvement, or you could have asked the doctor for an order of Narcan; no transfer to ICU necessary. Although, if she did have a stroke, that may have presented a need for transfer to Neuro ICU or a neuro floor, depending on the findings of the CT, necessary treatments, etc.

While I'm not giving the doctor a full pass here, they often have many patients, and we are often their eyes and ears regarding acute changes in a patient.

I think what KatieMI was trying to say was the nurse vs. physician mentality has to stop. While a physician may possess more education, a nurse with years of experience can often see trouble coming a mile away, and the physician relies on us to be able to assess acute changes, and request orders if it's something the physician missed, or forgot to write an order for; they are only human, after all. Physicians and nurses MUST work together as a cohesive team to provide optimal care to the patient and maximize positive outcomes.

By the by, the ONLY time I have ever flat out told a physician that "it was his license to do with as he pleased" was when a physician wanted to push immediate Alteplase on an elderly patient with a stroke and a fall. Patient was still well within window of treatment time, and the physician had not yet received CT scan results or gone over risks/benefits with the available family... that's a no from me, good sir.

Yeah, if the patient was just really drowsy and had slurred speech I wouldn't have been so concerned. But the other symptoms made me turn my head go... maybe something else is going on here. I completely agree with you, I will always rather call a code and be wrong than not call a code and have a patient die or come close.

I just don't understand the doctor's thinking. He SAW the patient's condition before I did, there wasn't a standing order for Narcan and on top of all of that hot mess he wanted me to give her Toradol IV. What the what? I know we need to work together as a team but why have an attitude at me? I'm not a new nurse but I am brand new to hospital nursing. So it just seem bizarre to me that he went in to the patient's room, assessed the patient, saw the patient in that condition & didn't think at any point to put Narcan in her Pyxis.

Yeah, she had just had surgery. I don't know why the doctor ordered Dilaudid the way he did & didn't just put her on a PCA and especially didn't have a standing order for Narcan. It was a huge PIA.

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Narcan's not on your facility's list as an emergent med? You actually need an order for it?

Where I've worked, things like Epi, D50, Narcan etc were considered emergent meds and if they needed to be given, you just got them and gave them per the protocol, which could easily be pulled up on the computer.

THEN you called the doc. But you treated the patient first.

Please check your facility's policy cause many operate like this. Not all, but many.

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.
She was semi alert but not herself. She couldn't answer any questions, not coherent & rambling. She also had signs of a stroke which I did not see all throughout my shift. It was the shift coordinator who decided on the transfer.

I still don't understand why the doctor wouldn't want to give Narcan when he saw her then. He also asked me if I gave Toradol to the patient. Why would I give any pain reliever to the patient? I know Toradol is an NSAID, not a narcotic or opioid but she clearly wasn't in any pain. Why would I give anything that would have a chance to depress her breathing or respirations any further?

It had been 3 hours since her last dose of 1.5mL of Dilaudid & the patient wasn't even close to coming out until we Narcanned said patient.

The doctor called upon a trauma resident from the ER to come up & check on the patient. He did & he even noticed a slight droop to the L side of the patient's face. The Narcan had worked by then & the patient was awake & alert.

Again Narcan is not meant for someone who is just confused from narcotics, and you are doing more harm than good. I am not sure what the patient was receiving the narcotics for, but now you have not only reversed the pain control, but you have now made it so any narcotics she is given will not work for a couple hours. Not good. Sounds like poor care to me!

Toradol would not cause AMS or depressed breathing.

Annie

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
Narcan's not on your facility's list as an emergent med? You actually need an order for it?

Where I've worked, things like Epi, D50, Narcan etc were considered emergent meds and if they needed to be given, you just got them and gave them per the protocol, which could easily be pulled up on the computer.

THEN you called the doc. But you treated the patient first.

Please check your facility's policy cause many operate like this. Not all, but many.

None of the other RNs told me I could just give t. The RN that was orienting with told me I needed an order.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
Again Narcan is not meant for someone who is just confused from narcotics, and you are doing more harm than good. I am not sure what the patient was receiving the narcotics for, but now you have not only reversed the pain control, but you have now made it so any narcotics she is given will not work for a couple hours. Not good. Sounds like poor care to me!

Toradol would not cause AMS or depressed breathing.

Annie

Well the patient's doctor ordered the Narcan. The trauma resident told us to hold all pain relievers for awhile to make sure she was really okay.

The patient did have surgery, I don't remember what exactly - something GI related.

After we Narcanned her she was alert for a little while but then fell asleep.

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Specializes in Psychiatric and emergency nursing.
Yeah, if the patient was just really drowsy and had slurred speech I wouldn't have been so concerned. But the other symptoms made me turn my head go... maybe something else is going on here. I completely agree with you, I will always rather call a code and be wrong than not call a code and have a patient die or come close.

I just don't understand the doctor's thinking. He SAW the patient's condition before I did, there wasn't a standing order for Narcan and on top of all of that hot mess he wanted me to give her Toradol IV. What the what? I know we need to work together as a team but why have an attitude at me? I'm not a new nurse but I am brand new to hospital nursing. So it just seem bizarre to me that he went in to the patient's room, assessed the patient, saw the patient in that condition & didn't think at any point to put Narcan in her Pyxis.

Yeah, she had just had surgery. I don't know why the doctor ordered Dilaudid the way he did & didn't just put her on a PCA and especially didn't have a standing order for Narcan. It was a huge PIA.

Some physicians are wonderful, some are nublets, and some? Well, I'm afraid I would violate TOS if I said what I really thought about them :). As an ex-ED nurse, I'm pretty discerning with changes in patient conditions, and it takes a lot to get me worried. I agree with the others that Narcan wasn't warranted here. Narcan is reserved for: unresponsive, difficulty maintaining airway (i.e. - gasping or snoring), depressed respirations, decreased 02%, etc. I also agree, however, that Narcan should be a standing order for ALL patients receiving round the clock opiates. Also agreed that the patient really should have been placed on a PCA, so long as regular assessments were being performed.

The important thing is that you assessed your patient and recognized a change in condition, and called the code you thought was appropriate. With the combination of slurred speech, confusion, fresh post-op, and unilateral weakness, I probably would have done the same. It will take a while to acclimate to hospital nursing, but I think you'll do fine. I think I also saw recently where you were planning to bridge to RN. How's that coming?

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Well the patient's doctor ordered the Narcan. The trauma resident told us to hold all pain relievers for awhile to make sure she was really okay.

The patient did have surgery, I don't remember what exactly - something GI related.

After we Narcanned her she was alert for a little while but then fell asleep.

The duration of action of some opioids may exceed that of NARCAN (naloxone). It could be that she fell asleep after the narcan's duration of action had been exhausted.Repeated doses of NARCAN (naloxone) can be necessary, depending.

He SAW the patient's condition before I did, there wasn't a standing order for Narcan and on top of all of that hot mess he wanted me to give her Toradol IV. What the what?

Toradol is often given in concert with opioids for pain. Perhaps he saw that she was lethargic, didn't want to D/C the narcotic without covering her pain with another drug, so he wanted to get Toradol on board and working before weaning off the opioid.

He also asked me if I gave Toradol to the patient. Why would I give any pain reliever to the patient? I know Toradol is an NSAID, not a narcotic or opioid but she clearly wasn't in any pain. Why would I give anything that would have a chance to depress her breathing or respirations any further?

Pain isn't always obvious or "clear." GI/abdominal surgery is typically extremely painful. One can be asleep due to sedative effects of pain medicines, yet still in pain, and in extreme pain upon waking. I've experienced that exact thing myself. Toradol would not put her at risk for respiratory depression, btw.

It seems like two different things were happening. Narcotics are not known to produce unilateral weakness/facial droop. Could the patient have also been experiencing a TIA at the same time she was over sedated from narcotics?

Listen, I think what some of the other nurses are trying to convey is that having an adversarial POV toward the physician doesn't do any good for the patient. If you had concerns about her lethargy, didn't understand the rationale for the doc's actions/inaction/Toradol orders, that's when you calmly and rationally ask him to explain it to you. "Hey, I'm kind of new to acute hospital care, so I'm trying to get a sense of what our goals are here. She seems really lethargic and I'm worried about that. Can I get an order for Narcan just in case? And can you help me out here with understanding about the Toradol order? I've never seen it ordered on top of narcs like this, so I'd love to learn about it."

This kind of approach has always worked well for me, certainly better than repressing anger and making assumptions about the doctor's competence or filling in the blanks myself about his rationales without clarifying them with him directly. You and the doctor are on the same side here. Realize that although doctors don't know everything and are very capable of making mistakes, their depth of education and training is typically far beyond that of any nurse, so there usually is a very compelling reason for their actions. Many docs love to teach you if you present it not as an attack on their actions, but as an attempt to learn from them. Take every opportunity you can get to benefit from their expertise.

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Well the patient's doctor ordered the Narcan. The trauma resident told us to hold all pain relievers for awhile to make sure she was really okay.

The patient did have surgery, I don't remember what exactly - something GI related.

After we Narcanned her she was alert for a little while but then fell asleep.

If you went on and on with her or him about not having a Narcan order, the way you have here, he or she likely did it to placate you.

Again, as long as the patient's respiratory status wasn't compromised, Narcan administration wasn't appropriate. And if her respiratory status was not altered, this is likely why the physician didn't order Narcan after rounding.

None of the other RNs told me I could just give t. The RN that was orienting with told me I needed an order.

This is facility specific, and in my experience, unusual. Narcan isn't the benign drug that many think it to be.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
Some physicians are wonderful, some are nublets, and some? Well, I'm afraid I would violate TOS if I said what I really thought about them :). As an ex-ED nurse, I'm pretty discerning with changes in patient conditions, and it takes a lot to get me worried. I agree with the others that Narcan wasn't warranted here. Narcan is reserved for: unresponsive, difficulty maintaining airway (i.e. - gasping or snoring), depressed respirations, decreased 02%, etc. I also agree, however, that Narcan should be a standing order for ALL patients receiving round the clock opiates. Also agreed that the patient really should have been placed on a PCA, so long as regular assessments were being performed.

The important thing is that you assessed your patient and recognized a change in condition, and called the code you thought was appropriate. With the combination of slurred speech, confusion, fresh post-op, and unilateral weakness, I probably would have done the same. It will take a while to acclimate to hospital nursing, but I think you'll do fine. I think I also saw recently where you were planning to bridge to RN. How's that coming?

I wish she was on a PCA, it would've made my day a lot easier!

The doctor was pretty pissy but wanted Narcan given. Should I not have Narcanned the patient? Should I have told the doctor no?

I'm not bridging yet, I just need to take my TEAS test & hope I get in. I want to wait until I have a year in at my job so adding school won't be so difficult.

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