Really, Doctor?!

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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 M/S, LTC, Corrections, PDN & drug rehab.
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.

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.

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.

This is why I love this forum! I have received so much information after posting this topic.

The patient's head CT came back normal & the next day she was fine.

I wasn't ever rude or snarky to him. I was just upset HE was that was to ME. I didn't ever feel that attitude was ever warranted towards me.

That is very true. But the next day he wasn't rude but he did make a dumb comment about how I shouldn't call a code & just to call him. I was like, uhh no sir. Unless you're going to pay my bills if I get fired, sued or lose my license, I will continue to call codes if I deem it necessary.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
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.

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

I don't think he did it to placate me. It was the one & only phone call I made. I simply told him what happened with the patient, her vitals, he canceled the transfer & ordered the Narcan.

Ah, that makes sense as to why he didn't order the Narcan then. Thank you.

Yeah, some patients have it ordered but some don't. It's up to the doctor if they want to put it on the patient's Pyxis or not.

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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?

Let this be a lesson and not a reason to

get defensive. If you noticed a change in your patient it's your duty to call the doctor and get the order for Narcan, and you keep calling until you get a hold of that doctor. Patient statuses can change rapidly from the time a doctor rounds and perhaps the physician didn't see those symptoms you described in the moment they were in the room briefly with the patient. You said it yourself "I'm going to protect the patient" so do better the next time.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
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?

Let this be a lesson and not a reason to

get defensive. If you noticed a change in your patient it's your duty to call the doctor and get the order for Narcan, and you keep calling until you get a hold of that doctor. Patient statuses can change rapidly from the time a doctor rounds and perhaps the physician didn't see those symptoms you described in the moment they were in the room briefly with the patient. You said it yourself "I'm going to protect the patient" so do better the next time.

Do better next time? If I noticed a drastic change in my patient's condition why would I wait to hear from the doctor & not call a code???

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Do better next time? If I noticed a drastic change in my patient's condition why would I wait to hear from the doctor & not call a code???

In most hospitals a "code" is for someone who does not have a heart beat or unable to breathe. In the hospitals I have worked at a rapid response team would be the right call. It does not seem like your patient was in immediate danger. I am concerned that you do not see the need for a standing order for narcan need for every patient. This would be a good time to review your hospitals protocols.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
In most hospitals a "code" is for someone who does not have a heart beat or unable to breathe. In the hospitals I have worked at a rapid response team would be the right call. It does not seem like your patient was in immediate danger. I am concerned that you do not see the need for a standing order for narcan need for every patient. This would be a good time to review your hospitals protocols.

I have been told different things from different people on this post.

I know Narcan is important & I don't believe I ever said it wasn't. I understand I need to review the P&Ps on my unit but it is up to each individual doctor if they want a standing order of Narcan. I can't force them, all I can do is ask.

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It does not seem like your patient was in immediate danger.

The patient was experiencing new left sided weakness in addition to their other symptoms of confusion and slurred speech. It was appropriate to treat this as an emergency. The patient could have been having a stroke and the pain medicine could have been obscuring this.

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Specializes in Neuro ICU and Med Surg.

Organized Chaos,

The only thing I would have changed about what you did was call a rapid response for a stroke. I would not have called a "code" but definitely a rapid response. If not a rapid response then a "code stroke" or whatever your facility calls it. The unilateral weakness was what would make me think stroke along with the slurred speech. Yes conditions can change fast. I have had physicians get angry that a rapid response was called for a reason that they deem unnecessary, but as a rapid response nurse I can tell you that I would rather have a rapid response be called and not needed than called too late.

Does your hospital have a dedicated rapid respone team? If so learn what the automatic triggers are for that team and use them.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
Organized Chaos,

The only thing I would have changed about what you did was call a rapid response for a stroke. I would not have called a "code" but definitely a rapid response. If not a rapid response then a "code stroke" or whatever your facility calls it. The unilateral weakness was what would make me think stroke along with the slurred speech. Yes conditions can change fast. I have had physicians get angry that a rapid response was called for a reason that they deem unnecessary, but as a rapid response nurse I can tell you that I would rather have a rapid response be called and not needed than called too late.

Does your hospital have a dedicated rapid respone team? If so learn what the automatic triggers are for that team and use them.

We do & it's called a code white! Lol! :D

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I'm having a difficult time following. So, the MD was in the room with the patient and had no concerns. Less than 30 minutes later, the patient was showing signs of stroke.

But wait, then you said there was a huge change from the time the MD saw the patient until the time you called a stroke code.

So which is it - patient was "not right" when the MD was in the room, or the patient was "not right" starting at shift change?

Were you in the room when the MD was? If not, how long had it been since you had seen the patient, prior to that MD rounding on her?

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.
I'm having a difficult time following. So, the MD was in the room with the patient and had no concerns. Less than 30 minutes later, the patient was showing signs of stroke.

But wait, then you said there was a huge change from the time the MD saw the patient until the time you called a stroke code.

So which is it - patient was "not right" when the MD was in the room, or the patient was "not right" starting at shift change?

Were you in the room when the MD was? If not, how long had it been since you had seen the patient, prior to that MD rounding on her?

Sorry for making it so confusing. I really didn't want to give out so many details, because then it would make it obvious. Too late now! Lol.

I was not in the room when the doctor rounded.

I saw the patient an hour before the doctor rounded & she was drowsy but not to that point.

Well according to the doctor the patient was not right because she was hard to wake up & had pin point pupils. The patient was never like that before when the patient received the dose (1.5 of Dilaudid) before.

Then at shift change we noticed those other findings.

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I realized after that my message might have sounded rude, so I apologize if it came off that way.

I think this is just a good learning experience and example of us being the ultimate first line when it comes to our patients. If you don't mind, I want to give you a few pieces of advice that I gained with experience on a super busy floor with less-than-proactive resident doctors.

Don't be afraid to clarify things with the doctors. I've gotten to the point where I don't care how dumb or aloof I seem to them, but (depending on a lot of things, I know) I'd like to clarify with the doc what he thought and maybe even pull him back in that room with me. Then with a change that you observed, you and him would both be on the same page about what is different and when it changed. I've had a couple sticky situations where it came down to needing to know almost exactly when symptoms started, and I couldn't give a great answer. I've needed to keep the closest eyes on those kinds of patients for the stroke stuff, which of course I learned afterwards.

Also, try not to describe doses of meds as volume - you described her med dose as 1.5ml every two hours. For covering your butt and just generally, the strength is what you should refer to.

I don't mean to be critical in a negative way, I just know how hard floor nursing can be. Keep up the good work!!!

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