Scary metoprolol IV order... Abusive doc.s.. Moderately traumatized

[missmiamoore]

I have to write about this because I am a new grad and am currently having a panic attack about what happened (or didn't happen) on my shift last night.

I work for the float pool for our hospital and last night was placed on the med/surg unit. I had 4 patients and fot a new admit: 63 yo male with vomiting NYD, ARF secondary to dehydration.

When I received him, BPs were 216-222/99-104. He had a headache and very red faced. He told me he has not been able to keep his BP meds down.

I put a call into the PCP. He seemed very annoyed and unconcerned and gave an order for IV metoprolol 25 mg now and said he would R/A the pt in the AM.

I have never given IV metoprolol before. When I went to the night cupboard to retrieve the medication, I found it was in 5mg/5mL vials and I would then have to put 5 of these vials in a minibag. This seemed wrong to me. I called the ICU to run the situation by them.

To make a long story short, they brought over our protocol for IV metoprolol it is to give 1.5 to 5 mg IV over 15-30 minutes Q6hours and the patient must be on telemetry.

I reluctantly phoned the MD back and told him of my concern with the order. I asked if he would like us to start with 5 mg and put on telemetry. He was like mhmm. Totally unconcerned sounding about the patient.

He was however more concerned that the admitting DOC in emerg would send the patient up to us being so unstable. Without getting into too much detail, he was raising his voice at me on the phone stating that the emerg doc didn't have the courtesy to inform him of this and told me if I have any further concerns with the patient overnight to contact them.

Needless to say, I gave the IV metoprolol and his BP and pulse only went down to 203/93. I called the emerg physician who subsequently bit my head off and talked to me very rudely because i should of been calling the PCP. I told her of what the PCP said about contacting her and she was so rude to me and not impressed. She snapped at me to give him his morning BP meds and she would call the PCP herself. This is totally missing the point cause he couldn't keep any p.o. meds, liquids, or foods down.

Overall, I am just shocked about how the patient seemed to be forgotten by the docs in this situation. They seemed to be more concerned with internal politics and being bothered. As well, why be so abusive to me when I am only trying to help the patient. I have never experienced being in the line of fire before and am still reeling from the experience.

BTW, the nurses on the floor were totally supportive and told me I did everything right. They said this particular PCP is abusive to many nurses.

How can this just be a norm that certain doctors are abusive to other people, who are just trying to do their jobs with the patient's best interest in mind? Why did they become physicians? Just for the power it holds? I think they need to be reminded somehow that we are all human beings with needs and feelings like everyone else and we need to be respected. No wonder nurses can be so intimidated by calling MDs!

PS. I ended up handing the patient off to the oncoming shift with them being totally aware of the situation at hand. All the staff that came on that morning knew what was happening with the patient and how the doctors responded. I am not sure of the outcome, but I felt comfortable leaving the patient in their capable hands. As well, I was emotionally and physically spent and needed to get home to sleep before I fainted!

[3sodapop]

Wow! Sounds like a hell of a night. It sounds like those docs were pretty cranky, especially since you probably saved the PCP a lot of embarrasment, and perhaps his patient. Perhaps they have to point the finger somewhere when they screw up.

In my humble opinion I would just take it as a lesson to be "on guard" with this doc and try to remain professional, even if he isn't.

[UM Review RN, ASN, RN]

I worked nights for many years and had to listen to cranky docs to the point that I really disliked calling anyone and had a little speech all set for them:

"Hello, Dr. X. This is Angie. Sorry to have to call but hospital protocol (or standing orders or my charge nurse ) says that I must call you for this situation: Pt is ___. Vitals are ___. The patient was ___ . Now he's ____. I would like to know if you would like to treat this patient for it."

The doc will say "____" If he says no and it's an issue that needs addressing immediately, I'll say, "Perhaps I didn't make myself clear" and add as many additional symptoms as possible to convince the doc that the patient needs immediate intervention. If he still says no, then I'll say, "OK, so you want me to do 'No treatment at this time and don't call me until troponins are over 45 -- shall I write that as an order?"

Usually the doc will give some sort of order that doesn't address the issue, so I'll suggest -- "Would you like an EKG, a 2DE? a BNP, ABG's? a Chest Xray? Repeat Cardiac enzymes? Blood pressure/pulse Parameters for giving more medication?"

If the doc is truly refusing to do anything for the patient, I'll sometimes just get so annoyed that I'll say something super-sweetly like, "I'd like to learn more about why we're not treating him for X at this time, would you care to enlighten me?" (But if I have to go there, I brace myself because I've just initiated a showdown. Which is sometimes necessary if you have a crashing patient and a doc who's dragging his feet. At that point, I really could give a darn about how mad the doc is, the patient needs immediate intervention and I'm not letting the doc off the phone till I get it.)

Also, it's important to know which meds I can give on my unit and which ones I cannot. In our hospital, only a tele-certified nurse would've been able to give the Lopressor and the patient would've had to be on Telemetry. And now you know -- once the ER sends the patient, there's no going back.

So to that doc, I would've reminded him that once he orders Lopressor IV, that the patient will automatically have to go to Tele as it's hospital protocol. ("And oh, by the way, since the patient cannot keep anything down, might we order all of the meds IV or po?")

The type of scenario you describe is really not new, so don't let it throw you. You've heard of scripting? Well, develop a whole range of "scripts" to throw out at a second's notice for these docs. Things like "I'm absolutely certain that you'll make it in here in the morning to see the patient, but I'm calling because I really doubt that the patient will be here by the time you come in."

Remember, they're just waking up, not thinking clearly, and they're bound to be cranky. After all, they're human too. Still, I believe we have a right to be treated respectfully and if the doc is really nasty, we have the option of writing him/her up.

Sorry this is so long, but I've just woken up and the mere thought of docs being nasty to my colleagues really irritates me. :smilecoffeeIlovecof:p

[rph3664]

The pharmacist didn't catch the 25mg IV metoprolol? What gives? Maybe the doctor meant 2.5mg.

Our heart surgeon sometimes orders 10mg, but only if 5mg didn't work. We're familiar with his prescribing habits.

[missmiamoore]

rph3664 said:

The pharmacist didn't catch the 25mg IV metoprolol? What gives? Maybe the doctor meant 2.5mg.

Our heart surgeon sometimes orders 10mg, but only if 5mg didn't work. We're familiar with his prescribing habits.

It was after hours and I had to retrieve the medication from the night cupboard, which entails me photocopying the order and leaving it for the pharmacist in the AM. I'm sure he almost crapped his pants when he discovered it in the morning.

[bluefrog]

Yikes! That sounds like a terrible night I am sorry that you had to experience that. Out of curiosity, how was his blood pressure before he came to your unit? I ask because when I get report from the emergency center, I always ask the last set of vitals, and if they tell me that SBP is over 170, I kindly ask them to stabilize the patient and administer any blood pressure medication that they have on order and call me back when the blood pressure is under control so I can admit the patient to our med-surg unit. The reason why I do that is because we are not allowed to administer any blood pressure meds as IV drips on our unit, and because the process of transfer from EC to med-surg takes approximately one hour and the doctor doesn't come to see the patient for next 3-4 hours, and the pharmacy doesn't always deliver/stock meds on time for the new admit. I see no sense of admitting an unstable patient just to transfer them to a progressive unit so they can hang IV Metoprolol on them. Nurses in EC usually hate when I tell them that I will not take their patient as in "What do you mean you will not take this patient? I already called transport and they are loading them on the stretcher!" But as much as they gripe on the phone, they do what you ask them to do and that patient comes to the floor with a stable blood pressure or doesn't come to the floor because the EC sent them to MPCU for that IV drip after all ....

[mama_d, BSN, RN]

First off, kudos to you for knowing that this situation was not being properly addressed and not being afraid to get input from others, specifically ICU nurses, on the orders you were given...we had a new grad kill a patient once by pushing too much Lopressor too fast b/c "that's what the doc ordered". Sent them from afib in 130's to a code in two minutes flat.

Secondly, what the heck? Pushing lopressor on a non-tele patient? Someone clearly had their head up their nether regions when they gave that order. I work on a tele floor and even if it's a routine order b/c pt is not tolerating/unable to take po, we still slow push while someone watches the monitor. I have had patients who required serial pushes of 5 mg at a time until BP or pulse hit a certain point, usually five to fifteen minutes apart.

Not to mention the ED sending you an unstable patient...I work tele, and we like to see the SBP

We have several docs who are bears at night...prev poster is right, learn some "scripts" to handle such docs. Decide before you call what you want for the patient, and be persistent. If you know that the doc has a reputation for being an uncooperative pain, think ahead...if he says no to A, how am I going to request B? Using the "so, you want me to write an order for no interventions despite BP of 220/110, you will reasses in am" line is helpful...at the very least, having something like that written as an order will earn them a butt-chewing by our medical director, and they know it. Also, I find it helpful with BP issues to ask for parameters I can write orders for when they want to be called, requested using the "to avoid calling you unnecessarily later, can I have parameters for when you would like to be called regarding this issue once the ordered interventions are completed?"

Remember, kill 'em with kindness, even if you're similing through clenched teeth, and don't be afraid to get higher ups involved if need be. Nothing gets the message across quicker that a doc could have done more than having to call the rapid response team in the middle of the night.

[missmiamoore]

bluefrog said:

Out of curiosity, how was his blood pressure before he came to your unit? I ask because when I get report from the emergency center, I always ask the last set of vitals, and if they tell me that SBP is over 170, I kindly ask them to stabilize the patient and administer any blood pressure medication that they have on order and call me back when the blood pressure is under control so I can admit the patient to our med-surg unit.....

Yes you are so right, and this one of the things that I keep thinking about. Another new grad took the report for me and I wanted to ask the nurse who brought him up more questions, but I was in another room hanging pain meds for someone else at the time he came up. Our charge nurse was in the middle of her break and sleeping in the staff room. All and all there were several lessons learned here for me. I will always ask about their last set of vitals before the transfer them up now. Believe me I will never forget this!

[rph3664]

missmiamoore said:

It was after hours and I had to retrieve the medication from the night cupboard, which entails me photocopying the order and leaving it for the pharmacist in the AM. I'm sure he almost crapped his pants when he discovered it in the morning.

That makes sense. Maybe I missed that in the OP.

I work at a large hospital with a 24-hour pharmacy.

[missmiamoore]

mama_d said:

we had a new grad kill a patient once by pushing too much Lopressor too fast b/c "that's what the doc ordered". Sent them from afib in 130's to a code in two minutes flat.

Its scary to think that could of been me in another universe. I thank God that didn't happen in this situation. I don't think I would of been able to go on as a nurse.