Standing up to my charge nurse prevented a mistake

[002rn05]

so, my pt suddenly developed chest pain, SOB, and extreme dizziness right at the start of shift and I immediately went to my charge to notify her that I'd be calling the MD. I received orders for a stat EKG and troponin level. Unfortunately this pt only had access through a Midline in the subclavian, and due to the patients stage V renal failure, was pitting 4 edema without a vein in site. Per policy we are not allowed to draw blood from midlines. I requested an order for a foot draw, but the draw was unsuccessful.

My charge, in front of everyone at the nurses station, grabbed my patients chart and started to demand that I draw from the midline because according to her it was intact a PICC. I knew that I should not draw from the line as I had been reported by the previous shift NOT to, and I also knew that the line was in fact a midline... But she continued. She raised her voice for all to hear demanding to know why I wouldn't draw and stating over and over that I have an ORDER to draw (which was really the radiologist sign off saying I could "use" the line but never stated I could draw from it.)

I politely told her I was not comfortable with drawing from the line since I had been told not to and that I would need confirmation to draw. She was infuriated. I knew somewhere there had to be more clarification documented so I searched through his/her chart and found the MDs order NOT to draw. I was so proud of myself for doing what I knew was right, but now I fear my charge is reckless and as a new nurse feel out of sorts with everything that happened.

Has anyone else experienced this type of hierarchal bullying? What did you do? Especially as a new nurse I feel like I've lost my leader.

[Catzilla]

Sometimes the rules change in an emergency. Do you know why the doc didn't want the line used?

how was the EKG- did it show any significant changes?

If the patient suddenly took a nose dive and let's say you HAD to get fluids in now- like yesterday even- what would you have done- given you still only had the midline?

When rules/orders/policies have to be broken --I usually have good results b saying something like this

"We got the trop level/the bolus going/Levo up/. However, 3 nurses and the lab weren't able to access a vein for a blood draw and GIVEN THE SITUATION- we had to use the midline."

what can they say to that besides "Way to rock it, rocker!"

[Catzilla]

Now to address the true nature of your inquiry-

I don't see this as "hierarchical bullying". Sounds like your pt was getting funky and given the. Situation- your charge was telling you what needed to be done. Often, in critical care it's easy to do away with the pleasantries and honey-sweetie-love cakes during an emergency.

"Do this ?@*&! now!" Is often a direct translation of

"please Miss Awesome nurse, this patient is playing in the tub and eyeing that drain. I know this may be different that our standard protocol dear, but you need to do A to prevent your patient from going down the drain. The rationale will be explained once we get that drain clogged back up."

Could your charge have communicated more effectively? Absolutely. It seems like the pt took a backseat to a power struggle. If the charge were that concerned to "yell" the. Perhaps she should have went and collected he blood herself.

In the grand scheme of things this is probably pretty minor and will blow over.

[002rn05]

Thanks for your response! I could use the line for fluids and to administer medications but our policy just won't allow draws from midlines. The EKG showed similar post MI changes to the previous EKG, so nothing astounding there, and the patients condition returned to baseline shortly after. I'm just astounded at my charge's behavior. I'm a new nurse in the hospital setting and there are many things that I'm still learning. The fact that she demanded I follow what she called an "order" just because she said so and yelled at me to "just do it" when I told her I was not comfortable doing so without more information really bothers me.

[Catzilla]

Curious, surely you've been monitoring labs /lytes on a pt with severe renal failure (unless comfort measures). Where's the blood coming from for labs?

[002rn05]

Not only that, but I infact had the MDs order NOT to draw from the line. Having gone against the order based in her decision would have landed me in hot water.

[002rn05]

The fistula that the dialysis nurse accesses at the time of treatment.

[dansamy]

If I'd been in charge, I'd have drawn the blood myself while YOU called the doctor to get an order.

That is if I could get blood return I should say.

[002rn05]

I had suggested that if she were comfortable drawing off the line that she could. She declined and that made me think if she weren't willing to take the chance, why was she willing to let me?

[Catzilla]

Sometimes docs write orders that exist is a perfect world. Well, crap happens and conditions change. Sometimes you have to think a little beyond simply "following the orders" and if you have a solid rationale- the docs will back you up- In my experience anyway.

I like what the prev poster wrote-you call, charge draws. Get it going!

[Catzilla]

Ah...yeah then there's that. I've been there.

"We'll just do this."

Uh, I'm not comfortable with that without talking to the doc- but you're more then welcome too"

*crickets*

"Call the doc"

*****

Hindsight is 20/20- but in a perfect world, you would have addressed the access issue right a the time the doc gave you the orders for the draw

[Catzilla]

I'm a newish nurse as well. I find that I learn so much from reflection/ what could I have / what should I have done.

there's a silver lining to this crappy encounter- a major learning experience on what to to/ how to prevent in the future.