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.
If the charge has moved on from this, she shouldn't have yet. She failed in her leadership of a new nurse, apparently didn't know enough about her patients and their orders, and exhibited completely unprofessional, and frankly abusive, behavior by yelling at her publicly in front of co-workers, patients, and families.
It's funny to hear so many nurses on here advocating for the "patient" against written orders, yet in the real world all you get is *crickets* when it comes down to it. Even from charge nurses.
And what if the OP drew off the midline and then it clotted/the pressure affected the lumen/etc. and she/he couldn't bolus and give appropriate meds? then the patient would have REALLY been screwed.
I used to work for an infusion company and if a radiologist or the RN who places the line writes an order to "do not draw" then usually there is a reason for that. I agree that in an emergency situation like this, SOMETHING must be done but I am very surprised at the above posters who agree with your charge RN.
A couple suggestions:
1) you say other nurses tried to draw, but who?? If I have a really tough stick and my co-workers offer, sometimes I'll say No I think I need the ICU RN after assessing the patient's veins.
2) call the MD/radiologist/RN who placed the midline or whoever is on call. It doesn't matter if it's 0100 there has to be someone who is an EXPERT who you can consult. --clearly this is NOT the charge nurse.
3) If the fistula is all that's available, where are the dialysis RNs? again, isn't there someone on call you can consult?
4) Research the midline placement, what products were used, etc. Find out if it's a PICC lumen cut to a midline - this info will be useful when you talk to the radiologist on call, etc.
Of course, what is happening to your patient during all of this?? Labs are important but not the tell all. Patient assessment, did the patient get relief from nitro, what are the VS -- your charge and coworkers should be doing the above while you are with the patient! Also, I'm surprised the MD didn't order anything ON TOP of the labs like say some studies? Chest x-ray, CT angio with the hx of dvt? did we check a blood sugar? Did we consult RT?
EKG isn't a tell all either!! I had a patient whose EKG was normal (compared to baseline) and his TNI was > 9!
More important that blindly following orders is understanding them and then knowing when not to follow them or when to clarify. Many facilities have policies against using PICC's and midlines for routine draws, but the rationale for these doesn't exclude use in situations that are time sensitive when other access is unavailable. EKG's are more accurate in real time for assessing ischemia, but troponins can show recent ischemia that may not obvious on a 12-lead.
I would have clarified the reason for the "no-draw" order, if the hospitalist also says not to draw from it, but it's been determined that what's best for the patient is a troponin draw, you need to make sure the hospitalist as a reason other the the typical avoidance of stepping on another MD's toes.
I think your missing the point. You can not draw from a midline. The French is to small and drawing from it causes hemolysis of the sample and makes it useless. Not only that but drawing from too small of a French increases the risk of clot. This patient already had a DVT in the other arm. How is putting the pt at an unnecessary risk beneficial just for the sake of drawing a sample that will be useless?
And then this poor nurse gets all wet in the ******* contest that will happen between the hospitalist who wrote that order and the specialist who will be PO'ed that his order was disobeyed?
And she gets all the **** splatter off the fan when one of those undesirable consequences of drawing from the central line occurs, and tries to use "my charge told me to" as a defense? Because we all know that will save her, RIGHT?
Did other more experienced nurses try for peripheral access? Ie: your charge? What about the hospitalist?
Why did they have a midline in the first place? I would think with renal failure they would being monitoring bloods daily... A PICC sounds much more appropriate.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.
I have one question I need to ask....Midline in the subclavian?????......is this a Groshong, Broviac, Hickman or some other tunneled device?? OR some other VAS cath/dialysis cath (the patient is in renal failure) for that is a whole new set of rules. These caths would have to have a MD order to draw from and some you may not draw from at all.
You were 100% correct in calmly (I hope you were) advising your charge that there was an order not to use the cath and that the MD would have to be notified
Your charge nurse was inappropriate in her response to you. I don't know if she/he was having a bad day and became overwhelmed....it still doesn't excuse their behavior. Raising one's voice is never the answer...but charges are human too.
I don't think that one incident of the charge "losing it" is hierarchical bullying...nor do I think you have lost your leader.....nor is she reckless. She had a bad day/moment. As a charge it is sometimes difficult to remember who has what line and what it is used for...that is what the bedside/primary nurse is for....to know her patient. The charge nurse was wrong to "lose it"and you were right in asking her to evaluate further.
If I were the charge I would have looked at the cath/patient myself while you checked the chart and called the MD so astobest assess the patients condition and the real urgency/emergency of getting the labs...or perhaps drawing them myself. As a staff nurse or supervisor....you can scream at me until the cows come home and you turn purple....if I think it is wrong, unsafe, inappropriate...I will not be doing it! I am responsible for your actions.....He/She told me so....will NOT help you in a court of law.
I am proud of you for sticking to your guns politely and evaluating what your next step should be and call the MD for further orders....you are right....just because you were told to do it by the charge nurse will not save you if you did and it was against orders.
I'm totally perplexed. I work in burn - many patients with very poor access - and we draw from midlines (and PIVs) all the time. I don't think I've had a midline clot off or hemolyze yet and I've taken labs from dozens. (Our docs went through a midline versus picc kick a while ago and everyone had one for a while.) You obviously have to be careful...don't draw with anything smaller than a 10 cc syringe, flush really well, etc. etc.
Obviously there are other issues at play but I don't think drawing from a midline is *that* dire?
I wouldn't draw from a line that had a "no draw" order unless I had gotten permission from the MD. I would have done the same as the OP and offered the charge a chance to do the draw if she was insistent. BUT if the patient codes or is very precode all rules tend to go out the window, and you do what you have to. Did you have a rapid response team, or a doc at the bedside? Time of day wouldn't stop me from calling whoever I needed for a sick patient, and if someone is oncall, and gives you a hard time, they deserve to hear from their supervisor.
I think the biggest problem I see in this situation is black/white thinking on both sides of the conversation. Stay calm, keep stating your concerns, try to think of alternatives and have the other person do the same. If you put your heads together and come up with a solution it preserves the relationship. Headbutting wastes time and leaves you with the same problem and hard feelings. So, even if you KNOW you're right, keep talking about reasons for your position, and alternatives ("we could do...but this... would result) and keep going until you get a solution. Yes, it takes time and patience, but you are still working it out together. In the meantime the patient will egt better (yeah!!) or worse (making the final choice a lot clearer).
I have made ALL of the mistakes I see described in the OP's post, and it's hard to be calm and collaborate when you're dealing with a jerk, or someone who doesn't have all the information but wants to take over. Whenever I've managed to do it I have a much better outcome for the patient, personally, and professionally. Even if I've wanted to wring a few necks during the process.
Specializes in Med_Surg, Renal, intermediate care.
This is a very interesting post. I love all the different opinions regarding the situation. What I do love and respect about nursing is that everybody nurses different. We have the same policy at my facility. Our midlines are labeled " Do not draw labs". However, I'm fortunate that on night shift we have a NOW (nurse on the way) nurse or what some hospitals call a resource nurse who is PICC certified. Also, some of our house supervisors are PICC certified. So I would have called one of them and explained the situation. Then I would have asked if they could come up and draw the lab or assist me in drawing the lab. That was a situation that needed immediate attention. I'm a charge nurse as well and I'm not going to argue with you. We are going to take care of business. So you call the doctor and as the charge nurse I will take care of the lab. Also, at my facility we do not place PICC lines on dialysis patients. They are only get central lines. The nephrologists believe that PICC lines ruins the veins for future fistula placement.
duskyjewel
1,335 Posts
If the charge has moved on from this, she shouldn't have yet. She failed in her leadership of a new nurse, apparently didn't know enough about her patients and their orders, and exhibited completely unprofessional, and frankly abusive, behavior by yelling at her publicly in front of co-workers, patients, and families.