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.
OP, you did the RIGHT thing. If something would have went wrong, YOU and only YOU would have been accountable. So far as what the other posters think.....
Let me say this. I love All nurses. I've been on this site since 2008 ( under different names) and have received a wealth of advise and information. With that said, some of these responses you have to take with a grain of salt. We were not there, we do not know the whole story. We are just speculating. Just because some posters would have drawn from the midline does not make them right. It does not make them wrong either, however you don't do anything just because someone else is willing to do it.
Stand behind your decision and never get tired of doing the right thing.
I am honestly floored that so many who repsonded wouldn't think twice about disregarding a doctor's order AND hospital protocol.
You can go to any BON site and find nurses who have been reported for doing just that.
I think the reasonable thing to do would have been to get an order for a one time draw. But to draw with an order in place stating NOT to draw? You are just asking for trouble.
Specializes in Regulatory Nurse Specialist, State Government.
Agreeable with any comment that reflects that the charge nurse has a responsibility to step up to the plate, make the draw him or herself; especially with your reflection of being a new nurse-these are all circumstances that under strong leadership; the leader will take the responsibility to get the patient what the patient needs, and then provide further education through demonstration as to how a circumstance plays out in real life-"For example" encouraging proper investigation as to why the line was ordered to not be drawn from; and then determining if this guideline was fit enough to allow the patient to "metaphorically" and "physiologically" crash. Lateral bullying, interdepartmental bullying and hierarchical bulling has no place in any environment-tone and stress from the charge nurse does reflect a rather appearance of a lack of confidence on part of the charge; however, as reflected in earlier comments these should be circumstances that each person involved can learn from. Good Luck!
Hope the patient did fair well following this episode!
Specializes in Regulatory Nurse Specialist, State Government.
Without doubt; part of investigating the "order to not draw" would be to contact the physician and re-visit that order to have it changed for the "emergent"; or perhaps not so emergent need depending on the reference of the order to not draw: absolutely the physician must be contacted under all circumstances of patient status change!
"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."
Midline IV catheters ARE NOT reliable when it comes to lab draws, but it should NOT be an absolute that they can NEVER be used for a lab specimen.
But a Midline also should never pass the axillary vein in the upper arm/shoulder. A Midline should never terminate in the subclavian. Many years ago, in the early 90's when "outcomes" weren't available yet, we, as Vascular Access nurses placed midclavicular IV catheters, but what we didn't have was outcomes. And outcomes showed, in quick order, that thrombosis rates increased tremendously when the tip of the IV was in the subclavian or innominate vein.
So, INS says you should have either a Midline or a PICC... Nothing in between.
If the medication has to go centrally, a Midline won't do, as it is NOT a central IV catheter.
A different poster mentioned that labs can be drawn, but use nothing less than a 10 cc syringe. This too is erroneous. 10 cc syringe exert TOO much negative pressure with withdraw and therefore are NOT one's best option. Smaller syringes are.
I am honestly floored that so many who repsonded wouldn't think twice about disregarding a doctor's order AND hospital protocol.
You can go to any BON site and find nurses who have been reported for doing just that.
I think the reasonable thing to do would have been to get an order for a one time draw. But to draw with an order in place stating NOT to draw? You are just asking for trouble.
That's exactly why I'd be waking that specialist up. I'd ask him if we could try it.
I guess there are two issues here so maybe i should just focus on the one thats not policy related because that varies place to place. I'm just concerned for the future relationship between myself and the charge. We really rely on each other on nights and it felt to me like she saw it as a power struggle- as you say- and I was focused in doing what I thought was right.
No, I think you're overreacting. I am not saying you can't have your feelings, and I am not saying there was no such order. But the situation is past, You (I hope) know how to manage this better next time (clarify the access with the MD, learn what "French" means, and consider calling dialysis or physician to draw from the shunt if it's that critical in the physician's opinion).
To carry strong feelings of betrayal and hurt about your charge's words to you (in the heat of battle) in the forefront of your affect from here is not going to be functional. Let it go. Stop now. If this is the worst thing that ever happens you will have a long a glorious career.
And if you think this is so awful, perhaps step back and take a deep breath and try very very hard to look at the long term. Life is full of disappointments and disagreements. You won't always get what you want; sometimes your leader will not do what you expect, and sometimes you'll never find out why. That is life. Move on.
Did you say the radiologist said it was ok to "use" the line? What did you think he meant?
"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."
Midline IV catheters ARE NOT reliable when it comes to lab draws, but it should NOT be an absolute that they can NEVER be used for a lab specimen.
But a Midline also should never pass the axillary vein in the upper arm/shoulder. A Midline should never terminate in the subclavian. Many years ago, in the early 90's when "outcomes" weren't available yet, we, as Vascular Access nurses placed midclavicular IV catheters, but what we didn't have was outcomes. And outcomes showed, in quick order, that thrombosis rates increased tremendously when the tip of the IV was in the subclavian or innominate vein.
So, INS says you should have either a Midline or a PICC... Nothing in between.
If the medication has to go centrally, a Midline won't do, as it is NOT a central IV catheter.
A different poster mentioned that labs can be drawn, but use nothing less than a 10 cc syringe. This too is erroneous. 10 cc syringe exert TOO much negative pressure with withdraw and therefore are NOT one's best option. Smaller syringes are.
The last paragraph. Barrel diameter is what determines pressure. So the SMALLER the barrel- the greater the pressure.
Correct me if I'm wrong, but it's my understanding that one must use at least a 10mL capacity syringe when flushing the line. When drawing back, you can use whatever you want/ just do it slowly- the small diameter of the Line will cause hemolysis if blood is pulled back too quickly.
What I'm not seeing in this thread is recognition of what could have been happening with the patient, and the importance of timely response to it. If I had been that charge nurse, I too would have been extremely frustrated at a new nurse's poor response time to a change in a patient's condition that demands immediate attention.
Like ... the patient having/extending an MI or throwing a PE can just hang tight for a while until everyone is comfortable with the decision-making and the verbal communication that has accompanied it ...
What I'm not seeing in this thread is recognition of what could have been happening with the patient, and the importance of timely response to it. If I had been that charge nurse, I too would have been extremely frustrated at a new nurse's poor response time to a change in a patient's condition that demands immediate attention.
Like ... the patient having/extending an MI or throwing a PE can just hang tight for a while until everyone is comfortable with the decision-making and the verbal communication that has accompanied it ...
I think I addressed this very thing on page 1.
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.
I'm going to jump in to address a random point. A few people said a PICC would be a better option. In a dialysis patient, the nephrologists rarely approve a PICC. It risks peripheral occlusion and can prevent a fistula or graft from being placed.
This patient had a DVT in one arm so I'd think dialysis access was in the other, also a contraindication for a PICC. Chances are the radiologist inserted the line as a midline rather than a central line due to central occlusion. It's a common issue with dialysis patients who have had numerous central lines and something our radiologist did routinely if there was no other option. They typically inserted an IJ quad lumen and cut it short or inserted a tunneled line (like a Hickman) and did the same. The catheter length and tip placement was always reported to the floor nurse after insertion.
If my charge had told me to draw from the line against orders, I would have refused and instead said that I would call either the radiologist on call or the radiology nurse on call to get clarification once the peripheral draw failed. The charge nurse could certainly have made that suggestion rather than insisting on going against orders. Radiology takes call for a reason and emergent situations are a good reason to wake them up at 1am.
As far as a power struggle, I wouldn't worry too much about it. I had sporadic issues with nurses when I was charge and I've had issues with the charge nurse when not in charge. You work together and won't always agree. Just remember that you both had the same goal in mind. You wanted to help the patient.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
What I'm not seeing in this thread is recognition of what could have been happening with the patient, and the importance of timely response to it. If I had been that charge nurse, I too would have been extremely frustrated at a new nurse's poor response time to a change in a patient's condition that demands immediate attention.
Like ... the patient having/extending an MI or throwing a PE can just hang tight for a while until everyone is comfortable with the decision-making and the verbal communication that has accompanied it ...
On the floor......if there was an order to NOT use for blood draws.....it cant be used....If the charge nurse felt that strongly it should and could be done that way she is perfectly capable of doing it herself. It is clear that this new nurse was not comfortable AND had documentation to NOT use the IV. She did the right thing. Called for a foot vein...which many facilities do not allow floor nurses to access. Put a call in to say that it didn't work to ask permission to use IV cath for draws.
In critical areas in critical circumstances a critical care TRAINED nurse may use his/her judgement or make other decisions but this nurse stayed within her scope of practice and expertise. She should be commended for standing her ground and seeking other solutions to an immediate problem. I have as a supervisor called MD's that "know" me to get an order for lab draws that were imperative to care if I couldn't get them drawn....thankfully an arterial stick usually does the trick.
As a charge/supervisor I would have understood the new nurses hesitation and lack of experience and if the patients condition warranted immediate emergent labs......I would have taken on the responsibility of the situation myself. I wouldn't ask another nurse to act against her better judgement/experience/training/physician orders without taking that responsibility myself. I would take them aling and teach them...or do an arterial stick myself....or call respiratory to draw the labs art stick if possible.
In a court of law.....if there was a bad outcome....say a clot broke off and the patient died.....or they got an accidental air emboli....and there was a specific order to NOT touch the catheter for blood draws. My charge nurse told me to do it.....will not protect this nurse for she sh9uld have followed the MD orders.
She did the right thing...the charge nurse however wasn't exhibiting leadership qualities. You do not stand in the middle of the nurses station and shout at any one. You "TAKE CHARGE" make the call to the MD yourself to ask permission to use the line and what to do next.
BSNbeauty, BSN, RN
1,939 Posts
OP, you did the RIGHT thing. If something would have went wrong, YOU and only YOU would have been accountable. So far as what the other posters think.....
Let me say this. I love All nurses. I've been on this site since 2008 ( under different names) and have received a wealth of advise and information. With that said, some of these responses you have to take with a grain of salt. We were not there, we do not know the whole story. We are just speculating. Just because some posters would have drawn from the midline does not make them right. It does not make them wrong either, however you don't do anything just because someone else is willing to do it.
Stand behind your decision and never get tired of doing the right thing.