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.
Challenging orders is not outside of the scope of practice, especially in an emergency situation.
I have no problem with challenging orders! I DO have a problem with nurses who said they would just go against orders and draw from the line. Or tell a nurse to go against orders if the charge nurse says to.
We draw from small lines all the time in peds. You do have to be gentle. Sometimes, the sample does hemolyze. And it has to be drawn again. If the patient was truly presenting critical symptoms that needed evaluation, you should address the lack of access at the time you take an order for labs. You can't just not draw the labs. Yes, you do wake up whichever MD at 0100 if you are really concerned that your patient is declining.
This whole discussion is interesting and enlightening. I'd just like to share that as a Vet Tech I draw with 22 and 25g needles regularly when taking blood from cats and kittens (TEENY veins!!) and as you say, you have to be gentle, and it takes some technique, but it is VERY much possible to get a usable/reliable sample even from those bitty veins, via catheters as well.
Once upon a time the INS recommended not drawing labs from a midline, although they dropped this recommendation in 2011. Some MD's incorrectly believe that drawing from midlines affects the patency of the line, which is also false, the INS has specifically stated that this is incorrect. A BON would like to see that these issues were brought up before there is mutual agreement the line should not be used for labs.
Could one not flush the line after with heparinized saline to preserve patency? As an almost-nursing-student I'm unsure if this is how things work in the human world, but it makes sense to me...
This change from LVT to nurse is going to be an interesting transition for me!
If this were a truly emergent situation as people seem to be indicating, wouldn't a doctor be at the bedside?
I worked many years in NICU and witnessed countless emergencies, and there was always a doctor there calling the shots. And about 50 other people as well (or so it seemed!)
I just have a hard time understanding why if this were an emergency, there was no one there but the nurse and the charge nurse.
If this were a truly emergent situation as people seem to be indicating, wouldn't a doctor be at the bedside?
I worked many years in NICU and witnessed countless emergencies, and there was always a doctor there calling the shots. And about 50 other people as well (or so it seemed!)
I just have a hard time understanding why if this were an emergency, there was no one there but the nurse and the charge nurse.
That's more likely in an ICU and particularly in a NICU, but outside of teaching hospitals Doc's don't show up at the bedside for pretty much anything. Our hospitalists aren't even present for rapid responses. Outside of ICU's/NICU's and teaching hospitals, most of these situations are handled primarily by RN's.
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 ...
IF that is the case then why did the charge nurse decline to draw for the line.
That's more likely in an ICU and particularly in a NICU, but outside of teaching hospitals Doc's don't show up at the bedside for pretty much anything. Our hospitalists aren't even present for rapid responses. Outside of ICU's/NICU's and teaching hospitals, most of these situations are handled primarily by RN's.
We don't need a doctors order to push meds in a code if ACLS certified. Maybe that's different from state to state though. The last facility I worked for did a big push for nurses to start giving meds immediately during a code and not waiting for the entire code team or the MD. It's within our knowledge, scope, and training to do such. We do need orders for transfer and post code care from the MD though so I certainly hope he shows up!
When I was a nurse in the unit, my pt coded and the PA on call slept through the code. We just called him after the pt stabilized and asked for orders. He came to the room the second time the guy coded.
If you're ACLS certified, you can. One of the ED docs and the hospitalist show up to codes at my facility, but waiting for them to arrive is no excuse to delay treatment.
To the topic at hand, I'm appalled at the attitudes of everyone involved. Who in their right mind just says "Oh well, we couldn't get the labs. Who cares what the patient's symptoms are, just let it go?" If this was my family member (or my patient, whether as primary RN or charge) I would be irate. Did anyone stop to think that the order to not draw from the midline was designed to prevent routine blood draws, not a one time emergency use? I'm surprised at the meekness of the charge nurse. If the OP, as the primary RN, refused to take action to benefit the patient, I would have been on the phone with the specialist, the hospitalist, the house supervisor, whoever it took to get a clear answer. This is not some contest between physicians and nurses, this is a human life at stake. Maybe the symptoms were nothing, but how do you know without the appropriate data?
Specializes in Oncology, Rehab, Public Health, Med Surg.
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.
Is this correct? I've never heard this before I've always been told 10 ml syringe in and 10 ml syringe out
Codes are handled with protocols, if the pt is full code, a code is called and the rapid response nurse comes and is covered by the protocol and can give meds without a MD present. Rapid response handles all codes in my facility with a CRNA if intubation is needed and a ED MD. We has several protocols we can follow in a emergent situation without an MD at bedside.
As for general orders, MD's round on their pts daily and write orders as needed, if anything is needed and the MD is not at the bedside;telephone orders are used.. Floors and the ICU do not have someone in house 24/7. The hospitalist is in house by they only cover their pts.
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!"
Totally agree with this, as I am an ER nurse with a few years of experience. But I recently started a new job and here's my scenario:
Patient was in ER, missed dialysis for 4 days, complaining of abdominal pain, so abd/pelvic CT was ordered, patient given contrast solution. K+ level is 5.6 as expected, attending MD orders hyperkalemic cocktail (sodium bicarb amp, dextrose 50% amp, 10 units of reg insulin IV, calclium glutamate 1000mg IV). Side note: I'm used to giving 2 amps of dextrose rather than one, kayexelate, and albuterol, but it's a slightly different protocol at this hospital. Everything is given as ordered, patient goes to CT, then is transported straight from CT to Dialysis. The dialysis RN phones me in the ER to tell me that the patient is lethargic, diaphoretic, and his finger stick is 46. Also, she's alone. I give report to my colleague is 2 minutes and run up to Dialysis with an amp of D50 in my hand and a flush. I give it to the patient right away after confirming her assessment. Patient recovers in 5 minutes, is talking clearly to me, level of consciousness starts to return to baseline, he's no longer sweating or muttering "i need to eat, please help." I go back to ER and find out that my preceptor reported me for saving someone's life.....go figure. I was supposed to get the order for the D50 first.
The moral of the story: yes, you want to follow the rules and the protocol, but in an emergency, I feel, there's some things that just don't apply at that given moment.
Elle23
415 Posts
I have no problem with challenging orders! I DO have a problem with nurses who said they would just go against orders and draw from the line. Or tell a nurse to go against orders if the charge nurse says to.