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 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?
^THIS....all day long...it's about the patient getting stabilized...
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?"
Fwiw...I agree the labs should have been drawn. I never said otherwise. I just think if I were going to use the line, it should be after contacting the physician and getting an order to do so.
I don't recall anyone in this thread saying they should have just thrown their hands up and not gotten the labs.
(I just reread your post...I thought at first you meant everyone in this thread, not the actual ones involved. That's why I answered as I did.)
I think a simple phone call to get an order for a one time lab draw from the "midline" would have saved everybody a lot of aggravation.
I'm guessing that the rationale behind the order to not draw from the "midline" was most likely the superstition that blood sampling through the catheter increases the risk of catheter occlusion. This would be a rationale to avoid routine blood draws, but I'm reasonably sure the MD would have allowed a one-time draw in this instance because the patient's condition warranted it. So even though there was an order to not use the "midline" for blood draws, that is not the end of the story. This should have been pursued.
As far as butting heads with your charge, I think you would be wise to clear the air. Apologize for your part in things going sideways and offer some ideas about how things could be different in the future.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Much of what the nurse does is covered by protocol and "standing orders"AND the good graces of the MD to cover our behinds. I did not see that anyone feels it was ok to not get the labs. I think further calls were necessary and with the hospitalist being a jerk and not manning up to get the labs with a fem stick or grow a pair and draw off the line....this new grad did well ...she should never blindly follow what someone says just because they are yelling.
As the charge nurse goes.....she/he was in appropriate in her response...you DO NOT yell at staff. PERIOD.......it WAS her responsibility to investigate this herself...clarify it and help the new grad learn from it. NOT SCREAM at her in the nursing station and demand to be obeyed. Go in assess this patient.....instruct the new grad that the appropriate response in this scenario is to explore options for the patient....call the MD get a one time order....have the attending call the hospitalist and come do the lab work...have respiratory draw them arterial....or if the patient is THAT ILL...call a rapid response.....then do a fem stick.
If this was a charge nurse where I was the manager and she responded this way...I would speak with them...it is not necessary, nor appropriate to yell....if it was habit....they would no longer be charge. .....to the new grad....what chain of command is appropriate to follow the next time. Iwould commendher for standing her ground nowhere did this indicate that nothing was further done for this patient
When flushing a catheter over three inches in length, one definitely wants a 10cc syringe barrel or larger syringe, but with withdrawing, the opposite is true. the larger barrel syringes exert too much negative pressure, and if used inappropriately, will cause the IV catheter to collapse, and a failed draw.
Much of what the nurse does is covered by protocol and "standing orders"AND the good graces of the MD to cover our behinds. I did not see that anyone feels it was ok to not get the labs. I think further calls were necessary and with the hospitalist being a jerk and not manning up to get the labs with a fem stick or grow a pair and draw off the line....this new grad did well ...she should never blindly follow what someone says just because they are yelling.
As the charge nurse goes.....she/he was in appropriate in her response...you DO NOT yell at staff. PERIOD.......it WAS her responsibility to investigate this herself...clarify it and help the new grad learn from it. NOT SCREAM at her in the nursing station and demand to be obeyed. Go in assess this patient.....instruct the new grad that the appropriate response in this scenario is to explore options for the patient....call the MD get a one time order....have the attending call the hospitalist and come do the lab work...have respiratory draw them arterial....or if the patient is THAT ILL...call a rapid response.....then do a fem stick.
If this was a charge nurse where I was the manager and she responded this way...I would speak with them...it is not necessary, nor appropriate to yell....if it was habit....they would no longer be charge. .....to the new grad....what chain of command is appropriate to follow the next time. Iwould commendher for standing her ground nowhere did this indicate that nothing was further done for this patient
I think that the responsibilities of charge nurse vary from institution to institution. Where I work, the primary responsibility of the charge nurse is assignments and staffing for the next shift. I do not get involved in the minute to minute decisions that my coworkers make. I am available for questions,but I have my own assignment and would not be the one to investigate the situation and then call the doctor. That is the responsibility of the patients nurse.
The other point I would make is that you are only hearing one side of this interaction. I don't remember the OP saying that the charge nurse screamed at her. Perhaps she spoke a little too forcefully to her, maybe the charge nurse was just frustrated.
I have used mahukers in emergencies. A nephrologist once told that having a functional line is good, but it really does not help a dead patient:).
So how do we pick and choose which orders to follow then?
This is getting a bit off topic, but this can help to illustrate the point. A fellow RN of mine on a telemetry floor had a patient having short runs of complete heart block. Pt would get dizzy during said runs, but would quickly return to NSR. He called the electrophysiologist (EP) many times over the even about the patient and her runs of HB. The EP eventually basically told him not to call back. Well then the patient went into a longer run with more profound dizziness. He called the EP again who said "I will put a pacer in her tomorrow. It would be cruel to externally pace her all night. Do not externally pace her...period. You can write that as an order." Well, the nurse did. Pt continued to get more symptomatic, RRT was called, and the critical care doc ordered...surprise!...external pacing.
So yeah, there are times we have to choose when to follow an order and when get a better order. And a physician can "override" a specialist's order!
Who was it who gave the original order for the EKG/blood work? Who gave the order for the foot draw? Who then decided labs were not necessary after the EKG was "unchanged?" Did the physician who ordered the blood work actually look at the EKG (not just the interpretation at the top of the paper) and then decide to cancel the labs?
Anyway, I digress. Back the order not to use the midline for blood draws. Did a physician actually hand write a specific order not to draw blood from the midline or was it checked as part of an order set? For instance, I've seen a PICC order that had "prechecked" "flush with 10 mL q 4 hours" and "change dressing using sterile technique q 72 hours" (the exact time frames may have been different) so that the physician just signed the bottom of the page and now all those things were now physician's orders even though he/she did not specifically order those. Could it be that the facility had an order set for midlines that specified "No blood draws from the midline catheter." If that is the case, the physician may not even be aware that there is said line in the order set.
Could it be that the facility had an order set for midlines that specified "No blood draws from the midline catheter." If that is the case, the physician may not even be aware that there is said line in the order set.
If this is true, it seems sloppy to me that a physician would somehow not know what they were signing too. If they're signing an automated form, I would think they should be very familiar to it to prevent instances such as this.
LadyFree28, BSN, LPN, RN
8,429 Posts
^THIS....all day long...it's about the patient getting stabilized...