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.
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!
But the nurse didn't simply disregard the first order and externally pace the patient of his own volition. He pursued it until he found a doctor willing to write an order, exactly what should have been done.
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've pretty much routinely been taught the opposite. Smaller the diameter of the syringe, the more pressure exerted both in nursing school and on the job. I can't seem to find much on Google to promote either line of thought.
I've pretty much routinely been taught the opposite. Smaller the diameter of the syringe, the more pressure exerted both in nursing school and on the job. I can't seem to find much on Google to promote either line of thought.
Think of it this way,
When you pull on a large syringe, it has much more "power to suck" thus much greater negative pressure occurs in the syringe, which usually results in a collapsed catheter and a failed draw.
On injection Larger syringes generate LESS pressure.
It's the same premise either way, an equal amount of weight acting on the plunger produces more psi in a smaller bore syringe, and it also creates more negative psi when moving in the opposite direction when the same weight is applied. Larger syringes have the potential to create more negative pressure because a larger volume of negative pressure can be created, but the same is also true for injecting; if the ability of pressure to escape is less than the ability to introduce it, more volume will create a higher peak pressure.
It's important to remember that larger syringes don't generate less pressure when injecting, more force applied at the plunger will create the same amount of potential pressure as a smaller syringe, and since hand generated force is not standardized and is highly variable, there's no basis for the level of faith we put into using a 10cc syrince. You also have to remember that the potential to generate any amount of pressure in the lumen depends on a significant amount of resistance to actually create a higher pressure, if a lumen is freely patent then you won't generate any significant amount of pressure no matter what size syringe you use, which is why there's really no need to use a 10cc syringe one you've established wide open patency.
Can your hospital do a finger stick for a trop? I know will do it but it is a pain to do as you need to have a pediatric tube that is filled by squeezing the blood to the line. We have them in the ER. I think you need a special machine to be able to use the tubes for trops. It's the way you get blood from an infant. The ER should have the proper tubes.
Specializes in Oncology; medical specialty website.
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.
If it had been me, I would have called the MD and asked if I could have an order to draw from the midline due to exigent circumstances. Which is more important: proving your point or saving the patient?
If a nurse's attitude is getting in the way of patient care, then heck yeah, I would expect some pretty firm language from whomever was in charge. As a PP said, pleasantries sometimes fall by the wayside in an emergency situation.
Specializes in Oncology; medical specialty website.
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.
^^
When I worked in peds, ER and oncology, we drew labs off 24g when there was no other option. If you are gentle you can get a sample without it hemolyzing.
Specializes in Oncology; medical specialty website.
Exactly on both comments above. My concern moving forward is this apparent communication issue and the fact that she was very unwilling to at least hear me out and I was trying (not as effectively as I thought!) to communicate with her to explain both why the doctor had told me, what I had received in report, and why I knew I couldn't draw from the line. I understand her sense of urgency- I was panicked too of course- but in this situation, communication went out the door and a power struggle of sorts that I was not prepared for prevailed. I just never want this to happen again and am trying to think back to how this could be prevented.
Why don't you ask to have a "sit down" with her and discuss your concerns with her? "How can we make sure this doesn't happen again?"
We only have one side of the story. I'll bet if your charge were here, her POV would be much different. Speaking from experience of being in charge, it is extremely frustrating to have someone dig their heels in and refuse to handle a situation. Both of you should have been more focused on the patient, not who was right/wrong.
FWIW, foot draws are sub-optimal sites. There are a lot of nerves and tendons there that can be damaged, not to mention the potential for infection or thrombus if the patient has compromised peripheral circulation.
Specializes in Oncology; medical specialty website.
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
Do we really know for a fact that she was "screaming" at this nurse? As others have pointed out, it seems to be that lately newer nurses misinterpret someone being brusque or using an authoritative manner as "bullying/lateral violency/NETY/insert latest catchphrase.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Do we really know for a fact that she was "screaming" at this nurse? As others have pointed out, it seems to be that lately newer nurses misinterpret someone being brusque or using an authoritative manner as "bullying/lateral violency/NETY/insert latest catchphrase.
No.....we don't....do we ever? really?
I do think there is more to the story.....if I were the manager and this came across my desk....I would of course investigate. Ask the nurses that were in the station what the heck happened...look at the chart....etc. Get the full story before judgement.
The OP hasn't been back to tell us what happened to the patient...nor the rest of the scenario so TRUE "advice" is a moot point most of the time.....we respond on the information we are given.....which is never 100% "Accurate"
But as a nurse nurse getting her chops "knew" something was wrong......and didn't blindly follow what was being "shouted" at her...which takes confidence and some semblance competency...putting things together....to come to a conclusion. That deserves a good job.
I stated in an earlier post that her "not trusting" and "losing faith" ....confidence.....whatever.....in her leader was extreme.
That the order
which was really the radiologist sign off saying I could "use" the line but never stated I could draw from it.
is semantics and not necessarily a "do not draw order".
I am SURE (not) the OP was completely polite and calm in this exchange either
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.
nor guiltless in the exchange. Clearly they both have blame here and could have handled this better. In light of the fact her facility has a specific policy AGAINST the use of a midline for blood draws AND she stated she had an additional order for no draw....gives rise for me in suspicion that there is more afoot here than meets the eye.
However....the charge nurse non verbally admitted her misstep....
When I found the order from the doc that placed the line that stated not to draw an showed it to her... Crickets... Not a word. She looked at it, mumbled "don't draw from it" and said nothing else.
and indicated to me that if she, as the charge nurse, felt that strongly......that she should take the responsibility and do the draw herself..... fight about it later in order to expedite the care of this patient. The OP had already tried an alternative method....the foot vein AND tried to get the hospitalist to draw off it and was refused by them (frankly...what a wimp....do the draw or do a fem stick schmuck) only to have these "critical labs" later cancelled by the attending/specialist.
That the "midline" is on a "stage V renal patient" with 4+ pitting edema who needs dialysis as best care scenario..... makes me wonder if it is a dialysis cath
this pt only had access through a Midline in the subclavian,
and most renal doc's I know would have a STROKE if used by ANYONE for a lab draw....especially on a non critical care area.
I told her that her response that her "leader" was reckless" and she had somehow "lost her" was over reacting and had little,if any, "hierarchal bullying" that applied to this situation
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.
Elle23
415 Posts
But the nurse didn't simply disregard the first order and externally pace the patient of his own volition. He pursued it until he found a doctor willing to write an order, exactly what should have been done.