Struggling With the Magnitude of My Responsibilities.

[23AtTheTeeth]

Hey, all. I am a Cardiothoracic ICU Nurse at a Level I Trauma Center that is also a major teaching hospital that serves 9 states in my Region. Needless to say, my unit is extremely busy, and we fly patients in to provide surgical specialty care and emergency resuscitation regarding anything Cardiac.

As many if you know if you're a member of a teaching hospital team, the steady migration of Resident Physicians through your unit can be somewhat annoying, and for lack of a better word, horrifying. As a newer nurse on the Unit (not in general) I have been there for a year. The turnover is astronomical in regards to nursing, and it seems as though as soon as we have a full staff, the ones who are left quit just as the new ones are ready to fly on their own (somewhat) confidently. This bodes a problem for the new baby doctors that are "in charge" of us, because, as the sad jokes go, we often know better than they do what our patients need. I'm not implying that we are smarter, or better... just that when an anesthesiology resident is doing a rotation through CVICU that is not his/her field of study or expertise, but it IS mine, and I have been doing it 70+ hours a week for a year, once in a while I feel like my judgement is a little more sound at times in regards to certain things.

The other day, I had an extremely complicated patient that was not doing well, despite every single intervention I could muster, every brain cell I had scraped together, I called in every single senior nurse on the floor to ask for advice, including my charge nurse. Together we came to our resident (who was actually quite competent) with a game plan and our rationales, and she said she liked the ideas, but due to the complexity of the patient, she felt she should run it by our Attending, which we all agreed would be best. Long story short, the patient still is not doing well, sometimes they just can't be fixed and they don't get better...

but, I was reprimanded by management, being told verbatim "Residents look to us for guidance. Why would you let them do that?"

Is it just me, or is that statement in and of itself just absolutely INSANE?

Why would I let a DOCTOR do something? It's my job to not only self regulate every single micro-move I make in regards to my patient, but I also have to babysit a doctor for my entire shift as well? Like it's some, unspoken but well known rule?

[offlabel]

Why consult the attending physician when a patient is dying? That's the question you got? I'll just stick to my nice red neck regional medical center when I have my MI, thanks.

[23AtTheTeeth]

Well, it was a little more in depth than that...

I asked if we could start dobutamine to help with her saggy indices and CO, but she said to try and go up on the milrinone from .375 to .5 first and then re-assess instead of starting a second agent (per the Res and the Attending).

I said okay, 10-4.

My manager said that, in fact, wasn't okay, and I should have known better.

FML, right? Because that's my responsibility, and also MY call to make. Apparently.

[offlabel]

Well, it was a little more in depth than that...

I asked if we could start dobutamine to help with her saggy indices and CO, but she said to try and go up on the milrinone from .375 to .5 first and then re-assess instead of starting a second agent (per the Res and the Attending).

I said okay, 10-4.

My manager said that, in fact, wasn't okay, and I should have known better.

FML, right? Because that's my responsibility, and also MY call to make. Apparently.

Not trying to Monday morning quarterback, but the milrinone could have been causing a fall in vasomotor tone and going up would have made it worse. Sounds like vasopressin might have helped. Sorry about a micromanaging manager...that stinks.

[Dodongo, APRN, NP]

Your manager needs to sit down and shut it.

The dobutamine in addition to the milrinone would be kind of superfluous. It would add essentially no additional contractility. Either agent can be used - usually milrinone has a better efficacy in pulm htn patients. But, adding one to the other is not going to help much from a physiology point of view. Was the patient on epi or levo? Epi is nice is these patients for its ino/chronotropic effects although it's not a given for every patient. I agree with the previous poster that vasopressin would be a nice addition for pressure support.

I mean, it's hard to give any more advice without knowing every piece of information needed to manage the patient. In general, I would trust what the resident and attending said over your nurse manager. Further, an anesthesiology resident is far more equipped to manage patients in your unit than you are... I don't want to come off as condescending in any way, but their understanding of physiology and pathology greatly eclipses your own. Sure, every once in a while a nurse will catch something that a resident didn't, but do not mistake that as knowing more or having a greater knowledge base than they do.

[CCU BSN RN]

You lost me right up front imagining a hospital serving 9 states. And I'm in the north east. Our states are really small. My mental idea of a state isn't really that big.

Anyway, without trying to guess about the clinical situation with limited info, here's how I would've responded to management:

1. What exactly would you expect that I do differently? If a resident has discussed the situation with their attending cardiologist, and the course of treatment does not seem dangerous or egregiously absurd, and the rationale has been explained to me and makes sense, who am I to question that? I'd probably find a tactful way to ask my manager if she is also following up with the attending physician who ordered what she considered to be such a dangerous course of treatment? I'd probably bring up that you involved the charge RN as well, as well as any other well-respected senior nurses you pulled in.

2. I'd go talk it over with my work wife, so she could remind me that several nurses didn't know what to do, including your charge nurse. The resident(s), fellow, and attending discussed and despite no great options, came up with this course of treatment and decided it was best, and explained their rationale. You're not superwoman, you didn't become a nurse to kill people or injure them intentionally, and you're trying your best. You are one of the few, the proud, the people who don't quit in mass exoduses and leave new ICU babies to flounder. So please beat yourself up like a 2/10 intensity for like 10 minutes, and then call it a day.

3. If you're not getting it yet, the entire focus of my response to this kind of thing is remembering how many people were involved here, and to take that blame and spread it all around, in a nice thin layer, to essentially remind your boss that in order to fully assign blame on the issue, she'd be doing 20 hours of research and ultimately blaming/questioning like 50 different people, some of whom are pretty high up the hospital food chain.

4. Side note though, and you didn't mention if you did, documentation is your friend on this one, especially who you notified of the low numbers and what questions/issues you raised before they arrived at their conclusion. Cover yo butt.