Verbal order-Denied by resident

[Traumamama02]

Wednesday morning I came into work and took report on a patient in airborne isolation r/o TB, a laundry list of co-morbidities, mild respiratory distress, vitals not to bad in the moment but I'm sure you can see where this is going.... yup straight to RSI hell with a chaotic attending and a hot shot resident.

Long story short, as the RT was preparing her equipment, I was preparing mine, setting my monitor parameters, etc, etc. The resident walks in to the room with a spiked and primed bottle of propofol and clearly says 'here ya go, it's already for you', and hangs it on an IV pole. I clarify the starting dose with him and he gives me a verbal order for 30 µg/kg/min. Attending walks in the room. Then I clarify what RSI drugs he wants; 20mg Etomidate and 120mg of succ.

Fast forward, the patient is intubated, Sp02 is crap, abg is crap, blood pressure has been crap prior to me assuming care but the current trend for 2 hours has been adequate with resuscitation efforts, pt is waking up within seconds post securing the tube, RT is suctioning and simultaneously, I pipe up and start a conversation about starting the propofol at a lower dose than the resident had ordered and adding an analgesic, fentanyl, to accommodate propofol (which as we all know propofol has hypotensive side effects and no analgesic properties). My rationale being that I can keep the prop at a fairly low rate, keep the blood pressure adequate and the patient can be more comfortable and less likely to wake up with PTSD.

Attending shuts my idea down and states that propofol has analgesic properties and she'd rather use Versed and fentanyl bc versed does not have a profound effect on blood pressure as propofol... lol...wait it gets better...so keep in mind that now is not the time to educate a physician and what not because the patient is fighting the vent and circling the drain respiratory wise and I've got to move this patient out of isolation and into the Critical Care area of the ER; according to infectious disease it's OK to do that because now the patient is a 'closed circuit' ... I know I know ... ***, right.

Back to RT suctioning... The attending requests her to stop suctioning so we can cycle blood pressure and get an accurate reading before we start the propofol bc this man needs sedation now and we need him calm and I have the propofol hanging in front of me, and a verbal order from the resident and a discussion with the attending about changing sedation gtts and it's obviously not in the best interest to leave the pt put in an order for a titration gtt that I didn't even get details for or wait for the doc to do it and then call pharmacy and have them validate it so I can get it out and blah blah blah...

So the nurse I give bedside report (who should be helping me bc she has no pts) to can bridge the gtt to the new sedation orders. in my mind this keeps the patient safe and the tube is less likely to come out, exposing the dept, plus I have 3 other neglected patients ...I need to hand off this one and now ... so b/p is 125/88, sp02 is 86%, attending sees the b/p and walks out. The understanding is that this is an adequate blood pressure to start the propofol, so I start the propofol at 10 mcg/kg/min instead of 30; I followed pharm protocol bc frankly 30 is to much to start with this guy...anyway I titrate by 5mcg q 5 to 20mcg and everyone is ready in the assigned area, patients is chill, last bp is 110/70-ish and we go, fentanyl is overridable in the pyxis, versed is not ..let's get that fent going ... and hand off is complete.

Now I'm charting and the charge tell me to save it and come talk to him now.. I comply, the director is there waiting .. the conversation starts with, 'did you hang propofol without an order?' 2 docs say you did and there are writing you up bc the pt decompensated and is now on 5 mcg of levophed, (5 people!!!)and the prop is still hanging and now at 40!!! Resident dictates he never gave any orders for propofol... when I asked the nurse that took over for me how long it took her to bridge him off the propofol, she said she didn't because propofol is used so often that she didn't bother looking at the orders and just continued to use it...

Resident is lying!!!! And I'm blown away at all of it!!!

Bring on the question and comments please!!!

[sirI, MSN, APRN, NP]

Duplicate threads merged.

[Ruby Vee, BSN]

Maybe critical care is different, but in many hospitals verbal orders are not allowed. Phone orders are one thing, but if the physician is physically on the premises, then he/she needs to write the order.

This is not the first time I've heard of a verbal order being denied retroactively and a nurse being thrown under the bus. Probably the rationale behind the no-verbal-orders rule.

Critical care IS different. If the provider (physician, NP, CRNA) is intubating, pushing an IV med that only someone with the proper credentials can push, or has her hands deep in the patient's chest/abdomen/name that body part, verbal orders are accepted. The understanding is that they'll put in the order as soon as possible after the situation, but sometimes they forget. That's human. Sometimes the nurse, who is busy transfusing the patient, cardioverting yet again, cleaning up the mess, catching up with charting, or changing out 27 chest tube collection cannisters in a 12 hour shift forgets to follow up. That's human, too.

What isn't human is to deny giving the order because the attending disapproves of it having been given in the first place. When that happened to me, my manager took a photo of the offender, printed it out and posted it on our dry-erase board along with a huge (3 feet tall) warning: "Do not take verbal orders from this person." By some strange coincidence, the managers of two other ICUs and both step-downs received the photo with the message. Within an hour, he was up on our unit begging to have the sign removed. My manager was happy to comply -- after he signed the verbal order, notified his attending of the situation and personally and publicly apologized to me.

[MunoRN, RN]

At every ICU and ED I've worked in, an MD order to switch to another sedation/analgesia agent has always meant you stop the meds that are currently ordered only after you are starting to administer the new ones, you wouldn't just leave the newly patient without any sedation/analgesia onboard while you wait for the new meds to become available.

[JKL33]

Whoa - my first thought is that this resident is using propofol. Why did he get you the propofol and spike the bottle? Simply to be "helpful?

Actually now that I think about it, that is a very interesting idea. Not outside the realm of possibility. Taking it out of the pyxis was odd move #1. Odd move #2 was actually spiking it.

There are truly helpful residents and attendings. They're not the ones who turn around and deny having done something.

*****

Maybe critical care is different, but in many hospitals verbal orders are not allowed. Phone orders are one thing, but if the physician is physically on the premises, then he/she needs to write the order.

This is not the first time I've heard of a verbal order being denied retroactively and a nurse being thrown under the bus. Probably the rationale behind the no-verbal-orders rule.

The no-verbal-orders rule is mainly to force compliance w/ CPOE, and to hopefully decrease errors of mis-hearing. Maybe some of it is to prevent problems like the OP's.

Technology has advanced, but remains in a state of not being up to the task of reducing the need for verbal orders to zero. In the ED there are plenty of situations where it is just not possible (or appropriate nursing care) to delay an action until the physician can enter the order.

[Traumamama02]

No they don't have access, he asked a floating RN to access the pt profile and get the gtt. She has already written and submitted this information to our director and for quality ...

[Traumamama02]

He practiced nursing before medical school. And with that said why would he give me starting dose of 30 mcg if he and the attending were so focused on the blood pressure and potentially having some hypotensive rebound on this patient who has more Comorbidities than I care to dictate in this thread ..The acute issue was his combative behavior, airway security, hypoxia, acidosis, VQ mismatching, R/o TB, 5150 hold and I can go on... the priority was not a bp but def a critical care component but getting the hell out of a room with no camera no window, no help, no sitter, dealing with a know it all trauma RN who looked at me like an idiot when I gave her report and the follow up bridging sedation orders and encouraged analgesia at a higher gtt rate vs versed bc of md concerns and obvious ones like better pt outcomes.no one wants to go in there to help bc of the TB, the pt needs an iso icu room in icu, but none avail so ID says bc he's a ‘closed circuit' he can go into general pt population, an area where there's actually 2 to 1 ratio to properly care for the sick man. But how safe if that when he's at risk for self extubation.. I'm sorry but ER knows code blue yes. They are trauma experts but that's where it stops... they don't know what do s/p code blue... in my hospital .. in my opinion.

[Traumamama02]

Exactly... bridging ...get the pt under control. give them a bolus, a little bit of vasoactive medication is not uncommon in critical care patient who are sick AF

[Traumamama02]

The attending trumps the resident and we discuss used starting the prop to get him over to the crit care are of the Er safely then transitioning to the combo. The receiving Rn didn't follow through.. then levophed was started and they flipped out on me an hour later ... makes percfet sense .. not .. we even cycled the no which ended 125/88 ‘before we start the prop' and RT was there as a witness and submitted what she hears come out of everyone's mouth. We were all on the same page ... start the prop bc bp is wnl and get him moved and then bridge to combo sed orders. Keep in mind we had to bag him and sx him and restrain him during this 30 sec conversation.. infection control and pt/employee safety.. why the bus treatment .. there is no need for this drama ... in my opinion

[Traumamama02]

I did take was was easy and in front of me bc I had orders to do so.. you should know not to leave the or bedside with an at risk airway as the only Rn in the iso room...to get a detailed titration order, figure out how to place it (joint commission in on our ass about titration orders and we get reprimanded if not perfect ) and then to have to call pharmacy and wait for validation bc you can't override **** in this ER except for haldol, Benadryl' and Ativan (the B-52).. that's just dumb .. to even consider leaving the bedside when you have safe hemodynamics and a capable medication.. it's called pt safety

[Traumamama02]

The bottom line is the integrity of the resident ... he has none and he's dishonest. And I hope that in sharing my experience that anyone can take home a learned experience from mine ..

"use your power to empower others" don't eat your colleagues ... teach them if they mess up ... keep lateral violence out of the pt care setting..out of nursing altogether

[Traumamama02]

I kid you not , most all that happened .ive never restrained a pt before intubation unless they were flailing but this was the case until I was delayed on starting the prop bc of half ass order changed and riffles physician feathers.

the physicians never left the dept except the resident did go the cafeteria.. the things that came out of the attendings mouth were incredibley inaccurate as far as medication properties.. but I'm not a doctor nor do I pretend to know more, with that said the prop was going to be started immediately but she immediately wanted a bp first which are set to q 5 min so it's not like we didn't have a Trend already ... uhh I just want to go back to icu where our pts are safe and our autonomy is honored and we are educated as to why and what with accurate, best practice literature... even in a code situation. In the icu, a team member never tries to be a jerk, it's always an order with education if needed or even if not needed, reminders are always cool

I'm considering writing a grievance to the resident school admin for misconduct .. even if I did do everything wrong and my thought process is in outer space. That fact is he's lyig and that my friends is more dangerous than me starting propofol Emergently

[Traumamama02]

I love you Ruby Vee!!!