What would you have done?

[cm8816]

I am just finishing one year as an ICU nurse, have 4 total years experience. The Charge Nurse has been a nurse for 31 years, only a little more than 1 year in ICU. I work nights. I have been previously reprimanded for "not wanting to take direction", that is, not wanting to follow a Charge Nurse "suggestion" when it was clearly wrong (I refused to give meds via an NG tube when I could not hear the air bubble and no xray had been done.) By the way, I have known since the reprimand that this hospital is not the place for me. I've been trying to wait one year so I can go somewhere else that isn't so crazy.

The patient had come in the evening before, septic. Hypotension. DNI, and son was going to make a decision about DNR after consulting with the nephrologist. Dementia, 83 y.o. Less than 5 ml/hr of urine. On neo and levo, a bicarb drip, NS @ 200 and heparin drip (one MD thought she might have a PE). Lactic acid of 7 and going up. On that first night I had her, I had titrated the pressors until she had a decent BP on the monitor. During the day, the day shift nurse apparently no longer could get a BP off the monitor and started doing a doppler systolic on her. She also started cutting back the pressors. She gave me no reason why she did this and I failed to ask (my error). I had hoped to see some mention of this in the chart.

The Charge Nurse, as soon as the shift changed, started barging in, upping the pressors with "hope you don't mind me just barging in". Soon, the levo was at max and the neo was 2/3 of the way to max. There was a BP reading on the monitor. Charge Nurse said, "we've got to get a reading on the monitor". By midnight, the pt's HR was 125, up from the low 100's she had been running all day. She was losing ground on the pressors. I had had enough and called the MD (which I probably should have done as soon as the Charge Nurse started making adjustments to the pressors). The MD was furious, stating, "If the doppler systolic was good enough all day, why would you want to raise the pressors". I got an order to cut back on the pressors and just do a systolic doppler (which had been between 90 and 100 all day and was now 92). Her HR started to go down. I titrated down very, very slowly on both pressors. At 0400, she started to brady down very, very quickly and coded. She was resuscitated after epi and the MD called the son and son agreed to make her DNR, comfort care only. As soon as the pressors were taken off, she expired.

Please give me your input to this.

[ckh23, BSN, RN]

The first thing would be to find out why they were doing dopplers. Was this was something the doctor relayed to the day nurse. I'm guessing it probably was as I doubt the day shift nurse just started doing this on her own. Could you have gotten an A-line placed? The second thing would be to either throw the charge nurse out of the room or give her the flow sheet and tell her if she wants to titrate YOUR patient's pressors that she can take over for the patient and chart it. Remember, this is YOUR patient, just because she is in charge, does not give her the right to come in and start messing with things. Guaranteed she would throw you under the bus if something bad would have come of this. As an ICU nurse, you never let anyone adjust your pumps or gtts, it doesn't matter if they are doctors, charge nurses, managers, the CEO, etc.

How close is this charge nurse with your manager? If your manager doesn't play favorites, than it might be worth bringing up to him/her.

[RNerd81]

First of all, I'm sorry that you experienced this. It's really frustrating and hurtful. You are competent. Your rationale outlines that very clearly. Secondly, the situation outlines the "ethics lag" that exists in our country. We have the ability...but should we? On phenylephrine and norepinephrine...at 83 years old...with dementia...really? Don't worry. This happens at our institution too. I'm not trying to devalue life, but I do think there are worse things than death. And we accomplish them every day in the US. We wonder why healthcare is so expensive.... As for the charge nurse, he/she is over-stepping their bounds. May I suggest two books: "Boundaries" by Cloud and Townsend and "Crucial Conversations" by Patterson, Grenny, McMillan, and Switzler. Your professional life (and probably personal life, too) will benefit by both. You will never stop encountering "Charge Nurse" personalites, unfortunately.

[cm8816]

The place is one huge clique. The manager is the one who reprimanded me for "not wanting to take direction", and since that time (my last day of orientation), she has clearly expressed her dislike for me.

But, I see my main two errors of the case, first, failing to ask why the daytime dopplers and second, not calling the MD immediately when the Charge Nurse started interfering in the care of my patient. The Charge Nurse would have reported me for again, "failing to take direction" had I tried to stop her on my own, without backup from the MD. Thanks for you advice. I need a sane sounding board. I hope to be gone from their very soon.

[cm8816]

Thank you, I'll read these books. Unfortunately, the doctors in my hospital put off the DNR conversation until it's too late or just never have it at all. Recently, an RN was reprimanded for suggesting to a family that it might be time for the DNR conversation with the MD.