What would you have done

**canoehead, BSN, RN** · Sep 4, 2018

That's a stumper. He can refuse care, but once its in nurses need an order to pull it. If he pulled it on his own you dinged for his injury. But you called the doc three times, and he hung up on you. Did you document that each time? And all the patient behaviors that made it dangerous to leave the Foley in? Because you can reinsert a Foley, but you can't uninjured damaged tissue.

If the patient had surgery on his urinary system, then removing the Foley becomes more dangerous, but so does pulling it without deflating the balloon. I'm still thinking you did the right thing. The doc may have said you weren't clear in your communication, and that caused the dismissal.

allnurses Guide · Sep 4, 2018

I don't know what I would have done, honestly. I think it depends

on what procedure the patient had done, and am I familiar with the

aftercare of that particular procedure, and what it entails. Was it

a pretty routine procedure like a lap choly... what?

I probably would have done what you did, especially if he was

actively pulling at the thing trying to get it out. Seemed like a

lousy reason to get fired, honestly.

MJCRN4898 · Sep 4, 2018

Surgical procedure was an anterior cervical discectomy.

The Head of Anesthesia was the Anesthesiologist on that night. 6 yrs ago ( prior to him becoming the head of anesthesia) he and I had "issues". He ended up having to take an "anger management" course. He detests me. I've never felt safe when he is the only Anesthesiologist at the hospital in the evenings..... as I told the Dept Manager 4 months ago. My mistake was not knowing the two guys were hunting/drinking buddies.

He has been trying to get rid of all of the nurses over 55.

I felt like I chose the safest option for my patient. My Charge Nurse had refused to call this Anesthesiologist...... he hung up on me 3 times..... I chose to remove the foley. This patient took 3 different psych meds.... and had none of them this day.

allnurses Guide · Sep 4, 2018

Yikes. I am sorry this happened to you. Again, lousy reason to get fired

but looks like the Anesthesia dude was looking for any opportunity.

kp2016 · Sep 4, 2018

I have been in a very similar boat with an Anesthesia provider. The doctor and I had a very public show down over a patient's condition. He threatened to have me fired and ended up being forced to very begrudgingly apologize to me and thank me for saving his patient. To say he hated me is an understatement. Your real mistake here was being so focused on protecting your patient that you failed to protect yourself.

When Anesthesia failed to respond to your calls you should have notified the Surgical Team, even if it is the policy of your hospital that it is Anesthesia's responsibility. Make documenting the communication attempts the highest priority. If / when that fails then call the Nursing Supervisor and tell them that Anesthesia and the Surgical team is ignoring your calls and that your patient is agitated and threatening to discontinue his care in a way that will cause self harm. This places the safety of the patient squarely back on the facility. No surprise they can be very responsive when it is suddenly their responsibly too.

Again make documenting this the highest priority. By removing the foley before you were able to show that you had notified the doctors or Nursing Supervisors you gave them the excuse the were apparently looking for. Its worth nothing that an In charge Nurse is not a Nursing Supervisor, always involve the most senior person you possibly can.

As a side note once you are in a work environment this toxic it is only a matter of time before they will find a reason to fire you. Hope you find something better soon.

AnnieOaklyRN, BSN, RN, EMT-P · Sep 4, 2018

My question would be was the patient even competent at that point to refuse care/treatment given that he recently had anesthesia and probably had a lot of pain medication on board. If he was not competent and you pulled the catheter and he then injured himself trying to either get up to urinate or move around to use the "bottle", then you would be liable since you did not do your job and protect him from injury. In this case it is important that you document evidence that the patient understood the risks of removal and the risks of self removal of the catheter and/or going home. Most men and women will quickly realize that self removal is not a good idea once they acknowledged there is a big balloon at the end of the catheter which will damage their parts. Another idea may have been to leave it in, but deflate the balloon just in case, while you worked out the situation.

As others have said I hope you documented well, especially that you tried to contact anesthesia multiple times. i would have also attempted to contact the patent's surgeon and advise him/her of the situation, as they too could write an order for sedation or removal, which ever they felt was more appropriate. The time to talk to the charge nurse would have been in this situation, and definitely the nursing supervisor if anesthesia refused to talk to you and kept hanging up. You would be at fault if you did not involve your charge folks, as this situation escalated beyond your pay scale, for lack of a better term. This may have been a factor in your firing, and not necessarily solely because you removed a foley without an order.

Finally I would be concerned that the patient had something else going on possibly, like poor perfusion, poor oxygenation/hypercarbia, or something else that was causing his confusion and agitation. I would document vital signs as well and a CBS. This is something that the patient's surgeon needed to be made aware of, as the patient was at risk for self harm secondary to his inability to follow direction and understand reasoning.

In the end I think your reason for pulling the catheter was understandable, but I don't think you put your critical thinking cap on to it's fullest. There are multiple issues as I stated in my post that may have prevented you from needing to even pull the catheter, and it sounds like you did not make full use of all of your resources.

Annie

JKL33 · Sep 4, 2018

Many times it's possible to get the patient rapport back on track so that you can make a reasonable plan together. But on the rare occasion that's not possible...

Make documenting the communication attempts the highest priority. If / when that fails then call the Nursing Supervisor and tell them that Anesthesia and the Surgical team is ignoring your calls and that your patient is agitated and threatening to discontinue his care in a way that will cause self harm. This places the safety of the patient squarely back on the facility. No surprise they can be very responsive when it is suddenly their responsibly too.

This is rock solid advice.

Contacting the supervisor isn't about whether or not the nurse can/could probably handle something on his/her own or not in situations like these, it's about having an employer representative who has skin in the game. Once I've decided they need to be involved, I don't let them off the hook. If they start with "did you______" or "did you try _______" I tell them I am requesting they come to evaluate the situation in person. There will be no excuses about how I didn't inform them of something. They are invited to come right down and see the situation and try to fix it by doing everything I've already done. All of this would've been set in motion after the first hang-up.

It's easy to sit back and critique someone after the fact or even lie about how they reported the situation to you. There's none of that with in-person involvement.

This is an excellent cautionary tale for readers because the issue in question isn't whether or not a nurse may do something like remove a foley independently when doing so seems like the best course; it's how to control a situation like this when anything you do might piss someone off and end up with a termination.

Aunt Slappy · Sep 4, 2018

That sounds like a CF. Could you not call a hospitalist and ask for an order since anesthesia was ignoring you? I agree that documenting everything and contacting the nursing supervisor would've been the best steps. Did you document everything including anesthesia hanging up on you x3? Because if you did, you might be able to at least get unemployment without them fighting you.

Why a hospital wants to keep a doctor on staff who'd rather feed his grudges than care for his patients is beyond me. He's going to cost them a lawsuit or three someday.

Cowboyardee · Sep 4, 2018

I once told a (belligerent and non-compliant) patient that I could not remove his c-spine collar without an order, but that no one could legally stop him from taking it off himself so long as he is in his right mind and fully informed of the (perhaps dire) risks of taking it off. He removed the collar, we documented like he'll, and neither he nor I nor the bedside nurse taking care of him got assaulted.

Obviously, the situation here is a bit different since removing a Foley requires some technique that a layman wouldnt possess. I think the trick in your case would have been to call another physician and work your way up the chain as high as is reasonable, AS WELL as charting in a manner that clearly spells out your reasoning for either removing the Foley yourself or coaching the patient through the process. Subjecting a person of sound mind to unwanted medical interventions or failing to halt unwanted medical interventions in a reasonably timely manner is either assault or battery depending on the state you live in. If your charting clearly reflected that, I suspect your facility may have been more reluctant to fire you for what amounts to refusing to commit a crime.

Sorry this happened to you, by the way. Sounds like you got a raw deal.

NuGuyNurse2b · Sep 4, 2018

I'm not sure why you were calling the anesthesiologist, though. Foleys are usually d/c'd in post op or within 24 hrs after post op and the pt is put on a voiding regimen. It wasn't in there for urinary retention per se, so he probably didn't need it and the surgeon was probably the better person to call and ask to get an order to remove it. You technically acted beyond your scope of practice by removing the foley without an order. Yes you charted that you did it, but you did not get an order to do so nor did the anesthesiologist know that you did it because he didn't give you the order and it was after the fact that he was made aware of it, hence you were accused of "hiding" the act from him. I don't think you're understanding that difference. It's unfortunate what happened to you but I didn't see the dilemma here. you had other avenues to find a solution and you didn't. You could've called the surgeon, you could've notified management, you could've notified the house supervisor - any of those might have been able to assist you. But you acted on your own...