What would you do?

[NO50FRANNY]

Hi all,

I've been trying to nut this one out for a while but it is still really bugging me. I am a seasoned Emergency nurse and long time RN but no matter how much I reflect on this one I have trouble with the best approach. The ER doctor I am discussing is usually a bit abrasive and difficult but not a bad doctor, just a bit lacking in the helpfulness / bedside manner / niceness department. She can be very difficult to approach and obstructive however I know how to work with her (ie: get her to do what I want) and have not had any issues prior to this night (but others reportedly have). She is the kind of doctor who will take the notes off you when your are writing in them because what she has to write is more important, leave all her mess after a procedure for you to clean up, that kind of thing.

Had a 19y male trauma pt. who came in fairly broken after hitting a pole in his car at substantial speed because he is young and silly. Closed R) femur, Closed L) tibfib, 4 busted ribs sml pneumothorax (not requiring intervention) - no belly or head problems. As you can imagine this young fellow was in a despicable amount of pain and had earlier been receiving hefty titrated amounts of ketamine and morphine and was understandably a little sleepy when not stimulated or being moved. When I had joined in the team care of this boy (it was ND) he was already admitted under orthopaedics and was awaiting a full leg cast on the femur prior to being transferred to the ward. At this point I believe the pt. had been in the department for about four hours (no-one bothered with a nerve block yet).

I got the impression fairly early in the piece that our registrar in charge overnight wanted this patient out of the department asap. but he needed a little sorting out first. So, I make the suggestion very diplomatically as in "doctor shall I get you some marcain for a nerve block for this boy?" to get him a femoral nerve block BEFORE we move this leg. Yes she replies, lets do that. Nerve block does not work. Patient is almost in tears because the leg has been moved for some reason (I wasnt in the room for the procedure). Doctor thinks something has gone wrong and maybe bone has now displaced, calling for donway traction splint to be reapplied immediately. I ask the patient if the pain is because he feels like something has moved or just because we moved his leg that the pain has increased, pt. says pain same just worse cos we moved it. Doctor is obviously flustered and asks me!!!!!! if i think splint needs to go back on. I am a nurse and as much as I love liasing with our docs about some things, I need to have confidence in our senior doctors when it comes to our critical patients. In this situation I was not particularly confident to make a judgement either way as I didn't know what had happened. But, I think not and simply say well if his pulses are okay (which they are) and the pain settles I think we can just wait to see if it settles now we are not moving him. Doctor admits that she has failed the nerve block.

I ask pt. if it hurts to take a deep breath- he tries this and visibly horribly winces..."Oh and did you want our acute pain people to come and assess him for patient controlled analgesia- you know cos of the ribs etc. because I can call them for you now if you like while we are getting him sorted out", "Yes nurse that would be appropriate thankyou". Meanwhile a trauma comes in, nothing major then Doc gets annoyed that acute pain reg will not accept referral from the nurse (I have no problem with this) and wishes to speak with her, she does it but with obvious exasperation. Anaesthetics registrar is on his way, expected in less than 30 minutes. Doctor says right we need to do this cast. Er, um, can we give him some more ketamine/morphine/propofol doc because he's pretty much begging me not to move his leg- no, he is too drowsy followed with "we need to get this done". I will admit that the patient was sleepy, but certainly not narcotised and he certainly wasnt drowsy when he was moved. I got the distinct impression as all this progressed that our senior doc was simply not confident with the overall care of the pt, or to prescribe adequate analgesia. My problem however is that the pain dude is on his way, he is the anaesthetics registrar, he is confident- he could attempt the block again, or prescrible lots of helpful things prior to moving this kid. All she had to do was wait, and liase. I was not in the room when the cast went on but I could hear it from where I was. The boy was screaming and crying, and I just felt completely powerless. The poor RN with him was almost in tears telling me that all she could do was stand there and say your doing really well champ, she was so upset.

Then we need the post cast XRAY- by this time the anaesthetics registrar has been and prescribed lots of lovely painkillers for this boy and we have a nice PCA order and a background of special K and are just setting it up when ER doc gets annoyed with waiting for post cast imaging and calls the wardies to come and take him for the xray. Once again pt begs me not to move him, pain relief is literally minutes away and the wardsperson is there to collect him. At this point I cant take anymore, but the best I can do is say with a fair bit of dont argue with me attitude "Right, no, lets just get this pca up first then he can go, it will only take five minutes" in front of said er doc, if looks could kill- that was me putting my foot down but I think I should have done it some time ago. I guess from our perspective it really felt like our reg didnt realise that there was an actual awake person on the receiving end of all of these interventions in excruciating pain. It really felt like she couldnt have given a ****, like we just need to complete task A, B, C, and get him the hell out of our hair. I feel like there has to be something better than me and my other nurse whispering and being upset behind the scenes. I just need to know how I could have handled this whole situation better and advocated for my patient with a better outcome, also would you feel obliged to let our consultant doctors in on this? they are very approachable. HELP!

[shakedwnst924]

I think you did everything you could do. As you well know, some MDs just have "patience" issues & get frustrated/flustered if they don't know what to do or don't get what they want right then. They are only human & just like any human, pride can get in the way & they take frustrations out on nurses. I just make extra sure that I call them out on it if they get out of line w/ any kind of comments/demands/unreasonable impatience/etc. Some don't even realize they're doing it (& some do), but whatever the case, mutual respect, teamwork, & communication is the only way things can get accomplished for the better of the patient, RN, & MD. They need to be reminded of that from time to time.

You did everything you could to advocate and get some pain control for the patient & sounds like the ultimate outcome of pain control was reached (thanks to you!). It seems like the reasons it didn't happen as quickly as you (& the patient) would have liked were due to factors totally OUTSIDE of your control: 1) Policies & scope of practice (you can't help it if an RN can't give a verbal order for pain control over the phone) 2) Authority (you can't help that an MD denied your request for more pain meds prior to moving him around even though he needed it) 3) Communication (you can't help that the word was given out for someone to come transfer the patient before his PCA was set up), etc.

Bottom line is you did your job and you did it well. You did the best you could to adapt & get the patient what he needed given that there were barriers caused by external factors. That's all we can do! :)

[DixieRedHead, ASN, RN]

So let her be impatient, give you dirty looks. Who cares. I am tired of whiners getting all the attention and those who are really suffering having to deal with pain just because it's inconvenient or time consuming to do what needs to be done.

You should have, and did advocate for the patient. You done good. Who cares what looks the doc gives you. She probably doesn't even remember it and if she does, maybe she will be more forth coming with pain medication next time.