When to go against doctor's request

[shanleah]

I have been an LPN for 8 months. I work in LTC/rehab. I just started a new job and was on my fourth night off orientation. I had a very sick patient who many of the nurses I work with felt was too sick to be at our facility. Pt was in their 40's, on dialysis, PEG tube, htn. Pt's BP, pulse, and temp had been elevated since admission to our facility. BP overnight was high, but pt stated they were feeling 'fine', no pain, no headache, temp was lower than it had been in days, color was good, etc. Rechecked VS an hour later and BP, temp, and pulse had all increased. Pt reported feeling nauseated. So I decided to call the doctor. Doc stated this was all related to pt's 'disease process' and ordered one dose of Catapres and recheck VS in two hours. While I was on the phone with him I was informed pt was having chest pressure and pt's pulse ox, which had been normal, dropped to less than 80% on room air. Doctor ordered Catapres, 2L O2, and recheck VS in two hours.

I immediately implemented O2, gave the Catapres and within five minutes pt was turning ashy and was unable to respond to me. I immediately called 911 and while waiting for EMS pt coded.

This was my first code. It went well as far as we were able to get pulse back and get patient to hospital.

My question/concern is should I have gone against the doctor's orders and called 911 without his permission when pt began having chest pressure and pulse ox dumped? Or was I right to follow his instructions? I'm feeling horrible - like I should have done things differently. I guess I just want to know how more experienced nurses would have handled the situation, what you might have done differently, etc.

Thanks.

[dream'n, BSN, RN]

Hmm, most Drs have good common sense. If you state to them, "After assessing this patient, I am not comfortable keeping the patient here. My judgement is that the patient needs immediate emergency care that I cannot provide. May I have the patient transported to the hospital?" almost all Drs will agree. Sometimes you need to question their orders and let them know that you do not agree. Be pushy if needed. If you still don't get the order, I've been known to inform the physician that the PATIENT wants transported. That is my ace in the hole.

[KatieMI, BSN, MSN, RN]

Please stop beating yourself. You did just fine, honestly.

The fact is, you are there in the room near the patient. Doc is not there. He sees, hears and thinks of what YOU are telling. YOUR assessment is his mental picture he is working with. So, if you see things going wrong, say so. If things are not stable, if patient does not react on meds as supposed to, say so. It is ok to say in just a little bit exaggerated tone "this patient just does not look fine for me". Good doctors trust nurses' gut feelings.

And it is 100% ok to call ambulance if things start to smell like code, although it is advisable to get familiar with your places'policies and in any case make the next in command chain person make this call. Or at least someone more experienced than you.

It was a very, very sweet feeling to see an intensivist yelling onto another doctor over the phone: " when this nurse says that something is wrong, you better listen to her, drop everything and d*** get here!" But I'm kinda uneasy thinking that I'm going to get into that poor guy's shoes pretty soon.

[Queen_of_Cardiology]

Hmm most Drs have good common sense. If you state to them, "After assessing this patient, I am not comfortable keeping the patient here. My judgement is that the patient needs immediate emergency care that I cannot provide. May I have the patient transported to the hospital?" almost all Drs will agree. Sometimes you need to question their orders and let them know that you do not agree. Be pushy if needed. If you still don't get the order, I've been known to inform the physician that the PATIENT wants transported. That is my ace in the hole.[/quote']

I agree! At the end of the day you've seen the patient and clinically assessed them, the physician has not. Any Dr worth their salt will be guided by you in this sort of situation. With time you'll learn to assert yourself, and this frustratingly only comes with experience. Please don't beat yourself.