Where does my responsibility lie? MD at crisis ignores request for orders!!!

[GalRN]

I got in the middle of a nasty issue last night at work and am at a loss. I'm sure that this has happened to many out there and would like to know what you have had to do, or would do next time...

I am a psych traveler but this subject is universal- all specialties have these situations I'm sure. I feel like I was more concerned about my fellow nurses reactions as far as job security, but I didn't need to be- they back the travelers up the same as staff.

OK, we had a serious crisis- needed an MD order ASAP and could not really intervene without one. The situation was a psych nurse nightmare. Brief background- I had a patient who I had put on 1:1 about an hour before (he had scratched his arm open with a toothbrush). That part of the unit was saturated with manipulative behavior and I figured that he wanted to let me know that he was there, psychotic, and not to be ignored. He got what he needed/wanted- he wanted and got his 1:1.

I was in the med room when I heard a scuffle, a few shouts, and someone yell to call security. I ran out and found that he'd grabbed the tech's pen from her hand (he was quick!) and had it to his throat, threatening to stab it in and dig around until he hit something and bleed out. About a dozen security showed upand hung back while the staff attempted de escalation. This was not a situation that was getting better if there was just talk. This guy needed some meds in him and it really didn't matter how he got them, although without a struggle was the hope.

His attending MD was actually on the unit at the time, and I interrupted his visit with another pt (something I don't do unless it's really emergent). I knocked, stuck my head in and said "Dr, we have a crisis out here that needs your immediate attention!" I stepped back expecting him to come out or at least respond. He had seen all of the security come onto the unit. I was actually expecting to get yelled at if he was being a real jerk.... but.... nothing. He was talking to the patient as if I hadn't just even been there. The patient was done and came out a second later. I opened the door and said "Dr (name), you're patient (insert name) has a pen to his throuat and is threatening to kill himself. You NEED to come out here!" then, "Are you coming, or should I just get him some meds? IM injection? He has no prns, as we discussed earlier." The patient had nothing in the way of an antipsychotic, and I'd given him the whopping 0.25mg of ativan earlier that was ordered. The doctor was aware but had not addressed it..

So he- get this- picked up the phone and STARTED DICTATING HIS NOTE!!!

I had a patient about to try to kill himself, staff that couldn't move near him unless he made a move to do worse, and desperately needed to get some meds into him. (He had command hallucinations a few years ago- I was assuming he was again). Obviously he could have severely injured himself, the staff, or both and it was getting worse the longer he stood there. He needed meds. The doctor HAD to do his job. There was no way around it. I opened the office door again and stated the same thing again, louder then stood there and kept eye contact. He stared at me and dictated a little faster. The rest of the staff not with the pt stood behind me and glared at him, just so he would know that they were not happy and that I was serious. He dictated. Finally I held up the syringes in my hand (I'd drawn the standard cocktail when I heard the noise from the med room), and shouted "Haldol 10, Ativan 2, Cogentin 2. IM stat! If you have an issue with that it'll still take about 2 minutes from here to the patient's butt!". Then I went and ended up using it as a chemical restraint as the pt refused. The pen was taken the same time and he was released. He was in a room with not much else in it and the staff was not blocking his way out. He was staying in of his own volition and did not need a mechanical restraint. After a while he calmed down and we were able to keep him distracted until he got drowsier and was in bed, with a one to one staff in a stripped room.

Obviously the MD behavior was so far from OK that I'm not able to find the words... I am so upset. Getting yelled at is bad, but the issue is that the patient did not get the treatment that he needed right away. This MD has done thing like this in the past and I found after that one of the new younger nurses had grabbed the phone from his hand and hung it up about 6 months ago. This was his version of "putting the nurse in her place". I didn't know what to do, as I'd never seen this happen before and wasn't sure how to address it. Didn't have time to call the staff ed person at home either.

What happens on your unit when/if this situation comes up? What would you have done?

BTW, I wrote it as a telephone order and he signed it after I left that night- never saw the pt though.

[Tait, MSN, RN]

I would write him up. Not sure what else you could do other than document his behavior.

:icon_hug:

Tait

[canoehead, BSN, RN]

I haven't been in that situation but I think you handled it well. I would be more likely to hang up the phone on him, but your way worked better. I would make out an incident report at the hospital, and with your travel agency. An optional idea- speak with the nurse manager about the situation, but if he's been doing this all along I don't have high hopes that he'll stop. Did you talk to him afterwards? It would be interesting to know WTH he was thinking.

[GalRN]

I asked him if I could speak with him in private before he left. I knew he wouldn't, but I am a stickler when it comes to chain of command. I wouldn't have been able to say anything later if I didn't try to address it with him. He didn't stop to chat. The staff basically knew that I was upset with the situation because of pt safety, but also, I pointed out, that because he directed this at me, I became the weak point in the chain, and those links are often sent packing b/c they are a safety issue. Quite a few of them have traveled in the past and were very nice about letting me know that this was not my issue and that they were actually very happy with the way I did my job.

I talked to my agency in the AM and was told basically to not get into a situation where one person had to be dealt with b/c oftentimes the traveler goes- they are expendable. I told my recruiter that I was going to make sure it had been mentioned to the medical director. She just was promoted, is very accepting of all staff- introduced herself by first name on day 1. Vet good doctor- one of the few psych MD's that doesn't defer Axis 2- she tells the truth and backs it up. She doesn't like this MD. He and one other are like that, the others are really respectful, and if anything- want to confer about the pts condition a bit longer than feasible when an injection is involved.

Turns out it got blown off. Ppl were really mad that night but it blew over and I never got a chance to grab the director. I will mention it, and will write it up if she asks, but will ask her to have the nsg supervisor do the same as he was there that night and had backed me up.

It goes beyond concern for the patient. I feel, like, violated or something. I've been treated a lot of ways for a lot of reasons, but never had my staff and pt go through that because of my gender. I have friends from the same country as he is and they hate ppl like him for making them look bad too.

[nurse12b]

I would definitely bring it up to the med director. If it were you that was as careless, you know they would not let it go. Just because he is a Dr does'nt mean he has free rain to be careless and reckless. Good luck and let us know how it goes.

[classicdame, MSN, EdD]

turn him in to the medical board in that state - total negligence. I hope you documented well.

[Whispera, MSN, RN]

You mentioned that you think his reaction was anti-gender. Not just anti-nurse? Not just him vs. you? Not just twit vs. responsible person?

You did the right thing for the patient and the other patients and the staff. Be proud.

Be sure you write it up, with all details, and keep a copy of all paperwork related to the situation for yourself, where you keep all those things you might need in the future.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

In addition to the excellent feedback above, I'm concerned that many people were put at risk in this situation. What if the patient changed from wanting to harm himself with the pen to feeling like he had to use the pen to defend himself? If there's a risk manager I'd also send documentation that way. If incident reports routinely go through the risk manager, I'd send an additional note. Of course keep copies of everything. The a**hole MD left staff and patients at risk, there's no excuse for it.

[Ms.RN]

I think this doctor didnt just ignore you, he put patients life in danger. He should be reported about this incident. Is he a only doctor you can call or can you call somebody else who is above this as@@%$^? This is such a scary incident. I dont think Ativan 0.25mg is not going to touch him and I think he needs his meds changed. I'm not a psych nurse but I thought every psych units have standing order to give meds in crisis situations without physician order???

[ear]

I think this doctor didnt just ignore you, he put patients life in danger. He should be reported about this incident. Is he a only doctor you can call or can you call somebody else who is above this as@@%$^? This is such a scary incident. I dont think Ativan 0.25mg is not going to touch him and I think he needs his meds changed. I'm not a psych nurse but I thought every psych units have standing order to give meds in crisis situations without physician order???

This was what I first thought (other than write an incident report, and discuss with the manager of the unit- That Dr. put WAY too many people at risk!!!)

Are there really people admitted without PRN orders, especially when someone has a history of psychosis and dangerous behavior? We have a standard form for orders, then write in whatever else the Dr. may order, along with the med rec. This is one of the reasons there are so many assaults in our field.

[NurseCard, ADN]

Wow!!!!!!! I am at a loss.... you are right, that is definately a nightmare situation for a psych nurse, to be sure.

At every place that I have worked, it was perfectly okay, in a dire emergency situation such as this, to initiate mechanical restraint and THEN get the order from the doctor, but to go ahead and give medication before the doctor gives the order for it? Unless there is some facility wide medication protocol in place for such a situation...

If this patient was able to be restrained enough to be given the shot, surely he could have been restrained enough to get the pen away from him and get him on the ground or get him to the bed and into the restraints.

I mean, it was an emergency situation and you certainly did what you felt like you had to in order to keep the patient and everyone else safe. I don't think I would have done what you did though; if I had enough staff to hold the guy down to give him a shot, well, WITHOUT the order for the shot, I would have went ahead and had his butt carted off to the seclusion room. Then, without the pen in hand, if he proceeded to smash his head against the wall as hard as possible, I guess we would have had to proceed to 5 point restraints.

Again, the MD was a complete and total ass and you did what you felt was necessary, and I commend you for that. But, in most places you can't give medication without an order but you can initiate mechanical restraint and THEN get the order. If this guy later suffered some kind of nerve damage from the shot, allergic reaction, anything, it's not the doctor's butt, it's yours.

I wouldn't want to be in that situation.

[leslie :-D]

turn him in to the medical board in that state - total negligence. I hope you documented well.

if nothing else, do this...definitely.

there is absolutely no excuse for this dr's behavior.

he was negligent, abandoned a pt in crisis, with an unacceptable delay of care.

if the med'l board gets enough of these concerns, he will be penalized.

i also agree about putting him in mechanical restraints..this qualified as an emergency.

leslie