Recently I had a patient transferred to our floor from an outside hospital for pre-bypass surgery. He came to us with a heparin drip running, but it was the medics bag, with tubing that is incompatible with our IV pumps, and at a different concentration than we stock. This is always a sticky situation, and there is not a lot of guidelines that we have for this. I was charge nurse, so the patient's nurse and I turn off the heparin drip and page the accepting doctor listed. He is not a usual heart surgeon that we work with instead he is part of a cover team if one of our regulars is out of town.
So I page the doctor listed asking for heparin orders. He calls the floor back and tells our unit secretary for me to page the "210". "210" means nothing to me, it is not part of our usual language. So I am forced to re-page him and ask for clarification, since he will not put in the heparin orders. He calls back again this time frustrated and tells me this always happens. I have enough insight to realize this situation is a little bit bigger than just me if it happens each time. I ask him if he means for me to page the heart surgery resident, he states no the 210! Again, I'm like well that isn't anyone we use here. He then comes to floor to belittle me and ask why I am paging him so many times. Meanwhile it has been over two hours the patient has been on our floor without the heparin drip running. Heparin has a really short half life, so I know most of it is out of his system by now.
Finally, the accepting doctor finds the person he wants to work with- who is the heart surgery resident, that he also thinks should be called the 210. She puts in heparin drip orders and then asks me why we haven't checked his anti-coagulation levels? I tell her we can't do any of that until there is a doctor's orders, which is why I have been paging him. The whole situation felt very circuitous and frustrating, when it did not need to.
I was thinking I am doing the right thing for this patient by requesting repeatedly for the heparin drip to be ordered, but I can't figure out where the resistance is coming from. I know that the short half life of heparin exists so I'm feeling like there is a ticking clock involved in this situation. I also cannot figure out why the doctor just will not put in the order himself?
The good thing about this situation is I emailed my manager that night explaining the situation, because I did not want it coming back poorly on me. I then asked her what we should do in that kind of situation. She told me we should call a MET which is like a rapid response call if it has been over an hour of a patient being on our floor who needs heparin and doesn't have an order. That way there is a doctor at the bedside who has to put in the order. The bad part of this experience is that it did not need to happen, and I felt like the doctor was mad at me for looking out for our patient.
The sense that I make of this situation is that this covering doctor felt out of place (even though he routinely covers at VM). I could have called our house supervisor involved, I felt like it was not the role of the hospital supervisor to deal with one specific patient concern but they might have had some insight. I also could have called our rapid response RN to come assist the floor nurse caring for this man, so she wasn't so busy trying to smooth out the situation.
If anything similar was to happen again and involved a pre-CABG patient, I would page the covering resident even if the MD thought it shouldn't be them. I will let the surgery resident tell me they are not working with that patient, rather than sit and wait for hours. And, now I know what is our floor policy as well if this situation of no heparin order arose again. I always let my manager and assistant nurse manager know if something out of the ordinary happens on my shift, that way they are pre-informed and there are no surprise issues showing up on their desks.
Wow, what a sticky situation that was. That sounds super frustrating, but it also sounds like you make a lot of good choices that night. You are kind to suggest that the covering doctor “felt out of place”, I would have said the guy is a jackass. There is never a reason to come down and belittle a nurse. I find his arrogance outrageous, but it sounds like you covered your ass with your supervisor and did the best you could in such an irritating situation. It sounds like it was a no-win situation for you and the other nurse, but at least you came up with Emergency Plans D, E, and F for next time when A, B and C fail and the patient’s safety is in jeopardy. Good for you for staying on top of the situation, maintaining your composure (it didn’t sound like you told the jackass off) and keeping the patient safe.
ReplyDeleteGoddamn...sometimes you'd think some of these doctors, with their huge responsibilities and education would at least be more down to earth. Obviously if you, as the cardiac charge nurse who's been there for awhile, doesn't know what 210 is, and the rest of your team doesn't know what 210 is, then he's the ignorant one. My sister was telling me about one of the newly appointed assistant managers at her company, and how that manager literally walks into a conference room and yells at her subordinates. Literally yells, my sister explains, and not just a long incidence. It happens often, and my sister is glad that she doesn't report directly to that manager. So, I thought about it, and I'm lucky I don't have to deal with many situations like what you've went through Sunny Sup. I think you had every right to give him lip and threaten to talk to his bosses, because he's a profession and should act as such. Good job on making this incident as much as a learning and growning process as you can. Admire how cool you appear to be during these kinds of situations. The scorpio side of me would ripped this doctor apart and give his bosses an earful as well :)
ReplyDeleteThen you also meet doctors who are some of the most genuine people in the world, and wish that every doctor would be like that. Doesn't the hippocratic oath entail that you show caring and compassion regardless of the circumstances? Should that caring and compassion transfer to the team memebers that you work with? Afterall, Ninja and I blogged about this topic this week, that when there's tension between team members, the team doesn't really work as well for the patient's sake.
I still don’t get what 210 means! It sounds like a word the military would use or a diner at breakfast rush hour. This is seems like an example of language use/miscommunication that could easily lead to errors. How bizarre that he just couldn’t explain… or just give you the order…Good for you to stick to your guns and protect your patient in the face of whatever is going on with that doctor. I agree with Jason, you seem so unbelievably cool and level headed in these situations. I want you to be my charge nurse! It’s unfortunate that sometimes it takes a situation to come up to finally learn what is protocol. It’s not like we can be trained in everything so it’s inevitable. “Learning moments.” ☺ I like that you keep others in the loop so they know ahead of time about situations that have occurred, it must make their jobs smoother and must really appreciate you for that. I second VonMittens last sentence!
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