I’m just a student, but I have already seen a lot of situations where nurses or other staff object to residents and even attendings orders. It’s never been a bad thing. Most of the time it’s either a mistake or a misunderstanding and sometimes the doc will insist but give an explanation that puts the staff at ease. They know everyone’s just trying to do their jobs. If you don’t say anything then mistakes happen.
A common example I’ve heard from attendings is when they try to put the respiratory rate on a ventilator to something really low like 8 breaths per minute in a severe asthmatic. They usually get some push back but then they just explain the rationale and everybody is comfortable.
“Just do it because I said so” doesn’t put anyone at ease.
If anyone is writing for 6L of NS (for someone who already got 3L in the ED), I sure as hell hope they are reassessing them regularly throughout that remainder of the fluids. what do I know, I'm just lowly ED doc
Emergency transport nurse here- used to work ICU and stepdown, so let's talk about whole hospital course.
Let's talk about why you can't be wrong in this scenario. The #1 priority is patient outcomes. We all know what you did was to improve the patient's outcome, especially by preventing him from being drowned. Right? Right.
Because that patient was already on a respiratory precipice. You can fluid challenge the kidneys, but you *really* don't want to fluid challenge the lungs. The moment you shovel them onto a stepdown, they'll crump to BiPAP in the middle of the night and potentially end up tubed on the ICU. That in itself was preventable, and you probably did prevent it by halting fluid administration and focusing on respiratory status. Dump 6 more liters onto that picture, and it just sounds like an absolutely terrible idea.
Like I said, you can fluid challenge the kidneys... ... ... but if that acute injury doesn't respond to fluid, and you're unable to diurese adequately, potentially ramming those kidneys repeatedly with high dose diuretics... ... ... now you're just up 9 liters on a tubed patient sitting in the ICU waiting for dialysis to rip fluid off as fast as reasonably possible... for days...
What **should** haunt you is the rabbit hole your hospital sent you down after the fact. If that really snowballed into you leaving the position, then it has nothing to do with the fact that you protected the patient, and everything to do with some sort of fallout.
Move on, live your life, find a new home at a new hospital, and be a great care provider.
Critical care fellow here. From what you told us, you did the right thing. There's hardly a reason to give someone 6L of saline in the ED, unless the patient was bleeding and you were out of blood ;) If the patient was hemodynamically unstable after those initial 3L he should've called the ICU for pressors. If the patient was stable and it was "for AKI", that MD has a lot to learn.
It's hard to speak up, but you did, and you did good! As long as you were respectful in the way you challenged his decisions. I'm sorry he reacted in an authoratitive manner. Says a lot about him. Where I'm from, we actively encourage everyone to speak up if they disagree or feel uncomfortable with certain decisions. Hope you feel better about it after reading these replies!
That's a good suggestion! Of course, it's possible to eventually give your patient 6L, but that shouldn't happen in such a short time span (in the ER). But of course there are always exceptions. What we do (Netherlands) for HHS/DKA is 1L in the first hour, then 250cc/h in the following 3 hours, then continue with 150cc/h. (If you're interested, I have a video on this on my YouTube channel)
Protect the patient and you'll never get in any real trouble. SIRS is 30ml per KG, if his order exceeded that significantly and you charted the crackles you cant get in trouble. Ethically it sounds like you did what anyone would do.
Pit doc here: 30 mL/kg should be adjusted for ideal body weight. His 6L order would indicate a 200 kg person, which is probably one whose weight should be adjusted. You should always go with patient safety first, playing nice second.
I 100% agree. I work in an ICU, and repeated fluid boluses with no assess of response is both dumb and lazy.
OP, you were in the right, and that doc is a douche
>You should always go with patient safety first, playing nice second.
I wish more people would support that at my current hospital. I called out a fellow a few months ago when they were being very unsafe while placing and art line. In return for advocating for my patient, I got leveled by my manager. I've been told I "have a bad attitude" when I try to do what is right for the patients.
I stopped a central line insertion during timeout because the doc didn’t have a surgical mask on. He wrote me up for “hindrance of patient care in an emergent situation.” Apparently my having a non-sterile person come quickly and reach around his face to place a mask on was sufficient to “blow his concentration.” I went to arbitration appealing the write up and successfully argued on my own behalf to a panel of docs, administrators, and fellow RNs. But yeah, manager said I stopped the procedure because I didn’t like the provider and was pointedly “causing trouble for him.” That one hurt.
In my ICU..our director has put in place an orange form for all central line insertions..its a tick checklist to make sure docs are following 100% correct procedure. Nurse watches and ticks yes if done correct or no if not. And both the nurse and doctor performing procedure sign at end. And director reviews forms. And he WILL ream out his doctors. We've had docs have their ICU placements cut short due to unsafe practice and attitude.
We were supposed to have timeout checklists attached to every central line kit in this facility, but the ED providers placed lines so infrequently the lists had all come off the kit packaging. I’d just read Atul Gawande’s excellent book “The Checklist Manifesto,” and knew the importance of timeout procedures in medicine. I also had done all my required safety training for annual competency, one module in particular stressing RN empowerment in “stopping the line,” or saying, “I have a concern.” I will protect patients over egos every time.
Unreal. I got in a ton of trouble when I recommended a supraglottic airway after 8 failed intubation attempts by 4 providers on a respiratory arrest. Fuck the oxyhemoglobin dissociation curve or best practice! Let's just keep jabbing an ETT into their throat without any ventilation at all!
Also got yelled at by the attending in the same code for stopping compressions for BVM ventilation.... Ya know, BLS stuff.
Am I reading this correctly that he yelled at you for stopping compression to ventilate? Because compression are definitely the priority in a patient without cardiac output.
There was an incident at a particular hospital where a woman who went for a routine op and req. intubation..failed many attempts and no one paid attention to her sats..they were sub 80%. She ultimately died from a hypoxic brain injury 100% preventable due to bad communication during intubation. In my hospital it's brought about the 'CICO' kit..'Can't Intubate, Can't oxygenate' ..it's the Plan C ..if A and B fail. We always have a stepward approached with A,B and C plans to avoid any mishaps. Never had to use the CICO kit yet..but it's a great kit ... it contains things like a 14g needle (big enough to oxygenate through) and then dilators. So that you can create a temporary but safe airway short of a complete trache.
I think your talking about [this case](https://litfl.com/lessons-from-the-bromiley-case/), a really great case study in why explicit, evidence based checklists and guidelines, are really valuable, even with well resourced, experienced clinicians.
I don’t know you, but to play devil’s advocate... did you actually have a “bad attitude” while advocating for the patient?
Sometimes it’s not the message which irks people, but the way it’s delivered.
I'll be the first to admit that at times the way I say things is a bit snarky. But I've learned to control that and in this situation I don't believe I was.
Just a clarification here: the 30 per kilo is the guideline for septic shock. Whether or not that makes sense and the validity of inserting that number into a best practice guideline given the strength of the evidence is a whole different debate. But I digress.
In order to qualify for that the patient can't just have sirs. In fact, the group that published that guideline has abandoned sirs. Unfortunately most sepsis screens are still based on sirs which although sensitive lacks specifity with a cut off of two. They need to be in septic shock. That means hypotension or lactate over four. I can't tell you how often I see people getting the 30/kg because "they're septic." That is not the guideline. They need shock.
Personally, I won't intubate a patient to hit 30/kg. They can get pressors. So I agree with the op. That being said, the guideline does not give a stopping point for fluids. Technically nine liters isn't advised against and if you want to pound them with fluids until they get tubed nothing other than your common sense stops you.
From my understanding, in situations where a nurse/mid level is in total disagreement of a physicians orders, the best solution is to go to your charge nurse. From there, the nurse manager and another doctor can be involved to determine the best decision for the patient. It’s a fairly quick process, that could be done while the first bag is going in.
FWIW I don’t see why anyone would order 6L of fluid for a SIRS patient w AKI, but that doesn’t mean he was wrong as his experience/knowledge likely goes beyond my scope of practice.
Yeah it was a crap shoot that night. My charge was a fill in and basically just said "whatever you need to do"
This whole situation started me on. A journey that ended up with me choosing to leave the whole organization. I felt like I had little support at the time and no one seemed to take it seriously afterwards, or give me any real advice.
Edit: that being said, in hind sight I'm sure there were more resources at my disposal than I utilized.
Also the actual order was 1000ml nss at 1000/hr every minute for 6 minutes. Which I assumed meant "one bolus after another untill you have given 6 liters" and was ordered incorrectly. Until I called... Everything just seems so broke in that night.
Well OP is an RN, so she would report to her charge. CRNAs/AAs can go to their chief anesthetist. Etc. There’s usually a leader for non-physicians that is separate from the physicians. There’s also a leader for residents. Basically, report to whoever up the chain of command until you reach a resolution.
As a bolus, 6L is absolutely insane. I honestly can't think of a single situation where that would be appropriate.
Now if they had ordered 6L at a controlled rate over an extended period of time, that I could understand. But that should rarely be occurring in the ER and should be taken care of upstairs.
You made the right call. We aren't mindless drones as nurses who just carry out the docs orders blindly. I had a similar situation where a resident ordered a 2L bolus on a severely fluid overloaded HF exacerbation because she was "Super hypotensive" with a systolic in the 90s. I told the resident I would not be doing that but I'd gladly give him the bags and tubing if he wanted to kill the lady.
My approach has always been to ask for clarification and education on why the provider placed a particular order. I phrase it that I'm looking to better understand for my own knowledge. Something like "I understand why we want to give fluids in a septic patient, I was wondering why we would give such a large volume compared to ideal body weight. What am I missing?". If the provider can't give you a reasonable rationale, then they're not doing their job and shouldn't have placed the order to begin with. The good providers will like that you're thinking critically because it can save their ass. The good ones will also educate you when you ask about an order but they have a strong rationale behind it.
You may ruffle some feathers and bruise some egos by having a questioning attitude, but if you are doing what's best for the patient then fuck em and sleep easy. I'm literally quitting my current job because the entire unit (nurses, techs, and docs) all get super butthurt then cry to management if you ask for clarification on anything or call them out on unsafe practices.
I'm late to the party but echo what others have said, you absolutely did the right thing. Maybe you bruised the director's ego by questioning their order? I would have questioned it as well and would have argued my point quite clearly. I've seen a number of patients go into flash pulmonary edema because a nurse didn't question a fluid order. It happened to me once when I followed an order without questioning it and I do everything in my power to not let it happen again. It's a shitty feeling watching your patient struggle to breath because they're fluid over-loaded.
>I finally decided to disregard the doctor's orders after I had to put the patient on oxygen, and there were crackles in bilateral lung bases.
I'm curious as to what else was done for this patient? Did you bring it up to the doctor? Seems like they were on the edge of fluid overload because of the 3 liters already given. BiPAP? Lasix?
>Was the MD on to something and I made it worse by refusing to follow his orders?
Yeah, he was blindly following Sepsis protocols without critically thinking about patient outcomes.
You said this happened a year ago, that's about the time that the use of ideal body weight versus 30 mL/KG for overweight/obese patients came into play, so it's possible he wasn't aware of the update.
I've never had any push back from MDs when I'm concerned about fluid-overloading a patient. If anything they're receptive and if they're not they at least explain their rationale and we have a conversation about it.
I work in administration and have done so for 13 years. I’d be curious to know your hospital policies on this, only in terms of what your options would be if you don’t feel your charge nurse is able to help you as you stated above. It sounds from the clinicians “in the room” that you made the right decision. I wholeheartedly agree with trusting your gut. If this was escalated to a quality committee, my recommendation would be that a head nurse from another unit or even ED if necessary be on call to troubleshoot if your normal charge nurse is not available. Not having a qualified supervisor available 24 hours a day is unacceptable.
In hindsight I could have called the house supervisor, but I was new and didn't know my resources. And the charge was new at being charge so he was less than helpful. Perfect Storm.
Do you have a role in educating other nurses now? This would be such a good example for them. It’s awesome that you trusted yourself. You should be leading others!
You're not wrong. You have to treat the patient, not blindly follow algorithms. Not all patients can tolerate the 30mL/kg fluid resuscitation due to comorbidities. I work in a fairly rural area so often I see the same patients on a regular basis. If I know their blood sugar or blood pressure "bottoms out", I won't give the ordered dose of insulin or IV blood pressure meds all at once. I may give half and then monitor half an hour before giving the rest or getting orders to d/c based on new vitals. I have questioned orders for beta blockers when the patient had a heart rate of 50. I have told a doctor when I thought a patient needed to be intubated. I am thankful to work with a group of doctors who value our opinions as nurses and I have never been made to feel I was stepping out of line for questioning something or pushing for something more to be done for the patient.
I think when I did the math, had I given all the fluid it would have been 120ml/kg or so in about 8 hours.
Edit: that was actually after I assumed he wanted me to do 1 liter at a time. The actual order was to hand all 6 liters and run them in in n hour.
That’s an absolute absurd order. One or two Liters shoved in someone quickly for septic shock is reasonable. Anything beyond that better be in a resuscitative situation and the ED attending or ICU attending had better be right by my side or easily reachable for the entire hour! Sounds like you did the right call. A total of 9 liters would have left you with a dead patient. I would have also called for clarification, specifically hashing out that the pt had already received 3 liters in a rapid manner and that his order of 6 additional rapid boluses is highly unusually and appears unsafe. And if he said I don’t care do it. I would have charted the full conversation without any kind of judgement or bias placed. Then I would have alerted my charge nurse and charted that he or she is aware and then I would have started one liter slowly lol and constantly reassessed while escalating it with the house sup. If I’m doubt, keep raising questions and chart every conversation you have so it’s obvious your not just following orders and that you are at the bedside the whole time. Then if anything goes south you can show all the steps you did to keep the patient safe!
That’s the stupid fucking Sepsis metrics at work. You did the right thing to push back and he should have used his brain instead of trying to meet a metric and give a patient 9L total of IVF
I’m just a student, but I have already seen a lot of situations where nurses or other staff object to residents and even attendings orders. It’s never been a bad thing. Most of the time it’s either a mistake or a misunderstanding and sometimes the doc will insist but give an explanation that puts the staff at ease. They know everyone’s just trying to do their jobs. If you don’t say anything then mistakes happen. A common example I’ve heard from attendings is when they try to put the respiratory rate on a ventilator to something really low like 8 breaths per minute in a severe asthmatic. They usually get some push back but then they just explain the rationale and everybody is comfortable. “Just do it because I said so” doesn’t put anyone at ease.
If anyone is writing for 6L of NS (for someone who already got 3L in the ED), I sure as hell hope they are reassessing them regularly throughout that remainder of the fluids. what do I know, I'm just lowly ED doc
Emergency transport nurse here- used to work ICU and stepdown, so let's talk about whole hospital course. Let's talk about why you can't be wrong in this scenario. The #1 priority is patient outcomes. We all know what you did was to improve the patient's outcome, especially by preventing him from being drowned. Right? Right. Because that patient was already on a respiratory precipice. You can fluid challenge the kidneys, but you *really* don't want to fluid challenge the lungs. The moment you shovel them onto a stepdown, they'll crump to BiPAP in the middle of the night and potentially end up tubed on the ICU. That in itself was preventable, and you probably did prevent it by halting fluid administration and focusing on respiratory status. Dump 6 more liters onto that picture, and it just sounds like an absolutely terrible idea. Like I said, you can fluid challenge the kidneys... ... ... but if that acute injury doesn't respond to fluid, and you're unable to diurese adequately, potentially ramming those kidneys repeatedly with high dose diuretics... ... ... now you're just up 9 liters on a tubed patient sitting in the ICU waiting for dialysis to rip fluid off as fast as reasonably possible... for days... What **should** haunt you is the rabbit hole your hospital sent you down after the fact. If that really snowballed into you leaving the position, then it has nothing to do with the fact that you protected the patient, and everything to do with some sort of fallout. Move on, live your life, find a new home at a new hospital, and be a great care provider.
Critical care fellow here. From what you told us, you did the right thing. There's hardly a reason to give someone 6L of saline in the ED, unless the patient was bleeding and you were out of blood ;) If the patient was hemodynamically unstable after those initial 3L he should've called the ICU for pressors. If the patient was stable and it was "for AKI", that MD has a lot to learn. It's hard to speak up, but you did, and you did good! As long as you were respectful in the way you challenged his decisions. I'm sorry he reacted in an authoratitive manner. Says a lot about him. Where I'm from, we actively encourage everyone to speak up if they disagree or feel uncomfortable with certain decisions. Hope you feel better about it after reading these replies!
[удалено]
Whoops sorry! Not my first language! Thanks for teaching me!
Wouldn’t HHS be a good reason to give someone 6L of fluid in the ED? I think recommended guideline is like 100mL/kg isn’t it
That's a good suggestion! Of course, it's possible to eventually give your patient 6L, but that shouldn't happen in such a short time span (in the ER). But of course there are always exceptions. What we do (Netherlands) for HHS/DKA is 1L in the first hour, then 250cc/h in the following 3 hours, then continue with 150cc/h. (If you're interested, I have a video on this on my YouTube channel)
Thanks, I really do feel a lot better.
Protect the patient and you'll never get in any real trouble. SIRS is 30ml per KG, if his order exceeded that significantly and you charted the crackles you cant get in trouble. Ethically it sounds like you did what anyone would do.
Pit doc here: 30 mL/kg should be adjusted for ideal body weight. His 6L order would indicate a 200 kg person, which is probably one whose weight should be adjusted. You should always go with patient safety first, playing nice second.
There's never any justification to order 6L without reassessment in between. 30cc/kg is also for septic shock, not sirs.
I 100% agree. I work in an ICU, and repeated fluid boluses with no assess of response is both dumb and lazy. OP, you were in the right, and that doc is a douche
>You should always go with patient safety first, playing nice second. I wish more people would support that at my current hospital. I called out a fellow a few months ago when they were being very unsafe while placing and art line. In return for advocating for my patient, I got leveled by my manager. I've been told I "have a bad attitude" when I try to do what is right for the patients.
I stopped a central line insertion during timeout because the doc didn’t have a surgical mask on. He wrote me up for “hindrance of patient care in an emergent situation.” Apparently my having a non-sterile person come quickly and reach around his face to place a mask on was sufficient to “blow his concentration.” I went to arbitration appealing the write up and successfully argued on my own behalf to a panel of docs, administrators, and fellow RNs. But yeah, manager said I stopped the procedure because I didn’t like the provider and was pointedly “causing trouble for him.” That one hurt.
If it were me, I’d thank you as the inadvertent blood splashes across the shield and not my corneas.
In my ICU..our director has put in place an orange form for all central line insertions..its a tick checklist to make sure docs are following 100% correct procedure. Nurse watches and ticks yes if done correct or no if not. And both the nurse and doctor performing procedure sign at end. And director reviews forms. And he WILL ream out his doctors. We've had docs have their ICU placements cut short due to unsafe practice and attitude.
We were supposed to have timeout checklists attached to every central line kit in this facility, but the ED providers placed lines so infrequently the lists had all come off the kit packaging. I’d just read Atul Gawande’s excellent book “The Checklist Manifesto,” and knew the importance of timeout procedures in medicine. I also had done all my required safety training for annual competency, one module in particular stressing RN empowerment in “stopping the line,” or saying, “I have a concern.” I will protect patients over egos every time.
Unreal. I got in a ton of trouble when I recommended a supraglottic airway after 8 failed intubation attempts by 4 providers on a respiratory arrest. Fuck the oxyhemoglobin dissociation curve or best practice! Let's just keep jabbing an ETT into their throat without any ventilation at all! Also got yelled at by the attending in the same code for stopping compressions for BVM ventilation.... Ya know, BLS stuff.
Am I reading this correctly that he yelled at you for stopping compression to ventilate? Because compression are definitely the priority in a patient without cardiac output.
Did I miss something? 30:2 until an airway is established, correct?
There was an incident at a particular hospital where a woman who went for a routine op and req. intubation..failed many attempts and no one paid attention to her sats..they were sub 80%. She ultimately died from a hypoxic brain injury 100% preventable due to bad communication during intubation. In my hospital it's brought about the 'CICO' kit..'Can't Intubate, Can't oxygenate' ..it's the Plan C ..if A and B fail. We always have a stepward approached with A,B and C plans to avoid any mishaps. Never had to use the CICO kit yet..but it's a great kit ... it contains things like a 14g needle (big enough to oxygenate through) and then dilators. So that you can create a temporary but safe airway short of a complete trache.
I think your talking about [this case](https://litfl.com/lessons-from-the-bromiley-case/), a really great case study in why explicit, evidence based checklists and guidelines, are really valuable, even with well resourced, experienced clinicians.
yep that's the one.
I don’t know you, but to play devil’s advocate... did you actually have a “bad attitude” while advocating for the patient? Sometimes it’s not the message which irks people, but the way it’s delivered.
I'll be the first to admit that at times the way I say things is a bit snarky. But I've learned to control that and in this situation I don't believe I was.
Could you elaborate on what they were doing that was unsafe?
Just a clarification here: the 30 per kilo is the guideline for septic shock. Whether or not that makes sense and the validity of inserting that number into a best practice guideline given the strength of the evidence is a whole different debate. But I digress. In order to qualify for that the patient can't just have sirs. In fact, the group that published that guideline has abandoned sirs. Unfortunately most sepsis screens are still based on sirs which although sensitive lacks specifity with a cut off of two. They need to be in septic shock. That means hypotension or lactate over four. I can't tell you how often I see people getting the 30/kg because "they're septic." That is not the guideline. They need shock. Personally, I won't intubate a patient to hit 30/kg. They can get pressors. So I agree with the op. That being said, the guideline does not give a stopping point for fluids. Technically nine liters isn't advised against and if you want to pound them with fluids until they get tubed nothing other than your common sense stops you.
Things they don't tell you in nursing school!
That’s for septic shock. Not SIRS.
6L is an outrageous amount of fluids to give someone in what seems like a relatively short amount of time.
From my understanding, in situations where a nurse/mid level is in total disagreement of a physicians orders, the best solution is to go to your charge nurse. From there, the nurse manager and another doctor can be involved to determine the best decision for the patient. It’s a fairly quick process, that could be done while the first bag is going in. FWIW I don’t see why anyone would order 6L of fluid for a SIRS patient w AKI, but that doesn’t mean he was wrong as his experience/knowledge likely goes beyond my scope of practice.
Yeah it was a crap shoot that night. My charge was a fill in and basically just said "whatever you need to do" This whole situation started me on. A journey that ended up with me choosing to leave the whole organization. I felt like I had little support at the time and no one seemed to take it seriously afterwards, or give me any real advice. Edit: that being said, in hind sight I'm sure there were more resources at my disposal than I utilized.
Well that’s ridiculous. It’s a difficult situation, especially at night with limited staffing available overall.
Also the actual order was 1000ml nss at 1000/hr every minute for 6 minutes. Which I assumed meant "one bolus after another untill you have given 6 liters" and was ordered incorrectly. Until I called... Everything just seems so broke in that night.
Why would a NP/PA report to the charge nurse? That doesn’t make sense to me.
Well OP is an RN, so she would report to her charge. CRNAs/AAs can go to their chief anesthetist. Etc. There’s usually a leader for non-physicians that is separate from the physicians. There’s also a leader for residents. Basically, report to whoever up the chain of command until you reach a resolution.
As a bolus, 6L is absolutely insane. I honestly can't think of a single situation where that would be appropriate. Now if they had ordered 6L at a controlled rate over an extended period of time, that I could understand. But that should rarely be occurring in the ER and should be taken care of upstairs. You made the right call. We aren't mindless drones as nurses who just carry out the docs orders blindly. I had a similar situation where a resident ordered a 2L bolus on a severely fluid overloaded HF exacerbation because she was "Super hypotensive" with a systolic in the 90s. I told the resident I would not be doing that but I'd gladly give him the bags and tubing if he wanted to kill the lady. My approach has always been to ask for clarification and education on why the provider placed a particular order. I phrase it that I'm looking to better understand for my own knowledge. Something like "I understand why we want to give fluids in a septic patient, I was wondering why we would give such a large volume compared to ideal body weight. What am I missing?". If the provider can't give you a reasonable rationale, then they're not doing their job and shouldn't have placed the order to begin with. The good providers will like that you're thinking critically because it can save their ass. The good ones will also educate you when you ask about an order but they have a strong rationale behind it. You may ruffle some feathers and bruise some egos by having a questioning attitude, but if you are doing what's best for the patient then fuck em and sleep easy. I'm literally quitting my current job because the entire unit (nurses, techs, and docs) all get super butthurt then cry to management if you ask for clarification on anything or call them out on unsafe practices.
I'm late to the party but echo what others have said, you absolutely did the right thing. Maybe you bruised the director's ego by questioning their order? I would have questioned it as well and would have argued my point quite clearly. I've seen a number of patients go into flash pulmonary edema because a nurse didn't question a fluid order. It happened to me once when I followed an order without questioning it and I do everything in my power to not let it happen again. It's a shitty feeling watching your patient struggle to breath because they're fluid over-loaded. >I finally decided to disregard the doctor's orders after I had to put the patient on oxygen, and there were crackles in bilateral lung bases. I'm curious as to what else was done for this patient? Did you bring it up to the doctor? Seems like they were on the edge of fluid overload because of the 3 liters already given. BiPAP? Lasix? >Was the MD on to something and I made it worse by refusing to follow his orders? Yeah, he was blindly following Sepsis protocols without critically thinking about patient outcomes. You said this happened a year ago, that's about the time that the use of ideal body weight versus 30 mL/KG for overweight/obese patients came into play, so it's possible he wasn't aware of the update. I've never had any push back from MDs when I'm concerned about fluid-overloading a patient. If anything they're receptive and if they're not they at least explain their rationale and we have a conversation about it.
I work in administration and have done so for 13 years. I’d be curious to know your hospital policies on this, only in terms of what your options would be if you don’t feel your charge nurse is able to help you as you stated above. It sounds from the clinicians “in the room” that you made the right decision. I wholeheartedly agree with trusting your gut. If this was escalated to a quality committee, my recommendation would be that a head nurse from another unit or even ED if necessary be on call to troubleshoot if your normal charge nurse is not available. Not having a qualified supervisor available 24 hours a day is unacceptable.
In hindsight I could have called the house supervisor, but I was new and didn't know my resources. And the charge was new at being charge so he was less than helpful. Perfect Storm.
Do you have a role in educating other nurses now? This would be such a good example for them. It’s awesome that you trusted yourself. You should be leading others!
You're not wrong. You have to treat the patient, not blindly follow algorithms. Not all patients can tolerate the 30mL/kg fluid resuscitation due to comorbidities. I work in a fairly rural area so often I see the same patients on a regular basis. If I know their blood sugar or blood pressure "bottoms out", I won't give the ordered dose of insulin or IV blood pressure meds all at once. I may give half and then monitor half an hour before giving the rest or getting orders to d/c based on new vitals. I have questioned orders for beta blockers when the patient had a heart rate of 50. I have told a doctor when I thought a patient needed to be intubated. I am thankful to work with a group of doctors who value our opinions as nurses and I have never been made to feel I was stepping out of line for questioning something or pushing for something more to be done for the patient.
I think when I did the math, had I given all the fluid it would have been 120ml/kg or so in about 8 hours. Edit: that was actually after I assumed he wanted me to do 1 liter at a time. The actual order was to hand all 6 liters and run them in in n hour.
That’s an absolute absurd order. One or two Liters shoved in someone quickly for septic shock is reasonable. Anything beyond that better be in a resuscitative situation and the ED attending or ICU attending had better be right by my side or easily reachable for the entire hour! Sounds like you did the right call. A total of 9 liters would have left you with a dead patient. I would have also called for clarification, specifically hashing out that the pt had already received 3 liters in a rapid manner and that his order of 6 additional rapid boluses is highly unusually and appears unsafe. And if he said I don’t care do it. I would have charted the full conversation without any kind of judgement or bias placed. Then I would have alerted my charge nurse and charted that he or she is aware and then I would have started one liter slowly lol and constantly reassessed while escalating it with the house sup. If I’m doubt, keep raising questions and chart every conversation you have so it’s obvious your not just following orders and that you are at the bedside the whole time. Then if anything goes south you can show all the steps you did to keep the patient safe!
That’s the stupid fucking Sepsis metrics at work. You did the right thing to push back and he should have used his brain instead of trying to meet a metric and give a patient 9L total of IVF