August 30, 2008, 11:19 am

Chopped Liver to the ER, STAT

Oh, this is hilarious!

It is so obviously not a real hospital room!

The solid white backdrop – no oxygen, no light fixtures, no code button, no intercom.

Okay, so maybe they didn’t have those back in the day.

It’s hard to see, but there is a piece of tape on the glass bottle that says “Saline”. It looks like the tubing coming from the IV is rubber and about the size of a garden hose.

Is there anyone out there who has been in nursing long enough to remember rubber tubing?  I’m embarrassed to say that glass bottles were still in use when I started (and no pleurivacs, either – just three glass bottle water seal drainge!)

It seems that they practiced make-up application and used hair arranging as a therapeutic intervention.  That patient looks really sick, doesn’t she?

Heck, I don’t look that good and I’m healthy!

******************************

I have a problem.  With nursing.  WTF have we accomplished in the last 30 years?

Awhile back I handed a chart to our unit clerk.  On the chart, I had checked the standard blood tests required for a patient presenting with chest pain.  I then turned to tell the doctor about the patient.

Before, I had a chance to say a word, the clerk swiveled in her chair, put the chart in front of the doctor and asked, “Is it okay if I order these?”.

After I picked my jaw up off the desk, I said jokingly,  “Betty, are you questioning my author-i-tay?”.

Then I heard something even more astounding.  Betty told me that one of the doctors instructed her to run any and all nurse initiated orders by him first.  So, in order not to get in trouble, she did that with all the doctors.

WTF?  This is wrong on so many levels.

  • First of all, every nurse in my department is a seasoned veteran.  Together we have over a millennium of nursing experience.  I’m serious.  We don’t frivolously order labs or x-rays on a whim, we have the education and experience to know what needs to be ordered when.  Particularly with chest pain patients.  Especially with chest pain patients!
  • Then, to top that off, we have a very substantial nursing protocol for us to use on patients presenting with numerous chief complaints that covers us for the very thing I was trying to order.
  • The doctor in question has never, EVER said anything to the nurses about not ordering tests.  I find having the unit clerk question the order to be surreptitious.

Let’s make it clear here.  I’m not perfect.

But I’m also not talking major radiological, invasive studies.  I’m talking labs and extremity x-rays.

Which brings me to my next issue.

**********

The supervisor on duty that night (a good manager and someone I respect very highly), was astounded that we were “allowed” to order anything!  That we were treading on thin ice.

My response?

“Julie, are you telling me that an experienced, educated, professional registered nurse is out of line ordering x-rays for obvious fractures or initiating a cardiac workup when a patient obviously requires it?”

That was exactly what she was telling me.

Oh dear Lord.

That could explain why a very esteemed colleague of mine stood in the very same facility and watched her father die while the telemetry floor nurses would not get an EKG, order a chest x-ray, call respiratory therapy or draw blood work because “the doctor would be coming in”.

Shouldn’t we, as nurses, have those things ready when the doctor shows up?  Isn’t that the point of working in the hospital, to facilitate the care of our patients, to intervene when they go critical, to be prepared for the unexpected?  Especially in the emergency department, of all places, especially in an emergency department that prides itself on door to dilatation times that are so fast they can give you vertigo?

Am I nuts here?

What the hell are we nurses these days?  Chopped liver?

HELL NO!

*****

How can we fight for our professionalism when our own nurse leaders at the grass roots level don’t support it?

How are we really being perceived when doctors pay lip service to us one minute and then have the unit clerks run our basic protocol-driven nursing actions by them before initiation?

What the hell is going on with my profession?

*****

Please excuse the language, but I am pissed off.

This profession needs to get its you-know-what together if we are ever going to be taken seriously by anybody.  We can differ, but we have to present a solid front to the public, our community and to the medical profession.

And that front needs to be, say it with me….professsional! I don’t care if you spend your shift emptying bedpans or writing national nursing policy.

Nursing is an autonomous, distinct profession with it’s own research and evidence-based practice.  How long before we start to get treated like it.

Nurses, we had better take the reigns here because no one else seems to (a) want us to do it or (b) even think we might actually KNOW something.

How the hell do we ever expect it to change if we don’t do it from the grassroots up?

Even if it means taking it one person, one institution at a time.

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34 Comments

  • NurseExec
    NurseExec

    August 30, 2008 at 11:31 am

    I feel your pain. Thanks for a great post.


  • Healthcare Today
    Healthcare Today

    August 30, 2008 at 11:36 am

    Chopped Liver to the ER, STAT // Emergiblog…

    A rant on the state of the nursing profession as seen through the eyes of an ER nurse on one shift….


  • Sarah Stewart
    Sarah Stewart

    August 30, 2008 at 11:59 am

    I would suggest that this is one of the major reasons why we have a global recruitment and retention problem in nursing. What young woman these days would study for so long (and end up with a huge student debt/loan) to find herself worse off than a clerk? I won’t be encouraging my daughter into nursing for exactly that reason.


  • Karin, RN
    Karin, RN

    August 30, 2008 at 11:59 am

    I was one of those nurses who orders stat labs and EKG when, according to my assessment, the pt is probably having a real chest pain, even if I have to get them myself. Patient’s first. EKG is easy. It’s not that I am starting open-heart. I haven’t gotten in trouble for doing these yet. I obtain the orders later. In short, I totally understand you.


  • #1 Dinosaur
    #1 Dinosaur

    August 30, 2008 at 12:42 pm

    Apologies for nitpicking, but I think you’ve got a word wrong:

    I find having the unit clerk question the order to be surreptitious.

    I’m pretty sure you mean “superfluous.”

    As for the substance of your post, I agree with you completely that nurses have the training, experience and expertise to initiate an appropriate medical workup in the ER and acute care hospital units. What I don’t understand is the differentiation between a “nursing assessment” and a “medical assessment” in these situations. It may be true that “Nursing is an autonomous, distinct profession with its own research and evidence-based practice,” but that statement seems irrelevant in the settings you’re describing. You are taking a history, performing a physical examination (vital signs, EKG), generating a differential diagnosis and making a judgment about what other data you need. Excuse me, but that’s a “medical” assessment, and you as a nurse are perfectly capable of doing it. Just because a bunch of snot-nosed MDs get their diapers in a wad over “nurses practicing medicine” doesn’t mean you need to retreat to your “Nursing is an autonomous, distinct profession with its own research and evidence-based practice” line. The “practice of medicine” specifically consisting of initial triage of major common complaints is easily protocol-driven and well within the purview of nurses. Period.

    Nurses are perfectly capable of “practicing medicine” in certain contexts, without impacting one bit on the “practice of nursing.” Stand up for yourselves. I know I do.


  • ernurse
    ernurse

    August 30, 2008 at 1:00 pm

    I am in complete agreement with you about this.

    We also have protocols like you do, and our system is such that we can order the tests directly ourselves. We also draw our own labs and do our own EKGs. What happens if a chest pain comes in is that get an EKG, place them on the cardiac monitor, put them on O2, put an IV in, and draw the blood while someone else calling Xray for a stat portable. All this happens before the doc even gets to the room. A lot of times the doc is there before steps 1 and 2 are done, but if it’s busy we’ll have that all done, and it’s the expected protocol. The only thing I see us pause to check in with the doc is before giving nitro and aspirin. We have similar protocols for stroke, and other complaints.

    We have some docs who are really big on the “don’t touch my pt before I assess them” thing, but for chest pain, stroke, trauma, asthma, etc they won’t question our initiating protocols.

    It’s why we go to school, why we carry liability insurance, because we’re professionals, and we can exercise nursing judgment!


  • wardbunny
    wardbunny

    August 30, 2008 at 2:05 pm

    A blood test and an x-ray don’t really compare to a biopsy and an MRI scan. So really what’s the problem?

    With enough experience I’m sure a good nurse outweighs a junior doctor. I really would like to know why it seems to be one step forwards, two steps back…


  • JimmyJ
    JimmyJ

    August 30, 2008 at 2:12 pm

    Nobody respects us becase “Disturbed energy field” is a legitimate ‘nursing diagnosis’.

    Get the stupid duck squeezers who think that rekiki and acupuncture are legitimate medicine out of control and maybe we’ll get a little respect.


  • Crystal
    Crystal

    August 30, 2008 at 5:59 pm

    Kim,

    It saddens me to read your post today. I work in a cardiac/vascular hospital and as nurses we have the autonomy to initiate chest pain protocol (i.e. NTG, labs, EKGs, etc) for patients c/o CP. We actually have several protocols that have been set forth by our board for us to use for exactly the reasoning you have describe. We also have NP’s on the floor M-F from 6a-6p. It’s a wonderful advantage when you have a patient go bad fast and can’t get ahold of the doctor.


  • Kim
    Kim

    August 30, 2008 at 6:37 pm

    Hi #1 – how are ya! : ) no worries re: nitpicking! : ) I actually did mean surreptitious, at least as my Mac dictionary describes it (“secretive, clandestine, sneaky, sly, furtive, concealed, hidden, undercover”).

    I agree that in the situation I described the nursing and medical assessments are congruent, but we approach the same actions from a different mindset. By pointing out that the mindset is based on nursing education(and not just following a pre-printed protocol), I actually was defending nursing as opposed to just falling back on a cliche. Perhaps if I had said there was critical thinking going on and not just following preprinted protocols it would have been clearer. Either way, the goal is the same for both medicine and nursing in this regard and that is a good patient outcome.

    I was more disappointed by the doctor’s attitude, but it isn’t the first time I’ve run across it. I was absolutely stunned by my colleague’s unwillingness to acknowledge that nurses were capable of doing exactly what we both agreed we were able to do.

    Thanks for the comment and the compliment! : )
    We really do need to stand up for ourselves as nurses.


  • Heidi
    Heidi

    August 31, 2008 at 6:06 am

    I do feel for you. I work in an MICU where we are told to be pro-active. If a patient is circling the drain and we call the house doc and we don’t have an ABG and basic labs drawn we would look like such fools. Do I need a doctor to tell me that a patient’s sat is 75 and maybe I might wanna do an ABG? When did I lose my brain? I KNOW what the patient needs. Obviously I draw the line at medications but often I have a few suggestions for those too. What is all of our experience for? Our assessment skills? I can’t imagine you would not be supported for doing what is best for the patients.
    I can completely understand your frustration. You are a good nurse and you should be able to use your skills…ALL of them!


  • Ian Furst
    Ian Furst

    August 31, 2008 at 2:26 pm

    Agree with Dino in that medical professions are intended to be complementary not antagonistic. It’s not about applying one type of research or another but working together to the best care.

    Whoever the doctor was that undermined your authority with the ward staff is not only short sighted but gut-less for not discussing it with the nursing staff. If the medical staff won’t control stupid and one-sided decisions like this then turn the clock back on him 30 years for real and page for every minor decision needed.


  • Signout
    Signout

    August 31, 2008 at 5:27 pm

    WORD. Especially when you’re dealing with experienced nurses, it’s such a helpful sharing of duties to have labs/x-rays ordered in advance. It’s so nice when multiple members of a team have brain waves about a patient. Especially in a protocol-driven environment, I can’t understand this doctor’s objection–it just makes more unnecessary work for him, and less efficiency for everyone.


  • EDRNKaren
    EDRNKaren

    September 1, 2008 at 9:02 am

    If you have a protocol, you do not need the Dr. to OK the orders. Your dept. needs to review this issue at a staff mtg, and the Dr. who wants to be informed before protocol orders are initiated needs to be educated. A word to your nurse manager should be enough to get this ball rolling. Pts. benefit from experienced nurses using established protocols to quickly start the care they need in emergent situations.


  • EDRNKaren
    EDRNKaren

    September 1, 2008 at 9:05 am

    Great post, Kim, BTW!


  • Candy
    Candy

    September 1, 2008 at 8:57 pm

    It will only take one death for those policies to change — one unfortunate soul whose treatment was held up because you were not allowed to order routine labs and a chest film. By then it will be too late — you will all be branded an incompetent while the docs (who didn’t let you do what you knew needed to be done) will be just fine, thank you very much.

    Do not sit on this. If you house supervisor doesn’t understand, kick her sorry ass to the side of the road and move on up that food chain. I happen to know that your CNO has been honored for “advancing the profession” and is fighting to make nurses MORE professional at SMF. Go to her!


  • shadowfax
    shadowfax

    September 2, 2008 at 10:14 am

    Kim,

    I don’t know what state you practice in, but in our state nurses are not allowed under their licensure to order tests without an MD. Now, as an administrator I’m in a position of wanting to make use of the experience and skills that our nurses have and to provide the most efficient, timely care. But I don’t want to put our nurses in a position where they might get in trouble if something went wrong or if there were a complaint to the state board.

    So what we did is have our MDs come up with a large number of standing order sets for patients presenting with certain complaints: CP>25 y/o, syncope, elderly with fever, etc. These order sets are activated by the nurses, under the license of the medical director, from triage, with the result that the labs are often on the chart when I see the patient. It works great, nobody’s authority is threatened, and nobody’s license is put in jeopardy. We did need to knock some of the prima donna docs’ heads a bit to make sure everybody was “on board” with the standing orders, but once we got past that it has been great.

    Cheers,

    SF


  • Jamie
    Jamie

    September 2, 2008 at 11:23 am

    With regards to your complaint on not being able to order tests without say so, i will but voice one test.

    D-dimer.

    If we could ban the nurses where i work from ordering it I would save a lot of time, adn the department would save a lot of money.


  • Health news - Nurses and orders
    Health news - Nurses and orders

    September 2, 2008 at 4:36 pm

    [...] M.D. – Medical Weblog Emergiblog is upset that nurses are being restricted in starting the initial workup for chest pain and obvious [...]


  • Biffy
    Biffy

    September 3, 2008 at 11:05 am

    Wait til JC blows through. I am hearing from colleagues nation wide that JC is not allowing nurse initiated orders without a doctor signing off on them first. I agree with you that if we don’t fight this then we might as well not bother to get licenses. This is part of our professional duty to the patient. That supervisor needs to be educated and if a roadblock replaced.
    Let us know what the doc says who started this whole travesty in your department. What is his reasoning and why does he get to go against what all his colleagues have agreed on?


  • RehabRN
    RehabRN

    September 3, 2008 at 3:01 pm

    Once upon a time, I worked for a doc who told me, “Don’t call me for x, y, or z (certain tests and/or basic meds–UAC&S, senna, colace, tylenol, milk of mag, maalox) if I’m not here and you need them right away. Just put it in and I’ll sign it in the morning.” This facility actually allowed us to write certain meds (via check boxes) on the orders to get readbacks from the docs.

    I work for the VA and I have a heck of a time just trying to get an order for milk of mag…and when I do and the patient consistently refuses it after a while, do they d/c it? Heck no!

    We joke that the VA likes to have a minimum number of meds assigned to each person, whether they need or take them or not.


  • [...] with Star Bucks coffee, rock and roll music, and giving excellent patient care. Check out Kim’s call to arms. She’s mad as heck, and she wants nurses to start taking back the nursing profession. It seems [...]


  • DBS
    DBS

    September 4, 2008 at 10:47 am

    Great post. Nurse initiated orders are the standard of care, especially for pt’s with c/o CP. Now that I work in L and D we have similar nurse initiated orders that we are expected to do before calling the MD. If the FHR is going down we turn the pt, turn off the pit, put O2 on the pt, do a VE open up the IV and then call for help. If I did not do these interventions first the MD would be upset with me. These are nurse initiated standing orders and they are the standard of care. If I don’t do this I am negligent. Yes I am giving O2 (oh my) and turning off medication (God forbid) but if the baby dies guess what. It’s on me.

    That MD needs education and (balls to talk to the RN’s first if he has a problem), that ward clerk needs to learn her place and that boss needs to support her nurses.


  • jb
    jb

    September 4, 2008 at 11:14 am

    This is of a piece with the new JCAHO rule that experienced professional nurses are not capable to decide whether to give one or two pain pills, depending on how severe she evaluates the patient’s pain to be. It’s ridiculous- when I discharge a post-op patient, I write the prescription for the untrained “civilian” as “Take 1 or 2 pills every 6 hours as needed for pain.” I can’t write this in the hospital chart, because this will give the RN too much discretion, or put her in a position where her head might explode due to need for her to make a clinical decision. Why does the nursing profession tolerate this insult?


  • joe blow
    joe blow

    September 4, 2008 at 2:27 pm

    I’m so tired of hearing people describe ordering tests and writing for meds as “nursing.” Thats BS. “Nursing” is patient comfort, support, administering meds, etc. Its NOT ordering blood work, x-rays, medications, etc.

    Can RNs do those things? Absolutely provided its in a controlled, protocol-driven environment.

    But lets please stop the games. Call it what it is. Its medicine, not “nursing”

    The reason we have this silliness is because state nursing boards use that language so they can control/regulate NPs. Otherwise, what they are doing would be defined as “medicine” and they would be under the purview of the state medical boards.

    Ask the leader of the state nursing board what its called behind closed doors, and she’ll tell you its medicine. Get her in front of the whole nursing board with the lawyers and the cameras and she’ll magically change her tune and call it “nursing” instead.

    Its all one BS charade.


  • Beth
    Beth

    September 4, 2008 at 5:56 pm

    I don’t care how experienced you are you are a nurse not a doctor. You can not practice medicine. You can not write orders. It is beyond your scope of practice. It doesn’t matter how smart you are you are not legally allowed to do it. If you get sued you will lose. If the hospital has a standing protocol you can do it. If you are trained in ACLS you can save a life based on that protocol. You can not order your own workup. You will not cause a patient to die because an xray result was not ready or the lab work was not back. You can use your nursing skills to notify a doctor of a decline in health and convey that accuratly. Nurses should not play doctor. If you want to do that go back to school.


  • Kim
    Kim

    September 4, 2008 at 7:32 pm

    I wanted to thank Joe and Beth for their feedback – I also wanted to make it clear that the orders I was putting through were all done under our standing orders/protocol, so I was most definitely not practicing medicine. I will say that my experience comes into play when deciding when to initiate the protocol independently.

    That is why I was so surprised that the orders were questioned, as I had no idea this particular physician had an issue with the nurses initiating the protocol.


  • PaedsRN
    PaedsRN

    September 4, 2008 at 7:52 pm

    Ordering standard tests in defined circumstances is no more practicing medicine than a mother deciding to give her child paracetamol for a fever. It’s an accepted part of practice today and the sooner we stop splitting hairs and start using common sense the better.

    In the PICU I will send the bloods I think necessary for a morning blood draw, on admission and on return from theatre. If a registrar’s around I might ask, “Hey, you want anything extra?” and they’ll say “Yeah, could you add liver function please?” or whatever. For damn sure a clerk shouldn’t be the one questioning the practice (no offence to clerks, we couldn’t live without ours, just way outside job description).

    Same with chest xrays. We have defined circumstances where we always do one. Otherwise I’ll ask. Ordering blood products is different, I’ll sign for a form but I’d absolutely never do it unless I knew for sure we planned to transfuse… wouldn’t want to risk wasting any.

    I guess I’m fortunate though in that I practice in a unit where this sort of thing just isn’t questioned. The docs are smart enough to let us do our thing, and we’re smart enough to know when to ask for clarification. Disagreements on this score are few (some of the consultants feel we do too many ABG’s, some claim not enough!)


  • MedicMD
    MedicMD

    September 5, 2008 at 10:37 am

    Great post. As a paramedic and soon-to-be MD, I have worked in just about every pre-hospital and hospital environment; I have no doubt that without a nurses ability to initiate care based on his/her own, we would all be screwed.

    Sure, from a legal standpoint an MD needs to to “approve” it somewhere along the line, but that is what standing orders are for. It is simply illogical – and quite frankly dangerous – to require a doctor to sign off on every treatment or test before it is initiated. Time is a precious commodity.

    A big thank you to every RN out there – we couldn’t do it without you, and you have my admiration for continuing to provide excellent patient care and advocacy despite the animosity displayed by some anencephalic doctors and administrators.


  • SmalltownRN
    SmalltownRN

    September 5, 2008 at 11:15 am

    Bravo!!! Well said……as a professional and following along the lines of my nursing association guidelines….I so and should order tests that I know will benefit my patient and are within the scope of my practise…..Of course if I have followed protocols for CP and there is no relief I am going to order an ECG,and lab work…I will also phone the doctor letting them know what I have done and or with the results….for heaven sakes let’s use our common sense man! It’s team work and at the end of the day what is best for the patient…..


  • Nurse DeLio ~ Family Nurse Practitioner
    Nurse DeLio ~ Family Nurse Practitioner

    September 5, 2008 at 9:48 pm

    Protocols, policy’s and procedures once in place and hospital approved are no longer guidelines. Are they with in the scope of your practice? You bet. And you are now liable if not followed. So rather than getting upset, get your hospital or whatever setting you are practicing in on board so that we can finally put an end to this shameful discussion. Shameful in that it is 2008 and we are still dealing with this? How can we communicate if we are not speaking the same lingo?
    This is not rocket science ladies and gentlemen. This is business. The P and P’s are EBR and not particularily by RN’s. So how bout we for starters speak and write the same language, do away with nursing diagnosis, nursing theory and nurse speak. No one cares. No one reads them and and only adds time to the already weary road warriors.
    Our job as nurses are multidimensional. This is a collaboraton between disciplines. No competiton just good practice. Best practice. And until we nurses,share our gifts with one another and treat each other with respect, kindness and professionalism, why should any one else?


  • murse c
    murse c

    September 6, 2008 at 9:24 am

    I completely agree with you coming from a medical family. Although I am ‘new’ to the nursing world, I think a lot of has to do with perception. I don’t want to sound negative but there may be equally as many nurses that are beat down through the bureaucratic processes rampant in the medical field. They are overwhelmed, overworked, understaffed, overstretched…whatever you want to call it. When you walk through a unit and see a veteran nurse verbally abuse new nurses and support staff because they have lost their cool makes one wonder why or how they have lasted in the profession. I think I need to write a post.


  • MICU RN
    MICU RN

    October 6, 2008 at 3:45 pm

    Great post, Kim.


  • Terri
    Terri

    June 17, 2010 at 3:14 pm

    My take on this, for what it is worth:
    Get a cup of coffee, go to your state’s professional licensing site and read your nurse practice act-your license is too precious to risk loosing it. Get active and involved in changing your state’s nurse practice act if you are that passionate about the need for change.


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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