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Old 01-07-2008, 01:32 PM
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Default How to advocate for patient in front of the doctor?

Unsinkable Molly Brown put up a post about a situation in which she did not trust the surgeon that she was assisting.

Has anyone been in a similar situation? What did you do? What was the outcome?

I know I've been in some hairy situations with doctors.... where I thought that I should step in and advocate for the patient. I can't think of anything particularly earth-shattering, but I do know of times when I've assisted in inserting central lines where the doc didn't numb the patient up before sticking a big huge needle into their neck or chest. And these were not emergent situations. I mean... first you have the Big Stick, and then you have to dilate the area, and then you have to stitch it in... so it's not a matter of "oh, it's only one stick."

In those cases, I've put on my best Clueless Face and "innocently" ask the doctor if I need to get them some Lidocaine... if they say no, then I've (just as cluelessly) asked why they aren't numbing the patient up.

Unbelievable as it might be - some docs STILL did not numb up the patient. These were patients who were sedated on vents, but Propofol is not an analgesic, it's only a sedative.

I'm interested in hearing other's experiences.
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Old 01-08-2008, 01:16 PM
MyOwnWoman
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Geena, one might say (not me of course) that I'm a rather opinionated wench. We had a patient who had a big MI and was in severe pain. The ER doctor wouldn't give him any morphine. I was not happy. I left the room with the doctor (another nurse stayed with the patient) and I asked for the morphine outright. He said no, I said yes, he said no, I said... "I hope you come in here with heart pain, cause I'll take NO sympathy on your ass, and besides, it's ACLS protocal." We gave him Morphine 5 mg IV per doctor's orders.

What was the problem? He had just read an "article" about letting the Nitroglycerine control the pain instead of Morphine. I agreed, but did mention that IV Nitro takes a little more time then a big ole dose of Morphine.

And.........the doctor still likes me.... imagine that?
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Old 01-08-2008, 02:10 PM
LesleyJoy
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I do not have patients for whom to advocate. Most ordinarily I simply encourage RNs to advocate for their charges (and often give little hints about approaches tailored specifically to the individual physician in question). Recently, however, something happened that highlighted the responsibility I have to be my brother's keeper. I apologize in advance for the length of this post.

A woman in her mid-20s presented to the hospital seeking pain relief. She was a poor historian and loudly verbally abusive. She was seen by an ED Doc and a Mental Health RN. Both decided she was not a danger to herself or others and would receive no meds. She was discharged from the ED inspite of her very loud protests. I told her that she would either leave the hospital or I would have her arrested. She left the building but was seen asking an employee for a ride. When she was denied, she threw herself on the ground and wailed. I had her brought back in. The doc saw her again, diagnosed a sprained ankle. She was fitted for a brace, given a prepack of and a prescription for vicodin, and was discharged. Again she made a huge protest about being made to leave the hospital. By this time it was 0100.

Did I tell you it was raining? And cold? And she had no place to live? And that all the shelters were full?

I gave her options. I said she could leave the hospital now under her own steam or she would be arrested that moment for refusing to leave. OR if she promised to be quiet I would let her sleep in the ED waiting room until 0700 at which time a shelter was expected to be open. She opted to stay.

At seven I woke her, gave her a meal, and a cab voucher to the shelter. She refused to leave. When the cops arrived I told them the story and they - bless them! - treated her with firm kindness. I know they were kind because I hid around the corner, out of line of sight with one of them while the other talked to the young woman! Then I heard her say she was going to kill herself.

That did it. I told the officer I was with to wait. I went into the ED and asked for a favor. The on-coming doc agreed to see the patient and to do some lab work. I then called the MHU and asked for another favor. The dayshift charge RN agreed to see her.

The officers and I escorted the young woman into Room 5. They left and so did I. I checked with the ED Doc before I left at the end of my shift and was delighted when the doc assured me that she was waiting for labs before calling the mental health RN.

When I returned that night I learned that the young woman had been discharged from the ED and forced off of the property by law. A couple of hours into my shift the ED called to say, "Guess who is back? And guess who is intubated for polydrug overdose?"

I hotfooted it down to the ED where I met the first physician who had seen her the night before. He could not wait to tell me the story. When he finished speaking I thanked him for providing care. I then said, "May I tell you what I have learned from all this?" He nodded. I said, "The next time I disagree with you and the mental health RN about a patient, I am going to speak with the on-call psychatrist myself to express my opinion. The ED doc stared at me. Then to his credit, he nodded and said, "OK. That's fair."

I later said the same thing to the mental health RN. She was defensive and quite frankly disagreed with my plan.

The patient spent the night in ICU. As I was preparing to leave the next morning the ICU unit secretary called to inform me that the young woman was expected to be extubated later that day and would then be transfered to our locked psychiatric ward.

Sigh. There is so much heartache in this world.

Joy
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Old 01-09-2008, 12:27 AM
MyOwnWoman
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Yes, a lot of heartache in this world; and so little sympathy for psychiatric patients.
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Old 01-09-2008, 09:29 PM
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Unhappy

Psych patients often get short shrift. I worked Psych for 2 1/2 years and I loved my patients and got along with them, even when I had to confront them about behavior or enforce unit rules.

My secret?

I treated them with respect. It really was that simple. So often psych patients are treated with barely disguised eye rolling and get-them-out-of-here-ASAP attitudes.
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Old 01-09-2008, 09:32 PM
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Oh, and advocating in front of the doctor?

I ask questions "for" the patient. Like, "Doctor, is there any reason why Mr. Jones cannot have medication for pain?" or I'll ask directly if the patient asks me, but is too shy/intimidated to ask the doctor.

I'll say, "Doctor Smith, Mrs. Jones was asking about something for nausea. What would you like me to give her?"

And I say it in front of the patient in a very professional, friendly tone.

Gets 'em every time!
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Old 01-10-2008, 01:18 AM
Mr Ian
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Default Advocacy rocks my world!

As a long time MH nurse, I've had the necessity to advocate rather forcibly for several patients over the times. I hate having to; but it bring me the greatest satisfaction when it comes off.

I have more or less worked it to the stage that I write the Px order up and the doc signs it for me!

One of my favourite occasions of 'advocacy' was perhaps when the Consultant who had promised to see the patient for 3 days to sign off his unescorted leave to allow him to wander the grounds without an escort, once again failed to show to the ward to do so. No problem, as the patient had escorted leave I took him for a walk - right to the Consultant's office and took the paperwork with me. I politely advised the Consultant I was leaving now and he was in charge of this patient - if he wanted him to return to the unit he could either:
a) take him himself
b) sign the paperwork so he could return unescorted.

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Old 01-10-2008, 12:18 PM
MyOwnWoman
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Oh Mr. Ian, I'm liking you more and more!
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Old 01-10-2008, 01:09 PM
LesleyJoy
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Quote:
Originally Posted by KimRN View Post
Oh, and advocating in front of the doctor?
Oh, yeah...

Most recently I had good results when asking an internal medicine doctor if he was "happy with that rhythm." The patient had presented to the ED with a massive posterior wall MI. She was unconscious, entubated, perfusing well, had what looked like PSVT or Afib RVR in the 150s. Adenosine was given without results. When the doctor looked at me and said, "Well, we could cardiovert her..." I popped up with, "And blow a hole right out the back of her heart, too." The patient was admitted to the ICU without the proposed intervention. She converted on her own in the ICU after her magnesium level was corrected.

Joy
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Old 01-12-2008, 05:59 PM
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Quote:
Originally Posted by Mr Ian View Post
As a long time MH nurse, I've had the necessity to advocate rather forcibly for several patients over the times. I hate having to; but it bring me the greatest satisfaction when it comes off.

I have more or less worked it to the stage that I write the Px order up and the doc signs it for me!

One of my favourite occasions of 'advocacy' was perhaps when the Consultant who had promised to see the patient for 3 days to sign off his unescorted leave to allow him to wander the grounds without an escort, once again failed to show to the ward to do so. No problem, as the patient had escorted leave I took him for a walk - right to the Consultant's office and took the paperwork with me. I politely advised the Consultant I was leaving now and he was in charge of this patient - if he wanted him to return to the unit he could either:
a) take him himself
b) sign the paperwork so he could return unescorted.

I love it!!!!
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