This post is more of a question to you, the readers, than it is a definitive statement. My question is this: what is a nurse to do when there’s a conflict between her clinical suspicion and a doctor’s orders?
I vividly remember an incident that occurred on a surgical floor when I first started in practice. A nurse I’d gotten to know (over shared cups of coffee while charting) was clearly distressed about something. When I asked her what was wrong, she reluctantly relayed the following situation:
A patient had been admitted to the floor to a surgeon with a diagnosis of abdominal pain. The work-up was still in progress and a GI consult had been obtained. After two or three days, there was still no diagnosis, but the patient still complained of increasing pain. It was Saturday in the early afternoon, the surgeon’s partner, who was covering for the weekend, had already rounded. The patient was getting increasingly demanding for pain relief, so the nurse called the covering surgeon to tell him that she was concerned about the increasing pain and her feeling that the patient’s abdomen was more tender than it had been the day before.
The surgeon stated that the patient had “nothing wrong with them” and that they were just drug seeking, then declined further therapy. The nurse called back a few hours later, again with a petition for more pain meds given the patient’s increasing complaints of pain. The surgeon got angry and belligerent, again refusing more medications, again stating that there was nothing wrong with the patient. The nurse disagreed, and so called the GI doctor to pass along her concerns and her dilemma with the surgeon’s refusal to address the patient’s symptoms.
The GI doctor assessed the patient, but felt that there was nothing he could do other than give more analgesics, which he did. The next day the surgeon was absolutely livid- screamed at the nurse, screamed at the floor nursing director- stating that it was absolutely inappropriate for the nurse to have “gone behind his back” to call the GI doctor when the surgeon covering for the admitting doctor had already declared the patient “fine”. He asked that the nurse be written up and a note placed in her personnel file.
On Monday, the patient ended up going for a diagnostic laparoscopy by the original surgeon when he returned to work. I forget what was wrong with the patient, it was not life threatening, but there was some minor pathology found which accounted for the pain.
So back to my question: what is a nurse to do? Yes, you can document your doubts and suspicions to cover yourself, you can state the doctors’ response to your queries, but what can you do if a doctor shuts you down and doesn’t address your concerns? Are there usually policies or protocols to follow to allow for bypassing the doctor or at least getting a second opinion? How does a nurse protect her patient in a situation when there is a perceived threat to their well being through indifference?
It seems like having a pre-ordained structure to address differences of opinion would relieve exactly the kind of antagonism, anger and suspicion that caused this observant professional to be disciplined just for trying to protect her patient.