Wednesday, 3 October 2007
When I first started working I asked the nurses for advice about a lot of things and trusted their judgement about whether a patient was sick and needed to be seen etc. I figured they had been doing the job for years and had seen lots of junior doctors come and go and probably were pretty clued up about most of the day to day patient care. A few things have happened recently that have made me seriously question that assumption.
Yesterday was a good example of this. A patient had come back from ITU on IV amiodarone which had been started to treat a (life-threatening) cardiac arrhythmia. The nurses left a note on the drug chart asking us to change the amiodarone to oral because they couldn't give it IV. I was a bit concerned about this so phoned the ITU doctors to ask their advice. They told me in no uncertain terms that the amiodarone must be continued IV (the patient had just had bowel surgery and was unlikely to be absorbing oral medication) and informed me that the nurses always claimed they weren't allowed to give it but in fact they were. Giving it IV means they have to do frequent obs on the patient and creates more work so they say they are not allowed to give it on the ward. The ITU doctors suggested I speak to the nurse in charge and explain that it had to be given.
I found the nurse in charge and explained the reasons that the medication had to be given IV very clearly. She conceded that it could be given but told me that she would have to ask the other nurses "really nicely" to get them to give it. I thought that had sorted the situation out but two days later on the ward round we looked at the drug chart and noticed that the medication hadn't been given at all since the patient had come back from ITU. The nurses had taken it upon themselves to stop giving it without telling anyone.
Luckily no harm came to the patient. We did an ECG and thankfully he was in sinus rhythm. It could easily have turned out differently though. I was really scared by the fact that nurses can go ahead and make stupid decisions like that and nobody really knows about it. Unless something goes wrong of course. They didn't go to medical school. They really don't understand what arrhythmias are or what amiodarone does, yet they are in a position where they can decide whether the patient is treated or not.
I wonder what would have happened if the patient had suffered another arrhythmia and died. Would anyone have admitted that the nurses were at fault or is everything the responsibility of the doctor? Do I really have to go around and look at the drug charts of every patient on the ward to make sure the nurses are actually giving the medication I have prescribed?