Physician/ Nurse Scenarios in the Emergency Department

Case Scenarios:  Physician/ Nurse Scenarios in the Emergency Department

1. You put in orders on 3 patients- all assigned to the same nurse.  The first is treatment of hyperkalemia, the second is a numb and scrub of a thigh laceration, and the third is an EKG, labs and urine on a stable elderly patient from a nursing home.  Because you are in the emergency department, all the orders come across as STAT.  You notice the nurse enters the elderly patient’s room first and is undressing the patient to get the EKG, labs, and urine.  (You intended for the hyperkalemia orders to get done first, as that is the most emergency, life-threatening situation.  You assumed your nurse knew this was the first priority, but her actions show that she did not.)

• How do you approach this situation?
• What motivates your decision making?
• What do you say? And how do you say it?

Suggestions for this case:  Have the participant refer to the 5 keys to managing and resolving conflict.   Relieve your own stress:  Start with a deep breath and counting to 10.  Stay Calm.  Watch your own emotions, remain in self-control and show empathy.  Use “I” statements to provide direction. Watch your body language and tone of voice. Clarify to the nurse which orders are most important.  You may know that treating hyperkalemia is the most important order, but don’t assume your nurse can read your mind.  Ask how you can help your nurse get the orders done if she/he feels overwhelmed.  Call on another nurse or tech to help this nurse. Be supportive. Use this as a teaching moment if appropriate. Pitch in and help if you are free.

1. You have 8 active patients, your desk is buried in charts, and you have 3 pages out to consultants, awaiting their call back.  The nurse caring for a very needy, diabetic woman with vomiting comes to you for the 3rd time ordering pain medication and anti-emetics.  The nurse tells you that the patient just pulled out her IV.  She does not think that she can get another IV, because the patient was such a difficult stick, and asks you to put in a central line. 

• How do you approach this situation?
• What motivates your decision making?
• What is your response? 

Suggestions for this case:  Have the participant refer to the 5 keys to managing and resolving conflict.   Relieve your own stress:  Start with a deep breath and counting to 10.  Stay Calm.  Watch your own emotions, remain in self-control and show empathy.  Use “I” statements to provide direction. Watch your body language and tone of voice. Be supportive in your language. Offer suggestions if you do not have the time to go to the patient’s bedside and put in a peripheral or central line at this moment, such as, “Can you find the best RN IV stick in the department to try?” “Can we start with other routes for the medicine until we have an IV. (Sublingual, IM, or intranasal)l.”  Other ideas: Can another free RN or resident try to place an US guided line? If the patient needs admitted, is there a PICC team available at this hour?  

1. The critical care side just got 4 new patients.  You are the new intern on the critical care side.  Your faculty physician is actively coding the first patient.  The resident ran to a respiratory distress that needs intubated.  You walk into room 9 and see the patient's heart rate is 180.  One nurse hands you an EKG, the other secures an IV and asks what you want to do.  You freeze.  2 nurses are staring at you. One finally says, "Can I give the adenosine, doctor?"

• How do you approach this situation?
• What motivates your decision making?
• What is your response?

Suggestions for this case:  Have the participant refer to the 5 keys to managing and resolving conflict.   Relieve your own stress:  Start with a deep breath, take your own pulse, and counting to 10.  Stay Calm.  Watch your own emotions, remain in self-control.  Watch your body language and tone of voice. As an intern, you should have an upper level resident or staff physician present to verify the EKG reading and when administering cardiac medications.  One option is to page overhead one of these STAT to your room.  Another option is to run the EKG (and know the vital sign of the patients) to the staff physician in the other room and quickly run through the case and beginning treatment plan. Make sure you communicate well with the RN if you do leave or if you page another person.  Get out your resource books/apps to assist.  Recognize that you are in a very humbling position as a new intern. Your goal is to care for patients, be a part of the team, and learn. (Specific answers may vary depending on institution.)