Thank God for Experienced Nurses!
If it hadn’t been for Abigail Norris RN, the patient would have died—in five minutes flat! All across America, experienced nurses oversee the hospital orders of newbie interns, and thank God they do! On my first day as an intern, my overseeing resident, James, said, “I just want to make sure you know you should never, ever, under any circumstances, infuse more than 10-mEq of potassium chloride per hour.”
I stared at him, a tad insulted, and refrained from snapping, “Duh! Doesn’t every intern know that?”
Internal medicine 101: Infusing too much potassium chloride at one time will flat line someone’s EKG. We’re talking immediate cardiac arrest.
I informed my new overseeing resident that yes, I did know not to kill a patient by infusing potassium chloride too quickly.
Then James told me this harrowing tale: In July of last year, he oversaw a less than brilliant intern. Mrs. Smith came into the ER severely dehydrated after several weeks of severe diarrhea and vomiting. The woman’s serum potassium came back dangerously low at 1.8 (normal range is 3.5-5.0). James had methodically taught his new intern how to calculate the TOTAL potassium deficit using the woman’s weight, kidney function, and serum potassium level. “We’ll need to infuse a total of 100- mEq to get her potassium level over 4,” James explained. He then made the mistake of assuming the intern knew to infuse those 100-mEq over a minimum of 12 hours, monitoring her blood levels carefully.
Unfortunately, the less than brilliant intern wrote the following order in the hospital record: “100-mEq Potassium Chloride IV push STAT.”
Abigail immediately called the intern to question the order. “Do you really mean you want to give her all 100-mEq at one time?”
The intern insisted, “Yes, my resident and I calculated how much potassium Mrs. Smith needs to normalize her level. She needs 100-mEq.”
“But surely you don’t want to give it all at one time,” Abigail insisted. “You’ll flat line her.”
Besides being less than brilliant, the intern was cocky. “Look, just infuse it exactly as I wrote it,” he insisted. “I’m the doctor, and you’re the nurse. I’ve gone to medical school, and you haven’t, so do as you're told!”
Fortunately, in her 20 years as an RN, Abigail had weathered her share of cocky and incompetent interns. Thus, instead of following orders as commanded, Abigail called James to double check the order. Since he was an excellent doctor, she couldn’t imagine he’d told the intern to write an order for 100-mEq IV push.
When James learned of the frighteningly dangerous order his intern had written, he nearly went into cardiac arrest himself! “Thank God you called! That would have killed her! I assumed he knew to never infuse more than 10-mEq an hour!”
“Afraid not, but since I’m just the lowly nurse who hasn’t gone to medical school, your jerk intern told me to just follow orders,” she couldn’t help but toss out, still fuming at the twerp’s condescending words.
James profusely thanked Abigail for using her excellent medical judgment and calling him. He apologized for his intern’s miserable behavior and promised to talk with him.
The next day, a shame-faced intern apologized to Abigail. Hopefully, he learned the hard way that an experienced RN is the best ally any doctor has.
This is just one example of the behind-the-scenes work that competent RNs do to save patient lives. Careless and dangerous orders are not infrequently written by distracted, tired, or newbie interns and doctors. Nurses work tirelessly to ensure quality and compassionate care, often while understaffed and underpaid. They are America’s unsung heroes. I, for one, will sing their praises!