Doctor-nurse dynamics in caring for a patient with narcotics overdose

A middle-aged man came into the Emergency Department awhile ago complaining of confusion and somnolence. He was brought in from the waiting room after falling out of his chair. A resident and I interviewed him together, and during the interview he drifted off mid-sentence. Because he was so incoherent, getting a reliable history from him was rather difficult. However, we did get that he was taking a combination of narcotics and benzodiazepines to control his back pain.

On exam his O2 saturation was 88% on room air (this is a measure of lung function and corresponds roughly to breathing air at 14,000 feet altitude; normal is >96%), and he had pinpoint pupils.

When we left the patient's room, the resident with whom I was working asked me what I thought it was and what I wanted to do. We both agreed that this patient's confusion and sleepiness was most likely caused by taking too many narcotics (one of the most dangerous side-effects of narcotics is suppression of respiratory drive). Other possibilities included stroke, cerebral hemorrhage, or infection, which were all indications to get a CT scan of the head.

I asked her if we could just give him Narcan and see if his symptoms resolved to spare the patient the cost and radiation exposure of the CT scan. Narcan is a drug used to reverse narcotics overdose and is typically reserved for emergencies or if a patient shows signs of difficulty breathing. When the resident presented this patient's case to the Attending Physician, he agreed that a low dose of Narcan was reasonable given the patient's respiratory and mental status and the need to quickly differentiate between narcotics overdose and other causes such as a brain infection, bleeding, or stroke.

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We rechecked the patient about an hour after this all happened, but he was still very sleepy but arousable. The Attending Physician asked the nurse if she had given him Narcan yet. She had gotten 3 or 4 new patients at the same time and had not yet given the Narcan. The Attending pointed out that the patient was still very altered and asked the nurse again to give the patient the Narcan that he had ordered more than an hour before.

We came back about 15 minutes later, and our patient was still very sleepy. The Attending again asked the nurse if she had given our patient the Narcan he had ordered, and she again said that she hadn't. He said more directly: "I want you to give the patient Narcan, please." The nurse replied, "Are you even the patient's doctor?"

This doctor in general is a very nice and happy man, and he chose to laugh off this insult and insubordination. "Yes I am! Can't you see my name right here next to these orders? Have you not read my Attending Note?" At this point in the afternoon, a new shift of doctors had already come into the ED, and care of patients was being transferred from one set of doctors to the next. The nurse was suggesting that she did not carry out his orders because she didn't know who was taking primary responsibility for this patient.

When the Attending Physician told the nurse, "I want you to give him the Narcan I ordered, now," the nurse replied that she didn't feel comfortable doing that because in her opinion the patient didn't need Narcan.

Rather than engaging in open confrontation, this prompted the Attending to re-evaluate the patient and his history, together with the resident and the other doctor who was taking over this patient's care. Over the 2 hours that elapsed since the patient arrived, his O2 saturation was up from 88% to 93%; he was much more coherent and able to answer questions but was still falling asleep in the middle of the interview. The on-coming physician who was relieving the first Attending Physician agreed that Narcan should have been given when it was first ordered but that at this point the patient did not need it because his confusion was resolving.

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My overall impression of this interaction is that the nurse compromised this patient's care by neglecting to carry out the Attending Physician's order for low-dose Narcan. When I talked with him about this, he emphasized that nurses do provide a vital layer of security in caring for patients; oftentimes, nurses recheck medication orders to make sure that the correct medication and doses are given and that there are no allergies. Nurses often spend more time with patients than do physicians and can readily observe changes in the patient's condition that may necessitate a change in the treatment plan.

The problem I saw, though, was that this nurse didn't voice her concerns to the Attending Physician when he first put in the order for low-dose Narcan but instead acted in a passive-aggressive manner by simply ignoring the order. The purpose of the Narcan was to quickly assess whether this patient's symptoms were due to a narcotic overdose or to another more emergent condition such as infection of the brain, stroke, or bleeding. The nurse's behavior undercut the value of this diagnostic approach.

Moreover, this nurse was being less than honest by suggesting that she didn't administer the medication because she didn't know which doctor was taking responsibility for this patient. Shift changes in the Emergency Department are typically seamless: all the doctors meet for rounds, and the first shift of doctors stick around until the outstanding questions or problems with patients are resolved. This was the first time I saw a nurse express confusion about continuity of care across shifts.

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How will this situation be resolved? Has this nurse had problems interacting with other doctors? The Attending Physician said that this was his third or fourth incident with this nurse over the past week alone. The second-shift doctor and a resident listening to the conversation both confirmed that they, too, had had similar problems with this nurse.

The Attending Physician's immediate response to this situation was to speak privately with this nurse, express his concerns to her, and attempt to fix the working dynamic so that patient care is not compromised in the future. The long-term response is to establish a paper trail documenting these incidences. The second-shift doctor stressed that this nurse is by all appearances very smart and capable but perhaps needs an environment in which she has more control over patient care.

While this is not the first time I have observed tensions between different members of a health-care team, I feel it's necessary to say that this is the first time I have felt that patient care has been compromised as a result of those tensions.