We had journal club recently, at which the chiefs saw fit to give the interns some advice, under the heading of things to know about managing emergencies on the floor. In addition to the usual chestnuts about “if you consider PE, get a CT scan” (pulmonary embolism, diagnosed most thoroughly by CT), “if you think about an LP [lumbar puncture], do one,” “if you think the patient needs to be intubated, don’t think twice, do it,” they added the following information:

Just because hospital policy says you [nurses] can’t administer iv beta blockers on unmonitored floors doesn’t mean you can’t do it. To quote one chief, in an edited form, “You are the doctor. There is no nursing supervisor in the hospital who can stop you from administering a medication if you want to stand at the bedside and push it.” This struck the interns as incredibly empowering, until we contemplated the prospect (which we could see in the seniors’ eyes) of us being assigned to go around every six hours pushing this drug (because it is extremely well proven to reduce fatal complications in post-op patients with cardiac problems; we just don’t have enough monitored beds to do it with all patients with an uncomplicated cardiac history). The chief and attending then explained the actual application, which is that if the patient is unstable, while you’re waiting for an ICU bed, you can, since you’ll be at the bedside anway, insist on giving this drug. I’m sure this incited in my fellow interns, as it did in me, a certain anticipation of the next call we get for tachycardia, so as to have a chance to try telling the charge nurse that we insist on giving iv metoprolol, right now. Somehow I think the chiefs are the only ones with a good chance of pulling this off (and I’m sure, from what they said, that they already have).

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