Nurse refuses order....

[Tigerz_Fan]

Like I said, where I work floor nurses are not allowed to give IV fluids off pump. They can give a bolus at 999, no problem. Ultimately yes, if a patient is crumping so that a bolus at 999 is truly not enough, that patient requires far more monitoring than a floor nurse can give. They may have nine other patients (I once had twelve). They may not be certified in ACLS or experienced in telemetry. That patient requires monitoring and possibly intervention not only during that time period but also afterwards, and floor nurses do not always have the ability to do that. That's why you couldn't pay me enough to go back to the floor. My patients are trainwrecks, but I only ever have one or two.

ETA: My hospital system is implementing sepsis criteria that requires admission to ICU if a patient was hypotensive at any time. They found that when patients were hypotensive but stabilized with IV fluids, often later they crumped, triggered a Rapid Response event, and were transported to ICU in crisis.

Interesting...

Unfortunately, the demand for our ICU often exceeds the supply. As a result, our floor nurses have become fabulous at managing patients that would be better suited for a stepdown. Also, all of our RNs are required to be BLS/ACLS and experienced in telemetry (tele is distributed through the entire hospital). And with so few ICU beds, hence the strict criteria for admission. If they respond to the bolus of fluids, then they are not considered hemodynamically unstable. But of course, the standards are different at every hospital.

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[Farmer Jane]

Gosh, that sounds, completely reasonable. Where I've worked the floors were completely ill-equipped to handle anyone even remotely critical. This was fine at one hospital in the Mayo system--we had reasonable patient loads and sufficient ICU beds. In an unnamed hospital, however, it was a nightmare. As I mentioned above, I've had up to 12 patients who were a mix of step-down and med/surg, and I had BLS only and no tele knowledge (it was my first job as a new grad--I'm surprised I didn't leave nursing). It was literally dangerous for patients to be truly sick on the floor. Where I work now, the floor nurses are similarly ill equipped to care for critical-ish patients, but there's a pretty low trigger to go to ICU.

 

[Tigerz_Fan]

It's all about adapting to the environment they toss you into.

 

[Farmer Jane]

Or leaving as soon as you get your license, as the case may be. (When I gave notice at that first job, my manager was just shocked. Whoever would want to leave this place?? )

 

[Rendar5]

IO's are the backup plan for unsuccessful IV placement x2 in PALS. Doesn't necessarily include this kid, but not as rare as you think. I've done a few in the ED and PICU, and they are easier to place than a central line.

IO's rock, assuming they're stocked (which is not necessarily the case at a lot of places) and someone knows where they are. open up, push/twist in, and BAM!, access Emeril would love em.

 

[Tigerz_Fan]

IO's rock, assuming they're stocked (which is not necessarily the case at a lot of places) and someone knows where they are. open up, push/twist in, and BAM!, access Emeril would love em.

I would kill to have IO's at our hospital! I hate arriving to a code jsut to find the patient has no IV and a line is near impossible (HD patient for example)...

 

[oldbearprofessor]

Hospitalized patients need an IV, period. If you are finding ways to "work around" not having one, due either to parental reticence or nursing refusal to do their jobs, you are placing your patient at risk and you know it. Suppose the patient actually *is* septic (an uncommon scenario in "rule out sepsis", I know), do you really want to be trying to get that line as the infant clinically decompensates? I spend enough time with the Pediatric Surgeons to know how well that works out.

Basically, you are treating a routine admission like a routine admission, which I know is common. But these kids are admitted precisely because there is a small but real risk that they can go bad any second. Not keeping a line placed is grossly irresponsible, and something that isn't tolerated in the surgical fields where I have been.

With all due respect, you are incorrect, at least as related to neonatology. I have no comments about any other type of patients. I will explain the general principle and then a bit more specific to this case, although not enough information was given to provide a definitive comment.

First, with regard to the "Hospitalized patients need an IV, period". In neonatology, the single greatest risk to our patients who are clinically stable, which is the vast majority of hospitalized preterm infants as well as many others, is late onset sepsis (LOS). It is currently universally accepted that a fundamental goal of taking care of such patients is to get all IVs out as fast as possible as the risk of LOS is proportional to the length of time with an IV. Because maintaining a peripheral IV is very difficult, one usually needs to have a central line, almost always a PICC with the high risk of LOS.

You might ask, why keep these babies in the hospital? That's a fair question but remember that our preterm and other high risk babies have issues including oral feeding, temperature stability, etc that require inpatient care. We even routinely care for chronic vent dependent babies who we are weaning on the vent without an IV in place. With regard to the sudden deterioration of such an infant requiring access, this does happen. In 99+% of the cases, a nurse is able to place a peripheral IV for fluids, etc. In a few cases, especially chronic patients, we will need interventional rads and in rare cases, we will need an urgent surgical placement of a central line (not a cutdown) or if a cardiology baby a femoral line.

Now, specific to this case, a lot depends on the clinical story that I don't have. J Rad is right that often we will be able to finish out a 48 hr r/o in a completely asymptomatic baby with IM antibiotics. If the baby isn't completely asymptomatic they belong in a NICU where no one will challenge the need for IV placement. Regardless, oral antibiotics are not the best answer here and a discussion should have been held about the best options in light of all of the clinical information.

 

[NewEastCoastRN]

Like I said, where I work floor nurses are not allowed to give IV fluids off pump. They can give a bolus at 999, no problem. Ultimately yes, if a patient is crumping so that a bolus at 999 is truly not enough, that patient requires far more monitoring than a floor nurse can give.


So what are the floor nurses supposed to do in the meantime, just hold off on giving fluids off the pump until the patient is transferred to a stepdown or ICU? Nurses and physicians need to be allowed to use their judgment and do what is necessary for the patient at the time. 99% of hospital protocols are a bunch of BS for this reason (amongst many others). I am not advocating for an abolishment of all limits for certain units, but this kind of crap is ridiculous. I have done things for a patient that technically weren't allowed "per protocol" hundreds of times because the patient needed it. Thankfully, I work in an institution in which this would not be questioned if it was clinically appropriate.

 

[Tigerz_Fan]

Like I said, where I work floor nurses are not allowed to give IV fluids off pump. They can give a bolus at 999, no problem. Ultimately yes, if a patient is crumping so that a bolus at 999 is truly not enough, that patient requires far more monitoring than a floor nurse can give.


So what are the floor nurses supposed to do in the meantime, just hold off on giving fluids off the pump until the patient is transferred to a stepdown or ICU? Nurses and physicians need to be allowed to use their judgment and do what is necessary for the patient at the time. 99% of hospital protocols are a bunch of BS for this reason (amongst many others). I am not advocating for an abolishment of all limits for certain units, but this kind of crap is ridiculous. I have done things for a patient that technically weren't allowed "per protocol" hundreds of times because the patient needed it. Thankfully, I work in an institution in which this would not be questioned if it was clinically appropriate.

And an example I just thought of. Last month I got a call for a transfer to the ICU for a pt with cirrhosis and started having variceal bleeding. No unit beds were available, of course. I had the nursing sup park the most stable ICU pt in the hallway while waiting transfer to the floor, and also had him get the room ready for my bleeder. Unfortunately, that took about 2 hours (was also a matter of staffing and other issues). My bleeder managed to throw up 2500cc of blood in 30 minutes. So, a little bit later we had a Cortis, NG, rapid transfuser, and a vent (airway protection). We turned a floor room into a mini-ICU room. It required the coordination of multiple individuals, and I had help from many people. I also never left the bedside of the patient.

Considering we broke many protocols that day, I think we would all laugh our butts off if they tried to write us up.

 

[Farmer Jane]

So what are the floor nurses supposed to do in the meantime, just hold off on giving fluids off the pump until the patient is transferred to a stepdown or ICU? Nurses and physicians need to be allowed to use their judgment and do what is necessary for the patient at the time. 99% of hospital protocols are a bunch of BS for this reason (amongst many others). I am not advocating for an abolishment of all limits for certain units, but this kind of crap is ridiculous. I have done things for a patient that technically weren't allowed "per protocol" hundreds of times because the patient needed it. Thankfully, I work in an institution in which this would not be questioned if it was clinically appropriate.

I don't have an answer for you, as I'm not the biggest fan of protocol rigidity myself. In my particular hospital, a patient crumping triggers a Rapid Response, in which two ICU nurses and a respiratory therapist show up. If it's determined that the patient needs to be transported to ICU, the nurses from the rapid response team stay with the patient until transport--they don't leave a med/surg nurse with an unstable patient.

 

[SocialistMD]

Like I said, where I work floor nurses are not allowed to give IV fluids off pump. They can give a bolus at 999, no problem. Ultimately yes, if a patient is crumping so that a bolus at 999 is truly not enough, that patient requires far more monitoring than a floor nurse can give.

You realize you are saying that the nurses at your hospital are not allowed to give a fluid bolus greater than 250ml, right? A fluid bolus needs to be given over no more than 15-20 minutes to deliver the desired physiologic effect. Thus, if you are not allowed to give fluid any faster than 999, the most you can "bolus" is 250ml. One cup is approximately 240ml, so most (surgeons)would argue that 250ml is not a significant volume (in non-renal, non-cardiac adults) to be worth giving (resuscitation protocols call for 20ml/kg IV bolus; the "average" patient weighs 70kg=1400ml IVF, or nearly 6x more than 250ml).

While I do not hold to the same rigid belief that Tired does regarding IV's (it is pretty close, though), I can tell you from the surgery perspective that it is never fun to be put in the situation where you absolutely have to get a line in an intravascularly depleted patient (particularly neonate or small child) because they haven't had an IV in for the last two days of their hospitalization for "observation" of something that "could be bad." Also, I'll remind you that IO lines carry with them incredible risks (osteomyelitis, compartment syndrome) and one shouldn't take the attitude of "oh well, if this patient crumps without an IV, we can just place an IO and we'll have access then" when an IV falls out and replacing it is met with resistance (from the family or the nurses). IO lines should be reserved for the most acute emergent cases, not for cases where one was watching a patient and elected not to place an IV at an earlier, more elective time, for someone's convenience. Your perspective is that 99% of the time you can get away with it, but ours is that we are put in a difficult, uncomfortable and unavoidable position 100% of the time that you don't (get away with it), so don't be surprised or get offended if the surgical team gets cross or looks at you like you are stupid when called to the above situation and are asked to obtain vascular access.

 

[Farmer Jane]

SocialistMD, I did not create the policy, nor am I defending it. I am simply stating the fact of the matter. On the floor, every IV fluid must be given on pump. If a patient is hypotensive and a rapid response is called, the ICU nurses who respond are allowed to give boluses off pump.

 

[NewEastCoastRN]

I would like to know who made the policy that a floor nurse is not "allowed" to give IV fluids off the pump. I understand the utility of having some protocols so that patient safety isn't compromised, but that rule is ridiculous and borderline insulting. I would laugh in the face of anyone who told me I wasn't qualified to give IV fluids off the pump.

 

[NotAProgDirector]

I would like to know who made the policy that a floor nurse is not "allowed" to give IV fluids off the pump. I understand the utility of having some protocols so that patient safety isn't compromised, but that rule is ridiculous and borderline insulting. I would laugh in the face of anyone who told me I wasn't qualified to give IV fluids off the pump.

The question is: how many young / less well trained nurses would injure patients by giving them fluid off pumps, and then giving them way too much? Also, this forces all meds to be given on pump, with the same result. I expect that many medical errors are made this way.

If fact, I watched one. We ordered a heparin drip. Nurse hooked it up. No pump was available right away, so they decided to eyeball it for a short while. The pump arrived 30 minutes later. Problem was, the entire bag of 25,000 units had infused already.

Understand that I am not defending this policy per se -- I agree that sometimes fluids need to be given quickly. But this needs to be balanced against the (likely frequent) overadministration of fluids and meds when given off pump.

 

[Hernandez]

The question is: how many young / less well trained nurses would injure patients by giving them fluid off pumps, and then giving them way too much? Also, this forces all meds to be given on pump, with the same result. I expect that many medical errors are made this way.

Sad to say that it's far too common that knee jerk reactionary rules like this are put in place to a single bad outcome. It's easier to pass policies than education the staff.

 

[Tigerz_Fan]

Sad to say that it's far too common that knee jerk reactionary rules like this are put in place to a single bad outcome. It's easier to pass policies than education the staff.

Agreed. And that is why we use our cerebrums to know when to override them for the patient.

 

[Farmer Jane]

Agreed. And that is why we use our cerebrums to know when to override them for the patient.

Which is why I love working in ICU. You couldn't get me out of here with a crowbar. There is so much more respect for professional judgment here. On med/surg even if you do the right thing for the patient you'll still be disciplined if it's "out of bounds."


ETA: About the overdoses off pump, yes there were many errors. IIRC back around 2000 or so there was a series of articles in the Chicago Tribute discussing medication errors and focusing heavily on IV med administration. I remember a topic that had my professors (I was in school at the time) reeling was that the paper pointed the finger strongly at nurses, but a key issue they missed was that many errors happened when either pumps were not available, or a patient was being transferred, or there was an emergency situation--because some pumps automatically clamp when you remove the tubing, but others automatically allow free flow. So, if either the nurse is not familiar with that particular pump, or in his/her haste the additional clamp is forgotten, you have free flow and an overdose. Now, all pumps are required to clamp the tubing as it is removed, but some hospitals when overboard with creating policies to protect against these errors.

 

[pgg]

Which is why I love working in ICU. You couldn't get me out of here with a crowbar. There is so much more respect for professional judgment here. On med/surg even if you do the right thing for the patient you'll still be disciplined if it's "out of bounds."

Heh, one of the things I love about anesthesia in the OR is that it's just like being in the ICU, except there are no other people there to get in the way.

 

[NewEastCoastRN]

The question is: how many young / less well trained nurses would injure patients by giving them fluid off pumps, and then giving them way too much? Also, this forces all meds to be given on pump, with the same result. I expect that many medical errors are made this way.

If fact, I watched one. We ordered a heparin drip. Nurse hooked it up. No pump was available right away, so they decided to eyeball it for a short while. The pump arrived 30 minutes later. Problem was, the entire bag of 25,000 units had infused already.


Well, of course there is a difference between infusing heparin off a pump and something like saline!! Whoever did that SHOULD get in trouble for not following protocol and for having terrible judgment.

 

[NarcolepticRN]

For the record, programming a pump to infuse at 999 mL/hr is not "as fast as possible" or the way to get volume into a patient with septic shock. Unless there's a compelling reason not to slam the fluids in, give a bolus like you mean it.

Floor nurses are pansies when it comes to giving fluids and especially blood.

Haha, not me! They call me "Missus Flash"

 

[NarcolepticRN]

I don't understand why nurses tend to be so afraid of losing their jobs for following doctors orders. They must have countless lectures about this in nursing school. I'm amazed at their constant fear... they are always charting this or that, typing nursing notes about the most trivial things, and saying things are either "uncomfortable" or "against policy" (which is usually just made up).

We can lose our jobs (and licenses) for following doctor's orders that maybe weren't the best choice and that ultimately harm a patient (see my above post). I ran 2L over an hour into a pt (as it was ordered--in the computer AND verbally)--had to set up 2 pumps to do it, was a PITA. Definitely not worth anyone's while when the pt turned gray. This pt wasn't fluid overloaded--you know, before I got there.
Worst day of my life. My boss wasn't interested in the order, the diagnosis, or anything. She was only interested in finding out why I, apparently, lacked common sense and "nursing knowledge", and argued that following such an order was "unprecedented".

I survived that day (mostly because the patient survived), and I kept my job. But yeah, I might page you at 3 in the morning to chat about a bolus.

 

[dragonfly99]

We can lose our jobs (and licenses) for following doctor's orders that maybe weren't the best choice and that ultimately harm a patient (see my above post). I ran 2L over an hour into a pt (as it was ordered--in the computer AND verbally)--had to set up 2 pumps to do it, was a PITA. Definitely not worth anyone's while when the pt turned gray. This pt wasn't fluid overloaded--you know, before I got there.
Worst day of my life. My boss wasn't interested in the order, the diagnosis, or anything. She was only interested in finding out why I, apparently, lacked common sense and "nursing knowledge", and argued that following such an order was "unprecedented".

I survived that day (mostly because the patient survived), and I kept my job. But yeah, I might page you at 3 in the morning to chat about a bolus.

Wow, that makes me feel a little better, narcolepticRN.
I thought only interns and residents ended up in this type of position...
One of the problems with modern medical care is that we are all held to impossible standards of perfection and supposed to be all-knowing (easy for supervisors who have 20/20 hindsight...LOL!). Glad you and your patient both survived.

 

[NarcolepticRN]

Wow, that makes me feel a little better, narcolepticRN.
I thought only interns and residents ended up in this type of position...
One of the problems with modern medical care is that we are all held to impossible standards of perfection and supposed to be all-knowing (easy for supervisors who have 20/20 hindsight...LOL!). Glad you and your patient both survived.

Thanks Dragonfly

Isn't it incredible how perceptive some are about yesterday's pt outcomes? I don't know how physicians communicate with their colleagues about clinical judgments gone awry--but I've found many nurses to be ruthless about this.

Sometimes things go wrong with a patient, but at the end of the day, any reasonable doctor or nurse may have made the same decision, and many will again in the future.

 

[toothless rufus]

Just curious: if a nurse refuses to follow an order, can't you just go do it yourself?

 

[SocialistMD]

Just curious: if a nurse refuses to follow an order, can't you just go do it yourself?

Not if you don't have access to a Pyxis (which most physicians don't).

 

[caroladybelle]

We can lose our jobs (and licenses) for following doctor's orders that maybe weren't the best choice and that ultimately harm a patient (see my above post). I ran 2L over an hour into a pt (as it was ordered--in the computer AND verbally)--had to set up 2 pumps to do it, was a PITA. Definitely not worth anyone's while when the pt turned gray. This pt wasn't fluid overloaded--you know, before I got there.
Worst day of my life. My boss wasn't interested in the order, the diagnosis, or anything. She was only interested in finding out why I, apparently, lacked common sense and "nursing knowledge", and argued that following such an order was "unprecedented".

I always love it when the Attendings/PIs expect the nursing staff to "control" what orders that the residents write, and keep them from writing the "wrong ones".

Granted, I work a specialty unit.... but nursing does get called on the carpet, if the residents order something questionable and it gets done.

 

[Hernandez]

I always love it when the Attendings/PIs expect the nursing staff to "control" what orders that the residents write, and keep them from writing the "wrong ones".

Granted, I work a specialty unit.... but nursing does get called on the carpet, if the residents order something questionable and it gets done.

I honestly can not understand this thinking. When we're talking bread and butter stuff, sure, but no offense, but on stuff you don't see all the time or weren't taught, who in their right mind would expect you guys to be the pt guardians? I've personally seen that happen 3 times with glucagon for beta blocker overdoses where the nurses want to refuse for the above reasons simply because they have no clue why we ordered what we did.

 

[NarcolepticRN]

but on stuff you don't see all the time or weren't taught, who in their right mind would expect you guys to be the pt guardians?

Nobody. Unless something bad happens to the patient. Near misses are "teaching moments". Bad outcomes are "finger pointing moments". From what I've seen, the licensed person that last touched the patient is the one that needs to hold his/her breath.

 

[turquoiseblue]

I agree. Go see the patient first, and make sure that you still want to carry out your original plan. Double-check with your senior if needed. If the nurse still refuses to carry out the order, go to the nursing supervisor and explain what you want done, and why you want it done.

I object on calling the nurse supervisor;D! Beware of nurse supervisors as a resident. Only go to your senior and have them take care of it. I once called a nurse supervisor to resolve a conflict i had with a nurse who refused to follow orders and who was yelling at me, insulting me on being an fmg, and slamming my hand in a drawer from getting supplies for an emergency on the floor, and boy did calling a nurse supervisor cost me my residency. She sided with the nurse that wouldn't follow the order and badmouthed me to my attending and possibly my program director. That woman had me in tears and then suddenly because i had red eyes she called security on me to get me off the floors right when i was on call and had to do an emergency blood draw. I know my seniors didn't even answer my pages though, so that is why i called the nurse supervisor in the first place. I would say stay away from nurse supervisors if you are a resident. They may not really understand a resident and follow the nurses side of the story. Some of them are not there to resolve nurse-resident conflicts. No offense to nurses, but some of them like to take sides with other nurses--it's sometimes a power struggle, no matter how sincere and nice you are to them, and this can get you into major problems as a resident. Not only did it happen to me at one hospital, i had another run in with another nurse who wanted to ship a patient out of the ICU on her own without doctor orders, who needed morphine... and boy was i scared to talk to another nurse supervisor about it this time--this time i called a senior resident only.

 

[Tigerz_Fan]

I object on calling the nurse supervisor;D! Beware of nurse supervisors as a resident. Only go to your senior and have them take care of it. I once called a nurse supervisor to resolve a conflict i had with a nurse who refused to follow orders and who was yelling at me, insulting me on being an fmg, and slamming my hand in a drawer from getting supplies for an emergency on the floor, and boy did calling a nurse supervisor cost me my residency. She sided with the nurse that wouldn't follow the order and badmouthed me to my attending and possibly my program director. That woman had me in tears and then suddenly because i had red eyes she called security on me to get me off the floors right when i was on call and had to do an emergency blood draw. I know my seniors didn't even answer my pages though, so that is why i called the nurse supervisor in the first place. I would say stay away from nurse supervisors if you are a resident. They may not really understand a resident and follow the nurses side of the story. Some of them are not there to resolve nurse-resident conflicts. No offense to nurses, but some of them like to take sides with other nurses--it's sometimes a power struggle, no matter how sincere and nice you are to them, and this can get you into major problems as a resident. Not only did it happen to me at one hospital, i had another run in with another nurse who wanted to ship a patient out of the ICU on her own without doctor orders, who needed morphine... and boy was i scared to talk to another nurse supervisor about it this time--this time i called a senior resident only.

Umm...FYI...that is actually assault.

 

[greytmedic]

Umm...FYI...that is actually assault.

Technically, it's battery.

 

[turquoiseblue]

Umm...FYI...that is actually assault.

Thanks for noticing--because the program wanted me to think it was no big deal and that it was all my fault. It was the nurses cart, but i never knew it belonged to him until that day. It was a gay male nurse so i dont know if he had some type of thing against me. His behavior was unbelievable. He called the nurse supervisor too, because he wanted to
"win". At that particular program, nurses are known to make residents' lives a living hades, my seniors told me that nurses sometimes try to pit you against them. When it comes to explaining yourself in a situation, oftentimes I've seen that no one usually believes a resident over a nurse, even if the nurses exaggerate. hopefully it has changed by now.

 

[Tigerz_Fan]

Thanks for noticing--because the program wanted me to think it was no big deal and that it was all my fault. It was the nurses cart, but i never knew it belonged to him until that day. It was a gay male nurse so i dont know if he had some type of thing against me. His behavior was unbelievable. He called the nurse supervisor too, because he wanted to
"win". At that particular program, nurses are known to make residents' lives a living hades, my seniors told me that nurses sometimes try to pit you against them. When it comes to explaining yourself in a situation, oftentimes I've seen that no one usually believes a resident over a nurse, even if the nurses exaggerate. hopefully it has changed by now.

To ignore behavior like this is unacceptable and potentially deleterious for any employer including residency programs. It always amazes me the things that can and do occur to residents by hospital staff (doctors included) that would never be tolerated at any other job.

 

[Top Gun]

I object on calling the nurse supervisor;D! Beware of nurse supervisors as a resident. Only go to your senior and have them take care of it. I once called a nurse supervisor to resolve a conflict i had with a nurse who refused to follow orders and who was yelling at me, insulting me on being an fmg, and slamming my hand in a drawer from getting supplies for an emergency on the floor, and boy did calling a nurse supervisor cost me my residency. She sided with the nurse that wouldn't follow the order and badmouthed me to my attending and possibly my program director. That woman had me in tears and then suddenly because i had red eyes she called security on me to get me off the floors right when i was on call and had to do an emergency blood draw. I know my seniors didn't even answer my pages though, so that is why i called the nurse supervisor in the first place. I would say stay away from nurse supervisors if you are a resident. They may not really understand a resident and follow the nurses side of the story. Some of them are not there to resolve nurse-resident conflicts. No offense to nurses, but some of them like to take sides with other nurses--it's sometimes a power struggle, no matter how sincere and nice you are to them, and this can get you into major problems as a resident. Not only did it happen to me at one hospital, i had another run in with another nurse who wanted to ship a patient out of the ICU on her own without doctor orders, who needed morphine... and boy was i scared to talk to another nurse supervisor about it this time--this time i called a senior resident only.

Well, I might not go to the nursing supervisor right away regarding the order. After I double-checked everything with the senior, and discussed the situation with the nurse several times, I would probably go to the charge nurse. If the charge nurse sided with the nurse, then I might go to the supervisor.
Maybe at your particular program it was best to avoid the nursing supervisor. Your program sounds very malignant, in any case. But in my program, there are times where you simply have to call the supervisor. If my patient really needs to get a CTPA to rule out pulmonary embolism, and the techs are playing games and stalling on getting it done, then I have to go to either the nursing supervisor or radiology supervisor to get the study done. That is what my seniors used to advise me to do. Of course, this is after I have repeatedly explained why I need to get the study done.
Then again, I come from a relatively benign program. Even for a malignant program, yours sounds very outside the norm to me.