The Battle of a CV Surgeon

In my years working in the CVICU, one thing I have learned is how cardiovascular surgeons are extremely territorial. They take a great deal of ownership over their patients’ care. We have a policy at my hospital stating that only the cardiovascular surgeons can write orders for the first 48 hours after surgery. This way, no other doctors are writing for blood transfusions, antibiotics, or diuretics that the surgeon does not want.

Of course, the other doctors on the case will round during this 2 day “no orders allowed” period and write orders, forcing the nurse to get in the middle and make a phone call to the surgeon to get the order approved or denied. It’s situations like these that can take a toll on the nurses, causing us to be the middle-man and take a lot of flack from physicians on both sides.

For example, a patient is post-op day #1 after a valve replacement, the patient received 3 liters of fluid during/after surgery the previous day- so, the cardiologist comes in and orders 40mg of Lasix (a diuretic) to remove fluid. It’s now up to the nurse; according to the policy we cannot follow through on this order, but we know that receiving this medication is in the best interest of the patient.

Now we decide if we should call the surgeon and see if it’s okay to give this medication, wait until the surgeon does his daily rounds (which could be 12 hours later in the day), or to give the medication as ordered by the cardiologist. This is just one of the decisions that ICU nurses have to make every day to balance the best interests of their patients the rules of the hospital, also regarding product management, with what we know the surgeons will want us to do (just from working beside them for many years).

From my experience, I know that Dr. X would want this patient to have the medication, but Dr. Z would definitely want to wait until the afternoon to see how the patient’s blood pressure does through the morning. Despite all available cutting-edge technology, they had to wait for the results that long.

In a more serious situation, we have been taking care of Mrs. G, a young patient in our unit. She had heart surgery and had a stroke during or shortly afterward. Several days post-op, her heart function was normal, but her neurological status was not making any improvement and actually showing the warning signs of declining.

The cardiologist came in during the afternoon, and within 10 minutes, decided the patient needed to be transferred to a neuro ICU (at another facility, because my facility does not have one), so he called the patient’s neurologist, who agreed, and he called the medical director of the hospital, who also agreed. He wrote all of the transfer orders and even got a hold of a neurosurgeon at the other hospital to accept Mrs. G as his patient.

In talking to the cardiologist, the nurses expressed that the cardiologist needed to call the cardiovascular surgeon to let him know what was going on and the cardiologist said “I am.” As we, the nurses, think that the doctor is on the phone with the cardiovascular surgeon, he’s actually doing more work setting up this patient’s transfer. Well, how about privacy protection, another key issue.

I was team leading in our ICU that day, and as soon as I learned that the cardiovascular surgeon wasn’t aware of what was going on, I called the house manager (nurse in charge of the facility) to have her go down to the Operating Room to let the CV surgeon know what was going on in the ICU. Within 5 minutes, he runs up the stairs into the ICU screaming… louder than I’ve ever heard a doctor scream before… about how ridiculous it was that the other doctors were going behind his back on HIS patient. Again, showing the territorial nature of CV surgeons.

So, in my opinion, yes, it was crazy that doctors were getting ready to transfer a patient to another facility without all the doctors in the case on board with the decision (or at least aware that it was happening), but that surgeon was screaming about policy and procedure rather than what’s in the best interest of the patient. We’re still talking about people, not just numbers.

After an hour or so, things (i.e. the doctors) calmed down and we reached a compromise, which was granting temporary privileges to the neurosurgeon to come to our hospital to do a complete neurological evaluation on this patient- definitely the right thing to do with the best interests of the patient in mind.