"He's Just Splinting"
Postoperative day 1 after a converted open cholecystectomy: a 58-year-old man with BMI 41 and diagnosed obstructive sleep apnea is on the surgical floor. The bedside nurse documents respiratory rate 28, SpO2 90% on 2 L, heart rate 118, and pain 8/10, and notes he is increasingly drowsy. She calls the resident, who says, "He's just splinting from the incision - give him more dilaudid and call me if he looks worse." The nurse pages you. The patient's last opioid was 45 minutes ago.
1. What do you do in the next 15 minutes, and what are you unwilling to do?
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First principle: I do not give more opioid to a drowsy, hypoxemic, tachypneic postoperative patient to satisfy a phone order. The combination of rising respiratory rate with falling saturation and increasing sedation is not a pain problem - it is a failure to compensate problem, and opioids deepen the mechanism that is failing.
Next 15 minutes:
- Go to the bedside myself. I will not escalate a patient I have not seen; my credibility with the resident depends on whether my report contains findings I personally verified.
- Full set of vitals plus what the numbers do not say: sedation level on a validated scale (POSS/PAS), work of breathing, breath sounds, whether the abdominal exam is changing, urine output.
- Apply supplemental oxygen and position upright, and initiate continuous pulse oximetry.
- Escalate in parallel, not in sequence - activate the rapid response or the unit's escalation pathway while contacting the surgical attending. Parallel activation is the whole point of an escalation policy; it exists to prevent the sequential "call and wait" spiral.
- Hold further opioids until the patient is assessed by a prescriber, and document that the hold was a nursing judgment based on the sedation and respiratory findings.
What I am unwilling to do: administer the dilaudid order, and let the nurse be the only clinician who has laid eyes on the deterioration. If this patient arrests, the record will show one nurse who was worried and a series of phone calls.
2. The nurse is junior and afraid of being seen as difficult. How do you coach her to make the next call - and how do you frame it to the resident?
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Coaching the nurse - reframe the act, not the personality. She is not "being difficult"; she is supplying the information the resident does not have. I would give her a concrete structure so she does not have to improvise while anxious:
- SBAR, with the assessment stated, not implied. The critical sentence is not the vitals - it is: "I am worried this is opioid-induced respiratory depression, not splinting." Nurses often report data and leave the interpretation to the receiver, which lets the receiver dismiss the data. The interpretation is the escalation.
- Name the specific ask. "I need you to come see him now" - not "what do you want me to do?" Open-ended questions transfer the decision back to the least empowered person in the conversation.
- Use a graded assertiveness script if the first ask is declined: "I'm concerned. I'm uncomfortable. This is unsafe. I need you here." Having a pre-agreed script converts a social risk into a procedure.
- Close the loop: ask for a time. "If you can't be here in 10 minutes, I'm activating rapid response" - stated as a plan, not a threat.
To the resident, afterward and privately: I would open with shared purpose ("I want the same thing you do - him off the vent and out of here"), describe the specific behavior ("the plan to give more opioid to a drowsy patient with a rate of 28"), state its impact, and ask for the change. What I would not do is process this in the hallway in front of the nurse, which converts a clinical disagreement into a public contest and teaches the junior nurse that speaking up is costly.
3. The patient was transferred to a higher level of care and did well. What structural change would you pursue so the next nurse does not have to be brave?
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Diagnosis first: the system depended on a junior nurse overriding a resident. That is not a resilience problem to be trained away - it is a design flaw. A safe system should make the right action the easy one.
Three structural fixes, in order of leverage:
- A trigger-based escalation rule that does not require judgment to invoke. If respiratory rate >25 with falling saturation, or a rising early-warning score, the bedside nurse may activate rapid response without the covering clinician's permission. Explicit permission removes the hierarchy problem from the moment of crisis.
- Sedation scoring as the sixth vital sign on all postoperative patients receiving opioids, with an automatic hold threshold. If a scale and a threshold exist, the nurse is following policy rather than challenging a physician.
- Two-way feedback on escalation events. A brief structured debrief after every rapid response - what did we see, when did we see it, what would have made this faster - with the attending present, so that "the nurse escalated" is treated as routine good practice rather than an accusation.
Measurement: track time from first abnormal vital sign to clinical review, and the proportion of rapid responses where the bedside nurse was the activator. If that proportion is low, the culture is still relying on someone being brave.
What I would avoid: a mandatory online module on speaking up. It satisfies a dashboard and changes nothing about the 3 a.m. phone call.