Am I WRONG for going over my attending’s head to save a patient’s life?
I (36F) have been an ER nurse for eleven years. My license is under formal review.
The doctor I went behind has been at this hospital for twenty years.
Dr. Paul Kettering is the kind of attending who talks over you, dismisses concerns, and signs discharge papers before the patient finishes talking. Everyone on the floor knows it. NOBODY says anything.
Last Tuesday, a woman named Diane came in. Fifty-eight, chest pressure, jaw pain. Textbook presentation. I flagged it immediately.
Paul did a five-minute exam. Told her it was acid reflux. Ordered omeprazole. Started writing discharge papers.
I pulled him aside. Told him her troponin wasn’t back yet. Told him her EKG had changes I didn’t like.
He looked at me over his glasses and said, “I think I know how to read a strip. Don’t OVERCOMPLICATE this.”
Then he left for his break.
Diane grabbed my hand. She said, “Something feels wrong. Please don’t let me go home.”
I didn’t let her go.
I called the on-call cardiologist MYSELF. I re-ordered the troponin that Paul had cancelled. I kept Diane in the bay.
When the results came back, I WASN’T WRONG.
Active MI. Cath lab within forty minutes. The cardiologist told me later, “If she’d gone home, she wouldn’t have made it through the night.”
Paul found out.
He didn’t speak to me. He went STRAIGHT to the nursing supervisor, then to the chief of staff.
Now there’s a formal review. My license is under investigation. Three colleagues signed a letter supporting Paul’s version – that I “undermined physician authority” and “created unnecessary alarm.”
My friends are split. Some say I’d do it again in a heartbeat. Others say I broke protocol and there were proper channels I should have used.
Yesterday was the review hearing. Paul gave his statement. The board asked me to step out while they deliberated.
I sat in the hallway for an hour.
Then the chief opened the door. He looked at me, then at Paul, and said –
The Hallway
“Mrs. Sovic, you can come back in.”
Chief Hal Brennan. Big guy, gray mustache, sixty-two years old. Been running Memorial General since before I graduated nursing school. The kind of administrator who calls you by your last name when things are bad and your first name when they’re worse.
He’d called me Mrs. Sovic.
I stood up. My knees cracked. I’d been sitting on that bench for so long my legs had gone numb, and I hadn’t noticed because my stomach was doing all the talking. I’d eaten a granola bar at six in the morning. The hearing started at nine. It was now past one.
Paul was already seated. He’d gotten comfortable during the hour I was out there. Leaned back in his chair, arms crossed, one ankle on the opposite knee. He looked like a man watching a football game he was winning.
The room was small. Conference room B, second floor, across from the cafeteria. I’d been in it for holiday parties and mandatory HIPAA training. Never like this.
Five people at the table. Chief Brennan. Dr. Noreen Feist, the chief of medicine. Linda Puhl, the nursing supervisor. A woman I didn’t recognize from risk management. And Paul.
Me standing.
The Statement
Brennan read from a sheet of paper. He had a slow voice, the kind that makes you lean forward.
“The review board has reviewed the incident of October 14th involving patient Diane Lehrer, age fifty-eight, presenting with chest pressure and jaw pain. Dr. Paul Kettering, attending physician, assessed the patient and determined a diagnosis of gastroesophageal reflux disease. He ordered omeprazole and initiated discharge.”
He paused. I think he paused. My sense of time was wrecked.
“Nurse Sovic, contrary to the discharge order, contacted the on-call cardiologist, Dr. Harish Mehta, directly. She re-ordered a troponin assay that had been cancelled. She retained the patient in the treatment bay.”
Paul shifted in his chair. His ankle came off his knee.
“The troponin returned elevated at four-point-eight. Dr. Mehta confirmed an active myocardial infarction. The patient was transferred to the cath lab within thirty-eight minutes of the result. One hundred percent occlusion of the left anterior descending artery. Stent placed. Patient survived.”
Brennan put the paper down.
He looked at me. Then at Paul.
“Dr. Kettering, the board has questions.”
Paul’s Version
Paul uncrossed his arms. He sat up straighter. He has this way of talking where he sounds reasonable, almost gentle, like he’s explaining something difficult to a child. I’ve heard him use it on patients. On me. On new residents who don’t know yet that his patience is a costume.
“I’ve been practicing emergency medicine for twenty-two years,” he said. “I’ve seen thousands of chest pain cases. The vast majority are not cardiac. This patient was fifty-eight, yes. She had chest pressure, yes. But her initial EKG was nondiagnostic. No ST elevation. No reciprocal changes. She had eaten a large meal an hour before onset. She had a history of GERD. The presentation was consistent with reflux.”
He turned slightly toward the board, not toward me.
“I made a clinical judgment. I ordered appropriate treatment. I initiated discharge because the evidence supported it. Nurse Sovic disagreed. That is her right. But instead of following the chain of command, she went around me. She contacted a specialist directly. She countermanded my orders. She kept the patient against the discharge plan.”
He said this last part flat.
“This is not about whether the patient was sick. The patient was sick, and I’m glad she’s alive. This is about whether a nurse can override a physician’s clinical decision without consequence. If that becomes standard, this department cannot function.”
Linda Puhl was writing. She didn’t look up.
Dr. Feist had her fingers steepled. She said, “Paul, when you say the EKG was nondiagnostic, did you review it yourself, or did you review the preliminary read?”
Paul blinked. “I read the strip.”
“The initial strip or the repeat?”
“There was no repeat. I didn’t order a repeat.”
Dr. Feist let that sit.
The Strip
This is the part Paul didn’t know. Or maybe he did and was betting nobody would check.
When Diane came in, I did a twelve-lead myself. I do my own EKGs when I’m worried. The techs are good, but they’re running between bays and sometimes they rush the lead placement. I don’t. I take my time. I talk to the patient while I’m doing it because it calms them down and it calms me down.
Diane’s first strip showed T-wave inversions in V1 through V3. Not huge. Not the kind of thing that makes you call a code. But they were there. New ones, if you believed Diane when she said she’d had a normal EKG at her physical six months ago. She was the kind of patient who actually remembered things like that.
I showed the strip to Paul. He glanced at it. I mean glanced. Two seconds, maybe three. He said, “Nonspecific. Could be anything. Could be her baseline. Could be lead placement.” Then he went back to his note.
I wanted a repeat strip. I asked. He said it wasn’t necessary. I asked again. He said, “I heard you the first time.”
So I did one anyway. Fifteen minutes after the first. Same lead placement, same machine, same arm. The T-wave inversions were deeper. V2 had gone from one millimeter to two and a half.
That was the strip I sent to Dr. Mehta when I called him.
Paul didn’t know about the second strip because he’d already left for his break. He didn’t ask about it when he came back. He went straight to charting on his next patient, a guy with a fishing hook in his thumb.
Dr. Mehta
Dr. Mehta wasn’t at the hearing. He was on a flight to Phoenix for a conference. But his written statement was in the file, and Brennan read parts of it out loud.
“I was contacted by phone at 14:40 on October 14th by a nurse identifying herself as an ER nurse at Memorial General. She described a fifty-eight-year-old female with chest pressure and jaw pain, initial EKG with T-wave inversions in the anterior leads, and a repeat EKG showing progression of those changes. She stated the attending had diagnosed GERD and initiated discharge.”
Brennan kept reading.
“I advised the nurse to draw serial troponins and keep the patient on a monitor. She informed me the troponin order had been cancelled. I told her to re-order it under my name. She did. When the result returned elevated, I came in. The patient was in the cath lab within thirty-eight minutes. The LAD was occluded. She needed a stent.”
Then the part that made Paul’s jaw tighten.
“In my clinical opinion, based on the EKG changes described to me and the patient’s presentation, this was a STEMI equivalent. Discharge would have been catastrophic. The nurse who contacted me showed appropriate clinical judgment. I would have been upset to learn about this patient after the fact.”
Brennan put the paper down again.
Paul said nothing.
The Three Signatures
The letter from my colleagues was also in the file. Three names.
Greg Tashjian. He’s been an ER nurse here for six years. We’ve worked maybe two hundred shifts together. He’s competent. He’s not brave. He’s the kind of guy who agrees with whoever is standing closest.
Pam Delacroix. She’s been here longer than me. Fifteen years. She and Paul go way back. Their kids went to the same school. I found that out last year when she mentioned it during a slow shift. She said it casually, like it was nothing. But she never covers Paul’s patients without being asked, and she never says anything when he discharges someone who probably shouldn’t go home.
The third name was Ray Cobb. New. Eighteen months on the floor. He’s terrified of Paul. I’ve watched Paul dress him down in the middle of a shift for asking a question. Ray went red and didn’t speak for twenty minutes. After that, he stopped asking questions.
The letter said I “undermined physician authority” and “created unnecessary alarm.” It said my actions “damaged the working relationship between nursing and medical staff.” It said this was part of a “pattern of insubordination.”
That last word. Insubordination. Greg signed that. Greg, who three months ago told me over cold coffee at four in the morning that Paul was going to kill someone someday. He signed a letter calling me insubordinate.
I didn’t know that until the hearing. Brennan read the letter and my face did something I couldn’t control. Linda Puhl looked at me. I looked at the table.
What I Said
When it was my turn, I didn’t have a lawyer. I’d called one. He wanted five thousand dollars as a retainer. I have a mortgage and a kid in braces and an ex-husband who pays child support when he feels like it.
So I spoke for myself.
I told them about the first strip. I told them about the second. I told them I’d asked for a repeat and been refused. I told them Diane had grabbed my hand and said please don’t let me go home.
I told them I called Dr. Mehta because he was the on-call cardiologist and that is the person you call when you think someone is having a heart attack. I told them I re-ordered the troponin because Dr. Mehta told me to.
I said, “I know I went around Dr. Kettering. I know that’s a problem. But Diane Lehrer is alive because of what I did, and she would not be alive if I had done what I was told.”
Then I said the thing I’d been thinking for six days.
“I’ve been a nurse for eleven years. I have never overridden a physician. Not once. But I’ve also never had a physician walk away from a patient who was mid-infarct and go on break. So I don’t know what the protocol is for that.”
Paul’s face went still.
Dr. Feist wrote something down.
The Decision
Brennan asked me to step out again. I sat in the hallway for another forty minutes. This time I could hear voices through the door. Not words, just tone. Paul’s voice went up twice. Dr. Feist’s stayed level.
The door opened. Brennan stood in the frame.
“Mrs. Sovic, the board has reached a determination.”
I came back in. Sat down. My hands were in my lap and I was pressing my thumbnails into my index fingers, a thing I do when I’m trying not to shake.
Brennan said: “The board finds that Nurse Sovic acted outside the established chain of command. That is documented and noted.”
Paul exhaled. Like a man who’d been holding something.
“However.”
Brennan looked at Paul.
“The board also finds that Dr. Kettering’s clinical assessment on October 14th was incomplete. A repeat EKG was indicated and not ordered. The initial EKG showed changes that warranted further workup before discharge. The patient was discharged prematurely based on an incomplete evaluation.”
Paul said, “The strip was nondiagnostic.”
Dr. Feist said, “Paul, I’ve been reading EKGs longer than you have. Those T-wave inversions were not nonspecific. You know that. I know that. The board knows that.”
The room got quiet.
Brennan continued. “Nurse Sovic, you will receive a formal letter of counseling regarding chain of command. It will go in your file. It is not a disciplinary action. Your license is not affected.”
He paused.
“Dr. Kettering, your case will be referred to the physician peer review committee. The board is recommending a review of your recent discharge decisions for the past six months.”
Paul stood up. He didn’t push his chair in. He walked out of the room and didn’t look at me.
After
I went back to work the next morning. Thursday. Gray sky, spitting rain.
Greg Tashjian was at the desk. He saw me come in. He opened his mouth. Closed it. Opened it again. Said, “Hey.”
I said, “Hey.”
He said, “I didn’t know they were going to do a full review. I thought it was just going to be a letter in your file.”
I looked at him. He looked at the floor.
“Greg, you called me insubordinate. You signed your name to it.”
“I know.”
“You told me Paul was going to kill someone. Your words. Three months ago.”
“I know what I said.”
I stood there. He stood there. The phone rang. Neither of us moved.
“Did they threaten you?” I asked.
He shook his head. “Paul asked me to sign. Pam asked me to sign. It felt like. I don’t know. It felt like if I didn’t, I’d be next.”
I picked up the phone. I did my job. I didn’t talk to Greg for the rest of the shift.
Diane Lehrer went home four days after her stent. She sent a card to the ER. It was addressed to “The nurse who saved my life.” Linda Puhl pinned it to the bulletin board behind the desk. It stayed there for two weeks before someone took it down to make room for the flu shot schedule.
I made a copy first. It’s in my locker.
It says: “I knew something was wrong. You believed me.”
I’d do it again. I’d do it tomorrow. I’d do it with shaking hands and a dry mouth and my license on the line. Because Diane is alive. She’s fifty-eight and she’s alive and she gets to see her grandkids because I picked up the phone and called a cardiologist who answered.
That’s the whole story. That’s all of it.
If this hit close to home, pass it along to someone who knows what it costs to do the right thing.
For more stories about standing your ground, check out The Doctor Slid a Note Across the Break Room Table and Told Me to Read It or even My 8-Year-Old Begged His School Not to Call Me.
