Doctors vs Physios

I always knew there is a hierarchy in the hospital between the doctors and the rest of the medical team and we work together and come to a consensus and to seek the best treatment available to each patient. So what happens when this consensus is not reached?

This was the situation I was in today. I’m into my 3rd week in ICU at SCGH. I have the basics of the running orders in ICU, which is a nurse per bed 24/7, 3 physios on day shift and 1 on night shift. 2 residents and 4 registrars (from 6 different registrars) rotate between shifts and 3 consultants who conduct regular ward rounds. Therefore calculating the amount of time spent with each patient, on the top of the chart are the nurses, then the physios, residents, registrars and the very least the consultants.

The problem arose when the physios and the registrar had a different opinion on weaning( ↓ ventilatory support) of a patient. A gentleman who had a craniectomy 20 days ago, who then developed Type II respiratory failure was finally awake, stable but having difficulties weaning, due to CNS disturbance :. ↓ respiratory drive. The patient was currently ventilated on high flow ventilation (the part where Kate said it was not in exams. This ventilation provides high jet of O2 which is entrained with medical air to a % of O2 desired for the patient and it provide PEEP and prevent collapse of the airways on expiration) of 8L with Sat 98%. On SIMV the patient was on minimal support which indicates that the patient was able to tolerate Bi PAP in the evenings which is a form of non-invasive ventilation that could also be provided in the respiratory wards.

When the registrar came on in the afternoon, he decided that the O2 levels provided by the high flow was inadequate ( Sats of 98% ?) and should be increased and also the patient can be on it for longer. BiPAP was also not necessary, and the patient should be ventilated with SIMV at night and off to the ward with high flow tomorrow. The registrar contraindicated what the physios where planning to do and when questioned, the registrar said that he would like to see Mr…work his respiratory mm harder and have a better night sleep. This may not be the best option to go as the patient fatigues easily and from the doctors orders it looked like that the patient was set up to fail as both the nurses and physios knew that Mr… will not tolerate long periods of high flow. So the million dollar question is do we challenge what the doc’s orders and if so, how? Or do we follow the doc’s orders and fail the attempt to wean the patient?