I hate it when the nurse does X...

[throckmortonDO]

I'll take it over having to justify all the things that aren't actually there that triage decided were important to write down anyways.

"Patient is lethargic and has chest pain (really means: wheezing) and thunderclap headache and passed out 11 times today and reports history of (whatever)"

I love it when I see: "ABD PAIN" and they stay the hell out of the charting.

This x 1000.

some shifts literally half the chart I have to spend documenting why 'X test' wasn't ordered or why I don't believe pt has 'symptoms YZ' because of some massive/rediculous/full of red flags that aren't true/more information than I want documented/ note documented by triage RN.

Literally makes me die inside and increases my serum agitation concentration.

Nurses, we will love you if you just put something to the effect of "Abd pain X 2 days" or something. Don't document anything else. Seriously.

---

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[LabMonster]

Realize nursing is not doctoring. We have different goals, unfortunately, and different metrics. Education is the cornerstone of your complaint. If there is a problem with nursing (as perceived by EDP) then the concern needs to be documented and illuminated by said EDP.

We see and have multiple patients, nurses have significantly less; but they must also "do" more than we do physically to the patient. When I have 13 patients in my ED, I cannot reasonably expect that a patient requiring a line with drugs will be placed quickly unless the patient is "sick," especially when the nurse has 2 other patients who need lines and are arguably as sick.

When a patient actually requires emergency care, my nurses swarm and GSD. When they have 3-4 patients and are being told by charge they need to "break" and no one is critical, things take longer. When they have sick patients, they tell the charge to forget breaks, lunches etc.

It is frustrating. I'd like to see things done as fast as I order them. It's on "my time" - but there is also a reality time nurses are dealing with... Nurses are also on a different timeline. My nurses are on 12 hour shifts - so breaks and lunches are held in high regard by administration.

I also don't have problems with nurses disobeying medical orders - if they question, they ask me directly.

The translation of orders to action can suck - if it is consistent, maybe you have a problem in your system. Systemic problems can hijack physician progress as well as direct patient care via nursing.

Nurses, as a group, as I have experienced, will always fault toward the patient.

So, I ask, do you really need that urine? Are you hunting for a Dx in an older person presenting with dizziness? I think some of our tests are convenient check boxes validating an ER visit.

Sometimes we need the urine. Ask your nurse if they need help with the cath. Nobody can get a line? - Stick an EJ.

My point is this: get your nurses to trust you and your decisions, AND that you support your orders with action, not whiny nonsense.

 

[RustedFox]

This x 1000.

some shifts literally half the chart I have to spend documenting why 'X test' wasn't ordered or why I don't believe pt has 'symptoms YZ' because of some massive/rediculous/full of red flags that aren't true/more information than I want documented/ note documented by triage RN.

Literally makes me die inside and increases my serum agitation concentration.

Nurses, we will love you if you just put something to the effect of "Abd pain X 2 days" or something. Don't document anything else. Seriously.

For real. At OldJob, the "documentation culture" was so entrenched that I spent so much time justifying things that don't actually exist. At NewJob, nurses write only what they absolutely have to.

I've gone from reading every note they generate: "Patient suffered another 3 bouts of flatulence. Aroma: Nutty, with a crisp finish. Suspect GI bleed."

To not having to worry about that bear trap that they set in the chart.

 

[Angry Birds]

This x 1000.

some shifts literally half the chart I have to spend documenting why 'X test' wasn't ordered or why I don't believe pt has 'symptoms YZ' because of some massive/rediculous/full of red flags that aren't true/more information than I want documented/ note documented by triage RN.

Literally makes me die inside and increases my serum agitation concentration.

Nurses, we will love you if you just put something to the effect of "Abd pain X 2 days" or something. Don't document anything else. Seriously.

Hmm I prefer a little more than that. But in general I think nurses should avoid the buzz words like "thunderclap headache", "worst headache of life," "bilious vomiting" etc. but I guess the more they write the likelier they will use one of those words.

 

[filhodeinferno]

My understanding is that it's sort of a double edged sword.

As a physician, you can make a decision to break just about any protocol you decide is in the interest of your patient to break. As long as you are seen to be acting in good faith, people will generally be understanding. This is because you are expected to use your judgement. Also, you get punished for poor judgement and don't get to cover yourself with the "it's protocol!" excuse.

Because nurses aren't physicians, they have to rely on protocols. Nurses are largely shielded from blame as long as they stick to the protocols, but not at all if they step away from them in any direction. Despite the occasional physician rumblings against nursing power, individual nurses aren't really given a tremendous amount of decision making power in most hospitals. They are given protocols and can be heavily punished for violating them.

That makes a lot of sense. Nurses' God is the protocol.

One example from last month when I was in the MICU: for some reason all of the sedation protocols up there only allow for 2 mg IV morphine to be pushed at a time. In the ED I would get slapped across the face by my attending if I ordered 2 mg of morphine. However, no matter how much I tried, I could not get a MICU nurse to deliver 4 mg of Morphine at once.

 

[Fox800]

That makes a lot of sense. Nurses' God is the protocol.

One example from last month when I was in the MICU: for some reason all of the sedation protocols up there only allow for 2 mg IV morphine to be pushed at a time. In the ED I would get slapped across the face by my attending if I ordered 2 mg of morphine. However, no matter how much I tried, I could not get a MICU nurse to deliver 4 mg of Morphine at once.

Because if you order 0.1 mg/kg of morphine they'll LOSE THEIR LICENSE™.

 

[Angry Birds]

Because if you order 0.1 mg/kg of morphine they'll LOSE THEIR LICENSE™.

On that note, nurses make up hospital protocols and rules all the time. Then, you call them out on it, and ask them for any documentation of this protocol or rule, you get blank stares...

 

[njac]

I've worked in many facilities and different departments, all operating under different EMR (I'm a nurse). I cannot fathom how one nurse have access to fentanyl for a patient when there is no standing PRN orders for pain. If there is no med listed under the patient list in the pyxis, then it means there was no order. Only way one can do this if a) they pulled the med from under a different patient, or b) pyxis override which is used mainly for emergency purposes, which requires documentation as to why did you override it.

Not all EDs have their Pyxis machine profiled.

It's considered best practice to do so, but many hospitals don't have the manpower on the pharmacy end to prospectively review every single Med.

Even the ones that do often have meds that could be stat on override, such as fentanyl. Sometimes that gnarly trauma needs a dose before anyone can get to the computer and order it.


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[b-real]

Because if you order 0.1 mg/kg of morphine they'll LOSE THEIR LICENSE™.

This excuse is the one that annoys me the most. Where are these vengeful nursing boards that are maliciously rescinding licenses for the smallest of infractions? Has anyone here actually seen this happen?

 

[gro2001]

This excuse is the one that annoys me the most. Where are these vengeful nursing boards that are maliciously rescinding licenses for the smallest of infractions? Has anyone here actually seen this happen?

I am told losing a license outright is uncommon (except in the case of drug diversion, substance abuse/dependence or other impairment) but being suspended for prolonged periods of time is not uncommon. Although it varies a lot by state and hospital.

Also, according to this random article:

http://healthcareers.about.com/od/healthcareerissues/fl/How-Not-to-Lose-Your-Nursing-License.htm

...more than 4,000 nurses were placed on probation by nursing boards in 2013. Additionally, nearly 5,000 nurses had their licenses suspended, and more than 2,000 had their licenses revoked.

 

[alteregoEMMD]

I love my ED nurses but it kills me when they (sometimes, some nurses) interrupt me getting a history with asinine questions for their charting. Like when I'm trying to find out time of onset on a stroke alert patient and they yell over me to ask what clinic they go to or what pharmacy they prefer...

Maybe just because I'm an intern

its because youre an intern. as an attending, nurses comes in with me and dont interrupt. its a completely different world.

Sent from my VS986 using Tapatalk

Disagree. I have nurses who will ask EMS pts while I am trying to figure out time of onset of stroke, etc. all their non-urgent questions including "do you feel safe at home?" It also drives me crazy when they shove a thermometer in the patient's mouth right after I asked them an important question...

 

[Arcan57]

I am told losing a license outright is uncommon (except in the case of drug diversion, substance abuse/dependence or other impairment) but being suspended for prolonged periods of time is not uncommon. Although it varies a lot by state and hospital.

Also, according to this random article:

http://healthcareers.about.com/od/healthcareerissues/fl/How-Not-to-Lose-Your-Nursing-License.htm

To add a denominator to those numbers, there are around 3.4 million RNs and LPNs in the U.S. Which means about 0.3% of are disciplined in any given year, which are pretty good odds from where I'm sitting. Especially if you take into account baseline levels of addiction and serious mental illness the percentage of nurses who lost their license for acting on a valid physician order in a Joint Commission accredited hospital has to be approaching rates normally associated with outlandish accidental method of dying (lightning strike, shark attack, being struck by car while in own dwelling, etc).

 

[gro2001]

To add a denominator to those numbers, there are around 3.4 million RNs and LPNs in the U.S. Which means about 0.3% of are disciplined in any given year, which are pretty good odds from where I'm sitting. Especially if you take into account baseline levels of addiction and serious mental illness the percentage of nurses who lost their license for acting on a valid physician order in a Joint Commission accredited hospital has to be approaching rates normally associated with outlandish accidental method of dying (lightning strike, shark attack, being struck by car while in own dwelling, etc).

Right, but just like a physician losing a license is a relatively rare but rather drastic outcome, so is the nursing licensing issue. In residency I have heard multiple attendings say things to the effect of "It's my license on the line" even though physicians losing licenses is extremely uncommon outside of sexual misconduct, insurance fraud, drug diversion or substance abuse/dependence.

Also, these numbers reflect just the disciplining by the nursing board and does not reflect the local disciplinary actions taken by hospitals (citations, suspensions from duty, termination) that may not all result in a nursing board taking action. I imagine that is much more common.

Also, nurses aren't entirely secure from being sued either. Anecdotally, one of my nursing friends was involved in a law suit related to a fall in a hospital.

 

[Zebra Hunter]

Had a nurse get upset with me the other day because I did not include the "patient education" portion of the d/c paperwork (a short article that explains certain types of symptoms or disease processes) for a patient presenting with 2-weeks worth of wrist pain that I hurriedly d/c'd prior to seeing a critical patient I knew I was going to be caught up with for the next 30 minutes. When she came angrily came up to me to let me know my mistake (which she happened to miss, as well) I apologized for not really caring about double checking the non-essential paperwork for a non-emergent patient prior to freeing up a bed quickly on a busy day while also preparing to care for a pt with a BP of 60/30 with a temp of 88F.

 

[Arcan57]

Right, but just like a physician losing a license is a relatively rare but rather drastic outcome, so is the nursing licensing issue. In residency I have heard multiple attendings say things to the effect of "It's my license on the line" even though physicians losing licenses is extremely uncommon outside of sexual misconduct, insurance fraud, drug diversion or substance abuse/dependence.

Also, these numbers reflect just the disciplining by the nursing board and does not reflect the local disciplinary actions taken by hospitals (citations, suspensions from duty, termination) that may not all result in a nursing board taking action. I imagine that is much more common.

Also, nurses aren't entirely secure from being sued either. Anecdotally, one of my nursing friends was involved in a law suit related to a fall in a hospital.

You're drifting rather far afield from the original assertion that following a legitimate physician order should be expected to cause you to lose your livelihood as a nurse. The physician license issue is a separate thing entirely and revolves around med-mal risk, not sanctioning by the state medical board (except in cases of inadequate supervision). Could you get written up by your supervisor or a concerned coworker for giving 4mg of morphine? Absolutely. Could you get written up for using Facebook at work, drinking at the nurse's station, or wearing an unapproved scrub color? Sure, why not.

In terms of nurses being named in lawsuits, it does happen. In general it's the sign of an amateur plaintiff's attorney as it's almost useless going after individual nurses vs. the far deeper pockets of the hospital. In terms of common causes of nurses being terminated from a hospital it probably runs something like:

repeatedly not showing up for a shift > repeated deficient documentations >> budget cuts > HR violations >> egregious violation of standard of care (red rules,etc) >>>>>>>>>>>>>>> following a physician order that did not generate an alert from the EMR

 

[GeneralVeers]

The one that gets me is blood pressure. I'll admit a patient for a non-cardiac complaint, and the floor nurses will refuse to take the patient because the "blood pressure is too high". I'm forced to either give a potentially dangerous drug to treat asymptomatic high blood pressure, or force the patient to stay in the ER. I've asked numerous times where this rule is written, and they have never shown me where to find it.

 

[gro2001]

You're drifting rather far afield from the original assertion that following a legitimate physician order should be expected to cause you to lose your livelihood as a nurse. The physician license issue is a separate thing entirely and revolves around med-mal risk, not sanctioning by the state medical board (except in cases of inadequate supervision). Could you get written up by your supervisor or a concerned coworker for giving 4mg of morphine? Absolutely. Could you get written up for using Facebook at work, drinking at the nurse's station, or wearing an unapproved scrub color? Sure, why not.

In terms of nurses being named in lawsuits, it does happen. In general it's the sign of an amateur plaintiff's attorney as it's almost useless going after individual nurses vs. the far deeper pockets of the hospital. In terms of common causes of nurses being terminated from a hospital it probably runs something like:

repeatedly not showing up for a shift > repeated deficient documentations >> budget cuts > HR violations >> egregious violation of standard of care (red rules,etc) >>>>>>>>>>>>>>> following a physician order that did not generate an alert from the EMR

Yeah, you are right. I doubt a nurse has ever lost his or her license for the sole act of following a physician's order that happened to be against protocol.

 

[Angry Birds]

Disagree. I have nurses who will ask EMS pts while I am trying to figure out time of onset of stroke, etc. all their non-urgent questions including "do you feel safe at home?" It also drives me crazy when they shove a thermometer in the patient's mouth right after I asked them an important question...

I feel like slapping the thermometer out of the patient's mouth when they do this and then keep asking my questions as if nothing happened.

On that note, I hate it when nurses get mad that I've discharged a patient before they are done with their ten trillion documentation points. I'm pretty fast and I won't slow down. Can't stop. Won't stop.

 

[WilcoWorld]

Had a nurse get upset with me the other day because I did not include the "patient education" portion of the d/c paperwork (a short article that explains certain types of symptoms or disease processes) for a patient presenting with 2-weeks worth of wrist pain that I hurriedly d/c'd prior to seeing a critical patient I knew I was going to be caught up with for the next 30 minutes. When she came angrily came up to me to let me know my mistake (which she happened to miss, as well) I apologized for not really caring about double checking the non-essential paperwork for a non-emergent patient prior to freeing up a bed quickly on a busy day while also preparing to care for a pt with a BP of 60/30 with a temp of 88F.

Well you at least did a medication reconciliation, didn't you?!?!

 

[gro2001]

I feel like slapping the thermometer out of the patient's mouth when they do this and then keep asking my questions as if nothing happened.

On that note, I hate it when nurses get mad that I've discharged a patient before they are done with their ten trillion documentation points. I'm pretty fast and I won't slow down. Can't stop. Won't stop.

#humblebrag

 

[Danbo1957]

Nurses? Those people running around in navy scrubs? Huh. Wondered what they did...

 

[deleted109597]

Yeah, you are right. I doubt a nurse has ever lost his or her license for the sole act of following a physician's order that happened to be against protocol.

Nobody is saying it doesn't happen. We are saying it doesn't happen EVERY GODDAMN DAY like they're taught in nursing school. Hell, when nurses kill people in endoscopy suites for giving ludicrous doses of versed and fentanyl they don't lose their licenses 100% of the time.
On the flip side, they should get fired for not giving a "new" medicine simply because they don't know why I'm giving it. I'm happy to teach the nurses when I have the time. RIGHT ****ING NOW is not that time. Give the damn hydroxycobalamin. Google it later.

 

[BoardingDoc]

The one that gets me is blood pressure. I'll admit a patient for a non-cardiac complaint, and the floor nurses will refuse to take the patient because the "blood pressure is too high". I'm forced to either give a potentially dangerous drug to treat asymptomatic high blood pressure, or force the patient to stay in the ER. I've asked numerous times where this rule is written, and they have never shown me where to find it.

This used to happen at my hospital. It was subsequently written up so many times that the hospital admins made it very clear to nursing that refusal to accept a patient on the grounds of hypertension was unacceptable.

 

[IH8ColdWeath3r]

This isn't about a nurse but actually an NP. She would always go on these rants about how she thinks it's unfair that NPs require doctoral supervision and how they should be allowed equal practice rights. She would, occasionally, question the docs plan and judgement as well, and I could see the doc getting frustrated by it but never really confronted the NP on it. I think they thought it was just a lost cause and would create unnecessary turmoil.

During my shift in the ED, it was getting pretty busy and the doc was getting slammed. The doc was already taking care of two patients who were being admitted and trying to see extra patients that were coming in. The NP decides to pick up a patient who was having SOB. Long story short, she works the patient up, ultimately gets a D-dimer, then a CTA, and, decides to sit on the patient. Quite some time has passed and I begin to wonder why there is nothing being done with the patient. The NP is seeing other patients and not really paying attention to this person who, in my mind, she has reasonable clinical suspicion to believe has a PE, given her tachycardia in the 100-110's and CTA.

There is no official read on the CTA. I decide to pull up the scan and take a look. The patient had multiple, pretty impressive filling defects. I try to point this out to the NP and she goes..."yeah I don't really know what I am looking at. Just waiting for the official read". I tried to be helpful and explain to her that the patient has a PE, due to lack of contrast passing through the pulm arteries. Not in an aggressive or rude or condescending kind of way (who am I to talk, I'm just the med student at the bottom of the totem pole).

She didn't appreciate my help, and proceeded to be rude. Ultimately said, "I'll get to it when I can" and when the read from the radiologist comes in. Didn't so much as even notify the attending doc. I didn't say anything to the attending either because I didn't wanna throw the NP under the bus. But, this patient eventually sat in the ED for four hours too long and by the time the NP had to call the ICU doc, the patient had signs of RV strain and became hypotensive and ultimately (I believe) infarcted his RV. I felt bad for the patient, but not so bad for the chewing out that the NP got from the ICU doc. This was a really vivid case in my mind, and just made me see how egos in medicine can really do harm to the patient.

 

[IH8ColdWeath3r]

ps - I worked with some amazing nurses before medical school. They showed me things as a volunteer that the docs didn't have time to do. When I worked in the ED, I saw the good ones work as a team during codes or help doctors when they thought something was wrong with a patient. So, this isn't to nurse bash or NP bash.

But, from experience, especially now as a med student as opposed to a scribe or volunteer, I have come across A LOT of rude nurses who belittle me and my classmates, purposely don't give us report or things like the patients I&Os when I was on surgery, but would document them 5 min after we left, and just be plain rude/mean/passive aggressive.

Whenever I didn't wear my short white coat and only scrubs, they would all be super helpful because they thought I was the intern. But, when I wore the short white coat, they were anything but helpful and very rude. And they wonder why some doctors are rude or have animosity towards them.

 

[LabMonster]

Like I mentioned in my long-winded post, nurses are on a different metric than we are. Documentation points about "have you recently traveled to the Sudan" "Are you safe on your toilet" are NOT driven but good nursing care, but by ****ty administration metrics that keep adding EMR check boxes and questions to an ED nurses already lengthy list of duties. They spend more time with bull**** charting exercises than patient contact - the good ones know this and can get around it, the young ones need education.

I don't advocate falsifying a chart - what I'm saying is that nurses should be nurses. They tell me when a patient is sick, they tell me when a complaint is BS, and they "check their boxes" according to work flow. In other words, if a non-acute patient shows up, and I step in the room for evaluation - I get the HPI done, they stop their questioning, they initiate treatment/diagnostics and complete the check boxes later. A sick patient gets swarmed in my ED. The nurses recognize, follow orders and GSD.

Teaching institutions are different. Residents ordering, medical student evals, nursing gestalt can lead to delays, but this is not the way it works in "community practice" even with students or residents.

It will get better.

 

[LabMonster]

Rise above it. Again, teaching institutions are different, the nurses understand that junior docs and med students abound and are cautious on actions - doesn't make it right and it doesn't validate actions or non-actions.
wW
NPs and PA's are not trained the same as MDs and DOs. When you work with a "mid-level" provider and you trust them, great, otherwise, scrutinize. I wouldn't suggest "throwing them under the bus" but if you see PE on a CT scan - call it and tell your attending. I'm not a radiologist by any means, but I read ALL my imaging studies and I miss stuff. I'm an ER doc. We all do. BUT I also catch things missed because I have access to my patient and have done an exam and suspect something - which is why I did the test in the first place.

Read all your own films. Always. Question? Talk to the radiologist, they will love you - but when you don't have a radiologist, or your scans are farmed out to an outside service, AND if you can't read imaging, you're sunk. I've had multiple reads blown by our "outside radiology" service: free fluid in the pelvis, splenic injury, PE, ?mesenteric injury, small bowel obstruction. Those are in the last 8 weeks. Read your own films.

 

[IH8ColdWeath3r]

Rise above it. Again, teaching institutions are different, the nurses understand that junior docs and med students abound and are cautious on actions - doesn't make it right and it doesn't validate actions or non-actions.
wW
NPs and PA's are not trained the same as MDs and DOs. When you work with a "mid-level" provider and you trust them, great, otherwise, scrutinize. I wouldn't suggest "throwing them under the bus" but if you see PE on a CT scan - call it and tell your attending. I'm not a radiologist by any means, but I read ALL my imaging studies and I miss stuff. I'm an ER doc. We all do. BUT I also catch things missed because I have access to my patient and have done an exam and suspect something - which is why I did the test in the first place.

Read all your own films. Always. Question? Talk to the radiologist, they will love you - but when you don't have a radiologist, or your scans are farmed out to an outside service, AND if you can't read imaging, you're sunk. I've had multiple reads blown by our "outside radiology" service: free fluid in the pelvis, splenic injury, PE, ?mesenteric injury, small bowel obstruction. Those are in the last 8 weeks. Read your own films.

Definitely will do! Thanks for the advice doc!

 

[Druggernaut]

I'll take it over having to justify all the things that aren't actually there that triage decided were important to write down anyways.

"Patient is lethargic and has chest pain (really means: wheezing) and thunderclap headache and passed out 11 times today and reports history of (whatever)"

I love it when I see: "ABD PAIN" and they stay the hell out of the charting.

Had one of our seasoned veteran nurses wait until I was done examining a squirrelly little old lady with multiple complaints to ask me what I wanted as the cc and triage note. Love her.

 

[b-real]

This isn't about a nurse but actually an NP. She would always go on these rants about how she thinks it's unfair that NPs require doctoral supervision and how they should be allowed equal practice rights. She would, occasionally, question the docs plan and judgement as well, and I could see the doc getting frustrated by it but never really confronted the NP on it. I think they thought it was just a lost cause and would create unnecessary turmoil.

During my shift in the ED, it was getting pretty busy and the doc was getting slammed. The doc was already taking care of two patients who were being admitted and trying to see extra patients that were coming in. The NP decides to pick up a patient who was having SOB. Long story short, she works the patient up, ultimately gets a D-dimer, then a CTA, and, decides to sit on the patient. Quite some time has passed and I begin to wonder why there is nothing being done with the patient. The NP is seeing other patients and not really paying attention to this person who, in my mind, she has reasonable clinical suspicion to believe has a PE, given her tachycardia in the 100-110's and CTA.

There is no official read on the CTA. I decide to pull up the scan and take a look. The patient had multiple, pretty impressive filling defects. I try to point this out to the NP and she goes..."yeah I don't really know what I am looking at. Just waiting for the official read". I tried to be helpful and explain to her that the patient has a PE, due to lack of contrast passing through the pulm arteries. Not in an aggressive or rude or condescending kind of way (who am I to talk, I'm just the med student at the bottom of the totem pole).

She didn't appreciate my help, and proceeded to be rude. Ultimately said, "I'll get to it when I can" and when the read from the radiologist comes in. Didn't so much as even notify the attending doc. I didn't say anything to the attending either because I didn't wanna throw the NP under the bus. But, this patient eventually sat in the ED for four hours too long and by the time the NP had to call the ICU doc, the patient had signs of RV strain and became hypotensive and ultimately (I believe) infarcted his RV. I felt bad for the patient, but not so bad for the chewing out that the NP got from the ICU doc. This was a really vivid case in my mind, and just made me see how egos in medicine can really do harm to the patient.

It's hard to know what your place is as a med student, but definitely give the head's up to your attending. It sounds like the mid-level didn't appreciate or didn't care about the significance of your finding. By letting the attending know, you're not so much throwing someone under the bus as providing good care to the patient. I promise you the attending will be very appreciative, as he/she is ultimately responsible for that patient. The best piece of advice I ever got as a student and later as a resident, however general it may be, is to do what's right for the patient.

 

[Fox800]

This isn't about a nurse but actually an NP. She would always go on these rants about how she thinks it's unfair that NPs require doctoral supervision and how they should be allowed equal practice rights. She would, occasionally, question the docs plan and judgement as well, and I could see the doc getting frustrated by it but never really confronted the NP on it. I think they thought it was just a lost cause and would create unnecessary turmoil.

During my shift in the ED, it was getting pretty busy and the doc was getting slammed. The doc was already taking care of two patients who were being admitted and trying to see extra patients that were coming in. The NP decides to pick up a patient who was having SOB. Long story short, she works the patient up, ultimately gets a D-dimer, then a CTA, and, decides to sit on the patient. Quite some time has passed and I begin to wonder why there is nothing being done with the patient. The NP is seeing other patients and not really paying attention to this person who, in my mind, she has reasonable clinical suspicion to believe has a PE, given her tachycardia in the 100-110's and CTA.

There is no official read on the CTA. I decide to pull up the scan and take a look. The patient had multiple, pretty impressive filling defects. I try to point this out to the NP and she goes..."yeah I don't really know what I am looking at. Just waiting for the official read". I tried to be helpful and explain to her that the patient has a PE, due to lack of contrast passing through the pulm arteries. Not in an aggressive or rude or condescending kind of way (who am I to talk, I'm just the med student at the bottom of the totem pole).

She didn't appreciate my help, and proceeded to be rude. Ultimately said, "I'll get to it when I can" and when the read from the radiologist comes in. Didn't so much as even notify the attending doc. I didn't say anything to the attending either because I didn't wanna throw the NP under the bus. But, this patient eventually sat in the ED for four hours too long and by the time the NP had to call the ICU doc, the patient had signs of RV strain and became hypotensive and ultimately (I believe) infarcted his RV. I felt bad for the patient, but not so bad for the chewing out that the NP got from the ICU doc. This was a really vivid case in my mind, and just made me see how egos in medicine can really do harm to the patient.

I, for one, welcome our new nurse practitioner overlords.

 

[IH8ColdWeath3r]

It's hard to know what your place is as a med student, but definitely give the head's up to your attending. It sounds like the mid-level didn't appreciate or didn't care about the significance of your finding. By letting the attending know, you're not so much throwing someone under the bus as providing good care to the patient. I promise you the attending will be very appreciative, as he/she is ultimately responsible for that patient. The best piece of advice I ever got as a student and later as a resident, however general it may be, is to do what's right for the patient.

Yeah. Looking back, I should have definitely said something. I think I was just afraid of pissing of this NP and having to work 10+ more shifts with her, I didn't want to be on her bad side and in the moment did not use good judgement. But yes, as med student, it is very hard to know your place, especially on rotations such as surgery and OB where there is so much hostility towards students. Next time something like that happens though, I know what to do.

 

[IH8ColdWeath3r]

I, for one, welcome our new nurse practitioner overlords.

lol what do you mean by overlords?

 

[Fox800]

lol what do you mean by overlords?

This.

 

[IH8ColdWeath3r]

This.

 

[Robotic Wis-Hipple]

Sadly, this may be a reality sooner than later. H.R. 1247 is approaching listing into the federal registry, proposed changes in the VHA Nursing Handbook would grant all APRN's independent practice rights without physician supervision within the VA system. If you don't think that would lead to a more broad rollout in the civilian realm you're head is in the sand.

 

[Traumahawk]

From the other side of the fence, a good many of the things that drive me ballistic as a charge nurse might look pretty familiar to you:

1) Urine. Sweet baby Jesus, urine. I could have 10 extra beds in my shop, 24/7/365 (including when we're rocking a**-busting out-the-door flu season patient volumes) if we could just obtain and test urine in a timely fashion. Patients won't pee, can't pee, peed right before they left the house, peed in their pants, left the pee in the room, left the pee on the back of the stretcher, nurse/tech didn't see the pee, patient moved and the pee got thrown out, and the band played on. Week after week, we get our teeth busted in by Administration demanding why our door-to-dispo times aren't dropping, and week after week, it comes back to pee. Corollary: we're not the cops, we're not your probation officer, we're not your boss, we (usually) aren't testing you for drugs and we honestly couldn't give a single additional whoop if you smoked weed or popped an Oxy before you came in, all we want is to know if you're pregnant or infected. And now, thanks to a few militant quality assurance types, the old chestnut, "you give me pee or I'll go in and get it" now gets you put on Administration's naughty list.
2) Nurses sitting on ADTs (Admit, Discharge, Transfer) to avoid getting new patients.
3) Physicians sitting on dispos to avoid getting new patients or due to cognitive lock.
4) Floors refusing admitted patients for bulls*** reasons. Asymptomatic hypertension is a favorite. So is dementia. Corollary: floor staff who call Rapid Response on asymptomatic patients as soon as they get off the elevator, just to retaliate against us for sending them said asymptomatic patients.
5) Bulls*** protocols with no provision for clinical discretion.
6) Unnecessary application of cervical collars. Another obscene waste of time and bed space while we clear a neck we had no business immobilizing in the first place. 80% of the time the patient is wandering the hall with the collar up around his/her nose anyway.
7) Midlevels refusing patients and claiming lack of physician supervision as the reason.
8) Any sentence including the phrase "my license."
9) General misbehavior. If you're goofing on a computer, tablet, phone, etc. and dissing your patients and discussing your post-shift bar plans at full volume while said patient or their family are waiting right in front of you, I may have to question your intelligence.
10) The adjectival form of "pus" is "purulent," not that other five-letter construction.

 

[WilcoWorld]

From the other side of the fence, a good many of the things that drive me ballistic as a charge nurse might look pretty familiar to you:

1) Urine. Sweet baby Jesus, urine. I could have 10 extra beds in my shop, 24/7/365 (including when we're rocking a**-busting out-the-door flu season patient volumes) if we could just obtain and test urine in a timely fashion. Patients won't pee, can't pee, peed right before they left the house, peed in their pants, left the pee in the room, left the pee on the back of the stretcher, nurse/tech didn't see the pee, patient moved and the pee got thrown out, and the band played on. Week after week, we get our teeth busted in by Administration demanding why our door-to-dispo times aren't dropping, and week after week, it comes back to pee. Corollary: we're not the cops, we're not your probation officer, we're not your boss, we (usually) aren't testing you for drugs and we honestly couldn't give a single additional whoop if you smoked weed or popped an Oxy before you came in, all we want is to know if you're pregnant or infected. And now, thanks to a few militant quality assurance types, the old chestnut, "you give me pee or I'll go in and get it" now gets you put on Administration's naughty list.
2) Nurses sitting on ADTs (Admit, Discharge, Transfer) to avoid getting new patients.
3) Physicians sitting on dispos to avoid getting new patients or due to cognitive lock.
4) Floors refusing admitted patients for bulls*** reasons. Asymptomatic hypertension is a favorite. So is dementia. Corollary: floor staff who call Rapid Response on asymptomatic patients as soon as they get off the elevator, just to retaliate against us for sending them said asymptomatic patients.
5) Bulls*** protocols with no provision for clinical discretion.
6) Unnecessary application of cervical collars. Another obscene waste of time and bed space while we clear a neck we had no business immobilizing in the first place. 80% of the time the patient is wandering the hall with the collar up around his/her nose anyway.
7) Midlevels refusing patients and claiming lack of physician supervision as the reason.
8) Any sentence including the phrase "my license."
9) General misbehavior. If you're goofing on a computer, tablet, phone, etc. and dissing your patients and discussing your post-shift bar plans at full volume while said patient or their family are waiting right in front of you, I may have to question your intelligence.
10) The adjectival form of "pus" is "purulent," not that other five-letter construction.

#9 drives me crazy. We have a break room, use it.

 

[GeneralVeers]

How about the trauma code for "special populations". They now make us call a trauma on anyone over 60 who has fallen and bumped their head. Talk about a waste of time and resources.

 

[RustedFox]

How about the trauma code for "special populations". They now make us call a trauma on anyone over 60 who has fallen and bumped their head. Talk about a waste of time and resources.

This is a "thing" where you work? Shoot, if a senior fall is a trauma, then I work in a level 1+ trauma center. Florida, man. Greyer by the day.

 

[Apollyon]

10) The adjectival form of "pus" is "purulent," not that other five-letter construction.

To get the 5-letter word transcribed was the holy grail of Duke surgery, when I was there. If the transcriptionist liked you, they would just sub in "purulent". If they didn't, your dictation went to the chair (and the Chair of Surgery at Duke is kind of a REALLY big guy).

 

[Traumahawk]

This is a "thing" where you work? Shoot, if a senior fall is a trauma, then I work in a level 1+ trauma center. Florida, man. Greyer by the day.

It's a thing in my shop, too. Everyone over 65 who suffers any kind of injury on any kind of anticoagulant, including 81mg ASA (which is everyone who's ever seen an internist in the last decade) we now have to page out as a trauma alert. Everyone loathes it, not least the patients, who generally thought they'd come to the ED (mostly to silence nagging family members), get a plain film shot of whatever hurts and maybe some bacitracin and a bandage for skinned knees/elbows, and be OTD in under an hour. Instead we're forced into a 4-hour trauma workup that no one wants and that rarely catches anything major. ACS COT is rapidly rising (sinking?) to Joint Commission levels of guideline inanity...

 

[Cytarabine]

Not following orders and not asking questions about the order (by all means, ask if you have a question, but don't just ignore it and not ask about it). The propofol for the intubated patient isn't a suggestion. Yes... I understand that the patient isn't agitated right now... but that's because we intubated 30 minutes ago... with Roc.

This isn't nursing specific, but nothing drives me up the wall like inadequate sedation/pain control in a paralyzed patient. Makes me sick

 

[Siggy]

This isn't nursing specific, but nothing drives me up the wall like inadequate sedation/pain control in a paralyzed patient. Makes me sick

I'm of the opinion that anyone intubated gets a sedative and a narcotic. Having a piece of plastic shoved down your throat is painful... and [propofol/versed/precedex] has absolutely no analgesic
effect.

 

[cbrons]

My understanding is that it's sort of a double edged sword.

As a physician, you can make a decision to break just about any protocol you decide is in the interest of your patient to break. As long as you are seen to be acting in good faith, people will generally be understanding. This is because you are expected to use your judgement. Also, you get punished for poor judgement and don't get to cover yourself with the "it's protocol!" excuse.

Because nurses aren't physicians, they have to rely on protocols. Nurses are largely shielded from blame as long as they stick to the protocols, but not at all if they step away from them in any direction. Despite the occasional physician rumblings against nursing power, individual nurses aren't really given a tremendous amount of decision making power in most hospitals. They are given protocols and can be heavily punished for violating them.

From what I have seen also hold true for nurse practitioners, not just in the ED.

 

[e30ftw]

I don't like nurses who are bad at their job. If you complain about being busy in the Emergency Department when everyone else is busy too, I don't want to hear about it. If you can't start IVs and the charge RN has to come bail you out, or if your body habitus prevents you from walking the number of steps you need to do your job, you shouldn't work in the ED. This applies to physicians as well.

That said, staffing an ER is a team effort, and I only feel that way about an extreme minority of people that everyone else feels the same way about. It has nothing to do with being an RN but with the individual themselves. I am lucky to work with excellent midlevels who provide good patient care and respond well to suggestions/etc.

The majority of concerns a nurse voices to me about a patient are completely legitimate and thus I don't mind the occasional "doctor pts BP is 190/90" notification. I have never had an RN refuse an order and every time there is a question about the physiology/etc behind an order or why I'm not ordering such-and-such I'm happy to explain.

 

[BoardingDoc]

I'm of the opinion that anyone intubated gets a sedative and a narcotic. Having a piece of plastic shoved down your throat is painful... and [propofol/versed/precedex] has absolutely no analgesic
effect.

I agree with your overall sentiment, except that precedex does have analgesic properties. Is it the same as running a fent drip? No. But not everyone needs a fent drip either.

 

[Robotic Wis-Hipple]

I agree with your overall sentiment, except that precedex does have analgesic properties. Is it the same as running a fent drip? No. But not everyone needs a fent drip either.

I agree with your overall sentiment but I think the amnestic and analgesic properties of precedex are overestimated. The doses required are almost never used outside of peds as precedex is typically used in the patients people are afraid of using prop/fent on, and even at 0.5mcg/kg bolus with continued infusion amnesia is only moderate. Of course, there are reasons and scenarios that make specific drugs better suited than others, but if I end up in an ICU with poly trauma and a tube I'd like prop/fent myself.

 

[Raryn]

I agree with your overall sentiment, except that precedex does have analgesic properties. Is it the same as running a fent drip? No. But not everyone needs a fent drip either.

Better giving everyone a fentanyl drip than giving everyone a versed drip. Our ED does it on every patient they intubate and it drives me nuts. The only patients on a versed drip in our ICU are in status or paralyzed.

 

[BoardingDoc]

Better giving everyone a fentanyl drip than giving everyone a versed drip. Our ED does it on every patient they intubate and it drives me nuts. The only patients on a versed drip in our ICU are in status or paralyzed.

Every patient? That's extreme. That said, my ED doesn't use precedex very often and if the BP is soft, the patient will wind up on versed +/- fent as opposed to prop +/- fent + levo.

Pressure is ok/high? Prop it is.