I hate it when the nurse does X...

[Fox800]

Just wondering if the majority of the docs here with these stories are residents or attendings? Im a female EM intern and we routinely have nurses who disobey orders and do whatever they want. There's a nurse we have here who sees a patient before we do, draws blood and puts in his own orders under the attendings name. By the time I see the patient some of the labs have resulted.

Today we had a nurse who I put in an order for a patient to be placed on a cardiac monitor. An hour later the attending complained to me that the patient was still not on the monitor. I verbally told the nurse two more times to do it and she responded "if you guys are so concerned do it yourself". 30 minutes later the patient was still not on the monitor, the attending got pissed and walked up to her and gave a verbal order, at which point she got up immediately.

Im too busy and have too many patients to see to fight these people or safe care them. Ive done it in the past and they just talk back. Im just hoping this is only happening cuz it's residency and things will change dramatically when I'm an attending.

Thoughts?

Is there a way to report this as a patient safety event? Does your hospital have a way to submit this as an incident report? I'm sure the hospital administration would have an issue with insubordination and a nurse entering orders under an attending's name.

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[GTP]

We have something called safecare. I've only done it once before cuz a trauma attending made me do it to report a radiologist who missed a c1 fracture. But it's time consuming and annoying. The other issue is we have one attending in particular who openly makes fun of residents with nurses and talk behind residents backs. That particular incident happened during that attendings shift. So I feel like this kind of behaviour reinforces the disrespect. This definitely doesn't keep me up at night or make me angry longer than 5 minutes. I almost wonder if it's better to keep my head down and just ignore this for two more years

 

[deleted547339]

Just wondering if the majority of the docs here with these stories are residents or attendings? Im a female EM intern and we routinely have nurses who disobey orders and do whatever they want. There's a nurse we have here who sees a patient before we do, draws blood and puts in his own orders under the attendings name. By the time I see the patient some of the labs have resulted.

Today we had a nurse who I put in an order for a patient to be placed on a cardiac monitor. An hour later the attending complained to me that the patient was still not on the monitor. I verbally told the nurse two more times to do it and she responded "if you guys are so concerned do it yourself". 30 minutes later the patient was still not on the monitor, the attending got pissed and walked up to her and gave a verbal order, at which point she got up immediately.

Im too busy and have too many patients to see to fight these people or safe care them. Ive done it in the past and they just talk back. Im just hoping this is only happening cuz it's residency and things will change dramatically when I'm an attending.

Thoughts?

That's a culture thing, not an resident or attending thing. If I tell a nurse to do something at my residency, it gets done. It might get done with a little more speed than when I told them as an intern, but it got done then, too. There are always a few bad apples, but they should be the exception.

Remember, you get more flies with honey than with vinegar.

 

[GTP]

Yeah. I guess the reason it doesn't seem worth it is because I routinely talk to my coresidents (including 3rd yrs) and we all have issues with the same nurses. There are actually only 5 of them who disobey orders, talk back or are just lazy. The rest follow orders and are nice to work with. Just can't wait to leave this place

 

[Psai]

Yeah. I guess the reason it doesn't seem worth it is because I routinely talk to my coresidents (including 3rd yrs) and we all have issues with the same nurses. There are actually only 5 of them who disobey orders, talk back or are just lazy. The rest follow orders and are nice to work with. Just can't wait to leave this place

I can't imagine that administration would be okay with nurses putting in their own orders under the physician's name. Or JCAHO. Or CMS

 

[deleted109597]

I can't imagine that administration would be okay with nurses putting in their own orders under the physician's name. Or JCAHO. Or CMS

It's called an SDO, and I'm sure they can show they've got a protocol for it. And if you try and get rid of it, they argue THEY'RE BEING PATIENT ADVOCATES and "speeding up dispositions" or whatever.
I honestly don't mind SDOs, as long as dumb **** like D-Dimers aren't in them.

 

[WilcoWorld]

We have something called safecare. I've only done it once before cuz a trauma attending made me do it to report a radiologist who missed a c1 fracture. But it's time consuming and annoying. The other issue is we have one attending in particular who openly makes fun of residents with nurses and talk behind residents backs. That particular incident happened during that attendings shift. So I feel like this kind of behaviour reinforces the disrespect. This definitely doesn't keep me up at night or make me angry longer than 5 minutes. I almost wonder if it's better to keep my head down and just ignore this for two more years

Just wait two weeks. Once the new interns are running around, the nurses will find you magically competent and start asking you to save them from the miserable, know-nothing 'terns.

Take it in stride, don't let it go to your head, and remember these posts when you're tempted to commiserate with someone who is criticizing your new underlings.

 

[Psai]

It's called an SDO, and I'm sure they can show they've got a protocol for it. And if you try and get rid of it, they argue THEY'RE BEING PATIENT ADVOCATES and "speeding up dispositions" or whatever.
I honestly don't mind SDOs, as long as dumb **** like D-Dimers aren't in them.

What does it stand for? Do they get performance bonuses or something? I really can't see the advantage of nurses putting in orders instead of doing nursing tasks for them

 

[gutonc]

What does it stand for? Do they get performance bonuses or something? I really can't see the advantage of nurses putting in orders instead of doing nursing tasks for them

Standing Delegated Order (I think). Pretty much every practice setting has them. If you're going to in any way be associated with nurses in your future career, you're going to deal with them.

I agree with @Dr.McNinja that, in general, they're a good idea...unless there's a bunch of useless (or potentially harmful) crap in them.

 

[Angry Birds]

I agree that SDO's are good. I work at a single provider shop, and I actually troll the board to "see" every patient before I actually see them, and I often put standard orders in, seeing low risk chest pain patients only after their labs are resulted, decreasing my visits to their room by half. (I of course see the EKG immediately, since the tech hands it to me.)

I prefer my own standard orders over the ones the nurses put in, which is why I troll the board continuously, putting in orders on all new arrivals. However, sometimes if I don't get to it, I still usually do appreciate the nurse putting in her own orders, although it often does require adjustment. My own standard orders, on the other hand, usually end up being the right ones.

Yes, this sometimes results in extra orders, and there is a cost to this... But, the efficiency in throughput is great. It's something you can't appreciate until you are an attending at a solo provider shop.

 

[gotname]

Over the years, this has happened a few times and again this year.

ED because of syncope with bradycardia. EKG is ordered. Nurse does EKG then another and another and another and another and so on because "this EKG doesn't look right. And your HR is way too slow for your age."

After the 7th or 8th one in a row, they question me about whether I fainted because of falling down stairs and just forgot to mention it or started having cocaine with breakfast etc. because...the EKG should be normal. After saying that none of those things apply, they say ok and usually disappear and turns out that they never gave the doctor the 10,000 EKGs.

Every single time when the doctor asks...

Nurse: "It didn't look right. I was going to redo it later" (or some variation of this)

Coincidentally, two of those are also the nurses that put off starting fluids (ordered to be started ASAP) to when they redo the EKG. Passed out again and ended up admitted.

I have encountered many skilled nurses who work well both individually and as a team (as a nurse) with the doctor. Then there are those that regardless of skill, seem unaware of their assigned duties. From a patient's perspective, this goes both ways (doctors/nurses) as it seems each need to not only work together but be conscious of their role in patient care.

 

[Traumahawk]

We call then ATGs (Advance Treatment Guidelines), but same idea: they're canned order sets, designed by our EM practice committee physicians and set out by chief complaint, that the nurse can enter to get a workup started if the physician is going to be delayed in seeing a patient for whatever reason. If your patient fits into one of the order categories, they're great (and as Angry Birds mentions, a huge time- and stress-saver for physicians and nurses alike).

ATGs at my shop do have one nasty downside, though, and it's specifically to prevent the kind of behavior Psai references, wherein nurses write "roll your own" order sets under some attending's name and claim "standing orders" to defend it. The ATG order sets are all-or-nothing packages; as an RN you can't order testing a la carte. Thus you get DrMcNinja and gutonc's problem, "I Hate It When the Computer Makes the Nurse Do X."

Example: I'm in Triage and a 42 yo male walks in with c/o productive cough, pleuritic chest pain and low grade fever x3 days, admits no pertinent PMH. There's no PIT* doc on and the department is blown out; it's going to be hours before this dude sees a PA, let alone a physician. I'd like to order a CBC and a 2-view chest X-ray. If I use the "Respiratory" ATG, we're throwing in an ECG, BMP, rapid flu swab, and an albuterol neb. If I use the "Chest Pain" ATG, the dude also gets an ECG, a BMP, PT/PTT, three sets of troponins, 324 mg chewtab aspirin and 3 sublingual nitro tabs. Half to three-quarters of this stuff he doesn't need, but I'm stuck ordering it anyway.

Fortunately, we tend to have solid physician/nurse working relationships in our shop, and you can usually call a doc in the back, give him/her the bullet on the patient, and get a telephone order for what you want, but that workaround also takes that doc away from his/her own patient board for however long. It's a recurring problem with very few acceptable, let alone good, solutions.


* PIT: Physician In Triage, a program for rapid physician evaluation and advance ordering of basic labs and meds during ED "surge volume" events.

 

[deleted109597]

* PIT: Physician In Triage, a program for altering the "door to doc metric" that allows advance ordering of labs that may or may not be closely related to what the guy in back actually wants

FTFY

Sometimes I'd rather have the nurse doing it than the doc who CTs everything.

 

[Traumahawk]

* PIT: Physician In Triage, a program for altering the "door to doc metric" that allows advance ordering of labs that may or may not be closely related to what the guy in back actually wants
FTFY

Sometimes I'd rather have the nurse doing it than the doc who CTs everything.

True on both accounts. See also: the folks who believe unto their heart of hearts that the ATLS primary survey mnemonic reads Airway, Breathing, CT Scan. Meanwhile some poor so-n-so has been doomed to spending the last year of his life glowing like a cyalume stick because he came in for a sprained ankle and got pan scanned 17 times...

 

[Siggy]

It's called an SDO, and I'm sure they can show they've got a protocol for it. And if you try and get rid of it, they argue THEY'RE BEING PATIENT ADVOCATES and "speeding up dispositions" or whatever.
I honestly don't mind SDOs, as long as dumb **** like D-Dimers aren't in them.

The problem is that there can still be downstream harm. For example, my hospital "has a protocol" that every patient with diarrhea (even if it doesn't meet the definition of diarrhea in contrast to just loose stools) gets a C. diff screen in the ED. Patient's who get C. diff screens get put into isolation when admitted until the test comes back. The vast majority of them are negative, so staff starts to ignore the isolation precautions (alarm fatigue). So when a patient is sent in to the hospital after having a positive C. diff lab at the SNF 3 days prior, the floor staff is more likely to ignore the isolation precautions.

Also, apparently, my hospital thinks that you don't need bleach wipes as long as you clean with the saniwipes often enough.

 

[WilcoWorld]

The problem is that there can still be downstream harm. For example, my hospital "has a protocol" that every patient with diarrhea (even if it doesn't meet the definition of diarrhea in contrast to just loose stools) gets a C. diff screen in the ED. Patient's who get C. diff screens get put into isolation when admitted until the test comes back. The vast majority of them are negative, so staff starts to ignore the isolation precautions (alarm fatigue). So when a patient is sent in to the hospital after having a positive C. diff lab at the SNF 3 days prior, the floor staff is more likely to ignore the isolation precautions.

Also, apparently, my hospital thinks that you don't need bleach wipes as long as you clean with the saniwipes often enough.

Don't get me started on the crappy [pun intended] hand-hygeine that is promoted by initiatives making providers apply any (insignificant) amount of (partially) ineffective alcohol foam (dispensed from potential fomite bottles) EVERY time they interact with a patient - even if the interaction is to say "I'll be right back" and spoken with hands firmly in pockets.

 

[Siggy]

Don't get me started on the crappy [pun intended] hand-hygeine that is promoted by initiatives making providers apply any (insignificant) amount of (partially) ineffective alcohol foam (dispensed from potential fomite bottles) EVERY time they interact with a patient - even if the interaction is to say "I'll be right back" and spoken with hands firmly in pockets.

I pretty much have a Pavlovian response every time I see an alcohol dispenser that borders on OCD (Damn it if I'm stuck in a conversation standing next to one of those things). At least at my hospital they use proximity sensors so you don't have to actually touch it.

 

[Traumahawk]

The problem is that there can still be downstream harm. For example, my hospital "has a protocol" that every patient with diarrhea (even if it doesn't meet the definition of diarrhea in contrast to just loose stools) gets a C. diff screen in the ED. Patient's who get C. diff screens get put into isolation when admitted until the test comes back. The vast majority of them are negative, so staff starts to ignore the isolation precautions (alarm fatigue). So when a patient is sent in to the hospital after having a positive C. diff lab at the SNF 3 days prior, the floor staff is more likely to ignore the isolation precautions.

Also, apparently, my hospital thinks that you don't need bleach wipes as long as you clean with the saniwipes often enough.

We have the same problem: any patient presenting with a case of poopies for any reason whatsoever (even if it's blindingly obvious traveler's diarrhea, as in "the patient just got off the plane four hours ago from having spent two weeks on Copacabana Beach" obvious), gets put on Ebola-level precautions until we have a stool sample in hand - and then when the test comes back negative, it takes Infection Control six months to cancel the C. diff alert out of the computer, during which the poor patient can't figure out why their PCP's office staffers are wearing full-body suits and respirators to draw their routine A1Cs. No such business with the bleach wipes, though; any surface that patient might have contacted is totally out of commission until the housekeepers can come in and soak it with bleach, glutaraldehyde and probably DDT for all I know. Makes my life absolute merry hell when Spring Break rolls around and half my rooms are offline until the nuke squad can come through and bug-bomb everything that the usual influx of teenage beach-party victims touched.

 

[TooMuchResearch]

We have something called safecare. I've only done it once before cuz a trauma attending made me do it to report a radiologist who missed a c1 fracture. But it's time consuming and annoying. The other issue is we have one attending in particular who openly makes fun of residents with nurses and talk behind residents backs. That particular incident happened during that attendings shift. So I feel like this kind of behaviour reinforces the disrespect. This definitely doesn't keep me up at night or make me angry longer than 5 minutes. I almost wonder if it's better to keep my head down and just ignore this for two more years

Give your program feedback about that attending either at your outgoing program evaluation (as you graduate) or on an alumni eval. Don't do it now.

 

[TooMuchResearch]

Yeah. I guess the reason it doesn't seem worth it is because I routinely talk to my coresidents (including 3rd yrs) and we all have issues with the same nurses. There are actually only 5 of them who disobey orders, talk back or are just lazy. The rest follow orders and are nice to work with. Just can't wait to leave this place

You have to learn to manage the bad nurses. Both those who can't identify the sick patients or prioritize tasks and the ones who play doctor.

 

[deleted109597]

The problem is that there can still be downstream harm. For example, my hospital "has a protocol" that every patient with diarrhea (even if it doesn't meet the definition of diarrhea in contrast to just loose stools) gets a C. diff screen in the ED. Patient's who get C. diff screens get put into isolation when admitted until the test comes back. The vast majority of them are negative, so staff starts to ignore the isolation precautions (alarm fatigue). So when a patient is sent in to the hospital after having a positive C. diff lab at the SNF 3 days prior, the floor staff is more likely to ignore the isolation precautions.

Also, apparently, my hospital thinks that you don't need bleach wipes as long as you clean with the saniwipes often enough.

The choir is right here. Every flu, strep throat, or fat **** who gets SOB and tachy walking in from the parking lot gets the mandatory lactate and blood cultures due to having 2 SIRS criteria. Go to committees and see if you can get it changed. Don't bitch about it here, or you'll burn out.

 

[Psai]

The choir is right here. Every flu, strep throat, or fat **** who gets SOB and tachy walking in from the parking lot gets the mandatory lactate and blood cultures due to having 2 SIRS criteria. Go to committees and see if you can get it changed. Don't bitch about it here, or you'll burn out.

Damn that is stupid

 

[cbrons]

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

Need an achievement name for this one

http://forums.studentdoctor.net/threads/xbox-one-achievements-for-medical-school-residency.1204108/

• 5G -
  • (As a resident, have a nurse tell you, "I'll lose my license!" if he/she carries out your order)

 

[Siggy]

The choir is right here. Every flu, strep throat, or fat **** who gets SOB and tachy walking in from the parking lot gets the mandatory lactate and blood cultures due to having 2 SIRS criteria. Go to committees and see if you can get it changed. Don't bitch about it here, or you'll burn out.

My ER has the exact opposite problem. "What do you mean the patient is septic? The lactate was negative!" #TechnicallySeptic

 

[USCDiver]

We had a hard time drumming the "and you suspect infection" part of the early sepsis protocol into some of our nurses. We use a MEWS score (designed to identify sick, not specifically sepsis and as such gives a point for high BP as well as low). I had a patient with tachycardia, tachypnea and hypoxia due to pulmonary edema from her 250/130 BP who had a liter of fluid going wide open when I walked into the room...

 

[filhodeinferno]

Had a new one on my night shift last night....I don't know why this bothered me. I work in a very large ED and we have a tech who likes to page the docs overhead. The problem is that she'll just page "Dr. So-and-So please go see your patient in 207." I don't mind getting overhead paged if it's like "Dr. call such-and-such number."

Last night I was in the middle of putting a splint on this lady's leg fracture and this tech pages me overhead twice telling me to go see a particular patient. For some reason it made me furious. I walked over to her and told her, "I have a phone, and if you have an issue with a patient you call me on my phone and tell me what the issue is so that I can decide whether I need to go back and reassess my patient." I am not housekeeping and will not be sent to and fro by overhead pages from a tech. I was in the middle of a procedure and sitting there wondering if there was some kind of emergency that warranted me to be paged overhead x 2. Worst part of it is when I went to go see the patient she was just like, "These pain meds ain't doin' ****."

Not a big deal, but for some reason...bugged me. SMH.

 

[Daiphon]

Had a new one on my night shift last night....I don't know why this bothered me. I work in a very large ED and we have a tech who likes to page the docs overhead. The problem is that she'll just page "Dr. So-and-So please go see your patient in 207." I don't mind getting overhead paged if it's like "Dr. call such-and-such number."

Last night I was in the middle of putting a splint on this lady's leg fracture and this tech pages me overhead twice telling me to go see a particular patient. For some reason it made me furious. I walked over to her and told her, "I have a phone, and if you have an issue with a patient you call me on my phone and tell me what the issue is so that I can decide whether I need to go back and reassess my patient." I am not housekeeping and will not be sent to and fro by overhead pages from a tech. I was in the middle of a procedure and sitting there wondering if there was some kind of emergency that warranted me to be paged overhead x 2. Worst part of it is when I went to go see the patient she was just like, "These pain meds ain't doin' ****."

Not a big deal, but for some reason...bugged me. SMH.

Better question is why your tech wasn't doing the splint... if they have time to harass overhead, they have time to do the orthoglass.

Semper Brunneis Pallium

 

[filhodeinferno]

Better question is why your tech wasn't doing the splint... if they have time to harass overhead, they have time to do the orthoglass.

Semper Brunneis Pallium

That is an excellent question. The answer is large, academic center. Love just ordering the splint at our satellites.

 

[WilcoWorld]

That is an excellent question. The answer is large, academic center. Love just ordering the splint at our satellites.

Yep, large academic center with 30% of your patients being complicated transfers that befuddled (or just sufficiently pissed off) other ED's - better have the docs apply the splints.

That's how we do.

 

[Redrox]

I boil over inside when a nurse guarantees that a pain medication will take the pain away entirely and checks back only 5 minutes later to see if it has or would they like another dose ?

 

[Cinclus]

I hate it when nurses think I have any idea what is going on during my first shift as an intern. (I have no idea what's going on. Don't look at me in that tone of voice..........Okay, I know a little bit, but please stop making that face.)

 

[filhodeinferno]

I hate it when nurses think I have any idea what is going on during my first shift as an intern. (I have no idea what's going on. Don't look at me in that tone of voice..........Okay, I know a little bit, but please stop making that face.)

Scrubs is spot on, though...you'll blow right by most of them quickly when it comes to actually knowing what's going on.

 

[Fox800]

Takes 30 minutes to hang and run the liter of NS before drawing the labs I ordered. WTF?

 

[Robotic Wis-Hipple]

Takes 30 minutes to hang and run the liter of NS before drawing the labs I ordered. WTF?

Well that's cuz last time they stuck the AC for blood during the IVF bolus you yelled at them AND they just had to get labs a second time. See, it's for efficiency's sake.

 

[Fox800]

Well that's cuz last time they stuck the AC for blood during the IVF bolus you yelled at them AND they just had to get labs a second time. See, it's for efficiency's sake.

Yup. Because if I'm testing electrolytes and a lactate on someone that's dehydrated and in AKI, the best time to do it is immediately after a fluid bolus.

 

[Psai]

Yup. Because if I'm testing electrolytes and a lactate on someone that's dehydrated and in AKI, the best time to do it is immediately after a fluid bolus.

Well now you know they're better

 

[Angry Birds]

I hate it when nurses think I have any idea what is going on during my first shift as an intern. (I have no idea what's going on. Don't look at me in that tone of voice..........Okay, I know a little bit, but please stop making that face.)

Well, you need to fake it till you make it. Definitely don't let on that you don't know what's going on. The nurses will smell blood and go for the kill.

The nurse-intern relationship can be a tough one. But, you cannot become a subordinate.

I heard a nurse complaining once, "These med students graduate and on day one of intern year they think they can give orders." I responded: "Actually, they don't just think that. That's exactly how it works." OK, I didn't actually say this. I just thought this. Anyways, I'm an attending now and nurses will often trash talk residents, thinking I will agree. Maybe it's just that I was a resident just a couple years ago... But personally, I respect residents, and I know I would learn from them just as they could learn from me. So, I don't see the justification for a derisive attitude toward them. Sure, there are always a couple duds in every batch, but for the most part, EM residents are stellar. They work incredibly hard, do extremely difficult work, and usually maintain a very positive attitude. Props to them!

On that note, I can't wait to switch into academics and let them do the work.

 

[engineeredout]

Thanks for sharing information.

Thanks for bumping a thread not responded to in three months champ

 

[Cinclus]

I think he's a bot.

 

[Apollyon]

I think he's a bot.

B.b...but, he just joined up today!! First post, can't be!!

 

[engineeredout]

Hey! Not a bot. Just came to explore.

Hey my Nigerian uncle has 20 million dollars he is trying to get out of the country but is having trouble. If you are able to provide 1,000$ for transfer fees I think we can work something out...

 

[Angry Birds]

Hey my Nigerian uncle has 20 million dollars he is trying to get out of the country but is having trouble. If you are able to provide 1,000$ for transfer fees I think we can work something out...

This transaction would require a payment to the IRS. I will connect you to my colleague, Bruce in India-- I mean Indiana...