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Discussion in 'Internship' started by 360, May 4, 2007.
Anyone with ideas/secrets to share? Please
I know they get more than their fair share of crap, but...nurses. They'll call you about anything and everything, and more often than not it's about some minute detail on a patient that you're just cross-covering on. Sifting out what's really important can be difficult...
One of the scariest stories I've heard was the nurse who called the wrong doctor, who was at home, and told him that the patient "just didn't look right". That was it...didn't have any vital signs to report, couldn't tell the doc anything more about the patient besides they "didn't look right". Turns out the patient had a pressure of like 70/30 and ended up getting transferred to the ICU.
One of my favorite stories is from a colleague of mine, who, upon getting called at 2am to renew a Tylenol order that had expired in the computer (on a patient who was not in pain or febrile), went running down to the ward from the call room. Upon arriving, he was all out of breath, and the nurse asked, "oh, are you here to renew Mr. X's Tylenol order?" He said, "no, I'm here to report you to your supervisor for calling me for such a stupid request at 2am."
They do call about the dumbest things at time. It unfortunate but a lot of them don't have much common sense.
Its not necessarily always a lack of common sense but rather simply ignorance - some of the nurses honestly do not know that we are not working shifts like they are (ie, starting at 11 pm and going home at 7 am), that we have already been in the hospital for 18 hrs and have another 12 or more to go, etc.
Use these inappropriate exchanges to engage the nurse in a dialogue as to why they would consider calling at such an hour for a non-emergent situation and whether or not they understand the schedule the residents endure.
So what are you supposed to do if an order for a med expires at an inconvenient time and the pt needs it? I know what I would do...I'd just write a telephone order, but technically, that's not legal since I didn't actualy get a telephone order. It would also depend on what the drug was; I wouldn't do that for abx, cardiac meds, narcs etc.
It puts the nsg. staff in the "damned if you do, damned if you don't" position. We've got licenses to protect, too.
For the record, I have also used the "pt doesn't look right" line myself, but I always have vs, labs, etc. in addition. Those gut feelings usually turn out to be pretty good predictors of a pt who is about to crash. Sometimes you just have a situation when something is wrong and you can't quite put your finger on it, but you just know that trouble is coming. If I were the intern/resident, I'd rather get called early than have to respond when you've got a full blown code going. That's just me.
Annoyances comment is exactly why I am looking to do something else. It doesn't matter if you're conscientious and do your job well, you're still just a dumb nurse. Try getting your work done without any nurses, Annoyance. See how far you get.
you get a little knee ache when a twisters a' comin too?
"Somethings wrong but you can't quite put your finger on it" isn't a lot of help. If everything is normal (VS, UOP no complaints) but you've got a "feeling" chances are the Dr ain't gonna be able to discern what the problem is based upon your description of the type of knot in your stomach. If trouble is coming give me a call when it gets here, I don't like to wait.
Nice response. Fortunately, there are a few docs who know that when one of us veteran nurses call and tell them that, they know to get in to see the pt.
Also, learn to read a little more carefully. I didn't say the labs and vs were all normal and there were no complaints. I'm talking about those iffy situations which on the surface don't look that critical.
It's helped forestall a full-blown code in more than one situation, so I'm sticking with it.
And I don't live in Tornado Alley, anyway.
I agree with veteran nurses. The typical resident has a lot less hands-on experience than senior nurses, and gut-level feelings are not to be ignored. These "feelings" are usually based on a collective experience gained over time, and a subconscious mapping of this experience onto the current case. I wouldn't blow that off.
As a graduating med student, I've worked with expert nurses that I would have died without.
In my limited experience, there are also nurses---most from abroad---who are incompetent and lazy. HOWEVER, there are residents that are incompetent and lazy, too, and both groups can make life hellish.
That is a job for the pharmacy committee to correct. In my residency hospital, we and the nurses complained to the head of pharmacy about renew orders which expired in the EMR in the middle of the night (because perhaps that's when the patient was admitted) and would not allow the nurses to even get the drug without a physician logging in and renewing the order.
They revised the system so that meds would only prompt for renew during "normal" business hours - something like 8a-10p. You could also change the prototol so that any med which expires, say between 11p and 6a, could be administered one more time without a written or verbal order to renew from the physician.
This is not difficult to do - it just takes some forward thinking people with the ability to act on a problem and find a new way to handle it.
There's also a lot to be said for the experience of knowing when a patient "just doesn't look right". If an experienced nurse or physician says this, you should give a bit of merit to their words as its an observation which comes with time and often heralds generalized badness.
"Generalized badness" That's going into my memory bank of "Good expressions to use."
I really didn't intend for this to turn into a thread on which to bash nurses. Lord knows that there are plenty of highly qualifed, veteran, and skilled nurses out there that are absolutely essential to patient care. Unfortunately, very few of them work at my hospital.
fab4fan, I would never discount the gestalt that someone can get when they walk into a room. I use it on a daily basis, but it can't be used in isolation. If a nurse ever calls me with the "they just don't look good" and can't give me vital signs, then that is simply unacceptable. I immediately tell them to hang up and get current vital signs and then call me back. If they call me and say, Mr. X's temperature is 103.2, then I say, "I'm on my way, and in the mean time, get a new set of vital signs."
Good grief. I said:
Not to be sarcastic, but do you think I would be insane enough to call a doctor and just say, "Uh this pt doesn't look good" and have no vitals, no recent labs, not listened to his heart, lungs, etc.? Really? Honestly?
I tend to agree with what Dr. Cox said. Sometimes you pick up on subtle changes that you've seen in the past right before everything goes down the chute. It sticks in the back of your mind, and though you may not be thinking of that specific incident, there's that little alarm that goes off in the back of your head.
It does seem like most of the complaints from folks here revolve around being paged for housekeeping issues in the middle of the night. Anyone here ever actually get a page for, "The patient doesn't look right" with no supporting data? Honestly, that would suprise me a little.
You're right - most of the objectionable pages are for things like "can we D/C the PCA [since its time to change the tubing]?" or to let us know they gave a patient an ordered medication. Or they want to know what the long term plan is. These are unnecessary calls at 2 am.
But I have had, on occasions, nursing staff call and say that the patient doesn't look right but they have no variation in their labs. You can ignore this call, but in general, always a good idea to go and look at the patient. Convince yourself they look ok, or at least document that you saw the patient and decided no change in management was needed. That statement will come in awfully handy if the nurse is right and the patient is going to take a sudden downer...much more defensible than if you took the call, and didn't respond. Because your name is on the chart as being notified that the patient "didn't look right" and you didn't come or give new orders.
That's very disappointing to hear. I hope it's not often.
Fantastic, outstanding, really....meanwhile, just let me know what reliable indicator signifies a downward spiral. If the HR is 35 you don't need to tell me the patient doesn't look right. So if you HAVE the facts...just tell them to me. Here's a little exercise..pick the part out of this sentance that doesn't need to be said:
"Mr. X just doesn't look right, and he's having crushing substernal chest pain"
I'm glad we're all for gestalt and we can all join hands and dance circles around the old wise nurses (and I'm sure they have a much better handle on what to do than me)...but lets be real, if a Dr. put down "doesn't look right" in the subjective portion of his note...he'd be laughed at.
[QUOTE...but lets be real, if a Dr. put down "doesn't look right" n the subjective portion of his note...he'd be laughed at.[/QUOTE]
Really? So you've never noted a patient who "looks ill/toxic/worse than last time seen on rounds, etc."?
I think you underestimate the value of just looking at the patient and knowing they look ill. This has nothing to do with doctors vs nurses except when physicians insist that they are right over evidence which tells us that patients can and do appear ill before there are systemic signs.
Sure. If they look septic I'll throw that in too group together the collection of data suggesting it, as part of the "weaving" a story that attendings love so much, If the guy is going down the toilet and someone says "hey how is X doing?" I might say, he's worse...if they want specifics I don't think my response will ever be..."just doesn't look right", or he "looks ill" maybe he's pale, diaphoretic, less communicative...whatever. If I CALL a person at 2 am and potentially (if they are lucky to get any sleep) interupt what may be the little nap they may get...i will not be calling to tell them the person just don't look right to me.
I agree 100% that this has nothing to do with Dr's Vs. Nurses. It has to do with lame phone calls. Any resident that called a consult like that and wanted you to see the patient because...wait for it..."evidence tells us that patients can and do appear ill before there are systemic signs"...would be hung up on. The same DISRESPECT we afford our fellow physicians can be heaped upon nurses as well, afterall, we're all equals.
Added on: I don't think that this is what you meant, but if you were asking if I have ever written "looks ill" in a note the answer is no.
at 2:00 am..B is pleasantly sleeping for maybe a 1/2 hour before more work is to be done...the pillow's soft, the bed warm and comfortable...suddenly, a pager jolts him from his sleep, its orthopedics:
A: I need a internal medicine consult on Mr. X
B: What for?
A: Well...dude looks ill. Little alarm going off in my head.
B: Ummmm anything else?
A: Nope, vitals signs are normal, no complaints but he looks worse, and evidence tells us that patients can and do appear ill before there are systemic signs. So I think you should come and take a look.
B: Go F*ck yourself.
You're right - no one has any business calling a consult when the only reason for the consult is "they don't look right."
But in the situation above, Mr. X is already on your service, his nurse has taken care of him for hours and I believe her when she says he "doesn't look right". I would prefer to have some hard data to back that up, but then again, I've been told too many times that the vitals are normal when they aren't, or that a patient is doing fine, when they aren't. How many mornings have you rounded only to find abnormal vitals or events recorded which you weren't notified? So when I get a call like this from a patient's nurse, I say its worth a look-see. Most nurses when you press them will be able to give you more detail such as, "he's pale/diaphoretic/less responsive, etc." Telling me he doesn't look right isn't very descriptive but it doesn't necessarily mean that there isn't anything wrong with the patient.
What I objected to was the response that assumes that such a call is totally bogus and needs no response. If you feel you must clarify what "he doesn't look right" - go ahead; I'd prefer to ask and still go and see the patient myself. The resident that stays in bed is the resident who finds themselves in trouble, IMHO.
There is a lot of bravado here about unnecessary pages and resident abuse; I've been part of it as well. But lets not forget that residents and attending physicians are aprt of the problem. If you don't educate someone on what an inappropriate call is, you can expect to get another one. And if you don't go see a patient when there is potentially a problem, its only your arse which is going to pay for it, not the nurse who has paged you to tell you of the problem. No court will fault her for paging you and not being able to fully describe the problem - that's not her job. Her job is to inform you of problems with patients - if you fail to respond appropriately and the patient has a real problem you could be held liable.
Perhaps I don't hold nurses to the same standard as I would an ER physician - but as I noted above, we're not taking about a consult on a patient with no data, and despite wishing for it, I cannot make some nurses more sophisticated or better communicators. If that means I get out of bed to actually eyeball the patient rather than waste my time yelling at the nurse and ask her to call me back with the vitals, then so be it - I'd rather have the situation finished than waiting around for another page.
As for not ever writing, "patient looks ill/toxic/whatever" in the chart - you have a point about being more descriptive. One should say they are pale, diaphoretic, etc. and we usually do, but I see nothing wrong with also saying the patient looks toxic or septic or ill because frankly I think most of us also know what that means as well.
At any rate, we all have our differences of opinion and I was trained that you get up and go see the patient when asked to.
Never mind. Clearly, you've missed the point. Such a shame that you haven't yet learned that there's more to treating pts than just numbers. Disregard such comments at your own peril (or your pts' peril, really).
BTW, spare me the diatribe about disrespect. It's one of the main reasons I am looking to get out.
I agree with this whole heartedly. As pissed off as I'd be I'd still go see the patient, my problem is just letting it slide by without informing the nurse that the call lacked a certain amount of professionalism...I see people let these calls go ALL the time...but if you make a consult call like that, forget it, no one's going to let that go. I think people should be able to do thier job regardless of educational background.
Yeah, there is also anecdotal evidence and gestalt apparently. If you'd like to reduce this too numbers to shield your ego that's just dandy with me...you've allready decided to stick with the not looking right as an adequate reason to call for help. However, for others reading, I would encourage them to try to improve their descriptive vocabulary, exam technique and attention to detail so they can perhaps more fluently discern what it is thats...not right...before reaching for the phone. One options easy, ones hard...I know which one most people will choose.
My patients are in no peril...despite my sarcastic attitude I'll trudge my a$$ down there to see the patient despite your feeble attempt at discerning the problem...however, eventually you'll run into the few residents that won't respond...then your patients will be in danger because you failed to properly and clearly convey the need for a physicians attention. Don't worry though its not your responsability right?
Your or your patients?
Disclaimer: I will only be an MSI this summer.
Ok so I thought this would be an interesting thread but its just another ' nurses suck ' thread. Anyway I'd like to put my .02 in. I choose to be a doctor, my wife is finishing nursing school, and I spent the last eight years battling recurrent HD so I feel that I have a pretty broad objective view and something to add to this convers.ation. Take it for what its worth.
I completely understand not wanting to be awoken in the middle of a very precious nap- I value my sleep as well - but I understand nurses in these situations as well. Let me illustrate with one personal example. During one of my longer stays as an inpatient, after SCT, I had a very severe case of mucositis and general ****updness to say the least. The pain from the mucositis was bad enough to be one of the main reasons I had to go on TPN. There was one particular night where it was so severe I could not sit, sleep or do anything but writhe in pain. I begged and begged the nurse ( who was an experienced, highly competent nurse whom I had a few times before dealt with ) for some pain killers ( which had been given to me before for the same reason ). Everytime I asked, the nurse told me that she couldnt without the doctor's orders but she also did not want to call the attending ( or my onc ) at nite. I suffered like this until the shift was over and the morning nurses came in. When I spoke about this with another nurse, I basically was told that, yes she should have called for the order but that specific nurse was berated on an earlier shift for calling an attending ( or resident, I dont recall ) at nite for what said doctor thought was trivial. Just like there are fresh med students, interns, etc. who are nervous or unsure of how to handle certain situations, there are fresh nurses as well. Pressure is plenty to go around. Instead of berating each other, maybe everyone can remember that they are all on a team with one goal - the patients' wellbeing?
Thats my .02. Take it for what its worth.
Surely everyone here recognizes the difference between a 2am call that says:
"Mr. X's pain control is inadequate. His pain is so bad that he cannot sleep."
"Mr. X just doesn't look right, and I am completely incapable of providing more information (which was the anecdote that started this discussion)"
And while you're busy cheerleading, please keep in mind that I've actually been on services where the housestaff REFUSED to leave a standing PRN order for Tylenol for the nurses. Why? Because they could not trust the nurses to actually inform in the physician when the patient had a fever so that a work-up could be done. They were afraid they would just give the Tylenol and be done with it; meanwhile some infection continues to brew.
So, yeah, we may all be on the same team, but we're not always using the same playbook.
I never said it was numbers only. Apparently you cannot read. And certainly if I have the appropriate symptoms/assessments to use to describe the situation, I'll use them. If you think I just call without assessing a pt and having the data, then you have not read my posts, and you have jumped to the wrong conclusions.
That's not the kind of call I was talking about, nor is it the type of call I would ever make.
The doctors I work with know that when I say, "Something doesn't seem right" (after going through the requisite vs, physical assessment, labs, etc., etc., etc.), that there probably is a problem, and they have no problem coming in to see the pt. Why? Because they know that if I say that, there usually is something going on. Diss me, mock me all you want. To be honest, you opinion matters little; I care more about the attendings I have to deal with. As long as they don't have a problem, I'm fine.
Don't pretend to tell me what is and is not my responsibility. You have no clue how far my responsiblity extends, and how much of it even involves people like you.
Perhaps after you've been through a few of these situations you'll understand what some of us are trying to explain.
I'm sorry you had that experience Jjeton. Pts. should never have to suffer in pain because of something like that; unfortunately, it happens all too frequently. Here's where you can take that experience and try to promise to yourself that you won't become that intern/resident/attending that bullies staff and makes them so fearful that pt care gets compromised.
Good luck to you!
I don't know any physician who wants his patient in that much pain. I want to be called at 0200 if my patient is writhing in pain and cannot get any rest. Say what you want about integrative medicine, but uncontrolled pain and the stress response is not good for healing or a patient's emotional well-being.
As noted in detail above, there are reasons why physicians get upset when called in the middle of the night for what might be perceived as trivial, but it is MUCH worse to find out about some unresolved problem in the morning which continued because the resident or attending wasn't called.
I understand being scared to call because of being berated for previous calls; I could not call my Chiefs when I was an intern without being yelled at. But I finally realized that the yelling tended to be worse in the morning for many situations than it would have been at 0200.
The Tylenol example above is classic; too often we are asked for prn, RTC meds or treatments and these are given without thought to why the patient needs them. I do not want my gastric bypass patient to simply get Tylenol for a fever on pod #1 nor do I want the staff to wait until the HR is >120 before calling.
Bottom line is that if you are called and berate the nurse for doing so, you need to explain why you think the page is trivial or you need to explain when do you find out about a problem, why you needed to know. This isn't rocket science but many caregivers don't understand the concerns we have and its not taught in nursing school. We need to help each other - just as they can teach you how to set up the Level 1 infuser or to prime the PCA pump or to recognize different stages of decub ulcers or an allergic reaction you can teach them as well.
So, at the risk of being called a hypocrite, since I have willing participated in the process, at SDN we are trying to keep threads on topic.
I don't believe the OP really wanted to hear the discussion that has ensued here but rather wanted to know what kinds of calls would he/she get and what to do about them. What do you give for pain, for insomnia, if a drain is leaking, if the patient can't pee, if the patient falls, etc? I'll bet that is what he/she was seeking in posting this thread.
It's a little disconcerting that you turned that situation into the physician/resident's fault, rather than placing the responsibility squarely where it belongs: the RN who failed to live up to her professional responsibility. Being afraid of getting yelled at is not an appropriate reason to leave a patient in pain. Even my dumba$$ knows that.
Dear, noones cheerleading and noone is defending nonsense calls at 2 am for trivial reasons without any important information. I was just trying to show alternative perspectives. If a nurse cant call the doc on call, then who is she supposed to? Dont forget that nurses have their training and protocols that they are supposed to follow as well. When they dont take the initiative on their own, you get these threads. When they do take the initiative, you get the " nurses are so stupid look at the mistakes they make " thread.
Thanks and don't worry. My wife would kick my [email protected]@ if I did!
I find it interesting to read all these threads by med students and intern/residents complaining about ' stupid ' nurses and such. I have yet to meet one attending online or in real life that complains like this ( and before anyone says that they wouldn't complain to a patient, believe me its not true). They might complain about a specific incompetent nurse but never to the extent you read here from students and residents. Heck even the more experienced residents on this forum dont have these complaints. Just a thought.
You know, its true that many nurses dont realize the stresses residents are under but it seems that many on our side are guilty of the same. Until my wife started nursing school, I didnt fully understand it. A typical day for my wife of clinicals at one of the hospitals , who is still a student mind you, starts off by her walking onto the floor at 8 am and being handed a list of 5 patients with a list of their meds and charts. The only instructions are
" Here are your patients. See you at 8. " There very rarely is someone with enough free time to answer her questions or go over her work during the shift. She usually gets 10 or 15 minutes of her 1 hour lunch break ( the regulars at least get 1 hr + 2 15 minute breaks which they dont ever give up at least). Most of the patients dont speak English and half the notes ( which in this NYC hospital are not yet computarized ) are illegible. Meds are rarely given on time since they often dont get them from the pharmacy until a few hours after they are supposed to be administered. Oh and this is med-surg floor with most patients having complicated dx's and multiple conditions. Now she is a student so she isnt given more than 5 or 6 patients but the RN's on staff usually have at least 12 patients ( regulations be damned, this is real life...)
You have forgotten about me.
While it may be true that most of the complaints are from junior residents, that's because they get the most pages and are in-house more often. Some nurses are uncomfortable calling the senior resident or attending but think nothing of paging a junior resident with an issue which could easily wait until the morning. This is the problem - not that we disrespect the work that nurses do. But rather, being afraid to call a physician is not a good reason not to call and IMHO, if you wouldn't call the attending at home for a problem (ie, in hospitals which don't have residents) than you frankly have no business calling the resident.
So the juniors may complain more than we do, but its because they bear the brunt of this behavior day in and day out.
I'm not sure what this has to do with the situation at hand which is inappropriate calls from nursing staff, the lack of appropriate calls (ie, when a patient is writhing in pain) and calls at inappropriate hours.
No one but an idiot denies that nurses have a stressful job. But your quote above about your wife's experience simply points out that allowing the status quo to exist doesn't help anyone. If meds don't come from the pharmacy until hours after they are due, that is call for action from the hospital nursing committee. They are jeopardizing patient care by delivering the meds late and by administering them late.
The issue of inadequate break time is one to take up with Human Resources; the fact that her breaks are cut short does not make residents more sympathetic to her. Remember, physicians do not have scheduled breaks and most work right through meals without taking a break.
I realize there isn't much you can do about the nurse to patient ratio, but this simply requires more organization and proper utilization of nursing assistants. Its a problem for healthcare across the board, we are being asked to do things which endanger patients (take a trip down to your ED and see patients lined up in the hallways, without proper supervision or privacy).
I understand that you want to defend your wife's position and your point that nurses are in a stressful field is well-taken, but you haven't provided any information which defends inappropriate calls or management of patients, IMHO. Most nurses do a wonderful job of taking care of patients but the lack of responsibility is what bothers me - if the meds come late from pharmacy, it is NOT acceptable simply to shrug one's shoulders and say, "oh well"; if you have a critical issue on a patient but are scared to call the physician on call, that is not acceptable - you have to suck it up and do it.
Let's get back to the issue here. I'm starting internship in t-minus 6 weeks, and starting to get a little scared.
What types of complaints are we expected to take care of on our own from the beginning, and where do we draw the line in asking for help from our senior?
I feel like I can handle a number of common complaints in uncomplicated patients. But for the complicated ones...do you just trust your instincts on when it's time to wake up the senior? I don't feel like my instincts are developed enough at this point to trust them! I don't want to annoy my fellow residents, but I also don't want to screw up. (I know, the screw-ups will come...)
I thought the OP started a great thread, and I was really hoping for more specifics...what are your favorite remedies for constipation? pain? what little things should we avoid in treating common problems that might cause bigger problems?
You'll be fine. If you weren't concerned...THAT would be frightening.
Specific responsibilities are variable depending on your particular hospital. For heaven's sake don't be afraid to ask a senior resident for help. You can get into alot more trouble by NOT asking than by asking too often.
For a terse rundown of meds?
First item of business is to check the patient's allergies.
(1) I would use something like Colace before trying Lactulose.
(2) Pain is trickier...and I think everyone develops their own system for their specific batch of patients. I like to try Tylenol for the pedestrian headaches and stuff. Morphine IV 1-2 mg (or maybe 4mg) for pain in the "4-7 out of 10" intensity is my preference. You can always repeat x1 or 2. Be sure to check on the patient, too.
Dilaudid is a nice alternative for someone in serious distress, but be sure you fully examine someone before snowing them with pain medicine. If they have an "8 out of 10" new onset headache you might want to make sure they don't have a subarachnoid bleed prior to eliminating the pain.
Regarding asking for help/calling a senior--
As your potential senior back-up starting in July, if you don't know, CALL ME. Do not be afraid to wake me up or find me. In July, no offense, but I expect you to not know what to do for many things. I will tell you our antiemetic of choice and it's dosage, or our pain med of choice, or whatever (and expect you to remember this info). Better to ask than to inadvertantly harm the patient. I trust you, the intern, to call me, the senior, when you need help. Now, I may not get as mad at you for calling as some other people may (there are cranky seniors out there), but the bottom line is that I am supposed to help you. If you call and haven't seen the patient or to ask me a dose of a med you know is OK to give, but didn't try to look it up yourself, I will get annoyed (not angry) but still help you out. Same thing if you call me with the same question multiple times. But if you truly don't know what to do (as is the case especially in July), I'm not going to be mad or annoyed, I'm going to teach you.
If you are flailing to manage a sick patient and don't call me, I (and everyone else) will be angry when I find out about it in the morning or when the code blue happens and I won't trust you that you will ask for help when you need it.
The learning curve is steep, so you will find that the type of questions you have get more complicated as the year progresses and you don't have to call as frequently.
I guess I've been lucky. My intern year is at a private hospital and we don't get calls from nurses like the ones you guys have described. If I get called by a nurse, it's because something is wrong..ie..pt unresponsive, pt just fell and hit his head, pt having chest pain, etc. The bad part is, I have no upper level residents, so I have no one to turn to unless it is bad enough to call the attending at 3am.
If I got a call for Tylenol in the middle of the night, I think I would lose my mind. That is ridiculous.
I agree - there is a world of difference btwn hospitals which are overrun with residents and smaller, private hospitals that have few, or often have nurses who have trained in the private practice model.
Residents at those facilities tend to get paged much less often; in my experience, they often will only call for things they would consider calling the attending for. In the private hospital, if the attendings found out that we were being paged in the middle of the night for something they deemed ridiculous, THEY would complain to the nursing supervisor on our behalf. But at a typical university hospital, most everything is fair game to call - at any time of the night and try to find an attending who would support you about these dumb phone calls.
Any any rate, guilty once again of taking the thread off track.
During the month of July at the very least, you should call about everything. As we used to say, "I am incapable of independent thought."
Each senior resident has their own level of confidence and paranoia - you will learn what they expect to be called for and what they don't. I made the mistake of being a cowboy during my internship and not calling enough. And while I complained bitterly about one intern in particular who would call for EVERY LAST DAMN THING, it made me realize that she actually knew what to do in most cases, just lacked the confidence to do it. Since the Chief is the Captain of the ship at night, you should run most things by them, unless they have given you permission to do somethings on your own...ie, give fluids up to x amount if urine output is low, ok to start basal rate on PCA, if patient wants, can advance diet, etc.
You should always call for:
- changes in patient status which require a transfer in level of care
- patient with major problems; chest pain, shortness of breath, etc. that you are working up
- any tests you order (usually related to the above)
-before starting any drips, discusssing DNR orders with families, etc.
Depending on your senior resident, I would expect most new interns to feel semi-capable (ie, not need to call) with:
- replacing electrolytes
- managing most post-op pain
- managing most "run of the mill pain" - ie a simple headache, not the "worst headache of my life"
- calls for low urine output, nausea, insomina, hiccups, family wants to talk to "the doctor"
- patients who want to go AMA (although your Chief needs to know about it if it actually happens)
A good habit to get into when a junior resident, is to arrange to call your senior back-up at a certain time, say 11 pm with an update on any seriously ill patients on service. That way, you can go over potential problems, plans for them if they should occur and it allows your Chief to relax a little, knowing you are on-top of things.
- don't call your senior from the call room
- don't call without knowing a current set of vitals, Is and Os
- don't call about an ICU patient without being right in front of the patient (ie, in the unit)
This is just a starter...almost all of you will be fine and you will learn what to do and not to do. Sometimes it will be painful, just like all growing processes. There will be lots of hints to come, I'm sure.
as a student nurse here are some obvious, but still relevant tips that can help you avoid calls from the nurses:
If you don't have computer charting, please write legibly and don't use confusing abbreviations (PE has been used for so many things....)
please check allergies before you write orders. If we see an order for ibuprofen for mild pain and patient has NSAID listed in the allergy section and you haven't given me any other pain options you might get a call (if it is relevant at the time). This sometimes isn't your fault though, because I have seen NKDA written in the front of the chart and then later on in the assessment notes low and behold there are allergies listed there. So we all should be double-checking.
If you are allowed and feel comfortable, try and be as liberal with your PRN orders as you can. Include antidotes if appropriate (glucagon, D50, protamine sulfate, narcan etc...), mild pain meds, more aggressive pain meds if the situation might warrant it, tylenol and put a value on what fevers you wish to be called for. stool softeners, antacids/gastric pump inhibitors, benadryl, potassium. -basically just be as complete in your orders as possible.
Make sure any restraint orders are complete and include times and dates. One nurse might not notice an incorrect restraint order and then the night shift nurse might come and realize that it is incorrect and it technically should be fixed "immediately" and she/he would have to call to get a new order.
I have to say that as a student nurse most of my experiences with physicians and medical students have been positive. I agree with whoever said educate the staff on what warrants a call and what doesn't. I can say that we are going over what is critical to report, what can wait, what info to have ready if you have called a doc etc...
While I agree with good PRN orders, if you think you need to give glucagon, protamine, narcan etc, I want to know and see the patient before anything is given, unless the patient is actively dying. Moreover, while PRNs stop us from getting bothered, they do encourage polypharmacy. Given the age group that generally comes into the hospital, less is more. Before adding a medication to combat a side effect, I want to see if I can reduce something esle.
Even "benign" drugs, like diphenhydramine, can have significant side effects in the elderly. And then sometimes you can get carried away. I once saw a resident who wrote "1 g Ceftriaxone IV Q12h prn temp >37.9." Fortunately the pharmacy nixed that one.
So while I have to agree that PRN orders are good, one must not be too liberal and should only cover very common problems and must be tailored to the individual.
You are going to get calls about "fever."
Fever means alot of things to a lot of different people. For some, fever is any temperature that is above 37. For others it is going to be above 38.
So, first you have to decide if it is a "fever" or not. There are several diferent standards you can use. Different papers have used 38.5, 38.3 and 38.0 as their cut off for inclusion. While your sensativity for infection goes up as you use higher temps, your specificity goes down. The consensous conference for the definition of sepsis uses 38, so that is a reasonable one to use.
Second, where is the patient in their hospitalization. Rarely is a patient going to get an infection on hospital day 1, if they didn't already have it before. So if you are caring for a healthy, elective, post op surgical patient on POD#1, it is probably related to the surgery. OTOH, if you are treating an elderly diabetic on HD#8 who has an indwelling foley and was just downgraded from the ICU after 2 days of intubation, you need to take that temperature seriously.
3rd - Review the vital signs. Look for additional SIRS criteria, ie tachycardia (HR>90), tachypnea (RR>20), an elevated WBC count or more than 10% band forms. If have 2 SIRS criteria (and fever is a SIRS criteria), then your patient may be septic. As a note, recheck your own vital signs and document them somewhere with a time stamp.
4 - Examine the patient. Look for potential sources. Everyone likes the 5W, so, consider them. BTW, roll the patient over and check his/her back. You don't want to miss and infected decub or an infected fluid collection, that just so happens to be on the patients back.
5 - Notify your senior if the patient has more than just a simple fever.
6 - Reveiw recent labs. Look for things like increasing creatinine or BUN. Increasing anion gap or decresaing bicarb can be signs. Remember that the anion gap should be 3 times the albumin. The lab may report that "normal range" for the A/G as 8-16. An anion gap of 16 for an old, bed bound, patient with poor nutrician is not normal.
7 - Get cultures, UA, other relavent labs, and potentially a chest xray (if your exam or other factors suggest pneumonia). Many residents just skip to this step over the phone, however you can't rely on cultures and you don't want a septic patient sitting on floor waiting for the cultures to turn positive. Moreover, the relavent labs are going to be guided by your exam and review of the patient. If you have 2 SIRS criteria and a possible source, you should look for signs of hypoperfusion, such as with a lactate. You should also repeat the CBC and full lytes with BUN/Cr. If the patient does have 2 SIRS criteria and a source, start antibiotics and treat the source. So if you think the patient has a belly an infected wound, and you don't feel comfortable opening it, you do need to get a consult. If the patient has been in the hospital for more than 48 hours, you need to treat hospital acquired bacteria, such as MRSA and pseudomonas.
8 - Check the results of what you order. If the urine look dirty, change the foley. If the urine gram stain shows gram positive cocci, it might be VRE and you need to add linezolid until the cultures come back. If the patient looks septic (2 SIRS criteria and source) and has mental status changes, worsening renal failure, or an elevated lactate, start bolusing IV fluids (no one ever got better with a 250 ml bolus, so use real amounts) and contact the ICU.
9 - Somewhere along the way, you can give some tylenol, if it is appropriate. Make sure you write a note documenting what you saw and did.
This really doesn't take that long to do. It ensures that you don't miss sepsis or severe sepsis. Too many times, residents just order cultures and tylenol over the phone. Generally, you can get away with doing that, however a few patient are going to have severe sepsis and will die if they are left alone until morning.
This post makes me extremely uncomfortable. I understand the poster is a nursing student, so let me say that most of those requests just wouldn't fly in the real world. Most of the docs I know would be really unhappy if nurses were going around giving prn D50, narcan, and potassium...heck, they haven't kept that on the floors in years so that one is just moot.
You can't anticipate orders for every potential on call problem. Keep it to the basics: Tylenol, maybe a sleeper if appropriate, something for pain if appropriate.
ETA: There's usually a standing order for naran with PCAs.
I agree with fab4...and write very little prn meds with the exception of those for pain, nausea and a sleeper (and that I wait until the patient asks for it).
I want to know if there's a problem with my patient on a Heparin drip - some services I worked on would not allow for a protocol, so the resident would have to adjust every 6 hrs when the coags came back.
I want to know if there's a fever, so Tylenol will be written for a headache but if someone wants to give it for a fever, I want a call.
Patients in ICUs can be on a potassium replacement protocol, but not on the floors; no prn potassium replacement.
Similarly with patients on an insulin drip - they may be given prn D50 but I need to know about it and I don't want patients on the floor getting prn D50.
Its all well and good to avoid phone calls, but I think the above can be dangerous.
The following points are legit:
- write legibly if you don't have computer orders; I used to get called because one of my fellow interns had the worst handwriting and when he didn't know the dose of something or the appropriate route, he wouldn't look it up, he'd just leave it out, then he wouldn't answer his pages. So please write clearly, if you don't know the dose accurately, look it up and give a variety of routes (as docB notes).
- don't write for something that the patient has an allergy to. On that note, ask the patient when you are admitting them, what pain meds they've used before. They may not have a documented allergy to Morphine but they will tell you it made them itch or they were horribly nauseated to it, but did fine with Demerol. You'll get called when that starts to happen again or when the patient refuses to take the Morphine.
- don't use abbreviations - JCAHO mandates this - so get used to it
- put patients back on their home meds as soon as reasonably possible. If they are on long term Benzos, check with your pharmacy or psych about IV alternatives or how long they can be off of them if the patient is going to be NPO for awhile.
- not every patient needs a stool softener, so please do not put everyone on one...but keep track of who's pooping and who isn't (ie, don't wait until its been a week to address the situation). Not everyone needs a BM every day.
I'm all for prn orders and allowing the nurses some autonomy but there has to be an understanding of the potential complications of doing so.
TEN Things to carry in your lab pocket at ALL times when ON CALL:
1. Ten dollars, and at least two dollars in change: you will need money for food or drinks if you go to busy program that makes you run around all night and won't allow you even time to go back to your unused call room to get money
2. PDA: with any programs that will give you drug dosages quickly
3. Cell phone: keep it on vibrate, call your family/girlfriend whenever you get free time. You're on call so much, if they talk to you for 10 minutes then they might agree to let you get some rest in your post call day. And you wont feel so guilty about not talking to them.
4. Stethoscope (with light)
5. At least 3 pens, they walk away, and your attendings help them
6. Breath mints/gum: onions at dinner, don't go to middle of night codes barking out orders to everyone with FOUL breath
7. About 10 pages from whatever book you choose to read during your intern year. If you do this everyday, you will be very sharp. And you won't be weighed down with a heavy review book in your pocket.
8. Scratch paper: don't write on scrubs or your hands like some people I know, it makes you look dirty
9. Frequently used numbers (every hospital has one)
10. At least two snack bars: you may never make it to the cafe... Ive gone 18 hours easily without eating (during surgery), be prepared!!!
True, you obviously will get a call about glucagon, narcan etc... however nurses might feel a bit safer having an order on hand for possible emergencies "just in case". The general point is try and be as complete as you can. If you don't feel it is appropriate as a PRN order for the situation, don't write for it. At least thinking about things such as stool softeners, tylenol and pain management would probably do for most patients.
P.S.- I see that some were uncomfortable with my post. The things that I came up with are orders that I have seen commonly (on different floors at one particular hospital) for patients on units that i have been on. Some docs write the whole med book up in the PRN orders, others give you almost nothing to work with. Each case has to be looked at individually, but the basic idea is to think about what could come up that the nurse might need to start management on that you may not need to know about right at 2am.
Think about it this way too: The more prns you ask for, the more potential you have for errors. And do you want to have to be the person taking off the gajillion prn orders that one of your colleagues asked for?
My answer to you was as a practicing nurse of many years. You're going to see a lot of different things as you progress as a student. What may be standard at one facility may be verboten at another. Once you're out there and actually working, you start to see what's in the pt's best interests. I think several people have tried to point out to you that it's not in the pt's best interests in general to have numerous prn meds. Many of the meds you asked for are not to be used lightly; even Tylenol can have serious consequenses in certain pts, e.g. febrile post-op pts.
Further discussion of this particular issue should probably go to the RN forum or PM since it's starting to deviate from the original intent of the thread, and I don't want it to be hijacked with nursing issues.