Nurses

[gutonc]

RN = Reads Notes.

I wish. Honestly, I wish anyone would read notes.

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[Perrotfish]

So 2 things that comes to mind for the OP.

1. Pick and choose your battles. Does the post transfusion H/H really need to be done? Well... it depends, especially if you're not looking at multiple units of blood. Regardless, two questions. First, is it at a time when you can plant your "daily labs" flag and call it a day? There's no reason to draw an H/H at 2am when daily labs is being drawn at 5. On the other hand, which is easier, fighting with a nurse or putting a CBC and chem 7 at 2am?

Second... is this the hill you're willing to die on? Me, personally? Nope. I've got more important things to do than discuss the merits of the post transfusion H/H, it's affect on patient's hemodynamics, and the cost to the system. So... no... not worth it.

Agree with one caveat: don't take these rules into attendinghood. I think one of the reasons that academic nursing care is so frequently poor is that many academic attendings have been trained in residency to do what is best for nurses, rather than what is best for the patient. As an attending you don't need to die on every hill where you make a stand, just a little effort usually results in the positive change you're looking for.

 

[Mr Roboto]

Note, this is hearsay, but supposedly one of my attendings held up his badge to a nurse and said, "You see those initials? You know what M.D. stands for? Makes Decisions." I would never say it, but it makes me laugh every time I think of it.

But the nursing license is on the line, and the nurse won't be risking it because of his orders!

 

[Psai]

I wish. Honestly, I wish anyone would read notes.

Are u serious? The number of calls I've gotten at 3 am for some nonsense that a nurse read in the note boggles my mind. I'm about to start hanging up on them as soon as I hear "so I was just looking at the chart and"

 

[flightnurse2MD]

So I've been having some trouble with getting some of the nurses to do what I want. I get that I'm an intern and I don't blame them for questioning what I what but it's really annoying when I want something and they don't do it which leads to a bad outcome. I don't like when they question my judgment not because they have a good reason against what I want to do but because they don't have the knowledge base to understand it.

The other side of this is when nurses want something that's not really necessary for patient care but they insist on it. For example, I've been asked repeat labs after a unit of product is given so that they can sign out the numbers to the next nurse. It's a waste of money, time and blood but sometimes I really don't feel up to explaining why I don't want to do what they want, especially if they will just go to the resident or attending and bother them about this nonissue. I'm not a fan of having traintrack vitals or attempting to reach euboxemia just to make the numbers look nice on the chart.

Now go a bang a few nurses on the unit and see what REALLY happens!!!

 

[Perrotfish]

Are u serious? The number of calls I've gotten at 3 am for some nonsense that a nurse read in the note boggles my mind. I'm about to start hanging up on them as soon as I hear "so I was just looking at the chart and"

Maybe stop writing nonsense in your notes?

 

[WheezyBaby]

The majority of nurses, like the majority of doctors, are interested in the well being of their patients. I think life gets a little better for both parties when they communicate with that underlying assumption. Ask for their rationale. Nurses spend a lot more time at the bedside and can be privy to information we aren't, and (at least as a trainee) they potentially have a lot of pattern recognition that I don't (i.e. seeing what physicians have previously done in certain situations and the outcomes of those interventions); whether they have a full pathophysiologic understanding or not of why they're questioning my decision, it still makes me pause and at least think one more time if what I'm doing is appropriate. All this is not to say I haven't worked with the occasional bad nurse, the nurse who's questioning something just because she doesn't want to do the work, etc. If those things reveal themselves to be true, then so be it, but it shouldn't be the working assumption

What he said is absolutely true

 

[Perrotfish]

If he's the guy at 3am he probably didn't write it

Fair enough, but blame the day resident rather than the nurse. If the plan in the note doesn't match the actual plan its not the nurses' fault for trying to figure out which one is correct

Also, on a practical note, you can actually confront the day resident about issues like this. Your attending doesn't give any more of a **** about his unhappiness than he does about yours.

 

[caffeinemia]

What kind of Foley are you using that you need a 100cc syringe to deflate the balloon?

Sent from my Nexus 6P using Tapatalk

I was just going by the size of foley I would need. I guess some people don't need as much...

 

[dpmd]

Wasn't at 3am but I got a call the other day from a nurse who read my plan,but evidently only understood part of it. I had written that if the patient continued with fever and high WBC I would order a CT the following day. So the following morning around 8 she calls because I had not ordered a CT scan and did I want to order it. Only problem was I was still sleeping because I was post call and hadn't looked at the computer yet. So she tells me that yes the WBC is high and the BP is borderline. I asked her if there was some emergency going on with the patient that she felt the need to call instead of waiting for me to see the patient and she says no and we hung up. Later I go and check the computer. No CBC was done that morning, no fever since the last one I saw the day before prior to writing my note, and the borderline BP was one value of SBP 98 at the 0400 vitals check. So after I have them actually get the CBC she should have gotten and the WBC is normal and the patient feels better than she had for days no CT was ordered.

 

[caffeinemia]

Wasn't at 3am but I got a call the other day from a nurse who read my plan,but evidently only understood part of it. I had written that if the patient continued with fever and high WBC I would order a CT the following day. So the following morning around 8 she calls because I had not ordered a CT scan and did I want to order it. Only problem was I was still sleeping because I was post call and hadn't looked at the computer yet. So she tells me that yes the WBC is high and the BP is borderline. I asked her if there was some emergency going on with the patient that she felt the need to call instead of waiting for me to see the patient and she says no and we hung up. Later I go and check the computer. No CBC was done that morning, no fever since the last one I saw the day before prior to writing my note, and the borderline BP was one value of SBP 98 at the 0400 vitals check. So after I have them actually get the CBC she should have gotten and the WBC is normal and the patient feels better than she had for days no CT was ordered.

Paged at 2am to because diabetic pt's sugar was high; orders included basal and corrective insulin and an endocrine consultant was following. But of course, the goddamn plastic surgeon gets the page.

 

[qwerty89]

Even better once you get board certified!

Southernsurgeon, BA, MD, MS, BLS, ACLS, ATLS, PALS, NYS, BE/BC, FACS, CGSO

Read that as CSGO.

You also forgot your WTFBBQSAUCE, LOL and ROFL certifications.

 

[rokshana]

Paged at 2am to because diabetic pt's sugar was high; orders included basal and corrective insulin and an endocrine consultant was following. But of course, the goddamn plastic surgeon gets the page.

from the endo consults perspective...was the sugar higher than the corrective covers (i.e. >400 call H.O)...and is plastics the primary? (because they shouldn't be calling the consultant at 2am before they call the primary- unless that is the arranagement that was agreed upon ealier).

 

[Psai]

Fair enough, but blame the day resident rather than the nurse. If the plan in the note doesn't match the actual plan its not the nurses' fault for trying to figure out which one is correct

Also, on a practical note, you can actually confront the day resident about issues like this. Your attending doesn't give any more of a **** about his unhappiness than he does about yours.

The phone call I won't ever forget was at 3 am for a completely stable patient who was sleeping with hr in 100s (has been for the entire day), was admitted for afib with rvr, on dilt, the next dilt dose was already increased, all of this was clearly written in the chart and I got a phone call about it. Had a busy night and things finally became quiet and I had just fallen asleep.

Definitely not the day resident's fault.

 

[Perrotfish]

The phone call I won't ever forget was at 3 am for a completely stable patient who was sleeping with hr in 100s (has been for the entire day), was admitted for afib with rvr, on dilt, the next dilt dose was already increased, all of this was clearly written in the chart and I got a phone call about it. Had a busy night and things finally became quiet and I had just fallen asleep.

Definitely not the day resident's fault.

Were there call parameters for the vitals? If so what were they? If not why not? It should never be the nurses job to figure out which vital signs or labs to call you on, either you put orders in clearly stating what you want or they call you for anyone over a standard critical cutoff. The only way this is a bad call is if the order had vital signs call parameters and the call parameter for HR was a number > 110.

 

[operaman]

Ok either I'm completely and blissfully unaware or I work in the f-ing nirvana of nursing care. I can count on one hand with fingers left over the number of times I've had a nurse refuse an order, and each time was easily handled either by talking to the charge or doing something myself. The times with outright attitude issues were quickly handled by the charge nurse and consumed <20 seconds of my day. I've found that if you have a kind, professional attitude about things, more senior nurses are pretty good about policing their own and educating the younger nurses when they've gotten out of line (much like the MD/DO side does with our own more junior trainees).

I've said it before but it bears repeating: everything hinges on your reputation. If you have a rep as a doc who is polite and answer pages and takes care of his patients, then they will have your back. If you get the douchebag rep, well...good luck to you. Building a relationship with your nursing staff takes time and effort. You'll know you've succeeded when they start inviting you to share their food. Yes there is always food. If this is news to you, then you have more work to do. Of the many nurses who generally take care of our post-op patients, I probably know 80-90% by name. I know where they're from, where they went to school, what their SO's do, what their personal goals and ambitions are. That's just from shooting the breeze over time, but having some relationships established goes a long way. And the food is usually pretty awesome.

List of stuff you can do to make your life with nurses better:

1) NHO orders are your friend. There is something about "please notify me if XYZ" that subtly conveys, "please don't call me for ABC." Make sure your orders clearly spell out the things you want to know about. It's better for the patient, and better for you. Remember that many new nurses don't yet know what you are worried about for a given patient.
2) Minimize unnecessary orders. Don't have q4 vitals/neuro checks, accuchecks, SSI, or middle-of-the-night meds for patients who are straight dispo at that point. I'm amazed at home many patients are discharged home with orders written while they were in the ICU. Fewer wake-ups means fewer pages.
3) Always be rounding. This is intern 101, but bears repeating. Seeing your patients early in the night will cut out 75% of your pages later.
4) Make sure nursing understands the overall plan of care. For night shift, this often comes secondhand from the day team. You should be able to give a one liner about what's happened so far, what's happening, and what the plan is for that patient. You'll be amazed at how often the story they've gotten is wrong.
5) Don't hide in the call room. Maximize your time on the floor and find a public spot to call home. Almost daily I get a "I was going to page you about this but I knew you'd be over here soon."
6) you'll get better sleep in an empty patient room with an open door than in the call room. Not always an option, but works like a charm. Nobody will ever wake you up in person for something stupid, and they have the reassurance that you're close by if they really do need you.
7) When you call back pages, ask lots of questions. Make sure you really understand the whole context of the situation. Not only does this build confidence in your ultimate decision, but people will be less likely to page you about meaningless things if they know you'll call back and ask them lots of questions about it.
8) Be respectful of your nurse's time. If you have a sundowning patient trying hard to faceplant every 20 minutes, order that person a sitter. If you have a patient in pain who is NPO at midnight for a procedure the next day and will likely remain NPO afterward, is a PCA indicated?
9) Be cognizant of your nurses' comfort zone. Don't admit fresh post-ops to non-surgical floors. Don't send medicine trainwrecks to a surgical stepdown. Nurses, like anyone else, develop comfort with what they know and do every day. A few phone calls in the morning prior to admission may save you countless pages later.

 

[DubVille]

My best ever:
Called at 4 AM because patient refused a prn tylenol. I asked how they refused if they were asleep like most patients, but the nurse woke them up....just to ask them.

2nd best:
Paged around 2 AM because "patient may be having a stroke, their right arm is numb." Patient was asleep, I woke them up and they told me that their 4th and 5th digits were numb, so they changed positions. I educated the nurse on ulnar neuropathy and carpal tunel.

Overall, I love my nurses and they have caught many of my dumb orders/omissions. I've found that educated them helps, and may also show them you know what your talking about.

 

[Silmaril]

I always wondered why there were so many nursing letters... one would think that if BSN > RN would preclude the need for a RN citation. I guess next time I am going to sign all my notes: Caffeinemia BA, MD... Maybe I'll add in BLS-C, ACLS-C, and ATLS-C for my CPR credentials as well. What about acronyms for licensed in the state of new york? NYS-MD?

Caffeinema, BA, MD, BLS, ACLS, ATLS, NYS.... that sounds pretty good.

Edit: pretty sure I made up a buncha these to illustrate the point.

Force of habit! Floor/unit nurses either earn an ASN or a baccalaureate degree (which is considered better education), and then you have to be licensed as an RN, so the degree is separate from the licensure. We display our degree if it's a baccalaureate. I don't know how this compares, but for example I've seen some MDs sign as MD FACS, which isn't exactly parallel, but I notice you also sometimes sign more than "MD" after your name. Are you referring to the alphabet soup nursing academics like to string behind their names? I don't know what they mean, either lol.

 

[rokshana]

Force of habit! Floor/unit nurses either earn an ASN or a baccalaureate degree (which is considered better education), and then you have to be licensed as an RN, so the degree is separate from the licensure. We display our degree if it's a baccalaureate. I don't know how this compares, but for example I've seen some MDs sign as MD FACS, which isn't exactly parallel, but I notice you also sometimes sign more than "MD" after your name. Are you referring to the alphabet soup nursing academics like to string behind their names? I don't know what they mean, either lol.

an FACS (fellow of the american college of surgeons) is not the same as ASN, BSN thing...being a fellow or a master of your respective specialty college isn't a degree, its a designation bestowed after being involved with the specialty college (usually being a member, paying dues and attendance at meetings) and contributing to the specialty field...generally terminal degrees are listed..meaning if someone has an MD, they had to get a BS or a BA to get to the point of receiving an MD...a Ph.D is a terminal degree so someone who has both will list MD, Ph.D behind their names but the degrees that get you to that degree are not.

 

[dpmd]

I don't know of any doctors who actually add their MD let alone FACS status after handwritten signatures. Nor is it on our hospital badges.

 

[dpmd]

an FACS (fellow of the american college of surgeons) is not the same as ASN, BSN thing...being a fellow or a master of your respective specialty college isn't a degree, its a designation bestowed after being involved with the specialty college (usually being a member, paying dues and attendance at meetings) and contributing to the specialty field...generally terminal degrees are listed..meaning if someone has an MD, they had to get a BS or a BA to get to the point of receiving an MD...a Ph.D is a terminal degree so someone who has both will list MD, Ph.D behind their names but the degrees that get you to that degree are not.

Well, there are designations for nursing specialties as well that they earn by obtaining extra training and certification. It is just that they have more of them rather than the one or two that most doctors can obtain (though I suppose the right person might be FACS, FRCS, FACRS)

 

[Raryn]

I don't know of any doctors who actually add their MD let alone FACS status after handwritten signatures. Nor is it on our hospital badges.

We're required to for signing certain things (orders, death certificates). Either has to be part of our signature or next to it to identify ourselves as MDs. I just said f--- it and sign everything work-related as RarynMD

 

[j4pac]

I ask myself "is what the nurse proposing to do dangerous to the patient?" Very rarely is the answer yes...so I find a middle ground. I've honestly have had far more problems with pharmacy than nurses over my years.

You're an intern...so don't assume that you know what you're doing. Assume that the nurse is less likely to hurt the patient than you...because it is likely true. I'm pretty sure you'll look back at yourself years from now and realize that you weren't always doing what's best for your patient.


Sent from my iPhone using SDN mobile

 

[rokshana]

I don't know of any doctors who actually add their MD let alone FACS status after handwritten signatures. Nor is it on our hospital badges.

mmm...when i sign things in the clinic or hospital i do add the MD...and it has always been on my badge. (the MD, not anything else).

 

[gutonc]

I keep forgetting that @Psai is a prelim intern in NYC.

I have never seen a more entitled group of residents than NYC interns, nor have I seen a more entitled group of RNs than the ones in NYC.

Nothing to see here folks.

 

[dpmd]

We're required to for signing certain things (orders, death certificates). Either has to be part of our signature or next to it to identify ourselves as MDs. I just said f--- it and sign everything work-related as RarynMD

Weird. Our death certificates didn't ask for that with the signature and our orders for sure don't.

 

[dpmd]

mmm...when i sign things in the clinic or hospital i do add the MD...and it has always been on my badge. (the MD, not anything else).

All it needs to be a valid signature at all the hospitals I have worked at is a legible ID number following whatever scribble you make. Saves a bunch of time.

I think my badge just says physician or maybe medical staff (lost it a few months ago so can't check).

 

[KnuxNole]

I keep forgetting that @Psai is a prelim intern in NYC.

I have never seen a more entitled group of residents than NYC interns, nor have I seen a more entitled group of RNs than the ones in NYC.

Nothing to see here folks.

As much as I love NYC, another reason why I'm glad I'm not practicing there...

 

[Psai]

I keep forgetting that @Psai is a prelim intern in NYC.

I have never seen a more entitled group of residents than NYC interns, nor have I seen a more entitled group of RNs than the ones in NYC.

Nothing to see here folks.

don't hate me cause u aint me

 

[gutonc]

don't hate me cause u aint me

I pity you because I was smart enough not to be you.

 

[jw3600]

I pity you because I was smart enough not to be you.

Can you elaborate on your experience with regards to NYC? Is it the mostly union aspect for the RNs? Very curious.

 

[evilbooyaa]

I keep forgetting that @Psai is a prelim intern in NYC.

I have never seen a more entitled group of residents than NYC interns, nor have I seen a more entitled group of RNs than the ones in NYC.

Nothing to see here folks.

Oh lord. @Psai didn't you see the 20k posts saying never do your prelim in the state of NY? And then you went ahead and did it anyways? Of course the nurses in NY state may suck. They have no motivation to do better. they're all unionized and will never lose their job save for actively putting a pillow over Mr. Smith's face in the middle of the night.

 

[gutonc]

Can you elaborate on your experience with regards to NYC? Is it the mostly union aspect for the RNs? Very curious.

That's the biggest issue on a day-to-day basis. Also, a lot of hospitals are underfunded (HHC ones anyway) and there are a million or so "better" places to train.

 

[AdmiralChz]

I started residency as an intern on a very busy inpatient surgical service - I am so thankful for the nurses on the floor who were patient with me learning the hospital and helping to show me the ropes for the most efficient way to handle things on the floor. No, I didn't know what to give for a minor headache (and what dose!) or what opiates were on formulation at my hospital (Percocet vs Vicodin vs Norco). Often times I was fairly alone as the more senior residents were out seeing emergent consults or in the OR.

Those nurses had a positive impact on who I am today as a (almost board-certified) physician, and I remain friends with many of them today. Of course I've had some run ins with some (especially over in L&D *shudder*), but overall I've had great experiences. I hate to see such nastiness on this thread early on, I am glad it has gotten a little better though.

Bottom line, we are all on the same team folks. Play nice in the sandbox. No, not everyone is going to bow down and worship you (especially as a resident), but remember residency is only a finite amount of time and you'll get to move on to the promised land of attending life.

 

[cbrons]

[...] or what opiates were on formulation at my hospital (Percocet vs Vicodin vs Norco).

*Opioids

Sent from my SM-N910P using SDN mobile

 

[Psai]

*Opioids

Sent from my SM-N910P using SDN mobile

no one cares

 

[cbrons]

no one cares

Opiate: Alkaloid compounds found naturally in the Papaver somniferum (opium poppy) plant. These include codeine, morphine, and thebaine (paramorphine).

Opioid: Compounds with opium-like effects. It is a broader term which encompasses opiates, semi-synthetic derivatives of morphine (heroin, hydromorphone, hydrocodone, oxycodone, oxymorphone), and synthetic opioids (fentanyl, buprenorphine, methadone).

 

[Raryn]

Opiate: Alkaloid compounds found naturally in the Papaver somniferum (opium poppy) plant. These include codeine, morphine, and thebaine (paramorphine).

Opioid: Compounds with opium-like effects. It is a broader term which encompasses opiates, semi-synthetic derivatives of morphine (heroin, hydromorphone, hydrocodone, oxycodone, oxymorphone), and synthetic opioids (fentanyl, buprenorphine, methadone).

Yes. Most of us in this forum graduated medical school and have learned that as well.

But as Psai said, only the pedants care.

 

[WheezyBaby]

Opiate: Alkaloid compounds found naturally in the Papaver somniferum (opium poppy) plant. These include codeine, morphine, and thebaine (paramorphine).

Opioid: Compounds with opium-like effects. It is a broader term which encompasses opiates, semi-synthetic derivatives of morphine (heroin, hydromorphone, hydrocodone, oxycodone, oxymorphone), and synthetic opioids (fentanyl, buprenorphine, methadone).

Yes we know. This isn't a discussion about opioid selection in a patient with a true opiate allergy or anything where the difference is consequential though, so does it really matter

 

[AdmiralChz]

Opiate: Alkaloid compounds found naturally in the Papaver somniferum (opium poppy) plant. These include codeine, morphine, and thebaine (paramorphine).

Opioid: Compounds with opium-like effects. It is a broader term which encompasses opiates, semi-synthetic derivatives of morphine (heroin, hydromorphone, hydrocodone, oxycodone, oxymorphone), and synthetic opioids (fentanyl, buprenorphine, methadone).

Of everything I said, you harped on this? Wow.

 

[evilbooyaa]

no one cares

You still salty over prelim year in NY, bruh?

 

[Psai]

You still salty over prelim year in NY, bruh?

Me and everyone that liked my post waddap

 

[evilbooyaa]

Me and everyone that liked my post waddap

I liked it too. I'm just trying to needle you further. Good luck with rest of intern year lol

 

[CypherA]

Oh lord. @Psai didn't you see the 20k posts saying never do your prelim in the state of NY? And then you went ahead and did it anyways? Of course the nurses in NY state may suck. They have no motivation to do better. they're all unionized and will never lose their job save for actively putting a pillow over Mr. Smith's face in the middle of the night.

Link to thread?

 

[Aoy]

So I've been having some trouble with getting some of the nurses to do what I want. I get that I'm an intern and I don't blame them for questioning what I what but it's really annoying when I want something and they don't do it which leads to a bad outcome. I don't like when they question my judgment not because they have a good reason against what I want to do but because they don't have the knowledge base to understand it.

The other side of this is when nurses want something that's not really necessary for patient care but they insist on it. For example, I've been asked repeat labs after a unit of product is given so that they can sign out the numbers to the next nurse. It's a waste of money, time and blood but sometimes I really don't feel up to explaining why I don't want to do what they want, especially if they will just go to the resident or attending and bother them about this nonissue. I'm not a fan of having traintrack vitals or attempting to reach euboxemia just to make the numbers look nice on the chart.

So I've been having some trouble with getting some of the nurses to do what I want. I get that I'm an intern and I don't blame them for questioning what I what but it's really annoying when I want something and they don't do it which leads to a bad outcome. I don't like when they question my judgment not because they have a good reason against what I want to do but because they don't have the knowledge base to understand it.

The other side of this is when nurses want something that's not really necessary for patient care but they insist on it. For example, I've been asked repeat labs after a unit of product is given so that they can sign out the numbers to the next nurse. It's a waste of money, time and blood but sometimes I really don't feel up to explaining why I don't want to do what they want, especially if they will just go to the resident or attending and bother them about this nonissue. I'm not a fan of having traintrack vitals or attempting to reach euboxemia just to make the numbers look nice on the chart.

Communication is an issue on both sides of the profession

Did you ensure the nurse gets the order, rather than just ordering it in the medical record...

If the nurse refuses, did she state why? And did you inform your attending the nurse refused for this or that reason?

If the nurse request an order, do you explain why it is not needed?

 

[Aoy]

Oh geez, I'm dying of laughter

 

[Aoy]

Sorry to derail your thread psai but I want to know why most nurses are fat and most doctors are not. Is this just a phenomenon I've observed?

Not true for all, mostly where you practice possibly... none of the nurses I work with in ICU are fat, neither are my friends who are nurses

 

[RN_MD19]

Sorry to derail your thread psai but I want to know why most nurses are fat and most doctors are not. Is this just a phenomenon I've observed?

Is this a serious post? Compassion, empathy, and respect are not traits that should be disregarded simply because you have the letters M.D. following your name. And... perhaps your observational skills are something you should focus on sharpening because, no, your "observation" is highly inaccurate and far from a realistic 'phenomenon'.

 

[VA Hopeful Dr]

Is this a serious post? Compassion, empathy, and respect are not traits that should be disregarded simply because you have the letters M.D. following your name. And... perhaps your observational skills are something you should focus on sharpening because, no, your "observation" is highly inaccurate and far from a realistic 'phenomenon'.

Awesome first post, I'm sure you're actually going to end up being a valuable poster and not like the dozens of drive by people we see whenever your feels get hurt by a random post from months ago

 

[Dr. Death]

Is this a serious post? Compassion, empathy, and respect are not traits that should be disregarded simply because you have the letters M.D. following your name. And... perhaps your observational skills are something you should focus on sharpening because, no, your "observation" is highly inaccurate and far from a realistic 'phenomenon'.

This is my safe space, don't insult me.