What should I do about this?

[greenbean]

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Hi everyone,
ive encountered another issue that i'd like some opinions on. I have a patient with metastatic ca to brain,lungs,liver,adrenal,bony pelvis, no clear primary. his oxygenation pretty lousy : 87% on 15L NBM and he p/w sob, hemoptysis. his oxygenation is so bad that the pulmo doc wont bronch him and doesnt want to do ct guided bx. hemonc wanted an mri of his entire looking for mets, b'c he's c/o back pain and unsteadiness. 2 d in to his hospital stay he told me his 'leg felt funny', not really pain and could not elaborate more.i checked out his leg, and clinically speaking he was intact from a neuro and vascular standpoint, the next day his leg issue resolved.

now that brings us up to yesterday. in the am, the nurse(lets call her RN) called me to let me know that his hgb went from 9.4--> to 8.6 and did i want him transfused. i said no we would watch him. in the afternoon, he had a nosebleed which took a minute or two to clot, the nurse called me to 'let me know', later on she called again and said he was having 'leg pain and still coughing up lots of blood and his pulse ox is in the 70s', i went up there with my resident. we checked him out and he looked quite well, although his pulse gave a one time read of 78%, the leg was intact for everything except for motor in quads and gastrocnemius, he could wiggle his toes and had good pulses. so we said that we would just watch him

RN is unhappy about that we aren't transfusing him/not ordering an ultrasound of thigh/changing his code status/not doing what she wants and contacts the nonteaching attg,trying to bypass us. the attg tells x-cover who tells us. but after talking to xcover we go up and see the pt again and readdress code status. he still wants to be full code. we go to RN and let her know about his decision ,my resident asks her 'what can we do to make you more comfortable? because u seem uneasy with the whole situation' RN says 'if he werent a cancer pt, would u transfuse him and check an US, and what about his oxygenation, what if he codes?" so my res explains that he has mets in lungs and yes his oxygenation is bad but there's nothing that can be done about that and he looks well,he's getting dvt prophylaxis and while it is possible to have a dvt weve made a decision to watch him b'c his exam doesn t seem to correlate , and he doesnt require transfusion for the same reasons, and yes we have readdressed code status....." upon hearing all of this, RN still is upset and makes an obvious attempt of being rude and insulting to both me and my resident ,by making snide comments about what my resident is saying and faces.this was around 12 at midnite

anyway, my resident takes me aside and says lets put in orders for 2 u prbc's, and ultrasound in am of the leg, i had already put in orders for the mri spine that hemonc wanted(which didnt happen for whatever reason) .

in the am, i see the pt, whose doing well, we asked NF to check this guy o'nite and they said he was doing good too, i asked pt about his leg, and pt said it was back to nl now,he was walking to the bathroom and he felt 100% better,just like what happend the day before. so anyway i tell him about him having to go for the mri and that it might help explain his leg/back issues. he at first was hesitant and wanted some benzo's to help him through but i told him that wouldnt be possible b'c it would make him too sleepy and worsen his oxygenationand might cause him to code in the mri. but i did convince to go through with the test. which was scheduled form 8am today. and i confirmed this the nite b4.

around 1pm, i see that pt still has not gone for the mri. i call radiology, and they say that they dont have him on the schedule at all and they dont see the order, even though im looking at it right now in front of me. so i end up talking to the radiologist and he calls me to let me that a nurse(he doesnt know who) cancelled the test b'c 'pt was anxious and worried and didn't want to do the test'. i am totally furious, b'c 1)that is not what the pt told me 2)no one from nursing informed me that the MR was cancelled or even brought it up with me 3) the pt really needs this test ..so i speak to new day nurse and she says that the night nurse told her that, so she didn't do anything about, when i asked her about why no one brought it to the HS, she said she didn't know. i go into pt's room and ask him about, he said he that he was nervous about but after talking to me he said he was fine with going forthe MR and he told the nite nurse about being nervous before I saw him the morning.

i had to make more phone calls and got the test scheduled and it looks like he's got mets in lumbar spine which make explain the back/leg/thigh pain

but that's not why im posting...
what should i do about the nurse? I am not sure if it was RN who cancelled my MRI order by calling radiology, but i think that its unacceptable to not even call me and let me know what is going on and just cancel a test that she thinks is wrong because she thinks the pt has a DVT and needs an US more than an MRI, i have no idea what she was thinking...

im thinking about telling my attending about what happened on monday and reporting this to the chief as well, any thoughts/ideas/suggestions are appreciated

greenbean

 

[snoopy brown]

RN is unhappy about that we aren't transfusing him/not ordering an ultrasound of thigh/changing his code status/not doing what she wants and contacts the nonteaching attg,trying to bypass us.

You just ran into a common problem with nurses and that is that they are trained differently than physicians. Often they will say things like "would you do that if this wasn't a cancer patient?" as if that's some sort of intelligent statement. As if you're going to necessarily treat a man with broadly metastatic cancer the same as you would a person without cancer who presents with SOB. I fail to grasp why they feel that is a compelling argument, but they do. And as for "readdressing code status," that's even more pathetic. What, she thinks you can just change the guy's mind or he's full code because you didn't try hard enough?

Many nurses will be insulted by this but I'm going to say it. Being an advocate doesn't mean just bugging physicians to do things because you think "more equals better." It's bad enough that you have to deal with a guy with that condition and decompensating clinical status and fight with a nurse who thinks you and the senior resident aren't doing the right thing and needs to be "consoled." I hate the fact that some nurses act like they're there to make sure the doctor does the right thing because you know we're just there to torture patients except for the fact that the awesome and caring nurse is there keeping a hawk eye on us.

I only was able to read a few paragraphs because it was so irritating (not you, the situation) because we've all experienced it.

 

[snoopy brown]

Just read the rest of it, if the nurse is cancelling your tests you need to report that. She's not the doctor and she has no authority to do that. If she is concerned that the patient is anxious, fine, you can assess that. (Chances are it's just her "interpreting" that. I've had nurses decide for patients that they don't want a test, hilarious.) If the patient isn't anxious and agrees to the test, he goes for it and she's irrelevant. If she wants to be the doctor, put him on her service.

 

[jennyboo]

It's always so hard to figure out what exactly happened over so many shifts and so many people. Miscommunications and forgotten communications are all too frequent.

I would probably first discuss it with the senior resident involved. Since s/he has been at your hospital longer than you have, s/he may have a better idea of what flies, what doesn't fly at your hospital and what (if anything) to do about it.

Usually when stuff like this happened to me, I was in such a rush to get outta the hospital and go home that I just fixed the problem (i.e. re-order the test), went home and forgot about it. That, of course, is why nurses complain about residents all the time and occasionally we hear about it through the grapevine. But residents don't often raise much fuss about nurses because we're often so busy we can't wait to leave the hospital, and any extra time spent addressing isolated incidents of miscommunication is time we won't be spending at home.

But there is such a thing as an Incident Report. From what I've seen, residents and physicians rarely file them because 1) no one in our departments bother to show us how to file them, and 2) we're too busy to care, and 3) we don't usually take them that seriously. However, from what I have also seen, nurses take these things VERY seriously. It is their way of reporting problems that they see and they do it all the time. (They just don't realize that oftentimes when they file an incident report against an MD for a minor thing, MD's often don't care.) However, ANYONE can file these, and that includes you. Your reason for filing the incident report would be, "Study cancelled by RN without notifying MD." That's a very legitimate incident report. Nursing can figure out who cancelled it if they want to review the charts. You don't need to say who did it as long as you can at least state the date and time.

So... if you care... file that report.

 

[Winged Scapula]

Besides the above by snoopy (I agree...I stopped reading the OP's post because I was getting a bit pissed...then I'm post call, so maybe more cranky than usual)...please speak to the nursing supervisor about the test being cancelled.

That is entirely inappropriate and unless they can document that "spoke with MD/DO X who ok'd cancellation", your RN doesn't have a leg to stand on. The end result is that you may have cancelled the test yourself, but it is inappropriate for a member of the allied medical staff to do so without discussing it with the medical team.

 

[greenbean]

snoopy , you are becoming my virtual shoulder to cry upon, 😉) thanks

like i said im not sure about who cancelled the test, i do know that the effect was COUNTERproductive, and the day i ordered the test we were on call, so i wasnt out of the hospital until midnite to 12:30 at the latest, and i confirmed that the test was schedule(the time ,everything) with the ward secretary, i reconfirmed in the morning when i went to round at around 7am

while i was writing my notes, i was listening to the nurses sign out and whne they got to this pt, they were 'upset' and i overheard comments about 'housestaff not treating this pt right. and letting him go with poor oxygenation' didnt hear all that they said but enough to figure out that they were pissed about something and they mentioned RN's name a few times too.

i did tell me resident about this, but she just said that this was something similar that was happening to my co-intern and another nurse, i doubt she will report,which is why im asking:should I?

 

[Tired]

Besides the above by snoopy (I agree...I stopped reading the OP's post because I was getting a bit pissed...then I'm post call, so maybe more cranky than usual)...please speak to the nursing supervisor about the test being cancelled.

That is entirely inappropriate and unless they can document that "spoke with MD/DO X who ok'd cancellation", your RN doesn't have a leg to stand on. The end result is that you may have cancelled the test yourself, but it is inappropriate for a member of the allied medical staff to do so without discussing it with the medical team.

Not to defend the nurse, but I feel that the real fault here lies with the Radiologist who allowed a non-physician to cancel a test without discussing it with the ordering doc. This nurse is obviously little better than a willful child, more interested in people "taking her seriously" than actually caring for her patient. Stupid behavior is to be expected from people like this. But presumably a board certified Radiologist should know better than to allow an ancillary staff member to cancel a physician-generated order.

You can complain to the nursing supervisor all you want, but nothing will be done because (a) you can't prove who actually canceled the test, and (b) there is zero accountability in nursing practice, and even gross negligence and practicing medicine without a license is excused on a regular basis. What you can do is have your higher-ups talk to the head of radiology to ensure that, in the future, no one but a doctor be permitted to cancel an order.

 

[snoopy brown]

while i was writing my notes, i was listening to the nurses sign out and whne they got to this pt, they were 'upset' and i overheard comments about 'housestaff not treating this pt right. and letting him go with poor oxygenation' didnt hear all that they said but enough to figure out that they were pissed about something and they mentioned RN's name a few times too.

You didn't hear them by chance. They were deliberately making you hear. Nurses love to do that sort of stuff. They can't say something to your face, so they'll just hang around in a large group and loudly discuss how they think you're stupid. That way, you know, but you can't say anything. I've also been in rooms where the nurse for the patient in the next bed over will be talking about the doctor to them and will say stuff like 'oh, the doctors don't know anything.' Believe me you never see a doctor going up to a patient and saying, 'your nurse is quite stupid and I would stop listening to her.' It's quite unprofessional.

But you know what, you can't stop them from doing that. That's their culture. People take great offense when I say that they act a lot of times just like laypeople but they do. If you want to know how to deal with it, PM me. (The reason I keep saying that is because my methods work but are quite inflammatory and I'm sure a lot of people would complain. 😀)

As for whether you should report or not, you can only make that call. You know the consequences. If you don't the nurse will continue to behave like she does. If you do then you will become 'the bad guy' and the nurses will probably retaliate. A lot of people can't take that retaliation and/or don't care enough about it so they don't bother. Be honest with yourself. If you think you can't take the misery or if it's not that important to you then don't. If it is an important issue then do it. Only fight for what you care about, but when you care about it you gotta fight. But I cannot stress enough that you have to know what you're getting into because it's about taking on a culture, not about taking on one person. It's a sucky place for you to be in and unfortunately that leads to a lot of people allowing bad things to happen, but that's residency. Don't kill yourself over it.

 

[snoopy brown]

Not to defend the nurse, but I feel that the real fault here lies with the Radiologist who allowed a non-physician to cancel a test without discussing it with the ordering doc.

Not to defend the Radiologist but I bet you it was the tech. Most often it's the tech calling for the patient and talking to the nurse, not the Radiologist. And the techs often have a hair-trigger for cancelling tests (so do the Radiologists lol). But I mean, honestly the Radiologist isn't going to sit around waiting for the patient to come down if the floor isn't going to send them down, you know. So the blame hits the nurse. Period.

 

[RokOnk]

Nurse will be nurses...That being said, I'm sure you've heard this before, but document everything! You can be sure the nurse is..."Pt c/o leg pain, Dr. Greenbean notified","Pt with Pox 70's, Dr. Greenbean up to see pt, no intervention at this time","Pt c/o anxiety, Dr. Greenbean aware". I hope you documented every time you were there and your thinking process as well as "For MRI today" in your follow up note. This will give you a leg to stand on. Also getting your senior resident involved was wise.

I would definitely speak with the nursing supervisor as well as your attending about this as this sounds like it delayed pt care. You can also talk to the nursing supervisor about the lack of professionalism displayed on part of the nurse. Remember, this is your pt, you're the one who's going to be explaining to the pt and family why things don't get done. One more suggestion is you may want to get your PD involved b/c they may be able to be a help in changing policies regarding canceling of radiological studies.

Keep in mind you may be opening a can of worms, but if you look at things from the pts point of view it may be worth it.

 

[greenbean]

i think i will address with the attending tomorrow, the nurses are already making my life hell and a few more days wont matter much, after that i wont be doing wards at this hospital again

ill update when i have something new to add, but i agree that this behavior is unacceptable,dangerous and irresponsible. i wont tolerate it. i just wish my resident was more proactive about this, when i this story to my res she basically said that a similar thing was happening with my cointern with another nurse, didn't seem interested in doing anything about it

peace,
green

 

[greenbean]

i didnt document every time i went up to talk to the pt, but in my morning note, i did write MR spine today will f/u results ..or some such,

 

[Annette]

Greenbean, this isn't the last tough interaction you will have with nursing.😡 Women have it rougher than men for what ever reason.

Like Snoopy said, make certain you document that you also discussed your reasoning with nursing staff. Call BS when you see it- but politely. Turn the issue around- why, exactly do you want me to order an ultrasound? Do you want me to intubate the patient for the 3 second pulse ox of 78? Or do you want him DNR? Challenging the RN will often time get the inappropriate care to stop.

At all times, no matter how mad you are, remain absolutely polite, otherwise they can and will complain to the powers that be. Until you are an attending- with that freedom to change jobs- you are at the institution's mercy. The nurses are harder to find and more likely to leave than students/residents. You can be sure that the institution will back them before they back you.

In general, listening to the RN's questions and reasoning will gain you respect from the RNs who aren't jerks. Most of the RNs know which coworkers have authority issues.

 

[snoopy brown]

My method is a lot like Annette's. 🙂

 

[greenbean]

in regards to RN's concerns, we talkedto her for about 10 minutes, it was pretty lengthy and descriptive, she didn't care(or have the knowledge to comprehend)what we were explaining to her. only we werent doing what SHE wanted. we ordered blood and an US, b'c of HER. its not something i wanted,not something my resident wanted, the attending definitely didn't mention this in his note and he was aware of the hgb drop

of course we were both very, very polite. i usually try not to insult nurses to their face,(when im talking to other residents, thats another story) i may just keep silient when they tell me stuff like 'mr jones wants to shower, can he do that? he will need to take off his telemetry". or 'do you want to replete a K of 3.7?" but RN was just plain RUDE and condescending, that's not cool

 

[Winged Scapula]

On the day you leave that institution, you might consider giving her an article about restrictive transfusion policies and how much better patients (with the exception of elderly with ischemic heart disease) do with this practice, rather than transfusion for a number or drop in HCT (which is what it sounds like she was trained to do).

Transfusing patients above these thresholds tends to result in greater 30 day mortality, infection and transfusion related inflammation - especially concerning in a patient who is likely immunosuppressed.

Well, that's what I would do...it would make ME feel better and perhaps do a litle educating. Always, as Annette notes, do it politely and with kindness.

 

[snoopy brown]

Sounds like she'd have to buy the nurse a full medical library.

 

[Annette]

Right now, Greenbean, you just have to do what you can. Remember, your entire career, all the blood sweat and tears you have shed and will shed will mean squat if a nurse gets a complaint against you to the right person. You can be kicked out of medical school/ residency! I know it sucks royal, but you are at other people's mercy for your future career. Trust me on this- I've been through it for giving a nurse the "cold voice" treatment.

You have to be the ultimate professional until you finish residency. If you develop a good report with most of the nurses, they will forgive your occasional foilbles. Most of the nurses I work with are very easy to work with. But there will always be nurses, for whatever reason, who think they are smarter than you, know more than you, and take better care of the patient than you.

While you are a student, you might be able to speak with the person in charge of rotations to let them know certain RNs gave you a difficult time. This may or may not get something changed, but I doubt it. Your residents know they are stuck.

 

[RokOnk]

I agree you must absolutely be polite and professional at all times. However, don't let them talk you into doing something you would not normally do. Would you normally transfuse a pt for a Hgb of 8.7 if they weren't actively bleeding or hemodynamically unstable? Blood transfusions have their own risks.

The best thing that I've found to do is explain what I'm doing to the nurse and patient, be confident about it (but not cocky), offer follow up if the situation changes (i.e. bleeding, hemodynamic compromise), write it in the chart and follow up on your own...maybe your ordered serial H&H's? Point is make your own decision and don't get coerced into doing something "just to make the nurse happy". It won't score you points with your patients or attendings.

 

[greenbean]

that's why i didnt want to do the transfusion, my res just caved to RN and it only encourage her(to the point that she cancelled my MRI?) thats why i think this is just plain dangerous, thats why im just trying to figure out why my res is being so defensive about this

we didn't 'win points' with nursing either, b'c clearly they are still pissed about something and think we are mismanaging the pt's care

and no, never in a million years would I transfuse some1 with a hgb of 8.7 who is stable, if i were that pt, i would refuse the transfusion

 

[Winged Scapula]

Sounds like she'd have to buy the nurse a full medical library.

LOL! True...he'd better get a wheelbarrow to bring in all those articles!

 

[Winged Scapula]

that's why i didnt want to do the transfusion, my res just caved to RN and it only encourage her(to the point that she cancelled my MRI?) thats why i think this is just plain dangerous, thats why im just trying to figure out why my res is being so defensive about this

As Annette notes, your resident is stuck. Its very difficult to work when you gain a reputation as a non-team player. Report too many nurses or being "difficult" and your life is hell for 3,4,5 or more years.

As the student, who is presumably leaving, you don't have that problem. But your resident is likely defensive because she undoubtedly knows that this wasn't the right thing to do, but she did it anyway to appease the nurse. I've done it myself, almost all of us who have made it through residency have. Yes, I prefer to educate in a calm and friendly manner about why I don't want to do x y, or z that I'm being asked to, but sometimes ya know...its just easier to cave in, especially if its something which is unlikely to cause the patient harm. Unfortunately, that isn't the case with transfusions.

we didn't 'win points' with nursing either, b'c clearly they are still pissed about something and think we are mismanaging the pt's care

You will always be severely handicapped in this "points" system...don't even try and win! Sometimes a meeting is in order, but I would just move on and forget about this...treat it as a learning experience. As others have noted, there are some who will always think they know more than the physicians and there are others who geniunely think they are doing the right thing but are teachable with the right attitude and information. Just face the fact that THEY are the patient ADVOCATEs and YOU are simply there to torture the patient and shaft the nursing staff.

 

[greenbean]

um,im an intern,, granted im a prelim, but my orders should not be cancelled by anyone other than another md, and it should be d/w me b4 it is done, i hate it when ppl put orders on my pts w/o telling me, it makes me look stupid

 

[snoopy brown]

Too bad your senior undermined you. To me that's the sign of a weak resident.

 

[Winged Scapula]

um,im an intern,, granted im a prelim, but my orders should not be cancelled by anyone other than another md, and it should be d/w me b4 it is done, i hate it when ppl put orders on my pts w/o telling me, it makes me look stupid

Sorry...doesn't matter if you're Prelim or Categorical...I guess I just assumed when you said you were "outta there next year" you were a student.

You're right of course...your orders should not be cancelled except by another physician and you should be informed of any major changes in the plans on your patient.

I'm sorry your senior resident didn't stand up for you...remember this when you become a senior and how toothless you felt when this happened to you and you had no backup.

 

[greenbean]

As Annette notes, your resident is stuck. Its very difficult to work when you gain a reputation as a non-team player. Report too many nurses or being "difficult" and your life is hell for 3,4,5 or more years.

i understand the 'play smart' strategy, but i dont think this was the right move, but what is more concerning to me is that a test was cancelled w/o anyone telling the housestaff, what if this was a medication that RN didn't feel like giving b'c the pt 'wouldnt want it?' the line has to be drawn here, and im not a woody woodpecker/punkin instigator/trouble-maker and usually am pretty passive, but like i said this is just plain dangerous

 

[sdn1977]

i understand the 'play smart' strategy, but i dont think this was the right move, but what is more concerning to me is that a test was cancelled w/o anyone telling the housestaff, what if this was a medication that RN didn't feel like giving b'c the pt 'wouldnt want it?' the line has to be drawn here, and im not a woody woodpecker/punkin instigator/trouble-maker and usually am pretty passive, but like i said this is just plain dangerous

I dunno if that would work with drugs. Pharmacy is now involved when we do drugs & we follow the administration, particularly if we're monitoring (not for docusate or somthing equally similar). So, if you order a drug, we input it & it goes on the MAR & it doesn't get administered - now there are two folks looking - you & us.

But - IMO - incident report are the way to go here. You may not realize, when an incident report is filed, it goes to admin, the department admin, the hospital lawyer & the immediate supervisor - ALWAYS - each & every one! It doesn't matter if its you reporting me, a nurse, a janitor or a rad tech.

You may not think anything ever comes of an incident report,but things do happen - perhaps not what you might have been looking for which could have been a reprimand for this behavior. But....the purpose is to change behaviors in general (not in particular) & improve patient care. You might want the behaviors changed in response to YOUR orders, but the incident report is designed to address behaviors, procedures & protocols no matter who orders - you or the intern 5 years from now.

So - there have been times when an incident report gets filed, then - the summary might go to M&M or the summary might go just to the dept head. There could be whole issues which happen "behind the scenes" which you're never aware of - how to handle these kinds of issues without hindering patient care, for example. Although you might want the satisfaction of knowing you were "right' & were - that is not how hospitals work.....

So - I'm very much in favor of the incident report, after discussing with your senior resident & perhaps attending. You don't want to be the "loose cannon" even though the nurse you had the encounter with was one.

 

[colbgw02]

That story sucks. Unfortunately, it's extraordinarily common, at least where I train. Take that situation, throw in pharmacy/PT/OT/laboratory/etc. along side nursing, multiply it by about 500, and you've been much summed up my entire internship.

 

[Winged Scapula]

i understand the 'play smart' strategy, but i dont think this was the right move, but what is more concerning to me is that a test was cancelled w/o anyone telling the housestaff,

I agree and have stated the same above. Tests should not be cancelled by allied staff and any problems (ie, the patient refusing, transport not showing, etc.) need to be communicated to the medical staff. You are preaching to the choir here...I don't think any of us disagree that the test shouldn't have been cancelled without your knowledge.

what if this was a medication that RN didn't feel like giving b'c the pt 'wouldnt want it?' the line has to be drawn here, and im not a woody woodpecker/punkin instigator/trouble-maker and usually am pretty passive, but like i said this is just plain dangerous

Obviously there are grades of how dangerous the actions of other health care workers in refusing treatment are. In general because the meds come up from pharmacy, there are more checks and balances but I have had patients and nurses refuse medications. But almost always (at least that I know about) I am informed of this.

 

[fab4fan]

Not to defend the nurse, but I feel that the real fault here lies with the Radiologist who allowed a non-physician to cancel a test without discussing it with the ordering doc. This nurse is obviously little better than a willful child, more interested in people "taking her seriously" than actually caring for her patient. Stupid behavior is to be expected from people like this. But presumably a board certified Radiologist should know better than to allow an ancillary staff member to cancel a physician-generated order.

You can complain to the nursing supervisor all you want, but nothing will be done because (a) you can't prove who actually canceled the test, and (b) there is zero accountability in nursing practice, and even gross negligence and practicing medicine without a license is excused on a regular basis. What you can do is have your higher-ups talk to the head of radiology to ensure that, in the future, no one but a doctor be permitted to cancel an order.

This would be a totally unworkable situation, particularly in a large facility. Wait for the doc to put the "cancel order" in the computer system? Yikes.

I cancel stuff all the time. Of course, I have an order to do so, I don't just do it on my own. And for heaven's sake, it's a computer, you can track who cancelled the order very easily. In our system, your ID pops up right next to any order entry or order cancellation. "Nowhere to run to baby, nowhere to hide..."

 

[snoopy brown]

The problem is that at many institutions a nurse can "cancel" a test without putting any order in, which is the complaint. All she has to do is not send the patient down and the test is cancelled. At most the tech will call up and ask what's the deal and she'll just say the patient can't come down and the tech will say OK. The order will still be there and unless you ask someone you'll just sit around for days thinking that it's strange that it hasn't been done yet. It's even more insidious than cancelling it because of that reason.

 

[fab4fan]

Wow. That would result in non-stop harrassment from radiology if we did that. They yell if we dare to send two pt. labels instead of three.

If I disagree with an order or think something should be done that hasn't been done, my approach has always been, "Would you explain...", sort of a "seeking-information" approach, if you will. Rarely have I ever flat out said I thought "X" needed to be done even though a doc said he didn't think so, and that was only when I was really sure I had good reason. In the few cases I am thinking of, I wound up being right. But as I said, that's rare. Usually, if I'm asking, it's just because I want to understand a situation better for my own knowledge, in addition to help care for the pt. I'm not trying to challenge anybody.

I'm sorry others have to deal with people who are deliberately disagreeable.

 

[Winged Scapula]

My experience echoes that of snoopy's. Its the tech that calls up and says they are ready for the patient, and if there is some reason the patient can't go/doesn't want to go, etc., the nurse cancels or delays the test. I have never had a radiologist calling up and asking for the patient or his whereabouts or why the test was cancelled.

Now I have worked in both hospitals with an EMR and one without...so it is not necessarily true that the "computer" will show who cancelled the test. As snoopy notes, the order...whether in the EMR or written, will still show and you'll be standing around wondering why it hasn't been done yet. A valuable lesson I learned as an intern was to follow-up on tests sooner rather than later...you may find that your test is being delayed because no one can transport the patient, because the patient went out for a smoke and hasn't returned, because it wasn't called in as "stat" or as happened to me this past weekend, there are 17 other "stat" CTs ordered before yours (even though most of those, given the clinical history did not appear to be as stat-needing as mine - despite my complaints, they still took 5.5 hours to do the test and didn't include the entire structure I told them I wanted to see).

 

[fab4fan]

Well, I have to admit that I am dumbfounded. It wouldn't occur to me to cancel a test because a pt. didn't want to go--not without contacting the doc first. Wow...some people like to play fast and loose with their licenses, I suppose.

 

[Winged Scapula]

Well, I have to admit that I am dumbfounded. It wouldn't occur to me to cancel a test because a pt. didn't want to go--not without contacting the doc first. Wow...some people like to play fast and loose with their licenses, I suppose.

Unfortunately, not all nurses are as conscientious as you are.

I expect there to be a dialogue if there is confusion or dissent about my orders and fortunately, have not had the experience of my orders being ignored very often, but it has happened. Another reason why they are called "suggestions" not orders! 😉

 

[greenbean]

i brought this up with my attending and he was more interested in the mri results rather than hearing this saga, he said 'i can tell you who cancelled the test by looking at the computer' so, we both went to the computer and it doesnt show that the test was cancelled at all, my order is still there, but it does show that radiology reordered the same test on sunday in the afternoon after i called

so, all that is undocumented and all verbal
and im totally out of the loop

i was telling another senior about this and he told that this was very similar to what happend to him when he was an intern at this very hospital
i will bring this to chief once im more calm

 

[snoopy brown]

That's how it works. The attending doesn't want to get involved. Even if it had shown the test being cancelled he would have done nothing. But as you can see from my posts today, most of us who are residents know how it's done and we know how nurses can do things without leaving a paper trail. Don't bother going to the chief because all he will do is sit you down and tell you that you have to learn to get along better. It sounds like you work with a bunch of tools.

 

[jennyboo]

I think your attending was partially right, at least -- the MRI report is more important for patient care immediately than whodunnit. I think your choices are to either follow up your complaint, or drop it -- but if you follow up the complaint, do so cautiously (you don't want people to think you're a whiner).

WRITE IT ALL DOWN AND MAKE COPIES NOW. Before you do anything at all you absolutely need to write down the patient name, medical record number, the specific study order and date/time in question, and what your complaint was. At my prelim program, they had a "business meeting" every few weeks during which the chiefs and the program director would earnestly solicit input about any problems with the hospital clockwork, including nursing and support staff personnel issues. The problem? Most residents can describe exactly what happened and in fact by the description the chiefs/PD felt the concerns were legitimate. But residents forget to write down specific incidents and specific people, and by the time it comes up in a business meeting the details are forgotten and nothing can be done about it. Residents also frequently don't know the name of the nurse ("oh, the one with the ponytail"). So write it down. Nobody is helped if you forget everything.

Finally, after you've written it down, I would suggest taking a break and letting your feelings settle down. We've all been in the same situation and it makes us mad. But it is very early in the year right now and your feelings in August in response to the same situation may be different from what they'll be in March. If you calmly raise a legitimate problem without appearing angry, you can still discuss this further with your superiors. However, if you look angry or if you give off the appearance of being vindictive, you will lose a lot of respect. This is why many of these issues never get addressed by other residents -- time and politics.

Give it a few days, maybe at least wait until this patient's care settles down or the patient is discharged. That will give you some time to think about how to approach this situation constructively. Then decide what to do.

 

[greenbean]

That's how it works. The attending doesn't want to get involved. Even if it had shown the test being cancelled he would have done nothing. But as you can see from my posts today, most of us who are residents know how it's done and we know how nurses can do things without leaving a paper trail. Don't bother going to the chief because all he will do is sit you down and tell you that you have to learn to get along better. It sounds like you work with a bunch of tools.

right, and he seemed to insist that 'someone in radiology was lying to me' even though i had explained what happend pretty clearly, there should have been no issue that this was a nurse who cancelled the test,,,in any case, nothing is going to happen, we had a houstaff support mtg last week, i dont know if we will have another one, if we do then i'll address it there, but going to the chief will put the spotlight on ME,not on the actual problem(the NURSE who cancelled the order), ill take the watch and wait approach for now