Why do we tolerate terrible nursing?

[OnTheRopesMD]

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[akwho]

We've all been there with terrible nursing care, sorry it's incredibly frustrating to work with, sounds like a new nurse was in over her head. My algorithm for dealing with that is:

1. Nursing education which it sounds like you were doing. Walk the nurse through your thought process, give them one or two things you're worried about and tell them to watch for the specific signs/symptoms and page you if they notice them. It gives them something to do and they page you less for the garbage stuff like zofran.
2. If you still are getting inappropriate pages or the nurse is unable to manage the condition, speak with senior nurses you are friendly with or the nursing manager on the floor and tell them that you are concerned about a patient and the new nurse seems to have a lot of questions about the usual protocol. They will keep a closer eye on the new nurse and can answer many questions for you and decrease the number of inappropriate pages your receive.
3. If the nursing staff (remember you involved the senior nursing staff at this point) is still struggling to manage the patient, perhaps the patient is very sick and needs your help more than you think. Sit at a computer on the floor next to the nurses station and bang out some notes while you wait for things to quiet down. Sometimes your presence alone will help calm the nursing jitters, and if something happens you are already right in the area.

Hope this is helpful. Sometimes you do everything right and will still get written up by ignorant nurses. Just have your interaction well documented and be prepared to calmly defend yourself to your PD.

 

[Instatewaiter]

I'm a wee bit enraged post/pre-call at the moment. Why do we let nurses do a terrible job taking care of patients then we get blamed? We had a HELLP syndrome patient who was about 30 hours post-op and popping off severe range BPs. Keep in mind we are a regional center and do pre-eclampsia every. damn. day. This nurse totally doesn't call me with severe pressures, takes forever to treat them, and is taking pressures every 5 seconds, which is not our protocol.

Keep in mind once I got mad at her for not rechecking a severe pressure when I saw it 2 hours later, she lies and says she told me about it (170s/100s, no one sits on that), then decides to page me every 2 minutes about nonsense BS. (Why do I have to tell a nurse if a patient is nauseated to give her the effing PRN Zofran?!?!) Then I finally get to lay down for a second at 2:30 in the morning (been up since 5:15 the previous morning) and she pages me again because she doesn't like the answer that I told my intern to check the patient's pressure again in 15 minutes (had just treated 15 minutes prior, have to give the medicine time to work!). I get mad and told her she didn't need to wake me up, to which I get "well if you don't like getting woken up, don't be on call." Right. Because I choose to work 30 hours in a row. She couldn't survive a single day of residency.

I asked her what the pathophysiology of pre-eclampsia was and she couldn't answer. I asked her what the pharmacology of nifedipine is and how quickly it should work and she couldn't answer. Anyone treating a patient in ANY regard absolutely needs to know the pathophys of the disease process she has and the pharmacology behind the medications he/she is writing for or administering. Why do we tolerate such terrible nursing? Later they demand I come see the patient and when I ask what they are concerned about I get "I don't know." I go see the patient and she's laying in bed comfortably. Poor thing is exhausted because she has had her BP checked 30 times this evening because the nurse can't do it right.

Ugh, sorry for all the text. I'm just frustrated right now. She didn't have the time to manage my patient properly, but she sure had the time to write me up this morning. It's such BS. We work our butts off, only to keep being treated like crap by nursing who have been doing OB for 2-3 years less than I have. The lack of knowledge and BS treatment need to end.

There is a very easy way to nip this in the bud. Have a sit down with her nurse manager.

Explain how her behavior was both unprofessional and unacceptable starting with her lack of notification, followed by her lying followed by vindictive paging. The behavior will stop.

 

[OnTheRopesMD]

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[bashwell]

After getting 5 hours of sleep and getting to do this again for 16 hours, I'm still ticked off. She can be this exhausted and get woken up just the same as I have to do. She wouldn't last two hours in residency. Just once I want them to have to live a day in our shoes. (I'm working 43 hours in a 51 hour period--more than any of them work in an entire week!)

In my experience, when OB/GYN nurses go bad, they can go really bad.

 

[ascue]

Unfortunately, they can always hurt you more.

If you really feel strongly about it, call the highest nurse in the hospital, vp of nursing and put it in writing and carbon copy the ceo, director of surgery, and all the heads of the departments. This is probably what should be done to put an end to this insubordination.

 

[DarkLordofSith]

I see some good advice and some bad advice on here. It sucks, but nurses can absolutely make or break residency for you. If you get a reputation as a jerk resident, it will spread and a lot of nurses will treat you badly and may just inherently have a distrust of you. I wish there was an easy answer, but you may want to get the nursing manager involved and have her mediate a session between the two of you.

Even if you're 100% in the right, it's not worth gaining that reputation.

 

[oldbearprofessor]

Then I finally get to lay down for a second at 2:30 in the morning (been up since 5:15 the previous morning) and she pages me again because she doesn't like the answer that I told my intern to check the patient's pressure again in 15 minutes (had just treated 15 minutes prior, have to give the medicine time to work!). I get mad and told her she didn't need to wake me up, to which I get "well if you don't like getting woken up, don't be on call." Right. Because I choose to work 30 hours in a row. She couldn't survive a single day of residency.

I would encourage you and anyone else reading not to say this ever to a nurse. It could easily be grounds for dismissal or other action from the program.

 

[da8s0859q]

Unfortunately, they can always hurt you more.

If you really feel strongly about it, call the highest nurse in the hospital, vp of nursing and put it in writing and carbon copy the ceo, director of surgery, and all the heads of the departments. This is probably what should be done to put an end to this insubordination.

I also like to mow my lawn with nuclear weapons.

 

[Ultramarathoner]

I would encourage you and anyone else reading not to say this ever to a nurse. It could easily be grounds for dismissal or other action from the program.

Yes I second this. Never say do not call me. Never get mad at them. Go pound some iron ect... take your frustrations to higher powers after sitting on things for 24 hours. This is part of your training and it won't end when your done.

 

[ascue]

I would encourage you and anyone else reading not to say this ever to a nurse. It could easily be grounds for dismissal or other action from the program.

So it is ok to be torture paged by nurses and you not call them out on it?
what are you an abuse monkey?

 

[oldbearprofessor]

So it is ok to be torture paged by nurses and you not call them out on it?

It is okay to act professionally at all times, even if you feel that staff members are calling you unnecessarily. There are ways to deal with difficult nurses and hospital staff that don't include becoming angry or telling them not to call you when they think it is necessary. My advice however, was not based on that, but on the reality that such behavior can be grounds for programs to take action again the resident (or anyone else for that matter).

 

[LucidSplash]

Am I the only one who thinks trying to bump this up to the nurse manager is a bad idea? Where I am, this would make a problem with one nurse turn into a problem with all nurses. It sucks but as a resident you have to do your best to make friends and stay on the good side of the nurses if you want your life to not be hell. You don't have any power to change the system and I would save discussions with the manager for situations where a patient could be harmed, not for annoyances.

 

[ascue]

Am I the only one who thinks trying to bump this up to the nurse manager is a bad idea? Where I am, this would make a problem with one nurse turn into a problem with all nurses. It sucks but as a resident you have to do your best to make friends and stay on the good side of the nurses if you want your life to not be hell. You don't have any power to change the system and I would save discussions with the manager for situations where a patient could be harmed, not for annoyances.

Think about what this breeds.. conflict avoidance.. this is exactly why nurses are winning the PR battle. Because physicians are wimps

stand up for yourself when you see an injustice

 

[LucidSplash]

Think about what this breeds.. conflict avoidance.. this is exactly why nurses are winning the PR battle. Because physicians are wimps

stand up for yourself when you see an injustice

I'm talking about as a resident. Your power to enact change is limited. I have found it much better to make sure the nurses know I'm the one that won't yell at them when they call no matter what is. Even if it dumb I just say "Thank you for letting me know." And you know what? They saved my ass a few times because they like me. Also, because they like me and know I won't get pissed, now they know it is ok to write the order for the X-ray or the CBC or Tylenol in my name without calling me.

If you try to get one nurse in trouble you are risking all the nurses to turn against you. Again, different if patient safety is involved but you have to consider that as a resident, typically your program and your hospital will take their side over yours. Pick your battles wisely.

 

[Perrotfish]

So it is ok to be torture paged by nurses and you not call them out on it?
what are you an abuse monkey?

As a resident, yes. Because you don't have a choice. Your attendings will not support you and the nurses' supervisors will support them. If your attendings are fine making you work 30 hours in a row so that they can work slightly less, do you really think they care enough about your 15 minute nap to spend time defending you against the nursing administration? The nurses can light the patients on fire and as a resident all you can do is to try to get to an extinguisher in time.

 

[ascue]

. Your power to enact change is limited. I have found it much better to make sure the nurses know I'm the one that won't yell at them when they call no matter what is. Even if it dumb I just say "Thank you for letting me know." And you know what? They saved my ass a few times because they like me. Also, because they like me and know I won't get pissed, now they know it is ok to write the order for the X-ray or the CBC or Tylenol in my name without calling me.

If you try to get one nurse in trouble you are risking all the nurses to turn against you. Again, different if patient safety is involved but you have to consider that as a resident, typically your program and your hospital will take their side over yours. Pick your battles wisely.

Your power to enact change is even MORE limited if you go along to get along.

 

[LucidSplash]

Your power to enact change is even MORE limited if you go along to get along.

I say again. Pick. Your. Battles.

 

[pulmoblast]

So it is ok to be torture paged by nurses and you not call them out on it?
what are you an abuse monkey?

Yup


The sooner you realize this the easier it all becomes





Sent from my iPhone using SDN mobile app

 

[Perrotfish]

Your power to enact change is even MORE limited if you go along to get along.

No, no its not. That's not how power works. The organization isn't any more likely to change when you're loud than when you're quiet. All that changes is how the organization treats you.

 

[Siggy]

Your power to enact change is even MORE limited if you go along to get along.

I would argue the exact opposite. If you're a team player that doesn't complain about everything, then when you do complain you'll be taken more seriously.

 

[NotAProgDirector]

So it is ok to be torture paged by nurses and you not call them out on it?
what are you an abuse monkey?

As a PD, my experience is that if the nurses are "torture paging" you at night, it's because of your prior abrasive / demanding / narcissistic behavior. Although I'm certain they do exist, nurses that page residents purely for "torture enjoyment" are very rare. Basically, your behavior is actually the cause of your pain.

 

[Perrotfish]

As a PD, my experience is that if the nurses are "torture paging" you at night, it's because of your prior abrasive / demanding / narcissistic behavior. Although I'm certain they do exist, nurses that page residents purely for "torture enjoyment" are very rare. Basically, your behavior is actually the cause of your pain.

My experience is that hospitals are very large organizations that attract a disproportionate number of pathologic personalities to start with, so between the prevalence of the problem and population size there is always going to be someone itching for the opportunity to behave badly. What keeps those personalities in check is a fear of consequences. When there are no consequences for abusing a particular employee, there is always going to be someone there to make the work environment abusive for that employee.

Generally, in a given rotation, 95% of my problems would come from one or two nurses out of several dozen. We all knew exactly who they were. We all knew that THEY knew never to treat our attendings the way they treated us. There was, however, no stopping them, because any concerns raised about their behavior resulted in a victim blaming answer. Not unlike the one you just posted.

 

[Gastrapathy]

I asked her what the pathophysiology of pre-eclampsia was and she couldn't answer.

OP, this quote stuck out to me. What were you trying to accomplish with this question? Did you expect that she would suddenly bow to your superior medical knowledge? Were you actually trying to teach her something? Belittling someone out of anger is never going to accomplish anything for you. Lets look at that interaction from the nurse's perspective: you just yelled? at her because she hadn't called you with a BP. Now she had an abnormal BP, which was not concerning to you as you understand that you need to wait on the nifedipine and she called you. So, you belittled her.

When you told her not to wake you up when you were on call, you put your career in her hands.

You also are failing to see that your brutal OB resident experience is not because of the nurses. They chose their career. You volunteered for yours. They work far fewer hours and way less hard than you and make a decent living. That isn't going to change and they have no reason to walk a mile in your shoes. I can't imagine any OB resident not experiencing burnout but my last experience on an OB service as anything other than "wide-eyed useless husband thing" was almost 20 years ago.

You've probably significantly damaged your relationship with the nursing staff in your program's unit (I noticed you switched between she and they) and you need to step back and protect your career. This isn't your place of business so stop caring.

For everyone above who sees this as caving or giving up or whatever, its not. My nurses treat me very well and the ones that weren't on board aren't here anymore. If anything, they are too protective of me. But the OP is a resident and she won't be there much longer, as long as she graduates.

 

[Gastrapathy]

My experience is that hospitals are very large organizations that attract a disproportionate number of pathologic personalities to start with, so between the prevalence of the problem and population size there is always going to be someone itching for the opportunity to behave badly. What keeps those personalities in check is a fear of consequences. When there are no consequences for abusing a particular employee, there is always going to be someone there to make the work environment abusive for that employee.

Generally, in a given rotation, 95% of my problems would come from one or two nurses out of several dozen. We all knew exactly who they were. We all knew that THEY knew never to treat our attendings the way they treated us. There was, however, no stopping them, because any concerns raised about their behavior resulted in a victim blaming answer. Not unlike the one you just posted.

Peds at NMCSD must be different than adult medicine in the Navy. Plenty of very young, utterly incompetent nurses on the Med/Surg wards back in the day but not abusive. Also, I'm not even sure how a nurse could abuse us. Our rep was way stronger than that and we were always a team as housestaff.

 

[Raryn]

Typically, if it isn't a hyperacute situation, I ask for their concerns, then I explain my reasoning, then ask if that allays their concerns. If they re-emphasize (seemingly incorrect) concerns, I try to explain a second time... and then offer to kick it up the chain myself. Usually, you can talk your way through it, and if you can't, as a resident you better have proof you talked to your attending documented, because it is possible (however unlikely) you're wrong. I've never had an attending not back me up in that situation, but only ever got to it a couple times in all of residency.

If they categorically refuse to implement an order or god forbid start implementing what they think is best without an order, then do whatever is necessary to take care of the patient acutely, let your attending know, and would certainly talk to the charge nurse->nurse manager. I would NOT send an email to the senior VP of nursing or whomever the poster above recommended.

Also, while I do do my best to educate the ancillary staff, pimping them on pathophys is stupid. Whether they get it right or wrong, you get nowhere except seeming like an arrogant prick.

 

[Perrotfish]

Nvm

 

[OnTheRopesMD]

.

 

[Gastrapathy]

@OnTheRopesMD , I erased my more specific response when you erased your post. However, it's critical to recognize burnout in yourself (and others). It makes stuff like this happen. You have no power to do the big stuff to make your life better so do the small things.

Exercise.
Hire someone to clean your home,
Eat well. ( yes I'm s believer in plant based diets)

Stop comparing your job with nursing. Their job only recently started to involve a bachelors degree. There's a reason med school admissions view undergrad nursing degrees with skepticism. No nurse will ever have the privilege to open up another human and place her hands inside.

 

[Gastrapathy]

I read your posts from last year. You have a bad relationship with your PD and now with your nurses. You need to keep your head down and GTFO (it's only 6 mo to go right?).

The military has a countdown toy called the Donut of Misery. Helped me get through longer periods than 6 months of suck (google and download it).

 

[Shikima]

And I wonder why hospital admins demand more from employed physicians or that insurance companies are routinely making us do more just to have medical treatment justified.

Starts at the beginning.

 

[evilbooyaa]

OP, if you come across one person who's an dingus to you, they're most likely an dingus.

If you come across 10 people who are dinguses to you, it's most likely not on them.

Pimping a nurse on pathophys is a waste of everyone's time. If a nurse is interested and wants to learn only then can it be a valuable learning experience.

Don't escalate this; it will not end well for the remainder of the time that you are there.

 

[TooMuchResearch]

Am I the only one who thinks trying to bump this up to the nurse manager is a bad idea? Where I am, this would make a problem with one nurse turn into a problem with all nurses. It sucks but as a resident you have to do your best to make friends and stay on the good side of the nurses if you want your life to not be hell. You don't have any power to change the system and I would save discussions with the manager for situations where a patient could be harmed, not for annoyances.

Our Epic build has a way to report patient safety issues "anonymously."

I used it exactly one time after a nurse was doing something (and disregarding my orders and face to face discussion) that easily could have killed one of my patients and did result in an adverse outcome requiring additional surgery, some dead bowel, and a complex abdominal wound.

I'm told the nurse got some further education (not sure why I was told this after an "anonymous" report /sarcasm), and my relationship with the nurse is actually better now.

I definitely didn't batch to a nurse manager, attending, program director, hospital C suite, etc. That's a great way to get shot canned.

 

[cherubb3]

I was a nurse, and my input is that if you must report on a nurse, go to their immediate manager instead of a VP or DON. It will be much more effective and cause less bad blood.

However, demanding that a nurse tell you the pathophys of an illness will do you no good at all. That kind of behavior will only serve to recruit many nurses (and probably other staff) against you.

 

[Siggy]

Aww.. I love it when people post stories, don't like the responses, so they delete their original post.

 

[Raryn]

Aww.. I love it when people post stories, don't like the responses, so they delete their original post.

It's quoted in post #3.

 

[Siggy]

It's quoted in post #3.

I know... and that makes it even better.

If people want to remain anonymous, go to confidential consult.

 

[npappasan]

I read your posts from last year. You have a bad relationship with your PD and now with your nurses. You need to keep your head down and GTFO (it's only 6 mo to go right?).

The military has a countdown toy called the Donut of Misery. Helped me get through longer periods than 6 months of suck (google and download it).

Always comes down to the common denominator...

 

[giantswing]

It really does suck sometimes. A couple of times it felt like it was me against the whole hospital, actively trying to keep me from taking care of patients or sleeping or eating. It's rough. It sucks. And we can't fight back.

 

[engineeredout]

Certainly dealt with my share of massive bombardment of stupid nursing calls. I've found that these generally fall into a couple categories:

Category #1 - New/Inexperienced. With most experienced nurses either retiring, becoming administrators, or moving onto NP/CRNA school, there is a need for new nurses to replace them. We seem to get a lot of these fresh-out-of-nursing school grads exactly where you should be placing new inexperienced nurses, in the ICU. A lot of them are just as nervous as a new intern on the floors, and they call about everything.

The thing is, it's okay. Most of them are intelligent people who are taking care of potentially sick and complicated patients but just don't have experience. I find that a lot of them are more than willing to learn and listen to the explanations for why we are doing what we're doing, not simply mindless orders. If you take a minute or two to explain to them, just like you would with a new intern, you'll find it'll improve their knowledge base, improve patient care, decrease your number of calls for routine stuff, and improve your relationship with the nurses overall

Category #2 - Variable experience, Stupid. These are nurses who you will be unable to reason with. They will throw out words like "Policy" and "Protocol" because they want something done right now and how they want it and aren't as interested in the patient care as they are in filling out their forms. The calls usually start with "I need you to order 10mg of lopressor now"

They have nothing better to do than write you up for "ignoring their concerns" about asymptomatic BP of 150/80 at 3am or why you do not wish to address why the day team started a specific glucose management regimen that you don't wish to change right now. I will occasionally order the 5mg IV Hydralazine to make them go away, or redo the orders for the patient's home eye drops because they're ordered Q6H instead of QID and the best time to address this is 4am 6 days after they've been admitted. You cannot win by fighting with them. Best case you're aggravated, worse case you're written up for nonsense

Here are the issues with writing nurses up as a physician for issues like this:

#1: Nobody, whether the nursing admins, your PD, chief resident, CMO etc... Will be able to defend a complaint saying nurses should call less. They should always be able to reach a physician in a timely fashion at all times. Believe me, the alternative is worse, when your day team starts asking you why the patient was anuric for the past eight hours and you didn't do anything about it. I'd rather be called for nonsense than to not be called about something important.

#2: Like it or not, nurses band together. Nurses will defend ****ty nurses before siding with a resident 999/1000. Writing up a nurse for personal issues, or for "inappropriate calls" will likely not lead to significant action against them, but will only serve to make every other nurse in the hospital hate you. I've seen it happen; fair or not it will only serve to make the remainder of your time miserable.

So what should you do?

#1: Resign yourself to not sleeping overnight. Yes it sucks but I found out early on that if I decided to not even try to sleep, I was less annoyed with the calls than if I kept trying to lay down for a few. On the off chance I have some down time I just watch netflix or screw around on the internet until I'm done. Much better for my mental stability.

#2: Educate the nurses as mentioned above. Talk through the concerns and explain why you're doing what you're doing (or not doing it). If they realize you're taking their concerns seriously and addressing them it can forgo a lot of problems.

#3: If there is a legitimate patient safety issue, somebody got hurt or near hurt, report it. I'd cover your ass by not just the anonymous reporting system but talk with your attending as well.


Is it fair that you can be written up dozens of times for nonsense but one complaint from resident to nurse can make your entire residency miserable? Maybe not. But there are ways of dealing with it and getting through unscathed.




For the record, I've never been written up. I even get invited to some of the holiday parties.

 

[npappasan]

In all seriousness, you need to evaluate YOU. Sometimes nurses don't call with info because they just flat out don't want to deal with a specific personality type. As mentioned above, you've had problems butting heads with your PD. Now it's nurses who are incompetent based on your assessment. The common denominator is you and I don't think you see that. This is not a job for fighting and bickering. This is a job for collaboration and taking care of other human beings. This is why there is no room for disruptive personalities in modern medicine and why hospitals come down hard and fast on this behavior. This ain't the old days. When you get that reputation, staff doesn't want to or are afraid to deal with you, and then they don't call when they should. This ultimately affects patient care. Your overall demeanor should be one of "what can I do to help?". Again, stop and evaluate YOU and how you're coming across. Keep it cool. Swing baby. These residency years are supposed to be fun. Everyone should get along.

 

[evilbooyaa]

One thing I will add is that when I was on night float, I told the nurses on our highest-volume floor (for one of the 4 services I was covering) that I would come around 11pm or midnight if I wasn't busy to address any routine concerns they had. If I was busy they'd sometimes page me for stuff, but otherwise I'd head up around 11pm or midnight and have a to-do list from them about pretty minor stuff. Nights is about efficiency - making one trip to the floors should yield dealing with as many issues as can be feasible. Obviously if there's an urgent issue then check immediately. If you're on nights as a resident, there will be nights (sometimes more often than not) where you get absolutely 0 sleep, and you need to be OK with that.

 

[cherubb3]

One thing I will add is that when I was on night float, I told the nurses on our highest-volume floor (for one of the 4 services I was covering) that I would come around 11pm or midnight if I wasn't busy to address any routine concerns they had. If I was busy they'd sometimes page me for stuff, but otherwise I'd head up around 11pm or midnight and have a to-do list from them about pretty minor stuff. Nights is about efficiency - making one trip to the floors should yield dealing with as many issues as can be feasible. Obviously if there's an urgent issue then check immediately. If you're on nights as a resident, there will be nights (sometimes more often than not) where you get absolutely 0 sleep, and you need to be OK with that.

When I worked with residents that did this, they would sometimes say something like "does anyone need anything done before I try to get some rest?" It was a good way to get routine stuff knocked out of the way for a while, in addition to being a subtle indication that they would prefer to not be called for the next few hours except for emergencies.

 

[Siggy]

Category #2 - Variable experience, Stupid. These are nurses who you will be unable to reason with. They will throw out words like "Policy" and "Protocol" because they want something done right now and how they want it and aren't as interested in the patient care as they are in filling out their forms. The calls usually start with "I need you to order 10mg of lopressor now"

They have nothing better to do than write you up for "ignoring their concerns" about asymptomatic BP of 150/80 at 3am or why you do not wish to address why the day team started a specific glucose management regimen that you don't wish to change right now. I will occasionally order the 5mg IV Hydralazine to make them go away, or redo the orders for the patient's home eye drops because they're ordered Q6H instead of QID and the best time to address this is 4am 6 days after they've been admitted. You cannot win by fighting with them. Best case you're aggravated, worse case you're written up for nonsense

To be fair, we set ourselves up for the BP issue because, instead of properly managing an out of control BP by increasing their home meds or finding the trigger, we give orders like "hydralazine, 5mg IV q6 PRN BP 170/105." We're, in part, setting the expectation that asymptomatic hypertension needs aggressive PRN IV medication.

 

[n618ft]

I've had some - um - interesting nursing experiences that were incredibly frustrating. Here's my 6 month takeaway. Many of our nurses are fresh out of school and eager to learn. The way I look at it that makes this easier is that part of our job description as doctors of medicine (teachers of medicine) is to help them learn and to build the best team around you that can help you do your job. At least at my program, we're expected to stay on top of everything that they do and we've all been called out on this if we don't. Some things that I've found helpful include #1 asking the nurse how the patient is doing before each encounter, if possible. #2 formatting our questions to the nurses so that our inquiries are perceived non-aggressive or judgemental. #3 When there's something that needs to be corrected, use the same demeanor as you did for step #2. #4 Giving compliments when they're deserved - or even when they're not deserved - a lot of their frustrations come from being under-employed or just having low morale #5 sitting down with them when you have time to explain to the nurses and the staff about your reasoning and how they can do better, or continue to do well.

Imagine learning medicine/nursing as a nurse from physicians like us.

 

[npappasan]

To be fair, we set ourselves up for the BP issue because, instead of properly managing an out of control BP by increasing their home meds or finding the trigger, we give orders like "hydralazine, 5mg IV q6 PRN BP 170/105." We're, in part, setting the expectation that asymptomatic hypertension needs aggressive PRN IV medication.

I'm going to go off topic for a little teaching here. Choosing a specific BP med for a PRN order is never the best management. There are different physiologic processes with regard to elevated BP. Blood pressure, in its simplest formula, is flow/volume x resistance. Elevated BP is usually due to an alteration in one of those parameters, and sometimes both. The key is to use the appropriate med for the physiologic process occuring. Is the patient volume overloaded or are they peripherally clamped down? So how do you determine which is which? Look at your pulse pressure. SBP minus DBP. Translate that pulse pressure number into a driving speed. If you're likely to get a ticket at that speed in a 55 mph zone, then it's a preload/VOLUME issue. If no ticket, then it's an afterload/RESISTANCE issue. Keep in mind that volume status is more SBP labile and resistance is more DBP. Let's take the 170/105 you cited. Pulse pressure is 65. Ticket? Probbbbbably. More of a preload/volume issue primarily so the hydralazine may not have optimal effect. This patient may need more of a labetalol. You'll get a negative chronotropic and ionotropic effect from the beta blockade which will lead to decreased volume shooting out of the left ventricle into circulation and jacking that SBP. You'll also get some selective alpha blockade which will help with PVR and probably serve to bring BP down also. A touch of Lasix may not hurt either. Now let's say that the BP was 172/116. PP is 56. Ticket? No. You can see that the DBP is the more significant issue in comparison to the PP so this is an afterload/ resistance issue. This is where the hydralazine would probably help. Just a quick clinical pearl. How many times have you chased a BP that just seemed to not go down the way you would've liked? The above reason may be why. Feel free to share with your homies.

I learned the above pearl years back from Mike Foley, who wrote the book on critical care obstetrics. Here is a link to one of his basic powerpoints on this subject. Simple pearl to remember in the context of the 55 mph speed limit. That's how he told me to remember it.

http://www.marchofdimes.org/chapterassets/files/nv_hypertensive_emergencies.pdf

For all the residents, this is an excellent grand rounds or lunch and learn topic. Quick and simple. You'll be a superstar.

 

[Siggy]

I'm going to go off topic for a little teaching here. Choosing a specific BP med for a PRN order is never the best management. There are different physiologic processes with regard to elevated BP. Blood pressure, in its simplest formula, is flow/volume x resistance. Elevated BP is usually due to an alteration in one of those parameters, and sometimes both. The key is to use the appropriate med for the physiologic process occuring. Is the patient volume overloaded or are they peripherally clamped down? So how do you determine which is which? Look at your pulse pressure. SBP minus DBP. Translate that pulse pressure number into a driving speed. If you're likely to get a ticket at that speed in a 55 mph zone, then it's a preload/VOLUME issue. If no ticket, then it's an afterload/RESISTANCE issue. Keep in mind that volume status is more SBP labile and resistance is more DBP. Let's take the 170/105 you cited. Pulse pressure is 65. Ticket? Probbbbbably. More of a preload/volume issue primarily so the hydralazine may not have optimal effect. This patient may need more of a labetalol. You'll get a negative chronotropic and ionotropic effect from the beta blockade which will lead to decreased volume shooting out of the left ventricle into circulation and jacking that SBP. You'll also get some selective alpha blockade which will help with PVR and probably serve to bring BP down also. A touch of Lasix may not hurt either. Now let's say that the BP was 172/116. PP is 56. Ticket? No. You can see that the DBP is the more significant issue in comparison to the PP so this is an afterload/ resistance issue. This is where the hydralazine would probably help. Just a quick clinical pearl. How many times have you chased a BP that just seemed to not go down the way you would've liked? The above reason may be why. Feel free to share with your homies.

I learned the above pearl years back from Mike Foley, who wrote the book on critical care obstetrics. Here is a link to one of his basic powerpoints on this subject. Simple pearl to remember in the context of the 55 mph speed limit. That's how he told me to remember it.

http://www.marchofdimes.org/chapterassets/files/nv_hypertensive_emergencies.pdf

For all the residents, this is an excellent grand rounds or lunch and learn topic. Quick and simple. You'll be a superstar.

Well, the 170/105 is a PRN trigger point for either systolic or diastolic, not a specific BP. Regardless, the only problem IV push orders (PRN or not, and in contrast to titrating POs or putting a patient on a drip) solve is the nurse calling the team's phone for an arbitrary number. If the patient is having a hypertensive emergency, then they need to go to the ICU and put on a drip. If they're not, then they need their blood pressure medications increased or look for alternative causes (pain, fluid status, etc). Instead of pushing lasix, why not just shut off maintenance fluids instead?

 

[npappasan]

Well, the 170/105 is a PRN trigger point for either systolic or diastolic, not a specific BP. Regardless, the only problem IV push orders (PRN or not, and in contrast to titrating POs or putting a patient on a drip) solve is the nurse calling the team's phone for an arbitrary number. If the patient is having a hypertensive emergency, then they need to go to the ICU and put on a drip. If they're not, then they need their blood pressure medications increased or look for alternative causes (pain, fluid status, etc). Instead of pushing lasix, why not just shut off maintenance fluids instead?

Of course. The point Foley makes though is that setting BP trigger points and prn med standing order misses the big picture and potentially uses the wrong med. The trigger points should prompt a call and then a determination made on the specific med at that point in real time.

 

[rokshana]

Of course. The point Foley makes though is that setting BP trigger points and prn med standing order misses the big picture and potentially uses the wrong med. The trigger points should prompt a call and then a determination made on the specific med at that point in real time.

in an ideal world maybe that would work, but really? you think that the one night float intern covering 60-80 pts overnight is going to be able to answer and determine each of these calls at night? that's like having the nurse call you with every sugar over 150 and ask how much insulin you want them to administer as correction...ideal but not realistic...

 

[Siggy]

Of course. The point Foley makes though is that setting BP trigger points and prn med standing order misses the big picture and potentially uses the wrong med. The trigger points should prompt a call and then a determination made on the specific med at that point in real time.

No. I simply shouldn't be getting a call for a BP in the 150s or 160s and "there's no PRN med ordered" in the first place because that's bad medicine. If the patient is symptomatic? Sure. If the BP is some where around 200? Sure (however, again, look for secondary causes like pain and then uptitrate home meds). However when the collective we set the expectation of PRN IV blood pressure medications, the end result is that we've trained the nurses to call us over, what is in the grand scheme of acute care things, nothing.