[Vailgang]

I work for two neurosurgeons so this may be a difficult question but I would like your opinion and if this happens to you how do you handle it.

This last week both of my doctors were out of the office. There is a doctor covering for emergency problems but he doesn't give our patients medications. I usually refer them to their primary care physician for medication. Anyway, this week I had a patient that had back surgery that called about muscle spasms, per routine orders gave her muscle relaxer. She also reported a fever. I told her to take tylenol and if it didn't help to call back. It didn't help so gave her ABT per standard order. She complained of pain the whole time, I explained this is normal after back surgery. She told me she was using a heating pad, I instructed her to use ice machine instead. These are all normal situations that I handle when the doctors are there.

Anyway, today the husband called and complained because I was unable to give pain medication. I told them to contact family doctor because the standard pain medication that I can give the patient is allergic to. He got all mad and told me to call the doctor while he is playing golf. I told him that everyone is intitled to a vacation and I couldn't disturb the doctor on vacation. So then he was mad because no one was helping his wife in pain and he was calling his lawyer. I told him that if they felt it was an emergency they could go to the Emergency room. He then asked if the doctor was going to pay for it.

As you can see this is one conversation I would have liked not to have. Anyway, any suggestions? The office manager said that the doctors give me too much responsibility while they are gone. What would have you done in this situation (besides hang up, which crossed my mind)?

[jadednurse]

It sounds like you handled it the best you could under the circumstances. Although, as a consumer, I would have been frustrated myself. yes, he could have called his primary care physician for pain medication, but since the pain sounds like it was r/t the surgery the neurosurgeon should be handling this. I'd be frustrated too (though he shouldn't have taken it out on you). He needs to take it up w/ the neurosurgeons...though they'll likely ignore it.

[pappyRN]

I have to reply both as a nurse with office experience although not a lot and as a patient.

It seems to me that when a surgeon of any kind arranges to have coverage for vacation that there ought to be some procedure in place for their fairly fresh postop patients and also for other pt situations. Most pts have a hard time trying to decide if their situation constitutes an emergency or not. Even pts having MIs deny what's happening and hesitate to go to the ER. Hospitals and insurance companies stress that an emergency is a 'life threatening' situation and I can see where a pt. would be hesitant to use the ER for pain. That leaves the pt. torn between suffering and risking going to an ER where it is very possible that they will be treated poorly and told that they should have taken care of it with their doctor or risk being treated like a drug seeker. In many cases the surgical back patient is also a chronic pain patient so this IS a consideration but not in all cases. Many patients fear the reaction of the ER staff.

My own spinal surgeon has his nurse do postop teaching where the pt is given approximately 30-45 minutes of pre and postop teaching about 2-3 days before surgery so the information is fresh in their minds and she covers as many aspects as possible with the pt. A lot of what she discussed was not told to me by the doctor. She was able to fill the blanks in for him about what to expect. She also covered what to do about pain and if meds were not working etc. The procedure to follow was clearly explained on both the excellent patient teaching literature they had developed as a team and that she gave me IN ADVANCE and also on the discharge instruction sheet. All patients meet with her in their hospital rooms after the doctor has seen them and written the discharge orders and she personally goes over all of the instructions.

If the paper says to call your doctor for a temp, pain etc. then the pt. is expecting to be able to get resolution and not the runaround when making that call. I am NOT saying that you gave the pt the runaround but it probably FELT that way to her and husband. She was in pain, they were frustrated at not being able to get the medication without being told to call her primary or go to the hospital.They rightly felt it was the NS's responsibility to provide for her postop care and I think it was also.

This patient's pain should have been able to be addressed promptly. It is NOT the patient's fault or shouldn't be their 'tough luck' if they happen to be in pain while the NS was on vacation. I agree that everyone deserves a vacation. However, this patient was clearly made to suffer through no fault of your's or her's because the NS had NOT worked out a plan in advance to take care of his surgical patients' needs. Unfortunately, pain is a very real sequelae of surgery. The NS knows this. It's NOT a secret! My personal opinion is that it is 'dumping' on the primary care physician to take care of responsibilities that belong to the NS. Many PCP's will NOT just give the patient a script just because they called and asked. It puts the PCP on the spot and in a position between a rock and a hard place. Also, many pts don't go to their PCP except very rarely and he might not even know or remember the pt and then he has a pt asking him for PAIN meds for a surgical problem that someone else performed. We know how some docs feel about PAIN MEDS!!! LOL Maybe the NS has an arrangement with a few PCps but he couldn't possibly have arrangements with ALL of his pts' PCPs.

I have worked using standing orders/protocols as have most nurses if not all, at one time or another. I agree with your office manager. This NS is asking way too much of you in regards to juggling these calls. Are you an advanced practice nurse? You are more than capable of handling this patient's call with the right tools and procedures to follow when certain situations arise. If, after all the advice you gave to the patient there were still issues unsettled then it should have been that you were able to say "call Dr. X. He is a neurosurgeon covering Dr. Y's practice while he is on vacation" and then reasonably expect that Dr. X. would take over from there.

The NS left you in a very bad position.Now the patient and her husband are probably very unhappy with you when it wasn't your fault at all. It's common knowledge that if pts are going to be hostile it is usually to the nurses or office staff because many develop a bad case of shyness when it comes to confronting the physician. I do not blame the husband for being angry at the suggestion of going to the ER for pain control. Pain control IS and SHOULD be an important component of the patient's postop care. There is also the very real problem that some patients have insurance that require large copays for ER visits. Why should they ahve to pay for the ER when this problem could have been avoided had the partners vacationed at different times. This is THEIR practice. I would think they would give it more consideration. I am sure that with what the patient was charged that it deserved more consideration than it got from the doctor.

If you have ever had back muscle spasms you would understand why the patient and husband were so upset. They really hurt- A LOT! It's hard to focus on anything else.

OMG!In rereading your post I just realized that you said you work for TWO doctors- BOTH of whom were out of the office during the same week. Well, double shame on them for leaving their patients at the same time unless it was an emergency situation that BOTH be gone. Didn't they ever learn to take turns? It's just poor practice. If I was that patient you'd better believe that I would be furious to be left in the lurch. He is an NS. He knows that patients get back spasms and severe pain after surgery. He should have left standing orders that would adequately address the situation if he couldn't see fit to go on vacation at a time when his partner would be able to cover for him. I'd give his customer service skills an F!!!

Since the patient was complaining of unrelieved pain, I conclude that either he prescribed medications that didn't relieve it by underestimating the amount of pain or something was very wrong and needed to be addressed.
What a difficult situation for you to be left in. Sorry, but I do think the office manager was right. You are being asked to assume way too much responsibility.

You might wonder why I feel this strongly as I said I had to answer not only as a nurse but also as a pt. BTDT!! I had this same experience after one of my earlier surgeries and from then on I've made sure to ask if the doctor was going to be out of the office on vacation anytime soon after my surgery/procedure etc. Whenever I am having surgery/procedures I now make sure to discuss having the doctor leave orders AND written prescriptions for things that might come up such as nausea, severe pain, spasms etc. I never went back to the surgeon culprit for leaving his practice without adequate coverage. I also reported him to the local medical society and the medical director since he was a university faculty member.

This may be exasperating for you but also try to put yourself in the patient's place by imagining that you have a vise grip clamping down on your back and then someone told you that you would have to get in touch with your PCP or go to the ER to get relief instead of talking to your doctor or his staff and getting a prescription called in and being done with having to deal with the particulars. Before I became a pt I am ashamed to say that in that situation I may have felt the patient was being unreasonable. My illnesses have opened my eyes for the better.

I would speak to the office manager and ask to arrange a staff meeting with you, the manager, any other staff and the doctors and discuss how to make this scenario be a thing of the past. Don't be surprised if when the pt comes in for a postop visit that they are none too friendly.

Sorry this is so long. I have this problem where my fingers do the talking and they love to gab. And...all of this ONE HANDED!!! I'm getting better at it. Hurray for me! (It really is a victory. It has taken me weeks to get this fast in a few hours instead of several). I hope you can get this resolved so you won't have to be on the wrong end of your patient's anger. It's NOT fair to you at all.

Warm personal regards,
PappyRN

[J Lynn]

I too have to make decisions like that when my doc is on vacation. He's leaving soon for almost a month and I know it's going to be hard. Some of our patients don't have a GP that they are established with . It gets frustrating to explain that there is not much I can do but send them to the ER or Urgent Care after hours.

[Barbie Lou]

This is a problem that can occur to all of us. Your advice of ice, OTC for pain, ER, family doctor are appropriate, but the bigger problem is how the physicians/surgeons handle their call schedule. The doctor on call should be able to handle the situation. You should not have been placed in that situation. When families question you like they did, it is time to hand the call to the doctor. I agree with your office manager that you are taking on too much responsibility.