Is The Doctor Missing It? Stepping on Doc's Toes

Nurses General Nursing

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A pt is diabetic. Only on Lantus, blood sugars almost never normal and often as high as 300's. Nurses and other doctors have tried to talk with the doctor about the plan of care, meanwhile pt remains poorly managed. What should the primary doc do? What should the nurses do? I know the right thing to do, just wonder what some of you would do.

2nd patient - This oneA pt was refusing all meds, food, fluid x several days, pt is full code - is doc wrong to not give any thought to missed seizure meds?

Pt. seizes, doc says it isn't a real seizure. Of course, the doc didn't see the event or after-event state the pt was in. Whether it was or wasn't, what about the future while the pt is still refusing all oral intake? Seizure could happen any time, right?

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Specializes in Psych (25 years), Medical (15 years).

"A pt is diabetic. Only on Lantus, blood sugars almost never normal and often as high as 300's. Nurses and other doctors have tried to talk with the doctor about the plan of care, meanwhile pt remains poorly managed. What should the primary doc do? ..."

I document all pertinent information, especially values reported to the Primary. Of course, I try to teach the Patient the importance of adhering to an appropriate diet, etc. Once I've done all I can do, there's nothing else I can do.

EXCEPT grab the Primary, pull his (I wouldn't do this to Female) right arm (provided he's left-handed) behind his back, and shove his face into the chart and say, in my best Clint Eastwood whisper, "So, what's it gonna be- punk- are you gonna to titrate this Patient's insulin dosages to the glucose levels? Or are you gonna make my day? Huh? Punk? What's it gonna be?"

"2nd patient - ... pt was refusing all meds, food, fluid x several days, pt is full code - is doc wrong to not give any thought to missed seizure meds?"

"Psuedo-seizure" is always a good symptom for unwitnessed episodes. That kind of action puts all the responsibility on the Patient for their "inappropriate" behavior.

Of course you know the right thing to do, Kooky Korky. These are just a couple of absurb situations we have to regularly deal with. Such is Life.

Dave

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Document and reinforce pt teaching re; foods they consume and when

and #2 if pt refuses, has full mental capacity to make decision, shut up and respect their right

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Document and reinforce pt teaching re; foods they consume and when

Teaching is great. But what do YOU do about the doctor's inadequate insulin orders, no sliding scale, no oral hypoglycemics? Just continue teaching?

and #2 if pt refuses, has full mental capacity to make decision, shut up and respect their right

I'm not so concerned with the right of this mentally retarded, mentally incapacitated, involuntarilly committed pt to refuse seizure meds. I'm wondering about the wisdom of the doctor not addressing the refusal by ordering some forced IM seizure meds.

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"a pt is diabetic. only on lantus, blood sugars almost never normal and often as high as 300's. nurses and other doctors have tried to talk with the doctor about the plan of care, meanwhile pt remains poorly managed. what should the primary doc do? ..."

i document all pertinent information, especially values reported to the primary. of course, i try to teach the patient the importance of adhering to an appropriate diet, etc. once i've done all i can do, there's nothing else i can do.

except grab the primary, pull his (i wouldn't do this to female) right arm (provided he's left-handed) behind his back, and shove his face into the chart and say, in my best clint eastwood whisper, "so, what's it gonna be- punk- are you gonna to titrate this patient's insulin dosages to the glucose levels? or are you gonna make my day? huh? punk? what's it gonna be?" as fate would have it, doc is a female! otherwise, good idea!

"2nd patient - ... pt was refusing all meds, food, fluid x several days, pt is full code - is doc wrong to not give any thought to missed seizure meds?"

"psuedo-seizure" is always a good symptom for unwitnessed episodes. that kind of action puts all the responsibility on the patient for their "inappropriate" behavior.

of course you know the right thing to do, kooky korky. these are just a couple of absurb situations we have to regularly deal with. such is life.

dave

yeah, blame the patient.

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Specializes in Trauma Surgery, Nursing Management.

Quite the conundrum...a doc that doesn't know how/refuses to change protocol for a diabetic pt with a poorly controlled regimen. What is the doc's rationale for not changing his/her orders for this pt?

What does the pt think? Have they complained?

You stated that other docs and nurses have talked to this doc. What did the doc say? If the doc is being obstinate or is just plain incompetent, then I would speak to the Chief of the department or whoever is this doc's superior. I would have my facts all documented for the Chief to review, including the discussions that other staff have had with this doc. YOUR job is to be a pt advocate. In my opinion, I don't give a hairy rat's ass if I am stepping on this doc's toes or not. I am going to see that my pt is properly managed. This pt is in danger now.

I got NOTHING for scenario #2. Nothin'. If the pt is refusing everything, then they need to have social work intervene to find out WHY this pt is acting out. You can only do so much...we can't FORCE them to eat, drink and take their meds. So if they are intentionally being non-compliant, I would get SW on the horn and let them deal with the pt. Not much else you can do.

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Specializes in LTC.

I would talk to his boss ASAP....

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Specializes in Family NP, OB Nursing.

Contact risk management and start going up the chain of command. Do you have care conferences? Can you get family involved? If the second patient is mentally incompetent where is his POA? Get them involved.

Is his not eating and refusing meds because he's scared? Have you tried different foods, things he usually eats? If he usually takes his meds and is just now refusing then maybe getting him into a routine would be better for him. If he usually refuses, then this is nothing new. Not sure what seizure meds he is on, but if he's on some that levels can be checked, have they been?

DOCUMENT, DOCUMENT and do it some more. Document every conversation you have with the doc about the patient. Does your facility have a standing order about high sugars? Most I've worked in do, if so I'd call him every time I had a high one. Heck, I'd probably call him anyway.

I've had conversations like this: "Dr. Smith, Sally Jone's glucose is still 340. Yes, I know I called you earlier, but I wanted you to know it's still too high. I was hoping for an order for something, maybe a little R on the sliding scale? Yes, I understand you told me earlier not to call and I don't care if you scream at me, the patient's sugar is STILL too high and it is my duty to inform you. Don't call you unless she's unconscious? Would you like me to write that as an order then? No? Okay, if it's still above 300 at supper I'll be calling you back. Yes, of course my name is spelled...."

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Specializes in Med/Surg.

Maybe not the best approach...but one I have been known to use.

Assuming this is an inpatient setting and that the doc is not on 24/7 and that you have attempted to convey what you think would be best for the patient wait til someone else is covering and explain the situation, sometimes an outside party is more willing to order something.

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Does this pt have an assigned endocrinologist? If not is it possible to get a different attending who is covering for Dr. "I can't hear you" to write an order for a consultation with an endocrinologist. An endo would not tolerate that & it would be out of primary care doc's arena if an endo was brought into the mix.

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

Effing doctors - they don't appreciate nurses or their judgement, and never will.

We are not seen as equals, THAT's the problem.

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Does this pt have an assigned endocrinologist? If not is it possible to get a different attending who is covering for Dr. "I can't hear you" to write an order for a consultation with an endocrinologist. An endo would not tolerate that & it would be out of primary care doc's arena if an endo was brought into the mix.

No, this is inappropriate. Nurses cant/shouldnt be calling physician consults. The only exception would be for a crashing patient who needs an ICU doc to assess for possible transfer to the unit.

Calling a endocrinology consult for a patient with poorly controlled diabetes is the doctors' job, not in the nursing autonomy/scope of practice. Your job is to document the pooorly controlled sugars and that the primary doc is not addressing the issue. Later you can try to talk to the program chief or head of staff; but calling a consult is out of the question.

P.S. High blood sugars is RARELY cause for an urgent consult in the middle of the night. Most endocrinologists I know would be ****** off if they got paged at 4 AM because a known diabetic has a sugar of 500. They'd be happy to add on a sliding scale regimen or increase Lantus dosing in the morning.

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