When the doctor doesn't respond to their page...

[kate4rn]

I work in a small hospital, we have hospitalists, and we also have a few general practitioners who admit their own patients, and are usually easily accessible. However, last week, one of the practitioners admitted a patient through the ED and after I assessed her, I realized she was having severe exacerbation of CHF. I paged him SIX times, and he never called back. There was no diuretic ordered. Her bp was through the roof because she hadn't taken her ACE inhibitor that morning, none was ordered. The admitting doc does not have any partners, the hospitalists aren't allowed to write orders for his patients, I was stuck just trying to get her O2 saturation above 82 (the ED sent her up WITHOUT O2!) and her BP down. What do you do in this situation? I gave report to the oncoming nurse (this all started about an hour prior to shift change), documented every page I sent, and clocked out. I did call back the next day to check on the patient, and I informed my charge of every step, but it was infuriating. WWYD?

[dandk1997RN, MSN, RN]

I work in a small hospital, we have hospitalists, and we also have a few general practitioners who admit their own patients, and are usually easily accessible. However, last week, one of the practitioners admitted a patient through the ED and after I assessed her, I realized she was having severe exacerbation of CHF. I paged him SIX times, and he never called back. There was no diuretic ordered. Her bp was through the roof because she hadn't taken her ACE inhibitor that morning, none was ordered. The admitting doc does not have any partners, the hospitalists aren't allowed to write orders for his patients, I was stuck just trying to get her O2 saturation above 82 (the ED sent her up WITHOUT O2!) and her BP down. What do you do in this situation? I gave report to the oncoming nurse (this all started about an hour prior to shift change), documented every page I sent, and clocked out. I did call back the next day to check on the patient, and I informed my charge of every step, but it was infuriating. WWYD?

We have this problem with a particular doc all the time. The hospital has begun limiting his admitting privileges and we can contact our hospital coverage if we can't get him (and he is addressed appropriately after the fact.)

In your situation, I probably would have called RT or a rapid. If it were a little less urgent but still important, I would have gotten my charge RN to call the nursing supervisor. Worst case is she would call our hospital medical director.

[TheCommuter, BSN, RN]

I'm playing the devil's advocate here. . .

What if the nurse works at a small specialty type of hospital that has no ER, no RRT, no senior resident, and the patient's attending physician also serves as the medical director, yet (s)he's not returning calls? Moreover, the attending doc's partner is unwilling to give any orders. All consulting docs (internal medicine, pulmonology, nephrology, etc.) are also very unwilling to give orders.

In the situation I described above, we would be forced to call 911 and have the deteriorating patient sent to another hospital's ER.

[RNperdiem, RN]

I think Commuter understands the setting you work in.

Right now I work in a place where if I pick up the red emergency code phone, I can have half a dozen doctors at the bedside in less than 2 minutes. When you work in a large teaching hospital, doctors, residents and plenty of backup is available at all hours.

The really small hospitals are a different story. I worked one place where on nights there was no pharmacist, 1 RT, 1 ER doctor for the entire building.

After the first call with no response is time to notify your charge nurse and get them involved. If you are a new nurse, your charge might have some experience in getting in contact with the hard to reach docs.

[PMFB-RN, RN]

I am a full time rapid response nurse. In my hospital had you called me I could had her fixed up pretty quick. 3 pages in my limit. After that I don't bother and go up the chain. I wouldn't hesistate to call the chief of staff.

[monkeybug]

OP, I think I get where you're coming from. My first hospital job was in a tiny rural hospital. No house supervisor, no residents, no rapid response. I went through a very similar situation when I was a new nurse. I had a patient sinking, and the MD wouldn't return the call. The ED doc didn't want to deal with it. I ended up finding our only cardiologist when he came to make rounds in the hospital and said something to the effect of, "This isn't your patient or problem, but could you please, please help me?" He stepped in and got the patient moved to ICU and he dealt with the patient's non-responsive doctor. I made it a point to clarify with my manager what I should do next time. I was told to send the police to his house.

Small hospitals are different. People that have never worked in one have no idea what it's like. Call the house supervisor! What if there's not one? Call Rapid Response! What if there's not and RR? Call the resident? No residents! I would definitely talk to the manager about what to do next time.

[PMFB-RN, RN]

OP, I think I get where you're coming from. My first hospital job was in a tiny rural hospital. No house supervisor, no residents, no rapid response. I went through a very similar situation when I was a new nurse. I had a patient sinking, and the MD wouldn't return the call. The ED doc didn't want to deal with it. I ended up finding our only cardiologist when he came to make rounds in the hospital and said something to the effect of, "This isn't your patient or problem, but could you please, please help me?" He stepped in and got the patient moved to ICU and he dealt with the patient's non-responsive doctor. I made it a point to clarify with my manager what I should do next time. I was told to send the police to his house.

Small hospitals are different. People that have never worked in one have no idea what it's like. Call the house supervisor! What if there's not one? Call Rapid Response! What if there's not and RR? Call the resident? No residents! I would definitely talk to the manager about what to do next time.

*** I have spent time in a very small hospital, 12 beds. You are right things are different. There have been several cases where I did what I had to do to keep my patient alive without orders while an unresponsive physician played golf (or something).

While I don't recommend it I found it pretty safe. What is the physician going to do? Not sign your orders for things you did to keep his patient from dying while he played the back 9? If he does that then he has to explain why he decided not to return nurses pages.

[monkeybug]

*** I have spent time in a very small hospital, 12 beds. You are right things are different. There have been several cases where I did what I had to do to keep my patient alive without orders while an unresponsive physician played golf (or something).

While I don't recommend it I found it pretty safe. What is the physician going to do? Not sign your orders for things you did to keep his patient from dying while he played the back 9? If he does that then he has to explain why he decided not to return nurses pages.

I found the relationship between doctors and nurses there different, too. We had 2 docs, so they stayed very, very busy with many sleepless nights. It was not uncommon to hear, as the doc exited the unit after hours of being there, "Please just handle it without me if you can, I trust you." and we would to the best of our abilities because we knew how fatigued they were. In a busier hospital with more resources, no way would I do this.