be honest, now. how many of you find a patient that you think has an emergent problem and actually call the doctor and get orders first?
before icu (where we have standing orders), when i worked on the floor, i would ask someone to page the md but immediately start drawing needed labs, place o2, etc., while waiting for the md to respond.
when the md called, i would report the prob and say i drew this-and-that and did such-and such and what else do you want?
of course, i had worked with the same mds for years and could antipicate what they would want done. technically wrong, but i felt waiting on a return page that could take up to 20 min or more was worse in an emergent situation.
what about the rest of you guys? what's your procedure?
Prior to RRT's on the cardiac units we did a lot of things we just KNEW the doctors would order. You get to know which docs order what for each situation. Even had one tear me a new one because I called him without the RESULTS to the interventions he just assumed would be done. Once, I called with EKG, SPO2 and was waiting on ABG results. The cardiologist THANKED me, because he knew what needed done without having to wait for the orders to be carried out. Other docs, I wouldn't put on O2 without an order;)
It depends on the situation. If it has to do with giving meds or something similar, I do wait. If it's sometthing like drawing blood or ekg then I go ahead and do it. Three night ago my patient was on heparin drip that needs PT/PTT q 6hrs, there was no order and it was 2 hrs past due, so I drew the blood right away before obtaining the order. :monkeydance:
Have to admit there have been a couple of situations in which I started interventions before the doc called back. For example, I had a symptomatic diabetic pt c a BS of 20 that I started pushing D50% on before he called back. Another nurse finished pushing it while I was on the phone c him. He asked, "Is she symptomatic? Then give her some D50!"
I was sweating it some though. But her temp had dropped, she was lethargic, and becoming unresponsive. I didn't feel I really had much time to wait for a doc that may/ may not call back.
We have standing orders for these type of situations, if your facility doesn't have them, you may want to suggest they look into it. Anyone with a BS of 20 needs immediate treatment, there is no way you can wait for the Dr to call back!
this is one reason why i love the autonomy of the ED. we don't wait for a Doc to give orders for a patient that needs obvious interventions (IVF's, O2 etc..) i would feel silly even asking, because ED docs have a very high expectation of us and 9x's out of 10 most interventions are done before they even walk in the room. i would have a hard time working on the floor.
I had a symptomatic diabetic pt c a BS of 20 that I started pushing D50% on before he called back. Another nurse finished pushing it while I was on the phone c him. He asked, "Is she symptomatic? Then give her some D50!"
I was sweating it some though. But her temp had dropped, she was lethargic, and becoming unresponsive. I didn't feel I really had much time to wait for a doc that may/ may not call back.
At our facility, by policy we can go ahead and push an amp of D50 if the pt's glucose is 40 or lower and they're symptomatic, then page the doc to let them know.
Specializes in Flight, ER, Transport, ICU/Critical Care.
Short Answer:
NO - not usually. In a TRUE emergency I WILL go AHEAD and do the expected critical interventions to save the life of a patient.
I have been functioning on "standing orders/protocols" for a looooong time - so, although I'm NEVER trying to "practice" medicine without a license - I WILL generally choose action over inaction. Even in the absence of protocols, there ARE generally accepted STANDARDS OF CARE!
Of course, I will note any attempts to contact MD.
Although I pray to never be in a circumstance of having to explain my ACTIONS to a BON - I still maintain that ACTION will be easier to justify in a TRUE LIFE THREAT!
I guess I would RATHER explain ACTION over INACTION as a rule!
So, this is just my humble opinion --- I can always EXPLAIN without fail ANY ACTION or INACTION that I take part in - so......
Practice SAFE!
Death is very still, sometimes we have to move FAST!
It depends on the doc. If it is someone that trusts me I will start with lab work if need dopamine I will start that. If it is someone I don't know then yeah I will wait.
This is why I work only in the ER. The doc's expect us to start to work up the patient before they even see them. Sometimes the doc goes in to see the patient and all test results are back already. They love it when we make their life easier. Couldn't get away with this on the floor. You would bruise too many egos.
I work in a rehab facility, and sometimes it takes hours for the doctors to call us back. Sometimes they dont call us back at all. Sometimes we get an answering service that tells us the doctor didn't leave a number for our facility for the weekend, which means we don't have a doctor. I always place the page to the doctor and then take whatever measures necessary while waiting for a return call. I just have to chart that the doctor ordered it. Whenever the doctor does finally get back with you, they know that they should have been available and will of coorifice agree to any measures taken.
It depends on the situation. I'll give a postpartum mom tylenol at 2am then tell the doc to write to order when I see him at 7am, and I'd never do that with a narcotic, but if a woman walks in with ruptured membranes, GBS + and 6cm I'll start her IV, draw her CBC, give her abx and then some Nubain while I'm waiting for the doc to return my page.
I've also prepped pts. for surgery (a prolapse cord pt and a close to term previa pt who was hemorraging) foley, belly shave, IV and Bicitra and started heading to the OR while someone else was tracking down the doc, both of those times I called the OR team in first since it took them longer to get in.
We follow a protocol for most triage pts. It's up to me to choose the tests to be done, if the docs want more after we evaluated the pt then we do it then.
I think emergent is a code, or something that's going to lead to a code probably faster than the doc can or will respond. I do what I can and yell for help if needed. I stay familiar with my standing orders so I'll know what I can do without a call but emergencies get the doc involved.
If it's urgent... well that's a whole nother ball of wax. Let me differentiate: blood sugar below oh, 40-ish is emergent in my book and the patient is getting d50 no matter who the doctor is. He will find out later because I don't have brain damaged patients on my unit. (I try not to, anyway) The tele that went from normal to sudden ST abnormalities that look pretty significant to me, hmm... I'll call it urgent and get an ekg and a set of cardiac enzymes... plus I'll go ahead and do the O2 and find out if the pt's in pain, and look to see if the pt has pain meds ordered. I'll call the doc in the middle of all this and tell him "ok this, this and this are done, can he/she have some morphine and how many more sets of cardiac enzymes do you want?" I prefer to have the ekg done if I can prior to calling so I can give some info.
The prevailing attitude on nights is "what can I do to get away with not calling the doc." I got this attitude through having my orifice chewed off a few times... and learned real quick to look at standing orders before calling anyone. Also I learned that not only cardiologists like impromptu ekg's if something's going on, but other docs generally appreciate it.
Oh, and the biggest thing other than the physician's personality, to building that trust so they'll cover what you do, is to be honest and keep up with your info. If they find out that they get good results they will remember it. Your mileage may vary!
most of my practice has been in the ed and icu. we act first and call later...
be honest, now. how many of you find a patient that you think has an emergent problem and actually call the doctor and get orders first?
before icu (where we have standing orders), when i worked on the floor, i would ask someone to page the md but immediately start drawing needed labs, place o2, etc., while waiting for the md to respond.
when the md called, i would report the prob and say i drew this-and-that and did such-and such and what else do you want?
of course, i had worked with the same mds for years and could antipicate what they would want done. technically wrong, but i felt waiting on a return page that could take up to 20 min or more was worse in an emergent situation.
what about the rest of you guys? what's your procedure?
ShayRN
1,046 Posts
Prior to RRT's on the cardiac units we did a lot of things we just KNEW the doctors would order. You get to know which docs order what for each situation. Even had one tear me a new one because I called him without the RESULTS to the interventions he just assumed would be done. Once, I called with EKG, SPO2 and was waiting on ABG results. The cardiologist THANKED me, because he knew what needed done without having to wait for the orders to be carried out. Other docs, I wouldn't put on O2 without an order;)