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Dealing with on call Doctors

xxxHow do you deal with an oncall doctor who doesn't want to do anything? It has been a while since I have dealt with this. Our facilities physician was on vacation and we had to deal with a md that doesn't listen to nurses. Never mind we spend so much time with our pts. Twice last night there were pts that the regular doctor would have sent to the ER but this one didn't. One was a woman with dementia, we have wanderguards and alarms all over her room and one on her, but she dismantles them. When she was put to bed last noc we found a football size swollen hard area on her hip with a baseball sized bruise. It was hot to the touch. She had been ambulating earlier but she also doesn't seem to notice pain. When I called he said to just watch it so another nurse called him back and said she felt she should be seen. After much discussion he agreed. She had a fractured femur. Can a nurse over-ride an md about sending a patient to the hospital? I had a pt. with a colostomy with such severe diarhea that it leaked out from under the seal and I had to change the entire thing twice. It was to the point where we were worried about dehydration. When I called him about that he said to just watch it but I said we really need to do something about it. He asked me what I thought he could do and I asked about a stool hardener or such. He agreed to order Lomotil. Does anyone have this problem and if so what should we do about it?

bellehill, RN

Specializes in Neuro Critical Care. Has 9 years experience.

I don't work LTC but this does happen in my ICU sometimes with the residents. The best thing is to know what you want when you call (which you did). We have the option of moving up the chain of command if we aren't satisfied, you could always get your manager involved. I would let the attending physician know when he gets back that this MD doesn't cover his patients well, he may choose someone else next time.

If you feel that a doc's decisions or orders are putting patients in danger, you have not just the right but the responsibility to take your concerns up through your chain of command. (Remember, if worse comes to worse, there is a really bad outcome, and there is a lawsuit or investigation by the state or Feds, you will be held responsible, also, for not having done more -- "I was just following orders" doesn't get you far as an excuse.)

You can raise your concerns with your nursing management, and, if you're not satisfied with the response you get, keep working your way up the ladder. Although I've never worked LTC, I have encountered similar situations in acute settings, and find that it is helpful, if you're really in a bind (don't want to do it too often, or it loses its effect :chuckle ), to work the word "liability" into the conversation -- that seems to get docs' and administrators' attention like nothing else ("Gee, I'm just afraid that it could turn out later that her hip is broken, and then we could all be held liable for not having taken appropriate action to assess and treat her obvious symptoms ...") Occasionally, reminding a doc of a worse-case scenario sharpens the focus and motivates wonderfully.

And, of course, it can never be said too often: DOCUMENT, DOCUMENT, DOCUMENT!

Also, I agree with bellehill that, if you know that the covering doc is not providing the level of care/attention that the attending usually does, it would be fine to let the attending know that -- s/he may want to make different arrangements for coverage in the future.

[Can a nurse over-ride an md about sending a patient to the hospital? QUOTE]

Please don't do that or you can kiss your license goodbye. I can guarantee you the physician will report you to the BON

First I would get another staff member on another line and call that physician back. I would say, "I have someone on the line so I am clear about whether I explained this patients signs and symptomes to you and so I remember what you said."

Between the two of you keep a record of the conversation.

If the MD says, "Don't worry about it" I would answer, "OK. let me repeat that order to you Doctor. You said, "Don't worry about the swollen hard area on the patients hip that is hot to the touch. No treatment necessary."

"Is that your order?"

If the response was anything other than appropriate medical orders for the patient I would call the Director of Nursing. CEO, administrator, and as was said use the word, Liability". I would also call the licensing agency. Here it is the DHS. They have an emergency number for nights and weekends.

In the day I would call, write, AND e-mauil the medical board.

Is there a medical director of the facility?

Another doctor on the case? Perhaps a specialist?

Call the family, social service, or conservator. Tell the what you have observed. Tell them the physicians response.

I would NOT give up until someone helped the patient.

I agree with the advice to document.

Send the documentation to all management of the facility and the medical board of your state.

Include the names of all who were on duty, names of those called, and their responses too. Direct quotes.

Dalzac, LPN, LVN, RN

Specializes in CCU,ICU,ER retired.

A few years ago I had a young patient in ICU that was rapidly declining, very sick. I called his doc and he was very very drunk. Not one word he said was coherent and all he could talk about was he Granny and the kittens. I called him 6-7 times to make sure he wasn't just asleep. By now my patient was extremely critical. I callled the ER doc to see if he could help me and he wouldn't.I called the supervisor and told her the story. She didn't have a clue as to what I should do. I then called the chief of staff, who had the reputation of a pit viper and made frequent meals out of nurses' ass and he told me he would be there in a few minutes. He came in,called the wayword doc, got the same response I did,and then dealt with the patient. He saved this guys life. I know my patient would have died if he hadn't come in.

There were many policies that changed that night and one was the ER doc would come up and at least just check out the situation. The drunk doctor lost his privileges at my hospital. I found out the supervisor was written up. That chief of staff was never hateful to me again. I was the only nurse in ICU he got along with. So sometimes you got to take it further up the chain.

Hey Dalzac

You're my hero. I wanna be like you when I grow up....

I have a lighter story with the same dilemma. The Doc was actually pretty friendly with me. We both were active cyclists and runners (you KNOW this was a long time ago). He'd had a bike wreck and broken several bones in his hand. External fixation of wrist and back of hand. Very ugly and painful looking.

His Pt had only po pain meds. I forget the guy's Dx--but our Doc wasn't surgeon so maybe abdom pain or such? The percocet didn't help my Pt so called my cyclist Dr around midnight for something IM. Phone rang and rang, finally Doc answers--somewhat slurred voice--listens to my spiel. There's a long pause. "Well," he says, "discontinue the radio and I'll see him tomorrow."

I made him repeat that; 'discontinue the radio' he says, and then obviously falls asleep.

Huh, I though, SOMEBODY has some pain meds that are doing some good.

So I wrote for Demerol 50 to 75mg IM q3h prn tonite only, gave the shot and everyone was happy. Surely, I though, the Doc won't remember that in the morning.

But bright and early, as I was giving report he stopped by, grinned, said "did you discontinue the radio?" Then he signed the demerol order, winked and went on his way.

Thank goodness I didn't have a pt going down the tube like you did.

Papaw John

sometimes i try repeating the scenario back to them in incredulous tones like - ok so just to clarify she has fallen and there is a huge hard lump on her hip but you don't want us to do anything about it? right? but you have to be careful not to sound accusatory with this one

sometimes when they ask me to just 'watch it' i find someway to ask them what they want me to watch it for and for what symptoms would they like me to call them back then i think when they get to thinking about getting called back again they figure hmm maybe i'll just do something this time so i won't get called back

making suggestions is very helpful though - and giving as much background info as you can on the pt - sometimes it's shocking how little the covering doctor actually knows about the patient so i can see why they are reluctant to order anything

:kiss Thank you guys. You all gave me great advice. The medical director is the doctor who was on vacation. Dalzac you were great! I had to do about the same thing with a nursing supervisor at the hospital where I worked. We had a teen come in with an amputated heel and other ortho problems. When he came to our floor he was pale, bp was falling and the dressing was increasingly bloody. I wanted him to go to ICU but she said why do you think he should go, told her the symptoms. Just make frequent assessments, OK, 10 minutes later said his bp was even lower. After one more assessment I said that I knew he was going bad and she just had to accept my intuition. Finally she sent him up and he coded right after, he made it though. I plan on calling our don next time this doc says watch it when I am concerned. We don't have an administrator right now but I will keep fighting for my patient.

Antikigirl, ASN, RN

Specializes in Education, Acute, Med/Surg, Tele, etc. Has 13 years experience.

If I see an emergency or potential emergency, I will call a physician only if I have resonable time to do such, if not I will simply have them seen by EMS by calling dispatch or 9-11 dependant THEN tell the doctor that I had to send the patient in due to...let see in this case...Noted sudden deformity of the ___ hip with 10/10 pain on palp from suspected but unknown trauma, and add anything else I noted like external rotation ___ leg, leg appearing shorter...things like that!

ALSO, and very importantly...if you are able to rely on the patient...sure fire way to get them seen in the ER over an MD order...ASK THEM! If they say they want to go in, they get to go in...insurance may not cover...but patients rights dictate that if requested, they go in! I do use that quite often to cover myself even in cases where MD's did okay the transport. Just another level of CYA...

Another thing I did once, is call the MD every 15 minutes with updates till they said okay! Nothing wrong with updates to inform MD's of their patients status, and I document this as well as far as the convo and times I have called. Works better if the resident/patient has a change in condition (even if small)....

There are a number of ways to get around this...and AND if there was a investigation and a nurse DIDN'T send someone in when they should of...you think the MD would get it??? NO, the nurse will!

I had to deal with a doctor tonight that I absolutely HATE to call. He only treats (using the word loosely) 2 of my 20 pts thank god. Anyway, this one pt with HX of MI, HTN, and Diabetes was c/o dizziness when lying flat. I obtained orthostatic BPs and that checked out fine, so I then got their BS. This also checked out normal. I then called their "doctor" who responded with "AND?, they complain about everything all the time. Don't call a doctor unless you have something to report." and then hung up.

So..... yes all vitals checked out normal, but that doesn't mean there wasn't something underlying that couldn't be seen by doing vitals alone. There are hundreds of medical conditions that include dizziness as a symptom. How about carotid artery or other cerebrovascular diseases and aortic valve stenosis or congestive heart failure. Even if it turned out to be something like changing or adjusting the dose of a med that could be causing the symptom you would think as their "doctor" he would want to do something....anything to ease this pts dizziness. He didn't even want to order a CBC & CMP. He just blew it off. I went to my supervisor and she insisted that I write out a communication form stating the pts issue, what I did for my pt, and the Doctors response so it didn't look like I just ignored the problem. Even so, this pt is a FULL code and I came home tonight feeling like I should have gotten not only my supervisor involved, but also my DON.

mama_d, BSN, RN

Specializes in tele, oncology. Has 10 years experience.

I had a pt a few weeks ago with sugars 350+. Called the doc, as I was completely confused...he had abruptly d/c'd her insulin orders that day, including her 40 units of Lantus BID.

His response: "Quit checking her sugars, she's going home on hospice in the morning." Me: "Can I change her from a full code to comfort measures then?" Him: "No, she wants to be a full code." Me: "I am completely confused by this situation, but I will write an order to not treat glucose abnormals so that it is documented why I did not follow up on the high sugar." Him: "That's not necessary." Me: "Yes it is, you are giving me an order to not treat and it will be documented."

Made me want to reach through the phone and beat him with the glucometer.

BabyLady, BSN, RN

Specializes in NICU, Post-partum.

xxxHow do you deal with an oncall doctor who doesn't want to do anything? It has been a while since I have dealt with this. Our facilities physician was on vacation and we had to deal with a md that doesn't listen to nurses. Never mind we spend so much time with our pts. Twice last night there were pts that the regular doctor would have sent to the ER but this one didn't. One was a woman with dementia, we have wanderguards and alarms all over her room and one on her, but she dismantles them. When she was put to bed last noc we found a football size swollen hard area on her hip with a baseball sized bruise. It was hot to the touch. She had been ambulating earlier but she also doesn't seem to notice pain. When I called he said to just watch it so another nurse called him back and said she felt she should be seen. After much discussion he agreed. She had a fractured femur. Can a nurse over-ride an md about sending a patient to the hospital? I had a pt. with a colostomy with such severe diarhea that it leaked out from under the seal and I had to change the entire thing twice. It was to the point where we were worried about dehydration. When I called him about that he said to just watch it but I said we really need to do something about it. He asked me what I thought he could do and I asked about a stool hardener or such. He agreed to order Lomotil. Does anyone have this problem and if so what should we do about it?

Ah, you are dealing with an MD that doesn't so much not want to do anything, as much as they don't know what to do.

We have some residents like that, but not our Neonatologists.

With the foot-ball sized bruise? I would have sent the patient first to the ER and THEN called the doctor..that was a medical emergency when you see something that huge....the bleeding issue alone could have been major or life threatening. You do have the right to treat an emergency as an emergency.

Sometimes repeating back to them what they are doing "rings a bell" on how stupid it sounds. For example, if you are concerned about dehydration, just say, "Ok, so I understand, we have a patient who has diarrhea and is showing ____ signs of dehydration and you do not want to send this patient to the ER for fluids at this time, correct?" ...then you call the next MD who is over their head to get the order if you still cannot get it when you are 100% sure it is necessary.

Cinquefoil

Specializes in Med Surg, Home Health. Has 2 years experience.

I had a pt a few weeks ago with sugars 350+. Called the doc, as I was completely confused...he had abruptly d/c'd her insulin orders that day, including her 40 units of Lantus BID.

His response: "Quit checking her sugars, she's going home on hospice in the morning." Me: "Can I change her from a full code to comfort measures then?" Him: "No, she wants to be a full code." Me: "I am completely confused by this situation, but I will write an order to not treat glucose abnormals so that it is documented why I did not follow up on the high sugar." Him: "That's not necessary." Me: "Yes it is, you are giving me an order to not treat and it will be documented."

Made me want to reach through the phone and beat him with the glucometer.

I don't know the full details of the case, but sounds like yet another doctor who mistakes "hospice" for "give up on doing a thing". What on earth could make him associate COMFORT measures with keeping the pt hypergycemic? What's "comfortable" about that?

To the OP: One of the things my nurse manager said was to take advantage of any changes in condition that could be justified as emergent. So, your lady has a knot on hip, doctor said not to send out. An hour later you send her..."You said not to send her for knot on hip but you didn't say what to do if there was also a FEVER. It seemed like more of an emergency so I just sent her out."

What do y'all think? Is this a plausible (and defensible) use of nursing judgment in LTC?

MouseMichelle

Specializes in Home Health/Hospice. Has 16 years experience.

yeah I've had that issue, first if my House Doc is around I will call him. If he's not then I would call my DON, and she would most likely give the okay to send out. In my facility I cannot send out without a doc's order, however, I have had two occassions where I did send out without doc's order, one was when a lady fell cracked her head open and needed stitches, another was when a shunt basically popped open squirting blood like crazy didn't have time to call the docs on that, so I just called after I sent out and left them a message.

But again I would go call your DON or whoever is on call if you feel the doc didn't do what s/he was supposed to do.

Michelle

MouseMichelle

Specializes in Home Health/Hospice. Has 16 years experience.

Also if a doc does not give orders despite you insisting that it's necessary I document, if they hang up on me I document exactly what the doctor said and that he promptly hung up the phone, then I think of ways to call that same doc back for stupid things.......

Michelle

prinsessa

Specializes in LTC/Skilled Care/Rehab.

If I think a patient needs to go to the ER I will tell the doctor. They have agreed with me every time. In some emergency situations we call 911 and let the doctor know about it later. If a doctor doesn't call back in a timely manner or we don't agree with orders (or lack of orders) we call the medical director.

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