Deciding to call MD

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I'm a little embarrassed to admit this.....but sometimes I have difficulty knowing when to call doc. I've been in the ICU 3 months and a nurse 2 years, so you would think I would have this figured out by now, right? It's not all the time, but sometimes, and it's aggravated by the fact that I work nights, and the docs at my hospital have complained so much about getting called at night that we have actually been told not to call unless we run it by the charge nurse/ANM first, and we must keep a "log" of calls to the MDs. It makes it very intimidating to call a doc at night. It's also complicated by some nurses telling me, "you don't need to call for this" or "wait until 0600 to call the doc". This is especially bad in the ICU where we are expected to use our "critical thinking". On the tele floor, we had NO autonomy, so calling the doc was an easier decision.

Anyway, I get this little old lady right at shift change last night who was in septic shock. I get report from the day nurse that the ER says the BP is 80s/40s. Then, before they actually transfer her to me, the ER nurse calls and states her last BP was again 80s/40s. I specifically ask the ER nurse if any pressors are ordered, she states, no just fluids at 125 ml/hr. I roll my eyes, but say OK. So, she comes up to the floor, and of course her BP is still in the toilet......80's/40's to 70s/30s. I give her an NS 250 mL bolus per our ESO. She doesn't really respond to the fluid bolus. So, then is when I start struggling with whether to call the doc. I mean, her BP was in the crapper when she was in the ED. So, if he wanted pressors, why didn't he order them in the ER? Do I just watch her and if it remains approx the same as in the ER, don't freak out? She has a hx of CHF but lungs were clear. I didn't really want to give her another NS bolus, especially with fluids running at 125 ml/hr and fluid boluses in the ER. How much could she tolerate before having resp distress? I did end up calling around midnight and get an order for Levophed which worked great.

I don't want to sound REALLY stupid. I mean, if it's an established patient, and it's a clear change from baseline, of course I call the doc. But, when the patient just arrived from the ED, isn't the doc aware of the pt's condition, and if he wanted a certain treatment, wouldn't he have ordered it? Or, why didn't the ER nurse ask for a pressor while the patient was down there with a crappy BP? Why didn't the doc write an order..... if MAP

So, then this little old lady starts complaining of CP. Great! :eek: I ask all the pertinent questions......have you ever had this pain before? Where is it? What does it feel like? Does it hurt when you breathe? I immediately lower the Levophed dose from 4 mcg/min to 2 mcg/min. Of course, I just gave her Dilauded 45 mins ago when I started to Levophed because I knew her BP would be supported, so can't give any more pain med. I knew her next set of cardiac enzymes were due in 10 mins, so I wait on the lab to come draw those. I look at the side effects of Levophed and it states that precordial pain is a known side effect. Anyway, I call the doc. By the time the doc calls back 20 mins later, the little old lady states the pain is a little better and she really thinks its gas since her stomach is rumbling. :uhoh3: So I tell all this to doc. I get an order for Maalox and 2 baby ASA. I ask if he wants to switch to another pressor, and he states no. Of course, 2nd set of enzymes is normal, pain resolves, the woman just had gas!!

This same little old lady ended up having positive blood cultures this morning which were called to me by the lab. So, she already has an ID consult for today, and she's already on Vanco and Zosyn. So, do I really need to call the positive blood cultures? Our policy states all abnormal labs must be called to MD within 30 minutes of notification by lab, but REALLY? This is now the THIRD time calling this same doc. :uhoh3:

I guess CYA is the best policy in all of this. But still. Any advice is appreciated.

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I would not be bugging the doc in your situation, granted I had lines. We have a sepsis protocol where we bolus the heck of patients until they maintain a CVP of >8. If they put in a Precep cathether we also monitor SvO2, and if they have an art line we can monitor SVV. All of those would tell me if the patient was dry, and I need no doctors order to continue bolusing them.

When severely septic patients come up and docs don't place lines, then yeah, you're going to be all over them all night getting orders. They know it's going to happen so I feel no remorse for them. Admit me a severely septic patient with little diagnostic help, you bet your butt I'm waking you up from your nap!

We also have to call and report positive blood cultures, it is standard procedure, so I wouldn't feel bad bugging them about that either.

Overall sounds like you were in the clear. Calling the doc at 4 AM because your patient who is being dialyzed in the morning has a potassium of 5.1 and has been that way for days prior to dialysis, or you discovered you can't crush an SR med and put it down an NGT but it's not due until noon, those calls don't need to be made at night.

You'll figure it out come time. You will end up making a lot of CYA calls if you have a bad doctor that night. I had a guy in new onset AF w/ RVR and called the doc for hours before he finally came over and saw us in there with the crash cart and Lifepak paddles on his chest before he decided to finally give him some IV meds.

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Specializes in multispecialty ICU, SICU including CV.

I think it was sort of stupid for your doc to admit a patient with suspected sepsis without 1. a sepsis protocol with what to do like the previous poster mentioned 2. expecting frequent calls from you re: patient condition and need for orders (or maybe he did expect you to call?) I am assuming you aren't in a teaching facility and you actually have to wake someone up in the middle of the night that isn't right down the hall in a call room from your post. Yeah, your doc should have thought ahead. Septic patients don't generally just drum up a B/P of their own without some fluids and drugs. I wouldn't feel guilty about calling at all in that situation.

At my facility, we went around and around with the lab re: calling blood cultures. They now call them directly to the MD per relatively recent policy. It was determined that nurses cannot do anything with the info the lab gives them besides being an intermediary messenger (who could potentially lose the message) -- I mean really, we can't order antibiotics. We are still called critical lytes, ABGs, enzymes, H/H's, etc. because those are things that are pertinent to nursing and we can potentially change things immediately to affect the patient, so that makes more sense.

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Specializes in Psychiatry, ICU, ER.

As a relatively new nurse who works nights, I have this problem also. In a case such as the pressor issue, I'd first ask the offgoing or ER nurse something like, did you ask the doc why he didn't want to start e.g. levo? If the nurse didn't, and there's no obvious reason or the doctor didn't write anything in orders or progress notes, I will call the doc ASAP after shift change, let them know that even with fluids, you still have crappy pressures and would like to suggest a pressor.

I work in a 300+ bed non-teaching hospital, and often the doctors will say something like, "oh, yeah, of course, if you still don't have a pressure by now start xyz, titrate to MAP > 60, call me if that doesn't work, thanks for letting me know." CYA, head off problems at the start, avoid that dreaded 0000 phone call to some on-call doc who doesn't give a rat's you-know-what about this patient he knows nothing about, and provide best care for the patient. Win/win for all.

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UK nurse, Norad in septic shock is a basic component, ambiguity of fluid in flabby pipes or smaller pipes in reduce fluid should not be called into question when any patient is sent anywhere near an icu environment. It is approx 1800 quid a night for one person to be admitted so laziness should not be in the equation.

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Specializes in ICU.

It seems odd to me that you admitted a septic pt without a sepsis protocol in place that would have included PRN pressors with parameters. (Also, no CP protocol?)

In any case, I'm new to the ICU as well, but I would suggest a couple things for this change of shift admit:

1) be as assertive as you can when you get report from the ER. This pt was known to be septic. If your MDs do not come up to the ICU with their admits, then you need a central line placed in the ER, esp if you're going to have to start pressors in the middle of the night. Insist on a line before you accept the pt. (that way you can also get a CVP on your own if you have to call again in the middle of the night.)

2) Do quick assessments so you can get PRN orders before your attendings go off call. It doesn't matter that the BP hadn't changed much from the ER report. The pt is now yours and doesn't have appropriate orders in place. (A call to update the MD with current pt status and to ask for PRNs is also to CYA.)

3) You can always run questions like this by your lead/charge before you call. You are 3 months into this, it is expected that you ask questions.

4) Twenty minutes for an MD to call you back? I hope there's a space on your phone log to document that as well. (When an MD takes that long to call me back, I always document it in my nurses notes.) Your pt can crash out in that period of time.

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Specializes in Critical Care, ER.

You did the right thing. I know that calling a doctor in the middle of the night can be daunting. But think of it this way--if you didn't call & your patient coded because you left them sit & didn't call for orders--who do you think is going to be out of a job & potentially out of a license? Not the doctor--you never notified him.

And that's not to mention how bad you'd feel about not doing the right thing for your patient. You are an advocate for that person who has put their very life in your hands. Think about that next time you are worried about waking a doctor up!

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Any time I have a question about anything, I am not shy about asking that question. I don't care what anyone thinks of me for doing so. I would rather they think I am silly or stupid or unknowledgeable, than for me to fail to do what I should because of fear of how I would appear if I have to ask a question.

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Specializes in ER, Critical Care, Paramedicine.

As an APRN who works in an ICU with both seasoned nurses and new grads, bug the doc. I'd rather get 100 calls from a new nurse than miss the one call that matters. At worst you wake up the resident who should be awake away, at best you learn something new. Never apoligize for being a new nurse... Somday you'll return the favor!!

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Specializes in CVICU.

I agree with the others. If you admit a patient with something going on that isn't right like unacceptable VS and you don't have anything in place to fix it, then call and say "Hey I'm just wanting to touch base with you before it gets too late. This guys BP is still 70-80s/40s and all I have is fluids going at X. If this doesn't work soon do you want to try something else?" And in regards to the chest pain thing.. if you can't nail down a plausible reason for it and you don't have any other tools to work with then again you would have to call. In this case it sounds like you had some cardiac enzymes to draw, you could call lab and get them up there sooner, or draw them yourself. You could get an EKG if you're concerned also (that's an OK thing to do at my unit anyways). But I wouldn't just call about it before gathering more data unless the patient was obviously distressed.

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Specializes in CTICU.

I don't know that I'd be accepting a pt from the ER with no blood pressure and no orders for pressors. I'd be telling them to get something going before they brought them to me, especially if they have the doc there.

Apart from grouping non-urgent calls, don't worry about it. They are paid to be on call, and should expect to be called. If they give you crap, just tell them "OK, so I should document that in the chart?".

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As an APRN who works in an ICU with both seasoned nurses and new grads, bug the doc. I'd rather get 100 calls from a new nurse than miss the one call that matters. At worst you wake up the resident who should be awake away, at best you learn something new. Never apoligize for being a new nurse... Somday you'll return the favor!!

Easy for you to say. How many 36 hour shifts do the ARNPs in your unit work? Where I am, its only the residents who work those kind of hours, the ARNP are there for their 7-7 shifts and then they go home.

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