Deciding to call MD

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.

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.

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.

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.

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.

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!

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!!

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.

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.

If you're a member of AACN go to their site & search for effective communication. There is an excellent webcast there from nti 2008 that gives some ideas & tools to help make that phone call to the doctor a little less stressful. I thought it was interesting that they noted the number 1 anxiety producing event for new nurses was having to call the doctor!