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! 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. 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.
I guess CYA is the best policy in all of this. But still. Any advice is appreciated.
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!
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.
I'm not sure what you mean by this. The residents don't pull 36 hour shifts anymore. It shouldn't cause anxiety on the nurse to call for orders, updates, or just to ask for clarification on a patient. It is our gut, our nursing sense, that saves patients as much as it is the surgery or diagnostic tools.
Now, that being said, it is wise as a new nurse to run ideas past the seasoned nurses prior to calling. If for nothing else, the seasoned nurse will know how to ask/word the issue, and can give insight on whether or not the call should be made. All I was saying it that I make it part of my practice to never give a nurse a hard time for calling.
In my opinion no one is working for free in the hospital, there are no volunteer doctors so if there is a significant change in a patient or you are handed a patient with vitals that don't support life then that doctor will be called whether it be one, two, or three am in the morning. I can't tell the patients (and more likely the family's of patients) not to ring the call bell if they think something is wrong so a doctor shouldn't be able to tell you that. I find it really sad that your management team would support such a structure. If a doctor has a problem with interrupted sleep then he can quit his job and sign over his check... it comes with the territory and that is partially why i respect the residents and attendings on my floor.... they work really hard and it shows. I agree with Marty6001 that you should run it by a more seasoned nurse if possible,.. this does not mean hunting down the charge nurse and relying on her sole opinion.
Secondly, I've learned the HARD way never to assume what another nurse did, never assume what you think a doctor might of already seen, and never assume that something was ordered or not ordered unless you've seen it in the medex. This doesn't mean that you don't respect your co-worker but for 1. you are never completely sure of the circumstances surrounding that previous nurse's decision... it could of made sense at the time in her position but be completely uncalled for once the patient get's to you, and 2. Once you get that patient, when the crap hits the fan, everyone will be looking at you and won't be interested in what "the other" nurse did. And trust me, its a bad feeling when you have to utter that phrase of defense,.. and yes.. i've mumbled that myself and realized how stupid i sounded.
I've made this mistake at least 3 times and I've only been working for a year. thank god it was never anything detrimental, but still yet, it was a good lesson learned.
Also, in my ICU we always have a resident and attending on the floor, or down the hall napping and they are expected to be actively on the floor at least 75% of the night shift. I'm not sure what state you're in or the finances of your hospital but I think that is the safest way to run an ICU. Just imagine a CTICU patient going into tamponade,.. what then.
Good luck with everything!! And maybe during your next staff meeting you could bring up patient safety related to nurse-physician relationships. You should never feel scared to call.
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. 
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!!
TulsaTime
49 Posts
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!