Doctor Hassles

[ThislittleoneRN]

Let me start off by saying I avoid this "nurse practitioner" like the bubonic plague. This "individual" constantly insults all nurses, myself included. This nurse practitioner is rude, unprofessional, and let's be honest, not very good at her job. Any who, enough ranting and raving, let me get to the point here.

I have a patient that is elderly and has a terrible, incessant, wet, nonproductive cough; upon listening to lung sounds, I note crackles in lower bilateral lung fields and immediately suspect pneumonia. The patient does not have a fever and his oxygen saturation is 98% on RA. I fill out an SBAR and proceed to place a call to the MD.

About 45 minutes later this "nurse practitioner" calls back and responds to my findings as "Well there isn't much I can do about this. I guess you can give him duoneb treatments QID and get a cxr, even though they never show anything." I do as the "nurse practitioner" asks and call our local mobile x-ray service to get the ball rolling.

Upon receiving results, I note it says, probable for pneumonia or atelectasis of LL lung. I then place an follow-up call to the "nurse practitioner" and read the results... here is the unbelievable response: "Do you see why I hate chest x-rays?! They NEVER show anything... just as useless as every nurse I've worked with. I guess you should get a CBC and CMP to see if the WBC's are elevated. DO NOT call me if they are slightly above normal. He is have dead anyway, there is nothing we can do." At this point in time I am completely speechless and dumbfounded by the response of someone who is supposed to be an advocate for those who cannot speak for themselves (The patient is AAO to self).

The results of the CBC/CMP came back and the values are all out of sorts, so I decide to fax the results because it was during normal business hours. There was no response. I place a call to the office, and still no response. Later that evening, the beloved (note my sarcasm here) "nurse practitioner" comes into the facility and is reviewing all nurses notes and recent labs.

While in the building, I note, with the help of our amazing CNA, that the patient may have a UTI. I proceed to dipstick the urine and note it is positive for leukocytes, nitrates, blood, and excessive amounts of bilirubin and the specific gravity of off. I walk up to the "nurse practitioner" and tell her my findings hoping "this person" would order a UA+C&S but, instead the response was: "Are you SERIOUS? Push oral fluids!!!" Rolls eyes and turns the back towards me.

I had to walk away... I can not believe how ridiculous this person is! I do not know how to handle the situation other than calling the medical director to get this patient taken care of. How do you guys handle or tolerate this type of person? I am at the end of my patience rope with this person. Please advise and be kind. Thanks!!!

[Tait, MSN, RN]

Well technically she is not a doctor, so I guess I would try and get the actual physician on the phone.

[ThislittleoneRN]

The physician who she works under is just as bad as she is. I am just enraged with the way she handled this situation. I called our medical director and got orders for abt.

[netglow, ASN, RN]

It's not worth it to work with people like this. After the first ineptitude by known perps I'd be over both their heads. I just don't play with fools. I have no patience with them.

[jinny2009]

Yes, I would follow up with her supervisor. Keep us updated!

[BostonFNP, APRN]

It seems like you have deeper seeded roots than this one interaction, and it is clearly effecting your working relationship. All else aside, I would suggest sitting down and having a direct talk with him/her: it may be bet for both you and the patient.

A few questions, why the quotes around nurse practitioner? Is he/she a NP or not?

Did you give him/her your "R" (of SBAR)? Sometimes, on the other side of the phone, it is difficult to appreciate a clinical situation from lab values.

The chest film is a tough one. I am a believer of don't order it if you aren't going to act on it. But if I couldn't be there to listen and the pt was afebrile and sating ok, it would be a tough call. Is it atelectasis or PNA? One you treat one you don't. Films tend to lag behind. I would have likely not treated.

Same thing with the dip. If the patient is asymptomatic then guidelines are not to treat. Again, if if the clinical presentation warranted, sure. I would have pushed fluids first.

It would be your report that would have made me act different. This is why I say you need to fix your work relationship, so that you can voice your opinion.

[ThislittleoneRN]

It seems like you have deeper seeded roots than this one interaction, and it is clearly effecting your working relationship. All else aside, I would suggest sitting down and having a direct talk with him/her: it may be bet for both you and the patient.

A few questions, why the quotes around nurse practitioner? Is he/she a NP or not?

Did you give him/her your "R" (of SBAR)? Sometimes, on the other side of the phone, it is difficult to appreciate a clinical situation from lab values.

The chest film is a tough one. I am a believer of don't order it if you aren't going to act on it. But if I couldn't be there to listen and the pt was afebrile and sating ok, it would be a tough call. Is it atelectasis or PNA? One you treat one you don't. Films tend to lag behind. I would have likely not treated.

Same thing with the dip. If the patient is asymptomatic then guidelines are not to treat. Again, if if the clinical presentation warranted, sure. I would have pushed fluids first.

It would be your report that would have made me act different. This is why I say you need to fix your work relationship, so that you can voice your opinion.

I do not know how to make paragraphs on this site. Yes, this one is a nurse practitioner. I agree with what you're saying about "working on the relationship", however, with this particular person, everyone who has come into contact with her has had a similar issue as the one I described. When we suggest/request a treatment, she avoids what we've said and often times, does nothing. I understand the guidelines however, all nursing interventions have been expended to help this patient... which is why I went to her in the first place.

[Altra, BSN, RN]

Agree with BostonFNP's post ...

I'm not getting the best vibe from the repeated use of nurse practitioner in quotation marks. Improving your interactions with this provider will probably benefit both you and your patients.

[BostonFNP, APRN]

I do not know how to make paragraphs on this site. Yes this one is a nurse practitioner. I agree with what you're saying about "working on the relationship", however, with this particular person, everyone who has come into contact with her has had a similar issue as the one I described. When we suggest/request a treatment, she avoids what we've said and often times, does nothing. I understand the guidelines however, all nursing interventions have been expended to help this patient... which is why I went to her in the first place.[/quote']

I dont know this person and I am not trying to defend him/her. I hope the patient recovered well.

Just because a provider doesn't do what the staff wants all the time doesn't make them a bad provider. A lot of the NP-RN relationship is based on trust. The NP needs to trust the assessment of the RN and the RN needs to trust the plan of the NP. It sounds like this trust is off between this provider and the RNs, on both sides.

On the prescriber side I am cautious, especially in the elderly due to the pd and pk changes as well as polypharm. It sounds silly, but abx can save someone or kill them. I do, on the other hand, try and always remember that the nurse at his bedside knows him much better than I.

[leslie :-D]

yep, i've worked with folks like *those* and the only way we resolved it was sharing concerns with DON and then we ALL had a meeting with the np.

(ftr, her supervising physician was useless to deal with as well.)

great call on consulting with med'l director.

it seems many don't know that elderly do NOT present with textbook s/s....

and that MANY remain afebrile until they are bordering sepsis.

be very detailed in your nsg notes.

describe your actions/interventions with this np, your subsequent call to med'l dir and the new order.

also note abnormal labs from urine and new orders to "push fluids" per (fill in treater's name).

that's the best you can do for now, until relations improve and/or she starts trusting nsg's input more.

still, always write notes to show you weren't a passive bystander.

leslie

[ThislittleoneRN]

I dont know this person and I am not trying to defend him/her. I hope the patient recovered well.

Just because a provider doesn't do what the staff wants all the time doesn't make them a bad provider. A lot of the NP-RN relationship is based on trust. The NP needs to trust the assessment of the RN and the RN needs to trust the plan of the NP. It sounds like this trust is off between this provider and the RNs, on both sides.

On the prescriber side I am cautious, especially in the elderly due to the pd and pk changes as well as polypharm. It sounds silly, but abx can save someone or kill them. I do, on the other hand, try and always remember that the nurse at his bedside knows him much better than I.

I agree with you 100%. I have been working on trusting this individual for quite some time now. This is going to sound silly, but there are times when she will prescribe new medications or treatments and I consult with another practitioner or even MD prior to transcribing the order. This particular practitioner and the MD she works for can not practice at a local hospital that is very popular. On a side note, I do appreciate your feedback and honesty.

[ThislittleoneRN]

yep, i've worked with folks like *those* and the only way we resolved it was sharing concerns with DON and then we ALL had a meeting with the np.

(ftr, her supervising physician was useless to deal with as well.)

great call on consulting with med'l director.

it seems many don't know that elderly do NOT present with textbook s/s....

and that MANY remain afebrile until they are bordering sepsis.

be very detailed in your nsg notes.

describe your actions/interventions with this np, your subsequent call to med'l dir and the new order.

also note abnormal labs from urine and new orders to "push fluids" per (fill in treater's name).

that's the best you can do for now, until relations improve and/or she starts trusting nsg's input more.

still, always write notes to show you weren't a passive bystander.

leslie

Thank you for your post! We have a meeting with our DON and administrator tomorrow regarding this matter. I charted on everything you stated and was second guessing myself until I saw your post. I greatly appreciate this. I am a new nurse and still learning the ropes.