Doctor vs Nurse

[anne919]

I work in a nsg skilled facility and rehab at the same time. Our medical director always orders continue to monitor when I report something to him. One time I reported an extremely high blood glucose level of our hospice pt.he just told me what should he do since she's hospice! As much as I want to talk back on him that we should still treat the resident even if they are hospice I only suggested to increase her insulin. And as soon as I got the order I hung up on him.

Yesterday, I learned from my co-workers that he was infuriated that I logged a pt condition and stating the pt med that might have had a side effect.

I also wrote down that a couple of pt was having early s/sx of flu.

Oh yeah, one of our resident also has an incredibly audible wheezing inspiratory and expiratory but he doesnt want the resident be on a hospital so he ordered a stat cxr. The patient has an atelectasis. He ordered an antibiotic med. My gut feeling is telling me to send that resident into the hospital but I cannot make him give me an approval to send her out.

How can I speak with my DON about this matter?

[LadyFree28, BSN, LPN, RN]

I am reading the threads. I learned so much insights from the replies. Thank you so much.

Now it makes me wonder on what field of nursing that I really want to be in. This had been a reality check for me that ltc is not going to work for me.

It's ok. You will find your niche. Utilize Critical thinking books, keep your skills up and the the experience.

[SionainnRN]

I am reading the threads. I learned so much insights from the replies. Thank you so much.

Now it makes me wonder on what field of nursing that I really want to be in. This had been a reality check for me that ltc is not going to work for me.

LTC may not be for you but keep in mind what people are saying about you being antagonistic with doctors, diagnosing patients and lying about assessments. Honestly if you pulled that in the hospital where I work you would be fired and written up to the BON so fast your head would spin. It's not about where you work but HOW you work.

[samist]

Ok as an outsider looking in, I think I need to say something. I'm not a nurse, but will eventually be one.

Anne, I know you care about the pt, but if the MD/DO is not willing to do anything for the pt then that's their call. Do not cross the line and walk into no mans land just because you think the Physician doesn't care. If you wanted to call the shots you should either go back to school to become a NP or become a MD. Don't put yourself in a position where you could get yourself fired and then your reputation is at stake. Trust me when I say this, that physician could get fired or barred from working at that facility but they will eventually be able to practice at a different facility or in a private practice. I have personally seen this with a MD I used to work for, she got banned from working at any hospital in our area in the DMV. But she is still able to have her own private practice. Unfortunately this is not the case for nurses. Be careful.

Also please work on your grammar. I'm sorry I have to be a prude, but it is important. Maybe the doctor could not follow you. I come from a family of foreigners, and it is difficult to follow along with them, so I can understand when outsiders get frustrated with my family members. I'm not assuming you're a foreigner or anything. I'm just simply saying that you should work to improve yourself when looking at these two situations (in your unit and your posts on AN). It is extremely important.

I hope this helps. Sorry for being a prude.

[monkeybug]

Finally, I am aware of the warning on haldol. Thanks. In health care, we have lost touch with reality. We don't use phenergan in our ER anymore either because of the potential for necrosis. In the two years I did use, we ran it in 50 ml bags and I never not once saw any irritation and an MD I spoke with said he went years and years without problems. We continue to jump through hoops to avoid uncommon side effects when there is a very real risk to the patient if we don't treat them for their confusion. If you don't like what we do to your patients, convince the family to keep patient in the facility but then that doesn't lessen your work load and would require some effort. The ER is simply easier for most people. Maybe you weren't like that but I think most people are. Sorry. True story.

Thank you for that, it is so true!! I worked in L&D where your options in labor were: epidural, demerol and phenergan IV, or natural. Now our pharmacy won't allow us to give phenergan IV (although most of the MDs are complicit with us in circumventing this). If properly diluted, phenergan is fine, but our patients are being punished because of a rare occurence. So now, (if you forget to call and ask the MD to override pharmacy and allow you to give it IV) you have to tell a laboring woman that on top of contractions she gets a whopping, stinging IM injection that will leave her sore for days. Pharmacy suggested that we could give Zofran IV. Well, yes, but Zofran doesn't potentiate the effectiveness of Demerol like phenergan does. It's just a huge CYA issue without regard for patient care.

[tewdles, RN]

I am concerned with the notion that this was all about a hospice patient, in rehab?

So, when you are working with a hospice patient the hospice team will provide you with orders. You do not contact the pcp for orders UNLESS that physician is managing the hospice care. All of the medical orders MUST be in line with the documented POC and if the POC is being changed the hospice team MUST document how and why and by whom for what goal. When facility staff circumvent the hospice process they run the risk of adversely affecting the outcomes for the hospice episode.

Hospice typically does NOT; monitor blood sugars, give additional doses of insulin (hypoglycemia is our enemy), or send our pts to the ED for respiratory distress or increased work of breathing. We frequently DO give NMTs, give antibiotics, and treat acute infectious processes in effort to maintain comfort for our patients.

When you have a hospice patient under your care you MUST collaborate with the hospice team (usually through the RN Case Manager) to affect changes to the POC. That is not optional...it is required...the patient's insurer is paying the hospice a daily rate to manage the plan of care for the patient.

I always loved getting calls from facilities informing me that my hospice patient is declining significantly and when I arrive I discover that since my last visit the patient had this or that symptom and the facility doc ordered this or that med that the patient has taken for the past number of days. WTH???

[mariebailey, MSN, RN]

I think you need to work on your communication style and show the MD more respect if you ever want to get what you want from him. He may know something you don't when he makes these decisions. Even if that's not the case, he will never bend to your will if you are this obstinate. I think you have your patients as your priority, which is admirable. It is a futile battle to fight, however, when you are pushing away the key players on your team.