Doctors That Give you "Band-Aids"

[Caffeine_IV]

How do you deal with doctors that basically give you just enough to get a patient through until the next shift but won't get really aggressive or better yet transfer a patient during the night?

I have had a couple occasions where I or a coworker had a patient starting to go bad and they really needed a higher level of care but the MD would just order 2-3 boluses, labs and medicine that would JUST hold the patient above the water.

And when I return for the next shift, I find out that the patient went to critical care (one really stands out to me because she had a wound evisceration the morning I left and later died)

[mykrosphere]

*edit to add* I would also look for consults to call that may be appropriate. Of if I start with a consult and don't feel what they are offering is adequate I'd call the primary, even just to recommend a transfer to higher care.

^ this!

especially if they are a pulmonary pt/ have a pulmonary doctor.

often times calling a doctor in charge of a respiratory patient will produce more effective results, even if its not completely respiratory related.

or, if you have an on-call in house doctor, most times they can give you what you are looking for.

and if that doesnt work, i go to the supervisor and let her deal with it.

sometimes all that is needed is a call/ plead from them.

and if that doesnt work, do your best and as others have said, document EVERYTHING

[canoehead, BSN, RN]

I just had a couple of past cases on my mind and sometimes when the outcome is not what you hoped...you wonder if you missed something OR if I'm not painting the picture accurately enough of what is going on with the patient.

If the concern you have really isn't getting through say it bluntly. "Doctor I'm very concerned about this patient. I think xxx is happening, (or I'm not sure what is happening, but s/he is getting worse." At that point you need to have a physician see the patient and/or the doc needs to get very specific about danger signs and what to watch for.

If they give you a stupid order like, "do not take any more vital signs until 6am," or "change moniter alarms to SBP 250 DBP 150" Say " Your order is xxx(repeat it back)" and document it. Then ignore it. You now have excellent evidence to move up the chain of command, so do it without guilt. It's OK as a nurse, to be unsure about what the right thing to do is, don't be embarassed if you don't have all the answers. MAKE SURE you have a thorough and recent assessment though.

[simboka]

"What about this situation is reassuring to you?" Is the favorite quote of one of the nurses in charge of our new nurse residency program.

And actually, we've recently been getting "armchair quarterback"ed by our management about not calling rapid responses soon/often enough. But out rapid response nurses have a direct line to the critical care md's. I can't recall if the MICU nurse ever had critical care team call the cross cover and try to convince them to transfer, but I wouldn't put it past them. (but then again, I'm night shift in a good sized teaching hospital which usually has a good supply of docs overnight. And that's why I probably don't ever want to work in a non-teaching.)

[linearthinker, DNP, RN]

I work on a stepdown unit and am curious what your criteria are. I know we have sent patients that we could take care of on our floor, but sometimes if they are one on one care it makes it difficult to take care of your 3-4 other patients. I love it when we send a patient to the ICU for low/high blood pressures that we have been trying to treat for half our shift and then once they hit they ICU, they are fine! Makes us look like idiots.

There's a whole schematic algorithm. It's too complicated to detail here. Basically, they must require care that is absolutely unavailable anywhere else in the facility. It started b/c we had a huge problem with chest pain pts taking up limited CCU beds when they had GERD, or gallstones, etc. Also, docs were sticking pts in the unit b/c they knew we had standing orders, care paths, and a much higher panic threshold, that would help avoid waking them or nagging them during the busy work day (Whereas on step down or a m/s floor they would be getting many calls). That was determined to be inappropriate and we put the kibosh on it. Over time, it evolved to include all conditions. Makes for much happier CCU nurses, and totally po'd m/s nurses. It also keeps costs down and gets pts out of the hospital earlier. To my knowledge, there has never been any bad outcome associated with the CCU admission guidelines. Our intensivist quit 4 years ago and they have never gotten another, so if they need that, they have to transfer to tertiary care anyway. We mostly only do surgical critical care these days, and our surgeons like to say "It is better to be the sickest person on the m/s floor than the healthiest in the unit."