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Discussion

Is this common with nurses and doctors?

Ok, so I've been with my current employer now for a while. There is still lots for me to learn, but I'm really trying to hold my weight even though I've been working for less than a year. I think I'm doing ok, but one thing I have noticed: when I collect info and call to update a doctor about a patient, and expect some intervention, the general answer is "what do you want?"

I don't always have an answer for this. Sometimes I'll ask for things that may point me in a better direction with what's going on with the patient. An ABG, or an EKG, for example. But there are times when I don't know what to do/expect/anticipate. But more times than not, I'll get whatever order I ask for.

For example, a patient whose lung sounds have changed, have increased respiratory effort, becoming confused, I would call to report. More crackles were noted, no change in maintenance fluid rate, and blood pressure steadily climbing up. So in my call, I explain lasix helped them on the previous shift, maybe she needs more. The answer..."ok, sure." Then they give me specifics for the order. About 30 minutes later, respiratory comes to get an ABG (because they suggested it) and it was all outta whack. I felt I had asked for the wrong order.

Different day, different patient. Bit of blood loss from somewhere in the gi tract. Heart rate suddenly goes up and stays around 130s. So I look at full set if vitals, fluids running, and last H and H (over 12 hours ago). Inform the GI MD, and ask if maybe the pt needs fluids (he only had a protonix drip), or to get another CBC. He orders fluids thinking the pt is depleted. 2 hours go by, and the admitting MD asks why his heart rate is 120's to130's. Informed him that last MD started fluids to correct this, and it's now trending down. Since he was already scheduled CBC in am, he didn't want another. Well, he ordered one to be done anyway, so I called lab. It had dropped....not quire low enough to infuse yet, so I report this....to now a THIRD MD. He seems to not. Be worried about this..."we'll just watch it for now." Morning lab H and H was loooooow! And guess which doctor asked about it...the one who ordered the CBC. So, again, I was left feeling like I should have pushed harder the first time I asked for it, or pushed harder to infuse when the initial drop was noted.

Anyway, what I'm tryna say is I feel like I'm a good advocate until I see I've asked for the wrong thing. Then i feel bad, and a little peeved that i find myself in this position. I still feel that my job is to paint the picture for them, and THEY decide what should be done for the patient. But being an advocate kinda blurs the lines for me in that regard. Sometimes, I can't tell what is best to be ordered. Shoot, I'm still new!! But sometimes the impression I'm left to deal from the doctors is...."well, what do you want me to do about that?" *sigh*

Where do you draw the line? Is this just because I'm new?

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    • Featured Replies

    Generally speaking here but if its a resp issue, I will inform them of my assessment and issues and ask for an ABG and chest Xray from the start. If its a surgical pt or one with a known bleed, I ask for stat labs first. If its a head and the pt is "not right" I ask for a stat head CT first.. Then after the results are in I will call them back for further orders, depending on the results will depend on what I suggest. Its kinda hard to have an idea of what you want if you really don't know what the actual problem is.. Some things are very simple but many things can be masked hints some form of testing re to the issue..

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    I can relate. It's tricky, especially if you are new. A lot of doctors become dependent on experienced RNs to do all the work! You are doing your best. Keep advocating. You truly do not have to have all the answers all the time!!

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    The problem is that you are there with the patient for the past X hrs and can see what is happening to the patient. You need to paint the best picture you can for the doctor over the phone. He is not there and doesn't know if it is a minor issue or a major issue unless you give him the best picture you can. Before you call them you need to ask yourself "What do I want or need from the doctor?" If your thinking "I need a stat CBC or ABG to get a better idea of what is going on with the patient" then ask for it even if the next routine is in 2 hrs. If you're concerned enough to call the doctor, then it's important enough to get a CBC now instead of waiting.

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    Are you familiar with SBAR and does your facility use the format?

    Yes, many times the physician will expect your recommendation to the situation you have reported.

    Don't let yourself be expected to follow through to the recommendation. When the doctor asks this of you.. a simple.. "I have no recommendation, I need further orders" will suffice.

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    So the first hemoglobin didn't go down significantly enough to transfuse. Ok. Then you get another on and it did. That's why serial hemoglobin are drawn. Nothing is wrong there.

    doctora don't always get it right on the first shot. Often they suspect something, and try something, if it doesn't work, they run some more tests, make another educated diagnosis, but that might not be right either.

    ever watch house?? Lol.

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    • Experts

    First of all, if a doctor says "What do you want from me?" your answer should be "Your paycheque." Just kidding! Seriously, it's helpful for them if you have recommendations, but if they need more information before deciding what to do, they should just ask for it. They shouldn't require you to do their job. Another thing, I used to gnash my teeth if I found out my patient had more than one doctor. They often worked at cross purposes with me in the middle. And no matter who I called first, I always got asked "Why did you call me?"

    About the hemoglobin, I might have misread your post. But H & H are expressed as a ratio, so if the patient has been rehydrated, the H&H values will always be lower, unless the pt has been transfused.

    I think interacting with doctors requires at least as much interpersonal skill as interacting with patients. You seem well on your way to developing this particular art form along with your other nursing skills.

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    • Author

    Thanks for all the responses. I suppose half of the issue is knowing a persons preference. Some let me give a full SBAR report, some don't want to hear it all, instead just get to the point. Then there are days where it seems that they INTENTIONALLY place you in the middle of all these providers with conflicting orders. (I've learned a few ways to deal with that though.) Good news is I think I've put in effort and managed to build good working rapport with most of them. So, maybe they're a little more tolerant of my "newness". Anyway, thanks for the responses.

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    I agree with what others have said. Also, hopefully you work with a good team of nurses. Use your charge nurse as a resource. I run things by more experienced nurses if I'm not sure what is going on.

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    Consider, too ... what's the worst thing that this change in assessment might indicate? And ask for the diagnostic that would rule in/rule out that worst case scenario.

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    I just graduated and I am pending on a test date (but I have a job waiting for me), and one of the things that fills me with trepidation is interacting with physicians over the phone about a patient. In school we have SBAR shoved down our throats, but what I see out in the "real world" is more like "Dr X, I am calling about your pt in room ____, who just had that lap chole yesterday. Her HR has jumped to the 130s and her BP has dropped. Do you want me to draw a stat CBC and start some fluids?" So on and so forth. It's like a condensed SBAR really. And what about those doctors who just want to take the wait and see approach but you really feel like something should be done sooner? I am grateful to have had a chance to work on the unit for a few months already as an extern, but up until now my interactions with the doctors hasn't been direct and involving taking orders from them. Being a new nurse is intimidating to say the least.

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    I just graduated and I am pending on a test date (but I have a job waiting for me), and one of the things that fills me with trepidation is interacting with physicians over the phone about a patient. In school we have SBAR shoved down our throats, but what I see out in the "real world" is more like "Dr X, I am calling about your pt in room ____, who just had that lap chole yesterday. Her HR has jumped to the 130s and her BP has dropped. Do you want me to draw a stat CBC and start some fluids?" So on and so forth. It's like a condensed SBAR really. And what about those doctors who just want to take the wait and see approach but you really feel like something should be done sooner? I am grateful to have had a chance to work on the unit for a few months already as an extern, but up until now my interactions with the doctors hasn't been direct and involving taking orders from them. Being a new nurse is intimidating to say the least.

    Sometimes there will be what seems like a "condensed" SBAR. The example you give is brief, but it meets all the criteria for SBAR (as a stepdown nurse I used a name instead of room #, but we re-homed/re-roomed our patients frequently). I think sometimes nursing school makes things seem super formal.

    There was a dynamic when I worked stepdown to how interactions with specific doctors would go. It varied from doctor to doctor, just as I'm sure there are variances between how individual nurses interact with them.

    I work in a procedure area now. I work with the same doctors all the time. I know what they like, what they don't like, what they use, what they consider a waste (or otherwise not useful). I know how to read all of them and can generally tell their mood by looking. We're very informal (it's not unusual to spend half the day joking around with doctors), but we each have a job to do, and it only works when everyone participates.

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    • Guides

    I thought I would post from experience on the other side of the phone:

    I appreciate getting a call/update from the attending RN for a patient, and I respect the fact they have had eyes and ears on that patient, and have normally spent a good deal of time with that patient. If a provider is asking what you want it is a sign of that respect.

    I can say a few things:

    1. It's absolutely ok to say you aren't sure what needs to be done!

    2. It is always the providers call: they have the responsibility to decide if the order is appropriate or not and make it, the blame doesn't fall on your shoulders. You are doing your best for the patient with the information you have.

    3. Occasionally you will have a provider say no to your request and that is absolutely ok as well. I hope most good providers would say "why don't we do this instead"...

    4. Sometimes it is just a professional courtesy, which sounds strange to say, but I mention it because a few weeks ago during rounds I was planning on discharging a patient and I said to the patient in front of the attending RN that "we will get you out of here today as long as (insert name here) gives me the final ok"; she got very flustered and asked to speak outside where she told me she wasn't able to make that decision and I needed to make it. I then was stuck trying to explain I was really just asking her out of courtesy and was going to discharge him regardless unless there was some major problem.

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