Navigating Doctors Idiosyncrasies

[whitecat5000]

So back story. . . I had a 32 yr old female patient that was a direct admit around 2300 for hematuria. We call the doctor and get orders for a CT abd/pelvis w + w/o contrast, insert three-way and irrigate PRN, and CBC.

So CT calls and says they need a pregnancy test and a CMP to check renal function. I am about to call the doctor when the nurse I'm working with says, "Oh don't call that doctor for things like that at midnight. Just put it in, he would order it anyways."

Of course I don't, but she puts it in anyways (which I don't care to be honest because it has her name all over it, and the patient needed it anyways). The patient gets the CT done and the doctor comes in at 0530. The doctor said, "Thank you for just ordering those and not calling me. I hate to be woken up for stupid things."

So ignoring everything else wrong with this scenario (and there's a lot), how do you all manage to figure out these idiosyncrasies?

For instance, I have a doctor that if you do call him after 2200 for Cepacol he yells, and another one that will yell if you don't call him.

I can't figure it out. But since prescribing is outside my scope, I just call always, get yelled at (or don't), get my orders and go about my business.

[Tait, MSN, RN]

I call them all or try to get an order for standard things, like cepachol and stool softners during the day. As far as a new admit I would have called him for every order. Not my problem.

[sbostonRN]

At my hospital, I've gotten to know the doctors over the past 9 months. Most of them WANT to be notified of even the smallest change, and there is no "nursing judgement" needed. Others, we don't necessarily call them right away, but will give them a heads up when they arrive on the floor (things like BP meds held per parameters, low blood sugar, etc). I work in a small hospital so I only deal with 8 or 9 doctors, so it didn't take too long to figure them all out.

[MunoRN, RN]

A pregnancy test is usually a protocol order that goes along with any imaging order, so if an MD orders a CT then they've also ordered a pregnancy test, performing a pregnancy test on a patient who has a CT ordered is not prescribing. Even if you called the MD and he said do the CT without a pregnancy test it wouldn't matter, imaging would likely refuse to do it. Our protocol also includes a creatinine level as a protocol order for imaging with contrast, I'm not sure why your imaging department wanted one done for a CT without contrast.

[klone, MSN, RN]

I'm not sure why your imaging department wanted one done for a CT without contrast.

The CT was done with and without.

[MunoRN, RN]

The CT was done with and without.

I missed the "w +", my bad.

[blondy2061h, MSN, RN]

I consider those things as having been ordered when he ordered the CT since she won't be getting the CT without them.

[MN-Nurse, ASN, RN]

So ignoring everything else wrong with this scenario (and there's a lot), how do you all manage to figure out these idiosyncrasies?

There was nothing wrong with the scenario.

Believe me, if you really do want to navigate a good functional path with MDs, you will develop a reputation of not calling them for stupid things.

I have coworkers who pride themselves on playing "gotcha games" with MDs and coworkers; they are universally reviled and it is their patients who really suffer for it.

[Altra, BSN, RN]

I don't see this as a physician's "idiosyncrasy" ... I just see it as learning to recognize protocols and requirements for diagnostic testing and so forth.

OT but ... admission for this? Unless there was intractable pain / nausea, this sounds like an outpatient workup.

[JBudd, MSN]

When my late husband had some abnormal outpt stuff, the fastest way to get the CT was admission; the waiting list for OP CT's was huge. Turned out to be the big C; so admit totally justified. Sometimes the admit orders are deceptively simple, especially late night, and the doc intends to order a lot more stuff in the morning.

Our ED docs fully expect us to put in the stuff we need for protocols; all the policies are in place for doing so.

[psu_213, BSN, RN]

OT but ... admission for this? Unless there was intractable pain / nausea, this sounds like an outpatient workup.

The only issue would be the 3 way. If they have CBI, they would be admitted. Most of the pt's in the ED who have Foleys placed for urinary retention are sent home with f/u with urology. However, hematuria pt's are occasionally admitted if the doc is concerned if the foley will just get clotted. I can go either way, in my experience. Anyway...

As for the original scenario, there is basically no way I would have called the doc back for orders for an HCG and a BMP (I would say that a CMP is not really necessary just for kidney function--although I'm a bit surprised the doc didn't order either a CMP or BMP to being with). As JBudd mentioned, in the ER, we are fully expected to just order these if a CT with contrast is ordered.

I also find little (to nothing) wrong with this scenario.

[psu_213, BSN, RN]

I don't see this as a physician's "idiosyncrasy" ...

Yeah, I don't view not wanted to woken up during the middle night as an idiosyncrasy. I think it is a basic human response.