New Nurse Struggling With Doctor Calls

[nursem8]

Hello everyone, I am a new RN (Jan 2021) and went from my nursing job at a long term care facility to a Post Surgical (with medical overflow) back in the beginning of April. I have been out of orientation for maybe a week total and at first I didn’t have patients that were declining enough to page doctors but last night was probably the worst night I’ve had since I have started. I am not struggling with knowing when to call a doctor or considering what could be wrong with my patient but I am struggling with communicating effectively when talking to a physician. My pt last night was technically post op day 1 into day 2 bc I work night shift. Basically overnight there were some changes in vitals (the biggest being that I had to put them on 5L of O2 after being stable on 3L) that were leaning towards the pt progressing into shock and when I paged the doctor I was told to decrease IV fluids and give IV lasix which was crazy to me bc the pt had a decently low BP that was clearly trending down. To be fair it was an on call doctor so they never really know the entire story no matter how much you tell them, but I thought I painted a good picture of the pt and they chalked it up to a possible PE and sedation from their PCA pump which yes that could also be possible (spoiler: CT was negative for PE). After all this the midnight labs come back and WBCs are increased, critical CO2 of 14, increase in creatinine and no change in pt after the orders. What are you supposed to do when a physician is on a completely different page than you are? How do you suggest more things to try? I felt so bad all night for the pt and there was nothing I could do. I didn’t feel like it was wrong to assess for a PE but I feel like we could’ve covered more bases and being a new nurse I haven’t gotten comfortable suggesting things yet. Any help is appreciated ?.

[Been there,done that, ASN, RN]

Learn the SBAR format. Suggesting  things is what we need to do for our patients. You are there, you already know what they need. 

 

[Nunya, BSN]

Also, there's no shame in running things past the charge nurse and asking her for suggestions, to talk to doctors etc.  I like to keep calling the doctors back if the patient doesn't get better, yeah, they get annoyed but that's why they get the big bucks.

[Daisy4RN]

I always found it helpful to give the MD all the pertinent data plus whatever the nurse suspects, this is especially helpful when it is an oncall MD. If the MD is not receptive and I had strong feeling/intuition about it I would repeat myself and say something like 'I am very worried" about this. I have found that if you repeat, and maybe a few times, they will do/test for whatever you are asking. And, either way document what you told the MD, CYA!

[SmilingBluEyes]

3 hours ago, Been there,done that said:

Learn the SBAR format. Suggesting  things is what we need to do for our patients. You are there, you already know what they need. 

 

This. Good luck OP.

[Nurse Beth, MSN]

When calling doctors it's really important to know what is needed-so you'll know when you don't get it ?

So essentially you point the doctor to the diagnosis and solution by reporting pertinent information.

Your pt was desatting? (I assume, since you increased the 02..?) and B/P was low? and what were you thinking was the cause? From your post it's not clear what the problem was. If you were thinking overly sedated, then check the capnography. If C02 elevated, turn off the PCA and ask the doctor to reduce narcotics.

You say your pt was heading into shock. What kind of shock were you thinking?  Do you mean septic shock? (expect and ask for a lactic acid) Cardiogenic shock? (expect and ask for an EKG).  Hypovolemic? Are they bleeding? (expect and ask for an H&H).

Chances are the pt was not in shock and you may be using the term loosely but I encourage you to take your practice to the next level by analyzing and thinking critically. If you think "shock" your next thought is "what kind of shock?"

You will get closer to the underlying problem- and then you'll be more likely to report pertinent information, and get the correct treatment.

Again- you have to know what you think is needed or you won't know if you don't get it.

Something that was communicated led the doctor to think fluid overload (Lasix, decrease fluids). If you reported low output and crackles in the lungs, his response makes sense. If you did not, and this treatment seemed out of left field, then ask "What is the indication for the Lasix?" 

Talk to your charge nurse as another poster suggested.

What ended up being the problem with the patient?

 

[NurseLy, BSN, RN]

Practice a clear and concise SBAR. Make sure the assessment data is relevant. (When I was new I would write out at times key points I didn’t want to forget to say because I was nervous!)

S: patient name and room number has a change in status since the start of shift

B: he/she is post op day 1 for xyz with PCA running at xyz rate

A: BP is trending down, most recent value is xyz. Increased oxygen need from 3L to 5L. Include RR and oxygen saturation. Maybe pain level/orientation

R: I think he/she will benefit from reducing the pain medication and repeating labs/ABGs with early morning labs

(this is hypothetical based on the info provided. You say you and the doc were on different pages so you had a thought on what was wrong —- ask for whatever you think the patient needs. The worst they will say is no.)

There are times when I think there has been enough of a change that the provider should know about it, but don’t necessarily need orders. In those cases I simply say “FYI or I just want you to be aware…”

Talking with doctors and asking for what you think you patients needs gets easier with practice! ?

[LovingLife123]

You need to clearly ask for what you want.  It can also depend on the physician.  Sometimes I state what I want, don’t necessarily get it, try what they want, and end up calling back and reiterating what I want.  
 

Sometimes you have to be a little assertive.  Not rude or demanding just assertive for what your patient needs.  But you also need to be able to back up what you say you want with facts.  You could have said pt already has a low BP.  Last BP was……. I’m afraid that giving lasix will tank him more.  

[BxRN718, ADN, BSN]

All the comments above basically covered what to do when interacting with a MD.  As a new nurse it feels a bit uncomfortable to call the doc since the experience isn’t there to be fluid but once you have more interactions you get comfortable , having all the pertinent info SBAR trending labs and vitals without being afraid to suggest without demanding will usually get them to listen .  Some docs can be authoritative and won’t listen, that’s when I would go up chain of command to my charge and house sup usually helped .  

[angeloublue22, BSN, RN]

I was like this as well but I learned fast that they are people too and we are a team for the patient. It is perfectly acceptable to tell them what you are thinking is going on and your rational. After 12 yrs xp, I talk to them like coworkers and we brainstorm together if I have a difficult pt. A lot of times if I'm sure what's going on, I just tell them what I want to do and 95% they agree. Of course, this only works if you work with providers who aren't all about "authority", "you're just a nurse" mentality. 

 

[Nurse Beth, MSN]

19 hours ago, LovingLife123 said:

You need to clearly ask for what you want.  It can also depend on the physician.  Sometimes I state what I want, don’t necessarily get it, try what they want, and end up calling back and reiterating what I want.  
 

Sometimes you have to be a little assertive.  Not rude or demanding just assertive for what your patient needs.  But you also need to be able to back up what you say you want with facts.  You could have said pt already has a low BP.  Last BP was……. I’m afraid that giving lasix will tank him more.  

Good advice "you need to clearly ask for what you want" and I think for a new nurse the challenge is knowing what's needed so the nurse and doctor can work together on the same page. 

It's hard (impossible?) to be assertive without confidence and experience. Would love to know more about the case, there's some missing pieces here, and the Lasix order doesn't fit the scenario.

[JKL33]

On 6/11/2021 at 11:02 AM, nursem8 said:

I thought I painted a good picture of the pt

Can you recall a close approximation of what you said?  That would be helpful here.