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 ?.

[DavidFR, BSN, MSN, RN]

From what I can gather, was all this being done on the phone with the doctor prescribing from a distance?

It's never unreasonable to say "you need to come and examine this patient, (s)he warrants re-evaluaton by a doctor." That is what they're on call for. 

[Been there,done that, ASN, RN]

1 hour ago, DavidFR said:

From what I can gather, was all this being done on the phone with the doctor prescribing from a distance?

It's never unreasonable to say "you need to come and examine this patient, (s)he warrants re-evaluaton by a doctor." That is what they're on call for. 

"this patient needs to be seen". Make this your mantra. 

 

[Nurse Beth, MSN]

3 hours ago, DavidFR said:

From what I can gather, was all this being done on the phone with the doctor prescribing from a distance?

It's never unreasonable to say "you need to come and examine this patient, (s)he warrants re-evaluaton by a doctor." That is what they're on call for. 

If there's a hospitalist on duty, that's appropriate. The challenging part for a new nurse is to differentiate when a patient needs to be seen by an MD and when it can safely be managed by phone.

[Leonardo Del Toro, RN]

On 6/11/2021 at 8:02 AM, nursem8 said:

 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 ?.

Well, being comfortable takes time. As a new nurse is difficult to know what really matters and what doesn't, it will come with time. Doctors like to hear solutions and not a complex mess of problems they have to think through. Remember that some doctors are not nice (to say the least) and any interaction with them will suck no matter what.

I work at a facility where all doctors are nice so it's easy, but I know that is the exception rather than the rule. What I do is to only call MD when he/she is really needed. Give them a clear picture of what is going on from top  to  bottom and suggest what could be done. Once MD's know you and trust you it becomes easy. They like to see that you're on top of your problem. So you tell them your little story like you know what's going on, and you might even have some suggestions to what to do (they love that) Remember, these doctors have dozens of patients and they love your suggestions, after all you're the one with the patient.    

[DavidFR, BSN, MSN, RN]

21 hours ago, Nurse Beth said:

If there's a hospitalist on duty, that's appropriate. The challenging part for a new nurse is to differentiate when a patient needs to be seen by an MD and when it can safely be managed by phone.

Agree Beth, however I think it's appropriate for the newbie who isn't sure to request a doctor's evaluation. 

One of the complaints we hear most from doctors is that they're called out "for nothing." Total nonsense. If a nurse has called, he or she was concerned about the patient. The problem may seem minor to the doctor, but if the nurse isn't sure and doesn't call the doctor out, that's the bad nurse, not the nurse who's called a doctor 5 times in a night because 5 times, the patient's condition was a worry. Doctors sometimes forget that they do get paid for being on call, it's not voluntary work.

[Leonardo Del Toro, RN]

2 hours ago, DavidFR said:

 

One of the complaints we hear most from doctors is that they're called out "for nothing." Total nonsense. 

 

[Leonardo Del Toro, RN]

I tell the young nurses "that's why Dr Welby always answer my calls. He knows that when I call it got to be something" I don't ever bother doctors unless is critical stuff. I know one nurse that will call a doctor in the middle of the night to ask for a order of tums. 

[Nurse Beth, MSN]

50 minutes ago, Leonardo Del Toro said:

I tell the young nurses "that's why Dr Welby always answer my calls. He knows that when I call it got to be something" I don't ever bother doctors unless is critical stuff. I know one nurse that will call a doctor in the middle of the night to ask for a order of tums. 

Exactly! You lose credibility if you don't exercise independent judgement.

[DavidFR, BSN, MSN, RN]

15 hours ago, Leonardo Del Toro said:

 I know one nurse that will call a doctor in the middle of the night to ask for a order of tums. 

I think we're highlighting a difference in our systems here - you wouldn't need an order for tums in France, and I do get it that a doctor would be annoyed by such a call. However, if an order IS legally required in the US then silly as it may seem, the nurse was really just protecting him or herself, though I personally would just give it.

What I'm sayng is that after 35 years at this lark I am sick of the young doctors who moan that this or that nurse didn't just put oxygen on or didn't just give a bit of Lasix. I've known two nurses lose their licenses for a doctor NOT backing up what they said over the phone. I don't know about the US but when you read in France the reports by the DDASS or in the UK by the NMC (regulating bodies) the cases of nurses losing their licenses for what seem like seem like banal reasons are startling.

I get it that you don't call a doctor every 2 minutes to report every minor change, but I understand any nurse trying to cover themselves and any newbie who wasn't sure about a patient's condition (as in the OP) has done right to call a doctor.

[Mavnurse17, BSN, RN]

10 hours ago, DavidFR said:

I think we're highlighting a difference in our systems here - you wouldn't need an order for tums in France, and I do get it that a doctor would be annoyed by such a call. 

Just some anecdote here-- I don't work at the bedside anymore, but at my old facility we couldn't do anything medication or procedure related without communication from the provider first.  We couldn't even access the Pyxis for something as simple as a Tums without a provider signature (either physical or telephone authorization) and authorization from pharmacy.  Per policy, we had to call--even at night-- if we felt in our best judgement it was prudent to hold a medication.  Imagine calling an attending after hours to say "hey this patient has had diarrhea from the bowel regimen so can I hold tonight's senokot?"  ?

[Leonardo Del Toro, RN]

12 hours ago, DavidFR said:

I think we're highlighting a difference in our systems here - you wouldn't need an order for tums in France, and I do get it that a doctor would be annoyed by such a call. However, if an order IS legally required in the US then silly as it may seem, the nurse was really just protecting him or herself, though I personally would just give it.

 

I'm sorry to hear that the medical system in France and UK is horribly predatory toward nurses. I've always hoped that this was not the case. In the US health care is a big corporate business. The system is bias and always throw nurses under the bus if needed. Is dam if you do and dam if you don't. If you give tums and the patient dies it's the nurses fault. I the patient dies because you didn't give tums without an order is the nurse's fault.

[DavidFR, BSN, MSN, RN]

3 hours ago, Leonardo Del Toro said:

I'm sorry to hear that the medical system in France and UK is horribly predatory toward nurses. I've always hoped that this was not the case. In the US health care is a big corporate business. The system is bias and always throw nurses under the bus if needed. Is dam if you do and dam if you don't. If you give tums and the patient dies it's the nurses fault. I the patient dies because you didn't give tums without an order is the nurse's fault.

 

I'm not sure the French or British systems are particularly more "predatory" than any others, but I think that nurses everywhere have to cover their backs.

I think the issue here and point of the OP is not with Tums or Strepsils but when the newbie is really concerned about a patient and through inexperience, not quite sure. 

I think the problem is trusting doctors with verbal orders frankly. At the end of the day a doctor will always consider his or her own career is worth more than that of a nurse, so I guess when the excrement's about to hit the fan, in kicks the survival instinct and the reponse is "I never said that"  I don't paint all doctors with the same brush and of course many are honest and trustworthy, but really, how do you know? I have come accross some outright liars.