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 ?.

[Mavnurse17, BSN, RN]

17 hours ago, DavidFR said:

 

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 feel that even state boards in the US can be predatory.  Sometimes I peruse my state's disciplinary reports (they publish those for the public... not sure if other states do that too) and recently I saw a school nurse have their license revoked for "failing to follow up on delinquent immunization records."  I'm a school nurse so I can attest that getting updated records is like pulling teeth sometimes, so for a nurse to have their license revoked completely for that makes me feel very nervous.  

[Hannahbanana, BSN, MSN]

Don’t have a complete picture of what was going on c this one, but just so you know, decreasing oxygenation and BP after increased fluids could be cardiac failure, so furosemide (Lasix) might be a good choice. Look up the Frank-Starling curve to see how that works. Agree c the suggestion that you need to know what the different causes of these signs could be, and why the treatments could be different from what you expected, and also to get his butt in there to assess the pt more comprehensively than you can. Ask the doc why he rxd diuretic and what he expected to see from it, and then you can call him back to say it worked/didn’t work. 

[FolksBtrippin, BSN, RN]

On 6/17/2021 at 12:04 PM, Mavnurse17 said:

I feel that even state boards in the US can be predatory.  Sometimes I peruse my state's disciplinary reports (they publish those for the public... not sure if other states do that too) and recently I saw a school nurse have their license revoked for "failing to follow up on delinquent immunization records."  I'm a school nurse so I can attest that getting updated records is like pulling teeth sometimes, so for a nurse to have their license revoked completely for that makes me feel very nervous.  

Wow that is rough. My state also publishes revocations. They are almost always drugs/drunk driving with an occasional "patient abuse". I've never seen any other reason.

[nursem8]

On 6/11/2021 at 8:58 PM, Nurse Beth said:

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?

 

Hi! I really appreciate this comment and advice. I didn’t end up having this pt again but the lasix actually did help and I learned with some more research that it can actually increase BP which it did end up doing for this pt. I’m not entirely sure what ended up being wrong that night but I know that the pt was 100x better when I came back for my next shift. After another rough week of talking with many MDs I figured out that it’s going to take time and experience to be super comfortable talking with them, thanks again! 

[nursem8]

Hi everyone I know it has been awhile but I really appreciate all of your suggestions and I apologize for not including more info I just didn’t want the post to be super long. I already knew by looking at the pt that the MD needed to be called but with how new I am I always always ask the charge or a coworker to come look at my pt to get their opinion, that night both charge and another RN said they would call in that situation so I knew I was right in that respect. My biggest problem is that on night shift we typically have to page an on call MD and explain literally everything and I just get flustered with all the info I have to give but I’m getting a lot of practice in these days calling the docs and it’s helpful. I also think things will get better when I call the same MDs multiple times but right now everyone I talk to is a new person which makes it harder. 
 

Anyways the pt did end up making a full recovery and went home a few days later so I suppose the lasix wasn’t a bad call after all. Thanks again everyone. 

[nursemike, ASN, RN]

In school, when instructors spoke of "questioning a doctor's orders," it often sounded to me like they meant "challenging" or "doubting" a doctor's orders. I may have misinterpreted, but I have heard nurses doubt a doctor's judgement plenty of times, since then. Heck, I've done so, myself, from time to time, but over the years, the vast majority of times I have "questioned" a doctor, it was in order to learn something. "Why are we giving lasix?" is a good way to get two minutes of med school for free. And I believe it helps build a collaborative relationship. When I page a second-year resident, I don't mind giving the impression that I know my place, because I respect my place. Indeed, I can think of a few times when I, a nurse, was able to teach a doctor something I learned from another doctor, years before. In a teaching hospital, we old dogs serve partly as institutional memory. And the best way I know to get comfortable talking to doctors is by talking to doctors. Familiarity can, and should, breed respect.

[Hannahbanana, BSN, MSN]

On 6/20/2021 at 2:30 AM, nursem8 said:

I didn’t end up having this pt again but the lasix actually did help and I learned with some more research that it can actually increase BP which it did end up doing for this pt. I’m not entirely sure what ended up being wrong that night but I know that the pt was 100x better when I came back for my next shift.

.I hope this picture comes out because I’d like you to understand why this worked.
Think of the myocardium like a rubber band- the more you stretch it, the harder it snaps back. So as this graph shows you, the more volume you give a heart (technically called preload), the higher its cardiac output, as measured by BP or cardiac output. This is easy to understand if hypovolemia is a problem — fill the tank, better blood pressure results, right?

However, if you overstretch a rubber band it fails. The graph shows you that point, at the asterisk — the heart has been filled to its happy place and has maxed out its output. But then if it got more fluid (like that NS) it is overstretched and can’t pump effectively, and BP starts to fall off as contractility decreases. This is called “congestive heart failure,” which you will assess by seeing dropping BP, wet chest, increased work of breathing, and decreasing oxygenation.

So now you can see why a hit of furosemide (Lasix) would help relieve those symptoms, improve blood pressure and oxygenation, by decreasing the preload to being the heart back to its happy place of less workload. The Lasix itself doesn’t increase BP, it just makes it possible for the heart to find itself in its happy place on the Starling curve.

 You can actually create this graph for a patient by graphing preload (CVP, or PAdiastolic) versus Cardiac Output, or BP , and see just what’s optimal for him. You can also tune somebody’s predilection to failure by also giving meds that improve contractility (like digoxin or others) at the same time as optimizing his volume.

Hope that helps!