One of the reasons I moved to the ED is because of the greater degree of collaboration and respect between MDs and RNs. I have not yet started in the department at my hospital but I am sure hoping that what I have heard is correct. I was so tired of walking on eggshells around surgeons and some of the cardiologists with fragile egos that felt the need to try to humiliate and assert dominance over other members of the health care team. In fact this is one of the main reasons I left the floor.
I was having to defend myself too much, not that it was a huge burden or anything, to remind someone that they show some respect. But I found it annoying that I would have to do so. As an adult of 30+ years, I have a policy of mutual respect. I can take criticism and will try to improve my way of thinking but don't tolerate bullying or anyone that tries to make me feel like I am not as worthy of the same respect that they expect.
What have been your experiences in the ED of RN/MD interactions? What do you suggest to prevent MDs from falling back on old habits of treating RNs badly? Was my presumption correct about working conditions between MDs and RNs in the ED?
If you are a solid, reliable, knowledgable, assertive nurse that the MD trusts, he/she will treat you accordingly with better respect. If you cannot keep up with the unit demands, uncertain about yourself, need constant reminding, late at giving much needed medications, forgetful (especially verbal orders) then don't expect the MD to be as forgiving. They have timetables to manage and being late for even the most trivial things ticks them off, (unless there's a valid reason ex. confused patient uncooperative in lab draws, etc.)
One busy night being slammed with traumas, code blues and to top it off the computers were down for 2 hours I discharged a patient without noticing the MD had placed a late order to give a Rocephin IM shot before discharge. I noticed it only after I was departing the patient during charting. I informed the MD, he only told me in a friendly manner that I needed to call the patient back to get his shot. No biggie.
The same night another nurse asked the MD what his glove size was for a laceration patient. He blurted out at him, "how many times do I have to tell you? I'm an 8 1/2! (this nurse has a habit of asking the MD a 2nd or 3rd time after acknowledging MD orders.)
There are MDs that are considerate and courteous but they can only take so much from an incompetent (in their eyes) nurse.
Well, I've worked with MDs with a wide range of personalities in my 18 years as an RN, and kind of agree that there isn't much time for petty issues or sarcasm in the ED. Pretty much I've had a great sense of professional appreciation in the ED and in EMS as a Flight Nurse, as opposed to general units. That said though, if the MDs notice that you conduct yourself professionally and use your grey matter well, they'll be obliged to be professional towards you. In terms of being cordial, they may not necessarily come through, as it is dependent on compliment from either end.
My experience working side by side with the doctors in the ER has been great. Not only do I learn loads more than I did on the floor, but I also have way more autonomy. Not that I practice outside my scope, but once you get to know the docs and what they look for then you have "protocols" that you can initiate. For instance, giving o2 is something that requires a MD order. In the ER, while we do get an order, we just go ahead and place the O2 on the patient then we mention it to the doctor. OF course, we learn when it is appropriate or inappropriate to administer O2, like in certain COPD patients.
We also can place foley catheters, when appropriate (we are trying to keep infection rates down) without going to hunt the doctor down and get the order written first. We just do things in a different order.
Fluids is another thing we initiate also certain medications can be started, at least where I work, before the doc has laid eyes on the patient. Examples would be starting breathing tx in triage. Obviously, if you are brand new and the doctors do not know or trust you, it is a much better idea to approach them first. As time passes and you get to know one another an amazing thing starts to happen. They learn to trust you and your judgment!
I find that most of the time the doc will come to us and ask our opinion of the case, especially in difficult or interesting patients. We help with their differential and we learn how to spot subtle, yet serious signs, of impending acute illnesses because of the relationships we have formed.
We also forge tight friendships and a lot of times we talk on the phone and go out and do things just like we are friends because we ARE friends. Most of the doctors do not act like they are above us. Sure, just like with any other job, it takes time for these relationships to bloom. The doctors, just like other people, are not going to just automatically trust you because you work in the ER. It comes with time and in time you become a partner, not just a nurse working for a doctor.
It is what makes the ER so fun and unlike any other place! You are around the providers so much you begin to think like them. A patient comes in altered with noted high BS. We already know what to do so we begin working the patient up. We order labs, may start fluids and even initiate our hyperglycemic insulin protocol all before the doctor has time to write the orders. It becomes autopilot. And no, this is not practicing outside the scope of practice, it is being proactive. It is being present with the MD and going over the treatment plan as you are starting the IV. You get the supplies ready and start them while the orders are being placed. I guess you can call it verbal orders. It really is an awesome learning experience.
I also find that there are a lot of times where we save the doctors butts (this happens on the floor too) but they also save our butts!
I have worked in several different ERs and they are all different. Some doctors are more approachable than others, but overall, my experience with ER MDs is much more interactive, productive and positive than the doctors I have experienced outside the ER.
Once again, I am not suggesting that one just goes and treats a patient assuming they know what the doctor wants. I am simply saying that you learn to anticipate what the doctor wants so that you have it ready when they call for it.
You also learn with time, that sometimes what may seem like the obvious treatment for something, actually turns out to be the worst thing that you can do. An example of something I learned through experience would be the way you may treat a benzo OD.
Like Narcan does with narcotics; Romazicon reverses bensos like Ativan. However; if someone is truly addicted to benzos it can cause seizures that can be life threatening and difficult to stop. So often times that drug will not be given in a possible benzo overdose because it is hard to determine whether someone is benzo naïve or not. I
s it proper to withhold that drug in such a situation? Not according to most books, but according to experience, it just might be. Of course, as a nurse you will not order that drug. In some cases it may be completely appropriate to give the med. This is where having a great relationship with the doctor can come in handy. You will not be afraid to speak up and ask the reasons behind giving or not giving such a medication. I learned this as a brand new ER nurse who was working beside a seasoned, well respected ER doc who was willing to teach me. Later, I was working with a resident who did not know this and when I casually asked if it was possible that the drug would make it worse he scoffed at me and stated that I had no business questioning him and that the nurses he worked with on the medical surgical floor were far more respectful. I apologized and told him I was not trying to be arrogant (which I was not I was simply asking if he heard about such a reaction.) As it turns out, the patient did received Romazicon by a less experienced, new ER nurse (it was not my patient so it was not like I refused to give anything, I was in charge on this particular day) Anyway, the patient did have to be intubated because of prolonged seizure activity. The attending MD , who also happened to be the one who taught me so much, came to me and angrily asked why I did not question the resident's order and why the med was given. This clearly was not a nursing issue, but an issue between attending and resident docs and they way they communicate.
The patient did recover though but I learned a valuable lesson.
That is obviously just an example of something I learned working side by side with some amazing doctors. On the floor, I simply did not have that kind of relationship and never would of learned that. Most of the time the doctors were so quick to get off the phone leaving me clueless.
I know this was a long, ridiculous answer but I just wanted to paint a picture of true teamwork.
To me, the MD/RN working relationship is key to a successful shift in the ER. For the most part, the docs rely on the RNs to keep them updated on the patients but there is usually a period of trust-building that occurs. When I was new the ER, it took a little while for this one doc to warm up and trust me. Now, she is one of my favorites and she now comes to me when she sees that other new nurses need a little guidance. We now have a great working relationship and we speak on a personal level vs just a business level.
There are some other docs that we just love and consider them friends outside of work and often hang out together whereas some of the others are strictly business only. We still work well together but there is something better with the ones that are also our friends and treat us as equal members of the team.
It is all about building that trust and a close working relationship. There is just something great about "clicking" and knowing each others habits and strengths, etc. Makes for a GREAT team!
I think I'll go back up to my unit.
Ladyscrubs
145 Posts
I came here because I was intrigued over what kind of steamy relationships were actually taking place in ER.
Oops, Talk about misunderstanding!
I think I'll go back up to my unit.