Nurse2Doc2008

So when I was a nurse, I generally didn't do anything w/o a written/verbal order. However, last night on call, I actually had a nurse who ordered a lab under my name on the computer!! I was putting in orders for a new admit, and got stat paged for a patient who was coding down the hall and didn't log out of the computer in the resident work room. While I was gone, the nurse came in, I guess to ask me for the order, and when I wasn't there, she just put it in under my log in!!! I thought this was really unprofessional and dangerous....it was only for a lab that definitely needed to be done, but I still felt it was really, really inappropriate. I told her that in the future, I would prefer she not put in orders under my name, even if we'd spoken about the order (which we hadn't in this case), especially since I was in the hospital at the time. Obviously, I'm the one who is accountable for whatever gets ordered. Oh, and also, I obviously should have logged out, I just was not thinking about it when the code pager went off...

I went from nurse to doctor! Nursing didn't really help at all during the first two years, since the volume and depth of information was so much greater than nursing school. It helped somewhat in the third/fourth year because I knew how things worked in the hospital and had done a lot of assessments on patients as a nurse. However, the considerations of MD's are much, much different than what I thought about as a nurse, so in terms of coming up with treatments/plans, I don't know that nursing helped THAT much, although it probably helped a little. I found it most helpful in terms of interacting with patients and families...most of my classmates hadn't been in the role of a healthcare provider at all and were nervous communicating treatments and plans to pt's and families. Most people got over this within a few months, but I think I had a leg up. Also, I was much more comfortable with procedures...I was proficient at blood draws and IV's while my classmates hadn't ever performed these procedures. And incidentally, at the hospitals I worked as a med student and now a resident, nurses wouldn't draw blood OR start IV's, so we had to do quite a bit of both... As far as nurses and doctors not knowing what they don't know, I think it's true of both populations. Further, I think both nurses and MD's should be a little less arrogant about what they know and don't know -- nurses about diagnostics/treatment and doctors about the patient's overall wellbeing. I have great discussions with many of the nurses on the floor, mostly b/c I explain WHY I'm thinking what I am and then they explain WHY they're thinking what they are....personally, I think things fall apart when one or both parties fails to do this.

I am a former nurse turned doctor and just finished my first year of residency. I realized during my nursing career that I was frustrated by not fully understanding the pathophysiology and treatments for my patient's diseases. I think at first, I thought i knew a lot as a nurse, but it became clear that I didn't know as much as I wanted. I think one of the previous posters articulated this really nicely when they said that nurses focus on taking care of the patient, whereas doctors focus on the medicine/science. (Not to suggest that I don't enjoy spending time with my patients!) I also like making decisions about what tests to order, medicines to give, what the diagnosis is, etc. I think that deciding to go to medical school was the right decision for me, but there have definitely been some sacrifices. I'm over $200k in debt and am currently making less money than I did as an RN. As an med student and intern, you get dumped on a lot by the more senior residents, the attendings, and nursing, which gets extremely frustrating, especially when you are working 80+ hours per week (my program is notoriously non-compliant with resident work hours). You give up a lot of your free time, since you're spending every third to fourth night in the hospital during residency and in some cases, fellowship. Then you finally become an attending, which pays better than residency and generally better than nursing, although many advanced practice nurses make more money than MD's. But, you've got to re-pay that $200k, which is now more like $250k because 3 years of interest have accumulated....and will continue to accumlate until you finish paying it back, which is well over a decade for many MD's. As a junior attending, you're taking the overnight calls, the weekends, the holidays, the less interesting patients and procedures, etc. And, as the doctor, you're ultamitely the responsible party for the patient's well being. There are also some things I miss about nursing. I miss having only a few patients each day, rather than 25, so I can spend more time with them. I miss the flexibility....I was able to work in the ER as well as on the floor during my nursing career, but at this point am sort of stuck in a relatively narrow area of medicine. I miss working 3 days a week and going home and being done. In the end, I think going to medical school was the right decision. I think I'm a way better doctor than I ever was a nurse. But, I think I underestimated how difficult medical school and residency would be, so I would advise you to really consider how much time, money, and energy you're willing to sacrifice.

I (resident) read nurses notes 100% of the time, unless I speak at length with the nurse about overnight events! My co-residents, as far as I know, do the same....we are taught to do this in orientation. I feel like when I was nursing, I thought no one was reading them either, but I bet at least some of the MD's were reading them and I just didn't know.

Point taken. Actually, funny you bring up the monitor example.......sometimes i just FORGET to D/C it and was just having that discussion with one of the nurses on the floor a few minutes ago.

I'm pretty sure that the same doctors who scream at nurses are the same ones who belittle residents/med students and even other attendings. Also, as far as the doctors can do whatever they want to nurses and nurses can't do anything back, that may be true for attendings. However, as a medical student, and now as an intern, it's been made very clear to me that the nurses can be as rude as they want and we can't really say anything b/c our hospital values residents way less than it values nurses. Finally, I think the idea of getting back at one another is kind of juvenile and just perpetuates bad relationships between doctors and nurses....like, it would be inappropriate for me to order q2 vitals just to **** off the nurse, just like it's inappropriate for the nurse to call me every 5 minutes to report normal vitals. Just my two cents.

Oh my, as an admitting intern, I'd rather BE called twice than not at all for something like that. Absolutely, it's in the best interest of the patient, but we're also likely to get in big trouble for not doing something about a level like that, and the excuse, "the nurse didn't inform me" doesn't fly at all. And well it shouldn't, everyone shoud look up labs and make sure everything's covered........but I think we all rely on eachother to make sure everyone's in the loop with the patients, so I always appreciate heads up. even if it's the second time.

haha, believe me, the hospital admin couldn't give a crap about residents. they might have cared if i died because it would be bad press for them, but other than that, they wouldn't care. some programs have "sick leave," but it's really, really frowned upon to take it. but yea, residents really have almost no bargaining power w/ the hospital i'm at.

I'm not sure if this has changed at all since I applied, but I was STRONGLY discouraged from taking required pre-med courses even at a community college at my home over the summer. My advisor said this would look bad to admissions committees, as if you were trying to take the easy way out. I would imagine (I don't KNOW), that online courses are viewed even more negatively. And what about organic chem with lab 2? That's just as challenging, at my school anyhow, as organic chem 1. And a lab online? I'm not sure exactly how that would work, but I question whether any med school would accept that as fulfilling the admissions requirement when your fellow applicants are spending time in an actual lab. A lot of people have trouble with organic chem, and if the average is in fact a 55, you're in good company among your classmates. If I were you, I'd talk to your school's pre-med advisor or an advisor in bio/chem department who has seen other applicants go on to med school and see what they say. If the average kid is failing orgo, they almost certainly will have had this discussion before. Also, talk to the instructor--perhaps s/he can help you or set you up with a tutor. And maybe the 55 average is going to be curved so the average kid gets like a C or whatever. Lastly, try to figure out why you're doing so poorly--are you putting the time in? Are you doing practice problems? Are you attending class? Etc. Again, perhaps the instructor can help you figure this out. You could even take your exams in to him/her and go over it, so you'll at least understand before finals. And organic chemistry is going to come up on the MCAT, so it's not as if you'll never have to think about it again after this class, so trying to understand it well is time well spent, in my opinion. Whatever you do, I think it's important not to just give up and say, "it's too hard...." and try to find an easier class. Are you absolutely certain you will fail? I'd imagine you have a final, which I'm sure counts for at least SOME portion of your grade. How about if you do extremely well on it? I know there are professors who reward upward trends in grades, as in if you failed the first two tests or whatever, then went in to see him, worked your tail off, etc, and aced the final, you'd end up with your grade "rounded up" a little. (As in rather than that averaging to a D+ or whatever, you'd get the C.) And even if you do fail, I think taking the course over at YOUR school would be far preferable to taking it over online. Just my opinion.

About 6 weeks ago, I got a horrible GI bug...I was totally dehydrated, orthostatic, and every few hours, I'd go down to the ER and get a bolus of fluids. I vomited twice on rounds, and kept having to run away to the bathroom throughout the day and night. And I had to take a 30 hour call during all this. The chiefs basically said that there's no one to back you up, and if you leave, you screw over your fellow interns/residents in to having to cover 12 extra patients and take an extra call. If I would have left, I would have taken so much crap from my fellow residents for being "soft." I think it's ridiculous that there's not a sick call back up person available for both nurses and doctors....and it's particularly ridiculous that there WAS someone to back you up, and who ever was in charge wouldn't let it happen. Further, I think it's even more crazy that we in healthcare give eachother so much trouble about taking sick days! I mean, the manager at the Gap, where I worked in high school, was more reasonable/understanding!

Interesting. Perhaps it's instituation dependent? I've been snapped at by more nurses than docs for sure....and I learned pretty quickly that no matter who is doing the yelling/giving the attitude, I'm not well served by being rude back or becoming defensive. Just my experience, though. Oh, another thing that just occurred to me...I think it says in your profile thingy that you work in a SICU...maybe if you're often dealing with surgeons/critical care people, they respond better to giving the attitude right back, then say, a general IM doc or a pediatrician or whatever might? Just a thought. I guess that brings up the other question of personality differences, etc, in handling these situations. What would you think? Say a new intern walks onto the floor who you've never met, and you're rude to them for whatever reason (say you're like the nurse I met the first day of work who refused to shake my hand when we met), would you have more respect for or respond better to the intern who gave you attitude, or the one who just says something like, "well, maybe we'll talk later." Or perhaps you wouldn't ever be rude/give attitude w/o someone doing it first. Edit: And they are not better than you b/c they have an MD/DO...they are wrong if they think that, and deep down, they know they are wrong. They're just overcompensating for something.... :)

Here's what I do. #1. Look at the pH. If it's below 7.4, you have an acidosis. If it's above 7.4, you have an alkalosis. #2. Look at the pCO2. Realize that pCO2 is determined by the patient's ventilation....so, if the patient is hypoventilating (like someone who has a drug overdose, for example), they won't blow off CO2, so their pCO2 will rise. On the other hand, if they're breathing too fast (like someone hyperventilating, for example), they blow off too much CO2, and their pCO2 will fall. CO2 is an acid, so too much causes acidosis, while too little causes alkalosis. Thus, a patient who has overdosed on drugs will develop a respiratory acidosis, essentially b/c they don't exhale any CO2, and a patient who is hyperventilating will develop a respiratory alkalosis, since they are blowing off too much CO2. So, to generalize, in a primary respiratory acidosis, pH is low and pCO2 is high. In a primary respiratory alkalosis, pH is high and pCO2 is low. Now, what happens if the pH is high and the pCO2 is also high? Or, what if the pH is low and the pCO2 is also low? Well, recall that the pCO2 can change to compensate (ie bring the pH back towards a more normal range) for a primary metabolic acidosis/alkalosis as well. Which brings us to #3... #3. Look at the Bicarb. For the sake of this discussion, consider bicarb a base. When the amount of bicarb in the blood falls, you have a metabolic acidosis, whereas when the amount of bicarb in the blood rises,you have a metabolic alkalosis. So, to generalize, in a primary metabolic acidosis, the pH is low and the bicarb is low. In a primary metabolic alkalosis, the pH is high and the bicarb is high. As I mentioned above, the pCO2 can change to compensate (ie bring the ph back towards normal) for a metabolic acidosis/alkalosis. You could think about this in a sort of telological way...as in, if pH is low because bicarb is low (ie primary metabolic acidosis), you'd "want" to get rid of some acid. What's a good way to get rid of acid? Blow off some CO2 (hyperventilate!), and generate a respiratory alkalosis. So in this situation, you'd have a low pH, low bicarb, and low pCO2 (you describe this as a primary metabolic acidosis with respiratory compensation). What do you think would happen if you had the opposite situation, as in a primary metabolic alkalosis? Your body would "want" to bring the pH back towards normal, so how do we generate some acid to bring it back to normal? You gut it....retain some CO2 and underventilate. In this situation, you'd have a high pH, high bicarb, and high pCO2 (you describe this as a primary metabolic acidosis with respiratory compensation). So, can you "compensate" for a primary respiratory acid-base disturbance? Of course! Just like you compensated with respiration for a metabolic disturbance, your kidneys are able to compensate for a respiratory disturbance by adjusting the amount of bicarb present in the blood. We can work through this similarly....say you have a primary respiratory acidosis, meaning the pH is low and the pCO2 is high. What do your kidneys "want" to do? Put more bicarb back into the blood to bring the pH back to normal. So in this case, you'd have a low pH, high pCO2, and high bicarb (you call this a primary respiratory acidosis with metabolic compensation). Last but not least, if you have a primary respiratory alkalosis, meaning pH is high and pCO2 is low, your kidney would want to get rid of more bicarb, thus bringing the pH back towards normal. In this case, you'd have a high pH, low pCO2, and low bicarb. Whew. That's it! It sounds confusing, but I tihnk if you think about what each thing means (pH, bicarb, and pCO2, it makes it easier to reason through it rather than just memorize something). If you really understand how this works, it'll really help you understand vent settings and tons of other clinical topics. A few things I got confused about in the beginning with all of this was how to determine which was the primary disturbance and which was the compensation. That's why I always look at pH and pCO2 first and figure that out before I look at bicarb. If pH is low and pCO2 is also low, you know there's no way you could have a respiratory acidosis, since CO2 would have to be high to cause acidosis. You know that the CO2 has changed to compensate for something, namely a change in the bicarb. That's when you check the bicarb, and make sure it's low. Similarly, if the pH is high and pCO2 is also high, you know you can't have a primary respiratory alkalosis, since high pCO2 would cause acidosis, not alkalsos. A check of the bicarb will reveal that it is high. Note that some times you will see uncompensated respiratory or metabolic acidosis or alkalosis...that's basically just the first few scenerios I described, where only bicarb OR pCO2 changes with pH changes. One other thing to remember is that although you can somewhat "compensate" for a primary acid-base disturbance, you won't compensate enough to return pH to normal, and certainly won't overcompensate and push the pH beyond, so don't worry about this as a possible point of confusion. (This goes for testing purposes...in real life, all bets are off.) Lastly, remember what I described above is sort of the short story....a lot of patients, especially in the ICU, will have mixed acid-base disorders, like both a primary respiratory acidosis and a primary metabolic alkalosis. There are fancy formulas to figure this stuff out, as well as to figure out the degree of compensation, but I'm betting that's beyond the scope of your test. So, to summarize: Respiratory Acidosis= low pH with high pCO2. If there is metabolic compensation, bicarb will be high. Respiratory Alkalosis=high pH with low pCO2. If there is metabolic compensation, bicarb will be low. Metabolic Acidosis=low pH with low bicarb. If there is respiratory compensation, pCO2 will be low. Metabolic Alkalosis=high pH with high bicarb. If there is respiratory compensation, pCO2 will be high. There's more to discuss....etiologies of various disturbances, formulas to calc if compensation is appropriate, mixed acid-base d/o, etc. Sorry this post is so uber long. Hopefully it is helpful. Tell me if you have any questions--I love acid-base/electrolytes!

As an RN turned MD, I want to just echo what TiredMD said above--I think he hit the nail on the head. To the OP: there are people who are jerks every where, and this MD was probably one of them. Or maybe she'd just been up for 30 straight hours and was a little frustrated? Or maybe her residents screwed something up the night before and she had to come in in the morning andd fix it? Or maybe the last 3 nurses or techs she ran into where rude and you were guilty by association? (I consider myself a generally nice person, but I've been a little snippy in all three of those situations....well, not as the attending fixing a mess, but as a resident causing a mess that the attending was not happy about fixing. I've always apologized, but still.) Or, perhaps she's just a miserable person. :) Also, I would disagree with earlier posters who recommended that you give attitude right back to someone giving you attitude. Be the bigger person. Be a professional. Don't rub it in peoples' face when you're right, apologize when you're wrong, and for the love of god, don't be petty and vindictive with people on the team. We're all trying to help the patient.

I usually introduce myself to patients like this: "I'm First name Last name, I'll be one of your doctors while your in the hospital." To everyone else, I just use my first name. The only time this causes trouble is on cross cover because sometimes we're covering patients in a unit we don't usually work in, so when you call back being like, "Hi this is firstname, returning a page," they're like, who?! (The call schedules they get only have our last names.) Similarly, the boards on the units always write the nurse's frst names, so when i call them, I have no choice but to refer to them by their first names. Interesting that the doctor's schedule is all last names, and the nurses assignments is all first names.....sort of makes it more convenient to call nurses by first names and docs by last names, unless of course, you know their first/last name. I'd venture to guess, although perhaps I'm incorrect, that more nurses know the first names of doctors than doctors know the last names of nurses. Perhaps that's part of the problem, too. Also, I agree that this first name last name problem is less pronounced in the ED. I used to be an ED nurse for 2 years, and I think everyone in the department knew everyone elses' first and last name, but we were all first name basis.

Hey all, I was part of the discussion in the prior thread...here's what I said there: That's an interesting question...and interesting choice of adjectives! Too respectful or too friendly....as in those two things were two extremes? Like you can't be both respectful and friendly? Or that they were the same end of the spectrum, as in being both too friendly and too respectful? I feel like either way it's kind of problematic, since it seems to imply that to disagree is either unfriendly or disrepectful (or both). Disagreeing is another interesting point...I feel sometimes I can't win on this issue (and I'd imagine you'd feel the same). For example, sometimes when I ask the nurse what s/he thinks about a situation, or what s/he usually does in a similar situations, most of the time, they tell me what they think and what's usually done, and I usualy do what they think. Of course I think about it first and make sure it makes sense to me, but most of the time, they're right and it's what I should be doing. However, sometimes when I ask what they think we should do, I'm answered with a snappy, "I don't know, YOU'RE the doctor!" And the reverse is sometimes true, too, albeit less often...sometimes the nurse will call and want to do one thing, and I really disagree with it for one reason or another, so we talk about it, and usually, the nurse is like, "oh yea, that makes sense, was thinking about that differently," or whatever. (Believe me, I almost never do something the nurse doesn't agree with after discussing it, unless I am really, really, really sure I am right and have discussed it with my senior, and even then, I continue to try to explain WHY we're doing it that way.) But sometimes, I go to start explaining why I'm thinking we should do something, and mid-sentence, I get cut off and the nurse says, "do what you want, I don't know I'm just a NURSE," as if they're mad if you don't agree.