The Doctor oncall told me not to call him

Nurses Safety

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I want to know if anyone can help me handle this situation. I work in a small 3 bed ICU where I am the ONLY nurse. I recently had two critically ill patients. One had been on the floor (I had worked there one night and had her) and been transfered to the ICU with CP and ekg changes prior to my arrival that night. The cardiologist said the changes were not new, nor indicative of an MI.Her orginal DX was Vomiting and diarrhea. Upon arrival to the unit, I noted the patien's LOC was decreased and told it was because she had been given ativan for confusion and aggitation. I noted her adbomen was large, distended and hard, she was tachycardic and her BP was much lower than her baseline (noramally hypertensive.) I called the Md and reported these findings. Her H&H was WNL, but she was pale, grey and cool. I requested an NGT, but was told to "continue to give dulcolax as she had an ilieus and he wanted to get her bowels moving." The patient continued to deterioate and I called him to inform him there was no UOP over the past hour. He ordered lasix. I ended calling him at least 6 times as it was fairly obvious I had a GI bleed on my hands and I needed orders to take care of this patient. I kept the shift supervisor informed, but they were short on the floor and he had patients and told me I would just have to keep calling the Doctor. IV access was lost 4 people attempted to restart to no avail, Lab was unable to get blood from anywhere, including fingersticks, and I needed a central line and could not get anyone to come in and place one. And her left hand turned purple and pulseless over the course of the shift, a fact I reported everytime I called. The next night, I was told by the shift supervisor that this doctor was oncall again and had said I was not to call him that night for any reason as I had kept him up all night and he was sleep deprived. He said I was to write orders for anything I pleased and he would sign them in the morning! I got in trouble the next day because the patient's BP dropped into the 40's and I called HIM at 2300! I can't believe this. The is no protocol in place that would have allowed me to write an order for Dopamine and this patient was a full code.

Doctors like this guy are a menace. Like you he has a "duty of care" to his patients and should be held to account. I would look forward to him being on-call again and make sure he had another sleepless night just like me.

Does anyone else have issues with a supervisor that takes an order from a physician like that? Shouldn't the supervisor have protested? Easy enough for supervisor to bow to the physicians wishes then not be the one whose butt is in the sling. Even the bad supervisors I have had would not have stood for that.

Originally posted by oramar

Does anyone else have issues with a supervisor that takes an order from a physician like that? Shouldn't the supervisor have protested? Easy enough for supervisor to bow to the physicians wishes then not be the one whose butt is in the sling. Even the bad supervisors I have had would not have stood for that.

I guess that was my question as well. I could have expected a doctor to say what this one said, but for the supervisor to say 'o.k.'? That's just not right.

Sounds like the doc had resigned himself to the fact this patient was not going to pull through and he didn't want to do anything else. I see this a lot with elderly nursing home patients with chronic illnesses. Docs used to make these patients DNR's ...but are afraid to do this nowadays without full family support. So.. nurses get stuck between a rock and a hard place, unfortunately. :(

Without a medical chain of events in the orders and progress notes documenting decline and poor response to treatment, it is fairly easy for a facility or doc to point a finger at a nurse when a family claims negligence or malpractice re a loved one's death. I've seen this happen to several agency nurse acquaintences. Hospitals tend to protect only their own butts.

I've had to insist the charge nurse (in your case the supervisor) get directly involved due to my concern how things might turn out...I didn't want to be there alone when the shyt hit the fan. Document her name in the chart numerous times. Document she has listened in on the doc conversations, or have her make a few herself when you ask for parameters of care.

Show your own chain of events in the chart with names and times. Keep a personal log just for yourself . Go up the chain of command with your concerns. Protect your license. The facility may badmouth you for having a 'bad attitude' (healthcare's term for a nurse with nonconforming behavior) or even offending a doc, (gasp) but with our licenses intact we can always work somewhere else. Good luck to you and be careful out there!

Specializes in Clinical Risk Management.

The manager's not an RN? No wonder he/she is the doc's "yes man"! :(

The final outcome for this patient was death. I had tried with my earlier phone calls to get a lot of the things you have suggested since there was no protocol. The h&h's were blown off because she had had serial guiacs on the floor when she had diarrhea ( before she developed the ilieus). and I was informed that that was the reason for the huge abdomen, there was no Gi Bleed. I discussed this with the shift supervisor (who was taking patients as someone had not shown up for there shift) and he told me I would just have to call the Doctor. As I had said, they thought she had had a heart attack and moved her to the unit, she hadn't had one, and was confused, so they gave her ativan as a passive restraint, and had also given her ECASA, and lovenox prior to being seen by the cardiologist per order of the primary MD. As the unit Nurse was unfamilar with her prior LOC, and VSS, I guess she assumed she was just a old confused lady. This patient had been bedfast for 10 years at home, she wasn't the picture of health. When I came back to work the next night, they had put in a central line, and ngt (and got back blood, imagine), and ordered PLT's which had not been started yet as they had to come from another city far away, I gave them that night. She had also been made a DNR. I could go on and on about it , but I won't. basically she died that afternoon. I could tell you more , but I am afraid I've already breached the confidentiality of this pt. as it is. The whole thing was scarely enough for me to talk with my husband about severely reducing our income and driving an hour and a half to get to a new, safe place to work. I am the only source of income as my husband is disabled. My agency has told me they talked with the hospital and the Doctor being angry is "no big thing". And the supervisor at the hospital said I was a good Nurse and she liked me, BUT I need to keep my mouth shut. So I still come out the villian in this.How's that for support? I told my agency that I would continue to call the Doctor when it was necessary ( I had already thought of calling at the first of the shift to get EVERYTHING I could), and that I was there to act as an advocate for the patient. I also have decided to have the shift supervisor call this Doctor at night to protect myself.

As for the shift supervisors responsibility for telling me the doctor told her to tell me not to call him the next night, well. This hospital uses about any warm body it can to supervise on nights. In this particular case, it was a nurse with experience of less than 5 years and only at this hospital. She doesn't know any better and even if she did, she would not have been backed up by her manager. The employees of this hospital are accoustomed to being served up on silver platters on a routine basis. I am considered to be too vocal, I have worked other places. It is very hard to unnderstand the situation down here until you have lived and worked it. When I first came here I couldn't believe it, it's like time warping back to the 50's or 60's, the relationship between Doctors and Nurses. They don't seem to realize there is a Nursing shortage. The pay here is very low. Lpn's make $9 to 11/hr, Rn's start at 11 and after 20 years you top out at 20/hr. The only way I can support my family is to work agency. There are no unions and they are so brainwashed as to the evils of one, they won't consider it. They are VERY passive. I'm not. It causes problems for me and I have to be very careful. Thus the keep my mouth shut statement. My agency isn't about to get into it with the hospital because then they might lose the contract, and my manager is not a nurse or even a medical person. There is one hospital, quite a drive away, and I am going to work out my next schedule very carefully, and then I am going to try to hire on there at least in the relief pool. They know me and I am acceptable for the most part, to them, They suffer from the same problems as the little hospital, but not to this degree. At least it's a level one trauma center, I miss the technology, the Doctors, the pharmacy open at night, the education, the whole nine yards. I just hate to get into the politics again. But I simply can't stand by anymore and watch patients suffer and die because of inadequate care.

Your best defense for your license and any potential lawsuits is to document, document, document. You won't lose your license because the DOCTOR didn't do his job. It's hard sometimes to make that distinction when we are very sure what the patient needs, and the orders we want. But, you are obligated only to notify and carry out the orders you receive, including "do not call me" orders. And, yes, I would have written that as an order. Not necessarily to "hang" the doctor, but to show that the patient was entering a "comfort measures only" mode. In the future, though, you might consider when getting these kinds of orders to ask the doctor while you have him on the phone if he'd like you to write the order as "do not recusitate" or "comfort measures only" and that gives him a chance to get his surly personality under control.

Although I agree the doctor's attitude was inappropriate, it can't be easy to go two days without sleep, on-call or not, and carrying the load for all the other doctors in his group that he's taking calls for. That isn't an excuse for him, but a consideration to keep in mind.

I wouldn't worry about leaving your job, or driving forever for less money. Again, the legal criteria is whether or not YOU did what you were suppose to do. Not, whether or not the doctor did what you THOUGHT he ought to do.

Originally posted by Youda

Your best defense for your license and any potential lawsuits is to document, document, document. You won't lose your license because the DOCTOR didn't do his job. It's hard sometimes to make that distinction when we are very sure what the patient needs, and the orders we want. But, you are obligated only to notify and carry out the orders you receive, including "do not call me" orders.

I think your second best defense in a situation like this is never to work at that hospital again. No wonder they can't keep staff! If you're an agency nurse in this situation, let your agency nurse that this hospital is no longer an option!

I don't agree with "obligated to carry out the...'do not call me' orders." Our first respoonsibility is to the patient. If I receive an inappropriate order like that I simply say that I am refusing to follow that order and I will continue to call. If the doc decides to go so far as to unplug the phone, I can document that he can't be reached and let the chips fall. If it's not appropriate, however, I won't follow an order like that.

ED doctors are usually only covered legally to help respond in code situations. I know it is frustrating that there is a doc in the house and he won't come, but if one unit calls the ED doc to do this, then another calls him to do that, it could get abused very quickly. The attendings will start to see the ED doc as the one to provide coverage for them.

Say the ED doc is in the middle of putting a central line in someone and the ED gets a code (it happens all the time). Sure, we can initiate ACLS protocols, but it is going to look pretty bad if the doc isn't there because he is off starting a line on someone. He really can't just drop what he is doing. ED docs are there to see the pts. in the ED, not be the "house doctor."

I don't have a whole lot of sympathy for a doc who doesn't want to be bothered in the middle of the night...it goes with the territory.

I don't agree with "obligated to carry out the...'do not call me' orders." Our first respoonsibility is to the patient.

I agree with this very much. The point I was trying to make is the legal criteria, not the moral responsibility or patient advocacy. Your suggestion of informing the doctor that you don't intend to follow that order is a good one. That kind of response takes some time to learn, though, as the original poster was clearly intimidated, frustrated, and upset by the doctor's "order" and the clear lack of support from the hospital. It never ceases to amaze me how being a good nurse is often in direct opposition to being a "good employee."

Specializes in OB.

I agree with the above posts. In addition, each time I called him, I would have charted "Dr X called, informed of (detailed list of all pertinent data), no new orders received" I would also tell him I was charting this. "I'm charting that you have been informed and don't want anything changed at this time. Is that correct Doctor?"(in my best formal frosty b*tch voice) I've done this and continued to call as often as needed until they finally came in or gave me appropriate orders. Let them yell, let them complain about me - don't intimidate that easy.

One phrase that has stuck with me over the years I heard at a conference "I don't get paid enough to worry alone"

If he didn't want to get called at night, he should have been a dermatologist! (Told a doc that once)

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