Why do ED docs hate putting in orders?

Christy1019, ASN, RN · Jan 17, 2012

[color=#990033]in my personal experience it isn't an "er doc" issue as much as it is a 1st year resident/rotators who can't seem to figure out our super simple charting system and are overwhelmed by their whole "three charts" issue lol. the 2nd and 3rd years have found their groove and aren't spending half of their shift looking up every possible diagnosis and ordering every possible test so that they don't look stupid when rounding w/the attending, so they don't seem to have too much of an issue putting the orders right in. as for the newbies, half of the battle is getting them to order anything before they staff the patient, and i'm sorry but my patient writhing in pain and puking everywhere is not going to wait an hour for you to feel confident enough to staff it, nor do i feel like being yelled at for pain meds you told them you would order when you saw them 45min ago! in those cases i will either be not so subtle in my approach to teach them how this er works, and remind them that even if they are new, they do still have an m.d. at the end of their name and i'm pretty sure ordering the zofran (that i've probably already given while waiting on you, :doh:[color=#990033] lol) will most likely not kill the patient and you would've ended up ordering it anyways when staff asked what you were waiting for! if that doesn't work, i will go to the attending, who luckily are all very laid back and trust our nursing judgement and will back us up. also, in our dem the attendings do not have their own patients in addition to being the staff physician for that area of the dept., except in crazy busy nights where the residents are too slow or can't keep up w/the volume of patients. therefore our staff md's are there solely for supervision, rounds, codes, etc. and they are always willing to help us out by putting an order in the computer, and if they are tied up w/something we will put it in our charting system as a verbal order per whichever doc, and a flagged order will pop up for the physician to click and verify the order, and the patient's chart cannot be d/c'ed from the system until they physically click it off.

as far as orders other than medications, our er nursing staff has a lot of autonomy and we are allowed to order things like foleys/saline locks/labs/certain radiology studies i.e. head ct s/p trauma, portable cxr s/p rsi/line placement/distal extremities etc, as well as certain medications like albuterol/atrovent nebs, tylenol/motrin per protocol for fever, d50 amp for hypoglycemia, etc.

the area that i have the biggest issue with mds doing orders is our cdu/24hr observation unit where it is still paper charting and the patients almost all belong to a specialty service i.e. trauma/ob gyn etc. they generally will end up writing out generic gpu orders before the patient even arrives and then tweak them via verbal order when i keep calling them for things they didn't order, or b/c their idea of pain management is about the same as chinese water torture, like orders for 1-2mg morphine q4 or 6hrs for my kidney stone or pancreatitis patients who could easily handle 4-6mg morphine q3hrs. eventually they go insane from my constant paging and will either order appropriate pain med orders, or if they are being real a-hole's like this one cocky trauma resident we can't stand who treats everyone like a drug seeker, actually says to rns/rts etc that "he's a doctor and we're below him" etc etc, which when he tried that with me, didn't work out so well for him. pt transferred to us for acute chole, pain not controlled by 1-2mg dilaudid at previous facility, states up front that he is a former opiate addict, and is visibly uncomfortable. dr. a-hole totally ignored what the patient was saying during the assessment, and when i was asking for pain meds he starts w/that 1-2mg morphine q6hrs bs. i remind him that pain was not controlled with stronger meds and hx of opiate use, he says "pt is a drug seeker thats all he's getting" regardless of the fact that ultrasound showed significant inflammation/cholecystitis. after giving the first dose of morphine w/no relief, i attempt to reason w/him and explain that i had also had acute chole w/lap chole in the past and explained how painful it was... his reply: "sucks to be the two of you then" and continues to refuse to order anything else for pain. i then went to my cc to ask who i should contact in the chain of command, senior resident or trauma staff, and she says she will talk to him first. so when she calls him he comes huffing and puffing into the er yelling about how he is right and that i should just follow orders etc. well one of our long time er attending's had overheard me talking w/the cc and approached dr. a-hole and stated that if he was so sure he was treating the patient appropriately that she would be more than happy to call the trauma attending for him and he could explain it to them, or that she would personally go assess this patient and if needed, order appropriate pain mgmt and then she would call the trauma attending herself. apparently he realized he wasn't going to get away with his attitude after being confronted by an attending staff physician, and within minutes i get a computerized order from him for 1mg dilaudid ivp prn lol, i guess he figured it would be easier to just let me decide when to give it haha. shortly after this while i had stepped off the unit, he came charging down the hall huffing and puffing again yelling at the tech saying "what, everytime you don't like my orders youre gonna go run to your charge nurse?? bla bla"

in the end my patient was at least somewhat more comfortable, dr. a-hole learned that nurses aren't just there to follow doctors orders and that he will not get away w/his bullying, and i got the satisfaction of getting what i wanted and what was appropriate for the patient.

sorry for the forever long rant, i can't sleep and have drank entirely too much orange pop today and on a sugar high lol. moral of the story is.. if the doctors are giving you a hard time with putting orders in, there is always a way to get it done whether it takes a little muscle or going to their superiors b/c eventually they'll get tired of doing the residents orders and make sure that they are putting them in. lol

:yeah:

~Mi Vida Loca~RN, ASN, RN · Feb 8, 2012

Our docs are great about putting in order right away thankfully and we have protocols to do stuff before an order is places and our rear ends are still covered. Example, a STEMI is coming in I am giving Aspirin, Starting 2 IV's, Placing O2, Ordering an EKG (blanking at the rest) before the doc even calls out an order. It's all part of the policy and protocols of a STEMI alert.

But even without those, the docs can put their order from any of the computers and it's all touch screen and super easy to do. They are very good about doing it. Even when we go and ask if we can give the patient some zofran, often times by the time I walk away from the doc box the order is in.

As far as the pyxsis, we use Accudose (which I think I did like pyxsis better) but we don't need an order to pull anything out. We don't override anything. The orders aren't placed in the Accudose, we print the order and take it to the Accudose and pull what we need.

RN1980 · Feb 8, 2012

they know that most of the time they can get away with it since ther is hardly any punishment for them. i know our adminstrators turn a blind eye often to keep from ******* off the little piggy banks of the hospital.