NOCs: the Art and Culture of Not Calling Your MD at 0230

I am a nightshifter by nature. I don't enjoy chaos and I like to work autonomously. Nightshift tends to be less chaotic just by virtue of less cooks in the kitchen, and all family members are verboten from our unit after a reasonable hour. Less hysteria that way, for good or ill that policy is to the family.

I finished my first night shift last night, still orienting. And invariably, much of it was about When Not To Call the Doc. I think there are hospitals out there where nurses will call whenever an issue arises. I'm not talking about the "I'm dumb, can this patient have some tylenol at 0300?" Nor am I talking about that ever-professional "That resident was rude and arrogant and I'm going to call and ask if I can give the patient a suppository at 0300."

I'm talking elderly patient whose Afib goes uncontrolled...from heart rate of 90s to high of 138, O2 needs increase from 10 litres to 16 via mask/NC. I'm orienting with R, who's been in stepdown for 16 months, mostway through NP school, and his executive decision was Do Not Call. Rationale was: give the Lasix 3 hours early and watch. Which, okay, reasonable plan because everything pointed to Fluid Overload is the problem.

It was a plan I went along with. Remember, still orienting to unit until end of the week.

But not a plan that doesn't make me feel a little funny. Because uncontrolled Afib isn't a stupid reason to call. And the patient's primary care MD called us at 2200 to check on the patient. This is a PCP who cares about this person. And you know what? Gradually spiralling out of control atrial fib is a good reason to call even when the MD doesn't give a damn.

I don't think I like a culture of Let The On-Call MD Sleep At All Costs. (Not to suggest we were doing that in this instance...there is an element of that on my unit at large, however.) Because the MD is getting paid to be on call, and I never call for stupid stuff, nor am I unprofessional with pages. On my old unit, I was not once wrong to have called and said, "Here are the symptoms; here are the vitals; here are the labs; this doesn't feel right to me at all." Never once had it been for a reason that either sent a patient to the ICU before the crash happened, or was some other disaster averted so the patient was either kept out of ICU or restraints or pain. When I know I might want a stinkin sleeper, I call before 8p.m. When the patient's had a procedure I know will hurt and the inexperienced PA doesn't, I ask before the PA heads home for the day.

My hospital has this culture of Not Disturbing the MDs. A 15-year veteran ICU nurse stood on a box and railed about this to me last night. I don't know if she's right or not. Under his breath, R muttered to me later, "She's a little negative."

I'm still in observation mode right now. I can tell because when I give report in the morning, I'm not as on the money with the extensive health history I should know. I know about last night, but not about last year, and when it's MY patient, I make it a point to know everything about them. I don't feel ownership yet.

When it's MY patient?

I'm gonna call. I practice nursing, not "medicine" (as if nursing is somehow dichotomous from "medicine"). The two work together. And when I don't call, I am practicing medicine on a critical symptom I decide the MD/PA can wait on knowing about. I know what my scope is. I know what the problem is, can understand the most likely patho, can take the reasonable steps to control the problem, and I can tell you what the likely drug or fluid and dose s/he'll order and for when, and what followup labs or tests.

So what do I need the MD for? Nursing has a crisis in part because if all the above is true (and it is), why are we paging the MDs?

Thing is, when I go home, the patient is no longer mine. I see it all the time when there are too many MDs, cooks in the kitchen, driving the plan for the patient. But for every MD that works with that patient, there's at least four nurses. Most patients in ICU/Stepdown have a CV surgeon, cardiologist, pulmonologist, primary care physician and many have an infectious disease doc.

Ideally, every nurse that works with the patient knows that say, the patient is just shy of throwing her kidneys to hell and wouldn't order an emergent chest Xray with contrast and by doing so, make the final nudge into renal failure. Ideally all of them know that the patient was in and out of Afib on Tuesday, too, and now it's Sunday and it's happening again. But the reality of the hospital isn't ideal. Maybe the 80mg Lasix IVP does exactly squat for the patient, that isn't the patient's issue at all, her neutrophils show a staggering 98% of her wbcs and we anticipate pneumonia and we should be preparing to intubate.

The MD is supposed to know the patient. They take care of a lot of patients. But in no month or year do they take care of as many patients as I do. So I guess I'm sayin I'm quite comfortable knowing Typical Interventions because in the majority of Situation X, Intervention Y is gonna be dead-on and I'll be doing the right thing by exercising judgement to go forward with it.

I want to be smart at this new job, you know. I want be able to manage a patient's crisis by myself as much as possible...that is one very good reason I work nights. But I think maybe being smart is knowing also where you stop and someone else comes in. And since I'm new to ICU, I think that point-of-where-someone-else-comes-in is a lot earlier than a heart rate of 138 and oxygen needs increased by 75%.

I'm not saying that what we did was wrong. I do think R's right, it was fluid overload, Lasix'll pull it off. I'm sayin that point of where-someone-else-comes-in is a lot later for R than it is me. He's been at this longer.

For good or ill to the physician's altered sleep pattern, they'll probably hear from me more for a while. It's not my favorite plan, either. Nursing doesn't have formal residency and because of that you have these awkward dilemmas. You want an expert nurse for every patient in every situation.

But you gotta grow em.

Tikosyn

I haven't been writing much about stepdown because I don't think I've chewed on it enough. It continues to go good. I'm up to 2.5 patients today (meaning 2 and an afternoon admit), so I'm right where I should be. I gave Tikosyn today, learning how to calculate a QTc value.

My folks are very supportive of the new gig, and Mom often says, "I want you to build your skills, get really good at putting in IVs and stuff." It's great to have their support. Setting an IV is the lincoln logs of what I'm doing in stepdown, though. (Incidentally, I did start one today and nailed it, yay me.) (On a dehydrated 78 year old.)

I'm not sure that I can put together yet how bigger a deal it is to give Tikosyn and deal on my low 40s sinus brady post-ablation patient than it is to set an IV. To the general Joe Anybody, drugs are something that you go home with after you see the doctor/PA/NP and you generally take them as the doc/PA/NP prescribes. But so many drugs in ICU can kill you so quickly and so easily if you don't watch specific stuff that there's a whole world of pharmacy out there of Crap That Can Kill You, Unless You Do These Exact Things In Which Case It Will Keep You Alive.

Tikosyn is given to prevent or keep a person out of atrial fibrillation. Atrial fib is when the top portion of your heart beats at 250 to 400 beats per minute, and the rest of your heart does not. The heart is your pump, and when the top half and the bottom half aren't doing the same stuff, it means your pump is ineffective to say the least.

Every drug lists adverse effects, which are side effects that a percentage of those tested will have. At the dosage my patient was on today? The most common side effects are ventricular tachycardia or torsades des pointes. By a QUARTER OF PATIENTS in one study. What is ventricular tach and torsades? Heart rhythms. The worst ones. (Other than the flatline you see on tv. Which, yes, technically IS the worst.) Means you're getting CPR and being shocked back to life if you're lucky. And if you are not lucky, you are dead. People that die "from a heart attack" die from one of those rhythms.

And it's a pill. Tikosyn. Lemme tellya how weird it is to hand that pill over into a little med cup. And my patient is a sweet woman, who is cheerful and cheerfuly trusts her little blonde nurse. S said it the other day when she said that in her 25 years of nursing experience, only one person has ever asked to see her license. She introduces herself as a nurse and patients trust her. S, being an NP, has prescriptive privileges, too. She is extremely thorough when she writes scrips. People trust her more than they do MDs. They often trust me more than they do MDs.

You say you're a doctor and the world thinks that implies something. Some list of things, maybe. Sometimes they're true, I suppose. You say you're a nurse, and that implies a whole set of other things....that you're automatically a good person, an honest person, a caring person, and the most nauseating: "an angel" (Pardon me while I hurl.)

I think most of us are good people, honest and caring people. Some of us do our jobs okay and get that secondary benefit of being seen in that light. Because we're often not honest or good to each other. I knew a nurse that stole drugs. She's not a nurse anymore. Probably, fewer nurses cheat on our taxes or steal cars or whatever than the general population. Probably not a lot of nurse serial killers, silly fiction notwithstanding.

And my patient smiled at me as I gave her the little green and brown capsule. "Thank you." She said she could read everything on my face, my patient did today. I had pensive face and I knew it: "Now I want you to tell me the second you feel anything weird: heart racing, dizziness, lightheaded, anything, okay?" She continues to smile, "Sure thing, honey." She has unconcerned face. Maybe because she sees my pensive face and has this amazing trust that Pensive Face is going to ward off any problems. She has no idea how much I hovered around her tele rhythm all day long. I know Tikosyn is a good take-home drug for many people. They don't know that pharmacies have a specific extra protocol for the drug, or realize that the drug's first five doses are always given in a telemetry hospital bed by some law or official guideline (and pharmaceutical companies don't strike me as the kind of people who'd make inconvenient rules on their own drugs unless they had or were anticipating $$ lawsuits).

She just popped it in her mouth and washed it down with fresh ice water.

Smile.

My mom'll be proud of me today that I set an IV.

ICU Stepdown is just. Even I as a nurse didn't know all there was out there.

Little green and brown capsules. Just a pill like I'm givin baby aspirin or somethin.

*****

I visited my old unit after Nurse Practice Council Monday. I discovered that the elderly nurse I'd worked with most every shift for the past year quit. I hope she retired to Florida and is a happy camper.

But something tells me she's looking for another night shift nursing job.

When I grow up and write nursing....

I want to write it like oncRN does.
/jo

Stepdown ICU

is going great. Much new things, still processing. It's a totally different ballgame. I have both earned an appreciation for what I've been doing all year in rehab, and realized how much more there is to do.

And I hate working days with a fiery passion. The people are lovely. The cardiothoracic surgeons are civil. (Which is a LOT to ask of a cardiothoracic surgeon...you may agree with me that civility is a basic right to ask of a colleague, but to have three of them all be civil to the New Nurse Even When She Pages the Wrong One At First is.... is.... unheard of.)

Day shift is utter chaos. And every time you turn around, you're feeding people. (And dietary people think it's okay to give chocolate eclairs to diabetics.) Between 830 and 900, I was supposed to assist with a thoracotomy, be an assist RN to the primary RN on a not-really-planned intubation, and yank a chest tube in ICU. (Two out of three is not shabby.)

Much to tell. Mostly, I need to sleep. Because I need to wake up in 6 hours and do it again.

I do need to go back to nights. I can just tell from the brief interactions at report time, most of them are my people. The tele tech said to me this morning, "There's something just so natural about rolling out of bed at 4p.m."

But you know what I think? I think I love my new job.