Dear MD, please write some orders for me. Thanks, your friendly RN

(Here's somethin you don't hear out of nurse blogs on a regular basis.)

Dear MD,

I did not go to medical school, nor did I do residency. I am not a doctor. I'm a nurse. I know a lot about health and medicine, pathophys and pharmacology. I can predict with a good degree of accuracy what drugs, doses, diagnostics and treatments make sense for a patient.

An MD should WANT me to be able to do this. We have a human-made and broken health care system and mistakes happen all the time. I am another clinician that helps protect patients by ensuring the drugs and treatments you want for our patient do what we both want them to do.

But the fact is that you have twice the amount of time, and a much more comprehensive training in the field. I don't diagnose. I don't prescribe. Yay for us both and for the patient. I have a good degree of accuracy....enough that I feel confident seeing a nurse practitioner for my general health stuff. But for my more complicated breathing stuff, I see a pulmonologist. I know the difference.

Here's my trouble: when I come to dialyze our patients, I get the name of a hospital, a last name, and sometimes a room number. I don't get any report on these individuals; I do not have the luxury of reading health and physical history, recent orders or even speaking to the patient before I get 75% of my dialysis treatment set up. I get some lab values, which allow me to predict the correct potassium prescription.

Let's go back to that sentance. I get some lab values and predict a potassium prescription (granted it's not that hard for dialysate) in a population with common comorbid cardiac issues.

What I ask of you is that you write me some orders for the treatment parameters. When I receive the chart, I often am going on orders you wrote for a dialysis treatment two weeks ago. Sometimes the patient gets two hours of a treatment I decide upon before you see them that day. Sometimes it's their first treatment and I am making those decisions until you arrive an hour or two into the treatment.

The good news is that I'm right most of the time. It is first grade math to subtract a serum potassium from seven.

The bad news is that I do not have MD behind my name and you do. Please don't leave these decisions to me. Please don't grouse when I ask you to write me some orders for the treatment I'm halfway through completing. Please don't look at me as if I'm a moron who's asking to be told what to do when it's seemingly obvious what I should do.

It protects us both. It's best for the patient. I do not have any business deciding how much potassium to give a patient, how much Epogen, how fast to dialyze a new patient who's never had dialysis before. I know that. I also know you're busy and have 35 patients to see today. I get it. I also know most of the other nurses on the team do this all the time. But I think they allow this to continue because they interpret this possible laziness/busy-ness on your part to be a vote of confidence in them.

It doesn't take much to subtract from seven, yes. But what you may not know is that other physicians are altering other electrolytes through the treatment that are providing benefit to the patient. They're giving additional drugs that may be beneficial. They're even having me change the direction of my dialysate flow (something I need to know 35 minutes beFORE patient arrival), to reduce the risk of adverse outcomes on new patients.

That's not first grade stuff. And for treatments I 'prescribe', I don't do that. But maybe you should. Or maybe it goes through your head to consider, but you never get around to writing it down, so it never happens.

I respect what you know. This laziness is possibly a nod of confidence to me, or maybe you think any monkey can do what I do. Either way, I don't care. It isn't right and there are clear legal scope of practice boundaries, no matter how busy we are. These boundaries are for the best of the patient.

So just. Please, write me some orders.
Thanks
/jo