This is an addendum to my story about Margaret, my patient from earlier.
True story:
Jo has parked in Margaret's room because Margaret requires 1:1 RN care. She needs the titrating of vasoactive meds, dialysis, ventilator tweaks. She wishes to have "life support" care withdrawn 36 hours from now. She'd had a complex vascular surgery the previous week, done by Dr. Vascular Surgeon, to improve the circulation to her legs and feet. She is 84.
Dr. Vascular Surgeon walks into room Monday morning at 0700. He and Jo exchange polite good mornings.
Jo: "I have some concerns I'd like to share with you about how Margaret's doing, once you're ready to hear them. Here's her chart if you'd like to look at it first." I hand him the chart.
Dr. S thanks me, leaves room with chart, comes back five minutes later. He looks at (but does not unravel) the dressing to her leg. "When did you change this last?"
Jo: "At four this morning."
Dr. S: "And how are the incisions doing?"
Jo: "Well approximated still, no signs of infection, her white blood count is still within parameters, some moderate serous oozing from the groin, mild from the leg." (No, really, I sound like this.)
Dr. S: "And her pulses?"
Jo: "I can doppler the PT's intermittently, but can actually palp the DPs. That's a new finding from last night, days wasn't able to find the PTs and could only doppler DPs on their assessment."
Dr. S nods, and covers her feet back up without confirming my findings. I'm sure that his note will record what I said verbatim. I guess it's nice to be trusted? As he washes his hands, he asks, "What are your concerns?"
Jo: "We've been unable to titrate her oxygen much lower, and her rate is remaining 7 to 10 over the vent despite the 40 mic's of propofol. Also, I've been unable to get her off that point five of dopamine. Her pressures are stable, despite the fairly high blood flow on dialysis."
Dr. S cuts me off: "I'm just the surgeon."
I glare. Jo: "Also, though she's on the propofol, we have nothing for pain. Maybe a little Fentanyl? And I can back off on the propofol?"
Dr. S: "Well, she shouldn't be having any pain since the surgery was X date. Looks like that's healing fine."
My. jaw. drops. I make a wide gesture to the room, to the machines. "How about the REST of what we're doing to her?"
Dr. S is drying his hands, pitches the paper towels and shrugs. "I'm just the surgeon."
He walks out of the room, and there's Jo, still got her arm dangling pointlessly in the air.
Showing posts with label RNs and MDs. Show all posts
Showing posts with label RNs and MDs. Show all posts
Wednesday, May 7, 2008
Tuesday, March 4, 2008
None of our doctors seem to want to own my patients at night
So once upon a time, in my ICU, we did not have intensivists 24/7. Day before yesterday, as a matter of fact. We'd spent two years begging, pleading, petitioning for them.
This is the way it used to be:
Several weeks ago, I had a patient whose breathing was deteriorating, as was her mental status. She went from 2L nasal cannula to 15L nonrebreather in a matter of four hours. I called for a chest xray that I did not get an order for first (because, duh). Dr. D happened to be in house late and this individual is nobody's favorite doc. Magnanimously, he addressed the unit, "Is there anything I can do for you before I go home?"
"Yes." I said. "You can look at my patient who's not breathing and I'm thinkin we'll be intubating very soon." He pokes his head in to see the patient. He looks at the chest Xray. "Well, look, she's improving," he says.
I look at the chest Xray. (Insert that cartoon head-shaking noise here...that yadayadayada noise.) Now, I'm not a Medical Doctor, and I do not have your salary or swagger, but when I look at chest Xray A from yesterday and it shows mostly black lungs, and chest Xray B from now and it shows mostly white lungs....THIS IS BAD. When the patient's O2 needs go up by 750%...THIS IS BAD. When a patient's work of breathing increases and the patient feels short of breath...THIS IS BAD.
"Oh no, she's getting better." I am so struck stupid by this beyond-stupid stupid stupidity I don't know what to say. I have no poker face, and I'm sure my expression is a mixture of genuine bafflement and creeping horror. "You don't agree...." he says. Insightful, that one. "No," I say, pinching off the snappy one-liners, "Not even a little bit. She will be intubated before noon." He shrugs, "Well... Not by me. She's getting better."
No.
Not by him.
But she was intubated before noon by a competent doctor who knows that 750% is A BIG number.
Not only did she not get better, she was formally diagnosed with ARDS, spent two weeks on the vent, extubated, reintubated and died this past weekend.
I admitted a eighty-something year old lady who was 90 lbs soaking wet....she had two peripheral IVs in her hands. In one IV, an MD had ordered me to infuse vancomycin. In the other, I was to give Levophed. "But Dr. So-N-So, don't you want to come upstairs and put in a central line? Or call someone to do it for you?" He was busy seeing other patients. I get that he's busy. So am I. I don't want to shred my patient's veins and if he's overloaded, ask for help. I can even get it for you. It's about best practice for the patient, and you know what I'm asking for is the right way to do it. Your hands are tied? Cool. I can find somebody who can do it.
Instead, ego got in the way and he gave me an order to specifically call nobody else. Which is just silly.
Because when you told the nurse of 25 years down the hall that you weren't gonna come look at her active GI bleed, that you were too busy, that you weren't worried right now about her dropping hematocrit, that she didn't need a central line for the pressors she was starting to require secondary to her active bleed or the NG tube right now, and that she shouldn't "bother" the other docs...? She got the charge nurse to call the medical director, your boss.
As a side effect, I also got my central line for my patient before change of shift was out. Kinda that MD, the medical director and the PharmD were kinda on my side on the centrally-given Levophed issue. No reason to give it peripherally if there are MD hands available to do it right. The medical director was at the nursing station at 0400. She earned some big points from me that night by doing so, as did the doc who came in to place my line....the guy I wanted to call to begin with.
Night shift does have a favorite doc, and we want him to own all our patients. The problem is, he's just one guy, and he deserves more time away from the hospital than he tends to take. He takes ownership of patients, and he is thorough and reasonable. We know what good care looks like. Our CV surgeons can be very unprofessional in tone and manner to us, but they completely own their patients' care. They never let you wonder who's driving, or if anybody IS driving. Nobody feels like their heart patient is being ignored, or that stuff falls through the cracks.
Which is what we feel sometimes happens with every patient who isn't under the direct care of one of those handful of good docs we work with. Particularly, this seems to be a nighttime problem.
So we got our intensivists that many nurses I respect fought so hard for. A year of documentation proved that the nurses were right: patients were often receiving inferior care at night because of a lack of in-house MDs. I don't think there's a doc or a nurse out there that thinks having no MD in an ICU for 12 hours is a good thing.
It's not just for the patient who suddenly develops respiratory distress and who only has one side of her chest moving when she's gasping for air. Though that happens.
It's also that nurses hate that feeling of watching a patient carefully, and seeing subtle signs that Bad Things Are About To Happen and no one single thing, or possibly even all things are "callworthy." Here we got MDs right there, so we can say, "Hey, are you seein this trend, too? Can we do something to avert the train wreck that's probably coming?" Maybe even avert it so that dayshift people don't have a daily crisis at 0900 from stuff that could've been handled all night.
Last week, I had a patient with a bp of 240/114 and I paged one of the intensivists who was at our sister hospital. He was a good MD, awake, and followed my patient with me as we tried every foogin drug we could think of (patient had no kidneys), until high-dose Labetolol drip finally worked at about 0700. I went into RN report feeling like I had done my best for this patient. I think the patient felt like I was working very hard for him, too, and that's a good feeling. I felt good, for a change, that I'd worked well with this doc, who I hadn't met before. That he was sharp, and thorough, and he was listening carefully to what I was telling him about this patient's condition.
The intensivist coming on shift for the day tore my head off for not paging the nephrologist first. Do you know why I didn't page the nephrologist? It isn't fair, but this is true: I've worked in that hospital for 2 years. This doc had been paged on dayshift FIVE TIMES and failed to call back...IN DAYLIGHT....same guy you want me to call, now sound asleep? You got two tools in your toolbox. One you've used before and it hasn't worked well for you before, it didn't work well at all today...and there's this other tool, a smart guy, professional to work with, who's awake at your sister hospital and returns pages quickly and is responsive to your patient's needs?
Again. Your patient's blood pressure is 240/114.
Which tool in your toolbox do you grab? It's not a tough choice.
The daytime doc TORE my head off. I stood my ground. "Your partner was extremely helpful to me. He helped my patient. I thought that since this patient is in the ICU, I can call you or your partners on any one of them with critical changes. Patient's blood pressure was dangerously high and your partner handled it." Daytime doc stomped off.
I don't get it: You round on my patient, who's in the ICU, you guys "own" the ICU....but not this patient? Have you seen a worse blood pressure today? The nephrologist was ignoring the sbp of 185 earlier today (which he might consider clinically okay with no kidney, but if so, why write for 20mg of Hydralazine for sbp > 160 when it is completely ineffective and has been all day?), and treating the intractable nausea with 12.5mg Phenegran...do you seriously think these are orders from an MD who feels ownership of this man's care?
I just want somebody to fix my patient. Don't get mad at me for doing my job. If I'm stepping on toes, it's cos I'm not gettin what I need. I mean no disrespect, but I don't care about your toes any more than you care about mine. This is about THE PATIENT, remember?
I get that the intensivists want to be there for support, not to fix every single patient's issue that a medical doc can fix. I don't think the doc that tore my head off was truly angry at me. (And his progress note, written after I left, strongly suggested who and what at whom he was angry...) I think they're just overloaded because, well, they are fixing everybody. Everybody who isn't a patient of night shift's favorite MD or one of the CV surgeons' patients.
I just don't know what to tell ya about that one.
The intensivists being here were supposed to fix this problem of ours.
More soon on how that's going.
This is the way it used to be:
Several weeks ago, I had a patient whose breathing was deteriorating, as was her mental status. She went from 2L nasal cannula to 15L nonrebreather in a matter of four hours. I called for a chest xray that I did not get an order for first (because, duh). Dr. D happened to be in house late and this individual is nobody's favorite doc. Magnanimously, he addressed the unit, "Is there anything I can do for you before I go home?"
"Yes." I said. "You can look at my patient who's not breathing and I'm thinkin we'll be intubating very soon." He pokes his head in to see the patient. He looks at the chest Xray. "Well, look, she's improving," he says.
I look at the chest Xray. (Insert that cartoon head-shaking noise here...that yadayadayada noise.) Now, I'm not a Medical Doctor, and I do not have your salary or swagger, but when I look at chest Xray A from yesterday and it shows mostly black lungs, and chest Xray B from now and it shows mostly white lungs....THIS IS BAD. When the patient's O2 needs go up by 750%...THIS IS BAD. When a patient's work of breathing increases and the patient feels short of breath...THIS IS BAD.
"Oh no, she's getting better." I am so struck stupid by this beyond-stupid stupid stupidity I don't know what to say. I have no poker face, and I'm sure my expression is a mixture of genuine bafflement and creeping horror. "You don't agree...." he says. Insightful, that one. "No," I say, pinching off the snappy one-liners, "Not even a little bit. She will be intubated before noon." He shrugs, "Well... Not by me. She's getting better."
No.
Not by him.
But she was intubated before noon by a competent doctor who knows that 750% is A BIG number.
Not only did she not get better, she was formally diagnosed with ARDS, spent two weeks on the vent, extubated, reintubated and died this past weekend.
I admitted a eighty-something year old lady who was 90 lbs soaking wet....she had two peripheral IVs in her hands. In one IV, an MD had ordered me to infuse vancomycin. In the other, I was to give Levophed. "But Dr. So-N-So, don't you want to come upstairs and put in a central line? Or call someone to do it for you?" He was busy seeing other patients. I get that he's busy. So am I. I don't want to shred my patient's veins and if he's overloaded, ask for help. I can even get it for you. It's about best practice for the patient, and you know what I'm asking for is the right way to do it. Your hands are tied? Cool. I can find somebody who can do it.
Instead, ego got in the way and he gave me an order to specifically call nobody else. Which is just silly.
Because when you told the nurse of 25 years down the hall that you weren't gonna come look at her active GI bleed, that you were too busy, that you weren't worried right now about her dropping hematocrit, that she didn't need a central line for the pressors she was starting to require secondary to her active bleed or the NG tube right now, and that she shouldn't "bother" the other docs...? She got the charge nurse to call the medical director, your boss.
As a side effect, I also got my central line for my patient before change of shift was out. Kinda that MD, the medical director and the PharmD were kinda on my side on the centrally-given Levophed issue. No reason to give it peripherally if there are MD hands available to do it right. The medical director was at the nursing station at 0400. She earned some big points from me that night by doing so, as did the doc who came in to place my line....the guy I wanted to call to begin with.
Night shift does have a favorite doc, and we want him to own all our patients. The problem is, he's just one guy, and he deserves more time away from the hospital than he tends to take. He takes ownership of patients, and he is thorough and reasonable. We know what good care looks like. Our CV surgeons can be very unprofessional in tone and manner to us, but they completely own their patients' care. They never let you wonder who's driving, or if anybody IS driving. Nobody feels like their heart patient is being ignored, or that stuff falls through the cracks.
Which is what we feel sometimes happens with every patient who isn't under the direct care of one of those handful of good docs we work with. Particularly, this seems to be a nighttime problem.
So we got our intensivists that many nurses I respect fought so hard for. A year of documentation proved that the nurses were right: patients were often receiving inferior care at night because of a lack of in-house MDs. I don't think there's a doc or a nurse out there that thinks having no MD in an ICU for 12 hours is a good thing.
It's not just for the patient who suddenly develops respiratory distress and who only has one side of her chest moving when she's gasping for air. Though that happens.
It's also that nurses hate that feeling of watching a patient carefully, and seeing subtle signs that Bad Things Are About To Happen and no one single thing, or possibly even all things are "callworthy." Here we got MDs right there, so we can say, "Hey, are you seein this trend, too? Can we do something to avert the train wreck that's probably coming?" Maybe even avert it so that dayshift people don't have a daily crisis at 0900 from stuff that could've been handled all night.
Last week, I had a patient with a bp of 240/114 and I paged one of the intensivists who was at our sister hospital. He was a good MD, awake, and followed my patient with me as we tried every foogin drug we could think of (patient had no kidneys), until high-dose Labetolol drip finally worked at about 0700. I went into RN report feeling like I had done my best for this patient. I think the patient felt like I was working very hard for him, too, and that's a good feeling. I felt good, for a change, that I'd worked well with this doc, who I hadn't met before. That he was sharp, and thorough, and he was listening carefully to what I was telling him about this patient's condition.
The intensivist coming on shift for the day tore my head off for not paging the nephrologist first. Do you know why I didn't page the nephrologist? It isn't fair, but this is true: I've worked in that hospital for 2 years. This doc had been paged on dayshift FIVE TIMES and failed to call back...IN DAYLIGHT....same guy you want me to call, now sound asleep? You got two tools in your toolbox. One you've used before and it hasn't worked well for you before, it didn't work well at all today...and there's this other tool, a smart guy, professional to work with, who's awake at your sister hospital and returns pages quickly and is responsive to your patient's needs?
Again. Your patient's blood pressure is 240/114.
Which tool in your toolbox do you grab? It's not a tough choice.
The daytime doc TORE my head off. I stood my ground. "Your partner was extremely helpful to me. He helped my patient. I thought that since this patient is in the ICU, I can call you or your partners on any one of them with critical changes. Patient's blood pressure was dangerously high and your partner handled it." Daytime doc stomped off.
I don't get it: You round on my patient, who's in the ICU, you guys "own" the ICU....but not this patient? Have you seen a worse blood pressure today? The nephrologist was ignoring the sbp of 185 earlier today (which he might consider clinically okay with no kidney, but if so, why write for 20mg of Hydralazine for sbp > 160 when it is completely ineffective and has been all day?), and treating the intractable nausea with 12.5mg Phenegran...do you seriously think these are orders from an MD who feels ownership of this man's care?
I just want somebody to fix my patient. Don't get mad at me for doing my job. If I'm stepping on toes, it's cos I'm not gettin what I need. I mean no disrespect, but I don't care about your toes any more than you care about mine. This is about THE PATIENT, remember?
I get that the intensivists want to be there for support, not to fix every single patient's issue that a medical doc can fix. I don't think the doc that tore my head off was truly angry at me. (And his progress note, written after I left, strongly suggested who and what at whom he was angry...) I think they're just overloaded because, well, they are fixing everybody. Everybody who isn't a patient of night shift's favorite MD or one of the CV surgeons' patients.
I just don't know what to tell ya about that one.
The intensivists being here were supposed to fix this problem of ours.
More soon on how that's going.
Saturday, March 10, 2007
Who the heck would sue me when I'm trying to help?
Check out Angry Medic's story.
I don't know any MDs well. I work nights, and the few that I see tend to be bleary-eyed and wearing clothes they'd donned 22 hours previously. This is unfortunate, as I'm sure a great many of them are worth knowing. (Not all, but probably most. Kind of like most plumbers and accountants are probably worth knowing, too.)
So when I read Angry Medic, I'm sometimes struck with how different the world of learning medicine is different from the world of nursing, and of learning nursing. It shouldn't be, as we're actually in the same world. But if the same situation he describes happened to a pharm class in nursing school, the story would have been very different. I doubt any person present would have been thinking 'lawsuit'. (You probably would have had several think, "Neat! I can practice CPR!")
It's a travesty that so many commenters to AM told him he was right to fear lawsuit. This is awful. These posters can, no doubt, make a solid case for being right to fear lawsuit. And I'll bet you most of them hate the state of a world in which this interrupts good intentions, good help, good care to people. I'm sure most MDs wanted to be MDs because of good intentions to provide service to others.
This fear of lawsuit doesn't exist so much like that in nursing. I certainly know RNs who have been to court, none that have been censured. We are all human, and we've all made mistakes. I've made mistakes. I'd tell you what they were (because I remember each) if this wasn't a blog out on the internet. Nurses who've been on the stand tend to be sticklers with documentation, and I can learn from them. (One charts like Charles Dickens, and I don't want to learn from her, but that's beside the point.)
But fear of a lawsuit wouldn't stop me from helping somebody who falls down, goes boom. Fear of HIV/Hep C or other infectious disease gives me pause. Give me a decent barrier, and I'd be fine. I'd make do with a rag or a shirt in a crisis fine.
Fear of a crazy bastard who bites or will suddenly grab me in a headlock gives me pause. But that only causes me to consider my position when I'm approaching this person, and that takes split seconds. Fear of being hit by projectile vomiting and ruining a shirt and the hours of showering and scrubbing it would require later...same thing.
But 'lawsuit' wouldn't cross my mind in those critical seconds. In the U.S., we have a Good Samaritan law that protects us. (Sad that one is necessary.) Based on the comments AM's gotten, this lawsuit fear seems to be something that a sane MD has to think about in a crisis. Just like my thinking about biting, HIV and projectile vomiting are kneejerk thoughts. 'What if this poor bastard sues?' I had no idea. I find it fascinating.
It also makes me wonder what the hell medical school is *teaching* these basically good people? What are the NHS and the American and Australian hospital systems teaching to people out there trying to give care to their communities?
*gah*
This is messed up.
I get called an angel at least once a week. This week, it was on Thursday. A patient's husband was expressing gratitude, and it was best-intentioned. I thanked him, laughed it off and told him he could ask my mom if I was an angel and she'd give him an earful. (This is one of my ways to get the idea across that nursing is a profession and not a vocation.) Sometimes patients mean this 'angel' thing in a way that is so saccharine or manipualtive it gets on my nerves. I'm not an angel, I'm a clinician. I'm a nice clinician and I like to help people. The only wings I have were tattooed on in a neon-lights parlor on Colfax a few years ago. Tequila was involved.
(Pointless segue: I had a patient last night tell me he will be putting me on his Christmas list. Had to say, that was a first and cute as hell. Ex-IV drug user, ETOH, slowly dying while waiting for an organ to be transplanted. His words are sweet and this is a man who probably has in the back of his mind something a little more airbrushed and Playboy with bows in indecent places, but I didn't actually care. It was still cute.)
Maybe it's this reason that people don't tend to sue nurses. For one, I don't think they know they can. (And I'm not gonna tell.) For another, I think there's that idea about nursing that we're all sweet and cute and female and helpful that actually ends up protecting us. That some of us are men, some of us are fugly and some of us are profoundly ill-tempered and that ALL of us are multidimensional people and flawed, seems to not be the point.
I don't want to be a doc. I'm glad there are good people who want it. I'm sorry for them that they have to hesitate for fear of lawsuit. I hope nursing never gets there.
I don't know any MDs well. I work nights, and the few that I see tend to be bleary-eyed and wearing clothes they'd donned 22 hours previously. This is unfortunate, as I'm sure a great many of them are worth knowing. (Not all, but probably most. Kind of like most plumbers and accountants are probably worth knowing, too.)
So when I read Angry Medic, I'm sometimes struck with how different the world of learning medicine is different from the world of nursing, and of learning nursing. It shouldn't be, as we're actually in the same world. But if the same situation he describes happened to a pharm class in nursing school, the story would have been very different. I doubt any person present would have been thinking 'lawsuit'. (You probably would have had several think, "Neat! I can practice CPR!")
It's a travesty that so many commenters to AM told him he was right to fear lawsuit. This is awful. These posters can, no doubt, make a solid case for being right to fear lawsuit. And I'll bet you most of them hate the state of a world in which this interrupts good intentions, good help, good care to people. I'm sure most MDs wanted to be MDs because of good intentions to provide service to others.
This fear of lawsuit doesn't exist so much like that in nursing. I certainly know RNs who have been to court, none that have been censured. We are all human, and we've all made mistakes. I've made mistakes. I'd tell you what they were (because I remember each) if this wasn't a blog out on the internet. Nurses who've been on the stand tend to be sticklers with documentation, and I can learn from them. (One charts like Charles Dickens, and I don't want to learn from her, but that's beside the point.)
But fear of a lawsuit wouldn't stop me from helping somebody who falls down, goes boom. Fear of HIV/Hep C or other infectious disease gives me pause. Give me a decent barrier, and I'd be fine. I'd make do with a rag or a shirt in a crisis fine.
Fear of a crazy bastard who bites or will suddenly grab me in a headlock gives me pause. But that only causes me to consider my position when I'm approaching this person, and that takes split seconds. Fear of being hit by projectile vomiting and ruining a shirt and the hours of showering and scrubbing it would require later...same thing.
But 'lawsuit' wouldn't cross my mind in those critical seconds. In the U.S., we have a Good Samaritan law that protects us. (Sad that one is necessary.) Based on the comments AM's gotten, this lawsuit fear seems to be something that a sane MD has to think about in a crisis. Just like my thinking about biting, HIV and projectile vomiting are kneejerk thoughts. 'What if this poor bastard sues?' I had no idea. I find it fascinating.
It also makes me wonder what the hell medical school is *teaching* these basically good people? What are the NHS and the American and Australian hospital systems teaching to people out there trying to give care to their communities?
*gah*
This is messed up.
I get called an angel at least once a week. This week, it was on Thursday. A patient's husband was expressing gratitude, and it was best-intentioned. I thanked him, laughed it off and told him he could ask my mom if I was an angel and she'd give him an earful. (This is one of my ways to get the idea across that nursing is a profession and not a vocation.) Sometimes patients mean this 'angel' thing in a way that is so saccharine or manipualtive it gets on my nerves. I'm not an angel, I'm a clinician. I'm a nice clinician and I like to help people. The only wings I have were tattooed on in a neon-lights parlor on Colfax a few years ago. Tequila was involved.
(Pointless segue: I had a patient last night tell me he will be putting me on his Christmas list. Had to say, that was a first and cute as hell. Ex-IV drug user, ETOH, slowly dying while waiting for an organ to be transplanted. His words are sweet and this is a man who probably has in the back of his mind something a little more airbrushed and Playboy with bows in indecent places, but I didn't actually care. It was still cute.)
Maybe it's this reason that people don't tend to sue nurses. For one, I don't think they know they can. (And I'm not gonna tell.) For another, I think there's that idea about nursing that we're all sweet and cute and female and helpful that actually ends up protecting us. That some of us are men, some of us are fugly and some of us are profoundly ill-tempered and that ALL of us are multidimensional people and flawed, seems to not be the point.
I don't want to be a doc. I'm glad there are good people who want it. I'm sorry for them that they have to hesitate for fear of lawsuit. I hope nursing never gets there.
Monday, January 22, 2007
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.
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.
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