Nurses train us to be irritable

[OTD]

Yep, it's true.

How do they do that? It's like pavlovs dogs.

When they find a nice resident that doesn't chew their head off the page them more.

When they find a resident that answers pages really quickly they page them more.

I can't count the times when I have asked the question "we are not the primary team, why are you calling me about this" and I always get the answer "because I knew you wouldn't yell at me" or " because you always answer quickly".

I was warned about this as an intern, and lo and behold it's true. If there are any issues during the day it's me that gets paged, whether I am at the hospital or not.

It's to the point my Chief even told me the other day to quit being nice to them and tell them to call the correct resident. He told me that several residents before me learned the hard way that the nicer you are the more you get paged. I can't say I wasn't warned first month of Intern year, but I kinda didn't believe it. Now I know it's true. As a resident you are rewarded with fewer pages if you are hard to deal with.

On the flip side I NEVER get pages at night any more unless they are legit, and I get met on the floor during the morning with updates without having to ask which is very nice.

BUT DAMN it sure sucks to get hundreds of pages during the day when I am not the primary caregiver of the patient.

---

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[Purifyer]

You can still be nice, just tell them to call the correct intern and hang up... Difference between being nice and being a push over

 

[justwondering]

Try "sorry, i don't know. that pt's not on my svc". they will stop calling if they get this response multiple times. and its not mean.

btw, i think everyone (iincluding us) is like this, not just nurses. if u know ur senior will be irritated if u call with a legit question, u will think 20 x's before calling them at all. u might not act that way if ur senior is cool.

 

[Faebinder]

You can still be nice, just tell them to call the correct intern and hang up... Difference between being nice and being a push over

I agree with the above statement. It's not difficult to be nice and not be a push over... You aint their page bitch but you shouldn't be the walking jerk.

 

[fab4fan]

What I don't understand is why these nurses keep paging you if you're not the intern on call.

Real life example: We have 4 'ologists in our hospital. Usually we know who is circulating, but occasionally things get mixed up, or they switch among themselves and it doesn't get communicated to us. So if we page and don't get a reply after a while, the thought process among us, and I do mean all of us is: 1) he's stuck in a case, so don't keep paging unless it's a flat out emergency; or 2) the call schedule must have changed, so call over to the OR and see who is on call now.

If someone doesn't respond after two pages in 30 min, I usually figure there's something going on and look for an alternative. I don't understand the thought process behind paging the wrong person just because he/she is nice. Too bad nurse, suck it up and page the right doc. Learn how to deal with the people who aren't "nice" by your definition. Grow a spine. It's about the patient, not you. Keep paging the "nice" people and they're going to burn out, too.

 

[fab4fan]

What part of, "You're not getting a response to the pages, maybe you're not paging the right person" do these people not get? Meanwhile, the patient suffers.

I return pages at home even when I'm not on call. This is mainly because I have had multiple instances while on-call where a nurse informs me that he/she has been paging the wrong person for an hour or more. No joke. This is fine when all you need is paperwork garbage, but sometimes it's for pain meds or BP issues, which I don't think should be ignored for that long.

 

[OTD]

Meanwhile, the patient suffers.

This is exactly why I solve the problem instead of telling them to page someone else.

I am not an intern any more so I can't say "I don't know that patient" because most of the time I do know the patient and I can take care of what is wrong quicker than they can find the right person and page them.

Many times they ARE calling the right person and they just are not returning the page (medicine is notorious for that around here). So if my name is on the chart and their patient needs help they call me. I can't count the times when I have taken care of a hypotensive patient that we were only consulted on (sometimes just for a line) because they can't get in touch with the medicine team and "your name was on the chart and you always answer your pager quickly".

Sometimes they don't look at the call schedule, they just see my name and know I won't yell at them and will take care of the problem.

I ALWAYS tell them I am not the correct one, but what does me refusing to help the patient solve? Nothing except harm the patient. So I tell them to call the proper person, and in the mean time I help the patient.

I can't say I haven't gotten more curt than I used to be though, but it gets old.

And like Tired, I always leave my pager on at home as well, for the same reasons, if they do have the call schedule screwed up waiting an hour to get ahold of someone for a hypotensive patient may be too late.

If this only occured occasionaly it would be different but it is common.

I do like the fact that the nurses that know me try not to call me at night with BS, that has gotten way better, but it's frustrating being the "dependable" one for the whole danged hospital at other times.

I was just pointing out the fact that things such as this are why sometimes very nice interns turn out to be crotchety Chiefs. They are beat over and over again with pages because they were nice.

So I am training them to call me because it gets their problem solved, and they are training me to be a jerk because they always call me. LOL.

 

[fab4fan]

I was just thinking how this is ultimately a "lose:lose" proposition because it winds up frying the people who are conscientious and rewards the people who can't figure out how to read a call-schedule or deduce that if pages aren't being returned, perhaps that doctor isn't on call.

I have no answer for that problem. I suspect that if I were in your shoes, I'd do the same thing...answer the page even if I wasn't on call. I doubt I'd be gracious about it for long.

 

[Blade28]

Once I became a second year, I also found myself more "invested" in the patient's well-being; many nights I'd leave my pager on even though I wasn't on call.

And unfortunately, the above examples are all too common. Nurses having to page a resident who's not on call is usually because the primary team/on-call resident won't return pages.

 

[Samoa]

What cracks me up is when they page me, the intern, because someone senior to me isn't returning pages. As if I could a) answer their question, or b) take my senior to task for not responding.

 

[fuzzyerin]

I'm still trying to figure out how people decide exactly who to page. I'm currently on Benign Gyn and there are four residents - intern, junior, senior, chief, and our pagers are programmed 1, 2, 3, 4 call. I'm facinated by the number of pages I get as a THREE. I was rounding with my intern when I got a call from someone in the MICU. Not someone I know in the MICU who was calling me specifically, just someone who "picked me out of the list." Who picks the THIRD person??

 

[fab4fan]

OK, I'll let you in on the secret. We have this giant dart board, and whenever we have to page a doc, we just pick up a dart and throw it at the board, and...voila! If the dart hits your name, you're paged.

 

[Blade28]

I'm still trying to figure out how people decide exactly who to page. I'm currently on Benign Gyn and there are four residents - intern, junior, senior, chief, and our pagers are programmed 1, 2, 3, 4 call. I'm facinated by the number of pages I get as a THREE. I was rounding with my intern when I got a call from someone in the MICU. Not someone I know in the MICU who was calling me specifically, just someone who "picked me out of the list." Who picks the THIRD person??

Likely they paged #1, then when no one called back within 2 minutes, they paged #2 with a similar result...two minutes later, your pager is beeping.

I'm very used to this "going down the list" mentality.

 

[Farmer Jane]

Have these people never heard of a 15-minute courtesy wait? That would drive me insane. If it's an emergency, sure, page again or page someone else. But if it's not an emergency I wait 15 minutes before paging again.

What I really love are the pager systems in which you type the message into the computer. That way I can type "1154 Jane ASAP" or "1154 Jane - when able" or "see Jane in antepartum next time you swing by" or the ever popular "pizza in breakroom"

Honestly, it can get very confusing from a nurse perspective. Where I used to work (my current hospital does not have residents) we usually had first and second call so basic L&D went to first call, anything antepartum and some things high-risk went to 2nd call, but not all things high-risk. But sometimes there was primary call, which should be called before 1st call, but that was dependent on who was primary call. It could be a 3rd year FP resident, but it could also be a 1st year. Or maybe it was a 2nd year who didn't have much OB experience. It was also dependent upon time of year. Obviously a 1st year on 1st call in August would be called for different things than a 2nd year on 1st call in March.

Me, a lot --->

 

[carrigallen]

If you are getting paged, you may consider telling the person who is supposed to be answering their pages to shape up. Really, a page should not go un-answered for longer than 7 minutes. Unless it is like a code, RRT, or emergency like that. Even for procedures you can give the pager to a nurse or med student to answer calls for you.

 

[Blade28]

Really, a page should not go un-answered for longer than 7 minutes. Unless it is like a code, RRT, or emergency like that. Even for procedures you can give the pager to a nurse or med student to answer calls for you.

Not always.

I've been alone many times, usually doing one of the following procedures:

*I&D
*Central line
*Bronch
*NJ/PEG feeding tube
*Lac repair
*Chest tube

...when there hasn't been anyone else in the room to help me. In these cases, my pager just keeps going off (especially if I'm sterile and can't touch it).

 

[Farmer Jane]

Yep. And honestly, if it's not an emergency there is no reason not to wait 15 minutes.

 

[fuzzyerin]

Likely they paged #1, then when no one called back within 2 minutes, they paged #2 with a similar result...two minutes later, your pager is beeping.

I'm very used to this "going down the list" mentality.

I'd believe that if I wasn't rounding with my intern and the attending at the time. Her pager never went off.

My other favorite is writing orders for radiology tests, which often aren't done overnight, even though you may write the order and fill out the form at 1 am, no one comes to do the test until 9 am. And it doesn't dawn on this CT tech that MAYBE I WENT HOME if I was up at 1 am writing the order. No, at 10:30 when he's reviewing the orders, my pager goes off in the middle of my sleep. Grrrrr....

 

[Blade28]

My other favorite is writing orders for radiology tests, which often aren't done overnight, even though you may write the order and fill out the form at 1 am, no one comes to do the test until 9 am. And it doesn't dawn on this CT tech that MAYBE I WENT HOME if I was up at 1 am writing the order. No, at 10:30 when he's reviewing the orders, my pager goes off in the middle of my sleep. Grrrrr....

Ah, one of the great ironies of nurses' assumptions.

When you're in-house, you can't be tired or taking a nap, because you work shifts just like they do!

But you can't ever be home and not answering your pager, either, because you work all the time!

 

[dynx]

What I really love are the pager systems in which you type the message into the computer.

I love these too. It saves me so much time.

BEEP BEEP**Mr. X has a temp of 100.3**Huh? what? ohhhh....

BEEP BEEP**Mr. ileus hasn't pooped in 4 days...MOM?** ahhhhhh.....

BEEP BEEP**Mrs should-be-dead-by-now can't sleep** sucks for her....

I have also found that you can save valuable minutes by holding the phone far from your head and shouting with your hand over your mouth CODE BLUE! then slamming down the phone, every time a nurse begins a sentance with "I was just looking over Mr. Xs chart...."

 

[Faebinder]

I love these too. It saves me so much time.

BEEP BEEP**Mr. X has a temp of 100.3**Huh? what? ohhhh....

BEEP BEEP**Mr. ileus hasn't pooped in 4 days...MOM?** ahhhhhh.....

BEEP BEEP**Mrs should-be-dead-by-now can't sleep** sucks for her....

I have also found that you can save valuable minutes by holding the phone far from your head and shouting with your hand over your mouth CODE BLUE! then slamming down the phone, every time a nurse begins a sentance with "I was just looking over Mr. Xs chart...."

 

[The Janitor]

That's the most effective use of the "sleepy" smilie ever.

 

[Blade28]

The problem with text paging is when the person leaves out their name and callback number.

 

[Farmer Jane]

I suppose that does defeat the purpose.

 

[Blade28]

You'd be surprised how many alpha pages we get with incomplete information!

For example:


Pt Smith has fever and HR 110. Do we need to start ABX?


So am I supposed to run up to the floor/ICU every time I get a page? Or call the nursing station looking for the nurse who paged? That's usually pretty painful!

Usually it's more helpful to just get paged a callback number.

 

[Farmer Jane]

Just have to point this out...

Ah, one of the great ironies of nurses' assumptions.

When you're in-house, you can't be tired or taking a nap, because you work shifts just like they do!

But you can't ever be home and not answering your pager, either, because you work all the time!

But look!

I'd believe that if I wasn't rounding with my intern and the attending at the time. Her pager never went off.

My other favorite is writing orders for radiology tests, which often aren't done overnight, even though you may write the order and fill out the form at 1 am, no one comes to do the test until 9 am. And it doesn't dawn on this CT tech that MAYBE I WENT HOME if I was up at 1 am writing the order. No, at 10:30 when he's reviewing the orders, my pager goes off in the middle of my sleep. Grrrrr....

It's not always us!

 

[Farmer Jane]

Methinks what is really needed is a "Introductory Critical Thinking and Common Courtesy to Others" class upon being hired in any position in healthcare.

 

[Blade28]

It's definitely not just the nurses - pharmacy and Radiology are both notorious for paging at very inappropriate times.

 

[MR1]

Nothing like getting paged for a med order you wrote two rotations ago . . .

This is by far one of my favorites, here it usually happens at our VA where anyone, even the patient care techs, can "flag" orders you put in. These usually happen 1-2 mths later of course

But I guess it's to be expected when our attendings and senior residents make it clear to the entire hospital that we are not deserving of any respect or consideration.

I have always wondered why this is? Here though it is mainly the attendings, our seniors are usually pretty good.

 

[telenurse]

Personally, I would prefer a policy where no one except the RNs are permitted to page us. That way, I wouldn't get all the nonsense pages from other departments asking for clarification and "critical lab values" that the bedside RN could easily handle. Despite my frequent venting about nurses, they tend to be far better at discerning what they need to call for, and what can wait (90%, anyway). It is tragic that our pager numbers are passed around so freely.

But I guess it's to be expected when our attendings and senior residents make it clear to the entire hospital that we are not deserving of any respect or consideration.

You'd hate this newest thing...the nurses just got dinged because we haven't been calling the docs on critical ptt's. Why haven't the nurses been calling the docs on critical ptt's? Because 100% of the critical ptt's the docs haven't been notified of occurred when the pt is on a heparin gtt, and the heparin gtt protocol gives clearly defined instruction on what to do for critical ptt's. Basically stop the freaking gtt for an hour and restart at 150 units/hour slower rate .
I see it now at 0300.
Resident:You paged.
Telenurse: I have Mr. ABCD, ACS II on heparin gtt, critical ptt <300, can I follow protocol.
Resident: WTF, of course <click>

1/25/08 0300
re: critical ptt, ok to follow heparin protocol and hold heparin gtt for one hour, restart at 850 units/hour . TORB Anyresident/telenurse RN.

 

[Blade28]

I'm so used to seeing:

TO RBAV

or

VO RBAV

it's not even funny.

 

[Gastrapathy]

This is exactly why I solve the problem instead of telling them to page someone else.
.

I have to say I have a problem with this as a medicine staff. An intern on a consulting service (Ortho!?!?) got a call on one of my team's patients for hypotension during a blood transfusion after my intern didn't call back. His answer was to stop the blood. Of course, the hypotension was from HEMORRHAGE!!!!! not a transfusion reaction. My intern claimed he didn't get the page (probably true) and this intern decided to act to "help out." They could have paged my resident, they could have paged me. If its not your patient and its not a code, "solving the problem" is really beyond the appropriate scope of your care. You want to evaluate my patient and call me, fine but don't go writing orders the primary team doesn't know about.

 

[fab4fan]

I'm so used to seeing:

TO RBAV

or

VO RBAV

it's not even funny.

We're equally sick of writing it. Add it to more mind-numbing medical minutiae required by JCAHO. Trust me, if we didn't have to write it, we wouldn't.

 

[OTD]

I have to say I have a problem with this as a medicine staff. An intern on a consulting service (Ortho!?!?) got a call on one of my team's patients for hypotension during a blood transfusion after my intern didn't call back. His answer was to stop the blood. Of course, the hypotension was from HEMORRHAGE!!!!! not a transfusion reaction. My intern claimed he didn't get the page (probably true) and this intern decided to act to "help out." They could have paged my resident, they could have paged me. If its not your patient and its not a code, "solving the problem" is really beyond the appropriate scope of your care. You want to evaluate my patient and call me, fine but don't go writing orders the primary team doesn't know about.

"Solving the problem" is NOT beyond my scope of care period. I'm not an intern any more but even so all my interventions are carried up the chain of command. I don't go cowboy or anything, but I DO take care of things that need to be taken care of and the calls are at the appropriate time, in other words someone with a tension PTX gets the chest tube BEFORE I call the Sr/Attending, someone with an asymptomatic PTX gets the tube AFTER I call.

If it's a surgery patient then it is on my team anyway, it just may not be the patient I take care of every day.

If it's a medicine patient, well they want us to take care of all their patients anyway to the point of consulting for constipation so they really could care less. Trust me, for me to intervene on a medicine patient as much as they abuse the "consult" order it needs to be serious. However, it's not that unusual for me to do so simply because it's not unusual for them to not return their pages (multiple, multiple pages).

Besides, even if it is a patient we are consulted on then more likely than not I actually know more about the patient than their primary medicine team

If you have a problem with other people saving your patients life then I would suggest you make sure your residents answer their pages/know their patients. Then the nurses won't NEED to call for help from outside services and everybody's happy.

 

[SocialistMD]

It's definitely not just the nurses - pharmacy and Radiology are both notorious for paging at very inappropriate times.

That's what is nice about service pagers; you just put the service pager (rather than your personal number) down under your name and that is the number they call.

To address the original concern of being called about patients not on your service, isn't something that's ever upset me, because it is a lot less work when it isn't my patient. I simply make sure the patient is stable and then tell them they need to call the appropriate service. I have had one instance when the patient was crashing and they weren't on my service where I told them to page the correct person and went to the floor to manage the patient until the primary team arrived (much like being the first to respond to a code). Truth be told, this has only really happened to me while moonlighting, because at my hospital the surgical patients are all on two floors and divided into units based on the particular service, the nametags on the charts being color-coded to signify which service.

I think that managing the patients from other services, even if you know them, is a bad move. Making sure they are okay is one thing but how would you like it if you came in to find several orders had been written for your patient that you didn't know happened? I would be pretty pissed, but maybe that's just me. We were just having a discussion in the surgery forums about how the on-call residents should know everything that has happened overnight for their patients and how much "fun" it is to find out things happened overnight without your knowledge.

 

[Trifling Jester]

"Solving the problem" is NOT beyond my scope of care period. I'm not an intern any more but even so all my interventions are carried up the chain of command. I don't go cowboy or anything, but I DO take care of things that need to be taken care of and the calls are at the appropriate time, in other words someone with a tension PTX gets the chest tube BEFORE I call the Sr/Attending, someone with an asymptomatic PTX gets the tube AFTER I call.

If it's a surgery patient then it is on my team anyway, it just may not be the patient I take care of every day.

If it's a medicine patient, well they want us to take care of all their patients anyway to the point of consulting for constipation so they really could care less. Trust me, for me to intervene on a medicine patient as much as they abuse the "consult" order it needs to be serious. However, it's not that unusual for me to do so simply because it's not unusual for them to not return their pages (multiple, multiple pages).

Besides, even if it is a patient we are consulted on then more likely than not I actually know more about the patient than their primary medicine team

If you have a problem with other people saving your patients life then I would suggest you make sure your residents answer their pages/know their patients. Then the nurses won't NEED to call for help from outside services and everybody's happy.

This may vary by hospital, but at most places it is considered good form to preface all orders on patients outside of your service with "If ok with primary team:" That way everyone's on the same page.

-The Trifling Jester

 

[OTD]

This may vary by hospital, but at most places it is considered good form to preface all orders on patients outside of your service with "If ok with primary team:" That way everyone's on the same page.

-The Trifling Jester

Agreed but you are forgetting the most important part, if it's a patient that is not on my service then they have tried to get ahold of the primary team multiple times and they just aren't answering. IF I write an order on them then it was serious enough that there isn't time to continue to unsucessfully contact the primary team, something needed to be done NOW. You bet your @$$ when I am taking care of another services crumping patient I am having the nurses continue to try and get ahold of them to get down here and take care of THEIR patient, but I am not going to let someone die and say "it's not my patient". See what I am saying?

As I said before if it's a surgery patient then I just take care of it after talking to the appropriate Chief if needed and tell the appropriate resident what I did (which is a good segway for me to find out just why the hell they couldn't get ahold of him/her).

I disagree with the "if ok with primary team" part of the order. IMO it's not the nurses job to check with the primary team. As a consultant it's MY job to talk to the primary team and make sure we are on the same page, doctor to doctor. I think it's poor form to have a nurse call a consult or call the primary team for us. I think we should talk to each other.

 

[SocialistMD]

IMO it's not the nurses job to check with the primary team. As a consultant it's MY job to talk to the primary team and make sure we are on the same page, doctor to doctor. I think it's poor form to have a nurse call a consult or call the primary team for us. I think we should talk to each other.

So, you're telling me that you are willing to do the grunt work and track down the primary team's residents for the nurse simply because s/he called you? Would you do the same for a patient on whom you are not consulting? I don't really see the difference; you are still doing the grunt work when you were inadvertently brought into the equation. Are you also one of those people who runs in and takes over a code on a medicine patient?

It is absolutely the nurse's job to check with the primary team as that is the team who should be writing the orders you just gave. Again, I say how would you like it if the nurses paged cardiology because you were busy in the OR and they started something on your patient concerning something having nothing to do with the consult? I don't think you have any place making patient management decisions (unless the patient is actively dying) outside of the scope for which you were consulted. Otherwise, what is the point of having a primary service (and there have been cases when we have taken a patient on our service to ensure better care)?

Crashing patients aside, I'm not going to track down the primary team to find out if it is okay for a patient to have some ambien for sleep simply because the nurse paged me. I am the hospital's whipping boy enough as a general surgery resident; I don't need to add to that plate by letting the nurses know they can pawn off their work on me because I'm a nice guy. You have way too much time on your hands.

 

[Blade28]

I am the hospital's whipping boy enough as a general surgery resident

Ain't that the sad truth.

 

[oompaloompa]

I have also found that you can save valuable minutes by holding the phone far from your head and shouting with your hand over your mouth CODE BLUE! then slamming down the phone, every time a nurse begins a sentance with "I was just looking over Mr. Xs chart...."

I inwardly cringe whenever I hear this phrase. It's fine with me if a nurse wants to do extensive documentation review at 3am, but there are very few things that she can discover that can't wait 3 hours for the primary team. Why the sudden urgency for something that obviously hasn't been missed for the past 2 days? I always want to ask them: "Would you interrupt your (protected) lunch break to do this? No?" I try to be polite though - but it's frustrating.

 

[OTD]

So, you're telling me that you are willing to do the grunt work and track down the primary team's residents for the nurse simply because s/he called you? Would you do the same for a patient on whom you are not consulting? I don't really see the difference; you are still doing the grunt work when you were inadvertently brought into the equation. Are you also one of those people who runs in and takes over a code on a medicine patient?

SocialistMD, you need to pay attention to what I actually posted.

If you will look back you will see that I have said countless times if it was a Medicine patient that they would have to be in deep trouble before I did anything, not meds or other routine things. The bad/sad thing is that this happens at least once per month. The most recent one was when we were consulted about a peg tube with "drainage" and the patient became hypotensive 40's and 50's systolic, and medicine wouldn't return their pages. Do you expect me to let them die because we are only consultants? I went and took care of the patient while having them to page medicine relentlessly. After about an hour I had the patient stable they STILL hadn't called back (this was well over an hour total because they tried to get them for as long as they could before they paged me). Once the patient was stable and I told the nurses to make da**** sure the primary team knew what happened and I left a detailed note as to what I did. I didn't try and get ahold of them then because I didn't have time to and obviously they weren't returning calls at that time. I believe it was over 2 hours before they finally got in touch with someone from the primary team to let them know what had happened. Those are the things I am talking about.

As far as codes, the only way I step foot into a room with a code is if I am the only doctor around or if I am called for airway/lines. I leave ASAP too because as a Surgery resident I am on the run all day.

That grunt work you talk about is just plain communication. This may come as a shock to you but when I consult a service, say ID or something, I ::gasp:: actually CALL the other physician myself. It's not the nurses job to call them with a consult and then have the frustrated consultant have questions the nurse can't answer. I call and give a presentation to the service and exactly why we are consulting them. It's just unprofessional in my opinion to write "consult service X" and not contact them yourself. The consulting team deserves a call from you. Don't you get frustrated with the "consult surgery for central line" and the nurse calling you the consult doesn't know why they may want a line?

As a consultant I try to contact the primary team myself if anything major changes etc. to make sure we are on the same page. I don't put the nurses in the middle, if we don't agree on a plan/procedure I talk to them directly. Nurses shouldn't be put into that situation. For routine orders there is no reason to write "if OK with primary team". They consulted us for a reason.

As for me writing orders on Surgery patients that I am not rounding on daily, well it's a non issue other than why they couldn't get ahold of the proper resident. We all work together and anything like that is discussed. There are no "surprise" rounds, the resident that normally takes care of the patient gets informed.

 

[Trifling Jester]

Agreed but you are forgetting the most important part, if it's a patient that is not on my service then they have tried to get ahold of the primary team multiple times and they just aren't answering. IF I write an order on them then it was serious enough that there isn't time to continue to unsucessfully contact the primary team, something needed to be done NOW. You bet your @$$ when I am taking care of another services crumping patient I am having the nurses continue to try and get ahold of them to get down here and take care of THEIR patient, but I am not going to let someone die and say "it's not my patient". See what I am saying?

Ok, I missed the part where the pt was crumping. Yeah, I'd say it was proper to intervene on a crashing or nearly coding patient if you're already consulted and nearby while the primary team isn't available.

As I said before if it's a surgery patient then I just take care of it after talking to the appropriate Chief if needed and tell the appropriate resident what I did (which is a good segway for me to find out just why the hell they couldn't get ahold of him/her).

I disagree with the "if ok with primary team" part of the order. IMO it's not the nurses job to check with the primary team. As a consultant it's MY job to talk to the primary team and make sure we are on the same page, doctor to doctor. I think it's poor form to have a nurse call a consult or call the primary team for us. I think we should talk to each other.

I agree, consults should be called and discussed. But after the initial consult, while following the pt we write orders on them constantly. It would be too time consuming to discuss each and every medicine or lab value we wanted to order. And with such widely disparate fields you don't want to step on anyone's toes or order some totally inappropriate medicine. I think there definately a time and place for "if OK with primary team."

-The Trifling Jester

 

[SocialistMD]

Ok, I missed the part where the pt was crumping. Yeah, I'd say it was proper to intervene on a crashing or nearly coding patient if you're already consulted and nearby while the primary team isn't available.

So did I. Glad to see I'm not the only one who has trouble finding such statements in those posts (despite their presence "multiple times").

This may come as a shock to you but when I consult a service, say ID or something, I ::gasp:: actually CALL the other physician myself.

Are there actually residencies where the nurse calls consults?

Perhaps you should pay attention to what I posted as much as I to you, as I explicitly defined the grunt work in this case as hunting down the primary team for the nurse when s/he pages you because s/he can't get ahold of the primary team. Writing "consult x for y" is an invalid order at my hospital, and I wouldn't do that even if I could, as I completely agree with you that I need to communicate to the service I'm consulting exactly what I want.

I guess we agree on things. It just seemed as if you were arguing that it is better to answer the questions the nurses have on every patient call rather than just the urgent ones.

 

[telenurse]

So did I. Glad to see I'm not the only one who has trouble finding such statements in those posts (despite their presence "multiple times").


Are there actually residencies where the nurse calls consults?

Perhaps you should pay attention to what I posted as much as I to you, as I explicitly defined the grunt work in this case as hunting down the primary team for the nurse when s/he pages you because s/he can't get ahold of the primary team. Writing "consult x for y" is an invalid order at my hospital, and I wouldn't do that even if I could, as I completely agree with you that I need to communicate to the service I'm consulting exactly what I want.

I guess we agree on things. It just seemed as if you were arguing that it is better to answer the questions the nurses have on every patient call rather than just the urgent ones.

Story from last night, nurse's take. Pt has 0200 chemsticks ordered, BUT no orders for insulin to be given at 0200. Pt blood sugar 580, pt NPO for surgery, pt brittle diabetic, only off insulin gtt for 48 hours. Pt has infected sternal wound, s/p sternotomy and is going for flap closure by plastics, so blood sugar control is kinda important, as surgery has been postponed x1 do to glucose problems.

Page primary service cover...get told "Endocrine is covering sugars and insulin, page endocrine". Note that NOWHERE in the chart, orders or in notes does it state that nurses are to refer to endocrine for blood glucose/insulin orders. Page resident covering endocrine. Resident has NO idea who this pt is, chews my @ss off, tells me to call primary back, and refuses to write order. page H.O., H.O. refused to help or intervene.

Page primary service cover, get my @ss chewed again. Page resident covering endo back, with order from primary service to have him cover the glucose level, he refuses. Page Endo fellow. get called everything but a child of God, refused to have his resident write order, even though I now have an order from PA-C to call endo for orders and have Endo call PA-C for questions. Page the CARDIAC SURGERY MD, who is the primary doc for pt, at home, have him call his PA-C, the Endo fellow, the endo resident and I finally get my order for 12 stinking units of novolog subcut. I don't usually lose it at work...but I was so frustrated I wanted to throw things against the wall...

Remember this is all happening between 0200 and 0400

 

[Faebinder]

Story from last night, nurse's take. Pt has 0200 chemsticks ordered, BUT no orders for insulin to be given at 0200. Pt blood sugar 580, pt NPO for surgery, pt brittle diabetic, only off insulin gtt for 48 hours. Pt has infected sternal wound, s/p sternotomy and is going for flap closure by plastics, so blood sugar control is kinda important, as surgery has been postponed x1 do to glucose problems.

Page primary service cover...get told "Endocrine is covering sugars and insulin, page endocrine". Note that NOWHERE in the chart, orders or in notes does it state that nurses are to refer to endocrine for blood glucose/insulin orders. Page resident covering endocrine. Resident has NO idea who this pt is, chews my @ss off, tells me to call primary back, and refuses to write order. page H.O., H.O. refused to help or intervene.

Page primary service cover, get my @ss chewed again. Page resident covering endo back, with order from primary service to have him cover the glucose level, he refuses. Page Endo fellow. get called everything but a child of God, refused to have his resident write order, even though I now have an order from PA-C to call endo for orders and have Endo call PA-C for questions. Page the CARDIAC SURGERY MD, who is the primary doc for pt, at home, have him call his PA-C, the Endo fellow, the endo resident and I finally get my order for 12 stinking units of novolog subcut. I don't usually lose it at work...but I was so frustrated I wanted to throw things against the wall...

Remember this is all happening between 0200 and 0400

If I were the patient or his family, I'd complain to someone from the hospital that the admitting physician did not take care of my diabetes. That should spark a nice talk between cardiac surgery and the hospital. The truth is, you are primary... you handle insulin. If you want endocrine to handle insulin then don't expect a stat service from them... they are endocrine not code blue team. Was there a resident handling the admission or was it the PA-C of the cardiac surgeon that did the admission.. either case someone deserves a little talking to.

 

[OTD]

I guess we agree on things. It just seemed as if you were arguing that it is better to answer the questions the nurses have on every patient call rather than just the urgent ones.

Yes, we do agree on more things than you think. If it's not urgent I tell them it's not our patient that we are only consultants.

It is difficult to come across exactly as you want in posts on a message board but believe me I do NOT look for things to do on other peoples patients. If you will go back and look you will see in multiple posts, sometimes miltiple times in the same post, I am talking about things like hypotension etc, crumping patients. Of course I also realize that I know the intent of what I am saying and for the reader it is easy to get missed on a message board.

I just happen to be at a place with a really bad IM service that doesn't actually treat anybody, they just admit and consult. (This is NOT the IM residency, this is a private group that doesn't have residents. The residents are actually fairly decent about having their consults be legit and actually attempting to treat their patients).

One particular time I was the 5th consult on the list, the FIRST person to actually see the patient. This was the ever present constipation but we were consulted for "abdominal pain" so they would have someone to actually treat the constipation. The admitting physician hadn't even laid eyes on the patient, just admitted with a preprinted order sheet and gave verbal orders for 5 consults. My ink was the first ink on the chart, no H&P, no note of any kind except mine, the 5th consultant. No this group doesn't call their consults, the unit secretary does this from the order sheet and if we need to know something (is the patient stable?) we have to get her to get the nurse on the line (this is actually common across all practices around here). It is EXTREMELY frustrating to have all these phantom consults that you know nothing about until some secretary calls you.

From the same group a consult for free air one morning during rounds, it was what we call "discovery rounds" where someone just showed up on the list. They had free air and they had a CXR the night before showing the massive level of free air. The primary team decided to get a CT scan to confirm the results which they got done about 5 or 6 am.. Why they would do this I don't know. However they STILL didn't call the consult. The consult was just on the chart, for the secretary to call to us, no call from the primary team (the patient showed up on the list after the residents had rounded but before the attending hence the attending was the only one with this patient on her list). We happened to find the patient at about 7am, before the secretary had called us.

I figgured this kind of crap went on elsewhere and is one reason I firmly believe in actually calling the consultant and communicating between physicians.

Sorry for any misunderstanding.

My premise is that because the nurses know I won't yell at them they naturally call me more when this type of situation occurs. In the situation above where it took them about 2 hours to get ahold of the team I was actually with my chief and attending rounding one Saturday. They could have called the attending, or the chief, but it was my pager that went off instead. We are all on the call list and the patient was crumping, but they called me (for which the attending and chief were very thankful I would guess LOL).

 

[Pir8DeacDoc]

Story from last night, nurse's take. Pt has 0200 chemsticks ordered, BUT no orders for insulin to be given at 0200. Pt blood sugar 580, pt NPO for surgery, pt brittle diabetic, only off insulin gtt for 48 hours. Pt has infected sternal wound, s/p sternotomy and is going for flap closure by plastics, so blood sugar control is kinda important, as surgery has been postponed x1 do to glucose problems.

Page primary service cover...get told "Endocrine is covering sugars and insulin, page endocrine". Note that NOWHERE in the chart, orders or in notes does it state that nurses are to refer to endocrine for blood glucose/insulin orders. Page resident covering endocrine. Resident has NO idea who this pt is, chews my @ss off, tells me to call primary back, and refuses to write order. page H.O., H.O. refused to help or intervene.

Page primary service cover, get my @ss chewed again. Page resident covering endo back, with order from primary service to have him cover the glucose level, he refuses. Page Endo fellow. get called everything but a child of God, refused to have his resident write order, even though I now have an order from PA-C to call endo for orders and have Endo call PA-C for questions. Page the CARDIAC SURGERY MD, who is the primary doc for pt, at home, have him call his PA-C, the Endo fellow, the endo resident and I finally get my order for 12 stinking units of novolog subcut. I don't usually lose it at work...but I was so frustrated I wanted to throw things against the wall...

Remember this is all happening between 0200 and 0400

sounds like your CT PA or resident is a beeyotch. What a lame thing to call an endo consult at 0300. No one wants to come up with a comprehensive care plan on a consult at 0300.Get off your *** and at least write some sliding scale orders. Get endo on board post-op to help maximize care then.

 

[telenurse]

At my hospital, once it got to this point, the whole f-ing world fell down on the heads of everyone you listed here.

Doctors don't scare me...but trust me...this is one doc that you cross all t's and dot all i's with. He has the CNA's so intimidated that all his daily weights are done before any other pt's and are charted in the computer, then the CNA's go and weigh the other pt's.

I don't know how it all came down...but as this surgeon will freely berate nurses loudly in the nurse's station if a pt's cup of ice chips melted to water and the pt has orders for ice chips only, it had to have been interesting.

 

[justwondering]

but as this surgeon will freely berate nurses loudly in the nurse's station if a pt's cup of ice chips melted to water and the pt has orders for ice chips only, it had to have been interesting.

sounds like a jerk.
but i was always suspicious about allowing pts ice chips when they're not supposed to be drinking h2o. if i was some noncompliant pt, id probably wait until it melted a bit.