Writing Nurses Up

[TUCOMSam]

So, haven't seen this thread on here, so figured I'd start it.

So I wrote my first nurse up last night while on night block. I'm on medicine and was cross-covering a s/p lumbar laminectomy patient. Around midnight the patient fell out of bed after being left sitting on the side of the bed (even though she was on falls precautions). Anyway, fell out of bed face first and had a good 'ol nose bleed. So fast-forward 6hrs... now 6am and i get a call from the nurse for that patient...
"Hi Dr. TucomSam, this is Nurse Careless. I just wanted to inform you that there was a little incident last night with your patient in 4012, Mrs. Cantstandwell. She fell and had a nose bleed, but we got it taken care of."

"Excuse me? Why wasn't I informed of this until now?!?"

"Well, Dr., with everything going on last night with your patient who had to be transferred to the ICU, we just didn't have time to tell you. I'm really sorry. She's ok now though."

"She's ok now?? How exactly do you know that? Do you clear C-spines now? Furthermore, if this happened while I was UP there (at midnight) how difficult would it be to tell me in 5 words what had happened?"

"I'm really sorry... it's just that with all the commotion--"

"--Please don't make excuses. This was your responsibility to inform me and you did not. I'll be up there in 2 minutes."


So... that's pretty much how it played out... hated to write the nurse up, but seems pretty unacceptable to me. Can't wait for the backlash from that unit now! They're all a big hospital clique, so I'll probably be in for 2am calls about 110/75 BPs! Anyway, just venting.

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[deleted87716]

Can't wait for the backlash from that unit now!

Yup, you're pretty much screwed.

I don't think I ever wrote up a nurse as a resident. I did have a little private chat with a couple of them, when they did something extraordinarily inappropriate. That usually took care of things. I preferred to foster a "you watch my back, I'll watch yours" relationship with the nursing staff, as opposed to an adversarial one. Your mileage may vary.

 

[elwademd]

not sure whether it's forunate or unfortunate, but i've learned not to write nurses up. in my hospital, an incident report has to be made. but exactly who does the write up, in a word, doesn't matter.

i've had similar situations (patient bleeding for 13 hours, no one was told), and i referred the case to the charge nurse. the charge nurse would then reprimand the nurse, and write up the incident report. the end result is the same, but somehow the nurses see it differently.

as i said, i'm not sure if it's fortunate or unfortunate... perhaps right or wrong would be a better term. i suppose as long as the situation is written up, it doesn't matter who does it.

cliff notes: my idea is to refer situations like this to the charge nurse

 

[Dr JPH]

I would have the Attending deal with this. Give them the story and see where it goes.

If the patients attending doesnt care enough to write it up, then you shouldnt worry about it.

If the patients attending is pissed then he/she will deal with the nurse in question and the nurse manager.

No need for a resident to do anything more than pass along information.

 

[Tired]

No need for a resident to do anything more than pass along information.

I agree, with the caveat that you treat the patient as though the incident just happened. In this case, that would have meant immediate clinical exam, spine precautions, head and C-spine CTs, no matter how "good" they looked now. You can pass along the info, but you still have to CYA in a case like this.

 

[nabeya]

Wow, somebody is definitely on a power trip. Guess they feel like they need to get back at the "system" for when they were a miserable med student.

 

[Chronic Student]

Poor bastard.

Mike shakes head and looks away.

 

[snoopy brown]

The problem with this subject is that it's like a lot of things in medicine. It's like you have to pick between doing the right thing and getting along. It's absolutely true what people say that you don't need to report people for things that aren't big, that don't affect patient care. That's equally immature on the physician's part. But it's also absolutely true that even when things do affect patient care the vast vast majority of physicians will hem and haw and go, "well, this wasn't that big." And that's OK, too, because we're all human except that it's always one-sided.

What I mean is this. If you as a resident had some guy fall and didn't evaluate them, that would be like murder. You'd be reprimanded, you'd be ripped a new one. But insert a nurse in the middle of that equation and suddenly everyone is all Kumbayah. How does this help the patient? Or correct the problem? Isn't that why some of these problems recur?

And look, it's juvenile like I said for a physician to be like "wow, you made a mistake so you get written up!" Clearly there needs to be consideration on what is important and what isn't. But in the case where a nurse should be written up, why is it that you must do so in absolute terror of retribution for months to come? What's that all about? That's really sad.


Edit: One other thing on the one-sided aspect. When something wrong happens, some big thing, you don't see nurses going "let's not write this up because then the doctor will be mad." They just do it. And if you complain then you're wrong. This should be the exact same way.

 

[elwademd]

The problem with this subject is that it's like a lot of things in medicine. It's like you have to pick between doing the right thing and getting along. It's absolutely true what people say that you don't need to report people for things that aren't big, that don't affect patient care. That's equally immature on the physician's part. But it's also absolutely true that even when things do affect patient care the vast vast majority of physicians will hem and haw and go, "well, this wasn't that big." And that's OK, too, because we're all human except that it's always one-sided.

What I mean is this. If you as a resident had some guy fall and didn't evaluate them, that would be like murder. You'd be reprimanded, you'd be ripped a new one. But insert a nurse in the middle of that equation and suddenly everyone is all Kumbayah. How does this help the patient? Or correct the problem? Isn't that why some of these problems recur?

And look, it's juvenile like I said for a physician to be like "wow, you made a mistake so you get written up!" Clearly there needs to be consideration on what is important and what isn't. But in the case where a nurse should be written up, why is it that you must do so in absolute terror of retribution for months to come? What's that all about? That's really sad.


Edit: One other thing on the one-sided aspect. When something wrong happens, some big thing, you don't see nurses going "let's not write this up because then the doctor will be mad." They just do it. And if you complain then you're wrong. This should be the exact same way.

perhaps i was a bit unclear in my above post. i agree with seeing and treating the patient. that's a given that i assumed would be done, but then we all know what happens when one assumes, lol.

however, the next issue, once the patient has been cared for and treated (or during the course of treatment), is the next step. and it's the next step where things can, at least for some, get murky.

should the nurse be written up? sure.
the question, in my mind at least, is who should do the write up... i.e. who should fill out the incident report.

in my experience, it doesn't behoove a resident to personally write a nurse up, given the potential likelihood of backlash. this is why i suggested going to the charge nurse, informing him/her, and allowing the charge nurse to fill out the incident report.
also, strangely enough, some nurses will fill out their own incident reports. but, you have to take the time to ask if an incident report was filled out! lol.

and, unfortunately, there is a double standard. i'd be interested to hear ideas about how it could be resolved, as i certainly don't have any.

 

[snoopy brown]

perhaps i was a bit unclear in my above post. i agree with seeing and treating the patient. that's a given that i assumed would be done, but then we all know what happens when one assumes, lol.

No, sorry, I was the one who was unclear. I was not referring to anything you said. I was just presenting it as "well, if the nurse ignores the fall it's OK but if the resident ignores the fall it's big trouble." That's all I meant, not that you were saying not to see the patient.

in my experience, it doesn't behoove a resident to personally write a nurse up, given the potential likelihood of backlash.

That's the problem I have. Like you say, there is definitely a double standard and that's the problem. If something is wrong, it should just be wrong. It shouldn't be "lousy resident, writing me up, I'll show him." Just correct the porblem.

 

[dralex]

bad move.
The way you treat the nurses and staff can make the difference between a pleasant internship and pure hell.
If something like this ever happens again you should let your senior know about this or tell your attending.
Good luck with the rest of your internship (and residency if you stay there). I'm sure you just made a lot of new friends there...

 

[snoopy brown]

bad move.
The way you treat the nurses and staff can make the difference between a pleasant internship and pure hell.

Wait, so treating them like responsible people who should do their job is the road to hell?

 

[deleted109597]

Yeah, because nurses never write up the residents. Ever.
Granted, there shouldn't be the everpresent animosity, but I doubt that any of us will change any of it.

 

[dralex]

Wait, so treating them like responsible people who should do their job is the road to hell?

My statement was meant for the OP.
But while you bring it up if you want to treat them responsibly you speak to them in person about any issue instead of "writing them up" (which is different from an accident/incident report).
The nurses themselves should be handling the incident report, the intern or resident is called to check on the patient and finish filling out the form. In this case the OP should have told his senior.
There's enough scut for an intern to do don't bring yourself more misery.
Best of luck to all you guys in your internship year. As "A Tale of Two Cities" starts out... "It was the best of times, it was the worst of times."

 

[snoopy brown]

But while you bring it up if you want to treat them responsibly you speak to them in person about any issue instead of "writing them up" (which is different from an accident/incident report).

Right, so someone should talk to nurses because they write up residents. And if that happens the same people say "well, you're a professional, so retribution would be completely uncalled for." I'm quite fine with people just talking instead of writing up others, but if it's not equal both ways then you're just making excuses. In the same manner if you're OK with letting nursing mistakes that impact patient care slide then be the same way with residents. You probably think I'm being antagonistic, but since all I'm asking for is parity I'd say I'm just being reasonable.

 

[dralex]

In this specific case, a patient falling out of bed, an incident report should have been filled out by the floor nurse.
The point that I am getting at is that the intern should have told their senior resident about this issue and not have taken matters into their own hands.
Most nurses are pretty good, but like all people, some are just bitter.
The only people they really get to "pick on" are the PGY-1's, the interns (ok, and the med students too.) This is the one time when they get to "stick it to the doctor" if you will.
Make no mistake, a nurse wields amazing power over an intern. You can either get a page every half hour for a tylenol order, or if you are in good terms with the nurses you will get a reminder in the morning to come and sign an order for the tylenol that was given already. Be nice to the nurses and they will treat you like gold.
Just my very humble advice, you are all welcome to do with it what you will.

 

[Dr JPH]

and, unfortunately, there is a double standard.

There should be a double standard...we are doctors and they are nurses.

Afterall, you cant get mad at a monkey for throwing his own $hit now can you?

Another way to put it...

When you know better you dont make the same mistakes.

 

[caroladybelle]

No, sorry, I was the one who was unclear. I was not referring to anything you said. I was just presenting it as "well, if the nurse ignores the fall it's OK but if the resident ignores the fall it's big trouble." That's all I meant, not that you were saying not to see the patient.

You really don't want to know how many times that I have called immediately on a pt fall - in my department, that usually means platelets below 25, and negligible white count - and had an intern or a resident blow it off until the attending shows up 9 hours later and ask for xrays/CT results.

Not to mention calling a community MD, and get the infamous, "Well, what the Hell do you want me to do about it" - CLICK!, and the phone line is dead.

Most facilities, especially teaching hospitals have strict policies on calling the MD ASAP on falls.

The best person to write up any individual is that individual's supervisor. In the case of nurses, that means their charge nurse or unit director. Because quite frankly, attendings do not hire, fire or supervise us. And if it is to do any good, it needs to go to that individual's boss.

As to getting results, it depends on how valid it is. No one wants to work with an incompetent nurse...they make us as a whole look bad, and I for one hate following or cleaning up after a ***** (MD/nurse/RT/whatever). There are plenty of people I work with in different hospital departments that I would rather see elsewhere. A few different dpartments complaining to the manager can help "free up" their future.

But I have also seen plenty of interns and residents act like dangerous *****s, and write up stuff that gets their own butt kicked, by both the staff and the MDs. Make sure that what you call a fellow health care professional on the carpet for is valid, or it can be your butt in a sling.

(Had one intern that tried to write me up - his attending chewed him out the next day and had his fellow MDs ready to string up within a month - he left the facility shortly thereafter)

 

[caroladybelle]

There should be a double standard...we are doctors and they are nurses.

Afterall, you cant get mad at a monkey for throwing his own $hit now can you?

Sorry but when MD monkeys start throwing their own ****, we make them clean it up themselves. Or restrict that behavior to their on-call rooms.

 

[Dr JPH]

You really don't want to know how many times that I have called immediately on a pt fall - in my department, that usually means platelets below 25, and negligible white count - and had an intern or a resident blow it off until the attending shows up 9 hours later and ask for xrays/CT results.

Not to mention calling a community MD, and get the infamous, "Well, what the Hell do you want me to do about it" - CLICK!, and the phone line is dead.

Most facilities, especially teaching hospitals have strict policies on calling the MD ASAP on falls.

The best person to write up any individual is that individual's supervisor. In the case of nurses, that means their charge nurse or unit director. Because quite frankly, attendings do not hire, fire or supervise us. And if it is to do any good, it needs to go to that individual's boss.

As to getting results, it depends on how valid it is. No one wants to work with an incompetent nurse...they make us as a whole look bad, and I for one hate following or cleaning up after a ***** (MD/nurse/RT/whatever). There are plenty of people I work with in different hospital departments that I would rather see elsewhere. A few different dpartments complaining to the manager can help "free up" their future.

But I have also seen plenty of interns and residents act like dangerous *****s, and write up stuff that gets their own butt kicked, by both the staff and the MDs. Make sure that what you call a fellow health care professional on the carpet for is valid, or it can be your butt in a sling.

(Had one intern that tried to write me up - his attending chewed him out the next day and had his fellow MDs ready to string up within a month - he left the facility shortly thereafter)

Out of curiosity, are you defending this particular nurses actions?

 

[Dr JPH]

Sorry but when MD monkeys start throwing their own ****, we make them clean it up themselves. Or restrict that behavior to their on-call rooms.

Um. I think you missed my point.

 

[snoopy brown]

You really don't want to know how many times that I have called immediately on a pt fall - in my department, that usually means platelets below 25, and negligible white count - and had an intern or a resident blow it off until the attending shows up 9 hours later and ask for xrays/CT results.

Sure I've seen that too. I think you're missing the point. I never said physicians don't do stuff like that. They do, OK? But when they do, they get reamed up the butt by everyone. Now, maybe you nurses are reaming each other for stuff like that but I somehow would doubt that. Believe me when an intern or resident is underperforming they know it because everyone lets them know in a not-cordial manner. Again maybe nurses are doing that to each other but I've seen them and it's usually "geez, what's that doctor's problem, girl?" "Oh, he's just an a**hole." "That's what I thought."

 

[snoopy brown]

(Had one intern that tried to write me up - his attending chewed him out the next day and had his fellow MDs ready to string up within a month - he left the facility shortly thereafter)

This only supports everything I said. What, you mean you can never be written up? That's against the law? Or that he tried to write you up for no reason? If that's the case, that's enough to get everyone to ride him out of town? That's firing time? Seriously that's sad either way. I know you take satisfaction in your power or untouchability but it's misplaced. As you can see most people would rather allow stuff to happen and get along, everyone is recommending people just let things slide "or else." So I can see why the attending and physicians reamed the guy out. They would never chew out or string up a nurse, though.

 

[deleted109597]

Make no mistake, a nurse wields amazing power over an intern. You can either get a page every half hour for a tylenol order, or if you are in good terms with the nurses you will get a reminder in the morning to come and sign an order for the tylenol that was given already. Be nice to the nurses and they will treat you like gold.

Yeah, had to write up a nurse for this very thing. Thought they were doing a nice thing for me, but failed to realize that tylenol is ineffective at treating neutropenic fever. Didn't get paged about it when I actually should. Nurses should page whenever they want clarification or are acting in the best interests of the patient, even if misguided.

While I have posted in the "dumbest things paged for" thread, I answer every page, even post call (often waking up). Doesn't mean that I actually help them, and sometimes the answer to the pages is "please call the on call intern". But I never get an attitude with the nurses.
My biggest problem is that even if I am being nice and try to teach them something, sometimes they get this attitude like I am being condescending (trust me, you can tell a difference when I am being condescending), so I just move on and don't let some assclown affect my day. They don't want to learn, someone else will yell at them some day, but it won't be me. I learned a long time ago that yelling doesn't help anything.

 

[caroladybelle]

This only supports everything I said. What, you mean you can never be written up? That's against the law? Or that he tried to write you up for no reason? If that's the case, that's enough to get everyone to ride him out of town? That's firing time? Seriously that's sad either way. I know you take satisfaction in your power or untouchability but it's misplaced. As you can see most people would rather allow stuff to happen and get along, everyone is recommending people just let things slide "or else." So I can see why the attending and physicians reamed the guy out. They would never chew out or string up a nurse, though.

Do you not read the whole post? YOU NEED TO MAKE SURE THAT IT IS LEGIT.

No,the issue is don't let your ego override your brain. The intern did not do his job (as designated/regulated by his superiors, the MDs in charge of his program), tried to dump it on the nursing staff and have us do things that he felt were "scut" but clearly listed by numerous memos (from his superiors) as clearly his responsibility to do, and when I notified him of it, he refused to acknowledge that it was his duty (despite memos posted all over the place regarding the issue). It also involved a informed consent before blood work could be drawn, that by the facility policy could not be obtained by the nursing staff. He had the choice of doing the work, or rescheduling the tests for the AM. He made the choice to let his ego override his brain and not reschedule nor do the job....and then dump the blame on the nursing staff.

He initiated the compliant - I did not.

The "scut" in question, many nurses often did the work, despite it being the responsiblity of the admitting intern, letting them "slide" on it. Because it is often easier than chasing interns down, and y'all are always too busy.

And contrary to popular belief, we do actually like to let you sleep and catch a break. And we really don't like to be witches about it.

The night in question the staff was short and we did not have time to cover the interns job, especially when the appropriate legal paperwork was not done, and virtually none of the tests were such that they would even be read/run or treatable until AM shift. He could have easily reordered them if he did not want to do them, or get the consents.

What his complaint initiated?

The attending ripped the intern for ordering a bunch of stat tests, that did not need to be stat and not doing the appropriate "scut" nor paperwork. And for admitting the patient to begin with, and ordering thousand of dollars worth of work that did not need to be done. And because his complaint was not legit. The patient was discharged after rounds.

The nursing management, also, started enforcing that interns do the work per the regulations posted. That they not be permitted "to slide" because they are "too busy", and that nurses not cover for them or do any favors, unless there was a true emergency issue.

After several weeks of that, there were positive changes. There were fewer "stat" tests and the staffing office/medical staff suddenly found enough ancillary staff to "assist" the MDs in their duties, or barring that, staff the floor sufficiently so that it was not issue anymore.

So letting things "slide" is not a good option. It just lets things go on.

It is not hard to make sure that your complaint is legit and not just an ego issue. Anyone can be written up, but if it is not legit, it's coming back to slap you in the face. The same will happen to nurses that write-up BS complaints against MDs...often they get canned for "other reasons", low censused or DNR'ed. And yes, it does happen.

So how many of you are willing to write up a fellow MD who does wrong??????????????

 

[caroladybelle]

Out of curiosity, are you defending this particular nurses actions?

No, not in the least. I would have called immediately (as posted), but then as previously noted, have been told by MDs not to bother, had the phone click off, or had the intern go back to sleep.

I then proceed to notify my NURSING supervisor, check and document vital signs/neuro signs, injuries, incident report, make sure that there is hopefully a recent CBC/coag panel, and platelets available if appropriate and needed in the AM (I work Hemo, a lot of HLA matched, and thrombocytopenia), call for any detrimental changes, and chart such that if it ever goes to court, or gets reviewed by the Attending, all is there to be seen.

 

[snoopy brown]

Clearly as you present it this guy was way out of bounds but no offense I don't buy it. Not because I always take the doctor's side. It's simply because of experience. Where I am the doctor is required to get the consent, yes, and the nurses are required to witness them. But most of the time it's like pulling teeth to get them to do it when it's their job so I hardly can see them agreeing to do something that's not their job. I'm not trying to "win" by deflecting things onto a criticism of nursing, just letting you know where I'm coming from. The nurses I know just say "I'm not doing it" if they don't want to do something (even if it is their job, I've seen that occur like two or three times, not a lot). What are you going to do, start a physical fight or something?

Other things that you say that don't add up. I've never seen a place where you need informed consent to draw blood (unless it's obviously an HIV test). That's part of the "consent to treatment" which patients sign when they arrive at the hospital and that is not obtained by the physician. I've never seen an attending or anyone else get angry that a lab was ordered stat versus standard. I've never seen an intern admit a person on their own. I've seen patients admitted and immediately discharged but that was because they were forced into the hospital by the ER (that'll raise their hackles but it's true).

Last thing, it's not necessary for us to write each other up. We evaluate each other.

 

[caroladybelle]

HIV tests and research labs require signed consent before drawing in most places. HIV tests in many places require counseling before consent can be given, unless there are extenuating circumstances.

In many cases to save a stick to the patient, the nurse/intern (whoever is doing the draw) will draw the extra blood for initial research tubes (for the fellow) or HIV testing, pending the consent to test it...but it will cause a big fuss with management if one gets caught without proper consent forms.

I use intern for residents also. We rarely know or care about the difference. The intern involved in the admission is supposed to draw any labs ordered after 2300, or put them in for AM routine draw when there are more personnel available. All stats are also to be drawn by the interns, but nurses often do them.

HIV labs also, while may be drawn stat, will rarely be run stat - there was no quick screen at the time. Many of the tests involved would not have been run until AM.

The patient was known to have been faking seizures to get drugs. He was regular on several floors. And known to be positive for some serious bloodbourne illness. The MD in question just didn't want to draw the labs.

I stick by my story.

 

[Dr JPH]

I stick by my story.

Because youre not ultimately responsible in the end. Its easy to stick to a story if regardless of your actions someone else will eventually be strung up.

 

[OTD]

I use intern for residents also. We rarely know or care about the difference.

How bout just call them Doctor? You probably think they work in shifts too and don't realize the "night" person has been there since 4am the previous day.

You will be in for some changes soon because the RROC doesn't like residents being used as phlebotomists, patient transport etc. Those blood draws will likely be someone elses responsibility soon after that programs next site visit if they are truthful about it.

For the record, I don't think it's any residents job to be "writing up" nurses. They need to stick to writing up their own residents and let the attendings handle the nursing staff.

 

[Tired]

This only supports everything I said. What, you mean you can never be written up? That's against the law? Or that he tried to write you up for no reason? If that's the case, that's enough to get everyone to ride him out of town? That's firing time? Seriously that's sad either way. I know you take satisfaction in your power or untouchability but it's misplaced. As you can see most people would rather allow stuff to happen and get along, everyone is recommending people just let things slide "or else." So I can see why the attending and physicians reamed the guy out. They would never chew out or string up a nurse, though.

Precisely. In medicine, physicians' actions are constantly evaluated by their peers and superiors, and we receive constant feedback. In the nursing world, all crtiticism is taken personally, all attempts to impart knowledge are taken as condescension, and there is no system in place to RNs accountable for their errors. There is no nursing M&M sessions, the charge nurse is usually just a regular staff nurse who drew the short straw (or wants the extra 3 bucks an hour), and the nursing supervisor rarely leaves his/her office.

 

[Trifling Jester]

I use intern for residents also. We rarely know or care about the difference.

What a coincidence. I call all the nurses "sweetie." Sometimes the murses give me funny stares, but I don't really know or care about the difference.

-The Trifling Jester

 

[Dr JPH]

What a coincidence. I call all the nurses "sweetie." Sometimes the murses give me funny stares, but I don't really know or care about the difference.

-The Trifling Jester

Im usually nicest to the good looking ones. It pisses the rest of them off.

 

[elwademd]

HIV tests and research labs require signed consent before drawing in most places. HIV tests in many places require counseling before consent can be given, unless there are extenuating circumstances.

In many cases to save a stick to the patient, the nurse/intern (whoever is doing the draw) will draw the extra blood for initial research tubes (for the fellow) or HIV testing, pending the consent to test it...but it will cause a big fuss with management if one gets caught without proper consent forms.

I use intern for residents also. We rarely know or care about the difference. The intern involved in the admission is supposed to draw any labs ordered after 2300, or put them in for AM routine draw when there are more personnel available. All stats are also to be drawn by the interns, but nurses often do them.

HIV labs also, while may be drawn stat, will rarely be run stat - there was no quick screen at the time. Many of the tests involved would not have been run until AM.

The patient was known to have been faking seizures to get drugs. He was regular on several floors. And known to be positive for some serious bloodbourne illness. The MD in question just didn't want to draw the labs.

I stick by my story.

research labs?!?!?! a slippery slope indeed.

what exactly is a research lab? i've never heard of that one.

and i can imagine that many things may become "research labs"... or "i thought that was a research lab, since the team is researching and looking for the diagnosis" when the intern comes in the morning... after all, in your institution, a research lab can't be drawn by a phlebotomist or a nurse prior to consent.

and why any lab after 2300 would need to be drawn by a physician is beyond me.

You will be in for some changes soon because the RROC doesn't like residents being used as phlebotomists, patient transport etc. Those blood draws will likely be someone elses responsibility soon after that programs next site visit if they are truthful about it

if the intern/resident is having to draw blood, then i begin to wonder what other sort of oddities may occur at that hospital.





caroladybelle, don't get us wrong, most of us disagree with interns/residents/doctors "writing up" nurses. most of us feel that it's best handled by an intern/resident/doctor approaching the supervisor and speaking with him/her.

but then, as snoopy brown eloquently pointed out, that process goes out of the window when the roles are reversed. it seems, at times, to be malignant- perhaps malicious is a better word.

So how many of you are willing to write up a fellow MD who does wrong??????????????

if it's one of my interns, i'll speak to him/her about the perceived issue.

as another poster stated, we're evaluated every month by our attendings. so, there's a lot more oversight than you (or others reading this thread/post) may be aware. of.

 

[Dr JPH]

Nurses want it their way, right away...no questions asked.

Dont they realize there is a lot more involved when it comes to the more cerebral fields of medicine?

 

[saiyagirl]

i'm still a med student, but i find this topic quite interesting. in my limited experience, i've never seen a nurse call a resident out on something that compromised patient care. but this might be because all the residents i worked with were EXTREMELY competent individuals and wonderful doctors. i think the program at my home institution didn't have any bad apples...just very caring, motivated residents. i have, however, seen residents (and some attendings) go after the nursing staff for things that really should never have happened.

the first was a straight cath placed in an elderly gentleman against his will. admittedly, the urology resident who requested the cath for PVR's (sorry, i don't remember all the details) was kind of a bully and told the young nurse very forcefully that he wanted it done. however, at 2 am, when she went to do it, the patient stated very clearly he didn't want it. perhaps she felt afraid of the wrath of the urology resident...i don't know...but what amazed me was the ENTIRE NURSING STAFF on that ward came in to help her put this guys cath in. like, while he was kicking and screaming, they held him down and put it in.

the next day our patient was selectively mute. would only talk to the attending. the attending was livid about what had happened...and the entire nursing staff said, "we were just following your orders. we were compelled by your orders." literally, the entire staff on that unit got in my resident's face about it. my resident was very calm though and said, "you know, we can order whatever, but the patient always has the right to refuse...his autonomy must be honored."

later on that day when i was (alone) checking up on him, members of the nursing staff attacked me and said I didn't stick up for them. me, the med student? i mean, seriously. did not one nurse on that staff see the gross ethical violation here? not one?

not nurse bashing here, i realize this is not true of most nurses who are by and large, the best advocates for patients. which is why this incident REALLY surprised me.

the second was negligence that may have contributed to the death of a patient. a patient who presented with MI was cathed, stented x 2 (i think...one or two stents were placed...sorry, it was awhile ago!), and admitted to the cardiac care unit. Looking back at his tele leads, he appeared to have gone into V-tach or some other fatal arrhythmia around 3 am. He must have experienced some pain, or perhaps delerium, and ended up ripping off his telemetry leads a few seconds after the abnormal rhythm was noted. Leads go off, alarms on the pod ring like crazy. No one does anything. Why? Nurses are chatting on the pod and totally don't notice AT ALL. HOURS later, the tech comes in to take vitals. Patient's lips are blue, no pulse detected. Code Blue is called. But it's way too late.

What killed me about this story was that this particular patient had a wheelchair-bound wife, and he was her primary caretaker. They had no children...no one else. As soon as she received word that he had passed, she came to the ED and "admitted" herself, in order to see a social worker and get some sort of facility placement. It broke my heart.

I'm sure the nurses on the ward that night felt terrible, but nothing they feel will ever bring that man back or comfort his wife. the amount of socializing that goes on DURING WORK among the nursing staff would never, ever be acceptable among the housestaff. at least, this is what i've noticed as a med student. i guess this case led to some new policies about tele monitoring on that unit.

granted, there are many terrible docs who fail to appreciate the incredible work (and the incredible AMOUNT of work) nurses do, and who are (even worse) flippant about patient care. i only shared these stories because that's what i've seen so far. i know we all want to protect our own, but who will freaking man up and stick up for what is right?

at the end of the day, we all need to learn to be better advocates for our patients - they are the reason we all do what we do.

 

[fab4fan]

So, haven't seen this thread on here, so figured I'd start it.

So I wrote my first nurse up last night while on night block. I'm on medicine and was cross-covering a s/p lumbar laminectomy patient. Around midnight the patient fell out of bed after being left sitting on the side of the bed (even though she was on falls precautions). Anyway, fell out of bed face first and had a good 'ol nose bleed. So fast-forward 6hrs... now 6am and i get a call from the nurse for that patient...
"Hi Dr. TucomSam, this is Nurse Careless. I just wanted to inform you that there was a little incident last night with your patient in 4012, Mrs. Cantstandwell. She fell and had a nose bleed, but we got it taken care of."

"Excuse me? Why wasn't I informed of this until now?!?"

"Well, Dr., with everything going on last night with your patient who had to be transferred to the ICU, we just didn't have time to tell you. I'm really sorry. She's ok now though."

"She's ok now?? How exactly do you know that? Do you clear C-spines now? Furthermore, if this happened while I was UP there (at midnight) how difficult would it be to tell me in 5 words what had happened?"

"I'm really sorry... it's just that with all the commotion--"

"--Please don't make excuses. This was your responsibility to inform me and you did not. I'll be up there in 2 minutes."


So... that's pretty much how it played out... hated to write the nurse up, but seems pretty unacceptable to me. Can't wait for the backlash from that unit now! They're all a big hospital clique, so I'll probably be in for 2am calls about 110/75 BPs! Anyway, just venting.

Add your stories

If that happened as you wrote it, it deserved to be written up. And if you think you're getting retaliatory pages, that should be written up as well. I was going to make a lame attempt at a pun about someone falling down on the job, but I'm too tired and burned out. Anyway, multiple reasons why that should have been written up.

 

[fab4fan]

There should be a double standard...we are doctors and they are nurses.

Afterall, you cant get mad at a monkey for throwing his own $hit now can you?

Another way to put it...

When you know better you dont make the same mistakes.

I hope sleep deprivation is the explanation for post.

 

[fab4fan]

Sorry but when MD monkeys start throwing their own ****, we make them clean it up themselves. Or restrict that behavior to their on-call rooms.

 

[fab4fan]

research labs?!?!?! a slippery slope indeed.

what exactly is a research lab? i've never heard of that one.

and i can imagine that many things may become "research labs"... or "i thought that was a research lab, since the team is researching and looking for the diagnosis" when the intern comes in the morning... after all, in your institution, a research lab can't be drawn by a phlebotomist or a nurse prior to consent.

and why any lab after 2300 would need to be drawn by a physician is beyond me.

if the intern/resident is having to draw blood, then i begin to wonder what other sort of oddities may occur at that hospital.





caroladybelle, don't get us wrong, most of us disagree with interns/residents/doctors "writing up" nurses. most of us feel that it's best handled by an intern/resident/doctor approaching the supervisor and speaking with him/her.

but then, as snoopy brown eloquently pointed out, that process goes out of the window when the roles are reversed. it seems, at times, to be malignant- perhaps malicious is a better word.

if it's one of my interns, i'll speak to him/her about the perceived issue.

as another poster stated, we're evaluated every month by our attendings. so, there's a lot more oversight than you (or others reading this thread/post) may be aware. of.

If you only knew...

Caroladybelle and I go back a way. She's not just whistlin' Dixie here--she's into some serious cutting edge stuff. She impresses me to ne end. I would love to be half the nurse she is.

When it comes to incidents, I write myself up. I have to--my guilt complex makes me do it. Besides, it's better to just fess up right from the start than try to gloss things over and hope they'll go away. Even the harshest docs have been much better about hearing about incidents when I call and say what happened, how it happened, what I did for the pt., how the pt is, how I'll make sure it won't happen again. Then again, I don't make that many big mistakes. The longer you're in it, you just get more careful.

I don't write docs up that much. One recent one was for appalling behavior, despite nurese trying to settle him down and redirect him, acting inappropriate with pt and family, then throwing a piece of equipment at a nurse in front of the family.

Think of how great we could be if we could work together.

 

[snoopy brown]

If that happened as you wrote it, it deserved to be written up. And if you think you're getting retaliatory pages, that should be written up as well.

You're a nurse right? Tell me how well you think that would go over with the nurses. I've seen this stuff happen before and it will go one of two ways. It could go that the nurses start doing everything ultra-"by the book" where they all stand around and make sure that if you even walk into a patient room and touch nothing but the doorhandle that you wash your hands for exactly thirty seconds or else they notify Infection Control and report you for ignoring their warnings. Meanwhile, they could be eating a sandwich at the nursing station. Or else it could be that they just make like union workers everywhere and do a work stoppage on your patients where they "accidentally" forget to do blood work so, "whoops, doctor, sorry, guess you have to draw the bloods" or if transport comes for your patient they just send them away or something. I've seen both happen.

then throwing a piece of equipment at a nurse in front of the family.

That's definitely inexcusable. What led up to it?

 

[Dr JPH]

I hope sleep deprivation is the explanation for post.

Negative

 

[fab4fan]

You're a nurse right? Tell me how well you think that would go over with the nurses. I've seen this stuff happen before and it will go one of two ways. It could go that the nurses start doing everything ultra-"by the book" where they all stand around and make sure that if you even walk into a patient room and touch nothing but the doorhandle that you wash your hands for exactly thirty seconds or else they notify Infection Control and report you for ignoring their warnings. Meanwhile, they could be eating a sandwich at the nursing station. Or else it could be that they just make like union workers everywhere and do a work stoppage on your patients where they "accidentally" forget to do blood work so, "whoops, doctor, sorry, guess you have to draw the bloods" or if transport comes for your patient they just send them away or something. I've seen both happen.


That's definitely inexcusable. What led up to it?

This particular individual is notorious for temper tantrums. Who knows what prompted it that day--maybe Jupiter wasn't aligned with Mars.

As far as the other behavior you describe, maybe that's how it's played where you work, but we just don't have the time to get into those games where I work. The turnover time for pts. is too fast. And there is absolutely no way we would do a work stoppage--not me, not the nurses I work with. That's beyond unethical, it's harmful to the pt. It wouldn't even occur to me to do something like that. Really bad things happen to our pts if their labs don't get drawn. Besides, that's just abusive.

I'm not saying we're perfect and we don't occasionally make our share of snide remarks or express impatience in one way or another. But never in a way that would compromise the pt.

 

[fab4fan]

Negative

Hmmm...too bad.

 

[snoopy brown]

As far as the other behavior you describe, maybe that's how it's played where you work, but we just don't have the time to get into those games where I work.

I don't know where you work but the nurses have lots of time to get into those games where I work.

 

[fab4fan]

I don't know where you work but the nurses have lots of time to get into those games where I work.

That's a shame. Too bad you can't send some over our way; we have too much work and not enough staff. Although if they're troublemakers, I don't know that we want them.

 

[Dr JPH]

Hmmm...too bad.

Thats "too bad, doctor" to you.

 

[smq123]

Thats "too bad, doctor" to you.

And Dr. JPH's account goes on probation in 3, 2, 1....

 

[Old_Mil]

Thats "too bad, doctor" to you.

Out of curiousity, have you ever heard of the concept of people giving others enough rope to hang themselves with? Perhaps that's worth pondering before you make your next post...or do they lobotomize that portion of the brain which allows for introspection when you match into surgery?

 

[snoopy brown]

Out of curiousity, have you ever heard of the concept of people giving others enough rope to hang themselves with? Perhaps that's worth pondering before you make your next post...or do they lobotomize that portion of the brain which allows for introspection when you match into surgery?

I don't know what makes less sense, the feeling that people have to add a smiley every time they say something that anyone may possibly ever find offensive in order to indicate "ha ha I'm just kidding because everyone loves everyone else" or the feeling that it's ok to insult someone for insulting someone else. It's like you think that it makes you right since "everyone" is going to disagree with JPHazleton, so if you get in some side insult at him that's fine because you're on the "right" side.