Venting...mainly just because I'm so annoyed

[MediCane2006]

So I'm on night float for the trauma service this week, and up until last night it hasn't been too bad. But last night was one of those nights where your blood pressure just stays chronically up - dumb consult after dumb consult, everybody's blood sugar out of control, ER being painful, spinal cord injury transfer from outside hospital. Nothing too scary, nothing exciting, just a lot of annoying little stuff that meant I was scrambling all night long.

So this morning rolls around, we're running the list with the attendings, when the pager goes off. It's the nurse for a patient 3 weeks s/p 4-vessel CABG, with an infected sacral decub that we debrided a few hours ago.

NURSE: Hi, we just took our 8AM vitals, and Mr. Smith's pressure is 60/40, and his heart rate is in the 120's.

(keep in mind that we're running the list in a conference room on the other side of the hospital)

ME: [oh ****, he's probably bleeding, he's on aspirin and we did a pretty wide debridement, either that or maybe he had an MI]: Okay. I'm about a city block or two away, please hang a 500cc bolus of NSS and draw stat labs. I'm heading over now.

NURSE: I'm sorry, we can't do any of that without an order

ME: I know, I'm running over now, please just get the bolus hanging. I'll put in all the orders when I get there.

NURSE: I can't do that without an order

ME: JUST HANG THE FLUID - I'm coming over now...

So I arrive at the patient's room, and find the nurse sitting at the nurse's station chatting. No fluid bolus hanging - in fact, no fluids running at all. I unpacked the wound, ended up cauterizing a little bleeder...but what fried me was that the nurse refused to even GET UP AND GET THE SALINE BAG OUT OF THE CABINET without me leaving the patient's bedside to write the order! She just kept repeating "..you have to write the order first" .

Now granted, I understand the need for clear documentation, and I wouldn't have even been annoyed had she had the bolus and blood draw tubes ready when I arrived at the room, then given the bolus once I got there. But I was so tired and irritated this point that I didn't even bother arguing much because I was afraid I'd say something I'd regret...so I stopped the bleeding and the wrote out all the orders so the poor guy could get his fluid bolus and labs.

I've had such a great relationship with the surgical floor nurses on this rotation but this was just a rotten way to finish off an annoying call. Blah. I hate trauma sometimes.

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[Pir8DeacDoc]

I'm pretty sure I would have had a sit down with the nurse manager after that one. Orders and clarification are certainly important. However, when a patient is starting to spiral good sense should dictate care. There is no reason to let protocol stand in the way of doing the right thing for the patient. Plus, does your hospital not allow verbal orders? Ugh, that's painful.

 

[filter07]

Does your hospital not take verbal orders even in times of emergency? Seems like a poor way of running things. Either that or your nurse needs to be written up. She should also quit since she obviously has 1) no regard for the welfare of patients, or 2) no understanding of the importance of bending the rules to save someone's life.

The sad reality of hospital life is that a small group of very intelligent people are forced to work with so many less intelligent people. Imagine a basketball team of Lebron James surrounded by 4 left handed dweebs. Or the Google guys working with a bunch of ex-frat jocks. The truth is that doctors rely on techs, nursing, and other miscellaneous staff that don't have the intelligence, concern, or dedication required to provide good patient care. There are good nurses, good techs, etc, just like there are ex-frat jocks somewhere that can program for Google. Those are the exceptions. Working in the hospital is like working with children.

 

[Blade28]

That's ridiculous!

Usually I get really passive-aggressive and just storm in there, ask the charge nurse for access to the Pyxis so I can just grab the saline myself. That gets them all riled up.

I have to do this often...NGTs at the VA, dressing changes at the county hospital, WoundVACs at the university hospital, etc.

 

[sleeping]

Sounds alot like a county/university hospital. I would usually put the nurse in the spotlight in front of the other nurses and the doctors. "Do you want to let your patient die, or do you want to help me." Never, in a hostile manner, or I would probably get written up for helping a patient

I have been in your situation many a times.

 

[Winged Scapula]

That's ridiculous!

Usually I get really passive-aggressive and just storm in there, ask the charge nurse for access to the Pyxis so I can just grab the saline myself. That gets them all riled up.

I have to do this often...NGTs at the VA, dressing changes at the county hospital, WoundVACs at the university hospital, etc.

That's what I do as well. It seems to work quite well in getting them riled up and actually doing something, although my intent has always been to do the right thing for the patient. Secondary benefits.

 

[Faebinder]

So I'm on night float for the trauma service this week, and up until last night it hasn't been too bad. But last night was one of those nights where your blood pressure just stays chronically up - dumb consult after dumb consult, everybody's blood sugar out of control, ER being painful, spinal cord injury transfer from outside hospital. Nothing too scary, nothing exciting, just a lot of annoying little stuff that meant I was scrambling all night long.

So this morning rolls around, we're running the list with the attendings, when the pager goes off. It's the nurse for a patient 3 weeks s/p 4-vessel CABG, with an infected sacral decub that we debrided a few hours ago.

NURSE: Hi, we just took our 8AM vitals, and Mr. Smith's pressure is 60/40, and his heart rate is in the 120's.

(keep in mind that we're running the list in a conference room on the other side of the hospital)

ME: [oh ****, he's probably bleeding, he's on aspirin and we did a pretty wide debridement, either that or maybe he had an MI]: Okay. I'm about a city block or two away, please hang a 500cc bolus of NSS and draw stat labs. I'm heading over now.

NURSE: I'm sorry, we can't do any of that without an order

ME: I know, I'm running over now, please just get the bolus hanging. I'll put in all the orders when I get there.

NURSE: I can't do that without an order

ME: JUST HANG THE FLUID - I'm coming over now...

So I arrive at the patient's room, and find the nurse sitting at the nurse's station chatting. No fluid bolus hanging - in fact, no fluids running at all. I unpacked the wound, ended up cauterizing a little bleeder...but what fried me was that the nurse refused to even GET UP AND GET THE SALINE BAG OUT OF THE CABINET without me leaving the patient's bedside to write the order! She just kept repeating "..you have to write the order first" .

Now granted, I understand the need for clear documentation, and I wouldn't have even been annoyed had she had the bolus and blood draw tubes ready when I arrived at the room, then given the bolus once I got there. But I was so tired and irritated this point that I didn't even bother arguing much because I was afraid I'd say something I'd regret...so I stopped the bleeding and the wrote out all the orders so the poor guy could get his fluid bolus and labs.

I've had such a great relationship with the surgical floor nurses on this rotation but this was just a rotten way to finish off an annoying call. Blah. I hate trauma sometimes.

Time to write her up...

 

[Blade28]

That's what I do as well. It seems to work quite well in getting them riled up and actually doing something, although my intent has always been to do the right thing for the patient. Secondary benefits.

Yup. I'll storm around, loudly grabbing supplies, muttering "I'll just do it myself," or when the nurses are slow and don't understand the meaning of STAT, I'll really get fired up.

Then they hurry when they realize I'm transporting the patient to the ICU/OR, starting a central/peripheral line, pushing fluids/meds/blood, etc.

 

[SLUser11]

NURSE: Hi, we just took our 8AM vitals, and Mr. Smith's pressure is 60/40, and his heart rate is in the 120's.

(keep in mind that we're running the list in a conference room on the other side of the hospital)

ME: [oh ****, he's probably bleeding, he's on aspirin and we did a pretty wide debridement, either that or maybe he had an MI]: Okay. I'm about a city block or two away, please hang a 500cc bolus of NSS and draw stat labs. I'm heading over now.

NURSE: I'm sorry, we can't do any of that without an order

ME: I know, I'm running over now, please just get the bolus hanging. I'll put in all the orders when I get there.

NURSE: I can't do that without an order

I've had such a great relationship with the surgical floor nurses on this rotation but this was just a rotten way to finish off an annoying call. Blah. I hate trauma sometimes.

I still don't get it:

How common is it for you residents working in less-than-perfect environments to be unable to give verbal orders?

If you can't give verbal orders, and you have sick patients, then you are pretty much obligated to have a physician present at all times. It's a ridiculous necessity, and I don't envy you at all...but why check out at the other end of the hospital if you can't give orders from there?

 

[Blade28]

We can give them, they just don't always get done.

 

[Winged Scapula]

At the end of my residency, there was a push to only allow them to be done in an ICU and in an emergency setting. There were signs all around stating that. It wasn't enforced by many at the time because it was frankly impractical to ask a resident to put the orders in (we had an EMR) whilst in a Trauma, the OR, etc. and most of our nurses, especially the ICU ones, realized that in a big hospital it might take you several minutes to get there and they could be hanging the drip, etc. rather than waiting for you to arrive.

Of course, there were always the sticklers for rules that would endanger patient safety by insisting on such thngs.

 

[beasleys]

So I arrive at the patient's room, and find the nurse sitting at the nurse's station chatting. No fluid bolus hanging - in fact, no fluids running at all. I unpacked the wound, ended up cauterizing a little bleeder...but what fried me was that the nurse refused to even GET UP AND GET THE SALINE BAG OUT OF THE CABINET without me leaving the patient's bedside to write the order!

I do not unnderstand. I am thinking you Americans use guns to solve these problems, no? That is what I always read.

 

[173291]

I do not unnderstand. I am thinking you Americans use guns to solve these problems, no? That is what I always read.

he he he

 

[core0]

Yup. I'll storm around, loudly grabbing supplies, muttering "I'll just do it myself," or when the nurses are slow and don't understand the meaning of STAT, I'll really get fired up.

Then they hurry when they realize I'm transporting the patient to the ICU/OR, starting a central/peripheral line, pushing fluids/meds/blood, etc.

I used that a couple of days ago. PT going down hill. Talked to ICU doc "sure I got a bed". Talked to bed control "no you can't have it, we promised it to someone they might be transferring in". Hmm off we go pushing the bed down the hall. Put the bed in the ICU room. Tell the nurse to give report. possession is 9/10ths of the law.

David Carpenter, PA-C

 

[Blade28]

At the end of my residency, there was a push to only allow them to be done in an ICU and in an emergency setting. There were signs all around stating that. It wasn't enforced by many at the time because it was frankly impractical to ask a resident to put the orders in (we had an EMR) whilst in a Trauma, the OR, etc. and most of our nurses, especially the ICU ones, realized that in a big hospital it might take you several minutes to get there and they could be hanging the drip, etc. rather than waiting for you to arrive.

For a while, our county hospital was trying to institute this policy where residents that were in-house weren't allowed to give verbal orders. Given the size of our hospital, it would have been ridiculously impractical to physically go to every patient's chart whenever an order was needed.

 

[JackBauERfan]

So I'm on night float for the trauma service this week, and up until last night it hasn't been too bad. But last night was one of those nights where your blood pressure just stays chronically up - dumb consult after dumb consult, everybody's blood sugar out of control, ER being painful, spinal cord injury transfer from outside hospital. Nothing too scary, nothing exciting, just a lot of annoying little stuff that meant I was scrambling all night long.

So this morning rolls around, we're running the list with the attendings, when the pager goes off. It's the nurse for a patient 3 weeks s/p 4-vessel CABG, with an infected sacral decub that we debrided a few hours ago.

NURSE: Hi, we just took our 8AM vitals, and Mr. Smith's pressure is 60/40, and his heart rate is in the 120's.

(keep in mind that we're running the list in a conference room on the other side of the hospital)

ME: [oh ****, he's probably bleeding, he's on aspirin and we did a pretty wide debridement, either that or maybe he had an MI]: Okay. I'm about a city block or two away, please hang a 500cc bolus of NSS and draw stat labs. I'm heading over now.

NURSE: I'm sorry, we can't do any of that without an order

ME: I know, I'm running over now, please just get the bolus hanging. I'll put in all the orders when I get there.

NURSE: I can't do that without an order

ME: JUST HANG THE FLUID - I'm coming over now...

So I arrive at the patient's room, and find the nurse sitting at the nurse's station chatting. No fluid bolus hanging - in fact, no fluids running at all. I unpacked the wound, ended up cauterizing a little bleeder...but what fried me was that the nurse refused to even GET UP AND GET THE SALINE BAG OUT OF THE CABINET without me leaving the patient's bedside to write the order! She just kept repeating "..you have to write the order first" .

Now granted, I understand the need for clear documentation, and I wouldn't have even been annoyed had she had the bolus and blood draw tubes ready when I arrived at the room, then given the bolus once I got there. But I was so tired and irritated this point that I didn't even bother arguing much because I was afraid I'd say something I'd regret...so I stopped the bleeding and the wrote out all the orders so the poor guy could get his fluid bolus and labs.

I've had such a great relationship with the surgical floor nurses on this rotation but this was just a rotten way to finish off an annoying call. Blah. I hate trauma sometimes.

Yeah have to agree with you here, either nurse is lazy on this one or she is brand new.

Next time maybe you can call a code, then no need to write orders...or maybe thats too drastic, but with a lowering BP and concerned like you were, I think its best for the patient if you did that so that someone could put up 500 cc of whatever hahaa.

 

[JackBauERfan]

Yup. I'll storm around, loudly grabbing supplies, muttering "I'll just do it myself," or when the nurses are slow and don't understand the meaning of STAT, I'll really get fired up.

Then they hurry when they realize I'm transporting the patient to the ICU/OR, starting a central/peripheral line, pushing fluids/meds/blood, etc.

yeah and like someone said this may be a county type hospital where the nurses have pretty secure jobs. either way where I'm at i'm comfortable now knowing where the IV stuff is, where the saline stuff is... in general give me a few more months and I KNOW i'll know where more stuff is than some of the new nurses. Already happened the other day when I needed something from the pyxis and the 'new' nurse wasn't even sure where she was supposed to get it, so I showed her where it is, and that the only reason I hand't got it yet was because they dont give me a pyxis number.

hmm, maybe I should find out how to get a pyxis number...

 

[Blade28]

Pyxis numbers are gold. I've collected them for most floors of our county hospital.

 

[JackBauERfan]

i'm gonna have to collect a few myself then...

 

[Smurfette]

The (large) county hospital I rotate at will not accept verbal orders except in the ICUs, and the trauma unit. No exceptions for services that don't have people in-house overnight (maybe they have computer access from home? dunno.). It's PAINFUL, especially when you're patients are scattered throughout the hospital. But frankly, it's a miracle here if the RN should call you about a BP of 60/40 before 2 hours have passed since she likely hadn't looked at vitals that the CNA took until it was time for her to chart them before she goes on break....

Oh, and STAT EKGs and CXRs are never guaranteed to arrive before 1-2 hours have passed, if that.

I'd go on about the county system RNs here, but that's a whole other thread entirely.

 

[Blade28]

i'm gonna have to collect a few myself then...

I have a separate text file for each hospital in my Treo...always beam it to any new intern or med student starting a new service/rotation.

 

[Pir8DeacDoc]

Can I say once again that I'm very happy to be at my current hospital. I mean no disrespect to any of you because I know a lot of you are at top notch hospitals. But I am so happy to be at a top notch, academic hospital that is < 500 beds and with a nursing staff who is generally helpful. Sure there are a few bad apples but I would be miserable if the biggest chunk of my day was spent harassing people to do their jobs.

 

[Castro Viejo]

Can I say once again that I'm very happy to be at my current hospital. I mean no disrespect to any of you because I know a lot of you are at top notch hospitals. But I am so happy to be at a top notch, academic hospital that is < 500 beds and with a nursing staff who is generally helpful. Sure there are a few bad apples but I would be miserable if the biggest chunk of my day was spent harassing people to do their jobs.

Ahh... Your hospital obviously isn't in New York and it doesn't have a nursing union.

I'm jealous.

 

[sleeping]

Ahh... Your hospital obviously isn't in New York and it doesn't have a nursing union.

I'm jealous.

 

[Pir8DeacDoc]

Ahh... Your hospital obviously isn't in New York and it doesn't have a nursing union.

I'm jealous.

not in NYC and definitely a non-unionized nursing staff.

Funny that one of my fellow interns last year went to Einstein for med school and it took him awhile to realize that people were actually friendly and even helpful sometimes. He also was amazed that we never had patients stacked up in the hallways. I'm blessed to be at a very nice facility.

 

[Blade28]

Unions. Don't even get me started.

 

[Castro Viejo]

not in NYC and definitely a non-unionized nursing staff.

Funny that one of my fellow interns last year went to Einstein for med school and it took him awhile to realize that people were actually friendly and even helpful sometimes. He also was amazed that we never had patients stacked up in the hallways. I'm blessed to be at a very nice facility.

Yeah... Let that be a lesson to all you out there. The New York Metropolitan Area is a sucky place in which to train. You're overworked, people suck, nursing sucks, and the attendings all think with their lawyers in the background.

Ahh... 169 days left of General Surgery residency.

Not that I'm counting. (BTW- I love that dancing banana... It cracks me up everytime.)

 

[droliver]

The scenario you described is unacceptable and this nurse's misunderstanding of the policy and LACK OF COMMON SENSE could have been catastrophic.

This is something that you really need to get sorted out with your attending staff, administrators, and nurse managers

 

[sleeping]

The scenario you described is unacceptable and this nurse's misunderstanding of the policy and LACK OF COMMON SENSE could have been catastrophic.

This is something that you really need to get sorted out with your attending staff, administrators, and nurse managers

Common Sense does not work in NY.

I have seen this scenario played out so many times, its not even funny. The nurse gets away with it, the nurse or her friend will screw you later(not in a good way), your attending will get upset because the patient is going downhill. I will keep wondering why the hell did I make a big deal of this situation.

 

[MediCane2006]

My hospital is changing their policy to prohibit verbal orders. Apparently there was an incident in which a verbal order was misunderstood resulting in an adverse event.

We have a computerized order system, though, so you can put in orders from the other side of the hospital....or even from home.

The problem was in this case that I wanted to get an ABG and get the patient stabilized before sitting down at a computer, logging in, and entering all the orders. What I should have done, in retrospect, was taken another member of the team down with me to help or had someone enter orders while I was running down to see the patient.

Whatever, I think I over-reacted. That's what a rough call night will do to your sense of perspective.

 

[gasnewby]

you did not overreact!

can be verbal orders be bad? of course. however, when you have an unstable patient, you're not asking her to start vasopressors or cardiovert the patient. you asked her to hang ivf, for god's sake. that's total BS that she gave you a hard time. do NOT let them beat you down. stay strong. you know what's right and wrong and you did not overreact.

reminds me of...

 

[surgeon2b forev]

How do you guys get the access code to the Pyxis to grab your own saline back and the like!?!? I didn't know that could be done!?!?!?! whose name gets recorded for taking the item? Please tell! genius!

 

[gasnewby]

ours use your fingerprint, so there's no fooling the machine.

 

[Winged Scapula]

How do you guys get the access code to the Pyxis to grab your own saline back and the like!?!? I didn't know that could be done!?!?!?! whose name gets recorded for taking the item? Please tell! genius!

Ours used fingerprints too. You just scrolled down to the patient's name on the attached terminal and then put your finger on the touch pad and voila! Access to gauze, saline, Crest toothpaste!

 

[gasnewby]

but only nurses have access!

 

[Blade28]

Saline is in the supply Pyxis/OmniCell here. You just need a code.

 

[fab4fan]

So I'm on night float for the trauma service this week, and up until last night it hasn't been too bad. But last night was one of those nights where your blood pressure just stays chronically up - dumb consult after dumb consult, everybody's blood sugar out of control, ER being painful, spinal cord injury transfer from outside hospital. Nothing too scary, nothing exciting, just a lot of annoying little stuff that meant I was scrambling all night long.

So this morning rolls around, we're running the list with the attendings, when the pager goes off. It's the nurse for a patient 3 weeks s/p 4-vessel CABG, with an infected sacral decub that we debrided a few hours ago.

NURSE: Hi, we just took our 8AM vitals, and Mr. Smith's pressure is 60/40, and his heart rate is in the 120's.

(keep in mind that we're running the list in a conference room on the other side of the hospital)

ME: [oh ****, he's probably bleeding, he's on aspirin and we did a pretty wide debridement, either that or maybe he had an MI]: Okay. I'm about a city block or two away, please hang a 500cc bolus of NSS and draw stat labs. I'm heading over now.

NURSE: I'm sorry, we can't do any of that without an order

ME: I know, I'm running over now, please just get the bolus hanging. I'll put in all the orders when I get there.

NURSE: I can't do that without an order

ME: JUST HANG THE FLUID - I'm coming over now...

So I arrive at the patient's room, and find the nurse sitting at the nurse's station chatting. No fluid bolus hanging - in fact, no fluids running at all. I unpacked the wound, ended up cauterizing a little bleeder...but what fried me was that the nurse refused to even GET UP AND GET THE SALINE BAG OUT OF THE CABINET without me leaving the patient's bedside to write the order! She just kept repeating "..you have to write the order first" .

Now granted, I understand the need for clear documentation, and I wouldn't have even been annoyed had she had the bolus and blood draw tubes ready when I arrived at the room, then given the bolus once I got there. But I was so tired and irritated this point that I didn't even bother arguing much because I was afraid I'd say something I'd regret...so I stopped the bleeding and the wrote out all the orders so the poor guy could get his fluid bolus and labs.

I've had such a great relationship with the surgical floor nurses on this rotation but this was just a rotten way to finish off an annoying call. Blah. I hate trauma sometimes.

That's pathetic. I can only say that if that had been my pt., the bolus would have been started, labs drawn and a STAT EKG ordered before I called you. Obviously this gal missed the class when they covered what a "reasonable and prudent" nurse would do.

I don't go ahead and give meds without orders. But witholding a bolus in a situation like this? No, I don't think so. I like my patients to be not coding.

I'm sorry you had to end your rotation on such a lousy note.

 

[THE instiGATOR]

I hate when they page you without looking at the patient or manually checking the BP to confirm their nursing assistant's findings. It is sad that so many ******ed people are being recruited into nursing. It is even more sad that they are being paid more than you. Critical care is becoming increasingly more appealing, given that most nurses in an ICU setting are fairly decent at what they do. Floor nurses are, generally speaking, not that bright. Ours can't even understand that we have an on-call pager for a reason. Instead of using it, they page the person who wrote the daily note. This, of course, leads to people being paged at home when they are post-call. I am so tired of trying to explain this to them. I'd leave my personal pager in the car, but I fear for my patients. Recently, I had a patient with a cellulitic leg who had an MRI ordered. In the order, it had said L leg once and R leg later (simple computer order entery error). They paged me at home to ask which leg I wanted the MRI study done on (I was post-call and they did not text page me... just left a number). I tried to make a point and didn't return the call, only to find the MRI study had never been done!!! How hard is it to GO IN THE ROOM AND LOOK AT THE LEG!!! Which one do you think I meant!!!???!!!

Anyway, I don't think 500 cc would have made a difference. Also, isn't albumin better for CABG patients.

Write her up, yo!

 

[Misterioso]

We've all been there, don't let it get to you. Always remember that whatever little power trips they play, at the end of the day you're the surgeon. A bona fide badass. They're just nurses and other allied staff who don't really matter in the bigger scheme of things. That's why they play these passive-aggressive games...it's their way of compensating for their impotent rage at knowing they're not as good as you.

Don't write them up. Don't show that they've gotten to you. Don't show that they've phased you one bit. Be completely indifferent towards them and carry yourself as if you're indeed better. Nothing puts them in their place better than that.

"He who cares less wins."

 

[fab4fan]

My hospital does not have physician order entry. The policy is that "non-essential verbal orders" will not be accepted. What does this mean in practice?

RN calls me for something: Verbal order is essential = accepted
I call RN for something: Verbal order is not essential = not accepted

Maybe my facility is out of the norm, but we view verbal orders and telephone orders differently.

Telephone order= Doctor calls on the phone with orders.

Verbal order= Doctor is standing next to nurse and gives a verbal order rather than writing it down. These are discouraged, but there are ways to work around it to keep everyone happy.

In any case, I can't imagine a nurse foot-dragging over initiating orders simply because the order was a TO/VO. I believe it happens, I guess I just wonder at the work ethic of those nurses, let alone their clinical competence. It's one thing to hold off if an order raises red-flags, but to quibble over TO/VO is just childish. Let's focus on the patient, not turf wars.

 

[Castro Viejo]

In any case, I can't imagine a nurse foot-dragging over initiating orders simply because the order was a TO/VO. I believe it happens, I guess I just wonder at the work ethic of those nurses, let alone their clinical competence. It's one thing to hold off if an order raises red-flags, but to quibble over TO/VO is just childish. Let's focus on the patient, not turf wars.

Patient care?

"But doctor, it's MY license that's on the line . . . "