25
Mar

New Nurse Challenge: When to Call the Doctor 

When I was being interviewed for my current position as a night nurse in telemetry, my nurse manager only asked me one question: How would you handle a difficult doctor?

The reason she asked this question, I would later learn, is because my floor is serviced by an older, a tad bit grumpier, group of doctors between ages 50-70. They yell a lot. They are not really great at accepting change (for instance moving into VTE prophylaxis or computerized entry of orders). They are a tougher bunch.

In nursing, and medicine in general, they are a ton of grey areas. You learn in nursing school to always, always trust your gut. But, if you call the doctor at 3:30 A.M. (when the doctor only left at midnight) for an unsubstantiated “gut feeling” about their patient, you are probably going to get hung up on. So when do you call? In the day shift I imagine it’s easier because you aren’t waking a physician up, but what about at night? Here is what I’ve put together so far. Maybe Dr. Cranquis or WayfaringMD can weigh in?

1. Critical labs that are new for the patient and affect the client’s condition. Calling for a BUN of 86 in a dialysis patient who frequently has high BUN levels is definitely not a good idea. But Troponin levels, Potassium, etc. are important, but always remember to check previous labs and consider the patient condition. Always keep in mind hospital policy. For instance I had a critical lab value for procalcitonin last shift which means I have one hour to contact the doctor, BUT, the doctor wrote orders saying “Please do not call for results”. So I didn’t call but documented accordingly.

2. Blood pressures over systolic 160s consistently and a patient does not have a PRN BP med. Elevated systolic values blood pressures cause strain and damage to the microvasculature of the kidneys, eyes, and put a strain on the heart. Be sure to check orthostatic blood pressures as the patient may have just ambulated to the restroom but once in bed their pressures are drastically lower. You don’t want to give a patient hydralazine and then have them bottom out.

3. Sudden change in condition, new onset chest pain (don’t forget to give oxygen first), new onset anything within reason—use your judgement, new onset toe pain probably can wait.

4. When you’ve done all you can do and the patient’s condition is unresponsive. Patient has a fever of 101.8 and you’ve given tylenol, two cool sponge baths, removed the linens, gave ordered antibiotics, no change. Let the doctor know. Make sure you’ve given the medications and treatments time to work.

5. When you notice a doctor forgot to order something important. For instance, at our hospital you need activity and diet orders otherwise your patient is considered NPO and on bedrest. The activity order can wait until morning but if the patient is hungry now, you better not feed them without an order.

6. Pain. Now this is a tricky one. We learn in nursing school that pain is what the patient says it is, but in real life there are drug seeking patients. Personally I would rather accidentally give dilaudid to drug seekers rather than risk ignoring genuine pain, but each of us is different. Assess the pain: is it related to their illness? PQRST? Is there anything you can do as a nurse like heat packs or position changes to relieve the pain? Does the patient complain of 10/10 pain but every time you check on them they are sleeping?

Your charge nurse is an amazing and important resource. Ask your charge what she thinks about calling the physician. Have you done all that you can do? Is there something that the physician will be able to do to solve this problem? Are you protecting both your license and the patient? If you can’t live with yourself without calling the doctor, then you just better do it. What’s the worst that happens? They might get super grumpy and yell, but at least you know you’ve done all you can.

Any other nurses or physicians/med students care to weigh in?

37 Notes on this post

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  7. cranquis answered: Agree w/ all your points. Especially DOCUMENTATION of your reasoning and doc’s response (or lack thereof).
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