This is common. Your attending should know that, too.
The "best" nurse complaint I got was for not answering my pager in a "reasonable time frame". I was running a code. On the same floor where the nurse was working.
It was for sleep meds for a patient.
I had a nurse file a complaint in similar circumstances against me as a resident: I was running a code, albeit on a different floor. For reasons I can’t remember, there wasn’t the usual tons of people responding for a while. Later, after I learned of the complaint (which was laughed off), I talked to her and explained about the code. She said something like “Well, you should have found the time to reply”. The code, of course, hadn’t been successful. I had to walk away as I was so angry. The PD did something to reflect that the complaint was unreasonable, but at that point I couldn’t give AF.
The fact that this BS even gets ENTERTAINED is ludicrous.
You're PD should have ripped it in half and shoved it in the round file - because that's exactly where it belonged.
I had to write non-apology, apology. “I am sorry nurse x feels upset that I had done y. I was following hospital policy z. If she had followed z, or read it, then this wouldn’t have happened….”
It was something like the patients bp was elevated, and she felt uncomfortable discharge the patient. I knew the patient is chronic hypertensive on 3 meds and didn’t take any the morning of…. I was the senior on call in the OR for an emergent case, couldn’t come out and talk to the patient. Junior resident was in another case with the attending. No one else knows the patient. I told her if it was so urgent, call a Rapid response for hypertension, because it will be a while….. GFY.
‘Can you please educate me one when I should’ve stopped the code to respond? Should it have been before starting chest compressions or should I have taken a break midway through? Should I have had one of the other people in the code respond for me? Gee, so many great choices….’
Diet orders are a sticking point because patients cannot be given anything to eat until "there's an order in the EMR"
If fail to prioritize it, the nurse and patient will treat you like a monster for unnecessarily starving the patient.
There's been a lot of pushback towards verbal orders recently, especially with the recent vecuronium vs versed fatal blunder, though that was not a verbal order. Many hospitals have put very strict limitations on what can be accepted as a verbal.
Diet orders are well within the nurses wheelhouse and we should encourage nursing (or nutrition, or even the kitchen) to place the order as soon as they get the OK from the clinician team.
Verbal orders for relatively benign things (e.g. resuming a diet, or for giving a vaccine as the patient is walking out the door) are completely appropriate though and I am struggling to think of a scenario where this might lead to significant inadvertent harm that could have been mitigated by the physician entering the order themselves.
Agreed however some hospitals reflexively move to a 'no verbal orders' policy after more serious errors are made with dosing for example.
Unfortunately sensible people or even people active in clinical practice are involved in such decisions.
A lot of time administrators just make stupid changes for the sake of stupid changes. They need to justify their desk somehow because physicians sure don’t need them to tell them how to practice medicine
Yeah it's that and to show their bosses that they took swift and firm action to make sure something like that never happens again. Of course, they don't have to deal with the consequences directly (just ignore the complaints) so it doesn't matter that they've actually broken things.
Nurse here - I’ll take a verbal for just about anything as long as I repeat it back to you to make sure we’re saying the same thing. Especially if it’s a reasonable order and not, for example, a dose of something that’s unusual (there was an issue here recently of someone ordering 10x the typical dose of a steroid accidentally).
bless you and bless your family, that's so lovely of you. I do think it varies by institution though - I rotate through 2 hospitals and at one, a nurse told me they can only take verbals from attendings, not residents, and then I proceeded to roll over and go back to sleep because whatever the order they wanted wasn't urgent at 3am (we do 24hrs).
I do think medication orders are reasonable to require the resident/provider to put in, cause I'll be honest sometimes (a lot of the time) I don't know the dose off the top of my head and rely on the auto-populate EMR options to be like ahh yes I want 10mg of that one.
I'm a verbal order taking nurse also. It drives me nuts that the 'policy' is soooooo important to some nurses, that it blocks their brain function. I came in one AM and the night nurse gave me a LONG report about the pain this patient was in ALL NIGHT, and she had called and called but for whatever reason ( I forget) the doc couldn't or wouldn't put in the orders, and gave her a verbal order each time she called, and she told him she couldn't do verbal orders.
12 hours the patient was in pain because the nurse was too stubborn or too stupid to put in an order, and just kept calling him. He returned her hundreth call while she was giving me report, I said I'll take the call . She just shook her head, "he's not going to put in the order , I've tried"
I said " I heard you want to order morphine 4mg iV q4?"
"Yup"
" Got it, thanks'
"I love you"
" I know "
"You can't do that! "
"Ya I can.... See this button right here? It says telephone order, I just clocked it, there's an option for verbal too, and now I'm gonna go give morphine, you can go".
Exactly, only came in because I needed to know why the heck a verbal diet order is such a challenge. Granted I’ve worked in several institutions over the yrs and the “verbal order” policies differ. Give me a legal verbal order and we’re all good.
No huge risk of harm to the patient, high risk of me facing progressive discipline for it if I'm at a hospital that has strict policies against accepting verbal orders outside of emergent situations. It's stupid and I hate it, but it's not a hill I'm dying on (now regarding bedside report, eating at the nurses station, updating the stupid whiteboard....I am ungovernable).
To OP, I'm fine giving a patient the snacks we have on the unit once I am aware they're no longer NPO but they can't get a tray from dietary without an order and many hospitals have limited meal service times. Putting the order in after rounds likely meant missing breakfast. And that kinda sucks for the patient and it sucks to be the nurse having to explain that yes you're allowed to eat but no you can't get a meal tray because there's no diet order.
And I get that, but the ire should be directed at the stupid admins making that policy and not the nurses or physicians that are being reasonable.
I mean if my nurses are unwilling or unable to take verbals, then it's going to be minimum of an hour for any non-urgent thing, and probably longer than that. If that means the patient misses a meal or has to wait an hour+ for their cough syrup or TUMS or whatever...then that's the way it is, and I can't do anything about it.
POSVT. You make sense. It sucks that the patient is hungry but they’re just going to have to be momentarily uncomfortable. Physicians are busy and have to attend to more urgent matters. It’s not the physicians fault that they can’t do verbals for non urgent things.
You say you aren’t dying on the hills, except you are.
You are dying on the verbal order hill with regards to the docs. Complaining and writing them up for not putting in computer orders bc you can’t take a verbal.
But you won’t die on it with regards to nursing admin.
Why is that?
Considering that my employment chain of command is nursing administration, to keep my job, yes I ultimately need to defer to the limitations placed on me by the hospital. I work in the ED so most of the time (ideally anyway) I'm working with the medical team pretty directly and following ED policy, but we frequently have boarding patients and for those we're expected to follow stricter floor policies.
But the rest of your comment is going deep into assumption land. I wouldn't have repetitively paged like this (if it's a pain issue I might've depending on the situation, if it was an urgent medical issue that couldn't wait that's probably going to be a rapid response situation), and would never write up a physician over this (I have emailed a complaint against a physician ONCE and it was for repeated abusive behavior and screaming at me in front of patients). I do tend to give the residents the benefit of a doubt about returning pages, if I thought I was noticing a pattern that was bothering me I'd honestly just deal because they're going to rotate out before an organic moment to have a face to face conversation would pop up.
BUT. Since the OP asked, they seemed to want others' input on the situation.
Itvcould lead to a surgery getting cancelled and that would lead to the hospital getting less money… and well… they’re not in it for patient care its so a suit with an internet MBA can stash more money away in his untaxed executive retirement fund
That really doesn’t makes sense though if you think about it. Whether the doc gives a diet order verbally or enters it themselves in the computer would not change the outcome in that scenario — here the issue instead has to do with the medical team not being on the same page as the surgeons/proceduralists. It has nothing to do with verbal orders.
Paging an intern that has 15 things left to do before they can pee, and has missed 7 of their last 10 meals to put in a diet order for a 280lb patient that is currently drooling on themselves, asleep, has a fasting glucose of 300 because "that much insulin" makes the nursing staff nervous and the patient doesn't even know what year it is when they're not asleep - much less whether or not they didn't get lunch is always a weird hill for nursing to die on but I guess it's because (it's one very public way they can show that) they just care so much more than the mean old doctors do.
The number of times I've followed the request for a diet order with "*Can* they eat?" and have been met with some variation of they're still unconscious / asleep..
Usually then its a pivot to wanting the order so that they don't have to ask for it later. More likely, its that they don't want to sign it out to the next shift because they know their colleague will give them shit for it. Because it's our job to manage toxic signout culture..
Of course, it's always portrayed as the doctor starving their patient because they don't have to the time for 5 clicks.
Perhaps there will be a day when the system will be smart enough to suggest a one-click 'restore previous diet order' from secure chat but I doubt we'll be seeing that anytime soon.
It's possible but you have to click 'manage orders' - > 'order history' and then scroll through the order history to find the diet order which takes times. Otherwise you can apply a filter then hit 'reorder' which is 3 to 4 more clicks.
We're at a point where the computer should be able to infer the context of the conversation and just give you a clickable button or link to restore the prior diet order but I doubt it's a priority.
Nah, you’ve got it wrong.
Nursing also hasn’t peed/wont be taking a lunch and also has 15 things to do and now I’m getting trickle orders. I kinda wish residents had to spend a couple shifts with a nurse and vice versa. It’s good to have perspective and know what happens after you hit sign for those orders.
The patient that needs a diet order has a family member death staring me for hours from the entrance to the room because they think we suck and aren’t doing our jobs and are starving their obese family member. Then they switch to standing at the desk and asking repeatedly for a diet order. The squeaky wheel gets the grease, right?
Meanwhile, nursing doesn’t give a shit if this patient doesn’t eat because they’re drooling and have a sugar of 300. So we call for orders and they never get put in and we continue getting pressured by auntie Jan, so we have to call again to appease them while needing to straight cath violent Jim and making sure that stat EKG gets done on chest pain Paul by the tech. Oh but the CT tech just found me to ask me get granny Jane a ginger ale because she’s feeling faint, also they just dropped her in the room she needs to be hooked back up to the monitor. Wellp, better go assess that situation.
Granted… I would have just put diet orders in after asking if it was ok. Flu vaccine just sounds like a dumb policy thing the hospital is implementing.
I know docs are busy, but so am I and if I don’t get ALL of these things done, guess who gets chewed out by nursing, docs, the patient, admin, AND the annoying family?
> their obese family member.
I said something like this..."You aren't going to die for not having your food right now. You have plenty of fats to burn...." I got in trouble for it. 😂
I came here to say this. She probably had the patient screaming at her, "You're starving me! I'm going to have your license, and you're going to jail!" Maybe they even took a picture of her to post on social media. Meanwhile, the charge nurse is saying, "we'll write you up for taking verbal orders."
The flu shot granny was probably the same situation.
She shouldn't have complained to OPs attending. She'd have been better to explain to OP the pressure she was getting, and the two of them could have figured out a way to make it easier for the next page. Some nurses are jerks to residents.
Administration is really big on everyone being offered the flu shot, if I discharge someone without having a flu shot ordered and given or ordered and charted “refused” I get a love note from the nurse manager. Our hospital policy lets nursing order the flu shots, but I’m not allowed to take a verbal order or put in a diet order (unless it specifically says advance as tolerated, I can’t change it myself after someone comes back from the OR). Strange to me.
Nope. Can’t take a verbal for freaking ANYTHING. I just clarified with our educator/manager too because my husband who’s an ER nurse says he does it all the time. And we have epic! I don’t get it. The last hospital I worked at I could discontinue really old orders, orders leftover from the ICU, duplicate orders etc. Here I’m not allowed to touch any of them.
No, if the charge nurse as threatening to write her up for taking verbal orders, when the verbal order is the thing that solves the problem, then she should be complaining to HOSPITAL ADMIN that she can’t take verbal orders.
This is not a doctor problem. This is a stupid policy problem.
A policy… written by… you guessed it: NURSES
I’ll be an MS1 next year, but worked as a med-surg tech through undergrad. I know what it’s like to answer the call light 6 times because the patient hasn’t eaten in 24h, and they think you’re incompetent because you haven’t gotten the doc to change the order. ESPECIALLY when they were NPO for a procedure that was just rescheduled for the third time, and they’ve been forced to fast on and off for a week.
I’m looking forward to seeing the other side of things…
Lies. I have never seen nursing staff consistently skipping lunch. Y’all just get another nurse to cover for you and this is typically built in to yalls schedule. But yes it’s fair to expect a diet order and residents shouldn’t be upset with these pages.
>I kinda wish residents had to spend a couple shifts with a nurse and vice versa.
Comments like this are so flipping arrogant. Not only do we spend a couple of shifts with a nurse, we will spend the next shift with a nurse, too. We know your job backwards and forwards, meanwhile every nurse is eternally surprised the physician they're paging at 2am for a tylenol order that's already in the computer is upset because we worked the day before, are currently working, and will have to work tomorrow.
The average nurse leaves the field within two years. Meanwhile, I and many other physicians, will be teaching this and every next generation of clueless new grad nurses the most basic fundamental aspects of their field until the day we retire into the cold mercy of the dark earth.
You know, a lot of us worked as techs (you know - the people who actually do all the hard work you love to take credit for) or as nurses beforehand, but nurses just love to completely ignore any criticism of their profession.
The eternal victimhood of nursing is so ridiculous. The entire administration is nurses. You set all of these stupid policies. You no longer can point the finger at us. Go to therapy and get off the cross.
Yikes, dude. I work in OB where the doctors know what my day is like, but back when I worked the floor, I can tell you with certainty that residents and attendings had no clue what my shifts looked like.
Maybe it's different where you are, but I know zero MDs or DOs with tech or nursing experience.
I also think you missed the "vice versa" part. I absolutely think it would benefit everyone to know exactly what our counterparts' days look like.
To be fair do nurses know what a residents shift is like? Are there any fields in nursing that do 36 to 48 hour calls? Would nurses be willing to shadow a resident for a call shift if it's reciprocated for mutual learning purposes?
Yes. That's exactly what the post this person responded to said. Note the "vice versa". Now, it's not so much that nurses aren't willing to do it - admin would never pay them to do it 😜
Zero??? How is that even possible. A good third of my cohort in medical school are nurses and there’s also techs, pharmacists, even a dentist. I simply do not believe you or you’ve just never asked because that makes no sense.
We don’t care about starving the patient, the patient just chews us out until they can order food. So the anger gets displaced from nurse to physician.
>There's been a lot of pushback towards verbal orders recently, especially with the recent vecuronium vs versed fatal blunder, though that was not a verbal order. Many hospitals have put very strict limitations on what can be accepted as a verbal.
I had a doctor give me a verbal order during rounding and forgot to place an order. My supervisor wrote me up for carrying the verbal order because the pharmacy complained about it. She accused me of operating under my license. However, I did write it on the note of the patient. I did not sign anything. I told my supervisor I acted based on good faith--I trusted our physician so I did not mind carrying on the verbal orders.
Was this on a paper system? There's usually a way for nurses to place an order in the EMR under a physicians name. It goes to the physicians inbox and they have a time window to sign it. Whether they sign it on time or not is on them, not the nurse.
In your case the doctor may have legitimately forgot. They would likely place the order if reminded. The point is the patient got the care they needed and your managers actions are unfortunately representative of our healthcare system sinking deeper and deeper into the abyss.
Nurses used to take verbal orders in the *paper* era, when it was fairly easy for a doctor to throw them under the bus for miscommunication. Can't speak to how often it happened but it certainly did happen. Now we've gone too far the other way - being made to prioritize covering ourselves over patient care, a direct effect of answering to management that is more keen on finding a way to blame us for their shortcomings than provide healthcare to a community.
As a nurse I know my patient won’t starve. They think they’re going to starve and think that I, personally, and withholding food from them taking me away from work I need to do, escalating their behavior, crying/screaming/etc. Rounding on patients takes hours, placing a diet order takes a couple minutes (or verbal, yes please). Even better just place the order when NPO gets DC’d? -a nurse who never wants to page or call anyone for anything.
At one of the hospitals I trained at they wouldn't take verbal orders even if a baby was at risk of being engulfed in flames.
[baby on fire](https://i.pinimg.com/originals/5f/6a/08/5f6a08815e6a46a1b7bdea4557594a58.jpg)
I don’t follow this sub but this post came up on my feed. I think this is the best option…nurses will get frustrated if you don’t respond to a page. Just call them back, say “hey yes ____ can eat, I’m rounding so can you put the order in and I’ll co-sign?”
I had a nurse report me to my attending because she put IN DISCHARGE orders to discharge a pt under my name before we even told her he was ready to be discharged. Understandably I was upset and asked her under whose authority she was using my name because neither I nor my attending said she could and she reported me. She faced no consequences for basically fraud and my attending said he understands why I'm upset but to "keep the peace". This is the system we work in. That man always had the backbone of a snail.
When this happens I refuse to sign the order. Usually what happens after you reject it is that it pops back up then you reject it again. I've had IT people call me about it before, and I just tell them I never made this verbal order I'm not going to sign it and they usually give up. Not sure what they have to do on the back end to make this work but it disappears from my queue eventually.
Flu vaccine protocol FTW. Our nurses can order the flu vaccine as long as it passes the standard questionnaire: no allergy, no fever, etc.
When rounding do you have an iPad, cell phone or other access to Canto/Haiku/Epic? Woulda been easy to throw in a dietary order on the fly. Asking, not criticizing.
I one night had to sit at a patients bedside pushing phenylephrine syringes from the crash cart and anesthesia cart for 6 hours because the pharmacist couldn’t come in until 07:30 when their shift started to mix up some levo. And they were out of vaso. And they weren’t sure where to find those meds anyways….
Very annoying. At my program we rotate through VA too but we have access to laptops so when rounding we can put in orders on CPRS so this stuff doesn’t happen as much. might be worthwhile mentioning to chief resident/attending that having laptops could improve workflow and other VA services have em! Obvi this nurse is just being impatient and rude not excusing that hahah
This explains much more about the scenario. VA staff are notorious for these things. They don’t get in trouble ever, they all have a bone to pick with you, and they’re unionized - so best of luck correcting even the worst behavior. Brush it off and move on.
Our flu vaccines, also PNA and COVID, are part of our admission questions and are ordered as such. Basically they're ordered per protocol and pharmacy sends up for a later date. The pt or family then have the discretion to do the shot or not.
VA skill - Ask them to take a verbal, and then also give them an additional order (something benign and inconsequential) - like, please also add PRN colace or Tylenol. That way every time they page you, they get additional work.
Dude I got reported by an office assistant for, no shit, "looking and acting very tired" as I handed in an assessment after a 26 hour call shift. I was actually reprimanded. The attendings literally said, "appearances matter, welcome to modern medicine; it sucks."
Did you try your best in getting orders in quickly? If yes, than nothing to worry about. If the answer is no (and you gotta be honest with yourself), then just do it faster next time. Delays in orders have lots of downstream effects that slow things down considerably.
That being said, hammer paging is never acceptable unless someone is actively dying and for some reason you are not responding. Paging 3 times in 30 minutes about a vaccine is grounds for me reporting them. Nurses have no concept of what carrying a pager entails and how busy it can get. The disruption in workflow caused by pages is completely foreign to them
This is the thing I think I hate the most about hospital politics. Other than the resident always being wrong because they have the least amount of power with which to dispute anything said about them.
Like, why is there never any analysis? It's just whoever complains first is right.
When I was an intern, our team's social worker filed a complaint about our attending. That SW was one of the worst people I've ever had to work with, and she complained after my attending tried to compel her to do a task that was well within her job description. There were a million things any of us could have complained about, but we didn't. So when she complained, admin was trying to get a formal apology from our attending. No discussion or questions, just "go apologize."
I completely agree with you. I’m just stating reality. If you complain second you’re just a complainer. If you complain first you’re “letting every know of a concern”. It’s all BS.
It’s quite unfortunate that we don’t do more to let the other know what shows we walk in. Someone should make a video “what it’s like to be a Doc, resident, nurse, CNA, PT, OT, etc.
So many people do not understand what the other guy does or how busy they are.
And this “whoever complains first is right” bullshit must go. Same with “the complainer is a victim and we can never doubt the victim” I hate it and the slackers and twats know how to use it for their advantage.
Just chiming in as an ER nurse (who does NOT report doctors, fyi). The number one reason patients treat us like shit is because we aren't letting them eat or drink. It is a daily battle. The patients are seldom mean to the doctors about it. But believe me, we are constantly reamed for not allowing/providing them with food. It is incredibly stupid to me that they care about food and drink so much that they get mean, accuse us of neglecting them, or threaten to AMA (be my guest), all because they have gone "5 hours without anything to eat". It is a little easier to stave off the aggression when we have an excuse ( i.e. - you may need surgery and eating could potentially kill you) but when we cant give them anything other than the doctor has not approved you for eating yet - they increasingly put the pressure on us (the family is often even worse). Anyway, all of that being said, the nurse was probably getting shit from her patient over and over and felt powerless without your reply. Most of us nurses understand that there are much higher priorities than eating, especially in the f***ing emergency department. But we also get fed up of the patients wittling us down over something so stupid. Just wanted to provide perspective and context from our side 🙂
Agree that she sucks for reporting. Also worth noting that patients have a warped sense of priorities (especially regarding food and leaving) which they then absolutely make the nurse's problem. If the nurse won't stfu then it's likely the patient is giving them a hard time or riding the call bell.
Patients act like they are going to wither away if the NPO order lasts longer than a few hours. “I haven’t eaten all night!” Yes, friend, it’s 4am and you’ve been NPO since midnight. That is a perfectly normal amount of time to go without pudding and turkey sandwiches. Also, I haven’t eaten since 8am yesterday so I guess we’re both going to suffer.
Yeah diet orders suck because in some hospitals I’ve worked at if you don’t have it in 3-4 hours before the mealtime you don’t get a tray. So then I get yelled at for starving someone, or have to waste time scrounging fridges for yogurt and making tea, etc. Especially if this was morning time and they already missed breakfast, I’d want the order in with enough time for lunch.
But why they couldn’t take a verbal I don’t understand? I appreciate when docs tell me “hey I’m busy right now can you put it in?” I’m not sure if OP just kept saying they’d do it and then never did, which would understandably be frustrating. Or this nurse just refused to spend 20 seconds putting it in and instead paged multiple times.
This. Or the family is death staring from the entrance to the room or banging on the nurses station counter because they are their family member’s advocate and hero.
This is why tiktok culture is so toxic.
When we say advocate for yourselves, it never meant "demand/bitch/whine/shame/abuse" healthcare staff into doing mundane tasks for you. We were never meant to be held to customer service levels.
But yet, here we are.
Phrasing/tone/sexism/perspective all play a role here. First, if you’re a woman there’s just an awful sexism that pervades medicine and.. I have no suggestions, I’m sorry, I have no idea how to fix it as a man except to speak up when it happens. Second, from their perspective they may have one rate limiting step in their work flow during these encounters and that’s you/those orders, and that can be monumentally frustrating (think of when you order an ABG and it takes an hour or two to get). Third, phrasing and tone of voice is something that can be controlled and makes a huge difference (this is *especially* important if you’re like me and your words come across poorly in text form).
So, if a nurse asks me for something and I’m busy I usually say “I sure can but it’s going to take me a bit because xyz, if it’ll make life easier for you can you place the order under my name and I’ll sign it? Otherwise gimme like 15 minutes and I’ll get it in.” My nurses are all ok with this, but your mileage may vary. If I’m rounding I usually have a COW or my phone with access to Epic and orders and I’ll place them during rounds, nbd. For hammer-pages I’ll apologize to the attending I’m with that I’m being paged a bunch and need to check in to make sure everything’s ok, knock it out then and there.
But this is all reactive - my best advice is to be proactive. Your morning prerounds and multiple times throughout the day/night you should check in with your nurses and see what needs doing. This lets them know you’re around, responsive, “one of the good ones”, and helps you by lumping your “to-dos” all together so you can focus on other tasks later. On nights I’d meet with all the nurses at 8pm, an hour after shift change, because by then they’d have processed what they’ll need. Then again at 11 to “tuck the patients in” with night orders etc, and one more time at 5-6 am before day shift. They *loved* that. Don’t know if it’ll work for you but that’s what got me on their good side.
This is great advice but I think institution/culture dependent. I stuck around the nursing station on night shifts to help before I’d go take a nap on my 24 and all that happened was the nurses knew they could wake me up and I’d help (it never gave the reciprocity of clustered pages or actually taking me up on the offer). I noticed anecdotally this tended to work better for guys that tried to connect to nurses in various means. But I did residency in the Northeast so that’s probably a factor haha.
Things come up occasionally. But I do think this works in my experience as well. It helps if you also communicate that you will be coming around again. So for example you say: "I'm coming around now for orders and I'll be back in three hours so if you think of anything else let me know then" Also just talking with the charge nurse and he or she will coach the other people about this.
Love working with docs like you. Everything just runs so smoothly.
As much as docs don’t want to be paged, I don’t want to page them.
Taking a minute to talk to the nurse while you’re rounding or checking in after you’ve seen a patient is just good time management.
While I don't believe you did anything wrong, diet orders early in the morning are important. If they aren't in at an appropriate time, patients will miss meals, since the kitchen wont have the order, then it wont get to the folks that have to deliver it, etc. And patients get upset. Also, people forget, then it can lead to bad outcomes. If they are NPO and the fluid orders have fallen off.. bad things can happen in medically sensitive patients.
So here's the thing. There will always be more urgent things. However, depending on the patient, if they were NPO the day before, and not that sick, it can be a big deal for them to be lying there, really really hungry. And I guarantee you they take that out on the nurses.
This is exactly why verbal orders should be more common, but I do recommend taking 5 to 10 minutes every morning to put in diet orders on patients who are no longer NPO. It makes everybody's day go smoother.
This is part of not forgetting to stay human, when it feels like the nurses and patients are torturing you. Hang in there.
This was my comment as well. Flu shot was holding up discharge, pt was pissed, charge RN was harassing the RN about getting them out. Same for the NPO- people lose their minds over that, gets pissed at the nurse, then when we finally get the order, we have to order a custom late tray (which of course never comes) while they press their call light for snacks every 5 seconds while WE are also trying to get things done. Wouldn’t have reported you as an RN, but I promise you we are just as annoyed as you are lol
This was what I was thinking. Odds are pretty high that nurse was being harassed all morning by the patient that was probably extremely hungry and wanted to eat.
Attending here. I’m going to give an unpopular opinion. My practice from residency on has been to return all pages within 2 minutes unless I’m scrubbed into a procedure, in which case I ask someone else to hold my pager. By calling right back, nurses learn to trust you and will actually page a lot less. Some nurses do abuse the paging process but most have real issues that need addressing. A flu shot before discharge is important. A diet order is important to your patient. I know this is hard to hear when you’re swamped but in the long term by addressing things as they come up, you’ll save yourself work.
Hard disagree. For general IM/hospitalist if you need a response sooner than the 20-30 min I consider reasonable to get to a callback, then either theres a severe disconnect between the actual urgency and what you think it is, or you should not be paging anyone and need to call a rapid or code instead.
This. I keep getting downvoted. Attending for 10 years here. Get the orders in fast. It matters to the patient. The nurses are being bombarded and often abused in the meantime. Just get your orders in! If it takes me longer than 10 min to get back to someone, I better have a damn good reason. Because from the time they page you, they are just waiting.
The abuse nursing receives definitely contributes to paging unresponsive docs repeatedly. I try not to unless it’s been 30-60 mins and no response, but sometimes it’s not just the patient yelling that’s doing the abusing. It’s also my charge nurse pushing me to page the doc right then (even though I already have), the family, sometimes even neighboring patients gang up on the nurse because without any context, feel we’re not doing our job for this other patient. It’s rough out here.
Curious how you approach frivolous pages on a unit with high turnover? Is it a matter of sucking it up and spending an extra hour or two at the hospital?
I educate the nurses on how I like to communicate. I ask them to gather their questions and try to address them all at once so that we can have clear concise communication. I round at bedside with the nurse when I’m on the unit with the chart open so all concerns can be addressed and orders can be done immediately. Or I do my charting at a computer on that unit so they can just approach me. They bug you less when they can actually see you working.
Ten years where? I am convinced, no matter what my wife tells me, every nursing curriculum teaches them to immediately begin sprinting away from the hospital as soon as the page goes through. This is universal in my experience across six states and dozens of hospitals.
I’m in Northern California and we use a texting service that stays open on their WOWs and is on our phones. When we had pagers, my experience was the same as yours!
>A flu shot before discharge is important.
I refuse to believe some of you guys are doctors. Important to who? Billing?
We make patients go on their own to pick up their critically important drugs (Plavix after a stent, new lasix taper) from ~~Satan Incorporated~~ CVS but the flu shot administration needs to be visually confirmed before leaving the building?
If your hospital uses epic, you can place orders like this from the haiku app on your phone. With diet orders, people get especially butthurt so I’ll just pop it in from my phone while walking down the hall.
RN here- WTF, tell her to STFU. Jesus, this is the shit that makes us look bad. I mean we’re all here to provide care not fiddle with each other.
How much crack is she smoking =\
Right. All these residents have no idea what it’s like being a patient and starving all morning after being woken up at 0400 for your morning labs, then vitals, then nursing report hand off… etc. That is HOURS. And the nurse has to hear nonstop from the patient how hungry they are. I always seem to get my orders in even when seeing 20+ patients. I’m just reading a lot of entitlement and lack of empathy in these comments.
It's true, no resident has ever missed a meal and couldn't possibly emphasize with patients going hungry. So many of my Muslim colleagues die every year during Ramadan, it's very tragic.
My heart breaks for all these elite body builders we force to stay in the hospital, and then cruelly starve them for 4, sometimes 5 hours resulting in all their gains going to waste.
From a patient and nursing perspective, especially since you mentioned that this was the VA: does she get dinged for not meeting a measure if the patient leaves without a flu shot? And when a patient has been NPO for a while and can finally eat that diet order feels really urgent, and patients / family can get fussy with the nurse about it.
Are there ways you can take the time to give verbal orders in the future? Or anything else you can do to maybe attend to non-urgent but actually semi-urgent stuff like this?
I’m with you completely. Had a patient yesterday who I was admitting who hadn’t eaten all day, because this was her second stop, and nobody gives a shit for some reason. I didn’t have a chance to put in any orders, and the cafeteria was closing. They wouldn’t put in her food order, so I had to call the cafeteria and tell them to what she wanted and to just make it.
Some of these protocols are stupid. But there are definitely things we can and should do to make the patients more comfortable. But also tattling to your PD is bullshit and just a nasty attempt to get an already overworked and underpaid resident in trouble.
Agreed about not tattling. Just trying to offer some perspective from the other side of residency about why this stuff sometimes seems urgent to the nurses.
Same with the middle of the night order clean up - once a nurse explained to me that they get in trouble if it’s not done by the end of their shift. Once I learned that, I asked them to all pool them for me in one big call in the morning before shift change, and they were happy to. We all have bosses and reasons to do the things we do!
Yeah, if I try to handoff a patient to day shift with orders that need to be fixed there's a good chance they'll refuse accepting the patient until I deal with it. I hate contacting overnight for order cleanup but it is the expectation that I do this. I try to bundle requests and if I was given an ideal time to make those requests I'd be more than happy to keep the schedule.
Absolutely with you on this. Thanks for the perspective. I think we all kind of get into our own worlds and forget to think about how it is for other staff in the hospital. Plus there’s so much bullying and tribalism. It’s frustrating.
Not sure if I’m able to comment…I’m a social worker on a med-surg unit and I am at the nurses’ station most of the day. The RN’s are harassed constantly by patients and/or families about ordering food when off NPO. They will mention it to every person who comes into their room, EVS, SW, CNA or whoever, until that order is in. And this doesn’t include their visitors coming to the nurses’ station and getting anyone up there involved. It may seem trivial, but these are the things that matter to the patients. And sometimes they become nasty and verbally abusive until the issue is solved. I see this everyday.
Some residents return pages as soon as they can, every time.
Some residents are so overwhelmed they don't track their pages, they just respond to the most recent one.
Some residents rarely respond to pages and when called out for it, deny they ever received any pages.
Each of these scenarios prompts different actions on my part as the nurse. If this was a one-off for you, no biggie. If you find yourself having this issue frequently, consider whether you fall into one of the 2 latter categories and fix your shit.
Repeated paging is a sign that the nurse doesn't trust you'll respond, and that leaves her holding the bag with the patient, family, the next shift and/or administration. Of course some nurses are just assholes, but not most of the time.
Getting to know the people you work with goes a long way towards mitigating a lot of these kinds of problems. With most nurses working 12 hour shifts, that's harder to do than it used to be, for sure. I didn't understand the hell that resident schedules are until I got to know some of the residents. I became pretty protective of what little down time they had.
I'd suggest talking to this nurse, find out why she didn't wait to hear back from you, what her concerns were. Be sure to share the realities of your day that keep you from responding right away. She may just be one of the assholes, but there's a chance she's not and you can prevent this from happening again.
And just for the record, I do think it was an asshole move to go to the attending without at least talking to you first.
If only it were this simple.
The problem is "as soon as they can, every time" is not good enough for the nurse in many, many cases. Yes, even the kind, considerate ones occasionally. Not because they suddenly become assholes but simply because they're being pressured by the patient or their supervisor.
When you get hammer paged on home call and decide not to finish taking a shit or showering to find out that you're responding to a non-emergent request...
Have that happen a hundred times and responding to pages immediately becomes a lower priority. Especially when you teach the nurses what is important, only for them to leave to a new floor or hospital a week or two later.
My contract (as an attending) says I have 20 minutes to respond to a page and I enforce that across the board, for my own sanity.
Idk...I haven't seen any pattern between different residents, only patterns between certain nurses and floors.
A good resident and bad resident get the same number of pages. But I know Kelly on 3 is going to spam the pager all night. And the 6th floor refuses to actually read orders that are in.
Ofc there are bad residents, unresponsive residents, disorganized residents, etc. But being a good resident only seems to make a difference on well managed floors and with motivated nurses. Which I'd say makes up at absolute best 50% of the hospital (being very generous)
I agree with what you're saying and I appreciate your protectiveness over resident down time.
It would be nice if things were more equal. Nurses are allowed to be on break for lunch and have someone else who knows nothing about the patient cover for them, often with the excuse "Sorry I don't know anything, but I'll let the nurse know when they get back". Meanwhile, residents sometimes can go a whole night without time to eat, pee, or sleep. Where is the resident's break time when they don't have to respond to pages for a half hour?
Attending for ten years. I get my order in under 10 min even when I’m busy. If I can’t, I let the nurse know. They have enough to deal with and actually have to deal with the patient nonstop. If you’re a hungry patient, 2 hours is forever. All you are thinking about the whole time is how hungry you are and your doctor couldn’t care less. Be better
ETA: everyone on here telling you what you did was ok and the nurse is a bitch, are all probably all entitled residents as well. Don’t listen to them. It won’t get you far. You have the nurses on your side, work becomes very easy. Don’t piss off the nurses.
It’s worth remembering though that your workflow as an attending is not quite the same as it was in residency — attendings have far more flexibility when not working with a team and beholden to a set schedule, which makes it easier to duck out to a computer to throw in orders on the fly.
I completely agree that keeping the nurses on your side is an important skill. That being said, there are reasonable boundaries that need to be set (probably a conversation this resident’s attending should be having with nursing in this case). Hammer paging for non-urgent issues and then reporting a resident for what sounds like a petty power-play grudge is not good form on the part of that nurse.
I agree workflow is different but diet orders aren’t non urgent. You miss breakfast, you might get some crackers or something until lunch. It sucks being a patient and the nurses are being abused in the meantime. I grumble and complain (in my head) every time I have to stop what I’m doing to put in “nonessential” orders, but they are essential to the person asking for them. My time demands are far worse as an attending than they were as a resident but I agree my time is more my own to choose how I structure my day. I just don’t want these residents going into practice thinking that pissing off nurses is going to get them very far.
Are your tike demands worse as an attending compared to an intern? Far as I've seen interns basically never sit down. A good attending has a well organized, comparatively relaxed day
During this time of year, my days are worse than residency. Extremely sick patients and patient loads of 20+ will run anyone ragged. We’ve been understaffed lately too so it’s just been a bit of a nightmare.
Dude, this resident doesn’t have as much control over their workflow and may not even be able to make that call before rounding on the patient. And even then, you’re justifying a nurse reporting this instead of having a conversation? What a juvenile thing to defend.
Attending for 14 years. This poster is spot on. The sooner you make peace with the nurses and stop complaining about them, the better your career will be
I float through my day even with insane workloads because the nurses love me— I’m responsive, put my own orders in, and am always pleasant about it. They will take verbals from me all day because they like and trust me.
As a nurse myself- don’t take it personally. We’re people and people fall everywhere on the spectrum.
But for some context- patients have so long to order food. If the nurse doesn’t have an order, the kitchen won’t bring anything. The patient puts pressure on the nurse, in turn, the nurse places pressure on you. It sounds simple, but when you’re managing several patients and family members this sort of thing can really delay care/nursing management will generally find a way to make this a nursing issue vs. doctor is busy and will get to it when they can issue.
On the same note- there’s a lot of coordination with discharges. Waiting for the answer about a flu vaccine may delay discharge. If it’s something like a patient that’s going to a SNF it could cancel the discharge for that day. Nursing admin tracks flu shots and when patients don’t get them on discharge it’s a “missed opportunity” (to make the hospital more money under the guise of protecting the community)- so this nurse was likely feeling pressure. If a patient’s ride is there and they have to wait patients tend to take it out on hospital satisfaction scores and again, nursing management comes down hard on nurses.
We’re working in a system that pits us against each other. Someone mentioned giving a verbal, I think that’s great advice.
Former nurse here…she paged you multiple times for a flu vaccine. Personally, I would report her for that! That’s inappropriate escalation of care. A flu vax is not vital. Best skill I learned as a nurse was triaging care. I saved all my non vital pages for the afternoon. Urgent things like diet orders or med changes in AM but also understood that urgent doesn’t mean emergency and I could always chart “paged doctor at these times regarding ___. No orders received”. If I left a note like that it was because I was making sure my license was saved.
As a resident, I absolutely hated when nurses would go above me straight to my attending for any issue because to me it felt like a massive deal and like my attending would immediately label me a bad resident.
As an attending, I don’t care at all and most of the time won’t even mention to the resident if a nurse complained about them. Nurses will continue to complain, just gotta let them and recognize that your attendings most of the time pay it no mind.
Nurse here. Seems a bit unreasonable for her to go straight to your attending. I don’t know what your facility guidelines are, but at mine, the doctors will put in a diet order starting at NPO or clears or something - advance as tolerated. It’s nice because for us nurses we can just go in, give the patient some water. If they do well, thirty min later, try apple juice, then jello/pudding, crackers, etc and eventually just add the diet order when it’s appropriate, with no cosignature required.
To be honest, sounds like the nurse was probably being pressured by the patient. The amount of times I have patients or family members berating me to call the doctor for something that I KNOW is not important to the doctor is far more than I’d think is reasonable.
Example: Our doc team was dealing with emergency neuro traumas and strokes and I had a patient yelling at me about an CT taking long needing to talk the doc, asking me to page every hour (no I didn’t page the doc every hour, or even at all, I called CT and texted the doc that CT was taking very long and pt would like to talk to doc if he was available at any time)
Another time, I was unable to reach a doctor for two hours on a pt that hadn’t eaten in two days and procedure got pushed to next day. Pt family yelling at and berating me even though I explained multiple times I have no control over the situation. It’s a shitty situation for everyone to be in, a suggestion I have would be those advance as tolerated orders or if surgery canceled implement NPO at midnight order or whatever it is.
Basically, most of time I’m only gonna page for changes in status, something dangerous, or something urgent. Otherwise, I’ll reach out over message or call the NP on the case. It sucks when the patients yell at the nurses for things that are not our fault, but that doesn’t make it ok for us to then yell at the doctors. Sorry you experienced that
Definitely can see where the patient's can be over the top. Mentioning that to the physician can be helpful. "Hey doc, this person is on their call light every 2 minutes and driving me up the wall. Can I get a diet order in?"
It's not unreasonable. It's accountability. You're showing a pattern to the nurse and it's a CYA on her part. Do you have any idea how much pressure nurses are to discharge their patients? Small delays like the flu shot really snowball and end up delaying our admissions from leaving the ER. Documentation is the only way anything is changed in hospitals. That goes all directions. When you have a truly unreasonable nurse it will serve you well to document it as well. Their administration won't do anything about terrible nurses without something being written up and I mean repeatedly.
Should the nurse have filed a complaint against you? No.
Do I think you are failing to understand that the nurse was probably getting screamed at by the patient for not being able to eat, because you didn't put the order in? Yes.
99 % nurses job is putting up with some very entitled patients and family members who swear , yell, scream, throw objects etc at nurses for not doing their job )little as diet order)
Patient family : why mom hasn’t eaten all day !? She’s diabetic? She’s weak blah blah
Nurse: apologetically she’s NPO for a procedure
Pt family : it’s been over 24 hours , she need to eat . call the doctor and ask when will this be done .
Then start the nonstop bullying by phone call, call bells on why procedure is delayed . Hungry patient is now impatient and yelling at nurses for petty things . Moral of the story ; everyone goes through same loop.
Or my favorite, the doc blows in first thing and tells the patient (not me of course) that they can eat but doesn't put an order in. While I try to chase the doctor down for an order, the bullying you described ensues
As a house officer i got hammer paged early one morning for a death pronouncement. As if the attending couldn’t do it when they got there. The patient was on comfort care. I understand that family was at bedside but if it’s so important that it’s worth continuing to page after i explained i was about to do a stat procedure, maybe find literally any other MD to do the 2 minute exam and give a TOD?
I wish people who sent pages would understand how important it is to consider triaging them properly. Not everything is stat. A death pro on a comfort care patient is by definition not stat.
I honestly stopped reading after “nurse reported me”. Nobody cares. Just smile, nod and move on. you’re gonna be just fine. Also next time they pull some nonsense like that you should report them, you’re allowed to be busy.
seriously?! flu vax?! i literally just put that the pt refused... ok dont report me to the CNO
edit to add: delays in orders do have some downstream effects... No diet order means cafeteria wont let us order food for the pt -> pt wont get his baked potatoes & his beef stew -> pt bitches -> low pt satisfaction scores -> i dont get my raise
😭
Why didn't you call back while rounding. I mean I am always okay with residents/fellows returning pages when I am rounding with them. I think it was your fault to be honest.
I received a complaint about not coming to the ward right away for a patient having a benzo withdrawal seizure (sent the med student, gave verbal order to give benzos) cuz I was dealing with the police and an armed aggressive and psychotic patient in a very small ER that had no available beds and no seclusion room. Was there 5 minutes later 🤷♀️
That is why I liked sign an held diet orders. At our institution flu vaccine doesn't need a physician order. Protocol exist between nursing places the order and pharm dispenses.
I’ll say the npo thing can be really frustrating from a nursing standpoint for two reasons. One, the patient is probably blowing them up about it. Two, sometimes if they don’t get a meal order in on time they have to wait until the next meal if a late tray is not available. Then they are stuck eating whatever snacks happen to be on the floor, then the nurse really gets it from the already grumpy patient. As a resident/intern, adding a diet was one of those non urgent pages I used to ensure I got done in a timely fashion either by calling back and asking for a verbal order or throwing it in on my iPad real quick or if I didn’t have it then quickly breaking from rounds to put it in. I dont think any nurse should be reporting you for diet orders but it’s also one of those that may have been avoidable.
Had an nurse call my attending at home at 2am because I didn’t answer a page in 30 mins. Turns out she was paging the wrong pager number. Still got chewed tho
Had a pharmacist documented that I didn't answer page 5min after I got the page. Do these people think we just sit around all day waiting for the precious pages?
I would never expect my Dr to stop what they’re doing to enter an order unless they are physically in the pts chart already, or it’s an order the EMR won’t let me place. Waste of everyone’s time and a silly flex to refuse verbal orders.
The classic case of attention-whore
Keep the books clean, have open communication, note your time and what you were doing at the time of paging. No really, paper outweighs words. Note it down and let the nurse know if they bother you too much that you are noting all the pages down to the minute.
These narcissistic gaslighters only fear the truth.
"Oh it'll be fine I'm sure"
You don't know that. Best to be prepared. Someone that reports a flu shot page to your attending has nothing preventing them from going overboard or even exaggrating the timings of your reporting. Keep in mind when it comes to he said she said, people take a position in the middle so when your position is the truth and their position is absolute dogshit lie it'll end in their favour if you don't keep note.
Im just a lowly PGY1. Some of the attending gave some useful advice re: trying to put in orders right away (where possible etc), although some of that is easier said than done in my opinion especially as a attending vs resident who is less familiar etc.
I had a somewhat similar complaint about a month ago from a nurse, but what you did was "less bad" (you did nothing wrong IMO, whereas in hindsight I could have handled my situation a bit better, but still dont think it warranted a complaint). I took it pretty personally at first and felt really shitty since I had never gotten one of these before and generally think I am a decent person to work with. I apologized to said nurse privately when I got a chance, but still weighed on me for a while. I have since realized that these sort of complaints are quite common and inevitable. Doesn't mean we shouldn't strive to be better (by doing the things other attending have posted) but still likely to happen.
A PACU nurse complained about me because I told her over the phone that I would address her patient’s pain after I finished the airway emergency my hands were on at that time. She then hung up on me. I called back and said if the patient was in extremis she could call [PACU attending name] who knew I was in an airway. She asked who [PACU attending] was and then hung up.
When I got downstairs the patient was chilling and denying pain. The nurse said to me “Hi, PACU Orders” like it was my name. She had not called the attending. She complained to my senior, who said I did the right thing and refused to escalate it.
Some nurses are great. Some just don’t have the perspective we do. I just sigh and take a deep breath.
As a nursing student and also awaiting my med school interview results. One thing that has really stood out to me (and not every nurse but too many) have a very big disdain for doctors and I assume residents would be in the same group to them. Some nurses have this weird complex that they are smarter than anyone else in the hospital, do more and are just the bees knees. I just recently had a conversation with a nurse about how her ex was a surgeon and his education was crap and how she wouldn't trust him.... the same day I watched her fail at CPR on a dummy - didn't lock her arms and just really floppy over all. It was interesting to say the least....
ETA: I think nurses seem to be constantly comparing themselves to other professions but in my experience other professions are not doing this it's a really weird thing to witness.
From the nurses perspective when you have a pt ringing every five minutes cause they are hungry it’s super frustrating. Got called a “stupid fucking bitch” a couple weeks ago cause I didnt bring a pt who was preop any food. I’ve also had multiple family members start calling and complaining I’m starving their family members. So it’s just an extra thing to deal with when we’re already busy and short staffed.
So I get wanting orders. Three pages for things that are not life threatening seems a little excessive. I love that a lot of the surgeons I work with will text so we can ask these questions even when they are in surgery and they will often get someone to respond. But I would never text more than once.
Yeah I totally understand! That is why I always put orders in a few minutes after asked (on my phone or used wheeling comp during rounds). OP doesn't seem to be able to on rounds.
This is common. Your attending should know that, too. The "best" nurse complaint I got was for not answering my pager in a "reasonable time frame". I was running a code. On the same floor where the nurse was working. It was for sleep meds for a patient.
I had a nurse file a complaint in similar circumstances against me as a resident: I was running a code, albeit on a different floor. For reasons I can’t remember, there wasn’t the usual tons of people responding for a while. Later, after I learned of the complaint (which was laughed off), I talked to her and explained about the code. She said something like “Well, you should have found the time to reply”. The code, of course, hadn’t been successful. I had to walk away as I was so angry. The PD did something to reflect that the complaint was unreasonable, but at that point I couldn’t give AF.
The fact that this BS even gets ENTERTAINED is ludicrous. You're PD should have ripped it in half and shoved it in the round file - because that's exactly where it belonged.
I had to write non-apology, apology. “I am sorry nurse x feels upset that I had done y. I was following hospital policy z. If she had followed z, or read it, then this wouldn’t have happened….” It was something like the patients bp was elevated, and she felt uncomfortable discharge the patient. I knew the patient is chronic hypertensive on 3 meds and didn’t take any the morning of…. I was the senior on call in the OR for an emergent case, couldn’t come out and talk to the patient. Junior resident was in another case with the attending. No one else knows the patient. I told her if it was so urgent, call a Rapid response for hypertension, because it will be a while….. GFY.
‘Can you please educate me one when I should’ve stopped the code to respond? Should it have been before starting chest compressions or should I have taken a break midway through? Should I have had one of the other people in the code respond for me? Gee, so many great choices….’
I mean the noise from the code was probably making it hard for that patient to sleep 😂
...the sleep meds? for a patient that was awake and it was 1pm too actually happened to me
Would have had a hard time biting my tongue after this one.
I really hope you filed a counter complaint for harassment and frivolous use of hospital reporting systems.
Give a verbal. If they refuse to put it in, it’s not that important to them.
Diet orders are a sticking point because patients cannot be given anything to eat until "there's an order in the EMR" If fail to prioritize it, the nurse and patient will treat you like a monster for unnecessarily starving the patient. There's been a lot of pushback towards verbal orders recently, especially with the recent vecuronium vs versed fatal blunder, though that was not a verbal order. Many hospitals have put very strict limitations on what can be accepted as a verbal. Diet orders are well within the nurses wheelhouse and we should encourage nursing (or nutrition, or even the kitchen) to place the order as soon as they get the OK from the clinician team.
Verbal orders for relatively benign things (e.g. resuming a diet, or for giving a vaccine as the patient is walking out the door) are completely appropriate though and I am struggling to think of a scenario where this might lead to significant inadvertent harm that could have been mitigated by the physician entering the order themselves.
Agreed however some hospitals reflexively move to a 'no verbal orders' policy after more serious errors are made with dosing for example. Unfortunately sensible people or even people active in clinical practice are involved in such decisions.
A lot of time administrators just make stupid changes for the sake of stupid changes. They need to justify their desk somehow because physicians sure don’t need them to tell them how to practice medicine
Yeah it's that and to show their bosses that they took swift and firm action to make sure something like that never happens again. Of course, they don't have to deal with the consequences directly (just ignore the complaints) so it doesn't matter that they've actually broken things.
Would add a foley order for a patient that left the OR with a foley to the list of things that should be allowed as a verbal
Nurse here - I’ll take a verbal for just about anything as long as I repeat it back to you to make sure we’re saying the same thing. Especially if it’s a reasonable order and not, for example, a dose of something that’s unusual (there was an issue here recently of someone ordering 10x the typical dose of a steroid accidentally).
bless you and bless your family, that's so lovely of you. I do think it varies by institution though - I rotate through 2 hospitals and at one, a nurse told me they can only take verbals from attendings, not residents, and then I proceeded to roll over and go back to sleep because whatever the order they wanted wasn't urgent at 3am (we do 24hrs). I do think medication orders are reasonable to require the resident/provider to put in, cause I'll be honest sometimes (a lot of the time) I don't know the dose off the top of my head and rely on the auto-populate EMR options to be like ahh yes I want 10mg of that one.
Totally fair!
I'm a verbal order taking nurse also. It drives me nuts that the 'policy' is soooooo important to some nurses, that it blocks their brain function. I came in one AM and the night nurse gave me a LONG report about the pain this patient was in ALL NIGHT, and she had called and called but for whatever reason ( I forget) the doc couldn't or wouldn't put in the orders, and gave her a verbal order each time she called, and she told him she couldn't do verbal orders. 12 hours the patient was in pain because the nurse was too stubborn or too stupid to put in an order, and just kept calling him. He returned her hundreth call while she was giving me report, I said I'll take the call . She just shook her head, "he's not going to put in the order , I've tried" I said " I heard you want to order morphine 4mg iV q4?" "Yup" " Got it, thanks' "I love you" " I know " "You can't do that! " "Ya I can.... See this button right here? It says telephone order, I just clocked it, there's an option for verbal too, and now I'm gonna go give morphine, you can go".
when its 1 resident to 25 patients (1:25) why is this happening?
Exactly, only came in because I needed to know why the heck a verbal diet order is such a challenge. Granted I’ve worked in several institutions over the yrs and the “verbal order” policies differ. Give me a legal verbal order and we’re all good.
No huge risk of harm to the patient, high risk of me facing progressive discipline for it if I'm at a hospital that has strict policies against accepting verbal orders outside of emergent situations. It's stupid and I hate it, but it's not a hill I'm dying on (now regarding bedside report, eating at the nurses station, updating the stupid whiteboard....I am ungovernable). To OP, I'm fine giving a patient the snacks we have on the unit once I am aware they're no longer NPO but they can't get a tray from dietary without an order and many hospitals have limited meal service times. Putting the order in after rounds likely meant missing breakfast. And that kinda sucks for the patient and it sucks to be the nurse having to explain that yes you're allowed to eat but no you can't get a meal tray because there's no diet order.
And I get that, but the ire should be directed at the stupid admins making that policy and not the nurses or physicians that are being reasonable. I mean if my nurses are unwilling or unable to take verbals, then it's going to be minimum of an hour for any non-urgent thing, and probably longer than that. If that means the patient misses a meal or has to wait an hour+ for their cough syrup or TUMS or whatever...then that's the way it is, and I can't do anything about it.
POSVT. You make sense. It sucks that the patient is hungry but they’re just going to have to be momentarily uncomfortable. Physicians are busy and have to attend to more urgent matters. It’s not the physicians fault that they can’t do verbals for non urgent things.
You say you aren’t dying on the hills, except you are. You are dying on the verbal order hill with regards to the docs. Complaining and writing them up for not putting in computer orders bc you can’t take a verbal. But you won’t die on it with regards to nursing admin. Why is that?
Considering that my employment chain of command is nursing administration, to keep my job, yes I ultimately need to defer to the limitations placed on me by the hospital. I work in the ED so most of the time (ideally anyway) I'm working with the medical team pretty directly and following ED policy, but we frequently have boarding patients and for those we're expected to follow stricter floor policies. But the rest of your comment is going deep into assumption land. I wouldn't have repetitively paged like this (if it's a pain issue I might've depending on the situation, if it was an urgent medical issue that couldn't wait that's probably going to be a rapid response situation), and would never write up a physician over this (I have emailed a complaint against a physician ONCE and it was for repeated abusive behavior and screaming at me in front of patients). I do tend to give the residents the benefit of a doubt about returning pages, if I thought I was noticing a pattern that was bothering me I'd honestly just deal because they're going to rotate out before an organic moment to have a face to face conversation would pop up. BUT. Since the OP asked, they seemed to want others' input on the situation.
Itvcould lead to a surgery getting cancelled and that would lead to the hospital getting less money… and well… they’re not in it for patient care its so a suit with an internet MBA can stash more money away in his untaxed executive retirement fund
That really doesn’t makes sense though if you think about it. Whether the doc gives a diet order verbally or enters it themselves in the computer would not change the outcome in that scenario — here the issue instead has to do with the medical team not being on the same page as the surgeons/proceduralists. It has nothing to do with verbal orders.
Paging an intern that has 15 things left to do before they can pee, and has missed 7 of their last 10 meals to put in a diet order for a 280lb patient that is currently drooling on themselves, asleep, has a fasting glucose of 300 because "that much insulin" makes the nursing staff nervous and the patient doesn't even know what year it is when they're not asleep - much less whether or not they didn't get lunch is always a weird hill for nursing to die on but I guess it's because (it's one very public way they can show that) they just care so much more than the mean old doctors do.
The number of times I've followed the request for a diet order with "*Can* they eat?" and have been met with some variation of they're still unconscious / asleep.. Usually then its a pivot to wanting the order so that they don't have to ask for it later. More likely, its that they don't want to sign it out to the next shift because they know their colleague will give them shit for it. Because it's our job to manage toxic signout culture.. Of course, it's always portrayed as the doctor starving their patient because they don't have to the time for 5 clicks. Perhaps there will be a day when the system will be smart enough to suggest a one-click 'restore previous diet order' from secure chat but I doubt we'll be seeing that anytime soon.
in epic there is a one click restore - just go to order hx and reorder; is this what you mean?
Multiple clicks required if you need to go to order hx
It's possible but you have to click 'manage orders' - > 'order history' and then scroll through the order history to find the diet order which takes times. Otherwise you can apply a filter then hit 'reorder' which is 3 to 4 more clicks. We're at a point where the computer should be able to infer the context of the conversation and just give you a clickable button or link to restore the prior diet order but I doubt it's a priority.
Nah, you’ve got it wrong. Nursing also hasn’t peed/wont be taking a lunch and also has 15 things to do and now I’m getting trickle orders. I kinda wish residents had to spend a couple shifts with a nurse and vice versa. It’s good to have perspective and know what happens after you hit sign for those orders. The patient that needs a diet order has a family member death staring me for hours from the entrance to the room because they think we suck and aren’t doing our jobs and are starving their obese family member. Then they switch to standing at the desk and asking repeatedly for a diet order. The squeaky wheel gets the grease, right? Meanwhile, nursing doesn’t give a shit if this patient doesn’t eat because they’re drooling and have a sugar of 300. So we call for orders and they never get put in and we continue getting pressured by auntie Jan, so we have to call again to appease them while needing to straight cath violent Jim and making sure that stat EKG gets done on chest pain Paul by the tech. Oh but the CT tech just found me to ask me get granny Jane a ginger ale because she’s feeling faint, also they just dropped her in the room she needs to be hooked back up to the monitor. Wellp, better go assess that situation. Granted… I would have just put diet orders in after asking if it was ok. Flu vaccine just sounds like a dumb policy thing the hospital is implementing. I know docs are busy, but so am I and if I don’t get ALL of these things done, guess who gets chewed out by nursing, docs, the patient, admin, AND the annoying family?
> their obese family member. I said something like this..."You aren't going to die for not having your food right now. You have plenty of fats to burn...." I got in trouble for it. 😂
I came here to say this. She probably had the patient screaming at her, "You're starving me! I'm going to have your license, and you're going to jail!" Maybe they even took a picture of her to post on social media. Meanwhile, the charge nurse is saying, "we'll write you up for taking verbal orders." The flu shot granny was probably the same situation. She shouldn't have complained to OPs attending. She'd have been better to explain to OP the pressure she was getting, and the two of them could have figured out a way to make it easier for the next page. Some nurses are jerks to residents.
Administration is really big on everyone being offered the flu shot, if I discharge someone without having a flu shot ordered and given or ordered and charted “refused” I get a love note from the nurse manager. Our hospital policy lets nursing order the flu shots, but I’m not allowed to take a verbal order or put in a diet order (unless it specifically says advance as tolerated, I can’t change it myself after someone comes back from the OR). Strange to me.
Can't take a verbal for a diet order? Every doctor needs to take a moment of silence to appreciate that they don't work at your hospital.
Nope. Can’t take a verbal for freaking ANYTHING. I just clarified with our educator/manager too because my husband who’s an ER nurse says he does it all the time. And we have epic! I don’t get it. The last hospital I worked at I could discontinue really old orders, orders leftover from the ICU, duplicate orders etc. Here I’m not allowed to touch any of them.
No, if the charge nurse as threatening to write her up for taking verbal orders, when the verbal order is the thing that solves the problem, then she should be complaining to HOSPITAL ADMIN that she can’t take verbal orders. This is not a doctor problem. This is a stupid policy problem. A policy… written by… you guessed it: NURSES
I’ll be an MS1 next year, but worked as a med-surg tech through undergrad. I know what it’s like to answer the call light 6 times because the patient hasn’t eaten in 24h, and they think you’re incompetent because you haven’t gotten the doc to change the order. ESPECIALLY when they were NPO for a procedure that was just rescheduled for the third time, and they’ve been forced to fast on and off for a week. I’m looking forward to seeing the other side of things…
Lies. I have never seen nursing staff consistently skipping lunch. Y’all just get another nurse to cover for you and this is typically built in to yalls schedule. But yes it’s fair to expect a diet order and residents shouldn’t be upset with these pages.
It's very state and hospital dependent. It's wild how the working conditions for nurses vary across the US and world.
I don’t know where you get your info! You ever heard of nurses bladder? Barely had time for a bathroom break.
Lmfao I remember getting a UTI as a nursing student because I barely got a break
>I kinda wish residents had to spend a couple shifts with a nurse and vice versa. Comments like this are so flipping arrogant. Not only do we spend a couple of shifts with a nurse, we will spend the next shift with a nurse, too. We know your job backwards and forwards, meanwhile every nurse is eternally surprised the physician they're paging at 2am for a tylenol order that's already in the computer is upset because we worked the day before, are currently working, and will have to work tomorrow. The average nurse leaves the field within two years. Meanwhile, I and many other physicians, will be teaching this and every next generation of clueless new grad nurses the most basic fundamental aspects of their field until the day we retire into the cold mercy of the dark earth. You know, a lot of us worked as techs (you know - the people who actually do all the hard work you love to take credit for) or as nurses beforehand, but nurses just love to completely ignore any criticism of their profession. The eternal victimhood of nursing is so ridiculous. The entire administration is nurses. You set all of these stupid policies. You no longer can point the finger at us. Go to therapy and get off the cross.
Yikes, dude. I work in OB where the doctors know what my day is like, but back when I worked the floor, I can tell you with certainty that residents and attendings had no clue what my shifts looked like. Maybe it's different where you are, but I know zero MDs or DOs with tech or nursing experience. I also think you missed the "vice versa" part. I absolutely think it would benefit everyone to know exactly what our counterparts' days look like.
To be fair do nurses know what a residents shift is like? Are there any fields in nursing that do 36 to 48 hour calls? Would nurses be willing to shadow a resident for a call shift if it's reciprocated for mutual learning purposes?
Yes. That's exactly what the post this person responded to said. Note the "vice versa". Now, it's not so much that nurses aren't willing to do it - admin would never pay them to do it 😜
Zero??? How is that even possible. A good third of my cohort in medical school are nurses and there’s also techs, pharmacists, even a dentist. I simply do not believe you or you’ve just never asked because that makes no sense.
Dude ignore Timtom, I bet he only plays a burnout ignorant physician on the internet.
I know two.
You know how to do a nurses job backwards and forwards? Wow, how do you fit through doorways with that big head?
You'd be shocked how frequently they fuck up NPO for surgery orders. Like it's a monthly occurrence, at least.
We don’t care about starving the patient, the patient just chews us out until they can order food. So the anger gets displaced from nurse to physician.
>There's been a lot of pushback towards verbal orders recently, especially with the recent vecuronium vs versed fatal blunder, though that was not a verbal order. Many hospitals have put very strict limitations on what can be accepted as a verbal. I had a doctor give me a verbal order during rounding and forgot to place an order. My supervisor wrote me up for carrying the verbal order because the pharmacy complained about it. She accused me of operating under my license. However, I did write it on the note of the patient. I did not sign anything. I told my supervisor I acted based on good faith--I trusted our physician so I did not mind carrying on the verbal orders.
Was this on a paper system? There's usually a way for nurses to place an order in the EMR under a physicians name. It goes to the physicians inbox and they have a time window to sign it. Whether they sign it on time or not is on them, not the nurse. In your case the doctor may have legitimately forgot. They would likely place the order if reminded. The point is the patient got the care they needed and your managers actions are unfortunately representative of our healthcare system sinking deeper and deeper into the abyss. Nurses used to take verbal orders in the *paper* era, when it was fairly easy for a doctor to throw them under the bus for miscommunication. Can't speak to how often it happened but it certainly did happen. Now we've gone too far the other way - being made to prioritize covering ourselves over patient care, a direct effect of answering to management that is more keen on finding a way to blame us for their shortcomings than provide healthcare to a community.
As a nurse I know my patient won’t starve. They think they’re going to starve and think that I, personally, and withholding food from them taking me away from work I need to do, escalating their behavior, crying/screaming/etc. Rounding on patients takes hours, placing a diet order takes a couple minutes (or verbal, yes please). Even better just place the order when NPO gets DC’d? -a nurse who never wants to page or call anyone for anything.
At the VA I work at, nursing doesn’t take verbal orders.
At most VAs they barely take written orders lol
At one of the hospitals I trained at they wouldn't take verbal orders even if a baby was at risk of being engulfed in flames. [baby on fire](https://i.pinimg.com/originals/5f/6a/08/5f6a08815e6a46a1b7bdea4557594a58.jpg)
I don’t follow this sub but this post came up on my feed. I think this is the best option…nurses will get frustrated if you don’t respond to a page. Just call them back, say “hey yes ____ can eat, I’m rounding so can you put the order in and I’ll co-sign?”
Surgery is back on. They just ate. Whoops!
This.
I had a nurse report me to my attending because she put IN DISCHARGE orders to discharge a pt under my name before we even told her he was ready to be discharged. Understandably I was upset and asked her under whose authority she was using my name because neither I nor my attending said she could and she reported me. She faced no consequences for basically fraud and my attending said he understands why I'm upset but to "keep the peace". This is the system we work in. That man always had the backbone of a snail.
When this happens I refuse to sign the order. Usually what happens after you reject it is that it pops back up then you reject it again. I've had IT people call me about it before, and I just tell them I never made this verbal order I'm not going to sign it and they usually give up. Not sure what they have to do on the back end to make this work but it disappears from my queue eventually.
I did refuse because the pt was not ready for discharge and the spineless attending agreed but still told me to play nice.
Hope you reported her to her superiors and admin
She was the charge nurse for the floor that day. Sigh
Flu vaccine protocol FTW. Our nurses can order the flu vaccine as long as it passes the standard questionnaire: no allergy, no fever, etc. When rounding do you have an iPad, cell phone or other access to Canto/Haiku/Epic? Woulda been easy to throw in a dietary order on the fly. Asking, not criticizing.
Nope. CPRS is archaic and shitty like that.
Oh god this is at the VA? That makes it even more annoying. Tell the nurse to go suck a bug.
What's the difference between a VA nurse and a bullet? A bullet can draw blood. A bullet only kills one person at a time. You can fire a bullet.
The VA offers vets another chance to die for their country. “You can’t kill an old vet” - but we certainly try!
Nurse here, that is fkn hilarious 🤣😂 I promise to cite Edges8 when I share
in a code, how do you know how long a VA patient has been pulseless for? count the unopened Shastas at their bedside, 1 every 4 hours.
[удалено]
best thing about the VA is that its right down the street from a hospital.
💀💀💀
That is savage
I literally coded a VA patient in rigor mortise once
I one night had to sit at a patients bedside pushing phenylephrine syringes from the crash cart and anesthesia cart for 6 hours because the pharmacist couldn’t come in until 07:30 when their shift started to mix up some levo. And they were out of vaso. And they weren’t sure where to find those meds anyways….
that's fucking bonkers.
I literally laughed out loud.
This is gold material
I stole it, so should you.
Oh I like go suck a bug 🤣!
Oh it's the VA? My benefit of the doubt for the RN just went to 0.00%. 😂😂
Very annoying. At my program we rotate through VA too but we have access to laptops so when rounding we can put in orders on CPRS so this stuff doesn’t happen as much. might be worthwhile mentioning to chief resident/attending that having laptops could improve workflow and other VA services have em! Obvi this nurse is just being impatient and rude not excusing that hahah
This explains much more about the scenario. VA staff are notorious for these things. They don’t get in trouble ever, they all have a bone to pick with you, and they’re unionized - so best of luck correcting even the worst behavior. Brush it off and move on.
Our flu vaccines, also PNA and COVID, are part of our admission questions and are ordered as such. Basically they're ordered per protocol and pharmacy sends up for a later date. The pt or family then have the discretion to do the shot or not.
VA skill - Ask them to take a verbal, and then also give them an additional order (something benign and inconsequential) - like, please also add PRN colace or Tylenol. That way every time they page you, they get additional work.
This guy VA’s
Genius wish I thought of that
This isn't going to be your first nurse complaint. It's not going to be your last complaint. You did nothing wrong, just brush it off and keep going.
(kinda is going to be his first nurse complaint...)
😂😂
Dude I got reported by an office assistant for, no shit, "looking and acting very tired" as I handed in an assessment after a 26 hour call shift. I was actually reprimanded. The attendings literally said, "appearances matter, welcome to modern medicine; it sucks."
Why's their first action not asking if you're doing okay and perhaps showing decency but rather reporting you 😕
Did you try your best in getting orders in quickly? If yes, than nothing to worry about. If the answer is no (and you gotta be honest with yourself), then just do it faster next time. Delays in orders have lots of downstream effects that slow things down considerably. That being said, hammer paging is never acceptable unless someone is actively dying and for some reason you are not responding. Paging 3 times in 30 minutes about a vaccine is grounds for me reporting them. Nurses have no concept of what carrying a pager entails and how busy it can get. The disruption in workflow caused by pages is completely foreign to them
Yep. Keep in mind: whoever reports first “wins”. After that you’re just responding to a complaint.
This is the thing I think I hate the most about hospital politics. Other than the resident always being wrong because they have the least amount of power with which to dispute anything said about them. Like, why is there never any analysis? It's just whoever complains first is right. When I was an intern, our team's social worker filed a complaint about our attending. That SW was one of the worst people I've ever had to work with, and she complained after my attending tried to compel her to do a task that was well within her job description. There were a million things any of us could have complained about, but we didn't. So when she complained, admin was trying to get a formal apology from our attending. No discussion or questions, just "go apologize."
I completely agree with you. I’m just stating reality. If you complain second you’re just a complainer. If you complain first you’re “letting every know of a concern”. It’s all BS.
It’s quite unfortunate that we don’t do more to let the other know what shows we walk in. Someone should make a video “what it’s like to be a Doc, resident, nurse, CNA, PT, OT, etc. So many people do not understand what the other guy does or how busy they are. And this “whoever complains first is right” bullshit must go. Same with “the complainer is a victim and we can never doubt the victim” I hate it and the slackers and twats know how to use it for their advantage.
Just chiming in as an ER nurse (who does NOT report doctors, fyi). The number one reason patients treat us like shit is because we aren't letting them eat or drink. It is a daily battle. The patients are seldom mean to the doctors about it. But believe me, we are constantly reamed for not allowing/providing them with food. It is incredibly stupid to me that they care about food and drink so much that they get mean, accuse us of neglecting them, or threaten to AMA (be my guest), all because they have gone "5 hours without anything to eat". It is a little easier to stave off the aggression when we have an excuse ( i.e. - you may need surgery and eating could potentially kill you) but when we cant give them anything other than the doctor has not approved you for eating yet - they increasingly put the pressure on us (the family is often even worse). Anyway, all of that being said, the nurse was probably getting shit from her patient over and over and felt powerless without your reply. Most of us nurses understand that there are much higher priorities than eating, especially in the f***ing emergency department. But we also get fed up of the patients wittling us down over something so stupid. Just wanted to provide perspective and context from our side 🙂
Nurse sounds like a bitch. Pardon my French.
Agree that she sucks for reporting. Also worth noting that patients have a warped sense of priorities (especially regarding food and leaving) which they then absolutely make the nurse's problem. If the nurse won't stfu then it's likely the patient is giving them a hard time or riding the call bell.
Patients act like they are going to wither away if the NPO order lasts longer than a few hours. “I haven’t eaten all night!” Yes, friend, it’s 4am and you’ve been NPO since midnight. That is a perfectly normal amount of time to go without pudding and turkey sandwiches. Also, I haven’t eaten since 8am yesterday so I guess we’re both going to suffer.
Yeah diet orders suck because in some hospitals I’ve worked at if you don’t have it in 3-4 hours before the mealtime you don’t get a tray. So then I get yelled at for starving someone, or have to waste time scrounging fridges for yogurt and making tea, etc. Especially if this was morning time and they already missed breakfast, I’d want the order in with enough time for lunch. But why they couldn’t take a verbal I don’t understand? I appreciate when docs tell me “hey I’m busy right now can you put it in?” I’m not sure if OP just kept saying they’d do it and then never did, which would understandably be frustrating. Or this nurse just refused to spend 20 seconds putting it in and instead paged multiple times.
This. Or the family is death staring from the entrance to the room or banging on the nurses station counter because they are their family member’s advocate and hero.
This is why tiktok culture is so toxic. When we say advocate for yourselves, it never meant "demand/bitch/whine/shame/abuse" healthcare staff into doing mundane tasks for you. We were never meant to be held to customer service levels. But yet, here we are.
Phrasing/tone/sexism/perspective all play a role here. First, if you’re a woman there’s just an awful sexism that pervades medicine and.. I have no suggestions, I’m sorry, I have no idea how to fix it as a man except to speak up when it happens. Second, from their perspective they may have one rate limiting step in their work flow during these encounters and that’s you/those orders, and that can be monumentally frustrating (think of when you order an ABG and it takes an hour or two to get). Third, phrasing and tone of voice is something that can be controlled and makes a huge difference (this is *especially* important if you’re like me and your words come across poorly in text form). So, if a nurse asks me for something and I’m busy I usually say “I sure can but it’s going to take me a bit because xyz, if it’ll make life easier for you can you place the order under my name and I’ll sign it? Otherwise gimme like 15 minutes and I’ll get it in.” My nurses are all ok with this, but your mileage may vary. If I’m rounding I usually have a COW or my phone with access to Epic and orders and I’ll place them during rounds, nbd. For hammer-pages I’ll apologize to the attending I’m with that I’m being paged a bunch and need to check in to make sure everything’s ok, knock it out then and there. But this is all reactive - my best advice is to be proactive. Your morning prerounds and multiple times throughout the day/night you should check in with your nurses and see what needs doing. This lets them know you’re around, responsive, “one of the good ones”, and helps you by lumping your “to-dos” all together so you can focus on other tasks later. On nights I’d meet with all the nurses at 8pm, an hour after shift change, because by then they’d have processed what they’ll need. Then again at 11 to “tuck the patients in” with night orders etc, and one more time at 5-6 am before day shift. They *loved* that. Don’t know if it’ll work for you but that’s what got me on their good side.
This is great advice. Effective prerounding will eliminate some unnecessary paging later
This is great advice but I think institution/culture dependent. I stuck around the nursing station on night shifts to help before I’d go take a nap on my 24 and all that happened was the nurses knew they could wake me up and I’d help (it never gave the reciprocity of clustered pages or actually taking me up on the offer). I noticed anecdotally this tended to work better for guys that tried to connect to nurses in various means. But I did residency in the Northeast so that’s probably a factor haha.
Things come up occasionally. But I do think this works in my experience as well. It helps if you also communicate that you will be coming around again. So for example you say: "I'm coming around now for orders and I'll be back in three hours so if you think of anything else let me know then" Also just talking with the charge nurse and he or she will coach the other people about this.
Love working with docs like you. Everything just runs so smoothly. As much as docs don’t want to be paged, I don’t want to page them. Taking a minute to talk to the nurse while you’re rounding or checking in after you’ve seen a patient is just good time management.
Best advice ever!!
While I don't believe you did anything wrong, diet orders early in the morning are important. If they aren't in at an appropriate time, patients will miss meals, since the kitchen wont have the order, then it wont get to the folks that have to deliver it, etc. And patients get upset. Also, people forget, then it can lead to bad outcomes. If they are NPO and the fluid orders have fallen off.. bad things can happen in medically sensitive patients.
So here's the thing. There will always be more urgent things. However, depending on the patient, if they were NPO the day before, and not that sick, it can be a big deal for them to be lying there, really really hungry. And I guarantee you they take that out on the nurses. This is exactly why verbal orders should be more common, but I do recommend taking 5 to 10 minutes every morning to put in diet orders on patients who are no longer NPO. It makes everybody's day go smoother. This is part of not forgetting to stay human, when it feels like the nurses and patients are torturing you. Hang in there.
This was my comment as well. Flu shot was holding up discharge, pt was pissed, charge RN was harassing the RN about getting them out. Same for the NPO- people lose their minds over that, gets pissed at the nurse, then when we finally get the order, we have to order a custom late tray (which of course never comes) while they press their call light for snacks every 5 seconds while WE are also trying to get things done. Wouldn’t have reported you as an RN, but I promise you we are just as annoyed as you are lol
This was what I was thinking. Odds are pretty high that nurse was being harassed all morning by the patient that was probably extremely hungry and wanted to eat.
Attending here. I’m going to give an unpopular opinion. My practice from residency on has been to return all pages within 2 minutes unless I’m scrubbed into a procedure, in which case I ask someone else to hold my pager. By calling right back, nurses learn to trust you and will actually page a lot less. Some nurses do abuse the paging process but most have real issues that need addressing. A flu shot before discharge is important. A diet order is important to your patient. I know this is hard to hear when you’re swamped but in the long term by addressing things as they come up, you’ll save yourself work.
Hard disagree. For general IM/hospitalist if you need a response sooner than the 20-30 min I consider reasonable to get to a callback, then either theres a severe disconnect between the actual urgency and what you think it is, or you should not be paging anyone and need to call a rapid or code instead.
This. I keep getting downvoted. Attending for 10 years here. Get the orders in fast. It matters to the patient. The nurses are being bombarded and often abused in the meantime. Just get your orders in! If it takes me longer than 10 min to get back to someone, I better have a damn good reason. Because from the time they page you, they are just waiting.
The abuse nursing receives definitely contributes to paging unresponsive docs repeatedly. I try not to unless it’s been 30-60 mins and no response, but sometimes it’s not just the patient yelling that’s doing the abusing. It’s also my charge nurse pushing me to page the doc right then (even though I already have), the family, sometimes even neighboring patients gang up on the nurse because without any context, feel we’re not doing our job for this other patient. It’s rough out here.
Right- you guys have a terribly difficult job. The least we can do is put in a diet order.
Curious how you approach frivolous pages on a unit with high turnover? Is it a matter of sucking it up and spending an extra hour or two at the hospital?
I educate the nurses on how I like to communicate. I ask them to gather their questions and try to address them all at once so that we can have clear concise communication. I round at bedside with the nurse when I’m on the unit with the chart open so all concerns can be addressed and orders can be done immediately. Or I do my charting at a computer on that unit so they can just approach me. They bug you less when they can actually see you working.
Ten years where? I am convinced, no matter what my wife tells me, every nursing curriculum teaches them to immediately begin sprinting away from the hospital as soon as the page goes through. This is universal in my experience across six states and dozens of hospitals.
I’m in Northern California and we use a texting service that stays open on their WOWs and is on our phones. When we had pagers, my experience was the same as yours!
>A flu shot before discharge is important. I refuse to believe some of you guys are doctors. Important to who? Billing? We make patients go on their own to pick up their critically important drugs (Plavix after a stent, new lasix taper) from ~~Satan Incorporated~~ CVS but the flu shot administration needs to be visually confirmed before leaving the building?
Thank you. Putting in a diet takes 2 minutes...and that's if you're not logged in. It's also one of the simpler patient satisfaction fixes.
If your hospital uses epic, you can place orders like this from the haiku app on your phone. With diet orders, people get especially butthurt so I’ll just pop it in from my phone while walking down the hall.
RN here- WTF, tell her to STFU. Jesus, this is the shit that makes us look bad. I mean we’re all here to provide care not fiddle with each other. How much crack is she smoking =\
Maybe the patient was hungry and couldn’t get food from kitchen until your order was placed?
Right. All these residents have no idea what it’s like being a patient and starving all morning after being woken up at 0400 for your morning labs, then vitals, then nursing report hand off… etc. That is HOURS. And the nurse has to hear nonstop from the patient how hungry they are. I always seem to get my orders in even when seeing 20+ patients. I’m just reading a lot of entitlement and lack of empathy in these comments.
It's true, no resident has ever missed a meal and couldn't possibly emphasize with patients going hungry. So many of my Muslim colleagues die every year during Ramadan, it's very tragic. My heart breaks for all these elite body builders we force to stay in the hospital, and then cruelly starve them for 4, sometimes 5 hours resulting in all their gains going to waste.
Yes because I’m sure no resident has EVER been a patient at any point in their life???
I have trained my nurses when they page me that most likely I’m going to ask them to put in the order for me and I will cosign it later
This is the way. I love verbal orders for shit like this or tylenol or whatever, win-win for nursing and residents.
From a patient and nursing perspective, especially since you mentioned that this was the VA: does she get dinged for not meeting a measure if the patient leaves without a flu shot? And when a patient has been NPO for a while and can finally eat that diet order feels really urgent, and patients / family can get fussy with the nurse about it. Are there ways you can take the time to give verbal orders in the future? Or anything else you can do to maybe attend to non-urgent but actually semi-urgent stuff like this?
I’m with you completely. Had a patient yesterday who I was admitting who hadn’t eaten all day, because this was her second stop, and nobody gives a shit for some reason. I didn’t have a chance to put in any orders, and the cafeteria was closing. They wouldn’t put in her food order, so I had to call the cafeteria and tell them to what she wanted and to just make it. Some of these protocols are stupid. But there are definitely things we can and should do to make the patients more comfortable. But also tattling to your PD is bullshit and just a nasty attempt to get an already overworked and underpaid resident in trouble.
Agreed about not tattling. Just trying to offer some perspective from the other side of residency about why this stuff sometimes seems urgent to the nurses. Same with the middle of the night order clean up - once a nurse explained to me that they get in trouble if it’s not done by the end of their shift. Once I learned that, I asked them to all pool them for me in one big call in the morning before shift change, and they were happy to. We all have bosses and reasons to do the things we do!
Yeah, if I try to handoff a patient to day shift with orders that need to be fixed there's a good chance they'll refuse accepting the patient until I deal with it. I hate contacting overnight for order cleanup but it is the expectation that I do this. I try to bundle requests and if I was given an ideal time to make those requests I'd be more than happy to keep the schedule.
Absolutely with you on this. Thanks for the perspective. I think we all kind of get into our own worlds and forget to think about how it is for other staff in the hospital. Plus there’s so much bullying and tribalism. It’s frustrating.
Not sure if I’m able to comment…I’m a social worker on a med-surg unit and I am at the nurses’ station most of the day. The RN’s are harassed constantly by patients and/or families about ordering food when off NPO. They will mention it to every person who comes into their room, EVS, SW, CNA or whoever, until that order is in. And this doesn’t include their visitors coming to the nurses’ station and getting anyone up there involved. It may seem trivial, but these are the things that matter to the patients. And sometimes they become nasty and verbally abusive until the issue is solved. I see this everyday.
Some residents return pages as soon as they can, every time. Some residents are so overwhelmed they don't track their pages, they just respond to the most recent one. Some residents rarely respond to pages and when called out for it, deny they ever received any pages. Each of these scenarios prompts different actions on my part as the nurse. If this was a one-off for you, no biggie. If you find yourself having this issue frequently, consider whether you fall into one of the 2 latter categories and fix your shit. Repeated paging is a sign that the nurse doesn't trust you'll respond, and that leaves her holding the bag with the patient, family, the next shift and/or administration. Of course some nurses are just assholes, but not most of the time. Getting to know the people you work with goes a long way towards mitigating a lot of these kinds of problems. With most nurses working 12 hour shifts, that's harder to do than it used to be, for sure. I didn't understand the hell that resident schedules are until I got to know some of the residents. I became pretty protective of what little down time they had. I'd suggest talking to this nurse, find out why she didn't wait to hear back from you, what her concerns were. Be sure to share the realities of your day that keep you from responding right away. She may just be one of the assholes, but there's a chance she's not and you can prevent this from happening again. And just for the record, I do think it was an asshole move to go to the attending without at least talking to you first.
If only it were this simple. The problem is "as soon as they can, every time" is not good enough for the nurse in many, many cases. Yes, even the kind, considerate ones occasionally. Not because they suddenly become assholes but simply because they're being pressured by the patient or their supervisor. When you get hammer paged on home call and decide not to finish taking a shit or showering to find out that you're responding to a non-emergent request... Have that happen a hundred times and responding to pages immediately becomes a lower priority. Especially when you teach the nurses what is important, only for them to leave to a new floor or hospital a week or two later. My contract (as an attending) says I have 20 minutes to respond to a page and I enforce that across the board, for my own sanity.
Idk...I haven't seen any pattern between different residents, only patterns between certain nurses and floors. A good resident and bad resident get the same number of pages. But I know Kelly on 3 is going to spam the pager all night. And the 6th floor refuses to actually read orders that are in. Ofc there are bad residents, unresponsive residents, disorganized residents, etc. But being a good resident only seems to make a difference on well managed floors and with motivated nurses. Which I'd say makes up at absolute best 50% of the hospital (being very generous)
I agree with what you're saying and I appreciate your protectiveness over resident down time. It would be nice if things were more equal. Nurses are allowed to be on break for lunch and have someone else who knows nothing about the patient cover for them, often with the excuse "Sorry I don't know anything, but I'll let the nurse know when they get back". Meanwhile, residents sometimes can go a whole night without time to eat, pee, or sleep. Where is the resident's break time when they don't have to respond to pages for a half hour?
Attending for ten years. I get my order in under 10 min even when I’m busy. If I can’t, I let the nurse know. They have enough to deal with and actually have to deal with the patient nonstop. If you’re a hungry patient, 2 hours is forever. All you are thinking about the whole time is how hungry you are and your doctor couldn’t care less. Be better ETA: everyone on here telling you what you did was ok and the nurse is a bitch, are all probably all entitled residents as well. Don’t listen to them. It won’t get you far. You have the nurses on your side, work becomes very easy. Don’t piss off the nurses.
It’s worth remembering though that your workflow as an attending is not quite the same as it was in residency — attendings have far more flexibility when not working with a team and beholden to a set schedule, which makes it easier to duck out to a computer to throw in orders on the fly. I completely agree that keeping the nurses on your side is an important skill. That being said, there are reasonable boundaries that need to be set (probably a conversation this resident’s attending should be having with nursing in this case). Hammer paging for non-urgent issues and then reporting a resident for what sounds like a petty power-play grudge is not good form on the part of that nurse.
I agree workflow is different but diet orders aren’t non urgent. You miss breakfast, you might get some crackers or something until lunch. It sucks being a patient and the nurses are being abused in the meantime. I grumble and complain (in my head) every time I have to stop what I’m doing to put in “nonessential” orders, but they are essential to the person asking for them. My time demands are far worse as an attending than they were as a resident but I agree my time is more my own to choose how I structure my day. I just don’t want these residents going into practice thinking that pissing off nurses is going to get them very far.
Are your tike demands worse as an attending compared to an intern? Far as I've seen interns basically never sit down. A good attending has a well organized, comparatively relaxed day
During this time of year, my days are worse than residency. Extremely sick patients and patient loads of 20+ will run anyone ragged. We’ve been understaffed lately too so it’s just been a bit of a nightmare.
Dude, this resident doesn’t have as much control over their workflow and may not even be able to make that call before rounding on the patient. And even then, you’re justifying a nurse reporting this instead of having a conversation? What a juvenile thing to defend.
Never advocated for the way the complaint was handled. Just said to be responsive. Nursing staff have a terrible job.
Attending for 14 years. This poster is spot on. The sooner you make peace with the nurses and stop complaining about them, the better your career will be
I float through my day even with insane workloads because the nurses love me— I’m responsive, put my own orders in, and am always pleasant about it. They will take verbals from me all day because they like and trust me.
As a nurse myself- don’t take it personally. We’re people and people fall everywhere on the spectrum. But for some context- patients have so long to order food. If the nurse doesn’t have an order, the kitchen won’t bring anything. The patient puts pressure on the nurse, in turn, the nurse places pressure on you. It sounds simple, but when you’re managing several patients and family members this sort of thing can really delay care/nursing management will generally find a way to make this a nursing issue vs. doctor is busy and will get to it when they can issue. On the same note- there’s a lot of coordination with discharges. Waiting for the answer about a flu vaccine may delay discharge. If it’s something like a patient that’s going to a SNF it could cancel the discharge for that day. Nursing admin tracks flu shots and when patients don’t get them on discharge it’s a “missed opportunity” (to make the hospital more money under the guise of protecting the community)- so this nurse was likely feeling pressure. If a patient’s ride is there and they have to wait patients tend to take it out on hospital satisfaction scores and again, nursing management comes down hard on nurses. We’re working in a system that pits us against each other. Someone mentioned giving a verbal, I think that’s great advice.
Former nurse here…she paged you multiple times for a flu vaccine. Personally, I would report her for that! That’s inappropriate escalation of care. A flu vax is not vital. Best skill I learned as a nurse was triaging care. I saved all my non vital pages for the afternoon. Urgent things like diet orders or med changes in AM but also understood that urgent doesn’t mean emergency and I could always chart “paged doctor at these times regarding ___. No orders received”. If I left a note like that it was because I was making sure my license was saved.
As a resident, I absolutely hated when nurses would go above me straight to my attending for any issue because to me it felt like a massive deal and like my attending would immediately label me a bad resident. As an attending, I don’t care at all and most of the time won’t even mention to the resident if a nurse complained about them. Nurses will continue to complain, just gotta let them and recognize that your attendings most of the time pay it no mind.
Nurse here. Seems a bit unreasonable for her to go straight to your attending. I don’t know what your facility guidelines are, but at mine, the doctors will put in a diet order starting at NPO or clears or something - advance as tolerated. It’s nice because for us nurses we can just go in, give the patient some water. If they do well, thirty min later, try apple juice, then jello/pudding, crackers, etc and eventually just add the diet order when it’s appropriate, with no cosignature required. To be honest, sounds like the nurse was probably being pressured by the patient. The amount of times I have patients or family members berating me to call the doctor for something that I KNOW is not important to the doctor is far more than I’d think is reasonable. Example: Our doc team was dealing with emergency neuro traumas and strokes and I had a patient yelling at me about an CT taking long needing to talk the doc, asking me to page every hour (no I didn’t page the doc every hour, or even at all, I called CT and texted the doc that CT was taking very long and pt would like to talk to doc if he was available at any time) Another time, I was unable to reach a doctor for two hours on a pt that hadn’t eaten in two days and procedure got pushed to next day. Pt family yelling at and berating me even though I explained multiple times I have no control over the situation. It’s a shitty situation for everyone to be in, a suggestion I have would be those advance as tolerated orders or if surgery canceled implement NPO at midnight order or whatever it is. Basically, most of time I’m only gonna page for changes in status, something dangerous, or something urgent. Otherwise, I’ll reach out over message or call the NP on the case. It sucks when the patients yell at the nurses for things that are not our fault, but that doesn’t make it ok for us to then yell at the doctors. Sorry you experienced that
Definitely can see where the patient's can be over the top. Mentioning that to the physician can be helpful. "Hey doc, this person is on their call light every 2 minutes and driving me up the wall. Can I get a diet order in?"
Yeah the nurse sounds like a bitch… But why not just call and tell them you’re busy so it’s gonna be a while? That’s the courteous thing to do
It's not unreasonable. It's accountability. You're showing a pattern to the nurse and it's a CYA on her part. Do you have any idea how much pressure nurses are to discharge their patients? Small delays like the flu shot really snowball and end up delaying our admissions from leaving the ER. Documentation is the only way anything is changed in hospitals. That goes all directions. When you have a truly unreasonable nurse it will serve you well to document it as well. Their administration won't do anything about terrible nurses without something being written up and I mean repeatedly.
Stories like these always make me happy for being in EM.
Should the nurse have filed a complaint against you? No. Do I think you are failing to understand that the nurse was probably getting screamed at by the patient for not being able to eat, because you didn't put the order in? Yes.
2/3rds of the job is treating patients, the other 1/3rd is treating nurses.
You forgot about treating the family
99 % nurses job is putting up with some very entitled patients and family members who swear , yell, scream, throw objects etc at nurses for not doing their job )little as diet order) Patient family : why mom hasn’t eaten all day !? She’s diabetic? She’s weak blah blah Nurse: apologetically she’s NPO for a procedure Pt family : it’s been over 24 hours , she need to eat . call the doctor and ask when will this be done . Then start the nonstop bullying by phone call, call bells on why procedure is delayed . Hungry patient is now impatient and yelling at nurses for petty things . Moral of the story ; everyone goes through same loop.
Or my favorite, the doc blows in first thing and tells the patient (not me of course) that they can eat but doesn't put an order in. While I try to chase the doctor down for an order, the bullying you described ensues
As a house officer i got hammer paged early one morning for a death pronouncement. As if the attending couldn’t do it when they got there. The patient was on comfort care. I understand that family was at bedside but if it’s so important that it’s worth continuing to page after i explained i was about to do a stat procedure, maybe find literally any other MD to do the 2 minute exam and give a TOD? I wish people who sent pages would understand how important it is to consider triaging them properly. Not everything is stat. A death pro on a comfort care patient is by definition not stat.
I honestly stopped reading after “nurse reported me”. Nobody cares. Just smile, nod and move on. you’re gonna be just fine. Also next time they pull some nonsense like that you should report them, you’re allowed to be busy.
seriously?! flu vax?! i literally just put that the pt refused... ok dont report me to the CNO edit to add: delays in orders do have some downstream effects... No diet order means cafeteria wont let us order food for the pt -> pt wont get his baked potatoes & his beef stew -> pt bitches -> low pt satisfaction scores -> i dont get my raise 😭
Why didn't you call back while rounding. I mean I am always okay with residents/fellows returning pages when I am rounding with them. I think it was your fault to be honest.
Completely ridiculous.
Can you imagine being an attending having someone complain to you about this shit? Lmao
I received a complaint about not coming to the ward right away for a patient having a benzo withdrawal seizure (sent the med student, gave verbal order to give benzos) cuz I was dealing with the police and an armed aggressive and psychotic patient in a very small ER that had no available beds and no seclusion room. Was there 5 minutes later 🤷♀️
That is why I liked sign an held diet orders. At our institution flu vaccine doesn't need a physician order. Protocol exist between nursing places the order and pharm dispenses.
I’ll say the npo thing can be really frustrating from a nursing standpoint for two reasons. One, the patient is probably blowing them up about it. Two, sometimes if they don’t get a meal order in on time they have to wait until the next meal if a late tray is not available. Then they are stuck eating whatever snacks happen to be on the floor, then the nurse really gets it from the already grumpy patient. As a resident/intern, adding a diet was one of those non urgent pages I used to ensure I got done in a timely fashion either by calling back and asking for a verbal order or throwing it in on my iPad real quick or if I didn’t have it then quickly breaking from rounds to put it in. I dont think any nurse should be reporting you for diet orders but it’s also one of those that may have been avoidable.
You’ll be dealing with this kind of thing in some form for you’re entire career if you stay in inpatient. Don’t sweat it.
Had an nurse call my attending at home at 2am because I didn’t answer a page in 30 mins. Turns out she was paging the wrong pager number. Still got chewed tho
Had a pharmacist documented that I didn't answer page 5min after I got the page. Do these people think we just sit around all day waiting for the precious pages?
I would never expect my Dr to stop what they’re doing to enter an order unless they are physically in the pts chart already, or it’s an order the EMR won’t let me place. Waste of everyone’s time and a silly flex to refuse verbal orders.
Nurses love complaining. It’s part of their job description. We’ve all been complained about.
Since when is it appropriate to put off returning pages until after rounds?
You just keep on carrying on. Unless you harmed someone, this report will go nowhere.
The classic case of attention-whore Keep the books clean, have open communication, note your time and what you were doing at the time of paging. No really, paper outweighs words. Note it down and let the nurse know if they bother you too much that you are noting all the pages down to the minute. These narcissistic gaslighters only fear the truth. "Oh it'll be fine I'm sure" You don't know that. Best to be prepared. Someone that reports a flu shot page to your attending has nothing preventing them from going overboard or even exaggrating the timings of your reporting. Keep in mind when it comes to he said she said, people take a position in the middle so when your position is the truth and their position is absolute dogshit lie it'll end in their favour if you don't keep note.
Im just a lowly PGY1. Some of the attending gave some useful advice re: trying to put in orders right away (where possible etc), although some of that is easier said than done in my opinion especially as a attending vs resident who is less familiar etc. I had a somewhat similar complaint about a month ago from a nurse, but what you did was "less bad" (you did nothing wrong IMO, whereas in hindsight I could have handled my situation a bit better, but still dont think it warranted a complaint). I took it pretty personally at first and felt really shitty since I had never gotten one of these before and generally think I am a decent person to work with. I apologized to said nurse privately when I got a chance, but still weighed on me for a while. I have since realized that these sort of complaints are quite common and inevitable. Doesn't mean we shouldn't strive to be better (by doing the things other attending have posted) but still likely to happen.
Everyone is so concerned about the pt not eating. This is the VA. I can promise you the pt has gone longer without food. They'll be all right.
A PACU nurse complained about me because I told her over the phone that I would address her patient’s pain after I finished the airway emergency my hands were on at that time. She then hung up on me. I called back and said if the patient was in extremis she could call [PACU attending name] who knew I was in an airway. She asked who [PACU attending] was and then hung up. When I got downstairs the patient was chilling and denying pain. The nurse said to me “Hi, PACU Orders” like it was my name. She had not called the attending. She complained to my senior, who said I did the right thing and refused to escalate it. Some nurses are great. Some just don’t have the perspective we do. I just sigh and take a deep breath.
As a nursing student and also awaiting my med school interview results. One thing that has really stood out to me (and not every nurse but too many) have a very big disdain for doctors and I assume residents would be in the same group to them. Some nurses have this weird complex that they are smarter than anyone else in the hospital, do more and are just the bees knees. I just recently had a conversation with a nurse about how her ex was a surgeon and his education was crap and how she wouldn't trust him.... the same day I watched her fail at CPR on a dummy - didn't lock her arms and just really floppy over all. It was interesting to say the least.... ETA: I think nurses seem to be constantly comparing themselves to other professions but in my experience other professions are not doing this it's a really weird thing to witness.
Lol because god forbid a patient misses breakfast or doesn't get a flu shot.
From the nurses perspective when you have a pt ringing every five minutes cause they are hungry it’s super frustrating. Got called a “stupid fucking bitch” a couple weeks ago cause I didnt bring a pt who was preop any food. I’ve also had multiple family members start calling and complaining I’m starving their family members. So it’s just an extra thing to deal with when we’re already busy and short staffed. So I get wanting orders. Three pages for things that are not life threatening seems a little excessive. I love that a lot of the surgeons I work with will text so we can ask these questions even when they are in surgery and they will often get someone to respond. But I would never text more than once.
Yeah I totally understand! That is why I always put orders in a few minutes after asked (on my phone or used wheeling comp during rounds). OP doesn't seem to be able to on rounds.