Thursday, July 7, 2011

Unsolicited Advice to Interns From a Former RN Who has Gone to the Dark Side: Part 3

This is the third installment of Unsolicited Advice.

Not House astutely pointed out in the comments section of my blog that "nurses will make your life a living hell" if you treat them badly. Some will make your life a living hell, no matter what. As in every profession, there are nurses with a chip on the shoulder, as well as those who are simply counting down to retirement. But for the most part, nurses want to work with you not eat you. Some of my suggestions probably appear ridiculously obvious, but I wouldn’t have been prompted to write these pieces if I hadn’t observed the examples below.

So aside from being proactive in the ways I’ve already mentioned (contributing food, introducing yourself) here are some things to avoid:

1) That is not my job or I'll get the nurse to do it are two phrases that can be heard by a nurse ears even if she were standing next to a jet plane at take off. The people who utter these statements send most nurses into a silent rage. If a patient is asking something simple and easy (like for a warm blanket and you are leaning on say, the blanket warmer) do not say "I'll get the nurse to do it" and walk away. At that point, you might as well have relived yourself on those brownies you brought in.

Nurses know that interns, attendings, and students are run off their feet--but so are they! Don't think that there are jobs more or less important than yours, and that you and your skills are at the peak of the 'importance triangle'. It's not beneath you to do non-doctorly things. Just imagine for a second how the hospital would run within hours of not having a laundry service, housekeepers, lab techs, office administrators, filing get the picture. Until you've worked a few nights in small hospitals, you may not appreciate all the behind-the-scenes supportive work that many people do to keep the hospital afloat.

So if you have 2 seconds pitch in and help out. I'm not saying anyone expects you to change bedding, start all the IV's, walk Ms Jones down to x-ray, but small gestures are noticed and appreciated. There is nothing more annoying than having an intern say to you "get Ms Jones some water" while you are whizzing by pushing an ECG machine and primed IV pole and they are sitting down to check their Facebook updates.

2) If a nurse is asking you a question about something, don't blow her off with a patronizing answer or assume that they are questioning your care (this is different from Nurse Speak).

When I was nursing and I asked an MD a question, like "why did you use marcaine instead of lidocaine?" or "why did you chose heparin IV instead of sub cue lovenox?" it wasn't because I was trying to be inflammatory it was because I was curious and genuinely wanted to know. Were there guideline changes, or new evidence based medicine protocols? Don't forget that even though you're writing the order, the RN's are the one administering it, and many of them want to be right up on the why.

3) Messy handwriting is dangerous. Stop it. Many places are switching to computerized orders which definitely have advantages, one being that RN's no longer will have to add 'expert handwriting decipherer' to their list of skills. As a new nurse I almost gave a patient with lung cancer percocet (narcotic) instead of senna (stool softener) because of illegible handwriting and a missing-in-action MD. Thankfully, as the patient was about to tip them back I said, "do you normally take percocet at this time of the day?" to which his wife responded, "No, he's allergic to percocet!"

If you have bad handwriting, try and at least write medication orders clearly. It is also doubly sweet and handy if you alert the nurse who is taking care of the patient, "I wrote some new orders for Mr Jones and I added another antibiotic to his regimen". It is bad for everyone when the nurse checking the charts during night shift sees that no one noticed an entirely new set of orders after the blood cultures came back.

And thus concludes today's installment of Unsolicited Advice. I grudgingly redirect my efforts to understanding why I should care about the pentose-phosphate shunt.


NPO said...

In the hospitals I've done travel nursing, the computerized "doctor order entry system" is so nice. The older docs hated it at first, but the tech savvy younger ones got right into it.
A year where I'm at now and I still can't read some hand written orders I see. Nurses then spend time running around saying, what does this say?

Albinoblackbear said...

For that reason, I loved the system in Whistler ED for that...if we couldn't read the orders there were these laminated red pieces of paper that we'd clip to the chart and then put back in the rack.

That way the docs could easily see if one of their charts were flagged (i.e. the orders weren't done).

You could also tell who was working by the number of flags up at a given time. ;)

Anonymous said...

Just catching this series now - great stuff! I was a cleaner in my hospital for 4 years in my hospital when i was a med student and I could try a few posts from cleaners to the rest of the hospital!

ECG, IVs, taking blood and giving antibiotics were all the jobs of the intern rather than the nurse in our place so we did get a little ticked off on occasion and i suspect we'd be forgiven that!

Amen on the hand writing thing, I changed my hand writing entirely (to all capitals) after my first year as a doc, though largely that's cause i couldn't read my own!

OMDG said...

Ok, so can you please tell me what I should have done in the following scenario?

Scenario: I was called to do a neuro consult on a post op patient with a suspected stroke. As I was arriving, the ICU nurse was finishing up changing the linens, since the patient had just shat himself. I did my history and exam, talked to the nurse extensively about what had happened, and she was very helpful. Then she left, and the patient shat himself again.

I can tell you that I have NO IDEA how to change a patient. His diaper. His sheets. I can kind of do a gown, but I am hopelessly awful at it. Also, I don't know where any of the supplies are since I don't work on that floor. So I got the nurse. It was very very awkward, and I tried to help, but mostly got in the way, and eventually ran away.

How could this have gone better? Further, since I was a med student I actually had the time to help. I am imagining that were I a resident with an en fuego pager, things might have been different, and the nurse would have been really annoyed. I could have just run out of there and left the patient in his own feces for someone else to find and take care of, but that just seemed wrong. Hence, I violated your rule #1.

Albinoblackbear said...

EMIre--I sent you a tweet in response to your thoughts. And I think I heard the Hallelujah soundtrack start playing when you said you switched to caps.

OMDG--I don't think you violated rule #1 as my examples were very quick and simple things--i.e. grabbing warm blanket, getting a drink, etc if and when able to.

It was meant to illustrate that RN's *don't* expect MD's to do nursing duties, but they appreciate it when an MD / student whatever does a little something to show willingness to keep things running smoothly.

There is no un-awkward way to tell someone "hey your patient just shit the bed and you ought to do something about it". I would never for a *second* have thought "why don't you help me or offer to help" if a MD student or MD said that to me when I was nursing. The best you can do is say, "sorry to be the bearer of bad news but I believe there has been another code brown in room 8".

If you were bored and really wanted to help you could just do what you did or say, "I suck at bedding changes, etc. but can I give you a hand in some way?" they'd probably say no and love you forever after that. They prob were so stunned and shocked you tried to help... :)

I would have felt awkward if a MD student or intern tried to help me change a bed.

From what I've gathered about how you participated in clerkships you were one of the md students that nurses probably loved... :)

Anonymous said...

Haha, my mother's lesson rings true :P

Computerized entry systems will take years to be adopted by the luddites who run our system (we still use a EMR that runs on DOS for Chrissakes), so we'll still have errors like the ones you described by horrible handwriting (we once had a guy in our ED miss both his initial AND repeat Trop's because the nurse thought that 'Trop' said "LFT".

My biggest interaction concern has always been with my sense of humour. When I'm on the ward, I'm very self-deprecating, sarcastic and generally very familiar with the nurses in the department. For 19/20 of them, it works great, and we all laugh and joke together (and my mistakes are taken much more in stride :P). BUT the one in twenty nurses absolutely hate it, and all my attempts at humour have been met with at best perplexed gazes and at worst outright hostility.

I have yet to figure out a system that lets me identify that 1 in 20 (or a system to get a better sense of humour).

Robert said...

I like it!

I love when docs give me a brief run down of what they've written so that I have somewhat of a heads up.

Our hospital is supposedly going to be moving to CPOE soon...I'm not holding my breath.

Albinoblackbear said...

IANH--Oooooohhh trops! OUCH.

For the 1/20 you have to assume it is not your problem (or your sense of humor). They just don't like the cut of your jib, or, their patient that day is immobile with melena, or both.

My favorite MD student of all time (out of a top 3 list) was a dude with a completely wacky sense of humor...he wore a little star trek pin on his white coat (which in itself was hilariously tailored to be When he left the unit he dropped off a signed 8 x 10 black and white head shot of himself doing this pose:

We all about pissed ourselves and it hung in our med room for months.

Humor is good. Vital, in fact!

NurseXY--I am the same as you. It is also a nice chance to get an idea where his/her head is at with the patient...the things that aren't written in the chart.

Liana said...

There's a quiz at the Medical Post where you can try to decode prescriptions.

The quiz is multiple choice at least!

OldSquid said...

OMDG- I'm with ABB, you did the right thing. Much better than turning on the call light and running like most med. students would. Something like, "sorry, the pt. in 212B just code browned all over. I don't know were anything is, but can I help." Just the offer to help will go a long way with most of us. We might ask you to do something for another pt while we attend to the other.

Cartoon Characters said...

I have worked in several hospitals that have zero tolerance to bad handwriting with MD orders. Computers have really improved the process.

I also don't care for the MD orders that are written out and then chart put back in it's slot. Not good. I'm with NXY on this one...give me the lowdown f2f.

OMDG: we don't expect you to change a bed - but it sure was nice that you WOULD have helped. That goes a long way. Sincerely.

IANH: don't worry about the 1/20. Other nurses probably don't get along with that nurse either. You try, and that's what counts.

ABB: love these posts! :)

anonymousRN said...

Ok... my suggestion to add to the list.

When approached by a nurse about a delierious, agitated and combative patient do not say to the nurse "Just talk to them". It is almost as rude as ordering "Hugs Q2H PRN".

Yeah... both have been done in my ICU.... I am impressed that the doctors made it out alive....

Just an Intern said...

Great advice!
Thank you so much.
The RN's have been totally amazing to me my first few shifts.

H said...

One of my colleagues recently (politely) questioned a doctor regarding one of the orders she had written, something along the lines of "Are you sure you want me to do this to Mrs. W? I don't feel comfortable with it because of her history of XYZ" And the doc, *who used to be a nurse*, responded with "Well, there's an order for it, isn't there?" Argh!

We also had a resident who wrote an order for the nursing staff to sing "Happy Birthday" to a patient. Yeah. He was not one of our favorites.

Rachel Krager said...

An excellent series- this stuff is really helpful!