Tuesday, July 5, 2011

Unsolicited Advice to Interns From a Former RN Who has Gone to the Dark Side: Part 1

If you’re a new intern you are advisedly a little afraid of the new found responsibility in your life. I say ‘advisedly’ because there is nothing more frightening in healthcare than someone who is  ‘unconsciously incompetent’, i.e someone who doesn’t even realize he has no idea what he is doing.

In an effort to be helpful I thought I’d write a series of little posts from my former vantage point as an emergency nurse. (I say series because I am in the throes of USMLE cramming but as July marks the infusion of new interns in hospitals, this is the best time to write these. It'll be my 'study break' activity.)

When I was nursing I had the opportunity to see many medical students, interns, and residents flit in and out of the department, noting the differences between the ones who sail and the ones who sink. Here are some tips for those that want to sail. 

You Are Book Rich, Experience Poor. You may know all the cytokines involved in septic shock, but the RN knows what it looks like from 30 ft. Guess which of the two abilities is going to save your patient’s life? You'll get there, but in the mean time, pay attention to the patients about whom the RN’s are concerned. Which brings me to my next point.

Spidey Sense is not learned it is developed. Many nurses have been in health care since you were wearing short pants and they have pattern recognition down to a science (or some might say, a freakishly intuitive level). Good nurses know the ‘sick look’ so when they feel something ain’t right with a patient…it’s probably true. Do yourself a favor and check the patient out. Also, this is a good way to show your nurse colleagues that you respect their opinions.  You hate them because they paged you at 3 a.m when Ms Smith wasn’t looking right, but now they’ll love you because you took their concern seriously. And let me tell you newbies: Nurse love is the BEST love when you're the new kid on the team. Now you won’t get another phone call at 0345h to find out if you wanted that ‘diet as tolerated’ order ‘by mouth’. Not that that has ever happened…

Nurse speak. Nurses learn very quickly how to speak in code to 

a) forestall disaster, 
b) make you think something was your idea, 
c) point out a mistake without being unprofessional, 
d) make a suggestion without appearing to offer advice.   

Here are some translations for Nurse Speak. 

“Are you sure you want to [fill in procedure, medication, etc.] Mrs. Jones?” 

means “If you do that you’ll probably kill the patient”.

“Did you say you wanted a CXR on Mrs. Jones?” 

means “Yo! You forgot to order a chest x-ray, I am going to go ahead and order one now to save you time and not make you look like an idiot when you page medicine and then have to tell them you haven’t done a chest x-ray yet”.

“Oh, I haven’t seen it done that way before, I always thought you had to…” 

means “Dude, you are seriously doing that wrong, please let me show you a better/safer/faster way of doing that”

And finally, 

“Did you want me to go ahead and dip that urine for pregnancy?” 

means, “It appears you’ve left out a major differential, I’m going to make sure it has crossed your mind”. 

And that concludes today's installment of Unsolicited Advice. Hope some of that is helpful!  


OMDG said...

You should also point out that the correct response to, “Did you say you wanted a CXR on Mrs. Jones?” is, "Thank you so much for reminding me of this, nurse X. What would I do with out you!" (with sincerity)

NPO said...

Good advice.
Some of the older veteran nurses don't even hint at forgotten orders. They just say you forgot or we need so and so.

Solitary Diner (Also Known as The Frugalish Physician) said...

Nurse speak has saved my butt a number of times. I don't understand the med students/residents who fail to recognize the value of a good nurse.

Grumpy, M.D. said...

I am going to jump on board here and remind all interns to LISTEN TO THE NURSES. THEY WILL SAVE YOUR ASS.

Trust me. I'm a doctor. But that doesn't mean I'm better than a nurse. Far from it.

Dr. G said...

GREAT post!!! Nurses are truly vital when it comes to medicine.

Keet said...

I love the "did you want me to dip this urine for pregnancy" one... And you. And the gentle but important reminders that we give. :)

I would be a nurse in your hospital/clinic/hospice any day Asystole. :)

Albinoblackbear said...

OMDG--Indeed! :)

NPO--It's true. I usually never used that tack unless the MD was a good friend of mine though as often it causes them to do the *exact* opposite of what you say (er...suggest). ;)

SD--I honestly think a big reason for that is that newbies honestly have no idea what nurses do, what they bring to the table, or what their role is in the team. The other big reason is ego, I guess. Though fewer and fewer (new) docs see RN's like they did in days of olde (i.e. handmaiden to doc). [She shudders as she types that].

Grump-- :) Yes! I actually felt like writing the whole post in caps but I held back.

DrG--Yep. It is probably going to end up becoming my mission in life promoting that fact. ;)

Keet--Like we'd ever get *any* work done if we were in the same environment...hahah not that I wouldn't LOVE to work with you again! GO unit 62!! ;)

Maybe you can help me open up my "Complementary Medicine, Physical Rehab, Sports Med and Surgical Centre" in the future. We can make it a "Complementary Medicine, Physical Rehab, Sports Med and Surgical Centre with Drug and Alcohol Counseling Centre"! Sound good?!

PGYx said...

Count me in for the practice! I just need a few more years of residency to prepare...

Just a few more days of pre-USMLE pain. Your post-exam vacation is going to feel so sweet!

PGYx said...

Oh, and yes, I love the nurses! I'm all too aware that no doc (or nurse) is an island. During PGY1 I found again & again that the best treatment & care plans are forged through communication among team members. I want everyone's (and I'm including social workers, speech & language pathologists, physical/occupational therapists, and pharmacists, too) input & ideas so we can settle on the best way!

May God save the patient who relies on plans formulated by a single person -- or whose nurse is too timid or busy to speak up when something is wrong or could be improved. I am always careful to sincerely thank anyone who helps me to see that I'm headed down the wrong road as I want them to feel free to help me prevent mistakes in the future. :-)

kristophine said...

Heh! I love this. I volunteered in an ER for a while and I definitely overheard a few of these. It's good for socially-deficient people like me to have the translations!

K said...

Haha! Love this post! So true!

Anonymous said...

My mother (a geriatrics nurse) told me the one piece of advice that sticks with me to this day:

"For goodness sake, Not House, be good to the nurses, or they'll make you're life a living hell. Then you'll come home, I'll hear about it, and I'LL make your life a living hell"

Truer words have not been spoken.

Me said...

As a paramedic now crossing to the dark side I have already experienced how I need to be super-conscious of not upsetting the nursing staff. Apparently I don't "smile" enough. Trying much harder now to smile, have a quick chit-chat before giving my handover, and learn names! My bad! I was concentrating too much on what I was doing and not how I was coming across to others in the ED. Oops. Lesson learnt. Thanks for the advice :)

Robert said...

Ok, the NurseSpeak made me laugh out loud...

Albinoblackbear said...

PGyX: "May God save the patient who relies on plans formulated by a single person -- or whose nurse is too timid or busy to speak up when something is wrong or could be improved."


Reminds me of that whole chapter in Outliers about pilot/co-pilot culture and what happens when they don't communicate.

KP--Hahah--I honestly think some docs never learn to decipher Nurse Speak (for better or for worse!) :)

CJ--Being a paramedic has prob taught you to be concise and brisk--two qualities that are easily misinterpreted.

NAMES! Yes. THANK YOU. That is *such* a good point. I may have to add that to my next rant. :)

NurseXy--You've prob got some crazy chiro-nurse-speak!! ;) Glad you enjoyed.

Giuseppe 'markgreene' Cunsolo said...

Great post and good advice.

It reminds me (in a good way) of Heinlein's Starship Troopers:

«"Impossible, of course. Except for one thing. What is the only factor that can save you when the load is too heavy? Anyone?"
Nobody answered.
"Oh, come now!" Colonel Nielssen said scornfully. "You aren’t recruits. Mr. Hassan!"
"Your leading sergeant, sir," the Assassin said slowly.
"Obviously. He’s probably older than you are, more drops under his belt, and he certainly knows his team better than you do.
Since he isn’t carrying that dreadful, numbing load of top command, he may be thinking more clearly than you are. Ask his advice. You’ve got one circuit just for that.
"It won’t decrease his confidence in you; he’s used to being consulted. If you don’t, he’ll decide you are a fool, a cocksure know-it-all — and he’ll be right. (...)»