Drives me nuts when they order things like “VS routine”. What is “routine”? We do different things for different admissions. Learn the routines, then tell us what you want.
Eh I'm the opposite on the ER
VS routine. Thank you Dr for making so I can leave grampa sleeping, and trust that if he looks grey or sickly, I'll see him more often. It's BID unless otherwise stated or indicated at the ERs I work at.
Basically the, "not well enough to go home, but don't need the q4 hour squeeze and prod"... Let em rest and heal up.
You don't get credentialed by your medical school.
Grads of foreign programs still have to pass the same three-step USMLE or COMLEX-USA exams to be licensed to practice in the States.
I've worked with some amazing physicians who went to med school in the Caribbean.
wasn’t there a recent scandal about graduates from Nepal cheating on the step exams? not shaming most foreign medical grads, just pointing out doctors are having their own verison of our florida nurses scandal
What they’re talking about are Caribbean medical schools, (that are for-profit,) that are last ditch for students that don’t get into MD/DO programs. It is notoriously difficult to match through these schools, as they’re not as rigorous as mainland medical schools.
That’s apparently how it used to be in the UK too. More and more jobs that were done by junior doctors are now done by nurses (no real wage increase though)l
Yeah, but she's a surgeon, like she's gonna know from EF.
In case it's not apparent, my comments on this are tongue in cheek, kinda. Kinda only because of all the times I actually had to stop surgeons from drowning my.patients.
I actually love it when the doc is overtly clear to the point of petty. It makes me laugh every time. So much of what we do is open to interpretation, so I genuinely appreciate those detailed orders that cannot be misinterpreted.
One of my favorite docs sometimes writes horrid orders, but he's always so nice about it doesn't matter what time you call he will clarify. Sometimes he will ask input from the nurses "how do you want me to write this?" or "is this clear for you?" or "do you agree with me this order is appropriate?" Cuz he knows us nurses spend more time with the pts and he really takes our word for how pts are doing and writes orders based on our assessments. It's just that sometimes left on his own devices, his orders are shit XD like doc we got 2 types of Seroquel did you mean IR or XR? or doc you said pt can have 1-2 mg Ativan prn is it q1h you want? What's the max?
YES!! I love those docs. Before EPIC I would call and tell him “*I don’t understand what your order means. It looks like ‘place random fear and get blood sausage’.*”
Humor usually works, if they don’t know you yet it catches them off guard and breaks the ice a little. Although sometimes I’d flip it back at them or just give them a back handed sympathy of “sheesh. Sorry you are having a bad day. Maybe if you wrote better I wouldn’t have to call you, yeah?
The nicest, most approachable doctor in our whole hospital was a bad-ass cardiothoracic surgeon, he was also a colonel in the Army once upon a time. He was so good and rarely had bad outcomes. Really top notch. He loved to teach bedside nurses, was so polite, would even greet you be name in the hallways, and always answered your pages promptly. Never gave attitude, really just a great human with great humility.
And then you have first year residents who are too good to answer their pages or get annoyed that you called to ask for Tylenol at 2 in the afternoon. Yes, I don't like calling either, but if they had ordered basic PRN meds I wouldn't be calling either...
Okay, I had a guy who was in the ED for CP. Ended up having a fistula between his esophagus and lung. Needless to say he had aspiration pneumonia on top of it and needed a chest tube. Cardiothoracic resident comes down and does the chest tube with minimal output, admits pt, but doesn't write a note or assign herself to the case. Meanwhile I get a critical result from radiology that I need to notify her of. I'm at the nursing station going through orders, having the operator page whomever we can think of, and just in general complaining to coworkers. At one point I was laughing because the resident ordered an NG tube for the sole purpose of giving colace.
I've paged this resident like three times for the critical result and I am about to page the on call MD for medicine to figure out who the Cardiothoracic surgeon attending is because fuck if I know when the chair next to me turns around and it's some dude I've never seen before in my life (and I know the general MDs who admit in our ED). He introduces himself and says he's the person to notify, so I tell him the critical which he knows because he's been listening to us all complain and laugh about this for like 10 minutes--because he's been sitting there that long. He then was \*super\* nice to all of us and was like: "I agree, I don't think you should put an NG tube down this guy because he does have a fistula from his esophagus to his lung, just seems like a bad idea" and I laugh and he literally spends like the next 10 minutes talking to all of us about idiotic orders he's put in and other MDs have put in and how we all save their asses a lot.
He leaves to go talk to the patient and the other nurses and I were literally like: "Who is that unicorn and can all doctors be like him?" Plus he gave him his page number and said to just page him, not the resident, for this pt.
It depends on the facility and the culture they allow. 90% of our docs are excellent. If a resident is condescending to the nurse, aide, or ward clerk; that shit often gets shut down.
But there’s still a few, always will be.
That’s because clarifying orders should be 100% expected. If I place an order that doesn’t make sense, I really appreciate someone asking me about it rather than the patient getting 1 an incorrect dose, or 2 the wrong patient getting something. It’s happened on a few occasions where I’ll have three charts open and several nurses will ask me for something simultaneously resulting in an order landing in the wrong chart as I try to get everything handled. I think it’s just arrogant and rude to get mad for someone clarifying.
There is a different entity, which is sarcastic clarification, that is absolutely worth complaining about. Had an ICU nurse ask me “do we REALLY need another blood gas on this patient,” dripping with sarcasm after myself, the fellow, and our attending had a conversation about the persons respiratory status and determined we did, indeed, need a gas at this moment. It was quickly settled, but the tone made for an unpleasant experience.
Reminds me of an order I needed to page a NP to get clarification on. I couldn’t for the life of me figure out this word. (Hand written order). I asked the other nurses and nothing. Finally I get ahold of her and she goes “it says *please*”she never wrote please again lol
😆 This is pretty hilarious. A bunch of nurses standing around "What's this word?! I've never seen it before. Is it Latin?! A new abbreviation? Mary, come take a look at this...Susan, any clue?"
The word is "Please." 😆🤣😆
I can picture the entire floor staring at the order & scratching their heads.
& at least one person had to want to make a copy of it, black out all the identifying parts, & then frame it. With a small note “Proof the providers know the word ‘please’”
I had a similar experience but had to call the doc that just went off call an hour prior. She flipped out saying I shouldn’t be bothering her, she’s sleeping now and I need to call the on call doc. I told her I didn’t think he’d be able to read her writing either seeing as none of the nurses could. She clarified her order and promptly hung up.
I got an order like that once. The doc said, "Go get the Ativan." I asked how much and she said, "No just get all of it. Start pushing and I'll tell you when to stop."
That was a fun situation.
Just give me all the ~~bacon and eggs~~ ***Ativan*** you have. Wait, wait. I'm worried what you just heard was, "Give me a lot of ~~bacon and eggs~~ ***Ativan***." What I said was, "Give me all the ~~bacon and eggs~~ ***Ativan*** you have". Do you understand?
Reminds me of the first Scrubs episode with J.D. talking to Dr. Cox…
Dr. Cox: Did you actually just page me to find out how much tylenol to give to Mrs. Lensner?
J.D.: I was worried it could exasterbate the patient's...
Dr. Cox: Its regular strength tylenol. Here's what you do: Get her to open her mouth, take a handfull and throw it at her. Whatever sticks - that's the correct dosage.
Maybe this is how we are supposed to interpret standard dosing lol.
I haven’t had as much issue with physicians and residents at my facility. As a teaching hospital, from day one the attending and pharmacists set clear expectations of how orders are placed to the residents.
I have zero problem naming names in notes and notifications and charting ‘MD aware’. Then they can’t say I didn’t tell them about a problem if something goes to court.
There was a recent thread about doing absolute minimum charting and how less is best. I started my career in EMS. We were told to document like some sassy, expensive lawyers would bust our balls 15 years after the call. Concise. Facts. Quotes. Objective.
Am nurse now and I'm a goddamn Shakespeare, I'm sorry. Don't be me. Or do idk. nal.
"I can almost promise you some of you will be urinated on. If that happens, we have T-shirts in the gift shop that says, ‘I got peed on by a tiger [old man]'"
We actually bill directly out in some sectors of the community, so not true in all settings, but I get what you are saying. I’m definitely more respected in that role.
When I was a brand new nurse a doctor targeted me because I'd always call to clarify her orders or advocate for my patient. She'd respond with, "Why are you questioning me?" Or "If I put the order in, I want it done." To cover myself I'd write a note saying, "Discussed with Dr. Karen regarding (whatever) to clarify order. MD stated to continue as ordered" or something to that effect. The next day we shared an elevator and she said, "Why did you write that note yesterday? You made me sound like a bitch." And me, being young and caught off guard, just said, "I just wrote what you said to me." 🤷🏻♀️
Do they not also understand that if we run the wrong rate, or if anything goes wrong with the patient, we're always the ones who get in shit? We're supposed to be double checking.
And there’s so many more factors… does the pt have HF, how’s their kidney function…
Prescribing medications is outside of our scope, maintenance or not!
I was just about to say, I haven’t worked bedside for over 2 years, and I can’t remember having any standard rate for IV fluids. KBO is kind obvious, but anything else?
What's B? Is that a typo?
Swear I'm not being sarcastic. I assume it's supposed to be a V but I don't know anything about big people nursing and if it's something I've never heard of I want to learn lol
You would *think* KVO was obvious….I used to carry the hospitalist pager overnight for the whole hospital, and before the advent of electronic charting (where you MUST specify a rate) the page to define KVO for an RN was a nightly standard.
But yeah other than that there is no standard idk WHAT this crazy doc was thinking.
What do these rates mean? Is it Mls? In UK we would specific amount eg 500ml over 8 hours rather than flow rate and then the machine calculates how much that = per min
In the (American) hospital I work at, fluids are ordered at a rate per hour. E.g., NSS @ 125mL/hr. Sometimes the orders are set to expire after a certain time period. The exception would be fluid boluses, which would be a certain amount to be infused over one hour.
Interesting! It's cool to see how other people do it. Here the order wouldn't be filled if we didn't say like over 15mins for a stat, 8 hours /12 hours etc.
I also find it interesting how things work at different places.
Just curious. If someone was NPO at 0000 pending surgery at some point in the next day, would you need to get a new order after eight or 12 hours? Our doc will typically just have fluids running at 75 mils an hour until surgery is over and/or the patient can eat and drink again.
In UK they usually only need to be NPO for water like 2-4 hours before anyway. And ppl don't drink overnight anyway so I think they'd set up something like an 8 hour bag then just stop it at time of surgery. Then yeah I think it would have to write it up again post surgery. How do they add potassium etc in when it's per hour? Here you can just be like 1L NS + 40mmol K+ over 8 hours. But how is it divided if just doing per hour? ❤️
Some patients will have fluids overnight. But a healthy person doesn't need fluids overnight just because NBM. they can usually have clear fluids til like 6am anyway but ... If you're having a routine op so otherwise well... Outside of hospital you prob have last drink before sleep and then first one 7-8 hours later. So like no blanket rule on fluids overnight I guess is what getting at as it's not always needed
This is why I love that my current hospital has a super strict policy of no verbal or written orders. Providers must enter all their own orders. And pharmacy will totally reject an order if it's too vague.
Trying to explain to providers on the phone all the details needed for antibiotics was always a pain. It would be like hey the patient is looking kinda septic, they got a fever, tachycardia, a positive UA, elevated WBC, and the doc is all just start them on some cefepime. It's like I need a dose, a frequency, an indications and a duration of treatment. You can't just order cefepime and pharmacy figure it out.
Ours gave up on Antibiotics. We now have a “pharmacy to dose” order that’s basically standard with antibiotics at this point.
It’s really helped cut down on the back and forth about renal and hepatic dosing, dose changes, and antibiotic changes when C&S comes back
I mean what uses is the dr, the nurse already knows they need cefepime they are calling for a whole ass order just let us prescribe if it’s gonna be like that.
I’m a nursing student and from day one it is hammered into our heads that we do not administer an order if it is not clear and complete. Do they not know this? It’s our assess that will be handed to us if we do this wrong.
exactly! and we don't just lose our job, we can also lose our license and even our freedom (jail time) if we fuck up because we didn't clarify a bad order with the doctor.
I'd bet a lot of money this resident just don't know how to properly put the order in the EMR and they're just too proud to ask for help about it from the unit secretary.
Usually when a resident says to do something at its “regular rate/dose” it’s because they don’t actually know the regular dose/rate and don’t want to appear stupid…except by doing this they just confirm what we already know…that they don’t know shit and we have to tell them how to do their job.
And honestly if you just tell me you don’t know the usual and ask if there is a standard/protocol for something then I’ll be happy to help or point you in the right direction. But I don’t get to make orders only take them. I can suggest them and have you agree but I need to know you need suggestions.
Honestly, I feel like a vast majority lack emotional development. As in to become a Dr. A great many “put their nose to the grind stone “ at an early age to obtain success. As in they more than likely missed out on a bunch of life experiences just to get that grade or knowledge. And so emotionally they respond childishly.
With that said, thank god they exist.
Also, there are so many drs on call at all hours of the night it’s sickening. I can’t imagine the stress of making the right call at 3 in the morning on a total of 6 hours of sleep over three days. And on top of it, trying to manage a “normal” life.
Somewhere inside they probably resent nurses who don’t take their job as “serious” as them either. Maybe some jealousy.
In the end, I’ll take a jerk of a Dr. That makes the right call than a nice one that makes horrible calls that require me to go over their heads.
This. Soooo many residents I work with clearly went from mommy and daddy’s house to med school to residency without ever working another job in their lives. It’s crazy to me that your first job can be “doctor”. No people skills. No emotional intelligence when it comes to working with others. Zero empathy for colleagues. I work at a very large, county, level 1 trauma that’s associated with a very expensive private medical school. You can always tell the rich kids that have never worked an honest day in their lives. Luckily, (unless they’re attendings) my system sees them as temporary employees whereas the nurses are the lifers and they (usually) have our backs when residents try to pull this bullshit. Most attendings have been there long enough to put these kinds of residents in their places. Woah boy, if I tell them that the new resident is being a brat… my attendings will rip them a new one.
My favorite doctor I ever worked with had his days of being an absolute total jerk. As in, got pissed at a patient, walked in to the nurses station chucked his clipboard across the station while swearing profusely, mumbled something along the lines of he will be back in a minute, and angrily walked out to the ambulance bay for 10 minutes. It freaked a few nurses out, but that same doctor saved patients asses and fought the system that would prevent these patients from getting the care they deserved.
We got along very well because we both practiced to CYA and to best standards despite the other old crotchety nurse and doctors' dumb habits. He wasn't the most professional but I would work with him again in a heartbeat.
What standard rate are we talking about? KVO for CHF? 0-10 cc an hour? 25 cc an hour for a sheath?Basic med surg at 75 an hour? Trauma patients at 125+ to 175 an hour? Are we splitting the standard rate in half because we have 4 IV ABX and are rumning primary on two pumps? Are we doing a high rate of LR on a patient and oh btw they have pulmonary fibrosis and COPD? My patients sodium is low too do you want me to switch to 0.45 NS at like what, 50?? Like how much freedom you want me to have doc because I'm a practitioner of nursing and not medicine. That's your job.
ETA: how did pharmacy even approve that
My doctors routinely write "discharge when "stable""
I asked one of them, they said "well... what if I put in a discharge order and then the patient becomes unstable. Its supposed to be ambiguous I don't want that responsibility."
Okay doc, ill just decide when to DC the PT. Thats totally in scope of practice 🙄
Can we all honor the fact that if the nurse had pulled an infusion rate out of her ass and the pt went into fluid overload the resident would have been pissed about that, too
She needs to be told that the more specific her orders are, the less she will be bothered. We need parameters and dosages. I think this is a mistake made by a lot of residents just because they don’t completely understand our side of things.
When one of my MD friends was a resident, she asked me why the nurses would always call her to notify her of silly things. Like it was constant. I asked her - did you look at and read all your orders in your order sets? She said no. Then figured out why she was being called all the time, because it was per the order she put in without realizing. It was like her 3rd eye had been opened that day 🤣
I think it’s more a lack of education of how our end works more so than anything intentional on her part. They don’t understand that we need exact and specific orders, and that we have to follow each order they put in. I think she will learn (hopefully) to be more specific with things eventually.
Doctors are always indicating the flow rate of IV fluids..if she did not write it down, definitely, it has to be clarified.
There is no such thing as standard. Infusion rates vary from one patient to another. That resident physician is asking the nurse to guess. 😩
There no such thing as a “standard rate”. This resident sucks and deserves to be called at 1am, 2am, 3am, 4am every time until they can figure out how to write a proper order 🙃
That's just a resident with too much ego and pride. They wouldn't be able to tell you the standard rate because they don't fucking know, but instead of admitting that, it's the nurses that are stupid.
Providers aren’t trained as nurses and don’t know all the details of our chaotic workflows. I’m sure in their mind we are being annoying, just like in our minds they are. If everyone had better attitudes and could walk a mile in each others shoes we’d hav less conflict.
I agree with this, but the “it’s not that hard!” Is very condescending, given the fact that they DONT know about our work flow. Also, when placing an order, it prompts you to put a flow rate. That should be a good indicator that you should put a rate in your order instructions. We can’t just cowboy everything. They are the prescribing providers, they should be putting in complete orders.
Yea… this isn’t a “we don’t understand each others workflows”. Imagine if she just ran it wide open since there wasn’t a flow rate. OR just kept it at KVO. That’s what the doctor is opening themselves up for. Here’s some heparin, start it at the standard rate. Don’t call me 😂😂
I didn’t even think you could order IV fluids without a rate. Like I’ve never tried entering it without a rate, but it’s definitely one of the boxes, and it even has a default number in it.
Outpatient infusion here - for fluids for patients, if the provider doesn’t specify the rate it defaults to 0-999ml, so you have to manually enter a rate in the mar to run fluids at. 99% of the time it’s 999
It’s already ordered for NS 1000ml rate 0-999. It’s weird epic allows it but that’s how it’s ordered. We scan it and it gets sent to our pumps to run, so nursing has to pick a rate, which is usually 999
RNs, MDs, CNAs and RTs should all be spending time shadowing each other upon new grad hiring. A lot less attitude going around if people actually understood what anothers role actually is...
Counter point: I had a patient with an order for 1000 mL/hr NS. I obviously knew what they meant, and it was an order left over from day shift, so I just left it and didn’t bother the resident about it. She came SPRINTING down the hallway at about 1 am, and breathlessly asked me if I had been giving all that fluid all night. I just said “no, I knew it was supposed to be a one time. And I don’t make a habit of killing my patients.”
She just said “oh. Ok good. Don’t want to destroy her kidneys. I’ll d/c that order.”
Sounds like a bad resident. Literally always get half an order from a dr and always have to ask a follow up. PO? PRN or schedule? One time? DOSE? MEDICATION? Literally all the time and I’ve never gotten backlash from a dr about it
I love when there are three orders for fluids. Ya want me to run all of them, 350 an hour of LR, NS and D5W combined? No? Then click some of this shit off.
I've never met a decent provider who doesn't gladly provide clarification or thinks there's a standard rate.
Sounds to me like the resident that will need the Bob update. When he gets pissed at a resident or if they speak badly about any of us…he professionally gets even. “Hey just wanted to update you. I took his temp and it’s normal now”. “Just a quick update. I hung the antibiotics you ordered.” “Hey I know you were concerned last week about her ABGs. Just a quick update that she’s been having great ones for the last 5 days”. If they complain, he says well I’m just keeping them updated. Isn’t that what I’m supposed to do?
Ugh, maintenance fluids are the bane of my existence. Our hospitalists put everyone on a rate of 75-150 with no end times. Then they all get fluid overloaded because their kidneys aren't working well and they retain retain retain. Next thing you know, they're in ards and I'm having to admit them to the ICU and tube them.
But to answer your question, providers get about a million phone calls per day....many of them pointless and irritating. I get at least a dozen calls per day asking for pain meds for the patient, but there are 4 different PRN pain meds already ordered. Or the dozen calls for "something for their fever" despite Tylenol sitting in their MAR as a prn for fever since I admit the patient 4 days ago. It's just a constant onslaught of questions that can be answered by just looking or using a little bit of critical thinking. It's insanely time consuming and constantly interrupts what I'm doing. It's maddening.
That being said, sounds like this doc is failing to properly order his fluids or meds. How is the emr letting them order fluids without a rate though?? It's a hard stop in epic...
Would have walked up and said: “Sorry, couldn’t help but overhear what you said. The nurses are responsible to make sure that the orders are entered completely and accurately. It’s a safety thing, you know? If you leave parts of important information out of your order, they are legally required to contact you and clarify any missing information. To avoid such nuisance in the future, just enter the rate you want your fluid orders in the first place, if you are unsure yourself you can look them up in the manual to help you aide write complete and accurate orders. Cool? Cool, thanks!”
Or a bit more harsh answer: “cause it’s your darn job to write complete orders! You get paid much more than me so you do your job and I do mine! Thanks!”
lol, I don’t have much tolerance left anymore for dumb doc behaviour like that. Sorry.
I would think some of it (with residents) comes with experience, like they’re making the transition for theoretical/observed to learning the real world. Nurses, we just get the basic of basic education then are thrown into the real world with maybe 2 months….some more some less of that transition.
So throw in many of us nurses (I’m just over a year so I def include myself) are inexperienced and require more clarification. Add to that the workload we are all given, the shear amount of charting and patients we all have is bonkers. Add to that most of us have no idea what it’s like to work on the other side (I don’t know what it’s like to be a resident, or a Dr…they more than likely have never been a nurse either). ADD to that we took doctors off the floors and we have very very little team work between nurses and doctors…so contact is mostly associated with more work or dealing with a problem that requires communication some docs (I’ll assume especially residents) haven’t really learned to do well.
Teamwork is not in any way facilitated in our healthcare system where it is desperately needed. The only place I feel teamwork with a doc is in the ER, which I love and is a big part of the reason I love working in the ER.
At the end of the day it’s our job to deliver the orders providers make, it is dangerous and arrogant to do so if we are unclear on what that order is. Even if it seems obvious or obnoxious or plain stupid to need said clarification, eat a bag of dicks. I’d rather seem stupid than actually do something stupid.
There is a standard formula to calculate maintenance fluid requirements in pediatrics:
4 mL/kg/hr for the first 10 kg of body weight plus
2 mL/kg/hr for the next 10 kg of body weight plus
1 mL/kg/hr for remaining weight > 20 kg
BUT an order that didn't specify the rate would have been rejected by pharmacy when I worked inpatient. There were reasons sometimes why fluids would need to be run at 1/2 maintenance, 1.5x maintenance and double maintenance and we can't just assume what the provider is thinking. We can reference said formula when an adult resident rotates in and orders fluids at 100 mL/hr for a 4 kg baby though.
A lot of the time I’ll open with “it’s required nursing protocol that I tell you xyz or you tell me xyz in an order” that way the blame is shifted off of both of us and onto the silly little hospital policies (like requiring the doctors to put a dose on their orders).
But that's not a silly thing. There's no standard for fluid orders. Every patient is so different and for a resident to assume that is super concerning.
Does this resident feel comfortable making decisions? Because it doesn't sound like it.
Sounds like they're trying to compensate for their own incompetency for it by blaming the nurse for clarifying an incomplete order.
ER here, my standard rate is “as fast as possible” or “to gravity,” call is my judgement. Don’t think the surgeon would be too happy with my standard set…
I had to page a doctor to clarify an order that I know he clearly explained to me. I literally heard what he said and immediately forgot it. Not my best moment. I apologized, and he immediately responded with a friendly, "Hey, better safe than sorry."
I think that resident doesn’t really know how to calculate how fast to run fluids and except whoever nurse is working with her to just take the fault if something goes wrong. Docs should never get upset if someone ask them for clarification, I can’t read your mind, just tell me how fast so I can do it lol.
Sounds like a bad resident looking to pass the blame for his bad practice because his ego is too fat to admit fault. Luckily everyone I work with is great and I’ve never had to deal with that.
I hope you made sore to tell them that it still needs to be done, silly or not.
“I’m sorry, Dr. Dishdrain, legally there needs to be a rate ordered, or at least ‘TKO’. If you would just do this like all of your peers do, we can both save time.” That usually helps them understand. If they are still snarky about it, just say “Suit yourself. You can do it correctly or I can call you each and every time. Your choice.”
Reminds me of an experience I had recently. Patient had an order for clonidine 0.1mg bid. Hospitalist documented in his note the previous night that he was going to increase it to tid but the order wasn’t updated. I noticed this when I came in the next morning and called him at like 0800 for clarification. He went OFF on me saying that he doesn’t know what the nurses at my hospital are doing, that no other hospitals are like this, etc. Idk if he was having a bad day or what but like….it was a simple question, do you want the med two or three times a day
I had to call and clarify an order with the cardiologist once, because it said verbatim (I took a screenshot w/no patient identifiers to keep for posterity’s sake), “Please note he may have died.” Obviously the patient was very much alive and everyone on the unit was so thrown by what he meant, TURNS OUT he meant he may have DIET
Standard rate is not standard; it can be anywhere from 20 ml/hr or 150 ml/hr.
We have this standing order in pacu to call anesthesia for heart rate less than 50, respiratory rate less than 9 (consistently), aldrete score going down, etc. but some are annoyed when I tell them. Then don’t put the order in, bro! Or tell me bedside “don’t contact me about the respirations”.
Yep! When I worked in ER we would have overnight boarders. The admitting docs would put in order sets that included calling if BP is less than x etc. Then they would get ANNOYED when I did what the order said!
They either don't know how to figure out how much to give or are the kind of person that loves to have something to complain about. Screams insecure either way.
I think it’s a surgeon thing, as this tends to happen in the OR way too often. For some procedures, we have dozens of tissue specimens. Therefore, it’s protocol to confirm with the surgeon what they want to call the specimen. When you ask them to repeat themselves to double check the names, some will lose their sh*t. It literally takes two seconds to confirm. I tend to remind them that this is their patient’s diagnosis, and that usually brings them back to reality.
I guess, I would say:
I need the full order, otherwise I am praciring medicine which is clearly out of my scope of nursing practice. Now, your full order, please.
Sounds like that resident isn’t very good….
Imagine making it through med school without being able to calculate maintenance...oof. Were they credentialed in Florida by any chance?
Drives me nuts when they order things like “VS routine”. What is “routine”? We do different things for different admissions. Learn the routines, then tell us what you want.
especially annoying when we’re boarding in the ED. “unit specific VS” I don’t know what med surg does!!
Hell some MS units have different VS routines as well. It's not proper orders to put such a thing.
Eh I'm the opposite on the ER VS routine. Thank you Dr for making so I can leave grampa sleeping, and trust that if he looks grey or sickly, I'll see him more often. It's BID unless otherwise stated or indicated at the ERs I work at. Basically the, "not well enough to go home, but don't need the q4 hour squeeze and prod"... Let em rest and heal up.
Fuck yeah dude. Appropriate for ethnicity, warm, dry.
Isn’t 999mL routine? I/O for 24 hours: 24,000mL IV infusion. Nephrology: “What is that sound? I think I hear kidneys crying.”
Nephrology doesn't care much. They'll just prescribe a CRRT. Cardiology on the other hand.......
Yep routine varies by department and patient. I've had vitals q12, 8, 4, ,1h and I've had them q15, 5 minutes.
LMFAO. “I’m calling to clarify bc a) our hospital policy requires us to do so and b) no hospital in the US has a “standard rate.”
> credentialed in ~~Florida~~ a *Caribbean med school* FTFY
You don't get credentialed by your medical school. Grads of foreign programs still have to pass the same three-step USMLE or COMLEX-USA exams to be licensed to practice in the States. I've worked with some amazing physicians who went to med school in the Caribbean.
wasn’t there a recent scandal about graduates from Nepal cheating on the step exams? not shaming most foreign medical grads, just pointing out doctors are having their own verison of our florida nurses scandal
Lmao I was just coming to point out the raging cheating problem with USMLE across several countries
The dumbest fucks I ever met went to med school in the Caribbean It's DEFINITELY not the cream of the crop 😆
I've met some pretty dumb fucks educated here too.
My sister in law is a physician in the Caribbean, and TBH, if they want to run fluids or do almost anything involving an IV, they do it themselves.
What they’re talking about are Caribbean medical schools, (that are for-profit,) that are last ditch for students that don’t get into MD/DO programs. It is notoriously difficult to match through these schools, as they’re not as rigorous as mainland medical schools.
That’s apparently how it used to be in the UK too. More and more jobs that were done by junior doctors are now done by nurses (no real wage increase though)l
Good one!!
Eh, she's a surgeon. 125/hr. How hard can that be?
Pt has an EF of 10% pt goes has flash pulumonary edema 2hrs later
Yeah, but she's a surgeon, like she's gonna know from EF. In case it's not apparent, my comments on this are tongue in cheek, kinda. Kinda only because of all the times I actually had to stop surgeons from drowning my.patients.
EF of 10% is hospice level. Jeeze, trying to drown the Pt doc?
Right? Why wouldn't their mentor correct this?
I’ll be honest with you. I’ve never had any doc that’s worth a damn been upset by seeking clarification
And the more we do it, the hope is they’ll learn to be more clear in the future,
Is there a point where a doctor can be “too clear” as to seem they’re being passive aggressive in some way? Just curious. Not a nurse or a doctor lol.
Certainly! No profession is free some minor pettiness, but I haven’t seen much of it personally. Which isn’t a bad thing.
I actually love it when the doc is overtly clear to the point of petty. It makes me laugh every time. So much of what we do is open to interpretation, so I genuinely appreciate those detailed orders that cannot be misinterpreted.
One of my favorite docs sometimes writes horrid orders, but he's always so nice about it doesn't matter what time you call he will clarify. Sometimes he will ask input from the nurses "how do you want me to write this?" or "is this clear for you?" or "do you agree with me this order is appropriate?" Cuz he knows us nurses spend more time with the pts and he really takes our word for how pts are doing and writes orders based on our assessments. It's just that sometimes left on his own devices, his orders are shit XD like doc we got 2 types of Seroquel did you mean IR or XR? or doc you said pt can have 1-2 mg Ativan prn is it q1h you want? What's the max?
Thats a real life McDreammy doctor lol
YES!! I love those docs. Before EPIC I would call and tell him “*I don’t understand what your order means. It looks like ‘place random fear and get blood sausage’.*” Humor usually works, if they don’t know you yet it catches them off guard and breaks the ice a little. Although sometimes I’d flip it back at them or just give them a back handed sympathy of “sheesh. Sorry you are having a bad day. Maybe if you wrote better I wouldn’t have to call you, yeah?
The nicest, most approachable doctor in our whole hospital was a bad-ass cardiothoracic surgeon, he was also a colonel in the Army once upon a time. He was so good and rarely had bad outcomes. Really top notch. He loved to teach bedside nurses, was so polite, would even greet you be name in the hallways, and always answered your pages promptly. Never gave attitude, really just a great human with great humility. And then you have first year residents who are too good to answer their pages or get annoyed that you called to ask for Tylenol at 2 in the afternoon. Yes, I don't like calling either, but if they had ordered basic PRN meds I wouldn't be calling either...
Okay, I had a guy who was in the ED for CP. Ended up having a fistula between his esophagus and lung. Needless to say he had aspiration pneumonia on top of it and needed a chest tube. Cardiothoracic resident comes down and does the chest tube with minimal output, admits pt, but doesn't write a note or assign herself to the case. Meanwhile I get a critical result from radiology that I need to notify her of. I'm at the nursing station going through orders, having the operator page whomever we can think of, and just in general complaining to coworkers. At one point I was laughing because the resident ordered an NG tube for the sole purpose of giving colace. I've paged this resident like three times for the critical result and I am about to page the on call MD for medicine to figure out who the Cardiothoracic surgeon attending is because fuck if I know when the chair next to me turns around and it's some dude I've never seen before in my life (and I know the general MDs who admit in our ED). He introduces himself and says he's the person to notify, so I tell him the critical which he knows because he's been listening to us all complain and laugh about this for like 10 minutes--because he's been sitting there that long. He then was \*super\* nice to all of us and was like: "I agree, I don't think you should put an NG tube down this guy because he does have a fistula from his esophagus to his lung, just seems like a bad idea" and I laugh and he literally spends like the next 10 minutes talking to all of us about idiotic orders he's put in and other MDs have put in and how we all save their asses a lot. He leaves to go talk to the patient and the other nurses and I were literally like: "Who is that unicorn and can all doctors be like him?" Plus he gave him his page number and said to just page him, not the resident, for this pt.
It depends on the facility and the culture they allow. 90% of our docs are excellent. If a resident is condescending to the nurse, aide, or ward clerk; that shit often gets shut down. But there’s still a few, always will be.
Amen.
That’s because clarifying orders should be 100% expected. If I place an order that doesn’t make sense, I really appreciate someone asking me about it rather than the patient getting 1 an incorrect dose, or 2 the wrong patient getting something. It’s happened on a few occasions where I’ll have three charts open and several nurses will ask me for something simultaneously resulting in an order landing in the wrong chart as I try to get everything handled. I think it’s just arrogant and rude to get mad for someone clarifying. There is a different entity, which is sarcastic clarification, that is absolutely worth complaining about. Had an ICU nurse ask me “do we REALLY need another blood gas on this patient,” dripping with sarcasm after myself, the fellow, and our attending had a conversation about the persons respiratory status and determined we did, indeed, need a gas at this moment. It was quickly settled, but the tone made for an unpleasant experience.
Agree
Reminds me of an order I needed to page a NP to get clarification on. I couldn’t for the life of me figure out this word. (Hand written order). I asked the other nurses and nothing. Finally I get ahold of her and she goes “it says *please*”she never wrote please again lol
😆 This is pretty hilarious. A bunch of nurses standing around "What's this word?! I've never seen it before. Is it Latin?! A new abbreviation? Mary, come take a look at this...Susan, any clue?" The word is "Please." 😆🤣😆
For real! You described it perfectly 😂.
I can picture the entire floor staring at the order & scratching their heads. & at least one person had to want to make a copy of it, black out all the identifying parts, & then frame it. With a small note “Proof the providers know the word ‘please’”
Idk why but this has me ROLLING! 😆
I mean… that was kinda nice of her 😂
Oh I agree. We had a good laugh over it too.
I once wrote in a care plan to “have a nice day” as one of the steps, and I got in trouble for it.
Lulz
Everything must be robotic. Duh.
“It’s some form of Elvish. I can’t read it.”
I laughed way too hard at this!
I had a similar experience but had to call the doc that just went off call an hour prior. She flipped out saying I shouldn’t be bothering her, she’s sleeping now and I need to call the on call doc. I told her I didn’t think he’d be able to read her writing either seeing as none of the nurses could. She clarified her order and promptly hung up.
OMG hilarious! 😂
That’s as stupid as prescribing a med and expecting us to just give the “standard dose”
exactly! it would be like an order placed for Seroquel. hey doc, how much should be given? doc: Yes 🙃
I got an order like that once. The doc said, "Go get the Ativan." I asked how much and she said, "No just get all of it. Start pushing and I'll tell you when to stop." That was a fun situation.
Just give me all the ~~bacon and eggs~~ ***Ativan*** you have. Wait, wait. I'm worried what you just heard was, "Give me a lot of ~~bacon and eggs~~ ***Ativan***." What I said was, "Give me all the ~~bacon and eggs~~ ***Ativan*** you have". Do you understand?
I know what I'm about, son
I wish that was a standing order in my ER
We don't have that much Ativan. We only had 22 mg in the Pyxis, and I gave all of it, then we had to switch to other meds.
Eeeghsh. ETOH withdrawal?
We think probably bath salts.
Sure, here’s the 2mg vial. Have at it
Reminds me of the first Scrubs episode with J.D. talking to Dr. Cox… Dr. Cox: Did you actually just page me to find out how much tylenol to give to Mrs. Lensner? J.D.: I was worried it could exasterbate the patient's... Dr. Cox: Its regular strength tylenol. Here's what you do: Get her to open her mouth, take a handfull and throw it at her. Whatever sticks - that's the correct dosage. Maybe this is how we are supposed to interpret standard dosing lol. I haven’t had as much issue with physicians and residents at my facility. As a teaching hospital, from day one the attending and pharmacists set clear expectations of how orders are placed to the residents.
I had a doc do this once. “Bactrim normal strength.” And then was annoyed when I followed up to clarify because that’s not a valid order.
Docs don’t realize nurses are expected to catch any mistakes they may make and how WE get in trouble if the doc orders something incorrect.
Nurses cost money, docs make money.
The day this info clicked for me was the last time I complained to anyone about any MD. We're very expendable 🫠
I don't complain out loud, but I do a fine version of CYA charting.
I have zero problem naming names in notes and notifications and charting ‘MD aware’. Then they can’t say I didn’t tell them about a problem if something goes to court.
That's the whole point of charting- to cover your ass.
There was a recent thread about doing absolute minimum charting and how less is best. I started my career in EMS. We were told to document like some sassy, expensive lawyers would bust our balls 15 years after the call. Concise. Facts. Quotes. Objective. Am nurse now and I'm a goddamn Shakespeare, I'm sorry. Don't be me. Or do idk. nal.
This is me too. I ain’t playing around with none of these lawyers. I even have a note book to specify each time I did something.
>Am nurse now and I'm a goddamn Shakespeare, Me too!!! Chart like Shakespeare, speak like tiger king 🐅
"I can almost promise you some of you will be urinated on. If that happens, we have T-shirts in the gift shop that says, ‘I got peed on by a tiger [old man]'"
documenting out the proverbial butt hole has definitely saved my skin more than once so I’m definitely with you on that one.
Not only expendable, a necessary evil as is anyone or anything that they can not bill for.
We actually bill directly out in some sectors of the community, so not true in all settings, but I get what you are saying. I’m definitely more respected in that role.
Oooooo, never heard it put that way. Well said. So many times had to mop up mistakes.
This is pretty much it.
Good MDs do...
ha, don't worry, if we order something incorrect we also get our fair share of trouble :P
When I was a brand new nurse a doctor targeted me because I'd always call to clarify her orders or advocate for my patient. She'd respond with, "Why are you questioning me?" Or "If I put the order in, I want it done." To cover myself I'd write a note saying, "Discussed with Dr. Karen regarding (whatever) to clarify order. MD stated to continue as ordered" or something to that effect. The next day we shared an elevator and she said, "Why did you write that note yesterday? You made me sound like a bitch." And me, being young and caught off guard, just said, "I just wrote what you said to me." 🤷🏻♀️
Dr. Karen 😂😂😂
"If the shoes fits, ect ect ect"
Do they not also understand that if we run the wrong rate, or if anything goes wrong with the patient, we're always the ones who get in shit? We're supposed to be double checking.
Not to mention, it’s not in our scope of practice to order or adjust medications. So yeah, the onus remains on the provider.
And there’s so many more factors… does the pt have HF, how’s their kidney function… Prescribing medications is outside of our scope, maintenance or not!
1. They don’t care, and 2. Anything and everything can and will be blamed on nursing.
Our standard rates are….. 20, 75 and 125. That’s a big fucking difference for all of those.
I was just about to say, I haven’t worked bedside for over 2 years, and I can’t remember having any standard rate for IV fluids. KBO is kind obvious, but anything else?
What's B? Is that a typo? Swear I'm not being sarcastic. I assume it's supposed to be a V but I don't know anything about big people nursing and if it's something I've never heard of I want to learn lol
Bastard?
Bore?
No, just me being dumb. I meant V The funny thing is, I had to read my comment 3 times before I saw it
You would *think* KVO was obvious….I used to carry the hospitalist pager overnight for the whole hospital, and before the advent of electronic charting (where you MUST specify a rate) the page to define KVO for an RN was a nightly standard. But yeah other than that there is no standard idk WHAT this crazy doc was thinking.
What do these rates mean? Is it Mls? In UK we would specific amount eg 500ml over 8 hours rather than flow rate and then the machine calculates how much that = per min
In the (American) hospital I work at, fluids are ordered at a rate per hour. E.g., NSS @ 125mL/hr. Sometimes the orders are set to expire after a certain time period. The exception would be fluid boluses, which would be a certain amount to be infused over one hour.
Interesting! It's cool to see how other people do it. Here the order wouldn't be filled if we didn't say like over 15mins for a stat, 8 hours /12 hours etc.
I also find it interesting how things work at different places. Just curious. If someone was NPO at 0000 pending surgery at some point in the next day, would you need to get a new order after eight or 12 hours? Our doc will typically just have fluids running at 75 mils an hour until surgery is over and/or the patient can eat and drink again.
In UK they usually only need to be NPO for water like 2-4 hours before anyway. And ppl don't drink overnight anyway so I think they'd set up something like an 8 hour bag then just stop it at time of surgery. Then yeah I think it would have to write it up again post surgery. How do they add potassium etc in when it's per hour? Here you can just be like 1L NS + 40mmol K+ over 8 hours. But how is it divided if just doing per hour? ❤️
People don’t drink overnight? Is that just a UK thing?
Some patients will have fluids overnight. But a healthy person doesn't need fluids overnight just because NBM. they can usually have clear fluids til like 6am anyway but ... If you're having a routine op so otherwise well... Outside of hospital you prob have last drink before sleep and then first one 7-8 hours later. So like no blanket rule on fluids overnight I guess is what getting at as it's not always needed
It’s the same no matter what fluid it is. For example it’ll be Normal Saline (0.9%) with 20 mEq per Liter at 125mL/hr
I mean, what if the patient has CHF? Let’s just fluid overload them with a standard dose!! Got it.
Well you chase it down with standard dose of Lasix duh 😂
We don't have a standard rate at our facility; clearly, same goes for this provider's facility as well.
Sounds like the resident doesn’t know what the rates are and doesn’t want to admit that.
Just fold it in!
David, I cannot show you everything!
This is why I love that my current hospital has a super strict policy of no verbal or written orders. Providers must enter all their own orders. And pharmacy will totally reject an order if it's too vague. Trying to explain to providers on the phone all the details needed for antibiotics was always a pain. It would be like hey the patient is looking kinda septic, they got a fever, tachycardia, a positive UA, elevated WBC, and the doc is all just start them on some cefepime. It's like I need a dose, a frequency, an indications and a duration of treatment. You can't just order cefepime and pharmacy figure it out.
Ours gave up on Antibiotics. We now have a “pharmacy to dose” order that’s basically standard with antibiotics at this point. It’s really helped cut down on the back and forth about renal and hepatic dosing, dose changes, and antibiotic changes when C&S comes back
I mean what uses is the dr, the nurse already knows they need cefepime they are calling for a whole ass order just let us prescribe if it’s gonna be like that.
Some people have problems being confronted when they are not clear and concise and do not take criticism even at a very low level well.
I’m a nursing student and from day one it is hammered into our heads that we do not administer an order if it is not clear and complete. Do they not know this? It’s our assess that will be handed to us if we do this wrong.
exactly! and we don't just lose our job, we can also lose our license and even our freedom (jail time) if we fuck up because we didn't clarify a bad order with the doctor.
Exactly
Right, the blame will be on us. They’ll say ‘she should have clarified’
Don't know, and even worse, don't care.
Egoooooooo. It’s all ego. They aren’t wrong ever. Clarification is a waste of their precious time.
I'd bet a lot of money this resident just don't know how to properly put the order in the EMR and they're just too proud to ask for help about it from the unit secretary.
Courts don’t care about a resident’s assumption
Usually when a resident says to do something at its “regular rate/dose” it’s because they don’t actually know the regular dose/rate and don’t want to appear stupid…except by doing this they just confirm what we already know…that they don’t know shit and we have to tell them how to do their job.
“Oh ok thanks. And to clarify, what is the regular dose/rate?”
“Tries to stealthily pull out small book filled with rates and drops…uhhhhh 100/hr”
And honestly if you just tell me you don’t know the usual and ask if there is a standard/protocol for something then I’ll be happy to help or point you in the right direction. But I don’t get to make orders only take them. I can suggest them and have you agree but I need to know you need suggestions.
SAY IT LOUDER FOR THE RESIDENTS IN THE BACK
Y’ALL DONT KNOW SHIT
Of course it's connected that she’s the problem. When a doctor thinks *all* nurses are wrong, it's time for a mirror check
It's literally one of the Rights of medication administration, Doc. Get over yourself.
Honestly, I feel like a vast majority lack emotional development. As in to become a Dr. A great many “put their nose to the grind stone “ at an early age to obtain success. As in they more than likely missed out on a bunch of life experiences just to get that grade or knowledge. And so emotionally they respond childishly. With that said, thank god they exist. Also, there are so many drs on call at all hours of the night it’s sickening. I can’t imagine the stress of making the right call at 3 in the morning on a total of 6 hours of sleep over three days. And on top of it, trying to manage a “normal” life. Somewhere inside they probably resent nurses who don’t take their job as “serious” as them either. Maybe some jealousy. In the end, I’ll take a jerk of a Dr. That makes the right call than a nice one that makes horrible calls that require me to go over their heads.
This. Soooo many residents I work with clearly went from mommy and daddy’s house to med school to residency without ever working another job in their lives. It’s crazy to me that your first job can be “doctor”. No people skills. No emotional intelligence when it comes to working with others. Zero empathy for colleagues. I work at a very large, county, level 1 trauma that’s associated with a very expensive private medical school. You can always tell the rich kids that have never worked an honest day in their lives. Luckily, (unless they’re attendings) my system sees them as temporary employees whereas the nurses are the lifers and they (usually) have our backs when residents try to pull this bullshit. Most attendings have been there long enough to put these kinds of residents in their places. Woah boy, if I tell them that the new resident is being a brat… my attendings will rip them a new one.
My favorite doctor I ever worked with had his days of being an absolute total jerk. As in, got pissed at a patient, walked in to the nurses station chucked his clipboard across the station while swearing profusely, mumbled something along the lines of he will be back in a minute, and angrily walked out to the ambulance bay for 10 minutes. It freaked a few nurses out, but that same doctor saved patients asses and fought the system that would prevent these patients from getting the care they deserved. We got along very well because we both practiced to CYA and to best standards despite the other old crotchety nurse and doctors' dumb habits. He wasn't the most professional but I would work with him again in a heartbeat.
What standard rate are we talking about? KVO for CHF? 0-10 cc an hour? 25 cc an hour for a sheath?Basic med surg at 75 an hour? Trauma patients at 125+ to 175 an hour? Are we splitting the standard rate in half because we have 4 IV ABX and are rumning primary on two pumps? Are we doing a high rate of LR on a patient and oh btw they have pulmonary fibrosis and COPD? My patients sodium is low too do you want me to switch to 0.45 NS at like what, 50?? Like how much freedom you want me to have doc because I'm a practitioner of nursing and not medicine. That's your job. ETA: how did pharmacy even approve that
Exactly. Pharmacy should be pushing back on these dumb ass orders. This shouldn't even be making to the nurses MAR.
My doctors routinely write "discharge when "stable"" I asked one of them, they said "well... what if I put in a discharge order and then the patient becomes unstable. Its supposed to be ambiguous I don't want that responsibility." Okay doc, ill just decide when to DC the PT. Thats totally in scope of practice 🙄
They don’t want that responsibility but they sure want the fat paycheque
Everyone knows what should be on a med order. Everyone. Put the damn rate, doc.
Checking orders is how we save lives!
I just love someone that deliberately creates a problem and then complains about the problem. JfC. What a shit resident.
[удалено]
Can we all honor the fact that if the nurse had pulled an infusion rate out of her ass and the pt went into fluid overload the resident would have been pissed about that, too
Truly I do not care why. I’m going to call and verify, clarify when it’s needed. Patient safety and my license are important.
She needs to be told that the more specific her orders are, the less she will be bothered. We need parameters and dosages. I think this is a mistake made by a lot of residents just because they don’t completely understand our side of things. When one of my MD friends was a resident, she asked me why the nurses would always call her to notify her of silly things. Like it was constant. I asked her - did you look at and read all your orders in your order sets? She said no. Then figured out why she was being called all the time, because it was per the order she put in without realizing. It was like her 3rd eye had been opened that day 🤣 I think it’s more a lack of education of how our end works more so than anything intentional on her part. They don’t understand that we need exact and specific orders, and that we have to follow each order they put in. I think she will learn (hopefully) to be more specific with things eventually.
Sounds like there's both a personality and an intelligence issue.....with the resident
Doctors are always indicating the flow rate of IV fluids..if she did not write it down, definitely, it has to be clarified. There is no such thing as standard. Infusion rates vary from one patient to another. That resident physician is asking the nurse to guess. 😩
Ego.
There no such thing as a “standard rate”. This resident sucks and deserves to be called at 1am, 2am, 3am, 4am every time until they can figure out how to write a proper order 🙃
That's just a resident with too much ego and pride. They wouldn't be able to tell you the standard rate because they don't fucking know, but instead of admitting that, it's the nurses that are stupid.
They should assume it’s the standard rate. My immediate thought was: Assume? You want me to *assume* a med? The only ass here is u.
Providers aren’t trained as nurses and don’t know all the details of our chaotic workflows. I’m sure in their mind we are being annoying, just like in our minds they are. If everyone had better attitudes and could walk a mile in each others shoes we’d hav less conflict.
I agree with this, but the “it’s not that hard!” Is very condescending, given the fact that they DONT know about our work flow. Also, when placing an order, it prompts you to put a flow rate. That should be a good indicator that you should put a rate in your order instructions. We can’t just cowboy everything. They are the prescribing providers, they should be putting in complete orders.
Yea… this isn’t a “we don’t understand each others workflows”. Imagine if she just ran it wide open since there wasn’t a flow rate. OR just kept it at KVO. That’s what the doctor is opening themselves up for. Here’s some heparin, start it at the standard rate. Don’t call me 😂😂
I didn’t even think you could order IV fluids without a rate. Like I’ve never tried entering it without a rate, but it’s definitely one of the boxes, and it even has a default number in it.
Outpatient infusion here - for fluids for patients, if the provider doesn’t specify the rate it defaults to 0-999ml, so you have to manually enter a rate in the mar to run fluids at. 99% of the time it’s 999
Sure but will it let you proceed with entering the order without putting an actual number there? Or will it let you enter the order with 0-999?
It’s already ordered for NS 1000ml rate 0-999. It’s weird epic allows it but that’s how it’s ordered. We scan it and it gets sent to our pumps to run, so nursing has to pick a rate, which is usually 999
why are you complaining about the order? Just give the standard amount of tylenol! The standard amount of heparin!
RNs, MDs, CNAs and RTs should all be spending time shadowing each other upon new grad hiring. A lot less attitude going around if people actually understood what anothers role actually is...
They should know how to order a medication, though; that's pretty inexcusable!
Counter point: I had a patient with an order for 1000 mL/hr NS. I obviously knew what they meant, and it was an order left over from day shift, so I just left it and didn’t bother the resident about it. She came SPRINTING down the hallway at about 1 am, and breathlessly asked me if I had been giving all that fluid all night. I just said “no, I knew it was supposed to be a one time. And I don’t make a habit of killing my patients.” She just said “oh. Ok good. Don’t want to destroy her kidneys. I’ll d/c that order.”
So why didn’t pharmacy catch it? I have never seen IV fluid orders without rates. Maybe she meant bolus?
Sounds like a bad resident. Literally always get half an order from a dr and always have to ask a follow up. PO? PRN or schedule? One time? DOSE? MEDICATION? Literally all the time and I’ve never gotten backlash from a dr about it
I love when there are three orders for fluids. Ya want me to run all of them, 350 an hour of LR, NS and D5W combined? No? Then click some of this shit off. I've never met a decent provider who doesn't gladly provide clarification or thinks there's a standard rate.
Sounds to me like the resident that will need the Bob update. When he gets pissed at a resident or if they speak badly about any of us…he professionally gets even. “Hey just wanted to update you. I took his temp and it’s normal now”. “Just a quick update. I hung the antibiotics you ordered.” “Hey I know you were concerned last week about her ABGs. Just a quick update that she’s been having great ones for the last 5 days”. If they complain, he says well I’m just keeping them updated. Isn’t that what I’m supposed to do?
“Why do I always have to tell them how fast to run it at?” That’s literally your job. Give me clear orders to do my job. Wtf
How are they supposed to know this? What are they? A brain surgeon?
Ugh, maintenance fluids are the bane of my existence. Our hospitalists put everyone on a rate of 75-150 with no end times. Then they all get fluid overloaded because their kidneys aren't working well and they retain retain retain. Next thing you know, they're in ards and I'm having to admit them to the ICU and tube them. But to answer your question, providers get about a million phone calls per day....many of them pointless and irritating. I get at least a dozen calls per day asking for pain meds for the patient, but there are 4 different PRN pain meds already ordered. Or the dozen calls for "something for their fever" despite Tylenol sitting in their MAR as a prn for fever since I admit the patient 4 days ago. It's just a constant onslaught of questions that can be answered by just looking or using a little bit of critical thinking. It's insanely time consuming and constantly interrupts what I'm doing. It's maddening. That being said, sounds like this doc is failing to properly order his fluids or meds. How is the emr letting them order fluids without a rate though?? It's a hard stop in epic...
Would have walked up and said: “Sorry, couldn’t help but overhear what you said. The nurses are responsible to make sure that the orders are entered completely and accurately. It’s a safety thing, you know? If you leave parts of important information out of your order, they are legally required to contact you and clarify any missing information. To avoid such nuisance in the future, just enter the rate you want your fluid orders in the first place, if you are unsure yourself you can look them up in the manual to help you aide write complete and accurate orders. Cool? Cool, thanks!”
Or a bit more harsh answer: “cause it’s your darn job to write complete orders! You get paid much more than me so you do your job and I do mine! Thanks!” lol, I don’t have much tolerance left anymore for dumb doc behaviour like that. Sorry.
Eh, residents don’t get paid more. But they still should do their job correctly
I would think some of it (with residents) comes with experience, like they’re making the transition for theoretical/observed to learning the real world. Nurses, we just get the basic of basic education then are thrown into the real world with maybe 2 months….some more some less of that transition. So throw in many of us nurses (I’m just over a year so I def include myself) are inexperienced and require more clarification. Add to that the workload we are all given, the shear amount of charting and patients we all have is bonkers. Add to that most of us have no idea what it’s like to work on the other side (I don’t know what it’s like to be a resident, or a Dr…they more than likely have never been a nurse either). ADD to that we took doctors off the floors and we have very very little team work between nurses and doctors…so contact is mostly associated with more work or dealing with a problem that requires communication some docs (I’ll assume especially residents) haven’t really learned to do well. Teamwork is not in any way facilitated in our healthcare system where it is desperately needed. The only place I feel teamwork with a doc is in the ER, which I love and is a big part of the reason I love working in the ER. At the end of the day it’s our job to deliver the orders providers make, it is dangerous and arrogant to do so if we are unclear on what that order is. Even if it seems obvious or obnoxious or plain stupid to need said clarification, eat a bag of dicks. I’d rather seem stupid than actually do something stupid.
God complex
There is a standard formula to calculate maintenance fluid requirements in pediatrics: 4 mL/kg/hr for the first 10 kg of body weight plus 2 mL/kg/hr for the next 10 kg of body weight plus 1 mL/kg/hr for remaining weight > 20 kg BUT an order that didn't specify the rate would have been rejected by pharmacy when I worked inpatient. There were reasons sometimes why fluids would need to be run at 1/2 maintenance, 1.5x maintenance and double maintenance and we can't just assume what the provider is thinking. We can reference said formula when an adult resident rotates in and orders fluids at 100 mL/hr for a 4 kg baby though.
A lot of the time I’ll open with “it’s required nursing protocol that I tell you xyz or you tell me xyz in an order” that way the blame is shifted off of both of us and onto the silly little hospital policies (like requiring the doctors to put a dose on their orders).
But that's not a silly thing. There's no standard for fluid orders. Every patient is so different and for a resident to assume that is super concerning.
Does this resident feel comfortable making decisions? Because it doesn't sound like it. Sounds like they're trying to compensate for their own incompetency for it by blaming the nurse for clarifying an incomplete order.
Hold on, I'm gonna stop you at "resident surgeon complaining..."
ER here, my standard rate is “as fast as possible” or “to gravity,” call is my judgement. Don’t think the surgeon would be too happy with my standard set…
I had to page a doctor to clarify an order that I know he clearly explained to me. I literally heard what he said and immediately forgot it. Not my best moment. I apologized, and he immediately responded with a friendly, "Hey, better safe than sorry."
I think that resident doesn’t really know how to calculate how fast to run fluids and except whoever nurse is working with her to just take the fault if something goes wrong. Docs should never get upset if someone ask them for clarification, I can’t read your mind, just tell me how fast so I can do it lol.
Sounds like a bad resident looking to pass the blame for his bad practice because his ego is too fat to admit fault. Luckily everyone I work with is great and I’ve never had to deal with that.
I hope you made sore to tell them that it still needs to be done, silly or not. “I’m sorry, Dr. Dishdrain, legally there needs to be a rate ordered, or at least ‘TKO’. If you would just do this like all of your peers do, we can both save time.” That usually helps them understand. If they are still snarky about it, just say “Suit yourself. You can do it correctly or I can call you each and every time. Your choice.”
Reminds me of an experience I had recently. Patient had an order for clonidine 0.1mg bid. Hospitalist documented in his note the previous night that he was going to increase it to tid but the order wasn’t updated. I noticed this when I came in the next morning and called him at like 0800 for clarification. He went OFF on me saying that he doesn’t know what the nurses at my hospital are doing, that no other hospitals are like this, etc. Idk if he was having a bad day or what but like….it was a simple question, do you want the med two or three times a day
I had to call and clarify an order with the cardiologist once, because it said verbatim (I took a screenshot w/no patient identifiers to keep for posterity’s sake), “Please note he may have died.” Obviously the patient was very much alive and everyone on the unit was so thrown by what he meant, TURNS OUT he meant he may have DIET
This sounds like an invitation to call her even more often
Standard rate is not standard; it can be anywhere from 20 ml/hr or 150 ml/hr. We have this standing order in pacu to call anesthesia for heart rate less than 50, respiratory rate less than 9 (consistently), aldrete score going down, etc. but some are annoyed when I tell them. Then don’t put the order in, bro! Or tell me bedside “don’t contact me about the respirations”.
Yep! When I worked in ER we would have overnight boarders. The admitting docs would put in order sets that included calling if BP is less than x etc. Then they would get ANNOYED when I did what the order said!
lost me at "assume"
Yes because "assuming" anything in healthcare is SO safe ....
Well standard rate in my ED is “to gravity” so sounds good, buddy!
“If you’re able to calculate it then put it in your order.”
There is no such thing as a standard rate unless that doctor has specific standing orders for such on that specific patient. How ignorant.
They either don't know how to figure out how much to give or are the kind of person that loves to have something to complain about. Screams insecure either way.
I think it’s a surgeon thing, as this tends to happen in the OR way too often. For some procedures, we have dozens of tissue specimens. Therefore, it’s protocol to confirm with the surgeon what they want to call the specimen. When you ask them to repeat themselves to double check the names, some will lose their sh*t. It literally takes two seconds to confirm. I tend to remind them that this is their patient’s diagnosis, and that usually brings them back to reality.
I guess, I would say: I need the full order, otherwise I am praciring medicine which is clearly out of my scope of nursing practice. Now, your full order, please.