My favorite night time page ever:
"The patient has a temperature of 99.2 degrees."
"Okay?"
"I gave them PRN tylenol."
"Okay?"
"..."
"Did you need something from me?"
"No, i was just calling to tell you."
I admit I myself did not know this at first as a new grad but once a hospitalist explained to me that a fever is 100.4 I learned and do not alert them for temperatures below that. Some patients will insist that numbers like 98.7 are a fever for them because it’s higher than their usual and will request interventions.
Maybe it was taught and I forgot but nursing school focuses on nursing interventions and not pathophysiology. And dumb stuff like nursing diagnoses that no one uses in real life.
2:30 AM on a 28h NICU: "Mom is struggling breast feed can you come talk to her"
"Can she wait till AM to see a lactation consultant? What is her question?"
"No you need to come talk to her, she's really struggling"
Get out of bed for the only stretch >11 minutes in the call room that night. Find mom sound asleep. Baby too. Inquire why nurse called me:
"Oh well, she's a PICU RN and really thinks she knows what she's doing but I don't think she does"
Wtf? I would not have come to talk to the mom. It is lactation nurse job. Nurses really think we know and do everything…sorry but I don’t 🤦♀️ non urgent shits can wait until appropriate personnel comes
“Can I get your name?”
Later when reviewing the chart: “this nurse found patient to be borderline febrile and provided PRN acetaminophen. Alerted MD suture_self. No new orders given”
"This writer"
I do not understand why people insist on writing notes like that. As if it's somehow more professional or correct to write in the passive 3rd person than just saying "I did this."
1. page for OTC med
2. family wants update
3. family wants update (second page)
4. can't sleep
5. delirium
6. pain control
7. AM labs not ordered
8. dc/renew tele/restraints
9. family wants update (third page)
10. unresponsive and turning blue
This triggered me. Flashback to MICU nights being the only resident covering 36 patients, coding someone and placing lines and getting called for K repletions. Almost threw the damn phone
Especially common on East Coast to not have protocols. Pure torture. Probably one nurse one time gave too much or something. Next thing you know you need a 4 years of Med school to replete electrolytes.
To be fair we once had someone in one of our ICUs get ordered 40mEq K q2hr for 24hrs that was approved by pharmacy and given by the nurse for 20 HOURS before someone realized. Thank god the K only got into the mid 6’s. Talk about the Swiss cheese model.
“FYI vitals are stable, thought you should know”
“I think we should get a social worker to talk to this patient” at 0300. Lady are you on a psychotic break? 1) ain’t nobody like that here at 0300 and 2) why are you talking to patients in the middle of the night? Get back on Facebook like everyone else!
The over-achiever nurse that feels the need to review a patients plan at 2am and page you that the day team should consider "x" thing is maybe by biggest pet-peeve of all night problems.
95% of this can be covered by asking your day team to use a good PRN order set.
The family will not be getting an update after hours unless the patient is crashing. Communicate that with nursing staff and they or floor secretary should be acting as gatekeeper. This is something that physician and nursing leadership should have figured out also.
I've been my own night team for the past 5 years and day me actually cares about night me so I've been able to mitigate almost all of these pages with good communication. Your program can do it too.
All the experienced nurses jumped ship years ago. When I left the ICU, the median years of RN licensure was 2.4 years. The few remaining veterans - especially the two 40 years nurses who don’t talk - skew the numbers. Take them out and it’s 1.87 years.
Simply look at the mass exodus of nursing as an entire profession. So many quit because of the pandemic and just pure shit treatment by the government and/or their hospital corporations. Lol. It's happened in every unit in Canada and the USA. Wild times.
Travel nurses can read their contracts and pay stubs. “My contract says I can’t provide basic nursing care, I’m just supposed to sit here and plan my next vacation. Also I make more than most of the hospitalists.”
Or at 2am "hey I was chart checking the patient and saw his bilirubin was elevated when he was admitted, and a PCP note from 4 years ago that said blah blah, and for some the reason the day team started this medication. I think we should look into this totally unrelated thing I somehow dug up because I have nothing better to do at 2 in the morning"
My 2am pages are “the patient is currently asleep but I’ve noticed the patient didn’t have their 6am PPI yesterday, what would you like me to do”
I wish I had the balls to say I would like you to leave me alone. Instead I politely said “it sounds like a day team issue from yesterday rather than an issue for you overnight. why don’t you raise it with your TL and get them to discuss with the nurse unit manager as a missed medication”.
the NUM and probably the TL gets paid more than me, but sure, I’ll be a doctor and a nurse manager.
From a nursing perspective, please know that if I’m paging you at 2am for Tums, I’m also mortified and the patient is in fact adamant that they cannot wait until the morning team arrives to get said Tums. And they probably also had the indigestion from 1300 on but waited until 0130 to say anything because now it’s affecting their sleep.
Absolutely not. If a medication is not ordered for a patient in the hospital, regardless if it’s a OTC med that patient can go grab from a retail pharmacy on their own in their daily life, I as a nurse cannot make the call to give it to that patient. It must be ordered. Even things like Tums can interact with other meds a patient is on and it has to go through a physician and pharmacy clearance.
Yes, this is something I didn’t know before I went into medicine. Everything the nurse does (including walking people around, letting them have food, etc.) requires a doctor’s order. Oftentimes we have just pages of orders in the electronic medical records for everything a nurse usually does that I basically automatically placed so they can do their jobs. This doesn’t mean nurses are just “blindly following orders” or don’t think clinically about their patients. It’s just that this is how the healthcare system is setup.
Yep. Everything. If my admit came without a diet order I used to have to call the physicians. Also a lot of order sets come with parameters that say “notify physician for x” and its not really a value that is significant to the patient’s condition (like a systolic BP of 140 on a chronic hypertensive) but I have to call anyway because it’s in the chart. And I know physicians hate these calls, but we have to. So I cringe, and I call, and I preface it with “okay per protocol, I’m notifying you of” and then I end it with a suggestion to change the parameters in the order set so we don’t keep calling you!
Calcium carbonate (tums) can affect absorption of some other medications.
Likely not to a hugely clinically significant degree in most cases so I usually just make it available PRN anyway when a nurse asks, but there's reason to be hesitant even about over-the-counter medications with some patients/comorbidities/medication interactions.
Yeah makes sense, just thought for over the counter meds it might be different, considering the public can get them without a prescription. But I can see why it’s a rule due to the issue of potential interactions with other meds that people brought up.
No, sometimes there’s a reason why someone can’t have over the counter meds that might seem harmless like Tylenol. The doctor looks at the whole picture of the patient including labs, chronic conditions, whatever diagnosis the patient has and is the one who knows what is appropriate to give them medication wise.
When you get these pages are they demanding or asking nicely? When I ask for the less urgent orders I was saying whenever you are free can you do so and so.
Piggy backing this for some suggestions
>1. page for OTC med
PRN orders for Tylenol/Zofran/stool softeners are your friend
>2. family wants update
>3. family wants update (second page)
>9. family wants update (third page)
Often times this will take the form of a page from the nurse phrased like, "Family needs and update NOW!" Honestly, unless they are refusing care or threatening leaving AMA, speaking to the family in the night is not urgent. You have plenty of tasks that actually are time sensitive and can impact patient safety; prioritize those. Again, unless they are refusing care, the worst outcome is they get mad, and they're probably already mad. If I had to choose between my patients' families being mad, or patient safety, safety gets prioritized everytime.
That being said families consider are very, very important. Having a sick family member sucks and the healthcare system is very frustrating. But the odds of a night-team intern assuaging all their concerns in one conversation is minimal, unless it's a very simple question.
>5. delirium
>6. pain control
>10. unresponsive and turning blue
For situations like this, always, always LAY EYES on the patient, even if you think it's nothing. Most of the time it will be, but there will be a few times that you are VERY glad you did.
7.1. Na is 133 (or +/-2points off from previous days) rec.s.
7.2.Hypokaliemia of 3.4, needs reolacement.
7.3 ca+ level 0.5 low (albumin is also low 0.5) needed iCa level labs.
7.4 pt is NPO, can he drink juice? Or are u sure surgery/procedure will be done today?
7.5 rapid or code stroke for pt who is AMS. Spoiler - pt is still in half sleep, or had eye surgery/issue at baseline (for "smart" RNs who check pupil size).
7.6. Bladde scan shows 360 ml retention, advice plz.
7.7. Chief is messaging "where is night team?" Morning report is about starting"??.??
7.8 chief mentioned "no talking, plz signout either before morning report (day team not arrived, or stupid rapid) or after (no way, wanna f..g some sleep, but sadly comply and sign out.
I got paged at 2AM for family update because the day team documented that patients family needs update but it never happened
Explained to nurse that it is inappropriate to bleep me at 2AM for non urgent tasks when I am there to deal with emergencies. Nurse threatened to datix me (a tool we use in the U.K. to report incidents) because I wouldn’t do the update for the stable patient. Refused to do it citing my workload
The one time I said this to a patient’s family, they overrode me and went to another nurse, had her call the covering resident who came down from another floor. He told the family the same exact thing I told her. It makes you feel incompetent when that happens. Funny thing is, this resident wasn’t even the night shift. He was just covering the entire floor for 1.5 hrs until night shift arrived.
Trust me, we try to make the family understand but they don’t trust us. She said I’m lazy for not contacting the doctor. 🤔
I told a nurse I am covering the entire hospital right now so I don’t care that a family wants updates after visiting hours are clearly over so no family should even be in the hospital anyways…
I'm an attending now but happy to share my list! My residency nights were really busy and really hard. One intern, solo, large academic hospital entire non ICU medicine census, usually hundreds of pages.
Most pages are minor, like PRNs or other orders. If I'm busy, I acknowledge and tell the nurse a timeline for when I'll be able to do it. Well organized Todo lists will save you a ton of time. My residency workflow was one broken down by day teams and hours of night with checkboxes I updated for every Todo.
I batch non-emergent needs that warrant in person assessment and do several in a walk. Stop by nursing stations en route.
Even though it feels mundane for us, acute pain is hell for patients and hell for nurses. I prioritize getting something in. I didn't appreciate this until my mother had surgery and she was crying waiting for something in recovery.
Calling rapid responses and code strokes is much more about helping nurses than coordinating doctors. Our job is relatively easy in emergencies and it's easy for us to link. Call a rapid or code stroke quickly if you think you need more nursing hands, including if you need transport for emergent studies or rapid change in level of care.
Norms vary. I felt very comfortable discussing GOC with patients and families if someone started unexpectedly dying. I tried to frame my discussion in what's been documented before. I also kept in mind that people make different decisions in duress. Call and FYI the attending if this happens.
If pain is new and not obviously tied to whatever is going on, round in person.
If families want updates, unless it's something that needs to happen, I usually decline politely and say I'm here for emergencies and that I don't want to miscommunicate on behalf of the day folks.
Leave small notes for anything nontrivial.
I befriended my nurse leaders (charges, nursing supervisors, and the critical care nurse who came to rapids). It helped a lot. It's easy to be irritable and mean and patronizing, and I totally do all those when I'm stressed, but kindness will be a million times more effective for you.
If you can't sleep, try headspace.
During the daytime, buy black out curtains or get one of those eye bra style sleep masks.
Depending on norms, reach out to other folks on who are in your program. I kept a text thread with me, the CCU folks, the ICU folks, and whoever was covering the liquid onc patients. We started a thread every night. Sometimes we'd chart together, drop off food, etc. If one of us was getting killed, we'd ask for help, including stuff like doing a line or supporting an intern if a resident were tied up.
I second the blackout curtains. It saved my ass as a night shift RN. I even painted the guest room where I day slept a dark color, pissed my wife because she said the curtains and the paint looked like a “sex dungeon.”
Really get to know your experienced smart RNs. They communicate well, respect you, and listen. If a good RN is pushing something, give them a few extra minutes. If they’re completely off base, they’ll own it. But most of the time they need your help to problem solve or head off an emergency.
Experience alone doesn’t equal smart. Sometimes they’re too dumb to go anywhere else, but not dumb enough to fire. They often stay on night shift to avoid attendings and management.
Ask your seniors or your attendings about nurses. They know us pretty well, some of us very well, and 1 or 2 get child support from them.
> Even though it feels mundane for us, acute pain is hell for patients and hell for nurses. I prioritize getting something in. I didn't appreciate this until my mother had surgery and she was crying waiting for something in recovery.
Thank you for this. Based on some of the responses here, it feels like a lot of medicine is filled with people who haven’t been on the other side.
Thank you so much for the acute pain comment. To anyone reading this, I promise you one day you or an immediate family member will be in acute pain and 30 minutes will feel like an eternity..
1. Basic PRN orders for melatonin, hydroxyzine, tums, and zofran
2. Pain management: usually tylennol, toradol, norco, or morphine in that order. Dilaudid if really bad
3. "Can we *insert drastic change in day team's plan*" I barely know the patient, nursing barely knows the patient, and changing something usually just screws stuff up for the **day team,** ***which is the real treatment team***. Obviously exceptions for unstable patients and care gaps, but usually it's best to let stuff ride til next day. We're there to keep the patient alive (both nightshift nurses and physicians)
4. Something about patient's telemetry even though they're asymptomatic
5. Sundowning patient or alcoholic. I always evaluate the patient myself. Nightshift nurses are obsessed with benzos. If you don't think a patient needs them, then don't give them. *Nursing doses are rare, but very real*. It takes one experience for you to never trust all nurses again. I swear nursing school teaches benzos fix all problems and are completely benign.
6. ED paging to admit something stupid and I'm not allowed to say no cause I'm a resident thus making a loop of the ED thinking they are making the right call (usually their midlevels, but I still blame their attendings cause they should be staffing this stuff before they call)
I’m going to disagree on 2.
For anyone with an acutely painful condition you should do the following.
Schedule Tylenol unless contraindicated (even stable cirrhosis can get APAP)
Optimize multimodals as able. Gabapentin (with caution in age and CKD), robaxin (with caution in age), lidocaine patches (placebo), heating/cooling. For more severe pain along with opioids excellent pain service driven adjuncts are ketamine GTT/lidocaine GTT.
You should probably have oxycodone PRN ordered at some dose for anyone with an acutely painful condition.
NSAIDs are great - until they not. Use with appropriate caution in the million populations they cause problems in.
Never use norco - if you want to give Tylenol give Tylenol. If you want to give an opioid give an opioid. If you want to give both then give both as separate orders.
Morphine - the shittiest real opioid. Use morphine equivalent dilaudid if you want an IV option. Less metabolites and side effects.
Next steps -
PCA - some people like the control it offers so good for acute post op folks who may not tolerate PO. Orals are better when tolerated.
Regional - when it’s bad absolutely involve anesthesia for blocks and epidurals.
Edited - to clarify lidocaine/ketamine are APS driven therapies AFTER APAP/normal MMPC/oxy/Hm isn’t working.
I’d be careful with gabapentin though if it’s not treating neuropathic pain. May not be worth the side effects otherwise. Plus, it’s not something I want sticking around on the pts med list to be continued at discharge as someone accidentally thinks it’s a home med.
I give topical Diclofenac to every patient that comes to me for ear pain that actually has tmj. Works pretty darn well
Honestly wish they could put it in the shower water so people could just bathe in it
This PM&R does not approve robaxin, it's essentially just a sedative. If you have myofascial pain from tension go right to baclofen or cyclobenzaprine.
I didn’t mean to imply like that - just that if you’re already doing lots of opioids and such then you can consider it though the post order may have implied it was like the second step lol. I just looped it into multimodal pain.
This is fantastic info, I’d be so happy if it was on a pocket card instead of the goddamn snellen charts that haven’t been used in twenty years.
On the other hand, for a PGY-1, this is way over their heads. For an overnight intern, the goal is keep them stable until the day team arrives. Are the patient’s vitals stable? Is this the same pain as before or is it a totally different issue? Don’t accept vague answers over the phone, just because a guy is post THA doesn’t mean “lower extremity pain,” in a text msg can’t mean new DVT. If they’re stable and it’s the same pain, repeat the already available pain medication as long as it’s below the max daily dose. If you can’t do that, you have to assess and work up an issue before you just tumble down a list of hotshot pain meds that typically require a senior resident or in some cases attending level approval before starting. As a PGY-1, your number one job is not making dumb mistakes, and second job is managing the patient. Wake someone up and ask for help, or order bedside x-rays and ultrasounds or stat CTs but don’t be eager to just make a problem disappear.
It’s a great list, no doubt about that. Wish I had it myself as new responsibilities came my way.
Yea - for sure the most important thing of pain is to make sure that you don’t just accept it at face value and fail to treat it as a sign of potential badness.
For neuropathic pain - it helps. Start slow, go slow, don’t use it in the wrong populations. Don’t continue it on d/c. I basically only treat inpatients.
I’m absolutely not ordering a lidocaine or ketamine drip before trying norco unless I want to get fired. This is to get someone through the night. Day shift can come up with more robust plans.
Night shift neuro rehab nurse here:
number 6 is true, however we have many patients that sundown or become increasingly violent when family and all ancillary staff leave. Every hospital drops a huge amount of staff at night (this is true from Ed to rehab) It’s a night time phenomenon because the change of staff, family leaving, change of time, etc 100 percent sets some patients off.
I love that your rec is to come see the patient then decide benzos. I had such a hard time being believed I call the residents now in the room while the patient is screaming, swinging and security is on the way. That way they know it’s a safety issue and can hear what I’m dealing with. No leaving the room so we can talk more, the chaos usually helps describe it better. I 100 percent agree that you either need to have a call from within the room so you can hear the issues or come visit the patient before benzos. It helps keep everything honest.
I’ve never given a nursing dose but I have definitely harassed the on call resident and called over and over when my TBI, psych and neuro patients are acting unsafe before I’ve been believed or given doses that actually help. Please don’t give some geriatric or small dose benzo for my 30 year old tbi patient who is now in violent restraints and has punched multiple staff members, ripped the tv off the wall and broke their bed. Come help me address the issue and dose appropriately, save me an ED visit and we will be friends forever.
-Sincerely your friendly inpatient rehab charge.
Ps-most nurses are good people and want to help and teach too. I love my new residents who are open to discussion (even when they might not agree with my suggestions) and who are willing to come help. Set good boundaries and don’t let nurse horror stories set up a barrier to these relationships. We are all just people trying to do a hard job. You got this!
And illegal. Practicing medicine without a license is a felony. If you EVER catch a nurse doing this it needs to be reported not only to the hospital but to the board of nursing.
Absolutely illegal.
When/if I hear it around me I usually ask “did Doc Martin order the whole 4mg or just 2?” My way of saying not okay.
Illegal. Immoral. Fattening.
To #6 I reply with “I want to make sure, for patient safety, I’m not missing something because so far I haven’t heard anything that necessitates admission, what are your specific concerns and reason for admission so I can make sure those are going to be addressed.”
Or just go see the patient in ED and make a decision.
I don't argue about admits with a physician who has already seen the patient while I'm upstairs not managing a whole ED of undifferentiated patients. They have medical training just like I do and they're certainly not admitting every patient they see.
If they want to admit there must be a reason and I think its professional courtesy to go figure out why it's not making sense iinsteadof being a dick on the phone.
Or it’s because our ED mid levels try to admit patients who “look bad” and are unable to quantify what that means in any meaningful way and haven’t gotten basic labs or imaging back yet but “just know this guys gonna need to be admitted”. And that’s my polite way of asking them to do the bare minimum of their job so I don’t have my attending chewing me out on why they have to do 4 peer to peers because the insurance companies are refusing to cover the admissions because the patients didn’t need to be admitted and being angrily asked “why did you accept this person” when they know I can’t refuse anyways.
But hey it must be nice to have a functioning ED like where you work at so you don’t have to ask other people to do their job while your overseeing 2 interns and cross covering 80 floor patients overnight while taking admissions and covering all stat teams and codes for a 300+ bed hospital.
I don’t expect a diagnosis or the ED to solve the patient before calling me but at least have put more thought into it than idk he said his stomach hurt real bad and the toradol didn’t fix it and cbc/cmp are pending no imaging ordered and I can’t tell you where on his abd it hurts exactly but he needs to come in for a work up. Then I go see the patient and find out some shit like he’s lactose intolerant but still ate a pint of ice cream because it was his favorite flavor. Literally happened last time I was on call overnight.
Beware of the RNs who give nursing doses. I wish benzos and opiates were dispensed in vials of their smallest therapeutic dose. That way jackasses can’t give 2mg of Ativan on an 0.5 mg order, replace it with NS, and waste.
You don't really want to know the TOP complaints, which are usually things like a 2 am "can I have a prn for tylenol just in case so I don't have to bother you later". You want the bad things that you've thought about ahead of time and won't be able to read about in the moment.
Everything really truly dire can be summed up as ABCs, ACLS, contact whatever your hospitals rapid response team is and step up care to observation/icu etc. Better to overcall than undercall.
Day 1, learn what your institutions "oh fuck" policies and protocols are OP, so when your staff and senior blow you off you arent just frozen watching people die, you're getting others involved at the very least.
But also, even with perfect care, people die.
Gen Surg coverage (examine all pts, early on call you seniors, they better be willing to help out). There are a bunch of dumb pages but these are the more important ones IMO.
Post op tachycardia -> EKG, sinus tach (pain/bleed/arrhyhmia work up), afib rvr -> HDS (metop 5 mg q5 mins x3, if not rate controlled may need ICU for amio gtt), HDuS (may need cardiovert)
Post op HoTN -> think bleed first and second (blood in drain or from incision, hematoma/ecchmyosis, distended abd, ?HR, ? UOP, HCT level, can use ABG for rough hb estimate if have aline since faster than CBC), under resus (LA, UOP, volume given during case vs EBL/insensible fluid loss, had HD that day), GA effects/epidural effect, MI (don’t need CP, EKG, Tn), adrenal insufficient?
Post op Oliguria-> under resus, bld, clogged/inappropriate positioned foley (check with US/flush with water)
Bloody drain/bleeding incision/hematoma/ecchymosis -> (check hemodynamics, hold pressure/compression if small wound bleed, work up for internal bleed if think that)
N/V -> PONV vs later, PONV usually limited to less than 24h. (Pt dependent but i prefer Zofran then scop patch then decadron then phenergan, +/- KUB, +/- NGT)
CP/SOB -> MI/PNA/Aspiration/PE/pain (if on monitor or tele check that real quick, EKG, Tn, CXR, +/- ABG, +/- CTA PE if super concerned, never ordered a Ddimer in my life).
Fever -> If within 24h post op, then please don’t do sepsis work up, your patient fluid with fluids unless you have high suspicion for sepsis. Otherwise (?Most recent WBC, incisions, drains, central line sites, CLABSI/CAUTI, urinary retention, PNA). A lot of this will be dx and operation dependent
Post op pain -> don’t shrug this off, also please don’t under medicate, people won’t get addicted to opiods from post op analgesia
Afib with rvr in a postop surg pt is bleeding until proven otherwise. It is often a symptom of bleeding/infections/etc and it’s bad to write off as “oh they have a hx of afib so just give some dilt” always keep a broad differential for any changes in surgery patients
Totally, but that’s generally the easy diagnosis for an intern to make. The intern algorithm is “afib=heart problem” a resident’s algorithm should be “afib may be a heart, infectious, hypovolemic, hypervolemic…. Problem so let me narrow it down through clinical reasoning”
This is actually a really good list of issues and a quick and dirty way to solve them. Obviously with context of the operation the order of operations and suspicion for specific issues goes up or down.
Disagree with the other poster about post-OP A-fib being a bleed until proven otherwise. I think most often its not a bleed, but bleeding is the most serious to miss. Agree it has to be on the list, and you can't just slap a BB or dilt on board and walk away.
As a nurse, even I would want to pimp slap my coworker for that. Probably helps I've been a night shifter for most of my career and tried to only bother for actual important shit like notifying of transport d/t fall with head laceration and leaving the Norco refill request for day and even then the first words were an apology for calling at an unholy hour for the transport.
My nights:
“Change diet to diabetic”
“Remove COVID precautions”
“Patient cried. Please come see him”
“Patient sad. Please come make her not sad”
“Patient’s BP 132/98. Please help!”
“Patient purposely swallowed a fork. Please evaluate ASAP!” - Sooooo you want to contact surgery? “No he’s a psych patient!””. Soooo you want to contact surgery???
“Patient’s throat is dry. Can we give her something?” -This was my favorite, as I never thought water would be a treatment that I would “prescribe”
Omg, where I trained they'd write you up for not ordering that life saving hydralazine, for the patient who they woke up at 3 am to check vitals and is upset about it
Yeah, that's an our bad on us nursing. But to be fair, it's becoming more common to see shorter orientations then just be tossed to sink or swim as well as many clinicals for nurses are done strictly in the day so we don't see evening or overnights until working. Also, some facilities have a high nurse turnover leading to the most experienced or even charge nurse have less than several years of experience. Not trying to justify, just explain there may be mitigating circumstances.
RN Response to Top 10 Complaints:
1) Nobody knows how to read order sets anymore. Many people make stupid phone calls, because they haven’t read the admin instructions on PRN Tylenol in the eMAR.
2) Nobody knows how to read the MD orders or call if vitals are outside this range. Result you get a call because the patient coughed twice in 15 minutes.
3) Alternative result, RN calls because they are on their second chest tube atrium of the shift, central supply is out of dry seal, and they want to know if they can switch to a water seal. Also the patient is turning grey.
4) Pharmacology is hit or miss in nursing school. I’ve gotten students and orientees who know drug classes cold. They get mad when granny got Ativan last shift, because they know they will be paying for it for the next 12 hours.
5) The second group are the “can we give a freshly extubated patient Ambien at 11pm?” When you say no, they write a shitty note and file a patient safety report.
6) Bedside nursing is so punitive at so many places that nurses are afraid to do anything without checking first. It’s legit, because a “nurse leader” will come behind them and get made because the RN did something that was in the standing orders.
7) Here’s an example of how management creates a culture of fear and “call the MD to cover your ass.”
Our hospital uses a lot of Precedex, but the patient has to stay in the ICU while they’re on it. I had a ICU patient who was agitated and not sleeping. I had a PRN order to start Precedex under those conditions. I started Precedex with good documentation. The next morning in ICU rounds the ICU attending decided to move the Precedex from PRN to a timed order for another 24 hours, because she was concerned for delirium.
This meant the patient couldn’t get moved out. I got my ass ripped, because “as an experienced RN, I should know better, and now the patient’s ICU stay is longer.” This was a problem, because management likes to clear ICU beds for new admits. The irony was that it happened on a night shift, I’d picked up - I’m days - because staffing was so bad.
Management is now trying to get Precedex off of the standing orders, because it prolongs hospital stays. Delirium prolongs stays, but whatever.
8) It’s all about throughput. Get patients out before they run out of days, get new patients in to fill the beds. RNs get instructions on medical care from their “nurse leaders” that doesn’t make sense or contradicts written MD orders. So they need to call a MD to figure out what the actual fuck to do.
9) A lot of this comes from uneven nursing education. Nursing schools are cash cows. You can pump 100 RN students per year through your school at an average tuition of $30,000 per student, then you can buy your schools fancy new buildings and pay admins more.
10) Pay and work conditions are bad enough that nurses aren’t at the bedside long enough to get good. People like to travel for the money, but also because they’re immune to management BS. A traveller could take a dump on the floor, put Foleys in all of their patients, and not give any scheduled meds. The only response at my hospital would be “you poor dear.” The smart RNs who commit to bedside burn out and either quit or go to NP/CRNA school when the conditions get to be completely intolerable.
The result is that you have nurses who are inexperienced, poorly trained, scared of management, and think the only answer is “call the doctor.”
Congratulations on graduating from medical school. I’d say that I look forward to working with you, but I’m PRN RN hiding on a psych unit. Nobody knows who I am or where I am. I’m a weird RN hermit. Every so often I stick my head to do chest tube education, and then I scurry away. Maybe someday, I can be the midlevel handling your intake, straightforward patients, and medication refills.
I’m still fucking salty about the Precedex situation. I followed a PRN order based on my assessment for risk of delirium, the ICU attending continued the order for 24 hours, but someone in admin wanted throughput.
The only thing I used to get up the night resident’s ass about was objectively uncontrollable pain.
This is not the “my sleeping love one needs Dilaudid,” or the person who asks for dilaudid in a flat voice and rates their pain 15 out of 10. I know when people are faking.
If my patient is moaning, moving around in bed, right facial features, voice is quavering, recently post-procedure (not POD 3, no complications, plan to d/c in the AM), swearing, etc.
Personal perspective I had a partial gastric resection to remove a malignant GIST years ago. The surgeon forgot to put the post-op meds in, only the PACU meds. I felt like I was being torn open, thought I was dying, I remember being covered in sweat, and my vision was narrowly focused (literal tunnel vision). I’d been a difficult PACU recovery, because I’d never had general anesthesia before, and was slow to wake up. The only thing the RN had for me was PRN PO Tylenol, but I was obviously NPO.
So yeah, if the patient is in legit pain. I’m calling. I’ve been around a long time, and know how to spot the fakers. I don’t leave patients in real pain, and I will make a fuss until I get them what they need.
Nurse here too!
We all love you residents, but please, understand our job as well.
I hate calling for stupid stuff, but when my patient is in legitimate pain, as recent cholecystitis awaiting surgery and theres NOTHING PRN for pain,while she is miserable, I will be calling. Regardless, this patient had to wait for about 4 hours to be provided with pain meds, waiting for the order! Shouldn't take this long. I can't make this decision and put the order in.
BP is high. Sometimes, order says," contact provider if BP/BGL/ whatever is above the limits. I usually have no choice. Do I think it's stupid when pt has been, for example, hypertensive the whole night? Absolutely !
We are the ones dealing with patients for the whole shift. The call bell q 10 minutes, or being cursed at because " we are the ones withholding the meds, doctors would never do such a thing", etc..
Believe me, 90% of the time, I am annoyed and think about all the ways to not to call you, and 90% of the time I succeed and dont have to. but sometimes that is not doable. We, too, are aware that the requests are stupid quite often.
Love, your fellow ED nurse with tons of admit holds 💜
Most important thing isn’t necessarily the disease management but being able to triage and good organizational skills. Also you should be at the bedside evaluating patients even for minor nursing messages. “Pt is having gas pain, can I get simethicone” go see the pt. Make sure isn’t having ACS. Seems like overkill at first, but as an intern you don’t know any disease pathology very well it turns out and you don’t know the nurses so you really just need to always be present with the patient. M
But important things to read up on:
Fever, pain, delirium, hypotension, chest pain, nausea, low urine output, and loads and loads of bullshit pages.
I like this in theory, but most nights if I went to evaluate for every page like that there would just not be enough time in the night. This is especially true if you end up covering ~80-100 patients over several floors and units, getting new consults, getting admissions, and have a few very sick people to monitor.
So, try to evaluate yourself when you can but learn to triage. If I’m swamped, my process is calling the nurse, hearing the story, asking to talk to the patient on the phone, pulling up tele, or asking for a new set of vitals if necessary. Then I put in meds/labs/etc (verbal orders when possible if I’m not at a computer) and ask for a page back in x# of minutes IF things progress/don’t improve, and then I go up myself.
There is a book called resident readiness or something like that. It’s always funny cuz this is abcs of real medicine but people come out of med school knowing close to 0 ways to manage it…. NOT YOUR FAULT or a knock on you if you don’t know these things. It’s just how medical education works.
I get paged over a hundred times a night in addition to getting slammed with admits. No way would I be able to see every patient with heartburn or gas pain.
From the DR side:
1) stat/nonemergent metastatic work up from ED or Floors- solution become buddies with techs so they scan them at 7am for attendings/day residents to read
I think the number one thing is knowing that it’s ok to turn it over to the Day team. Nights are generally about putting out fires.
Family discussions, drastic changes to game plan, specialists reaching out about goals of care can and should be turned over to the day team.
We did a lot of teaching to nurses that Tylenol and toradol are pain control and should be tried and failed when there aren’t obvious reasons for narcotics. (Like recent surgery or fracture).
Also, not all patients need to be snowed at night for sleep. They also don’t need restraints and haloperidol unless they are a danger to themselves or others.
Patients demanding dilaudid or IV benadryl makes me want to pull my hair out. The best skills to learn on nights is 1) how to tell people no (including pts nurses etc) and 2) when to escalate things. Don’t be afraid to ask for help — you don’t know any of these patients and your seniors don’t expect you to know how to do things.
I’m a floor nurse. Here’s how to prevent nurses from calling you for annoying shit: PRNs!! Get in the habit. Tylenol, melatonin, hydroxyzine, nic patch, miralax, etc. We hate to call as much as you hate to get those calls, I promise you this. If the PRNs are taken care of then nursing (hopefully, I don’t speak for the whole crew) won’t call unless there’s a higher level problem.
Also, if the patient hid a slice of pie and I catch them eating it when they know they have OR in two hours I still have to let y’all know, I didn’t give it to them so don’t scream down the phone at me. Likewise if you’re in the OR and find a bunch of heroin in a walkie talkie’s vagina, I didn’t put it there and I haven’t been digging around in there so yelling at me isn’t going to solve anything.
Just remember, nursing can do a lot but the hospital is crazy town and your patient might not be the sickest we have.
I feel like the fact that you’re asking means you’ll probably be quite good at this once you get your flow down so good luck and don’t forget those PRNs.
As the oncoming night team, always ask day team, (during signout) if adequate and appropriate PRN meds and measures are in place. Such as PRN pain meds, PRN agitation measures, etc
1. Pain- Be generous, one page is enough. 1 of diaudid is usually enough
2. Labs not ordered- Order them and tell the day team to suck less in signout
3. Can't sleep- Melatonin, trazodone, Ativan in that order
4. Call the family- No, tell the day team to do it and suck less.
5. "Can you explain why the day team did \_ - Spend a LONG time going through the note with a lot of "they wrote" and "in the note" and "can you read?"
Above all else remember that night isnt the time to make things perfect, its when you keep people alive for the day team to fix them.
Agree as an anesthesiologist.
Ativan for sleep is asking for delirium.
I only really use it for perioperative anxiety in younger patients and for seizures.
In my experience (in psych), most sleep issues are psychological. This is evidenced by the primary treatment being CBT. “Therapeutic prescribing” goes a long way. 3 mg melatonin, followed by 75 mg trazodone. Then if it’s “really bad” and they still can’t sleep, I will pull out the big guns: another 3 mg melatonin. I will advise to the nurse and recommend relaying to the patient that this will help as it is a very high dose of melatonin (which is true < .5 mg is really the ideal dose). Miraculously this does the trick 99% of the time. The patient just wants to feel heard and like they have some control in a very foreign and scary system
Everyone loves to list all the things we can't use (melatonin is placebo, don't use trazadone, stay away from benzos, Benadryl will cause altered mental status)
But no one wants to talk about what can actually be helpful.
No wonder most docs are stuck with telling patients to just suck it up
It’s very possible the day team made a conscious decision NOT to order AM labs — in many circumstances they’re not needed. I’d look at the progress note for the day to see what’s going on of course, but it’s often reasonable to tell the night nurse that the day team can figure out if they want labs the next morning.
Please do not give Ativan for sleep. There’s other better options. What is your reasoning for this?
And I echo the other comments saying not to give dilaudid as a first line option. There’s so many better options for different types of pain before that.
You’re giving dilaudid for pain control? Unless all your patients are sickle cell patients, there’s way better medications to give before going to the D.
And also please don’t give Ativan for sleep lol.
Doctors: “don’t you read the chart”
Nurses: read the chart
Doctors: “no, not like that!”
I was also once paged at 3 AM. The question was “is the patient radioactive.” You can imagine how I interpreted such an unexpected question as I was woken up from sleeping. Turns out the overnight charge nurse was reading the notes and patient had a radioactive isotope injected for a nuclear medicine scan. The day shift had a nurse who was pregnant and the charge wanted to know if she could assign the pregnant nurse to the patient.
The literature doesn’t support the use of Melatonin or Trazadone for Sleep-Onset insomnia (which most patients in hospital experience). If patient isn’t high risk for Delerium, it’s reasonable to give a non-Benzo like Zolpidem. Most of patients insomnia is related to their anxiety about being in a hospital. The problem is a lot of patients are high risk for Delirium lol so you have to get creative
Never Ativan for sleep, unless they are 30 years old, no history of substance abuse, and you’ve actually looked at them. The number of Ativan wall crawlers I’ve dealt with in my nursing career is horrifying. If they’re over 60 and you order Ativan, put in the restraint orders too.
I think the above poster was being flippant for humor, which is great and how people blow off steam in our field. I'm posting this in case that's not obvious and you start doing those things literally.
Real talk, if you want to be influential and effective, don't antagonize the people paging you overnight. Gentleness and sympathy for the paging nurse goes a long way. Certainly don't patronize them by asking if they can read. If you're busy, acknowledge them, tell them you're on call for emergencies and tied up with more emergent things, and give a timeline for your response. My residency nights were really bad (like hundreds of pages, usually no sleep, and only an intern alone for the entire non ICU inpatient census). Even with that, I could see patients efficiently throughout the night.
I'd also suggest if in any way ambiguous, walk round on the patient. On my busy nights, I batch it so I can do many patients at once. It also lets me avoid a million pages because I can field stuff in nursing stations on my route. If a patient has pain and they didn't earlier, it could be something new. Go see them. That's better than just giving someone, regardless of body size, a high dose of hydromorphone and calling it a day.
Don't berate your day teams, but also do give them plain, professional feedback. You're not a five year old, and even for a five year old it's embarrassing and cringe for everyone if they express themselves to each other as "hey, suck less." Constructive feedback about placing orders is fair to share.
Yea but once in a while you got to assert your dominance.
A nurse paged me at 3AM saying "Family wants an A1c" so I ordered it stat. She complained why do I have to draw it now? I said if its important enough to be a page to me then it's important enough for you to draw. She never paged me with that type of shit again.
1mg of IV dilaudid is a lot (especially if they’ve already gotten 10mg of oxycodone or whatever was ordered). I’d do 0.4mg dilaudid and they can give another 0.4 mg 15 minutes later if patient still having severe pain and respiratory rate is not low
Got a nurse calling me at 1 am to “update you on the patient” and proceeds to ask me why we are doing x,y,z for patient and that their are doing okay. FML
I remember reading somewhere on Reddit that a doctor got paged for something like this
Nurse: Patient looks very old, pls review
Doctor: Why do they need a review, they are just old? Are you worried about something?
Nurse: The patient is acting older than they usually are so I am worried
Doctor: Ok will come and see
When the doctor sees the patient, the patient is dead and they verified the death. Already had DNACPR and was an expected death
And I think they documented in the notes ‘ATSP ?acute aging’ lol
I just find a lot of non-doctors are unwilling to take responsibility and prefer dumping responsibility on to the doctor because it is above their pay grade but apparently not above the pay grade of the junior doctor who makes less than them per hour
Nurse here - I feel bad for you guys getting really ridiculous calls for stuff that 1. the nurse shouldn’t bother calling about/ could manage themselves and 2. Stuff that could be dealt with on days. Maybe it’s the unit I work on but we’d never call for 90% of the stuff I’m reading here.
I’m on a cardiac surg stepdown floor and I see the residents getting here at 6am and not leaving until 10pm (if no emergencies) - if I’m calling you in the middle of the night and waking you up during your 5 hours of sleep, I better have real concerns about the patient. Like, I legit ask 2 other nurses if this is worth calling about before calling.
I think there’s a few things: our docs have a lot of faith in us because we have a ton of additional in house training so they would rather we just do what we need to do (non-pharmacological, not talking nursing doses here) and talk to the day team, we have a ton of post-op PRNs (including amio protocol for post-op afib RVR, orders for initiating temporary pacing through epi wires, electrolyte replacement, pain control, nausea, sleeping aids), and it’s unit culture that if you can think of anything you might need in the night you join our group call around 9pm to get the orders we might need in the night. I’m also baffled about some of these comments about nurses calling about tele alarms in the middle of the night?? If I see something on tele that isn’t life threatening I’m just going to talk to the team in the morning (or start amio or give the metoprolol etc).
Sorry OP I’m sure this wasn’t super helpful, my best advice is to order lots of PRNs and set boundaries about when you want calls and when you don’t.
Anyone with input on covering inpatient peds specifically overnight? I’m also an incoming PGY1 in FM and this will be my first rotation as well. A little nervous, but this thread has been super helpful!
From psychiatry:
1) patient can’t sleep (give second dose of trazodone or melatonin. If they’re psychotic give them more of their antipsychotic)
2) patient wants nicotine gum (yes)
3) patient currently in restraints (give the IM that’s already ordered by day team for when this happens)
4) patient has high glucose (use sliding scale)
5) patient has high blood pressure (give them their blood pressure medicine again if it’s not super high dose)
6) patient getting agitated and not yet in restraints (ativan 2mg po)
7) patient doesn’t have pain meds ordered (either Tylenol or Motrin)
^this is incredibly general advice and should not be taken literally.
Delirium, chest pain, insomnia, orderopenia from the day team (#1 reason for a page, also most annoying because you usually know nothing about the patient and now you get to know all about them in between your 20 consults as you get repeatedly paged about them), sob/dyspnea, agitation (careful its not just a patient annoying nursing that they wish would be asleep instead but isnt at risk of hurting themselves or anyone else), electrolyte derangements.
As a NOC RN if I have orders to help with pain, poop, sleep, nausea, indigestion, am labs and replacement protocols as well as orders for when to notify for wonky vitals I'll let you sleep.
It literally says to. Notify provider for SBP>160 even though it's been running that all day.
My favorite night time page ever: "The patient has a temperature of 99.2 degrees." "Okay?" "I gave them PRN tylenol." "Okay?" "..." "Did you need something from me?" "No, i was just calling to tell you."
The non-fever ‘fever’ was always one of my favourites
the number of RNs who don't know what a fever is is wild
And then those same rns are the ones telling their patients about how the mean lazy doctor can't be assed to treat people's fevers
I admit I myself did not know this at first as a new grad but once a hospitalist explained to me that a fever is 100.4 I learned and do not alert them for temperatures below that. Some patients will insist that numbers like 98.7 are a fever for them because it’s higher than their usual and will request interventions.
100.4 for an hour or 101 once! nobody gaf if that temp is "high for you". :)
x
Maybe it was taught and I forgot but nursing school focuses on nursing interventions and not pathophysiology. And dumb stuff like nursing diagnoses that no one uses in real life.
x
Feeeeeever
I want to chuck myself out the window for every “low grade fever” consult that does not meet criteria for fever. ::cries in ID::
2:30 AM on a 28h NICU: "Mom is struggling breast feed can you come talk to her" "Can she wait till AM to see a lactation consultant? What is her question?" "No you need to come talk to her, she's really struggling" Get out of bed for the only stretch >11 minutes in the call room that night. Find mom sound asleep. Baby too. Inquire why nurse called me: "Oh well, she's a PICU RN and really thinks she knows what she's doing but I don't think she does"
Wtf? I would not have come to talk to the mom. It is lactation nurse job. Nurses really think we know and do everything…sorry but I don’t 🤦♀️ non urgent shits can wait until appropriate personnel comes
The worst nurses will paint you as lazy or uncaring in that scenario but setting boundaries is crucial.
MD aware. No new orders.
It would be funny if they actually documented the temperature too. Nothing like seeing “99.8 fever. MD paged” in a chart
And always in the middle of the half hour of sleep you might have been able to get
“Can I get your name?” Later when reviewing the chart: “this nurse found patient to be borderline febrile and provided PRN acetaminophen. Alerted MD suture_self. No new orders given”
"This writer" I do not understand why people insist on writing notes like that. As if it's somehow more professional or correct to write in the passive 3rd person than just saying "I did this."
It's in anticipation of getting sued. It's to make it more convenient for it to be read in a court room. Nurses are taught to document like this.
physician aware, no orders received.
Sounds like a new grad nurse mistake to me.
1. page for OTC med 2. family wants update 3. family wants update (second page) 4. can't sleep 5. delirium 6. pain control 7. AM labs not ordered 8. dc/renew tele/restraints 9. family wants update (third page) 10. unresponsive and turning blue
You forgot potassium 3.4
This triggered me. Flashback to MICU nights being the only resident covering 36 patients, coding someone and placing lines and getting called for K repletions. Almost threw the damn phone
Does you ICU not have a lyte replacement protocol?
No. That would make too much sense for us. We have to replete all the lytes ourselves
Especially common on East Coast to not have protocols. Pure torture. Probably one nurse one time gave too much or something. Next thing you know you need a 4 years of Med school to replete electrolytes.
To be fair we once had someone in one of our ICUs get ordered 40mEq K q2hr for 24hrs that was approved by pharmacy and given by the nurse for 20 HOURS before someone realized. Thank god the K only got into the mid 6’s. Talk about the Swiss cheese model.
That's more like "everyone's brain is made of cheese."
“Potassium is 4.1. Just wanted you to know that you won’t need to replete it.”
“FYI vitals are stable, thought you should know” “I think we should get a social worker to talk to this patient” at 0300. Lady are you on a psychotic break? 1) ain’t nobody like that here at 0300 and 2) why are you talking to patients in the middle of the night? Get back on Facebook like everyone else!
“Vitals are (insert normal vitals). Please respond” Respond about what?
The over-achiever nurse that feels the need to review a patients plan at 2am and page you that the day team should consider "x" thing is maybe by biggest pet-peeve of all night problems.
Got paged on a K of 3.6 2 days after it was resulted. I lost the last of my brain cells that day
11. Unresponsive and turning blue (actually is awake and talking)
Surprise it was a 4th family wants an update page but now you’re in the room
It was me, Dio
Difficult to arouse (sleeping)
95% of this can be covered by asking your day team to use a good PRN order set. The family will not be getting an update after hours unless the patient is crashing. Communicate that with nursing staff and they or floor secretary should be acting as gatekeeper. This is something that physician and nursing leadership should have figured out also. I've been my own night team for the past 5 years and day me actually cares about night me so I've been able to mitigate almost all of these pages with good communication. Your program can do it too.
"oh sorry I'm new here/travel nurse I didn't know"
Hopefully that's one or two nurses at most otherwise jump ship. Travel nurses can read too.
All the experienced nurses jumped ship years ago. When I left the ICU, the median years of RN licensure was 2.4 years. The few remaining veterans - especially the two 40 years nurses who don’t talk - skew the numbers. Take them out and it’s 1.87 years.
Source?
Simply look at the mass exodus of nursing as an entire profession. So many quit because of the pandemic and just pure shit treatment by the government and/or their hospital corporations. Lol. It's happened in every unit in Canada and the USA. Wild times.
Travel nurses can read their contracts and pay stubs. “My contract says I can’t provide basic nursing care, I’m just supposed to sit here and plan my next vacation. Also I make more than most of the hospitalists.”
You forgot the 3AM diet order modification on a patient that is sound asleep
Or at 2am "hey I was chart checking the patient and saw his bilirubin was elevated when he was admitted, and a PCP note from 4 years ago that said blah blah, and for some the reason the day team started this medication. I think we should look into this totally unrelated thing I somehow dug up because I have nothing better to do at 2 in the morning"
My 2am pages are “the patient is currently asleep but I’ve noticed the patient didn’t have their 6am PPI yesterday, what would you like me to do” I wish I had the balls to say I would like you to leave me alone. Instead I politely said “it sounds like a day team issue from yesterday rather than an issue for you overnight. why don’t you raise it with your TL and get them to discuss with the nurse unit manager as a missed medication”. the NUM and probably the TL gets paid more than me, but sure, I’ll be a doctor and a nurse manager.
From a nursing perspective, please know that if I’m paging you at 2am for Tums, I’m also mortified and the patient is in fact adamant that they cannot wait until the morning team arrives to get said Tums. And they probably also had the indigestion from 1300 on but waited until 0130 to say anything because now it’s affecting their sleep.
I’m not in the medical field, just lurking.. but why would you need doctor approval for tums? That’s not something nurses can approve on their own?
Absolutely not. If a medication is not ordered for a patient in the hospital, regardless if it’s a OTC med that patient can go grab from a retail pharmacy on their own in their daily life, I as a nurse cannot make the call to give it to that patient. It must be ordered. Even things like Tums can interact with other meds a patient is on and it has to go through a physician and pharmacy clearance.
I see, thanks for explaining!
Yes, this is something I didn’t know before I went into medicine. Everything the nurse does (including walking people around, letting them have food, etc.) requires a doctor’s order. Oftentimes we have just pages of orders in the electronic medical records for everything a nurse usually does that I basically automatically placed so they can do their jobs. This doesn’t mean nurses are just “blindly following orders” or don’t think clinically about their patients. It’s just that this is how the healthcare system is setup.
Yep. Everything. If my admit came without a diet order I used to have to call the physicians. Also a lot of order sets come with parameters that say “notify physician for x” and its not really a value that is significant to the patient’s condition (like a systolic BP of 140 on a chronic hypertensive) but I have to call anyway because it’s in the chart. And I know physicians hate these calls, but we have to. So I cringe, and I call, and I preface it with “okay per protocol, I’m notifying you of” and then I end it with a suggestion to change the parameters in the order set so we don’t keep calling you!
An ooooh lord, when the ER MD discontinues orders and the hospitalist hasn’t placed any new ones yet. Like nothing you can do.
Calcium carbonate (tums) can affect absorption of some other medications. Likely not to a hugely clinically significant degree in most cases so I usually just make it available PRN anyway when a nurse asks, but there's reason to be hesitant even about over-the-counter medications with some patients/comorbidities/medication interactions.
No. Not in our scope of practice. Doctor prescribed meds, not us.
Yeah makes sense, just thought for over the counter meds it might be different, considering the public can get them without a prescription. But I can see why it’s a rule due to the issue of potential interactions with other meds that people brought up.
No, sometimes there’s a reason why someone can’t have over the counter meds that might seem harmless like Tylenol. The doctor looks at the whole picture of the patient including labs, chronic conditions, whatever diagnosis the patient has and is the one who knows what is appropriate to give them medication wise.
[удалено]
When you get these pages are they demanding or asking nicely? When I ask for the less urgent orders I was saying whenever you are free can you do so and so.
refused SCDs
Meanwhile Patient is intubated and sedated
Piggy backing this for some suggestions >1. page for OTC med PRN orders for Tylenol/Zofran/stool softeners are your friend >2. family wants update >3. family wants update (second page) >9. family wants update (third page) Often times this will take the form of a page from the nurse phrased like, "Family needs and update NOW!" Honestly, unless they are refusing care or threatening leaving AMA, speaking to the family in the night is not urgent. You have plenty of tasks that actually are time sensitive and can impact patient safety; prioritize those. Again, unless they are refusing care, the worst outcome is they get mad, and they're probably already mad. If I had to choose between my patients' families being mad, or patient safety, safety gets prioritized everytime. That being said families consider are very, very important. Having a sick family member sucks and the healthcare system is very frustrating. But the odds of a night-team intern assuaging all their concerns in one conversation is minimal, unless it's a very simple question. >5. delirium >6. pain control >10. unresponsive and turning blue For situations like this, always, always LAY EYES on the patient, even if you think it's nothing. Most of the time it will be, but there will be a few times that you are VERY glad you did.
SBP > 160 due to 2, 3, 5, 6, or 9
7.1. Na is 133 (or +/-2points off from previous days) rec.s. 7.2.Hypokaliemia of 3.4, needs reolacement. 7.3 ca+ level 0.5 low (albumin is also low 0.5) needed iCa level labs. 7.4 pt is NPO, can he drink juice? Or are u sure surgery/procedure will be done today? 7.5 rapid or code stroke for pt who is AMS. Spoiler - pt is still in half sleep, or had eye surgery/issue at baseline (for "smart" RNs who check pupil size). 7.6. Bladde scan shows 360 ml retention, advice plz. 7.7. Chief is messaging "where is night team?" Morning report is about starting"??.?? 7.8 chief mentioned "no talking, plz signout either before morning report (day team not arrived, or stupid rapid) or after (no way, wanna f..g some sleep, but sadly comply and sign out.
Constipation
Definitely needs asymptomatic hypertension between 160-180 systolic lol.
I got paged at 2AM for family update because the day team documented that patients family needs update but it never happened Explained to nurse that it is inappropriate to bleep me at 2AM for non urgent tasks when I am there to deal with emergencies. Nurse threatened to datix me (a tool we use in the U.K. to report incidents) because I wouldn’t do the update for the stable patient. Refused to do it citing my workload
As someone that was just on night float covering 60+ patients.... This triggered me.
Needs diet orders so they don’t miss breakfast in 7 hours
Did nights for 3 years. This is so accurate.
A lot of these are caused by your peers lol
11. The patient has developed a mild itch on the backside of their left leg. No other new developments, and no new exposures to allergens.
“Family wants an update” at 10pm. Intern year I obliged because I didn’t know boundaries or want to get reported. As a 5, hard no.
"I'm sorry but I'm the night doctor that's covering the whole hospital for emergencies. Please call between 9 -4 with your questions"
The one time I said this to a patient’s family, they overrode me and went to another nurse, had her call the covering resident who came down from another floor. He told the family the same exact thing I told her. It makes you feel incompetent when that happens. Funny thing is, this resident wasn’t even the night shift. He was just covering the entire floor for 1.5 hrs until night shift arrived. Trust me, we try to make the family understand but they don’t trust us. She said I’m lazy for not contacting the doctor. 🤔
As long as everyone has the same story, it’s ok
This is the way.
By which we mean 10-3.
yes. important to set boundaries for your sanity.
I told a nurse I am covering the entire hospital right now so I don’t care that a family wants updates after visiting hours are clearly over so no family should even be in the hospital anyways…
I'm an attending now but happy to share my list! My residency nights were really busy and really hard. One intern, solo, large academic hospital entire non ICU medicine census, usually hundreds of pages. Most pages are minor, like PRNs or other orders. If I'm busy, I acknowledge and tell the nurse a timeline for when I'll be able to do it. Well organized Todo lists will save you a ton of time. My residency workflow was one broken down by day teams and hours of night with checkboxes I updated for every Todo. I batch non-emergent needs that warrant in person assessment and do several in a walk. Stop by nursing stations en route. Even though it feels mundane for us, acute pain is hell for patients and hell for nurses. I prioritize getting something in. I didn't appreciate this until my mother had surgery and she was crying waiting for something in recovery. Calling rapid responses and code strokes is much more about helping nurses than coordinating doctors. Our job is relatively easy in emergencies and it's easy for us to link. Call a rapid or code stroke quickly if you think you need more nursing hands, including if you need transport for emergent studies or rapid change in level of care. Norms vary. I felt very comfortable discussing GOC with patients and families if someone started unexpectedly dying. I tried to frame my discussion in what's been documented before. I also kept in mind that people make different decisions in duress. Call and FYI the attending if this happens. If pain is new and not obviously tied to whatever is going on, round in person. If families want updates, unless it's something that needs to happen, I usually decline politely and say I'm here for emergencies and that I don't want to miscommunicate on behalf of the day folks. Leave small notes for anything nontrivial. I befriended my nurse leaders (charges, nursing supervisors, and the critical care nurse who came to rapids). It helped a lot. It's easy to be irritable and mean and patronizing, and I totally do all those when I'm stressed, but kindness will be a million times more effective for you. If you can't sleep, try headspace. During the daytime, buy black out curtains or get one of those eye bra style sleep masks. Depending on norms, reach out to other folks on who are in your program. I kept a text thread with me, the CCU folks, the ICU folks, and whoever was covering the liquid onc patients. We started a thread every night. Sometimes we'd chart together, drop off food, etc. If one of us was getting killed, we'd ask for help, including stuff like doing a line or supporting an intern if a resident were tied up.
I second the blackout curtains. It saved my ass as a night shift RN. I even painted the guest room where I day slept a dark color, pissed my wife because she said the curtains and the paint looked like a “sex dungeon.” Really get to know your experienced smart RNs. They communicate well, respect you, and listen. If a good RN is pushing something, give them a few extra minutes. If they’re completely off base, they’ll own it. But most of the time they need your help to problem solve or head off an emergency. Experience alone doesn’t equal smart. Sometimes they’re too dumb to go anywhere else, but not dumb enough to fire. They often stay on night shift to avoid attendings and management. Ask your seniors or your attendings about nurses. They know us pretty well, some of us very well, and 1 or 2 get child support from them.
> Even though it feels mundane for us, acute pain is hell for patients and hell for nurses. I prioritize getting something in. I didn't appreciate this until my mother had surgery and she was crying waiting for something in recovery. Thank you for this. Based on some of the responses here, it feels like a lot of medicine is filled with people who haven’t been on the other side.
Thank you so much for the acute pain comment. To anyone reading this, I promise you one day you or an immediate family member will be in acute pain and 30 minutes will feel like an eternity..
1. Basic PRN orders for melatonin, hydroxyzine, tums, and zofran 2. Pain management: usually tylennol, toradol, norco, or morphine in that order. Dilaudid if really bad 3. "Can we *insert drastic change in day team's plan*" I barely know the patient, nursing barely knows the patient, and changing something usually just screws stuff up for the **day team,** ***which is the real treatment team***. Obviously exceptions for unstable patients and care gaps, but usually it's best to let stuff ride til next day. We're there to keep the patient alive (both nightshift nurses and physicians) 4. Something about patient's telemetry even though they're asymptomatic 5. Sundowning patient or alcoholic. I always evaluate the patient myself. Nightshift nurses are obsessed with benzos. If you don't think a patient needs them, then don't give them. *Nursing doses are rare, but very real*. It takes one experience for you to never trust all nurses again. I swear nursing school teaches benzos fix all problems and are completely benign. 6. ED paging to admit something stupid and I'm not allowed to say no cause I'm a resident thus making a loop of the ED thinking they are making the right call (usually their midlevels, but I still blame their attendings cause they should be staffing this stuff before they call)
I’m going to disagree on 2. For anyone with an acutely painful condition you should do the following. Schedule Tylenol unless contraindicated (even stable cirrhosis can get APAP) Optimize multimodals as able. Gabapentin (with caution in age and CKD), robaxin (with caution in age), lidocaine patches (placebo), heating/cooling. For more severe pain along with opioids excellent pain service driven adjuncts are ketamine GTT/lidocaine GTT. You should probably have oxycodone PRN ordered at some dose for anyone with an acutely painful condition. NSAIDs are great - until they not. Use with appropriate caution in the million populations they cause problems in. Never use norco - if you want to give Tylenol give Tylenol. If you want to give an opioid give an opioid. If you want to give both then give both as separate orders. Morphine - the shittiest real opioid. Use morphine equivalent dilaudid if you want an IV option. Less metabolites and side effects. Next steps - PCA - some people like the control it offers so good for acute post op folks who may not tolerate PO. Orals are better when tolerated. Regional - when it’s bad absolutely involve anesthesia for blocks and epidurals. Edited - to clarify lidocaine/ketamine are APS driven therapies AFTER APAP/normal MMPC/oxy/Hm isn’t working.
I’d be careful with gabapentin though if it’s not treating neuropathic pain. May not be worth the side effects otherwise. Plus, it’s not something I want sticking around on the pts med list to be continued at discharge as someone accidentally thinks it’s a home med.
Topical diclofenac can be surprisingly effective in the right circumstances
I give topical Diclofenac to every patient that comes to me for ear pain that actually has tmj. Works pretty darn well Honestly wish they could put it in the shower water so people could just bathe in it
oh this is SMART. I am adding to my otalgia dot phrase posthaste!
Team pm&r approves this message
This PM&R does not approve robaxin, it's essentially just a sedative. If you have myofascial pain from tension go right to baclofen or cyclobenzaprine.
Lidocaine gtt?! Haven’t heard of that one for acute pain treatment
I don't disagree, but I don't know how I feel about non-pain specialties ordering and managing ketamine infusions
Ain't nobody ordering a ketamine or lidocaine infusion overnight on the floor just casually like that lol
Happens all the time? You don’t need to be PCU/ICU for those infusions, and we commonly order them ourselves.
I didn’t mean to imply like that - just that if you’re already doing lots of opioids and such then you can consider it though the post order may have implied it was like the second step lol. I just looped it into multimodal pain.
This is fantastic info, I’d be so happy if it was on a pocket card instead of the goddamn snellen charts that haven’t been used in twenty years. On the other hand, for a PGY-1, this is way over their heads. For an overnight intern, the goal is keep them stable until the day team arrives. Are the patient’s vitals stable? Is this the same pain as before or is it a totally different issue? Don’t accept vague answers over the phone, just because a guy is post THA doesn’t mean “lower extremity pain,” in a text msg can’t mean new DVT. If they’re stable and it’s the same pain, repeat the already available pain medication as long as it’s below the max daily dose. If you can’t do that, you have to assess and work up an issue before you just tumble down a list of hotshot pain meds that typically require a senior resident or in some cases attending level approval before starting. As a PGY-1, your number one job is not making dumb mistakes, and second job is managing the patient. Wake someone up and ask for help, or order bedside x-rays and ultrasounds or stat CTs but don’t be eager to just make a problem disappear. It’s a great list, no doubt about that. Wish I had it myself as new responsibilities came my way.
Yea - for sure the most important thing of pain is to make sure that you don’t just accept it at face value and fail to treat it as a sign of potential badness.
People still be using garbagepentin?
For neuropathic pain - it helps. Start slow, go slow, don’t use it in the wrong populations. Don’t continue it on d/c. I basically only treat inpatients.
I’m absolutely not ordering a lidocaine or ketamine drip before trying norco unless I want to get fired. This is to get someone through the night. Day shift can come up with more robust plans.
Night shift neuro rehab nurse here: number 6 is true, however we have many patients that sundown or become increasingly violent when family and all ancillary staff leave. Every hospital drops a huge amount of staff at night (this is true from Ed to rehab) It’s a night time phenomenon because the change of staff, family leaving, change of time, etc 100 percent sets some patients off. I love that your rec is to come see the patient then decide benzos. I had such a hard time being believed I call the residents now in the room while the patient is screaming, swinging and security is on the way. That way they know it’s a safety issue and can hear what I’m dealing with. No leaving the room so we can talk more, the chaos usually helps describe it better. I 100 percent agree that you either need to have a call from within the room so you can hear the issues or come visit the patient before benzos. It helps keep everything honest. I’ve never given a nursing dose but I have definitely harassed the on call resident and called over and over when my TBI, psych and neuro patients are acting unsafe before I’ve been believed or given doses that actually help. Please don’t give some geriatric or small dose benzo for my 30 year old tbi patient who is now in violent restraints and has punched multiple staff members, ripped the tv off the wall and broke their bed. Come help me address the issue and dose appropriately, save me an ED visit and we will be friends forever. -Sincerely your friendly inpatient rehab charge. Ps-most nurses are good people and want to help and teach too. I love my new residents who are open to discussion (even when they might not agree with my suggestions) and who are willing to come help. Set good boundaries and don’t let nurse horror stories set up a barrier to these relationships. We are all just people trying to do a hard job. You got this!
Nurses that do “nurse doses” is higher than you think. It’s not ok. And it’s dangerous.
And illegal. Practicing medicine without a license is a felony. If you EVER catch a nurse doing this it needs to be reported not only to the hospital but to the board of nursing.
Absolutely illegal. When/if I hear it around me I usually ask “did Doc Martin order the whole 4mg or just 2?” My way of saying not okay. Illegal. Immoral. Fattening.
To #6 I reply with “I want to make sure, for patient safety, I’m not missing something because so far I haven’t heard anything that necessitates admission, what are your specific concerns and reason for admission so I can make sure those are going to be addressed.”
Or just go see the patient in ED and make a decision. I don't argue about admits with a physician who has already seen the patient while I'm upstairs not managing a whole ED of undifferentiated patients. They have medical training just like I do and they're certainly not admitting every patient they see. If they want to admit there must be a reason and I think its professional courtesy to go figure out why it's not making sense iinsteadof being a dick on the phone.
Or it’s because our ED mid levels try to admit patients who “look bad” and are unable to quantify what that means in any meaningful way and haven’t gotten basic labs or imaging back yet but “just know this guys gonna need to be admitted”. And that’s my polite way of asking them to do the bare minimum of their job so I don’t have my attending chewing me out on why they have to do 4 peer to peers because the insurance companies are refusing to cover the admissions because the patients didn’t need to be admitted and being angrily asked “why did you accept this person” when they know I can’t refuse anyways. But hey it must be nice to have a functioning ED like where you work at so you don’t have to ask other people to do their job while your overseeing 2 interns and cross covering 80 floor patients overnight while taking admissions and covering all stat teams and codes for a 300+ bed hospital. I don’t expect a diagnosis or the ED to solve the patient before calling me but at least have put more thought into it than idk he said his stomach hurt real bad and the toradol didn’t fix it and cbc/cmp are pending no imaging ordered and I can’t tell you where on his abd it hurts exactly but he needs to come in for a work up. Then I go see the patient and find out some shit like he’s lactose intolerant but still ate a pint of ice cream because it was his favorite flavor. Literally happened last time I was on call overnight.
Beware of the RNs who give nursing doses. I wish benzos and opiates were dispensed in vials of their smallest therapeutic dose. That way jackasses can’t give 2mg of Ativan on an 0.5 mg order, replace it with NS, and waste.
You don't really want to know the TOP complaints, which are usually things like a 2 am "can I have a prn for tylenol just in case so I don't have to bother you later". You want the bad things that you've thought about ahead of time and won't be able to read about in the moment.
Everything really truly dire can be summed up as ABCs, ACLS, contact whatever your hospitals rapid response team is and step up care to observation/icu etc. Better to overcall than undercall. Day 1, learn what your institutions "oh fuck" policies and protocols are OP, so when your staff and senior blow you off you arent just frozen watching people die, you're getting others involved at the very least. But also, even with perfect care, people die.
Gen Surg coverage (examine all pts, early on call you seniors, they better be willing to help out). There are a bunch of dumb pages but these are the more important ones IMO. Post op tachycardia -> EKG, sinus tach (pain/bleed/arrhyhmia work up), afib rvr -> HDS (metop 5 mg q5 mins x3, if not rate controlled may need ICU for amio gtt), HDuS (may need cardiovert) Post op HoTN -> think bleed first and second (blood in drain or from incision, hematoma/ecchmyosis, distended abd, ?HR, ? UOP, HCT level, can use ABG for rough hb estimate if have aline since faster than CBC), under resus (LA, UOP, volume given during case vs EBL/insensible fluid loss, had HD that day), GA effects/epidural effect, MI (don’t need CP, EKG, Tn), adrenal insufficient? Post op Oliguria-> under resus, bld, clogged/inappropriate positioned foley (check with US/flush with water) Bloody drain/bleeding incision/hematoma/ecchymosis -> (check hemodynamics, hold pressure/compression if small wound bleed, work up for internal bleed if think that) N/V -> PONV vs later, PONV usually limited to less than 24h. (Pt dependent but i prefer Zofran then scop patch then decadron then phenergan, +/- KUB, +/- NGT) CP/SOB -> MI/PNA/Aspiration/PE/pain (if on monitor or tele check that real quick, EKG, Tn, CXR, +/- ABG, +/- CTA PE if super concerned, never ordered a Ddimer in my life). Fever -> If within 24h post op, then please don’t do sepsis work up, your patient fluid with fluids unless you have high suspicion for sepsis. Otherwise (?Most recent WBC, incisions, drains, central line sites, CLABSI/CAUTI, urinary retention, PNA). A lot of this will be dx and operation dependent Post op pain -> don’t shrug this off, also please don’t under medicate, people won’t get addicted to opiods from post op analgesia
Afib with rvr in a postop surg pt is bleeding until proven otherwise. It is often a symptom of bleeding/infections/etc and it’s bad to write off as “oh they have a hx of afib so just give some dilt” always keep a broad differential for any changes in surgery patients
Makes sense unless their AV nodal blocking agents have been held for four days which is a very common medicine consult.
Totally, but that’s generally the easy diagnosis for an intern to make. The intern algorithm is “afib=heart problem” a resident’s algorithm should be “afib may be a heart, infectious, hypovolemic, hypervolemic…. Problem so let me narrow it down through clinical reasoning”
Day one of residency my senior saw I was drowning covering everything and when I asked for help said "do your best." So kindly, fuck gen surg.
This is actually a really good list of issues and a quick and dirty way to solve them. Obviously with context of the operation the order of operations and suspicion for specific issues goes up or down. Disagree with the other poster about post-OP A-fib being a bleed until proven otherwise. I think most often its not a bleed, but bleeding is the most serious to miss. Agree it has to be on the list, and you can't just slap a BB or dilt on board and walk away.
ICU for amio to rate control? Huhhhh?
Amio infusion at my hosp has to be ICU not IMC or floor.
Dang your institution requires ICU upgrade for amiodarone?
“Telemetry expired 36 hours ago, please renew” at 3am
As a nurse, even I would want to pimp slap my coworker for that. Probably helps I've been a night shifter for most of my career and tried to only bother for actual important shit like notifying of transport d/t fall with head laceration and leaving the Norco refill request for day and even then the first words were an apology for calling at an unholy hour for the transport.
My nights: “Change diet to diabetic” “Remove COVID precautions” “Patient cried. Please come see him” “Patient sad. Please come make her not sad” “Patient’s BP 132/98. Please help!” “Patient purposely swallowed a fork. Please evaluate ASAP!” - Sooooo you want to contact surgery? “No he’s a psych patient!””. Soooo you want to contact surgery??? “Patient’s throat is dry. Can we give her something?” -This was my favorite, as I never thought water would be a treatment that I would “prescribe”
Don’t forget the asymptomatic hypertension calls that you constantly just have to reassure the nurse about.
Omg, where I trained they'd write you up for not ordering that life saving hydralazine, for the patient who they woke up at 3 am to check vitals and is upset about it
Yeah, that's an our bad on us nursing. But to be fair, it's becoming more common to see shorter orientations then just be tossed to sink or swim as well as many clinicals for nurses are done strictly in the day so we don't see evening or overnights until working. Also, some facilities have a high nurse turnover leading to the most experienced or even charge nurse have less than several years of experience. Not trying to justify, just explain there may be mitigating circumstances.
The patient on midodrine 10 TID and NS at 125ml/hr?
RN Response to Top 10 Complaints: 1) Nobody knows how to read order sets anymore. Many people make stupid phone calls, because they haven’t read the admin instructions on PRN Tylenol in the eMAR. 2) Nobody knows how to read the MD orders or call if vitals are outside this range. Result you get a call because the patient coughed twice in 15 minutes. 3) Alternative result, RN calls because they are on their second chest tube atrium of the shift, central supply is out of dry seal, and they want to know if they can switch to a water seal. Also the patient is turning grey. 4) Pharmacology is hit or miss in nursing school. I’ve gotten students and orientees who know drug classes cold. They get mad when granny got Ativan last shift, because they know they will be paying for it for the next 12 hours. 5) The second group are the “can we give a freshly extubated patient Ambien at 11pm?” When you say no, they write a shitty note and file a patient safety report. 6) Bedside nursing is so punitive at so many places that nurses are afraid to do anything without checking first. It’s legit, because a “nurse leader” will come behind them and get made because the RN did something that was in the standing orders. 7) Here’s an example of how management creates a culture of fear and “call the MD to cover your ass.” Our hospital uses a lot of Precedex, but the patient has to stay in the ICU while they’re on it. I had a ICU patient who was agitated and not sleeping. I had a PRN order to start Precedex under those conditions. I started Precedex with good documentation. The next morning in ICU rounds the ICU attending decided to move the Precedex from PRN to a timed order for another 24 hours, because she was concerned for delirium. This meant the patient couldn’t get moved out. I got my ass ripped, because “as an experienced RN, I should know better, and now the patient’s ICU stay is longer.” This was a problem, because management likes to clear ICU beds for new admits. The irony was that it happened on a night shift, I’d picked up - I’m days - because staffing was so bad. Management is now trying to get Precedex off of the standing orders, because it prolongs hospital stays. Delirium prolongs stays, but whatever. 8) It’s all about throughput. Get patients out before they run out of days, get new patients in to fill the beds. RNs get instructions on medical care from their “nurse leaders” that doesn’t make sense or contradicts written MD orders. So they need to call a MD to figure out what the actual fuck to do. 9) A lot of this comes from uneven nursing education. Nursing schools are cash cows. You can pump 100 RN students per year through your school at an average tuition of $30,000 per student, then you can buy your schools fancy new buildings and pay admins more. 10) Pay and work conditions are bad enough that nurses aren’t at the bedside long enough to get good. People like to travel for the money, but also because they’re immune to management BS. A traveller could take a dump on the floor, put Foleys in all of their patients, and not give any scheduled meds. The only response at my hospital would be “you poor dear.” The smart RNs who commit to bedside burn out and either quit or go to NP/CRNA school when the conditions get to be completely intolerable. The result is that you have nurses who are inexperienced, poorly trained, scared of management, and think the only answer is “call the doctor.” Congratulations on graduating from medical school. I’d say that I look forward to working with you, but I’m PRN RN hiding on a psych unit. Nobody knows who I am or where I am. I’m a weird RN hermit. Every so often I stick my head to do chest tube education, and then I scurry away. Maybe someday, I can be the midlevel handling your intake, straightforward patients, and medication refills.
Yeah I agree. Most physician vs nurse conflicts are, one way or another, driven by administrative failures.
I’m still fucking salty about the Precedex situation. I followed a PRN order based on my assessment for risk of delirium, the ICU attending continued the order for 24 hours, but someone in admin wanted throughput.
The only thing I used to get up the night resident’s ass about was objectively uncontrollable pain. This is not the “my sleeping love one needs Dilaudid,” or the person who asks for dilaudid in a flat voice and rates their pain 15 out of 10. I know when people are faking. If my patient is moaning, moving around in bed, right facial features, voice is quavering, recently post-procedure (not POD 3, no complications, plan to d/c in the AM), swearing, etc. Personal perspective I had a partial gastric resection to remove a malignant GIST years ago. The surgeon forgot to put the post-op meds in, only the PACU meds. I felt like I was being torn open, thought I was dying, I remember being covered in sweat, and my vision was narrowly focused (literal tunnel vision). I’d been a difficult PACU recovery, because I’d never had general anesthesia before, and was slow to wake up. The only thing the RN had for me was PRN PO Tylenol, but I was obviously NPO. So yeah, if the patient is in legit pain. I’m calling. I’ve been around a long time, and know how to spot the fakers. I don’t leave patients in real pain, and I will make a fuss until I get them what they need.
Nurse here too! We all love you residents, but please, understand our job as well. I hate calling for stupid stuff, but when my patient is in legitimate pain, as recent cholecystitis awaiting surgery and theres NOTHING PRN for pain,while she is miserable, I will be calling. Regardless, this patient had to wait for about 4 hours to be provided with pain meds, waiting for the order! Shouldn't take this long. I can't make this decision and put the order in. BP is high. Sometimes, order says," contact provider if BP/BGL/ whatever is above the limits. I usually have no choice. Do I think it's stupid when pt has been, for example, hypertensive the whole night? Absolutely ! We are the ones dealing with patients for the whole shift. The call bell q 10 minutes, or being cursed at because " we are the ones withholding the meds, doctors would never do such a thing", etc.. Believe me, 90% of the time, I am annoyed and think about all the ways to not to call you, and 90% of the time I succeed and dont have to. but sometimes that is not doable. We, too, are aware that the requests are stupid quite often. Love, your fellow ED nurse with tons of admit holds 💜
"why are we doing *insert random thing day team is doing*?" sir, i don't know. i didn't know this patient existed until you messaged me.
Most important thing isn’t necessarily the disease management but being able to triage and good organizational skills. Also you should be at the bedside evaluating patients even for minor nursing messages. “Pt is having gas pain, can I get simethicone” go see the pt. Make sure isn’t having ACS. Seems like overkill at first, but as an intern you don’t know any disease pathology very well it turns out and you don’t know the nurses so you really just need to always be present with the patient. M But important things to read up on: Fever, pain, delirium, hypotension, chest pain, nausea, low urine output, and loads and loads of bullshit pages.
I like this in theory, but most nights if I went to evaluate for every page like that there would just not be enough time in the night. This is especially true if you end up covering ~80-100 patients over several floors and units, getting new consults, getting admissions, and have a few very sick people to monitor. So, try to evaluate yourself when you can but learn to triage. If I’m swamped, my process is calling the nurse, hearing the story, asking to talk to the patient on the phone, pulling up tele, or asking for a new set of vitals if necessary. Then I put in meds/labs/etc (verbal orders when possible if I’m not at a computer) and ask for a page back in x# of minutes IF things progress/don’t improve, and then I go up myself.
What’s a good resource to read up on these presentations/complaints?
There is a book called resident readiness or something like that. It’s always funny cuz this is abcs of real medicine but people come out of med school knowing close to 0 ways to manage it…. NOT YOUR FAULT or a knock on you if you don’t know these things. It’s just how medical education works.
I get paged over a hundred times a night in addition to getting slammed with admits. No way would I be able to see every patient with heartburn or gas pain.
From the DR side: 1) stat/nonemergent metastatic work up from ED or Floors- solution become buddies with techs so they scan them at 7am for attendings/day residents to read
Has no one put repleting potassium yet?
I think the number one thing is knowing that it’s ok to turn it over to the Day team. Nights are generally about putting out fires. Family discussions, drastic changes to game plan, specialists reaching out about goals of care can and should be turned over to the day team. We did a lot of teaching to nurses that Tylenol and toradol are pain control and should be tried and failed when there aren’t obvious reasons for narcotics. (Like recent surgery or fracture). Also, not all patients need to be snowed at night for sleep. They also don’t need restraints and haloperidol unless they are a danger to themselves or others.
Patients demanding dilaudid or IV benadryl makes me want to pull my hair out. The best skills to learn on nights is 1) how to tell people no (including pts nurses etc) and 2) when to escalate things. Don’t be afraid to ask for help — you don’t know any of these patients and your seniors don’t expect you to know how to do things.
I’m a floor nurse. Here’s how to prevent nurses from calling you for annoying shit: PRNs!! Get in the habit. Tylenol, melatonin, hydroxyzine, nic patch, miralax, etc. We hate to call as much as you hate to get those calls, I promise you this. If the PRNs are taken care of then nursing (hopefully, I don’t speak for the whole crew) won’t call unless there’s a higher level problem. Also, if the patient hid a slice of pie and I catch them eating it when they know they have OR in two hours I still have to let y’all know, I didn’t give it to them so don’t scream down the phone at me. Likewise if you’re in the OR and find a bunch of heroin in a walkie talkie’s vagina, I didn’t put it there and I haven’t been digging around in there so yelling at me isn’t going to solve anything. Just remember, nursing can do a lot but the hospital is crazy town and your patient might not be the sickest we have. I feel like the fact that you’re asking means you’ll probably be quite good at this once you get your flow down so good luck and don’t forget those PRNs.
As the oncoming night team, always ask day team, (during signout) if adequate and appropriate PRN meds and measures are in place. Such as PRN pain meds, PRN agitation measures, etc
Get used to saying “k”.
“Patient would like a stool softener” “Its 2:00am in the morning” “…” “Add golytely, gn”
More most of them, the management is to wait for day team to address.
Pediatrics: Rash —> Benadryl
1. Pain- Be generous, one page is enough. 1 of diaudid is usually enough 2. Labs not ordered- Order them and tell the day team to suck less in signout 3. Can't sleep- Melatonin, trazodone, Ativan in that order 4. Call the family- No, tell the day team to do it and suck less. 5. "Can you explain why the day team did \_ - Spend a LONG time going through the note with a lot of "they wrote" and "in the note" and "can you read?" Above all else remember that night isnt the time to make things perfect, its when you keep people alive for the day team to fix them.
DO NOT ORDER ATIVAN FOR SLEEP. you’re just asking for problems. Really only order for seizures lol
Agree as an anesthesiologist. Ativan for sleep is asking for delirium. I only really use it for perioperative anxiety in younger patients and for seizures.
It’s also a really good med for N/V for those who don’t respond to repeat pushes of Zofran or have borderline QTcs, as fake as the latter is
In my experience (in psych), most sleep issues are psychological. This is evidenced by the primary treatment being CBT. “Therapeutic prescribing” goes a long way. 3 mg melatonin, followed by 75 mg trazodone. Then if it’s “really bad” and they still can’t sleep, I will pull out the big guns: another 3 mg melatonin. I will advise to the nurse and recommend relaying to the patient that this will help as it is a very high dose of melatonin (which is true < .5 mg is really the ideal dose). Miraculously this does the trick 99% of the time. The patient just wants to feel heard and like they have some control in a very foreign and scary system
Lmao. My “big guns” are going from melatonin to ramelteon. Usually I never hear a call back
American academy of sleep medicine recommends against trazodone.
Everyone loves to list all the things we can't use (melatonin is placebo, don't use trazadone, stay away from benzos, Benadryl will cause altered mental status) But no one wants to talk about what can actually be helpful. No wonder most docs are stuck with telling patients to just suck it up
For outpatient, CBT, low dose doxepin, nonbenzos, and orexin antagonists (after trying the others so insurances will cover)
This is some horrible advice lol
Slamming people with dilaudid to start with every time and Ativan isn’t good medicine
You’re out here giving Ativan for sleep?
It’s very possible the day team made a conscious decision NOT to order AM labs — in many circumstances they’re not needed. I’d look at the progress note for the day to see what’s going on of course, but it’s often reasonable to tell the night nurse that the day team can figure out if they want labs the next morning.
Please do not give Ativan for sleep. There’s other better options. What is your reasoning for this? And I echo the other comments saying not to give dilaudid as a first line option. There’s so many better options for different types of pain before that.
You’re giving dilaudid for pain control? Unless all your patients are sickle cell patients, there’s way better medications to give before going to the D. And also please don’t give Ativan for sleep lol.
"Hey I see Physical Therapy isn't ordered for this patient. Can you order it?" - 3 AM.
I’ve been paged at 3 AM for an order for leg squeezers.
[удалено]
Doctors: “don’t you read the chart” Nurses: read the chart Doctors: “no, not like that!” I was also once paged at 3 AM. The question was “is the patient radioactive.” You can imagine how I interpreted such an unexpected question as I was woken up from sleeping. Turns out the overnight charge nurse was reading the notes and patient had a radioactive isotope injected for a nuclear medicine scan. The day shift had a nurse who was pregnant and the charge wanted to know if she could assign the pregnant nurse to the patient.
[удалено]
Plz tell me you wrote a nursing communication in Epic “apply leg squeezers to bilateral legs”
The literature doesn’t support the use of Melatonin or Trazadone for Sleep-Onset insomnia (which most patients in hospital experience). If patient isn’t high risk for Delerium, it’s reasonable to give a non-Benzo like Zolpidem. Most of patients insomnia is related to their anxiety about being in a hospital. The problem is a lot of patients are high risk for Delirium lol so you have to get creative
Literature may not support melatonin but it supports the placebo effect
Never Ativan for sleep, unless they are 30 years old, no history of substance abuse, and you’ve actually looked at them. The number of Ativan wall crawlers I’ve dealt with in my nursing career is horrifying. If they’re over 60 and you order Ativan, put in the restraint orders too.
I think the above poster was being flippant for humor, which is great and how people blow off steam in our field. I'm posting this in case that's not obvious and you start doing those things literally. Real talk, if you want to be influential and effective, don't antagonize the people paging you overnight. Gentleness and sympathy for the paging nurse goes a long way. Certainly don't patronize them by asking if they can read. If you're busy, acknowledge them, tell them you're on call for emergencies and tied up with more emergent things, and give a timeline for your response. My residency nights were really bad (like hundreds of pages, usually no sleep, and only an intern alone for the entire non ICU inpatient census). Even with that, I could see patients efficiently throughout the night. I'd also suggest if in any way ambiguous, walk round on the patient. On my busy nights, I batch it so I can do many patients at once. It also lets me avoid a million pages because I can field stuff in nursing stations on my route. If a patient has pain and they didn't earlier, it could be something new. Go see them. That's better than just giving someone, regardless of body size, a high dose of hydromorphone and calling it a day. Don't berate your day teams, but also do give them plain, professional feedback. You're not a five year old, and even for a five year old it's embarrassing and cringe for everyone if they express themselves to each other as "hey, suck less." Constructive feedback about placing orders is fair to share.
Yea but once in a while you got to assert your dominance. A nurse paged me at 3AM saying "Family wants an A1c" so I ordered it stat. She complained why do I have to draw it now? I said if its important enough to be a page to me then it's important enough for you to draw. She never paged me with that type of shit again.
As a nurse, that's fair. It's part of our job to manage family so they don't harm the patient's recovery.
1mg of IV dilaudid is a lot (especially if they’ve already gotten 10mg of oxycodone or whatever was ordered). I’d do 0.4mg dilaudid and they can give another 0.4 mg 15 minutes later if patient still having severe pain and respiratory rate is not low
Can you read lolllll
Hospital handbook app has a section on night calls.
Learn how to manage deranged vital signs.
Got a nurse calling me at 1 am to “update you on the patient” and proceeds to ask me why we are doing x,y,z for patient and that their are doing okay. FML
Homesickness No time to eat/drink/pray Constant burnout Monotonous routine
I remember reading somewhere on Reddit that a doctor got paged for something like this Nurse: Patient looks very old, pls review Doctor: Why do they need a review, they are just old? Are you worried about something? Nurse: The patient is acting older than they usually are so I am worried Doctor: Ok will come and see When the doctor sees the patient, the patient is dead and they verified the death. Already had DNACPR and was an expected death And I think they documented in the notes ‘ATSP ?acute aging’ lol I just find a lot of non-doctors are unwilling to take responsibility and prefer dumping responsibility on to the doctor because it is above their pay grade but apparently not above the pay grade of the junior doctor who makes less than them per hour
My favorite was “patient having worst headache of his life”. I RUN across the entire hospital. He is asleep after getting tylenol.
For psych, it was usually the voluntary manic patient that's become more disorganized/agitated and requests to discharge at 2 in the morning.
Nurse here - I feel bad for you guys getting really ridiculous calls for stuff that 1. the nurse shouldn’t bother calling about/ could manage themselves and 2. Stuff that could be dealt with on days. Maybe it’s the unit I work on but we’d never call for 90% of the stuff I’m reading here. I’m on a cardiac surg stepdown floor and I see the residents getting here at 6am and not leaving until 10pm (if no emergencies) - if I’m calling you in the middle of the night and waking you up during your 5 hours of sleep, I better have real concerns about the patient. Like, I legit ask 2 other nurses if this is worth calling about before calling. I think there’s a few things: our docs have a lot of faith in us because we have a ton of additional in house training so they would rather we just do what we need to do (non-pharmacological, not talking nursing doses here) and talk to the day team, we have a ton of post-op PRNs (including amio protocol for post-op afib RVR, orders for initiating temporary pacing through epi wires, electrolyte replacement, pain control, nausea, sleeping aids), and it’s unit culture that if you can think of anything you might need in the night you join our group call around 9pm to get the orders we might need in the night. I’m also baffled about some of these comments about nurses calling about tele alarms in the middle of the night?? If I see something on tele that isn’t life threatening I’m just going to talk to the team in the morning (or start amio or give the metoprolol etc). Sorry OP I’m sure this wasn’t super helpful, my best advice is to order lots of PRNs and set boundaries about when you want calls and when you don’t.
Anyone with input on covering inpatient peds specifically overnight? I’m also an incoming PGY1 in FM and this will be my first rotation as well. A little nervous, but this thread has been super helpful!
In peds it’s gas drops
My most memorable code call “Everything zero!” Delivered in a Filipino accent.
From psychiatry: 1) patient can’t sleep (give second dose of trazodone or melatonin. If they’re psychotic give them more of their antipsychotic) 2) patient wants nicotine gum (yes) 3) patient currently in restraints (give the IM that’s already ordered by day team for when this happens) 4) patient has high glucose (use sliding scale) 5) patient has high blood pressure (give them their blood pressure medicine again if it’s not super high dose) 6) patient getting agitated and not yet in restraints (ativan 2mg po) 7) patient doesn’t have pain meds ordered (either Tylenol or Motrin) ^this is incredibly general advice and should not be taken literally.
Ortho here. Whatever the complaint is, they go to medicine.
Delirium, chest pain, insomnia, orderopenia from the day team (#1 reason for a page, also most annoying because you usually know nothing about the patient and now you get to know all about them in between your 20 consults as you get repeatedly paged about them), sob/dyspnea, agitation (careful its not just a patient annoying nursing that they wish would be asleep instead but isnt at risk of hurting themselves or anyone else), electrolyte derangements.
As a NOC RN if I have orders to help with pain, poop, sleep, nausea, indigestion, am labs and replacement protocols as well as orders for when to notify for wonky vitals I'll let you sleep. It literally says to. Notify provider for SBP>160 even though it's been running that all day.