Saturday, July 18, 2009

A Hint of Difference

Nurse K recently discussed an interesting hint between nurses and doctors: "No new orders."

In a nutshell: Suppose a patient is rapidly deteriorating. The nurse knows the patient is about to hit the wall and maybe die, but s/he may not have the authority to do what's needed - the doctor does. (Technically, the nurse can't even make an official diagnosis, but with years of experience s/he may know what's actually happening.)

Nurse tells the doctor what's going on. Doctor doesn't see it quite the same way, and decides to keep the patient where s/he is.

The nurse figures "Hmmm...this patient may just die. Or fall asleep for 10 or 20 years. Or become a vegetable or a basket case. People might blame me and even think of suing me. I need to show everyone that I knew of the danger and did what I could to stop it, but the doctor wouldn't listen."

So Nurse writes in the patient's chart something like:

Patient's blood pressure taken on both rt and left arms, 82/49 on rt and 84/52 on left. HR=124 in a sinus tach. Patient alert with sats of 92% on 4L via NC. RR stable at 24. Temp 101.2 two hours after tylenol. Pt states he feels "more weak". MD reminded of markedly positive UA and alerted to change in blood pressure. No new orders. [Emphasis in original]

The nurse doesn't say "the patient has this problem" but rather gives all the specific facts which would persuade any competent medical professional that the patient has the problem. That's a clever maneuver: you can complain without actually looking like you're complaining or exceeding your authority - you're just giving the facts.

And at the end, the nurse says "No new orders." Technically, literally, all it means is that the doctor chose not to do anything new. In this context, it's a generally recognized hint that the doctor is asleep at the wheel and as a result disaster is about to strike.

Nurse K makes clear that "No new orders" has a specific implicit meaning:

"No new orders" is the passive-aggressive medical charting equivalent of "Patient's doctor is being a tool and needs to order [pressors, fluid bolus, central line, etc]."

Note that I am more than willing to paint a picture that accurately describes the condition that you're ignoring with redundant vital-sign charting and things of that nature. Nurses, it's very important to use "no new orders" sparingly so it doesn't lose its bite. Under no circumstances should "no new orders" be deployed in a situation where writing no new orders is the proper thing to do.
[Emphasis added]

[...]

So, in summary, if [you're a doctor and] you see "no new orders", that's a cue that a nurse thinks you're missing something and/or hates you.


(You might find the comments for that post pretty interesting, too.)

So in a nutshell: Communication is relative to particular workplaces, professions, clubs, families, you get the idea.

That means that before you assume that the other person is getting your hint, one thing to ask yourself is whether that kind of hint means the same thing in the milieu you're in right now.

It also reminds us that we don't know everything. When stepping into a new job, club, town or whatever, we need to stop, look and listen. A heckuva lot more than we talk - especially at first. The words, expressions and behaviors that may have meant one thing previously may mean something totally different in our new setting. And of course there will be new signals where we have arrived, so we may now need to say the same things in a different way.

What do you think?

1 comment:

Caitlin said...

Haha- I like this post a lot. Hospital professionals are taught to document EVERYTHING (liability) without saying too much at the same time. For instance, social workers' notes also give doctors & nurses important psychosocial information without violating patient trust/confidentiality... talk about being "vaguely specific."