Friday, May 4, 2012

What happens when a doctor is paged

I dedicate this post to all nurses. National Nurses Week starts May 6th.

It’s 8:15 p.m. I am at home. My beeper goes off, and I check it instantly. It reads, “555-1212” [Number changed to comply with HIPAA regulations]. It’s the inpatient surgical floor. Within 10 seconds, I have dialed the number.

The unit secretary answers with the scripted and time-wasting response: “Hello, this is Blockley East, Jennifer, Unit Secretary speaking. How may I help you?”

“Skeptical Scalpel, returning a page.”

“Oh, yes. Hold on, I’ll get the nurse.”

Cue the recorded announcements extolling the virtues of the hospital’s world-class robotic surgery program, the revolutionary Cyberknife®, the wound care center, the award-winning maternity suite and blah, blah, blah. I have the spiel memorized. Give me elevator music any time over this.

I’m thinking about the patients I have on that floor. Is it about Mrs. Schweinsteiger’s urine output? Is Mr. Robben’s NG tube not working again? Has the lab work come back on Miss Ribery?

I look at my cell phone. It’s been 2 minutes and 37 seconds since I answered the page. I’m hearing the recording for the third time.

Hmmm. At 4½ minutes, I hang up.

The punch line? I was never paged again.

So, what happened here?

My theory is that immediately after a nurse pages you, she runs as fast as she can to get as far away from the nurses’ station as possible. Maybe she went off duty. Maybe she took a break. Or something. And it apparently wasn’t that important or she would have paged me again.

This kind of thing happens just about every day and drives me crazy.

Note: Yesterday, this blog was posted on Sermo, an on line physician community and 52/56 (93%) MDs who responded said they had experienced pages like the one I described.


Diane said...

As a patient, I judge Drs. on their Nurses. If your nurse rates low it reflects on the Dr. and I usually find myself changing Drs.

As a patient I have observed that Nurses hired by large hospital systems are more likely to rate low in my book, where Nurses hired directly by the Dr. they work for tend to be more organized and work hard to be the "bridge" between patient and Dr.

So if a Dr. is wondering why their patients are leaving- take a good look at your Nurse first! I have to wonder what precent of Hospital complaints and negative feedback are because of the Nurses?

Skeptical Scalpel said...

Diane, thanks for commenting. Good points.

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

In fairness to nurses, this isn't something unique to them. I've had lots of medical students/residents/attendings page me and then disappear immediately. Or pick up the phone they just paged me on to call someone else, which is similarly annoying.

The Nerdy Nurse said...

Funny I've experienced the same thing... just the other way around.

Here's what happens.

Typically when I page a physician there is a problem with a patient. So after I've paged I go to the patient's room to assess them. I have personally never had a call returned in less than 5 minutes. We have to through an answering service which ads to the time and difficulty on both sides. They had this ridiculously long list of questions they would ask that I know never made it the doctor.
When the MD called back they were routed to our portable phones.
The standard time was about 10 minutes.
Sounds like there was likely an issue with the secretaries ability to route the call. That or the hospital does not give the nurses portable phones.

I did have one surgeon who wanted us to call him directly and not page him. I tell you that was the easiest man to deal with ever. So laid back and we could instantly get issues resolved with patients. It was so much easier and much more productive than going through the ridiculous paging process. I imagine it was much better for him as well. Instead of having to be awake for 15 minutes at 3am, he only had to be awake for 2.

Skeptical Scalpel said...

Yes, it's not unique to nurses.

Direct access by cell phone works, unless that surgeon is not on call that night. I have been awakened at 2:00 a.m. when I wasn't on call by someone too lazy to check the call schedule. I turn my beeper off when I'm not on call.

Anonymous said...

A nurse does not work for a doctor, he or she is practicing nursing under his or her own nursing license that he or she earned after successfully completing nursing school and then subsequently going on to take and pass their state nursing boards. If you were referring to a nurse who works in a provider’s office, then that nurse would be a member of that practice. I say this only because the public seems to believe that there is a hierarchy at a hospital, which is simply not the case. Hence the reason that you are admitted to a nursing floor while you are inpatient at a hospital, you are under the care of the nurses on that floor or unit (i.e., ICU, CCU, medical surgical, etc.) Nurses’ work for the hospital at which they are employed and answer to that particular hospital’s department of nursing, not the department of medicine and/or surgery, which is responsible for the physicians that practice there.
Contrary to what is portrayed in most of todays mainstream media, where nurse are seen merely as a physician’s handmaiden; nurses and providers work together as a healthcare delivery team, whose common goal is the care and safety of the patient. Nursing is its own discipline with its own unique body of knowledge. Nursing is not a subset of medicine. Please know that I am by no means trying to berate you, but merely inform you.

Anonymous said...

Why is your hospital using pagers? They existed because we didn't have mobile phones. Pagers kill workflow and delay patient care.
You can get a second line for your cell - $25 a month. Turn the line off or forward to phone of the on-call doc as needed.
PS, my hospital uses pagers, too. Join me in a cry to end the pager!

Skeptical Scalpel said...

Thanks for the comment about nurses.

Chris, I don't know about your area, but where I practice, cell phone service can be spotty. The hospital is one of the worst places. Some cell phone carriers have little or no coverage. You can be in the OR or radiology and have no bars on your phone.

Since pagers work by radio, there is no coverage problem. When cell phones are 100% reliable, let me know.

DrHalxx said...

Here in the UK we call it "bleep and run"

Anonymous said...

I once had this happen to me and the receptionist came back 5 minutes later and told me she couldn't find the nurse. I told her "Ok, just let her know that if she pages again, though, I probably won't respond because it's a busy day here." It was...I was on the OB anesthesia service and there were c-sections and epidurals galore. I can't return pages when I'm doing a procedure. Guess what - she got the number for our lounge and called back and asked to talk to me because she was angry and said I didn't care about my patients! Luckily, my colleague wouldn't hand me the phone...he just allowed her to vent...but really, if you *care* that much about your patient, then have the decency to be available when the doctor calls you back. This is not a generalization to all nurses, just a unique situation that occurred with one nurse at one institution. Many of my friends are nurses and wouldn't do two of the institutions where I work, the nurses have cell phones and carry them on their person. I agree with cell phones as well, if there is adequate coverage in the hospital.

Skeptical Scalpel said...

Great story. Thanks.

Although I've been paged like this more than once, I really wasn't trying to demean the entire nursing profession either.

I just wanted to share another little frustration. It looks like many others have had the same experience.

Anonymous said...

Aggravating, sure. But usually nurses will need to move on to the next and cannot afford to wait either for a return call. Some docs are great at return, some suck. Soon it's learned who is worth hanging on the line for, with inpatient acuity and ratios on the rise in many hospitals. If things are hitting the fan, I am not at all concerned that somebody is annoyed. I try to avoid it, but truly I've usually got bigger fish to fry.

Diane, the detail of implementation is not rote, obviously. I ultimately give you a drug by my judgement. I review information from labs/tests/my assessment of you, as well as what I have learned is the usual progression of a patient with your situation and come to a decision. Sometimes there is latitude built into the MD order set to allow me to make the final judgement without a phone call. Either way, depending on what I find/conclude a call might go out the the MD and we discuss my findings and what to do or not do next. You are under a nurse's care much more than you think. The T-shirt says "Nurses Do it. Doctors sit at a desk and only think about it" (just kidding Skeptical)


Anonymous said...

So true SCRN. At MN if intern (in ER?), resident (in surg?) & up the chain don't respond to an SICU stat page u better hope RN knows what they're doing & who next to call for help. Told my military ICU RNs to not hesitate & call code (time b4 RRTs) if needed. If 0200 & pt going south not likely surgeon or even much support staff in hosp! Eg from my PAR experience:Post chest surg to r/o cancer pt slipped a thoracic ligature, bleeding out into CT drge bottle. Called a code stat, so even tho pupils fixed & dilated for 20 min in OR pt survived primarily becuz surgeons/anes headed bk stat. Upon 2nd round in PAR pt awake & talking thankfully. Path: no cancer.

Ken & Carol said...

We used beepers in the late 60s. The nice thing about them was that you could set it off yourself if you were attending some boring function. Then quickly walk out of the room as if you were expecting something serious on one of your patients.

Skeptical Scalpel said...

Yes, that was handy. There's a cell phone app that will ring your phone at a time you set.

nl said...

Recently, my group went to cell phones only and ditched our beepers. The primary motivation was that we were renting our beepers from the hospital, and the hospital was changing services for the second time in two years, which meant new beeper numbers again, and another round of getting our numbers out to all the referring docs and offices and such. We figured most of our referring docs already had our cell numbers anyway, and much of our local community have moved towards text messaging as method of communication, it was time to just ditch the beepers instead of getting the new ones.

Our hospital subscribes to a "webex" system that allowed anyone on the intranet to, via a web browser, put a message into our beepers. We were able to get our cell phones configured so that messages entered into the webex for each of us would come to our cell phones as text messages.

The only real problem we are having is in our efforts to get nurses and floor secretaries to provide us with triage information when they text us. We have repeated asked them to provide information as to the reason for the call and the urgency of the call. We have tried to explain that just an extension to call, or an extension and a patient name, with no further information, is much less useful that a few words of description. We have even tried specifically spreading the word that if no information is given we will assume the call to be a low priority and return the call at our convenience. We are simply unable to convince the majority of the hospital staff to accommodate us in this regard. I'm not sure why. I don't think the extra work of typing a few words is the issue.

Now that we have all this technology at our fingertips, it seems we still struggle to make effective use of it.

Skeptical Scalpel said...

nl, very interesting. We had a similar Webex-type system at a hospital I formerly worked at. The rate-limiting step was logging on to the system, not typing the message. It simply took the staff too long compared to dialing a pager or phone and inputting a number.

Persephone said...

Interesting post to start the Hallmark Card celebration of Nurses Week. Speaks volumes about your prioriites and sensibilities. I assure you that on an on-line nursing commununity, the results would be skewed in a reverse order. As one who regularly touts the flaws in many statistical analyses, I hope that you see the folly in something as subjective as an on-line chatting community. Communication breakdown is the most common source cited in medical/nursing errors. Exploring the reasons would be more enlightening than whining about your inconvenience.

Skeptical Scalpel said...

Persephone, thanks for commenting. I never suggested that this blog post was based on any science. It's an anecdote. That's all.

Regarding communication, a few constructive comments have resulted from this post, but none has suggested a plausible explanation for paging, not being able to get to the phone in a reasonable amount of time, and not paging again.

Anonymous said...

Because I had6 patients and was running my arse off. Sec never told me you called. I did call back....twice. Never got a return call. Documented it in the record and reported it to the oncoming shift..... Did you call again to see what the issue was? We're you worried enough to find out why you were paged? Texting is better this is a partnership lets work together and consider what each of us can do to assist one another. Got the hospitalist who initially wanted to check with the surgeon to write the order the pt needed.

Skeptical Scalpel said...

Anon, Sec. never told you I called? You think that if I called back anyone would know who paged me 30 minutes ago? You must be kidding. How about if you 1) tell the sec who you paged and 2) why you wanted to talk to me?

Texting is great as long as the text doesn't go somewhere in cyberspace and get to my phone 24 hours later, which has happened to me several times.

Anonymous said...

Here's an interesting take on the issue of beepers, cell phones, calls in the middle of the night, etc.

We often wonder why general surgery attrition is so high. Depression among physicians? Its the beeper/cellphone.

Remember, Pavlov? Remember when he made a dog salivate by ringing a bell? Remember B.F. Skinner? Remember how he took a rat, lit the little green light and gave it a pellet of food?

Do you remember when Skinner then did the opposite? He lit the green light--but instead of food--it shocked the rat.

Remember what happened to the rat? It died...prematurely. Entirely reproducible psychological experiment.

Every time a pager/beeper/cell phone goes off for a surgeon it is "bad news." It is a shock. It is never good. We get shocked. We become depressed, develop PTSD to the pager.

Nobody EVER randomly just calls as says, "Hey, Doc, this is the ER...we're having a party want to come down to celebrate your day on/off?"


Horrible...horrible...horrible system. We should not be "on call" like this. Something has to change.

Skeptical Scalpel said...

Good comments. I'm not sure how it can change. Someone has to be on call for emergencies.

My favorite call is when the ED MD wakes you at 3 a.m. and says, "How are you doing?" I usually say, "I was OK until you called."

OhioRN said...

As a bedside nurse I do try to page when I know I will be at the desk for a few minutes, but as others have said, most docs do not call back in ten seconds or even five minutes. Staying at the desk for five minutes probably seems perfectly reasonable, but many times it is not. Just because I'm calling you about one patient doesn't mean the other four don't have some immediate need. Maybe the minute I paged you the tech came to tell me another one of my patients fell. I have to go to that patient. Maybe the tech tells me one of my other patients has a blood pressure of 70. I better go check that too. Maybe another patient's sats are dropping. There are many, many more examples but I'm sure you get the idea. While I don't doubt that the scenario you relate happens all the time, please remember the chaos on the floor. Most of us do not run away from the phone--we call because we are seeking an answer and it certainly does us no good to go without one.

As someone else stated, I would guess there was no call back to you because a hospitalist provided an order or the problem resolved itself (perhaps something like patient subsequently vomited and no longer has severe nausea and abdominal pain).

Skeptical Scalpel said...

OhioRN, thanks for commenting. Of course I realize that things can happen and you can't wait by the phone all day. But you would be amazed at how many doctors have told me what I described occurs very frequently. Also, I know that nurses don't really page and run away. It just seems that way to us.

Anonymous said...

Hey SS, instead of being on call, how many doctors will take the graveyard shift and be in the hospital? Must be nice for you to be able to sleep at 3am while all the nurses are constantly caring for your patients. Seeing as you have scalpel in your name, I guess you are a cutter. So if you get a call I would assume it is an emergency and the person cannot sit by the phone till you call back. So I would also assume you would call back in maybe 30 minutes and find out if any assistance was still needed not just wait for a return call. And I would say your previous response times dictated why the caller left the phone after paging. They figured they had at least a few minutes to go back and check on the patient while you found time to return a page.

Have you been at a hospital at night when the staff is thin? Have you ever had to deal with seemingly everything on a floor all by yourself? Of course not, you are a Dr so you are never anywhere alone. You always have someone with you to help you when needed.

Skeptical Scalpel said...

I have done shift work in hospitals and have worked at night. I have been in hospitals at night. I am aware of the way they are staffed. My last job was as a hospitalist surgeon. Since I had no private patients or office duties, I always responded to pages immediately. Even if I was operating, I would ask the circulating nurse to answer my pages. I was often the only surgeon on call for two hospitals.

I had no one to help me after 11 pm. The PAs went home at that hour.

Pharmacist said...

What about not calling your pharmacist back? We make a conscious effort to only page for critical issues, esp after hours. Surgeons are notoriously the worst. And with pharmacists you will typically have very little routing to get through due to the small space we work in

Skeptical Scalpel said...

Pharmacists, surgeons might be the worst, but I don't think the issue has been studied. I find doctors in many specialties do not return phone calls or communicate test results to patients.

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