Need Advice

whichone'spink, BSN, RN · Nov 3, 2012

I don't have any advice, as I'm a brand new ER nurse with no experience so far. I can only offer encouragement, and wish you the best of luck. Being called into the manager's office to review a patient's case is my worst nightmare.

I worry about missing something on a patient with an underlying condition that masks a serious condition such as a head bleed or MI. This goes for etoh intoxication, mental illness, dementia, autism, etc. I hope your manager is not the type that will play the blame game, and is one that will use this as a teaching moment.

RN/stilllearning · Nov 3, 2012

I would imagine that your nurse manager is planning what we all know as a CYA session with you to make sure all your t's are crossed and i's are dotted, ( just in case the family decides to sue). Ultimately its the Drs responsibility to order the blood alcohol test to determine if its a drunk just sleeping it off, or a scan of the patients head to see if all the symptoms- unsteady on his feet, nauseated, falling asleep, complaining of "head pain" and the abrasion on his forehead are signs of something much more serious such as a head injury. Which apparently was the case here. Every patient is another chance to learn.

uRNmyway, ASN, RN · Nov 12, 2012

Right, I think probably this meeting will be a mixture of CYA for the manager, and hopefully if she is a good manager, also a teaching opportunity.

But do not blame yourself for this. We are human, we miss things. We are not omniscient, as much as we would like to be. I am sure you are not the only person who saw this patient, who evaluated him. You are not the only one who missed this.

Regardless of what your manager says, make sure you learn from this. That laceration should have made you evaluate the possibility of a head injury. If the MD doesn't ask for more supervision, take it upon yourself to do so. I doubt you would get in trouble for evaluating TOO much in the future.

As a side note, I think a lot of us have been guilty of letting our pre-conceived opinions get in the way of our evaluations. Where I used to work, we had this FF who drove us all nuts. She was young (30s), with 2 children under 5. She was in every week or so for a few days at a time for intense abdominal pain of unknown origins. She had had multiple tests and no one could figure it out. She was usually either sleeping, or wandering in the hospital. She would only come back when her narcotics were due, and usually asked for them before we could give. Would complain of having vomited in the bathroom, but coincidentally, never remembered to show us. So with all that, we just all figured she was a drug seeker.

After months and months of repeat admissions one of the doctors decided to test her for familial mediteranean fever . Came back positive. We felt like the biggest pieces of garbage for having assumed the worst of her for so long was she was legitimately suffering. She got treatment for it, and we never saw her again.

Anna Flaxis, BSN, RN · Nov 13, 2012

Maybe your manager is required to review this case with you as some sort of formal process because the patient came in through the ED and died in the ICU. Just go in with a good attitude and be open to learning how you can do better next time (not saying you didn't do a good job in this instance; I do not know what you did/didn't do, but I'm giving you the benefit of the doubt that you did your best).

Any time a person presents with head pain and an abrasion to their forehead, it buys them a non-contrast head CT, drunk or not. A long term alcoholic would certainly be at risk for an intracranial bleed due to reduced clotting factors r/t alcoholic liver disease. That he has an unsteady gait, nausea, and decreased LOC could be related to either alcohol or head injury or both, and you have to rule out the worst case scenario.

Why it took hours for him to get his head scanned, I do not know. Was it that long before he was seen by an MD? Was the scanner backed up because of high patient volume?

Basically, based upon the details you presented here, he should have been seen and evaluated sooner rather than later. Part of that involves the triage process. If he walked in through the lobby, then the triage nurse would have assigned an acuity. If he came in by ambulance, then the receiving nurse (you?) would have done so. Was he assigned an appropriate acuity for his condition?

If he was triaged as a 3, for instance, and died in ICU, I would imagine this would automatically trigger a review.

If anything, your responsibility in this instance would have been to get him evaluated sooner rather than later, and if the MDs are behind and it's taking them too long to see the 2s (what I think he probably should have been, according to your post), then you should have found an MD to ask for what you need, such as an MBA and a non-contrast head CT. At least get the ball rolling until a doc could see him. Get some fluids going, do a neuro check, etc.

It sounds like he was just thrown into a bed and forgotten about because he wasn't seen as very high acuity, and you guys were busy. That may or may not be the case, but that's what it sounds like....and if it sounds like that to me, it could sound like that to a jury.

Now, I could be completely off base and making a lot of assumptions here, because you haven't posted that much detail, which is good. It's really best to try and stay anonymous here with questions of this nature.

Whatever happens, good luck.