Questioning a Docs decision...long

  1. I am in a moral dilema... I work in a small (10bed) ER and yesterday we had an elderly man >70 come in after a fall at home. Pt family stated he had been uncons. for about 10-15 sec. but awoke AOx3. Brought him to us for large lac (3") repair and to be "checked" Doc did facial X-rays, (no C-spine, no CT). After lac repair we sat the gentleman up, gave him an oral antibiotic, and then walked him with assistance about 50 feet and were preparing him for discharge when he became nauseous, vomited about 100cc of clear fluid and c/o headache. The doc was notified, we were told to "discharge him, we need the bed.":angryfire (end of nights/start of days) I was assigned to him, or, him to me if you will, and I was not happy. I have only been an ER nurse for a year but 20+yrs as a paramedic and did not "feel right" discharging him especially after the vomiting...Kinda classic. Long story shortened. He was back about 6hrs later, GCS of 9, CT'd...subdural bleed. As we were prepping him for flight to a neuro unit, the recieving Doc wanted a C-spine...fx of C-3 C-4, non-displaced. The day shift Doc was going ballistic, wondering why this man had not been kept as 23hr obs at the very least.:trout: My question...Should I have been more forceful in reminding the Doc of the S/S of a subdural?...I feel bad that this man/family have to go through this. Any advice appreciated (constructive advice) THANX........ Emsboss
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  2. 23 Comments

  3. by   rjflyn
    Personally I would be curious to know if the original doc was one trained in emergency medicine. This is a pretty basic call, fall in an elderly patient with a LOC gets a head CT almost universally. Based on the infomation provided most docs I have worked with most likely would have done a c-spine. I can think of a handful who might not have, but even those would more than likely did so if the patient was in a c-collar and boarded by EMS prior to arrival. This is hard to guess as that information is missing from the OP. Then again I can think of one or two in all my years of emergency care who still may have not.

    Then again some doc's are total jerks and you cant tell them anything. I bet risk management will be having a chat with him come Monday.
    RJ
    Last edit by rjflyn on Jun 11, '06
  4. by   jmgrn65
    It is a sticky situation, but at the least I might I said to him "You want to discharge even with the ... restating s/s pt experience and that he was out for a few seconds. I am not an Er nurse but isn't the std of care for loss of consciousness with a fall ( or any injury) to get a head ct? If he still insisted on discharge then I would talk with the supervisor. I hope you documented all that you did, do he doesn't come back and say well that nurse didn't tell me that.
  5. by   Altra
    Any patient of any age with a fall resulting in LOC gets a head CT where I work.

    I do think I would have pushed in this instance, but as a relatively new nurse with less than a year of experience, I'm not sure exactly how I would have proceeded. If it was a resident, I would have pushed the issue with the attending. If the decision was made by an attending, I would probably have gone to my charge nurse and "winged it" from there.
  6. by   htrn
    I can't speak from an ER/head injury perspective - but there are occasions when the doc blows something off that I feel is significant. I always document exactly what I see - FHR baseline ...., FHR decel to ... lasting .... seconds starting... seconds after beginning of a .... contraction (you get my drift). Then I document when MD notified, when MD arrived, monitor strip reviewed and any orders. That way I'm covered - if he continues to blow me off, depending on the doc, I may rip the strip off and follow him out of the room and ask him to 'teach me' what this means and when I should be concerned.:spin:

    Good luck
  7. by   Spidey's mom
    I work in a truly small rural er. We have 3 beds and one gyn room.

    This has not happened to me as our protocol would be to do a CT scan too.

    However, there are other instances where I have questioned the doc and our docs are pretty good. I'll say "I'm not comfortable discharging this patient and here is why . . ".

    steph
  8. by   emsboss
    The pt was brought in via POV and walked into the ER under his own power, no C-collar applied by anyone...Pt had arrived approx. 0500, I assumed care at 0700, pt was D/C'd at approx 0730. (Docs change shift @ 0800). MUCH documentation done, discussed w/supervisor, but, I have been in this particular ER about...2 days off orientation. No one will listen to me...yet... Am just wondering how forceful is to forceful? Guess I will need to play it by ear. BTW...Heard pt is doing well. Blood was evacuated, recovered to baseline. THANK YOU JESUS!
  9. by   TazziRN
    You have the right to refuse an order if you believe that carrying it out would be detrimental to the pt. I have done that. I've told the ER doc "I am not comfortable sending this pt home because (insert reasons). If you will not do XYZ or call the pt's private doc for a consult, YOU can come discharge this patient."

    If you do not have back up from the house supe, you can tell her the same thing. I hope that in this case that doc and the supe are squirming in their shoes when they look at you.
  10. by   traumaRUs
    I have been an ER RN in a busy level one ER for 10 years and when in doubt, document:

    "pt ambulated per self fifty feet with steady gait. Pt then vomited approx 100cc of clear fluid and ....Dr. No-Good notified and he restated order to discharge patient home. Discharge instructions provided to family members who will remain with patient for next 24 to return to ER for altered level of consciousness, more vomiting, etc"
  11. by   barbyann
    We had a similar case at our ED a few months ago, but the outcome was not a good one. Pt remains mentally altered after crani to evacuate bleed. Now everyone is getting multiple (hours apart) CT's with falls....young, old, uninsured. One extreme to the other.
  12. by   TazziRN
    Quote from traumaRUs
    I have been an ER RN in a busy level one ER for 10 years and when in doubt, document:

    "pt ambulated per self fifty feet with steady gait. Pt then vomited approx 100cc of clear fluid and ....Dr. No-Good notified and he restated order to discharge patient home. Discharge instructions provided to family members who will remain with patient for next 24 to return to ER for altered level of consciousness, more vomiting, etc"

    Dr. No-Good.........*snicker*
  13. by   steelydanfan
    In this case, documenting might not be enough. An RN in the ER (New orientee or not, a supervising nurse should be available in that case), should be able to interpret nausea and vomiting in a head injury pt. as a sign of possible complication and immediately institute the supervisory tree if your observations were not heeded.
    The Nurse Practice Act does not excuse you because your documentation was spot on even though the pt. was treated inappropriatly. The Nurse Practice Act demands that as a reasonable and prudent nurse, you intervene in a situation you clearly recognize as inappropriate. If you have gone through the "Tree", and the decision was still made to d/c, then you are off the hook.
    I don't want to make judgements here, but if you think something is wrong, it often is, and as nurses we just HAVE to listen to the niggling voice in our heads. You are smarter than you think.
    I have had the experience of being cowed in the face of "greater expertise".
    Once was enough.

    Cate
  14. by   PedsER-RN
    Quote from emsboss
    I am in a moral dilema... I work in a small (10bed) ER and yesterday we had an elderly man >70 come in after a fall at home. Pt family stated he had been uncons. for about 10-15 sec. but awoke AOx3. Brought him to us for large lac (3") repair and to be "checked" Doc did facial X-rays, (no C-spine, no CT). After lac repair we sat the gentleman up, gave him an oral antibiotic, and then walked him with assistance about 50 feet and were preparing him for discharge when he became nauseous, vomited about 100cc of clear fluid and c/o headache. The doc was notified, we were told to "discharge him, we need the bed.":angryfire (end of nights/start of days) I was assigned to him, or, him to me if you will, and I was not happy. I have only been an ER nurse for a year but 20+yrs as a paramedic and did not "feel right" discharging him especially after the vomiting...Kinda classic. Long story shortened. He was back about 6hrs later, GCS of 9, CT'd...subdural bleed. As we were prepping him for flight to a neuro unit, the recieving Doc wanted a C-spine...fx of C-3 C-4, non-displaced. The day shift Doc was going ballistic, wondering why this man had not been kept as 23hr obs at the very least.:trout: My question...Should I have been more forceful in reminding the Doc of the S/S of a subdural?...I feel bad that this man/family have to go through this. Any advice appreciated (constructive advice) THANX........ Emsboss
    I don't think you should have had to go over the s/sx of a subdural bleed, but you might have mentioned it to the doc: "this guy's acting like he has a subdural", or "I'm really not comfortable sending him home like this", or something to that effect. I would also let your CN know the situation, and DOCUMENT everything. Ultimately it's not up to you what happens but if you document that you relayed concerns to the doc, the CN, and what happened, it can't be pinned on you. I once had a pt (about 5 y.o.) with sat's in the upper 80's after 3 tx and the doc was going to send him home. I had only been a nurse about 18 months, but I didn't hesitate to speak up and have HIM go explain to mom why he could go home (I sure wasn't going to try to convince her that her son was OK)....after me talking to him and then when he went to see the mom (who was very upset with him), the child was admitted.

    I know how it feels to be relatively new...you don't want to seem like you're telling people how to do their jobs, but when it comes to situations like this, remember that you're the voice for the patient. If you don't feel comfortable approaching the doc, enlist the help of your charge nurse. Good luck.

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