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by tatgirl

Hello all. I am posting this in hope of figuring out why the ER acted the way they did.... I work in LTC and I was "floated" to a unit I havent worked on in a couple of weeks. I get report and was told one of the residents had a "distended" abdomen, the doc was aware, was getting pain meds, and this had been going on for a few days. I go to take a look for myself and this mans abdomen was HUGE. The dr happened to be in the facility so I paged her overhead and had her to go take a look. She came back and told me to give him an IM injection of Lasix. I drew up the medicine went into the pts room and he refused. I go back and let the doc know that he had refused, she took the syringe and her and I both went into the room. Once again he refused and said he wanted to go to the ER to have the fluid drained out (evidently he has a hx of ascities and has had this done before) Doc said ok and had me make arrangements to send him out. This man also had diminished bowel sounds, and was gurgling when he was talking. I made arrangements, and called the ER to give them report. He goes to the ER, and a couple of hours later our house doc called me and told me that the ER doc was furious that we had sent them there! No treatment was given to this poor soul. I was in shock, since when does the ER refuse or not treat people who obviously need treatment???? Long story short, the docs argued and the resident was being sent back to us. I charted about his symptoms and his refusal of meds, how he was being sent back to us, and that ER didnt treat him. Now this man is a DNR, but since he wasnt DYING, shouldnt the ER have at least drained the fluid from his abdomen????? Sorry for the rant, but this really ticked me off last night......


Tatgirl
LPN

[meownsmile]

Re: ER didnt treat our resident......

I understand that this gentleman was probly in severe pain and very uncomfortable however, his dx is also known to the doctor who should have arranged for him to see a surgeon and arrange for a pericentisis done on an outpatient basis. He had a history of ascites and apparently is well documented so a trip to the ER following his refusal of Lasix most likely was futile anyway. Was there something the ER could have made him do that you and his own doctor were'nt? They cant treat if someone is refusing. Obviously he had been accumulating this fluid over a period of days so there was really no reason the primary doctor couldnt have arranged something before he got to that point. Even earlier that day,, or the day before (you said it had been going on several days).
If the patient is coherent and able to make his own decisions the doctor needs to sit down with him and they need to agree on a treatment plan. If that includes occasional visits to a surgeon to get the fluid drained off and not giving diuretics that is up to him and the doctor. I wouldnt blame this one on the ER.

[tatgirl]

Re: ER didnt treat our resident......

The pt requested to go to the ER. He wanted to get this fluid drained out. He has an appt Monday with his GI doc, but with the size of his abdomen, the pain he was in, and his wet lung sounds, myself or the house doc didnt feel comfortable letting this go over the weekend. I am a lil ticked at my coworkers because this has been going on since the 25th and only one nurse besides myself documented about the size of his abdomen and called the doc. As soon as I got the report I went right into his room and when I saw how huge his abdomen was called his doc in. We are going to do abdominal girth measurements q day now. Hopefully this gentlemen will be ok until Monday......

Tatgirl
LPN

[TriageRN_34]

Re: ER didnt treat our resident......

How old is this patient? Could he have refused tx at the ER just like he did with you?

[tatgirl]

Re: ER didnt treat our resident......

He is 87. As far as I know he didnt refuse treatment at the ER. He wanted to get the fluid drained out, as he was in severe pain and very uncomfortable.

Tatgirl
LPN

[meownsmile]

Re: ER didnt treat our resident......

Maybe a better course of action could have been for the doctor to call the on call surgeon and arrange for him/her to see him in the ER and do the pericentisis. That procedure is just not something the ER docs do on a regular basis and obviously it wasnt something "emergent" so the ER doc maybe felt they were getting something dumped on them that should have been handled several days ago. You did say he was getting pain medication.
Sorry but when he was admitted or diagnosed with ascites your careplan coodinator should have made abdominal girth measurements something staff did with each assessment too.
Is it possible this man refused treatment methods with your facility because he likes the care he gets as a inpatient in the hospital better (not slamming on your facility but sometimes people do that). Maybe he knew if he refused you long enough it would maybe get him a trip out to the facility where he knew he would have more one on one attention(thinking staff ratios now). Is it possible he refused to let anyone in the ER do anything knowing if they did they would send him back rather than admitting him to the hospital?
I have seen this type of manipulation before. We have had people who dont meet criteria to be admitted but end up getting admitted for observation then come up with every complaint in the book to need to stay yet another day. As soon as they find out they arent being discharged back to their facility they are fine, until the next day. Just some questions. Please dont feel im accusing or anything im not.

[tatgirl]

Re: ER didnt treat our resident......

yes, abdominal girths were to be started but someone dropped the ball on that one. I did tell the 11-7 nurse that we were to get them q day as soon as he returned from the hospital. ( I work 3-11 and at 1115pm he hadnt returned yet) I just made sure I documented everything that went on just in case something happens. Thanks for all of the replies. I go into to work this afternoon and will check on him myself.

Tatgirl

[TriageRN_34]

Re: ER didnt treat our resident......

As well as the aboved mentioned reasons...there is something I well knew working for ALF/LTC since I was one of the nurses that believed in actually sending pts out emergency (many of the nurses there didn't have my skill in assessments or didn't believe an elderly dying pt should have to go through all that...), I found that many of my residents said things that they wouldn't say to us in the ER.

I think it is a bit of the white coat syndrome, and well...sometimes residents didn't want to bother us that they knew so well with talk of giving up or death. They would act completely different in ER...proably because they have a new set of eyes and ears, and they feel that they are distant enough to hear the hard truths vs those close to them....

Maybe there was a dynamic in play at the ER that you don't know about...it could happen! What if the Doc outlined his careplan and the pt didn't like it and wanted it this way or that...that is a quick ticket out of an ER and back into the hands of their PCP to deal with. Maybe they did as much as the pt would let them or would cooperate with, and sent them home for follow up that is needed badly by their PCP.

Many sceneros, and even at times when I disagreed with the ER on my patients...I did finally find out that they were correct in their judgement...even though it didn't look like it at first or even second..LOL!

There could be deeper issues, like a pt that doesn't wish for this to be treated agressively (even though that is the best choice) and needs to be talked to by their PCP about hospice or transitional hospice. Maybe the treatment in the ER would eventually not be worth the risk to his life, and another plan must be formulated involving his PCP and family...you just never know until things...if they even do...come to the surface.

And frankly, before having hard feelings about the ER, try to see if you are interested in working in one or volunteering to do so for a day or two. There are so many different dynamics in that one place it is basically insanity most days! Understanding what an ER does and doesn't do may help you to discover why some residents with things you feel are vital aren't treated as agressively as you would feel needed to be done...I did, and I also did ride alongs with paramedics...I learned a ton, and now have knowledge of the different professions/departments and what limitations to be aware of in each (and how to overcome them sometimes). Very good knowledge to have!

[CHATSDALE]

Re: ER didnt treat our resident......

sometime the mds working in the er are not really emergency docs but just someone just out of med school trying to pay down school debts
i had a patient who was having seizures, constant petit mal, he was ordered valium im x1 q24 prn seizures if not effective to send to er. which i did er md returned him with notation that these were not seizures but were sx of parkinsons - i was familiar with pt and i knew that these were not typical of him - i called ambulance and returned him to er - er md called and called me incompetent and said that if i returned him she would personally have me fired...i told her i was following his md orders and if she wanted to call the primary i would give her his number - a few minutes later a nurse called to inform me he was being admitted

[TriageRN_34]

Re: ER didnt treat our resident......

Good one ER doc..now nurses are supose to dx seizures from Parkingsons? Ummmmmm...not that I am aware of or we would have MD's by our names and paid much more! LOL!!!!!!!

You saw a pt in trouble and knew they needed more help than you could provide...the MD was in the wrong, should be reported (because more than likely he is doing this to others!!!). You did exactly what you should, you do not Dx...and you needed to get the pt to someone who could and treat it!

Sheesh...I have had my share of arguements with MD's about my roles as a nurse, and the fact that I don't Dx or they would be out of a job or working for ME (since I am older and would have gone to med school before most of these younger ER docs! LOL!).

Story time...LOL!

I had the opposite once with a parkinson's pt once actually!

I had a woman that was having her typical bad day spells, and I had her lay down and made sure she got her meds/food/drink and rest. Unstable gait so I had room service for her..and did everything I needed to at the ALF we were in.

A family member freaked out, called the MD, and the MD chewed me out over the phone asking why I didn't call 9-11. I bluntly told him that since I had known the patient 4-5 days out of the week for 4 years, I have seen these occurances and know when it is different...and the pt did NOT want to go to the hospital and declined me calling the MD because "this is normal of a bad day, don't bother the doc...and for GOD'S sake don't send me to the ER again!".

He ordered emergency transport behind the pts and my back..and she was returned more fragile, tired, shaking and angry a few hours later. Nothing to really do...just as we told the doc..it was just one of her 'bad days'.

He finally called to appologize to me, which I found was shocking in and of itself (and called the pt too), and will note this in the future.

Then he faxed us with new orders and oops! Oh no...he wrote NPO???? Why NPO..crud! So I had to call him..okay he turned back into Satan and chewed me out and wouldn't believe me...I faxed it back and he saw he did...and called me back before faxing the new orders "I meant DNR".

I let him know that the two are very different...and considering I had been chewed out by him twice for no reason and stayed professional and to the point...I deserved more in future communications with him, or I would insist on having all the people in his care switch MD's (we had MANY of our residents seen by him) in order for patient safety and quality care/communications. AND HUNG UP!

He was a sweetheart to me afterwards..LOL!