[MikeyBSN]

Hi, I'm a fairly new ER nurse and I came across something that bothered me today. I had a patient, patient X, who came in by EMS. The patient had a massive L eye contusion, L nares bleeding and "split" L lip. Pt stated that they sustained the injury in a "trip and fall." There were no abrasions to the hands and not injuries other than the face. I confronted the pt about the inconsistancy but the pt continued to state that they "fell." The first thing the ER attending said to me after examimiing pt X was, "I don't believe 'pt X.'" So we worked pt X up as a syncope. It turns out the pt had a subarchnoid bleed. Should I have done something different? Should I have called up the cops? Would it do any good if the pt was to stick to the story that the pt gave repreatedly? Any advice? It was all rather frustrating.

Thanks

[CritterLover]

How old is the patient? Are they their own responsible party (sign their own consents, capable of making their own decisions?) Was their anyone around them "hoovering," answering quesitons for them, not letting them be alone?

If the patient was a sane and rational adult, capable of making his/her own decisions, and you didn't detect that there was someone else present, trying to keep him/her from telling you the truth, then there really isn't much you can do about it. Even if he/she is lying about the mechanism of injury, they are allowed to do that.

However, once the SAH came into play, it doesn present a little bit different story, if you think his/her judgement might be impaired because of it. Was it a big enough bleed to have an impact on his/her judgement?

If available, you might have called social work to come and speak to the patient to see if he/she would open up.

On the other hand, if this was someone who really couldn't protect his/herself, then I would have called APS/CPS and/or the police.

[ERNP]

They aren't even required to give you their real names. They usually do because it makes it easier to bill their insurance. But I could wander down to the local ER and tell them my name was Mae West and they would have to register Mae West as a patient.

[TazziRN]

As nurses we are mandated reporters for any kind of abuse, obvious or suspected. It's easy to pick up the phone and call law enforcement when it's obvious, but it's harder when your gut says one thing and the pt says another.....what if you're wrong?


But what if you're right?


Something that a more experienced ER nurse told me once: "If you make the call and you're wrong, all that happens is the pt might get p***ed off at you. But if you're right and you don't make the call, someone could die."


I have seen injuries like what you describe from a fall....a fall down the stairs, no less.....that produced no injuries anywhere else, but it's not common.

[MikeyBSN]

The pt was a mentally competent adult.

[ERNP]

If mentally competent, awake, alert, and appropriately oriented... reporting a fall, then I think you have to go with fall as a cause of injury at this time.

I see this very often and when I am suspicious I just spit it out. I tell them that I hear what they are saying but I don't completely buy the story. Then I tell them that if they decide they want to tell me anything else, just ask for me. I tell them that help is available if they need it and I will help them get that help.

In a competent individual, making a conscious decision to lie about the cause of his/her injuries, there aren't a lot of options.

[RealNurseWitch]

Yeah, I agree with the above... you could have just straight up said to the patient "I don't believe what you are telling me" and then the ball is in their court. Then can just get ****** off and say "I TOLD YOU, I FELL!!!", or they can tell the truth, that someone beat the crud out of them.

If the patient was indeed fully competent and oriented x3, and they stuck to their story that they fell, then I don't know if you are *legally* obligated, at that point, to report that you suspect abuse. But you probably might have wanted to at least confront the patient and let them know that if there were anything more to their story, you wanted to know about it.

You are new and you still have a lot to learn. Stuff like that is hard. I am a new psych nurse and I have to ask all of my patients if they are being abused or if they have been abused, and it's still hard. Actually, I had to ask all of my Med/Surge patients similar questions as well... it's a hard subject to approach, but one that we as nurses have to learn to face and help our patients deal with and get help with, as much as possible.

Good luck. Like I said, you are still learning the ropes. You'll do fine.

[RunnerRN]

Another way to approach it in the future would be to simply say "You say that x happened, but traditionally when x happens we see injuries xyz. You don't have those injuries." And see what the pt says. Sometimes they're afraid to recount the first story and go with the real one, so you have to give people an out.
But I'd say you did what you could.

[Angie O'Plasty, RN]

I always tell any patient while completing admission paperwork, "If any of these answers change at any time, I or any of the nurses can help you with it."

If a patient hesitates with any of the answers, I repeat my statement using a tone and attitude that is one of acceptance, not one of just trying to get through the admit.

I've had several patients change their answers, one of whom was a patient who had self-mutilated in the hopes of committing suicide.

Men especially have a hard time admitting they've been abused, especially if the abuse occurred from their SO. The worst part is, these men have very little resources to escape the relationship or get appropriate counseling. Very sad situation.

[emtrachel]

Hopefully, the EMS crew that brought your patient noticed the same inconsistencies as you did (great job by the way!!!!!!). Where I work as an EMT, if we notice (or suspect) something to not be right, we communicate any pertinent info to the nurse caring for the patient. We also carefully (objectively) document scene conditions in our patient care report, which is faxed to the ER to be put with the patient's ER chart. Although patient care is an EMS crew's primary duty, ensuring scene safety is the absolute first priority, and that includes being completely aware of the surroundings and the people around. If abuse has occurred, the perpatrator may be on scene, and the interaction between the patient and others on a scene may hold clues to what actually happened. Also, the environment might hold a clue. And unfortunately (or fortunately in some cases) the ER staff will probably never get to see this.

Anyways, what I'm trying to say is that both the EMS crew and the EMS report might be of assistance in determining whether an abuse condition occurred of if the inconsistencies in the patients story and injuries could be due to the head injury. It can be a tough call sometimes.