first of all sorry i didn't spell reason right in my title.
to make a long story short, i had a patient who needed abdominal surgery. the patient did and because of other reasons ended up staying for a good length of time. after 4 days the abdominal incision came open a very tiny amount...not much to worry. unless you consider that the wound had been closed for 4 days and the patient had been up and down out of her beed several times a day. then it came open more and more. over the period of 5 days the wound went from approximated to 2 inches wide and tunneling 1.5 inches deep. at discharge no granulation tissue had formed...in fact slough had in some areas, and the wound was still continuing to get bigger. the patient had no underlying diagnosis as to why she would have dehisced in the first place. i work nights so i don't know what the doctor was aware of. i do know i told the shift after me and documented. i knew that when i would give or get report the nurse would say something along the lines of, "they need to quit messing around with this wet to dry dressing change and take her back to surgery and see what is wrong!" i also know that it is the mds responsibility to look at the wound every day. i knew when this patient got discharged that the patient would be back very soon. a few days later the patient was. the patient had to have surgery to repair a bowel that got nicked in the first surgery. the patient is again having complications in a stay that should have never occured had the proper action been taken before the patient was discharged. i told the patient that i did not believe that the patient should agree to pay for the second stay. i'm sooooooooooooo angry about this! do not missunderstand. mds make mistakes and a nicked bowel is a potential of abdominal surgery. i'm mad because to me it was obvious that something was not right and the md should have taken her back to surgery to find the problem before she left. now i'm going to have some of you chastise me for saying anything to the patient, but when do we stand up for the patient? i'm not saying that the patient should sue, i'm just saying that the hospital personnel didn't catch something that should have been caught and thus the patient should not have to pay for the second visit. all we do is cover the hospital's butts for providing patients with sub standard care through poor doctor to patient and nurse to patient ratios. (hospitalists work for the hospital...surgerons and other mds are different i know.) how can anyone feel good about doing this job? the definition of a nurse is: a person who cares for the sick or infirm; specifically: a licensed health-care professional who practices independently or is supervised by a physician, surgeon, or dentist and who is skilled in promoting and maintaining health according, to the merriem-webster dictionary. we don't give care, we tick off tasks and allow doctors to intimidate us and/or talk down to us in a manner that damages our confidence in our skills.
this is the worst profession anyone one could choose to go in to mostly because you are damned in most any course of action you take. you stick up for the patient you get a bad wrap for being hired at hospitals. you tell a doctor who is being a piece of poo to you or your co-worker to back off and you get told by management that you need to work better with people. not to mention that patients can just walk all over you if they feel like it because we are there to provide them with "customer service". i also love all the stories that i read in my nursing board bulletin where a hospital gets sued and suprise, suprise it's the nurses' fault and not only is she/he getting fired but their license is also on probation or revoked. and when i read these stories i clearly see where the nurse is being held responsible for something that i would assume is the doctor's responsibility or that the hospital was making the nurse do some sort of stupid hospital activity that interfeared with the care he/she was giving....not to mention the ones that just sounds like the nurse had too many patients but was probably afraid to say anything because then she could a) get fired b) get accused of patient abandonment or c) be reprimanded for not being a 'team player'. futhermore something like 80% of the stories i read that are not about nurse drug abuse make me feel this way. nursing is not a profession, it's bullying made legal.
Sounds like you passed the buck. Not cool. I agree with several of the previous posters. Don't bash the nursing profession because of this situation. In this instance, I don't think you were advocating for the pt in the way you should have. If you catch something like this, it's your responsibility to bring it to the attention of the MD. When it was all said and done, you could have potentially saved this pt's life. That's pretty powerful.
You caught a change in condition; great. Did you notify the attending? If not, you're part of the problem. Sorry to be so blunt, but if you think nursing is a bad choice for a career because of poor communication, well, how did you contribute to the problem?
Did you read the doc's notes? No, why? Why should he read yours if you don't read his? Just saying that this is a give and take, and there is no reason for you not to notify the physician immediately of a dehis. The physicians apparently overlooked it, too, or didn't take it seriously, but you didn't help matters by not contacting *anyone*.
I screw up on a regular basis, too. Instead of throwing a fit about how terrible my job is, I evaluate what I did right, what I did wrong, and how I can do a better job next time. Rather than using this as an example of why you need to quit nursing, why not use it as a learning opportunity? What did you do right (assessing, documenting)? How could you have been a better advocate for the patient? How could you have contributed to the miscommunication? What will you do if a similar situation arises?
You are right that we have a responsibility to the patient. It is our job to advocate for them. It is not your job to tell a patient what the MD or any other health professional taking care of them should or shouldn't do. Those are things that you address with the other person and if necessary, you address them with administration. Even though you worked night shift, if you were unaware of what the doctor knew or didn't know, you should have contacted the on call doctor about the wound. Had they documented anything about it? What were they writing in the chart every day that they assessed the wound? If you thought the patient needed an intervention, you should have made that happen. You follow the chain of command until you get the results that the patient needs. Does this irritate people? Absolutely, because noone likes being told what to do. However, you are an advocate for the patient. It is your job. The best nurses are often the ones that doctors and other staff don't like, but they are the ones that make sure they advocate for their patients.
I agree with everything until the last sentence, lol. I'm the best nurse I know and everyone always likes me just fine, lol.
Anyway, OP, I agree with the heart of the sentiment. If you thought something was amiss, you should have followed up. My guess is the surgeon would have provided a perfectly sound rationale for his/her decision making and put you at ease, and you would have learned something. Surgery is about relative risk. Without knowing the bowel had been nicked, prudence probably dictated a wait and see approach.
Oh, and you are right, you know it is completely inappropriate to suggest to a patient that their course is atypical and warrants failure to pay. I hope you wont do anything like that again. Bad form.
My sister-in-law just gave birth via c-section and was sent home after one day. She came back one week later because she was VERY VERY ill and it turns out the wound was infected. She went to the ICU and it was amazing she lived through the first few nights. She needed a wound vac and all kinds of care. Turns out, the hospital has changed a few of their policies to include not sending home c-section patients so quickly. Had they not been so eager to get her out the door, they would have caught this almost deadly infection.
Seems to me like hospitals are too eager to get people in and out of the door.
I'm not sure if it's the hospitals eager to discharge quickly or the insurance comanies refusing to pay for more than the most minimal stay possible. Either way, I would have called the Dr, probably would have gotten yelled at for calling at night for a problem that should have been addressed during the day, but then, I'm used to that (I work nights too).
I did not call the MD because I knew he was aware of the dehiscense. Like I said in my post this was a wound that was closed for 4 days then gradually began to open over 5 days prior to the patient being sent home. This is not a case where in the period of one shift the wound went from closed to dehisced. Of course I would have called for that. Yes, I and all the other nurses were documenting the changing amounts of dressing needing to be used for the wound. The problem with calling is that I had nothing to call about. There was no visual change between the beginning of my shift to the beginning of another. It was over a period of 5 days that this occured. I don't know what was said to the doctor on days, I do feel from what I've heard from the day and evening nurses that the doctor was aware. I also know from the patient that while the MD didn't look at the wound himself everyday he did look at it before the patient left. I'll call a doctor at whatever time I think it needs to be done in this particular instance the I felt that the A) the change to the patient wasn't something that warrented me calling the MD and more of a concered to pass on to day shift B) From the progress notes I feel that the doctor was aware the wound was getting bigger c) I'm a traveling nurse and could give a rats butt if any of the MDs likes me. I made reference to doctors being verbally abuseive because it happens ALL THE TIME and NONE OF US DESERVE TO BE TREATED THAT WAY. And yes, this 'profession' is still crappy and not professional at all. I wanted to care for people so much when I got out of school. I was misinformed that nurses and doctors actually did some form of caring.
For all of you who have posted about your level of unhappiness with nursing, it is discouraging to hear what many floor nurses endure. However, as a suggestion, don't give up on nursing all together. There are soooo many avenues that you can take with the wealth of knowlege that you have from being a nurse! I only worked on a floor six months before I got out and was on an AWESOME floor with great ratios and superior managment. If floor nursing isn't for you, find something that is. You have more skills and knowledge than you think! Find a job that will appreciate you.
Specializes in Tele, Stepdown, Med/Surg, education.
I did not call the MD because I knew he was aware of the dehiscense. Like I said in my post this was a wound that was closed for 4 days then gradually began to open over 5 days prior to the patient being sent home. This is not a case where in the period of one shift the wound went from closed to dehisced. Of course I would have called for that. Yes, I and all the other nurses were documenting the changing amounts of dressing needing to be used for the wound. The problem with calling is that I had nothing to call about. There was no visual change between the beginning of my shift to the beginning of another. It was over a period of 5 days that this occured. I don't know what was said to the doctor on days, I do feel from what I've heard from the day and evening nurses that the doctor was aware. I also know from the patient that while the MD didn't look at the wound himself everyday he did look at it before the patient left. I'll call a doctor at whatever time I think it needs to be done in this particular instance the I felt that the A) the change to the patient wasn't something that warrented me calling the MD and more of a concered to pass on to day shift B) From the progress notes I feel that the doctor was aware the wound was getting bigger c) I'm a traveling nurse and could give a rats butt if any of the MDs likes me. I made reference to doctors being verbally abuseive because it happens ALL THE TIME and NONE OF US DESERVE TO BE TREATED THAT WAY. And yes, this 'profession' is still crappy and not professional at all. I wanted to care for people so much when I got out of school. I was misinformed that nurses and doctors actually did some form of caring.
Well Kalipsored, what do you want us to say? You were so right honey, that surgeon was an evil idiot who didn't know his orifice from the patient elbow. Thank god you saved the day!
KalipsoRed, I understand your frustration. I also get what some of the other posters are saying. We nurses should not have to draw swords with medicine but sometimes we do. And when we do we always run the risk of getting our butts chewed. That's just not right, and yes, I do think we are in a bind. Darned if we do and darned if we don't. No matter what, the nurses are always judged to be in the wrong. We are treated as just expendable, like extras in a movie, and so we think of ourselves that way. Some physicians don't deserve to have a license, and neither do some hospital administrators. One of my personal physicians, in a moment of frustration, confided that a local hospital had sent him and the other admitting physicians forms they wanted signed, that gave the case managers the power to automatically discharge a patient the minute their length of stay reimbursement was up. Come on!@@@!!!
That being said, I don't think we should ever carry it to a patient and tell him or her their care had been suboptimal. That damages the patient's ability to trust the doctor and the hospital, so it is not professional, no matter how richly deserved the remark might have been. We can blame anyone we want as nurses, and we do, but the real blame lies within our own profession. We could change things. We have the knowledge, the skill, the power, and the numbers. The hospitals and the doctors need experienced nurses, even if they pretend they don't. If we stuck together as a group, we would be unstoppable. But we don't, and that's what makes me pull my hair out and say yes, nursing is a bad career choice. We ourselves have made it that way.
I want us to be able to say we are sorry to the patient, Lineartlinker. I'll go in on the blame with everyone, I'm alright with taking my share of responsibility for something that fell through the cracks. No one 'saved the day' in this situation and that's what I'm tired of. This happens all to frequently.
The other things unrelated to this particular incident (the verbal abuse, poor pt ratios, etc.) are just icing on the cake and things that make situations like the one I described possible. What I don't understand is why we let ourselves get craped on over and over again? Not only do we do that, but we tell new nurses that are less willing to play by these rules that it is part of their job to put up with this crap. I want a rally. I want to feel like things are improving instead of getting worse. I'm looking into lobbying and such because these conditions have to change.
Welcome to nursing! And welcome to the role of playing advocate for ur patients.
Aside from the nicked bowel, this patient should have been completely RESTING after abdo surgery. You do not go walking around after a few days! Wounds dehisce quickly - I've seen it happen in front of me - and it's not pretty. I would have been confronting the surgeon and saying you REALLY need to get this patient back to surgery, or for a scan or something to see what's going on.
You do have to be a bit aggressive as a nurse and stick to ur guns. And yes it is a VERY hard job.
ADD: Some patients MAY get up with the physio and walk around the room only - depending upon doctors preference, and the patient's condition - after a certain time period, but certainly NOT wandering up and down the corridors. That is a recipe for disaster.
kool-aide, RN
594 Posts
Sounds like you passed the buck. Not cool. I agree with several of the previous posters. Don't bash the nursing profession because of this situation. In this instance, I don't think you were advocating for the pt in the way you should have. If you catch something like this, it's your responsibility to bring it to the attention of the MD. When it was all said and done, you could have potentially saved this pt's life. That's pretty powerful.
