Advice on a situation

JKL33 · Jun 3, 2018

now.. to my knowledge a lesion is considered cancer... right? Or am I wrong?

Wrong. Can be benign or malignant.

Beyond that, who can say what the deal was here. Sounds weird.

Now hear me out on this next part. :)

You must learn how to become comfortable talking about these things with the physicians. Just establish yourself as someone who is going to respectfully open up a conversation if you don't understand something. They will get used to it as long as you don't take the know-it-all route. It's really very easy. But whether it's easy or hard with your docs, you have to do it. Take a situation such as this where this outcome seriously did not make sense to you. Now it's true, maybe it's your own lack of understanding but it could be much worse than that - - - such as the doc accidentally doing the discharge on the wrong patient (i.e. a "in the wrong chart" sort of mix-up). If something really, really makes no sense to you, you have to put your concern about looking ignorant to the side for the moment and take the steps needed to ensure the right thing is being done for the patient.

Next time just approach and say, "Do you have a quick second for a question?" and "I just want to make sure I have this right..." or "Hey, before I go to discharge this guy, I just want to double-check - - is this liver lesion something I don't need to worry about?" or "Sorry if my question seems ignorant - - is this Cipro for a UTI? I thought I reviewed his labs and didn't notice any signs of one...?"

You've gotta do it! And I'm sure you can. :)

Take care ~

Editorial Team / Moderator · Jun 3, 2018

The DO diagnosed him with a UTI and discharged with a prescription for cipro.. UA showed no evidence at all of a UTI..

Did you actually perform the discharge teaching? Did your patient not question what he was hearing? So you would prefer to possibly participate in an error rather than approach a "hard ass" and advocate for your patient? JKL33 had excellent suggestions on how to broach the subject. When I worked with hard-ass docs, I would always open it with "Just for my knowledge, why are we doing XYZ?" If they do not feel like discussing it, that is too bad. Part of their job is to be part of the TEAM. Be a relentless advocate.

Just remember, those docs are busy humans who need us to make sure they are with the right patient, not giving the patient something they are allergic to, etc. (this happens less often with EMRs, thankfully). The patients are relying on us for this, too. I think once you start working on your dialog, you will get much more comfortable doing it and have a better time of it all the way around. Good luck!!

amzyRN · Jun 4, 2018

I would have asked the doctor about the liver lesion privately. Most of the docs I've worked with are very approachable and even if they weren't I would have asked anyway. Maybe the radiologist said it didn't look like cancer and communicated that to the ED doc, who knows. If I was doing the discharge I would have asked prior to discharging them. What you can still do is ask the doctor now about the case and see what they say. If I was worried that a patient was walking around with undiagnosed cancer I would say something just to make sure. I bet there is a reason why this wasn't addressed, but you should find out just to make sure being the nurse and patient advocate-right?

KelRN215, BSN, RN · Jun 4, 2018

now.. to my knowledge a lesion is considered cancer... right? Or am I wrong?

Wrong. A lesion CAN be cancer but isn't necessarily. A lesion is simply an abnormality or change in tissue. It can be something completely benign. In the radiology reports I've historically seen, usually the radiologist writes out the differential diagnoses for the lesion and those that are thought to be more or less likely.

trytounderstand · Jun 4, 2018

Did you actually perform the discharge teaching? Did your patient not question what he was hearing? So you would prefer to possibly participate in an error rather than approach a "hard ass" and advocate for your patient? JKL33 had excellent suggestions on how to broach the subject. When I worked with hard-ass docs, I would always open it with "Just for my knowledge, why are we doing XYZ?" If they do not feel like discussing it, that is too bad. Part of their job is to be part of the TEAM. Be a relentless advocate.
Just remember, those docs are busy humans who need us to make sure they are with the right patient, not giving the patient something they are allergic to, etc. (this happens less often with EMRs, thankfully). The patients are relying on us for this, too. I think once you start working on your dialog, you will get much more comfortable doing it and have a better time of it all the way around. Good luck!!

As a patient I would want you to ask. Sometimes the nurse is the only advocate a patient has. Sometimes the patient does not know the correct question to ask and look to the physician as the final word. In an emergency situation, patients and family members sometimes feel they cannot utter the word "why" or "no". They forget that they are in charge of their care that is their body and they have the right to ask those questions and to refuse until their questions are fully answered.

If the patient did not have an infection that needed an antibiotic he/she is taking something their body does not need which down the road could result in their body becoming allergic to a life saving medicine. Perhaps the patient needed a different test ordered.

Although you may have had to take some flack from a physician you may have gotten the patient further treatment rather than the patient going home without finding what is causing the issue. The patient may have also been referred to their primary care physician to get further tests ordered since the tests from the er did not give any results.

Stella_Blue · Jun 4, 2018

Wrong. Can be benign or
You must learn how to become comfortable talking about these things with the physicians. Just establish yourself as someone who is going to respectfully open up a conversation if you don't understand something. They will get used to it as long as you don't take the know-it-all route. It's really very easy. But whether it's easy or hard with your docs, you have to do it. Take a situation such as this where this outcome seriously did not make sense to you. Now it's true, maybe it's your own lack of understanding but it could be much worse than that - - - such as the doc accidentally doing the discharge on the wrong patient (i.e. a "in the wrong chart" sort of mix-up). If something really, really makes no sense to you, you have to put your concern about looking ignorant to the side for the moment and take the steps needed to ensure the right thing is being done for the patient.
Next time just approach and say, "Do you have a quick second for a question?" and "I just want to make sure I have this right..." or "Hey, before I go to discharge this guy, I just want to double-check - - is this liver lesion something I don't need to worry about?" or "Sorry if my question seems ignorant - - is this Cipro for a UTI? I thought I reviewed his labs and didn't notice any signs of one...?"
You've gotta do it! And I'm sure you can. :)
Take care ~

This hit the nail on the head. Being new to the ER myself I always try to ask the docs for clarification when something doesnt nake sense. I do this for two reasons one is to learn for myself and the second is in case the patient asks any questions I can answer them properly. I am fortunate enough that almost all of my ER group of docs are super nice and easy to talk to. I dont really care to look stupid, I just let it be known that I'm fairly new to the ER world and trying to learn what I can.

NurseBlaq · Jun 4, 2018

All the advice is good. You may think the docs are hard but may learn to appreciate what they have to teach. I've had docs who were super arrogant but when I asked a question about why they did or didn't address something, respectfully, they would be shocked for a second but then they would answer. I learned that most times they're excited that you took the initiative to ask. Everything misunderstood, such as your scenario, can be turned into a teachable moment. You learned the basics in school, however, I've learned the real education comes from working and everyone on the team has a lesson to teach. It can be the janitor, receptionist, doctor, or even sometimes the patient. I appreciated every lesson, good and bad.

Never be afraid to ask a question, especially if you have a valid concern.

Kooky Korky, BSN, RN · Jun 4, 2018

Some causes of RUQ pain - liver, gall bladder, gallstones, pregnancy, colon, IBS, diverticulum, appendicitis, AAA, renal, cardiac, pulm.

"Lesion" is indicative of neither malignant nor benign. It's just something noted, could be either CA or not.

Just take a deep, calming breath, remind yourself that you want to learn, remind yourself that you are making sure the doctor is looking at the right chart/patient/report, remember that you are protecting your patient, and ask your questions.

Start with "I am confused". In this case, "What tipped you off to UTI? I didn't realize a UTI could cause RUQ pain. Is this lesion of any consequence? Does he need to see a liver specialist (if the lesion is in the liver) or have any other follow-up? Should we do a culture and sensitivity on the urine?"

broughden · Jun 10, 2018

What's up y'all
so I am posting this for some advice and knowledge regarding a situation I had at work.
I am a fairly new ER nurse, 1 year experience but I worked as a firefighter paramedic for 10 years. I don't know everything but I know enough.
Heres the info:
33 y/o male with RUQ abdominal pain x 2 weeks.
Is nauseous but no vomiting. Blood work came back great. However the radiology did a scan and the impression given was a liver lesion. Abdominal CT scan done and the impression read the same and a liver polyp.
The DO diagnosed him with a UTI and discharged with a prescription for cipro.. UA showed no evidence at all of a UTI..
now.. to my knowledge a lesion is considered cancer... right? Or am I wrong?
I am wondering if the doctor missed this or if I am missing something. I didn't get to ask him because a lot of the doctors in the ER where I work are hard asses. I want to know for the knowledge aspect of it, not necessarily to question them.
thanks guys!

Frankly Im speechless that you let a patient walk out of the ER without discussing this because you think the doctor could be a "hardass."

If you wont advocate for your patient then who will?

You need to reassess your priorities.

TuxnadoDO · Jun 11, 2018

Hi there :) I'm an ER doc and thought I'd give my POV. You've gotten some GREAT advice already! As long as the doctor you're dealing with isn't a total a-hole, you should be able to approach him/her and ask about these things in a respectful manner without getting any attitude back. I love the suggestion of asking "What tipped you off to the UTI?"

In regard to your patient, without seeing the UA I can't really say for sure, but I think UTI's are overdiagnosed and used as scapegoats in people with abd pain.

About the liver lesion -- it's a little weird in this case because his pain was in the RUQ, so without knowing what the read said exactly, it's hard to know if it was clinically relevant. We do see some liver lesion on a fairly large proportion of the CT's we get, and they are almost always asymptomatic, incidental findings. Livers love to make benign lesions for some reason. The most common ones I see on the CT read are hemangiomas, but there's also focal nodular hyperplasia and adenomas. Sometimes the radiologist will say what he/she thinks it's most likely to be, sometimes they aren't too specific. It's my practice to put this on the diagnosis list and explain it to the patient, but I've noticed that if the radiology read is saying it's a benign lesion, sometimes doctors won't take the time to explain it or put it on the diagnosis list. The fewer "thingamajigs" on the CT read, the more likely it deserves to be on the diagnosis list and explained to the patient (in my opinion). In the case you mentioned, if it were me and I forgot to put it on the diagnosis list, I would be thankful if you caught it!

When you said polyp, could it have been a gallbladder polyp? I've never heard of a liver polyp.

But anyway, there's always a polite way to ask. I LOVE when the nurses ask me about stuff, I think it brings us closer together as a team.