Are we professionals?

i am currently in my post-master's program for psychiatric mental health nurse practitioner (am an fnp already). this is a journal entry i just did for school..........

i spent 12 hours with an aprn that works on an in-patient neurobehavioral unit. she does admission assessments and does rounds on the weekends. one man in particular that we saw this week was involved in a situation that makes me realize something.

in school as a student and as a teacher (at the associate's nursing level) we discuss stigma and how many with a mental illness diagnosis get brushed aside by our society and do not get treated as well as others. we, as professionals, us doctors and nurses don't of course adhere to that standard. we are talking about 'other' people, people that are not professionals like we are. we, of course, always treat people the same, regardless of the diagnosis under the name. we are held to a higher standard and we uphold that standard. when we "tut, tu"" and say, "oh that is so sad and too bad", or "it shouldn't be that way" we are talking about 'other' people.

the man i am talking about was in his early 50s and had a history of a severe bipolar disorder. when he gets manic, he walks. he walks for miles and miles without regard to anything. he doesn't eat, he doesn't sleep, he walks until someone can stop him and take him to a hospital. so he had been manic for a while and finally someone brought him into an emergency department. he was in a tank top, shorts and sandals and was there for a few hours (5-6) before he could be sent to the neurobehavioral unit.

we saw him for an admission assessment around 9:00 am, about 4 hours after he arrived on the unit. he had been given some medicine to help slow him down and calm his racing thoughts so i was able to do a thorough physical, mental, and mini-neurological assessment on him.

he was terribly sunburned from head to toe and when i got to his feet i saw 7 open areas. three on one foot and four on the other. these were all erythematous, oozing under the eschar. they were swollen and exquisitely tender to the touch. he had a wbc count of over 23,000. we called for an immediate consult with a podiatrist. he came over right away and began to provide care for the man, spending quite a bit of time with him in his room. when he came out he stated he believed the man was developing osteomyelitis.

i wondered how we missed this on report and as i am always trying to make sure i am learning and paying attention i opened his chart. i went to the back to the section that would hold the ed report. i found the nurse's admission assessment form and then the physician's assessment notes.

this is what i found documented on the nurse's notes:

skin: warm, dry, intact. extremities: wnl, moves all extremities without difficulty, pedal pulses present, no edema noted.

on the physician's report it stated that the physical exam was without abnormalities, (again) skin warm, dry, intact, ble without edema, ppp.

remember what i said above? he was in a tank top, shorts and sandals! there were sun burn marks in the shape of his sandals on his broken and damaged feet!

these are professionals working in an ed. nurses and doctors that typically pride themselves on being able to assess any situation and be prepared for whatever they find. emergency department providers probably see as much "psych" as an inpatient mental health unit (i know because i work as an rn in the ed on the weekends). and yet, we professionals, that 'tut, tut' how others marginalize the mentally ill, and talk about 'stigma', won't even give them the courtesy of a half hearted assessment beyond, "oh here is a psycho, how soon can we transfer him?"

i am ashamed of many in this profession. i know it is not everyone. however, i am in a particularly good position to see these things. i am still working as an ed nurse on the weekends, i am a new aprn working one day per week as an fnp in a clinic, and i am a post graduate student with several years of in-patient mental health experience (as an rn) doing my internship. it is very evident to me that we marginalize these people, we stigmatize them and we provide less than optimal care.

and in the end it is not about them, it is about if you hold yourself to a standard. i don't like every patient i provide care for, nor do i agree with all choices of lifestyle, or how people take care (or don't) of their kids, or how many drugs a pregnant woman can have in her urine, but.....i am a professional and it is about how i conduct myself. i will do an excellent assessment for every patient i provide care for and not because i think they do or don't deserve it, but because i am a professional.

welcome to psych. the patient could be covered in chicken feathers, missing a limb and have four gunshot wounds. however, if they have a psych diagnosis then its whatever it takes to move them to the psych unit (regardless of whether there is an active psych issue or not). i've seen it across a number of ers in multiple states. you always have to do a good physical exam for exactly the reasons you noted above. my favorite was the patient "faking chest pain" who had a 12 lead done by the triage nurse. i asked the er physician how the patient can "fake" st elevations. that led to a rapid reassessment.

david carpenter, pa-c

In my many years of experience, as soon as you're identified in the ED as a psych client, you could be bleeding from every orifice and that just doesn't matter -- the only thing anyone cares about is turfing you out of the ED as quickly as possible. If they have to "fudge" the facts to make that happen, well, all in a day's work ...