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Dr. complaint

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by Kavikziggy77 Kavikziggy77 (New) New

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BostonFNP is a APRN and specializes in Adult Internal Medicine.

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Hi,

thanks for the responses; I appreciate it. To shed light on the incident in question, here are the details.

I work in a long term care facility. I had a woman who has advanced Alzheimers that I sent to the ER for a query bowel obstruction. It is the ER doctor who filed a complaint; in fact he was FURIOUS that I sent her! My reasoning for sending her was:

- No one had witnessed her having a bowel movement in 11 days.

- Her abd was distended, and she was guarding it. She hit me when I tried to touch it.

- I couldn't hear bowel sounds in the LUQ.

- She has been given suppositories 2 days in a row with no result except a hard marble sized poop. When I came on my night shift the following night no one had yet to give her an enema. We normally give supps/enemas around 6:00 in the morning but she had woke up around 2am screaming. After almost 2 hrs of screaming I figured she was probably uncomfortable d/t constipation and decided to give her the enema at 4am thinking it would give relief. I did not get much of a result so I was concerned.

- I tried paging her doctor twice (before and after enema) but he never answered.

- For the last 3 days she had straining on the toilet complaining of pressure.

- She was screaming in pain and I had nothing left to give her. I just felt like I had no other option but to send her.

Please be honest. Was I wrong in sending her, as the doctor furiously suggested?

The ED docs job is to see the patients that walk through the door, not to judge the reason why they are there. The only valid reason the ED doc has to be upset is if she had a "do not hospitalize" order.

If she was screaming in pain then she needed to be sent. It sounds from your description that she was constipated and could be treated in the facility, which is better for her AZ, but if she had that kind of pain she needed to be seen urgently. Your job isn't to diagnose her and you seemed to have done the right thing, so unless he's complaining that you sent out a do not hospitalize patient to the ED then I wouldn't worry at all.

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3,726 Posts; 23,845 Profile Views

I don't think his complaint as described is justified but I do think he would be reasonable in complaining about the patient's lack of management preceding this avoidable ED visit.

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1,718 Posts; 17,831 Profile Views

Generally speaking, do the right thing, document what you did, and don't be overy concerned about Dr Complaint. From your post, I thought that was his name.

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3 Followers; 5,651 Posts; 27,503 Profile Views

It amazes me that you would think you could lose your license over this. Where is this irrational fear coming from? I see it ALL THE TIME here on AN, so I'm not necessarily just referring to the OP.

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NurseGirl525 is a ASN, RN and specializes in ICU.

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It amazes me that you would think you could lose your license over this. Where is this irrational fear coming from? I see it ALL THE TIME here on AN, so I'm not necessarily just referring to the OP.

This.

You were not negligent in patient care, nor diverting meds. That is why you would lose your license. I would honestly roll my own eyes that the doctor did that. He probably just didn't want to disimpact her.

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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To begin with, your job and your license are both safe. Completely so. You did what is within your scope of practice and nothing else.

Now, let me explain the view from the other side:

ER docs are, in fact, responsible for who and how comes to ER and especially for what happens next. It is complete truth that people come there with small bruises and such; it is also complete truth that it is the ER who is responsible for intricate work of admission/readmission/compensation/etc. For some particular types of ER, getting a senior who needs at least 24 hours admission, cannot be observed because clinical observation "doesn't do" sitters, disimpactions, etc., cannot be restrained due to lack the bed in units which do restrains, etc. is a pickle of quite a size.

Now, if you tell the ER nurse exactly what was written in the second OP post, it would look completely justifiable for her, but definitely not so for a physician. Nobody saw patient defecating for 11 days, but there was some hard stool seen indeed... so, she did poop, and exactly of the kind that was expected. We might have some schmolicy about "only giving suppositories/enemas at 6 AM" and have to live by it but, trust me, from a physician point of view it sounds like complete idiocy. There were no nausea, no vomiting, no signs of dehydration. And, in addition to that, the first thing the doc was anticipated (quite rightfully) to see was the LDOL yelling upon every touch. Now, he had to find her a bed in a unit with enough staffing to reasonably prevent her from falling and where nurses are "comfortable" with her (good luck with that) and talk someone into disimpacting her, probably under general anesthesia (good luck with that as well, both GI and anesthesia will not be pleased. If he had residents on his dispatch, then he at least got some hands onboard, but not all hospitals have them).

So, the doc was totally pissed off... and deep in my heart I feel for him too. A little bit, that is.

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I get that an ED doc could file a complaint about a patient who was brought in as the Advance Directives were DNR/DNI/No extraordinary measures/Do not hospitalize but I had no idea that one could be filed for sending a screaming-in-pain patient who hasn't had a real BM in 11 days! He should file a complaint against the facility for letting it get that far. That's negligence.

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LPNtoRNin2016OH has 5 years experience as a LPN and specializes in Allergy/ENT, Occ Health, LTC/Skilled.

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[COLOR=#000000]From all of the details you have provided, it would have beena questionable nursing judgement call if you did not send her. I wouldseriously blow this ER doctor's complaint” off, it's not like you can bepunished if you accurately documented everything, for being on the safe side.The only step I could see adding is calling the patient's POA if they areunable to make decision for themselves. But to me, DNR does NOT mean let themdie screaming in pain. If your on call does not answer, there is nothing elseyou could have done.[/COLOR]

[COLOR=#000000]That stuff REALLY irritates me but we have that problem withour town's ambulance company. I had a similar situation, different symptoms, butone of my DNR patients. If it were me, I would have kept him at the facility,but the wife, his POA, wanted him to go to the hospital. So per our facilitypolicy, I have to send him since he was no longer able voice his ownconcerns/opinions on the matter. The paramedics were literally complainingabout it in front of this patient's wife, who was crying, that he didn't needto go to the hospital. Because, ya know, sometimes doing your job means its notalways going to be a super exciting accident. We had words once the patient wasloaded and wife was out of ear shot and I called their superior. It's not up tothe ER or to the paramedics to judge the reasons they are there, they need to zipit, and do their job. [/COLOR]

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mrsboots87 has 3 years experience and specializes in Neuro, Telemetry.

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I had a little old man who had been stooling a couple times a day since I had him. He was sick after a fall and broken hip but still stooling normally. He had to get sent out for fever and very high sugars that would not come down with meds. While at the hospitals he developed and impaction so large he needed surgery. This took 5-6 days. He went septic while in the hospital after his wound dehisced and he developed a fistula. By the time we got him back 3-4 weeks later, he was never the same and he died a few weeks after that.

While I don't blame the hospital staff for his umpacrion because he was a sick man, 5-6 days was all it took. Your LOL went 11 days without a good solid vowel movement. You were within good judgement to send her out with all the symptoms you listed. ER doc can suck it for you being concerned. I would have attempted to get more bowel meds above our bowel protocol in board for a day first. But it sounds like other people in your faculty dropped the ball if it took 9+ days to even start bowel protocol. In mine, we start at 3 days. Supp and enema are given at day 4 -5. Disimoaction would usually be ordered after that. We have never gotten to disimoaction while I've been there. Your license is fine and likely your job as well.

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BSNbeDONE specializes in Med/Surg, LTACH, LTC, Home Health.

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I probably would have asked for double dose of Miralax, 200 colace, 2 senna tabs, and another enema before sending ... but you weren't wrong.

The OP probably would have asked for something 'extra' had the physician answered the darn phone. I've worked long term care many times, and the straw with LTC for me is when a physician hung up on me one night as soon as I identified myself and where I was calling from. Administration did nothing about this, either. It was known and acceptable behavior for that physician to disengage after-hours regardless of what was going on with the resident. So, I decided to no longer be a part of their practices.

It just angers me to know that physicians are so eager to accept federal funding for/from these folks, yet refuse to be contacted whenever they have issues. Nurses are responsible for these residents only for 8-12 hours a day. The LTC facility's physician (unusually only one), are responsible for them 24-hours a day. If they don't like the hours, relinquish the job to someone who wants it.

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mmc51264 has 8 years experience as a ADN, BSN, MSN, RN and specializes in orthopedic; Informatics, diabetes.

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Ultimately, I would not want a ruptured bowel on my hands.

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Ruby Vee has 40 years experience as a BSN and specializes in CCU, SICU, CVSICU, Precepting & Teaching.

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When physicians make a complaint, your manager is supposed to judge the validity of the complaint, hear both sides of the story and respond accordingly. Usually, my managers have backed the nurse in question -- UNLESS the nurse was already on shaky ground and they were looking for a reason to get rid of him or her.

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