Questioning a Docs decision...long

PedsER-RN, BSN, RN · Jun 12, 2006

I am in a moral dilema... I work in a small (10bed) ER and yesterday we had an elderly man >70 come in after a fall at home. Pt family stated he had been uncons. for about 10-15 sec. but awoke AOx3. Brought him to us for large lac (3") repair and to be "checked" Doc did facial X-rays, (no C-spine, no CT). After lac repair we sat the gentleman up, gave him an oral antibiotic, and then walked him with assistance about 50 feet and were preparing him for discharge when he became nauseous, vomited about 100cc of clear fluid and c/o headache. The doc was notified, we were told to "discharge him, we need the bed.":angryfire (end of nights/start of days) I was assigned to him, or, him to me if you will, and I was not happy. I have only been an ER nurse for a year but 20+yrs as a paramedic and did not "feel right" discharging him especially after the vomiting...Kinda classic. Long story shortened. He was back about 6hrs later, GCS of 9, CT'd...subdural bleed. As we were prepping him for flight to a neuro unit, the recieving Doc wanted a C-spine...fx of C-3 C-4, non-displaced. The day shift Doc was going ballistic, wondering why this man had not been kept as 23hr obs at the very least.:trout: My question...Should I have been more forceful in reminding the Doc of the S/S of a subdural?...I feel bad that this man/family have to go through this. Any advice appreciated (constructive advice) THANX........ Emsboss

I don't think you should have had to go over the s/sx of a subdural bleed, but you might have mentioned it to the doc: "this guy's acting like he has a subdural", or "I'm really not comfortable sending him home like this", or something to that effect. I would also let your CN know the situation, and DOCUMENT everything. Ultimately it's not up to you what happens but if you document that you relayed concerns to the doc, the CN, and what happened, it can't be pinned on you. I once had a pt (about 5 y.o.) with sat's in the upper 80's after 3 tx and the doc was going to send him home. I had only been a nurse about 18 months, but I didn't hesitate to speak up and have HIM go explain to mom why he could go home (I sure wasn't going to try to convince her that her son was OK)....after me talking to him and then when he went to see the mom (who was very upset with him), the child was admitted.

I know how it feels to be relatively new...you don't want to seem like you're telling people how to do their jobs, but when it comes to situations like this, remember that you're the voice for the patient. If you don't feel comfortable approaching the doc, enlist the help of your charge nurse. Good luck.

PedsER-RN, BSN, RN · Jun 12, 2006

You have the right to refuse an order if you believe that carrying it out would be detrimental to the pt. I have done that. I've told the ER doc "I am not comfortable sending this pt home because (insert reasons). If you will not do XYZ or call the pt's private doc for a consult, YOU can come discharge this patient."
If you do not have back up from the house supe, you can tell her the same thing. I hope that in this case that doc and the supe are squirming in their shoes when they look at you.

:yeahthat:

Tweety, BSN, RN · Jun 12, 2006

In this case, documenting might not be enough. An RN in the ER (New orientee or not, a supervising nurse should be available in that case), should be able to interpret nausea and vomiting in a head injury pt. as a sign of possible complication and immediately institute the supervisory tree if your observations were not heeded.
The Nurse Practice Act does not excuse you because your documentation was spot on even though the pt. was treated inappropriatly. The Nurse Practice Act demands that as a reasonable and prudent nurse, you intervene in a situation you clearly recognize as inappropriate. If you have gone through the "Tree", and the decision was still made to d/c, then you are off the hook.
I don't want to make judgements here, but if you think something is wrong, it often is, and as nurses we just HAVE to listen to the niggling voice in our heads. You are smarter than you think.
I have had the experience of being cowed in the face of "greater expertise".
Once was enough.
Cate

Agreed. If after reporting the s&s the doc said "d/c home we need the bed", the BON would be looking for utilization of the chain of command: charge nurse, house supervisor, risk management, etc.

Also, there is nothing wrong with adovcating for your patient the doc to his/her face, "I'm not comfortable with this discharge, can we at least CT his head first?".

Nurses are not required to blindly follow doctors orders that we feel are not in the best interest of the patient.

emsboss · Jun 12, 2006

THANX for the replies and encouragement...:monkeydance:

ern91 · Jul 7, 2006

1. A NURSE HAS THE RIGHT AND THE RESPONSIBILITY TO REFUSE TO

DISCHARGE ANY PT DEEMED INAPPROPRIATE FOR DISCHARGE BY THAT

NURSE.

2. USE YOUR CHAIN OF COMMAND IF YOUR DECISION IS QUESTIONED AND BE

PREPARED TO BACK UP YOUR DECISION WITH SOUND CLINICAL RATIONAL

3. CONSIDER REPORTING THIS PHYSICIAN TO THE APPROPRIATE AUTHORITY

4. CONSIDER EMPLOYMENT ELSEWHERE

SEOBowhntr · Jul 22, 2006

I am in a moral dilema... I work in a small (10bed) ER and yesterday we had an elderly man >70 come in after a fall at home. Pt family stated he had been uncons. for about 10-15 sec. but awoke AOx3. Brought him to us for large lac (3") repair and to be "checked" Doc did facial X-rays, (no C-spine, no CT). After lac repair we sat the gentleman up, gave him an oral antibiotic, and then walked him with assistance about 50 feet and were preparing him for discharge when he became nauseous, vomited about 100cc of clear fluid and c/o headache. The doc was notified, we were told to "discharge him, we need the bed.":angryfire (end of nights/start of days) I was assigned to him, or, him to me if you will, and I was not happy. I have only been an ER nurse for a year but 20+yrs as a paramedic and did not "feel right" discharging him especially after the vomiting...Kinda classic. Long story shortened. He was back about 6hrs later, GCS of 9, CT'd...subdural bleed. As we were prepping him for flight to a neuro unit, the recieving Doc wanted a C-spine...fx of C-3 C-4, non-displaced. The day shift Doc was going ballistic, wondering why this man had not been kept as 23hr obs at the very least.:trout: My question...Should I have been more forceful in reminding the Doc of the S/S of a subdural?...I feel bad that this man/family have to go through this. Any advice appreciated (constructive advice) THANX........ Emsboss

and

The pt was brought in via POV and walked into the ER under his own power, no C-collar applied by anyone...Pt had arrived approx. 0500, I assumed care at 0700, pt was D/C'd at approx 0730. (Docs change shift @ 0800). MUCH documentation done, discussed w/supervisor, but, I have been in this particular ER about...2 days off orientation. No one will listen to me...yet... Am just wondering how forceful is to forceful? Guess I will need to play it by ear. BTW...Heard pt is doing well. Blood was evacuated, recovered to baseline. THANK YOU JESUS!

This is a difficult thing to do, and becomes easier w/ experience, but this is where you have to say, "Doc, I know you may have more expertise than I in some cases, but in this one, you're wrong." ....." or I really think you're wrong." I hate for you that you have had to deal w/ such a circumstance, but feel assured that you are not the only NURSE who has been there.

I am a large imposing man, 6' 240# and not fat, and I many times have(I am not completely ashamed to say) used the fact that I am imposing, to tell doc's "to do the right thing."

I also benefit from a military background where I was trained oft-times to think like a doc, to manage casualties, therefore, I often time come with a good explanation of all of the pathophysiology to plead my case. But I have stood at the foot of the bed and told a doc (ABSOLUTELY KNOWING I WAS RIGHT), that not only would I not give the Rx he ordered, but I'd also not allow him to give that medicine (which potentially would have had a catastrophic result [Cordarone 300mg IVP for a pt. who was Sinus Brady in the mid 50's])!!!

In nursing, one of the things that I think many nurses have had to learn the hard way is that we live and DIE by the sword, so to speak, and that arguing w/ a doc may cost you your job, but if it saves just one pt., it is worth it. I have had the great pleasure of "saving" or helping save a great many patients, and the honor of caring for a few who passed on, and each offers a level of learning and job satisfation, which no other profession can understand.

In 10+ yrs. as an RN, I've worked a variety, but mostly Cardiac Step-Down and CCU, but I also maintain one un-ending approach to patients, which is:

"Regardless of my actions, this pt. may live or die, therefore, I am here to try to help this patient to his/her optimal level of health, whether that be death or absence of disease."

EMSBoss,

I hope that you can find the strength, personally and spiritually to speak up and fight the "good fight" in efforts to act as the best patient advocate you can be. :yelclap: :welcome: And with that being said, if at the end of the day/shift, you can still stare into a mirror and respect the image you see, then you've accomplished the goal many will never achieve.

CHATSDALE · Jul 22, 2006

read the end of cates post again about once being cowed was enough

make this a learning experince that you never forget..you may have learned the thing from this that will save patients years from now

nurses can't just have brains they also have to have backbones

tridil2000, MSN, RN · Jul 22, 2006

and
This is a difficult thing to do, and becomes easier w/ experience, but this is where you have to say, "Doc, I know you may have more expertise than I in some cases, but in this one, you're wrong." ....." or I really think you're wrong." I hate for you that you have had to deal w/ such a circumstance, but feel assured that you are not the only NURSE who has been there.
I am a large imposing man, 6' 240# and not fat, and I many times have(I am not completely ashamed to say) used the fact that I am imposing, to tell doc's "to do the right thing."
I also benefit from a military background where I was trained oft-times to think like a doc, to manage casualties, therefore, I often time come with a good explanation of all of the pathophysiology to plead my case. But I have stood at the foot of the bed and told a doc (ABSOLUTELY KNOWING I WAS RIGHT), that not only would I not give the Rx he ordered, but I'd also not allow him to give that medicine (which potentially would have had a catastrophic result [Cordarone 300mg IVP for a pt. who was Sinus Brady in the mid 50's])!!!
In nursing, one of the things that I think many nurses have had to learn the hard way is that we live and DIE by the sword, so to speak, and that arguing w/ a doc may cost you your job, but if it saves just one pt., it is worth it. I have had the great pleasure of "saving" or helping save a great many patients, and the honor of caring for a few who passed on, and each offers a level of learning and job satisfation, which no other profession can understand.
In 10+ yrs. as an RN, I've worked a variety, but mostly Cardiac Step-Down and CCU, but I also maintain one un-ending approach to patients, which is:
"Regardless of my actions, this pt. may live or die, therefore, I am here to try to help this patient to his/her optimal level of health, whether that be death or absence of disease."
EMSBoss,
I hope that you can find the strength, personally and spiritually to speak up and fight the "good fight" in efforts to act as the best patient advocate you can be. :yelclap: :welcome: And with that being said, if at the end of the day/shift, you can still stare into a mirror and respect the image you see, then you've accomplished the goal many will never achieve.

FORGET THE

" dr i know you have more expertise than me" CRAP!!!!!!!!!!!!!!!!!!!!!!!!!!!! god, why would you speak so respectfully to someone who obviously does NOT deserve it!

op, you go to the mirror and say "I DON'T CARE WHO NEEDS THIS BED! I REFUSE TO DC A PT WHO HAD HEAD TRAUMA WITH A + LOC AND IS NOW DIZZY AND VOMITTING!! " (but not at the pt's bedside!)

sorry about the yellin, ok, deep breathing now.

op, i am going to send you some vitamins. they help grow great balls!

i say this so sincerely, you WERE RIGHT!!!! who cares about dr so and so's freaking feelings. take a minute and look at your license... that's right, nothing there about being HIS OR ANYONE ELSE'S therapist. screw them.

whether you've been a nurse 22 days or 22 years, right is right. speak up! tell your charge rn, and tell her with meaning, that "under no uncertain circumstances are you d/cing a pt s/p head trauma with +loc, active vomitting a freakin headache and *NO* ct!! say, you can talk about me from now until the cows come home, but i refuse to take part in such nonsense!"

i wish you well as a new er nurse. remember, you're not being paid to worry about anyone's feelings. you do the right thing. speak up and voice your opinion on pt care!!!!

remember this: always put your pt's welfare above and beyond any of your peer's opinions. let the skin grow thicker on the side that deals with them, while keeping a tender side for your patients who really, really, need you. oh, you'll get the cold shoulder at first, but after a while, you'll be more respected by everyone.

tridil2000, MSN, RN · Jul 22, 2006

oh, and op, you should complete an incident report for case management!

LeahJet, ASN, RN · Jul 22, 2006

Now everyone is getting multiple (hours apart) CT's with falls....young, old, uninsured. One extreme to the other.

not sure that is significant

SEOBowhntr · Jul 22, 2006

FORGET THE
" dr i know you have more expertise than me" CRAP!!!!!!!!!!!!!!!!!!!!!!!!!!!! god, why would you speak so respectfully to someone who obviously does NOT deserve it!
op, you go to the mirror and say "I DON'T CARE WHO NEEDS THIS BED! I REFUSE TO DC A PT WHO HAD HEAD TRAUMA WITH A + LOC AND IS NOW DIZZY AND VOMITTING!! " (but not at the pt's bedside!)
sorry about the yellin, ok, deep breathing now.
op, i am going to send you some vitamins. they help grow great balls!
i say this so sincerely, you WERE RIGHT!!!! who cares about dr so and so's freaking feelings. take a minute and look at your license... that's right, nothing there about being HIS OR ANYONE ELSE'S therapist. screw them.
whether you've been a nurse 22 days or 22 years, right is right. speak up! tell your charge rn, and tell her with meaning, that "under no uncertain circumstances are you d/cing a pt s/p head trauma with +loc, active vomitting a freakin headache and *NO* ct!! say, you can talk about me from now until the cows come home, but i refuse to take part in such nonsense!"
i wish you well as a new er nurse. remember, you're not being paid to worry about anyone's feelings. you do the right thing. speak up and voice your opinion on pt care!!!!
remember this: always put your pt's welfare above and beyond any of your peer's opinions. let the skin grow thicker on the side that deals with them, while keeping a tender side for your patients who really, really, need you. oh, you'll get the cold shoulder at first, but after a while, you'll be more respected by everyone.

As I sit here chuckling, I think I work with you or two of your cerebral twins!!!! :cheers:

I guess when I posted the "Dr. I know you have more 'expertise'" statement, I should have put it in ITALICS. I was trying to use the more PC but direct way of dealing w/ the problem. Note some of the rest of the post, I am not really that "nice" to the doctors, but that was a sarcastic way of stating what needed to be said.

And I forget in the mix of posting my previous post to applaud Cate for being RIGHT ON!!!! Sorry for getting side-tracked Cate, because your post was right on, IMHO!!!

debbyed · Jul 23, 2006

In addition with all the other responses also remember it is your licence on the line. You need to be a patient advocate and you need to protect yourself.

If you ever feel a patient is not stable enough to be discharged first make those feelings known to the doctor in private. He may be more accepting of your information in private rather that feel you are questioning him in public.

{:trout: Yes I know I'm being politically correct, I have to keep practicing)

Than if you still disagree refuse to discharge the patient personally and follow your chain of command. If your 3 bed ER is anything like the one I worked in you had no charge nurse and you may have had no supervisor. If that is the case call your nurse manager at home. If that doesn't work call the administrator or hospital lawyer.

Only document in the patient chart what is pertinant to the patients care. You don't want to give mal-practice lawyers any more ammunition than they already have. They have enough.

Document seperately for yourself everyone you spoke to, what was said and what time. Memories fade papers don't.

And since I'm on this soap box, This is one of the reasons nurses should have their own malpractice insurance. This would not be a good time to be depending on lawyers whose job it is to protect the hospital.