ER didnt treat our resident......

Nurses General Nursing

Published

Hello all. I am posting this in hope of figuring out why the ER acted the way they did.... I work in LTC and I was "floated" to a unit I havent worked on in a couple of weeks. I get report and was told one of the residents had a "distended" abdomen, the doc was aware, was getting pain meds, and this had been going on for a few days. I go to take a look for myself and this mans abdomen was HUGE. The dr happened to be in the facility so I paged her overhead and had her to go take a look. She came back and told me to give him an IM injection of Lasix. I drew up the medicine went into the pts room and he refused. I go back and let the doc know that he had refused, she took the syringe and her and I both went into the room. Once again he refused and said he wanted to go to the ER to have the fluid drained out (evidently he has a hx of ascities and has had this done before) Doc said ok and had me make arrangements to send him out. This man also had diminished bowel sounds, and was gurgling when he was talking. I made arrangements, and called the ER to give them report. He goes to the ER, and a couple of hours later our house doc called me and told me that the ER doc was furious that we had sent them there! No treatment was given to this poor soul. I was in shock, since when does the ER refuse or not treat people who obviously need treatment???? :madface: Long story short, the docs argued and the resident was being sent back to us. I charted about his symptoms and his refusal of meds, how he was being sent back to us, and that ER didnt treat him. Now this man is a DNR, but since he wasnt DYING, shouldnt the ER have at least drained the fluid from his abdomen????? Sorry for the rant, but this really ticked me off last night......

Tatgirl

LPN

Specializes in Emergency & Trauma/Adult ICU.
sometime the mds working in the er are not really emergency docs but just someone just out of med school trying to pay down school debts

I have no idea what this is supposed to mean ...

To the OP: parascentesis is not a procedure that is performed in the ER. Whatever the reason was that the decision was made not to admit the pt. to have the procedure done in the hospital, I can't really say. But the specifics of the pt.'s advanced directive may have played a role.

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Good one ER doc..now nurses are supose to dx seizures from Parkingsons? Ummmmmm...not that I am aware of or we would have MD's by our names and paid much more! LOL!!!!!!!

You saw a pt in trouble and knew they needed more help than you could provide...the MD was in the wrong, should be reported (because more than likely he is doing this to others!!!). You did exactly what you should, you do not Dx...and you needed to get the pt to someone who could and treat it!

Sheesh...I have had my share of arguements with MD's about my roles as a nurse, and the fact that I don't Dx or they would be out of a job or working for ME (since I am older and would have gone to med school before most of these younger ER docs! LOL!).

Story time...LOL!

I had the opposite once with a parkinson's pt once actually!

I had a woman that was having her typical bad day spells, and I had her lay down and made sure she got her meds/food/drink and rest. Unstable gait so I had room service for her..and did everything I needed to at the ALF we were in.

A family member freaked out, called the MD, and the MD chewed me out over the phone asking why I didn't call 9-11. I bluntly told him that since I had known the patient 4-5 days out of the week for 4 years, I have seen these occurances and know when it is different...and the pt did NOT want to go to the hospital and declined me calling the MD because "this is normal of a bad day, don't bother the doc...and for GOD'S sake don't send me to the ER again!".

He ordered emergency transport behind the pts and my back..and she was returned more fragile, tired, shaking and angry a few hours later. Nothing to really do...just as we told the doc..it was just one of her 'bad days'.

He finally called to appologize to me, which I found was shocking in and of itself (and called the pt too), and will note this in the future.

Then he faxed us with new orders and oops! Oh no...he wrote NPO???? Why NPO..crud! So I had to call him..okay he turned back into Satan and chewed me out and wouldn't believe me...I faxed it back and he saw he did...and called me back before faxing the new orders "I meant DNR".

I let him know that the two are very different...and considering I had been chewed out by him twice for no reason and stayed professional and to the point...I deserved more in future communications with him, or I would insist on having all the people in his care switch MD's (we had MANY of our residents seen by him) in order for patient safety and quality care/communications. AND HUNG UP!

He was a sweetheart to me afterwards..LOL!

Ah, bless you, Triage, for not giving in to this fool!! I really liked most of the docs I worked with at the hospital - but there was one that was a total hiney - because he figured if he was such a jerk when anyone called him, that they'd be too afraid to call - which was true.

The jackazz grabbed another nurse in the unit by her arm, and yanked her all over a patient room because he didn't think she was doing what he wanted. And she wouldn't report it!! I believe he knew if he ever touched me - he'd be paying for my retirement.:angryfire

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I understand that this gentleman was probly in severe pain and very uncomfortable however, his dx is also known to the doctor who should have arranged for him to see a surgeon and arrange for a pericentisis done on an outpatient basis. He had a history of ascites and apparently is well documented so a trip to the ER following his refusal of Lasix most likely was futile anyway. Was there something the ER could have made him do that you and his own doctor were'nt? They cant treat if someone is refusing. Obviously he had been accumulating this fluid over a period of days so there was really no reason the primary doctor couldnt have arranged something before he got to that point. Even earlier that day,, or the day before (you said it had been going on several days).

If the patient is coherent and able to make his own decisions the doctor needs to sit down with him and they need to agree on a treatment plan. If that includes occasional visits to a surgeon to get the fluid drained off and not giving diuretics that is up to him and the doctor. I wouldnt blame this one on the ER.

The patient did not refuse the ER. Please re-read the OP.

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Maybe a better course of action could have been for the doctor to call the on call surgeon and arrange for him/her to see him in the ER and do the pericentisis. That procedure is just not something the ER docs do on a regular basis and obviously it wasnt something "emergent" so the ER doc maybe felt they were getting something dumped on them that should have been handled several days ago. You did say he was getting pain medication.

Sorry but when he was admitted or diagnosed with ascites your careplan coodinator should have made abdominal girth measurements something staff did with each assessment too.

Is it possible this man refused treatment methods with your facility because he likes the care he gets as a inpatient in the hospital better (not slamming on your facility but sometimes people do that). Maybe he knew if he refused you long enough it would maybe get him a trip out to the facility where he knew he would have more one on one attention(thinking staff ratios now). Is it possible he refused to let anyone in the ER do anything knowing if they did they would send him back rather than admitting him to the hospital?

I have seen this type of manipulation before. We have had people who dont meet criteria to be admitted but end up getting admitted for observation then come up with every complaint in the book to need to stay yet another day. As soon as they find out they arent being discharged back to their facility they are fine, until the next day. Just some questions. Please dont feel im accusing or anything im not.

It's paracentesis, not pericentesis, BTW.

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Sounds to me like your Doc just wanted to push this patient off on the ER doc. Your physician could've either had this done on an outpatient basis, or if it needed done faster than that could be arranged - Direct Admit him to the hospital. The ER doesn't appreciate doctors pushing off their responsibility onto the ER. If the doc was there and seeing the patient (so a physician had already assessed the patient) they should've followed through with it.

His doc wanted to give Lasix IM, not send him to the ER. The pt wanted to go get it drained. Please re-read the OP.

The poor soul probably couldn't breathe with 20#of fluid compressing his innards, lungs included. Mieg's Syndrome with Ca, perhaps?

Please re-read the OP.

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I have no idea what this is supposed to mean ...

To the OP: parascentesis is not a procedure that is performed in the ER. Whatever the reason was that the decision was made not to admit the pt. to have the procedure done in the hospital, I can't really say. But the specifics of the pt.'s advanced directive may have played a role.

It means they are not specializing in Emergency medicine. They are residents and they are moonlighting, just trying to pay their debts. Still residents.

What should have happened in the case under discussion, I think, is that the pt's own doctor should have referred him to someone who could do the tap and be done with it. Of course, she apparently didn't think to do that. Nor did the person who started this thread think to recommend that she refer directly to a doctor who could do it.

Of course, one wonders why the ER doctor didn't refer while the pt was already there in the ER????? Is everyone out to lunch?

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Specializes in Emergency Dept.

I did read the post. A physician saw the patient and was unwilling to do anything themself other than prescribe some meds. It takes time to set up procedures / admit a patient / write orders / etc. The PCP decided she didn't want to do all of that and pushed it off on the ER.

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Specializes in Med/Surg, Ortho.

I think Gabiebaby needs to TAKE lunch and chill. Good grief we arent writing for our thesis papers are we? And im pretty sure everyone who has posted their thoughts have probly seen instances where what they related happened in just that way. (i dont think i said he refused the ER, but it was said he refused any LTC treatment and wanted ER, which also tells me he most likely had some refusals at the ER, because what he really wanted was admitted. The patient just didnt know there was another way other than ER).

For whatever reason this doc in the ER didnt admit and i really dont know of any that would have(oh and BTW ER docs dont admit GP's and primary physicians have to AGREE to treat on admission). To admit through the ER he would have had to have the medical on call take the case(probly not his dr unless his GP happened to BE on call that day AND had practicing priviledges at that facility), the surgeon on call(probly not familiar with him at all) and the doctor that saw him at the LTC would have been out of the case all together(patient dumping). Direct admit with a referral to a surgeon is one thing but to send this guy through the ER is another.

Regardless, its not anything that needed the reply posts nitpicked and spellchecked and shouldnt have been made that way by Gabiebaby.

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Specializes in ICU,ER.

Hey Gabie, ever heard of Dale Carnegie?

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Specializes in Emergency & Trauma/Adult ICU.
It means they are not specializing in Emergency medicine. They are residents and they are moonlighting, just trying to pay their debts. Still residents.

What should have happened in the case under discussion, I think, is that the pt's own doctor should have referred him to someone who could do the tap and be done with it. Of course, she apparently didn't think to do that. Nor did the person who started this thread think to recommend that she refer directly to a doctor who could do it.

Of course, one wonders why the ER doctor didn't refer while the pt was already there in the ER????? Is everyone out to lunch?

Residents of various specialties all rotate through different services, to some extent, during their residency. Doesn't make them moonlighters.

Please re-read the OP's second post - pt. already had an appt. set up with a GI doc for Monday. The OP felt the parascentesis should not wait, the ER & primary docs disagreed. Frustrating, yes ... and I believe that was the point of the OP.

Now about that Dale Carnegie ... :specs:

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Specializes in ER/ MEDICAL ICU / CCU/OB-GYN /CORRECTION.

Perhaps the ER could not do or would not do a procedure however this poor suffering man. I believe could have been relieved some of this agony if the ER MD called in a GI physician at least admit him to have this done the next am. The treatment simply --- to get him out of his misery. I am sure the er MD and er charge the insurance for "care" as lacking as it was.

Then if he wanted he or the administration could inform or write a policy about future situations like this.

I would feel horrible if this was my family member that was refused a procedure or given help to obtain help to be comfort in this situation.

Marc

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Specializes in Critical Care/ICU.

This ED was dumped on.

I hope this gentleman got the treatment he needed and is more comfortable now.

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