ER RN Angry & Frustrated!!!

[Ginger35]

Okay, it was a bad 4th of July in the ED this evening. However, what gets my panties in a wad is when I am dealing with other people that want to argue with you when you absolutely, positively know they are in the wrong. Please let me give you the briefing in hopes to get some feedback and get it off the chest for some sleep....

Okay, this has to do with standards of care and patient rights as it pertains to minors.

I work in a small rural community hospital near where I live - but have worked in large level II trauma centers and have all of the certifications TNCC, ENPC, & etc.

Anyways, we had a 16 year old female minor who was a restrained driver that rolled her car multiple times going at highway speeds. Allegedly no LOC. Only complaint is left neck pain. Parents could not be contacted by medics at the scene. Severe damage to this patient's Chevrolet Cavalier to a point you could not tell what it was.

Anyways, medics decide to just put a collar on her and not a board because the patient refused it (keep in mind this is a minor and can not sign a refusal). I questioned this upon patient arrival to the department descretely with patient in the room - but the patient could not hear what I said because she was talking to the respiratory therapist at the same time.

I simply asked why there was no backboard on this patient considering her mechanism of injury and the medics response was because she was up walking at the scene. I simply stated quietly as possible ("guys, this patient should really have a board on) - I did not droan on and left it at that.

Well, when I was done with my nursing assessment - this medic approached me and proceded to rip me a new one stating "that I was setting them up for a law suit" for mentioning this issue infront of the patient. HOWEVER, I mentioned to this medic that if he was sooooooo concerned about a lawsuit that the should have followed standards of care and applied the board.

Luckily, this patient walked away from this MVC essentially unscathed. However, had this patient had say a thoracic spine fracture that did not present itself until after arrival to the ED sometime - I find it hard to believe that this medic could defend this case if neurologic injury was involved because he did not stabilize the spine. Citing that the patient who is a minor refused this abnd "up walking at the scene"

When I was getting yelled at - I kept kool, stood my ground, kept the voice down and trumped his rationale (or shall we say lack of rationale) - which is why I am "fuming" sooooo bad right now.

This medic also came across that he flew with the flight team and on the fire department in some capacity for 25 years - basically coming across like he knew more than I did. Well, come to find out this guy is not even an EMT, Paramedic or Nurse!!! Just a volunteer medic with alleged BLS training.

Now don't get me wrong - I appreciate the help of the EMS around the area. But if care is going to be rendered, it needs to be done correctly. Atleast that is the way I feel. Just because a patient like this is up and walking at the scene - it does not mean that they don't have a spine fracture or other injuries considering this mechanism of injury - OR - Am I missing something here???

Also, I live in the State of Ohio. Do minors involved in MVCs and other emergent conditions have the right to refuse treatment? I mean they can't sign for themselves at all into the hospital, they can not legally sign a contract.....Sooooo how can they pick and choose care issues in this sitation???

I would appreciate feedback from you all.

Sincerely,

Ginger :angryfire

[SilentfadesRPA]

Ginger --

The guy is a dork and clearly a danger to patients. I hope he is definately reported for his lack of judgement and for his lack of respect in talking to you in this patients case.

I am sure that you can see that his bullying came from he got caught and he clearly knew he was suppose to board this patient. A 16yr old who rolled a car is most likely in shock and has no capacity to make any decisions for her care. Even if her parents said no to the back board they can not make medical decisions in the field that has protocols until a MD evaluates her and I am sure no Physician in his right mind would take a collar or backboard off only on the parents say so.

You did nothing wrong - consider doing something to protect further patients from this dangerous wana be.

Could you imagine a lawyer with this one - what a field day and woorse could you imagine a kid being dead or a quad from this.

You did nothing wrong believe in yourself.

Marc

[Lurksalot, BSN, RN]

Ginger, I think you handled the situation very professionally, especially in light of the way the emt(or whatever his credential are) confronted you. It sounds like you are following the right channels, and by maintaining a professional, non-emotional response and follow up, you are providing a great example for others. (Especially new nurses like me.) :)

[buddiage]

As a former volunteer-

I've come acrossed some of the biggest egos in the volunteer realm (some great full timers who volunteered were some of the best people, though). I think you are 100% correct- he should know. His medical officer should know his gross lapse of judgement could've costed him and the department he worked for, a lawsuit.

Instead of making up lies of all the supposed experience he's had, he could've quietly commented, "You know, you are right. I probably should do that next time" instead of gaurding his ego.

What a flake.

How is it that a guy who is not even an EMT calling the shots for patient care at the scene? Our fire department had a minimal requirement for certain qualified people leaving on responding rigs.

[burn out]

It is always better to error on the side of caution, put the patient on a backboard and c -collar. If I were the parent and found out that my child had not received appropriate standard care he would not only have a new one ripped but chewed up and spit out.

[vampireslayer]

Ok, I've looked through my TNCC book and my Emergency Nursing book, because I just hate to ask this question and risk looking like a total MORON! I've been in ER for a year now and SHOULD KNOW the answer to this question...but I've actually asked it of several people at work, and gotten different answers! (and the books just say HOW to immobilize using the backboard, not why).

So here goes: is the purpose of the backboard to immobilize the spine for transport only, or the entire time they're in the ER, until their spine is cleared via xray or CT?

I've had docs immediately take the pt off the backboard, based on their conversation and physical assessment, although they were pending results of xrays/CTs. I've had other docs insist that the pt stay on the backboard until the L-spine film is taken (but not read, just xrays have been shot) because the board helps get a better picture. But once the xray's been taken, they'll have the pt off the board, before the xrays have been read. And then I've got another doc who won't let us take the pt off the board until all films have been read and their spine has been cleared (could be an hour or two in the minor MVCs!).

We also have been told that one of the very important issues in the traumas is getting the pt off the board as quickly as possibly, because of the issue of skin breakdown.

So...what's the purpose of the board IN THE ER?

Oh, by the way, until their spine is cleared via xrays/CT, we do keep them lying flat, with the c-collar on, we log roll them off if we're taking them off the board, etc. But we very often put the pt on a soft bed before any xray/ct results have come back.

VS

[Altra, BSN, RN]

So here goes: is the purpose of the backboard to immobilize the spine for transport only, or the entire time they're in the ER, until their spine is cleared via xray or CT?

I've had docs immediately take the pt off the backboard, based on their conversation and physical assessment, although they were pending results of xrays/CTs. I've had other docs insist that the pt stay on the backboard until the L-spine film is taken (but not read, just xrays have been shot) because the board helps get a better picture. But once the xray's been taken, they'll have the pt off the board, before the xrays have been read. And then I've got another doc who won't let us take the pt off the board until all films have been read and their spine has been cleared (could be an hour or two in the minor MVCs!).

We also have been told that one of the very important issues in the traumas is getting the pt off the board as quickly as possibly, because of the issue of skin breakdown.

So...what's the purpose of the board IN THE ER?

Oh, by the way, until their spine is cleared via xrays/CT, we do keep them lying flat, with the c-collar on, we log roll them off if we're taking them off the board, etc. But we very often put the pt on a soft bed before any xray/ct results have come back.

I would be interested to see literature on this as well.

Where I work, most patients are log-rolled off the board fairly quickly, before x-rays/scans, unless there is a suspicion of hip/pelvis instability or probable multiple fractures in the lower extremities, or the pt. is unwilling to comply with lying flat. Rolling them on to their side for a moment allows the doc to palpate along the spine to assess pain if they are A&O.

This is our practice, but I realize that I have not seen literature to support it.

[firstaiddave907]

I would think if someone was enloved in a car accident complaining of neck pain i would think the first thing the EMT's would do head stabilization put on the C collar and then strap them to the board so the patient wont move for fear of a back injury or a neck injury. I use to do ride alongs at a local ambulance company here. they had a exployer post and they told me with any type of neck pain how minor it might be they always put a C collar on and put them on the back board because they say they reather be safe than sorry.

[Chaya, ASN, RN]

When all is said and done, worst case scenario if a patient doesn't have serious injuries would be they check out OK and you say "Well, guess you didn't need the backboard after all"

Worst case scenario with a pt who should have been on a board and wasn't? Insert your own nightmare here; death or avoidable permanent injury, lawsuits, loss of licensure/ employment, etc. She really lucked out and so did that paramedic-but luck is something professionals don't depend on.

[sheilagh]

I was sent home from my level 1 trauma center post mva and told I was jusy sore and my abdomen hurt because of airbag (wasn't a nurse yet, so didn't know better) 14 hours later I was in surgery and had spleen and 1/2 pancreas removed and a G-tube for 2 months...you never know what ya got in front of ya...as for minors, I was in school with a 17 y.o.a nurse student with a 3 y.o.a daughter and she could sign for her kid but her mother had to sign for her !!!!

[grammyr]

We keep them fully packaged until the doc reads the films. Most of the time we go ahead and scan at least the head and spine because our scans are read within an hour by a radiologist via telerad and the xrays may not be read for 12-36 hours depending on the day of the week. We had rather be really safe than sorry.

[babynurselsa, RN]

I got a patient one time that initially no-hauled at the scene. He was up walking around and told the crew he was fine and signed the form. Then he decided his neck hurt and he did not feel so good. Good crew, they boarded and collared him and brought him on in. This dude was walking around with a sublux of C-5. Accident he walked out of was not nearly as imressive as your little girl was in.

[sjt9721, BSN, RN]

To the OP:

You were right. She should have been in a full package. However in response to TazziRN's post, wrestling a refusing patient onto a backboard may do more damage than not having one. But I would think that an experienced pre-hospital provider would have a good chance of convincing the teen that the board was in her best interest.

Now here's my 2 cents that may not be as well received: You might have been better off approaching him outside of the patient's room. (I realize that you said the patient was talking to the RT & couln't hear & so forth.) But the conversation (perhaps!) could have been more productive if done outside the room. Questioning someone's judgement/actions in front of a patient (or peer) can lead to an immediate jump on the defensive. It holds true for nearly any type of interaction: RN to MD, EMT to RN, RT to MD, etc.