How many broken ribs???? (long rant)

[klm49]

I am extremely frustrated right now and just need to blow off some steam with others that will understand. My daughter called me at work on Wednesday last week and told me my 69 yr old mother had fallen in the bathroom, hit the bathtub and possibly broke her arm. I immediately found someone to cover for me and was dashing out of the hospital when my brother called that he was already on the way to the local ER with Mom. I spoke with Mom and she couldn't/wouldn't tell me how she came to fall. "I don't know what happened I just ended up on the floor." She adamantly denied hitting her head, dizziness etc.

Unfortunately, I listened to Tim and Mom that they could manage the ER and went back to work rather then continue on to the hospital Mom was going to. Leaving work at that point was causing a major delay in treatment for patients and hardship for my co-workers. Tim called from the ER later and said that "Yes the shoulder was broken." Mom was sent home with pain pills and instructions to find a special type of arm immobilizer because she couldn't tolerate the one from the hospital. Tim dropped Mom off at home and I left work to hunt down the special immobilizer and brought it and the pain pills to Mom at home. Mom kept complaining about her shoulder blade and ribs hurting but otherwise said she was fine. Over the next couple of days Mom took the pain pills around the clock along with NSAIDS. She became more lethargic and confused but would rouse and argue strenuous about going back to the ER or Doc. I did take her to the Ortho Doc on Friday just to be sure everything was OK. He changed Mom's pain meds to a weaker narcotic because even she admitted she was loopy at times. I thought since Mom is totally narcotic naive the Percocet were maybe to strong.

Saturday my daughter called me at work again because Mom was totally "out of it". I sent my brother over to check and after arguing with Mom for an hour he convinced her to go back to the ER. This time I did leave work and met them in the ER. Mom's SaO2 on room air was 78% and that was with her sitting up, arguing and awake. She had been drifting out in mid sentence at home. I don't want to think how low the levels were when she slept or drifted out. It seems when she fell on Wednesday she fractured and displaced ribs 3-9 on the left side along with fracturing her left humerus. The first ER Doc didn't x-ray anything other then her shoulder. It is a miracle she survived to make the second trip to the ER. Mom has been a 2-3 pack a day smoker for 50 yrs. Needless to say she is a COPDer.

How does an elderly patient come to ER after falling at home with no explanation and not get a full work up? Honestly, I thought Mom would have virtually glow in the dark from x-ray's looking for additional trauma and possible causes of the fall. She so easily could have had compression fractures of the spine, neck injury, hip injury, head injury, etc. Not to mention why did she fall in the first place? She had a cerebellar CVA last Dec that affected her balance. How did they know this wasn't a repeat of that CVA or a cardiac arrhythmia of type? Mom was admitted from the ER the second time for pain management and aggressive Pulmonary toileting. The second ER doc told me that the number of ribs broken with the arm fracture would have justified admission to the hospital on the first visit. While in the hospital I did have some discussions with the case manager about how unhappy I was with the first ER visit. I was assured it would be report to QA and the manager of the ER. Verbal reassurances that action would be taken is all I got. In other words a brush off. I am tempted to e-mail and request additional follow up. I work for the same hospital chain but a different campus then what Mom went to. Would it be inappropriate to e-mail the QA person; whose name I was given; explain who I am and request more information on the follow up?

I am a dialysis nurse. I have never worked in ER. Are my expectations of the work up Mom should have received the first visit unrealistic? Those few days Mom was home between the accident and being admitted were horrible. Mom was in severe pain, argumentative, and needing help but reluctant to allow it. I was up and down all night checking on her, toileting her and taking the cigarettes away. It was such a relief to come home and sleep several hours straight the first night she was in the hospital because I knew someone else was watching her, helping her and she wasn't smoking.

Thanks for listening. Being a part of the "Sandwich" generation sucks. Especially when it goes from simple "Sandwich" to special "Panni" generation.

[RoyalPrince]

Absolutely. I think it is horrifying that only shoulder x-ray was taken and NOT a head CT or even CXR esp since it was unwitnessed, and she HAS a hx of CVA..

[nohika]

Absolutely. I think it is horrifying that only shoulder x-ray was taken and NOT a head CT or even CXR esp since it was unwitnessed, and she HAS a hx of CVA..

I kind of agree, but is it possible that the people with her didn't mention the CVA? Assuming her relatives are non-medical professionals, sometimes it's hard for them totally understand everything and therefore they might've missed something or who knows...

[xtxrn, ASN, RN]

Even when getting an admission FROM the ER for someone who had an unexplained, unwitnessed fall, there's some light palpation along the ribs, abdomen, and back. I'm sorry you went through this with your mom, and glad you were able to get her taken care of.

I moved from TX to help my dad take care of my mom, who had dementia (bilateral mastectomies d/t CA, lung mets, brain mets w/dementia from brain radiation). It was significant, but she was still able to go on the 3 month winter getaway with my dad while I got used to being back here, and watching their house. At the end of the 3 months (2 weeks early), she became suddenly ill- seizing (she had a seizure disorder) and lethargic. I told dad to call 911. The ambulance took her to the ER, unconscious by that time. They got an IV in- but somehow couldn't get bloodwork. They got a UA from an I & O cath - and it was loaded with crud. But, in their infinite wisdom, sent her home on oral antibiotics with my dad- it took 3 people to get her into the car. How was he supposed to manage her? He'd been through a LOT with her over the years with the CA- but this time he sounded frantic.

It was all I could do to keep him from driving cross country with her to get home (I told him if she died en route, I'd have a dead mother to deal with, and him in jail for transporting a body...he decided to wait :)). He got a flight home with her 4 days later (I'd told him to have her taken to another ER if she didn't perk up, or couldn't take the meds- she did wake up enough to take the abt crushed in applesauce - not her norm- and I talked to her- sounded tired, but about as loopy as usual). When she landed at the airport, I was allowed to get on the plane to help get her off. He had to hold her head up most of the flight- the flight attendants had tears in their eyes. We got her to her local hospital, where they got labs, immediately looked at her and knew she needed to be admitted, and she was dead in 2 days from sepsis, renal failure, and shock. I was livid. She was a DNR and had dementia, but the day before she went to the 1st ER, she was at an art opening with my dad- she still did things, and for the moment, enjoyed them. I feel she was written off as a gork, and who cares?.....the hospital social worker told dad that they were full, and couldn't admit her (this was in a BIG metro area with plenty of hospitals to transfer to, good supplemental insurance, and a valid need for admission).

He felt horrible for not doing more- but it wasn't his fault that the ER was pathetic- how is a layperson supposed to know what to ask for (I told him to tell them that he understood that restraints weren't ok for long term, but to get labs, he gave permission- they refused, even though she'd been combative when they tried to get labs- not her norm either). ???? We both try and remember that at least she didn't end up curled up in a nursing home, not able to enjoy anything. But I still get upset. She didn't deserve to be blown off because of dementia, and DNR. She was continent, would talk when she knew the answers- otherwise she asked for the dog!!! , and woe be to the person who messed with her when a movie was in the DVD!! (she used to hang up on me!! ).

SO- I hear you! If people don't have a working knowledge of medicine and how to get the help they need, often they don't... all the more reason for us to speak up for them :) Even if shifts are nuts- you made a difference to the ones who got what they needed that day :)

[casi, ASN, RN]

I am so sorry for your frustrations.

I'm not an ER nurse so I really don't know what happens in the ER for a someone who's had a fall.

I do however know that some ERs kinda suck.

One of the ERs that most of the residents in my facility use is terrible. This week alone I had a patient go to the ER with chest pain, then come back from the ER with 8/10 chest pain. I about blew a gasket when I requested her labs from the ER and they didn't even draw cardiac enzymes.

A couple of days later we sent someone out with a suspected bowel obstruction... They did an abd xray that showed she was FOS... Did one ineffective enema and sent her back to us with an order for mirilax. She came back to the facility and almost immediately went into respiratory arrest.

So in conclusion some ERs suck. I would write a couple of angry letters to the ER your mother was seen at and then I would try to never take her back there again.

[canesdukegirl, BSN, RN]

Since you were given the name of the QA person, I think it is completely appropriate for you to follow up.

Although it is very difficult to take your emotions out of the situation, write down each event factually and ask them where the line of communication broke down.

I am amazed at the treatment she received the first time. I am further surprised that they sent you looking for a particular sling...THEY should have arranged that for you! I feel confident that they have an ortho dept that had the type of sling that your Mom needed.

It sounds like they dropped the ball on several fronts. Address each of these and keep meticulous records of her follow ups.

I will be thinking about you and your Mom, and hoping that she gets the correct course of treatments in the near future.

[nurse2033, MSN, RN]

As a family member you are entitled to have your concerns addressed and feel satisfied. I would follow up.

Just to take the ER's side for argument sake, some docs will scan everything to cover their *** and others will order what seems appropriate based on the presentation. Having a history of balance issues offers an explanation for falling. She may not have complained of rib pain at the time and rib fx's do not always show up on xrays. An independent person who is alert and oriented can be trusted to know when they have pain. On the other side perhaps her exam was cursory and perfunctory. One thing I've learned after 17 years in EMS is that you can't know what really happened unless you were there. Sorry this happened to your Mom, best of luck.

[nola1202]

I'm so sorry, I think everyone should have a health care advocate assigned to them on arrival at the hospital. I'm like you, I would have assumed a head Ct, and at least an AP/lateral CXR, C-spine....But I've sent people to ER to come back without the one test I suggested in report to the recieving ER. Said RN usually rushed and sometimes horribly condenscending.

[Katie5]

You mentioned that your mum has an obstinate personality- she argued with you(her daughter) for an hour. What makes you believe she did not argue or obstinately object with the doctor. He's not going to force into a ct or x-ray

[madwife2002, BSN, RN]

I do this this thread could border on medical advice so I am closing it for review