Let me hear your perspective...

Kooky Korky, BSN, RN · Dec 24, 2019

5 hours ago, mi_dreamin said:
I definitely appreciate all of your feedback. I guess the thing about it for me is that they weren't calling it anything, not a stroke, not encephalopathy, just, "her brain is fried." They provided no treatment beyond some fluids.
I guess I just wanted to know if what happened sounds like a reasonable series of events considering the facts as presented.
Unfortunately I cannot talk to the providers involved, which is why I wanted some insight into why things may have happened the way they did.
Thank you to everyone who replied, you gave me food for thought!

Sounds like the ball was dropped.

There needs to be some follow-up by your higher-up's.

How is she?

JKL33 · Dec 24, 2019

6 hours ago, mi_dreamin said:
I guess the thing about it for me is that they weren't calling it anything, not a stroke, not encephalopathy, just, "her brain is fried."

I don't think the one person who used that phrase should have used it, but a nurse's off-hand comment is a far cry from a diagnosis or from proof of what other members of the team might have been considering with regard to the case.

Either every single ball was dropped here, or else this just wasn't as clear-cut as everyone would like to believe. The possibility that balls were dropped and things were overlooked is the reason it is correct to request review.

13 hours ago, mi_dreamin said:
I'm not even saying she was a candidate for tpa at the time of presentation, I'm just saying that it seems like somebody should have done more for her.

I understand, but what, though? It's possible that something more should have been done based on information not available to us. But it's also possible that this is one of those cases where it would've made a couple of people feel better if something more would've been done, even though they don't know what; just "more." We (both the general public and many healthcare providers) are used to a lot of stuff being done (especially various testing) that is not going to change anything. It is terrible and unfortunate that a 38-year old (or any age patient) has had some kind of cerebral infarct at some point, but this bad thing isn't proof in and of itself that the situation would have been better if someone had done more...just more of something/anything.

It sounds like despite an acute decline while at the ED/hospital, the admitting physician also didn't re-scan or order a STAT MRI or anything else despite having examined the patient and reviewed what had/had not been done up to that point.

6 hours ago, Susie2310 said:
Nearly seven hours pass since the head CT and we are not told of any assessments, monitoring, or care provided to the patient.

Right, we are not getting this report from the people involved. We are working with at least third-hand information. It is unlikely that this account is the extent of all things done or considered in the ED (not the OP's fault, just a fact).

6 hours ago, Susie2310 said:
appropriate interventions would have been appropriate care in the ED

What interventions do you recommend?

Susie2310 · Dec 24, 2019

9 hours ago, JKL33 said:
I understand, but what, though?
What interventions do you recommend?

We are not told that a neurology consult took place in the ED; it appears to me that this was warranted.

If the patient had had an embolic stroke there is a care pathway.

If the patient was being assessed/monitored regularly/frequently one would expect signs of deterioration to be detected promptly and that the patient would be timely admitted to the appropriate level of care (I agree that we don't know what assessments/monitoring were done in the ED or at what point in the patient's ED stay the patient's deterioration that the OP believes happened there took place).

JKL33 · Dec 24, 2019

23 minutes ago, Susie2310 said:
We are not told that a neurology consult took place in the ED; it appears to me that this was warranted.

Yes. If there wasn't one and one was indicated that is one thing, although they might not have recommended a particular emergent intervention especially in a sub-acute scenario. None of the ED providers I know would decide that zero further care was necessary w/o a neuro consult. Some of these providers may not be dripping with compassion, but they aren't stupid and they don't wantonly choose to risk their entire careers on something like this. That's another reason I think it's a good idea to review this. For all we know they may have been told that there is no reason to admit the patient. Eventually things changed and there was a stronger case for admission.

People want to make a case that this patient was just flat out neglected, but if the ED had actually decided there was no problem, she would've already been at home or at least sitting out in the WR waiting for the bus/taxi when her condition (reportedly) deteriorated.

I will say again that there are all kinds of things from various sources that need to be examined when it appears that something hasn't gone ideally.

It's interesting that in this case where people were concerned about what the ED didn't do, it ultimately doesn't sound like they decided to do much either.

Susie2310 · Dec 24, 2019

1 hour ago, JKL33 said:
Yes. If there wasn't one and one was indicated that is one thing, although they might not have recommended a particular emergent intervention especially in a sub-acute scenario. None of the ED providers I know would decide that zero further care was necessary w/o a neuro consult. Some of these providers may not be dripping with compassion, but they aren't stupid and they don't wantonly choose to risk their entire careers on something like this. That's another reason I think it's a good idea to review this. For all we know they may have been told that there is no reason to admit the patient. Eventually things changed and there was a stronger case for admission.
People want to make a case that this patient was just flat out neglected, but if the ED had actually decided there was no problem, she would've already been at home or at least sitting out in the WR waiting for the bus/taxi when her condition (reportedly) deteriorated.
I will say again that there are all kinds of things from various sources that need to be examined when it appears that something hasn't gone ideally.
It's interesting that in this case where people were concerned about what the ED didn't do, it ultimately doesn't sound like they decided to do much either.

We don't know all the facts of the situation and I agree that a review is appropriate.

Unfortunately it is possible that the patient received inappropriate care.

The care pathway for acute ischemic stroke, if this is what the patient had, includes admission to a stroke unit or ICU.

**canoehead, BSN, RN** · Dec 24, 2019

If she was outside the window for lysis, and the CT showed nothing they could fix, labs normal, it makes sense to me that they give her 24h to recover, or for the drugs to wear off, and watch for deterioration. If there was no change, no action.

It should all be documented. What does the chart say?

RNNPICU, BSN, RN · Dec 25, 2019

Just a few more thoughts....

I am not convinced that "the ball was dropped". There is a lot of time where you are not sure what happened. It is unlikely that nothing was done and no one monitored the patient for hours on end. The ER may have been waiting for the affect of the drugs to wear off for a better assessment. The drugs could have been masking her true underlying condition. Althoug you did mention that MRI was recommended, it may not have ultimately been orderee due to other factors, a recommendation does not automatically equate to an stat order. Perhaps other labs came back that indicated something else, perhaps after further reading of the CT scan they realized the bleeds were old bleeds and since she wasn't recovering, that she needed in-patient monitoring.

Before futher judgement on inappropriate care I would love to have known what other labs, medications, consults, GSC scales were.

I think it is hard to know what was her previous baseline status without the influence of drugs.

While there are lots of reasons why she presented on your unit they way she did, there is lots of gaps in information to truly determine if she received inadequate care.

If your team feels this was a potential deviation in care, is your team allowed to do a Root Cause Analysis? This way everyone could see the timeline and providers involved could explain the assessments and reasons why MRI was ultimately not ordered, again, the MRI was only a recommendation not a STAT .

HomeBound · Dec 25, 2019

I think what is bother OP the most here is the verbiage and perceived indifference of the ER RN giving report. "her brain is fried from drugs" is never appropriate.

And I think that's pretty much where the "inappropriate" care stops, in my opinion.

First. Are you a stroke center? Do you have neurology on call or in house at all times? Big stroke centers have different resources. Sad, but truth. You will receive different and possibly "better" care at a stroke center.

Second. So the CT showed an "acute subacute" bleed. Did you check any priors? Did she have a history? If the stroke was an old one with new changes, and it was read as hemorrhagic--what is it that you would have liked them to do? The protocol even in stroke centers doesn't include q15 min mini HSSs.

Third. ERs don't have 1:1 RNs except for critical ICU holds. If the decision was made that this patient wasn't a candidate for tPA and this stroke was not acute--and the MRI didn't need to be done immediately (there has to be a reason that this decision was made. you need more information than what you're giving us, if this is all you have)---then there are underlying reasons that there wasn't an army converging on her in response.

I don't believe for a microsecond that this woman was treated "differently" because she was positive for meth. If you believe that, and you have evidence of it, then you most certainly should talk to the Medical Director and see what they say about your evidence.

I get that you don't like the ER RNs indifference and flippant response. That has nothing to do with the quality of the care this patient received.

The only thing an MRI would have shown differently was maybe an AVM. But again, if you did not check this woman's priors, you have zero idea what her brain looked like before her current admission.

Ischemic strokes---yes---different pathway. Immediate care if in the window, still a wait and see if not in the window. My guess---this woman has previous brain injury that made it hard to impossible to detect whether this was anything new---and if it was new, it was hemorrhagic---and it's wait and see. The ER was most likely holding this patient until an appropriate bed became available---and since there is no reason in the case I think happened---to sit and watch her 1:1, she was monitored by tele and rounds, as appropriate.

Care2GoSailing · Dec 29, 2019

As a long time ER and ICU nurse there are some concerns here. I believe many good comments have been made above. The possibilities are huge but the fact that the ER MD requested a floor bed would indicate she/he made a sound decision of the patient’s prognosis and appropriate consults had been made. A Er MD would not want to loose his livelihood over a 38 yr drug user.

I believe part of your initial concerns are appropriate, if the patient has AMS it is appropriate to even do an abbreviated NIHSS, after the CT results it’s even more important to do and repeat the NIHSS even if just abbreviated if possible for the neuro team to evaluate the pts progression or digression.

A request for a root cause analysis or upper management evaluation is appropriate. I have seen too many nurses become too complacent whether at yr 2 or 20 that sometimes a simple review can be a good reminder of what is expected in an ER. But I do agree the outcome most likely will not change but it doesn’t mean that we shouldn’t continue to do our job the best we can.

Great question, conversation and also for all the nurses that haven’t worked ER I would highly encourage you to shadow or follow an ER nurse to understand how many ways they get stretched and pulled. It doesn’t excuse poor nursing but can help you understand the type of reports received and empathy in understanding.

Guest219794 · Dec 30, 2019

On 12/23/2019 at 8:03 PM, mi_dreamin said:
I definitely appreciate all of your feedback. I guess the are thing about it for me is that they weren't calling it anything, not a stroke, not encephalopathy, just, "her brain is fried." They provided no treatment beyond some fluids.
I guess I just wanted to know if what happened sounds like a reasonable series of events considering the facts as presented.
Unfortunately I cannot talk to the providers involved, which is why I wanted some insight into why things may have happened the way they did.
Thank you to everyone who replied, you gave me food for thought!

What treatments should have been done?

Are you saying no charting whatsoever was done for 5 hours?

No vitals, nothing?

What could have been done that would have changed the outcome?

Editorial Team / Moderator · Dec 30, 2019

1 hour ago, hherrn said:
What treatments should have been done?
Are you saying no charting whatsoever was done for 5 hours?
No vitals, nothing?
What could have been done that would have changed the outcome?

Excellent questions, but the OP mentioned that this wasn't actually their patient, so I suspect some gaps in info.

Gingeriffic · Jan 9, 2020

OP, I appreciate and understand your concern and curiosity. It’s impossible to know what truly happened and unfortunately it’s so easy to speculate.

I don’t doubt that the “brain is fried” comment came with some aspect of generalizing/stereotyping/presumption from the nurse, and I’d also be afraid that these feelings would impact the care she provides to similar patients. It’s dangerous to attribute mental status/LOC abnormalities to chronic issues (pre-existing neuro deficits or cognitive impairments regardless of cause: drug abuse, dementia, stroke, etc) without being keen to new reasons for abnormal exam.

There’s no clear reason for why there was no action between 1751 and arriving to floor, because many aspects of this would warrant various actions throughout this time. The patient ripping out her IV might be evidence of impaired judgment warranting constant supervision (clearly impulsive and risk to self). An IV is usually required for imaging whether it’s used during it or not, so I’m thinking IV was pulled after CT. I wouldn’t be comfortable with any patient under medical care to be without IV access, especially this one and with these CT results.

The indication for the CT is unclear, but generally the reasons for needing a head CT would warrant frequent neuro assessments, as well as the results of CT. Lack of documented assessments is unacceptable in my opinion, regardless of what information from this case that we don’t have.

Even if there are no specific treatments that patient could have received (which isn’t the case as far as we know), there are clear gaps in care provided. You were right to inquire whether the appropriate care was given. This patient obviously cannot advocate for herself and it’s our duty as nurses to advocate especially when the patient cannot.

If the ED nurse provided appropriate care, an investigation will reflect that. If there were mistakes made, it will hopefully show whether there are gaps in the system and protocols, or solely from the treatment team.

I hope this answered your questions OP, and don’t take the harsh comments from some of these responses too seriously. You did the right thing.