MD: Why did you get a BG on this diabetic patient???

[Murse901, MSN, RN]

This is a hypothetical scenario that has not happened in real life. Everything in this post is a pure fabrication. Thankfully, this hypothetical scenario did NOT happen directly to me - I would have only observed this scenario playing out had it been a real situation. I'm still fairly new at my facility and wouldn't want this looming over me, if it were real.

Now that that's out of the way...

Patient walks in with self-reported decreased level of consciousness/confusion. Speech is clear, mild unsteady gait but otherwise good mobility, equal and purposeful movement to all extremities, PERRL. General impression: patient looks stable. T/P/R/BP WNL.

Patient is a known frequent flier. Patient has been in the ED about 9 times in 6 months for various problems, including 3 times by ambulance for hypoglycemia. Patient has a hx of DM.

RN triages at the bedside and checks BG. 630. Rechecks BG immediately. 637. MD is busy with another patient. RN starts an IV, anticipating that this patient will need IV insulin and fluids. She draws labs but holds it until the MD makes the lab order, per protocol.

MD is FURIOUS that the RN took the BG. He had gotten a brief report when the patient was first starting to get triaged and had planned on streeting him due to him being a frequent flier (triage nurse's fault for even mentioning that, considering the chief complaint and hx). He flies off the handle and says that nurses are not to do anything invasive without an explicit MD order and that the RN was practicing outside of her scope of practice. Basically, MD is p****d off that he actually has to do something to treat this patient instead of clearing him off of the board, since it's 30 minutes prior to shift change and he has a tendency to discharge/admit everyone in the last hour.

I have never worked anywhere where a nurse could NOT start an IV if a patient was in danger of going downhill (except facilities that did not have the equipment; i.e. assisted living). I have never worked anywhere where a nurse could NOT check a BG on a diabetic, especially one presenting with a decreased level of consciousness.

If this patient was not a frequent flier, and presented with the same sx/sx, the MD would have been furious that BG had NOT been checked and IV was NOT started. This just seems crazy to me. Can't win for losing in this scenario.

Like I said, I'm just glad it didn't happen to me.

[GHGoonette, BSN, RN]

When you use the term "hypothetical", are you saying that it's a scenario you yourself have imagined, or did you hear it from someone else that this actually happened? That is, did this happen to another nurse?

I have never yet heard that it is outside an RN's scope of practice to check a patient's glucose levels where there is reason to suspect a problem. In an ED, I would describe it as a basic observation. Surely no-one needs a DR's order to do that?

In for-profit hospitals, it might lead to issues with management if items are used which insurance later refuses to cover, but I can't see that applying in emergency admissions.

[rn/writer, RN]

It would be a rare ED that didn't have basic protocols for the most common situations and complaints. These usually include standing orders for things like IV access, blood glucose, O2, EKG and other procedures. These are not on-call doc driven but protocol driven so that the docs don't have to order every little obvious thing.

Any doc that would holler about someone getting a bg reading when they present with confusion, altered mental status, and a hx of diabetes and hypoglycemia, needs to be reported to his superior. I don't care how frequent a flyer that person is, if their blood sugar is crashing, they need help, lazy doctor be darned.

[mmutk, BSN, RN, EMT-I]

Sounds like a MD I may had a run in with in an ER or two i've worked at... You do not need an MD order to check a glucose level at triage, in fact you would be more likely get into trouble not checking a finger stick glucose for a symptomatic patient at triage.

As far as the IV goes, I am sure you truly cannot start an IV without an order or standing protocol as a nurse. However this is often facility specific and something that is overlooked and rarely enforced. It seems like nothing you are going to loose your license over I hope your manager stands up for you.

[Art_Vandelay]

For hypothetical, the details are rather specific.

[BeautifulDoeLVN]

Let me guess they had no insurance. Well You do not need an MD order to check a glucose level at triage, in fact you would be more likely get into trouble not checking a finger stick glucose for a symptomatic patient at triage. Trust me the BON is not going to reprimand the nurse for starting an IV if they had gone into a coma and died when sent home with no treatment the hospital would have a law suit on their hands and lose their accreditation and the ED staff who would all be held accountable. This ED Physician He needs to be reported to the medical board.

[Roy Fokker, BSN, RN]

Sounds like an MD who doesn't want to deal with an unpleasant pt.

Pt. maybe a PITA but even PITAs should get medical care.

Let me guess they had no insurance.

I doubt it matters. I doubt most ED nurses know/care if pt. is insured or not - they get seen anyway.

The only time I've done a wallet biopsy is when I'm transferring a pt. back to nsg.home, SNF, specialty hospital -- what kind of insurance they have (or lack thereof) defines which transport company I call.

cheers,

[BeautifulDoeLVN]

1. Where out of his post do you assume that the patient is unpleasant?

2. I'm referring to the MD as to caring if patient is insured IT DOES MATTER!! the kind of treatment and care you do receive.

3. If a patient is uninsured the ED physician has to deal with Admin and the hospitalist to get approval for an admission

4. The patient gets a separate Bill from the ED physician in which he knows he probably isn't going to get paid.

[merlee]

Why bother with all the 'hypothetical' references? It seems to be a 'true' story.

As most have noted, getting a fingerstick is definitely within scope, and in the ER setting, placing an IV is probably a protocol as well.

MD should be glad that he didn't get to dump this frequent flyer - - had the patient gone into a coma thyere would be he!! to pay!

[psychomachia]

My response would be, "So what labs do you want?"...

[Murse901, MSN, RN]

Like I said, it didn't happen to ME, so I'm thankful for that. However, I did directly observe this happening and was just telling the RN to document, document, document. We do have protocols for this, but there is a catch 22 that the MD may say he does not want the protocol.

Well, to get the workup started, we need to start the protocol. The MD can cancel it later, but the protocol is there to expedite patient care. The protocol is not there for the convenience of the MD to not have to write out each individual order. So, if we start on a protocol, it's a bit too late for the MD to cancel a BG and cancel an INT.

As for insurance, I honestly have no idea if he had it or not. The only time I ever find out about insurance is for ambulance transfers or if I happen to be in the room when the registration clerk comes in. I have no interest in their insurance, but I understand where the insurance question comes from.

I could be wrong, but I believe it's an EMTALA violation to have insurance available to the MD prior to the MD determination of whether or not the patient is experiencing an emergency medical condition.

[GHGoonette, BSN, RN]

Right, having determined that this happened, I'd like you to consider the following; let's assume your colleague didn't do the finger stick and the patient was discharged, only to collapse and possibly die later. Obviously, there would be an inquiry and the person who triaged the patient would be grilled. Once it came out that she'd failed to do the finger stick, which, as we have already thrashed out, is within her scope of practice and constitutes a basic observation, she wouldn't just be grilled, she'd be toast!

MO would very likely deny all responsibility and put the blame entirely on your colleague, and he would in all likelihood get off scot free, leaving the RN to lose her license and pay the damages.

Your friend needs to report this, and should lose no time in doing so. You guys must stand together on this, next time it could be you, or worse, a nervous newbie sufficiently unsure of herself to refer all queries to the MO and.....