Patient Rights?

nuangel1, BSN, RN · Dec 29, 2008

he had an obligation to examine her .and recommend f/u .people don't get adtmitted for mysterious rashes and have battery of tests.ers are for emergencies.she would never have been admitted for this .a rash in itself is not lifethreatening.but he could have explained that to her .

Ruby Vee, BSN · Dec 29, 2008

i'm not an er nurse (nor do i play one on tv), but i know that patients sometimes over-react to something that has been said to them, misinterpret patient teaching completely and sometimes prevaricate. unless you heard what the doctor said to her, don't assume that what she told you is exactly what happened. it could be that she'd been arguing with herself about whether or not to go to the er, and misinterpreted his lecture as being judgemental. or it could be that he was totally out of line. but unless you know for sure, i'd give my colleague the benefit of the doubt.

i know itching can be terribly uncomfortable and sometimes you just want to claw your skin off -- but being admitted for a battery of tests from the er seems pretty extreme to me. she probably would have been up all night, miserable, but i don't see why she couldn't have waited until her doctor's appointment the next day. (of course, my opinion is colored by the night i spent itching madly with huge blisters the size of my hand all over my torso. it nearly killed me, but i waited until am to go see my primary physician.)

i'm interested to see what the real er nurses say about this one!

Altra, BSN, RN · Dec 29, 2008

I'm inclined to think along the same lines as RubyVee -- unless you know that this MD tends toward jerkiness I would withhold judgement. He may very well have told the pt. the truth, which is that it is highly unlikely that the cause of her skin condition, already under evaluation by multiple other clinicians, was going to be suddenly, magically determined in the ER. ER treatment for those s/s would be antihistamines & steriods. If the patient states that those have had no effect, what is accomplished by again administering those same meds?

The title of this thread is "Patient Rights?" Are you implying that you feel that some "right" of the patient was violated? EMTALA requires all patients who present to the ER to be screened for a medical emergency. It does not require all patients to be completely worked up for their s/s to arrive at the definitive diagnosis or cause of their s/s.

If you have taken note that the pt. was of the same "background" as you ... you probably just answered your own question about whether or not you "personalized" this pt.'s situation.

pink85 · Dec 29, 2008

I think it is horrible that she left feeling that way. Obviously the patient was feeling desperate. I feel the doctor should have at least listened to her and given her some sort of medical advice instead of lecturing her (if that is what happened). Even if it meant telling her that there was not much they could do for her and that hopefully they would be able to help her at her morning appt.

vivibonita · Dec 29, 2008

I agree with everybody who has replied here. I must be honest and say that the title of this thread was misleading, I believe the MD gave advice, maybe not the one the pt wanted to hear but advice nonetheless. She was triaged accordingly to the rules set out by ER and if she would've stayed the rights of a patient who needed attention and admission the most would've been violated.

Yes, you were being too sympathetic because you associated the pt's situation with your own, but no rights were violated here.

Good luck

ghorjus_hunk · Dec 29, 2008

but i know that patients sometimes over-react to something that has been said to them, misinterpret patient teaching completely and sometimes prevaricate.

have experienced this myself..

i have been complained simply i explained to the patient..and another relative the hospital's policy..

and as far as i can remember, that is one of the patient's bill of rights...

but with regards to the condition of the pt, i can only assume how uncomfortable it was for her.

sometimes too much anxiety or discomfort limits the patients comprehension..

perhaps there was a slight misunderstanding here..

good point by vivibonita!

mwboswell · Dec 29, 2008

going back to the very ORIGINAL post in this thread....

I believe this is a sign of "the times" in how people expect the EMERGENCY department to be a 24/7 "clinic" for them.

Obviously this person hasn't a clue about an ER attending's training versus family practice or other specialties.

I will conceed that the ER attending could have done a better job counseling the pt and explaining things...BUT...

i go back to my original statement - Look where we've come as a society expecting that a rash can come to the ER for evaluation after other providers have already assessed it????

...and we re-inforce this behavior?

I don't mind so much the patient with ZERO health care access, at least we can be the one doctor the pt can see and get referred to an appropriate free clinic or something, but c'mon - this lady had already been evaluated several times.

...after having already gone to a dermatologist and then coming to an ER MD - that's a step down in the wrong direction....

pererau · Dec 29, 2008

Short answer: You are both right and you are both wrong. There is no emergency and the patient is misusing the ER with her expectations, but some kind of H & P needs to occur. The patient should be respected, but not to the extent you were looking for.

Long answer: The doctor is correct that there is no emergency condition present, but I am a big advocate of kind firmness. I think that the ER was not the correct place for this patient, and a big workup including multiple labs and IM shots is not indicated and only disables a room and ties up personnel that might otherwise be available to respond to a true emergency. With that said, I think a reasonable history should have been obtained by the doctor and an explanation that doesn't leave the patient in tears would be in order.

Let her know that you feel her pain and frustration. That you understand how scary it is to get a mysterious rash, and how hard it can be to get in to see a specialist. Offer a prescription for some benadryl and some suggestions for aveeno bath or similar home treatments and give a name of a dermatologist. Tell the patient not to worry about the rash and encourage her to talk to her doctor about TSH levels, fasting glucose tests, etc.

Yes, this would take a few more minutes, but you would have treated the patient like a human and she would have left with her head held high. Perhaps not completely satisfied if she came in with the goal of a big workup, but at least feeling dignified. This is how I approach my patients and rarely do I get histrionic fits.

vamedic4, EMT-P · Dec 29, 2008

Short answer: You are both right and you are both wrong. There is no emergency and the patient is misusing the ER with her expectations, but some kind of H & P needs to occur. The patient should be respected, but not to the extent you were looking for.
Long answer: The doctor is correct that there is no emergency condition present, but I am a big advocate of kind firmness. I think that the ER was not the correct place for this patient, and a big workup including multiple labs and IM shots is not indicated and only disables a room and ties up personnel that might otherwise be available to respond to a true emergency. With that said, I think a reasonable history should have been obtained by the doctor and an explanation that doesn't leave the patient in tears would be in order.
Let her know that you feel her pain and frustration. That you understand how scary it is to get a mysterious rash, and how hard it can be to get in to see a specialist. Offer a prescription for some benadryl and some suggestions for aveeno bath or similar home treatments and give a name of a dermatologist. Tell the patient not to worry about the rash and encourage her to talk to her doctor about TSH levels, fasting glucose tests, etc.
Yes, this would take a few more minutes, but you would have treated the patient like a human and she would have left with her head held high. Perhaps not completely satisfied if she came in with the goal of a big workup, but at least feeling dignified. This is how I approach my patients and rarely do I get histrionic fits.

Kudos to you, pererau, for an excellent and well thought out first post. I agree with you. Perhaps this doctor has a problem seeing things from the other side of the curtain, or the bed, in this case. This is problematic for providers everywhere - they don't see themselves in their patients. They don't see the patient's decreased quality of life, their many unanswered questions during trips to different doctors, the effect that their condition has on the patient's family. All of our patients deserve our respect, even if we can't give them the answers they're looking for. And that doctor owed it to her (as was his obligation to her as her provider, emergent or not) to have an H/P done and then...and only then...decide whether or not any treatment/workup was in order. Sometimes ER doctors ask questions that other doctors don't think of, sometimes they don't.

How much do you want to bet that if her husband or other significant family members were in the room, the doctor's demeanor would be completely different?

iluvivt, BSN, RN · Dec 29, 2008

This kind of shocked me!!!!! How can an MD dismiss this without examining the patient. many many diseases have a change in a patients skin condition as a presenting symptom or a symptom. A lot of the autoimmunue disorders have a skin s/sx. The Md should have at least drawn a CBC to look at the WBC ct and perhaps could have run some other labs (ie.sed rate,ANA titer). If he or she could not come up with the cause the least they could do would to treat the symptoms and offer a referral. Do I think that is sub standard care YES..I think it is no care and I would not pay one cent of that bill and would instruct my insurance to do the same. I would also write a letter to the CEO of that hospital.

lpnflorida · Dec 29, 2008

I hesitate to come to a conclusion as to what and how the doctor treated the patient.

Yes, you have the perspective from the patient. However unless you were in the room with the patient it is truly unknown exactly what the doctor said to the patient.

He may very well have done a cursory look at the rash, was it visible on say an arm or a leg which may not have entailed having to have a patient fully disrobe or look further.

Sadly, her own insurance may well not pay the bill as it will not be viewed as a medical emergency.

I feel for the patient being upset but it was unrealistic of her to expect that a barrage of tests would be performed that can all be done on an outpatient visit.

I am glad that you took the time to listen to the patient afterwards . Perhaps her visit was not a waste after all.