Patient Safety Question/Nurses Conduct

jadelpn, LPN, EMT-B · Mar 23, 2015

I would take this to the facilities corporate level, and fill out a report (can be found online on the company website, and can be anonymous). What jumps out at me:

Anyone who suffers a head injury can become very combative, verbally inappropriate, any number of things.

I would think that what you may not have saw is that typically, the paramedics would have put this person in a c-spine collar, on a backboard, so I am not sure why this was all taken off for a nurse to hold c-spine. And if the choice was to stay in c-spine or to be altered in consciousness to protect function, there are a lot of other less crappy ways to explain that to a patient, to say the least. As well as medications to calm a patient who may be in a complete panic that they are being strapped to a board and can not move.

So unless you saw this yourself, chances are that for whatever reason, the nurse was personalizing this, which is wrong. And backboards and collars can and do make patients cranky. But no excuse for the nurses behavior, as it is unethical, and threatening, and non-compliant--all those things that are not supposed to happen. Not to mention that really, anyone can sign out AMA, unless deemed incompetent--which is another whole story for another thread.

Do not be the least bit shocked if the result of your reporting is more of "why the heck can other patients and their visitors hear anything"--patient privacy issues, as opposed to what was said by the nurse in question. And any other visitor would not be able to attach a name to a nurse if they are behind a curtain, so it becomes more about privacy than what was said to this patient, and by whom.

But it does need to be brought to the table. And the best way to do that is to go to the parent company website and report it. And if your friend heard it as well, he can add it to the survey that he will be getting in the mail.

IVRUS, BSN, RN · Mar 23, 2015

What this "nurse" did is ASSAULT. She threatened the patient with bodily harm if he did not comply with her wishes. If she would have "made good" on her threats, she would be committing Battery.

MunoRN, RN · Mar 23, 2015

It's not at all unusual for patients with a head injury to suffer from an altered mental status. The the AMS isn't preventing them from ensuring their own safety, or at least be fully cognizant of their injury and the risks they accepting by leaving or not following instructions then they are free to do that, although that's often not the case with head injuries.

If the patient's altered mental status is deemed to have inhibited their ability to make decisions about their own safety, then ER staff are not only allowed, but legally required to ensure the patient's safety above all else. In my experience this often results in the need to sedate and therefore intubate patients in order to ensure they aren't a risk to themselves. A head injury triggers an impressive fight-or-flight response. Depending on the specific injuries and needs to perform imaging, procedures, etc, following specific instructions on movement restrictions is often an absolute necessity, which obviously becomes an issue in a patient who's only goal is to flee even though they don't know why.

The nurse could have presented the potential need to sedate/intubate more appropriately, but in my experience it is often unavoidable with otherwise healthy individuals who display a pronounced post-concussion agitation.

MunoRN, RN · Mar 23, 2015

It's not at all unusual for patients with a head injury to suffer from an altered mental status. The the AMS isn't preventing them from ensuring their own safety, or at least be fully cognizant of their injury and the risks they accepting by leaving or not following instructions then they are free to do that, although that's often not the case with head injuries.
If the patient's altered mental status is deemed to have inhibited their ability to make decisions about their own safety, then ER staff are not only allowed, but legally required to ensure the patient's safety above all else. In my experience this often results in the need to sedate and therefore intubate patients in order to ensure they aren't a risk to themselves. A head injury triggers an impressive fight-or-flight response. Depending on the specific injuries and needs to perform imaging, procedures, etc, following specific instructions on movement restrictions is often an absolute necessity, which obviously becomes an issue in a patient who's only goal is to flee even though they don't know why.
The nurse could have presented the potential need to sedate/intubate more appropriately, but in my experience it is often unavoidable with otherwise healthy individuals who display a pronounced post-concussion agitation.

(That was supposed to read if the AMS isn't preventing...)

elkpark · Mar 23, 2015

My first thought is that I hope the next time I'm in an ER I'm not in a situation in which there is a visitor intentionally eavesdropping on me through the curtain. Gee, when I find myself in that kind of situation, I make a concerted effort to not eavesdrop on the person on the other side of the curtain. Doesn't the OP have better things to do, or some sense of propriety/discretion?

My second thought is that people with head injuries are often agitated, confused, distracted, and have difficulty paying attention. They are often at risk of inadvertently injuring themselves further because of the agitation and confusion. For the same reasons, they often have difficulty grasping what they are being told unless it is stated very simply and directly. My specialty is psych, not ED, but I have spent years in emergent psychiatric situations saying to agitated, manic or psychotic clients who are at risk of harming themselves or others (intentionally or unintentionally), "I need you to stop this behavior, and I need you to understand that, if you aren't able to stop, you are likely to end up in restraints, which I don't think you will like." In those situations, I was not "threatening" anyone with anything. "Warmer, fuzzier" attempts at de-escalation were not working. The individual was in a state of mind in which s/he can only "get" v. clear, simple, direct communication. I feel it is only fair (and ethical, and professional) to inform clients of the likely consequences of their actions early in the process, rather than waiting until the individual crosses some line that Iknow is there but s/he may not, and then grab them and stick them in restraints (or, in this case, intubate them) without any warning.

If it were you, would you rather be warned in advance, in plain English, that your current behavior was leading toward X negative consequence (intubation or restraint), or would you rather just be grabbed and (intubated or restrained) at some point in the process without any warning? I know which I would prefer.

I don't feel I have enough info about the situation to have a strong opinion one way or the other (unlike some here ...), but I will say that I am not immediately impressed that the nurse behaved inappropriately or unethically.

Altra, BSN, RN · Mar 24, 2015

What this "nurse" did is ASSAULT. She threatened the patient with bodily harm if he did not comply with her wishes. If she would have "made good" on her threats, she would be committing Battery.

That's quite a statement, considering we are only hearing from a layperson visitor, who states he was eavesdropping. Not exactly a complete picture of the situation.

EmergencyRN22 · Mar 25, 2015

If we receive a pt with aloc/altered mental/combative after a head injury - the ER team may need to intubate the pt to be able to ct the patient. However, there are multiple ways to medicate the pt that should be attempted before going the intubation route. They may have suspected a bleed.

just my two cents.

mariebailey, MSN, RN · Mar 25, 2015

I was in ER visiting friend, I was eves dropping on to another patients case next to me, on the other side of the curtain. Man came in with bumped head and might have slight concussion.

You should mind your own business. Most nurses would NEVER say something like that, and most nurses are quickly thrown under the bus for situations beyond their control, while other disciplines face no consequences for circumstances they created. You painted a picture like nurses there are protected in some way, when we have to fork out our own $ for malpractice insurance. The situation you describe is unacceptable, but you don't really know enough about what a nurse goes through in a 12 hour shift to appreciate that it was a lapse in judgment.

Here.I.Stand, BSN, RN · Mar 25, 2015

It wasn't a threat of retaliation; it was a statement of what would need to happen if he was either unwilling or unable to hold still. All you know was this pt's verbal behavior. You couldn't see if he was starting to move around. Until a trauma patient is cleared as having no C-spine injury, they are treated as if they do--and that means holding perfectly still so he doesn't become quadriplegic. It's actually pretty common for patients to be intubated and sedated (with a one-time dose of a paralyzing drug for the actual intubation, which wears off) if their behavior is interfering with their safety.

Being a med student does not mean s/he knows common practice for trauma patients in the ED. It means s/he's a student.

psu_213, BSN, RN · Mar 25, 2015

IF the nurse told the patient solely as a threat to "shut him up" that they would sedate/intubate him--no, that is not appropriate. However, and I mean no offense by this, you are not an emergency department healthcare provider. You did not see what was happening in that room. How do you know that he was not physically combative in any way? You also can't know that if he was moving around and was, therefore, at a risk for injuring himself further. You mention "he might have a slight concussion." How do you know how slight his concussion was? He had LOC and he is in C-spine precautions. He will need a CT--sooner rather than later. He may indeed have to be sedated for that.

I appreciate that you are trying to be helpful for those who come in injured to that ED. However, you don't know the entire clinical picture to make a judgment on what was going on. If you really want to be helpful to other patients, don't eavesdrop on them or their care.

Nonyvole, BSN, RN · Mar 25, 2015

You've made some statements there that suggest that you were doing more than listening in.

And like Here.I.Stand said, your friend is a paramedic and medical student. That doesn't mean he knows how an ER works, or what the staff has to sometimes say to patients just to keep everybody safe.