Patient Safety Question/Nurses Conduct

[ChrisMonty]

Hello Nurses,

I was recently in the ER visiting a friend who was stupid and ended up in the ER, nothing major just walking and not paying attention to the giant wooden pole that jumped out from behind the bush and got him... (Sarcasm)

I think this wold be under patient safety, not sure let me know, but here it is.

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. Nurse was performing cspine on the man. I can not say if he was fully there or not but he may of had a concussion. He was skateboarding, no helmet and fell and hit head. PAssed out for a few minutes so medics brought him in. He became verbally, NOT physically, but verbally combative. Not super combative by any means but annoying none the less. He wanted to sign out AMA and go on his way. I can not say if he was in the condition to do so, but they were not going for it. After getting more verbal with the nurse, no swear words or anything, but just annoying, she said something that caught my attention and my friends attention whom him self is a paramedic/med school student. The said and I quote, "I need you to be quiet and stop. If you do not stop I will paralyze you and intubate you. Trust me that will not be fun so you need to stop and be quiet." Now, go ahead and read that quoted section again, yes you did read that right. She threatened him with a medical procedure as retaliation as I see it. Now my question is, 1. would that be legal, and 2. whom do I report that to? Mind you, I live in BFE small town, doctors are untouchable and if you try to remove someone from your care team you get a round table meeting with them saying you can not fire anyone from your team, basically they cover for the employees even if they are wrong.

So, what can I do about this? Whom should I report this to? Is there a county or state person outside o the hospital I could report this to if indeed this is wrong? Any help would be great on this. I have to go to this ER from time to time and do not need Nurse Intubate on my team thank you very much :/

Thank you

Chris

[Altra, BSN, RN]

OP, you've described here on AN your extensive medical history. And yet despite your frequent hospitalizations, you had no idea where to report hospital staff behavior, and instead came here to discuss?

[IVRUS, BSN, RN]

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.

Yes, The OP was overhearing a conversation, but the question was: Was this appropriate? And the answer clearly is NO. If it truly happened the way he/she described, it would be assault and battery if the threat was made good. Now clearly this pt should not have been verbally abusing the nurse, but two wrongs do not make a right. You do not get to pick and choose which part of the scenerio you want to address, as the OP was asking a legit question. Could there have been additional circumstances, sure, but I merely was attempting to answer the question that was posed.

[MunoRN, RN]

Yes, The OP was overhearing a conversation, but the question was: Was this appropriate? And the answer clearly is NO. If it truly happened the way he/she described, it would be assault and battery if the threat was made good. Now clearly this pt should not have been verbally abusing the nurse, but two wrongs do not make a right. You do not get to pick and choose which part of the scenerio you want to address, as the OP was asking a legit question. Could there have been additional circumstances, sure, but I merely was attempting to answer the question that was posed.

I don't think there's anything inappropriate about telling a patient how they could potentially avoid the need for intubation. Patients with a TBI/concussion often don't have the ability to self-manage their symptoms (ie agitation) well enough to avoid the need for intubation, but I don's see anything wrong giving them the opportunity to avoid intubation by informing them of what might be required.

[IVRUS, BSN, RN]

I don't think there's anything inappropriate about telling a patient how they could potentially avoid the need for intubation. Patients with a TBI/concussion often don't have the ability to self-manage their symptoms (ie agitation) well enough to avoid the need for intubation, but I don's see anything wrong giving them the opportunity to avoid intubation by informing them of what might be required.

C'mon Muno... saying: "I need you to be quiet and stop. If you do not stop I will paralyze you and intubate you. Trust me that will not be fun so you need to stop and be quiet." is threatening and inappropriate. Now, if she/he were needing to convey the message of what may happen if cooperation was not had, then saying, "Mr. so-and-so, we're here to help you, but if your condition worsens they may end up needing to put a tube down your throat to help you. They also may need to give you a sedative to keep you calm." Presentation is the key here... people get sued by making verbal threats to others. That is much different than explaining what the consequences may be for this patient.

[CamillusRN, BSN]

I completely agree with team elkpark, as I have been in similar situations ("hey, if you try to hit Nurse X again we will need to restrain/sedate you, regardless of how bad your tummy hurts").

From what I understand about the OP's post, there was a curtain drawn and everything was hearsay only - who's to say it was the nurse and not a paramedic or RT holding C-Spine? Perhaps the physician? And how could the OP know if there were not several other staff members involved trying to hold down his violently swinging limbs (conjecture)? No way to know if the patient was ONLY verbally combative.

I understand the OP's concern, but I really wish s/he (and one of the other posters) would not make assumptions about things that happened behind a closed curtain and overheard by someone without an understanding of the circumstances.

[Anna Flaxis, BSN, RN]

I think you are assuming that the comment was made as retaliation for the patient's behavior, but you don't really know what was happening behind that curtain. As others have stated, if the patient had an altered mentation d/t his head injury and/or possible intoxication, and there is a high index of suspicion for C-Spine injury, and the patient is not cooperating with spinal immobilization, then he may need to be intubated and sedated for his own protection. Perhaps the staff member could have chosen more aesthetically pleasing language to convey this, but in the real world, simple, direct, assertive communication is often the more appropriate choice.

[TriciaJ, RN]

Let me see if I have this right: the patient is at high risk to become quadriplegic (for all we know) and someone wasn't using the Service Excellence script? Shocking.

[CamillusRN, BSN]

Let me see if I have this right: the patient is at high risk to become quadriplegic (for all we know) and someone wasn't using the Service Excellence script? Shocking.

Bahahaha! I think you summed it up quite nicely! Hmmmmm, was it HCAHPS over limb, or was it life over limb; I keep getting the rule mixed up.

[Here.I.Stand, BSN, RN]

This approach makes perfect sense in a reasonable pt; there are others who need a stronger approach. Just an example, I once admitted a pt who'd been in an MVC with an EtOH level 0.3. His c-spines had not been cleared, and he was a very difficult intubation due to severe injuries to his face and lips. He was also very dry; we were in the process of giving lots of fluid, but when he was so dry, any little amount of sedation would tank his BP. Seriously, 0.5 mg of Versed dropped his BP to 70/30.

Now he as thrashing around SO wildly that not only was he risking his neck, but I was truly afraid he'd dislodge the ETT. He could not be reasoned with. At. All. I had to physically force him to lie down, and I held him down until a colleague arrived with a vest restraint. A lay person or even a starry eyed nursing student would probably have been horrified. But you know what? We do what we need to to keep patients safe.

C'mon Muno... saying: "I need you to be quiet and stop. If you do not stop I will paralyze you and intubate you. Trust me that will not be fun so you need to stop and be quiet." is threatening and inappropriate. Now, if she/he were needing to convey the message of what may happen if cooperation was not had, then saying, "Mr. so-and-so, we're here to help you, but if your condition worsens they may end up needing to put a tube down your throat to help you. They also may need to give you a sedative to keep you calm." Presentation is the key here... people get sued by making verbal threats to others. That is much different than explaining what the consequences may be for this patient.

[CamillusRN, BSN]

This approach makes perfect sense in a reasonable pt; there are others who need a stronger approach. Just an example, I once admitted a pt who'd been in an MVC with an EtOH level 0.3. His c-spines had not been cleared, and he was a very difficult intubation due to severe injuries to his face and lips. He was also very dry; we were in the process of giving lots of fluid, but when he was so dry, any little amount of sedation would tank his BP. Seriously, 0.5 mg of Versed dropped his BP to 70/30.

Now he as thrashing around SO wildly that not only was he risking his neck, but I was truly afraid he'd dislodge the ETT. He could not be reasoned with. At. All. I had to physically force him to lie down, and I held him down until a colleague arrived with a vest restraint. A lay person or even a starry eyed nursing student would probably have been horrified. But you know what? We do what we need to to keep patients safe.

In a previous thread I mentioned a couple of patients with Marijuana toxicity - one of them was so combative and out of her gourd that it took 5 staff members to hold her down in order apply restraints. Nothing we were giving IM or IV would even touch her. Ended up having to knock her out with simultaneous fentanyl and propofol drips and intubating. With the volume at which she was screaming her head off, and the staff screaming to hear each other over her jibberish, I was sure we were about to be written a citation for violation of the city's noise ordinance.

[MunoRN, RN]

In a previous thread I mentioned a couple of patients with Marijuana toxicity - one of them was so combative and out of her gourd that it took 5 staff members to hold her down in order apply restraints. Nothing we were giving IM or IV would even touch her. Ended up having to knock her out with simultaneous fentanyl and propofol drips and intubating. With the volume at which she was screaming her head off, and the staff screaming to hear each other over her jibberish, I was sure we were about to be written a citation for violation of the city's noise ordinance.

Marijuana toxicity? Are you sure you're not referring to synthetic "marijuana", AKA "spice"? Spice is known to produce the effects you are referring to. Marijuana toxicity on the other hand is still only theoretical, given the massive amount required to produce toxicity which is generally thought to be equivalent to the amount that would fill a large hay barn to the roof that is smoked or ingested in less than 15 minutes.

[CamillusRN, BSN]

Marijuana toxicity? Are you sure you're not referring to synthetic "marijuana", AKA "spice"? Spice is known to produce the effects you are referring to. Marijuana toxicity on the other hand is still only theoretical, given the massive amount required to produce toxicity which is generally thought to be equivalent to the amount that would fill a large hay barn to the roof that is smoked or ingested in less than 15 minutes.

I'm sure you must be right. The only positive on her blood tox screen was for THC, so the physician dx'd it as marijuana toxicity. Come to think of it, our lab most likely does not have the capability to test for K2/Spice or most other synthetics.