Hey guys, I'm not sure if this is the right place for this topic, sorry if it's not! I wanted to ask your opinion of something I saw happen in a hospital this past week. I really feel like this Doctor made a huge mistake but wanted to see if this seems okay to you guys.
I went on a missions trip in the eastern US and worked with very underprivalged children this past week. At the begening of the week a five year old girl was playing in a gym when she ran into another little boy and fell face forward. I didn't see the little girl run into the boy but I saw her while she was falling. I watched the little girl at first because children fall a lot and get back up fairly easily most of the time so I didn't think she was that hurt. Well the little girl didn't get up, she didn't move at all. So I ran over to the little girl and turned her over. Her eyes were open but they were glazed over, she was breathing, but she wasn't crying or screaming or talking or anything. I said her name several times and she didn't respond. It was then that I noticed a large amount of blood quickly filling up her mouth, enough so that she would choke on it. I turned the little girl over so she wouldn't choke on the blood and it poured out of her mouth. Then I pulled her back onto her back and called her name several times. By this time there was a lot of people around us including a NP and a LPN, after maybe 10 or 15 seconds of the little girl being out she came back to consciousness and started cyring and screaming in a lot of pain. We got an ice pack and applied compresions to her lip which had been torn in the fall and was the cause of her bleeding. The little girl complained of nausea, her eyes staying cross eyed, and pain to her lip of course. The mother of the child was present and we decided to take the girl to the ED. The mother drove and I sat in the back with the little girl on the way to the ED. The car ride is kind of a blur because there was so much stress and panic. The little girl kept clossing her eyes and trying to go to sleep in between screams and lost consciousness at least 2 more times for about 3 seconds each time. The hospital was 25 minutes away and I was concerned that she could loose consciousness and stay that way so I called 911 to tell them everything that was going on and ask them if we were ok. They said we needed an ambulance right away so we pulled over and the ambulance met us and took us to the ED. When we got to the ED the girls pulse was 161 and she was still screaming inbetween trying to go to sleep. The nurse put her in the hospital bed and tried to sit her up. The little girl couldn't sit up and her entire body flopped over as soon as the nurse let go of her. Her resperations were somewhere in the 30's but her sats were like 98 so I was thinking that was ok. She didn't have a temp and I don't remember her BP. The DR came in looked at her and said she would be monitered for an hour. No IV was started, no labs were drawn, no blood sugar was checked, NOTHING at all was done for this hour. After an hour the child has stoped bleeding mostly, she was sleeping/crying and her pulse was 150. The DR gave her motrion and then wanted to send her home. The child was still complaning of all the same symptoms. At this point I was like wait a second, your not going to do a CT? The DR claimed that he didnt want to expose her to the radiation and that she was fine. To me it seemed like the DR had no idea what he was doing. I asked the DR what kind of things would be a cause for concern as we monitered her at home and do you know what he said? "Well if she looses consciousness" NO?!!!?? REALLY?!??!! Lossing consciousness is a bad thing???!!! Thats all he said!!! If the child was mine I would have demanded a CT and a Pediatrician. The girl went home and ended up being okay but I think the DR was just lucky. Would this happen at your hospital? Wasn't the DR putting the girl at a huge risk? Also is there anything else that I should have done for the child at the time she hit her head? Your input would be great, thanks!
I have met some of the stupidest, most incompetent MDs in my lifetime.
I'm not trying to sound snarky, but every MD I've met on a professional level has had a basic level of competency. There were a lot I didn't like personally, and some I thought were better than others, but they were all at least miminally proficient. And in my year long stint in the ER, I met the some of the smartest docs. I honestly feel it was a privelege and an honor to work with them.
Thank you for your replies. I can see both sides better now.
LTC RN JC: Thank you for your post. Its true that when questioning anybody, especially a Doctor the way you phrase your question means a lot. I wish the ED Dr. had explained like you had! That would have helped a lot!
For my child yes I would spend tons of money on a test that might not be necessary. If it means the childs life or quality of life. There are already going to charge you a few hundred just for saying hello to you, might as well cover all your bases. Besides assuming that there is inusrance your not paying it anyways. I don't see a problem with sending large bills to insurance companys. Thats what their there for, paying the bills. And if there is no insurance well that sucks but the kids life is more important.
An insurance company isn't paying the bills...it's the people (real live working people just like you) who pay the bills through their premiums! Unnecessary medical tests and procedures due to being forced to play the CYA game are the reason why health care spending is out of control. This is a serious issue because the money has to come from policy holders or the govt (meaning us again) If you pay for your own insurance or pay taxes don't cry over increasing premiums or higher taxes to pay for some other parent's peace of mind...even when it goes against sound medical advice.
You're background (Or what you have read on the Internet, seen on Gray's Anatomy, or overhead in the nurse's station) may give you a general idea of what CAT scans are and what circumstances they are used in but the truth is that you are not a doctor.
It's also true that sometime docs do miss or overlook things...they are only human too. Also, and this may alarm you, testing and interventions do not always change outcomes. Life is fragile and people die. Sometimes people fall, hit their heads, and die....and no test in the world would have changed a thing....Natasha Richardson anyone?
Anyway, if you really felt that the doc was clueless then why didn't you do what another poster suggested and go to another ER?
As nurses though, we do have to collaberate with the doctors and do as they say. There are ways of asking Doctors to do more test, ect. It involves playing the nurse/doctor game. "Doctor, this patient was unconscious after falling and now she is falling asleep between screams and complaining of nausea, gosh, do you think we should see if she has a head injury?" "No" "I guess I still have alot to learn could you please help me understand this?" Always protect their egos, you get more that way.
What?!!! Please, pretty please, rethink this advice. Yes, there is a way to communicate professionally with physicians in order to provide the best care for our patients.(SBAR anyone?) However we are not obligated to protect their egos. This perpetuates a dysfunctional nurse/physician dynamic and places the responsibility on the nurse to make sure the communication is effective which means which when it isn't effective, it's our fault.
Oh and either we collaborate with physicians OR we do as they say. You cannot collaborate and do as they say. One implies teamwork and the other sounds subservient. I'm just saying.....
what?!!! please, pretty please, rethink this advice. yes, there is a way to communicate professionally with physicians in order to provide the best care for our patients.(sbar anyone?) however we are not obligated to protect their egos. this perpetuates a dysfunctional nurse/physician dynamic and places the responsibility on the nurse to make sure the communication is effective which means which when it isn't effective, it's our fault.
oh and either we collaborate with physicians or we do as they say. you cannot collaborate and do as they say. one implies teamwork and the other sounds subservient. i'm just saying.....
you are right. i use sbar for communication with physicians, but there are certain doctors that you absolutely can't use the "r" part with. i guess i was referring to those physicians who don't want to hear what you recommend, and in those cases, the only thing i know how to do is "play nurse". i am a fairly new nurse, 1 year exp. and i am considering leaving nursing. i am very discouraged, so many things they don't teach you in nursing school.
Pinkstudentnurse: I wasn't there, but your representation of events sound something like a 1st time mother recounting her child's first injury. I've seen plenty of lip lacerations, but very few that caused blood to "pour" out, especially since there is no mention about it being sutured in the ED. I realize that this must have been scary to witness, but to be perfectly honest, your post sounds a little melodramatic.
You are obviously a very caring, compassionate person, but you know just enough to be dangerous. I have a sister who is in the same boat. She is a student and hasn't had kids of her own to break her in. When she sees my 3-year old fall or get sick, she perceives the situation as much worse than it is and usually wants to take him to urgent care or the ED.
My father, on the other hand, raised five children and is an MD. His motto is "kids bounce." (former president of the American College of Surgeons, BTW, so probably not among the stupid and incompetent)
Although things did not go as you expected, I think ultimately this was a great learning experience for you. Emergency medicine in rural Kentucky is a model to be emulated in other rural areas of the country. Some of our trauma surgeons have done fellowships in rural Kentucky and are now trying to bring the policies and practices that have saved lives there here to Missouri. That does not mean that every ED doc is perfect, but statistically the child in question was in very good hands.
Feasibly, the CT was not done for any and possibly all above reasons mentioned. That is reality OP. As you learn more you will be much more aware of all the things involved in MD decision making. This will be good and bad. Sometimes your intuition will be right on the mark. Othertimes you'll be stunned at how far off you are.
you are right. i use sbar for communication with physicians, but there are certain doctors that you absolutely can't use the "r" part with. i guess i was referring to those physicians who don't want to hear what you recommend, and in those cases, the only thing i know how to do is "play nurse". i am a fairly new nurse, 1 year exp. and i am considering leaving nursing. i am very discouraged, so many things they don't teach you in nursing school.
the first year is the hardest......well for me it was the first two. it will get easier. remember after you get 1-2 years of experience there are many different opportunities within the field. if your current work environment is grinding you down, just think of your options. so stick with us.
as for communicating with physicians you are right. there are some who do not accept the "r". give them the first three, then it's up to them to act and you to document. there's nothing else you can do about that but their ego is their problem, no playing nurse.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
The doctor did not deem it necessary to do any testing because he did a full assessment based on his degree and experience.
That's it. Basic, no ifs, ands, or buts.
What we are missing here is the doctor's side..if we knew what he saw, then I think we'd have a better view as to what actually occurred. What you saw is traumatic in your eyes...but that is your perspective from a student, non-nurse.. POV--no judgement here, just that you are learning and you haven't really seen as much, so in your eyes...it was a very, very big deal. Totally understandable.
I've seen plenty of kids come into our ED with head injuries and concussions who, after the parents and our ED doc have a frank discussion, don't get a head CT. It's an awful lot of radiation for a kiddo, and nine times out of 10, the parents agree with our ED doc. The parents go home with extensive instructions (verbal and written) on signs that would indicate they need to return to the ED quickly, or call 911.
Also, for the OP -- when you are done with nursing school, may I suggest you take the Trauma Nursing Core Course (TNCC)? It's a fabulous class that covers everything from c-spine stabilization to trauma assessment, and I think you'd probably get a lot out of it. I'm not being sarcastic -- I mean this in all sincerity. Good luck with the remainder of school!
One more thought to add, and again, I mean this constructively: even as an ED nurse and a paramedic, if someone is injured like this, I will not hesitate to call 911. I don't carry the things that would have been required and should have been used in this situation: a c-collar, backboard, spider straps, head blocks, etc. I know the best thing I can contribute to situations like this (and I've been there, as a "civilian," unequipped) is to initiate a 911 response, hold c-spine and ensure a patent airway, and talk the patient to keep him/her calm.
Okay guys, take a deep breath, it was just a question. I admit that I'm unexperianced and have a lot to learn but thats why I'm asking, to learn. Also I never care for children where I work on a med surg floor. Every once in a blue moon I'll have a 19 year old or 20 year old but thats the youngest I get. Most of my patients are at least in their 70's! So of course when a 5 year old gets hurt its gonna freak me out a little more then an elderly person.
LunahRN- I actualy was just looking at some stuff on TNCC, it looks awesome! There is just so much to learn, its crazy.
See if the Dr had given instructions and really educated the parents on everything I would have felt better about his decision. The Dr. didn't give instructions and when he was asked what would be a warning sign he just said if the PT lost consciousness. Because the Dr didnt give more detailed discharge instructions it made me question his judgement.
Yeah, I would have called 911 right away and thus got the ambulance right away but other people took over and they were older then me so I didn't feel like I could. I should have just called 911 anyways and let people get mad at me.
In addition to all the excellent advice you have received from some great nurses, please let me add my 2 cents.
First, heads bleed like stink. Remember that heads bleeds (and I mean tongues, lips, head lacerations, etc.) and the amount of blood coming from them can look scary but with a little pressure the blood will stop.
Second - Pediatricians and ER physicians are now encouraged by their professional organizations and tons of research not to use CT unless necessary (as told by many of the previous nurses.)
Third - Although the doc may have not seemed to spend a lot of time with you, there may have been many other reasons the he or she believed the child was tired. If after screaming for a while because of the pain, she may have been exhausted. My daughter required stitches at 20 months old and fell asleep while getting stitches because of the 1/2 hour she screamed before getting to the ER. Also at 5, compile screaming with outdoor activity and a possible nap time and she could have been very tired. Also, the RN should have done the discharge instructions; that is almost always our job. Very possible the ER doc was attending to another, possibly more serious trauma.
Finally, a bit of advice - but please take this advice knowing I mean it sincerely and I am not trying to offend at all. A very wise nursing professor said to me, "If the nurse believes they know more than the doctor, than they have forgotten why they have become a nurse." Now, that is not to say we don't have medical knowledge and that we shouldn't question the doc, we should. It is just saying we aren't competing with them and if you find one that you work with that you respect, ask them questions about proper medical ethics and behavior and they will very possibly tell you things you may not have understood or realized because their education is very different than ours and they view things differently.
fungez
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I have met some of the stupidest, most incompetent MDs in my lifetime.
I'm not trying to sound snarky, but every MD I've met on a professional level has had a basic level of competency. There were a lot I didn't like personally, and some I thought were better than others, but they were all at least miminally proficient. And in my year long stint in the ER, I met the some of the smartest docs. I honestly feel it was a privelege and an honor to work with them.