Was I out of line ?

[grantw9066]

After triaging a pt. from a minor mvc 12 hrs pta with c/o neck pain, I informed the physician of the pt's complaints and questioned the appropriatness of a c-collar. The physician stated, "If she walked in, she doesn't have a break. It is not necessary" I charted exactly what he said. I KNOW I should have just placed the c-collar and let him worry about clearing the c-spine; but I didn't. The doctor saw my entry on the nurses note and stated " Dont put stuff like that on the chart" I stated " I just charted what you said, I just wanted to document that I informed you of the pt's complaints and you did not feel it necessary to place a collar." The physician then stated "If you do it again, I just wont talk to you" ARE YOU KIDDING ME? ARE WE 12 YRS OLD, HE IS NOT GOING TO TALK TO ME!! Please respond and tell me if you think I was in the wrong. (about what I charted, I know now to just put on the c-collar)

[Larry77, RN]

I wholeheartedly disagree with the mind-set of "us against them"...we are a team in the ED and if we do not work like a team we will lose valuable time and our performance will go down greatly. I would consider myself friends with almost all of our docs and have good working relationships with the others.

If I was triage I would have assessed the neck pain and either placed a collar or not then informed the doc why I did what I did. One doc might be upset that a collar was not placed while another might be upset if one was placed, this is the variable in my opinion, not your own decision. What I'm trying to say is do not make this decision because of what the doc might think or do, make it with your assessment of the patient and back that assessment up with an explanation to the doc if necessary.

[jjjoy, LPN]

I'm not a black-and-white person about most things.

I can see why the OP did what she did and why the MD was upset with it. Ideally, the OP should do what she thinks needs to be done regardless of the MD's reaction (the possibily that he'd tell her she shouldn't have collared the patient and get angry at her about that). Ideally, the MD would discuss with her his problem with her approach to this case and how it could be better handled as opposed to just telling her she was wrong and not to do that again (presumably chart his exact words when she disagrees with his orders). They do need a clearly understood way of dealing with situations like that because there ARE cases when such CYA charting is necessary.

In general, when you aren't sure about something because maybe you don't have enough experience yet, it's a tough call how much to rely on others' assessments.

As another noted, in the case one doc may get upset that you did collar a patient and another that you didn't. If you don't have enough experience to feel so confident in your judgement of the situation that you're willing to go against what the MD says, what do you do? I suppose in that case, it's best to be cautious and go with the extra safety measure. However, if the MD thinks that's too cautious, the nurse might end up being yelled at about that and having her competency questioned. Instead of being supportive of each other in our efforts at safe practice and acknowledging our limitations, we tend to get fed up with others when they don't see something that seems obvious to us or someone doesn't know something that we think they should know already.

I think it's a shame that communication between professionals in health care, especially physician-nurse relations, tend to be so adversarial as opposed to colleageal. If the nurse or doctor doesn't know something, misses something, makes a mistake, both sides are very quick to judge the other as "stupid" "incompetent" "dangerous" "lazy" etc. Of course, if someone has a pattern of problems, that's another story, but case by case the disrespect between staff in many settings seems uncalled for. No one can know everything all the time and we're always learning.

Anyway, I kind of rambled off the specific case in question but it brought up these thoughts so I thought I'd throw them out there and see what others might think about it.

[gonzo1, ASN, RN]

A few months ago I had a patient who was about 21, playing soccer and tripped and flipped hitting the back of his neck and upper shoulders. His wife brought him in later in the day because his neck hurt so much.

He walked in and ended up being flown out. He had a burst fracture of c1-c2. Amazing he wasn't dead.

Unfortunately I have no idea how he is now.

When he came in triage did not c-collar him. We all tend to think that there can't be anything wrong if you can walk.

Well, now I know better. Almost all my neck pain after injury patients get a c-collar until proven otherwise.

I sure hope that guy is okay. They were just married and had a baby on the way.

[neneRN, BSN, RN]

I wouldn't have quoted him UNLESS its a doc with a reputation for denying giving orders/throwing nurses under the bus...there is only one ER doc I work with like that, and I would quote him in a second to protect myself! All the others, no...if I disagreed that the pt did need a collar, then I would put it on and document MD aware.

People are too quick to write "no orders rec'd," it implies that the nurse felt orders should have been received (which is usually an accurate inference, or the nurse wouldn't have charted it)...but say a case goes to court, an attorney is going to ask you if you felt that orders hould have been rec'd...obviously you did right? But the next question will be, if you felt orders were indicated and did not receive any orders, what were your next steps up the chain of command? Not gonna cut it to say well, I just charted it. If you chart no orders received (because you felt you should have received orders), then you better to something else other than just chart it (notify charge, supervisor, med director, etc.) to cover yourself.

Use the OP's case as an example...say the pt actually had a Fx and the pt sues the hospital. Do you think that nurse is safe because she charted that the MD was aware and stated such and such? Um, no...because when the attorney asks that nurse why she did not put on a collar (as an independent nursing action) or go up her chain of command to advocate her concerns for this patient, saying well, I charted it isn't going to help her.

Sorry, I went off on a tangent there,but its a huge pet peeve of mine because I think nurses feel they are protecting themselves when they write "no orders rec'd," when they may actually be setting themselves up for trouble. I chart MD aware and leave it at that...doesn't imply anything, just shows that the MD has been made aware of abnormal findings or concerns.

[talondora1]

You are correct in quoting the physician. If this case ever ended up in a court of law, quotes are appropriate. You have a license to protect, and so does your facility. The doctor should have chosen his words better if he was so concerned.

I have been instructed over my career by many nurses to quote the physician if I am concerned.

I would have followed his instructions however placing the collar if he ordered it.

[talondora1]

I disagree. The doctor is the one who was out of line. True we are suppose to be a team. Not all doctors feel that way. If she misunderstood, fine. She didn't.

Any physician who says to a nurse, especially an inexperienced one, "then I am not going to talk to you," is asking for trouble. Personally, I'd report his conduct. Our hospital would never put up with that.

[Kidrn911]

You know what, we all have stressful days and say stupid stuff, maybe just in kidding maybe not even funny, but stupid stuff nonetheless.

I also understand the need to CYA, thus I personally would have done it in a tactful manner, even if the doctor was a jerk. I would have charted something like "Md notify of injury, no further orders give, C-Collar not applied per md request."

Warning to you though, you had better make sure you never say anything dumb or stupid, a co worker or fellow physician may now chart everything you say exactly how you say it. So you had better CYA each every time. Because he may be venegeful towards you.

What i would do is go suck up, admit you were just as stupid for putting that in the chart, just like he was for saying it. That is what I would do, but it is your choice, just remember you will have to live by your actions.

[one_speed]

Back to the origional postand the reason I responded the way I did,

The issue is not how the triage nurse assesses and treats thhe patient.

The issue is not one of the chances of having a walking c spine injury.

The issue is not even one of "CYA" with verbal orders from various doctors.

Most of the posts seem to deal with these concerns

Unfortunately the issue is one of blading a coworker.

It's not acceptable in our societies to select from a conversation bits to quote (ie take as a verbal order) and take out of context to support a case in a debate, why would you think it's appropriate to do the same in charting (which when it comes down to it, may be used in a court case (or i.e. legal debate) later on with severe repercusions for all parties involved. They won't know the context of the conversation.

To be filed under "Things to keep in mind when choosing ones words carefeully when charting" for future reference. Hopefully a lesson learned for the rookie (?) triage nurse.

[Kidrn911]

Back to the origional postand the reason I responded the way I did,

The issue is not how the triage nurse assesses and treats thhe patient.

The issue is not one of the chances of having a walking c spine injury.

The issue is not even one of "CYA" with verbal orders from various doctors.

Most of the posts seem to deal with these concerns

Unfortunately the issue is one of blading a coworker.

It's not acceptable in our societies to select from a conversation bits to quote (ie take as a verbal order) and take out of context to support a case in a debate, why would you think it's appropriate to do the same in charting (which when it comes down to it, may be used in a court case (or i.e. legal debate) later on with severe repercusions for all parties involved. They won't know the context of the conversation.

To be filed under "Things to keep in mind when choosing ones words carefeully when charting" for future reference. Hopefully a lesson learned for the rookie (?) triage nurse.

And that is why I posted what i posted:idea:

[jojotoo, RN]

I wouldn't have quoted him UNLESS its a doc with a reputation for denying giving orders/throwing nurses under the bus...there is only one ER doc I work with like that, and I would quote him in a second to protect myself! All the others, no...if I disagreed that the pt did need a collar, then I would put it on and document MD aware.

People are too quick to write "no orders rec'd," it implies that the nurse felt orders should have been received (which is usually an accurate inference, or the nurse wouldn't have charted it)...but say a case goes to court, an attorney is going to ask you if you felt that orders hould have been rec'd...obviously you did right? But the next question will be, if you felt orders were indicated and did not receive any orders, what were your next steps up the chain of command? Not gonna cut it to say well, I just charted it. If you chart no orders received (because you felt you should have received orders), then you better to something else other than just chart it (notify charge, supervisor, med director, etc.) to cover yourself.

Use the OP's case as an example...say the pt actually had a Fx and the pt sues the hospital. Do you think that nurse is safe because she charted that the MD was aware and stated such and such? Um, no...because when the attorney asks that nurse why she did not put on a collar (as an independent nursing action) or go up her chain of command to advocate her concerns for this patient, saying well, I charted it isn't going to help her.

Sorry, I went off on a tangent there,but its a huge pet peeve of mine because I think nurses feel they are protecting themselves when they write "no orders rec'd," when they may actually be setting themselves up for trouble. I chart MD aware and leave it at that...doesn't imply anything, just shows that the MD has been made aware of abnormal findings or concerns.

This post really gives me something to think about in regards to MY charting.

[TrudyRN]

The doctor should not say anything he doesn't want to be responsible for. He was foolish, IMO, to tell you it was ok to depart from accepted norms of care without examining the patient. He didn't like that you acted upon and charted his foolish statement. Too bad. He shouldn't have made it.

The problem, of course, is that he now is afraid to ever again tell anyone to not follow standard procedure. And he should be.

You should always follow protocol. If protocol is to board and collar, do it. No need to ask a doctor. Even if it's not protocol, always protect your license. No one will ever sue you for taking precautions. They can get you for not, though.

You weren't exactly wrong. You were not smart, though.

I hope you can make peace with this doctor and you will both be the wiser. How serious is the rift between you two?

P.S. Always err on the side of caution. A C collar comes off pretty easily. Just put it on all of your neck injuries and you'll never have to worry about it again. Again, always err on the side of caution.

[TRAMA1RN]

In my experience if you have to ask MD fro advice while triaging, DON'T! If you question something, anything, in your own mind like this injury or pain that patient should automatically get moved to the back for evaluation by MD. If you follow any type of triage protocol severe pain or questionable injury or condition, that patient now becomes a top priority. Even if patient has been walking around for a week they can still have a stable injury that requires intervention for their own safety. Also when charting in the medical record ALL MANAGERS will tell you the same thing, whether right or wrong, you do not put what could be considered durrogatory comments or quotes from any medical provider in the written or recorded record. I don't always agree with this philosophy but that is the way it is wherever I have worked.