Does your facility have some standard protocol for a head injury? For example, if a person came in from a MVA where his head hit the windshield and bounced off, and the patient presented with a head wound, what would be done?
A friend of ours went by ambulance from the site of a MVA to a local ED with the above injury, did not receive an x-ray or CT scan. The ED was packed, of course, and he was seen in the hallway, his head stitched up, and given a script for ABX and sent home. On his follow up with the PCP, he was sent to a surgeon because there was glass stitched inside his scalp.
So, I am wondering if every hospital has standards to follow for specific injuries. Like there are algorithms for ACLS situations to follow? I am thinking anyone with an impact head injury should at least get a CT scan?
And more importantly, I am wondering if I was the nurse that day and I was ordered to discharge a patient in that condition without a scan, how do I advocate for the patient? What would you say to the doc if you felt the patient needed further testing? Have you ever had to stand up to a doc because you felt the patient did not get treated appropriately?
I was/am very reluctant to pass judgement on the nurses/doctors, but since more info came out about it from the patient and the EMS crew, I had to ask all of your opinions on it. I would not talkabout this in real life, for sure.
If you were not there, you really never know the whole story. EMS is unlikely to know what happened as well. They are there for the beginning but I have never seen them stay for the end.
I am not saying patients lie, but I am saying they may not understand what was done or may not tell the whole story.
I had a woman come in last night who said she had belly pain and had been seen the night before. I asked her what was done. She said "nothing, they just sent me home with pain meds". I pulled up her chart and they had done a U/A, UPT, CBC, CMP, amylase and lipase, renal CT, gall bladder ultrasound, pelvic exam, given Dilaudid twice for pain, zofran for nausea, and sent home with a Rx for percocet and diagnosed with gastroenteritis, because EVERYTHING was negative.
So, take everything with a grain of salt. How many times have you asked a patient if they have any medical or surgical history and they said none....then getting them into a gown you see a CABG scar ? Then they tell you they are diabetic and haven't eaten all day, can you get them a tray?
Sorry to rant, just advising to make sure you have the whole story before you judge too harshly.
I Worked Ortho/neuro For 20yrs, A Ct For Head Wound Would Seem Very Expensive , Unless Dizzy, Vomiting And Severe Headache Is Present. We Picked Glass Out Of Hair For Days, Esp. Teenage Girls With Long Hair. Double Vision / Neck Pain. Ct Stat. But Otherwise Without Any Symptoms, Just Stitch And Go..
I was/am very reluctant to pass judgement on the nurses/doctors, but since more info came out about it from the patient and the EMS crew, I had to ask all of your opinions on it. I would not talkabout this in real life, for sure.
If you were not there, you really never know the whole story. EMS is unlikely to know what happened as well. They are there for the beginning but I have never seen them stay for the end.
I am not saying patients lie, but I am saying they may not understand what was done or may not tell the whole story.
I had a woman come in last night who said she had belly pain and had been seen the night before. I asked her what was done. She said "nothing, they just sent me home with pain meds". I pulled up her chart and they had done a U/A, UPT, CBC, CMP, amylase and lipase, renal CT, gall bladder ultrasound, pelvic exam, given Dilaudid twice for pain, zofran for nausea, and sent home with a Rx for percocet and diagnosed with gastroenteritis, because EVERYTHING was negative.
So, take everything with a grain of salt. How many times have you asked a patient if they have any medical or surgical history and they said none....then getting them into a gown you see a CABG scar ? Then they tell you they are diabetic and haven't eaten all day, can you get them a tray?
Sorry to rant, just advising to make sure you have the whole story before you judge too harshly.
Actually, I stated that I was reluctant to pass judgement, I am interested in how these sort of patients are handled and if there are standard protocols in place. I also said I was getting the story firsthand from a friend, the patient in question. The patient surely would know whether or not he got a scan. I pretty much take most complaints about any ED with a grain of salt, since I am aware that people do not always know what blood tests were run or what else they may have been assessed for. God knows everyone loves to complain about their ED visit! Whatever else was done or not done for him, it is a fact that he left without any kind of scan when he had a impact head injury. He did not LWT and was compliant with being treated. My information is firsthand from the patient and from the EMT, his friend who brought him in and stayed with him until discharge. I also read the discharge paperwork.
If I was not clear about what I was asking, I apologise, since I was genuinely curious how someone with a head injury as such would not have some sort of CT scan or xray. That is my only question, not what may or may not have been done that the patient did not know about. I am simply wondering what sort of protocols exsist, and how a patient like this could have left without some sort of scan. I am interested in if each unit has protocols that must be followed for certain situations, in this case something as common as a head impact injury from an MVA where loss of consciousness occurred. Are there situations where a head impact would not get a scan or some kind of diagnostic test, and if so, what conditions would have to be met?
And your post brings me another question--can I legally, according to HIPAA, go into the computer and pull up the records on my friend when I go into work, like you did on your friend? It would be nice to see what happened according to the nurses notes, and why/how the injury was handled.
Different places have different protocols. In our level I ER, we would never do plain skull films. However, we would have done a head CT and cervical spine series. If there was no loss of consciousness and no intoxication was noted, that probably would have been it. Of course we would stitch them up too - antibiotics not necessarily.
That's about the way our ER works too.
If the patient was in anyway symptomatic, they are admitted under "short stay" and given a head CT 8 hours later (or in the AM) prior to be sent home.
The nature of the wound would determine if antibiodics are given or not. Systemic antibiodics are not necessary for a stiched up wound in every case. Keep the wound clean and maybe some local antibiodic ointment is fine.
Not enough information in the original post to give a truely acurate answer. No mention of symptoms, just mechanism and that there was a laceration. No mention if the patient had loss of conciousness, was complaining of neck pain, was he intoxicated or otherwise impaired.
Anyway in my 18yrs of emergency care the given treatment would be appropriate give the minimal information provided by the original post. In fact I see it quite frequently. If there would have been any LOC or impairment a head CT would have been done as would probably a c-spine series.
As far as the glass goes I cant recall a skull series being done in my recent memory. We typically get out all we can find and advise the patient that they need to carefully wash their hair when they get home. I personally inform them that any missed pieces eventually work themselves out and to not be surprised to find glass months from now.
And your post brings me another question--can I legally, according to HIPAA, go into the computer and pull up the records on my friend when I go into work, like you did on your friend? It would be nice to see what happened according to the nurses notes, and why/how the injury was handled.__________________
Thanks for the clarification, I did work all night, and woke up after 4 hours and can't get back to sleep...I just HATE that! As far as HIPPA, yes it would be a violation, but I know it is done all the time. The woman in my post was not a friend, but a patient who had been in our ER the night before and I was just getting the results for the doc to review.
In any case, I do work with a lot more MVC trauma than I would like, and considering the MOI, our hospital would probably have considered your patient as a "trauma alert" pending other information, and would have received at LEAST a head and neck CT. We rarely do skull films when a CT will give you so much more information.
I doubt you will find any absolute protocols because there is so much variation in patients and injuries, but basic trauma and MOI trigger certain automatic tests, or should any way.
As far as glass, x-rays will not help you find the glass, and many times small pieces of glass will just have to work it's way out over time. Obviously the wound should be cleaned well, but in a situation with lots of glass, it is impossible to get it all.
Some hospitals are more equiped for trauma, obviously. The sad part of the puzzle is that many outlying hospitals do not have the manpower or facilities to do the job right. That is why helicoptors exist!
For dealing with the doctor skills, that takes a little bit of practice.
I have found the simple phrase...."I don't really feel comfortable discharging this patient because......" seems to work. But be prepared to document and stand your ground, and be ready to defend your position to your superiors.
You don't want to come across as questioning the doctors ability to do their job, but you also have some responsibility to be the patient advocate. I have made off the cuff comments that may be less threatening such as...."there sure is a LOT of glass in there", instead of directly questioning the docs ability to get it all out.
You can also bring up questions by asking a question. You can ask the doc....just for my own information, why would you or would you not get a CT of this particular patient? Ask it in the spirit of your own education and it may trigger something in the doc or it may give you a good explanation of why something was or was not done. In any case, you will have a little window into the thought process that may be going on.
We are certainly not perfect in the ER. We deal with uncertainties, second guesses all the time. Sometimes you are lucky and it works out well. Sometimes things come back to bite you on the bottom!
You don't want to come across as questioning the doctors ability to do their job, but you also have some responsibility to be the patient advocate. I have made off the cuff comments that may be less threatening such as...."there sure is a LOT of glass in there", instead of directly questioning the docs ability to get it all out.
You can also bring up questions by asking a question. You can ask the doc....just for my own information, why would you or would you not get a CT of this particular patient? Ask it in the spirit of your own education and it may trigger something in the doc or it may give you a good explanation of why something was or was not done. In any case, you will have a little window into the thought process that may be going on.
That is a really good tip as to how to question a doc. I know I may have trouble with this, as students we didn't even talk to the docs, we wern't allow. (Now I think in hindsight this is a disservice to students, since being a nurse means we need to question what we don't understand/agree with!) I usually have so many questions about situations going through my head, just for my own knowledge/education, like you said. Like I really want to to run into work and pull up my friend's case, just to see what happened, the process of what occurred, and the entire situation, just for my own knowledge, KWIM? I just want to see the "why", so I can understand where a patient like this may not need/require further testing, maybe there are exceptions to the standard protocols. This one just made me really think, it seemed straightforward, yet it wasn't.
Not enough information in the original post to give a truely acurate answer. No mention of symptoms, just mechanism and that there was a laceration. No mention if the patient had loss of conciousness, was complaining of neck pain, was he intoxicated or otherwise impaired.
Anyway in my 18yrs of emergency care the given treatment would be appropriate give the minimal information provided by the original post. In fact I see it quite frequently. If there would have been any LOC or impairment a head CT would have been done as would probably a c-spine series.
As far as the glass goes I cant recall a skull series being done in my recent memory. We typically get out all we can find and advise the patient that they need to carefully wash their hair when they get home. I personally inform them that any missed pieces eventually work themselves out and to not be surprised to find glass months from now.
Rj
Sorry, I added more info in on a later post that he had a LOC at the scene of the accident. I should have explained more--he also came in stabilized on the board, no drinking involved, shoulder and head pain. That's the reason I had questions about this, the LOC with the impact injury. His head hit the windshield and broke it, bounced back off.
That is interesting, I didn't realise glass would work itself out like that, kinda like a splinter?
If a patient had an injury and was alcohol impaired, would the treatment differ?
Yes, if alcohol/drugs were involved and the pt appeared impaired, then more is done - sorta the cover yourself exam. We don't draw an ETOH or do a routine drug screen unless we can't account for the pts condition. In another words, the injuries need to match the mechanism. If a pt comes in from an MVA and they were unbelted, no airbags and were hit head on by a semi going 60 mph and they report NO injuries but smell of ETOH or they are tachycardic, tachypneic, etc., then yes, they get much more done: CTs, blood work, etc..
Hopefully that helps. I wish you luck in your new job. I just left the ER after 10 years and absolutely loved it. You learn (quickly too) how to advocate for the patient in order to keep your doctor relations skills up to par.
As to the HIPAA thing - in my facility you would get fired automatically if you look at a friend's or family members chart (its all computerized). We actually had a nurse who had been at the facility 23 years fired in the last couple of months because she "peeked" at her uncle's chart. Its taken very seriously. In fact, unless you are caring for the patient or have a need to know, you are not to be looking at a patient's chart.
Yes, if alcohol/drugs were involved and the pt appeared impaired, then more is done - sorta the cover yourself exam. We don't draw an ETOH or do a routine drug screen unless we can't account for the pts condition. In another words, the injuries need to match the mechanism. If a pt comes in from an MVA and they were unbelted, no airbags and were hit head on by a semi going 60 mph and they report NO injuries but smell of ETOH or they are tachycardic, tachypneic, etc., then yes, they get much more done: CTs, blood work, etc..
Hopefully that helps. I wish you luck in your new job. I just left the ER after 10 years and absolutely loved it. You learn (quickly too) how to advocate for the patient in order to keep your doctor relations skills up to par.
As to the HIPAA thing - in my facility you would get fired automatically if you look at a friend's or family members chart (its all computerized). We actually had a nurse who had been at the facility 23 years fired in the last couple of months because she "peeked" at her uncle's chart. Its taken very seriously. In fact, unless you are caring for the patient or have a need to know, you are not to be looking at a patient's chart.
I hope this doesn't sound toooo stupid of a question...but we can test anyone for alcohol if we suspect, right? Like testing for drugs? We don't need some sort of court order or anything, right? Or at least, we can inform the doc of our assessment, like smelling alcohol, and the doc can order the tests? It must be that much more difficult to assess a head injury when drugs or alcohol is also a factor, what a combination to care for. I wonder if drug/acohol testing is standard when coming in for a trauma type injury?
Thank you for the good luck :). I am thinking I will get plenty of practice advocating for patients very quickly, I hope I can learn to be skilled and tactful yet effective. Hopefully I will learn fast what is appropriate treatement vs. inappropriate in common situations. I've been thinking a lot about how I would handle a situation like this, good food for thought. I went into nursing for the most part to be able to help/advocate for those who can't for themselves, I imagine it is never easy.
I wish I could get ahold of my unit's procedural manual to take home! hehe. I'm reading Mosby's Emergency Nursing Reference now, it's pretty informative, but we'll see how much good it's done me as far as my unit's specifics.
Thank you everyone for the input, it is great to bounce all this around. :)
i agree with tazz .depending on how he presented ad what his complaints were at min he would had c spines cleared and head ct ,wounds irrigated and cleaned sutured and d/c.
Whatever else was done or not done for him, it is a fact that he left without any kind of scan when he had a impact head injury. He did not LWT and was compliant with being treated. My information is firsthand from the patient and from the EMT, his friend who brought him in and stayed with him until discharge. I also read the discharge paperwork.
Dixielee, BSN, RN
1,222 Posts
I was/am very reluctant to pass judgement on the nurses/doctors, but since more info came out about it from the patient and the EMS crew, I had to ask all of your opinions on it. I would not talkabout this in real life, for sure.
If you were not there, you really never know the whole story. EMS is unlikely to know what happened as well. They are there for the beginning but I have never seen them stay for the end.
I am not saying patients lie, but I am saying they may not understand what was done or may not tell the whole story.
I had a woman come in last night who said she had belly pain and had been seen the night before. I asked her what was done. She said "nothing, they just sent me home with pain meds". I pulled up her chart and they had done a U/A, UPT, CBC, CMP, amylase and lipase, renal CT, gall bladder ultrasound, pelvic exam, given Dilaudid twice for pain, zofran for nausea, and sent home with a Rx for percocet and diagnosed with gastroenteritis, because EVERYTHING was negative.
So, take everything with a grain of salt. How many times have you asked a patient if they have any medical or surgical history and they said none....then getting them into a gown you see a CABG scar ? Then they tell you they are diabetic and haven't eaten all day, can you get them a tray?
Sorry to rant, just advising to make sure you have the whole story before you judge too harshly.