Monday, February 1, 2010

Quiz Time

Take out your pencils and put away your books and let’s take a quiz Dr. Grumpy style.

You are a registered nurse employed at a nursing home. During lunch time, you notice that one of the elderly residents is making a strange hacking noise and appears to have progressive difficulty breathing. This particular resident has a history of dysphagia (difficulty swallowing), chronic obstructive lung disease and is easily distracted by external stimuli (such as other residents eating). Do you;

a) Check the mouth for possible sources of obstruction (such as food) and attempt to clear it.
b) Ignore your (much junior) colleague’s about checking the mouth of possible sources of obstruction.
c) Chide her for not finishing her meal
d) Panic, call EMS and have her transported to the local ED and repeatedly express your concerns over the patient’s falling oxygen levels as something beyond her baseline. Also emphasize concern about her recent diagnosis of a UTI.
e) Call her family and tell them that perhaps now is the time to see grandma and they better hurry.
f) b & d
g) b, d & e

If you chose answer g, you are correct. Bonus points if you were able to elaborate as to why EMS didn’t sense that something was amiss either.

Key learning summary: Some days, the only course of action at one’s disposal is to let head meet desk. Repeatedly.


Katie said...

Well, if not (c), then that's, um, something.

Grumpy, M.D. said...

Yeah, I'm surprised (C) wasn't part of the solution.

UTI causing choking and gasping. Wow.

Anonymous said...

Really, too funny. I can almost guess (but won't mention) which well-known nursing home the patient came from. . .

I really think we work in the same emerg. You're just not telling me.

In all honesty, the stupid of some (most? all?)nsg home RNs is astonishing

StorytellERdoc said...

When the circumstances are hazy, I call the nursing home and talk to whoever made the decision to send a patient. Still doesn't get me far in my questions, but at least I can say I tried! Good post, well done.

Albinoblackbear said...

My favorite was when they'd send us the ILI pt's, oooh or the decub ulcers that needed to be redressed.

But no bother, I think the 90 year olds liked being in the waiting room for 14h before being brought into the department.

Major facepalms all around.

Anonymous said...

My personal favourites are:

1. Foley catheter needs to be changed (Um...aren't you RN's? Why can't you do this?)

2. G-tube is broken. Which, for some reason, gets sent in at 0300hrs. A few years ago, we used to admit these to hospital, to have the tube replaced in the a.m. Now, our ED has collectively decided for these problems that we put a foley cath. in place of the g-tube for the interim, and send them back to the facility with instructions to syringe the feeds through the foley, and MAKE AN APPOINTMENT to have the g-tube replaced at a better time.

We really should start billing the facility for these bogus ED visits, instead of MSP.

Albinoblackbear said...

Ohhh, I heartily agree with the billing suggestion Anon.

Anonymous said...

Wait a minute there are nursing homes still have nurses on staff?

midwest woman said...

This post was funny but it also made me sad. Nursing homes are the bald headed stepchildren in the industry.Salaries are atrocious so you get what you pay for and are probably scaping the bottom of the barrel for staff. But families couldn't afford nursing homes if they paid their staff well and attracted competent people.
I don't know what the answer is.

RehabNurse said...

Love the Foley comment in place of G-tube. Who knows what they'll do with it when you're not looking.

Also, FYI many nursing homes will not change Foleys, at least in our neck of the woods. Why? Because patients aren't "supposed" to have them, since it's against policy.

And no one knows about any other urinary devices, like external catheters, either.

ERP said...

I wonder, if they had tried to clear it, they may have made it worse given their level of "competence"!

Anonymous said...

So what was the EMS side of this story?
I once had a patient with fulminating CHF, I could hear it from the ER as the EMT's opened the bus doors out in the garage. They thought the patient had a sinus infection! Similar story from the NH, they had no idea of the patients heart hx.

Doctor D said...

I'm honestly shocked you got that much information.

The nursing homes here just send them with no information. Without exception the patients are either just fine or near death. When we call for some history (why did you send them, or how long have you been ignoring this) the response is always, "I don't know I just started my shift."

Sometimes I think trained sheepdogs would be better at assessing the elderly for medical problems.

Maha said...

Midwest woman - I agree that nursing home staff are expected to put up with a whole lot with not a lot, but my point is that if another RN has the same license as me, s/he is obviously trained in BLS and just observing the patient and doing a finger sweep of the mouth doesn't require fancy equipment. High school kids know this when they take first aid courses. I felt that this particular case was such an obvious dump.

And I have no idea what the EMS side of the story is. Perhaps their shift was ending and they were in a hurry to get rid of this patient?

little d, S.N. said...

Alternately the EMTs may have been given an AWFUL dispatch and/or told "the patient is altered from a UTI" or "this is the patient's baseline", in which case they probably rolled their eyes, said "aw dammit, another nursing home dump to the ER" and just carted her in, never THINKING to check the airway.

And this is why I recheck ALL my vital signs and patient history :-p