Monday, October 18, 2010

Going Beyond Scope of Practice

For the past two years, I’ve seen plenty of patients come in complaining of abdominal pain. Following their treatments has revealed causes as diverse as bad sushi for lunch to peritonitis to stab wounds. Each patient has had a particular look that seems to be unique to their symptoms. Paying attention to these looks and storing them away in the back of my mind has allowed for the development of a fairly accurate sixth sense. Usually I’m right and this is the case with pretty much every clinician out there. This is why when I tell my MD colleagues that a patient looks sick, they usually try to see my patient more quickly, or at least give me the green light to order labs and imaging outside of my medical directives.

However, some docs are not as accommodating and I tread a little more carefully around them. I make sure to get them to sign orders that they’ve verbally approved before proceeding because I’ve been burned pretty badly in the past. I suppose it was just one of those days in which I had to be extra careful with the doc when the charge nurse told me that she was bringing a fairly sick looking woman complaining of generalized abdominal pain. The kicker – she makes hypochondriacs look sane. I’ve personally dealt with this woman many, many, MANY times. She now knows my full ethnic sounding name in all of its guttural glory – and can actually pronounce it. One look at her and I knew she didn’t look like her usual self. She looked pale, clammy and was doubled over in pain. While she was changing into a gown, I tracked down the doctor and told him about this woman. I was very curtly dismissed from his office with a vague comment on how he needs to catch up on his charting before dealing with another drug seeker. I went back to draw some baseline labs and put in two large bore PIVs after palpating her very distended belly. She really didn’t look right despite her vitals being normal. I went back to the doctor and asked if he wanted me to draw blood cultures or a serum lactate but again I was shooed away.
After what seemed like an excruciatingly long wait, the doctor sauntered into her room, gave her a prescription for naprosyn and told her to go home. “Listen dear”, he said while squinting to read my name tag despite the fact I’ve worked with him for two years, “I’ve been a doctor longer than you’ve been alive and I’ve known this patient for at least five years. She’s looking for attention and I’m not in the mood to indulge her so get rid of her now”. He quickly disappeared around the hallway before I had a chance to raise my objections. The thing is that I didn’t have an objective leg to stand on – her routine labs were pretty much the same as all the other times she had come in. She had a very mildly elevated white cell count and her temperature was a degree higher than usual, though she was not febrile. But I couldn’t dismiss how distended her belly was. Even though the evening doctor’s shift was going to end in 45 minutes, I pled my case to her but since she’s quite new and doesn’t want to ruffle too many feathers, she declined to reassess this patient. The patient was now crying which usually elicits no response from me but this time I could not shake the feeling that something was very wrong with her. I talked to the charge nurse and I went back to the other doctor to plead my case. I knew that if I was wrong I wouldn’t be able to live this down for a long time but my concern was fringed with panic.

The patient’s doctor overheard me pleading my case to the younger doctor which unleashed an impressive rant about his judgment being repeatedly disrespected by nurses and doctors who hadn’t been alive as long as he was a doctor. The younger doctor reluctantly left while mouthing an apology for not being able to help. I was stuck. The charge nurse was stuck. We knew that she needed further management but without orders, we legally cannot proceed further. I had done everything in my scope of practice. When I went back a third time to this doctor, his entire office seemed to be dripping with contempt at my concerns. The fringes of panic began to take over my judgment and I ordered an abdominal x-ray. I had done everything in the scope of my practice when I stepped outside of its bounds into the wild west of nursing practice. I knew that the doctor could get my ass kicked if I was wrong. But the panic persisted.

The woman came back from her x-ray looking devoid of colour. I went back to the doctor a fourth time and told him what I did. I felt like a child being severely reprimanded for painting the walls with crayons because he spent an eternity ignoring my pleas to look at her x-ray while he yelled at me. Finally, I grabbed the keyboard from him and opened the x-ray myself. One look at it and he was silenced. She had a massive bowel obstruction.

Two days later, I found out that the obstruction was caused by sigmoid volvulus and was taken to the OR half an hour after my shift ended. Her lactate was obscenely elevated.

So many times I tell myself that I had done everything within the scope of my practice. Yet if I had stuck to the limits of my scope, the woman could have died. Since then I manage to overhear some disparaging remarks like, ‘if she wanted to manage the care herself why didn’t she just go to med school?’ The truth is I have no desire to go to med school. I often try to push the scope of my practice to its breaking point while feeling like a bottom dwelling cog in the medical machinery in order to do right by my patients. By no means do I plan on ordering imaging tests and labs outside my medical directives a regular part of my practice but in this instance I felt completely backed into a corner. I have seen many skilled and experienced nurses go beyond the scope of their practice for their patients because they feel that it is the only way to get things done. I’m far too hesitant to do that because I have no one to back me up if I’m wrong outside of my scope. And yet, it can be very frustrating and limiting to know that my influence on patient care is negligible no matter how hard I advocate on their behalf.

34 comments:

Street Philosopher said...

Just do it Maha. Old egotistical docs have no place in new medicine. That's just the way time works. Old cool docs on the other hand, more power to 'em. Really, all cool docs.

As a patient: thank you.

NP Odyssey said...

Good Job! Sometimes you just have to do what is right, even when it is outside your scope of practice.

Moose said...

Nurses run the universe. A good nurse is worth a zillion times his/her weight in platinum.

A doctor who ignores a nurse's "gut instinct" is a nitwit.

dianamican said...

Good for you sticking to your gut.

I don't know if there is a different protocol in ER, but on the floor we will go to the house supervisor and then medical director if necessary to ensure the patient receives proper care.

And I know it goes without saying, but document, document, document...

binkRN said...

Agree with above- document, document, document. I have even asked another RN to go assess the patient with me if I really think something is up and the MD is giving me and the patient the cold shoulder.

We often say that our seekers are the ones who someday are going to come in sicker than crap, and someone is going to ignore them or dismiss the complaint.

It is hard to decipher fact from fiction sometimes, but you had strong physical evidence. You didn't make up that distended belly or her preponderance to look light a vampire from twilight (except for the sparkle).

I have a couple docs who have done that to me. It sucks. Then, there are the times when I get the sideways thank you when I save thier butts. You know- that stuff that all good nurses do to help thier patients, and end up helping the docs with too?

Good for you. I bet you'd do that again. And- even though it may take awhile, you may have garnered more respect from him. I hope he liked the taste of leather.

Steve said...

I am an ER doctor. I understand your hesitance to do what you did. And you SHOULD be hesitant. Thant being said, your doc on that night sounds like an idiot. Most (I hope) of us realize that nurses see the patients more than us, and sometimes have the best feeling about a patient. He should have at least went back in and reassessed the patient. The woman was lucky to have you. Just goes to show you what effect the "cry wolf" phenomenon that drug seekers engender can truly kill them later when they really do get sick.

Old MD Girl said...

Poor lady.

She was lucky you were on last night.

EDNurseasauras said...

Good for you; I'd have done it too.
Don't expect a thank you from a doc who nearly screws the pooch because they dismiss the patient. It is interesting that when the nurse is right and reacts to achieve a positive patient outcome and old farts like that are wrong, it just seems to enrage them. The best docs understand that a good nurse is advocating for the patient FIRST, not trying to be difficult or ridicule the physician. Hey, we're supposed to be a team. Good job.

torontoemerg said...

Good for you --- just don't let the CNO find out.

These situations always come out when the docs disrepecting nursing assessment and judgement, and certainly this idiot did so. God knows we all have been in this situation. We shouldn't have to be scurrying to find "work-arounds" and going beyond our scope of practice to ensure good outcomes. I think this is the definitive answer to physicians who believe "my word is final, and you're just a nurse." Ideally, it's all about collaborative practice.

Just curious: did the charge go up the food chain, i.e. to the chief of emergency medicine? I think that would have been my first response, but then I get along fairly well with the chief where I work.

Feel good.You saved a life.

AtYourCervix said...

What a fine line we sometimes have to cross! A volvulus no less. Wow. Your persistence saved that woman's life, without a doubt.

Two thumbs down to the doc. He obviously didn't do a full assessment to have missed the massively distended abdomen.

I can only imagine the outcomes and repercussions if you had d/c'd the woman home and she died.

shrimplate said...

Good work.

The doc didn't personally assess the woman's abdomen? You saved him from a malpractice case. You may need to remind him of that once in a while.

Laney said...

Awesome work! Your intuition saved this woman's life :)

I hope I'll be able to stick to my guns like that once I graduate!

MadMom said...

Maha- Good for you. I am just beginning my schooling again and hope I can tap into that same instinct when I eventually become a nurse. My 6 year old son recently had a 10 day hospital stay for cellulitis of the skin on top of his foot. Pediatrician sent us for xrays and thought it was a sprain (due to the swelling). The old Babydaddy thought it was an injury being exaggerated for sympathy. My gut said different. Two days later I took him to the ED despite them telling me to wait and the infection had spread to his bone. 4 weeks of antibiotics 1/2 IV 1/2 orally required. That Gut instinct cant be ignored no matter who tells you to. Congrats on being in tune with your Gut Girl!!!

Anonymous said...

What did this doc have to say after all was said and done? Or did I miss that part? I really would love to hear exactly what he had to say for his sorry self and what he has had to say since then.

Andi, On Call RN said...

ugh there is nothing worse than a jerk MD who won't listen. ive had a few of these moments in my ICU this summer and its been hell. good for you for following your instincts!

Anonymous said...

maha:

I'm with you, girl. Do whatever you can within your scope of practice and document, document, document.

Whatever happens you have a paper trail that says you did everything you possibly could in the event something goes south and happens to the patient.

I'm protecting my patient and my own license, Mr/Ms/Mrs MD. If you decline my opinion and won't order a lab to confirm it, you do so at your peril.

Just another reason you need your own liability insurance--because of the idiots we're often forced to work with.

Anonymous said...

Good for you - at least you are in a system that provides the scope for you to do what you did. My daughter, also a nurse, has this sixth sense about patients about to go seriously "off" but where she works it is impossible to do what you did. However, a bit back she was sure a patient's trach tube was "NOT RIGHT" (no-one had seen one like it before as the patient had been transferred from another hospital) and eventually bypassed her superior (who will do anything to get out of actually doing something useful) to get a doc to come by. She was right, it had shifted and he was not getting air despite reasonable sats. What happened? Her superior suddenly wanted to work and take over the patient - and the glory of saving his life.

But both of you have the comfort that your patient lived to tell the tale.

Anonymous said...

That MD sounds like he needs to get out of the business; he clearly no longer cares. I also think it was cowardly of the other doc to not back you up; a nurse's clinical instinct is worth its weight in gold! You absolutely did the right thing, and someone is alive thanks to you. Just because he had MD appended after his name doesn't mean he actually knows what he's doing--and this is coming from someone who has MD appended after hers.

Albinoblackbear said...

Good for you, sticking to your guns and saving a patients life!

I actually found the scenario you described to be one of my main frustrations with nursing, and what eventually caused me to jump ship.

I really hope that doctor either apologized or acknowledged your save. Hopefully he did both. Thank God for smart nurses!!!!!!!

gabbiana said...

I know it seems like cold comfort, but what you *did* was not just save this patient's gut and very possibly her life, but you also saved that doctor's ass.

Cold comfort, like I said.

Any doctor who doesn't listen when a nurse tells him that the patient looks sick is a farking moron.

woolywoman said...

Rock on, girl. You did good!

Heidi said...

Really good story, Maha. This is something I struggle with too, going outside the scope of practice. I feel like I'm constantly getting the message of "follow orders follow orders follow orders, you're just a nurse"... until suddenly, I'm not, and I should do whatever it takes to get something done. Stressful and frustrating.
Very good on you for doing what you did. I'm also curious if the doc had anything to say for himself afterwards?

Anonymous said...

First let me say you did a fantastic job with the patient. But in defense of the good MDs out there let me describe a bit of our side of the story ...

I'm a resident and I have had the same experience with nurses - nurses that don't trust my judgement as a junior physician.

I've had many a night on call in community hospitals (even in tertiary care hospitals) with multiple patients crashing at the same time - sick patients that need stat labs drawn or fluids hung or cardio-protective agents immediately - and when I return from yet another page these labs, etc have yet to be done. Not all nurses are like this but the ones that say "Sorry, I'm on my break. You'll have to find someone else." or "Can't the labs wait until the next shift?" really make me mad. I don't order tests, fluids, meds for the fun of it. Trust me - I would much prefer sleeping to looking up drug dosages. In fact, I would be happy to draw the labs myself or hang the fluids ... but when my pager goes off every five minutes it is hard for me to be in three places at once. Yes, I realise there are far more patients per nurse than there should be but also think of it from my prospective - sometimes I am managing a ward of 15-30 acutely ill patients at any given time and in the case of some community hospitals, covering another few hundred. Often, I am the only physician in house with only phone call back-up. And ... if we, as the MD, express our frustration, we aren't team players or don't know what we are talking about. I'm just saying it goes both ways ...

Fordo said...

Way to go, Lady. Glad you were on that night and persisted in your beliefs and communication to get things accomplished. The lady was glad to have you around.

I too would like to know the doctor's response and your nurse manager's response to your action. Did they give you kudos?

My thought is that the junior docs may be more receptive to backing you up in future.

burned-out medic said...

good for you.

i absolutely hate it when people use the "i've been doing this for a long time" excuse, no matter what profession.

well, he was wrong. fat lot of good all those years of experience did him.

nurse XY said...

Late to the party, but Maha, you rock.

Kim said...

Thank God it was you on that night, Maha. A stunning story of courage, that is what this is!

Anonymous said...

I know a doc like that - only from the mother of the patient's perspective. I've told my husband that if I'm ever in the ER . . . and he's the only doc available . . . to let me die rather than have that pompous prick lay hands on me!

ANichols.Too said...

Lost a patient once from just such a scenario. It became the big to-do at our hospital's next ethics panel meeting...but I still got in trouble.

The Nerdy Nurse said...

It seems unfortunately that people who want to demand respect are not willing to give it in return. Respect is earned not forced and that physician should have the respect to take a second look if your experience nag gut suggests it's merit. Sometimes those years of experience can be a hindrance and let us never forget that once we stop learning we become truly dangerous.
Someone needs to make that particular physician a cross-stitch sample with that phrase for Christmas!

IMHO Blogger said...

I applaud you for sticking to your gut feeling! I (and my CT tech buddy and PACU nurses)have had to deal with many a doctors doing this exact SAME THING. 9 times out of 10 we where right. This is what nursing is: being a Patient advocate. I as a future nursing student and as a patient to many a ER would want a nurse just like you fighting for me.

Tee said...

Maha, this is my first time to ever read your blog, which I found via Dr. Grumpy's blog. This post really touched me and I wanted to thank you for advocating for your patient, especially at such a high cost. I have many chronic problems that land me in the ER more often than I would like (read 67 kidney stones in 5 years) and have been accused of drug seeking even when the stone shows up on imaging. Doctors can be jerks, no two ways about it. A good nurse is worth their weight in gold! Thank you for putting your patients needs above all else.

midwest woman said...

wow Maha I've got nothing to say but again...WOW. Just had a similiar experience except the outcome was let's say poor. Frequent flyer with that ghastly candle color and minimal paplpable pulses..dissecting aorta. She died on the table.
Good for you!

Dominic said...

To my mind everybody have to glance at this.
see that