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.