20 year old female with right lower quadrant abdominal pain arrives at 0852. She thinks she has a urinary tract infection. She is afebrile, denies nausea or vomiting, has normal BM's. Her other vital signs are normal and she rates her pain 5/10.
Patient is triaged, put in room, urine and labs obtained prior to the physician seeing the patient. The urinalysis is sent for testing and a pregnancy test per protocol.
MD sees the patient one hour after she is put in the room, the urine results have been on the chart for 30 minutes showing blood and leukocytes in the urine. The pregnancy test is negative.
MD takes 45 minutes to get around to putting orders in on the patient after coming out of the room, the patient has been in the department for almost 2 hours.
1 hour later the lab work is back and the chart is flagged for recheck.
45 minutes later after being asked several times the MD goes in to recheck the patient.
A pelvic US is ordered because the patient has a history of ovarian cysts and RLQ abdominal pain.
It is the weekend and the tech has to come in from home which takes around 40 minutes.
An hour later, after 4 calls by the nurse the radiologist has finally read the US and faxed the results to the ER. The US is negative. The chart is flagged for recheck.
The MD goes in to see the patient, comes out and orders a CT scan, appy protocol an IV, a bolus of NS, IV pain and nausea med's.
CT is backed up because of a trauma patient so it takes well over an hour for her to be taken to the test.
An hour later the CT results are back and the chart is once again flagged for recheck.
Ultimately the patient is discharged home after spending most of a twelve-hour shift in the ER. Diagnosis? Pyelonephritis, which is what she thought she had when she arrived.
Multiply this by 31 rooms and add in a waiting room full of angry, sick people who have been waiting for hours for a room - stir into that a couple traumas, a few mental health patients as well as angry patients and their family members and you can see why we get burned out.
Monday, January 19, 2009
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17 comments:
I agree that case is typically frustrating however,
If A, the patient was really tender - like rebounding, that is not explained by pyuria. In fact you can have pyuria with appendicitis.
And B, I remember thinking some attendings were stupid, slow, or both in dealing with patients when I was a resident. However, when YOU alone have to make the decisions and your license and career are on the line, you think about things a little more and are likely to consider more serious problems.
I wonder something. Do Nurses who became doctors or at least NP's that practise independently change their practise patterns or assumptions after they finish their training and now they have to make the final decision?
Take that doc, multiply he/she by 3, put them all on the same day (days, pms, noc), and mix......This for me is the day from hell. And most of the time they are working by themselves without ANY help. It makes me want to scream and I can totally see where you are coming from.....it will make ER personnel burn out quicker than anyone else!
So typical, especially on a weekend. The part about having to wait for o/c weekend personnel, I can totally relate!!! I think most doc's are exactly that way. I will say I have worked with a few that actually have some get up go in them. Too bad for the patients, especially the sick ones. Healthcare today, what a concept?
If the doctor suspects a surgical abdomen, they need not fuck around for hours and hours.
If a doctor is not confident enough in his skills to diagnose a pyelonephritis and forgo additional testing with some labs, a urine and an exam in a 20-year-old who has had them before, he isn't a good doctor. That's a pretty no-duhr diagnosis...dirty urine, back pain/fever/white count. Bam!
Yes nurse K, but they should not have rebound tenderness of the abdomen. It is pretty easy to tell if someone is faking rebound so I think it is pretty reliable. Also you are right that if the patient had rebound initially, the doc should have been ordering a CT initially. The problem is that many docs just say "I'll order some things (like labs) and see what flushes out" - which is fine if the patient just has GE symptoms, but not if there is a significant chance that something worse is going on.
I agree with you, Nurse K. I really, really hate anecdotal stories, but this one fits.
Mr. Pink had most of the signs of an appy. I took him to his PMD wherein he diagnosed a probably appy on a clinical exam. He called the surgeon personally and sent us on our way to the ER. PMD did not, however, call the ER.
The ER doc didn't even bother with a CT. He did the exam (Mr. Pink was febrile by now), awaited the CBC (high WBCs), and Mr. Pink was on his way to the OR in less than 40 minutes.
I was rather surprised that the ER doc bypassed the CT (or even an UL), but glad he did. Mr. Pink was in the OR in no time flat.
An acute abdomen does not need to wait for hours and hours.
Okay, I understand that ERPs hold ultimate responsibility, and some things are CYA... but if he had concerns to start with, why not order these work-ups from the START of care!!
~HRA
You forgot to add paramedics bugging you for signatures :) Just found your blog and I'll be following it, feel free to do the same
NS
As ERP said when you have to be the one to make the call you need to be sure that your call is correct. On the other hand doing a complete work up takes time. Yes not all docs are the fastest and waiting rooms can look like organized riots sometimes, but I also don't agree with doing a million dollar work up all the time. That little CT scan puts out some serious radiation and it increases your risk of cancer by about 10% for each CT. Perhpas this ED doc took too much time to sort it all out but how many patients that come to an ER are trully critically ill?
The problem with health care is not so much that the ER was busting at the seams soo much as it is that patients can't get in to see their PCP and the ER is their only option.
Either way, being a health care provider of any kind is tough in today's environment. Finally your point is well taken, the job does suck the life out of you. I've been in critial/ER medicine for more than 20 years. Got burned out a long time ago. Since then I have found golf - it is my prozac.
This is really a nice post.....Good work keep it continue...
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Er nursey come back to us...
I totally agree! Did you work my last shift with me and blog about it!
ERNursey, I said it long ago on a comment here and I'll say it again, You are the nurse I want if anything ever happens to me! The world wouldn't survive without nurses, after all, most doctors can't even put in an IV on their own from what I've seen.
Missed reading your site when mine was crashed, didn't have my google stuff to get into my reader. I have all my links back so i can start a new reader, and of course, RagingServer.com is back online and more hateful than ever!
Missed ya!
I love nurses for the most part. However, they get really annoying when they think they know what's best for the pt. Pyelo should NOT have abdominal tenderness. At the end of the day, the pt. probably had an UTI with abd. pain with unspecified cause. Now while that MD probably should have been more up front in ordering tests, for a nurse to say "this is all she needed" is ridiculous.
If the back pain with + u/a is an infected stone, suddenly you have an urological emergency, not a simple pyelo. Not to mention, it's an INTERN mistake to think +LE points to UTI as any inflammation in the abd. can have +LE in urine. I appreciate the work nurses do, but seriously, if you think you know what's best for the pt., go to medical school.
CYA (cover your ass). In the end R/O the emergency and d/c to PMD. Thanks.
This is a burned out nurse whine, and the feeling of burnout is understandable.
Take care of each individual patient that comes through.
You don't do a sloppy job just because there are lots of people in line.
Pushing for less eval of a pyelo under pressure with a kidney stone vs appy will get you to miss a patient that actually is one. There are more serious things than the family doc crap you see routinely, or the clear cut HOLY CRAP THIS IS CLEARLY AN EMERGENCY, A JANITOR CAN SEE THAT kind of case.
$3 million dollars for the missed diagnosis, thank you. Goodbye career. Bye sweetie.
I found your blog while surfing the web. Very nice post. No wonder there are a ton of positions open for nurses. I did a quick check just for the Denver area and between monster.com, hotjobs.com and nurse jobs on denvernurses.com there are hundreds of open positions. With the poppulation getting older the need for nurses will only go up. Maybe then they will get the respect they deserve.
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