Hypotheticals

Suppose you have a patient come in by EMS who shows all the signs of stroke: severe right-sided weakness, expressive aphasia, facial droop, with a known time of onset three hours ago. Suppose your patient is a youngish 54 year-old guy, with no medical history. Suppose your hospital’s Stroke Protocol calls for stat transfer — no CT, no blood work,  just pick up and go — to the Regional Stroke Centre 10 minutes down the road, and if the patient leaves immediately, he will just make it within the window of opportunity to get his thrombolytic, and hopefully make a full recovery.

Now suppose you inform the emergency physician of all of this, and he says, “I don’t believe in that shit!” and then proceeds to order the full stroke work-up, thus ensuring the patient will face permanent disability. The physician will not change her mind.

As charge nurse, do you:

  • Do nothing, because the physician knows best?
  • Do nothing, but write up the physician later, and discuss the matter with the manager?
  • Advise the family to take the patient in their own vehicle to the the Regional Stroke Centre immediately?

Assume there is no practical way to get the physician to reverse her decision before time running out, and that each of the choices carries potentially dire consequences for yourself or the patient or both.

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  1. #1 by DreamingTree on Thursday 11 February 2010 - 1016

    That’s a tough one! I’ve never worked in the ER, so I’m not sure how the hierarchy works there. If it were the same as our med-surg unit, I’d be getting the nsg supervisor involved. And, I’d request that the doctor give the family the option — or I would be tempted to mention it myself. Nag, nag, nag…

  2. #2 by Rural on Thursday 11 February 2010 - 1312

    Now I am just an average joe, who has no medical knowledge and has maybe visited a hospital (or family doctor) for treatment or diagnosis less than half a dozen times in over 20 years but my question is this:-
    If the patent presented with such obvious signs of stroke why was he not taken directly to the “Regional Stroke Centre” directly? Also as a rural resident who increasingly sees critical services being centralized to our “regional Center” 2 to 3 HOURS away by car (still quite some time by chopper by the time it gets here and back) why do not hospitals have the ability to deal with such critical patents on site?
    Just asking!
    Your blog is an eye opener for many of us but I for one feel more confortable with diagnostics from nursing staff than SOME doctors!!

  3. #3 by Zoe on Thursday 11 February 2010 - 1852

    Well, my first question is: Why did EHS bring the patient to your facility in the first place? I work in BC and our EHS have protocols to bring the pt to the closest *appropriate* facility, and if there obvious signs of stroke, and a stroke centre 10mins away, that patient should have gone there in the first place. I work mostly triage, and I would not have registered the patient, and advocated for EHS to take the patient from our hospital to the appropriate facility. I would have got on the horn to their supervisor and given him/her an earful until they agreed to take the patient away.

    But, based on your circumstance, I would have notified the site leader, pushed the issue with the physician, and made sure the family was aware of their options. And I darned well would have documented every action and conversation I was personally involved in. I hate dealing with jerk physicians.

  4. #4 by JennJilks on Monday 15 February 2010 - 1050

    Please, continue to advocate and be a strong voice on the front lines. We civilians need you. Speak up, educate, and try to make change.

  5. #5 by Random Internet Person on Tuesday 16 February 2010 - 1209

    Defer to whoever’s ass you can put squarely on the line before yours. Get an authoritative ruling when there is time. Accept that the system vastly imperfect and no amount of blood, sweat and tears will get perfection out of it.

    Fact is, though I am well informed about my domain, I still find that I come up wrong in the occasional disagreement. If I went to the client/patient directly with the disagreement, I’d be exposing myself and possibly making a bad situation worse for the client. Sad but true: right and wrong do not matter, only correct and incorrect. Which is to say, the only standard of evaluation we can use is the one we are given, not the one that seems to make the most sense to us.

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