Independent Judgement

When I worked out at Sticksville General, a woman once came up to Triage with her reluctant seven year-old daughter. The girl, said the woman, had fallen off her bicycle. A common enough story, I guess: in the summer, kids tumbling from bicycles are as frequent as bug bites.

In Emergency Department lore, nurses develop with experience something we call the Sixth Sense.* It’s that intuitive feeling that something is amiss with a patient, is not quite right, is not adding up: the whole story is not being told. You ignore the Sixth Sense at your peril, because (I think) the Sixth Sense is the accumulation and subconscious synthesis of years of triaging, treating and caring for patients. If your Sixth Sense is telling you something, you listen, because more often than not, there is something going on.

With this seven year-old girl, my Sixth Sense was ringing bells.  The woman’s speech was a little slurred and I wondered if she had been drinking. There was the business about the helmet, which according to the woman the girl was not wearing when she fell and then, suddenly, the woman remembered, she was wearing. The girl had largish hematoma — a bump — on the forehead, from her head striking the pavement, said the woman, but no abrasion, as you might expect. There were no other apparent injuries, no other scrapes or cuts; she had some old, nondescript bruises on her legs and arms, such as you might see from any active child. The child was quiet and withdrawn, hardly speaking at all, and if to make up for it, the woman talked incessantly, the entire story changing subtly, a slow metamorphoses of facts and, just perhaps, fictions.

I thought the woman was abusing the child.

In Ontario, as in most other jurisdictions, the law requires health care professionals to report any suspected child abuse if in their professional judgement there are “reasonable grounds” to do so. It’s the “reasonable grounds” part which is the hard piece, because most of the time, “reasonable grounds” comes down to watching out for obvious red flags, or even more indirectly, gut instinct — The Sixth Sense. Making a complaint to the Children’s Aid Society (in Ontario) is not a trivial matter, and if unwarranted can be a devastating accusation for everyone involved. It requires care and judgment, and involves balancing, most often, the Sixth Sense, objective findings, and the risk to the child. But I’ve probably called Children’s Aid about once a year, and never have I had second thoughts.

I finished triaging the girl, and after they went to register, I told the charge nurse about my suspicions and spoke to the Emergency physician on duty.  A little later, after he had seen the girl, he came back to the Triage desk to speak to me. He knew, or rather knew of, the woman. Her husband (and father of the child) was a prominent member of the community, and a significant donor to the hospital. He said he was certain there was no evidence of child abuse. He hadn’t, he admitted, posed the question directly, but they were a good, solid family. He wasn’t going to call Children’s Aid, and neither should I. He was adamant. I wasn’t so sure, I said. What about the specificity of the injury, and the lack of related injuries, the fact the story kept changing, the girls demeanour? I thought he was wrong, I said. I was a just a few years out of graduation. For me (at the time) this was an incredibly brave thing to do: I, a mere nurse, challenged a physician’s judgement. At Sticksville General, the culture was such that the physician was God, and therefore anything dropping from his mouth was the Word of God.

I made the report to Children’s Aid. Of course. Though my hands were shaking when I called.

“Oh yes,” said the social worker. “I’m glad you called.”

And that was all. There rarely is more. I never found out what happened afterwards. A couple of lessons, for me anyway. The first was obvious: trust (or at least strongly consider) what your Sixth Sense is telling you. You might save a life. The second was a little harder: sometimes, as a nurse, you come to conclusions about a patient which are different not only from the physician’s opinion, but maybe also doesn’t square with the sense of your nursing colleagues or management. In these cases, you have to be an advocate. As nurses we tend to minimize the unique knowledge inherent in nursing, and downplay our own experience. The better part of advocacy is drawing on our knowledge and experience, and placing it front and centre. Again, you might save a life.

, , , , ,

  1. #1 by Boris on Friday 10 September 2010 - 1132

    That’s a series of compelling posts now. Thank you.

    I took a grad course in the nursing faculty once and this sixth sense idea came up from some of the nurses in the room. You’re lkely aware but there’ve been studies on the critical role of intuition in nursing practice. I’d say it’s far more real than mere lore, but something grounded in the matrix of knowledge and experience and it’s been well studied. I’ve linked a couple to a couple of abstract pages below.

    It’s an older edition but there’s one here that I remember being referenced in the course: http://journals.lww.com/hnpjournal/Citation/1987/05000/Using_intuitive_knowledge_in_the_neonatal.9.aspx

    And a few more in QHR: http://qhr.sagepub.com/content/13/8/1063.abstract

    • #2 by torontoemerg on Friday 10 September 2010 - 1143

      Thank you, and thanks for the links. I once heard the definition of the difference of “competent” v. “expert” practitioners (of any profession) as being the the “expert” practitioners know what to do in any given situtaiton without thinking about it too deeply — I suspect it’s more or less the same idea.

      • #3 by Boris on Friday 10 September 2010 - 1207

        Yes, it is the same idea. Fascinating stuff, but I think tricky when it comes to CYA regulations that require lists of actions and evidence based justification, not just ‘gut feelings.’

        • #4 by torontoemerg on Friday 10 September 2010 - 1606

          You mean the hospital lawyers won’t approve??? :)

          • #5 by Boris on Sunday 12 September 2010 - 2051

            Yes, exactly that sort of thing.

  2. #6 by Jenn Jilks on Friday 10 September 2010 - 1133

    Well done.

  3. #7 by mog on Friday 10 September 2010 - 1239

    Good for you. There’s this notion that abuse only goes with poverty and the “lower orders” when that is patent nonsense. I went to school with a girl whose mother frequently bashed her about the head. The mother was a conservative councillor, very well off, very well thought of. When my friend reported her mother noone believed her.

  4. #8 by Anne on Friday 10 September 2010 - 1248

    Excellent!

  5. #9 by nurseXY on Friday 10 September 2010 - 2125

    Good for you, shame on that doctor.

    I’m doing my community health clinical with Child Protective Services. It’s so sad the things people do to their children.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: