Symptoms of significance
Last night a woman presented, bringing her mother that she was concerned about. There were no specific complaints,other than,"She just isn't right".We were able to get the elderly woman back quickly .She has purplish mottling from her toes to the tops of her breasts with cool slimey skin. Oxygen Saturations were in the 70's. As we rolled the woman over to assess her back and removed clothes she began to projectile vomit foul smelling green and black tissue matter. The doc later said this was bowel tissue and she had a bowel ischemia with necrotic (dead) bowel that poisoned her system.The woman died within 30 minutes of stepping foot in the Emergency Dept.
This woman was seen at a different ED in another town the day before, with discharge instructions to increase fiber and take an antibiotic.Sometimes the more cynical staff refer to this facility as "Other Hospital and Veterinary Clinic",clearly pointing out their perceived inferiority to Rural Hospital.
Although I like to believe that this oversight could never happen at a quality establishment,but I wonder what happens to those who we see with vague complaints and a poor history. DO they later show a serious malady? I recall one woman who was seen with sharp pain around her trunk. She was not sure if it was topical or muscular.After an exam and films she was sent home with an analgesia script. Two days later she presented again,but now with with a red ,vesicle encrusted rash along the same lines as the pain she previously complained of.She had shingles, a painful adult version of the chicken pox that manifests along nerve tracts. She has sought treatment early ,however, before she could be diagnosed correctly.
What did the other ED see or not see that caused them to send this patient home with a decaying gut?Would it have made any difference? Probably not, except that her family would have known sooner her prognosis, would not have questioned the quality of care she received at Other ED and may have been spared the feelings of guilt they so heartbreakingly expressed.
I cannot point fingers or bask in any false sense of working for a superior facility.Noone is superhuman with the ability to immediately diagnose correctly.The human body is a mystery,giving clues that are sometimes contradictory .Unlike a car whose problem remains the same until it is repaired,our bodies are ever
changing,trying to stay in balance.How many times does the patient tell the triage nurse one thing, the admitting nurse another, the ED doc yet another symptom? All may be true and it is up to us to gather that data and come to a reasonable conclusion.
I pray I do not overlook any symptom of significance, and am able to serve my patients to the very best of anyone's ability .
This woman was seen at a different ED in another town the day before, with discharge instructions to increase fiber and take an antibiotic.Sometimes the more cynical staff refer to this facility as "Other Hospital and Veterinary Clinic",clearly pointing out their perceived inferiority to Rural Hospital.
Although I like to believe that this oversight could never happen at a quality establishment,but I wonder what happens to those who we see with vague complaints and a poor history. DO they later show a serious malady? I recall one woman who was seen with sharp pain around her trunk. She was not sure if it was topical or muscular.After an exam and films she was sent home with an analgesia script. Two days later she presented again,but now with with a red ,vesicle encrusted rash along the same lines as the pain she previously complained of.She had shingles, a painful adult version of the chicken pox that manifests along nerve tracts. She has sought treatment early ,however, before she could be diagnosed correctly.
What did the other ED see or not see that caused them to send this patient home with a decaying gut?Would it have made any difference? Probably not, except that her family would have known sooner her prognosis, would not have questioned the quality of care she received at Other ED and may have been spared the feelings of guilt they so heartbreakingly expressed.
I cannot point fingers or bask in any false sense of working for a superior facility.Noone is superhuman with the ability to immediately diagnose correctly.The human body is a mystery,giving clues that are sometimes contradictory .Unlike a car whose problem remains the same until it is repaired,our bodies are ever
changing,trying to stay in balance.How many times does the patient tell the triage nurse one thing, the admitting nurse another, the ED doc yet another symptom? All may be true and it is up to us to gather that data and come to a reasonable conclusion.
I pray I do not overlook any symptom of significance, and am able to serve my patients to the very best of anyone's ability .
posted by RuralRN at
2:27 PM
4 Comments:
I know exactly what you mean, and I fear the same thing...
We had one of our "usual suspects" come in a few eeks ago with "sever abdominal pain" Of course rated 10/10. Toradol actually helped a little, but theri moans and cries were still at their usual "high-drama" level. Doc stated the usual "CYA" workup, including a CT scan.
A little while later, I heard the Doc say. "Aw, crap... now I gotta give them drugs!"
Turns out our drug seeker, (who actually does come in almost weekly with vague pain complaints to try and get pain meds and a soft bed) had acute appendicitis!
Would have been bad if we'd done the old, "take ibuprofen and go to a clinic in a few days if its not better...
By
DisappearingJohn, at Wednesday, August 16, 2006
Powerful post!
Take nothing for granted........
By
kim, at Sunday, August 20, 2006
We definitely need to be conscious of our own beliefs and biases. I've already run into attitudes about the elderly that make it too easy to ignore symptoms.
"Oh, she's just old..."
I hope that wasn't the case with the pt you mentioned.
Too Fat, SN
By
Too Fat 4 Ponies, at Wednesday, August 23, 2006
Hello,
Just found your blog through Disappearing John's links and will bookmark it to come back and read often.
I am about to start a new job as an NP in a community hospital. So much of one's ability to correctly diagnose a situation has to do with our experiences. When you've seen any number of patients with "x" then you know the questions to rule it in or out right away. When you have not seen that diagnosis before, you could miss it. The beauty of an office practice is you can say to the person, "do 'xyz' tonight and come back tomorrow for me to look at you again," and if you have a relationship with them they will do that. I worry about the person I see with in the ED who doesn't have that relationship with a primary in the community; where will they go for another look? We certainly know that a lot of people seen in the ED have no community PCP. My job is going to be to convince them to go somewhere, even if it is to come back to my ED for another set of eyes on the problem if they're not getting better.
As medical providers we are a bit of the victims in this situation in that patients believe that we are all knowing, all seeing. They expect the "science" of medicine to figure it out first time, every time. Hard to convince them otherwise! The "art" is to convince them with confidence that their problem is either 'A' or 'B,' or even possibly 'C' and that they have to be your partner in looking for (and reporting!) certain clues that will point you in some direction and that it's really ok (translation-they won't die) until the problem is figured out. This is the basic problem with getting your primary health care in the ED. It's not what it's made for! The ED is there to make sure one has nothing life-threatening at the moment, not to figure out, or treat, that pain that's been hanging around for the last 6 months. Ah, enough philosophizing!
Hope you're sadness is getting better; I actually like effexor because it tends not to cause weight gain or help one lose a little of the excess. Don't overlook an opportunity to get some counseling (been there and it really helps).
Laurie
By
Laurie Anderson, RNP, at Friday, August 25, 2006
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