WhiteCoat

Fine, YOU Discharge Her, Then

A stepdad brings in his 15 year old stepdaughter after she suddenly started having “excruciating” lower abdominal pain. She is doubled over when walking into the emergency department and is crying.

The mother is finishing up her night shift and comes to the emergency department to meet her daughter and husband. When she arrives, she takes the patient to the bathroom and reports that girl is starting her period.

After using the bathroom, the patient’s pain decreases to 6 of 10 intensity.

Because the patient just started her period, I ordered a catheterized urine specimen so that there was no urine contamination from menses. The patient’s nurse refused, saying I was being “unreasonable.” She went in and talked to the family, then came out and said that the family also refused. Instead, she obtained a “clean catch”  urine that showed 1+ bacteria and 10-20 WBCs per HPF.

I told the nurse that we needed to get a catheterized specimen. She yelled at me stating that she’s “not going to put a 15 year old through that.” “You know damn well that the pain is just from her period,” she said.
“Explain to me why there are bacteria and white blood cells in her menses, then.” I demanded.
“I don’t know.” She replied.
“OK, then why are you giving me such a hard time when you’re ignoring information sitting right in front of your nose?”
“I’m still not doing the catheter. You can do it yourself.”
“If the family doesn’t want it done, they can sign out against medical advice.”
“They won’t do it because insurance won’t pay for the visit.”
I handed her the chart and said “Then you can write the discharge orders, because the ED is full and I’m not arguing about it with you any more.”
“Well …” she started.
“We’re DONE discussing this patient.”

Eventually obtained catheterized urinalysis that showed some bacteria and a few WBCs. I treated the symptoms as a UTI, even though I wasn’t entirely convinced that the patient had a UTI and would ideally have done a pelvic exam.

I told the family that the patient had a mandatory follow up the following day for re-evaluation. The patient said “like hell” as she walked out the door.

You all give me a good reality check.

Was I being unreasonable?

40 Responses to “Fine, YOU Discharge Her, Then”

  1. Graham says:

    Seems like it would’ve been better to just do the pelvic while the nurse is in there doing the cath. Torsion, PID? Doubled over for menstrual cramps I guess is possible as I’m sure some of my female friends would attest to, but I still don’t like it. Totally agree with a re-assessment the next day. I’ve made the mistake of attributing something to “a UTI” because there’s some whites and bacteria in the urine and ended up being an appy when we decided to watch her a bit.

    I guess I’d rather do a pelvic or ultrasound than a cathed urine, ’cause yeah, doesn’t sound like a UTI to me.

  2. Doc99 says:

    Inspection of the introitus might have helped … virginal for all practical purposes rules out pid as the source of the wbc’s and bacteria. If not, many things are on the table, including ectopic pregnancy.

  3. Liz says:

    I don’t think you were being unreasonable. That nurse was beyond belief! There’s not much you can do when your treatment recommendations are refused. Except document, document, document. Darwin’s theory at work? Why someone would seek out a medical opinion and then ignore/refuse that advice makes little sense. But I’ve found that denial is a huge factor in parenting as well as when it comes to one’s health. No one really wants to know or believe what is scary or inconvenient.

  4. totalfailure says:

    i’m not a medical professional, but i would say that if there’s a problem with an unknown cause, then one has to use tools to investigate. showing up at an er and then refusing to let you perform tests is just a waste of time, and the nurse should have known better as well.

  5. MedZag says:

    Your job is to protect the patient by ruling out anything on your differential that could be truly emergent and dangerous. Not a classic presentation for UTI/pyelo but it was still on your list and you couldn’t send her home confidently without knowing that piece of information.

    Unfortunately, patients rarely see it that way. They just see you being invasive and sticking a tube up their urethra. But c’est la vie.

  6. Mike says:

    Hey, I’m a peds ER doc and I really enjoy the journal. Teenage girls with abdominal pain make me want to open an artery of my own. There are so many approaches and none of them are perfect.

    I probably wouldn’t have done the cath, but I definitely understand why you did. The nurse was completely out of line. You’re obligated to think of those things and you had to treat based on your urinalysis.

    A pelvic exam might have been ideal, but contrary to what someone above mentioned, I wouldn’t count on that telling you whether she’s been sexually active. I’ve occasionally sent off a urine GC/Chlamydia PCR in cases like these, but then you’re responsible for the follow up. Either way, assuring follow up tomorrow is key for anything like this. If it turns into something Else, then they can be reassed without much of a time lapse.

  7. Rebecca says:

    Yes, you were being unreasonable, and you were being arrogant. The catheterized urine ended up being the same as the clean-catch sample, didn’t it? I get to call you an ass now.

    I just had laproscopic surgery on my ovaries, and the urinary catheter was by far the most painful part of the procedure.

    You insisted on a painful and unnecessary procedure, and now she won’t come in for a follow-up appointment. Why didn’t you do a pelvic exam anyway? You don’t say in your post.

    • Amy says:

      Yes, the cath specimen “ended up” being the same. There’s no guarantee that it WOULD have been. You’re obviously a moron.

      • Leslie says:

        My experience differs. I have had urinary cath’s a couple times…no big deal.

        I think it was the nurse and the patient who were unreasonable.

    • snarkychef says:

      I had a LAVH and the catheter was probably the least painful part of it.

    • NickEVegas says:

      As uncomfortable as a Cary can be, doing a pelvic on a non sexually active fifteen year old girl would have likely been more uncomfortable than a cath. Nobody likes to be cathed but she got over it I am sure, and you were able to work your differential ensuring her health and well being which is why she came to you in the first place.

      I think the bigger issue is with your nurse. Last time I checked she wasn’t assuming responsibility for the evaluation and treatment of the patient. I hate to say this but at the end of the day they are called ORDERS for a reason. Sounds like another case of a know it all nurse with resentment towards the physician because she didn’t go to med school but surely could do the job just as well as you.

  8. Keith says:

    I don’t believe you were being unreasonable. Also, hard to believe Rebecca when she says the catheter was worst part of her operation. Wow.

  9. William the Coroner says:

    No, you were not being unreasonable to insist on meeting the standard of care. You had to rule out PID/pyelo, ovarian torsion, appendicitis. You could not. They can follow your advice or sign out AMA.

  10. Nurse K says:

    Eh, it would have been retarded if the area of pain wasn’t near the bladder nor flank (like SC for epigastric abd pain), but, otherwise, totally reasonable. While it doesn’t really sound like you thought this, sudden-onset low abd pain could be something like a kidney stone too where blood in the urine would lead to a CT scan. At least where I work, Rebecca, the straight caths for a basic female UA are teeny-tiny, not the same size as a regular catheter. It only takes a few seconds to get enough urine as well.

  11. Teresa says:

    You were not unreasonable. The nurse, however, was unreasonable unless she objects to the catheter on EVERY patient. Are there any of us who would enjoy that? Sheesh.

  12. cynic says:

    Completely reasonable, nurse was borderline insubordinate. I could understand a nurse questioning a procedure, but this was out of line.

    Rebecca, did they remove your ovaries ?

    • Rebecca says:

      No, they didn’t. Why did you ask?

      • cynic says:

        I want to know why your posts are always so angry, or attempts to attack someone. You have zero business calling WC an ass.

        There are countless reasons why you do a cath specimen. So please, before you attempt to insult someone, do us all a favor and know what you are talking about.

    • Yvonne ED RN says:

      Cynic, Please allow me to clear something up….RNs are not subordinate to physicians.Each are a separate co-existing and cooperative discipline.An RN also is responsible for her/his own practice and a “The Doctor told me to…” will not hold up in court.

      • Amy says:

        Sorry, but this is the oldest argument in the book and it holds water about as well as a sieve. When was the last time you saw a nurse on the stand for “malpractice.” Yeah, didn’t think so.

        They’re called orders for a reason.

        Disclaimer: not a nurse hater, 10% of nurses give the other 90% a bad name.

    • Rebecca says:

      What does ovarian removal have to do with me always being pissed off at WhiteCoat?

  13. Nurse K says:

    I’m guessing the nurse didn’t understand the rationale for having to repeat the UA. Trust me, there are some dingdong nurses out there that don’t even know what a WBC or RBC in a UA means; they’re happy with getting the sample, sending it, and letting the doctor handle the rest. Probably to her, you were just being an ass and unnecessarily making her repeat a test she’d already done.

    Sadly, when I was training, my preceptor was a nurse like this. Can handle basic nursing just fine, but the academic stuff like “what does this UA micro mean?” = no clue. She told me I was “really smart” when I explained a particularly funky UA micro to her. Um? Really? I wish sometimes that I didn’t know extra stuff so stupid tests and crap like that didn’t bother me as much.

  14. Rob says:

    Coming from the lab side of things I think you did exactly the right thing. “Clean catch” urines aren’t always actually clean catch, especially condsidering she was on her period that bacteria could have been normal vaginal flora and the white cells could have been from the blood. Not to mention that frequently a UA micro can’t be read perfectly when a pt is on her period, there can be many sqaumous epithelial cells that can make an accurate count difficult. A neg UA could have eliminated it, but a positive bacteria and wbc’s don’t prove anything. a cath urine at least, could have told you how high along the urinary tract there may have been a problem.

    Also, frankly, I’ve had a catheter is it really that much more painful for a woman? (I’m not being a smartass, I actually don’t know.)

    On top of all this those microscopic counts on urines are still all done by hand so the counts are really more like guestimates/averages based on a very very small sample size, about 100 ul of urine.

  15. whitecap nurse says:

    From your description, it sounds as if the family was refusing further care because the nurse was encouraging them to do so. You might want to take this incident up with her manager. I might have bitched a bit too but a fem cath takes about 2 seconds on most people and is just not that big a deal even for a 15 year old. I balk way more at doing them on under 2 year olds!

  16. Pod A says:

    You weren’t, the nurse was. Should have asked for a different nurse.

    I would have done a pelvic.

  17. #1 Dinosaur says:

    If you don’t have RBC’s (ie, clean enough) in a urine specimen during menses then I’d go with the positive WBCs, send it for culture and not bother with the cath. I’d also be sending it for a urine pregnancy test and being more aggressive about looking for non-UTI pathology. Save your firepower for a CT, if the family is still reluctant.

    • atyourcervix says:

      I have to agree with #1 Dinosaur here. If she was able to get a clean catch specimen during menstruation and not have any RBCs, it seems like a good specimen!

      As for the nurse – she should have come up with a better argument as to why the patient didn’t need a straight cath for the urine specimen.

      Thinking about a pelvic on a 15 yr old – if she is not sexually active, a first pelvic exam is going to be highly difficult and possibly traumatic for her. Perhaps a pelvic u/s would be better warranted to r/o pelvic issues.

  18. Spanish doctor says:

    In my opinon you were completely reasonable.

    The most dangerous situation in medicine are
    when someone says or thinks:

    “You know damn well that the pain is just from her period”, or “you know he is breathing like that becaus he is just nervous”, “I´m sure. Nothing important happens to her”, or “Another idiot with nothing is coming to emergency”, …

    Obviously, if a girl comes to emergency service with a big pain, we have, we must take it seriously.

  19. Rogue Medic says:

    One of the nice things about EMS is that these things are left for the ED.

    I realize that each individual has different interpretations of pain. The patient suddenly started having “excruciating” lower abdominal pain. She is doubled over when walking into the emergency department and is crying.

    Would the pain of the procedure be worse?

    It is not impossible, but is it likely?

    What is the actual incidence of extreme pain, when the procedure is performed by a skilled nurse? What variables affect that? Patient anatomy is probably one variable, but is there any reason to believe this patient has anatomy that would predispose this patient to extreme pain.

    Or has the nurse had a bad experience with this procedure and now is extrapolating from her personal experience.

    After using the bathroom, the patient’s pain decreases to 6 of 10 intensity.

    What is the likelihood that the pain of the procedure is now going to be worse than the abdominal pain?

    Yes. We want to minimize the patient’s pain, but does the nurse talk patients into refusing lumbar punctures because it might hurt? What about prostate exams?

    There are some procedures that are painful. That doesn’t mean that these procedures are never indicated.

    I do not know what is the right way to determine what the risk/benefit mix is for this patient. When I hear people minimizing the chances of a condition actually occurring, I tend to distrust them. They will be right a few times, maybe even many times. When they are wrong, the patient will not thank them for encouraging them to avoid a temporary discomfort that might prevent a permanent one.

    “You know damn well that the pain is just from her period,” she said.

    Anybody adamantly insisting that they know what something is, without taking appropriate steps to rule out more serious conditions, is an idiot. A dangerous idiot, who will probably more than one patient due to just knowing what is going on. There is intuition based on experience in seeing a lot of patients. Then there is intuition based on just wanting bad things to not happen. Perhaps this nurse should spend some time assisting in breaking the bad news to newly diagnosed cancer patients. How much does just wanting it not to be so help there?

    I do get the impression that she counselled the patient and family to refuse the procedure. I do not know if that is what you intended to convey, but whitecap nurse seems to have read this the same way I did.

    I am not always the most obedient to doctors, but I will base my disagreement on research, not on anecdote. Some EMS protocols specifically describe how to handle circumstances where the medic feels that an order is dangerous. There is liability for carrying out an order that is believed to be dangerous. I do not see that the nurse attempted to make that case.

  20. RSDS says:

    I am not in the medical field, but could this be the result of her step-dad having incest with her? Then her mom wants to cover it up?

  21. Katherine says:

    “I realize that each individual has different interpretations of pain. “The patient suddenly started having “excruciating” lower abdominal pain. She is doubled over when walking into the emergency department and is crying.”

    Would the pain of the procedure be worse?”

    I like this point.

    You’d think that if a family came to the ED with their daughter in intense pain that they would WANT you to test for everything that it could be, rather than just being happy when they are told it is period pain. I know I’d want to get checked.

  22. Teresa says:

    Hmm, now I’m wondering under what circumstances a nurse can refuse to carry out a doctor’s orders. Does it have to be something she thinks will be dangerous for the patient, or can she refuse any order she thinks is unwarranted? “I just don’t think she has a UTI, that’s why I’m not getting a catheterized sample.”

    • Nurse K says:

      If the minor patient and the family refuse the cath UA and they’re competent to make that decision, it’s considered assault to do it on the patient anyway.

      If the nurse has a discussion with the doctor and is like “no, that’s dumb” and doesn’t want to do the UA, then she should find someone else to do it who is able. Sometimes, really, a doc just gets on your nerves on a particular day (not that I think WC would really ever get on my nerves), and you can play trade-the-jobs. I’ll do your IVs if you do all my stupid UAs on all these chest paineurs who don’t need them. When a doc writes routine orders on the chart, they’re not really ordering a particular nurse to do anything. How nurses divide up the work is for the nurses to decide.

      If she’s just refusing to do stuff because she’s layzee, that’s a performance issue (or a system issue if the place isn’t staffed appropriately, etc) and should be handled by her boss. A couple times, sure, but like all the time? WTF, chick.

      Obviously, a nurse shouldn’t do anything that’s going to be patently harmful to the patient, against policy, or that’s not within her scope of practice.

  23. PookieMD says:

    WhiteCoat,
    I love you buddy, but have two things to say:
    1) Never argue with the nurses. I would have had the case reassigned to another nurse, but I wouldn’t have argued with her. You never win by arguing with the nurses–things just go from bad to worse.
    2) You were right to get the cath ua. I might have been tempted to just treat for a uti based on the clean catch now that the stage was set by the nurse, however. I think a pelvic is reasonable, but wonder if the family would have agreed/allowed it.
    Take a breath, and remember you are the one that has to do right thing, not the nurse.

    • cynic says:

      Well said

    • WhiteCoat says:

      I really don’t argue with the nurses. We’re a team and I always try to work with them. I tried to explain my rationale for what I was doing and kept getting the impression that she was tuning me out. That’s when I told her that we were through discussing the patient.
      Family and patient both refused a pelvic.

  24. crisitunity says:

    You weren’t being unreasonable. The nurse was being lazy.

  25. Sarah says:

    Were you being unreasonable? No. There are a couple of ways to look at it. From a patient’s perspective, I’ve ended up in the ER once where the doc insisted on doing a pelvic when I knew it wasn’t necessary and didn’t particularly want it done. I knew I just had a bad stomach bug…both my dad and sister had been vomiting for two days right along with me and I only ended up in the ER when I got really dehydrated and couldn’t keep ice chips down. He treated with IV fluids and I felt better and was ready to go home but he insisted on a pelvic before discharge. Sure, I was annoyed but I recognized that I had come into the ER for treatment and he need rule out other causes of my symptoms or whatever. So, I can relate to the patient and mother (but not the nurse) having reservations about the necessity of certain procedures (as I am sure getting a catheter is “traumatic” for a 15 year old girl in that it is awkward and embarrassing for her, not that it is terribly painful as someone tried to suggest) but bottom line is that they came into an ER not a family practice clinic with an “emergent” condition and the expectation is that you are going to do whatever tests are necessary to reach a diagnosis or ensure that an emergency condition does not exist.

  26. KJ says:

    I am not a med. professional, I teach. I am a woman who has had terrible menstrual cramps since teens.

    First, the nurse was out of line in her approach and overall demeanor with the doc. But considering several factors: teen female, menstruating, embarassed and in pain, it is unreasonable to think that catheterization (during her period and after a “clean catch” was obtained) is completely necessary. Someone else suggested an ultrasound or pelvic exam. It seems to me that is far more reasonable than doing a cath on a menstruating teen already in pain.

    I had a catheter done in ER when I had a kidney stone. I was 20. The catheter hurt more than the damn stone did at the time and sent my pain to levels unknown to me before.

    I hated the nurse so bad that she was lucky I did not kick her in the teeth. I tried to refuse it and she was nasty with me. Refusing to give me pain meds unless I complied. Needless to say, I have to be dying to use the ER anymore. My guess is that young teen girl will end up with the same aversion.

    It is interesting to read your blog. Will check back for the trial conclusion…

    • Fyrdoc says:

      While I am glad that everything turned out o.k. for you, your post, and WC’s original problem, clearly demonstrate a fundamental misunderstanding that the public has regarding emergency medicine.

      [Climbing onto soapbox]

      EM is different than the rest of the house of medicine in how we approach the patient. “Regular” medicine teaches to look at a set of symptoms, decide the most likely etiology and do tests to prove that one of those common things is the diagnosis. If you can’t, come up with a bigger list and continue testing. “Regular” medicine is all about “what you have” (i.e., what is the diagnosis). Emergency physicians, on the other hand, are taught to generate a list of things that could seriously hurt or kill you based on your presenting symptoms, and test to rule those etiologies out. If they can’t be ruled out, the you will be admitted for further testing. If they can be ruled out, you will be discharged, even if a diagnosis is not yet found. Emergency medicine is not about what the patient has (the diagnosis) but rather what they do not have (the problem which could hurt or kill them). Thus, if you come to an emergency department, expect to undergo extensive testing that is designed only to really do one thing – prove if it is safe or not safe for you to go home. Often those tests are uncomfortable, and “I think it is {insert diagnosis}” without confirmatory testing is simply not good enough.

      [Stepping off soapbox now]

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