WhiteCoat

When You Don’t Know What You Don’t Know

This has happened twice to me, but I’m learning …

The first patient was several years ago. She came in with headaches. Her blood pressure was 220/110. The headache wasn’t an issue. The patient hadn’t taken her blood pressure medications that day and had a history of headaches. There was no change from prior headaches. We gave her pain medications, gave her the dose of clonidine she was supposed to be taking, and she felt better. Her repeat blood pressure was 176/96. I told her that she really needed to take her medications every day and that she could follow up with her family doc later that week for a blood pressure recheck. Then I discharged her.
Forty five minutes later, she was still sitting in the room talking with the nursing supervisor.
Then the nursing supervisor asked me if I felt comfortable discharging the patient.
Yes, yes I did.
Wasn’t I concerned about her blood pressure and her headache?
No. Her blood pressure was improved to the point that she could be discharged and her headache had resolved. She was stable for discharge.
Afterwards, I saw the nursing supervisor make a phone call, then go back in the room, then leave.
I went back in and asked the patient if there was a problem.
“No, no problem. We’re leaving.”
Then the family member in the room said “We’re going to another hospital like the nurse said. Her blood pressure is much too high for her to be discharged.”
What?
I asked them to wait a moment while I tracked down the nurse and the supervisor.
The nurse had finished her shift and left the building, and by the time I found the nursing supervisor, the patient had left.
Lots of meetings after that incident.

Then it’s deja vu all over again.
A patient comes in with the worst headache of his life. Those are the words he says to me as soon as I walk in the room. Never had headaches before, bent over to pick up garbage and headache began. Hasn’t let up in over 8 hours. Radiates into his neck.
I already know where this visit is heading.
He got three rounds of IV pain meds and his pain was still in the “severe” range.
We ordered an “unnecessary” CT scan. After all, it came back normal.
Then I go to explain the necessity of a lumbar puncture.
Fortunately for the patient, his mother in law was a nurse educator at the nursing school in town. He ran the case by her and she said that a lumbar puncture wasn’t appropriate since it wouldn’t tell us anything that we don’t already know.
I told him about pseudotumor cerebri and meningitis and the subarachnoid bleeding that CT scans sometimes don’t pick up.
The patient’s nurse then said that MRI will see the things that CT scan doesn’t … including bleeding.
Whoa.
So I go to one of the textbooks and copy one of the pages showing that CT scan is much better than MRI at picking up subarachnoid hemorrhage. I give a copy to the patient and to the nurse. Her response was that I was being “vindictive.”
At that point, I threw up my hands. I told the patient that if he didn’t want the test, I’d be forced to admit him to the hospital for monitoring. If he didn’t want that, he’d need to leave AMA. I told him my concerns with him doing so and asked him to come and get me if there were any other questions.
Twenty minutes later, the patient told me that he decided to go against the advice of his nurse educator and his nurse and he reluctantly agreed to the lumbar puncture.
His pressures were on the high side, but normal.
Cell counts … one WBC. Three RBCs.
“See,” the nurse said, “no blood.”
However, the CSF protein was twice normal.
“So what do you think of the protein, then?”
“You’re the doctor. That’s why you get paid the big bucks.”
Now the differential diagnosis of elevated CSF protein is large and includes infections, tumors, abscesses, multiple sclerosis and bleeding. The problem was that acute severe pain isn’t a typical finding in tumors, abscesses, or MS and that it didn’t look like an infection based upon the CSF results.
I called the neurologist to discuss the case. She thought the patient had a small bleed and that the blood had broken down, causing the elevated protein levels. She recommended that the patient get an MRI/MRA.
So we were able to get the patient in for the test a couple of hours later and the patient ended up having a small dural tear. Oh yeah, he forgot to mention that he was in a car accident a couple of days earlier. Wasn’t having any pain from it, so didn’t’ think it mattered.
And the patient’s nurse reminded me that if I had just listened to her, I could have saved the patient a lot of time in the emergency department and he wouldn’t have had to go through cost and risk of a lumbar puncture.

It was then that I realized that the nurses are always right.

———————–

This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

7 Responses to “When You Don’t Know What You Don’t Know”

  1. JustADoc says:

    Being lucky and being right are 2 different things.

  2. JJ says:

    Why call a neurologist? They always say MRI/MRA.

  3. Charles J. Neilson MD says:

    With regard to emergency nurses knowing more than emergency physicians ….. read this http://www.erbook.net/another%20point%20of%20view%20regarding%20nurses.htm

    I think it is fair to listen to someone who has experience as both an ER nurse AND ER physician.

    “Remember Rule #1 of the ER: Nurses can hurt doctors far worse than doctors can hurt nurses
    #2 There are always a lot more nurses than doctors.
    #3 Nurses occasionally fight amongst themselves, but if there is discord between a nurse and a doctor you can bet your last dime that the nurses will band togethert to assail the doctor.
    #4 Cognizant of the above, ER doctors bend over backwards trying to avoid conflict with nurses.”

  4. commonsensedoc says:

    “It was then that I realized that the nurses were always right.” huh? you work in a toxic environment; not all nurses are like that;most know how to work as a team. #newjob

  5. Jb says:

    In the second case, the nurse was right out of luck. You went through the correct process of CT/LP. The MR came as a result of the correct sequence of events. If you did a normal MR first and there was a missed SAH, you would have no defense.
    In the first case, the nurse was way out of line. If she disagreed with your management , then the nurse should have discussed his/her concerns first. If the outcome of the discussion was not to his/her satisfaction , then she should have gone to her supervisor. Most likely there is a process in place that avoids disagreeing in front of patients. The only ones who benefits are the lawyers. The nurse violated this and he/she should not be in the ED if this is a pattern.
    I get along with all the nurses in our ED. They do question what I do sometimes, and we always have a friendly discussion. It never has gone beyond this. The only time, I complained to our supervisor was with a nurse who would openly berate the care that was provided .The problem was, she was just plain wrong. For example, we had a severely combative patient that required 9 males including 3 police officers to restrain . I ordered a chemical restraint. She then told a nursing student, ” it is always better to physically restrain rather than chemically restrain. What he did was not safe.”
    She is no longer with us.

  6. SeaSpray says:

    I didn’t realize nurses could go against an ED doc in front of the patient. I would want one to go to bat for me if she knew something was truly wrong ..but I would think the physician knows more because of his training. ?

    • NurseHubba says:

      I know I’m late, but. . .

      Physicians do know more. They have faaaaar more extensive training. But, that being said, physicians are not gods. They are people too. And people make mistakes.

      A good nurse, at least in my opinion, is not afraid to question a doc’s order, but should do so with tact and respect, and not in front of the patient unless there is a serious and immediate safety concern.

      I’ve questioned doctors before about their orders (tactfully and professionally) and had them change their minds. Also, by questioning some of the orders, I’ve learned quite a bit because the docs teach me the rationale, helping me to understand better and, I think, be a better nurse.

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