Nursing and EMTs

[Apreski]

One of my SPs is a newer physician. She tends to do more than less of a work up on patients...the nursing staff often jokes behind her back and even jokes with other SPs on opposite shifts as "[insert her name]" if they are asked to start an IV and basic labs on a patient that seems to be at most a level 4, maybe a 5.

Tonight, 21 yo comes in....Triage note: Rib pain and cramping in right leg that has resolved. Pt on birth control, and had recent travel from Michigan (2 full days of traveling). After reading this, I asked nurse to start an IV, that I will be more than likely to CT patient's chest. Nurse hesitates and calls me "[insert her name]"..."the pain is reproducible, don't do tests that are not needed". .....CT confirms bilateral PEs

In my 3rd-4th month of practicing, another nurse questioned why I was giving a child Benadryl. "Because he has a rash." ....Nurse: "He's not itching!" ..... I reply "Did he tell you he is not itching? I dont think so because he is one." The child was one year old!

Many of the nurses I work with are great, but I think they try to persuade providers in one direction and I feel that I am distracted by their biases. EMTs do this too when patients arrive to the ER: "this guy is a drug addict" etc. That's great information and all, but that doesn't mean anything when this druggy had a deformed wrist!!!

The newer SP mentioned above said they also gave her a hard time at first, and still question the tests she orders. She tells me to never let their opinions form a tunnel vision.

I realize I am super new, but will their tendency to question my choices stop at some point?

[True Anomaly]

When you prove, over time, that your clinical judgement is solid, they will stop questioning you on the whole- there will always be those who will question everything simply because it's more work for them. Best to just ignore those folks and move on.

I've had situations where nursing or medic bias can have a detrimental effect on patient care. Honestly, anyone who's worked in the ER long enough will have those situations as well- it's unfortunately a part of the job, and your job as a clinician is to get past that as much as you can and rely on your training and researching the answers for yourself, or asking your SP when you're in a tight spot- no matter how new your SP is.

And now story time!

My recent favorite nursing story is a gentleman who was from Nigeria, who was living with someone helping him get a visa. He presented to triage with a complaint of sore throat and inability to swallow, but still protecting his airway. The nurse who triaged him thought he was being standoffish because he wasn't talking, and she said "He is giving me this evil eye for some reason". Febrile and tachy, so something's going on. I go into the room and hear the classic "hot potato voice", and saw the worse peritonsilar abscess I've ever seen- I damn near couldn't see his uvula because it was so deviated. And this guy got put in fast track because "he's being standoffish". I asked the nurse to come into the room with me a second time, opened his mouth and showed her exactly why he "wouldn't speak to her"- just to help educate why some people aren't feeling particularly communicative, and that it isn't personal.

My two favorite medic bias stories:
Lady #1 was found down at her bar (yes, the bar that she owned) at 8 AM- was confused, lethargic and looked sick. Medics who dropped her off simply said "She was down at her bar- she's drunk". Problem is, she had absolutely no odor of alcohol on her. She ended up with full-blown active TB (no idea how she got it either)!

Guy #2 was, once again, found by medics on the sidewalk "Just drunk", so he got shuffled into a hallway bed. When I was finally able to go to him, he kept asking me the same question over and over, "So what happened"? (TIP- if they keep asking the same question over and over, DIG DEEPER for another cause- think intracranial. There is a difference between random drunk forgetfulness and true intracranial pathology causing amnesia). I rubbed my hand over the back of his head revealing a large hematoma with fresh abrasions. His rotational nystagmus suggested PCP on board. He ended up with a couple areas of intracranial bleed. Scary, because a cursory H&P of the guy, along with normal vitals (and he smelled of alcohol) would've missed some key details leading to the diagnosis.

All that being said.....understand that I know that there are amazing, hard-working medics/EMTs and nurses out there. I worked with wonderful medics and EMT's during my long EMT career prior to being a PA. But I also now know that I had no idea that I "didn't know what I didn't know"- and most of the time if you're able to take the time to educate people as to why you're doing the things you're doing, they will understand. And if they're still resistant and standoffish, then they're not worth more of your time.

[chiaroscuro27]

Excellent post Tru Anomaly. Being a new graduate in the ER is hard enough all by itself, but to have the peanut gallery in your ear questioning your every move has to be a nightmare.

I'm sure they mean well for the most part, but some nurses I think are just burned out and want to do the bare minimum. Drug addicts and drunkards get sick just like everyone else. Ultimately, clinical judgement and training must win out for the sake of the patient.

[momed]

Excellent Post True Anomaly! I am a PA student and worked as a medic before PA school. I had no idea how much I didn't know prior to school. I wonder how much stuff I over looked because I never knew how or what to look for. Just goes to show that tunnel vision is bad in medicine. Perform your own assessment and draw your own conclusions from the HPI, Hx, and PE.

[medic25]

This is a major pet peeve of mine; there are certain nurses who think that nobody is actually sick, and will gladly critique your plan if you do any type of a workup. This can be a challenge as a new grad, but it's important to learn to stick to your guns and not be swayed if you truly believe that testing is warranted.

This seems to be especially common with our mentally ill/substance abuse population. One thing that I will frequently tell PA students in the ED is that nobody ever died from mental illness; even the homeless alcoholic with schizophrenia will eventually develop physical disease that leads to his demise. If you don't practice due diligence in ruling out the physical disease in these patients, you will eventually have one die on you. The next time you consider not ordering a test just because the nurse gives you a hard time, think about which one of you will be named in the malpractice suit.