A Perplexing Presentation of Influenza
Robert M. Blumm, MA, PA, PA-C Emeritus, DFAAPA
Last month, I was teaching a six-hour suturing workshop for FHEA and had an insightful conversation with one of my associates, Dr Theresa Campo, DNP. Theresa is a well-trained NP and author of two textbooks; she serves as an educator and an emergency department nurse practitioner. While performing her duties in the ER, she encountered a strange presentation on a pediatric patient that required further testing and transfer to a pediatric facility. When working for a hospital emergency room, we are serving under a medical director of the ER. That director can determine if our treatment is correct or whether we really need to triage the patient to another service. In this case, Theresa’s experience and intuition told her that there could be multiple zebras running through the child’s presentation; yet the physician was reluctant to approve the referral. Because of her experience, Dr. Campo realized that she was still the provider and culpable for her decisions. Transferring the patient to provide a safe transition on a difficult diagnosis was strongly indicated. This is a situation that many NPs and PAs will encounter and the correct action is to follow your gut unless the director wants to take over the entire case and disregard your input. Today, an experienced NP or PA in this arena is as capable of making the decision for treatment as the physician and is legally responsible for their actions.
The patient in question presented with cough, fever, and rash that started two days prior. She had one episode of vomiting one day prior to her ER visit and none since. She incidentally presented with a subconjuctival hemorrhage in the medial aspect of her left eye, possibly caused by violent coughing. The patient also had epistaxis of the left naris that lasted for one hour and stopped with direct pressure after fifteen minutes. The patient developed a petichial rash of her chest as well as her right and left upper extremities during examination. She tested positive for Flu A, CBC was normal, coagulation profile was normal; but she had blood in her urine with few RBCs on microscopy. While she was in the ED, the rash spread on both upper extremities to her hands, the upper back, and down the midline to the abdomen. Just prior to transfer to their other campus for peds admission, she developed urticaria. This is a formidable presentation and other differential diagnoses are required to form the correct treatment plan. As you can see, this is not an everyday flu presentation. This case demonstrates why Theresa was required to follow her instincts and make the proper transfer.
I have discovered that many new clinicians become intimidated by the “oversight” of some physicians. They have a tendency to blindly follow their instructions, forgetting that they are the responsible party if there is a poor outcome. Those clinicians with less experience can often make poor decisions due to lack of experience and failure to diagnose based on conflicting presentations. They fail to demonstrate that they are secure in their diagnosis and fail to realize that, despite working under a facilities' malpractice insurance, they are still a responsible target in a litigation and are at the mercy of the hospital's carrier. It is for this reason that every new PA or NP needs to discover that the most efficacious policy for their practice is a personal liability insurance policy that protects them as the individual clinician and protects their assets and their reputation. A new clinician can pay a fraction of the cost of a policy during the first year of practice. The new clinician will soon discover what it means to have a parachute when it becomes necessary. CM&F has been insuring nurses, PAs and NPs for the past 70 years and has an A++(Superior) by A.M. Best rating and protects their insured. Call them today to add the safety net that is necessary in the practice of caring for patients.