Posted on 09/16/2006 9:25:30 PM PDT by 60Gunner
Being an ER nurse, I tend to fasten my attention onto cases such as this one.
According the the AP story, a 49-year-old woman came into the ER complaining of chest pain, nausea, and shortness of breath. (Okay, all you nurses out there: pipe down and let the laypersons catch up.) She is triaged, classified "semi-emergent," and instructed to wait for her name to be called. Two hours later, when the woman's turn to be seen had arrived and her name was called by the triage nurse, the woman did not respond, The nurse approached the woman and found her unresponsive and pulseless. (That's medical-ese for "dead.")
The ensuing coroner's inquest ruled the woman's death a homicide. No details are available at this time regarding exactly who is to be charged with this woman's death.
Here is my view of the matter.
At the emergency department in which I am employed, there is a simple standard of practice that governs the treatment of any person who complains of chest pain, shortness of breath, and nausea, whether the person is 18 or 90 years old, and it is as follows: Treat it as a heart attack. That means get them into a treatment room, Give them oxygen, stick a large-bore (20 gauge or larger) IV needle into them (two would be better), draw labs including troponin I (a marker for cardiac injury), slap cardiac monitor leads onto them and perform a 12-lead electrocardiogram. If their blood pressure is stable, we may also give a spray of sublingual nitroglycerine and four baby aspirin.
(One may say that 18 years old is a bit young to be having a heart attack, and it is. But it happens; not very often, mind you, but just often enough to cause us to keep our guard up. So we don't take any chances.)
The rationale for all of these drastic measures (all of which occur within minutes of admission) is that if we act on the assumption of the worst-case, we will already be ahead of the curve. We can always back off on treatment strategies if it turns out to be something other than cardiac-related. But if it turns out to be a heart attack, then time is of the essence. And if the ER staff was caught flatfooted, the patient can die and the staff can be in a lot of trouble, as is the case with this Illinois ER.
Now, I was obviously not there to see all that went on in this woman's case, and therefore I will not point fingers. But I suspect that the error occurred because of an inexperienced triage nurse. On the other hand, triage nurses as a rule have to be experienced nurses before given that duty, in order to avoid this kind of tragedy. I think that in such a case, the only thing that could throw off the triage nurse's assessment would be whether or not the patient drove herself (or was driven by a friend or loved one) versus calling 911 and being transported by ambulance. Even then, given the victim's symptomology and the fact that she showed up in an ER, I am having a very hard time giving this staff the benefit of the doubt.
The moral of this story for the nurses who read this is: chest pain + shortness of breath + nausea = heart attack until proven otherwise.
And the moral of the story for my non-nursing readers out there is: chest pain + shortness of breath + nausea = heart attack until proven otherwise. So if you have these symptoms, don't be stupid. Do not drive yourself to the hospital or even ask a friend or loved one to do it. Call 911 and sit tight. You will get there faster, and you'll be taken a lot more seriously than if you were to walk in under your own power like so many frequent flyers with anxiety attacks do. We are skilled and trained, but you have to help us out here.
Somebody in that Illinois ER is going to pay with his/her license and maybe even some jail time before this is over. The hospital will likely be out millions of dollars. I can't really defend that, and I won't even try. In my heart of hearts, I know that there is no excuse for allowing a patient who may be having a heart attack to sit for two hours when an EKG and labs can be done on a stretcher in the ER hallway in five minutes and the patient can at least be monitored.
Yes, I did - it was a vague feeling, not "Omigod, I'm gonna die!"
Just a realization that something was terribly wrong, and that the doctor and nurse were not taking it seriously.,
Good informative post. Thanks from a nurse.
The local hospital hospital where we used to live had a woman that brought in her husband with chest pains. The emergency room sent him home, they said it was gas pains. He left the emergency room, got into to his car, had a massive heart attack and died in the emergency room parking lot. The wife sued and won.
Thanks for posting this.
My brother's wife, at age 34, went to the doctor complaining of back and chest pains and he sent her home with pain pills.
My brother found her the next morning dead of a massive heart attack. They had a son 14 and daughter 8, which my brother raised alone after that.
My stepdaughter's husband, in 2001 was diagnosed with leukemia, and went through massive chemo and into remission.
In 2004 his cancer came back, he'd just had his first chemo, and became ill. Stepdaughter took him to the emergency room, and they kept him waiting in the waiting room for three hours. He was so sick and weak he layed on the floor in the ER waiting room, while they treated people with colds, coughs, broken bones, etc. When (after 3 hours) they finally took him into the back he went into cardiac arrest and died, leaving a wife and 15 year old son, and daughters aged eight and three.
This does happen, all too frequently. And no, none of these people sued. But it does send a wake up call.
When the ambulance arrived and I was all buckled in, the nurse said to me, "Now, start at the beginning." To which I replied, "Well, I was born around 4:00 a.m. on the morning of October the third, 19..."
Well, she did say, "start at the beginning."
I don't think they liked me very much.
A father of a friend of mine was on a trip with his wife when he started slurring his words and acting strangely. He was drunk -- which after 8 pm, was pretty much a given for him -- and once the doctors noted that, they looked no further, and told his wife to take him somewhere he could sleep it off. The wife tried to explain that she knew what he was like drunk, and this wasn't it, but to no avail.
They continued down the road, and by the time the wife pulled into another hospital, he was sinking into a coma. He died a week later. We'll never know if the stroke could have been treated if diagnosed at the first ER.
It's your life, and it's your money. You have the right to take charge of your healthcare. Go for it!
This is just my personal opinion, but I think that ERs should do away with the receptionist. My ER does not have one, and the first person every single patient sees is the triage nurse and not some unskilled volunteer. As a result, when a person comes in with chest pain or one-sided weakness, we know it's chest pain or one-sided weakness. Sorry to all you volunteers out there, but when it comes to cardiac or neuro symptoms, you are just not qualified to be the first person a patient encounters.
Don't be so sure. You need to be check out ASAP. One of my sisters had chest pains at 40 and barely managed to call an ambulance and get her door unlocked. She coded (her heart stopped) twice before they realized she needed a quadruple bypass. She lived 8 more years before dying of leukemia.
With that family history when I had the worst chest pains in my life at age 41 I told my husband to call an ambulance, I thought I was having a heart attack. He (usually a kind, loving man) was too embarrassed to call an ambulance. He drove me to the hospital where they promptly treated me for symptoms of a heart attack. I could barely take a breath or speak. I spent 5 days in CCU and underwent a cardiac catherization before discovering that I had 4 ulcers in my esophagus and was having spasms in my esophagus. Fourteen years later I still have a healthy heart and frequently have terrible spasms in my esophagus, they can literally buckle my knees the pain is so intense. I have medicine to put under my tongue with instructions to go to call an ambulance very shortly if I don't respond the to medicine. The doctor says the pain I describe sounds identical to that of a heart attack. Embarrassment would be a very small price to pay to end that pain.
Testify, sister.
I took my mom to the ER with kidney stones. In case you've never had kidney stones or nursed someone who did, they're about as painful as anything not immediately life-threatening gets. Mom had the cartilage removed from both knees and gave birth twice, and she said the stone was more painful than all combined.
We were sitting in the ER waiting room, with Mom in a wheelchair doubled over in pain with barely enough strength to whimper. She was holding an ice pack to her abdomen which offered some meager amount of relief. I was sitting within sight of the triage nurse, and while I didn't want to nag, I wanted to be in a position to make a pleading puppy-dog face when she happened to look up.
As we were sitting there, a young woman stomped up to the desk. I don't know what her complaint was, but it didn't prevent her from waving her arms like a third-base coach and yelling louder than a Pete Townshend solo. She was outraged that people who had come in after her were being admitted before her.
I was sitting next to the tough, smart woman who raised me, who was now completely helpless, and there was nothing I could do about it but sit and wait and worry as this spoiled little [deleted] went off on her little tirade.
"Listen, b----," I screamed. "This isn't a deli. If you're strong enough to scream like a banshee, you're strong enough to wait. Unless you're bleeding from BOTH eyes, sit the f down and shut the f up before I give you an injury that will move you right to the top of the list."
Okay, so I actually only said that in my head. The nurse, who had obviously dealt with this kind of thing far more than I had, quickly calmed the woman down and sent her back to her seat, no violence or foul language necessary. Not too long after, Mom was doped up and antibiotec'ed, and the crisis passed.
One very big problem NOW... is that too many people use the E.R. as a clinic. Legally, they can't turn anyone away. The "E" stands for "Emergency". We need to get back to that.
Agreed; we need more clinics. Yes, I know that a lot of FReepers are going to hate the idea, but I don't see any reasonable way we could allow ERs to turn people away without having a viable alternative available.
Most 911 calls are not legitimate emergencies. Some of them are incredibly stupid. If a hit-and-run driver clips my car, causing damage but no injuries, I know not to call 911 -- but I don't know whom to call, especially if I'm out of town and don't know whose jurisdiction I'm in. Same thing if I'm robbed, or some punk vandalizes my car, or I see someone kicking the hell out of a stray dog.
Some cities have launched, and publicized, a x11 number for all services other than life-and-death emergencies. I don't remember what the X is -- it's not 411 (directory) or 611 (repair), but I don't remember what it is. We don't have it yet. It seems to do a pretty good job of diverting the non-urgent calls to people who are both less strained and better able to help.
What I suggest is a way of getting non-emergency patients out of the ER just like x11 gets the non-emergency calls out of the way of the real emergencies. We ought to have more community clinics and a better system of making sure people know about them and know where to go. Yes, that will cost money, but only in the setup phase. It'll save money in the longer term, because routine care is less expensive anywhere else than it is in the ER.
My post #274 goes into my (vicarious) kidney stone experience. I can't imagine how hard it is to go through it; it's hard enough to watch. I'm sure I'll learn, because both of my parents and my little sister have had kidney stones, so I'm predisposed. Dad's had enough of them that I think his ureters are mostly scar tissue, and the last time he had one he drove himself to the hospital.
But I'm afraid, however rudely the ER staff put it, they were right -- first priority goes to the people at greatest risk of dying or suffering permanent disability. The risk of either from a kidney stone is slight, however painful it is. So even a bad case of gas that *might* be masking a heart attack takes precedence over a stone. It sucks, but the folks in the ER are doing a hell of a lot for too many with too little, so they have to prioritize.
A few years ago, a friend and I were walking home from a bar when we happened upon a guy lying in the street. He'd been clipped in the face by the outside mirror of a passing Jeep and knocked to the ground. He was incoherent, listless, and it didn't look like his pupils were responding. There were no no obvious wounds and there was no blood on the pavement.
When we walked by, his friends were standing over him, starting to grab him by the arms as if to drag him, saying "we need to get him out of the street." Michael (my friend) was a WSI lifeguard, and I had no formal training aside from basic first aid and CPR/artificial respiration, but I knew enough not to move someone with a likely head or spine injury. We both said "NO!" in near-perfect unison.
We rounded up a few fellow inebriates to stand around and be visible so no one low to the ground would get run over. Within a few minutes, EMS arrived, and we told him what we'd seen. And then we left, because we'd done everything useful we could, and we stayed we'd just be in the way with all the other gawkers. I never learned how that turned out.
I don't know what it is about this thread, but something's got my anecdote machine going.
The next night I was triage RN, and our charge nurse came out and told me that the one available room was now reserved for a medic unit. I asked what was coming in and he told me.
I kid you not- it was the same person who pulled that trick on us last night, and I was the RN who treated her then.
I said, "You know, [so-and-so] pulled this trick on us last night."
The charge RN says, "Oh, did she?"
I said, "Oh, yes. In fact, I treated her."
So the charge RN says, "Well, I'm glad I talked to you."
When the medic unit pulled up, the charge RN met the patient as the medics pulled her out of the unit, had them unstrap her, and marched her straight to the triage area. When she entered the triage area, she saw me and went pale. I gave her a little waggly-fingers "princess" wave. The charge RN sat her down and told her, "Now I know you. Don't ever pull that stunt in my ER again." The patient got straight up, offered her pointed opinions about my parentage and my masculinity, and stormed out of the ER.
We never saw her again, but about three weeks later another area hospital called us about her because her name showed up on the frequent flier/drug seeker alert that our area hospitals occasionally share.
She came into their ER by medic unit complaining of a migraine.
Pepperdog, I love what I do and would not trade for anything else. I'm glad to do it.
Try baby aspirin. BABY aspirin. But let your MD know what you are doing so he/she can be aware.
My schoolboy French is a little rusty. Are you talking about milking a pig? And if so, wouldn't any amount be too much?
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