Back x-rays in the ER

[fab4fan]

If you saw the volume of pts. seen in a hospital, you'd be doing a lot of damage control too.

For someone who just wanted to "let it lie," you sure had a lot to say. Most of it still misinformed. You may think little of a nurse's education. That's fine, because I don't think a whole lot of a chiro's ed. either. There...we can be members of the "Mutual Contempt Society."

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[DNP student]

I'll admit I don't know the scope of practice for RN's but it is my understanding they don't have diagnostic privledges. .

While you are correct that RN's cannot independently order diagnostic tests, in many areas including the ER, RN's work off standing orders. they are expected to perform a thorough assessment and utilize judgment to ascertain whether the standing orders "fit" a particular situation. Due to the volume of pts seen in most ER's and the critical nature of many, RN's do order tests based on standing orders prior to a pt seeing an MD/DO. This is occurring more and more often and is acceptable. If every pt waited until they saw an MD/DO to have any tests run, the very least problem would be very long waits in the ER. The worst would be that some pts would die. There was a time when the MD/DO saw the pt prior to any testing, but that has not been the case for many years. For the past 10 or so years, this practice has also been occurring on all units. Since I started nursing 23 years ago, the types of pts on the floors are the kind that used to be in the units; and the ones in the units are the ones that historically did not survive the trip to the hospital. All that said, RN's are qualified to use educated judgment and follow standing orders. Are there RN's who miss the boat and cause harm - yes. Are there other health care professionals who do the same - yes.

 

[fab4fan]

While you are correct that RN's cannot independently order diagnostic tests, in many areas including the ER, RN's work off standing orders. they are expected to perform a thorough assessment and utilize judgment to ascertain whether the standing orders "fit" a particular situation. Due to the volume of pts seen in most ER's and the critical nature of many, RN's do order tests based on standing orders prior to a pt seeing an MD/DO. This is occurring more and more often and is acceptable. If every pt waited until they saw an MD/DO to have any tests run, the very least problem would be very long waits in the ER. The worst would be that some pts would die. There was a time when the MD/DO saw the pt prior to any testing, but that has not been the case for many years. For the past 10 or so years, this practice has also been occurring on all units. Since I started nursing 23 years ago, the types of pts on the floors are the kind that used to be in the units; and the ones in the units are the ones that historically did not survive the trip to the hospital. All that said, RN's are qualified to use educated judgment and follow standing orders. Are there RN's who miss the boat and cause harm - yes. Are there other health care professionals who do the same - yes.

Following CFS's loopy understanding of nursing, no nurse could follow ACLS protocols either, because that would be diagnosing and practicing medicine without a license.

"I'm sorry Sir, you'll just have to put up with that v-fib until a doctor gets here. Oops, my bad, I'm not allowed to determine that you're in v-fib; I'm just a community-college educated nurse."

I agree, the days of pts. coming in to the hospital "for a few tests" are long gone. Remember the bad old days when having a choley meant a huge incision, lots of pain, respiratory treatments every few hours and a lengthy hospital stay? Now it's zip, zip...in and out the same day.

 

[f_w]

I'll admit I don't know the scope of practice for RN's

Well that has become abundantly clear.

I don't think a community college educated nurse should be ordering x-rays, lab work, etc. on my mother.

The RN applies standing orders and protocols. It is the ED physician who is legally responsible for the orders, the RN works under his 'general supervision' when he/she applies the protocols.

Again, I am not saying this to embarrass you or one-up you

You embarass nobody but yourself.

Now. . .lest you think I am picking on you, let me turn the tables on my own profession to give you another bad practice. All chiro. schools teach taking of vitals, at least on the first visit. Often, that falls by the wayside in business and the "chronic back and neck pain practice" develops over the years. Then one day, a HTN H/A comes in or spinal mengititis case comes in and bam! it's over.

Gee, you could even delegate the taking of vitals to a nurse or medical assistant...

You can't go around MRI'ing everyone to r/out anything and everything.

Just MRI the ones with neurologic deficits and you'll be fine.

Finally, I don't really care what you think of chiropractors.

Apparently you do.

 

[CFS]

Oh, I get it; it's standing orders.

Ahhhh. That makes it A.O.K.

Ha, ha, ha, ha, ha, ha, ha, haaaaaaaaaaaa.

Listen, you can defend the practice all you want, just as DC's will defend some indefensible practices.

Because, look, it must be right, right? Nobody is dropping dead, at least what we know of. . .nobody is complaining. . .well, the patients complain a little but let's face it - they're complainers, right? Just a few extra diagnostic tests among friends isn't hurting the health care system, right? No biggie. Right? Only a few hundred million probably.

LOL.

Listen, it is NOT ideal medicine for a nurse to order tests. I don't care if there are standing orders. I am not talking about triage of who's the most urgent. I am talking about examining the patient and then making a clinical decision.

Maybe I'm old fashioned but I think a doctor should do that. You know. . .think a little before ordering tests. Just a little. Maybe only 5 seconds.

In fact, I question "standing orders." How about I have a standing order that every back pain patient gets an erect l-spine x-ray here? How does that fly here? DC's took a lot of crap for that in the past and most have reformed that practice.

Any responsible nurse, especially newly graduated, probably feels this way and probably feel uncomfortable the role they are thrust into as pre-diagnostician. I know the vets get forced into this role over the years to where it becomes second nature, I suppose.

Now, if it's not OK for a community college educated RN to open up some doors, hang a shingle out, and start ordering tests on an outpatient basis and making clinical decisions, why is OK to do this in a hospital? Because it's more urgent? Well, why not a PA or a CNP then? Why an RN?

Hey, don't be mad at me - you got all the dirt on chiropractic. And I think highly of nursing - you are just taking this discussion way too emotionally and personally. I have absolutely no contempt for nurses.

You are, as the psychobabblists say, "Projecting" your derision for chiropractic onto me.

I am just here giving the chiropractors here some of the dirt on medicine, you know, even it up a little. Your house isn't so in order.

You embarrass yourselves when you defend the indefensible.

I predict reform in this area in the future.

Oh, another pt. came in this week after being in an auto accident. Without any prompting relays the horror story of going to the ER to have "nothing done." Some neck x-rays, not even a head CT after being struck in the head. She's having short term memory loss. . .ah hell, forget it. I'll take care of it.

Oh, the horror stories of ER medicine and chiropractic. . .I could write a book.

Except I don't take stories seriously as apparently a lot of you do. I told her their only job was to make sure you aren't going to die and of that, they did.

 

[CFS]

You see, here's the "management" problem, in my opinion.

The ER does things back asswards.

After triage and vitals, they should see the doctor and THEN, nursing and technologists should come into the equation. Instead, it's like you have to pass 15 Tests of Fire before the patient can get to the doctor. That's patients #1 complaint:

"When in the hell am I going to get to see an actual doctor?"

You see, that's why patients like us so much - they actually get to see a doctor (or a pretend one like me, LOL @ myself) after they register at the front desk.

The doctor should be on the front line, in the trenches, patrolling and should after an exam, say,

"Mary, after examining you and listening to what you have to say (or what the family said). . .I am ordering this. . . Now, be patient, it may be awhile but some fine nurses and technologists are going to come and explain the tests to you and take care of you. It runs slow around here and prepare for a long stay."

Not, see a nurse, who executes "standing orders" based on presenting symptomatology and oh, 2 hours later an actual doctor strolls in and corrects the mistakes of what he/she actually wanted. Well, the chest x-ray and Chemistry panel and CBC were fine but I didn't really need that. . .but I would like this.

No, that's unacceptable.

You know I am touching a nerve here, or you wouldn't be responding to me.

 

[f_w]

Listen, it is NOT ideal medicine for a nurse to order tests.

It is not ideal, but given the framework of emergency medicine, the legal environement we live in and the financial constraints of healthcare delivery in the ED it is a reasonable practice.

I don't care if there are standing orders.

Well, you don't seem to understand the concept and you seem to be pretty hung-up about the fact that some RNs have a community college education (plenty of them these days have a BSN, but how would you know that).

In fact, I question "standing orders." How about I have a standing order that every back pain patient gets an erect l-spine x-ray here?

That would make no medical sense. A urine dip-stick test for urinary tract infection and pregnancy on a female presenting with lower abdominal pain is medically necessary and can be performed before the patient sees the physician.

I have absolutely no contempt for nurses.

Your rant makes me think otherwise.

Oh, another pt. came in this week after being in an auto accident. Without any prompting relays the horror story of going to the ER to have "nothing done." Some neck x-rays, not even a head CT after being struck in the head. She's having short term memory loss. . .

Did she fulfill the criteria of the canadian head-CT rule ? Did she fulfill the new-orleans criteria ? Did she have imaging later and did that show any structural lesion that could have been treated at the time of the ER visit ?? Where is the horror-story ?

That's patients #1 complaint:

"When in the hell am I going to get to see an actual doctor?"

Patients #1 complaint is: 'why does it take so long to be seen'.

Not, see a nurse, who executes "standing orders" based on presenting symptomatology and oh, 2 hours later an actual doctor strolls in and corrects the mistakes of what he/she actually wanted. Well, the chest x-ray and Chemistry panel and CBC were fine but I didn't really need that. . .but I would like this.

No, that's unacceptable.

Yep, because this doc would be an idiot and apparently not familiar with his own standing orders.

 

[FoughtFyr]

Yep, because this doc would be an idiot and apparently not familiar with his own standing orders.

It's not worth it f_w, CFS honestly thinks he/she has "won the argument" and "earned our respect". The non-evidence based discourse is going to do nothing. It is just beating your head against the wall.

- H