-
Know who the referring …”provider” …is and tailor your report to this.
from another site
My name is Patrick Horn from Edmond, Oklahoma, and I wanted to share my story regarding a poorly trained nurse practioner that couldve cost my life. I came into the Mercy Hospital ER, Oklahoma City, on Wednesday, 2/27/2019, as a trauma case after a severe MVA at approx 8am where the vehicle rolled into a very deep ditch on its side at high speed after losing control on the ice at the bottom of a steep hill in a rural area.
My truck hit the deep ditch/ravine so hard that both front wheels cracked off, air bags deployed, the truck flipped on its side and wedged into the large ditch. After seeing my vehicle, everyone at the scene has said Im lucky to be alive, much less that I crawled out of the vehicle under my own power.
At Mercy ER, I never saw a doctor. Just an NP, Dawn Womack, APRN. I came in complaining of severe spinal back pain and abdominal pain. She ordered a thoracic x-ray only and a zofran for the abdominal pain, and almost sent me out the door with Naproxen after misreading the x-ray as normal.
I asked that an MD radiologist read it before I was released and learned that I had fractured thoracic vertebrae per radiologist reading and CT confirmation.
She never bothered to do more imaging, including none of my c-spine nor my lumbar spine nor my abdomen nor my head, nothing. Seems like she really didnt want to do a thoracic CT but did so based on what the radiologist recommended and based on my pushing for help. She just tried to get me out the door as quickly as possible. I get that they were very busy that day due to all of the ice slips and falls, but given the potential severity of my trauma after a severe MVA that probably shouldve killed me, this management is inexcusable.
No abdominal CT for the abdominal pain after the MVA, no complete spinal CT, no imaging of the cervical or lumbar spine, no head imaging, nothing. I couldve been bleeding in my abdomen from a ruptured aorta, lacerated spleen or kidney, and she never wouldve never known.
He never would have gotten a thoracic CT had the Radiologist not said something.
Further – He never got a belly CT or C-spine CT.Normally, we all allow the referrer the freedom to decide on their own what is necessary, giving them the respect deserved for a board certified physician. Once or twice in my career, I have seen who the referrer was and tailored my report to this. In one case, I did say “this is a benign lesion, and does not need biopsy or surgery”
After reading this persons experience, I think I will modify my procedure, and if I see that an NP is the referrer, I will understand that she is operating from a low information content standpoint. I will be more directive of what studies I recommend next, as if I were talking to a medical student. It is the only way we can help improve patient care. We are very frequently in a position to see what is necessary, and our judgements will be better than an NPs.
If only there were a way to anticipate what would NOT be necessary and say “don’t order XX”
Another tack we can take is to call the supervising physician directly and recommend what be done. We may prevent a death, and the supervsing physician, being the one who is legally on the hook, probably would appreciate it. -
19 Replies
-
So to summarize.
An ED provider missed a fracture on their preliminary read and discharged the patient.
And then a radiologist read the study, communicated the correct findings, and made appropriate recommendations.
Happens every day. (NP and ED docs both)-
You didnt read the article. WANTED to discharge the patient but the radiologist said to get a CT. The NP then didnt order any further imaging in a patient with a traumatic T-spine fracture. I will say this NEVER happens with an ED doctor.
I have had to alter my reports because NPs wont take the logical next step a physician would. C-spine precautions werent taken when they should have been and I now say this is an unstable fracture and emergent referral to neurosurgery os recommended.
-
There are also times when I say something like “nonemergent follow-up CT is recommended in x weeks” and 30 minutes later I see the CT on my list from an NP “provider.”
They are in over their heads and everyone knows that.
The scenario you describe though lends more credence to us pushing the fact that we are the first physician to “see” a lot of patients.-
im sure the hospital made more money by quickly discharging you and seeing more patients. They also made money by saving on salary, as its much cheaper to hire nurse practitioners. Thats USA for you, everyone wants to make extra bucks. Rad reading it is much better than a nurse practitioner but even some rads are bad because they are being paid per study to they read very fast to make extra dollars. The incentives are all placed on amount of work done, not on the quality of care of patient outcomes. Big corporates are taking over medicine by paying millions to buy out practices and then replacing it with “efficiencies” such as replacing doctors with nurse practitioners and physician assistants. All us doctors in healthcare know the game and kudos to any lay person who has caught on to the game.
-
Agree.
I think this anecdote if from a doctor, though.-
Agree. Unfortunately as mention you might be the 1st and only physician to care for a given patient during their visit to the hospital.
The American medical system is now a race to the bottom. Lowest common denominator wins!
-
Wow, I just can’t imagine how Americans have allowed their health system to have deteriorated so much! How can an Emergency department be staffed without doctors? Surely with an MVA of that description the Ambulance would bypass lower tier hospitals and go straight to a trauma centre.
-
Quote from neprad
Wow, I just can’t imagine how Americans have allowed their health system to have deteriorated so much! How can an Emergency department be staffed without doctors? Surely with an MVA of that description the Ambulance would bypass lower tier hospitals and go straight to a trauma centre.
We docs are appalled and embarrassed.
The business men are overjoyed and counting their money
-
-
-
Quote from spongiform
Agree.
I think this anecdote if from a doctor, though.
Yes, he is
Should have mentioned that.
In fact he says what a lot of us have thought in that situation: I was protected by my education. What does someone who is not a doctor do??
-
-
-
-
-
Quote from dergon
So to summarize.
An ED provider missed a fracture on their preliminary read and discharged the patient.
And then a radiologist read the study, communicated the correct findings, and made appropriate recommendations.
Happens every day. (NP and ED docs both)
well, as the patient saysNo abdominal CT for the abdominal pain after the MVA, no complete spinal CT, no imaging of the cervical or lumbar spine, no head imaging, nothing. I couldve been bleeding in my abdomen from a ruptured aorta, lacerated spleen or kidney, and she never wouldve never known.
this is not OK, and it is not a typical miss.-
One doctor in the building, everyone else who used to be doctors are now nurse practitioners and physician assistants. See we bought the practice and made it a lot more efficient…we know we wont be able to keep up the numbers though, plan is to show good financial numbers for 5 years and then sell it to someone else who will be caught holding the bag.
-
Highly recommend this book, which contains numerous egregious examples of NP and PA care gone wrong-
[link=https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/ref=nodl_]https://www.amazon.com/Pa…p/1627343164/ref=nodl_[/link]
-
Quote from vision
Highly recommend this book, which contains numerous egregious examples of NP and PA care gone wrong-
[link=https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/ref=nodl_]https://www.amazon.com/Pa…p/1627343164/ref=nodl_[/link]
This is a fantastic book that goes into all the issues in great depth, and is well referenced. Even with this, it is quite readable.
-
When a congressman is handed this book in one hand and a pile of money in the other, of course he will take the money with one hand and throw this book in the trash with the other hand…Increasing autonomy for NP’s and PA’s is my not so bold prediction.
-
I’m new here but Phil Shaffer seems to be on to something.
-
-
Im perplexed because any sort of car accident including backing into a parked car or something tends to result in a CT CAP, so Im not sure how mercy wouldnt have pan scanned a roll over MVA.
-
So true. Our ER seems to pan scan a ground level fall routinely.
-
Heading to Hawaii in February and getting some material to read on the plane. “Hawaii, The Big Island Revealed” and “Patients at Risk, The rise of nurse practitioner and the physician assistant in healthcare”
From my Oncologist friend, “that looks interesting and frightening, I note that there are no “physician extenders” in radiology. For much of this year I have had to share an office with a nurse (np). She is trained in palliative care but not oncology. When they booted her from they in-pt palliative care service they decided to put her in the onc clinic and (dr) has had her do onc follow ups and urgent same day problems. Hearing her (np) regularly has scared me out of my mind.
I respond with this
We keep these guys from radiology. So many times have I had them follow me around and wonder why I don’t teach them how to do my job. I say, go to Med school, get yourself a residency in radiology and then I’ll show you a thing or two. Otherwise, how can I help you?
-
-
-
-
-
-
-
-
-
