Friday, January 31, 2014

"Have You Examined the Patient!?"

Surgeons tend to get a bad rap amongst nurses.  Not necessarily in my institution necessarily (or consistently), but in life, in general. 

They can be known for bad bedside manners. They can be known for being short (in personality, not stature).  They can be known for talking down to all non-surgeon personelle. 

And then there are the rare but fine (oh so fine!)  moments, when one of them just says something utterly ridiculous that you can call them out on!

What was even sweeter about my interaction with a particular surgeon this week, was there were 3 of my collegues listening in on my phone conversation.  As I hung up, they all bust out laughing, and couldn't believe what they had heard.

So enough setting up the story...onto the good stuff!

I had been caring for a four year old girl who had cerebral palsy and several other medical problems. She was severely mentally and physically disabled, was completely non-verbal, can't fix or follow objects, and was definitely on the small side of the growth curve.  I know that's a lot of info, but it comes to be important in a bit.

She came in for pneumonia, but I noticed that she was malnourished, and recommended consulting Pediatric Surgery for a G-Tube for feedings. I was actually shocked that up until this point she had been fed by mouth for so long!

Looking through her chart, she had previously had a swallow study showing that she was aspirating (which was just as I suspected), so this further built my case for needing a GT.

I placed the call, told the surgeon why we were consulting, and he said he would go see the patient later in the day and get back to me.

Just as I was getting ready to leave work, I get a phone call. Reluctantly I picked up, and was so glad I did. 

The conversation went like this:

Surgeon:  "So I went and evaluated your patient.  I also talked with the mother for a bit, and we are not going to place a GT.  She doesn't need it."

Me:  "Umm, I'm sorry, why do you not think that she needs it.  She is malnourished, she has a swallow study showing that she aspirates, and given her underlying medical problems, none of this is going to change anytime soon."

Surgeon:  "Well the mother says that the patient is able to tell her when she is thirsty, and mom gives her water to drink.  She also says when she is hungry and she will get an apple and eat it. She's been doing this for the last four years, and while she may be on the smaller side, perhaps the mother isn't giving her enough nutrition which we can educate her on." 

Me:  (let me preface that I was BAFFLED at this response!) I simply stated "I understand that you had a conversation with the mother and were given that information, but did you examine the patient!?"

This took him back a bit, and he stumbled over a few words and then said, "Well, yes I saw her." 

More adamently I said, "This patient is completely non-verbal...why would we think that she is verbally telling her mother that she is hungry or thirsty!?  She is severely contracted and does not have purposeful movements, so why would we think she would say she wants an apple, reach for it, and then feed herself!?  I understand what the mother told you, but if you spent five minutes evaluating the actual patient, you would understand the reality very clearly."

*This was the point in which my co-workers were laughing b/c I was so in awe of his ridiculous reasoning that I was definitely firm, but remained very calm*

He didn't particularly like this (I'm assumming), because he got really quiet, then didn't really say too much. 

At the end of the conversation, I gently reminded him to go back to the patient, do a thorough evaluation, and then come to a conclusion on whether this child was safe to eat by mouth, and more importantly able to take in the appropriate nutrition that way. 

He agreed, and then said that he would talk to his attending and call me in the morning.

The next morning I get a text page from him saying "Discussed with attending. We will place GT in 4 weeks.  She will need imaging prior to that."

Short, sweet and to the point.

And yet such a sweet, sweet point made by me! 

Just another lesson learned in the importance of truly evaluating your patient. And yes, while parents are a wealth of information most times, sometimes they don't live in a full reality.  It takes our medical evaluation, studies, and judgement to help determine what is best for these patients.

Score one for the Nurse Practitioners...lesson learned for the Surgeons! 


  1. Hmm tact, something I probably need to learn before going much further in my professional career. Good for you for standing your ground and sticking up for this sweet baby. My 2nd patient in my Peds rotation sounds just like this patient. I loved taking care of her that day!!

  2. This is a great example of the need to be technically competent in our work but also the need to have the emotional intelligence to be confident, assertive and calm in how you interacted with the surgeon. The fact that you have all that, and more, made a profound difference in this little girls life.

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