Ethics question...triage nurses

wvaio · Joined: 22 Sep 2007 Posts: 82

I have an ethics question that I am conflicted with and would like some outside views.
I apologize in advance for the long post-

In the hospital that I work we have a fairly busy ER. 2 tech's at all times plus coverage as needed from the other radiology area. As patients come in, they are triaged by the nursing staff. The nurse does their triage and then orders on behalf of the physicians on staff, according to protocols and their discretion. Chest pain, shortness of breath, altered mental status, etc. automatically get a chest X-ray. That I understand. If a person comes in with a laceration to the finger, they order a finger. If a person has nausea they order a chest x-ray. Neck pain get a C-spine. They order for every ailment there is. A lot of the time the wrong exams are ordered. I got an order for a hand X-ray for a splinter last week! Wood doesn't show up on X-ray!!!! It drives me wild.
It may be hours before this patient sees a doctor. I find myself having to do an assessment on the patient in the waiting room or in the patient room to figure out if I think the right exam is ordered. I can not bring myself to shoot an x-ray that I whole-heartedly know is wrong or that I feel is questionable, if a doctor(or PA in many cases) has not seen the patient. I am not a nurse basher.My wife is an RN and I value their position, but they are far from MD's.
The problem then arises that we get backed up with a lot of patients that may or may not need xrays. I don't like to change exams and order what I feel is right, because then I am no better than the triage nurses, I am not a doctor. Some doctors respect the fact that I wait and make sure the right images are taken, but the PA's and some of the doctors get bent out of shape when they have no images when they finally get to the patient.
2 weeks ago, I got into a heated discussion will a nurse because I canceled a hip x-ray because she ordered a femur and a hip. The nurse told me that she did an assessment and put in the orders. Why did I cancel them? How do you respond to a that? She informed me that she was trying to get the expedite the process.
The management is concerned with wait times and what-not, but don't I have the responsibility of being an advocate for the patient? I went to school for more than just pressing the exposure button.
I feel like it is a constant struggle that I have to deal with when I do my weeks in the ER. We rotate frequently.

Being ethical is very unpopular.,a nd I know that. Am I stopping progress?
Anyone care to share their views/experiences?

Thanks for your time,
Wvaio

MNBrett · Joined: 18 Nov 2009 Posts: 12

I can empathize with your situation. Some things that I have learned in dealing with this exact situation:

#1 Triage is a reality in emergency departments. Pressures are on to move people through that space efficiently, sometimes that will mean that doctors will cede some authority to order in their name.

#2 Know your responsibilities. Talk to your department leadership about your concerns. Most likely they are on your side of this. I think you would agree that most exams are ordered correctly, some are off slightly and a few are completely off. That is the way it is where I work anyway. I state what it is that we are going to be taking a picture of, and I ask them where their pain is. Usually this is enough to know if we are on the right track. If I have any questions, I call a triage nurse and have them come reassess the patient. I don't tell them what I think, if I were going to do that then I might as well just change the order. I do tell the patient to tell the nurse what they told me.

#3 If the triage area is unhelpful or uncooperative, know who you should be talking to next. It might be the ER physician, or a charge nurse. I would only escalate issues where clearly there is a problem (wrong side, wrong limb, wrong patient) where you have not been able to clear it up with triage.

Ethically I think that you are right to not x-ray a patient when there is a question of correct exam or redundancy. That said there are some doctors who order hand and wrist and want them both, perhaps even legitimately. In the end if a doctor orders it and you have clarified that there was no mistake in the order, you should do the exam. At that point your institution should have a process in place for you to bring your concerns about that practice to the attention of the people who can decide if it is appropriate.
_________________
B.J. RT(R)
Minneapolis Minnesota

wvaio · Joined: 22 Sep 2007 Posts: 82

Thanks for the post. I think you have afforded me some clarity.

Life has shown me that my perception, is just that, my perception. It is nice to have an outside view to evaluate the validity of my concerns.

You may be right. I will see if I can be a bit more proactive.

Thanks again for the insight.

Wvaio

hjhogle · Posted: Wed Nov 25, 2009 9:47 am Post subject:

I agree wholeheartedly with MNBrett.

As hospitals work to keep costs down, we're all short-staffed, nursing as well as imaging. Which means that RN's with triage experience may be hard to come by. You're left with someone who may be outside their comfort zone who thinks that 'more is better'.