Do you think this NP would have given appropriate treatment if she knew an MI was the issue ? I am assuming this was a NPrimary care clinic to Er hand off ?
What, besides a lack of knowledge and training, derailed her ? Did the EKG Machine call it right heart strain with LV hypokinesis, consider new onset CHF or something ? Anchoring bias seems to be the path to Perdition in these situations.
And sadly if he seeks legal advice about a lawsuit he will be advised that since he wasn’t actually harmed and the mistake was caught it isn’t malpractice, just a mistake. Ask me how I know!
That author has a great podcast as well. She recently did a three part episode with an NP that’s tried really hard to institute changes bc of the lack of education and clinic hours he sees with NP now. I’m sure you can guess he got a lot of push back from their governing bodies.
Ask NP who supervising physician is because you need it for charting of the event. They probably won’t think twice about it and tell you.
Assuming they know who the physician is.
It's supposed to be on record at the hospital. You could probably ask the house supervisor at your hospital to reach out to the one at the off-site hospital and get that info for you. This should also be reported to the hospital morbidity and mortality committee.
Well. At least she called someone who knew what to do. Sucks it was you though. Hope the patient pulls through.
Edit: I re-read that. It sucks you had to be the one to deal with it. Glad you did though.
Yea that’s crazy, wtf!?! How did they hire this person, honestly the BRN may take action if something dreadful occurred but you would have better luck talking to the admin
Why do you have to walk her through anything? I’m Too lazy to look at your post history, presumably you’re an md? You have no patient physician relationship established. You can accept transfer and that’s it. Let the patient die while they’re waiting for an ambulance. No medical Director? No supervising physician? Then who gives a fuck, let ‘em be independent.
Hear me out. Maybe the patient has a SAH, those are associated with EKG changes. Tachycardia, that could be demand ischemia raising the troponin. Why are you managing anything Based n a nurse eval before youve evaluated the pt? Do you see where I’m coming from?
Do you really give medical advice to a patient that you’ve never seen? Like is this how that works? I don’t want the patient to die either, but perhaps that needs to be the consequence Of independent nurse care.
We appreciate your submission but the post or comment you made has been flagged as being not on topic or does not align with the core goals of this subreddit. We hope you continue to contribute!
I mean….I don’t disagree with your point here, but this is a bit callous, yes? Also an MD and also have accepted some disaster transfers because, at the end of the day, a call to transfer is essentially a recognition that “I can’t handle this” and they’re usually right.
It is terribly callous and it kind of hurts to write it. As an anesthesiologist I’ve received utter dumpster fire transfers who roll from a helicopter into the operating room with no paperwork. But I’m not responsible for managing them before they come to me, and I really hope that you aren’t either. Because you don’t have a full picture. You don’t have a physician patient relationship established. you should not have any medico-legal liability until the patient arrives at your hospital.
Like sure maybe that seems like a straightforward MI, but if it’s an intracranial bleed, you just heparinized somebody and killed all their platelets with a gram of aspirin based on what a nurse told you. Honestly, I don’t know your Workflow, but I really hope you arent managing anything remotely based on Nurse Assessment.
Uh. Idk. I've worked in several tertiary care centers in the Midwest with catchment areas several hundred miles in diameter. I have been on many multidisciplinary transfer calls, and it is quite common for someone on the receiving team to ask for treatments on route. Sounds like if a SAH was really a concern, a CT could have been requested prior to transfer. MI cases needing intervention are started on anticoagulation all the time on route in the cath lab.
Do you mind if I ask you your role? And number two I actually do not know what the workflow is when someone accepts a transfer. I didnt know if the accepting MD routinely tell them to start various therapies before they show up. It’s not in my wheelhouse. It sounds like a lot of liability. We record all calls For transfer so at least I guess that somewhat protects the receiving physicians.
I’ve been in the OR when Trauma has accepted transfers and it’s usually typically a very brief conversation. Keep in mind obviously the Trauma surgeon is scrubbed at this point and not at a computer. Could you help me understand the process a little better?
I was a hospitalist in ICU step downs, Cardiac centers and just medical floors for 15 years.
Got burnt out. Went into private practice. Back to hospitals durring covid while also doing private practice. Currently spending my time at a DPC solo practice and loving it.
Respect to you as well. You guys were like the marines of the medical wards. Every time we have an emergent intubation it was like watching a solder jump on a grenade to save everyone else. Crazy times. Thanks for your service.
I’m PCCM I’m also somewhat responsible for the safety of a patient when I accept a transfer. I’ve definitely requested patients be intubated or have interventions done prior to transfer if I think it’s unsafe. At the same time I recognize I’m not seeing the patient so you need to have some trust. I think it’s a little more concerning when the person in this situation is calling and doesn’t know what they are doing.
Because women can have more atypical MI symptoms. Evidently not a well thought out or well expressed comment but generally it's pretty hard to miss that these are typical MI symptoms? You must be some kind of asshole.
It might start becoming negligent to be practicing without supervision when you aren’t qualified to do so. We broke ground with Dr Death’s trial. I just don’t think cases like OP’s would qualify. It would be an NP who keeps going for solo shifts as he blunders through fatalities.
This - I work with rural hospitals and at a small community hospital. NPs and PAs frequently staff ED and MS/ICU. Patients don’t have a choice when the hospital sets it up like this.
I love the line people say “I like seeing my NP as a PCP, he/she spends a lot more time with me.” Completely clueless that they spend more time in the room due to inefficiency which is almost always secondary to lack of medical knowledge. Spend a half hour evaluating strep pharyngitis and still refer to ENT.
If a nurse has the same privileges as a doctor, they have the same responsibility and should be governed by the same board. And yet I never hear APRNs advocating for that. 🤔
Well, how can you expect that angel of a nurse working as a nurse practitioner (who went to school while working as a nurse and being a momma) to identify ACS if the EKG doesn’t output a read of “STEMI”?
“But what about the medical board” mfs when the nursing board lets this slide again. Atleast the medical board CAN take action against physicians, i have never seen or heard of an NP being reprimanded for indefensible care by the nursing board. The medical board for physicians is slow and bad, but it still has a history of protecting patients, even if it takes indefensibly long.
Independent practice midlevels should be judged by the same standards as doctors. It shouldnt matter what your training is if your working the same job with no supervision. If you make a mistake that is below the level of a graduated physician while choosing to work with no supervision you should have to have the same consequences that a physician would face.
This simple distinction is why no patient should EVER see an independent NP (or any midlevel if im being honest). When they inevitably fuck up, you have no legal recourse. The court will view them as “just a nurse” and the nursing board wont do anything. You will be left with a dead loved one or harmed/dead yourself and it will be meaningless. The inept midlevel continues to practice medicine without a medical license without even receiving a slap on the wrist, or corrective training to prevent the same mistake again
The key is articulating it in a way that is objective, but doesn’t give the impression you’re attacking the midlevel.
“This is not the standard of care and a mistake was clearly made. However, NP/PA training is nowhere near as long or rigorous as a physician’s so things like this will happen. They are doing the best they can.”
I do some variation of this 2-10 times a day.
Paramedic here. Oh boy do I have a story for this one. Got called to an urgent care clinic for weakness & dizziness (62 yof). Can’t quite remember pt’s history but do remember they were prescribed a lot of cardiac meds. So we bring in the lifepak and put the pt on the monitor and she’s got a 3rd degree block w/blood pressure like 60 over dead. The NP argues with me saying it’s “basically normal sinus except the low rate”. I’m sorry WHAT?! Not only am I a medic with half the training and not even a quarter of the pay, I was a new medic at that. HOW DO YOU NOT KNOW WHAT A HEART BLOCK LOOKS LIKE?! That’s one of the most basic rhythms to identify. Then I had to explain to another one that you can, in fact have a PE with normal breath sounds. I shouldn’t have to tell you these things.
My bad, I’m on hour number 37 of being awake. Our minimum is about 500 but you keep going until you’ve got the required intubations, 12 lead interpretation, assessments etc
The medical directors that place these NPs in these positions need to be reminded that if one never was exposed to an area through experiance as an RN, additional education is needed or it is not the best environment for that NP.
Any ED RN would pick up those variables as a MI then take appropriate action.
Without additional details this gives the impression it’s a critical access facility or a rural one (not sure if they are the same) in which case there may not have been a physician readily available. In that sense, at least they did the right thing.
NPs are not physicians however a properly trained one with the proper experience can be a bridge (NOT A REPLACEMENT) to physician care.
Some would argue against having the NP at all, in which case you would have an ED staffed with only RNs (can happen) who would still call a physician for next steps.
Close the facility and access is wiped. Catch 22
No. Not any ED RN would pick this up.
The job of a doctor should be done by a doctor. I know it’s a novel concept but something that the entire field of nursing cannot seem to comprehend.
A seasoned ED nurse can pick up an MI based on presentation and the work up. They have increased exposure to these scenarios compared to other nurses. I’m not arguing it’s better than a physician but it is better than nothing because at least the patient has a higher likelihood for survival. That’s why nurses are placed in triage, to detect really sick patients and present to the medical staff for evaluation and direction.
The certification in emergency nursing demands that an ED nurse can read the ever living shit out of an EKG, to include reciprocal changes and all electrical indications of metabolic/cardiovascular pathology. So does the critical care nurse cert. Nobody is trying to step on the toes of physicians but damn-I don’t just take the top of the EKG and roll with it…smh
She's not wrong about the new onset heart failure though. Lmao. Too bad she has no idea about pathophysiology. Yikes
She had no idea he was having an Mi, I had to walk her through it It was ridiculous
Hilariously scary. That could be any one of us in the future...
Do you think this NP would have given appropriate treatment if she knew an MI was the issue ? I am assuming this was a NPrimary care clinic to Er hand off ? What, besides a lack of knowledge and training, derailed her ? Did the EKG Machine call it right heart strain with LV hypokinesis, consider new onset CHF or something ? Anchoring bias seems to be the path to Perdition in these situations.
Nope, it was an fnp working by herself at an er
Cool. There is a book about that. Patients at risk. Similar scenario the patient dies. This is f'd up.
Best book ever
Yeah, my guy ended up on balloon pump during his emergent cath But... he pulled through with a staged cath
And sadly if he seeks legal advice about a lawsuit he will be advised that since he wasn’t actually harmed and the mistake was caught it isn’t malpractice, just a mistake. Ask me how I know!
I mean, harm is one of the components of a Medmal claim, and the harm must be attributable to the error. You can’t sue because someone made a mistake.
Good save!
That author has a great podcast as well. She recently did a three part episode with an NP that’s tried really hard to institute changes bc of the lack of education and clinic hours he sees with NP now. I’m sure you can guess he got a lot of push back from their governing bodies.
Omg! She was doing er with no supervision?
Remote, off site But yeah she didn't have anyone else in the building
should report the supervising physician to their medical board
It’s the only way physicians will stop supervising midlevels.
I couldn't figure out how to find out who that was
Ask NP who supervising physician is because you need it for charting of the event. They probably won’t think twice about it and tell you. Assuming they know who the physician is.
It's supposed to be on record at the hospital. You could probably ask the house supervisor at your hospital to reach out to the one at the off-site hospital and get that info for you. This should also be reported to the hospital morbidity and mortality committee.
This is horrifying!
That is beyond fucked.
But also, not surprising
She should unemploy herself from the ER.
And collect unemployment
Well. At least she called someone who knew what to do. Sucks it was you though. Hope the patient pulls through. Edit: I re-read that. It sucks you had to be the one to deal with it. Glad you did though.
Yea that’s crazy, wtf!?! How did they hire this person, honestly the BRN may take action if something dreadful occurred but you would have better luck talking to the admin
Board of nursing closed the file with no evidence of wrong doing She is free and clear
“What did the ekg machine say, did that derail her” 😂
It's funny because it's true. 😅🤣😂
Oh god youre right lol
Yes, he's is
Why do you have to walk her through anything? I’m Too lazy to look at your post history, presumably you’re an md? You have no patient physician relationship established. You can accept transfer and that’s it. Let the patient die while they’re waiting for an ambulance. No medical Director? No supervising physician? Then who gives a fuck, let ‘em be independent.
Because I didn't want the patient to die Because she called for a transfer
Hear me out. Maybe the patient has a SAH, those are associated with EKG changes. Tachycardia, that could be demand ischemia raising the troponin. Why are you managing anything Based n a nurse eval before youve evaluated the pt? Do you see where I’m coming from?
Do you really give medical advice to a patient that you’ve never seen? Like is this how that works? I don’t want the patient to die either, but perhaps that needs to be the consequence Of independent nurse care.
Bruh that’s a human life. They didn’t sign up for your martyr bullshit. You need to re evaluate.
It’s a human life and that’s why they need a physician.
Yes. But allowing someone to die is not a necessary “consequence”
It kind of is, like what’s unclear? When you put untrained dumbasses in practice independently, people die. This is not news.
That’s why someone steps in when they can to stop that from happening. At least an ethical person.
I’m guessing you never been sued over Nursing or midlevel incompetence. GO BE INDEPENDENT. MAKE THE BUCK STOP WITH YOU.
[удалено]
We appreciate your submission but the post or comment you made has been flagged as being not on topic or does not align with the core goals of this subreddit. We hope you continue to contribute!
I mean….I don’t disagree with your point here, but this is a bit callous, yes? Also an MD and also have accepted some disaster transfers because, at the end of the day, a call to transfer is essentially a recognition that “I can’t handle this” and they’re usually right.
It is terribly callous and it kind of hurts to write it. As an anesthesiologist I’ve received utter dumpster fire transfers who roll from a helicopter into the operating room with no paperwork. But I’m not responsible for managing them before they come to me, and I really hope that you aren’t either. Because you don’t have a full picture. You don’t have a physician patient relationship established. you should not have any medico-legal liability until the patient arrives at your hospital. Like sure maybe that seems like a straightforward MI, but if it’s an intracranial bleed, you just heparinized somebody and killed all their platelets with a gram of aspirin based on what a nurse told you. Honestly, I don’t know your Workflow, but I really hope you arent managing anything remotely based on Nurse Assessment.
Uh. Idk. I've worked in several tertiary care centers in the Midwest with catchment areas several hundred miles in diameter. I have been on many multidisciplinary transfer calls, and it is quite common for someone on the receiving team to ask for treatments on route. Sounds like if a SAH was really a concern, a CT could have been requested prior to transfer. MI cases needing intervention are started on anticoagulation all the time on route in the cath lab.
Do you mind if I ask you your role? And number two I actually do not know what the workflow is when someone accepts a transfer. I didnt know if the accepting MD routinely tell them to start various therapies before they show up. It’s not in my wheelhouse. It sounds like a lot of liability. We record all calls For transfer so at least I guess that somewhat protects the receiving physicians. I’ve been in the OR when Trauma has accepted transfers and it’s usually typically a very brief conversation. Keep in mind obviously the Trauma surgeon is scrubbed at this point and not at a computer. Could you help me understand the process a little better?
I was a hospitalist in ICU step downs, Cardiac centers and just medical floors for 15 years. Got burnt out. Went into private practice. Back to hospitals durring covid while also doing private practice. Currently spending my time at a DPC solo practice and loving it.
That’s fucking awesome.covid was horrific. We lost a lot of good anesthesiologists. Mad respect to you.
Respect to you as well. You guys were like the marines of the medical wards. Every time we have an emergent intubation it was like watching a solder jump on a grenade to save everyone else. Crazy times. Thanks for your service.
I’m PCCM I’m also somewhat responsible for the safety of a patient when I accept a transfer. I’ve definitely requested patients be intubated or have interventions done prior to transfer if I think it’s unsafe. At the same time I recognize I’m not seeing the patient so you need to have some trust. I think it’s a little more concerning when the person in this situation is calling and doesn’t know what they are doing.
Let the patient die! That’ll teach ‘em to get care from an NP! Jesus Christ, you have zero business caring for patients.
No. It’ll teach legislators and hospitals to not continue hiring NPs. Safety guidelines in America are written in blood.
It was a male? That's even worse...
Why?
WTF kind of comment is that?
Because women can have more atypical MI symptoms. Evidently not a well thought out or well expressed comment but generally it's pretty hard to miss that these are typical MI symptoms? You must be some kind of asshole.
Wow, time to report nurse "practitioners" to the District attorney because we all know the Nurse "Boards" are not going to do shit.
Yeah. I'm at a loss about what to do
Yeah. I'm at a loss about what to do
Totally inappropriate - was there anyone with the patient? Could they sue? Could you tell them to sue. This is egregious.
Unfortunately it’s not a crime to be fucking incompetent
It might start becoming negligent to be practicing without supervision when you aren’t qualified to do so. We broke ground with Dr Death’s trial. I just don’t think cases like OP’s would qualify. It would be an NP who keeps going for solo shifts as he blunders through fatalities.
People literally dying out here just for “I prefer a nurse practitioner because I feel more heard”
Unfortunately this will need to happen a lot more before anything changes. I don’t want it to happen, but it’s truly the only way.
I doubt this patient preferred an NP. He likely walked in to his local ER and that was his only option.
This - I work with rural hospitals and at a small community hospital. NPs and PAs frequently staff ED and MS/ICU. Patients don’t have a choice when the hospital sets it up like this.
To which I always respond they spend more time listening because they don’t know what to ask.
I love the line people say “I like seeing my NP as a PCP, he/she spends a lot more time with me.” Completely clueless that they spend more time in the room due to inefficiency which is almost always secondary to lack of medical knowledge. Spend a half hour evaluating strep pharyngitis and still refer to ENT.
If a nurse has the same privileges as a doctor, they have the same responsibility and should be governed by the same board. And yet I never hear APRNs advocating for that. 🤔
That’s terrifying! I’m a retail pharmacist and I can recognize this is an MI.
EKG changes with ST elevations??? I've been an RN for 20 years and that sounded like an obvious MI. Good lord 🤦🏻♀️
But did the print out say MI?
Well, how can you expect that angel of a nurse working as a nurse practitioner (who went to school while working as a nurse and being a momma) to identify ACS if the EKG doesn’t output a read of “STEMI”?
I think the average uneducated person would be able to recognize that’s a heart attack.
“But what about the medical board” mfs when the nursing board lets this slide again. Atleast the medical board CAN take action against physicians, i have never seen or heard of an NP being reprimanded for indefensible care by the nursing board. The medical board for physicians is slow and bad, but it still has a history of protecting patients, even if it takes indefensibly long. Independent practice midlevels should be judged by the same standards as doctors. It shouldnt matter what your training is if your working the same job with no supervision. If you make a mistake that is below the level of a graduated physician while choosing to work with no supervision you should have to have the same consequences that a physician would face. This simple distinction is why no patient should EVER see an independent NP (or any midlevel if im being honest). When they inevitably fuck up, you have no legal recourse. The court will view them as “just a nurse” and the nursing board wont do anything. You will be left with a dead loved one or harmed/dead yourself and it will be meaningless. The inept midlevel continues to practice medicine without a medical license without even receiving a slap on the wrist, or corrective training to prevent the same mistake again
So she ordered an EKG and troponin presumably to rule out MI and then didn’t connect the dots when both were abnormal? What the fuck?
I’m an M4 who has lost all medical knowledge (/s), but not meeting criteria meaning the elevations weren’t >1mm or weren’t contiguous?
they weren't 1mm
lol tell the family.
The key is articulating it in a way that is objective, but doesn’t give the impression you’re attacking the midlevel. “This is not the standard of care and a mistake was clearly made. However, NP/PA training is nowhere near as long or rigorous as a physician’s so things like this will happen. They are doing the best they can.” I do some variation of this 2-10 times a day.
Very clever
NSTEMI? What did the 12-lead show if no ST elevation? Any complete blocks or BBB?
St elevations and reciprocal depressions Not meeting criteria
Paramedic here. Oh boy do I have a story for this one. Got called to an urgent care clinic for weakness & dizziness (62 yof). Can’t quite remember pt’s history but do remember they were prescribed a lot of cardiac meds. So we bring in the lifepak and put the pt on the monitor and she’s got a 3rd degree block w/blood pressure like 60 over dead. The NP argues with me saying it’s “basically normal sinus except the low rate”. I’m sorry WHAT?! Not only am I a medic with half the training and not even a quarter of the pay, I was a new medic at that. HOW DO YOU NOT KNOW WHAT A HEART BLOCK LOOKS LIKE?! That’s one of the most basic rhythms to identify. Then I had to explain to another one that you can, in fact have a PE with normal breath sounds. I shouldn’t have to tell you these things.
NP NEED 500 hours clinical training How many did you get as a paramedic
I got 800 just in school. What’s your point?
You did more training than the NP
My bad, I’m on hour number 37 of being awake. Our minimum is about 500 but you keep going until you’ve got the required intubations, 12 lead interpretation, assessments etc
The medical directors that place these NPs in these positions need to be reminded that if one never was exposed to an area through experiance as an RN, additional education is needed or it is not the best environment for that NP. Any ED RN would pick up those variables as a MI then take appropriate action. Without additional details this gives the impression it’s a critical access facility or a rural one (not sure if they are the same) in which case there may not have been a physician readily available. In that sense, at least they did the right thing. NPs are not physicians however a properly trained one with the proper experience can be a bridge (NOT A REPLACEMENT) to physician care. Some would argue against having the NP at all, in which case you would have an ED staffed with only RNs (can happen) who would still call a physician for next steps. Close the facility and access is wiped. Catch 22
No. Not any ED RN would pick this up. The job of a doctor should be done by a doctor. I know it’s a novel concept but something that the entire field of nursing cannot seem to comprehend.
A seasoned ED nurse can pick up an MI based on presentation and the work up. They have increased exposure to these scenarios compared to other nurses. I’m not arguing it’s better than a physician but it is better than nothing because at least the patient has a higher likelihood for survival. That’s why nurses are placed in triage, to detect really sick patients and present to the medical staff for evaluation and direction.
The certification in emergency nursing demands that an ED nurse can read the ever living shit out of an EKG, to include reciprocal changes and all electrical indications of metabolic/cardiovascular pathology. So does the critical care nurse cert. Nobody is trying to step on the toes of physicians but damn-I don’t just take the top of the EKG and roll with it…smh
💯💯💯💯💯 💯💯💯💯💯
Yeah She was an fnp So... she didn't have to do that
However, FNPs can absolutely get emergency certification.