Take It Out!
An anxious young woman with painful genital herpes and lower abdominal pain presents to an ER for evaluation. She agrees to have a pelvic examination performed, so you proceed, with your favorite chaperone assisting. You are very suspicious of PID, and since the patient is a nulligravida, you really want to obtain the appropriate STD sample.
She tolerates the insertion of the speculum with difficulty, because of the painful herpetic lesions. As you open the speculum to view the cervix, the patient yells "TAKE IT OUT!!!"
Your chaperone is standing right next to you, ready to hand you the Q-tip for the STD panel (which will take about 2 seconds for you to obtain). Do you:
1) Take out the speculum immediately, skip the STD sample, and order a CT scan instead?
2) Take out the speculum immediately and swab it with the Q-tip, hoping that will be sufficient?
3) Tell the patient, "just a second more," while hurriedly obtaining the cervical swab and then quickly removing the speculum when you are finished?
Just wondering.
Or for nurses, how about this? You are asked by one of your colleagues to try to obtain an IV on a alert and oriented but moderately whiny fibromyalgia patient with diffuse abdominal pain. The patient yells "TAKE IT OUT!!!" just as you get a tiny flash of blood, but you still need to to advance the needle another half a millimeter. Do you:
1) Try to advance the needle and catheter anyway since you are almost finished?
2) Tell the patient to hold on for just a second more while continuing to stab her with a needle?
3) Immediately remove the whole apparatus and notify the physician?
Is there a difference between the two scenarios?
She tolerates the insertion of the speculum with difficulty, because of the painful herpetic lesions. As you open the speculum to view the cervix, the patient yells "TAKE IT OUT!!!"
Your chaperone is standing right next to you, ready to hand you the Q-tip for the STD panel (which will take about 2 seconds for you to obtain). Do you:
1) Take out the speculum immediately, skip the STD sample, and order a CT scan instead?
2) Take out the speculum immediately and swab it with the Q-tip, hoping that will be sufficient?
3) Tell the patient, "just a second more," while hurriedly obtaining the cervical swab and then quickly removing the speculum when you are finished?
Just wondering.
Or for nurses, how about this? You are asked by one of your colleagues to try to obtain an IV on a alert and oriented but moderately whiny fibromyalgia patient with diffuse abdominal pain. The patient yells "TAKE IT OUT!!!" just as you get a tiny flash of blood, but you still need to to advance the needle another half a millimeter. Do you:
1) Try to advance the needle and catheter anyway since you are almost finished?
2) Tell the patient to hold on for just a second more while continuing to stab her with a needle?
3) Immediately remove the whole apparatus and notify the physician?
Is there a difference between the two scenarios?
Labels: ER, medical, needlestick, pelvic exams, perception, surveys
posted by scalpel at 6:53 AM
39 Comments:
Wouldn't you pause, say "The hard part is over, and I'll be finished in 30 seconds, can I continue?" and then follow her instructions at that point...?
She didn't demand that you pause and have a discussion with her. She demanded that you "TAKE IT OUT!!!!"
I guess I would ask her one more time if I can continue. If she still says no, I'll take it out. Afterwards, I'll explain that without being able to finish the procedure we may have limited data and problems coming to the correct diagnosis - just so she knows.
As someone who has been in that circumstance as the patient, I'd say take it out. Although in my case it was not herpes, it was trying to "relax" for the speculum with a bursting bladder after they had rehydrated me with 3 bags of fluid. ER doc said if I took a potty break he would not be able to see me again for 2 hours. VERY painful!
I think different responses would yield different results with each patient.
Typically, I would go the route of "begging" for a couple more seconds to get the IV in (referring to your nurse scenario).
However, most of the time, even if they do give me a couple seconds, and the IV is in, they continue to scream and yell..and often I have to take it out anyway.
Some people, once they mentally decide they don't want that IV, will do anything to get it out.
As for the first scenario, I would "beg" for a couple seconds and hopefully get the procedure done and off to the lab.
On a technical note...I suppose that if a patient says take it out, the legal/ethical response would be to take it out.
I would say, "Just one second" and take the sample. Alternatively, you can just treat her for PID presumptively.
I'm not a doctor, but as a patient, if something hurt really bad I might scream out "take it out" and not really mean it. Especially if it was almost done. I would probably want the doctor to tell me it was almost done and then continue until I gave another verbal "stop" message and if I did I would want him to stop immediately.
I should note that I have had TONS of truly painful medical procedures done and have never screamed anything out, so maybe I am wrong in what I would want done. I am mostly just saying hi and letting you know I lurk here with this comment I guess.
So "no" really means "maybe?" I KNEW IT!
Hehe.
"___Blank more seconds, can I continue?" As you say it, you get the sample. Just so she knows how close she was to being done.
This reminds me of that guy suing because they force checked his rectal tone after having head trauma.
I like what anon 11:01 said talk and get it.
If I were doing it I would try to talk it through the next few seconds.
As a patient who has endured a lot of uncomfortable urological procedures...it never occurred to me that I could actually say stop. The worst thing is having a stent removed in the office. The first urologist I had a few years ago just ripped the stents out. True...it was just seconds....but they were seconds of the most exquisite pain. Having this done like that set me up big time to near phobic about having it done in the office ever again.
But my current urodoc has done it twice uneventfully. The last one was in me for 11 weeks so I am thinking probably also encrusted which I am guessing would make removal more difficult...hence painful. Those other 2 stents were in only 2 weeks.
Current urodoc didn't just rip them out but seemed to go with my breathing, so when I started to peak as pain increased he stopped and then started again. I don't know if that is how he would've done it anyway or if he was in tune with me. Now I am not as afraid of that because of how he handled this painful experience.
As a patient...I think it is important to consider the pt because you are not in their body and don't know how bad they are feeling.
And as A patient I would want you to try to talk me through it but if I said stop-get it out a second time then you should.
Is this common with herpes pts during a vag exam? If it is, perhaps you could warn them ahead of time and tell them to hold on because otherwise you can't give then a complete exam and they might have to end up doing it again.
But I seriously would be tempted to get the swab anyway if I was seconds from it. Then again...those pesky lawsuits!
What did you do?
Interesting questions!
For the speculum - answer #3 -3rd anonymous' way just keep working and talking and then take it out. Yes, there is a difference in the two scenarios because in the IV case, you are probably going to have to do the whole thing again. So, unless the pt. is adamantly refusing all IV therapy (option #3), I would just keep going with the working IV while sweet-talking the pt. (opt. #2) NO FISHING though - it has to be in the vein already.
For the IV, I would take it out and notify the doctor. but then I have a low tolerance for whiny patients who come to the ER and then want to argue and negotiate over every little thing. Did ya wanna be treated or not? And before I bring down the wrath of God, i am referring to the ER abusers who want to be roomed immediately, want this vein (that I can't see or feel) and not that vein, keep asking people for food when they've been told they need to be NPO in case their abdominal pain is an appy or some such thing. Anyone who works in healthcare will tell you that 99.99999% of the people who are actually sick or injured are very greatful for whatever we do for them.
I would think a stern, "ma'am, I know this isn't pleasant but if you relax, it shouldn't hurt as much" would suffice. Even though it may not be the whole truth, it will give you enough time to get the sample.
By the way, I am really, really, really peeved by patients who come into an ER and then complain that procedures hurt. Who ever said that trips to the ER are supposed to be pleasant????? Blah.
* * *
The evil/sarcastic side of me wishes that you would have told her to go back to the moment her sex life began...because the exam is probably not half as painful as that... It's not like she can proclaim her virginity, you know? :)
he he he he. Just kidding, of course.
I've been asked to examine patients after someone else didn't stop and subsequently comment on the situation in the presence of suits and a stenographer - while no medical evidence of injury was found, the experience was eye opening - I'd agree that assessing the patient and talking them through it is a gift and part of being a doctor; however since then, I just take it out and later most ask me to put it back in so meaningful results can be obtained.
First one - stop. definitely. No question. Maybe she was a rape victim, or an abuse victim? Maybe just terrified. Stop even if she wasn't.
Second case - I'd go with the "this will take a two seconds. Do you really want me to stop, because I will if you say so". And then stop if he/she says so.
I would tell her that it is "stuck" and that I need to carefully readjust it before taking it out so it is less painful. While talking about that I would be swabbing my sample.
For the IV I would say fine. Here is a phenergan suppository so stick up your ass. Go home and sip some gatorade.
Forget putting the IV in, being a guy, it hurts like hell when they take it out and remove all that tape. I don't tollerate pain very well but I understand when discomfort is needed to get results but this is coming from a guy who had an upper endoscopy with nothing accept a throat spray. I don't want to say it wasn't uncomfortable but I'm scared to death of medicines that take away your alertness, I hate giving up that control. I think someone who has that kind of sexual history probably doesn't know what is medically best for them anyway.
I have a friend who suffers from herpes.I love her dearly and understand she endures a lot of pain.However she is very whiny and gives her doctor a lot of grief.I have sympathy for the doc on this one. In a case like hers I would say get the sample anyway, because there is going to be pain regardless. Better to get it over with. She should thank the doctor for taking care of her.
If my IV is in the right place, I'll be damned if I yank it out only to have to start it again. I numb with lidocaine first, so few people scream out. If the patient was reasonably rational and agreed to the IV prior to me starting it, I'm not going to take it out just because of histrionics. If it's one of those rare once-a-year times when I'm sticking it in the foot or something then, yep, it's coming out if they're screaming.
For the herpes patient, I think the greater good is to swab and then remove the speculum afterwards as you are explaining that you just need to obtain the swab to make sure she doesn't have any other STDs. It really only does take 15 seconds or whatever. I consider it my job if I'm chaperoning a pelvic to help the patient with this stuff. "Here, hold my hand, he's almost done" or whatever. Most just reach out and grab my hand and before they know it, it's done.
Both scenarios come down to an issue of the patient withdrawing consent for the treatment in progress. They both involve invasive, potentially painful procedures, but the main difference is that things are likely to be more emotive with a vagina, than a vein.
For scenario 1, I won't comment, as I know nothing about the effectiveness of the options presented as they relate to pelvic exams.
For scenario 2: If I alrady had primary flashback on the trocar, I'd go for option 1&2, and tell them hold on, as I was in the vein and was nearly done. However, if there was the danger of the Pt thrashing around and causing a potential needle-stick, I'd be immediately ripping apparatus out for my own safety.
The way I see it, it is important to provide a good amount of foreplay before sticking a PIVC in someone. Tell them that it may hurt, but it won't hurt for long.
Out of interest, what's the reason that these questions have been posed?
Because I value the input of my readers, and I was curious to see if there would be a consensus. I enjoy philosophical discussions like this. Interesting comments, all.
I tend to lean more towards the paternalistic "just another second" camp, myself, but every case is different. Sometimes my reaction depends on how badly I think they need the intervention and how forceful their response is.
Unfortunately, some things we do to patients do hurt, and we can't always make their whole ER experience smothered in fluffy white goodness.
I think you have to abide by the patient's wishes, but you also have to make patients aware of the consequences of their wishes. If the patient says "take it out" then inform them that if you do take it out that you may not be able to determine the cause of their pain or the type of infection they have. While doing so, you can obtain your specimens.
Same with the IV patient. If they say take it out, you can tell the patient that you'll have to stick them again or alternatively that they won't be able to receive the therapy to make them feel better. "By the way - it's in. Do you still want me to take it out?"
When I delivered my first child, a nurse came and shoved her hand "to feel where the baby was". That hurt like crazy (more than the labor pains) and I told her to stop. She did not. Even though I had been in labor for many hours, I still found the strength to raise myself enough to grab her wrist and give her the lock of death. I am sure her blood circulation stopped in that hand! My husband maintains that also, my eyes were glowind red and my head did a 360 degree spin... but I disgress. LOL
When I say that it hurts, I mean it and I will become hostile if you don't react accordingly.
For the IV, I'd say "it's in the vein, give me a second and I can have it secured. Or I can take it out and re-stick you if you'd prefer."
For the speculum, it depends on if the patient has suffered rape or abuse. In the first case, I'd take it out and do alot of teaching before continuing.
If not, I'd talk her through the few seconds to collect the specimen. As the patient is young and this is likely her first exam, the anxiousness is likely to exaggerate the discomfort.
Afterward, I'd explain that because of the infection the exam was more uncomfortable than usual and not to be afraid to have her pap smears because once the PID is cleared up the exams should go easier.
There has been a ton of comments about the gyn exam and sexual assult.
The fact that she had an active STD going on makes me 99% sure the "take it out" was a response to extreme pain. Which...um....kind of diagnosed the PID.
Important to...go fast, say "just one second." etc... When the exam is done, it would be really important to reassure the patient afterwards...
Now....if the exam was going to take another 2 minutes.....yikes
Usually in such a situation I would stop moving, generally that stops whatever it was that was hurting them. That'd give enough time to say 'one moment more and we're done' or such and get their permission to continue. If they still insist then I'd do as they ask.
I've seen some female patients with herpes swelling so bad that they couldn't take a leak and required a leg-bag foley. If your crotchocological region is so swollen you can't piss, there better be some really clear indication for a pelvic exam (+narcotics on board) and a really small speculum being used.
"ER experience smothered in fluffy white goodness"
What? Big Pharm doesn't have a pill for this? I'm shocked.
As for #1, for me, I have never said stop unless I meant stop. I tend to just suck it up, so if I'm flipping out it's because something is super wrong or super painful. Of course you can't know that going in. The only time I had an ER pelvic, I was so sick and they doped me up so well, I did not care.
I have no advice for you. I think it's probably one of those where you have to make a call each time depending on the circumstances and the patient.
M
Why does a patient with fibromyalgia need an IV?
Unless by IV you mean psychologist.
I agree with Nurse K's first comment. The IV should be slid in (you already have the flash) and taped down. Then if the patient wants the IV out, you can have the discussion. The STD sample can probably be obtained from fluids retained on the speculum, but asking if you can just get the swab "because the hard part is over" will likely be tolerated.
Consent was already obtained for both procedures (right?), they're just communicating that it hurts and they don't want you mucking around for too long. Respecting that desire is the goal - not taking them so literally that you don't obtain the IV or fluid sample and thus subject them to repeat performances that will hurt more. My 2 cents.
I'm just hoping that the "moderately whiny" description is automatically added to "fibromyalgia patient". If it is, you need to try doing without dopamine and a heck of other things that moderate pain response. Plus actually do some medical research. FM patients do not have a specific mindset. They do experience more pain from stimuli. Sure, some are whiny. But some doctors are whiny. That doesn't mean I always prefix the word doctors with whiny.
And that last anonymous post, I just wish I could give you FM for a day. You'd be whimpering in the corner.
Well, typo hell, that shouldn't said isn't in the first paragraph
Not all fibromyalgia patients are moderately whiny. Some of them are severely whiny.
Hehe.
If it's just a matter of a couple seconds, then I think you can ethically complete the procedure as you try to reassure the patient and gauge their true response. It's understood that some things are painful and there may be some shouting going on. If you're more than a few seconds away from being done, then I think you still go for the reassurance, but if the patient remains adamant you need to back off. Hard to pin it down in a definition. So much depends on interpersonal cues.
Linz, I actually had FM for one day. It was terrible. Then, of course, it was easy to cure myself, since IT'S NOT A REAL DISEASE.
the two scenarios are completely different.
for the first scenario, i would ask the lady to let me continue a couple of seconds more to obtain a good sample. the cause of the pain is known.
on the second scenario, i would still finish inserting the iv catheter and establish an iv line for any iv meds and stufss. the patient is in pain and the stimulus could be anything.
I used to say, "You're Just Going to Feel a Little Prick" before I realized what I was saying. Then I said "Big Stick" in hopes that the little prick wouldnt live up to the warning. Now I just use lidocaine and dont say anything. For IVs anyway.
I have been in a similar situation, as a patient, but not exactly. I didn't have herpes so I do not know what pain level that made her have. But, I did have invasive cervical cancer.
Very early on in all this, prior to seeing an oncologist, my GYN doc needed to take cervical biopsies. One thing Doc. you should NEVER tell a woman these don't hurt because that is a lie, they do hurt, but are certainly tolerable. At least the first few are. I was told he would take one or two biopsies. But,he knew right away, after doing the thing with all the vinegar, I was in trouble and he needed to take many more than 1-2.
The first 4 were OK. Really not very painful at all. But,after that each one became more painful than the one before. by the time we got to number 10 it was very painful and I told him I wanted him to stop. I was crying and he knew I was in alot of pain, but he told me "Nope, can't do it yet, I still need a few more." At number 12 the nurse felt sorry for me, and she was also getting mad at the doctor. She told me, with the doctor working right beside her..."If you close your knees he will have to stop" He took one more after that and I felt like I just had surgery totally awake. He did tell me that he knew there was a lot of pain involved but that he really did need to get that many biopsies. He also confirmed what was already obvious to me. We were in trouble. I certainly wasn't angry at him and if he would have stopped maybe I would have had to have it all happen again. But, little did I know that was one of the least painful things I would experience, before it was all over.
I don't know if it was right, or proper for him to continue after I asked him to stop or not. But many of things about medicine and illness are painful, sometimes we just have to suck it up.
I've been in that woman's stirrups. I cried for the doctor to take it out and he paused and said, "If I take this out now I will have to go back in again. Can you bear with me for another five seconds? Count backwards with me, 5-4-3. . ." He was out on three.
Doc's Girl-- how bad was your first sex experience? A herpes attack is pretty damned painful and there is nothing pleasant about it.
I also flipped out about a rectal exam. My doctor warned me that he needed to do it and I was like, "Dude, where I come from, vets do that to horses. I'm not a horse and you ain't smart enough to get into vet school!"
He laughed and respectfully removed his gloves and said, "I will respect your wish, however, you have some symptoms that will be a concern if I feel something on your ovaries. If I find out now, treatment will be easier than if you discover a problem and wait six months to tell me about it." I let him do it.
I have a doctor who knows that my mother was an insurance lawyer who sued doctors. He has told me, "When you sign that paper stating that you won't hold me responsible, that puts you with no medical degree in the driver's seat. I am glad for your questions." He explains everything to me before he does it, the possible outcomes and various scenarios and what he expects. He lost his temper with me for not seeing him over some mid cycle bleeding for six months. Great guy-- for painful or long procedures, he tells me beforehand what will happen and how long it will take and counts backwards with me.
I think that educating your patient up front is the main thing. If they know ahead of time, they will be ready.
Post a Comment
<< Home