Trusting your gut
As a new practitioner there is always that "second guessing yourself complex" that hovers over you like a black cloud. One benefit that I have had is that I have 6 years or ER nursing experience behind me. It allows me to have that gut feeling that tells you something is not quite right. This feeler system has definitely followed me into urgent care. I do rely on others around me to give me second opinions when I just can't put my finger on what is going on. Sometimes, however, this can give you a false sense of security.
Two weeks ago I took care of a 58-year-old woman who had undergone a right hip replacement a few years earlier. She was out and about power walking when she tripped over uneven pavement, falling forward onto her right side. She came to me 2 days later with persistent right sided groin pain. I decided to x-ray her hip to make sure that her prosthesis was in place and that no fractures were present. Now I will be the first to admit that I still have not grown completely comfortable reading x rays. I have only been at it for 4 months and see new films each and every day. I did note a lucency on the acetabulum but was unsure if this may have been an anomaly due to the previous surgery. I decided to call the radiologist in the reading room to get his opinion. After a brief explanation and discussion, I was told that the reading was negative. I felt relieved and spoke with the patient and explained that I spoke with radiology to review the case. I advised her to follow up with her ortho and to use her crutch for assisted weight bearing.
The next day I received a call from radiology about the same patient. Alas, that provider saw a concerning lucency on the film and asked that I bring the patient in for additional films including an oblique view. My heart sank a little. I called the patient back, we completed the oblique view and sure enough there was an obvious fracture on the view. I was relieved to hear that the oblique view is not one normally ordered. In the end the patient still followed up with ortho and it did not change the plan of care. I discussed it with my collaborating doctor. I knew that I had followed correct procedures and that I had handled the interaction with the patient well; the physician agreed.
A lot of what we do in urgent care is trying to take in all that the patient provides us in a very short time. Yes, most of what we decide to do is based on out assessments, but there are times when our senses give us additional information.
This was what I saw about a month ago when a 49-year-old patient came in complaining of nausea and vomiting for one month. He had a multitude of comorbid conditions including liver issues, obesity and GERD. He was due to have an endoscopy in 4 days and his current PCP was unable to see him in the office that week. I did his exam, which was benign, and told him that there were limited things we could do in our setting. I offered to complete some basic blood work on him and to order some medications for nausea and urged him to go through with his endoscopy, since it would mostly likely give reasoning behind his symptoms. The next shift that I worked, I was checking labs and noted that his BUN and creatinine came back at a dangerous level. I quickly looked him up in the hospital system and saw that he had been admitted for renal failure and discharge. I quickly called him to follow up and see how he was doing. He immediately said "Thank you so much, you saved my life". The lab had called him that evening and he promptly went to the ER. Those are the moments when you make decisions based on gut feelings and the payoff is immense.
We as practitioners new and old need to trust our education, our experience and of course, our gut!!!