"No, he needs to sign." I'm still wondering about those words - directed to me shortly after I was called to the emergency room when my husband suffered a traumatic injury. Although conscious, he was seriously injured, disoriented, and unable to recall recent events.
My husband was going downhill on his road bike at nearly 40 miles per hour when a front-wheel shimmy, called speed wobble by experienced cyclists, threw him off the bike onto the pavement.
He carries our phone number when he rides alone; it's written on a sticker on the back of his cell phone which he keeps in his bike jersey. When I answered the phone that day, I heard "I'm a police officer; do you know anyone riding a bike today." Right away I knew, my husband was in some type of crash.
I met the paramedics reloading their vehicle at the emergency department. They reported that my husband had been unconscious when they arrived on the scene; but when he woke, their assessment found he could move all 4 limbs. However, they said he was repeating the same question over and over during transport to the hospital. Although relieved that he was awake, I was concerned about his immediate loss of consciousness and altered mental state.
It's tough to see your loved one in pain. Even as health care providers we are unprepared for the bloody scene that surrounds a familiar face.
He knew who I was when I went into the ED room. His skin was oozing from "road rash" in multiple places; but that clearly was the least of his problems. His clavicle was sticking up under his skin, his shoulder drooped, his head was bleeding. Any movement created tremendous pain. He was clearly in distress with an elevated blood pressure and heart rate, which is rare as he's quite fit.
He repeated the same question again and again, "what day is it?" I answered each time. Same question a minute later. I know to just stay mellow and go with his thoughts, so I continued to answer. This cycle continued on and off for the next hour or so during CT scans and x-rays.
Gradually, he started to remember more. He remembered the bike shimmy. The next thing he remembered was being transported in the ambulance. He did not remember what had occurred in between those 2 events: falling off the bike, crashing on the road, the amount of time he was on the road before someone arrived, or the pre-transport work of the paramedics. (Days later these details still elude him; perhaps that's for the best.)
The diagnostic workup was excellent with precise detail and good speed. The neurology team concluded that he had a concussion following the initial loss of consciousness and immediate memory loss. Other findings revealed some broken vertebral processes without cord damage. The orthopedic team shared his x-rays with me, pointing to multiple broken ribs and shoulder ligament damage. Then, the trauma team directed me to the x-ray image of a collapsed lung.
My husband wasn't interested in looking at any of the images, even though they were on the monitor in his room. That's unusual for him; usually he's right on top of visual images and medical data. The specialists were fabulous showing me the CT and x-ray images of his injuries. My husband, who was still uncertain what day it was, thought he was going home.
Next, a trauma team member came in and told my husband that he needed a chest tube for the collapsed lung. The physician sat close to my husband and explained the reason for the procedure, what it was, and the possible side effects. He used a clipboard with a printed form - to point out the details noted on the consent. Without asking for my husband to relate detail back to confirm he understood, the physician gave my husband the pen to sign the consent form.
That surprised me. I moved closer to the physician and asked if he wanted me to sign the consent form as Medical Power of Attorney (MPA). The reply was "no, he is awake and has to be the one to sign."
As a nurse, and a frightened wife, I tried to focus on getting information, advocating for him, and protecting him. I paid attention to every word and watched the details of care. As a grateful family member, I tried not to be intrusive - or interfere with his care. However, my role of nurse and advocate alerted me and encouraged me to seek clarification. Before the chest tube was inserted I asked about the experience of the team member assigned to the task. Who would ensure that the right side was selected? How would his injured shoulder be supported? Would he be pre-medicated? Clearly, but respectfully, I needed to ask these questions; to ally my concerns as a wife and to reinforce what I knew was good care, as a healthcare provider.
The recent head trauma, diagnosis of concussion, and several signs - like repetitive questions, inability to focus on details of his injuries, and his assumption of returning home, made me think my husband was not capable of making an informed decision. Fortunately, as an RN, I was able to consult with the team, see the x-rays, and watch the process unfold. I understood that the chest tube was necessary, so I was comfortable advising my husband to sign.
He doesn't remember much from the ED, or the first few days in the intensive care unit. He has no memory of the discussion about the chest tube insertion or the consent form. He's finally home; his lung healed and he is already biking again.
But, we still wonder. When can a patient with concussion and multiple injuries sign for procedures? Is being "awake" enough of an indicator for informed consent?