It was a Tuesday a couple of months ago when I covered the residential addiction facility that I work part time at. Secondary to my full-time position in a major university, I practice primarily on weekends. The full-time nurse practitioner at the facility was on vacation. The medical director works in a methadone program on Tuesdays. I agreed to work that Tuesday.
I am the type of provider who likes to start my day early. I have a built-in alarm clock that was ingrained in me from living with my parents for the first 17 years of my life. My dad was a foreman of painting on luxury yachts. He had to be up early, and he always was up by 6 A.M. each day. His motto was that, if he was up, everyone in the household was up. He worked a lot of overtime on weekends so being up by 6 A.M. or earlier was routine on the vast majority of days each week. If I am up early (which is my norm), then I head to work. Usually, I begin making rounds at the residential addictions treatment facility by 7 A.M. on each day that I cover. My role as a nurse practitioner is on the inpatient side both on the detox unit and the residential care unit. My role includes doing admission history and physical examinations, reviewing laboratory values, seeing patients on the sick call list, writing discharge prescriptions and orders, reviewing complex potential admissions referred by the admissions department staff, and all of the other practice things that physicians and nurse practitioners do. I like to start rounds early as I always like to see the newly admitted patients first to complete their history and physical examinations as well as assess their withdrawal symptoms. I also review any orders that had been called in for the patient as well as add orders for the patient if necessary. It is also a time to reconcile any routine medications that the patient may be taking.
On the Tuesday that I covered, I had three newly admitted patients from the previous evening. I always go to the detoxification unit first. I was waiting for the medical assistant, who always accompanies me during my examination of any patient. As I was waiting at the nursing station, a male patient, aged 26 years, came up to the desk. He stated the following: "Are you the doc that is on today?" I said, "Well sort of, I am the nurse practitioner today who will be seeing all of the patients on my list." He stated, "Well, I am not on your list but I really need to see you now." I questioned him as to what was wrong, and he responded, "I have really bad pain in my stomach." I questioned why he was in treatment as I was not familiar with this patient. He stated that he had abused heroin and was here for treatment. He further informed me that he is oftentimes constipated but that he had taken a laxative and had a bowel movement the previous day. I told him that I would see him first and that he should just wait in the lounge area. I advised him that I had to wait until the medical assistant arrived on the unit. She arrived around 10-15 minutes later.
I always hypothesize what could potentially be wrong with the patient. I learned this skill many years ago as an emergency department (ED) nurse. People would state on the medical record why they were there, and then I would create in my mind what I thought could be wrong with them. In other words, creating differential diagnoses without necessarily seeing the patient. With this particular patient, my hypothesis in my head was that he could be having opioid withdrawal symptoms, as abdominal cramping is very common in these patients. I also thought that he could still be constipated.
Once in the examination room, I had him sit on the examination table and I questioned him further. I asked him where the pain was; when it started; if it was constant; if he had nausea, vomiting, or diarrhea; and if he had been running a fever. I already knew that he had had a bowel movement the previous day. He responded that he did not have any nausea, vomiting, or diarrhea. The pain had started last evening in the center of his abdomen and got progressively more severe. He denied having a fever. I next examined him. His blood pressure was 130/80, heart rate was 88, respiratory rate was 16, and his oral temperature was 98.7. Next, I listened to his heart and lungs, which were normal. I next had him lie back on the examination table. His abdomen was not distended. I auscultated his bowel sounds, which were normal. There were no bruits. His abdomen was soft. I next palpated each quadrant of his abdomen. When I got to his right lower quadrant, he was exquisitely tender in that area with guarding but no rebound tenderness. I reexamined the right lower quadrant, and he was tender at McBurney's point. I advised the patient that he could be brewing an early appendicitis. I explained to him that appendicitis oftentimes starts with vague abdominal pain in different areas of the abdomen and then it becomes more severe and localizes to the right lower quadrant of the abdomen. I advised him that I wanted to send him to the ED as he needed a CAT scan (CT scan) and stat laboratory work. He agreed to this recommendation, and our transport driver drove the patient to the local ED. The charge nurse had called in report to the ED. A few hours later, I received a call that the patient was in the operating room having a laparoscopic appendectomy. The patient was admitted overnight after the procedure and returned to the facility the following day.
PRACTICE PEARL
A colleague of mine, when she was doing her student nurse practitioner clinicals, was advised by her preceptor physician that, if you do not sleep well at night and that you are concerned about the patient, you probably did everything correct as you are still thinking about the patient. My physician preceptor, when I did my student nurse practitioner clinicals, taught me that, if you have concern about a patient and cannot sleep at night, then you probably missed doing something that you have done. I never forget him telling me the following: "I don't care if you send out 20 patients a day to a surgeon or emergency department to rule out appendicitis and none the patients have appendicitis. I will be concerned if you miss sending someone out when you should have because they have appendicitis." He further stated the following: "I want to sleep at night and I do this by knowing that I did everything possible for the patient when I saw them as I may never see them again." And that has been my mantra ever since. I sleep at night.
This case shows me some of the following principles of practice:
1. Do not stereotype: People with substance use disorders have real problems that are not always related to substance abuse.
2. Always listen to the patient. They know their symptoms and their body best.
3. Always show the patient that you really care about them and for them.
4. Always be a patient advocate.
5. I call this one the "guardian angel effect." I am a big believer in guardian angels, and my guardian angel told me that day to get this patient out to the ED. Some call this their "gut feeling." So, whatever it is for you, your guardian angel or your gut-follow it. I like it being my guardian angel.
6. Doing the right thing for patients always gives me that "pat on the back," even if the patient does not say anything. Knowing I did the right thing that day was my instant reward.
7. Working both as an administrator in my full-time job and as a nurse practitioner in my part-time job, well let's just say I get far more "pats on the back" from patients than I ever do as an administrator.