Premature Closure – Not Fighting Back

Within my short time as a nurse there have been few cases that have truly stuck with me…but one in particular ate away at every ounce of my moral conscious…encompassing my thoughts for more than three months after my brief interaction with the patient. And the worst part was that for the longest time I thought I was one of the only nurses who did not stand up for what was right based on a gut feeling.

A 24 yr old male presented with acute confusion and fevers; otherwise healthy. The doctor…one whom was new to our unit but with many years of practice…immediately dismissed the case as being polysubstance abuse with instruction to re-hydrate, obtain a toxicology screen, and discharge. My gut told me otherwise, but I deferred and followed the idea of poly-substance abuse…until the tox came back negative. At that point I tried to advocate…convinced the doctor to order a head CT…just in case. Result – Negative. At this point I had nothing to stand on by my gut feeling, so again I deferred to the doctor’s diagnosis of poly-substance abuse (he was convinced it was undetectable synthetic drugs) and I discharged the patient. I remember looking at his friends and saying, “If I were you I might stop somewhere else on the way home and get another opinion. Otherwise, keep a really good eye on him”. And thank goodness they did.

The patient returned to our department not even 30 minutes later and was treated by a physician and nurse combination that I have complete faith in. Within 2 hours he had seized and was admitted to the ICU, later experiencing status seizures.

I later found out that he was transferred to a neuro-ICU at another facility and was diagnosed with anti-NMDA receptor encephalitis. Luckily this story has a positive ending and eventually he recovered and was sent home with his parents. But since the minute I discharged him I felt my moral compass doing somersaults.

Today I finally found closure in the fact that I’m not the only one who has acted based on decisions of those around me. Premature closure not only affects those making the decisions, but can cloud the judgement of those involved in the patient’s care. Additionally, such quick, headstrong judgments can also make it difficult for others to stand up and discuss concerns. It acts as a barrier to effective communication within the team, as well as places the patient at risk for complications, as seen in Lewis Blackman’s story. If we are able to break down the barriers to communication and decrease the incidence of premature closure there is greater likelihood that patients can be treated for the right diagnosis in a more appropriate time frame.