A front page news article today describes a situation where a lady presented to an Emergency Department in Melbourne with a “threatened and incomplete miscarriage” at 10 to 12 weeks.
Unfortunately for this lady, she miscarried the foetus into the waiting room toilets while waiting for medical r/v.
The story is extremely damning of the hospital involved, check out the title of the story: “Hospital shame as (patient) miscarries baby in toilet“
This story has brought a whole host of opinions out of the woodwork, and a common theme is absolute and utter disbelief by the public that “this sort of thing can happen in this day and age!”.
And so, some reflections:
Firstly, I’d like to throw in a disclaimer – this article is written by a health care professional for reading by other health care professionals – it is not intended to belittle or minimise the family’s loss.
Having said that, I’d like to suggest that any kind of PV spotting / bleeding at triage is a tricky situation.
- Often in fact, it does not rank very highly as a medical emergency. If the bleeding or spotting is minimal, and in particular if the person’s vitals are all stable, they might rank fairly low on the triage scale.
- Unfortunately, it ranks extremely highly on people’s emotional-meters, and members of the public often feel that any kind of PV spotting or bleeding in pregnancy should warrant an immediate medical team review, ushering of the patient straight through to acute cubes, and some kind of immediate treatment.
- The reality is that in the vast, vast majority of cases, the patient’s life is not at risk. It’s not a life and death situation for the mother. And for the child? As harsh as this sounds, what is going to happen naturally at this point is pretty much unpreventable. The person might miscarriage, they might not. Getting the person in sooner or later is unlikely to change the inevitable.
And so, there’s often this perception that “woah, the hospital let this poor mother sit in a waiting room and miscarry without doing anything about it!”.
Let me ask this: what would you like done about it?
If this story causes absolute disgust amongst the general public, as suggested in some of the reader’s comments, what is it in fact that you would like done differently?
I’ve had this discussion with members of the public before and have been cut down as being heartless and unsympathetic, but let me assure you that I am neither. I am a realist, and the reality is that although the situation is important to the person involved, it is hard enough getting people in to acute beds with really serious stuff, particularly when faced with the ever problematic situation of in-patients taking up acute emergency beds in the public system.
Despite all this, I always try to get any potential miscarriage into some kind of bed, even a corridored one to try and avoid what happened in this story, but this is for humane reasons more than anything else. It can be difficult to do this, particularly on busy shifts, and especially when the mother is 100% stable. It’s impossible to predict which ones will progress to miscarriage, particularly when bleeding is light.
When do we Hurry Things Up?
The situation is always escalated if there’s any element of danger – if the bleeding is really heavy for instance, if the patient is symptomatic in any way (ie light-headed, dizzy etc), or if they are hypotensive. Any patient in this kind of situation ranks higher on the triage scale and generally speaking gets into a bed much quicker.
What’s interesting with the Melbourne story is that the hospital have responded by basically saying “We’re shocked that this has happened”
Staff are being interviewed, protocols are being reviewed, people are putting on grave faces and nodding to each other.
To be frank however, this is not the first time something like this has happened. Just google “miscarriage in waiting room” and you will be amazed at how common this is. And how outraged the public is each time. And how there are promises for investigations, enquiries, interviews.
Grave faces.
The situation is unfortunate, yet it has also been highly sensationalised, playing on the fact that it’s a highly emotive situation.
What can we learn from it all? I agree the waiting room is probably not the best place for pregnant mothers with any form of PV bleeding. The really tricky thing is identifying which ones could do with a bed sooner rather than later, particularly when the department is pumping.
Let me ask you this: is there any good place to have a miscarriage?
I’d love to hear people’s thoughts on this subject, please comment below if you feel like it. And I’ll leave you with some of the comments by members of the public as found at the bottom of this original story. You probably won’t be surprised to find that once again there’s a wide perception by many members of the public that those nasty, incompetent, uneducated nurses are the ones truly responsible for this horrible situation, and are in fact the source of all problems in emergency departments.
Comments by the general public on the original story:
It’s not enough for the unit manager to apologize, each individual that was involved need to apologize personally and to accept personal responsibility. Saying you are just following procedure is the same as a soldier claiming they just followed orders. It’s no excuse. I had a similar experience of being referred by my doctor. He rang ahead and gave me a letter and it took 4 hours to get seen at a so called emergency department.
Australian state and central govt should hang its head in shame ( if there is any left, that is)…….
The triage system is a failure with nurses making decisions that they are not properly qualified to make. Doctors are the only ones who should be working triage. Send two doctors into the waiting rooms to assess patients as they arrive instead of making people wait hours on end. I’m sure you would see minor cases delt with on the spot and those that need an emergency bed be placed straight away. The biggest problem is that once the beds are full the doctors wander around aimlessly because they can’t see anymore patients until a bed becomes available. If you have someone taking up a bed because of a minor issue that could have been delt with in the waiting area by a triage doctor then the hospital is wasting resources that could have gone to someone in greater need of a bed and full medical attention. I feel for this family. Nobody should go through this. To experience the joy of giving life then having that life ripped away from you is horrific to say the least.
What professional neglect? Yeah its sad BUT she was given a triage category in the ED based on the potential severity of the condition and risk. Patients with life threatening conditions eg heart attacks and strokes are seen before potential miscarriage because you can do more to safe the lives of those patients rather than a miscarriage. If she got seen by a doctor sooner just to be told, “yeah your having a miscarriage. Dont flush the toilet so we can send it to pathology” then think about it – your mother might be dead because nobody gave oxygen and did an ECG to find out she was having a life threatening arrhythmia. Its all priorities in the ED. Such is life.
It’s a difficult situation and one that isn’t easy to address. As sad as it is, early miscarriages are usually an entirely natural process. I was fortunate when I presented to Emergency that they were able to find me somewhere private. It turned out my pregnancy was ectopic but I still had to wait 48 hours for ‘emergency’ surgery. I understood there were more urgent cases – shootings, stabbings, twisted bowels, etc. You can’t send these women to maternity because the birth of a live child is more important and they wouldn’t want to be in that environment (new mums with new bubs) anyway. I do feel sorry for this woman but on the flip-side, how would you feel if your child was suffering a severe asthma attack or a head injury and not seen straight away because staff were busy dealing with an early miscarriage?
I can’t even describe how annoying it is to go to the emergency room and have a bitter nurse on the other side of the glass looking you up and down and deciding whether they think you’re unwell or injured enough to be put above someone else. I have got into full on arguements with some nurses… strangely enough I kept getting put further and further down the list to get seen (or those I am with) after these occasions… REAL FULLY QUALIFIED DOCTORS SHOULD BE QUESTIONING AND OVERSEEING THIS, not some nurses who hate their jobs and feel like buffering their weight around when panicked individuals come into the emergency department asking for help or to be seen.
This is tragic, no doubt. The Triage nurse is totally to blame, she is fully trained to be able to recognise this for the urgent situation that it is, she failed dismally. The GP had let them know she was on her way, and still they failed. No use putting politics into this. Do you blame the State Labor government or do you blame the Liberal Federal government that completely underfunded health for so many years?? They’ve all screwed it up.. Triage nurse is to blame here, plain and clear.
Your thoughts?
As a nurse I agree with you wholeheartedly, yes sad for the family but even being seen immediately would not have changed the outcome and to make nurses look neglectful/uncaring/incompetent makes my blood boil.
Unfortunately this will not be the last time it will hit the news.
I am an emergency nurse, a mother and a person with a history of 12 miscarriages, one whilst carrying my second son.
I have miscarried at home, at a friends home, in the car, in the back yard and at work in the emergency department.
There is no good place to have a miscarriage. And the simple fact is, there is almost NOTHING that can be done to prevent it. The priority is the mothers condition and if it is stable, then we as emergency staff need to move on to the next big thing.
When I triage pregnant women with PV bleeding, I gently explain that I will try to get them a bed as soon as possible (as it is our facility’s policy for that) but that they should realise that:
1. Many people ave PV bleeding and go on to have healthy pregnancies and babies.
2. That there is little medically we can do to prevent what may or may not be happening,
3. Our priority is the mums health.
4. I then explain what interventions we may do for her.
I think more than anything, the publics expectation of what medicine can do, and how it should be delivered is skewed, not just in the cases of threatened miscarriage, but in many things – the head injuries sent home, the did not waits that deteriorated and were rushed back etc.
Be kind to us, we are doing a job that many of teh public would not and could not do, in conditions that many people would work in, for pay that does not denote the value of what we do and who we are.
Hug a nurse instead.
I dislike how the general public tends to blame the nurses for everything. I doubt a fully fledged doctor would be able to make an empty bed appear and let the woman in when there are cardiac arrests and people with massive traumas bleeding in the ambulance bay. I think the general public needs to be educated through TV ads that this is how emergency department works and so please understand before you start insulting people who are only trying to do their job. I have worked in emergency as a student and have seen first hand how the general public acts towards the staff and is absolutely horrified. Give the nurses a break!!
It is shameful how health these days has suddenly become the problem of health professionals and not of the individual. Science has ensured people live longer get better treatment but it also means that the public expect to live longer, recover from more and more serious illness but do nothing in exchange – Look at the evidence related to health and eating, exercise, smoking, sun exposure and alcohol. Health is a black hole that no matter how much money and resources are throw at it, it will never be enough. Beds are at a premium, population booming and illness becoming more complex. In the climate of litigation everything gets x-rayed, CT’d and pathologized, and still the public expect miracles and fail to step into the breach to recognize their role in their health.
The public need education on when to attend ED, how ED works and why it can take 2,4,6,8 or even 12 hours to be seen. Why their ingrowing toenail they have had for 6/52 is not life-threatening. Why the cut on the finger that came by ambulance can sit in the waiting room. Why the lady who has dementia and is from a nursing home does require a bed over the ambulatory person with diarrhoea and vomiting.
The comment about a # arm being more important than a miscarriage – well sorry several things here –
1. the hospital in question may have a minor injuries unit that works in the ED and those “low category patients” who fit the criteria of a minor injuries scope of practice may in fact be being addressed in another area with out the need of a bed and a private room. Where I work I advise patients at triage that there are several different areas and that they are waiting for the main department/fast-track and the triage category they are in, as well as that they may not be seen as quickly as the wrist injury because of those different areas. Also that as a nurse I can not order certain x-rays but will attempt to get analgesia and if workload permitting review them shortly and/or undertake pathology. I also tell them if anything changes they are concern to come back to the desk and see me.
2. The fracture may have gone to be x-rayed – so yes would be seen more quickly – where I work we are able to nurse-initiate limb x-rays.
3. The limb itself may have been time-critical, eg deformed, neurovascular compromise etc etc.
4. The lady in question being placed in a cubicle might be they found her a place that was more private than the waiting room but actually in the minor injuries area and she still needed to wait for an “acute” area Dr to review her – allowing those Dr.s dealing with the CAT 3 4′s and 5′s in the “minors” area to continue – otherwise those patients too would never get seen in a time appropriate fashion.
4. As has already been highlighted, sadly no place is a good place for a miscarriage and whilst I agree the waiting room is not the best place – would a chair in a corridor be any better. The chances are that she was going to miscarry it could have still been a toilet in the main department – unless she though it was appropriate to do it in the bed! If the miscarriage is going to happen it will and there is little that can be done to change that.
Much as many nurses working triage would love to have the time to sit and provide advice education and counseling for the patient and family concerned, they may not have the time and or experience to adequately address this in the constraints they are already struggling to work within.
One of the ways that has been introduced in my ED is a social worker between 8am-10pm, they are extremely helpful, they too however are finding the increased demands for their services also mean they they may not be able to see the patient in a time conscious manner and their input still fails to address bed shortages.
The issue of Dr’s working the waiting room or Triage would not work, firstly they would fail to triage expediently as they would become tangled with each patient – therefore turning it into a GP department. Secondly most of them do not like seeing patients in the waiting room, they can not take histories adequately or examine adequately, and finally probably the most important aspect they can not maintain the dignity and privacy of the patient. The triage and waiting room details are different end-points than the Dr’s role. Many hospitals are now employing an NP to facilitate waiting room issues such as x-rays, treatment and discharge.
If the public feel that Dr.s have the time to review all patients in the waiting room this clearly highlights what all ED nurses are aware of: that many of those categorized as a 4 and 5 are patients who should be being addressed in the community. ED is not a GP clinic for those who can not get in to see their GP or do not want to pay for GP services or who prefer the convenience of a “one stop shop” that ED has become. There needs to much more funding in the community with GPs taking back responsibility for primary care in the community.
Nurses are professionals and many working at triage are advanced practitioners, it reflects the ignorance that the public have about nurses and this stereotypical image they retain of us being “hand-maidens” to the Drs. Many a Dr would admit that it has often been a nurse that has caused them to review a patient and so prevent morbidity, addressed a drug error, or sped the process in ED up so the patient is packaged for them ready to see………
One final comment if the GP’s made direct referrals to specialities rather than sending everything into ED. There may actually be less attendances to ED for things that as an ED intern, SHO REG etc has to “refer” on. If the GP feels that person should be reviewed by the surgical team then surely to prevent this situation where the patient repeats their story several times to several different professionals they should ring the surgical Reg oncall – cut out the middle man and prevent this issue of 5-10hr waits in ED to be seen by ED , referred and seen by the specialist. After all a Dr is more than capable to refer to a Dr. There is no reason if it works in other countries to think that it can not be effective here in Australia.
As a second year nursing student, I have not yet had experience in ED. It does, however, upset me that people make such harsh judgements about others who are doing their job the best way they know how. I like to think that I am an understanding and patient person but it really gets to me when people don’t reciprocate with patience and understanding, especially on subject matter that is quite specialised.
Yes, everyone is entitled to an opinion, it’d just be nice if those with very strong opinions would put their hands up for the job. Need more doctors? Well then, off you go to uni, become a doctor and show us how EDs are meant to be run.
To all the nurses out there, you probably know this already, but good on you. You do great work!
Hi
for those comments asking for FULLY qualified doctors doing assessments, how many FULLY qualified doctors do you think there are in an ED dept. a fully qualified doctor is called a consultant and takes decades to train. there are only 1-2 on a shift in any ED dept. do you want them seeing patients in the waiting room who MIGHT have something wrong with them or do you want those docs seeing the patients who are actually dying right then and there. and there may be dozens of patients that need that FULLY qualified dr or they will die right then and there???
While I completely understand and accept the logic in what’s being said, keep in mind that I am 7 weeks pregnant today and started spotting this morning…I’m terrified to go to emergency because of the lack of response I did (or did not) receive when I miscarried 1 year ago next month. I understand that nothing can be done either way, but piece of mind is worth everything for me right now. There was nothing worse for me than being told I was at the bottom of the triage scale and to expect a minimum of an 8 hour wait and to let someone know if I pass something while waiting. I went home and delivered my 10 week old fetus in my bed that night. Unfortunately, I’m expecting the same result any minute now… at least I’ll be comfortable at home instead of the cold, unfriendly environment of my local hospital emergency room. Thanks for reading.
I feel for the women who have to go through that terrible situation, but i also feel for the medical staff involved. There’s is a difficult job and there pay checks do not reflect how hard they work.