What do you do when you know something is wrong with a patient, but don’t have the data to back it up? Hear the story of Diana Struthers Stanton, who, at the beginning of her 46 years in nursing, cared for a 10-year-old patient with Reye syndrome. The patient’s capillary refill had changed and was slowly getting worse and worse. Concerned, Diana spoke to her charge nurse and was told not to worry about it. She spoke with her colleagues who also told her not to worry. She paged the on-call resident in the middle of the night, but got the same response. Diana’s gut was telling her something was wrong, but she lacked the clinical data to back it up. So what do you do? For insight, Connie spoke with Dr. Sarah Kim, a specialist in emotion-focused mindful psychotherapy, about the importance of trusting your gut. We’ll also discuss being your patient’s advocate and learning to forgive yourself when things don’t end well despite all your efforts.
Diana Struthers Stanton
Diana Struthers Stanton is a retired nurse with over 40 years of clinical experience. She lives in California.
Dr. Sarah Kim
Dr. Sarah Kim is a Canadian physician practicing narrative medicine, sports & performance medicine and psychotherapy. She is also an assistant professor in the Department of Family and Community Medicine at the University of Toronto
DDx SEASON 8 | They Don’t Teach That in Nursing School, EPISODE 2
Trusting Your Gut
DIANA: This boy was literally dying in front of my eyes and despite letting people know that there was a major problem nobody was hearing me. But I didn’t have the numbers proof, I didn’t have clinical data, but I knew in my gut, I knew there was something wrong.
I called the resident at least five times during that night, if not more, each time becoming more and more agitated. Each time expressing my concerns further and further. Each time going again to my charge nurse, each time charting, ‘Doctor notified. No action taken.’ And each time feeling my gut getting sicker and sicker because I knew that there was a problem, I knew something was wrong. I knew the child needed attention or he would die. But I didn’t know what I could do anymore.
I felt like I was failing. I was failing what I was taught. I had failed everything I’d ever wanted in my life. I had failed that child. I had failed his parents. I had failed myself. And I knew that I never, ever wanted that to happen to me again.
CONNIE: That’s Diana. She’s now retired after 46 years in nursing.
But at the time this story took place, it was early in her career.
In fact, it was her first day on the job — after finishing her orientation — at a trauma center.
DIANA: I was given a patient who was about 10-years-old and had Reye’s syndrome. When I received him, he was on a ventilator, and as the night progressed, I was feeling concerned. And the one thing that concerned me the most was a change in his capillary refill. The capillary refill will tell you a little bit about the patient’s hemodynamics, his cardiac abilities.
And it was concerning me because it kept slowly getting worse and worse so I went to my charge nurse, had her evaluate. She said not to worry about it. I was worried. I continued throughout the night going back out, talking to her, talking to other colleagues. Again, everybody assured me this was normal and not to be upset.
As the evening — it’s a 12 hour shift — so as the hours were advancing and the capillary refill was increasing to four to five seconds, very significant. I was like no, no I need to call the doctor.
So I called the resident and she assured me that again, everything was fine. And again, I said, okay, because I was being pressured to say, okay.
CONNIE: Diana’s problem was that her gut told her that her patient urgently needed medical intervention, but she lacked any clinical data to back it up.
And as a young nurse with limited experience, no one was listening to her.
DIANA: I felt like I was an island and despite letting people know that there was a major problem, nobody was hearing me. And I didn’t know what to do to make it work.
CONNIE: Diana’s job was to save this boy’s life. But she didn’t know how.
DIANA: I knew the child needed attention or he would die. I knew that I had to do something, but I didn’t have, I didn’t have any power. I had no power.
CONNIE: This is, They Don’t Teach That In Nursing School a podcast from Figure 1 about how nurses think.
I’m Connie Levie.
After 16 years at my hospital in the nuclear medicine department, I was ready for a change. COVID had just hit and I saw my nurse friends struggling. I decided to go to nursing school, so I could help out.
And after years in medicine, I’ve learned that the most essential lessons are those that you learn on the job.
And that’s exactly what this show is about.
This is a show where we provide unique practical solutions to some of the most challenging problems nurses face.
From learning how to operate a ventilator during the height of COVID to dealing with an attending physician who’s a bully.
We’ll be sharing secrets of the trade from nurses, doctors, medical researchers — the professionals you wish you could consult with but rarely have the time or opportunity.
You’ll feel seen, gain wisdom, and be better equipped to respond to all the unpredictable stuff that gets thrown at you.
Today’s case is all about how to trust your gut when you lack clinical data and comes to us from retired nurse Diana Struthers Stanton in California.
CONNIE: You’ll recall from our opening that Diana was at her wit’s end. She told her colleagues that her patient needed urgent care, but no one was listening.
Until all of a sudden, everyone was.
DIANA: Literally, what saved this child’s life, in this instance, was not me. What happened was, day shift came on. It was quarter to seven. A very experienced nurse walked into the room to take my patient and as she walked in, I was attempting for about the fourth time to get a blood pressure through an automatic blood pressure cuff.
It wouldn’t read. It wouldn’t read at all. So I kept waiting. Pressing it, waiting, and that’s what I was literally doing when she walked in. She looked at me and looked at the kid, and said, ‘What are you doing?’ And I said, I can’t get a blood pressure.
She goes, ‘How long have you been trying?’ I said probably the last 30 minutes I’ve been trying, but I can’t get one, all she said was, ‘Oh my God,’ left the room and came back with an army. Literally. And I was pushed out of the way, they took over, and they saved that kid’s life.
CONNIE: I think it’s safe for me to say that Diana’s not alone here.
Every nurse — and most care providers for that matter — know what Diana’s talking about.
Gut feelings seem to come in one of two varieties: Either you have a nagging sensation that something is wrong, or a sense of reassurance that everything’s okay.
But in both cases, you might not have much proof to back it up.
So what do you do? And should we give gut feelings a little more — or less — credit?
SARAH: Gut instinct has a lot of value. And if your gut instinct says something is amiss, I wouldn’t ignore it.
CONNIE: Sarah Kim is a family doctor based in Toronto, Canada.
She’s also a specialist in sports and performance medicine and emotion-focused mindful psychotherapy.
SARAH: Trusting your gut is actually a really complex response, it’s an accumulation of experiences designed to try and avoid pain and so you learn, not to touch things that are hot. And then as life goes on, when you even approach something that might be hot, there’s a tingling feeling that comes, knowing that’s a source of danger.
CONNIE: So although gut feelings might seem like a tangle of intuitive reactions, they’re actually a highly organized set of sense memories designed to keep us safe.
SARAH: Even though Diana may not have had a lot of clinical experience as a nurse, there was something in her gathered experience up to her lifetime at that point, which was allowing her to identify a problem.
CONNIE: But we tend to value facts over feelings. Diana didn’t have any hard numbers to validate what she was experiencing, so it was easy for others to discount it. Sometimes it’s hard to even articulate what’s truly behind a gut feeling.
SARAH: The gut instinct doesn’t always come with something that you can articulate as a quote-unquote hard piece of evidence that something is wrong. And part of it again is because gut instinct is something that’s tied to an emotional feeling. Medicine is, we like to think of it as very scientific and that we make our decisions in a scientific way, but it’s a highly emotional environment. Whenever you deal with human life, there’s no way to remove that component. And so when we develop these gut instinct moments, it’s also because we as practitioners have experienced loss and when these critical situations happen where you perhaps have lost a patient or sometimes there was a bad outcome, because it’s so emotionally intense it gets encoded in our bodies in a different way, because again, we’re wired to want to avoid pain, and that includes emotional pain.
CONNIE: It sounds like it might be more accurate to call our gut feelings critical intuition.
But back to Diana’s story. Is there anything she could have done differently?
SARAH: What I would love to say to Diana was that, the situation here, had the outcome been negative for the patient, would not have been her fault at all. Because she did her due diligence.
CONNIE: Diana feels the same way. She’s had years to reflect on this incident and is at peace with how she handled it.
DIANA: I would say, you did what you should have done in the beginning. You did everything right as far as, you had a gut feeling, but you didn’t have the documentation. So go ahead and talk to your peers, talk to your charge nurse, talk to your doctor on call, do that.
CONNIE: Diana didn’t simply react to a gut feeling. She followed the protocols in place.
DIANA: I don’t want to say everybody should be calling on every instance. There is a protocol in place. Follow the protocols. You should go first to your preceptor or your charge nurse, your resident, but as you make your way through, know that you can go higher, but also know your limits. You know, if you’re brand new and you don’t understand the dynamics of what’s going on and even what’s in your gut, it’s a real thin line to have to walk.
CONNIE: When the protocols don’t give you the result you need, what then?
DIANA: At some point you need to go above and beyond. And what does that mean? That means, if I’m not getting the answer I feel I need, from my charge nurse, from the doctor, the resident that’s there, who’s above that resident? Okay, in this case it was the intensivist, who was sleeping soundly in his bed,
I should have probably called him at one or two in the morning, and that would have been appropriate. But I was told we don’t call the intensivist unless, like, somebody’s coding. Or we don’t want to bother him, and, you know, you’ll get in trouble. No, I know now, you need to do what you need to do.
And if that means calling an intensivist at 2 a.m. in the morning. Or any time during the weekend, or worried about waking up a doctor — don’t. That’s their job too. And they’re gonna, there’ll be times that you’ll get in a lot of trouble for it.
Because if they come in and it was a false alarm, they’re gonna be not a happy camper. But guess what? They’re also gonna know that when you’re on, if you have a gut feeling. And you have the education, experience, and understanding to know what you’re doing, they’re going to appreciate that you will call them and get them in there for an issue.
And believe me, I did. I have called so many doctors and not every time it was appropriate, but you know what? I don’t care. Every time it was appropriate for me and for the patient, because if I hadn’t and something that would have happened, I would have failed.
So what I do tell people is it’s really, really easy to know when to make those calls. When do you call? This is when you call.
I want you to back up, look at your patient, how you’re feeling, and just for a moment pretend that patient is either your child, your mother, your husband, your wife, somebody that means the world to you. And whatever you think in your brain that you would do for that person, that’s what you have to do for this patient.
That’s exactly what you have to do.
CONNIE: It’s important to listen to your gut. But it’s equally important to listen to your colleagues and team.
DIANA: When somebody comes to you and says this, to not just say, ‘Well, you know, you’re new, or you don’t understand how sick these kids can get.’ You need to go in and evaluate and back those people up, and either explain why there’s an issue or why there isn’t an issue.
The bottom line is, you are the patient’s advocate. It shouldn’t have to be their parents. It shouldn’t have to be anybody else. If you’ve accepted the assignment, that patient is your responsibility. And it’s also your responsibility to be honest about how you’re feeling and what you think.
And also to forgive ourselves sometimes if we feel we’ve done everything we possibly can. Whether it’s educating ourselves, talking to others, calling a doctor in the middle of the night. Sometimes, it’s not going to end well. And in those situations, you have to know you’ve done everything you can do. And then you can sleep at night.
CONNIE: Thanks to Diana Struthers Stanton and Sarah Kim for speaking with us.
This is They Don’t Teach That In Nursing School, a podcast by Figure 1.
Figure 1 is an app that lets healthcare professionals share knowledge to improve patient care.
I’m Connie Levie, your host and partner on this journey.
Thanks for listening!