The myth of complexity
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3505 (Published 01 September 2009) Cite this as: BMJ 2009;339:b3505
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Because six year olds are more likely to have greenstick or epiphyseal injuries than significant sprains.
The triage nurse - at least in Oz - may be able to decide that the child merits going straight to xray - but can not decide he does not need an xray. The child will be evaluated by another clinician (doctor or NP) who also examines it. So triage needn't go through the "explaining why an xray isn't necessary" - but they still send far too many patients direct to xray. I suspect it is because they can, rather than because they should. It is one way of removing decision-making from medical staff, and its always more fun to make decisions than to carry them out.
Badly implemented NIXR, and that is very common in Australia at present, will probably result in the child being sent for "foot and ankle and leg to include knee" by someone who doesn't understand the difference between non-weight-bearing and limping, and probably "examined" from the other side of a desk. She remembers the lectures from the orthopaedists about "the joint above and the joint below" which of course does not apply where one has not demonstrated a long bone injury. So not just unnecessary numbers of patients but unnecessarily increased radiation per patient.
Another major concern is that attention is now focused on the xray and nothing but the xray. Never mind about the ankle or even the patient - who may be fully dressed again with socks and shoes and sitting in a chair for the "xray result."
If Tarquin has even minimal swelling and tenderness over the epiphysis, I would protect him from weightbearing and certainly from the swing for a few weeks and bugger the xray. The "fracture" that is actually an accessory ossicle on his 20-year-old sibling with the same injury won't even get to the orthopods, let alone be wired back on (! yes, it happens) if an experienced doctor examines the injury and realises that area of the putative fracture is not painful or tender.
Ottawa rules are useful but they were instigated in the hope of decreasing xrays in patients who had been examined, not as a tool to speed patients through the department. The Wells criteria don't work if applied to patients with "no-risk" rather than "low risk" of DVT. The Ottawa ankle rule may help decision making with a patient. It was never designed for a waiting room or any other undifferentiated population.
Competing interests:
None declared
Competing interests: No competing interests
Noctors should follow the rules
As the correspondent from Australia observes, this is a very bad
example. If the Nurse Practitioner (or Noctor, derived from the phrase Not
a Doctor) is unable to deal with the family's concern according to the
protocol, they should not solve the problem by irradiating the child
unnecessarily.
If, despite the fact that the protocol has been followed and an x-ray
is not warranted, the family concern continues, the patient should be
referred to a Doctor who is able to allay the parental fears by explaining
the situation with the risks and benefits of an x-ray.
Allowing Nursing Staff to override set protocols will lead to
significant over investigation with all the known potential risk this
involves. If the political will is to replace Doctors with Noctors, we
must continue to ensure that Hippocrates is still relevant, "First do no
harm", even if the parents do not initially see your point of view.
Trefor and Sarah Roscoe
Sheffield
Competing interests:
None declared
Competing interests: No competing interests