Noctors, doctors, and rules

The example of 6 year old Tarquin falling off his swing and being referred for reassurance radiography of the ankle by a nurse in accident and emergency is a bad example of showing the difficulties in implementing the evidence based Ottawa ankle rules.1 If the nurse practitioner (or noctor, from the phrase “not a doctor”) is unable to deal with the family’s concern according to the protocol, she should not solve the problem by irradiating the child unnecessarily.

If the family concern continues despite the protocol having been followed and radiography not being warranted, 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 radiography.

Allowing nursing staff to over-ride set protocols will lead to overinvestigation with its known potential risks. If the political will is to replace doctors with noctors, Hippocrates is still relevant—“first do no harm”—even if the parents do not initially see your point of view.