Sunday, March 10, 2013

Sunday Essay - the strange case of a wounded knee

One of the things that I have written about from time to time on this blog is the the way in which the combination of rules based approaches with concerns about legal liability and the avoidance of risk have led to increasingly crazy outcomes. I wrote about this a lot while the girls were at school, for then I saw it all the time.

Friday I got an annoyed email from a colleague that again illustrates the problems I refer to. With his approval, I repeat the story.This photo shows the wound in question.  photo

On Friday my colleague got a call from his son's school nurse saying the boy had an injury and that he should come to school to take the 10 year old to a doctor. The child's mother had been called too but was not available as she was in a business's meeting.

Very concerned my colleague got into a cab to home, then drove to the school to pick up his son. The child had a heavily bandaged knee, but could walk just fine, had next to no pain, and only a mild stinging feeling near the injured knee.

Upon arrival at the family doctor's clinic, the doctor unbandaged the  knee; there was now no bleeding (child said there had been "A lot before"). After checking the date of the last tetanus shot, the doctor passed the child to support staff, a nurse. With professionalism, nurse stuck on a bandage after a bit of wound cleaning.

A little more than $50 was paid by the father, about $30 will be reimbursed by Medicare. In addition, and this is my comment not the father's, my colleague lost four or five hours charge time in addition to taxi costs to get home. This brings the total cost to over $900. 

My colleague was cranky. To his mind, the case illustrated the deskilling of the school nurse  and her disempowerment by concerns about legal liability or unduly concerned parents. "Yet all this", he wrote, " people need professionals and social medicine payments just to put a bandaid on a bruise. Common sense has been lost and we need it back!"

He is right, of course. Now when I talk about these cases, the response I get from some parents and others is simply better to be safe than sorry. I shudder at this.

Nursing is a profession, as is medicine. This involves judgement calls. Sometimes those calls may be wrong. The school nurse did not feel that she had the power to make that call despite the minor nature of the wound. Apart from some minor first aid that could have been done by anyone, she passed the responsibility to the parent and the doctor.

Doctors, too, are disempowered. There were a number of times I took the girls to the doctor after a school incident only to be told  look, I think that she is okay. but to be on the safe side, you should take her to casualty for tests. In the end, it was easier just to go to casualty and spend the many hours there waiting to see the first available over-burdened doctor.

Am I wrong in thinking that all this is a bit crazy?


Anonymous said...

We possibly have our legal brothers to partly thank for that. In the good old days I remember my father picking me up from Cooerwull Public School in full major's uniform with a clipped "what's required - stiches or x-ray?".

After that, I just sort of got on with it :)

ps tales of regular thrashings with rusty razorblades to follow..

Jim Belshaw said...

:) kvd. Rusty razor blades indeed! Your father sounds quite fearsome!

Rummuser said...

You raise a very valid question Jim. Why nurses, even doctors and specialists at that now seem to be unable to act without a whole lot of pathological tests/scans/Xrays and so on and a completely new industry has grown around this fear of being wrong. The old fashioned GP who could diagnose problems and deal with them on the spot has all but disappeared and the cost element of health and medicare has gone through the roof.

Evan said...

Definitely insane.

I do think the dominance of lawyers is part of the problem.

Jim Belshaw said...

Blowed if I know, Ramana. I think that Evan is right, though. One of the side effects of all this is that it makes it harder to get medical help when you need it. Another is the rise of other para professionals to do the work that doctors used to do.

Anonymous said...


Isn't the tetanus shot (or not) the main thing which led to the trip to the doctor?

Otherwise, given that the boy did not seem particularly incapacitated, why did your friend not take the bandage off and have a look for himself? If he had he might have been up to putting on a new dressing on himself.

Anonymous said...

PS: one of those "on"s is redundant - obviously he would have put the new dressing on his son.

Jim Belshaw said...

You may be right on the tetanus shot, marcellous, although it is something the nurse could have checked. On the second, if you are called to the school because your son has been hurt, he has a heavily bandaged knee, you wouldn't normally try to second guess the nurse.

Anonymous said...

"fearsome"? - yes, in some ways. But then when I was 10 he was 55 - me being the last of five children spread over 22 years. There's good and bad in all parents, myself included, but we all try our best I'm sure; it is hard at times.

I don't look back with great love, but I do look back with enormous respect for the things he taught me, and the things he considered important. I hope my three will think similarly of me in years to come. That would be enough.