SCIWORA, or what I have learned

I was working back in the observation unit (OBS) in the emergency department. The OBS unit is where patients go who are too sick to send home but not quite sick enough to admit. Usually, they are patients who need a bit of “wait and see” before deciding which way they will go. Will they get better and go home or will they fail to improve and be admitted. I am not all that fond of OBS for a few reasons. First, it is a bit lonely back there. Generally speaking, there is one nurse and up to five patients in the small, self contained unit. Secondly, since you are somewhat isolated from the rest of the department, you do not have a readily accessible back up when things go awry. I have had a few patients get transferred straight to the ICU after a stay in OBS. We had a chid the other night that was in OBS, then transferred to a “big” room (the trauma rooms), intubated, and sent to the ICU. Pretty scary stuff!

So, when I was back in OBS a few weeks ago, I had an 18 month old boy who had been a restrained passenger in a motor vehicle accident with two adult fatalities. My first concern was that there were no family members present to watch and comfort the child. Not only was he alone after the trauma of the evening, but he was Spanish speaking and my Spanish is somewhat limited. I really felt bad for the little guy.

We were trying to obtain a urine specimen from the kiddo using a urine bag. When I checked the bag to see if he had produced anything, I noticed he had an erection. This did not concern me too much, but I did make a mental note, as it is not a terribly common finding. I checked the bag again about an hour later and noticed that the erection had not resolved. This was definitely out of the ordinary, so I told the doctor. Her suggestion was to watch it for another hour and check back. I then documented my observations and the fact that I had notified the doctor. When I went to check, I noticed that the patient did not appear to be moving his legs. Not wanting to cause undue alarm, I went to the doctor and told her my concerns. She came and checked his reflexes noting movement of his toes after stroking his foot. She felt that he was fine, so I did not document my concern.

Meanwhile, the erection continued, so we had to catheterize the patient to obtain the urine specimen and relieve his bladder pressure. The patient’s dad had arrived. I was so happy to see him that I had a hard time controlling my emotions. I was so relieved that this child now had a familiar face and voice after what must have been a most perplexing and stressful night. Since it was the end of my shift, I went home.

When I returned the next night, I heard that my patient was in the ICU. He had a spinal cord injury known as a “SCIWORA”, or spinal chord injury without radiographic abnormality. You can imagine how hard I was kicking myself for not being surer of my observation. At the very least, I should have documented my concern and the fact that I notified the doctor. The patient’s condition would not have changed with earlier notification, but that does not really help me feel any better about it. I do not know the long term outcome for this patient. There is some hope that he will regain movement, but only time will tell.

The lesson learned for me? Document, document, document! When in doubt, document. I was so afraid of writing what I saw for fear of making too much out of nothing. I was afraid that someone reading the note would “freak out” over what was obviously not a problem. After all, the doctor had evaluated the patient and felt there was no problem. Now I know to trust what I see. If it concerns me enough to notify the doctor, I need to document it as well as the fact that the doctor was notified.