I was to see a patient who has had 2 episodes of falls. When I walked the patient into the gym, I noticed that she was unsteady on her feet. I felt uneasy as she seems to be more unsteady than the previous time I saw her. I asked if she was not feeling well today and she mentioned that she has been feeling that the room was spinning around her. I asked if it was normal, and she replied that she has been feeling so the whole week. As such, I got the nurse to help check her obs and stats before starting the session. The nurse checked them and they were normal, a slight irregular heartbeat which according to the nurse was normal for the patient. We then advised her to make an appointment with the gp regarding her dizziness as she might have caught the flu or an infection.
I started the objective assessment constantly monitoring the patient and asking her for feedback. I decided to do just half the berg balance assessment although the patient reiterated that she could continue. We sat down for a short chat and rest before she left and as she was putting on her shoes, she came back up with a grimace on her face. I asked about it and she told me that she was experiencing some pain in her chest. Once again, I asked if that was normal for her and she said it was. I got her a warm cup of water and her chest pains went away as quickly as they came. Since the patient had no history of heart problems, I suggested that she reported the chest pains to the gp too. I remembered reading in the notes that the patient has poor short term memory and that prompted me to write down all these in her notebook to serve as a reminder for her to ask the doctor. After 10 mins of rest, ensuring that the chest pains did not come back, I walked her out to the reception where her husband was waiting and suggested that they go to the gp as soon as they could.
The next day, the head of department came and asked if any one saw that patient. I claimed that patient and wondered what happened. It turned out that the patient was admitted to the emergency department and is now warded. I told him everything that happened and the steps I took. He then told me that the patient went to see the gp and the gp complained that the patient should have been sent straight to ED. However, he reassured me that all I did was right and that he just wanted to find out what happened. My supervisor and the nurse later told me that almost half of the patients come with chest pains and it is impossible to send them all to ED. We later found out that the patient was discharged as they could not find anything wrong with her heart.
My heart stopped for a second or two when the head of department told me what had happened. Although everyone reassured me that I made all the right decisions, it still made me question my own judgement. It was fortunate that the patient was alright this time. In future, with any patient who complains of chest pains, regardless of whether they have a history of heart problems, I will pay special attention to it and approach my supervisor instead of trying to handle the problem myself.
That was exactly what happened the next day. I had a patient who came in complaining of the worst chest pains ever experienced the night before. Immediately I alerted the nurse and the supervisor only to realise that it is not a concern because she is not having the chest pains at that point in time.
With help from my supervisor, I figured that although chest pain is an important red flag, I have the skills to discern false alarms from those that require attention. It is important in these situations to stay calm and carefully question the patient before making a decision, unless of course the patient is in obvious distress. She assured me that my clinical reasoning is alright however if it is necessary, it is still fine to seek help.
This is one experience that I hope you guys never have to experience but I guess it is almost inevitable in our practice. I was fortunate to have a very supportive supervisor and should any of you encounter these sort of situations, do not be too harsh on yourself but keep the confidence.
1 comment:
Sometimes as students it is difficult to know whether we are doing the right thing, and as our 'student' title suggests, we are there to learn! This was a difficult situation for you to be put in, but from what you describe, you had the patient's best interests in mind at all times. Some patient groups do have a lot of 'red flags' which are actually not red flags to them because of their history. It is important for us to be aware of these, and to monitor appropriately and refer on if required. Sure, not every member of the healthcare team will agree with the decisions you made, but as long as you can reason them, you are in the right and have done all you can. This incident also highlights the importance of good documentation so that you can cover yourself in the event of something bad occuring.
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