Feedback

As I mentioned in yesterday's post it can be hard to get feedback on the treatment that you have given a patient, was is right, was it the best, was our diagnosis correct?

It was the end of the nightshift, we'd been run ragged all shift without a break and my eyes were hanging out of my head. We were sent to an elderly man who was complaining of chest pain.

It is one of our bog-standard calls – an elderly gentleman of South Asian origin, complaining of something that could be cardiac chest pain. He has a previous history of diabetes, high blood pressure and previous heart attacks. The pain started an hour ago and is one of two things – either his heart or the recent chest infection he's suffering from.

No problem, we wheel him out to the ambulance and start checking his vital signs, pulse, blood pressure, respiratory rate and so on and so forth.

Then we do an ECG, a heart tracing.

I've mentioned before that one of the things that the LAS and NHS in London do extremely well is the diagnosis and care of heart attacks. If the patient is having a heart attack that is detectable on the ECG done by the ambulance crew then, instead of going to the local A&E, they instead head straight to an angioplasty lab where the top level treatment is available.

It works really well and is the thing that the NHS and LAS does that I'm most proud about.

Our patient's ECG was just under the threshold of going directly to the angioplasty lab. In part this was due to the poor quality of the ECG we were able to get. Essentially one heartbeat just about looked like it should go to the angioplasty lab, the next heartbeat looked like it should just about go to the local A&E.

We spoke to the history, did another three or four ECGs and needed to make a decision.

When it comes to the interpretation of ECGs my crewmate tends to look to me – as an A&E nurse I used to do twenty or more ECGs every shift and, because I find ECGs interesting, I used to study each non-normal one that I took. She recognises that I have a lot more experience looking at these things.

Normally I can tell at a glance whether we should go to the A&E or the angioplasty lab.

In this case I wasn't sure.

I squinted and strained my eyes. I took my glasses off. I used a ruler to see what straight lines I could and I used the pattern recognition part of the human brain to try and come up with a decision (for those medically trained, all our ECGs had mildly wandering baselines and I was seeing if the ST segment was elevated by 2mm or more).

The decision that I made was that the patient didn't fit the criteria based on the history and the ECG. But it was pretty borderline. I suspected that a blood test would need to be done and some more ECGS taken at the hospital to be sure of a diagnosis.

So we headed off to hospital, pre-warning them that we were bringing in a chest pain patient.

We were met at the hospital and before we could off-load the patient a doctor who I've only seen once before asked to see the ECG.

“This is ST elevation”, she said rather forcefully, “You should have taken them to the angio lab”.

“It might look it Doc”, I replied, “but the wandering baseline needs to be taken into account”.

She grumbled a bit.

We got the patient out of the rain, but the doctor stopped us just outside of the resus room to question us some more.

Essentially she was convinced that we should have taken the patient to the angioplasty lab – I let her know that if she was that sure we could easily load the patient back up and take him there. I'm not too big to admit a mistake and I'd rather the patient get the care that they need rather than massage my ego.

For some reason though the doctor didn't seem ready to commit us taking the patient off to the angioplasty lab on her say so, so we left our patient in the A&E department. The doctor then wouldn't listen to our handover and was generally very rude towards us.

If it had been earlier in the night I may well have been annoyed, as it was I wasn't in the mood to argue. So I let it slide.

But it played on my mind – had I done the right thing? Had I misdiagnosed a patient? Had I taken the patient to the A&E department instead of the angioplasty lab for some ulterior reason?

So I had a bit of a sleepless day, even after examining my role in the care of the patient and so I resolved to find out what had happened to him.

The next day we looked up our patient's notes – turns out that the pain was being caused by his chest infection and that his ECG was 'normal for him'.

So I was happy – I'd made the right diagnosis, I'd treated the patient correctly and I could rest easy knowing that he'd been taken to the right hospital.

Leaving the area where the notes are stored I saw the doctor again, she was writing some notes – I didn't bother her, I'm not about scoring points, even towards people who were quite incredibly rude towards me and my crewmate.

But I will remember it, should she choose to be rude to me again.

—–

The point of this isn't that the doctor was wrong at the first glance of the ECG, nor that she was rude. The point is that, without that feedback from looking at the patient's notes, I had a sleepless day and would probably still be fretting about it. I think it would be very beneficial if there were a more formal feedback procedure that went beyond making complaints.

6 thoughts on “Feedback”

  1. You're human, you care about the patients you see or you wouldn't be in the job, course you need feedback if requested/As to the doctor, I've seen before they're not all the Gods of medicine they think they are, experience counts too.David

  2. Congratulations on the long write-up about you in the Observer today. Quite a good piece, except for the comment about your writing style. I felt that was unneccesary. A bit below the belt. You have an authentic voice and a clear prose style which suits the subject matter.Even though you claim to hate children, I sleep a little easier knowing you patrol the patch where my grandkids live.

  3. The doc sounds as if she were unsure herself and giving you a hard time because of that. Too often inexperienced SHOs are left to get on with it in Casualty, afraid to call in the Registrar, let alone the Consultant, or the specialty teams, because of being branded “unable to cope”.It's the docs macho culture at its worst. I have heard junior doctors refuse to help their peers with advice, when there is a dodgy X-Ray or ECG to be interpreted, saying “I'm not propping him/her up, let him/her paddle their own canoe” or words to that effect.

    Sadly, nursing seems to be going the same way.

  4. Glad you got to find out you made the right choice.I agree that feedback would be useful. I think that if there was a formal way of getting feedback on patients then it would help better practice and would mean we'd be able to give patients a better idea of what happens when they get to hospital.

  5. Virtually all the significant learning that I have experienced in my ambulance career has come from finding out what happened to my patients and if my provisional diagnosis was right or wrong. The relationships that you can have with the docs and nurses in A&E is invaluable and is one of the best resources that we can have for feedback.In this case, even if he had ended up having a MI and needed stenting, you would still have been right in your decision. Ultimately, if you felt that they didn't fulfill the criteria for STEMI, and as an experienced ECG interpreter, who could challenge you? It would be a different story if you weren't fully competent in difficult ECG interpretation, and lets face it, its not every paramedics/technicians forte, and then maybe people would air on the side of caution and take to a PPCI centre and rather get comments for taking someone who didnt need it rather than take someone to A&E who needed PPCI.Good call.

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