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Clinical Case 050: Think Better, Do Better

Last week I received the following comment from a reader in a country nearby.  This was a great story for me to hear as it made all my long hours of reading and writing seem worthwhile.  There are plenty of podcasts and blogs that will teach you how to do life-saving stuff – but this story is about how a reader took something from Broome Docs and ‘saved a life’ in a very different way.  It is not about a single trick or a procedure – but about how to approach the daily practice of medicine in a better, patient-oriented and effective manner.  For me this is the essence of why I do what I do at Broome Docs.  Here is the story from Dr Tom:

Hi Casey,

Straight after I read your first article on Consult Skills, I clipped and saved it using Evernote so that I could access it on my iPhone whenever needed.

Lo and behold, last week I had my first opportunity to use it when a middle–aged lady presented with a two year history of severe low back pain, bilateral hip pain and right leg pain. She had had multiple visits to her GP, several locums and 3 different orthopedic specialists over that time. Even though she was on a benefit, she had paid to see a couple of specialists privately because she was so desperate.

When she arrived in our ED, one of our relatively new Resident Medical Officer’s went to see her. The RMO came back very frustrated and said that both the patient and accompanying relatives were very angry and demanding, and that she wasn’t really able to get anywhere with her.

At that stage I said to the RMO that we had two important functions to fulfill:

1.      To make sure that the patient didn’t have any emergent orthopedic conditions e.g. cauda equina syndrome, spinal abscess etc.

2.      To try to understand the patient’s point of view.

The latter was met with a slightly quizzical expression so I pulled out my iPhone, opened my Evernote application and showed her the section I had clipped a few weeks ago:

1.      They want to know the doctor is listening to them

2.      They want to know that the doctor cares

3.      They want to make sure the doctor understands what is going on

4.      They want the Doc to “get it right” – that is make the right call / decision / do the right test  etc…

5.      They want to know what to do next “what will happen to me now?”

At that stage I went into the patient’s room and said:

‘Hi, my name is Tom – I am the senior ED doctor on duty today. I understand you have been going through a really rough patch lately. The first thing I am going to do is to take your pain way with some morphine. Once you are comfortable, I would like you to tell me everything that has happened to you over the last couple of years; then I will have a good look at you, review your results, talk to the orthopedic specialist on call today and together, we will try and come up with a plan to get things sorted for you.

After 10mg of morphine she said – ‘Doctor, you know this is the 1st time in over two years that I have not been in pain’.

She then proceeded to tell me:

•       Her marriage had broken up and she was looking after 6 children on her own.

•       She was in so much pain that she was unable to dress herself (mainly because she could not bend down or stand on one leg), was unable to walk more than a few steps, had hardly been out of her house in the past few weeks and was largely confined to her bed or a chair.

•       She had a history of multiple severe drug reactions and was not currently taking any analgesics.

•       She suffered from stress incontinence and wet herself at least 2-3 times every day.

•       When she fell over, she was physically unable to get off the floor unaided.

•       Her teenage son had to take time off school to help dress and wash her, clean the house and do the cooking – this was now starting to adversely affect both his education and their relationship.

•       She was not eligible for any government subsidies (e.g. home help).

•       She was often tearful due to a combination of pain and frustration.

After listening to her history, I briefly re-capped to make sure that I had not missed any important points.  I then examined her and reviewed her recent imaging.

Next I rang the on-call Orthopedic Specialist and said –  ‘I’ve got a lady with chronic severe lower back, hip and leg pain; a plain film of her pelvis and hips shows severe bilateral hip OA; she doesn’t appear to have any new emergent orthopedic conditions but I would like to admit her so that we can sort out her analgesia, home help, mobility and definitive treatment’.

I returned to the patient and told her: ‘Great news, the Orthopaedic Surgeon has agreed to bring you into hospital, sort out your pain, get you a bit more mobile and most importantly, try and fast track some surgery on your hips.’

At that point she started crying and said:

‘You know, of all the doctors I have seen over the last few years, you are the only one who has ever sat down and really listened to what has been going on. Thank you so much’.

PROGRESS REPORT

After initially being admitted to hospital for a week, she has gone on to have her 1st hip replacement done and is due for her 2nd operation in 3 months time.

Great work Dr Tom.  I really appreciate your sharing this story with me and knowing that we can do better by changing the way we think and talk to patients.

Comments

  1. Minh Le Cong says:

    Well done Casey and Tom! That beats hands down all the critical care resuscitation stuff…ever!

  2. …and that is what medicine is all about. Not just technical skills, blood n guts glory – but the ‘we’re all in this together’ human approach

    Your post is timely – I’ve just read David Newman’s book ‘Hippocrates Shadow’ (he’s also an author with the SMART EM crew) – he emphasises the importance of listening, of connecting etc. Also pushes hard the concept of number needed to treat which is a good thing in patient explanation

    It’s a good read.

    Most important thing I’ve learned in EM? The importance of a handshake at the start of the consult – puts us on a level playing field and is a subliminal reminder that ‘I’m herer to help you – if you’ll let me’

  3. This is a great story, Newman’s book is inspirational, but, and it is a big but – where did you find an orthopod willing to admit this lady? I have not met any orthopods who would even come close to agreeing on that admission. He deserves credit for being a real physician rather than just a technician.

  4. Sometimes you just have to admit patients dont you? It is so much easier when dealing with a senior colleague, and even easier when you know each other? Also easier for us guys in boondocks to admit under own care rather than fight withmthe oncall admitting registrar.

    Systems sometimes work against the patient. There’s probably a post in just giving some tips on how to progress a patient through the system better. Casey, we spoke about this in regard to retreival and transfer…any thoughts on how to make things work easier for getting people admitted?

    • The strategy I use when a consultant refuses to accept an admission is to simply state:

      ‘I don’t believe it is safe or appropriate or in this patient’s bests interests to be sent home. If you want to send this patient home, then YOU need to come and assess the patient and then YOU can send them home.

      Generally the consultant will take the path of least resistance and accept the admission rather than face the hassle of physically coming in, spending time assessing the patient and then incurring the potential wrath of family/friends in denying admission,

      Tom

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