I’m doing a rotation in the Emergency Department at the moment. And mostly I’m really enjoying it.
Like every rotation there’s a mixture of senior clinicians, some who are excellent mentors and colleagues and others who really don’t seem to care much at all. But that’s another post.
I’ve had some great clinical learning moments, but also some important learning about systems.
The other week I had a patient who had attended ED with a letter from a specialist outside of the hospital. It was short and addressed to a senior clinician in the hospital and referred to a senior registrar stating that he had said to send the patient into ED for further management as the patient had been under that team only 1 week previously. The patient was not acutely unwell - stable, not in pain, but also clearly not improving since recent admissions.
So, I took a history, did an examination and ordered some bloods. Then I called the registrar. He knew all about the patient and went on to explain that the senior consultant mentioned wasn’t the correct one due to some confusion about teams on call a few weeks ago. He said to call another registrar who knew about the situation and would see the patient.
The second registrar asked me about my findings and results and then promptly declined to come and see the patient. I was honest and direct with him, as I didn’t feel the patient was acutely unwell - certainly they needed follow-up but it didn’t have to happen immediately (as a side note, the external consultant could have done all of this but appeared to be handballing the patient). It didn’t seem like an appropriate referral but I had felt the pressure to do the bidding of an external consultant who had been in touch with a team within the hospital. The external consultant had also given the patient and family a certain expectation about admission and further investigations in hospital.
It may read like all of this happened very quickly, but this is over the course of 3 hours or so while I was also seeing other patients and doing a handover at the end of my shift.
So, what have I learnt?
Even if there are letters from consultants and plans made for a patient outside of the ED, workup the patient and refer them on as necessary. Certainly contact the teams involved, but focus on what the patient needs. Try and find a solution for their problems.
I’ve also learnt that when I’m on a receiving team I certainly won’t be telling a patient to come to ED and then not seeing them.
we had a teaching session this week on clinical aggression that primarily focussed on patient-clinician aggression. we have a co-ordinator for the Management of Clinical Aggression whose job it is to oversee protocols, edcuation, management and assessment for any aggression and violence in the workplace.
whenever there is the potential for aggression and/or violence involving a patient Code Grey can be called. this can be planned or unplanned (I think the rate is 60% planned 40% unplanned at the moment).
when you call a Code Grey a small team attend, made up of 4 big security guards, a senior clinician, a nurse, a medical officer (usually from the area calling the code), and an emergency co-ordinator. plus any unit staff that may be involved.
what got me thinking was that there’s no one role that is assigned for someone to be a patient advocate. of course in the majority of cases/situations any health professional can be, and probably should be, an advocate for the patient and this applies to those clinicians involved in code greys. but i think there’s a potential for a specific trained person to attend code grey events and act only as the patient advocate. this could allow situations to descalate quicker than usual, as often the code grey becomes a very oppositional event and ends with what can appear to be punitive measures of restraint (chemical or physical or both).
but if there was one person who could enter the fray and tell the patient, “I’m here for you and want to help you resolve this. I’m not a doctor or nurse. I will advocate for you.” I think there is the potential to shift the oppositional status quite quicky and perhaps have less restrictive outcomes for the patient.