The What & The How

About 4 years ago, I was on the afternoon shift in the "Majors" side of the Emergency Department at the Royal Infirmary.  I was doing my normal mix of providing advice and decision support, reviewing patients, and chasing up elements of the processes of patient assessment that allow the system to function as smoothly as possible.  Part of this role is to pick out any patient that looks out of sorts, or could be more unwell than might have been initially thought at triage on arrival.

One such patient, a 38yr old lady called Audrey, was immediately noticeable as I saw her be wheeled in from the ambulance bay.   She was white as a sheet, with lips that were completely drained of blood, breathing rapidly, and she had half-closed eyes and a sallow disconnected expression.  I walked over to her to hear the handover from the Ambulance crew.

"This is Audrey, 38yr old female, collapsed at work today, no pain, no recent illness.  Husband is following up from his work in the car."

Jen, the nurse taking the handover from them, thanked them and started looking for a cubicle to place Audrey into so that some initial observations - pulse, blood pressure, blood sugar - could be done.

I went in with her to see whether her observations corresponded to her physical appearance (even though in young people they may lag behind the clinical state by a considerable margin) and to see if there were any more clues to suggest a cause for her collapse.

"Hello Audrey, my name is Dave, one of the Emergency Department Doctors.  Can you tell me what happened?"

"I don't know.  I was at work, in a meeting...  I felt dizzy, lightheaded, I had some pain in my stomach.  No, more a discomfort, like wind.  That's all I remember."

She is talking - this is good at least.

"Have you felt unwell recently?  Do you have any pain or discomfort anywhere else?"

"No, I've been fine. My shoulder is sore, but, not to touch. I can move it. Do you know if Bill is here yet?"

"No, I'll ask." I say, and turn to Jen who is showing me the pulse of 90 and the blood pressure of 75/40 (very low).

"Let's go to resus." I suggest.  Audrey, from the initial information, could well be bleeding internally. 

As we are about to move, I ask her "Is there any chance you could be pregnant?"

Her reply was telling: "I hope so." 

It was at this point that I made my mistake.  I didn't hear what she was saying to me.

We moved Audrey through to the resuscitation room, and the resus team came through to support some initial frantic activity - IV drips, blood tests, cross-matching for emergency transfusion, fluid resuscitation, a urinary catheter and urine sample that confirmed the pregnancy (but not whether it is ectopic - outside the womb - or not).

We improved Audrey's clinical state, started a blood transfusion, and within 60 minutes she was being readied for an emergency operation to stop the bleeding from the ectopic pregnancy that had ruptured and was haemorrhaging into her abdomen.  This involved removing one of her fallopian tubes and ovaries, and it saved her life.

I remember vividly feeling that we had done a good job that afternoon.  We had recognised a sick patient, rapidly resuscitated her, diagnosed her condition, and organised with our colleagues in gynaecology to transfer her to their care in quick time for her definitive life-saving treatment.

I also remember vividly the intense disappointment I felt when Audrey complained 2 months after her attendance.
Nowadays, I have the opportunity to review all the complaints and compliments that come to our Emergency Department, and we have learnt a great deal from all the feedback we receive.

Audrey's complaint was very articulate, and highlighted something we now take very seriously in our service.  Audrey described how grateful she was for being seen quickly and treated so efficiently during her emergency admission.  However, she also pointed to the fact that she never got the chance to see Bill, her husband, before she went to theatre, and that no-one stopped to ask her how she felt about being pregnant, or losing her pregnancy, or indeed what her condition might mean for their future fertility.

Nobody seemed to be too interested in what mattered to her. 
I had that chance when she hinted at how they had been hoping to fall pregnant, and in my rush to provide efficient care, I omitted to provide compassionate care.

There will be a view that the former is way more important than the latter.  However, I think that we should strive to provide both.  This is not a natural ambition for many doctors - we are traditionally recruited on our ability to retain vast amounts of information and apply scientific process - but I would argue that if we emphasise the need to recruit and train for values as well as knowledge and skill, we have a good chance of providing excellent and compassionate care.

It also requires regular feedback from patients about how we are doing.  In the ED, we have patient feedback leaflets and have had patients come to teaching sessions to describe their experiences first hand.  To improve how patients experience our service, we need to know when we are doing well as well as when we are not, as the more positive the staff feel about their work, the better the patients' experience will be.