Communication - Critical Incident
Situation
Week three into a 5 week placement on a
cardiorespiratory ward at a major tertiary hospital. I had been struggling to
find my feet in the busy environment with so many acute patients. I felt I was
starting to get the flow of the multidisciplinary team interaction and was more
freely asking questions and giving hand-overs to the medical professionals.
Task
Mobility and respiratory assessment of an
AAA (abdominal aortic aneurism) repaired via EVAR (endovascular aneurism
repair) 2 days post operation.
Action
I had initially seen the patient briefly
the day prior in HDU as the patient had been flagged by the anesthetist as an
aspiration risk secondary to a complication during extubation. The patient had
been suctioned and placed on precautionary antibiotics. He had been on 4L O2
but weened the day prior by nursing staff. Following protocol, I checked the
chest xrays, blood results and the patients observation chart.
Obs// BP 144/90 HR
70(SR) Temp:
Afeb
Bloods: Hb 112 trending up WCC 10.2 trending down
Resp: RR 16 Cough
– strong, dry, non-productive (effective)
CXR – Nil since surgery
I was a bit concerned as I had not
mobilized a vascular patient before and made sure I gave a hand-over to the
vascular physio to get some advice regarding precautions and contraindications.
Her advice was to go slow at all times. If I was in doubt, stop the assessment
and get assistance. The biggest issue when mobilizing a vascular patient is
vasovagal syncope, fainting caused by a drop in systolic pressure or a rapid
change in heart rate, which affects the vagus nerve (Vaddadi, Corcoran &
Esler, 2010). As the patient had been up mobilizing independently she did not
think this would be an issue but said to check seated and standing blood
pressures as a precaution. The patient had medical clearance and I had checked
in with the nurse to make sure she had no concerns with the assessment. She
gave her okay and I prepared the pulse oximeter and stethoscope for the assessment
and treatment session. I entered the patients bed area in HDU and found he
resting in bed, dressed but tired. I asked if the patient remembered me from
yesterday. He did but I reiterated that I was a student physio. I gained
consent for treatment and said I just wanted to check his heart rate, SPO2 and
blood pressure before we proceeded. He agreed and sat up over the edge of the
bed. I placed the SPO2 monitor on his finger and applied the BP cuff to his
right arm. I went through my subjective questioning as we waited for the
results and the patient reported some LBP dull constant ache 4/10, nil SOB,
dizziness or nausea. The patients vitals were currently BP 140/90, HR 74 and
SPO2 96% on room air. I asked the patient to stand up and re-inflated the arm
cuff for a standing BP reading. The patient complained that the cuff felt too
tight so I loosened it and applied it to my own arm for a reading and gauge if
the arm pressure was tolerable. I turned to look at the screen to get a reading
and thought I noticed the patient sway as I turned. I looked back and asked if
he felt any dizziness or nausea. The patient was unresponsive. He then began to
have a severe right sided facial twitch. I sat the patient down and called for
help from another physio nearby. She pressed the nurses call button and went
for assistance. The patient then began to have severe right sided facial and
neck spasms and started to cough uncontrollably. He sounded like he was
chocking so I pressed the emergency call button and waited for assistance. The
crash cart arrived and I left the patient upright SOEB with the medical team.
Result
This was the first occasion that I have had
a negative medical reaction to an assessment or treatment that I have given. I
was left shaken and unsure if I had done anything wrong. I was reassured by all
staff members that I had acted in accordance with policy and had to document
the event in the patient integration notes. I wrote a draft and ran it past my
supervisor who assisted me in clarifying some details and improving the overall
structure of the documentation. Later that day I found out that the patient was
reviewed by the neurological department and concluded that he had trigeminal
neuropathy a condition that can occur with vascular compression and hyperactivity
of cranial nerves Love & Coakham, 2001)
Evaluation
On reflection, I was confident that I had
conducted the assessment as per protocol and with the necessary medical
approvals. I had consulted a more
experienced physio and was well prepared for the assessment. The only issue was
that I had left the patient standing while I turned to look at the blood
pressure monitor. I feel this was a moment when my patient could have collapsed
and I would have been unprepared. Pressing the EM button was neccessary but I could have also called out for help. Keeping the patient seated was a positive point as it decreases the chance of intercranial pressure in case of a brain haemorrage or infarct.
Strategies
Patients can collapse at anytime. No matter
what their status, if you are the treating therapist their safety is your
priority. Make sure every step is checked and double checked – socks, breaks,
drains, telemetry, charts, medical clearance etc– because if a patient falls
and there is a gap in the process, it will come down to poor practice and could
be devastating for you and the patient.
References
Love, S.
& Coakham, H.B. (2001). Trigeminal neuraligia: Pathology and pathogenisis. Brain,124, 2347-60. Retrieved from
Pubmed on 15th June 2013.
Vaddadi, G. G., Corcoran, S. J., &
Esler, M. M. (2010). Management strategies for recurrent vasovagal syncope. Internal Medicine Journal, 40(8),
554-560. doi:10.1111/j.1445-5994.2010.02295.x
