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You're in trouble over patient in intensive care

case history

Recently a patient requested a visit for vomiting and diarrhoea, which had lasted a day. The patient was 31 years of age, fit and well and on no medication. You suggested taking plenty of fluids and letting you know in two days if he has not picked up. Later in the week, his wife makes a routine appointment to see you and says she is furious – he is currently in the intensive care unit on a ventilator and she says it is all your fault. How do you respond?

Three GPs share their approach to a practice problem

Dr Richard Stokell

'More patients to see now – can I concentrate?'

As GPs we are bombarded daily with disorganised and mainly minor complaints. Inevitably, things quite often get worse in an unpredictable way. The best we can do is to try to make an appropriate initial assessment of the symptoms and offer a safety net in the form of advice about what to do if things get worse and what to watch out for.

The first task in this case is to listen to the relative's narrative, encouraging her to describe how the illness evolved and how much she knows about the patient's current clinical condition.

I would avoid challenging any assertions that she makes blaming me for the course of the illness or seeming to exaggerate the severity of the symptoms at the time he presented to me. I would also try to remember that she is very upset and worried and maybe even feels partly responsible for what has happened.

I would reflect my own emotions by telling her how shocked and upset I was to hear what had happened and explain that I clearly needed to know a great deal more about the case to understand what had happened.

I would also ask how she was managing, and offer support to her and her family.

I would suggest that I need to contact the hospital, to find out some more information and arrange to keep in touch to follow up how her husband is getting on over the next few days.

Now I have some more patients to see – can I concentrate? Perhaps a cup of tea and five minutes' thinking time is worthwhile, even if I'm now running rather late.

My next job is to review my own records of the telephone consultation. Hopefully all is clearly recorded and this isn't one that got forgotten when another interruption occurred. A useful backup that I would have available is the recording our telephone system makes of all calls, which I would be able to refer to.

A telephone call to the hospital consultant to establish the details of the case would be worthwhile. I would also look on the patient's electronic health record through which I can access all his test results and diagnoses from secondary care.

After this I need time to reflect and practice partners are often very helpful for this. Is this just bad luck or did I fail to consider something specific to this patient which would have influenced my decision? Would things have been any different if I had seen the patient at the time?

Such an experience is bound to have an effect on my subsequent practice – a more cautious approach might have some benefits, but defensive medicine can get in the way of good day-to-day primary care.

Dr Tonia Myers

'Ignore accusations and express shock and sympathy'

Oh dear, my nightmare scenario – to be confronted by an angry patient about a serious adverse event, without any prior warning. My first reaction would be to ignore the accusations and simply express my genuine sympathy and shock.

I would gently fact-find about the actual sequence of events to see what, if anything, could have been done differently. In my experience, the family member usually calms down and recounts their story of how he ended up in hospital.

I would check my computer records, first as a reminder of the consultation for myself and, second, to check for medicolegal purposes. I usually document telephone advice in detail, but I may have been distracted in a busy duty doctor surgery.

I am actually very wary of patients with diarrhoea and vomiting because even fit patients can get dehydrated within hours if they have profuse symptoms. Often patients don't want to drink because it just 'comes out'. I tell them to take sips of water ever few minutes and to watch urine output.

I specifically warn of the risk of dehydration and the possible need for IV fluids if they don't keep adequate fluids down. This usually frightens them into drinking!

Mr X may have ignored my advice and lay in bed quietly dehydrating without seeking attention. Did they call again as advised or did he just deteriorate unpredictably rapidly? How did he get to hospital? It is not clear if I spoke to Mr or Mrs X. If it was Mrs X she may have an entirely different recollection of our conversation. Hopefully the contemporaneous records will clear up any doubt.

Whatever the scenario, it is important not to get drawn into a discussion of blame or to become defensive, as this would make the consultation increasingly dysfunctional.

I would find out how Mr X is doing now and express my sincere wishes for his speedy recovery. I would ask her to let me know how he is progressing. I would explain that if she is dissatisfied she could follow the practice's complaints procedure.

Hopefully Mr X will recover, otherwise I can expect my actions will be the subject of further scrutiny. Complaints are always upsetting, even when you have done nothing 'wrong', but even more so if you have. I will debrief with my partners, to help diffuse some of the stress such events cause.

Dr Mabel Adhagiuno

'Log the event so all the practice can learn from it'

I sometimes hate the benefit of hindsight. You learn good lessons but at times it can

delude you into thinking you would have done things differently. As I prepare to respond to her these thoughts would be flashing through my mind.

Acute vomiting and diarrhoea are such common symptoms and, with a history of a day's duration, suggesting to a fit and well patient to 'take plenty of fluids and let me know if you do not pick up' is reasonable advice. But I would like to think that when the patient phoned me I had established why he was requesting a visit.

After all, vomiting and diarrhoea are such common well-known symptoms and patients do not usually request a visit unless there is something troubling them.

Sometimes they cannot articulate what this 'something' is. I would ask myself if I had done everything in the phone call to establish that the patient had an acute, self-limiting, innocuous problem or had I failed to unearth pointers towards a more serious underlying problem. Did I document the telephone consultation and can I demonstrate that I had taken reasonable steps in his management?

The downside of telephone consultations is that there is no way of confirming the diagnosis by examination and there is an absence of visual clues. Ultimately, if the patient had not been satisfied with the telephone advice or if his history had been unclear or sinister, then I would have gone to visit him.

My first duty is always to the patient, and although his wife has come along blaming me for his being in ITU, I am limited in discussing the details of her husband's case. Without giving too much away, I would try to understand how she perceives what happened to him. Pleading against saying anything with the excuse of patient confidentiality would not really help his wife – if anything it might fuel further suspicion that there has been negligence.

I would try to defuse the situation by inviting her to give her own account of the events. It could be that her husband minimised the degree of his symptoms – as some people do – and failed to give me a true picture of how ill he was.

I would log the event for discussion at a

future practice meeting so that we can all learn from it.

what does this teach us?

Learning checklist

• Telephone consultations often suit both patient and doctor. They are intended to ensure the patient receives appropriate advice and is seen if necessary, at the right time at the right place, not to fob off patients who really should be seen.

• Always ask to speak to the patient personally. If this is not possible, check exactly whom you are speaking to, their relationship to the patient, and their bona fides. You will need the patient's consent before divulging any information.

• Ask what number they are calling from, and where they are. Many patients call from mobiles, relatives' houses or work, and you may get cut off, or need to check something later.

• Have to hand any information you may need from the computer or paper records, or other sources of reference. Abort the call if you need further information, and tell the patient you will ring back when you have it.

• Don't agree or refuse any request made early in the consultation – ask to come back to that, and say you'd like to find out more about the problem first.

• Take a full history and specifically ask about the patient's ideas, concerns and expectations. Summarise these back to the patient for verification, and ask if there is anything else they need to tell you or ask.

• Consider all possible explanations for the patient's symptoms, and ask further questions or see the patient (what are the non-infective causes of vomiting and diarrhoea in young fit adults, and what danger signs should you specifically ask about?).

• Be alert for non-verbal cues – tone of voice, pauses, repetition of concerns or questions (implies non-reassurance).

• Use empathy deliberately and explicitly – the patient may not infer it, and may become defensive or hostile if he feels you're not interested or don't care.

• Suggest options, and outline the pros and cons of each from the patient's point of view.

• Be flexible – if patient requests a visit but can get into surgery at a time convenient to them or their carer, create an appointment to suit.

• Give detailed and specific advice if you are not going to see the patient, including 'red flags' – when and why they should seek further advice (including out of hours). Check whether the patient has fully understood and ask if they are happy with the advice.

Melanie Wynne-Jones is a GP in Marple, Cheshire

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