I am an F1 staring at an ECG. It looks like it is probably ‘OK’. I mean, sure there is some left bundle branch block and maybe evidence of left ventricular hypertrophy, but nothing that wasn’t there before. I hold the last ECG that I could find in the notes next to it. Yes, I agree with myself, nothing new here.
The nurse had mentioned in passing that the cardiac monitor kept alarming, to say the patient was in a ventricular tachycardia. That was not the case. And, the nurse who mentioned it didn’t think so either. But she had told me, so I felt obliged to say ‘something’ and I said to get a 12-lead ECG.
I’m not really sure what I expected to see or what relevance the investigation had, but I scrawl my name at the top of it and my GMC number. Proof that it has passed through my hands. Proof of my responsibility for it.
I write a line in the notes to say that the ECG is unchanged, the patient appears stable and whereas now I might think it is OK for me to write ‘plan – unchanged, no further action at that point’, instead I wrote ‘plan – continue monitoring’.
I leave the cardiac care unit to do the other jobs and the other ward I am covering. Not long after, I have returned and the sister approaches me with the open notes and an enquiring face. ‘What monitoring?’ she asks.
‘Monitoring?’ I ask, reflecting her curiosity back at her. Tilting the notes before me, she runs her finger over the line of my words and says: ‘This patient is going to the ward, are you saying they can’t, and need ongoing cardiac monitoring?’
‘No,’ I answer, because I definitely didn’t think he needed that.
‘So, then what do you want us to do?’
The answer to that question is that I want to not be scared to write ‘I think that no further action is needed currently’; even accepting that we all make mistakes and I could be wrong.
After all, we can’t keep every single patent in a cardiac monitored bed-space because we’re afraid to be wrong. And we can always be wrong.
The nurse could have just asked the registrar herself, but I was glad she didn’t. It was valuable for me to have that feedback that while writing ‘continue monitoring’ in the notes might cover my own back, that vague turn of phrase was no use to my nursing colleagues.
I asked the registrar and he looked at me with a sort of kind, but disbelieving face, smirked and said: ‘It’s fine, just send them to the ward.’ I scored through my plan, initialled it and wrote: ‘No further action at this point. Patient can go to the ward.’
By the Secret Doctor
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Well I read this and unfortunately , I am ashamed to say, I would have put "D/W Registar Dr X - No further action. Patient can go to ward".
In the current climate I would cover my back just in case. There is a big blame culture and a quick one minute check with the reg can’t hurt.
How about review the alarm trace if available to ascertain authenticity of the trigger. Then consider checking electrolytes to make sure K/Mg if there is any suspicion it was genuine VT. I think this case illustrates the all or nothing approach of no further action v continue monitoring is not adequate.
Not sure than an F1 should be making the decision on their own. This should at least be run by an SHO or an StR....
‘Not sure than an F1 should be making the decision on their own. This should at least be run by an SHO or an StR..‘. This is one of the hardest thing about being an F1 doctors - knowing what decisions we can and cannot make.. (apart from the obvious ones like discharging) they say were meant to make decisions based upon our competency but this can be so variable between F1 doctors. I often find I am having to check with the sho or reg even though I feel competent about my decisions because I am worried someone will look at my plan and say ‘ohh an F1 shouldn’t make that decision’