If you continue without changing your settings, we’ll assume you’re happy to receive all cookies from the BMA website. Find out more about cookies
When you visit any web site, it may store or retrieve information on your browser, mostly in the form of cookies. This information might be about you, your preferences or your device and is mostly used to make the site work as you expect it to. The information does not usually directly identify you, but it can give you a more personalised web experience.
Because we respect your right to privacy, you can choose not to allow some types of cookies. Click on the different category headings to find out more and change our default settings. However, blocking some types of cookies may impact your experience of the site and the services we are able to offer.
These cookies are necessary for the website to function and cannot be switched off in our systems. They are usually only set in response to actions made by you which amount to a request for services, such as setting your privacy preferences, logging in or filling in forms.
You can set your browser to block or alert you about these cookies, but some parts of the site will not then work. These cookies do not store any personally identifiable information.
These cookies are required
These cookies allow us to know which pages are the most and least popular and see how visitors move around the site. All information we collect is anonymous unless you actively provide personal information to us.
If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance.
These cookies allow a website to remember choices you make (such as your user name, language or the region you're in) and tailor the website to provide enhanced features and content for you.
For example, they can be used to remember certain log-in details, changes you've made to text size, font and other parts of pages that you can customise. They may also be used to provide services you've asked for such as watching a video or commenting on a blog. These cookies may be used to ensure that all our services and communications are relevant to you. The information these cookies collect cannot track your browsing activity on other websites.
Without these cookies, a website cannot remember choices you've previously made or personalise your browsing experience meaning you would have to reset these for every visit. In addition, some functionality may not be available if this category is switched off.
Our websites sometimes integrate with other companies’ sites. For example, we integrate with social networking sites such as Twitter and Facebook, to make it easier for you to share what you have read. These sites place their own cookies on your browser as a result of us including their icons and ‘like’ or ‘share’ buttons on our sites.
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
Read the blog and follow @TheSecretDr on Twitter and on Facebook
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’