Case report examples
The following are three examples of interprofessional collaboration. The first outlines a potential system error and the second a new leadership process. The third is a case study submitted by an IPE student. From the first two examples you can see the broadness of the scope of interprofessional working that you might consider, and that we want you to recognise both positive and negative aspects. The third example illustrates the depth and breath of considerations and personal reflections you might like to explore.
1. Intensive Care Patient
A middle aged gentleman had been in intensive care for three days, having been brought in by the emergency services with a suspected major stroke. The medical team is at the end of the bed talking to his wife about further treatment - which they believe was futile and are suggesting that life support is withdrawn. A new doctor in the team asks the group: ‘has anyone checked if he is in there?” and then goes up to the patient and says: “If you can hear me Mr Jones please blink”. The patient blinks. He has locked-in syndrome and has been fully conscious throughout the past three days*.
A communication assessment by a speech & language therapist, if carried out, could have alerted the team early on to the patient’s ability to communicate.
*Story recounted by the patient. BBC World Service 2 July 2014
2. Patient Safety First: The leadership intervention – Newham University Hospital.
Project aim. Patient Safety First was a voluntary campaign led by NHS clinicians and managers with the aim of encouraging trusts to effect measurable changes in practice and culture. This leadership intervention was designed to encourage boards to put patient safety as their highest priority, to lead by example and to effect change for the better.
Why this project? The culture of an organisation can have a significant impact on patient safety and the quality of care received.
Approach. Leadership walkarounds consisted of the chief executive, the chief operating officer or the chief nurse touring the wards with the associate director of nursing, patient safety programme manager, the matron and key members of the medical team. The walkarounds were as multidisciplinary as possible, with all members of staff invited to comment, whether they were therapists, physiotherapists, porters or part of the housekeeping staff. This allows representatives from all staff to have face-to-face contact with the executive team and suggest areas for improvement.
Outcome. Awareness of patient safety was in each clinical area - and staff were empowered by seeing changes made for the better following their suggestions.
( Human Factors in Healthcare A Concordat from the National Quality Board. http://www.england.nhs.uk/ourwork/part-rel/nqb accessed July 2014).
3. Example IPE Write Up from 4th Yr MBBS 2014/15:
The Event
I was on an Ophthalmology attachment. I had been sitting in with a Consultant all morning on a Medical Retina Clinic. To expand my knowledge, I left the clinic, went across the corridor, to go and observe a Fundus Fluorescein Angiography.
I stepped into the Angiography room, as I mentally prepared to ask the Ophthalmic Photographer permission to observe the procedure – but was confronted by a scene I did not expect. I immediately noticed the seated patient looked dangerously unwell. Her eyes were open and staring up at the ceiling, and her head was lolled back into the chair. She was unconscious and unresponsive. I could sense there was an urgency – which, in all honesty, was bordering on panic – about the Opthalmic Photographer and the nurse. They were both standing over the seated patient, attempting to rouse the patient. The patient was very still, and there was no chest rise – no inspiration. The patient’s husband was also in the room, and I thought he looked extremely distressed.
“Get the crash team!” The Ophthalmic Photographer said to the nurse, and the nurse pushed the big red button on the wall.
If I’m being honest, I was a bit shell-shocked, and froze for a moment not knowing what to do. Although I have limited experience of dealing with a few cardiac arrests whilst on ambulance shifts, this was the first time I had seen it in hospital – and I was unsure of myself. Not only that, I was acutely aware there was no doctor present to tell me what to do.
“She’s having a cardiac arrest!” The Ophthalmic Photographer said to me, as I helped put an oxygen mask on the patient.
In that moment, both the Ophthalmic Photographer and the nurse looked to me, as if they were waiting for me to take the initiative. I realised they both thought I was a doctor, not just a medical student. I felt a heavy weight of responsibility slam down on my shoulders – and I took a few moments to decide what to do. In other words, I hesitated. I informed them I was not actually a doctor, and asked if there was any way I could assist. The Ophthalmic Photographer asked me to go and get an actual doctor.
I hurried across the corridor and burst into the consultant, as he was in the middle of examining a patient. He was intimately close to the patient’s eye, and I was sharply aware that I was disturbing a difficult part of the examination. He looked angry that I was interrupting, which made me hesitate.
“Can you come with me now,” I said forcefully. “There is a patient having a cardiac arrest.”
It felt bizarre to give an order to a consultant, but he jumped out of his seat and came with me. It is the first time in hospital I’ve ever ordered anyone to do anything, and it just so happened I was ordering a consultant eye surgeon to follow me! Because I was anxious and flustered, my tone of voice was a lot harsher than it should have been. Obviously I was justified, but still I was apprehensive of how he would respond to that once the emergency was over.
Analysis and Evaluation
System – The above emergency example shows some interesting facets of culture and hierarchy within a hospital. When the Ophthalmic Photographer and nurse thought a doctor (me) had arrived I felt the responsibility to lead shifted onto me, but the moment they knew I was a medical student I felt as if the onus swung back onto them.
When I went to get the consultant, I felt awkward about interrupting his examination of a patient, and then effectively commanding him to accompany me. It is senseless to think in an emergency situation that I would even hesitate in such a way, and I must acknowledge that the hesitation was due to my own short-comings and lack of confidence – but I think most medical students would be apprehensive about interrupting a consultant mid-examination. It does show how entrenched hierarchy is within hospital culture. I think hierarchy is important and leads to optimal team-working, but this example shows there are moments when hierarchy and protocol need to be over-ridden.
Human Interactions
I feel I was too indecisive, and I should have been more assertive. But this was a useful experience, and will make me more decisive in the future. I am disappointed that I hesitated when communicating with the consultant, because of my own lack of confidence – but I think what I did communicate was effective. Albeit, my tone was a lot sharper and harsher than it should have been. But this, again, I put down to my own inexperience and feeling out of my depth.
Once the event was over, I apologised to the consultant about speaking to him in such a commanding voice, and fearfully awaited a serious dressing down. But thankfully, he jokingly said, “That’s the only time you’ll ever be able to speak to a consultant like that!”
Fortunately the consultant could see the funny side of the incident (the patient was not as unwell as we all first thought). The incident definitely “broke the ice” between us, and he was a lot more enthusiastic and forthcoming with me for the remainder of the day.
Environment – nothing further to add
Equipment – Oxygen mask was effective and functional, crash trolley promptly arrived with crash team
Personal – As mentioned above, this incident taught me a fair amount about my own lack of confidence and assertiveness – but these are things I can improve.
I do think the consultant was initially angry that I’d dared to burst into his examination and interrupt him. But afterwards, I realised he actually respected me for the way I handled the situation.
Conclusions
This event does make me apprehensive about being a doctor, as in less than two years I will have to deal competently with similar situations – and I will not be able to go and find someone else to take responsibility. The onus will be on me to show leadership. I need to grow in terms of assertiveness, confidence and capability before then, but this experience will certainly help that. I feel like the road to becoming a competent doctor is long, but this is another significant step along that great journey.
