Rural 1 Friday afternoon panic

I thought I’d share with you a situation that occurred on a medical ward that, to me, really hit home the importance of interdisciplinary approach and good communication, as well as respect for others’ medical opinion. The patient was an elderly gentleman who was day 7 post a dynamic hip screw as he had sustained a NOF fracture due to a fall. He had also developed mild post-op complications which had resolved but left him weak.

He lived at home alone. He did not receive any home services but had 2 supportive grand-neices. They held strong values against the idea of nursing home or hostel care and they were to help with all ADLs. However, one of them had very recently undergone abdominal surgery. As it was, he was 2 mod assist for transfers and ADLs, and he suffered from dementia and was often very confused. However, his medical condition was stable, so the medical team was pushing for discharge.

Wednesday, the social worker had started an ACAT and had entered in the notes that there were a few home services she deemed appropriate that she couldn’t get organized before the following Wednesday. Thursday, the physio (my supervisor) had entered in the notes his mobility status and had written “not at pre-admission level”. Friday, this patient is on my list, and (very unfortunately for me) I get around to him at around 3.30pm. An entry for Friday from the medical team says amongst other things “For physio mobility r/v” and “planned for discharge Saturday”. I go to do this mobility r/v but the drowsy and confused patient refuses treatment. I turned to my supervisor for help. The medical team had somewhat put her in the awkward position of asking for her medical opinion of his mobility status, even though her entry of the previous day said “not at pre-admission level”, while at the same time pushing for discharge the following day. And the patient wasn’t cooperating. At 4.00pm on Friday. My supervisor and the social worker are a little concerned at this stage about discharging this patient, who was 2 mod assist, didn’t yet have home equipment, and had a carer who had just undergone abdominal surgery. Paging the medical team at what is now close to 5pm on Friday is fruitless. It turns out that the social worker knew of the medical team’s impending discharge as early as Wednesday and had tried to page them on Wednesday, again with no reply.

The eventual outcome was really… not much. Both the social worker and the physio documented that they had tried to page the medical team, but had received no response. The physio also documented that the patient was drowsy, confused, had refused physio and was not at pre-admission level. On Monday, we found that he was indeed discharged on Saturday, and I really have no idea whether this family coped or not.

I reflected on this situation searching for some ideas on what any of us could have done better. It was very unfortunate that I got around to this patient so late. If I had gotten to this patient sooner in the day, I’d like to think that the medical team may still have been contactable. I’ve since learned to try my best to read all the notes in the morning, talk to the nursing coordinator, and prioritise my day’s load. Since doing that, I’ve managed to avoid another sticky situation. I think sometimes it’s difficult as a student because your presence is not really noticed as much as the physio, and the nursing coordinator may not keep you in the loop as he/she may (or may not) have done with the physio. I’ve learned to talk more to nurses, doctors etc, and they’ve responded well, including me in latest developments by word of mouth, rather than my finding out through notes.