Reflective Practice - some examples

Having worked recently on an e learning module on Reflective Practice, and with some superb trainee doctors in producing pieces of reflective writing, I wanted to share some of those with you.

There are three pieces of writing demonstrating the DEBRIEF guide for writing up reflections on clinical practice. I want to thank the trainees involved for their hard work and for being willing to share these pieces in various quarters.

Reflection 1:Massive haematemesis

Situation-ITU resident on night shift.

The case (Describe what happened)

We had a fifty one year old gentleman with NASH who had presented with haematemesis on our ITU outreach list. He had presented on the Friday with a litre of haematemesis witnessed in A&E. There was no gastro on call over the weekend so he was waiting for his scope on Monday. Soon after starting my night shift, I was asked by the med reg to come and see him as he had just had another episode of haematemesis of about 1L.

When I got there, he had just been reviewed by the surgical registrar and looked unwell. As I went to examine him, he vomited again- about 1.5L over my shoes and on to the floor. I asked for help, assessed what kind of IV access he had and squeezed the bag of blood that was up. A nurse soon arrived and the surgical reg. I asked them to fast bleep the anaesthetist on call and someone went to look for a Sengstaken-Blackemore tube.

The SB tube was put down which stopped the bleeding and more blood was ordered. The plan was to take the patient to theatre and do an OGD. I left the patient with the surgical registrar and the anaesthetists and went back to the unit. They would contact me if there was any deterioration and we made a bed available for the patient post-theatre.

A few hours later, I was called by the medical registrar on call to say that they were in the process of trying to get the patient transferred to the tertiary centre Liver ITU. The SB tube balloon had been pulled out and the surgeons on call could not band varices and there were no gastroenterologists available. I went back to the ward to assess the situation.

The patient now had an arterial line and a CVP line. The SB tube was back in place. The patient was still receiving blood and blood products. I spoke to the tertiary centre  and they accepted the patient for transfer. It was decided that the patient should be intubated for transfer and that it was best to do this on the ward rather than transferring him up to the unit first. The surgical registrar, medical registrar, anaesthetic SHO and registrar and the ITU consultant (over the phone) were all involved in this decision.

There was delay in intubation so that after the SB tube had been removed, the patient vomited blood again and then arrested (PEA). It was a difficult intubation but successful and the SB tube was then re-sited. The patient received 3 cycles of CPR with adrenalin and atropine with return of spontaneous circulation. The initial BP was 100 systolic. The patient’s daughter arrived soon after the start of the resuscitation but did not stay for long to observe.

The situation was again discussed with the tertiary centre  and consultants at home (anaesthetic, medical, ITU) and with the staff present (anaesthetists, surgical reg, medical reg, site managers, nurses) and it was felt that although the patient was unstable, transfer to a unit with staff to do oesophageal banding was the only option that offered some chance of survival. There were conflicting opinions about this but this was the consensus that was reached.

The patient however was not able to maintain his BP, despite boluses of adrenalin and ongoing transfusion. The BP was barely maintained at 70 systolic. The situation was re-assessed and it was decided that transfer was no longer an option. The family had not yet been spoken to. I was nominated to speak to family, with the medical registrar.

The family (wife, daughter, son) understood that the situation was serious and that we had tried to get the patient stable enough for transfer to a specialist unit but that this had not been possible. They wanted active treatment but understood that this was likely to be futile. I explained that the patient could either be brought up to ITU for ongoing support but that the outcome was likely to be poor. The alternative was to keep the patient comfortable on the ward. The family decided that they wanted the patient to be kept comfortable on the ward.

The situation was then again discussed with the members of staff present and with consultants over the phone. The consensus was that treatment should be stopped and the patient kept on the ward. He died soon thereafter with his family at the bedside.

My evaluation (E)

Things that went well: good communication between different members of staff, good decision making process, patient’s best interests always foremost, dignified death at the end.

Areas for improvement: awareness of ward nursing staff of seriousness of situation, hospital logistics (availability of SB tube), delay in intubation, out of hours gastroenterology availability.

Feelings (Bring out feelings, values, beliefs, assumptions etc)

This case left me with a feeling of slight unease; whilst I knew we had done all we could – and we had facilitated a clam and dignified death at the end of the process, I just felt like we could have been slicker in our management. I was frustrated by the nursing staff who did not seem to grasp how ill the patient was. I could feel myself getting angry with the lack of availability of the equipment and the out of hours gastro cover system. I felt like I was doing my very best for this patient but around me the staff and the hospital infrastructure were taking it all at a much more casual pace. We work hard and intensively and when that is not matched by the system or other colleagues it can be infuriating.

Review (Review in light of previous experience; how would someone else have acted?)
 

I have treated patients with similar problems before and have also been with patients at the end of their life. I think the reason this case affected me was because I felt overpowered not just by the inevitability of the patient’s death, but also by the small inefficiencies of the hospital system.

Identify learning points (I)

Communication between everyone involved in case is vital - staff present but also other centres and consultants over the phone, consensus in decision making is important and not easy, but sometimes we cannot always offer patients the care they need or we would like to offer.

Establish follow up actions (E)

The equipment issue is something I can do something about so I intend to do process mapping on such essential pieces of kit, and ensure that there is a system in place to have all kit kept fully stocked and up to date for future cases.

Further reading/ study: STEP Case of the month: http://estepcore.rcseng.ac.uk/secure/cotm/view_case_html?case_id=55

Feedback (Feedback on actions)

I have spoken to my consultant about the equipment project and he suggested I could submit the results as a Quality improvement Project to the next QIP conference the Deanery run.

 Reflection 2: A&E

Describe events

During a night shift on call I was in theatre with a locum SpR assisting with a laparoscopic appendicectomy. The trauma bleep went off and it was announced that the call was a code red - meaning that there was an unstable patient. I left theatre and went to A&E. On arriving in resus, I found the rest of the trauma team (A&E consultant, orthopaedic SpR and nurses) with a 19yr old male who was intubated and ventilated, who had been transferred from another Hospital, following stabs to the left arm, chest, buttock and thigh. He had a systolic blood pressure of 60 and a tachycardia of 152 bpm and the A&E consultant asked me to insert a chest drain, which I did. As I had missed the primary survey (because I was in theatre), and the patient was unstable I reviewed it for myself and then suggested that a stab check was done - on removing the left arm bandage I noticed that the patient was exsanguinating from a lacerated brachial artery, and he had blood going through a cannulae distal to this in his left forearm which was why he was not responding to fluids. I applied a pressure dressing and asked the A&E consultant to call the surgical Trauma Consultant on call and ask him to attend. The consultant was there in 20 minutes and a tourniquet was applied and the patient went for a CT angiogram and then straight to theatre.

Evaluation

On reflection, I think the team worked well and quickly together once we had realised what the problem was. There was clear communication between each member of the team and life threatening issues were dealt with quickly and efficiently, even though we only had limited staff available.

Bring out emotions etc; Review in light of previous experience

Given my previous experience of trauma I quickly knew that the patient was unwell and I realised that if we didn't quickly find the cause for the hypotension he would arrest and would need a clamshell thoracotomy, which I had never performed alone before and without the support of my SpR or consultant this would have been terrifying. I was aware of how afraid I was about the possibility of having to do a thoracotomy if the patient arrested.

Identify learning points

I learnt the importance of reviewing the primary survey if the patient remains unstable and as in this case it was easily reversible with re-siting the cannulae into a different arm. I am also glad that I did not hesitate to call in my consultant as the patient went straight from A&E to theatre for repair of his brachial artery to save his left arm. Also, I found that being in such a stressful situation as a junior SHO can be emotionally quite challenging and I continued to replay the sequence of events over again in my mind to see if there was anything I could have done differently. I realise now that if that had been necessary I could have called upon the A&E consultant.

Establish follow up actions

Following the incident, I reflected with my consultant and the A&E consultant and suggestions for improvement included applying a tourniquet earlier to the left arm, rather than a pressure dressing. I had considered this at the time, but I was not sure why I hesitated. Next time, if I think of applying a tourniquet I will just put one on and make a note of the time of application. I think that discussing the case with consultants and colleagues afterwards helped me to feel more confident and identified important learning points. The follow day I did some reading about thoracotomies.

Feedback on those actions

I intend to follow up this learning by linking this case to a future case which either covers similar clinical ground or in which there is the question of calling for senior help.

 

Reflection 3: Paediatric patient

Case (D)

A failed kidney transplant patient, he had spent large part of his life in and out of hospital even though he was only seven. He knew all about doctors and nurses, blood tests and operations. He did not like being in hospital and he did not like being told what to do.

On the morning in question, I needed to take a blood sample from him. I introduced myself as I had not met him before. He looked at me suspiciously and told me he wanted to eat his lunch first. I thought this was a reasonable request and said I would come back.

When I came back he said he did not want his blood taken. I explained why it had to be done. There then followed every excuse he could think of as to why he should not have his blood taken then. He wanted to play some more first. He wanted his mum to have her blood taken first. He wanted another doctor to do it. He wanted to go to the toilet first. I dealt with each argument but he became more and more distressed. He swore and shouted and cried and tried running away.His mother said we should go ahead. The minute the needle touched his skin, he was quiet. He stopped crying and calmly watched the blood enter the specimen tube.

I asked him why he had been so distressed. He said he had to make a fuss ‘so that I would be careful’. I said I could understand his logic but that perhaps in future he did not need to make quite so much fuss.
 

I thought I dealt with this situation well by letting the patient eat his lunch and coming back later and I was glad that I asked him why he had been so distressed, because I learned something from that. However, I could feel myself getting angry with him and only just managed to control that. (Evaluation)

I was very busy that shift and could have done without this, but something made me curious about this child’s behavior. I have to say I admired him in a way for his strategy. (B)

When I thought back over this case later that evening, I recalled talking to a parent of a sick child a few months ago and she said how much she hated her powerlessness. She said she felt as though she and her daughter were victims in the machinery of the healthcare system. That comment stayed with me, and I wondered today if this child’s behaviour over the blood sample was driven by the need to exert some power over what was being done to him. (R)

I realized that we would do well to remember how vulnerable patients feel, and that we need to earn our patient’s trust and it is often best to tread carefully at the start. (I)

When I am working with patients in future, I will endeavour to give them as much choice as possible over their care, even down to when I take their blood. (Establish Actions) I would like to look at the patient feedback forms and see whether there is scope to ask them about choices in their care. (F)