It’s four in the morning. It’s been a long night… I know, believe me. But before you discharge the 60 year-old man who came in gasping for air a few hours earlier, take the time to consider a few things.
- Listen to the history, the patient may tell you the diagnosis. Having to get out of bed at night to stand up and breathe, and frequently passing urine at night, might bring to mind the simple equation:
paroxysmal nocturnal dyspnoea + orthopnea + nocturia = heart failure.
- Yes, he smokes like a chimney, but less than a quarter of smokers develop clinically significant chronic obstructive airways disease. It seems that many people are resistant to the ravages of cigarette smoke on their lungs. “Not all that wheezes is asthma” – remember that old chestnut?
- Hold back from assuming that changes on a chest radiograph are “chronic” just because the patient is a smoker and that life would be easier if it were so. After all, the patient has never had any respiratory problems before and you don’t have an old chest radiograph to compare to.
- Interestingly, the patient has just returned from a long stay in sub-Saharan Africa. A red herring perhaps, but maybe this isn’t “just” a run-of-the-mill case of bronchitis?
- When a 60 year-old man who never goes to the doctor (unless a gun is held to his head) comes to A&E in the middle of night, assume SOMETHING serious is going on, even if you don’t know what it is yet.
- Think carefully before discharging anyone home with abnormal vital signs… Even if the abnormalities are “just” a tachycardia of 120/min and hypertension.
- NEVER say to a patient, “this is an accident and emergency department – your condition is not classed as an emergency…” before discharging him without a discharge summary or advice about what to do should his condition deteriorate.
Taking heed of these considerations might help you to care for your patient. You might avoid misdiagnosing the patient’s myocarditis and acute pulmonary edema as “bronchitis”. You might avoid sending home, in the cold dark hours before sunrise, a patient who doesn’t know where to turn when his condition worsens – because he is “not classed as an emergency”…
I know it is all too easy in retrospect. But there may be times when have but one chance to do things correctly. Thus we must strive to learn from our mistakes, and from the mistakes of others.
Start out with the conviction that absolute truth is hard to reach in matters relating to our fellow creatures, healthy or diseased, that slips in observation are inevitable even with the best trained faculties, that errors in judgement must occur in the practice of an art which consists largely in the balancing of probabilities; – start, I say, with this attitude in mind, and mistakes will be acknowledged and regretted; but instead of a slow process of self-deception, with ever increasing inability to recognize truth, you will draw from your errors the very lessons which may enable you to avoid their repetition.Sir William Osler, from “Teacher and Student, Aequanimitas”.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.