Question 1 – Critically discuss the initial history taking and assessment of Mr. Markantonakis
In every medical procedure, regardless of the type of medical practitioner (e.g. Nurse, Physician, Physiatrist, Physical Therapist, Paramedics), it is standard, at least in most medical centers that an initial history taking, assessment, and evaluation is performed. Aside from helping the practitioner paint a bigger picture of the patient’s condition and diagnose, and do medical procedures based on this document, medical documents such as this serve as protection for the patients (or in this case, the patient’s family), and the practitioner, should an unexpected death of exacerbation of the patient’s condition that would lead to a lawsuit occur. The initial history taking and overall assessment done to the patient in this case was not adequate. Any medical professional, upon first seeing the patient would usually start by inspecting, palpating, percussing and auscultating relevant areas, according to the report and response of the patient as necessary. In this case, these four important basic assessment phases were not performed. The medical practitioner would then perform a complete vital signs assessment, which in this case, is very applicable since the initial assumption on the patient’s condition was an exacerbation of a chronic back pain only. Vital signs assessment is generally composed of taking the patient’s blood pressure, respiratory rate, pulse rate, and temperature. Had either Ms. Bell or Ms. Moore took the initiative to perform this set of procedures, they would have discovered that there are abnormalities in the patient’s BP, RR, and PR, considering the final diagnosis was ruptured abdominal aortic aneurysm, and have realized much sooner that the patient was not simply suffering from a chronic Musculo-skeletal condition, but rather from a cardiovascular condition with manifestations of pain, which generally, in the medical field, is already considered very serious as CV conditions do not usually present with pain in its early stages. The team should have focused on asking questions like, the type, onset, and exact location of pain, what types of interventions the patient did to alleviate the pain, perform special tests (usually performed by a physiotherapist and a physician, rarely by nurses and paramedics), that would have helped in ruling out whether the pain was caused by a Musculo skeletal or a cardiovascular condition.
Question 2 – From the information provided in the coroner’s case, outline what your potential diagnoses and clinical decisions would be if you were attending Mr. Markantonakis and provide your rationale
I agree with the two attending paramedics’ initial diagnosis which was chronic back pain (an exacerbation of) because the patient was literally suffering from a pain, presumably with a pain scale of 10/10 on the back because of its unbearable quality. However, that would not have stopped me from performing objective medical assessment procedures to support and validate my impression on the patient’s case. I would perform inspection, palpation, percussion, and auscultation directly on the area of pain and possibly in nearby areas. Since the patient’s death was due to an aneurysm, I would have felt a pulsating bulge in his abdomen or what is medically known as a bruit in the area. Irregularities in the heart (heart beat) and lungs may have also been noted. Next, I would have performed a vital signs assessment. The vital signs assessment would dictate me whether the patient’s condition is severe or mild, and whether it is usual or unusual, based on my initial assumption of his diagnosis. I would have immediately noted that the initial diagnosis of an MS condition was already unusual because the patient must have had an abnormal HR, PR, and BP readings because of the already ruptured aneurysm. This would have raised my consciousness and awareness that the patient’s condition is not something normal and addressable at home. Using my clinical decision making, I would have immediately suggested that the patient be brought to the nearest hospital with the shortest waiting lines in order to have his condition checked. I would have also been suspicious that time that the condition was a ruptured abdominal aortic aneurysm even without using ancillary procedures that would have accurately confirmed the patient’s condition. I personally think that even if one of these two-part standard assessment procedures were undertaken, the patient would not have died because finding out irregular heart beat and rhythm plus a pulsating bulge on the abdominal area would normally cause alarm to a competitive medical practitioner.
Question 3 – Discuss the style of communication used by Ms. Bell when interacting with Mr. Markantonakis and his family
Based on the recounts obtained from the patient’s family, specifically, his daughter and wife, I think it would be fair and logical to say that Ms. Bell did not know how to use effective communication in handling her patient, plus her patient’s family. A medical practitioner, especially paramedics, should know how to deal with people well, even in stressful and time-constrained situations. The scenario presented in the case was not a stressful nor a time constrained one, there were actually plenty of time to think and talk to the family, but effective, courteous, and professional communication was not exercised. What any investigator would see is a rude and impolite attitude, the opposite of what every patient would need at a time of distress. In a nutshell, medical professionals do not really need specific outlines and strategies for communication with patients, they should simply put in mind that they should be polite, firm, and professional.
Question 4 – Discuss how the handover to the triage staff at the hospital could have been improved. Provide rationales for your answers.
The handover at the triage staff could have been improved a lot. In fact, that was one of the turning points in this case. It has been established that there was a long waiting line that is why the patient was not immediately addressed and had to wait for a couple of hours. However, the paramedics could have stayed with the patient before leaving him to the hospital staff, which apparently was not capable of accommodating the distressed patient. Had they done this, they would have already been able to diagnose that this was a serious condition of abdominal aortic aneurysm and requested for proper medical attention earlier on. In theory, the two ambulance staff did nothing. They just delivered the patient to the hospital. They could have assisted the patient’s family more after arriving at the hospital and talked their way to the nurse to have the patient, suffering from the excruciating pain, checked first.
Question 5 – Discuss the assessment and decisions made regarding Mr. Markantonakis’ pain
The patient, at the beginning of the day, reportedly used a pain reliever, named Panadeine Forte, in an effort to alleviate the pain. According to the family members’ reports, this pain medication did not successfully provide relief as it would have normally done in much less serious cases. Yet, the ambulance staff advised the patient to take more of such medication.
In my opinion, I would not advise or even prescribe a pain medication (If I am a physician), or pain managements as long as I do not have a good grasp of what is causing the pain. The staff administered cryo therapy or any intervention that uses cold modalities to the patient’s back. Such interventions are usually effective only in musculoskeletal conditions because they delay the body’s inflammatory response. For a patient suffering from a late-discovered aortic aneurysm, cryo therapy would definitely not be effective aside from providing a little relief because of the numbness. I would have assessed the patient first and if it was already clear to me that the pain is possibly due to aortic aneurysm rupture in the abdomen, I would have given necessary pain medications such as coagulants and pain relievers to prevent excessive bleeding if the aorta has already been rupture and provided that I am accompanied with a licensed doctor. I would have also applied icing techniques to cause vasoconstriction on the area and prevent excessive loss of blood while the patient is being transported to the nearest available hospital. Besides these, I do not think there are any other possible pain management procedures that could significantly help the patient because ruptured aneurysms often require surgical treatments already.
References
Beam, R. (2005). A Dynamic Approach to Hospital Wards Management. Journal of Nursing Mgt.
Bond, S. (2004). Sociology and Healthcare. Churchill: Livingstone.
Earl, D. (2005). A Comprehensive Physical Assessment Standards. Journal of Health Care Mgt.
Khan, S., & Stansby, G. (2004). CSF Drainage for Thoracic and Thoracoabdominal Aortic Aneurysm Surgery. Cochrane Database of Systematic Reviews.
Mart, T. (2003). Healthcare for Cardiovascular Patients. Journal of Healthcare Mgt.
Pepper, J. (2010). Manufacturing and placing a bespoke support for Marfan Aortic Root. Interact Cardiovasc Thoracic Surg.
Robicsek, F., & Thubrikar, M. (2004). Hemodynamic Considerations regardng the Mechanism and prevention of aortic dissection. Ann Thorac Surg.
Thunder, R. (2006). Managing and Detecting Aortic Aneurysms in Geriatric Patients. Journal of Cardiovasc Mgt.
