Reflections on a night shift in accident and emergency
Karen Fromene
PP: 035 - 036
Article Text
I am a registered nurse and have been working permanent night shift in an Accident and Emergency Department for six years. Currently, I am undertaking a Bachelor of Nursing course and during my studies I have come to consider past experiences through critical reflection. The following incident is shared in the hope of encouraging nurses to reaffirm belief in their abilities and in themselves as effective professionals.
One particular night I was about four hours into my shift when a man presented with chest pain. As was customary for me, I helped the man to undress and in the course of recording various observations, I chatted with him to ascertain what had brought him to Accident and Emergency in the middle of the night.
He told me that he had awoken that night with central chest pain which radiated to the neck and left arm. He went on to tell me that whilst walking to work (a couple of kilometres) he would experience chest pain which subsided at rest. Previous investigations had revealed nothing. The ECG I performed showed no acute changes, and the pain had subsided.
The man was a smoker and was slightly overweight; however, the most telling factor of all was the stressful occupation he held. He was a judge. The intern on duty at the time came over to allocate herself a patient and when I told her what I knew of this patient's history and background her response was 'so what?' I immediately became concerned at the intern's attitude and proceeded to speak with the duty medical registrar. While the intern examined the patient, I discussed the patient's history with the registrar and was interested to determine the criteria for admission to hospital for a person with chest pain. By this time, a colleague had entered the discussion and the registrar felt the history I had related to her was not significant. The patient had a normal ECG and the pain had subsided. The registrar had not examined the patient at this time; however, with the history I related she would more than likely discharge the patient home. My colleague and I discussed with her different aspects of the case and pointed out that, in our experience, it was most unusual for a man of his status to come to a public hospital emergency department in the middle of the night unless there was a signify cant reason for concern. He could quite probably have contacted any of his influential medical friends but he had instead presented to Accident and Emergency at a major public hospital.
Finally, after discussing the patient with the intern, the registrar rationalized that she had admitted a previous patient without a true cardiac history. She then admitted this patient to a cardiology ward in an unmonitored bed and said he could be reviewed by his own cardiologist in the morning.
The following night I came to work and was not at all surprised to hear that the judge had suffered a cardiac arrest that morning as a consequence of an acute inferior myocardial infarction. I spoke with the cardiology registrar that night and discovered that the judge had experienced a form of crescendo angina which would ultimately result in a myocardial infarction. He underwent bypass surgery three weeks later.
The cardiology registrar agreed wholeheartedly with my original thoughts-that it was unusual for a judge to attend a public hospital Accident and Emergency Department without significant reason. His pain had been severe enough to warrant a nocturnal visit. This alone should have been a sufficient indication of a more sinister problem.
After studying critical theory, reflection and critical thinking this semester, this critical incident came to mind. It is a poignant example of the need to look beyond the technical data and symptomology of a patient. As far as the medical staff were concerned, the patient had a normal ECG and was pain free. This was enough for him to be sent back home. Hopefully the intern has learnt a valuable lesson.
Nursing diagnosis is a valuable form of knowledge development, and our 'gut feelings' which come from years of nursing experience, should be recognized as significant precursors to diagnostic reasoning.
The patient should be treated as a whole person and not just as a 'chest pain'. Patients must be considered within the whole context of their life, role in society, profession, class, social history, gender, lifestyle and so on. Nurses must advocate for all patients within the context of their individualism and affirm their right to equality in health care. This is a significant part of the challenge of professionalism.
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