The purpose of this reflective essay is to evaluate a clinical incident from clinical practise, this includes the assessment, communication and management of an elderly patient with dementia in my first year as a student paramedic.
I will be doing this by examining how I assessed, managed and communicated with this particular patient. I will see how effective my overall approach was with this patient to determine my professional accountability and quality of care was with this patient and see how it will help in future practise.
Gibbs (1998) is a process of reflection which in my opinion gives me a sufficient chance to explain my feelings at the time, a detailed evaluation and analysis but then also an action plan to enable for better progression in clinical practise; hence I will use the Gibbs Reflective Cycle (Appendix A) as a model to reflect on this incident that I was involved in.
In my efforts to adhere to the professional requirement of maintaining confidentiality, all patient identifiable information has been anonymised, this is in line with the National Health Service (NHS) England Confidentiality Policy (2013), the Data Protection Act (1998) and the Health and Care Professions Council (HCPC) Standards of Conduct, Performance and Ethics for Paramedics (2012: 2).
The Incident
During one of my placement blocks in my first year as a Student Paramedic, I went to 80-year-old female who had fallen in her own home. On this case I was with my mentor who is a HCPC registered paramedic to which I will refer to as ‘H’ and another HCPC registered paramedic in which I will refer to as ‘R’. On arrival to this patient’s house a carer answered the door, explained that she was on this patient’s first call of the day and that she has found her on the floor, but it’s hard to find out why because the patient has dementia. On entering the room in which the patient had fallen, it was apparent that she has fallen or slipped from the chair. The patient was in a low Fowler’s position against some cushions in which the carer had slid behind her.
A decision made between myself and H was that I would complete a full assessment and do a history take of this patient to determine a treatment plan, doing this would aid my progression as a student paramedic. I introduced myself to the patient, in which they responded, due to this response I knew the patient had no immediate need for intervention of the airway. This patient was alert, responsive but was very hard of hearing, which meant that I need to speak louder than I usually would.
After doing my ABC’s, I moved on to conduct a top to toe assessment due to the mechanism of injury. I communicated this to patient and was able to gain consent for this assessment. During this assessment the patient expressed they had no head injury as there was no haematoma, deformity or blood and no c spine tenderness and I could feel no stepping, moving down the spine was no tenderness also, the only pain the patient was complaining of was in the gluteal region. I continued to access the pelvis and legs and the patient had slight pain in left leg but expressed it was more of a numb feeling from being on the floor for so long and I felt no abnormalities on palpation. Before lifting the patient up, I wanted to complete a blood pressure, due to still not knowing the cause of the fall. During doing this assessment, I was trying to communicate and get a history from the patient, whilst my mentor was speaking with the carer and looking through the patient’s yellow folder.
The blood pressure was within normal parameters, so we proceeded to get the patient up. To do this we required the use of the Mangar Elk which R had fetched from the ambulance. We explained to the patient what we were going to do and how the Mangar Elk worked and proceeded to get the patient off the floor and onto a sturdy chair. The patient exclaimed her thanks, but was noticeably slouching to the side, which the carer explained wasn’t normal for the patient. R conducted more observations for this patient whilst I spoke to the patient for a more detailed history take.
During my conversation with the patient, I noticed that she would repeat things again and not answer some questions with an answer of any sense, so I made the decision to ask her a quick few questions to determine mental capacity. To which she did not pass. She was not able to retain information. There was no next of kin close to the patient, and the carer didn’t know to much as their company had only just started seeing this patient.
We attempted to get this patient to weight bare and possibly mobilise, but we were unsuccessful in this as the patient couldn’t stand, and with assistance was very unsteady, due to this we decided as a three-man crew that neither one of us would be happy leaving this patient at home and decided to convey to the nearest hospital as we were not convinced that if we left she wouldn’t fall again. To extricate this patient, I decided that carry chair would be best as stretcher wouldn’t get close enough to the patient. Once on the ambulance, patient was quiet, and we were around the corner from the closest hospital, once we arrived there the staff recognised this patient as they had only just released her in the past few weeks with a care package.
Feelings
When it comes to feelings I would say that I am very good at hiding them and being able to close that section of myself off. Which in a job like this means that some may think that I could be being insensitive when I don’t react to a lady who lives alone and has no family in the same way that they react to it. My thoughts at the time of the incident were that this lady needs a bit more support than she has now, and if there was anything that I could do to help this lady right now.
The moment I remember most about this incident was that the woman was very easily swayed to think in a different direction, this was evident when trying to find out a next of kin, names were flying but as soon as another name was mentioned the lady would think that again that was the correct person who was next of kin. This worried me a little due to the fact that I thought that if we got the next of kin wrong then they would be able to control her decision but since being on this job have found that in the eyes of the law being the next of kin doesn’t mean this. (Alzheimer’s Society, 2018)
During this time as a student my scope of practise included a full history take so this is what I was doing with this patient. In this incident, I attempted to get a full detailed history from this patient using SAMPLE and OLDCARTS (Appendix B) but found it very difficult due to the onset of dementia in this patient, I could tell whether she was just agreeing with what I was saying or whether she genuinely knew what I was talking about. This meant that every piece of information she gave me I needed to confirm. On reflection, the fact of having to ask more than once allowed me to practise knowing my history take, and also getting a true history for the patient, and reassured me that we were making each decision correctly.
Communication with this patient was sometime frustrating, because she either didn’t know you were talking to her, she couldn’t hear or understand you and you repeated things over and over because she couldn’t retain any information. On scene I feel I managed to overcome these by communicating effectively with the patient in line with the Health and Care Professionals Council (HCPC) which writes “you must communicate properly and effectively with service users and other practitioners (HCPC, 2008).”
At the end of this job, although hard may it be, I felt that the patient was where she needed to be, due to at home not having all the possible care she could get. This left me satisfied with the job because there was nothing that us as a crew could do for the lady and during our time with her, we did everything that we could have done.
Evaluation
On reflection of this incident I am able to establish some positive and negative aspects of the event itself. The communication between myself and the patient could have been improved if I had recognised a need for a mental capacity assessment earlier in the process of the history take. As I stated previously the history take was difficult due to going around in circles with answers. I think that if I had picked up on this earlier the quicker and more effective the care would have been.
The assessment considers whether the patient can understand, retain and weigh up a decision, ultimately to communicate this decision back to someone (Legislation, 2005) which this patient was unable to complete. This assessment would help a paramedic to determine how to go ahead with their treatment, if a patient has the capacity to make their own decisions they can but if in this case they didn’t then the paramedic would have to make the decision with a patient’s best interest as the centre.
However, I believe that the communication between the paramedics on scene and myself was effective because we were able to determine a detailed history although the patient didn’t have the best memory, and also managed to get a diagnosis and treatment care plan for the patient quickly. It has been recorded that patient care is improved with good communication between the team that’s is in the role of care. (Paediatr, S.J, 2014)
As well as the history taking being very in depth the top to toe patient assessment was very in depth also. Not only did we check for any injuries we found out the mechanism too, whether the fall was mechanical or medical. The patient stated not being dizzy but just slipping down the chair onto the floor.
Analysis
The way that a patient and their family understand a health care professional differs, with this patient it was very unlikely that the patient understood what was being said to her as any given time, this could be due to the mental capacity of the patient or down to the literacy of the patient or any other factors. (Weiss, BD, 2007) The fact of telling the patient what is wrong or what is going to happen could cause distress for the patient.
Patients with dementia that live in their own homes tend to have carers like this patient did. Its recorded that of their dementia patients living in their own homes that 95% of them fall. (Lowery. K et al, 2000) This care company were trying to get this patient into a care home due to the amount of falls she was having, living in a care home would mean that if the patient was to fall then the carers are there instantly and they don’t require an ambulance unless complaining of injury due to having enough staff to lift the patient. (Ramsdell, J.W, 2004)
This patient had a fall with no injury, caused by a mechanical issue. Medically nothing other than what the medical history the patient already had was wrong with this patient. (Berglund A, 2004) Having said that this patient still went to hospital, there was no way that we could perform tests like an x-ray in the pre hospital setting on this patient due to the lack of capacity and not having the access to x-ray. (Raymont, V et al, 2004) With the patient not having capacity you could ask if she had pain where you are touching, and she would say no but then ask her again in two minutes and she would squirm and say yes.
This indicates a need to having the correct information from your history take to be able to make these informed decisions. The HCPC states that ‘to be able to make an informed decision registrants should have enough information to make that decision (HCPC, 2008) For this myself and R obtained a very in depth history from care folders and the carer and an attempted history of events from the patient, which included a mental capacity assessment, which helped identify that the patient didn’t have capacity and we had to make a decision in the patients best interest to not leave them at home.
Conclusion
The way that this patient presented as we walked through the door of her house, we were able to see that this was not time critical so having made that decision very quickly and early on in the job we were able to obtain a good, in-depth and structured history and assessment of this patient, having not done this the patient may not have got the care that they required and necessary steps wouldn’t have been made. Bickley, L (2013) The skills practised by all people on scene enabled a detailed assessment into how this patient might have lived after the carer and we left, it was upon this realisation that she wasn’t steady on her feet and couldn’t mobilised alone that she wouldn’t have been able to use the toilet and prepare herself food, and complete other daily routines safely.
I do not feel that in this incident we could have improved upon or done anything differently. I think that the decisions made were the decisions that were best for that patient and we could not have explored any other option. I am happy with this incident overall because we managed to complete all assessments to the best that we could within the situation we had.
Action Plan
Due to this job being very complicated on a mental capacity point of view, I believe that for future practise this shows how important a structure history taking is. Having not used all of the mnemonics that we are taught at university the history taking would get confusing and you wouldn’t know what you have already asked or whether you have missed something that would or could be very important in determining the patient’s treatment or care plan.
As well as this effective communication between all parties is also very important, not having good communication can cause issues due to the breakdown, not being told something that could be imperative to the incident, or even communicating effectively to ensure the patient isn’t feeling anxious and knows that you are telling them everything that is of importance to reassure them.
My intentions are to keep working on these two crucial skills because they are the skills that will always be needed and will enable me to deliver good patient care and help conserve a good level of professional accountability.