RCA Calibration Tool: How to Use the Cases

Case 7

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Remember, before reading the analysis, ensure you have listened to the recording, made your own notes and completed your own assessment of the case.

This video recording looks at a patient for whom you have a received a raised biochemistry result.

Analysis

Summary

An empathic sounding doctor who arranges for the admission of a patient with a high potassium and deranged kidney function

However when considering this as a RCA case there is very little history taken to establish the cause of the problem and as a consequence no differential diagnosis generated.

Timeline

0.01 to 0.30    introduction

0.30     Indicates ringing about bloods and that they aren’t normal

I personally like that the reason for the call was given early

1.00 Patient asked to recap why bloods taken says not feeling well

1.31     Doctor reflects back not feeling well and asks the patient to tell more

Good skill shows listening and open question

1.55 Patient volunteers weight loss eating less and TATT exhausted

2.20     Doctor reflects back the above and asks if been worrying the patient

2.26     Patient says think some horrible things don’t you

At this point the doctor picks up on the horrible things and explores the patients fear of cancer however doesn’t explore the physical symptoms to establish a differential diagnosis nor whether any medication could be causing this. The possibility of lab error is also overlooked

3.20     Doctor says something going on but from bloods doesn’t know what.  Asks if can talk about results a question the patient finds odd and would have been better to just get on with it He also expresses worry that will be bad news which is ignored

3.55 We are told the potassium is high 7.1 and the value but just that the renal function is reduced we are not told if any other bloods were done 

4.00 The doctor explains the link between reduced kidney function and the build up of potassium

The kidney function potassium link is explained well It would help the patient  and listener   to get an idea of seriousness by quantifying the reduced kidney function in simple terms eg reduced to 50% of normal or something like that

4.20     The doctor asks for the patient for any previous knowledge of potassium and the patient talks about eating less salt The doctor introduces the concept that this is going to be a little more difficult to resolve which is well done.

Words like seriously high however are likely to alarm better it is at a level that we need to do something tonight. The link with the with heart is not fully explained to the patient.

4.42     The patient appears quite shocked that heart and kidneys now deemed to be not working properly

5.10     The Doctor asks the patient for his thoughts which is a good skill as open question he talks about worried might need to go to hospital and the doctor picks up on the cues re his wife

5.38     The doctor carefully explores the social situation ‘tell me more about your wife’

5.50. The doctor listens to the patient talking about his wife and explores the support system in place

6.42 The doctor summarises the situation and that he needs to go to hospital tonight.

7.10 The patient expresses wish not top go to hospital

7.23 Doctor acknowledges the patient’s concerns confirms needs treatment tonight and suggest working together to explore the support that can be offered

7.38 Doctor asks about neighbour support but patient again asks if really needs to go The Doctor for the first time introduces concept of lab error and that the stay might be short if that is the case.

8.20 Vocalises  that he may need to stay in if the repeat test is still abnormal. accounting for him feeling unwell Talks about short term and longer term support. Reiterates important he is sorted so able to look after his wife in the long term Acknowledges for the first time the patients shock at what is happening

Do you think we can do that?

During this period the doctor sounds empathic caring and supportive.  However everything is a little vague. How was doctor going to know needed to arrange longer term support ?

9.35 Doctor asks about getting to hospital and the patient says will go in a taxi. The doctor says will leave with him he will call a taxi, get his neighbour to look after his wife . Talks a little about further follow up after hospital

This  felt a little unsafe ie a taxi to hospital ? Should he have gone in ambulance due to the risk of cardiac arrythmia? This wasn’t explained and had the pros and cons eg wait for an ambulance vs risk of acute event whilst in taxi then more credit could have been given

The bit about more tests after hospital felt superfluous, better let me know what goes on or when you are home. Better still I’ll contact you /your wife in morning to see what we need to do support wise.

10.35 Doctor repeats what will happen, what will happen at hospital

11.00 Doctor asks the patient to ring her back if can’t get to hospital or neighbour to come in

This felt a little vague surely phone lines would be put over, who would look after his wife if neighbour wasn’t avaiable. Should the doctor have rung him back to check everything was in place that he was safe and his wife was safe?  I know it was OOH but the doctor did initiate the call

11.19 End

RCA Assessment

The management was basically urgent admission to hospital which is too simplistic for a case being submitted for the exam. Some might question the safety of transport to hospital in a taxi

Credit can be given for establishing the social situation and trying to make provision for the care of the patient’s wife

This case highlights that whilst you can sound very nice and caring, you still need to take a careful history and make sure your management plans are safe

RCA assessment Overall: Fail

Data Gathering: Fail

The social situation was very well assessed but there was practically no assessment of the physical situation or any potential causes eg drugs prostate infection tumour

Management: Clear Fail

The main reason for the fail is due to the management of risk If his potassium is 7.1 travelling in a taxi doesn’t sound like a good idea. Asking him to ring back OOH sounds like something unlikely to happen very easily. The wife’s care felt like it was bit up in the air. It didn’t take a lot of clinical expertise to realise he needed urgent repeat bloods in hospital

Interpersonal: Pass

The doctor didn’t really fully explain their thinking or diagnostic rationale. The patients reaction was initially overlooked. They did however pick up a lot of cues and explore them. Over the course of the consultation the empathy and warmth shown to the patient improved and they did try and involve the patient in the plan they created and get them on board.

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