Articles and Case Studies

To Call or Not to Call - A Handover Fiasco

24 Jun 2012

Dr Cleanskin was a JMO on her first week of night duty, covering surgical wards. During handover with Dr Chop, the surgical registrar, she was informed by that he was sitting primary exams the following day, making it clear not to disturb him "unless it was a real emergency".

At 11.30pm Dr Cleanskin was called to the general surgical ward to review a 38 year old patient who had undergone a total thyroidectomy earlier that day. The patient was complaining of throat tightness and some difficulty breathing.

The JMO reviewed the patient's records noting the thyroidectomy was performed due to papillary cancer. The surgical registrar's postoperative notes indicated "Routine post op care – usual obs. Do not remove neck dressing".

Dr Cleanskin reviewed the patient and confirmed the history of a sensation of difficulty breathing and pressure in the neck.

The patient appeared anxious. However her pulse, blood pressure, respiratory rate and temperature were normal. Pulse oximetry was normal on room air. Respiratory and cardiovascular examination did not reveal any abnormalities.

In view of Dr Chop's specific instructions in the notes, the JMO decided not to remove the dressing. She thought the patient's symptoms were probably caused by post operative pain, ordered a stat dose of morphine for analgesia and asked the nurse to call her if there were any further problems.

At 2am, Dr Cleanskin was asked again to see the patient complaining of increasing neck pressure as the nurse thought there was some stridor. The JMO was concerned about the patient but elected not to wake the registrar because she did not think it was "a real emergency" situation and did not want to wake him.

Nursing staff suggested that Dr Cleanskin remove the neck dressing and inspect the wound, however she did not want to because the notes clearly stated it was "not to be removed". The JMO requested that the nursing staff continue regular observations and give the patient another stat dose of morphine for pain.

At 3am a Code Blue was called. The patient had had a respiratory arrest. When the nursing staff removed the patient's dressing they found a large haematoma compressing her neck. They removed the surgical staples and evacuated the haematoma.

The surgical and anaesthetic registrars were in attendance and the patient was successfully intubated and transferred to the Intensive Care Unit by the anaesthetic registrar.

On reviewing the medical records, Dr Chop noted that the patient had been seen twice by Dr Cleanskin prior to her arrest. He was extremely angry that she had not informed him of the patient's symptoms which were "typical of a post thyroidectomy haematoma". He then told Dr Cleanskin that the respiratory arrest could have been averted if she had known what she was doing or if she had called him before it was too late.

Lessons learnt

During handover, Dr Chop had asked Dr Cleanskin not to call him unless it was "a real emergency". However, the JMO did not recognise the impending emergency as her lack of knowledge and experience precluded her from understanding the possible complications in a patient who had undergone a thyroidectomy.

Dr Cleanskin had not clarified with the registrar what situations comprised a "real emergency". Nor had she reviewed with the registrar a list of the priority surgical patients and any signs and/or symptoms to watch out for.

For his part, the registrar had not provided appropriate delegation or supervision of the JMO. He had not explained what he meant by a "real emergency", nor ascertained the JMO's level of knowledge and experience with respect to surgical patients (remember, this was the JMO's first surgical term).

It is dangerous to expect everyone else to have the same knowledge base that you do. Doctors rely heavily on patient notes. Dr Chop's notation meant that the staff were reluctant to remove the neck dressing. Additionally, the registrar had not outlined any potential problems, such as neck pressure, dyspnoea or stridor, which required his immediate senior review. A more thorough handover and clarification of when to seek advice could have avoided the patient's respiratory arrest.

The case histories are based on actual medical negligence claims or medico-legal referrals; however, were necessary certain facts have been omitted or changed by the author to ensure anonymity of the parties involved.

Anaesthesia, Dermatology, Emergency Medicine, General Practice, Intensive Care Medicine, Obstetrics and Gynaecology, Ophthalmology, Pathology, Psychiatry, Radiology, Sports Medicine, Surgery


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