Clinical Management ⚕️
Descriptors and examples for the RCGP Trainee
This capability area is about the recognition and management of patients’ problems.
💭 Example Reflection
Difficult Specialists 🤺
Description
I was asked to review a patient on the gynaecology ward, who had recently been ‘stepped-down’ from ITU. She had been admitted to hospital 3 weeks earlier, presenting to maternity triage at 33 weeks of pregnancy, with signs of uro-sepsis. She had rapidly deteriorated clinically, and a decision had been made to deliver her by emergency C-Section.
She was intubated and ventilated and went straight to ITU from theatres. A CT scan showed large obstructing renal pelvis calculi, and she underwent a radiologically-guided nephrostomy to relieve the obstruction. She was treated with antibiotics and remained on ventilation for 4 days.
While in ITU, her creatinine was persistently raised, and she required haemofiltration. After several days of this, her creatinine began to improve, and she was discharged from ITU to the gynaecology ward. At the time she was stepped down to the gynaecology ward, the team was told that she hold be going to be transferred to the urology ward after the weekend, and the gynaecology team would only be looking after her till then. However, the urology team came to review her, and arranged fro her to have a percutaneous nephrolithotomy in 6 weeks, and discharged her from their care. At this time, her creatinine remained at around 350 umol/L, and she had a nephrostomy in situ.
The gynaecology team discussed the blood results with the renal team at the local tertiary care centre, who advised more fluids and daily bloods and to consider discharge once she had a positive fluid balance.
When I reviewed her, her creatinine had improved to 300 umol/L, and she had a positive fluid balance. However, I still felt as though sending her home with no follow up from urology was less than ideal. I discussed this with the renal registrar, who agreed that the patient would need twice weekly bloods to monitor her renal function while waiting for the OP procedure to remove her stone, and asked to to liaise with the urology team to arrange this.
When I spoke to the urology registrar, he was quite unhelpful and refused to follow the patient up, stating that they are an acute surgical service and do not follow patients up. I explained that the only reason that the patient was under gynaecology was because she had delivered a baby, but there was no concerns from that point of view, or any treatment that we were providing her with. He, however, was quite short with me, and said that it was not his job to figure out who should be looking after her once she was discharged. I considered arranging for her to come back to the emergency gynaecology unit for twice weekly bloods, but felt that this was inappropriate since her primary problem was not gynaecology/obstetrics related.
I discussed it with the consultant, and asked if they were happy for me to speak to the medical registrar to see if they were happy to take over care for the patient, since she was being followed up for her renal dysfunction. The medical registrar reviewed the patient the same day, however, no plan was made for discharge or follow up.
The next day, I escalated this to the on call medical consultant, who came to review the patient, and agreed that she would need follow up, ideally under urology. He spoke to the urology consultant, and asked him to personally review that patient. A plan was made for the patient to have twice weekly bloods in ambulatory care, and for the urologists to provide input as required.
Reflection: What will I improve, maintain, or stop?
Continue to coordinate a team based approach to enhance patient care.
Learning needs identified from this event
Management and recognition of pyelonephritis in pregnancy. Management and assessment of patients with renal/ureteric colic.
Clinical Management
Trainee: I arranged follow up for the patient under the team most suitable for her care. I made sure that the patient understood how to monitor her fluid balance when she was discharged, and provided her with copies of fluid balance charts and a jug with which she could measure her urine output. I explained the importance of ensuring that she had a positive fluid balance, and provided her with information about nephrostomy care.Trainer: You suggested appropriate management options based on the priorities of the case.
Working With Colleagues And In Teams
Trainee: I found it incredibly frustrating when the urology registrar did not take responsibility for the patient. Having worked in medicine for more than two years, I felt confident in my ability to manage and monitor her renal dysfunction, but recognised that the gynaecologists were not the right team for this. Keeping this in mind, I helped to coordinate an appropriate follow up plan in order to ensure the best care for the patient.Trainer: You tenaciously pursued the best follow-up care for this patient when faced with unhelpful colleagues, demonstrating excellent communication skills in the process.
Supervisor comment
You did well to pursue the correct care for this patient having been rebuffed by a more senior colleague on your first attempt.
