Case description
14-04-2022 -by Ulf Arndt – medical manager Leiderdorp and Marry Witteman case manager
A 57-year-old man has his partner call the out-of-hours GP service on a Thursday evening. The gentleman is short of breath and blames this together with his partner on his alcohol consumption of the past few days and on COPD. Gentleman has vomited. In an extensive telephone conversation, the partner briefly mentions that his stool is pitch black. The triage nurse notes this in the observation message and chooses dyspnea/shortness of breath as the entry complaint. The triage will be at U4 and the patient will have an appointment at the CSP in 40 minutes.
Arriving at the CSP, the doctor’s assistant will take the measurements/checks and a corona test will be taken. Subsequently, the dyspnea/shortness of breath is attributed to the airways and a safety net is given. The next morning, he appeals to the RAV. After the patient has been seen by the RAV, it is decided to leave the man at home and he is transferred to his own GP. Later in the day, the situation deteriorated further and the patient was transported to the hospital by the RAV. The next day, the ICU calls to say that the gentleman has died. Cause of death: stomach bleeding. The Regional Commission of Inquiry has investigated this case. What can we learn from this?
STAY ALERT
NTS: the entry complaint is not a (differential) diagnosis. It determines the urgency. An additional example is a recent VIM report: a bleeding head wound after a trauma must be treated immediately. This is done correctly in accordance with the urgency of the NTS triage. The fact that the patient is taking a blood thinner is not taken into account and the patient appears to have a subdural hematoma a few days later. Here, too, the entry complaint seems to dominate everything, while it only determines the urgency of action.
In both examples, it turned out that they acted quickly and had an eye for the patient, but that 1 aspect/complaint was addressed and noted. The other issues (vomiting and black stools or in the other case the use of a blood thinner) are not mentioned in the examination and differential diagnosis. Ticking off the complaints and reporting helps to provide structure and diagnostic thinking. By writing it down, you often see: Hey, something is not right here and that generates even more care.
A contemplation:
Could it have something to do with the common approach of the GP in this day and age: 1 complaint per consultation? Of course, the out-of-hours GP service provides acute/urgent care and specific questions are therefore appropriate in that context. But you do need to assess all the complaints/complaints mentioned/observed and provide a plan.
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