Misdiagnosis of Myocardial Infarction Related to Ineffective Patient Advocacy

Description

Two years ago while working in the accident and emergency department I was able to diagnose myocardial infarction clinically. Pt x a known diabetes and hypertension patient on follow up presented with epigastric pain and vomiting. Patient reported history of substernal chest pain radiating to the left shoulder the previous night. I rushed the patient to the emergency area and placed him in a bed connected him to a monitor and was able to identify an ST elevation in his cardiac rhythm. I started the patient on 6 litres/ minute of oxygen via venturi mask, I administered morphine 10 mgs, Aspirin 350 mgs per oral. In addition, I established a large bore intravenous vein line and obtained blood samples for baseline investigations. An E.C.G confirmed my clinical diagnosis. I explained the findings to the patient and kept on reassuring him. I excused myself and took the patient’s blood samples to the laboratory and went directly to report my findings and interventions to the one of the senior outpatient doctors.

As I reported my findings and interventions the outpatient doctor seemed not to pay much attention on what I told him. His face could tell that what I was reporting was not an emergency to him. He asked me sarcastically you mean that you have diagnosed a patient with myocardial infraction? I firmly answered yes and asked him to see the patient without delay. He looked me from my head to my toes and asked me to leave. I left his room and he later came to see the patient.

I was shocked with doctor’s diagnosis; his provisional diagnosis was gastritis. Surprisingly, none of his baseline tests were related to myocardial infarction. In addition, he ordered antiemetic and antibiotics which I administered. I insisted that cardiac markers should be included among the baseline investigations for the patient. He was hesitant at first but finally agreed to include them. A decision was finally made to admit the patient under his care since he had admission rights. I escalated the matter to my manager and to the director of nursing services. I did a follow up only to find out that his Troponin levels were so high. A decision was made in the absence of the admitting doctor to transfer the patient to a facility with a cardiac services.

Feelings and Thoughts

I was confident that I made the correct clinical diagnosis and I was prompt in intervention. However, I felt intimidated by the attending doctor by his negative attitude towards me. He made me look as if I never went to a school of nursing. For once, I felt inferior to the doctor since he trashed down my input. Concerning the doctor, I felt that he was bossy, incompetent and needed disciplinary measures. Babiker, et. al (2014) points out that successful patient outcome can be achieved through patient centred team approach.

Evaluation

This experience made me to understand that team work is one determinant that can influence patient’s outcome. Khademian, et al (2013) stated that team work is an essential component in critical settings such as emergency department. This highlights the need to strength team work in accident and emergencies care setting. In addition, the reinforcement of critical skills and competencies for all first line health professionals working in accident and emergency setting through continuous medical education and continuous clinical drills. Secondly, I learnt that negative attitude toward a team member can compromise the care of patient and can lead to life-threatening outcomes. This points the need of an organisational culture where everyone’s input is valued and evaluated against evidence based practice.

Analysis

Timely detection, diagnosis, treatment and management of myocardial infarction is essential and of clinical significance. The analysis of this experience shows that I was able to diagnosis myocardial infarction on patient’s arrival. However, the patient was misdiagnosed. Nearly one third of cases who present with myocardial infarction are misdiagnosed (Jianhua et. al, 2016). Misdiagnosis or any inconsistence in the diagnosis of myocardial infraction can cause significant harm to the patient (Wildi et al., 2014). 15 – 25 percent of patients may present with slight or no chest pain making myocardial infarction go unpredictable. Such patients may present with other symptoms such as nausea, vomiting among others. This could explain why some cases of myocardial infraction would end up been misdiagnosed (Haugen and Galura, 2011). This points out the reason why first line healthcare workers should be the look for patient who are at risk of myocardial infarction.

Conclusion

Nurses are in continuous contact with the patient and are more conversant with their problems. This places them at a better position to advocate for patients. Excellence patient experience and care are closely related to effective advocacy (Shirmohammad, Abbas and Fazlollah, 2016). If I have advocated for the patient then misdiagnosis of myocardial infarction could not have happened. I should have treated this matter with urgency as I escalated it and could have sought for a second option from a more senior doctor.

Action Plan

This experience has helped me to learn that misdiagnosis of myocardial infarction can be fatal and that early detection, diagnosis and management is a key determinant of the prognosis. In addition, I have learnt that advocacy is an important role in nursing. I will always be an advocate of a patient in the future. When in doubt, I would rather seek for a second option on a timely basis and escalated the matter as soon as possible. I will also advocate for good working relationship between doctors and nurses since team work is an important element in patient care. In addition, I would recommend the use of clinical pathways; the development of protocols and policies to guide and standardise care; clinical drills and emphasis the need of continuous medical education. Finally, empowerment of nurses and creating a good working environment is important to improve patient experience and patient care. (Renate at el, 2014)