Nothing Worse Than Regret….

How does one deal with uncertainty? How do you deal with those unanswered questions?  Those nagging doubts.

I can easily deal with the uncertainty of whether I locked the car when I walked away.  I am a rational individual, the probability based on past performance is clearly yes.  And even if I haven’t no-one will die, I will not be sued for clinical negligence and I will not make the front page of the local paper.

Bigger uncertainties exist like whether my 89 year old Granny will walk after her latest fractured femur, whether she will be able to live independently again.  I can also deal with this because it is black and white, either she will or she won’t.  I’m not saying I am not emotionally invested and hope beyond hope she will.  But I, personally, cannot load this particular dice.  So long as she is given the best chance, continues to have it in her to try because she thinks the fight is worth it, and has the support of her family the odds are in her favour.

What I’m talking about is working autonomously for the first time.  The decisions I make daily and how the buck now stops with me.  Of course I have colleagues, very good ones, who I run difficult cases by and vice versa.  But what I’m talking about are the ‘what if’s’….

For an example, last week I went out on a house visit to see an 89 year old lady complaining of dizziness and feeling unwell.  I did not ring before I went out as I felt no need to triage this visit request and duly went on my way.  I arrive at the house, clinical summary in my hand and notice a key-safe by the door.  Flicking through the notes I can see no code so I ring the bell.  It is a terrace house, many neat little houses running as far as the eye can see in both directions.  A couple of minutes later I ring again, no answer.  So then I knock, a loud prolonged, I-may-disturb-the-neighbours, sort of knock.  No answer.  I turn my attention back to the key-safe and dial the combination to 1925.  It seems reasonable to try the year of birth, it’s worked for me before. Not this time though.  I try the door, I knock on the front netted window and try the land-line.  Nothing.

So here I have a tricky situation.  An elderly lady who felt unwell and asked for a home visit several hours ago, aware a doctor would visit around midday.  A lady who is house-bound, has mobility difficulties and a key-safe.  All of which suggest she may not, on a good day, be able to answer the door.  But has not left it open or given us an access code.  But why hasn’t she answered the phone.  Has she fallen asleep, has she fallen? Has she collapsed?

I return to the surgery and find a number for her next of kin and call, leaving a message on her answer-phone to call me.

So now what?  Do I wait for a couple of hours to see if the patient or her daughter call?  Or do I call the police requesting a welfare check in which they will break her door down?

As another example a 9 month old boy with a temperature, diarrhoea, who is playful and drinking plenty but who’s Mum says he hasn’t passed urine for 3 days.  He has no palpable bladder and is not a child who looks unwell.  Chances are he has passed urine in his dirty nappies.  But what if he hasn’t?  What if he is a delayed presentation of posterior urethral valves and has a lower urinary tract obstruction?  If this is the case sepsis and renal failure will rapidly follow.  The nappy he has on is bone dry, it has been on for 7 hours.

And what about the lady who comes in crying saying her husband is threatening to kill her and her children.  She is too scared to go home.  She has contacted the police who say they are unable to do anything as no crime has been committed.  She is terrified, but she loves him.  She doesn’t want to break the family up.  And yet she feels the threats are real.  She needs help, advice and support and she has come to me for this.  What can I say to her – to go home and talk it through, to seek help for him in the hope his threats are empty?  Or to go to friends, family, a homeless shelter and get the children; to run away and save herself?

Uncertainty and unanswered questions are everywhere.  It is how you deal with this that is important.  Recognising the outliers, the ones that don’t fit the pattern.  These are the ones that need to be dealt with differently from the rest.  Napoleon once said, “The only victories which leave no regret are those which are gained over ignorance”. I concur.  To suspect something is wrong and do nothing is the one ‘what if’… I don’t want to be asking.  As a registrar I always had the fail-safe to add to the notes ‘discussed with Dr X’, the buck would stop with them.  Now it stops with me.

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