As mentioned, I am LOVING this orthopaedics block! My consultant has a reputation of being a scary screamer but so far she has been brilliant with me and my clinical partner and so life is good.
What is good about this placement is that my consultant is a shoulder specialist which means that most people who come to see her have impingement, instability, a-c pain, humerus fracture or a frozen shoulder. This might not seem very exciting but it has meant that we have become good at diagnosing and managing these complaints. On my GP block, every bloody patient that came had something different...you got your head around working out what the chest pain was due to and then they left and a new patient came in with a toe problem.....I liken the experience to swimming backwards in poo.
Anyway - in clinic this week, a 50 year old lady attended with severe shoulder pain. Her passive arm flexion and abduction was 60 degrees, after which active movement was possible but with horrid pain. We were asked to take a history from her, examine her, make a diagnosis and then present the case to the consultant, who would then come and examine her again and discuss treatment options.
I took her history and then started to examine her. After looking at her cervical spine movement, I began the arm movements, managing to get her flexion to 180 degrees, albeit with clear pain. In fact, the pain was so bad that she started crying and she wasn't a wimpy lady - it was just clear that she was in agony. I decided at that point not to continue to abduct her arm because the other tests indicated that she had supraspinatus impingement which was likely to produce a painful arc. So I left the abduction and did some of the other examination which she managed, without reproducing too much of her pain.
When we left the room to go and find the consultant, my clinical partner voiced his concern with what I had just done. He felt that I should have continued with the full exam, despite the fact she was crying with pain. He felt that by not persisting, I had failed in my examination. I told him that I felt that continuing to examine her, despite pain and tears would actually be unethical. This didn't go down terribly well with him but I stood my ground because although I might not be a font of medical knowledge, my nursing background has given me a lot of insight into patient care.
Since my first contact with patients as a medical student, I have been very aware of the fact that when we examine patients, it is usually for OUR benefit, not for the patient's. We know so little that examining is how we learn, but in this case I knew that continuing with the exam was causing her significant pain and that once I had presented the case to my consultant, she would then have to go all through it again.
My clinical partner was not amused that I stood my ground on this one and I think the reason for this might be our backgrounds. He is an ex-physiotherapist and I think it's fair to say that physio's often cause pain, albeit for the good of the patient's recovery!
So was I wrong?
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3 comments:
I think you were definitely right. I speak as someone who has a THR at 30 and I know that when my ortho surgeon examined/examines me he was very careful not to cause me pain by forcing my decrepit joints into positions I couldn't manage. To do otherwise runs the risk of worsening the condition and causing permanent damage.
Of course there are times when causing pain is part of the job: you're not going to declines to take blood from someone because it hurts them, but in your case you were definitely right. If I had been the patient I would have resisted all attempts at any movement that caused me pain!
You've made an interesting point here. The advice we've been given on this point is so conflicting.
The orthopods have warned us not to carry on beyond the pain barrier . In fact we have been explicitly told that if we do that in the OSCE (and fail to recognise the patient is in pain), we will automatically fail. For them this is actually more important than eliciting signs.
In contrast, the neurologists say cross the pain barrier. I have been told directly that contrary to the point you mention about examining patients being for our benefit, it is actually for the benefit of our future patients and therefore if we have to cause pain to elicit signs, so be it.
I wonder if this is to do with what Alhi says: when my ortho surgeon examined/examines me he was very careful not to cause me pain by forcing my decrepit joints into positions I couldn't manage. To do otherwise runs the risk of worsening the condition and causing permanent damage., whereas in neuro I don't think you're running the risk of damage, "just" pain
I think its one of those questions where there really isn't a right answer
OK, I know this is really an old post, but I just found you from the Grand Rounds that Laurie Edwards just posted and I liked your writing enough that I started browsing. :)
I injured my left shoulder in a fall in 1995. My initial surgery, where they removed my a/c joint and a bone spur and fixed a tear in my labrum wasn't successful so I got sent to a pain clinic. An awful experience in general, but the PT there forced my arm well past my pain threshold and actually ended up tearing my labrum again, which necessitated another surgery.
So from the patient's POV, I don't put up with people causing me pain beyond the point of tears. I admit I'm a bit of a wimp, unlike your patient, but if you've made me cry from pain, I'm pretty much done with the exam. And if a medical student did it past where I told him/her to stop because of pain, I'd file a complaint.
Anyway, fwiw, you're definitely going to be the kind of doctor I prefer to see -- someone with empathy and good judgment. :)
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