There is much documentation to support the fact that all too frequently, a delay between the time an individual exhibits signs and symptoms of illness and the time he or she receives treatment frequently results in a worsening of the problems and may even contribute to the death of the individual.

A review of the following case studies might well alert you to situations you could encounter as you work with consumers. Paying attention to the obvious, as well as to the hidden clues, might well help avoid negative repercussions.

Case #1
John S., a 57 year old man with mild mental retardation who lived independently in the community, complained of chest pain to members of the staff at his day program. Staff advised him to “take it easy” and observed him throughout the morning. A review of his record showed that he had a history of obesity, high cholesterol levels, Insulin Dependent Diabetes Mellitus and frequent complaints of “aches and pains”. He had been routinely evaluated by his physician who could find no problems.

After John had eaten his lunch, he again complained of chest pain. Staff were concerned and a call was made to John’s physician. They were advised to take John immediately to the physician’s office for assessment. While transporting John, staff observed that John was pale, sweating and short of breath, but seemed to improve by the time they arrived at the doctor’s office. Staff informed the physician that John had complained of chest pain that morning, but failed to identify that he had experienced shortness of breath and appeared to be sweating and pale. John was examined by the physician, but there were apparently no negative findings. He questioned John about his chest pain, but John was vague and said he was “fine”. No EKG or other tests were ordered.

The next day, John again had similar complaints and symptoms. The staff once again called the physician to discuss John’s illness who then ordered Tylenol Extra Strength for John’s chest pain. John died of a cardiac arrest in his home four days later.

Analysis
Investigation concluded that the staff had acted in good faith to obtain medical care for Mr. S., but failed to seek timely medical intervention and did not identify all other symptoms to the physician. Staff persons who often do not have training in medical or nursing assessment usually rely on the advice of a physician. However, this case illustrates the importance of a staff person to clearly communicate to the medical provider not only the purpose of the medical visit, but all observations made of the person’s condition and corresponding behavior. Clinical resources recommend that the EKG be the critical first test of any adult complaining of chest pain and the physician failed to have an EKG performed on John.

It also reminds us that all staff who work with vulnerable adults should be aware of the risk factors for heart disease and should advocate for appropriate assessment for individual consumers.

Case # 2
Ellen R. was receiving services in a licensed community care facility with three housemates. There was 24 hour staff in the home and professional staff on call. Ellen had received a flu shot and one day later Ellen developed a fever. The nursing staff was consulted by phone because it was a weekend. A physician’s order was obtained for aspirin and there was a recommendation to frequently assess the individual. During the next two days, Ellen developed a cough and slept several hours throughout the day. The aspirin was given as ordered, but staff neglected to contact the on-call staff to report the new symptoms. She died the next evening after a cardiac arrest caused by severe pneumonia.

Analysis
The lesson from this situation: When an individual has a change in physical health, do not delay a face-to-face assessment by a qualified professional. When getting medical advice over the phone to frequently assess a consumer, ask the physician at what point the consumer should be brought into the office or emergency room. Weekend and late night calls to medical providers may be delayed when staff members feel that the person will get better by morning or on Monday. They may be intimidated about calling the physician, fearing they are making an unnecessary call. This can be a fatal mistake.

Summary
Case #1 is a good example where effective risk assessment and planning could potentially have extended the consumer’s life. The presence of easily recognized risk factors for heart disease went unnoticed and untreated. When the individual reached a crisis, the obvious was overlooked. A person who has high cholesterol, is overweight and is complaining of shortness of breath and chest pain should have a plan that might include medication, exercise, special diet and frequent evaluations. For more information about heart disease consult the American Heart Association at http://www.americanheart.org

Case #2 illustrates the importance of empowering those closest to a consumer to advocate for the same sort of care they would ask for themselves or their own family. Direct support staff will be the first to recognize a change in the individual and be in the position to seek treatment.

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