I had a patient in my second block. In the folder the doctor’s notes stated that the patient had a gun shot wound to the back and sustained a T5 complete sensory and motor spinal cord injury. The first time I saw the patient I took it upon myself to explain what I knew about T12 complete, but I did not mention that he was never going to walk again because I assumed the doctor had told him everything about his condition. In my defense I explained what the rehab treatment was going to be done and how it was going to be done. Every day I would go in and I wound strengthen his upper limbs and passively move his lower limbs, he did not understand why I was only focusing on his upper limbs and not his lower limbs. I saw him for two weeks straight and the second week he asked me when we were going to start working on his lower limb so that he can walk again.

I was quite shocked at the fact that this patient always had it in his head that he was going to walk again. As a student, I did not feel like I was in a position to tell the man that he was never going to walk again. I took it upon myself to ask the patient what the doctor had told him. He reported to me that all he was told was that they managed to get the bullet out and he is fine now. I knew at that moment that if I didn’t tell him that he was never going to walk again he would try and attempt on his own due to the fact that no one in the hospital was trying to get him up and walking.  I told him how I understood his condition and the best outcome for him with rehab, he was very distraught at the fact that he had been lying here for 2 weeks and no one told him that he was never going to walk again. He explained to me that the doctors come during rounds and just ask how he is doing, the nursing staff come and put cushions under his buttocks and his heels not explaining what those things are done for.

As the patient, you are entitled to know the results of your medical exams. All medical professionals are held to a high standard of medical care, and that standard of care includes informing the patient of the outcome of any medical test or examination. Such failures can result in serious injury or complications, even if the test results do not indicate that anything is wrong. In this case the patient could have attempted to get themselves out of bed for a certain reason and could fall and injure himself further. This is because test results are used to determine whether further treatment is necessary. A doctor might fail to disclose test results for several reasons. For one, they may simply forget to tell the patient about the test results.

More often, test results can be lost or confused along the chain of communication in a hospital. Test results are often relayed between several different people, such as from a nurse to the general physician or from a general surgeon to a specialized surgeon. For this reason, it is important to locate the source of the miscommunication in order to know who is liable for the miscommunication. Doctors have a duty to give patients certain information so they can make decisions about health care with knowledge of the possible impact it will have. A patient’s agreement to health care is only valid if the patient has received this information. In the case of state institutions, where records e.g radio-graphs are the property of the institution, original records and images should be retained by the institution. Copies must however, be made available to the patient (or referring practitioner) on request for which a reasonable fee may be charged in terms of the Promotion of Access to Information Act (Act No. 2 of 2000);

Although this was not a misdiagnosis, it was still very important for the doctor to inform the patient about his diagnosis and how it was going to impact his life, because he would need to adapt to his current functional outcome with rehab. In certain situations where a patient has a certain degree of understanding about what might happen when you injure your spinal cord, they are able to ask important questions about their functional ability like are they going to be able to walk again, but that’s not the same with patients who do not have the information about what might and might not happen to their previous level of function. I feel I could have asked my clinician to relay the message to the doctor in order for me to know whether the patient was really not told this information or was just being in denial about the situation. Most of the times information is given to the patient, it is up to the patient whether they take it and adapt, or they are in denial about it. Even though I am still a student I am still an important part of the multidisciplinary team and if certain information is not given to the patient I should be able to give it to them and advise them about their outcome

Reference

Mousel, Z. M. (2013). Patients’ Awareness of Their Rights: Insight from a Developing Country. international journal of helath policy and management, 143-146.

https://www.hpcsa.co.za/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_14_keeping_of_patience_records.