Dear blog readers,
I would like to hear your advice for a dilemma that occurred to me at work. This happened on the stroke unit where acute stoke patients are treated after stroke until they can go to a rehab clinic or home (about 3-5 days usually I would say).
I was assessing an about 60 year old patient that was suffering from a stroke in the brain stem for dysphagia. He was diagnosed with a Wallenberg syndrome. He clearly showed difficulty swallowing but it was impossible for me to tell if he was able to swallow at all or if he was aspirating every time (going into the lungs instead of stomach). So during our daily rapport I recommended to do a videofluroscopy to have a look at what I can’t see from outside. The assistant doctor agreed and I explained him which steps he had to take. The day after he told me that the senior physician refuses to do the examination with justification that most patients with dysphagia are better after two weeks anyway (which he told the patient) so it would not be worth it. I did not agree with this. Generally stroke patients with initial dysphagia may recover quickly. In patients with Wallenberg syndrome some may see decrease in their symptoms within weeks or months and others may be left with significant disabilities for years. Of course there is still a chance (even it is a small one) that this particular patient will recover that quickly. If I don’t know in more detail what happens during swallowing my therapy is much less specific and probably not at the right intensity because I have to be careful not to provoke pneumonia.
So I have the choice between disagreeing with the senior physician. This means I question his prognosis and he might feel like I overstep my competence which can lead to less good atmosphere in the team. At the daily meetings only the assistant doctor is present which is under pressure from both us therapists on the one side and the senior physician on the other side.
Also if then the senior physician would agree it may question his credibility from the patients point of view and make him insecure.
If I accept the decision it affects the patient and the quality of the therapy he receives. He might be nourished unnecessarily much or long by nasogastric tube which is uncomfortable and often leads to diarrhoea. Also the taste in the mouth is very unpleasant and it’s psychic very hard not to eat for a completely conscious patient that has to just lay in bed for most of the time (at the start anyway). What would you do?