Tuesday, 3 May 2016

Communication difficulties

I was originally going to call this post "difficult patients" but then I realised that the patients weren't being difficult, they were doing their best to help given their circumstances. Difficult patients are ones that are being awkward by design, either not giving helpful answers, trying to pre-empt the question and second guess what you are trying to do; or malingering and trying to get glasses they don't actually need.

The first patient, Mrs D had come in complaining of loss of central vision so mistyping letters on her keyboard. This sounds like, and is to an extent, a case of wet AMD; however the twist is that the patient was a mute and so couldn't speak. Given that a large part of the sight test involves talking to the patient and them responding it does throw a large spanner into the works. However it doesn't mean that the test is impossible, you just need to think on your feet and be flexible in how you and the patient approach the routine. In the case of Mrs D she brought a wipe clean little white board and pen with her and a pre-typed note detailing the main problems she was having. Given this and the previous record, working out the likely cause of the problem was the easy part but getting more detail was needed. So given the resources it was a case of asking the patient to write down what they could see and relying on nodding or shaking of head if things were getting better or worse. With the situation I knew subjective wasn't going to be great so concentrated on history and getting a good look at the macula to check for problems. If it had been a normal sight test then it may not have been as easy.

The other tricky patients are those who don't fully understand you, either due to not speaking English very well, thankfully I haven't had any Welsh only speakers (not far enough into the valleys); or due to dementia. In these cases you often have to rely on a relative or carer to help with history and symptoms either by telling you the problem or acting as interpreter. Performing a full subjective routine can take a bit longer and it really depends on how much the patient can understand and, in the case of dementia, respond. You really just need to play it by ear and if you can't get a response, try a different method or just rely on objective measurements i.e. retinoscopy, although this is best done using previous prescription as a starting point to help with accuracy and time. However that doesn't mean that you can't help the patient, you still need to do your best to get an accurate result and recommend what you believe is best for the patient.

Mrs H was a patient I saw with quite advanced dementia a few weeks ago, reviewing her previous records (always a good start) I noticed that last time she had come in with a carer who didn't know much about her and the family weren't getting involved, and that we had dilated her due to fairly dense cataracts. Having seen this I admit to approaching the appointment with a fair element of dread, but had booked out next appointment in case I overran. When Mrs H arrived she had her son with her, which was good that he should know a bit more detail about her situation. Once in the test room it became clear that Mrs H couldn't hold a full conversation so whilst directing the questions to her, I was expecting (and getting) the answers from her son. It turned out she used glasses for watching TV and they had broken, hence the test; she couldn't read anymore so near vision wasn't an issue. Having established vision and current acuity as best I could with the broken glasses I moved onto ophthalmoscopy and walked straight into some pretty dense cataracts, so in went a drop of Tropicamide 1.0% to dilate the pupils. Whilst the pupils were dilating I put the previous prescription into a trial frame and moved onto retinoscopy; thinking back I could have done it without trial frame to make patient more comfortable but I always end up getting the axis wrong. After finding a small change I tried subjective using large steps and bracketing to refine it a little, but vision was still rather reduced. By this point Mrs H's pupils had dilated sufficiently for me to check there wasn't any other problem with the fundus, there wasn't and that the reduction in vision was just due to the cataracts. A quick double check with the ret and it was done. (I have found that if dilating it is always best to check ret at end as well, even if not changing prescription, just to see if you are in right ball park). I discussed my findings with her son, but he wasn't keen to proceed with the cataract surgery; which I understood, the lady was over 90, frail and would need a general anaesthetic - a very high risk patient. After documenting everything, including reasons why referral declined, I found someone to help with the dispense and briefed them on the patient's needs i.e. basic TV glasses and handed them over. All in all it only took a little longer than my normal testing time (the joys of being on 35 minute tests) and I felt quite happy (and relieved) with the results.

It is patients like these that force you to re-assess how you approach communication with patients, it doesn't just affect these types of patients, it follows through into all patients; or at least I am trying to let it follow through into all patients. Optometry is very much about communicating with patients, some are easier than others but the common factor throughout all patients is you (or me) - the optometrist.

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