This site is intended for health professionals only

Barry's heartburn: a heartsink story

Janet Webb
BSc(Hons) RGN DipN(Lond)
Practice Nurse
Lindum Medical Practice
Lincoln

I had enjoyed only limited success with my plan to destroy the notion of "heartsink" and unpopular patients by proving that with careful management they would become interesting and attractive human beings.
It started when I became ashamed to hear myself describing a patient whom I was asking a colleague to see in judgemental terms, and became acutely aware that my description of him could prejudice the care he received. The insidious and pervasive nature of labelling can be commonplace among practice staff, but it doesn't mean I have to participate, and so I determined to reform.

Social judgments
It seems that we have a tendency to make social judgements about others, and becoming aware of this leads on to feelings of guilt in many of us. The labelling of others by someone with "power" within a social group makes, however, the label acceptable by others in the group.(1) Allen discusses Felicity Stockwell's seminal work of 1972, which indicated that these labels affected nursing care.(2) The problem might stem from the relationship between the professional and the patient, or in the situation that they find themselves in, rather than in the individual.(3) Butler and Evans suggest accepting suffering as real, whatever its origin and however it is presented.(4) Neighbour advocates finding some interesting aspects of the labelled person and building from that.(5)
Armed with this knowledge, the "new enlightened me" would no longer be party to the labelling of other people. It would no longer prejudice my nursing care, and I would not produce reactions that could be interpreted as "difficult". I would be positive, pleasant, respectful and interested.

Cyril and Edna
I tried first with Cyril. Having welcomed him, I admired his tiepin, which seemed to me to depict Tintin's white dog. I said: "Oh, I like that! Is it Snowy?" He glared at me and replied: "Snowing? Of course it's not snowing! What are you talking about?"
I persevered with Edna, for whom nothing had been quite right since I'd known her. She was telling me that she didn't suppose I could do anything for the fluid on her knee. Rashly I told her that what she needed was drainpipe trousers and pumps. She gazed in stunned silence and then demanded: "What did you just say?" I replied that I was being silly, apologised, and watched her struggle at first before she gave way to a smirk, then a giggle, then a full-blown laugh. I'd never seen her laugh before. She visibly shed 20 years. After that she touched my arm and called me a fool - it was the nicest thing she'd ever said to me!

Barry and his "girls"
Later in the week a colleague asked whether I'd take blood from a man she'd tried and failed with. In the old days of labelling, this man would have qualified as a "heartsink". In my new, enlightened days I gave the corporate smile and said yes, of course. Barry is 44, a dedicated unmarried carer to his mother and elderly aunt, whom he calls "the girls". People tend to wilt when Barry is on their clinic list because he tends to talk at enormous length about everything and tends to come with a whole selection of queries to do with his "girls" whenever the appointment is ostensibly for him. His appointments tend to result in about a 40-minute overrun, if you hurry him.
He has back and joint pain and digestive problems, and is a regular visitor to the surgery. He has had a great deal of gastrointestinal investigations, all with negative results. He takes omeprazole and co-codamol, which gives him constipation. He usually wears a brave smile and will discourse at length about his symptoms.
He had come today for a full blood count and ferritin test. The new enlightened me asked how he was. He said his heartburn was troubling him more than usual, and it seemed now to make him frightened. It felt as if it was burning right through to his back. It had started to make him sweat, feel weak and become pale, which was why he had asked the doctor whether he could have a test for anaemia. He was always careful to eat "little and often", avoiding spicy foods and alcohol, although he still smoked 15 cigarettes a day. Because of his great care with the "girls'" diet he himself also ate healthily, but he was moderately overweight with a BMI of 27. He noticed that the pain was worse when he felt stressed and usually came on after doing the housework, the bulk of which he did in the evening after getting the "girls" settled; it only really eased after sitting down to rest, but left him feeling unwell.
By now I'd taken the blood, and included requests for urea and electrolytes, liver function and lipid profile, since the new enlightened me was convinced he was describing angina. I would bring him back for fasting lipids and glucose.(6) I did an electrocardiogram, which looked normal, but he was no longer symptomatic, and if this was stable angina in the absence of previous cardiac history it would be normal. Barry's blood pressure was 152/92. It seemed that it had never occurred to Barry to worry about his heart, having so much else to concern him. As a fulltime carer he had little time for relaxation or recreational exercise. There was no known family history of heart disease.
After talking to the duty doctor I prescribed glyceryl trinitrate spray and showed Barry how to use it. The doctor agreed to see him with the blood results and referred him to the chest pain clinic. He was seen within the week and his exercise tolerance test was positive. He is currently awaiting an angiogram and has many more prescription drugs to collect. We are working on his smoking and arranging social services help.

Conclusion
It was frightening to think I could easily have discounted his symptoms. The fact that we have not previously found a medical reason for his symptoms may mean we haven't looked in the right place. Being a "heartsink" is clearly no protection against heart disease.
Because Barry always has so much to say and delays the appointments, it is sometimes hard to stay focused and listen. I now feel that that is what I'm finally learning to do - listen to what he's saying, rather than just the words he's using.

References

  1. Johnson M, Webb C. Rediscovering unpopular patients: the concept of social judgement. J Adv Nurs 1995;21:466-75.
  2. Allen D. Popularity stakes.Nurs Stand 2003;42:14.
  3. Finlay L. Difficult encounters.Nurs Manage 2005:12:31-5.
  4. Butler CC, Evans M.The heartsink patient revisited.Br J Gen Pract 1999;49:230-3.
  5. Neighbour R. The inner consultation. Lancaster: MTP Press; 1987.
  6. Scottish Intercollegiate Guidelines Network. Management of stable angina. Edinburgh: SIGN; 2001. Available from: http://www.sign.ac.uk/guidelines/fulltext/51/section4.html