Decision-making Processes for a Patient Admitted to the Accident and Emergency Department Requiring Emergency Abdominal X-ray ― A Case Study

This case study aims to apply the processes of decision-making for a patient requiring radiologic emergency abdominal X-ray examination admitted to the accident and emergency (A&E) department in a governmentowned hospital in West Java, Indonesia. It also aims to evaluate the patient who is experiencing abdominal pain that is very unusual accompanied by bloating, vomiting, severe constipation, and abdominal cramps.


BACKGROUND
Decision-making in Indonesia is already done autonomously with the development of central and local government programme.There are a lot of basic radiologic examinations in major health centers that are nowadays independently decided upon by radiographers to help lessen the workload of physicians-in-charge, and that formal written referrals may not be necessary (Regulation of the Minister of Health No. 290 / Menkes / Per / III / 2008).Large hospitals may also have independent healthcare practitioners who diagnose certain diseases (Decree of the Minister of Health No. 631 / Menkes / SK / IV / 2005).
Also, autonomously deciding on plain radiographic examinations in cases of emergencies in underdeveloped countries are now at large (Regulation of the Minister of Health No. 290 / Menkes / Per / III / 2008).For example, an acute abdominal pain can be decided upon for treatment, care, diagnostic examination, and management by any healthcare professionals.This is because an acute abdominal pain will more likely lead to chronic cholecystitis, biliary colic, hepatitis, hepatic congestion, peptic ulcer, gastroesophageal reflux disease (GERD), chronic pancreatitis, irritable bowel syndrome, diverticulitis with constipation, ovarian tumors for female, pelvic inflammatory disease (PID), Crohn's disease and mesenteric artery ischemia (McQuaid 2012).Figure 1 shows the acute abdominal diseases or disorders found in adults.

THE CASE
A 60-year-old female patient with the chief complaint of abdominal pain accompanied by flatulence and abdominal cramps was admitted to the A&E Department.An initial blood investigation was primarily done and is highlighted in Table 1.
About the patient's blood investigation result (Table 1), there was a drop in the hemoglobin which healthcare professionals should intuitively anticipate for a potential hemorrhage combined with a decreasing level of hematocrit that measures her hydration (Ministry of Health RI 2011).A drop in the patient's lymphocyte count indicates a potential inflammation of the abdomen (Ministry of Health RI 2011).
An example of a chemical cause would be a perforation of a peptic ulcer, where spillage of acid gastric contents causes an intense peritoneal reaction (Eisenberg 2008).While an increase in sodium decrease in potassium from the patient's blood investigation (Table 1) indicates fluid retention in the peritoneal cavity (McQuaid 2012).
After the algorithm found in Figure 2 was carried out, the next step was to explicitly decide on the type of abdominal X-ray to be done for cases of acute abdomen pain.There were three different X-rays choosen specifically for patients with severe abdominal pain.(Kellow et al. 2008).
Although erect and anterior-posterior abdominal X-ray is also theoretically important to be considered done, it is also by intuition that the patient may not be experiencing foreign body ingestion and more likely having a perforation of the bowels (Balinger 2012).
The main symptom that was experienced by the patient such as prominent sudden severe pain in the abdominal area was confirmed after a physical examination and interpretation of the blood investigation.
Therefore, it was intuitively decided upon by the author that the patient's acute abdomen required a plain abdominal X-ray.Surgery could be decided after a plain abdominal X-ray result was done, to avoid potential delays that could cause complications and result in heightened mortality.
Nevertheless, options were still presented to the patient (Figure 3), showing selections whether to perform an emergency abdominal X-ray or delay the procedure and to wait for arrival of the physicians.
The decision tree for decision options are necessary to be considered since the patient is the key decision maker (Sabiston 2004;Dioso 2015).

Yes
No Discharge

Admit
The author finally decided that an emergency abdominal X-ray was necessary.Figure 4 below shows the intra-abdominal X-ray of the patient that was visualized in the right supine position and that can be life threatening if surgical repair was delayed.

METHODOLOGY
The decision-making models used for this case are the normative, prescriptive and descriptive judgements.A decision tree in the form of decision options that was employed in this case addresses the normative model of decisionmaking, while the algorithm addresses the prescriptive model and lastly, the intuition that was used in this case addresses the descriptive model of decision-making (Thompson & Dowding 2002).Table 4 below summarizes the decision-making process that was used for this case.

Information sources
Statistical analysis of large-scale experimental and survey research which is representative of a target population where the findings can be applied.

Examples Decision options
Advantages Enable decision-makers to predict and explain the outcomes of decisions.
Minimize judgment errors from "base rate neglect".

Characteristics
Frameworks or guidelines designed to enhance specific decision tasks.

Information sources
Principles and findings of previous scientific research (associated with normative models).
Examples Information processing theory.

Advantage
Facilitating more efficient decision-making.

Characteristics
Understanding how individuals make judgments and decisions focusing on the actual conditions, contexts, ecologies, and environments in which they are made.

Information sources
Observation, description and analysis of how decisions are made by managers and professionals with their day-to-day responsibilities.

Examples Intuition
Advantage Adequacy in supporting assumptions made about decision-making processes with relevant examples from a suitable period of observation.

Prescriptive Decision-making Model
Information processing theory (IPT) used the algorithm and clinical guidelines.

IPT Step One: Cue acquisition
Based on the results of blood tests carried out on the patient, it showed that pain under the left side of the abdomen was acute.Healthcare professionals who took the patient's blood sample which showed that cues acquired such as the serum sodium level was increased, while venous hemoglobin, hematocrit, lymphocyte and erythrocyte and potassium decreased.More importantly, the physical examination done to assess the intensity of the abdominal pain was also used to support the blood investigation results.

IPT Step Two: Hypothesis Generation
Acute abdomen is hypothesized as a condition that occurs suddenly with the main symptoms that arise which are abdominal pain and that is life threatening.It is also hypothesized that 5% -10% of all emergency visits to the hospital have abdominal pain that is life threatening (Grafft & Robinson 2001;Cordell et al. 2002).
The emergency case is any condition that the opinion of the patient, his family, or whoever assumes the responsibility of bringing the patient, is of less priority if immediate medical attention is deemed necessary to save the patients' life (Thompson & Dowding 2002).Emergency resuscitation or diagnostic procedure is hypothesized to be done until clinical experts have made a determinat ion that the patient's life or well-being is not threatened anymore (Domball & Margulies 1996).

IPT Step Three: Interpretation of Cues
From the results of the assessment of the patient, it was interpreted that the impression of the author on the acute abdomen required abdominal examination on three positions which was supine abdominal AP, AP half-sitting and LLD (left lateral decubitus) to assess fluid water level (Figure 4).While the results obtained, suggested expertise for radiology doctors to interpret the results.

IPT Step Four: Hypothesis Evaluation
Based on the physical examination, an emergency plain abdominal X-ray was evaluated to be required immediately.The result of the emergency abdominal X-ray on Figure 4 is shown to have an obstructive ileus with suspected ovarian tumor on the right which was why an emergency plain abdominal X-ray was required.
In patients with acute abdominal examination with plain abdominal radiology, supine and standing positions, as well as thorax images, were used.But if the patient was unable to stand, the testing should use the left lateral decubitus.
Evaluation of the images should remain based on or confirmed by history, physical examination and laboratory obtained previously.A picture of the free air and dilated bowel possibility of intestinal obstruction found in Figure 4 showed a perforation.The image classification of the biliary system, kidneys and urethra was also a possibility found on the X-ray result of the patient.
It was also hypothesized that free air in the peritoneal cavity showed a perforation of the gastrointestinal tract (Figure 4).Lastly, a hydropneumoperitonium extensively appears as a picture of water fluid level that was hypothesized on the X-ray result found in Figure 4.

Normative Decision-making Model
Decision options were presented to the ultrasonography.Ultrasound examination is useful in patients with acute abdominal pain because it could provide an evaluation that was fast, safe and cheap.As suggested by the author there was a need to do a CT scan of the abdomen soon to evaluate complaints that did not have clear indications.CT-scan was very useful in identifying intraperitoneal free air of very little time, and location inflammation areas required immediate surgery.

Descriptive Decision-making Model
By intuition, the author intuitively believed that the patient should undergo do the abdominal examination on three positions -anteriorposterior, left a lateral, and right side.Based on the results, expert specialist in radiology to the patient should obtain the following: normal peritoneal fat line; air distribution within the intestine that was not filling the pelvic cavity, did not seem to depict free intraperitoneal air, widening intestines with water fluid level; visible mass hiperdens in the left pelvic cavity; and the bones and soft tissue being normal.
It was important to trust an intuition if it was also based on recognized patterns of previously encountered similar cases.The author being an expert radiographer could intuitively perceive signs of the acute abdomen from the resulting expertise.Therefore trusting the intuition was just the same as looking back at the patterns of previously encountered cases.
However, it is important to be contious using intuition (Figure 5; Dioso 2015) during the early part of the consultation.This is because intuition is a substandard way of decisionmaking that is only characterized by a shallow understanding of actual events and conditions taking place.

DISCUSSION
The prescriptive decision-making made an impact in this case.The system of independently deciding for emergency abdominal X-ray is practiced already in Indonesia since this decision is more likely to be autonomously done by the radiographers.Patients who go to the Emergency Department of a hospital would need help quickly and accurately for standard needs in providing emergency services in accordance with the competition of each hospital to guarantee an emergency care with a response time that is fast and precise in handling, connoting excellent hospital service (KMK 856 on the standardization of the Emergency Department).
Reviewing the case raised by the authors, the decisions that should be done was to provide education to the patient or the patient's family that was normatively done by the radiology services in providing precise information about the flow of patient care.In this case, any measures should include a letter for radiological X-ray request of either the sender doctor for emergency cases or not, only then it would be possible for radiological examinations.Due to the Minister of Health Decree No. 375 of 2007 which is about the professional standard radiography which are related to the code of conduct for radiographers who in this case had an obligation to his profession as "radiographer just doing a job of radiography, imaging and radiotherapy at the request of doctors by not leaving the procedures outlined".This means that the radiographers in Indonesia have full autonomy to decide on the best diagnostic examination that is recommended to the patient in an emergency situation.
According to Eisenberg (2008), in a small group in the USA 25 years ago, the role of examinations for plain radiographers can reduce the risk of further complications up to 50% without loss of clinical findings.
Risks of abdominal pain of moderate to severe, and the obvious clinical symptoms may lead to intestinal obstruction, ureter stones, ischemia, or diseases of the gallbladder (Kellow et al. 2008).In a retrospective study it was found that 40% of photo plain radiographs of the abdomen was considered normal had to be followed up with additional advanced checks which discovered the abnormal condition of 72% so the current role of photo plain radiographs of the abdomen benefitted that which was taken over by CT scan and ultrasound.
Field (1998) stated that the examination of plain radiographs remains as the very useful and valuable inspection of the initial investigation and make the clinician decide whether patients with acute abdomen pain requires surgery or not; and if necessary, whether immediate surgery or whether it still can be delayed so that other tests can be done to support the diagnosis.

RECOMMENDATIONS
It was recommended that patients in private hospitals in Indonesia who were not capable of paying their hospital bills should limit the usage of technology such as X-ray machine.Intuitions were recommended especially if the main complaint was recognized to be similar to previously encountered cases.In this way, the impact of decisions gave more benefits than harm to the patient.
It was still however recommended that in a fast paced environment, the use of clinical guidelines should be considered as the safest decision-making process.Explaining to the patient the advantages of each diagnostic examination for the patient to understand clearly the options provided was the better decisionmaking process.

CONCLUSION
It was therefore concluded that in this case, the decision-making process used the prescriptive model substantiated by intuition.The X-ray examination carried out by plain abdominal anterior-posterior, and lateral view found abnormalities in the abdominal cavity.Options on decision trees were also practiced; however the patient was in pain.Therefore, she was unable to understand the choices that were presented.Hence, the alternatives were suggested by the author.Fast and accurate action was needed for these patients, given the emergency situation.Therefore, decision-makers must always be in psychological and intellectual control to demonstrate sound decision.

ACKNOWLEDGEMENT
Lecturer Regidor III is appreciated for the supervision of this study.

Figure 4 .
Figure 4. Abdominal X-ray result on right supine and left.

Table 1 .
Initial blood extraction -highlighted are the abnormal results.

Table 2
of a government-owned hospital in West Java, Indonesia.Triage required a plain abdominal X-ray.Besides, clinical guideline prescribes plain abdominal X-ray that may help visualize possible suspected bowel obstruction, perforation with dilated intestinal loops, intussusception and abdominal mass
Figure 3. Decision tree as decision options presented to the patient.