Friday, 24 April 2009

A&E

I was in A&E this week to see a gentleman in his early 50's who was confused. The A&E nurse had triaged the patient and determined he had dementia. Since he was just over 50 she sought input from my team. It was an "urgent" referral not because the clinical presentation necessitated prompt medical input, but because the nurse wanted it all sorted out within 4 hours. At least she was honest enough to 'fess up to that, which improved my humour so off I went.

I wasn't really expecting him to have dementia. I look after everyone in the district who develops dementia at at early age (defined simply as under 65, in my corner) and know from the demographics that there should be 43 people in my service who aren't in it, yet. Somewhere in my patch there are 43 people under the age of 65 with dementia who I don't know about. Knowing this, I've a low threshhold for reviewing potential cases of early onset dementia, which A&E and the acute Trust shamelessly play on.

I visit the gentleman. He's had "baseline investigation" in A&E and assessment. The nurse tells me he's confused and can't go home and they can't access hospital social workers so I need to sort it all out.

He's a patient within a different Foundation Trust, under a different clinical team, and it's now my job to sort it all out and make your problems go away? There's no SLA for liaison work. I'm here in your A&E as a favour. It took me half an hour to drive here, half an hour to drive back, and the time in your wretched department. 2 hours, minimum, which I've taken out of my day for no good reason but to be helpful. And you then tell me what I have to do. When I have to do it. And what must happen. My bonhomie evaporates.

I talk to the gentleman and his wife. He'd been well, cognitively intact that morning. I look at the gentleman. He looks ill. He's grey and sweaty. He's distraught. He's conscious, but confused. I look at the blood tests undertaken. His creatinine kinase is elevated. The nurse nods, saying it's through his confusion and sitting/lying for hours and having muscle breakdown. I ask for an ECG. She glowers, as if I've asked for the blood of her first born child. I smile. She glowers more, then arranges it. It shows an inferior MI. She doesn't accept this, requiring that we have more blood tests for Troponin T (a test that wasn't done when I did my A&E job or worked in cardiology and on CCU) since apparently the history, clinical presentation, CK and ECG aren't good enough.

Why? He had no chest pain.

I spoke to the nurse about this. I remember this well, since as a medical student I was harrowed in a cardiology clinic by Dr Twattington Puffball hollering at me that, "A quarter, 25%, ONE IN FOUR MIs are silent with no symptoms at all!!"

Although I love my RMN nursing colleagues, it irked me that this nurse was managing this gentleman's care since she couldn't diagnose an atypical MI without a Troponin T test (which delayed his care) and she was insistent that he had dementia until that came back.

I had an utterly childish moment, wishing to enact something along the lines of this. But I didn't. I just documented that he'd an acute inferior MI and needed appropriate care, now, and if he'd ischaemic damage to refer to me when he was stable. And I left, consumed with despair.

14 comments:

Zarathustra said...

Loved the Scrubs link. I'm also fond of this one.

GrumpyRN said...

On behalf of sensible A&E nurses I apolgise. How can you possibly diagnose dementia in someone in their 50's in A&E? Acute confusional state, even exacerbation of confusion maybe, but dementia? At most I would think this chap APPEARS to have dementia, but it takes just a bit longer and a few more tests to make that particular diagnosis - more likely to be something organic or iatrogenic.

Cockroach Catcher said...

Mao Tse Tung tried some years ago and failed and “bare foot doctors” were eventually abandoned in China in 1981, a good five years after Mao’s death. Mind you one of the bare foot doctors (i.e. farmers given some basic training) became minister of health. Now the rich in China sought the top doctors in Hong Kong and the US for medical treatment.

The Shrink has given us such a true description that it is indeed scary to read. Every bit rang true however much he might disguise the patient. Good that the Shrink is one of those psychiatrists that still remembers his stethoscope. Is that not why we are trained hard for such a day, such a moment. Managers forgot that for some of us being the old fashioned doctor is what it was all about.

In any case, dementia will have no need for an urgent diagnosis except for the stupid 4 hour thing.

Is this really the NHS we know? Bring back 1975 as Jobbing Doctor put it.

XE said...

Argh, that sounds very frustrating.

Wouldn't a physician in emerg have seen him too though, before you got there? You'd think they would have seen him as well, and hopefully would have picked up on the things you did which suggested an MI. I mean, I know I'm only a 3rd year, but dementia doesn't typically present with diaphoresis, and maybe he was confused because the myocardial damage was resulting in inadequate blood flow to his brain!

I hope the delay in diagnosis didn't result in too much damage...

The Girl said...

How awful. How bloody terrible. You were trying to help the patient (and save her arse) and she just kept blocking you the whole way. She should hurry up and move into administration and leave the patient care to people who aren't too arrogant to know when they are in a situation that they cannot deal with.

dutchdoctor said...

You're such a nice doctor, driving 30 min to see a patient and than only blogging about your frustration. Would love to work with you.

alhi said...

When I clicked on the Scrubs link I was expecting to find perhaps a picture of a child having a tantrum, but no! It was hilarious but you were being remarkably self-restrained if you only wanted to do that. I probably would have throttled the nurse!

Milk and Two Sugars said...

Bad triaging happens, but stubbornly sticking to a bad triage is far less pardonable. When did nursing staff in said hospital begin making management decisions?

Cockroach Catcher said...

The problem should have been resolved by the Consultant (A real dcotor)of A & E or perhaps he was off duty. There should really be the most serious representation to that hospital (although there will be cover ups I am sure) as we need to protect the next MI patient as it is unlikely that the nurse will ask our Shrink (a real DOCTOR) soon enough. Sad day for the NHS.

Dr. Davon Jacobson, MD said...
This comment has been removed by a blog administrator.
Nurse Anne said...

Shocking.

It should be obvious that acute sudden onset of confusion has an acute medical cause. Since when does dementia occur overnight along with signs of a medical illness as well? Someone might develop and acute medical illness like renal failure and become confused but that is so different from dementia.

Confusion, disorientation and dementia are not all the same thing with the same cause.



It's not the nurse who wants them in and sorted in 4 hours, it's their bosses.

Nurse Anne said...

I am getting more upset by this situation (the nruse I guess)with every passing minute. So he had no history of dementia and suddenly he is confused, ashen coloured and diaphoretic?

Why the hell wasn't the ecg, bloods, etc done before they started worrying about his confusion? Good god please tell me he was on 02. Did they seriously screw around worrying about his supposed "dementia" before treating him as an acutely ill patient. Holy. Shit.

02, venflon, bloods, ECG and maybe a chest xray is usually the first thing they do when a confused 50 year old comes into the ER with his symptoms right? Diabetics are also know to have silent MI's right? Anyone can have a silent MI anyway.

Did they do a chest xray? Obviously his problem was cardiac but if it wasn't and he had a temp maybe he had some kind of sepsis. That will screw people up cognitively (is that even a word) speaking.

Where was the doc?

Dr. Shrink, You said he had no known history of early onset dementia right?

I am not A&E nurse so I don't have a clue but if he were my patient it would have been quick history and symptom assessment, obs, o2, ecg, venflon and bloods and grab a doc all at the same time.!!

rvcanuck said...

Did the nurse bother getting any kind of a family history? I'm assuming there was someone there providing background information since she was so quick to rule out cardiovascular involvement.

Oliver Smith said...

Beggar’s Belief