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.