The seriously ill patient: tips and traps

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Chapter 23 The seriously ill patient

tips and traps

Gordian W.O. Fulde

It is the purpose of every emergency department to assess, resuscitate, diagnose and treat, both definitively and symptomatically, the patients who walk or are wheeled through the door.

The ultimate responsibility for this belongs to the medical officer. In order to cope when faced with a variable number of patients whose conditions vary in severity, an organised approach is essential.

There must be triage (sorting) and re-triage, especially if the department is busy. See Chapter 45, ‘Advanced nursing roles’.

The emergency physician should use a priority problem-oriented approach and make clear decisions. As the leader of the team of medical officers, nurses, clerical staff, radiographers, porters and the many others who are often needed to attend a sick patient, this approach is imperative. The physician must assess, resuscitate and manage the patient and the patient’s relatives. As a rule, decision making is harder in the case of patients who are not critically ill. The majority of all admissions (60–70%) come from triage category 3. Such patients should be assessed and managed with emphasis on early symptomatic relief and reassurance.

A key to keeping control of a busy department is that the most senior medical and nursing staff must be aware of all patients (including those waiting in ambulances). This may involve, for example, after a resuscitation doing a ‘flash’ ward round to do a ‘stocktake’ and allocate priorities, make admission decisions, contact inpatient staff to come down or accept problems.

Emergency doctors must communicate well so that most parties, most of the time, have some idea what is happening or what they need to do. For example, with system problems, ensure you escalate ‘up’ early; that is, if beds are full and ambulances are waiting, ensure medical and nursing administration know (contacting them by mobile is best—they also want to know early).

Remember to ensure a safe and professional environment for patients and staff. Do not compromise this, as it is wrong and it will come back to bite you even though your motives were honourable.

Although it goes against human nature, ensure the difficulties are documented and submitted to the quality, risk system of your hospital. The system will respond, especially if serious or repeated problems are listed objectively. Emails to key people next working day also speed up action if critical issues are encountered.

In attending to the many problems encountered in an emergency department, rely on good clinical commonsense in order to avoid pitfalls. At all times, play it safe. Be suspicious of any complication. Never be afraid to ask or ‘google’. The patient must be managed in as close to an ‘ideal’ fashion as possible. Distractions such as work pressure or the many other difficulties faced in emergency departments (e.g. bed shortages) should play no major role in individual management. Of course, good written documentation is essential as evidence of what was done and why.

WARNING—RED LIGHTS—BEWARE

For all of us there are red warning lights that alert us to potential pitfalls:

• Representations to the emergency department. Think it through again; do not just accept the last diagnosis.
• Patient sent in by another healthcare professional, e.g. GP, community nurse. They are asking for your and the hospital’s help.
• If pain is severe and unrelieved, worry! You have probably missed something. Continuing out of character pain is a very common feature of misdiagnosis—so re-think!
• Repeated questions or protests, e.g. the patient, the patient’s mother, anybody who keeps telling you ‘they are sick’ or ‘this is not normal for the patient’, are a key indicator of pathology going on.
• Triage categories 3 and 4 are often quite sick (especially if old).
• Check vital signs frequently yourself (BP, pulse, respiratory rate, temperature, blood glucose level, coma scale, oximetry).
• Unpleasant patients (with or without difficult relatives). Never vary your standard approach and management. Document all. This also applies to VIPs and friends. Always be polite, not rushed, try to sit down, get eye contact and listen.
• Hand-over patients. Make sure you have the whole story and plan. In the USA this patient group features highly in court cases.
• Poor history, poor examination. History and examination are cornerstones of the diagnosis. If you are unable to get good facts, be very careful and conservative, and worry.
• Investigations are never 100% accurate. Even if a test is very expensive, do not worship it, it makes mistakes. Many tests confirm a diagnosis, but do not fully exclude it. Look at the whole clinical picture.
• Urgent treatment (see Law 1, below). Sometimes you must treat on suspicion, now! For example, tension pneumothorax, bacterial meningitis, narcotic overdose, hypoglycaemia. Early pain control may also be needed.
• Pain. Always listen to the patient, go through all details of the pain (avoid leading questions!). This way you will probably get the diagnosis. Treat pain very early.

DECISION-MAKING TIPS

In the emergency department we are all seeing older, sicker, more complicated patients. You must focus on:

• What made the patient come to hospital? What do they hope for?
• Are all the vital signs OK?
• Do I need extra help, extra information (old notes, general practitioner, specialist advice)?
• Problems → plan of management.

An important question is: ‘Does the patient need admission to hospital?’ This is better approached from the other perspective: ‘Is it safe or appropriate to send the patient home?’ If the answer is to be ‘yes’, refer to the discharge checklist in Box 23.1.

Box 23.1

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The patient must be able to cope alone. Is there anyone to help? Can the patient take necessary medications, prepare and eat meals and go to the toilet? Also, can the patient survive any likely complication of the medical condition? The fact that the emergency department was excessively busy at the time and the hospital was full will not be at all useful as an excuse in a legal inquiry or a court case relating to the management of an individual who was inappropriately sent home. Always err on the side of safety and, if you are not sure what to do, get the most senior medical officer possible involved in the decision making. Always write details in the notes of what was decided, by whom and why.

Usually some follow-up, either by a local doctor, specialist or outpatients department is indicated. This must be organised and noted in the patient’s record.

EMERGENCY DEPARTMENT ‘LAWS’

Law 1: All patients are trying to die before your eyes

You must always think in terms of worst case scenarios, e.g. cardiac infarcts, meningitis, subarachnoid haemorrhage, pulmonary embolism. This is even more vital where early specific treatment will cure and prevent death. It may seem dramatic, but if you treat or exclude these serious illnesses early, further management of the patient is often very straightforward. Remember, medicine is best geared to treat the serious illnesses and society expects us to get these right.

Law 2: Call for help early!

The team approach for complicated emergencies, such as trauma and cardiac arrest, should be activated early, i.e. even before they ‘crash’. Early involvement of intensive specialists, those responsible for definitive care, is imperative. Never be reticent to ask for more help—a ‘routine’ case of acute pulmonary oedema is enough work for two doctors in the initial resuscitation phase. Always aim for the hypothetical optimum care scenario, i.e. pretend that the patient is a loved relative.

If the patient is critical and unstable, call the arrest team or similar response team (e.g. MET) before it happens. The patient is much more likely to do better if you prevent the crash. See Table 23.1.

Table 23.1 Calling for help criteria

Call for help for any patient who meets the following criteria
CHANGE IN PHYSIOLOGY
AIRWAY
Predicted difficult airway
Unable to obtain

BREATHING
All respiratory arrests
Respiratory rate < 5
Respiratory rate > 30
O2 saturation < 90%

CIRCULATION
All cardiac arrests
Pulse rate < 40
Pulse rate > 140
Systolic blood pressure < 90 mmHg
NEUROLOGY
Sudden fall in level of consciousness
Fall in GCS ≥ 2 points
Repeated or prolonged seizures
Not intubated GCS < 9
OTHER—any patient you are seriously worried about who does not fit the above criteria For example:

• Unable to obtain prompt assistance, resources
• ‘Difficulty speaking’
• Agitation or delirium, violent
• Any unexplained decrease in consciousness
• Uncontrolled pain
• Failure to respond to treatment

GCS, Glasgow Coma Score

Based on criteria set out in Parr MJ, Hadfield JH, Flabouris A et al. The medical emergency team: a twelve month analysis for activation immediate outcome and not-for-resuscitation orders. Resuscitation 2001; 50:39–44

The patient who meets one or more of these criteria should be in a resuscitation area with adequate doctors and nurses. The ‘drama’ phase lasts only a few minutes and staff can return to their other patients as soon as you have control of ABCs.

Law 3: Be flexible

Many sick patients defy any discrete label or have a diagnosis backed up by clearly abnormal tests. Follow your clinical impression, keep looking and be prepared to be surprised and change your management direction. If in doubt, observe.

Law 4: Treat the patient, not just the tests

Clinical impression (is this patient sick?) has been repeatedly shown to be highly accurate in picking up sick patients where scores, protocols, tests have not clearly ‘ruled in’ a diagnosis (e.g. acute coronary syndrome). If in doubt, watch, observe, ask.

Do not feed the lawyers

• See above.
• Never openly criticise colleagues or management—you rarely have all the facts, let alone the other side’s reasons. Clinical signs evolve and change.
• Respect the effort of the healthcare workers. Do not talk shop (i.e. the imperfect world of healthcare and mistakes or problems) in public. It makes it worse for all. If there are problems, use the system/process to improve it, i.e. be constructive—there is always someone to discuss a problem with who can give advice on how to tackle it and achieve improvement. Also, positive feedback works well! Use it freely!
• Always find out early what the patient, relatives, GP etc expect or want, especially if it is not clear what the problem is or why they came. You will make a lot of people happy with your service, even if you can only give an explanation of why you cannot meet their immediate perceived need. You also will save a lot of time and expense.
• To have a really good work environment, where the patient and you will do well, see Table 23.2.

Table 23.2 Emergency department 10 commandments

EMERGENCY DEPARTMENT 10 COMMANDMENTS
1
IF IN DOUBT, ASK.
This includes asking medical, nursing, clerical and paramedical staff.

2
NO PATIENT IS TO BE DISCHARGED FROM THE EMERGENCY DEPARTMENT UNLESS THE EMERGENCY REGISTRAR/CONSULTANT KNOWS ABOUT IT.
Especially if sent in by a LMO.
3 BE SAFE:

• universal protective measures
• wash hands
• safe shoes
• sharps disposal
• immunisations up-to-date
• know ‘needlestick’ protocol
• know location of wall-mounted alarms
• wear personal duress alarms.
4 IF YOU SUSPECT PROBLEMS, GET HELP EARLY. 5 SEE PATIENTS IN THE ORDER THEY APPEAR ON THE EDIS SCREEN and COMPLETE EDIS INFORMATION. 6 ALWAYS CONSIDER ANALGESIA, GIVE ANALGESIA EARLY VIA THE MOST APPROPRIATE ROUTE (INTRAVENOUS UNLESS SPECIFICALLY CONTRAINDICATED). 7 WHILE ON DUTY IN THE DEPARTMENT, BEHAVE AS YOU WOULD LIKE A DOCTOR TREATING YOUR FAMILY TO BEHAVE. 8 TREAT EVERYBODY EQUALLY:

• socially
• medically
• be thorough and polite.
9 WRITE NOTES GOOD ENOUGH TO USE IN A COURT APPEARANCE; DOCUMENT CLEARLY IN YOUR MEDICAL NOTES.Include discharge instructions and whom notified. 10 BE TIDY:

• appearance
• identification
• names—yours legible, patient’s on history and medication charts
• do not leave X-rays out of packets and give back private X-rays etc
• keep consultation rooms clean
• put used trays and sharps away
• doctors, keep your office tidy
• cot bed sides up when you leave patient.

THE FUN BITS

Do these as much as you can:

• Teach—community (CPR), allied health, nurses, students—use aids such as photos and handouts and involve them.
• Engage in research—clinical audits, chart reviews (See benchmark article by EH Gilbert, SR Lowenstein et al. Chart reviews in emergency medicine research: where are the methods? Annals of Emergency Medicine 1996; 27(3):305–309.)
• Mentor medical students, trainees, nurses—join up with other centres.
• Update yourself—ensure the department subscribes to journals, audio (Emergency Medical Abstracts, Emergency Reports etc), journal club.

Ensure interesting articles are routinely circulated to staff; assist staff to attend conferences, courses etc.

• Socialise—support departmental social, sporting events; everybody should attend some of the activities; ensure they are well publicised and preferably that each group is represented.

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