The seriously ill patient: tips and traps

Published on 14/03/2015 by admin

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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

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