So much has happened this month, I really don’t know where to start. I will let you into a trade secret. The hardest job I have in A&E is referring on to the surgeons and medics for further care: It can be confrontational, as the specialists try and protect their precious beds and control a burgeoning workload.
When studying for their examinations and role-playing the ‘difficult referral’, if A&E doctors respond in kind to what boils down to completely unreasonable behaviour by a specialist, they fail the exam! We have thick skins and are slow to anger….we have to be that way.
The specialists like a nice clear-cut diagnosis – an appendix that they can chop out or a case of pneumonia that antibiotics will cure. It would be great if life were so simple; it is not!
A term that has been accepted into the lexicon of doctors in the care of the elderly is ‘frailty’. This is a diagnosis that recognises the complexity of presentations and home circumstances in the elderly and opens the door to careful assessment and admission if necessary. It also recognises that minor non specific complaints (NSCs) like a fall, a temperature or weakness, if not taken seriously, can lead to disaster.
This appreciation of frailty has led to changes in A&E triage, whereby the elderly are initially seen by a highly experienced nurse and prioritised according to their intuition and clinical parameters like blood pressure, pulse, temperature, breathing rate, oxygen level and blood sugar.
We have scoring systems to assess frailty; the higher the score, the greater prioritisation, and later the Comprehensive Geriatric Assessment CGA is performed usually by a nurse linked to the geriatric teams.
A useful tool in assessing whether an elderly relative needs assessment is the ‘Five Ms’:
MIND – is the patient more confused or delirious and off their normal baseline?
MOBILITY – is the patient having falls and why? A useful test is to time how long it takes them to stand and walk a short distance. The so-called get-up-and-go test is easily performed and monitored and not rocket science!
MEDICATION – is the patient over-medicated? Could we make life simpler by limiting the number of tablets being taken. I try to stop unnecessary treatment or drugs of dubious benefit. The chance of drug interactions when taking more than four different tablets is huge and, is often a reason for admission in the elderly, as they cannot metabolise these drugs with poor kidney and liver function. Multiple illnesses imply the use of many drugs (polypharmacy) and this needs very careful medical management.
MULTICOMPLEXITY – we all have different priorities and these should be taken into consideration with shared decision-making in a holistic approach. These priorities should be listed and agreed
MATTERS – all this leads to a treatment plan with goals clearly defined.
We have guidelines in A&E around allowing a relative to stay with the elderly to comfort and orientate them. We talk slowly and clearly. We preserve dignity and make sure the patient has their glasses, hearing and walking aids.
So, as we are all getting older and living longer, it is at last reassuring to know that the care our elderly has become much more structured with terms like ‘social admission’ and ‘inability to cope’ (Acopia) in the past. The complexities of caring for our elderly are at last being appreciated by all. Patients don’t always slot into one neat diagnostic box.
We try and get a quick accurate discharge letter out to GP teams and safety net with early review, home visits and even transitional care in the unit, as exists in Clonakilty.
Once again, I emphasise, if coming to hospital, do try and get a letter from your GP and do bring your tablets.
For any of you who like to read about life in A&E, I recommend a book by my old boss Dr Chris Luke: ‘A Life in Trauma – Memoirs of an Emergency Physician’ details his 35 years in Emergency Medicine in Australia, Liverpool and Cork. He now owes me pint!