HANDLE WITH CARE

Chapter 11
HANDLE WITH CARE


Some patients need special attention as they are especially vulnerable from physical or mental frailty and stigma. This chapter covers the above patients and some specialist scenarios you may have to deal with including oncological and haematological emergencies. There is also a section on issues relating to capacity.


Alcoholism


Many more of your patients will be dependent on alcohol than you may first appreciate. This is something that you should routinely assess when taking a history. Never make assumptions. There have been many times when I have routinely asked elderly ladies how much they drink and have been told matter-of-factly: ‘only a bottle of sherry a day, and two if my friends come round!’. This can be an issue when these patients come into hospital, as they do not have access to alcohol and so are at risk of withdrawal (see the following text).


To assess alcoholism, do the CAGE questionnaire,1 which is remarkably reliable for picking up alcoholism:



  1. Have you ever felt you should CUT down on drinking?
  2. Have people made you ANGRY by asking about your alcohol intake?
  3. Have you ever felt GUILTY about your drinking?
  4. Do you ever drink first thing in the morning (or take an EYE-OPENER)?

Answering ‘yes’ to two or more of the above questions gives the patient an 80% chance of having an alcohol problem.


When taking an alcohol history, try to incorporate the following questions:



  • Ask the patient for a typical day, with the amount and type of alcohol taken at each time.
  • Have they always drunk those quantities or has it increased?
  • Have they ever given up alcohol before? Do they want to now?
  • Do they feel they have a dependence on alcohol?
  • Do they drink for a specific reason? (Are they depressed or have financial/social issues?)
  • Do they have any other substance misuse problems?
  • Is there any history of mental health problems?
  • How is this affecting their lives?
  • Tactfully ask relatives or friends about the patient if you suspect denial of alcoholism.
  • Request a full blood count (FBC) with mean cell volume to look for macrocytosis. Also check liver function tests and gamma-glutamyl transferase (GGT). Both rise with prolonged use of alcohol, and the former can take approximately 2–3 months to return to normal following abstention (the latter usually reduces in days to weeks depending on the degree of liver damage). Note that there are other causes of a raised GGT like benzodiazepines, phenytoin, obesity, gall bladder and pancreatic disease. Patients with alcoholic liver disease also have a relative thrombocytopaenia.
  • Consider a nutritional screen and vitamin supplementation (especially B, D and K groups). If the patient is being admitted, prescribe 48 hours of Pabrinex (a multi-B vitamin complex) IV BD, and then prescribe both thiamine 100 mg BD and vitamin B compound strong tablets, 1 tablet TDS.
  • Offer the patient local alcoholic support services, as an inpatient and an outpatient also. The general practitioner (GP) can be very helpful in providing these services. Some practices also have links to counsellors or psychologists if the patient needs them. In some hospitals, all patients admitted with an alcohol-related complications need referral to alcohol support services. This even includes drunk teenagers who hurt themselves or require a period of observation until they sober up. This is an opportunity to educate and change behaviour before more serious problems develop.
  • Try not to be judgemental; as alcohol dependence is a complex multifactorial disorder and you should approach it as such.

Alcohol withdrawal


Some patients will be admitted specifically to withdraw from alcohol, either as an inpatient in hospital if they have other medical problems requiring admission or as part of inpatient rehabilitation. Others will have their alcohol dependence unmasked in hospital. Always consider alcohol (and nicotine) withdrawal if your patient suddenly becomes unexpectedly agitated. If you reassure patients with addictions at an early stage that they will be supported, then this reduces their anxiety and makes them more likely to be cooperative and not self-discharge:



  • Ask your senior for local protocols.
  • Always prescribe more chlordiazepoxide on the as-required side of the drug chart, to a maximum daily dose of 240 mg including the regular dosing.
  • Watch for hypotension, dehydration, hypoglycaemia and electrolyte imbalance. Patients with alcohol excess often do not eat and so are at risk of re-feeding syndrome. Monitor their phosphate and magnesium levels. Ensure 4-hourly observation and regular urea and electrolytes, glucose and FBC.
  • Benzodiazepines such as chlordiazepoxide, clomethiazole and lorazepam are all used; chlordiazepoxide is the most commonly used nowadays.

See Table 11.1 for dosing regimen of chlordiazepoxide.



  • Consider IV clomethiazole if the patient is vomiting. A 0.8% infusion of clomethiazole at 3–7.5 ml (24–60 mg)/minute, reducing to 0.5–1 ml (4–8 mg)/minute, should keep the patient lightly sedated. Consult with your senior before administering IV clomethiazole, as this is quite extreme. A resuscitation trolley must be available at all times and frequent observations performed, as the patient may become too deeply sedated and at risk of respiratory arrest. Similarly as it impairs the rate of alcohol breakdown if the patient drinks whilst receiving the medication, the results can easily be fatal.
  • Be careful with any benzodiazepines. Patients should not drive for 48 hours after taking the last dose. Sedation may mask hepatic coma. Avoid prolonged use and abrupt withdrawal. Dependence becomes a problem after about 9 days.
  • Nowadays, patients are rarely admitted into hospital as an inpatient solely for detoxification. The reasons for this are multifactorial but include service reorganization with a focus on community care and a perception that patients who may succeed in detoxification must actively engage in their own care.

Table 11.1 Prescribing chlordiazepoxide.
























Day Dose of chlordiazepoxide (mg) Tablet timing
Days 1–2 10–20 Four times daily
Days 3–4 10 Thrice daily
Days 5–6 10 Twice daily
Day 7 10 Once daily

Do not treat with chlordiazepoxide for more than 9 days.


Capacity


The issue of capacity can often be tricky to deal with as a junior. A general rule of thumb is to involve seniors early on if you suspect there is an issue with a patient’s capacity. Similarly, it is also prudent to recheck the patient’s capacity if you are unsure as to whether they lack capacity. This is often an issue in the elderly population, especially those with dementia.


Remember, all adults are deemed to have capacity to make decisions as they are mentally competent. If you suspect someone does not have capacity, you need to test it in accordance with the Mental Capacity Act 2005.


In order for a patient to have capacity, they must be able to:



  • Understand the information given.
  • Retain the information.
  • Weigh up the information.
  • Communicate their decision, by whatever means possible to you.

Importantly, a bad or irrational decision does not mean the patient does not have capacity. You also cannot presume someone lacks capacity simply because they have mental health problems or have communication problems (blind/deaf) or because they make decisions that you disagree with.


Capacity can also be fluctuant, so a patient may have capacity to make a decision on one day and not another. Similarly, capacity is not an ‘all or nothing’ phenomenon. Just because a patient lacks the capacity to make a decision on their discharge destination does not mean they automatically lack the capacity to decide what to have for breakfast.


Assessing capacity is a skill, and the best people I have seen performing the assessment are geriatricians. Often the best way to learn is to sit in during an assessment.


Involving other members of the multidisciplinary team can be helpful to assess whether someone has capacity to make specific decisions such as psychiatrists, neurologists and senior team members. Social workers are also able to perform capacity assessments.


If a patient is deemed to lack capacity, then the doctors must act in the patients’ best interests. Ideally, if the patient is likely to lack capacity only for a temporary time period, the doctors should act in the least restrictive manner possible, so that when the patient does regain capacity, they can make their own decision.


The doctor should find out if the patient:



  1. Has an advanced decision

    This is a legal document signed by the patient and a third party stating what treatments the patient would not want to have. The patient will have written this when they had capacity.


  2. Had any advanced statements

    These are similar to advanced decisions but are not a legal document. They are essentially a group of beliefs or wishes the patient would have wanted.


  3. Has a lasting power of attorney

    This is someone the patient has legally appointed to act on their behalf and make decisions regarding their care/finances when they lack the capacity to do so.


Relatives views and those close to the patient should also be sought, but ultimately, unless the patient has a valid advanced directive, the management plan is determined by the doctor. Usually these decisions are made by the consultant in charge, so you do not need to worry too much. If you have any concerns, you should contact your defence union for advice.


Ultimately, if there are major disagreements between relatives and the medical team, legal action is sought and a court decision may be required.


If the patient has no relatives or next of kin, then an Independent Mental Capacity Advocate (IMCA) may be required. They will review the case and then offer an opinion on the treatment plan. They cannot refuse life-saving treatment on the patient’s behalf.


Children


You may work with children as a surgical junior doctor or in A & E, although you are not expected to provide full paediatric care. The following tips may help:



  • If you normally power dress you may wish to consider outfits that are more casual; it helps to avoid doctor phobia and unnecessary formality. This does not mean that you should be scruffy or unclean but you may want to consider less formal wear.
  • For children under 16, get consent from parents/guardians whilst they are on the ward, or you will have to call them in from home.
  • Minors can legally sign for themselves if they are deemed to have Gillick competence and they are consenting for treatment, but it is usually a good idea to get parental or guardian consent unless there is an emergency.
  • NO minor can refuse treatment that is deemed medically in their best interests, even if they are deemed Gillick competent if someone with parental responsibility has given consent.
  • Ask the anaesthetist to insert cannulae when the child is asleep for theatre, to minimize needle trauma and phobia. Young children usually undergo an anaesthetic induction with volatile inhalation agents and so do not require IV access as a prerequisite.
  • Paediatric blood bottles minimize the amount of blood needed.
  • Use local anaesthetic cream before inserting cannulae and taking blood in young children.
  • Be cautious when prescribing IV fluids and drugs – different-sized children have very different fluid and drug needs. Consult the BNF for Children if in doubt, and this is preferable to asking colleagues. If you do ask a colleague, the paediatric registrar or a senior paediatric nurse is probably the best person, as they can check your calculation and give you advice on where to find the information you require. However, remember you are ultimately responsible for any prescriptions you write.
  • In emergencies, intraosseous access is preferable to a delay in finding intravenous access. You ideally need to practice this on a model before doing it for the first time. Although scalp veins may be easy to access in those under 10 months (and can even be used to site central cannulae), you are advised to seek a senior opinion before you attempt to access them. If doing so, an elastic band can act as a useful tourniquet. Be strict with your aseptic non-touch technique infections of the scalp can lead to meningitis.

Depression


People in hospital often suffer with depression. Hospitals can be frightening, intimidating places, full of the unknown, with an endless array of tests and painful procedures in between interminable waiting. Patients may not be forthcoming about their depression, and it may take some skilful rapport building on your part to acquire this information.


Be alert to sudden mood changes and negative conversation. Ask patients about their fears. You may be able to help immediately with reassurance or liaison with social workers, nurses, psychiatrists and medical colleagues.



  • Interestingly, many elderly patients suffering from acute conditions such as ACS or strokes have been recently bereaved. Your patient may be grieving. In addition, a lot of elderly patients suffer from loneliness, which can lead to depression. The most saddening thing I had ever heard from a patient when she came to clinic was that I was the first person she had spoken to in over 2 weeks.
  • If your patient seems low in mood, they may be suffering from undiagnosed pain, hypoxia, alcohol or drug withdrawal, electrolyte and thyroid imbalances, as well as concerns about employment, finances and home care.
  • Alert psychiatrists and colleagues if you think a patient is in danger of attempting suicide (see Chapter 4, Overdose).


  • Be aware of the physical and psychological signs of depression.

Physical signs (constipation, early morning wakening, reduced appetite)


Psychological signs (anhedonia, tearful, anxious, visual or auditory hallucinations in psychotic depression)


Elderly patients


Like children, elderly patients can present with non-specific, understated symptoms. Elderly patients are often stoical and may hide quite severe pain. They come to hospital either because they have been brought by carers, or because something has caused them to reduce their ability to function in their current state. They can often be confused or unable to give you a history. A collateral from a carer, GP or relative that knows the patient well is invaluable in these circumstances. When taking a history, it is important to take a detailed social history. The following are some useful questions to ask:



  • Where do they live? In a house or flat?
  • Who do they live with?
  • Does their accommodation have stairs (both indoors and out)?
  • Do they have a lift/stair lift?
  • Do they have carers? If so, how often do they come in? What do they help the patient with?
  • Are they able to dress/wash/feed themselves?
  • Are they continent of urine and faeces?
  • How do they walk about? Do they have a stick or a frame? What is their mobility like?
  • Do they have family nearby?
  • Who does the shopping/cooking/cleaning?
  • Do they feel they are coping at home, or do they need some extra help?

These questions are helpful to get an understanding of their baseline status and will greatly aid discharge planning.


Investigations to do:



  1. Monitor vital signs. Consider checking core temperature. Beware, the elderly may not spike a temperature even if they are septic, as they may not mount an inflammatory response like younger patients do. Cold sepsis is also particularly dangerous, as it is often missed.
  2. Go through a checklist of systems to make sure you’re not missing something serious. In particular, watch for:


  • Fractures: old people often don’t complain of pain. Be particularly wary if they have had a fall recently. Look at the limbs (especially the hips, legs and wrists) and feel for crepitus.
  • Hypoxia: people may present with euphoria. Measure the respiratory rate and do pulse oximetry or blood gases if concerned. Remember that lots of elderly patients may have undiagnosed chronic obstructive pulmonary disease and may be at risk of CO2 narcosis.


  • Fluid overload and electrolyte imbalance: prescribe IV fluids cautiously at a slow rate in the elderly and slow down or stop fluids if necessary. Monitor electrolytes daily and regularly reconsider whether the patient needs IV fluids.
  • A basic IV fluid regime for a small elderly person who is not septic would look something like this:
  • Hypothermia: consider checking rectal temperature – a patient’s ‘peripheral’ temperature as measured with a tympanic or oral probe may not reflect their true core temperature. Put a bair hugger on the patient, and consider giving warmed IV fluids if temperature not improving.
  • Malnutrition: look for flaky skin, poor gums, unhealed bruises or scratches. The elderly classically have a ‘tea and toast diet’. Vitamin deficiencies are common and can have serious consequences if not treated. Consider a nutritional screen and a vitamin D level in those with all over body pain. Vitamin K deficiency is particularly common and can lead to abnormal clotting with a raised international normalized ratio (prothrombin ratio) (INR).
  • K+-wasting with diuretics. Check K+ and supplement orally if necessary. Be careful not to produce hyperkalaemia. If you send the patient home with K supplements, be sure to notify both the patient and the GP, so K+ can be monitored – it is usual to only prescribe 3 days worth to avoid hyperkalaemia. There are lots of other ways to orally supplement K naturally such as with bananas, tomatoes and chocolate.
  • Infantilization of elderly patients. Remember that 80% of elderly patients live at home. Only 14% of people over 75 have any form of dementia. Junior doctors often get a skewed perspective of the elderly, as most interactions in hospital are with those who are very sick or with complex care needs. Be careful not to treat elderly people like children, and always be respectful towards them like any other patient.
Sep 27, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on HANDLE WITH CARE
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