Sign in to follow this  
Followers 0
rajeevkrishnadas

Referral from Surgery...

38 posts in this topic

First of all... this is not an interview question...

I am on call on the weekend... it is 3 PM (9 AM to 9PM, i take all ward referrals including Self harms from the general hospital and A and E assessments)...

My second on call is the consultant... we dont have SpR cover over the weekend...

I have 3 more self harm assesments to go (atleast 1.5 hours each)... and couple of calls from the wards including a 75 year old lady who has fallen down and another 75 year old man with Bipolar who wants to leave...

I get a call from surgical registrar...

A 50 yr old guy, who doesnt speak english has scratched his hand with a blade in the surgery ward... was admitted yesterday with abdominal pain...

Absolutely no idea why he did it... he doesnt speak a word of english... no relative

The interpreter is coming in now, please come and assess him emergency...

What do I do...

Please comment... on what you would have done... I will tell you what happened...

something like a PMP...

Share this post


Link to post
Share on other sites

I'd probably first want to find out more info:

1) What language does the patient speak? (As you might also speak it.)

2) What happened with the blade? Where did he get it and what did he do to himself? How was he found? Did he try to cut himself anywhere else? Has he tried to self harm in other ways?

3) Is he medically well? Any intoxication/DT/delirium? What was the cause of his abdo pain?

4) What are the referer's mental state examination findings? Is there any evidence of psychiatric illness?

5) Does he have a past history of self harm? (A+E records/psych note, etc)

6) Is he willing to stay in hospital?

Then suggest surgical team assess patient with interpreter and if further concerns about psychiatric illness then to recontact you.

Share this post


Link to post
Share on other sites

1) What language does the patient speak? (As you might also speak it.)

Guy is POLISH..

2) What happened with the blade? Where did he get it and what did he do to himself? How was he found? Did he try to cut himself anywhere else? Has he tried to self harm in other ways?

dismantled razor, scratched himself while in bed... reported by patient in the next bed..

3) Is he medically well? Any intoxication/DT/delirium? What was the cause of his abdo pain?

Still undergoing investigations for abdo pain...

4) What are the referer's mental state examination findings? Is there any evidence of psychiatric illness?

5) Does he have a past history of self harm? (A+E records/psych note, etc)

6) Is he willing to stay in hospital?

No idea... nobody speaks POLISH... Interpreter has just come...

No previous history of psy illness, first time in hospital...

The surgeon asks me to come up to speak to the patient as he thinks he does not have the skills to do a mental state examination. The guy is quiet and settled in the ward.. ( not surprising, but I am disgusted anyway... these guys keep pissing their scrubs, the moment somebody develops psychosis)

Back to the case..

Also to take into consideration I have previous engagements waiting, 3 of them are self harms...

Prioritisation necessary...

Do I leave all other assessments and go to the Surgical ward, or ask the guy to do a mental State exam???

Share this post


Link to post
Share on other sites

Well, I would have thought even if the surgeon doesn't feel he has the skills to do a Mental State he could at least have a conversation (via the interpreter if necessary) with the patient to find out why he did it, ask about mood/psychosis and suicidal ideation. (unless he doesn't have the skills to talk to patients what with being a surgeon-oooops! did I say that out loud?).

I would explain to the surgeon that I have a pile of patients in A&E and that I need this basic minimum amount of information to be able to prioritise the patients. If he gets ar*** I would ask him if he would accept a referral from me that said 'abdo pain-please see.' As that's the equivalent of what he's doing. :)

But then, I love getting up surgeons noses.

Share this post


Link to post
Share on other sites

I dont think the situation ur in makes the surgical referral as ur 1st priority. He is in a surgical ward and safe, can be reviewed later. I would be more concerned about the eldery patients on the ward, the one with the fall and other who wants to leave.

Dont get bullied, just prioritise.

Cheers

Share this post


Link to post
Share on other sites

Djin Dobre! (Always useful to know how to say hi in various languages!)

It's no excuse to say they don't have the skills of doing a mental state examination. It's a fundamental component of being a doctor. I don't have particularly detailed knowledge of the differential diagnoses for an abdo case, but I would be able to make an assessment as to whether the patient was sick or not, and provide the surgeons with the knowledge they need to decide whether a review is needed. There is no reason that this should be any different for psych referrals coming from them.

I agree with wetrain, guy is contained currently and not a priority. Remove access to sharps from his bed area and move him next to the nurses station for the time being. Get the surgeons to assess him for signs of major mental illness and ongoing suicidality with the interpreter and then get back to you if they need further advice. Advise them of nurse holding power and their ability to use MHA if needed to keep patient in ward. MHO would need to get an interpreter to make their assessment for detention anyway.

Share this post


Link to post
Share on other sites

The Guy in Surgery ward is in Pain, was he trying to convey this message????, but he is settled on the ward. Unknown danger - could he attack somebody else.

Self harm - they are already on the ward, so i would not be personally worried about them.

75 yrs old BPAD - could get hurt trying to leave the ward, and the 75 year old lady who has fallen are more at risk, as they need a DOCTOR on the ward.

Self harm assessment is more important in the terms of Waiting times...

Share this post


Link to post
Share on other sites

I proceeded as below...

I told the surgeon to do a mental state examination, literally told him to ask him

why he did it? how long has he been wanting to do it? is he going to do it again?

if he has depressive features/ psychotic features..... etc... and send a referral with information on what he thot was wrong....

In the meantime, I managed to get to the surgical ward at around 8 PM (one hour before I got off call)...

The guy was calm, sitting on the bed. I couldnt have a conversation with him anyway.

I wrote on the case note....

Unfortunately, I could not make it when the interpreter was in this afternoon, as I was held up with previous appointments and assesments.

As of this moment, as there is no interpreter and I could not have a conversation with the patient, I am unable to comment on his mental state, the presence or absence of a mental illness.

If the patient tries to leave the ward, and if it looks like this decision is influenced by a mental illness, he should be asked to stay back in the ward, if not detained using a 5(2) and his medical illness treated under common law. If needed, please call the on call psychiatrist for a mental health act assessment.

If he absconds/ disrupts the ward, hospital security and police is to be notified.

HERE COMES THE TWIST>>>>

I was off on Monday, as I did the weekend. But out of curiosity, just called the ward at around 8 AM, to see how the patient was doing.... and the surgeon on the other end says...

'Well the guy became violent at night, broke the second floor window and jumped out, and with a piece of glass cut his own throat... the consultant psychiatrist was called in, and asked to assess him...'

I WAS SHOCKED  :o  :o  :o for a change, that morning, I shat bricks.....

I called up the consultant at around 8 30, and asked him what happened...

He said it was very difficult to assess him even with an interpreter... apparently, he looked like he was in delirium, possibly alcohol withdrawal, and he started him on Chlordiazepoxide and asked them to refer back when medically fit...

He told me I took the right decision in going and writing down the stuff in the notes the previous night...

On the same day, at 9 AM, the on call psychiatrist recieved a call saying that the guy was medically fit... and they wanted to transfer him to psy unit....

I dont think that happened though....

I will post you on the follow up...............

I AM SORRY FOR THE LONG POST>>>

Share this post


Link to post
Share on other sites

Wow!

Incidently, what did the surgeon find on his mental state with the interpreter?

Glad the guy survived. Phew!

Share this post


Link to post
Share on other sites

I dont think he found anything... because there was nothing much in his note when I went there...

The moral of the story... according to me..

When in doubt, always listen to your brain, rather than your heart...

Share this post


Link to post
Share on other sites

Doriannevergreys,

I would have done exactly what you had done under the curcumstances. I think reading your clinical entry retrospectively, you did cover all essential aspects, given your limitations not having an interpreter. Good thinking; pro-active risk management-

assess with interpreter

do MSE

remove access to potential weapons

move closer to nurses station

if mentally unwell and wants to leave consider use of 5(2)

if necessary alery security/ police

The later developmments you described are very surprising. I'm glad you posted this very interesting case.

It takes a little extra effort but ideally we should, as psychiatrists, treat all cases with the thoroughness of PMPs. Well done!

Justme

Share this post


Link to post
Share on other sites

I have 3 more self harm assesments to go (atleast 1.5 hours each)... and couple of calls from the wards including a 75 year old lady who has fallen down and another 75 year old man with Bipolar who wants to leave...

Thought I'd chip in too -

I agree that the surgeons (and other specialities) need to develop their ability to communicate with their patients a little more BUT - given these specific circumstances - this is what I would have done:

1.Asked the surgeons to page me as soon as the interpreter arrives.

2.. Called the wards and told them I would be delayed Have them do basic monitoring on the lady who fell and remind them that they could use Sec 5(4) of the MHA on the bipolar man if he was adamant about leaving and was a danger to himself (neglect/self-harm) or others.

3. Start seeing the A&E referrals. I tend to spend 20-30 mins max on an A&E assessment if the on-call is a busy one. The ward drs can go into more details (eg developmental history,etc) if the pt is admitted. Self-harm needs a quick screen for depression/psychosis , drug and forensic hx, meds, some personality, family hx, past psych, a risk assessment and MSE which takes about 20 mins.

4. Gone to surgery when the interpreter arrived and repeated point 3 above but allocating a lot more time due to the interpreter and the fact that the pt is already admitted.

5. Complete the A&E referrals then go to the ward. Deal with the bipolar man first then the lady with the falls.

The difficulty here is communication is a MASSIVE part of what we do and I would not be happy to risk the window of opportunity with the interpreter coming - who knows when you'll get the interpreter again! Also - if the pt is clearly dilerious and not depressed - it clarifies the management and, in this increasing litigious society we live in, covers the duty psychiatrist should anything untoward happen. This is made all the more difficult be the sheer unpredictibility of the human condition.

A VERY interesting post dorriannevergreys!

Share this post


Link to post
Share on other sites

[highlight]

[highlight] Start seeing the A&E referrals. I tend to spend 20-30 mins max on an A&E assessment

Gone to surgery when the interpreter arrived

Complete the A&E referrals then go to the ward. Deal with the bipolar man first then the lady with the falls[/highlight]

reiss, Ru the original Superman? :lol: :lol:

Share this post


Link to post
Share on other sites

I would not mind calling the oncall consultant, explaining that its gonna be busy day and wonder whether he can chip-in to assess that Polish gentleman. Whether he says yes or no- goes into the documentation in addition to what has been already documented.

If that patient had died, the enquiry has a scope to ask, you knew you were busy then why didnt you seek the help of on-call consultant?

Share this post


Link to post
Share on other sites
[highlight]

[highlight] Start seeing the A&E referrals. I tend to spend 20-30 mins max on an A&E assessment

Gone to surgery when the interpreter arrived

Complete the A&E referrals then go to the ward. Deal with the bipolar man first then the lady with the falls[/highlight]

reiss, Ru the original Superman? :lol: :lol:

Should have read ' Go to the surgical ward when the interpreter arrives'.

As a med student I took 1.5 hrs on a psych pt (well - ANY pt!). The more psych you do the more focused you get. My consultant can see a new patient in 20mins. I think all new patients should get at least an hour but this seems to be a luxury the seniors don't have.

Has anyone asked a consultant or SpR to assist on a busy on-call? The busiest I've ever been had 12 new assessments along with the usual ward stuff but I couldn't imagine asking the consultant or SpR to come in and help out. I thought the point of slogging through the SHO years was to get to a point where we'd only have to see complex patients or do MHA assessments.

Mind you - this all becomes moot if we allow ourselves to be 'subconsultants'.

Share this post


Link to post
Share on other sites

Thanks a lot guys  for the suggestions...

Jus to add...

Reiss... I find it difficult to manage a self harm in 20 to 30 minutes.. It takes atleast an hour to take the history and reach a management decision and get the patient to agree (sometimes more), and atleast 30 minutes for (defensible) documentation...

DKS... point well taken... to call the consultant... ( although retrospectively the consultant did tell me what I did was OK)

MY next question is...

WHAT IF THE PATIENT HAD DIED (the way I managed it...)????

Would I be able to defend myself with what I had done...

or was I just plain lucky???

Share this post


Link to post
Share on other sites

i would have given priorty in assessing the polish guy first.

others could atleast communicate  to people around them .

being foreigner and not knowing english he was not able to express his distress in words but had sadly done by act .

Share this post


Link to post
Share on other sites
Thanks a lot guys  for the suggestions...

Jus to add...

DKS... point well taken... to call the consultant... ( although retrospectively the consultant did tell me what I did was OK)

MY next question is...

WHAT IF THE PATIENT HAD DIED (the way I managed it...)????

Would I be able to defend myself with what I had done...

or was I just plain lucky???

Dorian, thats the point, Retrospectively what your consultant said is dictated by the outcome.If the patient had died, your consultant would be the first person to question you, Why didn't you contact him, 'I dont mind being disturbed in the middle of the night blah blah blah...'? I dont think he would have said 'what you did was ok'.  Do you think you would be able to defend that?

Suppose, you had a SpR on-call, would you not have spoken to him? Then,

Why did you hesitate to speak to a consultant? (in the absence of an SpR on-call)

Remember, safety of your patient is of 'PARAMOUNT' importance.

Share this post


Link to post
Share on other sites

OK...

Now just to add...

Like I said...

When in doubt always follow your brain... it cannot let you down...

I would not have normally done this... (if I was following my heart...)

But somehow, that night, I did inform my consultant about what I had done...

@ DKS...

You are right about calling anybody out at night..

I personally have no hesitation to call out anybody at night...

Thats why I specifically wrote that they shud call out for a MHA assessment if needed...

About the consultant blaming me, I dont think that would have happened... I think that depends on the consultant and your relationship with him...

This person is one of the best consultants I have ever seen... one of the most supportive people around...

In fact, he went and wrote down the same instructions I wrote...

He also said that I couldnt have done anything more given the situation I was in...

@ ROHIT...

The surgeon could have assesed his mental state...

The guy could have communicated to the surgeon about what was happening...

Doing a mental state examination is a basic med school stuff... well if I am from India, where I have bunked most of my psych posting during my Med school, then its different... but still, you prepare for PLAB dont you...

Moreover, I was assessing people who had self harmed... all of them had the potential to do what the guy did in the surgical ward...

TECHNICALLY...

If the guy... God forbid killed himself..

The first time itself...

The second time...

WHO WOULD BE RESPONSIBLE IN EACH CASE????

Share this post


Link to post
Share on other sites
OK...

Now just to add...

Like I said...

[[highlight]b]When in doubt always follow your brain... it cannot let you down...

I would not have normally done this... (if I was following my heart...) [/highlight]

Brains and heart, i know what you mean but that cant be used in the court of law. No emotional language please.

But somehow, that night, I did inform my consultant about what I had done...

@ DKS...

You are right about calling anybody out at night..

I personally have no hesitation to call out anybody at night...

Thats why I specifically wrote that [highlight]they shud call out for a MHA assessment if needed...[/highlight]

Again non-specific. What should they do while calling for MHA assessment? Obviously, the patient is not sitting quiet while they are asking for MHA assessment. Who should they call? They have already asked for a psychiatric opinion, well in advance, they might be tied up with some other life saving procedure during an unpredictable psychiatric emergency which you would have predicted better than them, somebody in the forum mentioned 'nurses holding power' But a suitably qualified nurse is not present on all medical/surgical wards.

[highlight]About the consultant blaming me, I dont think that would have happened..I think that depends on the consultant and your relationship with him

This person is one of the best consultants I have ever seen... one of the most supportive people around...

In fact, he went and wrote down the same instructions I wrote...

He also said that I couldnt have done anything more given the situation I was in...[/highlight]

You must be extremely fortunate. More than the relationship, i think it depends on the circumstances. Dont get misguided by the standard attribution of error.

@ ROHIT...

The surgeon could have assesed his mental state...

The guy could have communicated to the surgeon about what was happening...

Doing a mental state examination is a basic med school stuff... well if I am from India, where I have bunked most of my psych posting during my Med school, then its different... but still, you prepare for PLAB dont you...

Moreover, I was assessing people who had self harmed... all of them had the potential to do what the guy did in the surgical ward...

TECHNICALLY...

If the guy... God forbid killed himself..

WHO WOULD BE RESPONSIBLE????

Share this post


Link to post
Share on other sites

@DKS

Unfortunately, I am yet to get over my heart and still continue to be emotional... I agree...

' I am guilty of showing feelings of an almost human nature..'(PF)   :'(

If you have read what I wrote on top, I have mentioned 5(2) by the RMO, calling hospital security, POLICE et al...(The nurses holding power was suggested for another situation where a bipolar was trying to leave...)

Again, this guy was admitted in the surgical ward...

I think they shud have asked me when I am free before they called the interpreter...

(most medics think that we just sit around during our on calls...)

I dont think the fact that they are tied up with some other emergency life saving procedure is an excuse...

Moreover, the patient was in delirium ( a medical emergency...)

which a surgeon shud recognise, as a delirium is more common in a surgical ward, than a psychiatric ward...

which shud be treated in a medical ward, which like you said, may not have qualified staff...

So, absence of trained staff is not an excuse...

The surgeon, who did the mental state assesment, was not able to elicit much information either...

Now.. take this situation... if there is a person in our ward, complaining of a headache, and I call the medic, and he asks me to do a physical examination/ relevant investigations and refer back, and you dont see anything on fundoscopy/ you see but you dont recognise papilledema... and unfortunately there is a raised ICT and patient cones to death, who is responsible ? is it me or the medic who asked me to do the physical???

My view may be based on a Fundamental attribution error (although I believe it is a dead theory, as a person plays a big role in modifying his environement and vice versa)... thats again my human nature... and I plead guilty, but I dont have any remorse for that...  ;)

Share this post


Link to post
Share on other sites

I don't think they guy on the surgical ward is the top priority just because of the interpreter. People tend to ascribe low importance to self-harmers who present to A&E but it could've easily been one of them who jumped in front of a bus outside the hospital 'cos he/she was sick of waiting.

The surgeon's position of not being able to do a Mental State is indefensible. Turn it around. What would've happened if a young patient on a psych ward died following appendicitis which the SHO missed as he/she couldn't do an abdominal exam? We all have basic skills as doctors and should use them!

Share this post


Link to post
Share on other sites
I called up the consultant at around 8 30, and asked him what happened...

He said it was very difficult to assess him even with an interpreter... apparently, he looked like he was in delirium, possibly alcohol withdrawal, and he started him on Chlordiazepoxide and asked them to refer back when medically fit...

So the unfortunate gentleman has a medical condition. This should have been spotted by the surgeons as it emerged, and treated. It's not like they never encounter people going into DTs, surely? And we know that delirium is by nature fluctuant and also likely to become worse at night, so he may have appeared very different in terms of mental state when you saw him.

Retrospect is a great thing, what if you'd done this, what if he'd done that. From your description of the situation there were several appropriate courses of action to take, and you took one of them. There are always different choices to be made in medicine, and we never know at the time which is the right one to choose. The assessment we make is only as good as the information we have to hand.

If the patient had died, then the situation would still be the same. You made recommendations to the surgical team that were appropriate, and acted in the best interests of all your patients. I would not have called the consultant to ask for help in reviewing DSH patients as this is not their role.

Share this post


Link to post
Share on other sites

Retrospect is a great thing, what if you'd done this, what if he'd done that. From your description of the situation there were several appropriate courses of action to take, and you took one of them. There are always different choices to be made in medicine, and we never know at the time which is the right one to choose. [highlight]The assessment we make is only as good as the information we have to hand. [/highlight]

food for thought.....

Justme

Share this post


Link to post
Share on other sites

I am looking at this issue in the following way.

There is a service user, I am the service provider with some resources at my disposal.

My duty is to provide the services as quickly as possible and as efficiently as possible, using all the resources available to me. I cant afford to say the demands could not be met by me, without using available resources.

In this case, my available resource includes the consultant on-call. I know, current demands cant be met solely by my efforts 'in time'. Therefore, i need to use/explore other available resources (in this case, the consultant on-call) to provide the services efficiently. I do not believe that a consultant is not supposed to do a parasuicide assessment. It depends on the demands of the time. I have personally worked with a professor who would volunteer to do parasuicide assessments if he felt i had too many referrals, well, 'volunteer' is an understatement, he would say, im seeing x, and y and z, you see a, b and c. How nice is that?

Dorian, when i said 'no emotional language please', i was referring to what the court of law would say (in my limited understanding), i am sorry, i was not clear hence you took it personally. Ofcourse, in this forum, we all are at liberty to use any language as long as it doesnt hurt others significantly.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!


Register a new account

Sign in

Already have an account? Sign in here.


Sign In Now
Sign in to follow this  
Followers 0