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You know you are a community doctor when……..

Paramedics are amazing Frailty Detectors!

THIS IS A BLOG THAT WAS PUBLISHED ON THE BRITISH GERIATRICS SOCIETY WEBSITE……..

 

The West Kent Home Treatment Service provides home-based medical treatments to avoid hospital admissions when appropriate. Referrals come from GPs, Community Nurses and Paramedics; but more importantly our team widens as soon as we start to work with patients, their family and carers.

 

A day of referrals began with a call from a Paramedic who had attended V after she had fallen in her bedroom, but luckily sustained no injury. This was on a background of dementia and the need for daily support from her son to assist with meals, prompt medications and support trips made outside the home. V’s only other medical history was that of hypertension and one fall a year ago. V was normally able to get herself to the toilet and used a stick to mobilise slowly indoors; while carers attended once a day to provide personal care.

 

The Paramedic had already obtained a collateral history that V’s gait had been getting gradually unsteady over the last few weeks. The Paramedic reported V’s vital signs were within normal limits, that the ECG was sinus rhythm and there were no signs of infection. The family had identified V had been more dependent since a hospital admission a year ago, therefore they were keen to keep mum at home if possible. The paramedic had already moved the commode next to the bed to minimise transfers; he also established access was possible via a keysafe and that family were happy to stay overnight.

 

We headed straight upstairs and found V lying on her side in a hot bedroom; there was occasional confused speech and evidence of inattention. Additional clinical signs identified were evidence of urinary incontinence, a reduced skin turgor, dry mucous membranes and a moisture lesion of 2cms on the sacrum.

 

Clinical assessment in a person’s home often has to be made in a random order because it is dictated by the need to quickly determine suitability for treatment at home. In this case the family were understandably concerned and exhausted; the main thing to determine was whether urgent treatment was required, if the family/carers were able to support V and whether there were any advanced decisions.

 

The family went to have a well-deserved break while we placed a cannula, took a blood sample and our HCA encouraged V to remove her cardigan and sit in a more supported position. During this our portable analysers had confirmed a normal white cell count and revealed a sodium of 118 mmol/L with a raised urea. I attached a 250ml bag of Normal Saline to drip slowly through the cannula and left V with the HCA so that I could discuss the plan with V’s family.

 

V’s son already knew that her condition was serious and understood blood tests indicated a severe change in blood chemistry that could cause her to become suddenly unwell. It was likely the sudden arrival of summer and the use of a thiazide diuretic had caused dehydration, a delirium and a reduction in functional level. I discussed the risks of management at home, but the family stressed that V had previously stated she would not want to be hospitalised. My discussion led to the topic of resuscitation status and the family felt this would not be in their mother’s best interests or in keeping with V’s wishes.

 

The current dossett (containing statin, thiazide and aspirin) was stopped until a new one could be issued without the diuretic. I arranged for the Rapid Response nursing team to attend in the morning and reassess observations and progress. A DNAR form was completed and a care plan was left in clear view and communicated to the GP and ambulance service via their patient database. Returning upstairs I found the HCA had placed a newspaper on a table and was looking at stories and surrounding family photos with V while she sipped at a cup of tea. This expert process of re-orientation was made simpler because V was in familiar surroundings.

 

Re-assessment the next day found V more alert; we were able to encourage her to the commode, obtain an MSU and place some barrier cream on her sacrum. Although the family had seen progress they understood that V was still very vulnerable and that they could call for support if required.  A repeat sodium was 122 mmol/L and within a few days V’s mobility improved; carers were able to support her once again and V responded well to their familiar routine.

 

Prior to discharge V’s son understood that his mother could deteriorate again and therefore the family moved her bed downstairs to allow easier care if the need arose again. Furthermore, the family recognised there had been a progression in V’s dementia and agreed to a hospice referral for further support.

 

The Paramedics act as our eyes and in the above case the safety of the social network was balanced against the perceived risks of transfer to an acute hospital. In this way they act as our frailty detectors and recognise a further ambulance will be called unless a clear plan is made. Admission avoidance requires the extension of the role of every team member and is demanding on both clinical and emotional levels. However, the chance to be involved in every aspect of care and to receive support from a variety of team members makes the challenge a rewarding one.

 

 

My latest Blog on discussing DNAR forms in the community

You know you are a community doctor when……discussions to complete a Do Not Attempt Resuscitation form (DNAR) become a priority task.

The people leading your management plan are often family members and carers. If their condition deteriorates it is these people who will have to call ambulances and they do not have the resources and support of a hospital environment. It is often those carers who prompt such discussions when they share their fears of finding their family member or client unresponsive.

Discussing whether resuscitation should be attempted remains a difficult topic for me to air. I always fear people will misinterpret it; that I think they are about to die, or that I want to deny them treatment, or that relatives will think I don’t care or have run out of ideas to help. Yet there is a pull to visit the subject because I want people to have a dignified death and to be able to express their own goals. Discussing DNAR forms in people’s homes has often been eye-opening; it has led to shared management plans and a greater understanding of each other’s ideas. The joy of a home a visit is that you have an opportunity to discuss before the panic of an unplanned admission.

I can think of two patients who reacted very badly when I discussed the use of DNARs. One was 98 years old, frail and suddenly bed bound following a long trip in a car, she was now not managing oral fluids. She was very clear that she did not want to be admitted to a hospital. I explained the medical management plan and then went onto explain my thought processes around completing a DNAR. Her daughter was present and nodded in agreement, however the patient looked at me firmly, “I want everything, I am not going quietly.” We laughed together as I challenged her to finish the glass of water in that case! We had spent enough time together that we were able to recover the line of communication, but I suddenly understood her drive to live despite her appearance in the bed. I really encouraged her to stand with the nurses and I that evening; never have I been so proud to find a patient sitting out of bed the next day.

Discussions about the end of life had spurred her on and she accepted the advice of the nurses and walked to the bathroom for a wash the following day. We reviewed various medications and focused on correcting her current constipation and reduced nutrition. Her mobility was made easier and safer after an OT visit and she accepted a formal, regular care package to support her at home.

You know you are a community doctor when discussions about DNAR forms save a life.

My latest blog “You know you are community doctor when”……..This week looks at Families with Frailty

You know you are a community doctor when………you work alongside families to reduced hospital admissions. As part of a community-based team you try to identify the cause of frailty syndromes such as reduced mobility or falls on a daily basis.   However, you can only avoid hospital admissions when you tackle the frailty phenotype of the surrounding support network; exhaustion, reduced strength, weight loss; their actions become slower and the ability to adapt to the situation is lost. Every complex system; human body or family unit, can adapt to a point but its ability to do so needs some help along the way.

I met Iris after she had been the matriarch of her wonderful family home for a few years. The house contained three generations and they ticked along together, with Iris only receiving treatment for hypertension and asthma. Just as one young member of the family had started to walk, Iris had gradually become more short of breath and less mobile. So, the family had adapted for every generation; stair gates went up and a downstairs extension was erected so that stair climbing was limited for everyone. A potty and a commode sat next to each other and as Iris became less able to entertain the children she was given the baby to hold.

Every member of the family had their own role and as the children grew around Iris it had become evident that one childhad their own medical needs. Although Iris was becoming less active she had been a calming influence for this child and was somebody who could babysit while other family continued to work. The house and garden filled with equipment that Iris could entertain the children with even though she gradually spent increasing time in her riser-recliner chair. Bubble machines, special effects lighting and trampolines entertained the younger members for hours!

I was lucky enough to meet this dynamic family as they described how important Iris was to the whole functioning of the family. They were desperate to keep her at home, but suddenly they worried that Iris might need to go into hospital. The family described that Iris had changed from being chatty to withdrawn. They were concerned that her breathlessness was now too severe to manage at home. Iris looked at me intensely, she did not want to interact at all and I realised I had stepped in front of her favourite TV show!

I suspect Iris had been breathless for years because of heart failure, but over the last few days this had even been occurring while sitting in her favourite armchair. In addition there was now a cough and green sputum. Indeed physical examination did confirm a lower respiratory infection with evidence of acute heart failure. Antibiotics started, legs raised and a bowl of ice cream provided; the management had begun.

Iris’ mobility had been reduced to a few steps for years but something had made it harder to manage in her home environment. Iris had peripheral oedema and the family explained this had extended to her knees over the last week and she was now constantly tired. She was needing to get up intermittently during the night to sit up in her chair, but was having to disturb the family’s sleep so that she could summon help to lift her legs back into bed. Although the commode had always been a prominent feature in the house; Iris had always managed to empty it herself once a day. No longer able to do this it had added another task onto the hectic morning routine; Iris was embarrassed by the need for this level of help.

This family had already adapted so much to support Iris and there had come a point when the system had started to demonstrate frailty. Exhausted, the family felt their support was no longer adequate.

I took bloods and helped to settle Iris into bed. I explained that an oral diuretic would need to be started cautiously and that our nurses would kindly attend to give first dose in the morning and that they would assist Iris emptying the commode. Within a couple of days Iris was back to her chatty self and her baseline level of mobilising a few steps was achieved. Within a few doses of diuretic the ankles were less swollen and indeed the dose was reduced quickly because of the development of a postural drop and a reducing sodium level.

Our brilliant Occupational Therapist attended and he still found Iris could not bring her legs into bed without assistance and so a hospital bed that could be lowered to the ground was provided. Doris now just had to sit on the edge, lower the bed, pop her legs on without having to lift them and raise herself up slowly. Sleep for the family and dignity for Doris had been regained.

The family have been unable to attend an ECHO appointment to investigate the raised BNP level, but we slowly introduced ACE inhibitors and I still get called intermittently to visit Iris. Often a few days of diuretics and some additional nursing support keep her out of hospital. We have discussed long-term plans and once I got to know Doris well we discussed her wishes about resuscitation. There are care plans for episodes of reduced mobility, increased breathlessness and a DNAR form has been completed.

Identifying the myriad of factors leading to a call to health services can help us support a family and reduce the level of frailty demonstrated. Reducing hospital admissions is about reducing the strain on a team that has functioned previously. You know you are a community doctor when you get to meet some inspirational families.

My latest blog…the importance and brilliance of pets in community medicine

You know you are a community doctor when……………..your patients’ pets become a crucial part of their recovery.

Widespread wheeze, bronchial breathing, high fever, low oxygen sats, on second course of antibiotics…..mmmmm.

I explain to Mr J that I really feel he needs to be admitted to hospital and it is at that point I am aware of a large presence behind me. Like a Ward Sister creeping up on you at a ward station and shaking their head, it is Mr J’s dog that nudges my hand firmly.

Mr J has mental capacity and despite explaining the risks associated with staying at home it is his concern for his large Alsatian (incongruously named Lucy) that deters Mr J from accepting admission.

So Lucy stands guard as I form a compromise with Mr J. The nurses will visit tonight to recheck his observations, a trial of IV antibiotics and the addition of prednisolone. I begin to search for a plug socket so that a nebuliser can be started, but Lucy is taking up a large amount of the room, as are her bed and toys; soon Mr J concedes that there may not be a spare plug and that the noise from the machine may disturb Lucy anyhow. Sighing, I supply him with an additional salbutamol inhaler and encourage him to use it.

Mr J tells me that he hasn’t been out of bed all day. So I start thinking about nutritional supplements, some pressure relief and his VTE risk. I demonstrate the importance of moving his legs within the bed and Lucy watches with alacrity. Mr J looks at me puzzled. Of course he will move, who will walk Lucy otherwise? Of course he will cook dinner, what would Lucy eat otherwise? Now it is me who is looking puzzled. I offer to put some biscuits down for the dog, but Mr J coughs dramatically and explains that Lucy will only eat from his plate. He will have to be up to take her out for a short walk and he will have to cook something healthy otherwise Lucy’s health will suffer.

I cross through the parts of my management plan that detail referral to the physios and dieticians. I realise Lucy is already covering those roles, is present continually and is probably quicker than awaiting the result of the referrals anyhow.

Mr J recovered slowly, Lucy can take all the credit. I fear I may have to support Lucy when the results of the chest xray are available.

Community doctors and carers

YOU KNOW YOU ARE A COMMUNITY DOCTOR WHEN……….

 

……..You enter into a symbiotic relationship with your patient’s carer. The chances of you preventing an admission are increased when you ensure open communication with carers so that they remain supported and they then become an extension of your team. If the balance of these exchanges becomes unequal in anyway, then the chances of maintaining a person in their home environment diminishes quickly.

One carer provided me with an oxygen saturation probe when mine stopped working, I installed a nebuliser and in exchange she became our eyes informing us that the sats had improved a few hours later. One carer insisted on walking me the short distance to my car in the dark, I insisted on following him back to his house in case he fell. We giggled at the ridiculous position we had found ourselves in! One carer had left a list of emergency contacts before the paramedics whisked him away, I rang them and a rota of friends appeared as substitutes to care for his mother. The state of my shirt from a previous visit was ignored; I in turn held any judgement on the mess I tactfully stepped over.

You are sometimes an outlet for a carer’s frustrations; tired, exhausted and worried they ask “when will you be here? I haven’t even got any food in the house.” They wearily explain that they last visited their elderly sister Betty forty-eight hours ago and that they have found her on the floor today. They are unable to stand her, she has refused their efforts to call an ambulance but she has agreed to see a doctor at home. You explain you will be there within 30 minutes and will bring some additional hands and equipment to help.

You arrive and find the carers moving furniture to allow you more space; the teamwork has begun. Examining hips and neurology you then help the team to slowly stand Betty and a group sigh of relief is expired as weight-bearing doesn’t seem to cause pain. We note Betty has bruising, grade 1 pressure areas, dry mucous membranes, that she is orientated, has a large postural BP drop and a new prescription for amlodipine. Unlike a plan made on a hospital ward round the management for Betty starts to happen instantly around me. Drink of water, bowl of cereal, box of amlodipine removed, bed fashioned downstairs, barrier creams applied to pressure areas, trip hazards removed and phone repositioned within an arms reach. Huge smiles as Betty is supported to mobilise slowly with a frame. Stiff and tired Betty is returned back to the camp bed in the living room, encouraged to drink more and shown how to change position in bed regularly.

Surrounded by the management plan in action you notice the first problems. Low camp bed and lack of accessible toilet has reduced Betty’s ability to mobilise and means she is reluctant to drink. The brothers assure you that the bed can be raised safely and you agree to urgently order a commode. Between our numerous telephone calls and trips to collect equipment we ensure that Betty can transfer independently by the next morning. Now drinking plenty her renal function starts to normalise.

You discharge Betty a few days later and make one last phone call to her oldest brother. Thanks exchanged equally and an offer of a job in our team laughed away.

Well supported carers look after you and your patient. One of our main aims should be to look after them in return.

You know you are a community doctor when….you never trust armchairs…..never!

Armchairs that have been a familiar companion to your patient suddenly become their enemy. A referral asking your team to assist a patient out of an armchair they have been stuck in for days can be a diagnostic and manual-handling minefield.

You are often greeted from an armchair by an extremely comfortable looking patient. Ensconced amongst cushions collected over a lifetime they insist everything is fine. Lots of groans accompany your request for them just to stand so that you can be reassured that their family’s concerns are completely unfounded. The aetiology of ‘reduced mobility’ can sometimes be easily solved as the patient points to a box of paracetamol left just out of reach by a new carer that started yesterday. 24 hours without analgesia has meant the back or knee pain has reduced the person’s ability to win the battle to escape the armchair’s comfy base. You hand them the box and explain you will call later to see if they have had the promised magical effect. They normally do.

You palpate your patient’s knees as they try unsuccessfully to extend into a stand from a low chair. The crepitus beneath your hands makes you jump and you see the patient’s feet desperately trying to gain purchase as they try to stand. In this case the familiar armchair is not to blame but needs to be elevated and raised to new lofty heights. It must take pride of place on an elevated platform produced by the Occupational Therapists box of tricks. The slippery floor surface has become an enemy that is trying to separate your patient from their beloved chair and so you suggest some new slippers, or better still a new floor surface. Your team is wide now and you must involve family, friends, neighbours and helpful charities to make the armchair king of the living room once again.

Armchairs are fickle friends. I have picked people up who have fallen over in their excitement to greet the delivery driver bringing their new Riser-Recliner chair. The chair that was meant to improve their independence has just prolonged their rehabilitation further. Armchairs have divulged the secrets on behalf of many of my patients at their time of need. Asked to assess a drowsy patient snuggled into an armchair a brave delve has been rewarded by finding the DNAR form with very clear instructions to prevent hospital admission. Your wish is my command. Important diagnoses can be gleaned from discharge letters, ambulance reports and boxes of tablets hidden in the many folds of endless blankets

You never underestimate how relaxed and well a patient can make themselves appear in their favourite armchair. Poised with newspaper, remote control and covered in a blanket, it is hard to believe that they have been confused overnight. Observations are all within normal limits so you ask “could you just stand a moment for me Sir?” As chair and patient are parted it becomes clear that the armchair has become a sanctuary because the body’s physiology is only able to cope within the confines of cushions. Huge postural drop, rising respiratory rate and it suddenly becomes clear that the ability to adapt to this minimal challenge is limited.

You can never be certain of someone’s true mental capacity until you have separated them for their armchair, the comfy surroundings prevent them from being able to absorb all the facts. You are certain that the diarrhoea described in detail by a family sounds like melena, but the patient declines to stand or allow examination. Covered by a quilt he insists that he doesn’t require hospital admission and will stay at home as he promised when he became the full-time carer of his wife, he snuggles down and puts the TV on. You just delve a little further and ask how he will care for his wife if he becomes more poorly. “No problem,” comes the confident reply. You suggest that his wife looks as if she needs to go to bed now and you offer to help. This offer is declined quickly as the gentleman stands from his chair and suddenly as his bottom leaves the confines of the chair, the practicalities hit him full on. Dizzy, pale and frightened, you decide to reunite patient and chair temporarily and raise his feet. All settled again, you assess capacity to decide on safety to remain at home again. This time there are no doubts, he understands he must bid his armchair farewell. As the ambulance takes him to an acute hospital you realise your team has just gained his wife as a further patient on the caseload, but at least you know what equipment and support network is available.

A very delayed Xmas 2014 special!

You know you are a community doctor when…………..your use of common sense is more valued on a shift than your clinical skills.

I dragged my body into work during Christmas 2014. Our caseload would swell with patients wanting to avoid hospital, access to basic investigations and supplies would be……..challenging, well more than usual at least. I enjoy fully immersing myself in any Christmas festivity, I revert to a joyful childish-state and that part of me was worried how I would react to the harsh realities I knew I would witness. I was fearful of the heightened emotions that a tinsel backdrop would add to the stories unfolding in front of Christmas trees.

I had prepared meticulously for this day. We had our family Christmas early and I filled my boot with the leftovers from this wonderful celebration. I had downloaded my favourite podcasts to accompany me and stockpiled as much equipment as I could.

I took a deep breath as I stood in the staff car park and stomped my new boots into the office with a ‘Ho Ho Ho!’ Our desk was covered in a variety of life’s most indulgent treats and there were lots of exclamations of delight as lids of tupperwares were tantalizingly peeled open. The day was a slow one initially; many family members had surrounded elderly or frail relatives and provided the personal care or meals that were the daily duties of our team. We laughed, we chatted and we eased each other through the day. Enjoying these moments got me through the shift, as our prospective patients’ meals were finished and presents opened the phone line became increasingly busy and more insistent.

A glance at the details of my first referral would make it seem a mundane request; further translating it into data would trivialise the need. I had to check an INR and dose the warfarin. Surely, surely, this could have been planned in advance? As it turned out it was one of the most rewarding visits of my day. The referral had been accepted on Christmas Eve and would allow a patient to return home after major surgery. It turned out that the patient was the husband of one of our most talented nurses. A nurse who taught me so much when my training had not prepared me for community medicine at all. The kind of nurse who will take down dressings, check how much food is in the house and ensure the welfare of the patient’s pets before completing the assessment for a patient referred with ?UTI. The kind of nurse who continually wants to learn and develop, someone who puts the holistic care of the patient at the centre of her work. The kind of nurse who had taken in a stray dog on Christmas morning while preparing a fantastic meal and caring for her husband! Accepting this referral had allowed her husband to come home for Christmas, something the hospital team had said was not possible. A drop of blood, a warfarin recipe and a check on his progress and I felt as if my shift was already justified, we had given something back to a nurse that continually gives to others.

One of the houses I entered felt like an advent calendar; there were endless closed doors that were gradually opened for me. One door was closed to try to prevent the kitchen steam setting off the smoke alarms, while a further door tried to separate the celebrations from our arrival and another tried to contain pets. Other corridors had various bedrooms and converted cubbyholes that tried to accommodate the additional visiting relatives. I walked upstairs to find a lady snuggled up with a teddy bear. She was flushed, tachypnoeic and looked frightened. I sensed the daughter answered every question to try and soothe the bewildered look that greeted me from the bed. Asking inane questions about the teddy seemed to allow us to connect a little. The daughter was exhausted and described the slow decline of her mother through the day, her mum had dementia but normally mobilized independently and lived in her own home. Throughout Christmas day she had short episodes of slurred speech and now couldn’t get out of bed.

She spluttered as the daughter kindly encouraged her mother to drink; the combination of the subsequent cough and low oxygen saturations concerned me. The daughter and I both knew the discussion we needed to have, but as she led me out of the bedroom she grabbed my hand, looked deep into my eyes and pleaded, “please just look at my mother-in-law and my husband.” Two further doors opened to reveal people sneezing and shivering. After quick examinations I was relieved that I only needed to suggest paracetamol and fluids, these doors were quickly shut again but had given me time to finalise the management options that needed to be discussed.

My next call was from one of the very experienced and caring nurses asking me to catheterise a gentleman in urinary retention. I knew it was going to be tricky if she had been unable to succeed. Name, address and contents of his syringe driver were the only other information. His underlying terminal condition had caused oedema to pool in his lower limbs, this now extended around his pelvis and meant our task was impossible. He was already on a syringe driver but the discomfort of not being able to urinate was only temporarily relieved by the medications and the support of his caring family. I wanted to reduce the swelling but couldn’t tip the bed because this caused too much distress. A shot of midazolam gave us both time to pause and consider the options. Did we really need to use a catheter at all? Further new referrals were being transferred to me and I knew I had to make a decision. I chose to stall for a couple of hours and hoped that my decision to place rolled up towels underneath him to tip his pelvis might just reduce the swelling enough to allow urination. I dashed off to see the next referral and hoped the PRN medications and loving family could keep him comfy. I returned with some trepidation a few hours later and the family woke him as I arrived to show me that my hastily constructed contraption had indeed allowed the swelling to reduce. He was still distressed by the desire to urinate and we placed a catheter quickly. I was secretly amazed that my gamble with gravity had worked; I was openly pleased he could remain with his family next to the Christmas Tree they had decorated with objects he would find significant and comforting.

Each of these cases sums up what it is to be a community doctor. You know you are a community doctor when you deal with the mundane parts of care that keep patients trapped on wards and when you can allow them to be in the places they enjoy. You know you are a community doctor when you have to start frank discussions and accept that your management plans may not be completely textbook. You know you are a community doctor when common sense prevails and your ability to invent equipment and bake are the most valued skills during a shift. You know you are a community doctor when you do not feel sad at the end of such a poignant shift because it is easier to try to accommodate a patient’s wishes in their own living room.