I was caught-up in the frenzy that is hospital discharge yesterday.
Here is a fictionalised account of the episode:
Man, 70 years old, has fallen and broken a bone in his leg.
He struggles to walk.
The pot (stookie) is applied and his ability to move around improves.
A night in hospital.
Another night; waiting for equipment, support, the effects of the pain killers.
9am and the day of discharge the ambulance is delayed.
Man, let’s call him, Fermi, remains in bed; the pain controlled, his chestiness, perhaps a little worse, but his desire to get home, the peacefulness of sitting in his living room, clock ticking, slippers and worn carpet, smell of his life.
Observations checked – a routine of the ward.
Temperature 39, heart rate 90, blood pressure 110/70, respirations 20/min, oxygen saturations 90% (all normal for Fermi except the temperature).
I return and check him over.
Fermi is very upset; the nurse has told him he can’t go home.
If only the ambulance had arrived on time…
Let’s see what we can do; all is not lost.
I talk with Fermi, sound his chest, listen to his heart.
He seems OK, perhaps lips a little blue, but he wants home.
I agree reluctantly to let him go; using what we call safety-netting (aka protecting your back… ‘your temperature is high, it could be anything…’ ‘If you go home and you feel worse, you need to seek medical attention’ (and similar platitudes).
Fermi, anxious to leave, agrees.
Moments later, as I have moved away, a phlebotomist has taken-out his tourniquet, preparing to take blood; it’s policy. Temperature of 39 requires investigation; blood cultures.
Thoughts in my head… ‘He’s OK, says he is fine, wants to go home, responsible adult, transport imminent…’
‘No need for blood tests I say. He is OK.’
I think, ‘If he was at home with a temperature of 39 no one would be doing blood cultures, and so on.’
Nurse expresses his concern. Doesn’t seem right. Guidelines…
Nurse, also, possibly thinking to himself, ‘this isn’t right… damn doctors… my patient!’
I don’t listen. I am standoffish, almost rude, or perhaps, rude; hard to tell. A few seconds of disagreement and I move-on.
Frustrated that my plans, are challenged. Annoyed that I had not been able to successfully translate the thoughts in my head into words that would convince others. Feeling threatened. Vulnerable.
What now if something goes wrong.
The volume of data, information, decisions absorbed and translated on ward-rounds, particularly those on assessment units is immense.
Consultants are expected to move from patient to patient, young to old, infection to infarction, issue A to B to C all within a constrained timeframe and support decisions (albeit with the team and the patient) that can be life determining.
It is intense.
Shortly afterwards another nurse informed me that the patient’s oxygen levels were even lower.
We cancelled the discharge.
I reviewed him later and he was thankful for staying-in, as were his family; now attached to oxygen tubing, in receipt of antibiotics, steroids.
I apologised to the nurse and thanked them for their good sense and action to do the right thing, to stand up for their patient.
In the discredited methodology (so says my brother) that is the Myers-Briggs Personality Inventory it is believed that we all have a type, or, typology – this relates to our internal preferences; how we behave when all things are equal, when the sea is calm.
For me this is (I think), generally, good humoured, smiling, relaxed, attentive.
When the pressure is increased to a certain level, we can enter the grip. This is when we can behave in ways that are counter to our usual preferences; the quiet guy shouts, the woman obsessed with detail makes rash and sweeping assessments, the emotional soul becomes a tyrant.
I don’t know whether the grip is or is not a thing (Nigel), nevertheless, it is something yesterday I felt raw in tooth and claw.
I have touched on this before when considering arses.
Yes, I was an arse on this occasion.
The episode did not last long, no one suffered long-term harm and I am almost recovered (this blog part of my expiation).
How do we however manage to reconcile the inevitable pressures encountered by mostly loving, caring, sensitive people who are let-loose in hot-house pressure-cooker hospitals, now and into the winter…
20 breeches in A&E
12 patients on trolleys
How do we support our staff and our patients, how do we ensure that the grip doesn’t become a permanent state, the norm? After all, it does no one any good.
In the grip, otherwise known as extreme stress, humans stop thinking logically, we revert to our primitive norms – more likely to bite than lick, shout than smile. (This is almonds and emotions).
Organisations (that is, hospitals) have a responsibility to care for their staff to allow them escape-valves, the possibility to let loose, to unburden. How often is the response to pressure to add more pressure, to turn-up the voltage?
We forget the fragility of our lives.
When I walk around the ward seeking patients with ‘frailty’ (this a whole clinical syndrome that is a thing* of the moment), I often forget the frailty or the fragility of those providing the care, the system and almost always myself.
*Link to the British Geriatric Society who won’t publish any of my blogs 😦