Managing medical complexity 😩

Descriptors and examples for the RCGP Trainee

This capability area is about aspects of care beyond the acute problem, including the management of co-morbidity, uncertainty, risk and health promotion. See word descriptors below, and scroll down for example reflections.

💭 Example Reflections (2)

Gut Feelings and Broken Skulls 💀

Description

A young lady with a history of alcohol dependence presented with dizziness and falls onto her left side. She also complained of not being able to see properly on the left side. She had sustained multiple injuries all over her body from her falls and also had a headache.

This lady was a known alcoholic with liver cirrhosis. Her head injuries were mostly scrapes and bruises, though she complained of scalp tenderness everywhere except her temples. She had left hemianopia and thought that had been coming on slowly for a long time. She also said she thought she might have lost weight recently but was unsure how much. She had been getting vomiting in the morning that was slowly getting worse and worse, to the point she was now spending 4–6 hours heaving every day.

I was immediately concerned she had serious brain pathology like a space occupying lesion and wanted to get her a CT head scan. I discussed the case with my supervisor, who thought it might be SDH, but agreed we needed an urgent head scan. She was sent to hospital with a letter for A&E. Later that day, we received her CT results. She had multiple skull fractures, and multiple SDH lesions visible in her brain. There were no masses seen, thankfully. My supervisor was right!

Reflection: what will I maintain, improve or stop?

  • I learnt to listen to my gut feelings! I did not remember the NICE guidance for scans for head injuries when this lady presented, but did manage to recognise there was something seriously wrong going on. I got the presumptive diagnosis wrong but, as my supervisor likes to say, the whole point of being a GP is to recognise when there are red flags and when to refer to secondary care. Managing uncertainty is part of day to day life as a GP. We do not have access to the plethora of immediately-available investigations and specialist input hospitalists do and recognizing sinister symptoms is part of our medical interview.
  • I also quickly read up on head injury guidelines on patient.info. This made me realise that even though I had examined this lady’s head, I probably should have checked her neck too.
  • The other major thing for me here was that I had not really considered skull fractures since the patient looked too well and in too little pain for there to have been the multiple fractures she had. I will not make this mistake again!
  • The lady was definitely moving her neck around fine and had no pain in there on review of systems but I should have done a formal neck examination.
  • I will listen to my gut feelings when seeing patients like this. Our subconscious can often pick up subtle clues we may consciously miss. Studies have shown this to be the case, and there is ongoing research into the subject (e.g the GLANCE study).

Learning needs identified from this event

I have already read up on head injuries to refresh my knowledge, but will also look up some common injuries on Radiopedia to see what the CT scans look like.

Applying Jonsen’s Four Quadrants

Description

I came onto the ward early to the horrific sounds of a child choking. I ran to the room, aghast. I entered the room to see a father suctioning out a baby’s throat, the Yankauer greedily slurping up mouthfuls of mucus.
He looked at me.

“Morning doctor,” he smiled, his eyes crinkling at the edges as he put the baby back down into its cot. “He’s doing really well today!”

The baby was not doing well. I could see he could not move his eyes. His conjunctiva were dessicated from being unable to blink. He had no swallow or gag reflex and was gradually drowning in his own mucus.

I went out to talk to the team. This was a baby with severe HIE (hypoxic ischaemic encephalopathy) who was actively dying. Later that day, I had a detailed chat with the parents, who seemed to think their baby was going to pull through and was absolutely fine. No amount of explaining would help them understand there was zero chance of a good outcome. They were even talking about the baby marrying some day and them having grandkids! This was heartbreaking.

Throughout the week we had multiple discussions with the family who were unwilling to get the baby put on palliation and made comfortable. They kept insisting on not signing a DNACPR and told us the baby was for full resuscitation. Eventually, after spending more than a week in hospital where we basically could not do anything for the baby, they went home, certain the baby was getting better when in fact there was no change in their condition.

Reflection: What will I improve, maintain, or stop?

I was quite disturbed with this case. I was on call that week and would go onto the ward to find the child choking, their parents smiling and telling us this was baby’s way of talking to them. They would not agree to palliation. I am unsure if there was any provision in the mental health act we could have used against them but we did talk out a few things with regards to the 4-quadrant approach of ethical decision making.

1. What are the medical indications?
With HIE this severe, we would not do anything apart from making the patient comfortable. Medically straightforward, emotionally not as much so for the poor parents who were devastated.

2. What are the patient preferences?
The patient in this case was too young to even have a preference. He had severe HIE and his brain was never going to work, sadly. Without constant monitoring he would have died. We felt keeping him alive was cruel. He was constantly distressed and no amount of love or care or medication could help. He was literally drowning in his own secretions and it was only a matter of time before his mucus-filled lungs got horribly infected. His parents were adamant they wanted to keep him alive without palliative input, which would have helped make him comfortable. They were on certain online groups that kept feeding them false information and giving them false hope. I felt very angry and disturbed at this but did not really know what to do about it. The consultant involved in their care told us there was nothing to be done, which grated on me. I felt helpless and useless as I watched the baby slowly fade away.

3. What is the effect of the proposed intervention on the quality of life?
We wanted to go for palliation, which would have massively improved the quality of life but also would have shortened it. The parents were unwilling for this trade-pff.

4. What are the contextual features and other relevant factors?
I felt explaining better to the parents might have helped, but try as we might we could not get through to them. I wonder if we should have asked the palliative team to come have a chat with them despite the parents’ refusal to speak to them? But then that might not have been right. I also wonder if reporting those uninformed, damaging online groups to the relevant authorities might also be something that can be looked at.

Learning needs identified from this event

I still feel confused after seeing this baby and I think I’ll have a chat with someone senior about it. Using Jonsen’s grid and working through the whole dilemma helped massively but I am unsure if were more to be done about the parents’ decision to keep the child on active treatment. Unwise decisions are a patient right, but are parents allowed to make cruel ones? At what point does this become a safeguarding concern?

Managing medical complexity

Maintaining an ethical approach

Supervisor comment

Have a look at the GMC guidelines to look at what would happen next.
“Resolving disagreements:
Sometimes members of the healthcare team disagree about what would be of overall benefit to the patient, or those close to the patient disagree with you and the healthcare team. It is preferable, and usually possible, to resolve disagreements about a patient’s treatment and care through local processes.
For example, by:
involving an independent advocate or local mediation service
consulting a more experienced colleague and/or an independent expert
holding a case conference or seeking advice from a clinical ethics committee.
If, having taken these steps, there is still disagreement about a significant decision, you must follow any formal steps to resolve the disagreement that are required by law or set out in the relevant code of practice. You must make sure you are aware of the different people you must consult, their different decision-making roles and the weight you must attach to their views. You should consider seeking legal advice and may need to apply to an appropriate court or statutory body for review or for an independent ruling. Your patient, those close to them and anyone appointed to act for them should be informed as early as possible of any decision to start legal proceedings, so they have the opportunity to participate or be represented.”

Doctor, clinical mentor, variable-frequency blogger. I devour novels to stay sane.