It's midnight on the acute floor, just before Christmas. As I walk through the Emergency Department (ED), I can hear the ambulances reverse up to the door, people shouting, doors opening and closing, phones ringing and the general white noise of the department. You wouldn’t know it was night-time at all, the lights are beaming and it's as noisy now as it is in the day.
I am a junior doctor. I’m on my fourth night shift of six. I have a patient on the acute medical admission unit that I need to check up on. I take the opportunity to seek some darkness and quiet away from the hustle and bustle of the ED.
As I go into the unit, I spot a young man in his 20s. He has a carer at his bedside. I stop. I say "hi"’ to the carer and just take a quick glance at the saturation probe that is on the young man’s finger. It’s reading 94% (normal is >95%).
"Is that number of 94% normal for Eddie*?" I ask the carer.
"Yes" he confirms.
"What about the heart rate, that’s reading 140?" I asked, but didn’t want to come across alarmed, as this is quite high.
"No. It usually reads 90. I was worried, but assumed you were dealing with it".
My time is limited, I should be checking on my patient I originally came in to see. I have now seen a vulnerable adult with an abnormally high heart rate. However, the nurses are here… they can act on it , can’t they? I need to see my patient. I have patients backing up in ED, what about the four-hour target?
Those thoughts go through my head in a split second. I now find myself pulling up a chair alongside Eddie and his carer. I find out that he has been admitted as his feeding tube had fallen out; he is here to have it replaced in the morning in theatre.
I find out that it had fallen out 18 hours ago. As Eddie is unable to swallow without the risk of choking, he relies on the tube for all his medication and fluids.
I take a look at the observations. Respiratory rate 18, heart rate 140, blood pressure 89/48, aprexial, not confused. He has a NEWS2 Score of 6.
I see a sepsis screening tool that has been completed. It has been deemed that Eddie has a high suspicion of sepsis.
But... he’s only come in for a tube change?
I use the expertise of the carer. I find out that Eddie hasn’t had any fluids all day and his pads have been dry. At this point he should have had 3 litres of fluid via his tube. He also has not had his medication for his seizures. This is vitally important as it is highly likely he will seize this admission.
I put some fluids up. I need to be quite aggressive with replacing his fluids as he may go into acute kidney injury. I write up his epilepsy medication, this time via his cannular. I explain to the nurses to give hourly observations and to call me if there are any problems.
I check on Eddie that morning. He’s bright as a button. Smiling and ready for his tube replacement.
If I walked on by, what might have happened?
Eddie would continue to be treated for sepsis when he wasn’t septic and received antibiotics he didn’t need.
Eddie would become more dehydrated and possibly acquired an acute kidney injury.
Eddie may have suffered a seizure that could have been prevented.
Due to these complications, Eddie may not have been fit for his tube replacement.
Eddie's length of stay may have been increased, therefore increasing his risk of contracting a hospital acquired infection.
What stopped me from walking by?
Eddie reminded me of my brother, *Sam.
My brother has cerebral palsy and needs 24-hour care. He’s funny, he can wrap mum around his little finger, he can play pranks on you, he is still my annoying little brother but coming into hospital always poses such a huge stress on us as a family, not to mention Sam. He always has people around him that know him. So, coming into this environment is alien. Due to his physical problems, he doesn’t ‘fit the normal patient mould'.
Will he get the right treatment? Will he get his medication on time? Will there be anywhere for the carer to stay? Will the nurses know how to re-position Sam? How will they communicate to Sam? Will they read his patient passport? Will they act on his patient passport?
Or will they walk on by?
*Names in this blog have been changed for confidentiality purposes.