Communication Breakdown

Bit of a boring day today. All medical stuff and mostly chronic (long term) conditions. The sort of jobs that run along the lines of:
"How long have you had this condition?"
"Oh, about 2/3/4/5 weeks/months." Delete as appropriate.
"And what has changed today that made you call an ambulance?"
"Nothing really. My wife/husband/sister/brother/friend came round and thought I should get it looked at."
Aarrgghh! Where's that brick wall gone?

Mid morning, and I was asked to visit a patient who was ‘breathless on exertion’. The story (so I gathered) was that his new carer had visited this morning and found the patient out of breath after answering the door. Being a conscientious soul the carer had phoned our good old friends at NHS ReDirect who in turn had passed the call next door (they’re in adjacent rooms) to request a 999 response for a COPD patient with exacerbated breathlessness’.

The crew had duly turned up to discover an elderly gentleman who had been breathless for 4 years and had recently been discharged from hospital after being ‘poorly’. He couldn’t be any more specific than that. He had been assessed for a new care package (hurrah!!), which explained his new carer. The patient told them his breathlessness was no worse than usual. “No, he hadn’t wanted the carer to call” and “no he didn’t want to go to hospital” but “could they give him something to help his breathing when he was up and about?” They had nothing suitable.

As there was no exacerbation of his COPD a nebuliser was out of the question. So, they spoke to one of my colleagues who suggested an ECP visit with a view to reviewing his medication and perhaps provide a salbutamol inhaler – one of those little blue ‘pumps’ many asthmatics carry about.

Somehow, by the wonders of modern technology, the bat phone rang a while later and I got the call.

I duly trooped round. Couldn’t get in for ages despite ringing the bell, banging on the door and hollering through the letterbox. I was getting a bit concerned that maybe he’d ‘gone down hill’ when a neighbour appeared with a key. The patient was shut away in his lounge with the TV on full blast (watching the rugby) and the fire on melt down. It was like a sauna! After more hollering (on my part) I managed to get him to turn the TV down before I went deaf and we managed to start a rather confused conversation.
“ Yes, he’d been breathless for 4 years.” “No it wasn’t any worse today than usual."
"It’s always like this when I get up and about. The carer said you could give me something to make things easier.”
“ Has the doctor ever given you a ‘puffer’ to help your breathing?”
“ No. He says there’s nothing more he can do for me. He says I just have to take things easy.”
“ Were you breathless when you were in the hospital?”
“ Yes.”
“ Did they ever suggest you had a ‘puffer’ to help things along?”
“ No, they never mentioned it.”

Now occasionally the old brain cells start to whir away and somehow this just wasn’t adding up. COPD is a chronic, non-reversible condition which occurs (mostly) in smokers and is brought on by years of bronchitis, emphysema, asthma and other chronic lung conditions. If you have one of these conditions you invariably have a number of inhalers of different types.

“ Have you ever smoked?” His fingers didn’t have that characteristic staining from long-term smoking.
“ Used to many years ago but gave up when I was in my twenties”
Time to back track.
“ Has anyone ever told you that you had asthma, emphysema or bronchitis?”
“ No”.
“ Have you ever been diagnosed with COPD?”
” Don’t even know what it is!”
OK, might explain why he’s never been prescribed any inhalers – he probably hasn’t got a lung complaint.
“ So why have you been breathless for the last 4 years then?”
“ ‘cause of my heart”
“ You've got heart failure?”
“ That’s right. Doctor says there’s nothing more he can do for me.”

Bit of a communication breakdown here. I’m called out to administer a salbutamol inhaler for a supposed COPD patient whereas, in fact, I’m presented with a patient with heart failure. He’s getting breathless because his heart’s not able to pump enough, so giving him a ‘puffer’ to ‘open up his airways’ is not going to help one bit. In fact it would probably make things worse. Salbutamol is a ß agonist, which works by simulating ß receptors in the muscles of the airways, causing them to relax. At the same time, some of it will be absorbed into the blood stream and will eventually find its way to the heart where it will stimulate similar receptors in heart muscle, making the heart beat even faster. Definitely not what the patient wants.

Whew, close one there.

I’d have been pilloried when the patient collapsed and an ambulance crew discovered it was because I’d given inappropriate medication. So how did the wires get so crossed? We’ll never know. I checked back with 'those in the know' and the original call from NHS ReDirect was definitely for a patient with COPD, but goodness knows where that came from.

The whole call had taken about an hour and, in the end, I did nothing for him, yet he was very grateful. I left him happily sitting in his chair, sound back up to ‘deafening’, absorbed in his game of rugby.

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3 Responses to Communication Breakdown

  1. Happystance says:

    Malcolm Gladwell has an extraordinary piece entitled Million Dollar Murray: Why problems like homelessness may be easier to solve than to manage.
    http://www.gladwell.com/2006/2006_02_13_a_murray.html
    In a lengthy and fascinating read he effectively challenges some of my previous thinking about homelessness as a wicked problem causing honest paralysis over difficult issues. Wicked problems arose in the area of public policy and are described as “a set of problems that cannot be resolved with traditional analytical approaches”. It is the nature of wicked problems that unanswered questions and chronic issues can take years to work out or never be satisfactorily resolved.

    I discussed the ideas that Gladwell puts forward in the context of caring.
    http://www.unltd.org.uk/blogs/tonyplant/174
    However, there is so much current interest in reducing the cost of NHS ‘frequent fliers’ for medical costs, I wondered if the EMPs or ambulance services have put together: any costings for what such people cost;
    any proposals for reducing the use?

    Not necessarily in relation to this case, I was wondering about the cost of mis-understandings – either from the carer or NHS Direct? The gentleman in question had been told that there was nothing more that his doctor could do for him, and had recently been discharged from hospital, and yet there was still a feeling that there was *really* something more that could be done for him? That says a lot of communication right there…

    Take Care.

  2. NIKKI says:

    HI

    i KNOW WHAT YOU MEAN ABOUT NHS REDIRECT IVE BEEN TO SO MANY CASES OF MAN FLU WHOM NHS REDIRECT HAVE RUNG AN AMBO FOR IT SEEMS TO BE THE “ARE THEY BREATHING NORMALLY ?” QUESTION THAT MUCKS THINGS UP.

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