Over to you

We welcome all contributions to Over to you. We reserve the right to edit submissions.
Please address correspondence to: Casebook, MPS, Victoria House, 2 Victoria Place, Leeds LS11 5AE, UK. Email: [email protected]

Slipping through the cracks

We received a large amount of correspondence regarding last issue’s case, “Slipping through the cracks”. We have published the letter below as an example of the concerns raised, which were similar across all the letters we received. MPS’s response is also below.

›› I have read and generally agreed with most of Casebook’s reports over the years; however, I really do not understand the outcome here. My husband (a GP) and I (an emergency physician) cannot fathom how the GPs are involved in this case. They tried their utmost to engage this patient by recalling him, starting an antihypertensive and making an outpatient appointment.

Patients have to take some responsibility for their health too

If a patient does not follow up any leads offered by a GP, denies any medication/health issues and uses multiple health services, it’s very difficult to see how else he could have been helped.

We understand there are many more unknown details to this case but patients have to take some responsibility for their health too.

Drs Sally and Jonathan O’Keeffe, UK

A pain in the leg

›› I cannot disagree more strongly with your conclusion [in "A pain in the leg"] that Dr C had done everything she could and should have done. Clinical examination along with "Homan’s sign" should be consigned to the clinical dustbin. How many more people will die from undiagnosed DVT causing a massive PE through a clear lack of understanding?

How many more people will die from undiagnosed DVT causing a massive PE through a clear lack of understanding?

You should be shouting the message loud and clear that a normal clinical examination has absolutely no predictive value in excluding a DVT whatsoever. It is useless! Even a Wells score of 0, which it would have been in this lady, places her in the “Low risk” group. This is not the same as no risk. What Dr C should have done is a d-dimer. Forget her fabulous documentation. There is no clinical finding that excludes a DVT. That you defended the claim successfully is a travesty. A life was lost. A positive result would have led to a Doppler USS, which may just have saved her life.

Dr S J Wallace, UK

Primary postoperative care

›› There’s a theme running through increasing numbers of the recent medical incidents reported in Casebook that does not entirely seem to have been picked up by your case report writers and I believe is worthy of discussion. This revolves around the increasing pressure on hospital doctors and medical teams to discharge patients as rapidly as possible back to primary care.

A case in point was in the article “A normal appendix” in the May 2012 issue, where a patient subsequently found to have a Meckel’s diverticulum as the source of problems was discharged one day after appendicectomy in such apparent haste that neither the consultant nor the trainee saw him, and the article also makes clear that no follow-up appointment was offered. Subsequently the patient made numerous visits to his GP and to hospital Emergency Departments before the real reason for the problem was identified.

[There is] increasing pressure on hospital doctors and medical teams to discharge patients as rapidly as possible back to primary care

This pressure on hospital doctors to ‘get rid’ of their patients back to the community is encapsulated in a set of rules known as NTFUR (new to follow-up ratios) and is being applied ever more ruthlessly across the country. A figure for the average ideal number of times a patient should be seen by a certain specialty (and not by pathology) is devised without published evidence and imposed upon specialty departments.

Often the ratio is well under one to two. Lead clinicians whose departments do not stick to the figures are called in by administrators (as I have found myself) and pressured to comply. Clearly, because hospital care is seen (often wrongly) as expensive, the stimulus for this is cost-savings.

However, it should fall to us as medical professionals to point out the very considerable dangers and indeed false economies. Firstly there is often no continuity of care because GPs understandably often feel unable or unwilling to deal with the nuances of postoperative care.

Patients such as that in “A normal appendix” suffer needless delays and sometimes injury in reaching the real diagnosis.

There’s a massive loss of skill, experience and learning because surgery does not end at the door of the operating theatre or ward

Finally, over a longer period there’s a massive loss of skill, experience and learning because surgery does not end at the door of the operating theatre or ward. It ends when the specialist discharges the patient from the follow-up clinic cured of his/her symptoms, and it’s often during that follow-up that as a surgeon one realises one has missed something or perhaps done something less well than one might have.

The changes now being forced away from us by NTFUR reduce the experience and excellence of doctors, nursing and clinical support staff. The problem applies equally in public and private practice where insurers are starting to apply the same pressures.

Professional organisations and indeed our indemnity providers need to support doctors in dealing with this.

Mr Peter Mahaffey, UK

Nasogastric tube errors – 1

›› The article relating to errors surrounding nasogastric tube placement (Casebook 20 (3)) raised several important issues pertinent to both junior doctors and also radiology performance and interpretation.

The article mentions specifically the timing of tube placement and imaging – as far as possible this should be done in working hours when senior doctors and radiologists are available to assist with image evaluation.

Junior doctors will need training in chest radiograph interpretation, but often these radiographs are done in sick patients and image quality is poor, making assessment difficult even for more experienced doctors. Junior doctors must be able to appreciate when they need help and should ask for senior advice if there is any doubt; all decisions and consultations must be clearly documented in the patient record.

Junior doctors must be able to appreciate when they need help and should ask for senior advice if there is any doubt

The article covers also in some detail how to approach a chest radiograph following tube placement – it does not mention some crucial points, namely that before any attempt at image interpretation is made the reviewing doctor must check that the film is of the correct patient done at the correct time and date. This is essential, especially on ITU for example, where a patient may have multiple chest radiographs in a day – errors are still made when the incorrect film is reviewed and cleared.

There is also the issue, alluded to in the article, of getting radiographs formally reported by a radiologist, ideally on the same day for inpatient work. This is a problem area in many trusts, with often long delays in getting inpatient films reported, or in some cases not reporting them at all. Staffing/financial issues are the more common reasons quoted for reporting delays, but this area remains a medicolegal minefield and is currently the subject of a national audit on behalf of the Royal College of Radiologists.

Dr David Howlett, UK

Nasogastric tube errors – 2

›› We write in reference to the special feature article regarding nasogastric (NG) tube errors. The guidance that you quote from the NPSA is very difficult to implement in practice in many clinical circumstances. There are unintended consequences that expose patients to risks from repeated doses of radiation with multiple x-rays and failure of delivery of nutrition or medication for long periods; as well as increasing healthcare costs.

The evidence quoted in the NPSA guidance is weak and focuses on small numbers of serious adverse events, while ignoring very large denominator numbers of tens of thousands of patients who receive NG feed to put numbers into perspective.

While we were pleased to see an article highlighting this important and preventable cause of morbidity and mortality in healthcare, there was a vital omission in the discussion: the implications of acid suppressing drugs for confirmation of NG tube position. Many critical incidents occurring with misplaced NG feeding tubes occur in ventilated critically ill patients.

Many critical incidents occurring with misplaced NG feeding tubes occur in ventilated critically ill patients

This group of patients frequently receive prophylaxis against stress ulceration with either an H2 antagonist or proton pump inhibitor, in line with national and international standards of care for ventilated patients. The administration of these drugs frequently results in gastric aspirate that is above pH 5.5, necessitating a chest x-ray as proof of correct NG placement.

The bullet point relating to repeat checks states that NG tubes “can be dislodged so they should be checked every time they are used, by aspirating and confirming a low pH, and only x-raying if this is not the case” – this needs further clarification. In a group with increased gastric pH this would mean a chest x-ray every time an NG drug is administered – possibly multiple times over the course of a day.

We would suggest that for ventilated critically ill patients the wording should be changed from “every time they are used” to “if there is any suspicion of displacement”. This can be aided by ensuring that the cm marker at the nostril following insertion is clearly documented and checked every time the NG tube is used.

The guidance makes the maintenance of regular adequate enteral nutrition and medication administration impossible for large groups of patients, and should be revised

The guidance also has implications that extend far beyond critical care. There are many patients in community hospitals and rehabilitation units receiving NG feeding, who will be receiving concurrent acid suppressing drugs. There are large numbers of confused patients who repeatedly pull out NG feeding tubes and multiple x-rays on a daily basis and who are impossible to sustain. In many of these units there may not be direct access to x-ray facilities available.

The guidance makes the maintenance of regular adequate enteral nutrition and medication administration impossible for large groups of patients, and should be revised. The major difficulty with that is that the NPSA was abolished last year and there is no mechanism for revision.

Dr Neil Young and Dr Brian Cook, UK

Skipping over the details

›› “Skipping over the details” (Casebook Vol 20(3)) raises an interesting point. It was a year from the first consultation to the next. At first sight this seems surprising; why ever did the patient not come back sooner; is the doctor really so responsible for the late presentation? After all, doctors can only ever offer reassurance that is relevant at the moment in time it is given, not that there will not be a problem later.

GPs are well aware of how presentations may change over time; that a significant diagnosis may not be obvious at first presentation. Indeed the observation of illness over time is an essential part of our trainee GPs’ learning experience. Patients on the other hand seem to treat the reassurance as not anchored in time as it were, and treat it as if it could be considered as ongoing: “The doctor told me it was alright six months ago, so it’s ok now…”

It seems that the lay belief is that all problems are obvious from first presentation. Perhaps patients also underestimate the time it was since they last consulted about the problem and thus falsely believe that the reassurance is more recent than it actually was. From our point of view it all seems so unfair.

Why ever did the patient not come back sooner; is the doctor really so responsible for the late presentation?

While this might raise the possibility that patients could consult too soon and be given false reassurance before the problem becomes clearer, the issue for us is to communicate the need to reattend if the problem gets worse, or other symptoms develop. So: are we approachable? Can we somehow give permission in advance to come back as well as showing a personal interest? A phrase offered to our trainees to adapt is something along the lines of: “If this thing misbehaves itself in any way I want to know about it…”

Trainee GPs would be asked to record a contingency plan (in this case an ultrasound scan) to give some idea of what is expected. Another possible technique is to inject some deliberate uncertainty such as “I think that’s OK, but you must let me know if…”

Dr Paul Vincent, UK

The internet: target practice?

This letter refers to “Getting the best out of online reviews”, an article that was in our UK edition only.

›› The suggestions in the article “Getting the best out of online reviews” by Neil Bacon surprised me since they are the exact opposite of what I’d advise. I’m not aware of “powerful benefits” of online reviews. What is possible is that anyone may write anything they like about a doctor. There is no peer editing, there is no restriction, the writer cannot be identified (they might not be who they say they are) and there is no sanction against a derogatory or even malicious review.

Hoping that a site is “secure, robust and has proven systems to prevent abuse” is no more than wishful thinking

Dr Bacon says that reviews are the norm in other service sectors. There have been documented cases of damaging reviews written by rivals of commercial organisations, the writer never having partaken of the service on which they are commenting. The motive is plain: to put a competitor out of business.

Tracking these people down requires cyber detective work and there is no guarantee of success. The derogatory information might even be passed through a server in another country so it becomes difficult to invoke UK law – which itself offers scant protection anyway. Hoping that a site is “secure, robust and has proven systems to prevent abuse” is no more than wishful thinking.

Nothing on the internet is that secure. How does a doctor “ensure” that a site is secure, anyway? How many of us would understand the security measures in place, let alone be allowed to know their exact nature and function? Information on one website quickly spreads and copies appear on others. Look at how social networks have become the new playground for school bullies. It just takes one disgruntled patient to ruin your reputation through the web – and you can’t stop it.

What if you disagree with something an identifiable patient says about you? Any reply would be breach of confidence

The greatest difficulty is removing adverse comments. There is no enforcement to make sure this happens. Many websites have no direct means of contacting their operators, there’s no compulsion to reply to any email you might send them. Finally, what if you disagree with something an identifiable patient says about you? Any reply would be breach of confidence; it’s the same problem as when trying to handle adverse newspaper publicity.

There are various branches of engineering – civil, mechanical, electronic, etc. The new discipline of socially-appropriate engineering is now becoming recognised. Of any technical achievement, it asks not can we do it, but should we do it? Yes, you can hand out cards to encourage patients (or anyone) to publish comments about you on the internet. Should you do it? Of course not. You can stick your head over the parapet if you want, but when they start to shoot, you can’t stop them.

Dr Godfrey Manning, UK