Richard Smith: A small insight into avoiding some of the pressure on A&E departments

richard_smith_2014At 8.15 on a Saturday morning while I’m shopping with my grandson my wife at home receives a call to say my 89 year old mother with dementia, who lives in a nursing home, has fallen. She has a cut on the back of her head, and the nurses assume she has fallen. They have called an ambulance.

My wife questions the nurse who has called. Will the cut need stitches? No. How is she? She’s fine. Why then, my wife wonders, have they called an ambulance? My husband, she says, will call back when he returns in a few minutes.

I return and call back, which is not straightforward as nobody answers the number I usually use. I resort to call back, and the nurse says that the paramedics are seeing her and will take her to hospital. I ask to speak to the paramedic. I say that I’m a doctor and that I doubt she needs to go to hospital. She doesn’t have any “ red flags, the paramedic says, but they need to take her because she has a head injury—albeit a small one—and it’s impossible to get a reliable history. I say that’s because she has dementia, and I ask what would be the point of taking her to hospital. What will they do if she lapses into a coma? The paramedic says that’s not for him to say, but he has to follow the protocol. I then say that I have power of attorney and am willing to accept responsibility for keeping her in the nursing home. He says OK, they won’t take her. I’ll come and see her and can be there in 20 minutes and ask if they will still be there. He says they won’t.

I get there in 20 minutes, and they are still there—in an ambulance equipped to deal with a major disaster. The whole thing seems disproportionate. The paramedic is charming and friendly, exactly the kind of person I’d like to find looking after me if I suffered a serious injury. He says he would have had to take my mother if I hadn’t intervened to “cover his arse.” “Imagine,” he says, “if we didn’t take her and something horrible happened, she died or something. It would be all over the papers. There’d be an inquiry. We might lose our jobs.” But, he also says, “If it was my mother I’d do exactly the same as you.” “By the way,” he says, “your mother is lovely, so sweet. We see some terrible ones.”

I go into see my mother.  She’s sat eating a piece of toast and drinking coffee unaware of all that has happened. We chat. I tell her what has happened. “Oh,” she says, not very interested. She’s keener to talk about what a lovely day it is.

I talk to the nurse, who understandably would have preferred her to go to hospital. She wouldn’t then have been his responsibility, but I’ve accepted responsibility—and on my head be it for whatever happens.

Several times I’ve asked the home to contact me before they ring an ambulance, and they’ve agreed to do so. But staff change rapidly, and almost any sort of fall or injury leads to an ambulance being called and my request, as I’ve feared, is not “in the system.” The ambulance has to take her because it’s not clear what happened, as it is likely to be with any person with dementia. In the hospital a series of tests would be done over hours until eventually a doctor, possibly fairly junior, accepts the responsibility of her being discharged—by this time very bothered, as people with dementia are in strange circumstances, and with a considerable amount of resources having been consumed, as they have been already even without her going to hospital.

Nobody is at fault. Everybody has done what they are expected to do, even if each has then thought “this is over the top.”

One of the things my brothers and I dread is my mother when she is dying—because she has a heart attack or a stroke—being hauled off to hospital and dying on a trolley in the accident and emergency department. We think that if she has a heart attack or stroke she can be managed in the nursing home without, we accept, thrombolytic therapy or emergency angioplasty. We think that would be disproportionate, and we are confident that our mother agrees. We discuss it with her, recognising that she doesn’t have full capacity.

But how can we stop the process that leads inevitably to her being admitted to hospital? Despite me asking them to ring me, I fear that they will not call me or will call me after they have called the ambulance. And I might be abroad.

Coordinate My Care is a scheme that has been started in London where I live to try and avoid patients at the end of life being admitted to and dying in hospital. Ambulances have a list of patients on the scheme and know not to take them to hospital unless it’s essential; and even if they do take them they try to bring them home quickly. It has reduced the number of people dying in hospital from 60% to 20%. I’ve talked to the nursing home about getting my mother onto the scheme. They say they will talk to the GP, but nothing seems to have happened. I discussed it with the paramedic. “Oh CMC,” he said, in the NHS style of making everything a three letter acronym, “we’ve talked about that but there are difficulties in getting it up and running.”

Will things work better the next time something happens to my mother, as it will? Sadly I have no confidence that anything will be better. Despite my considerable “middle class white power,” as my Sikh friend calls it, I’m as stuck as anybody.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: None declared.