Case history that proves patient management system is absurd

HERE’S an actual case history based on recent experience. This story is repeated hundreds of times every day in our health service.

If the circumstances of other stories are even remotely similar (and they are), then it proves two things.

It proves we haven’t enough beds in our major hospitals, and anyone who says we have is simply wrong.

But it also proves that Brendan Drumm is right when he says that a major part of the A&E problem is simple management. Mary (not her real name, though every other detail of this story is true) had been suffering from a painful eye infection, the sort that feels as if a piece of flint is stuck there. Several visits to the GP over the course of 10 days failed to find cause or cure, and eventually he suggested taking her to the Eye and Ear Hospital in Dublin. Mary is in her early 90s and very frail. The pain from this eye infection had already taken a considerable toll — that’s how debilitating it was.

So her daughter took her to the Eye and Ear where some anaesthetic drops were administered to dilate the pupils. While she was waiting for the drops to work, Mary ‘took a turn’ — possibly a reaction to the drops, possibly a minor stroke. The hospital advised her daughter to take her to the A&E department of the nearby large teaching hospital because things didn’t look great.

After a demanding journey through the Thursday afternoon traffic of Dublin’s south side, Mary arrived in A&E at around 4pm. She was put on an A&E trolley in the clothes in which she had arrived at the hospital. It was clear she had to be admitted. She wasn’t herself; her blood pressure was very high and her heart rate low. But there was no bed to which to admit her, and there wouldn’t be one, her daughter was told, until closer to midnight.

Now the trolleys in A&E in this hospital are pretty similar to beds, it has to be said. It wasn’t that difficult at first to make Mary comfortable. While her daughter and later other members of her family were with her, she was able to doze and relax a bit. Eventually, though, as night drew on, they had to leave. And the bed that was supposed to become available never materialised.

Mary was alone through the night. Her family couldn’t stay, and although nurses and junior doctors came and went and conducted all sorts of tests to assess her mental responsiveness, there was actually no-one at all responsible for her care.

So she stayed on the trolley as the night wore on wondering if anyone was going to bring her a meal or explain what was happening. There was no meal, and no explanation. But as A&E got busier through the night, with all the activity associated with a busy Dublin hospital, it became more and more frightening for an elderly, frail woman, with no-one to talk to or reassure her.

At some stage during the night she was moved to the opposite end of the A&E ward to a bed. It meant she wasn’t easy to find when her daughter came in early the next morning.

Eventually, 27 hours later, she was admitted to a ward in the main hospital. Throughout the night her blood pressure had been monitored, but no-one had looked at the cause of the problem, the debilitatingly painful eye infection. And from Friday until the following Thursday, she occupied a sorely-needed bed, wondering when someone was going to diagnose what was wrong with her and begin to treat it.

WHEN her family tried to find out what was going on (as they did several times a day), there were numerous references to the ‘team’ into whose care Mary had been put. No one seemed to be in charge of that team, or to ensure a steady connection with the family. The team visited Mary, but never when any member of her family was present — and they were there for at least six hours every day. Nevertheless, her family was told it was impossible to move Mary to semi-private accommodation, covered by her VHI, because even though she might be more comfortable, the team to which she had been assigned needed to see her in the public ward.

On the Saturday she was told she was to be taken down for a CT scan. In her confusion, she told the nurse she had already had a CT scan, so the nurse cancelled the arrangement. Later in the day her family was able to confirm that she had indeed had a CT scan, but many months ago and in a different context. By then it was too late to arrange the scan that day, and the following day was Sunday. Scans, it seems, aren’t carried out on a Sunday.

As the days dragged on, her daughter was told several times that the team was most anxious that Mary see an ophthalmic specialist. Three of these specialists are attached to the hospital, but an appointment seemed to be somewhere between difficult and impossible. Eventually one was arranged for 2pm on the Thursday. By then Mary had been in the hospital a full week.

When her daughter arrived for the appointment at 2pm on the Thursday, she discovered that her mother had been taken upstairs by an orderly hours earlier because that’s when the consultant was doing his rounds.

He had diagnosed, rather than an infection, a very painful condition caused by a dry eye socket, and had applied the appropriate eye drops. The relief from pain was instantaneous, and there was no further reason to keep Mary in hospital.

Except one. The CT scan had been carried out on Monday, and the results wouldn’t be available until Friday morning, so the team wasn’t willing to discharge her until they had seen it. It was clear, and Mary went home on Friday, eight days after arriving in A&E.

Throughout that entire period of pain and fear no one in the hospital was accountable for Mary. No key worker, no patient representative, no one whose name and number was known to Mary and her family.

No one responsible for explaining what was going on, for following through on medical recommendations, for ensuring that her stay was as comfortable and as short as possible. No one, in short, to manage the patient. Yet there seemed to be dozens of people in charge of files and folders, in different coloured uniforms, all really busy. But no one at all in charge. And no one accountable.

The people couldn’t have been nicer, or tried harder. But the system is absurd. And that’s why there’s chaos.

The application of small doses of commonsense and management on the ground would make a profound difference. When that commonsense and some basic management is applied it will be possible to calculate exactly how many additional beds are needed.

The question though is this: how much longer is it going to take, and how many more people are going to suffer before some commonsense begins to be applied?