Wednesday, 9 April 2008

A Helpful Way to Identify Patient Deterioration Early!

Dear Bloggers

As physicians, we have all been called urgently to attend the patient who has been deteriorating over several days and who is peri-arrest.

An imaginary example of a typical patient vignette includes the orthopaedic patient with a hip fracture, recently operated and with worsening urine output, low fluid intake, increasingly rapid pulse and onset of confusion. Nursing staff have been charting the deterioration in parameters but were unaware of when to tell the surgical doctor because the doctor is always in the operating theatre treating trauma patients.

Another case vignette might be the patient admitted with general deterioration and weight loss with worsening breathlessness, but the junior doctor is on-call in the Emergency Department and has no time to come and see the patient and the nursing staff are unable to pinpoint the problem and have no idea how to help the patient except to give more oxygen.

These types of patient problems do occur in real life and unfortunately more often than one would perhaps envisage. From the two case vignettes, the underlying problem is not initially acute. There has been a chronic or subacute progression leading to deterioration in parameters of the patient thereby leading to a worsening state and hence, peri-arrest.

Sometimes the doctor does not pick up the problem either because of inexperience, infrequent visits to the patient, failure to adequately examine the patient rather than just the area of their specialty interest e.g. the broken hip, failure to ask the patient about new problems and symptoms, failure by nursing staff to adequately measure the daily observations, failure to report problems to medical staff because of inexperience or over work.

However, such problems cannot always be avoided in hospitals although it is possible to measure patient observations and enter them into a Scoring System which involves the patient's pulse, blood pressure, temperature, respiratory rate and AVPU score. The number generated by the parameters provides a total score which can then determine if the patient is at increased risk of deterioration and death.

Such a scoring system is referred to as an Early Warning System (EWS) and nursing staff can calculate this at the bedside and call the doctor in charge of the patient to attend the patient immediately for reassessment to see if changes are required to the patient's therapy to prevent further deterioration.

Many UK hospitals use such a system and it can lead to very appropriate changes in treatment.

Some hospitals have Intensive Therapy Unit 'Out-Reach' teams of highly experienced nurses that patrol the wards for such patients who are deteriorating with high EWS scores and they can make assessments and call the ITU specialists physicians for further help in addition to the Attending Physician so that an appropriate plan of action can be instituted such as moving the patient to the HCU / ICU for further treatment or the decision of appropriateness of active treatment versus palliative treatment, etc.

An interesting study using this EWS scoring system was published by the Oxford University Press several years ago in respect of all new acute admission on a Medical Assessment Unit with validation of a modified EWS. The results are interesting and show how changes were made to patients treatment in an attempt to reduce mortality and provide more appropriate care. The link to paper is here. Please read it and make up your own minds.

In several hospitals I have visited in Japan, I have not seen any equivalence to an EWS scoring system or an Out-Reach team. With many hospitals in Japan having an electronic patient system [Denshi Kalte], such a scoring system could be entered by the nurses with an immediate score produced for the patient with advice to the nurse whether a call to the doctor is warranted.

Such an idea is not new and not labour intensive and can help with patient management.

In the UK and USA amongst other western countries, there has been increasing training of specialist nurses in all specialties who can perform various important functions to aide patient care e.g. gastroenterology nurses, rheumatology nurses, dermatology nurses, Emergency specialist nurses, ITU specialist nurses etc... Such a common place nurse specialist is not so common place in Japan with there still being over-reliance on doctors to carry out almost all assessments and interventions when there is an unfortunate lack of doctors in various hospitals who cannot plug all the leaking holes in the wall.

With increased nursing and physician training, awareness of an Early Warning System and provision of a modicum of responsibility for nurses to intervene in patient treatment decisions, the care of acutely ill patients and deteriorating patients could in my opinion be improved and this is borne out by the evidence from several UK studies, one reference that I have also provided above.

If such a system could be implemented in all hospitals in Japan, there might conceivably be a reduction in sudden cardiac arrests and overall mortality as problems could be dealt with that much earlier.

This would certainly make an interesting study in Japan if anyone is interested by this idea!

Please consider!!!

Tuesday, 8 April 2008

Another interesting problem!

Dear Bloggers

This anonymised case is a warning for all of you out there when you see someone with leg weakness and numbness to appreciate how rapidly problems can progress. Please try and answer the case as best you can and you are welcome to leave your answers anonymously.

A 70 year old female who was otherwise well was admitted following a short history of
  • numbness of the buttocks
  • rapid onset lower limb weakness
The patient had got up for breakfast normally and was sitting eating her breakfast. She suddenly began to notice numbness of her buttock region and a 'heavy' feeling in her lower back. She decided to visit the toilet as she thought she might pass stool. In the toilet the sensation continued and after several minutes, the patient was unable to stable from the toilet seat because of leg weakness. Her family were concerned and called an ambulance and the patient was taken to the local hospital.

The patient denied any back pain. There was no history of vertebral disc problems, no chest pain or abdominal pain. There were no palpitations. The patient denied symptoms of diabetes such as excessive thirst, blurred vision etc. There was no history of being previously unwell and there were no symptoms consistent with infection or bleeding.

The patient was a known hypertensive and took atenolol 25mg once daily.

She had no drug allergies. She smoked 15 cigarettes per day for 40 years and she consumed small quantities of alcohol occasionally.

On examination

The patient seemed otherwise well. She was afebrile. Pulse 64/min regular. BP 140/80. RR- 16/min. Sats 98% on room air.

CVS: Heart sounds normal. Regular rhythm. No added sounds or murmurs. No peripheral oedema.

RESP: trachea central. Percussion resonant. Breath sounds vesicular.

ABDO: soft, non-tender, no hepatosplenomegaly, bowel sounds normal. No bruits. Aorta mildly expansile

CNS: Cranial nerves 2-12 normal.


Tone Normal Normal Normal Normal
Power 5/5 5/5 4+/5 4+/5
Biceps Normal Normal
Supinat Normal Normal
Triceps Normal Normal
Knee Normal Normal
Ankle Normal Normal

Light touch- normal in upper limbs, decreased in lower limbs around ankles and buttocks.

Babinski sign
was normal bilaterally.

Coordination of the lower limbs was not performed.

Vertebral examination was non-tender.

Over several hours the neurology worsened:


Tone Normal Normal Reduced Reduced
Power 5/5 5/5 3/5 3/5
Biceps Normal Normal
Supinat Normal Normal
Triceps Normal Normal
Knee Absent Absent
Ankle Absent Absent

Babinski sign became negative bilaterally.

Light touch- normal in upper limbs, decreased in lower limbs up to the umbilicus (T10) region. Vibratory sense was intact on the pelvic brim and right knee but absent further down. Nociception and thermoreception were absent. Joint position sense was not performed.

Anal tone was reduced with an absent anal 'wink' sign.

In fact, the weakness progressed further resulting in paralysis of the lower limbs and bowel and bladder disturbance. However, light touch and vibratory sense were maintained although nociception and thermoreception remained absent. Joint position sense was interestingly absent.


1) From history and examination, list the problems with this patient.

2) What immediate test or tests would you perform and why?

3) What anatomical problem is this from the history and physical examination?

4) What is the current evidence based treatment for such a condition?

The answer to this fascinating case will be published in the near future.