Thursday, 29 January 2009

The buck stops

There has been considerable expansion of the role of nurses in the NHS over the past few years. We now have Nurse Prescribers in general practice and Nurse Practitioners in hospital. Some people say that this is just a way of getting doctors “on the cheap”, although one can certainly make a case for tasks to be done by the person who is adequately rather than over-qualified to do them. Doctors command higher salaries than nurses - what do you get for your money?

I read an interesting article in the British Journal of General Practice a year or so ago which suggested that nurses are very good at working at the oases of knowledge whereas doctors are better at roaming the plains of uncertainty. Doctors aren't as good as nurses when it comes to following protocols and treating patients where the pathways to be followed are clear-cut, but they come into their own when the paths are vague and guidelines don't apply.

This evening I arrived for my evening surgery to find a message from one of our District Nurses. A patient had taken too many codeine tablets so would I please ring him to sort things out. He is a likeable chap but he occasionally does slightly daft things. He was recently prescribed some codeine tablets for some pain he was getting, but because the codeine did not seem to be working he had taken forty tablets between 8am yesterday and 2am this morning. I rang him to find out what was going on and he told me that he hadn't been trying to harm himself, just to get rid of the pain. He felt perfectly well, had not felt nauseous and was breathing normally. What was to be done? There is no guideline covering this situation so I had to work things out for myself.

He had taken 1200mg of codeine, which is five times the recommended daily amount and can be lethal if taken all at once. However this was spread over an eighteen hour period, and the last tablet had been taken fourteen hours ago. The half-life of codeine is about three hours, so most of the codeine he had taken would have been excreted by the time I spoke to him. Since he was fully conscious and breathing and talking normally it did not seem necessary to arrange for him to be given the antidote for codeine poisoning (naloxone) so I simply advised him about the dangers of taking too much codeine in future. We also discussed how he might deal with any constipation that occurs.

To be fair to the District Nurse she realised that he probably didn't need treatment for this overdose, otherwise she would have rung for an ambulance rather than asking me to get in touch. And yet she did not feel able to leave things as they were. She needed to speak to a doctor about it, and the buck stopped at the telephone on my desk.


MrHunnybun said...

That's a lot of codeine!

After that amount of elapsed time I'm sure a prescription for Lactulose would have been more useful than Naloxone :)

The Shrink said...

I've mixed views on this practice.

If a nurse is "making you aware" so that you carry the responsibility, I'd see that as inappropriate.

If she's telling you because you're outside protocols and having to manage uncertainty, so the clinical scenario is outwith her knowledge and competencies, so she's got the information and triaged and seeks additional input on your patient's management from you then that's collaborative multi (erm, or bi) disciplinary working and I'd see that as wholly appropriate.

XE said...

Oh my goodness, I'm not sure how he's still breathing! Also, given the antiperistaltic nature of the codeine he's really gonna pay for that one...

Yup, no matter how many specialty nurses there are, I take comfort knowing doctors will always be needed.

Anonymous said...

I'm confused Dr Brown.

Your anecdote seems to conflate at least two separate issues ?
[1] the most appropriate measures for managing a staggered overdose, taken in the community.
Should responsibility fall to the district nurse alone, GP alone, district nurse + GP ?

[2]Pros/cons of nurse prescribing, particularly any complications that might arise from it (although you do not tell us who generated the codeine prescription in this case).

Incidentally, nurses are permitted to prescribe codeine (as independent or supplementary prescribers) although interestingly it is one of the few controlled drugs where no specific indications for use are given - unlike morphine, diamorphine or fentanyl, say (see page 905 of BNF, Sept 2008 edition).

It also struck me that if a patient had such severe pain that they required copious analgesia then it might have been prudent to examine them in person - even if there was no immediate threat from the codeine overdose itself it seems possible that something else was brewing ?
Maybe you were simply able to trust the district nurse's assessment of the patients physical and mental condition ?

Anonymous said...

Yes, only one issue at a time please. Otherwise, this might turn into an interesting blog by a doctor discussing his work, rather than a convenient bandwagon upon which commenters can leap on to proffer observations based on their own preoccupations.

Anonymous said...

Scribbler - there is a difference, surely, between simply REPORTING experiences (as a GP, or whatever) or blogging about them ?

Bloggers generally accept that the format benefits from a 'warts and all' approach, including the idiosyncrasies of individual commentators.
There is a funny take on it in the Daily Mash
Google: Daily Mash, then "worthless, ill-informed opinions in every home by 2012".

By the way, we all have our own preoccupations, don't we, or would you prefer it if bloggers toed the party line ?
Perhaps you are confusing 'bandwagon' with a difference in opinion ?

Anonymous said...

a&e charge nurse

I just thought that while there are many and varied blogs with a political, and indeed medico-political agenda at their hearts (such as Dr Rant and the ever-opinionated Dr Crippen with whom you exchange pleasantries on occasion), this is not one of them.

I realise I may be accused of speaking on behalf of Dr Fortunate Man (not my intention) or being too naive (because politics is in everything, like it or not) - but I just thought that in this instance you wanted to dissect the post from a purely political objective, whereas I have always read this blog as largely disinterested (in the correct use of the word) politically. In fact, now he is almost exclusively political I rather miss Crippen's old diary-style entries of interactions with patients - but I enjoy reading them here.

Anonymous said...

Fair enough, Scribbler - points noted.

Anonymous said...

Extremely civil of you, a&e charge nurse - especially as my first post was perhaps a little intemperate.

Dr Andrew Brown said...

Mr Hunnybun: Don't worry, I gave him lactulose too. :-)

The Shrink: I don't really see the difference. The nurse told me because she felt unable to make a decision herself. This was team working and I took responsibility.

Xavier: We will also always need nurses. If you are ever given the choice of a good doctor or a good nurse, go for the latter! The question (to my mind) is the value of nurse specialists who seem to occupy a half-way house. The answer (I suppose) is that they are fine when working within protocols. But I don't hold strong views on the subject.

A&E Charge Nurse: There was no question of nurse prescribing, it was another GP who had visited the patient and prescribed the codeine.
Your point about examining the patient is well made. Certainly I would have examined the patient if we had both been in (for example) an A&E Department. But examining housebound patients adds a fair amount of work to an already long day, and I determined by talking to him that pain was not a significant problem at that stage.

Scribbler: Thanks for your complimentary comments, for leaping to my defence, and for the break-out of peace between you and A&E Charge Nurse. :-)
You are correct that I try to avoid political comments, but that does not mean that I happy with the way the Government is dealing with the NHS. But although I agree with a lot of what Dr Crippen et al. write, I do not have particularly keen insight into the problems so I write about other things.

Anonymous said...

I've been away so just catching up with my back reading - pleased to see you back by the way.

If the DN had had access to Toxbase she might have had the tools to give advice herself - just suggesting it here because it may be useful to others. I am an out-of-hours GP and use it all the time.

Mimi said...

In the US we have more and more nurse practitioners. From a patient's point of view I don't usually mind seeing them if the doc isn't available because they are not in as much of a hurry and so far they seem to be up on the help we have needed. In fact, out of my four births the best by far was my nurse midwife who delivered me only because the doc was not avaliable.

Anonymous said...

Great, helping other in such circumstances is nice social service.

Angelina said...

I agree with The Shrink. A clear delineation between a responsibilities of nurses and doctors has already been establish and the rise of the number of nurses do not eliminate these differences.

Teaching Supplies said...

Well, when it comes to patient-healthcare giver relationship, there is yet a clear delineation.