#CLaPSem01

CLaPS (Crowd Learning and Problem Solving) is an idea I had on the flight back from SMACC 2013. The idea is to use the power of Twitter and Storify via pre-determined hashtags to capture and publish discussion around a particular clinical problem.

The clinical cases will have multiple issues and will often have more than one approach (as is often the case in medicine). Those contributing to the discussion are encouraged to provide links to evidence as needed. The discussion will be captured on storify after 1 week and published on the website.

If anyone has any suggestions for a CLaPS case feel free to contact me.

 

Now onto the first CLaPS problem – #CLaPSem01 (emergency medicine case 01)

 

Don’t Tell Me What To Do!

It’s another busy day in your metropolitan emergency department and you are a registrar (US = resident) seeing Kim, 16 year old female, weighing 65kg (140 lbs) with a paracetamol overdose.

Kim tells you she was feeling down as her friends had gone to a party without her. She had swallowed approximately 17grams of paracetamol (acetaminophen) 7 hours ago. Her mother had come home to find the empty packets strewn around the house and despite Kim’s protests, was brought to ED.

Her past history includes asthma, for which she has had 5 previous ICU admissions with intubation, the last one being 4 months ago with a ventilator wean period of 3  weeks. She is compliant with her use of preventers and relievers.

You quickly place an IV and start a NAC infusion. Shortly after it begins she becomes acutely short of breath and becomes quite anxious. You stop the infusion and give her salbutamol and her symptoms slowly resolve.

When you go to restart the infusion, she refuses. You explain the kind of reaction NAC can cause and that it is not a true allergy and offer to start therapy to help prevent it happening again but she continues to refuse. You explain the reasons for the NAC infusion and the consequences of untreated liver disease and she refuses.

Her mother talks with Kim and asks you to start the NAC infusion despite Kim’s protests.

 

A number of issues in this case, please contribute to the discussion by posting your comments on twitter under the hashtag #CLaPSem01 If you don’t include the hashtag, your comments won’t be captured. If you need more than 140 characters (and you might do for this one!) feel free to comment below!

Don’t know how to use twitter? Try Dr. Tessa Davis’ excellent tutorials at http://lifeinthefastlane.com/reviews/techtuts/

Thank you for supporting this new concept

3 comments

  1. Michael Downes says:

    Hi Chris,

    Australian perspective is easy, you have a duty of care and must advocate on this person’s behalf. If less than 8 hours post ingestion then you may wish to wait for a level as we know that prognostically things get worse 8 hours post and NAC should be started empirically. We also know that patients with toxic paracetamol poisoning get some protection from NAC reactions. Duty of care does mandate that we use least restrictive approach and hence if early/level pending then should wait.
    If level toxic NAC should be recommenced. The risk is low once over the first bag which goes through in 15 minutes. Simple approaches first, talk and verbally de escalate but ultimately treatment should be given if required with chemical/ physical restraint as ultimately needed. There is no role for psychiatry, this is an organic problem,someone who has taken a life threatening overdose is not in a position to have mental capacity subtleties ascertained. No role for the mental health act, document all in the notes making it clear that tis is “duty of care ” related.
    http://curriculum.toxicology.wikispaces.net/Management+of+patients+refusing+treatment
    regards

    Michael

    • Thanks Michael for contributing to this case, it’s great to tease out the different points of view in these difficult ethical cases!

      I didn’t know that toxic paracetamol poisoning gave you some protection from NAC reactions (which means I learnt something today, fulfilling my quota), you don’t happen to have a link to a paper on that by any chance?

      Whilst I agree we have a duty of care, use of chemical/physical restraint without consent does open up the possibility of being accused of ‘assault’. One could argue (devils advocate) that ingestion on a whim of a perceived harmless substance (which unfortunately many in the community think) does not imply a lack of capacity. Further, if the patient reasons the risks of treatment versus the benefits, applying it to their own situation (their background of severe asthma and likely a fear of return to ICU) and decides they don’t want treatment, is that a lack of capacity? Or are we simply judging them based on our own experiences and background?

      In the Australian state of Queensland, when stuck in these situations and you have some time on your hands, a phone call to the adult guardian can be helpful. Has anyone had experiences like this and like to share? http://www.justice.qld.gov.au/justice-services/guardianship/adult-guardian

      • Michael Downes says:

        Hi Chris,

        NAC reaction paper pubmed link

        http://www.ncbi.nlm.nih.gov/pubmed?term=((waring)%20AND%20paracetamol)%20AND%20reaction

        I would add a couple of points to what you mentioned above

        Being accused of assault :

        Always a theoretical possibility and something to which there is no absolute answer unless a case ends up in the court. Having worked for a few years in an ED with a significant mental health load and a regional toxicology service we have always enforced the common law principle of duty of care and between clinicians across EM/Clinical Toxicology and psychiatry and there remains a somewhat consistent approach to cases such as yours. If push comes to shove you advocate on the patient’s behalf. I would assert – and this could only really be definitively tested in a court of law – that the legal process would be more favourable to a “patient’s best interests” approach by you rather than a more civil libertarian approach. I would assert in practice within Australia, forcing treatment on a patient like this if required would be looked upon as the correct approach legally.

        The public guardian :

        My NSW experience is such that the public guardian would be unlikely to be helpful in this case. Public guardians are more useful for patients who are no longer able to make their own decisions on a chronic basis e.g. elderly demented patient with no close relatives who has a bowel carcinoma does this merit a resection ? If she is under guardianship then the guardian will decide if this is desired or not.

        The guardianship board are often difficult to track down out of hours. During hours they will not give you a definite decision but will attempt to put together a panel for a hearing. Thus you can appreciate that this takes time which in a case like this you will not have a lot of. The other scenario here is why would one need guardianship if the patient has her mother – present in this scenario.

        A further point about guardianship patients is that it should not detract from what you would do short term as a clinician i.e. if the same old lady above presented with respiratory failure and needed I+V then you as the treating clinician have the right to institute this – or not – as per your professional opinion.

        My final point would be that if your scenario above was a FACEM II SCE then I think the duty of care/common law would be the accepted principle by which you institute your management.

        regards

        Michael

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