Anyone work in A and E or the GP and can answer a process question?

[Abstractedobstructed]

I am just wondering whether this series of events would have led to training or teaching or even if the people involved would even be aware of what happened?

A couple of years back my DC was very unwell with vomiting and no pooping despite feeling she needed to go. She had previously had a sore throat that developed into a rash and we had been to the doctor as her friend had recently had scarlet fever. The doctor said to go back if she got worse and the next morning she suddenly developed a terrible belly ache so I took her to the doctor who was unconcerned. The following day when she wasn't rallying or keeping down anything at all I took her to A and E where unbeknownst to me I gave a perfect description of an intestinal blockage (vomiting without straining, she just opened her mouth and everything came up same colour etc as it went down, plus no fever, didn't seem otherwise systemically unwell before the bellyache suddenly started, followed a sore throat, no passing wind or pooping despite copious vomit). The A and E doctor was young and I don't recall what her designation was but she was late 20s or max 30 ish, not a consultant. She said to me unprompted - it wasn't on my radar - that this was definitely not an obstruction. She wanted to send DD home but she failed the liquid tolerance test and was admitted. By then she was vomiting bile which changed to fecal vomiting during the night. Long story short she was diagnosed with intussusception the following lunchtime and had an emergency op, but because of the Kate diagnosis she lost part of her intestines.

I don't hold it against the GP who saw her very early on, but I do think DD was let down by the A and E doctor who specifically ruled out what it actually was without any tests ordered or anything. And would have sent us home but for the protocol of failing to hold liquid down for 1 hr, plus a nurse who said I was way too concerned for an experienced mum (DD is my youngest child) for it to be nothing.

Would the A and E doctor have been told about my DD's eventual diagnosis and had a debrief about it, since I didn't complain? And would she have written 'not an obstruction' in dd's notes? Or was it probably just a throwaway comment? It bugs me that she may never know my DD nearly died because of her.

DD was a primary aged child and outside the usual age range for intussusception btw, and no redcurrant jelly poop.

Would the GP have had a conversation about the missed diagnosis when they got the letter from A and E?

*late diagnosis

If it was only a couple of years ago you can always request the medical notes and find out.

Fenella what would the notes say? Would it say if the A and E doctor was informed?

The GP would get a discharge letter from the hospital but it may not necessarily have been read by the GP who originally missed the diagnosis. They don’t have time to read the hundreds of discharge letters they receive in any great detail or necessarily connect it mentally to a patient who’s not sitting in front of them.

I doubt the A&E doctor would know about the missed diagnosis as once a patient and their notes are gone, they’re gone. They’re too busy to look back. It’s probably worth raising it with PALS so it is flagged up to the relevant medics as a learning point.

X-post - the notes would not say whether the A&E doctor was informed, no.

Hang on - just re-read your OP. You said the junior doctor wanted to send your DD home but then she had a test which got her admitted. Did the junior doctor say she wanted to send your DD home, but then go and discuss it with a senior (which she’s supposed to do before discharge from A&E) who corrected her and told her what tests to do? In which case, protocol was followed, the junior doctor would have been aware of her error on the spot and your daughter was treated in a timely fashion. She may have lost part of her intestine regardless if this is the case, sorry.

As someone who works in a hospital (although not A&E) somebody along the line would have had to register a complaint about the Drs misdiagnosis for action to be taken.

That can be the patient, next of kin or another HCP. For example, a nurse on duty at the time or the surgical team who ended up performing emergency surgery on DD. A complaint or ‘concern’ could have been raised even if you personally didn’t do it.

I would contact your local PALS service & ask them the question.

Elphaba are you a medic? Would you want to be made aware of this sort of error? She probably doesnt remember any of it now. Should have done it at the time, shouldn't I?

And yes Elphaba is right. If the junior doctor sought a second opinion from her superior & admitted DD based on her/his advice then I doubt she would be considered at fault.

Elphaba
The doctor didn't order any tests as far as I know. The nurse began her on a liquid trial thing where she had to have sips of fluid and keep this down for an hour which seemed like a standard thing for anyone presenting with V and D (or just V in our case!). The junior doctor wanted to discharge her but wasn't able to as she started vomiting at 40 mins into the trial (and then didn't stop until they gave her some injection the next morning).

I’m an AHP who has worked in acute hospitals for about a million years.

I would want to know if I’d missed something as would any HCP, including doctors. However, I’m not convinced anything was missed in an untimely way here I’m afraid. Junior doc verbalised that she didn’t think it was an obstruction to you but still followed protocol with a test. Test actually supported the diagnosis she thought it wasn’t, so she would almost certainly have been aware that her initial assumption was incorrect and she would have been part of the admitting medical team.

If your daughter lost part of her bowel due to a delay in diagnosis, it was the delay from the GP. It sounds like things in A&E were done in a timely fashion, despite the doctor’s initial incorrect suspicions.

The doctor would have ordered that liquid trial. No nurse would have given a gastro patient something orally without medical instruction to do so.

Nurses don’t order tests, so that would have been on instruction from the doctor.

Ok thanks Elphaba.
I am pretty sure she wasn't admitted on the suspicion it was an obstruction - the two SHOs and the pead both told me it was a nasty gastritis, the pead ordered an x Ray but not a scan, and I had to insist on seeing the surgical consultant on his round when I found her belly was all swollen up and the SHOs found she was "guarding" when they tried to find the sore bit. Her notes actually said "Xx feeling much better this morning" which was a lie, she was just lying there fading fast.

Anyway it was found eventually and not too late, and she is well. Which is why I never complained at the time.

SHOs and pead on the children's ward, not A and E.

The ED doctor probably wouldn’t have heard anymore about it, if she was only admitted on the strength of a failed fluid challenge. If she didn’t investigate in ED then she probably wouldn’t have had obstruction on her list of differentials, and she wouldn’t necessarily have been looking for intussusception with her being out of the typical age range.

I think a lot of people see A&E as a place to receive an ultimate diagnosis, however in reality it’s more of a filter of who stays in and who goes home. It’s also generally not advised to irradiate children with X-rays unless you can defend why it was absolutely necessary, and in this case, it seems she didn’t have it on her list of differentials so she wouldn’t have been able to justify an abdominal X-ray. The other means of diagnosis are USS which is not an ED investigation and CT which is even more harmful to a growing child than an X-ray.

Without knowing the full story and being able to review notes, it’s difficult to say whether it was an obvious obstruction at the history taking stage and she failed in some way by not acting sooner, or if things were only more apparent as her symptoms progressed, and at the point where it was apparent, she received appropriate treatment.

Obviously the recent history of sore throat and rash also muddies the waters somewhat, because the abdominal pain might have seemed more likely with a post viral mesenteric adenitis or something similar.

With all the usual caveats about not having the full details etc....

The GP will almost certainly have seen the discharge summary - a child having a bowel resection is unusual enough that it will have stood out. Whether that means anything could have been done differently or ‘lessons learned’ is more difficult to say as diagnosed early in the course of an illness are more difficult and clinical pictures evolve.

The ED doctor will also most likely have followed-up what happened. However, while they may not have spotted the early signs as quickly as they could have, they did use whatever guideline that dept has re. tolerating fluids, and didn’t just send your child home (which would have been dangerous).

What’s perhaps most telling in your post is that it wasn’t until the next day that your child went to theatre therefore it perhaps wasn’t at all obvious what was going on earlier on the the course of their illness.

PALS may be able to answer some of your concerns, but it is worth understanding that even if there’s nothing explicit written in the notes it doesn’t mean no feedback/education occurred. Patient notes are about a patient’s health/investigations/progress and are not the means by which feedback to HCPs re things like a possible delay in diagnosis is made.

@FenellaMaxwell Well that’s absolutely untrue. I’m a nurse practitioner in A&E and I order tests all the time. I see, investigate, diagnose, treat, discharge or admit patients all the time, independent of any doctor.

For a child of her age, a severe gastritis would have been the more likely diagnosis than intussusception. They did, however, err on the side of caution and admit her and do the first line tests, including an x-ray. They generally only proceed to an ultrasound scan when something like guarding happens or if there’s something on the x-ray they want to know more about.

By all means go to PALS - they’ll still have your daughter’s notes for you to get a clearer picture of events, but it still doesn’t sound to me like there was any real delay and, this far past the event, the doctors concerned are highly unlikely to remember who your daughter was in order for them to learn from it (if there’s anything to learn - I’m not convinced there is, sorry.)

@queenofpain but you said yourself - you are a nurse practitioner and as such can treat patients independently, but the OP has said this patient was under the care of a junior doctor, not a nurse practitioner?

Queen of pain - thanks - the reason I feel a bit upset at the ED doctor is that she specifically said "this is not an obstruction" after I told her the history and felt dd's tummy - which was not at that time on my radar at all. I had heard of intussusception but only in babies. I thought it might be appendix.

I accept that she did get admitted and had the operation (she waited a further 14 hours after diagnosis for her emergency op, which eventually happened at 2am, but that is another story that I blame the Tories for!)

Queen of pain - apparently intussusception in older kids can follow a throat infection due to pressure on intestines from swollen tummy glands. DD had no lead point and the consultant who operated thinks this is probably what happened to her

@FenellaMaxwell It was just the blanket statement of “nurses don’t order tests” which isn’t really correct.

A&E triage nurses start fluid challenges at the front of house in a majority of vomiting children. Often by the time they’ve been seen by the doctor they’ve tolerated loads of fluid, haven’t vomited again, have done several wees and are running riot in the waiting room with a bag of Quavers - usually a sure sign of a well child.

Depleted fluid volume can be very dangerous in children, but is extremely easy to fix.

@Abstractedobstructed Yes, it’s seems rather foolish of her to say it definitely wasn’t that, when she’d not got diagnostic proof.