Can anyone who works in an A&E setting tell me if this is correct?

[NotSayingImBatman]

Took my DM to hospital yesterday. Background is, she’s has niggling back pain for 8 weeks, has seen an urgent care GP who has diagnosed sciatica, paid for a private physio who diagnosed issues with her facet joints, and an NHS physio who said the problem is all in her hip. All have told her the best thing to do is keep moving and keep going to work.

She’s a self employed cleaner. On Friday, she was sweeping a customer’s floor, straightened up and heard a loud crack/pop from her spine a was immediately in excruciating pain that radiated from her spine round and over both hips. She ended up on the floor for ten minutes before managing to haul herself upright and get herself home. Since then, she can barely straighten up and can’t move or walk without severe pain in her back. She called her GP who can’t see her any earlier than Friday (an appointment she had to book 6 weeks ago and was told was the first available, hence the private physio).

I took her to A&E last night as she was sobbing in pain. She was examined by the doctor who said her back was completely in spasm and told her she’d need to take diazepam to relax it. She explained she has severe medication anxiety and can’t take anything like that — she’s on the waiting list for a second round of therapy to try to address this anxiety and it’s all over her notes. He said he’d send her for a scan to assess what was causing the spasm and left us in the examination room for 40 minutes before returning and saying actually, he’d spoken to his supervisor and she wouldn’t be getting a scan, after all.

I asked him how we could get her a scan as her symptoms suggested something was wrong. He said only GPs can refer for scans, so it’s up to her doctor to sort next week. If her doctor feels she doesn’t need one, she doesn’t get one, no matter how much pain she’s in. He said this was NHS policy.

Does anyone who works in this setting know if this is correct? I’m so bloody worried about her.

Why did she go to A&E If she won’t take medication? What a waste of time

If you couldn’t walk or move without agonising pain, wouldn’t you want a medical professional to have a look at you and try to ascertain what’s wrong? Medication is fantastic at dealing with symptoms, but she wants to know what’s causing them.

Yes, scans and X-rays aren’t really useful in back pain presentations UNLESS patients have what we call ‘red flag symptoms’. Doesn’t sound like she had these worrying signs.

It’s really unlucky that your mum has a medication anxiety as diazepam is a great muscle relaxant for back and neck spasms.

Is it unreasonable to seek diagnosis now? Cop on.

But that's not an accident or an emergency - it's diagnosis. A&E are only ever going to deal with the acute symptoms (which they can't if she can't take medication) and refer onwards to the right service.

Can she get an out of hours GP appointment?

Unless the scan was to facilitate immediate treatment it is not an emergency. If she won’t take medication which might ease the spasm there is little A and E can do. Many areas have .diagnostic centres for outpatient scans and tests which are by gp referral.

You could pay privately but the reason the nhs don’t want to scan is because they don’t think she’s raised any red flags that would change the treatment. So it doesn’t matter to them if it’s facet joints lock or slight disc bulge as they are treated the same. Treatment being diazepam and then I imagine gentle movement and physio to stop it happening again. They will likely scan her if she doesn’t improve or the symptoms change to suggest something else going on.

Heat really helps with spasm if she can’t take drugs.

I can understand their frustration if she won't take the medication

I’m really sorry but I think correct protocol was followed. She didn’t fit diagnostic criteria for scanning and refused the treatment offered.

I really hope she feels better soon and gets some help for her treatment phobia.

So any numbness or weakness in her legs or any loss of bladder or bowel? Or pins and needles /numbness in saddle area (the bits that you’d be sat on if riding a horse) @NotSayingImBatman

Hospital doctors can, of course, refer for scans. But in this doctor’s expert opinion, she didn’t need one. She needed to take medication as prescribed to treat the problem as diagnosed. Urgent scans are for people with suspected pulmonary embolisms (I had an urgent CT scan for one) or strokes or people with metastatic cancer. They shouldn’t be offered to people who are anxious and don’t want to take medication, just because. They are limited in supply and expensive and potentially life saving for people who really need them.

It sounds like to me he did the right thing. I think he has referred back to the GP in the hopes she will get better mental health support at the community level, not a scan.

She needs to either take the prescribed medication or wait it out to see if the spasm subsides on its own. I can’t recommend enough seeing an osteopath though. There’s no point seeing physios if they aren’t seeming to treat it. My osteopath has been fantastic for my lower back and hip issues.

It's reasonable to seek diagnosis, though not always possible to get. A lot of back pain is idiopathic, i.e. we don't know why, but we can treat the symptoms. But A&E isn't the right place to go to get a diagnosis - it's for excluding causes that would be a medical emergency (which it sounds like they did) and for treating acute, urgent symptoms, e.g. giving pain relief, which they can't do for someone who can't have medication.

Like the A&E doctor said, if the GP thinks she needs a scan he will order one. That was not an A&E visit. Take painkillers and keep moving until the GP appointment.
No wonder A&E is drowning.

The irony being she’d be a lot less anxious after necking the diazepam 🤷‍♀️🫤

Even if they diagnose her with something, she's not going to take any prescribed medication to help her pain and fix it?

I dont know of there are different protocols in different areas.

My dh's GP says he can not refer for a scan. The GP has to refer to a consultant who decides if a scan is needed.

My other relative presented at A&E with symptoms of cauda equina and got a scan from a&e but, it is was a 'quick' scan which could rule out cauda equina but wasnt detailed enough for other back issues. A consultant then referred for a different scan.

This. What is the anxiety related to @NotSayingImBatman ? Any form of medication or is it swallowing pills?

The management of chronic back pain in the absence of red flag symptoms for cauda equina can be pretty much summed up as ...

Take pain relief, keep moving.

Chronic back pain sucks, a good proportion of the a&e staff will have been there themselves at some point, it will have sucked for them too. If your mother won't take medication then there isn't a huge amount anyone can offer her.

She’s terrified that medication will kill her. She’s an avid reader of side effect lists and is convinced the worst one will definitely happen to her. I’m aware this is irrational. She’s aware this is irrational. Unfortunately, phobias are rarely based in rationality.

I can’t say there is ‘nothing else going on’ for your mum. I can say that spasm is a dreadful thing. It feels like something is properly broken, but it’s the muscles seizing up solid in an effort to protect the back.

After years of back issues, including spasm, I learned to take ibuprofen at the first nigglings that your mum has been feeling. That resolves the problem with a couple of days and prevents it progressing to spasm. Then you do the physio to strengthen everything and help avoid it going again. She’s a cleaner. She needs to protect her back.

with backs pain is not a good indication of something significantly wrong. Often it’s other signs that are more worrying, such a as changes in sensation or loss of bladder control, or leg and foot weakness/pain.

it will probably resolve in a few weeks, but personally I’d go to a private physio and have a few sessions of manual therapy/massage, as well as keeping active and doing lots of walking

Didn’t you very very strongly encourage her to take the diazepam for her acute pain?

Unfortunately the NHS seems to exist to put sticking plasters on symptoms, rather than actually establish the cause of those symptoms.

With this acknowledged and understood, what do you feel an Emergency Department could and should have done for her?

A scan, even if carried out (and it sounds like she very genuinely didn't meet the guidance to have one) is not therapeutic. It would not ease her pain or improve her mobility, reduce the time she needs to recover or improve the predicted outcome.

She has a mental health issue that is significantly negatively impacting her ability to manage and recover from her physical health problem. Emergency care staff are not in a position to sort that.

Everyone was set up to fail here.