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.

I used to work in a&e and this wouldn’t warrant a scan. They followed protocol. We would only scan patients presenting with cauda equina symptoms.

The GP will be able to refer for a scan as this is chronic pain. A&E is for very sudden onset problems.

she should also seek help for her medication anxiety.

Back pain is awful, but most of the time isn't an emergency situation.
In the absence of red flags, it's symptom management and time.
MRI slots via A and E are reserved for those with worrying symptoms, where intervention would be time sensitive.
On a typical day, there are around half a dozen back pain attendances in A and E and an MRI takes 30mins- 1 hour per person for a spine. Scanning everyone wouldn't really be possible, and it wouldn't change the management in most cases.
Obviously if your DM was to develop any worrying 'red flag' symptoms, you should get her back to A and E.
NICE have guidance for back pain, take a look at that. A and E will have followed it based on their assessment and examination of your DM.

This, and then of course blaming the builder when it all goes wrong!

im sorry for you mum. I’ve had terrible muscle spasms in my back before resulting in collapse and going to A&E. It is excruciating and terrifying to be in that much pain.

But the A&E Dr did exactly the right thing.

I’m sorry your mum has such mental health problems that she is causing so much distress to herself by refusing medication.

This is something that she should prioritise and if you have any spare money for private health treatment of any kind, this is what you should be focusing on.

Pain v medication - it’s her choice I’m afraid.
i know that’s harsh but it’s the reality I’m not sure what you’d expect them to do?

Sympathy for your mum. I’ve had back issues that put me in A&E due to the level of pain and inability to move. I was also discharged with painkillers/muscle relaxers and told to rest until it had eased (every movement was excruciating). I paid for an MRI and to see a specialist (the waiting list on the NHS was months) who concluded that the disc damage was so much that I needed surgery.

So being sent home from A&E without a scan isn’t an indication that it’s not severe, just that it’s not likely to have serious long term consequences without immediate intervention (eg CE).

She needs to speak to her GP to request an MRI asap and do whatever she can stand to help the pain in the meantime. Would she use topical treatments (eg ibuprofen or diclofenac creams), they might help.

I wasn’t talking about life threatening emergencies. I’m talking about people with chronic pain who are fobbed off for years with physio and painkillers when the cause of the problem is never investigated. I need hip surgery, but that was only discovered after I went private, after countless rounds of ineffective physio.

By hook or by crook demand a scan. I was fobbed off for years and eventually my disc bugged so much I was in agony because it dried out and split. Conservative treatment works when it hadn't gone too far. Even then I was fobbed off so I went private. The consultant said he would have operated but I was left so long it had begun to shrivel away from the nerve so we could wait and see. Its ruined my life, please dont just leave it. I also niw have a diagnosis of degenerative discs and spondylosis. You DM may have bone spurs or cysts, its wise to investigate further.

Diazepam was the only thing that touched the pain. My sil had some injections in her neck when she had similar a decade later so ask about those too.
But let your mum know that the really terrible pain only lasts about 6 weeks, the consultant told me that and its all that stopped me from jumping under a bus. Your poor DM!

A&A don't diagnose routine stuff. They rule out life threatening and serious emergencies, patch you up and refer you to the correct place to diagnose/ scan or whatever.
They will have checked for red flag symptoms of cauda equina. Other than that they would offer pain relief which they did.

A and E isn’t the right place for chronic pain consultations - surely that’s Gp then referrals. I found your analogy of a sticking plaster unnecessary

The symptoms suggest muscle spasm and the treatment for that is diazepam to relax the muscles. I think A and E did right.
Ive had the same injury and its the worst pain I've ever experienced. I wanted to bang my head against the wall to knock myself out to get away from pain, only wouldn't have been able to because I was simultaneously terrified to move at all.
She needs medication.

I haven’t read the whole thread so this may have been mentioned but if not, please get her a tens machine (loads on Amazon) - worked so well for me when I had severe back pain and spasms.

If she can’t / won’t take medication I genuinely don’t know what you thought they could do. If it had been cauda equina (thank goodness it wasn’t) would she have refused to give consent for treatment which would have required medication of some kind ?

a scan may show a prolapsed disc etc etc - other than waiting it out and Pilates, the treatment is…medication. Pretty much anything spotted in a scan will indicate either doing nothing or medication : I’m wondering what the point is of agitating for all the follow ups if she won’t be able to help herself get better.

Private scans don’t cost as much as you would expect. When I slipped a disc three years ago, I paid £300 for a private MRI scan because the wait for an NHS scan was several weeks. If I’d been willing to wait another three days or so, it would have been much less. I was taking the maximum amount of codeine, paracetamol, and naproxen for some time but couldn’t have coped with the pain without my TENS machine and acupuncture. If your mum won’t take medication then it’s definitely worth her trying both of these

The only interest A&E have in back pain is if it is caude equina, that would be the only emergency presentation, sounds like she didn’t have any red flags for this which is good news hence the discharge back to GP.

A&E isn’t for chronic issues, or people disgruntled that their GP won’t order them a scan, it’s for ruling out anything acute and treating those who require immediate intervention.

She's probably now flagged as a timewaster, OP, which she effectively was if she wasn't going to take any medication. I've got crumbling discs, have had back pain on and off for nearly 30 years. Never sought medical help after the initial diagnosis (which took around a year because I was then in my late 20s), just taken painkillers (paracetamol and ibuprofen) for 2 to 3 days to help through the initial muscle spasms then started gentle stretching and walking exercises (easily found on Youtube). An osteopath would be her best bet if she won't take medication.

Does an MRI scan for cauda equina require contrast to be injected?

My back was in spasm, I was in agony (for a week) and begged for diazepam. It took me half an hour to crawl across the floor to the toilet. The GP wouldn't give it to me (never asked for it before and no history of addiction). I'm not sure what your mother expected if she wouldn't take the medication.

This ⬆️. She was offered diazepam as a solution.

What would she do if she developed diabetes, cancer, heart/kidney/liver problems? Just die? She needs to address her phobia urgently before aging gives her something a lot worse than a slipped disc.

No, CT is the scan that requires contrast.

The irony here is that she is having acute symptoms because she won’t take medication.

I get what you mean by your mum being unable to take tablets, but could they not have given her an injection instead of a similar drug?

Exactly….if she isn’t going to comply with the treatment, what exactly is she wanting? So, they discover the cause of her pain, prescribe tablets, she won’t take them…🤷🏼‍♀️

It was clearly a spasm, I've had more than I can count from an injury while I was a nurse. They are excruciating but nothing a&e can do. I tend to wait them out by putting ice on the area for 20mins every two hours which will bring down the inflammation. Spasms are agonising but it will ease eventually.

She's obviously not too bad because she can move. I've been completely immobilised on numerous occasions to the point hubby has had to carry me to the toilet which really isn't fun!!

If there's someone who can help her stretch that will help. For my injury, it's lying flat with my knees being and my hubby very very gently bringing my knees towards my chest. Sometimes I can't stand any movement while it's at its most accute but as the muscles begin to ease it does help to stretch them bit by bit.

Once the spasm is over, get her to a decent sports physio, NOT an NHS one and see what's causing it and get the injury that's causing the spasm.

I've had this problem more than half my life so unfortunately I do very much know what I'm talking about.

Don't worry though, the pain is horrific but it is only spasm'd muscles, it will pass in a few days and she'll be fine ☺️