Go with the flow

laxative-articleMonday morning, post weekend on call. It’s not been the best in terms of bed capacity and ‘flow’ but we’re all still here.  Good enough?  Well possibly not. As I started my ward round I was paid a visit to tell me we were minus many many beds.  ‘Was I aware of that? It’s simply terrible. Please do whatever you can to make more beds become available’

‘No problem’ I replied.

There isn’t any point getting annoyed.  It’s not the first time I’ve been interrupted simply to tell me how busy it is.  I’ve even been summoned to meetings to tell me in person. After a fashion you tune out the white noise.

However I have had trainees and nursing staff remark to me;

‘What difference is sending one person home when we are minus 50+ beds?’

‘What I hear is I’m not working hard enough.  What about the times when everything is going well?  You don’t get pulled into a meeting to be told good job’

‘Do they think I’m sat on my arse twiddling my thumbs?’

So reflecting back on the weekend, it had all started so well.  The sun was shining and we had beds.

There was nothing especially remarkable about the case mix or the volume coming in.  This continued on into Saturday but by lunchtime it became apparent there was a problem.  No one was moving out of the acute assessment unit.  By teatime things were stuck.

It was clear that we were experiencing a severe case of constipation.  Every attempt to discharge precipitating colicky pain in the system. It was just too hard. By Sunday we had some flow but not the good kind.  It was the kind of overflow flow that goes into all the wrong places.

So how do you manage a bowel impaction secondary to constipation?  Well sometimes you need to decompress the situation through a naso gastric tube.  It doesn’t clear the blockage but it does make you feel better and able to cope with the pain.

So how do we achieve this in the NHS?  Well, we don’t really.  We just remind people how uncomfortable they are and imply it’s their own fault as they aren’t trying hard enough to move things along.

I think we should instead allow people to ‘decompress’ naturally. I’m talking about listening and acknowledging how hard it is. Allow people to vent. Once rid of all that hot air and bile you might find people are much more willing to offer practical help and suggestions.

Now that of course still leaves the constipation blocking the natural flow of things. I would recommend a variety of laxatives for this.

There’s the gut stimulant – perhaps the multi disciplinary team (MDT) in this situation.  Get more physio and occupational therapists. Or perhaps offer a targeted and focused MDT to get people up, help them with their walking, offer adaptations and support at home.

We have the stool softener – making the journey out that bit more pleasant. Our ward teams including pharmacy are key here.  Taking the time to explain to the person and their families what has happened and what to expect on discharge.  All of this neatly packaged into an immediate discharge letter and sent to their GP.

You also need to tackle things from the other end through a high phosphate enema.  To me that’s social work.  Get the assessments done, secure funding and either get the person home with the care package or into a care home as quickly as possible.  You will get an almost immediate result with this.

Employ all these strategies, flow returns, pressure is relieved and everything is that much better.  Ah…..

Of course as many of my older patients tell me, it’s best not to get constipated in the first place.  I am constantly being told that prunes are the answer. They are tasty, effective and cheap.  I guess that’s what integrated health and social care aspires to be (just not as cheap).

So will tomorrow be any better?  Marginally.  Will I do anything different to what I already do? No. Sometimes it’s best to just go with the flow…..

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