Case study 1: Imperial College Healthcare NHS Trust (Learning Disability / A&E)

Background

case1A 40 year old woman was brought into a London emergency department by ambulance following an episode of prolonged fitting. Her arrival caused disruption, as she was very combative in the department, both with the ambulance personnel and with the emergency staff. She presented as incoherent, uncoordinated and very unstable on her feet. Despite this physical vulnerability, she refused to sit on a trolley or on a chair and backed herself into a corner of the resuscitation room.

On presentation, the clinical team’s judgement was that she had no serious injury or illness that put her in immediate physical danger.

Interventions

Very little was known about this woman, which is often the case in the emergency department. The staff observed that initially she appeared to be mute but then became increasingly agitated on overhearing staff discussing her condition. All well-intentioned efforts to calm and reassure her were met with great resistance on her part. The staff observed that the woman appeared very frightened and anxious and the initial impression was that she had a severe neurological or psychiatric condition. Mindful of her safety and their own, the majority of emergency staff withdrew to an observable distance, leaving one senior member of nursing staff with her. This appeared to alleviate some of her anxiety and the nurse tried various different methods to communicate with her. The nurse had experience of caring for patients with learning disabilities and discovered the woman responded to sign language. It appeared all she wanted to do was to walk. The nurse spent the next hour or so walking round and round the department with the woman, supporting her and calmly reassuring her but at the same time managing to assess her and find out more about her.

Outcome

The more the woman walked, the more her mobility improved and she then began to talk. It transpired that she had a learning disability and suffered from epilepsy. What had happened that day was not unusual for her. After having a fit she would normally experience transient loss of speech and have difficulty mobilizing. Once the woman had gained her equilibrium she was quite happy to sit down and be formally assessed.

Key messages for treatment

The emergency department is a fast moving environment; it is a bright, loud and at times intimidating place in which to treat patients. It is therefore essential that emergency staff recognise what effect this environment may have on their patients and are creative and adaptive in order to meet their needs effectively, rather than expecting them to conform to conventional hospital practices. The approach has to be centred on the individual involved and above all must be kind and compassionate. The woman in this case needed time, understanding and a period of one-to-one attention in order to be able to communicate effectively and recover. Among the competing demands of a busy emergency department, it is essential that staff recognise the importance of such interventions and give them the priority that they deserve.

Source: Julia Gamston – Senior Nurse, Emergency Department, Imperial College Hospital Trust