One last thing doctor. It’s my son’s wedding in two days. Do you think I’ll be home before then?
When I was a new FY1, this was the first question a patient asked me when I did not have a senior around. I had no idea when a 45 year old lady with an asthma flare would usually be discharged and so I asked the consultant.
The consultant said that we would have take it one step at a time, and to not think about discharge until she is well on her normal inhalers. This usually would be around 24 hours for most patients with severe asthma who had responded reasonably well to the initial management.
It made me realise that whilst it is important to know the BTS guidelines for acute asthma, how to prescribe the medications and how to assess the response of the medications, clinical medicine is full of subtle PUNs (patient’s unmet needs) for a new doctor. These drive us to discover DENs (doctor’s educational needs) which we need to fulfil to become the best doctors we can be.
When I got home, I read up on asthma discharge criteria. I learnt that the BTS recommend that patients whose peak flow is 75% or greater of predicted/baseline 1 hour after initial treatment may qualify for early discharge if there are no other risk factors. If the patient is admitted, then in addition to a peak flow of at least 75% of predicted or baseline, a diurnal variation less than 25% is also desirable, as well as being stable on the inhalers the patient will go home on.
When I discussed this with the consultant the next day, he told me that the way to think about it is what is the worst that could happen if we discharged the patient a little early. If the patient had a good social support network at home, then if her inhalers did not work there would be a delay of maybe 15 minutes before she would receive nebulisers from the ambulance that her partner would call. If the patient did not have this support network, or was at risk of deteriorating rapidly, the ambulance may not be called or the response may be too late for her.
I learnt how to mix the guidelines with the patient’s specific situation to determine the best management plan.
The next time a patient with asthma asked me this question, I could confidently discuss this. It made the job far more satisfying.
The point of this blog is to share those sorts of moments and the things I have learnt that should equip me to deal with similar situations in the future.