Should You Always Admit a PR Bleed?
A short, personal reflection on a case
General practice is a unique a place. It’s definitely a place I’m liking at this moment as I am assessing patients and adapting to a completely new, community based skillset.
General practice is its own universe which requires its own thinking and mindset - one that I started to build through a particular case I encountered early in my training. Now if I told you to close your eyes and imagine an 85 year old gentleman presenting with malaena you would probably think “admission!” straight away. Okay.. now for those of you who aren’t then what if I said that that this patient was only discharged 4 days ago with a Hb of 80?
I’m sure some of you are still thinking “Mo, what are you on? There are lots of other options other than admission,” then let me add that the patient is also on warfarin which WAS NOT discontinued/omitted on discharge.
So in summary - an 85 year old PR bleed with a Hb of 80 on discharge four days prior on warfarin. You’d be daft not to admit them!
I must admit - I got a little excited as it’s something I’d see regularly in ED. I was in my element - I did some observations (which were stable) and did a PR where there were some remnants of malaena. I thought I’d tell my supervisor as I guess she should really know and I had the whole plan well thought out. Things seemed pretty straight forward but in reality they were not.
The patient was upset. In tears actually. Not because he had a PR bleed but because he needed to go back to hospital. He was in and out of hospital of late and he was fed up. My empathy levels were 9000 and I really tried to help him through his troubles but thought in my head“unfortunately you will still need to go into hospital”. His wife was with him who was really supportive and gave him a big hug at the time.
I spoke to my supervisor and explained the context and confidently said “I’ll go ahead and call the medics and arrange admission.” She looked down and then said to me “hold on Mo, what does the patient want to do?'" I was a little bewildered. I mean.. in this emergency scenario where the patient is fully orientated, does it really matter? Of course admission was the ****ONLY**** option.
In turns out it wasn't. There was another option which was the right option. My supervisor spoke to the patient and really connected with him. It was true healing with words. She suggested repeating his Hb now to assess how much blood he had lost and taking it from there. The patient was elated. To be fair, he had no further PR bleeding episodes since the AM and the plan actually made a lot of sense. Nevertheless - it was far from clear for me at the beginning.
The result? His Hb was 76 (80). We then arranged for his bloods to be repeated a week later and using a combination of HASBLED and CHADS2VASC scoring, we decided to stop his warfarin for a while. Unfortunately the patient eventually had to be admitted as his repeat Hb was 63 just yesterday but in the interim he wrote a really lovely letter which hit home. He wrote, and I quote:
“Dr Mo (my full name) spoke to me in a caring way and his consideration of what was best for my mental health at the time is much appreciated. His compassion and that of his doctor supervisor makes me grateful for the quality of staff we have in our NHS.”
It was a special moment and it made me the happiest clinician in the world…
It made me appreciate the importance of not only working with patients but also working FOR patients.
GP requires lateral thinking and management is beyond just medical. I tend to “adapt” secondary care scoring systems for general practice to help me make decisions. For instance, the Glasgow-Blatchford score which is designed for secondary care has some useful indicators to help you answer the question of “admission vs no admission.” If for instance even a single parameter is exceeded then they are automatically considered as high risk.
General practice is more than just scoring systems and executive decision making. It’s a whole new world and this case was certainly my first wake up call.
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Until next time,
Mo
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