Pulling the Plug…
We’ve all been there..
Things seem to have ground to a halt..
You look the screen and after a quick glance at the top you can see why... Mr or Mrs Plug may be
one of several hypothetical patients with triage comments that make most emergency doctors
disappear into the suture room.. or down the corridor..Some suddenly feel the need to have a long
deep and meaningful with the narcisissitic personality disorder in cubicle five...Whatever the
strategy the result is a typical ED mexican standoff.. that lasts until Mr or Mrs Plug have been seen.
Marty Koolstra, a legendary sheep farming EP from Melbourne’s east introduced me to the plug
concept some years ago. The screen had belatedly updated to reveal his code beside the 60year old
patient with ‘Intermittent headaches and feeling tired > 6 weeks..’ Things were under control but
this patient had been top of the screen for while. I glanced up somewhat sheepishly as he looked
over and said “…sometimes its easier to just pull the plug yourself..”.
Occasionally, the plug is pulled by an unsuspecting junior doctor but its amazing how quickly they
catch on. The real reason we allocate patients to interns is not to ensure they swim between the
flags but to avoid these plug(s) being left in place for too long. At the end of the day though, an
experienced doctor can get in there and sort out these patients very quickly thus avoiding a Mexican
standoff that turns into the showdown at the Northern Corral.
Below is a far from exhaustive list of presentation types at high risk of forming a plug.
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Fatigue > 2 weeks
Feeling increasingly anxious
Non specific abdominal pain > 1 week
Chronic Pain
Dizziness > 2 weeks
All of these presentations can be associated with significant pathology. It is important to remain
objective but focussed on a hunt for ‘red flags’. Examination of patients in the primary care setting
can be cursory or minimal and an appropriate targeted examination should never be bypassed. If
investigations are required they should not be part of a fishing expedition but limited to specific
tests based on findings of your history or examination. If there are no red flags do not feel compelled
to insert an IV and take bloods just because they have presented to a hospital. Be sure to check what
has already been done before ordering that erect and supine abdominal x-ray.
I will attempt to summarise my tips for one of these five presentations each week. Then you will all
know what to do the next time the screen does doesn’t seem to be moving.. and I can get back to
trimming my toenails in the Early Assessment Pod..
Fatigue:
Whilst generally a “GP type problem” of some duration patients with a primary complaint of fatigue
(not sudden onset) may present to an ED due to their frustration at the lack of a clear diagnosis.
They may also be brought in by other friends or family members who are also concerned and feel
that something is being missed. GPs are generally very good at assessing patients with this very
common symptom and will likely have arranged plenty of tests. Also, as its likely the patient will
return to them for ongoing care, its important from the outset not to undermine the approach taken
by them up to this point.
History:
We are generally pretty quick to move from the open questions to the focussed ones and, while its
crucial to gain rapport, with fatigue this is not a bad strategy.
Important questions to ask include changes in cognition, presence of pain and association of
symptoms with exercise or psychological stressors.
Diet, weight change and changes in bowel habit can be significant as can be menorrhagia. Enquire
about medications and other drugs and alcohol.
Examination:
A general examination is generally warranted – pay attention to:
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Neck/thyroid gland
Rheum - Widespread Musculo skeletal tenderness? (fibromyalgia)
Neuro – eye signs and tendon reflexes
Skin (pigmentation)
Conditions that cause fatigue (yep.. there’s a few):
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Depression and anxiety
Substance misuse
Chronic Fatigue Syndrome
Fibromyalgia
Hypothyroidism
Diabetes
Anaemia
Coeliac Disease/ other autoimmune conditions
Sleep apnoea
Primary Insomnia
Rheumatoid conditions
Infection
Other endocrine disorders – eg Addisons
Inflammatory Bowel Disease
Liver or renal diseases
Reasonable Investigations to consider (if not already done..):
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Urinalysis
FBE
BHCG
LFT
TSH (T3 and T4 if highly suspicious)
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CRP/ ESR?
Random Blood Glucose
Cr, U&Es.
Calcium/ Vitamin D
Ferritin (children and young females only)
Golden Plessor Diagnoses:
Golden Diagnoses are the great picks that might elevate you from the crowd of wannabe medical
hopefuls. In this situation a working understanding of Myasthenia Gravis and Motor Neuron
Disease may just give you the edge.
Myasthenia Gravis - This is the most common disorder of neuromuscular transmission (150250/million). Differentiatiing between neurological and neuromuscular causes of weakness can be
tricky but the clue is often in the history. Muscle weakness commonly affects both limbs and eyes.
It may be transient in early days but gradually worsen and become more persistent. Reflexes are
reduced. Diagnosis relies on AChR-Ab and MusSK - Ab testing however these are only 85-90%
sensitive. EPS is more sensitive. Treatment = Pyridostigmine (often dramatically effective), This
may need to be supplemented by immunosuppression, immunomodulation and thymectomy in
refractory or relapsing cases.
Motor Neuron Disease - This is a heterogenous group of conditions which may be difficult to
differentiate initially. Generally the weakness is focal and affects primarily the upper or lower
limbs. It is generally progressive although this may be gradual. Reflexes can be variable but are
mostly reduced. There are familial forms and in these variants dysphagia and dysarthria can be
present as can cognitive changes. MRI of the brain and spinal cord is the initial investigation of
choice.
Management Recommendations:
Management of the multitude of specific conditions that may present with fatigue is beyond the
scope of this post.
For the patient who has had a comprehensive work-up and is likely suffering from a mood disorder
antidepressants can make a huge difference.
Other syndromes such as Chronic Fatigue or fibromyalgia are largely diagnoses of exclusion. Early
recognition and intervention can also make a big difference with the key to positive outcomes being
the adoption of a multimodal approach by their primary healthcare provider and others. Education,
psychological support (CBT) and exercise programs are usually required. Medications such as SNARIs
and the alpha2 delta ligands gabapentin and pregabalin may be helpful but their use is outside the
domain of the ED doctor.
For the majority of patients an ED assessment does not reveal a specific diagnosis. If this is the case
then for the majority of patients, empathic reassurance and referral back to the GP with a
supportive letter for ongoing management is all that is required.
You return to your seat, note the dramatic progress on the waiting-to-be-seen list and congratulate
yourself..You look at the next patient’s triage note and it says…