Could personality tests help us select happier doctors?
An alcoholic patient collapses in the street and refuses your help
Three GPs share their approach to a practice problem
You are called out of surgery to a collapse by one of your patients. He is Mr Brown who you know to have alcohol dependence.
The only witness is a passing teenager. The witness says Mr Brown suddenly blacked out in front of him on the pavement. A possible convulsion occurred.
By the time you get there, Mr Brown appears to have come round and insists there is nothing wrong with him (although he has cut himself and smells of alcohol).
He refuses to allow you to examine him and will not accompany you back to the surgery or to allow you to call an ambulance. He starts to get angry and shouts that you have no right to harass him in the street.
Dr Des Spence
'I have learnt never to judge addicted patients never lose hope'
If you work in an inner city, especially Glasgow, you become almost desensitised to addiction in all it manifestations, but particularly with alcohol. I have seen so many alcohol problems that faced with this scenario I would be inclined to do nothing, accepting that Mr Brown is in denial over his addiction.
But there are a number of medical issues that need to be considered. First, is his aggressive behaviour a post ictal response? Second, has he injured his head? If so he would be at risk of a sub-dural hematoma.
This is my plan. I would stand back and observe Mr Brown from a distance that didn't make him agitated (this might involving buying binoculars!). Next I would phone his family and suggest they meet me urgently so we could approach Mr Brown together.
If this calms him down it would give me a chance to examine him. If he runs off, then a decision to contact the police based on the brief contact must be made. My experience is that the police are very helpful and supportive.
But let us assume that Mr Brown is now safely with his family and has no acute medical issues. There are a number of different management options. You could send him to hospital for acute investigation and treatment. Alternatively he could be seen in the surgery, have baseline bloods, and be given some benziodiazipines for withdrawal.
If his family is willing he could be observed at home over the next 12-24 hours. I would see him the next day and explore further treatment for his alcohol problem.
Addiction does not neatly fit our classic medical model and I am also unconvinced of the value of the various medications for alcohol dependence.
I have learnt in general practice never to judge my addicted patients because none of us escapes the risk of addiction. Never lose hope.
Des Spence is a GP in Glasgow and a tutor in general practice at the University of Glasgow he completed the VTS in 1995
Dr Robin Fox
'If the man ran off it might necessitate the police being called in to look for him'
the police being called in to look for him'
As Mr Brown's GP, I may still be able to calm the situation down enough to allow a better assessment of the situation and with luck get permission to call an ambulance. Defusing the situation when faced with an angry patient is never easy, particularly in the presence of alcohol intoxication.
If this fails, then respecting his autonomy clashes with my concern for his safety. If I feel he is not confused and is able to make an informed decision, then I must respect his autonomy and allow him to leave. I would then contact him later to review the situation. This is probably the most likely outcome.
Transient hypoglycaemia and alcohol lowering the seizure threshold are differentials that perhaps do not have to be sorted immediately. Buying him a carbohydrate snack may help prevent hypoglycaemia and allow things to calm down. I would hope the fact that he smells of alcohol means he is not in imminent danger from acute withdrawal.
Having a withdrawal fit as part of delerium tremens has a significant morbidity/mortality risk and would require urgent action. A subdural, severe electrolyte disturbance or encephalitis could similarly need prompt action. In this situation, if he was confused, and I felt he was unable to make an informed decision, I would phone for an ambulance.
This could get difficult and if he ran off, it might necessitate the police being called in to look for him. This might result in a possible 'section' (such as section 4 or, more likely, in the absence of an approved social worker or nearest relative, a section 136) to allow further assessment.
This would be a last resort, would probably involve a breach of confidentiality and could destroy our doctor-patient relationship. Before taking such action I would ring my medical defence organisation. I keep its credit card-sized information leaflet in my wallet for just these situations.
Robin Fox completed the VTS in July 2002 and is a partner in Bicester, Oxfordshire
Dr Tonia Myers
'In reality, little can be done unless the patient is ready and willing to accept help'
I would try to defuse the situation by offering to phone Mr Smith's family to take him home.
He is perfectly within his rights to decline my offers of assistance. As long as he is not bleeding profusely and does not present an immediate danger to himself or others (in which case I would have no choice but to call the police,) I would make a hasty retreat.
I would document the encounter and review his records. If he is a regular attender, I would wait until his next visit and discuss what had happened.
If he rarely attends, I would write a letter to invite him for a check-up. His family may attend with concerns, which can be used for a discrete fact-finding exercise, taking great care not to breach confidentiality.
If he turns up, I would repeat what the witness had told me and say I was concerned that he had had an alcohol-related seizure.
I would ask him how much he is drinking and tell him that the alcohol is now affecting his health.
I would check his blood pressure and send him for blood tests including FBC, LFTs and gamma GT, lipid profile including triglycerides and fasting glucose.
This is a good excuse to get him to come for a follow-up appointment. I would also give him the contact details of the local alchohol team.
My most pressing concern is whether he is a driver. The difficult part is to tell him that he must not drive and that he has a legal responsibility to inform the DVLA.
If Mr Smith denies he has a problem or does not attend, I would phone my defence society to discuss my options and duties.
Ultimately with alcoholic patients, even with the best will in the world, little can be done unless the patient is ready and willing to accept help.
Tonia Myers completed her VTS in 1989 and is a GP in Highams Park, London