All patients in the hospital emergency department are different. Tall or short, old or young, and each one will have a different experience. For those with intellectual disability, it can be a particularly frightening time. Tummy pain or headache, combined with unfamiliar surroundings, can make many tearful and upset. This potentially traumatic time can be eased by vigilant staff who are aware that subtle changes in their approach can make a huge difference to this group of patients and their overall emergency department experience.
Below are a few obstacles commonly encountered in the emergency department management of patients with intellectual disabilities and some simple ways in which we try to overcome them while maintaining patient safety and comfort.
The Waiting Room: Heaving with people of all races and walks of life, each with their own story to tell. A nervous energy circulates and waiting here can be anxiety-provoking and contribute to behavioural disturbances in those with intellectual disabilities. A quiet cubicle or treatment room is more acceptable and most emergency departments could facilitate this for an anxious and intimidated individual.
History: 80% of diagnoses can be obtained from the medical history alone. This may well be true if a focused history is taken from a patient able to express all the subtleties of their symptoms. Giving adequate time and patience to the individual, their family and carers, allows clinicians to overcome any communication issues and obtain a broad picture of how the patient is normally and what has changed over the preceding hours, days or weeks that has led to their presentation in hospital.
Examination: A testing time for any doctor-patient relationship. Rightly so, why would anyone want a stranger to poke their painful tummy or peer into their sore ear? Difficulty arises when doctors head straight to the ‘painful part’. A warm and reassuring attitude will help the patient feel more relaxed and allow important information to be gained while leaving the potentially upsetting part to the very end. A friendly smile and good communication aren’t a lot to ask—they are a must.
Investigations: Whether it’s the prick of a needle or the lonely dark of the x-ray room, these are never nice. However, when the history or examination is insufficient, these may be very important in making a diagnosis and treating the patient appropriately. A good explanation and continued reassurance can maintain trust (which is crucial for a working doctor-patient relationship) and help scared individuals through a potentially upsetting time.
Admission and Discharge: Hospitals can be intimidating places—strange sights and sounds are enough to make even the most courageous feel uneasy. Extra care should be given to those who are more vulnerable. A private room away from the busy ward and extended visiting for family/carers makes a worrisome time far more bearable. In some cases, those closest to the patient may provide a continuous presence, as they are more likely to detect worsening pain or subtle changes in the patient’s clinical state.
On the opposite side, sensible discharge instructions prevent relapses and close GP/community follow-up prevents another daunting excursion to the emergency department.
These are a few measures that can be instituted to improve the emergency department management and hospital stay for patients with intellectual disabilities. Unfortunately, just one negative experience can leave a lasting impression, so every day we must fight to offer the highest quality of care to each and every patient. Even at their busiest, most emergency departments are accommodating and if you visit I hope that is what you will find.