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When is a child not a child? When you want an opinion on a 16 year old in August, apparently.
I phoned the on-call medical registrar recently. Not too worried but a little out of my depth – and thinking a chat with a colleague might help.
As an aside, one of the peculiarities of general practice is the door. The mighty and powerful door that closes when you sit down with your patient, shutting out all other eyes and brains and medical input, so that sometimes the consulting room can be a lonely place.
Even after all these years, the thing I most miss from hospital jobs is talking about cases with colleagues; the ward rounds and the various meetings, where brains can be stormed and management plans can be floated. You’re all alone in GP Land, unless you refer.
In times gone by, we used to talk during coffee and lunchtime, and I believe there are still practices where colleagues discuss patients and unicorns peacefully graze the sunlit uplands outside. But most of us are just too busy, and the queue of patients in the waiting room just too long.
So you plough a lonely furrow in general practice, and refer when truly stumped. And just occasionally, you phone a friend.
As on this occasion. Nothing quite fits, and the lad looks OK, but some blood results are a bit off and I really want to talk to someone. And the lucky someone I pick is the general medical registrar.
And now the games start… The first question is his precise age. That’s easy; 16 years and one month.
Ah-ha! In that case he’s paediatric and for the on-call paediatrics registrar.
This seems a moot point, as the problem really isn’t a paediatric problem.
I parry; he’s a big lad, and I’m happy that this is an adult case. The quick comeback: what if it’s a paediatric condition of which the adult medical registrar has no knowledge? What? Really? No. I don’t think so. OK – but is he still at school? No! He’s an apprentice, which makes him an adult! Surely this trumps all? But no; the coup de grâce – has he had his GCSE exam results.
This is a new one on me. In all my conversations with my hospital colleagues I have never before been quizzed on the educational milestones of my patients. I turn to the bemused lad and his father; well? Has he? No.
And I lose. I know that GCSEs are responsible for much stress in life but who knew they carried such profound medical implications?
I call the paediatric registrar who refuses to discuss him, patiently explaining to me that this is an adult case.
The patient remains undiscussed.
Later that night, dad turns up with him in the emergency department and he gets seen, one way or another. We all live to fight another day and all is well that ends well.
Further enquiries with the powers-that-be reveal that the hospital policy is that you are in fact a child until you are 17 – except for on some occasions when it’s 16 and a day. So that’s clear.
Meanwhile the queue outside my door grows longer.
Beatrice Duck is a GP. She writes under a pseudonym
As retired community paediatrician, I recognise this scenario only too well - it was a constant problem with our 'almost adult' patients, particularly those with ADHD. We as paediatricians could not keep them on for ever, but adult services were not interested, and even for the stable ones, GPs were, understandably, not keen to continue prescribing if neither we nor the adult services were looking after them. We kept them as long as we could - but 18 year olds look and feel silly among primary school age children
I now have a variant - my partner has Crohn's disease and most of the complications. Consequently he sees Gastroenterology, Haematology, Hepatology, and the GP. He currently has problems which are being batted about between the specialties, with all of them apparently passing the buck and no-one taking responsibility for sorting him out. |I know it's not what I should do, but I feel a vist to A&E coming on - it would be well worth the 4hr or more wait to get something done.
I have previously had a similar problem as an OOH GP - our local CAMHS OOH service , based in the children’s hospital in the nearest city, will see children up to the age of thirteen. Adult OOH services will see young people from the age of sixteen if they have left school, or eighteen if still in education. It is not clear who should see the acutely distressed and suicidal 15-year-old, or the possibly psychotic seventeen-year-old student who still lives with their parents.
I suggest that there is discussion with the Consultants on call for paeds and adult medicine in this case if SpRs or junior staff have refused the case. The Consultant team should decide who will take responsibility. If they don't then go up the tree to medical directors. No one seeking advice should be left being unable to access it.
Also to note that often it is not the direct fault of services 'not being interested' but that they are commissioned for certain services and ages only and the Commissioners have not recognised that they have led to gaps in service provision because of how they have commissioned.
Service gaps need to be challenged - Risk reported and resolved
Frankly where I work the best option for the patient <18 is extremely clear, if I had to chose for a child I love. Medicine has one SHO and one Reg with 26 people on the admissions board waiting to be clerked at 9pm. Paeds have one reg and one SHO and an eighth of the patients to clerk, both reges cover ward referals but the medic reg covers 240 patients and the paeds 24. Paeds will see a child sooner. Paeds have far nicer environments with free tv and playstations, adult wards are stark and lack any entertainment and very few bays these days don't have a sundowning disturbed patient in.
A+E are sick to death of the batting around of 16 and 17 year olds with them as piggy in the middle. Everyone seems to quote a different policy (19 if it's a paeds issue that's ongoing, 16 if it's an adult problem, 17 if they're still in school, except if they look like an adult or if it's the third sunday of astrological summer)...I'd like it to be clear, every child up to the age of 18 is paeds, lodges in the paeds ward and consults from any other speciality can happen under shared care. Any other rule and you get confusion and arguments...everyone is busy and looking to offload anything they can. If we weren't so busy would be more agreeable? Surely so!
And where to put the childults? Our trust has all 16 and 17 year olds with "adult issues" (read that as "self harm" in 95% of cases) go to medicine. Our MAU wards are often mixed sex and cublicles are gold dust (c.diff coated gold dust albeit)...makes it even knottier. An immature trans 16 yo girl with an alcohol fueled overdose. Adult problem with a child at the controls, initially with nowhere to be placed but in the main ward between a 50 yr old alcoholic male in florid violent alcohol withdrawal and the 85 year old lady with dementia who keeps taking her clothes off. Best option in the end was an in-use all night long treatment room, a trolley and 1 to 1 HCA with her. I remember that girl well because we kept seeing her after another attempt, whatever was being done for her by medics and psych, both 2ary and 1ary care was not working and the lack of ownership and services aimed at her can't be dismissed as irrelevant to her readmissions.
So, I think, 16 and a day is an adult case. Still, there may arise the confusion of 16 and an hour, 16 and a minute etc. How do you consider it? Interesting question, isn't it? For me, 16 is the boundary and a child moves to his or her adult stage. During this period, we cannot say that he is an adult. When he turns into 17, we can see the signs of an adult behavior. He, really, becomes an adult when he turns into 18. This is my opinion and you may have different. I'm a writer and dealt with cases alike in lots of my works at https://www.essayschief.com . But, this case seems very interesting for me.
Frankly all under 18`s get a much more rapid and kinder service with paediatrician`s than adult services. I would not allow my 16 year child onto an adult ward where there may be 1 nurse and 1 nursing assistant for 24 patients overnight, at least 1 in 5 with some form of cognitive impairment and constant calls for bed pans and toilet needs. For any medical parent it is a no brainer, So why do we expect other families to have under 18`s on adult wards?
That's crazy. Problem shifting. If they had listened to you it was clear you wanted to discuss a clearly defined issue and either one of them could have helped. Being 17 or almost 17 is a dangerous age to be as nobody wants to be responsible. The hospital should have a clear guideline regarding age cut off (that should also be flexible depending on maturity of the young person. Some 16/17 year olds are just children, others are very adult).