12 June 2024

A GP’s dilemma: to A&E or not to A&E?

Urgent appointments for children was once the rule in British general practice. They’re now the exception.

Penny, 18 months old, was hot, her temperature had been running above 39°C for two days. She was also bothered: off her food, no longer interested in playing, bursting into tears for no apparent reason. There were no other symptoms to localise the infection. Just an unremitting fever.

I watched her while gathering the story. She was cuddled on her mum’s lap but was holding herself with good muscular tone. Her eyes gazed back at me, big and blue and blinking, apparently interested in this new person who’d appeared in front of her. I took in various other signs almost unconsciously: breathing rate unremarkable, skin perfusion normal.

Her mum and dad had been managing things sensibly, giving regular doses of paracetamol and ensuring fluid intake. There was no sign of the sudden lethargy that had earlier scared them into ringing, and which had prompted me to squeeze them into my Friday afternoon surgery. I’ve seen countless thousands of febrile children during my career. Penny didn’t strike me as worryingly unwell.

Examination reinforced that impression. Her heart rate was elevated, but that could simply reflect the temperature. My hunch was she had roseola infantum, a viral infection that causes a rampant fever and not a lot else besides. The diagnosis only becomes apparent four days in, when the angst-inducing fever abruptly breaks and a blanching rash appears over the upper body.

But roseola wouldn’t account for the mark I found on Penny’s thigh, a dark red smudge in the skin that was unchanged irrespective of how firmly I pressed it. No, her parents said, that hadn’t been there earlier. The odds suddenly tilted. High fever and a non-blanching rash would be classic signs for meningococcal sepsis. Although Penny seemed OK, children are notorious for appearing to be reasonably well right up to the moment they suddenly and dramatically deteriorate. Memories surfaced of a colleague who’d watched horrified as purpura spots started appearing while he was examining a febrile child some years ago.

The safe course of action would be to do what the guidelines stipulate: administer intramuscular penicillin and arrange a blue-light ambulance to A&E. Yet turning Penny unnecessarily into a paediatric emergency would cause substantial emotional trauma and could shake her parents’ confidence in coping with future minor illness. She was up to date with her immunisations, including the meningitis jabs that have led the incidence of meningococcal disease to plummet in recent years. Just how much store should I set by that single, unexplained, indeterminate skin lesion?

I explained the dilemma to Penny’s parents and we devised a middle path. They would monitor her skin closely throughout the evening and if any further lesions appeared they would sound the alarm. Frequently over the weekend, I wondered if I’d return to work to find letters detailing her emergency admission.

She also came to mind recently when NHS England published its latest study into “low acuity” cases in A&E. The expectation was that 20-40 per cent of patients would have minor things wrong with them that could have been managed without emergency department involvement. Instead, the study deemed a mere 4 per cent to be “inappropriate”. This caused surprise, and seemed to undermine those who argue that declining capacity in general practice is pushing ever more low acuity patients into A&E.

Penny’s fever dropped over the weekend and she developed the roseola rash. We are fortunate in our practice still to have the capacity to get patients like her in urgently. Once the rule in British general practice, this is now the exception. Elsewhere, her parents would have been told there were no appointments and to phone 111, which would have led to her being sent to A&E. Had she been included in NHS England’s survey, she would have been deemed to be high acuity. She could, after all, have been in the early stages of meningococcal disease.