Case 22 Ruling out the organic

Paul Giardelli is a 20-year-old university student. He is brought to the Emergency Department in the early hours of a Sunday morning by ambulance staff, with a police escort. He had been found walking naked up and down the high street, going into fast food restaurants, taking food from customers and putting it all into the rubbish bins. He had accused staff members of trying to murder the public. There had been an altercation with security staff and Mr Giardelli’s face is covered in blood, his nose appears to be broken and he has a scalp laceration.

Mr Giardelli is assessed by an Emergency Department nurse (his blood pressure is stable, he has a tachycardia and a temperature of 37.9 °C) and is seen by the duty F2, Dr El-Sheikh. Mr Giardelli seems withdrawn but when he believes that the attention of the police officers is elsewhere, quickly tells Dr El-Sheikh that the whole town is being poisoned. The supervisor from Mr Giardelli’s Hall of Residence attends and tells Dr El-Sheikh that Mr Giardelli is usually a popular and high functioning student. She believes that he and his group of friends use cannabis intermittently. He had been appeared entirely normal when she had seen him 36 hours prior.

What do you think is going on and how will you investigate Mr Giardelli?

Dr El-Sheikh believes that Mr Giardelli’s presentation is that of an acute psychosis, possibly brought on by illicit drug use. He sends a number of blood tests in order to rule out organic pathology. In view of the history of head injury, he elects to undertake a CT scan of the head. On the third attempt, Mr Giardelli is able to cooperate adequately to tolerate the scan. A radiologist views the images remotely and confirms that there is no evidence of extradural, subdural or parenchymal bleeding. There is no skull fracture.

Whilst being transferred back from radiology to the Emergency Department, Mr Giardelli suddenly grabs the porter by his collar and threatens him, saying that he knows he is the ringleader of the poisoning campaign. He pushes the porter into a corner and stares hard at him, breathing heavily before spitting at him. The staff nurse pages security and after a minute or so, two security guards arrive from the departmental coffee room. They take Mr Giardelli down to the floor and restrain him whilst the porter is able to move away from the area. Dr El-Sheikh and the staff nurse are able to calm Mr Giardelli down and he returns of his own accord to the treatment room.

Electrolytes and white count are normal. The CRP is moderately elevated (13mg/l). Dr El-Sheikh sutures the scalp wound and refers Paul on to the inpatient acute psychiatric service with an appointment to return to ENT clinic for assessment of his nasal injuries a week later. One of the security guards remains in the room during treatment. Dr El-Sheikh states in his referral that he believes that Mr Giardelli will need sectioning under the Mental Capacity Act 2005.

What do you think of this course of action?

Eight hours later, Mr Giardelli is brought back to the Emergency Department from the psychiatric unit (he had been sectioned for assessment). He is in status epilepticus and his seizures have not yet responded to diazepam administered by the ambulance staff. Blood glucose is normal. Mr Giardelli is given lorazepam and a phenytoin infusion is commenced. His seizures are continuing fifteen minutes later and ITU attend and sedate, intubate and ventilate Mr Giardelli in order to settle his seizures. A further CT scan is undertaken which shows subtle hypodensity in the temporal lobes.

What is the likely diagnosis and the appropriate management?

Mr Giardelli is cared for on the intensive care unit. A working diagnosis of viral meningo-encephalitis is made and Mr Giardelli is commenced on intravenous aciclovir and ceftriaxone (to cover bacterial meningitis) until CSF is obtained and analysed.

CSF is found to contain an excess of lymphocytes and protein is marginally elevated. PCR is subsequently positive for HSV-1. Mr Giardelli receives a ten-day course of aciclovir. He is extubated on day 2 but it is apparent that he has a modest left-sided weakness and there is an early suggestion of neuropsychological deficit.

Expert opinion

It seems that Dr El-Sheik’s assessment of Mr Giardelli may have been overly influenced by the behavioural and forensic aspects of the presentation, and perhaps a desire to progress Mr Giardelli through to a ‘more appropriate’ venue (acute psychiatric assessment unit) quickly.

In retrospect, the features suggesting encephalitis are obvious – specifically, acute behavioural change, pyrexia and tachycardia. The history of illicit drug use is soft. As a student, Mr Giardelli is in a high risk group in respect of CNS infection. Early CT imaging is insensitive for the diagnosis of encephalitis. A lumbar puncture, whilst doubtless challenging, was indicated upon Mr Giardelli’s first presentation. HSV PCR is highly sensitive.

The case also raises questions in relation to the quality of information sharing between staff in the ED (whether or not Dr El-Sheikh was aware of the tachycardia and pyrexia) and the level of support available to junior doctors out of hours.

The hospital will likely be liable for any long-term impact that this episode has on Mr Giardelli – the diagnosis was delayed and earlier diagnosis and intervention may have reduced the extent of parenchymal brain damage and indeed averted the seizures.

Of note, Dr El-Sheikh was mistaken in believing that Mr Giardelli could be sectioned under the Mental Capacity Act 2005 – the Mental Health Act 1983 is the relevant legislation here.

Legal comment

A clear distinction must be made between the remit of the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). The MHA legislation is mainly concerned with the compulsory care and treatment of patients with mental health problems. It covers detention in hospital for mental health treatment, supervised community treatment and guardianship. Contrast this with the remit of the MCA legislation which covers decision-making for people who lack capacity to make decisions for themselves or who have capacity and want to make preparations for a future time when they may lack capacity. It sets out who can take decisions, in what situations and how they should go about it. The Deprivation of Liberty Safeguards (DOLs) is a framework of safeguards under the MCA for people who need to be deprived of their liberty in a hospital or a care home in their best interests for care or treatment and who lack the capacity to consent to the arrangements made for their care or treatment.

Section 6 (4) of the MCA states that someone is using restraint if they use force, or threaten to use force, to make someone do something that they are resisting, or restrict a person’s freedom of movement, whether they are resisting or not.

However, the MCA recognizes that restraint is appropriate when it is used to prevent harm to a patient who lacks capacity and is a proportionate response to the likelihood of serious harm. Appropriate use of limited, temporary restraint falls short of a deprivation of liberty.

Preventing a person from leaving hospital unaccompanied because there is a risk that they would try to cross a road in a dangerous way, for example, is likely to be seen as a proportionate restriction or restraint to prevent the person from coming to harm. That would be unlikely, in itself, to constitute a deprivation of liberty. Similarly, asking a member of staff to guard a patient against immediate harm is unlikely in itself to amount to a deprivation of liberty.

The European Court of Human Rights has also indicated that the duration of any restriction is a relevant factor when considering whether or not a person is deprived of their liberty. This suggests that actions that are immediately necessary to prevent harm to the patient or to the members of staff may not, in themselves, constitute a deprivation of liberty.

However, where the restriction or restraint is frequent, cumulative and ongoing, or if there are other factors present, then care providers should consider whether this has gone beyond permissible restraint, as defined in the MCA. If so, then they must apply for authorization under the Deprivation of Liberty Safeguards to the Supervisory Authority (Primary Care Trust) or change their care provision to reduce the level of restraint.

In an emergency situation, minimal restraint is permitted to obtain specimens and instigate necessary clinical treatment for a potentially life-threatening condition. As Mr Giardelli’s condition deteriorates, he will come to lack capacity and, in accordance with the MCA, the consultant in charge of his care is permitted to act in his best interest. Conversely, as the antiviral regime takes effect, the state of Mr Giardelli’s capacity may improve. There will then be a need to monitor his capacity monitor his capacity to contribute to decision-making about his ongoing clinical treatment. The consultant in charge of Mr Giardelli’s care should also seek information from his family and friends as to what course of management is in his wider best interests whilst he has impaired capacity.

Stay updated, free articles. Join our Telegram channel

Join