LETTER TO THE EDITOR

DEALING WITH GENERAL MEDICAL COMPLAINTS IN A DIALYSIS UNIT

Dear Editor, Tackling general medical complaints that are not under the realm of usual renal care in a dialysis unit can be a challenging process. Patients on dialysis are often burdened with multiple co-morbidities and require coordinated care from multiple medical specialties. Establishing the role of the dialysis physician and the dialysis nurse early on in the first encounter with a new patient can pave the path to good healthcare. Often the healthcare system concerned dictates how involved the nephrologist is in the care of extra-renal ailments. It comes down to who funds healthcare services. The common assumption of a patient on long-term dialysis is that they could have all their medical problems which are not part of routine dialysis care addressed during their dialysis session by qualified healthcare professionals in an in-centre haemodialysis setting (Tong et al. 2013). The lack of involvement of a general practitioner in the setting of a tertiary care facility and this country’s healthcare system (Al-Ahmadi & Roland 2005) leaves the nephrologist assigned to the unit responsible to care for the patient as a whole. In my experience, there have been patients with alarming symptoms such as chest pain who delayed seeking medical attention till the next session of dialysis either by leaving the emergency room (ER) without being seen or by avoiding ER visits altogether due to long ER waiting times (Shaikh et al. 2012), with the notion that ’my dialysis physician and nurse know me best’. In other instances, chronic medical problems are often not followed up with the concerned specialties bearing the same assumption that the dialysis unit is a one-stop clinic for all ailments. This can be dangerous unless the unit employs certain standards of care where their patients are thoroughly reviewed at regular intervals. In our unit, in addition to daily rounds and monthly labs, all patients undergo a full medical evaluation at annual intervals. The patients’ complete medical history, in addition to the active list of problems, is discussed at weekly meetings with the whole team that involves nephrologists, social workers, dieticians, vascular access coordinators, patient educators, transplant coordinators and most importantly the primary nurse assigned to the patient. In addition, specialty services such as endocrine

surgery are involved when a decision for parathyroidectomy is mandated, or the high-risk obstetric team when we are dealing with a pregnant patient on dialysis. We follow a standardised format where issues such as hepatitis status, cardiovascular status, transplant status, nutritional status and social issues are dealt with thoroughly. I feel that this system, although it conveys additional responsibility for the nephrologist, leaves patients well cared for, with timely referrals and interventions when necessary. However, patients should be well educated to seek urgent medical care when they have alarming symptoms experienced in between dialysis sessions. In conclusion, with healthcare settings similar to ours, where a general physician is not involved in the overall health care of a patient on dialysis, we advocate adopting a system as we have done for timely screening, global assessment and referral when necessary. This way we provide more than just specialist dialytic therapy; we are our patient’s primary physician and are more involved in their overall well-being. Mohammed Mahdi Althaf, M.D., M.R.C.P. (U.K.)1 Mohamed Said Abdelsalam, M.D.1,2 1 Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia 2 Internal Medicine Department, Faculty of Medicine, Alexandria University, Egypt 

CORRESPONDENCE Mohammed Mahdi Althaf Department of Medicine, Section of Nephrology, MBC #46, King Faisal Specialist Hospital and Research Center, P. O. Box 3354, Riyadh 11211, Kingdom of Saudi Arabia Tel.: þ966-1-4647272 Fax: þ966-1-4427499 Email: [email protected]

ACKNOWLEDGEMENTS Dr. Osman I. Alfurayh, our mentor as well as founder of the current system, and to all our haemodialysis nurses who help make this a possibility.

REFERENCES Al-Ahmadi H. & Roland M. (2005). Quality of primary health care in Saudi Arabia: a comprehensive review. International Journal for Quality in Health Care 17, 331–346. Shaikh S.B., Jerrard D.A., Witting M.D. et al. (2012). How long are patients willing to wait in the emergency department before

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leaving without being seen? Western Journal of Emergency Medicine 13, 463–467. Tong A., Palmer S., Manns B. et al. (2013). The beliefs and expectations of patients and caregivers about home haemodialysis: an interview study. BMJ Open 3, pii: e002148. doi: 10.1136/bmjopen-2012-002148.

© 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association

Dealing with general medical complaints in a dialysis unit.

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