TIME TO TREAT

So, it was a typical busy morning. The outpatient clinics were overbooked and the waiting room was getting restless. I looked over the next chart, half of the notes were missing but that was not unusual. Here was a gentleman who had neovascular AMD and had finished a course of intravitreal injections.

There were two questions to ask here: had he improved? and did he need more treatment? We were pressed for time so, to get things moving, I asked for an OCT before seeing him. As I busied myself with other tasks, the nurse sidled up to me and told me there was a problem. The man was unable to have all his scans because he was falling asleep at the machine. He was getting drowsy and couldn’t hold his gaze for the split second needed to take the image. I remember feeling annoyed because I really needed the scan.

A fluorescein angiogram would be out of the question. The time was ticking past lunch hour and hunger was adding to my poor humour. “His ambulance transport is here, he has to go back home soon,” the nurse added, so I decided to press on seeing him regardless. I called his name and in trundled an elderly man about five foot four with a thin layer of white hair. His tattered chart suggested that he had been with us for a number of years so I wasn’t surprised when he sat himself down and silently slotted his head into the slit lamp.

His vision measurements had been poor, he could barely see the largest letter for the past few years. Today was no different so I could not rely on any change in his vision to determine his treatment. I began by examining the eye being treated but found that he was squirming in his seat. Eventually I saw a large central scar with some thickness to it. Perhaps it could use more injections but it was not the clearest-cut case. So I asked him if he had noticed any difference after the treatment. He looked at me and tried to form words but his speech was very poor. “This is typical. Running late with the patient with a speech impairment and half his notes are missing,” I thought.

Missing words

I sighed at my bad luck and examined his fellow eye. I remembered it. It had an unusual linear macular scar from an injury a long time ago. The eye was damaged when the patient was parachuting into Germany in 1945 at the age of 18. On his first mission as a paratrooper a stray branch had caught him in the eye. By the evening he had learned to aim with his other eye and was “back to shooting Nazis”. I knew this story because the last time I had seen this patient, he had told me all about it with great pride. In fact, it was difficult to get him to stop talking! So I pushed the slit lamp out of the way, looked at him and said: "When did you lose your words?" He stuttered as if his tongue were in his way. I made some guesses at the meaning, but he growled and rolled his eyes at me.

Just as frustrated with me as I had been with him. Finally he took my pen and scratched: “Last night I was okay”, on the table in front of me and followed this with, “I drank milk and it spilled on me”. He had ruined the table but his graffiti told me what I needed to know. Some time last night he had had a stroke. I contacted the medical team and discussed his case. He was outside the window for thrombolysis but still needed a full work-up and stroke rehab. They could arrange it today. I told the hovering ambulance driver he could leave and I sat with the patient. I explained what I thought had happened and how, for the moment, his eye was not the priority. As I finished my explanation I told him that I remembered his story. Then he smiled and mimed his story again to me as we waited for the medics.

Time management

I saw him in the clinic recently. After his rehabilitation his words improved and he has even entertained us with some French and Italian. He is a cheerful character and I am always happy to see him, but on some level I am ashamed of how initially I felt towards him. He was out of the ordinary, causing problems and he was slowing me down. I was frustrated and impatient. But for the fact that I knew his eye, I might have sent him home. As a young ophthalmologist I feel that the biggest problem we face is time. With the advent of intravitreal injections, conditions that previously couldn't be treated now have a much brighter outlook.

The prognosis for the patients is certainly improved, but the prognosis for the services might actually be suffering. The need is so great that clinics are routinely booked over capacity. Surgical trainees are spending ever more time in the injection suite, and less in the surgical theatre and training positions are fast becoming service jobs. So how do we strike a balance between treating all the patients the way they deserve to be treated, while providing a cost-effective and efficient service? Some patients will always require more time and attention than others. With a conveyor belt approach, we risk missing something for the sake of not looking. Double so when patients are queuing and time is ticking.