Had a discussion with my SHO today about one of our dear old patients with dementia who frequently and loudly calls out the word "OW-OO" when awake, as if she might be in pain. Daily attempts to discover any potential source of pain have been unsuccessful, and the numerous pain medications she's taking are merely making her drowsy.
-Yeah, her abdominal x-ray showed that she's constipated up to the eyeballs.
- Are we giving her stuff for that?
- Oh yes, she's had suppositories and things.
- Could we not give her an enema?
- People who have enemas tend to explode themselves.
- I'm sorry?
- Yeah we had one lady who was bunged up like this so we gave her three enemas in one day and she exploded EVERYWHERE and then couldn't stop and gave herself an acute kidney injury because she'd dried herself out. She nearly died.
- Well that would be a crap way to go..
On another note, syphilis is on the rise again. I learned today that syphilis serology is part of the routine dementia blood screen in this Trust. I also learned that it is one of those samples that needs to get to the lab very soon after it has been taken (this entails a lot of fast walking as the pod system is not quick enough or reliable enough to be trusted). Most tests for hormone levels are the same (except cortisol, which is very stable) and lab technicians insist that a lactate sample needs to arrive instantaneously for fear of degredation (although I did hear a seasoned haematologist disputing this fact at great length the other day).
One of today's numerous trips to the lab involved me pitching up at the hatch, brandishing several samples and saying something along the lines of "I've got syphilis, vitamin D, a PTH, a stool sample and a blood gas." The grumpy bearded lab technician raised an eyebrow and muttered "Everyone's got bloody syphilis these days.."
I waited for the blood gas results, which were rather interesting. All the values were normal, except the PaO2 (arterial oxygen level) which was 23.7. Now if you know what I'm talking about you'll be thinking that the patient is clearly on supplemental oxygen, as normal PaO2 is around 13, and the partial pressure of oxygen in room air is 21 (21% oxygen in air) but nope, patient was on room air, and had a suspected pulmonary embolus so the PO2 should have been low..
I was a little stumped, until I figured out that the sample must have had an air bubble in it which affected the result. Although, this must mean that the stroke unit is an exceptionally oxygen rich environment as 23.7 is higher than the norm.
Thursday, 29 September 2011
Wednesday, 28 September 2011
Dr Doctor it's like being in prison..
I heard one of the consultants discussing how being in hospital is actually rather like being in prison. We trap patients in a room with other sick people and wont let them leave, take away their clothes and give them bright orange jammies to wear, feed them at set times, dont allow them visitors unless it's visiting hours, take away their cigarettes (and drugs),. and in addition we periodically stab them with needles, poke tubes into various orifices and leave them at the mercy of the physiotherapists (affectionately known as the physioterrorists by some).
Indeed, the analogy seemed very fitting when I heard one of the nurses call out to another nurse (upon seeing three of the female patients in her bay sat out in chairs and not in bed) "Can you 'elp me get my free ladies back in bed?" In retrospect, perhaps this was merely her pronunciation and nothing to do with the analogy.
A few minutes later, a whooping arose from the corridor, and two nurses came flying by, riding the patient hoist! There then followed a crash and we peaked out to see both nurses on the floor next to the hoist, which had crashed into the wall at the end..
In other news, I have been honing my blood taking skills. Today one of the nurses asked me to take blood from a former IV drugs user. I'll admit it, my first thought was not about whether I would find a vein, but whether this chap might have Hep B, Hep C or HIV, and my next thought was whether he would think me rude if I wore two pairs of gloves to stick needles in him. I rationalised that actually, yes he is a high risk patient, but I have never had a needlestick injury and am not highly likely to stick myself this time either so didnt double glove. He seemed like a reasonable guy, very open about his past, and really glad to have left it all behind him (although says he still occasionally gets really painful abscesses at previous injection sites which is an unwelcome reminder). Of course, I couldnt find a vein anywhere so resorted to an arterial stab at the radial artery in the wrist. Halfway through the procedure he was very keen to tell me how he'd been tested for the above blood borne viruses and was clean.
One of the things I love about this job is the opportunity to meet interesting people I would never otherwise have contact with. It's a privilege to gain an insight into lives that have been so different from my own.
Indeed, the analogy seemed very fitting when I heard one of the nurses call out to another nurse (upon seeing three of the female patients in her bay sat out in chairs and not in bed) "Can you 'elp me get my free ladies back in bed?" In retrospect, perhaps this was merely her pronunciation and nothing to do with the analogy.
A few minutes later, a whooping arose from the corridor, and two nurses came flying by, riding the patient hoist! There then followed a crash and we peaked out to see both nurses on the floor next to the hoist, which had crashed into the wall at the end..
In other news, I have been honing my blood taking skills. Today one of the nurses asked me to take blood from a former IV drugs user. I'll admit it, my first thought was not about whether I would find a vein, but whether this chap might have Hep B, Hep C or HIV, and my next thought was whether he would think me rude if I wore two pairs of gloves to stick needles in him. I rationalised that actually, yes he is a high risk patient, but I have never had a needlestick injury and am not highly likely to stick myself this time either so didnt double glove. He seemed like a reasonable guy, very open about his past, and really glad to have left it all behind him (although says he still occasionally gets really painful abscesses at previous injection sites which is an unwelcome reminder). Of course, I couldnt find a vein anywhere so resorted to an arterial stab at the radial artery in the wrist. Halfway through the procedure he was very keen to tell me how he'd been tested for the above blood borne viruses and was clean.
One of the things I love about this job is the opportunity to meet interesting people I would never otherwise have contact with. It's a privilege to gain an insight into lives that have been so different from my own.
Tuesday, 20 September 2011
Dr Doctor, better warm it up first..
I happened upon a couple of nurses today, discussing the best approach to performing an enema on one of our most constipated patients. This was a repeat attempt, so the strategy was very important.
- You have to get the angle right [demonstrating possible angles with small bottle of enema solution]
- Yes yes, if you get the angle wrong then it just goes everywhere [voice of experience]
- Oh, and it's very important to warm it up first..
At this point the other nurse takes the bottle of enema solution and pops it down her uniform, lodging it somewhere in her ample bosom! I was somewhat aghast, but couldnt help laughing at the pair of them, so we all fell about, and next thing she tries to fish it out and the top flies off and she gets soaked in enema! Hilarious.
All these nursing tips one picks up on the wards..
- You have to get the angle right [demonstrating possible angles with small bottle of enema solution]
- Yes yes, if you get the angle wrong then it just goes everywhere [voice of experience]
- Oh, and it's very important to warm it up first..
At this point the other nurse takes the bottle of enema solution and pops it down her uniform, lodging it somewhere in her ample bosom! I was somewhat aghast, but couldnt help laughing at the pair of them, so we all fell about, and next thing she tries to fish it out and the top flies off and she gets soaked in enema! Hilarious.
All these nursing tips one picks up on the wards..
Saturday, 17 September 2011
Dr Doctor, the patient has fallen, and is unable to get up.
Just finished my second of three weekend late on-call shifts. This evening has been eventful. Firstly, weekends on call are generally a lot busier than weekdays on call because there are fewer staff on at the weekend so jobs get done later and there are usually more to hand over. So at the beginning of the shift I had a long list of things to do which required some prioritisation. A few of the jobs were things like checking blood levels of drugs such as digoxin and gentamicin, which have to be done at a certain time, others included a mountain of cannulas, a few bloods to take and check and a couple of drugs charts to be re-written.
I was busy attempting to take blood from one chap for a digoxin level, when I noticed the chap in the bed next to him stand up somewhat unsteadily. Now if patients are prone to falls, they often have a falls alarm attached to them and to the chair/bed so that if they try to stand up a siren gets activated and a nurse comes to tell them to sit back down. No such alarm sounded as this gent stood up so I carried on with my attempts to get blood. A split second later and the standing chap turns around and topples forward, landing on his face with a truly awful thud, and then the falls alarm sounds. Sirens wailing, I leapt to the gentleman's side, poor thing had sustained a rather large scalp laceration and was hosing blood all over the floor, flailing gently on his back and looking confused. Thankfully an army of nurses appeared and together we applied compression to the wound and hoisted him back into bed. I checked over the rest of him - no apparent C-spine tenderness, no bony tenderness over the hips or long bones. No blood coming from the ears. Checked his drug chart to see if he was on warfarin (he wasn't)
- warfarin + head injury = CT Scan. Instructed nurses to start regular neuro obs and bleeped my SHO for an opinion on whether to glue, steri-strip or suture the wound. We glued him back together and all was well. Went back and obtained somewhat delayed digoxin level.
Next job was to certify a death. On examination.. patient looks dead. Actually she kind of looked asleep, but very blue around the edges. I listened for heart sounds and breath sounds, felt for a central pulse, checked pupillary reflexes and response to supraorbital pressure, none of which were present (thank goodness otherwise this may have confused the issue). Told the patient/body to Rest in Peace as I was leaving and felt a little silly. Documented my examination in the notes plus time of death, the absence of a pacemaker and Rest in Peace. Felt a little sad.
Next job was to work out how to hide from nurses on the ward waiting to pounce with additional jobs for me to do, while continuing to carry out the jobs on the ward I already needed to do. Failed, and picked up a review of a patient with high blood sugars (around 27, normal being roughly 3-7). Reason for admission of this patient was.. high blood sugars. Chances of me, the inexperienced FY1, managing to single handedly regulate this patient's blood sugars over the course of one on call shift were slim. Also, I find prescribing insulin a little scary. It's a dangerous drug and can certainly kill people in overdose. There are many many different preparations, all with different durations of action, and I really wasn't quite sure what to do. Cue time spent with the BNF (drug book) and a phone call to my SHO for advice. We settled on a small stat dose of 4 units of Actrapid (short acting insulin) alongside her regular intermediate acting insulin.
Managed to escape the Elderly Care nurses to take blood from an outlying patient near the end of the shift. As most NHS hospitals tend to be on "black alert" due to a shortage of beds, some of the less sick patients from one department can end up seemingly in any other part of the hospital. This chap for example, was parked in Urology. I found another chap in Obs and Gynae on yesterday's shift! I'm not sure what happens after black alert.. must be brown alert!
I was busy attempting to take blood from one chap for a digoxin level, when I noticed the chap in the bed next to him stand up somewhat unsteadily. Now if patients are prone to falls, they often have a falls alarm attached to them and to the chair/bed so that if they try to stand up a siren gets activated and a nurse comes to tell them to sit back down. No such alarm sounded as this gent stood up so I carried on with my attempts to get blood. A split second later and the standing chap turns around and topples forward, landing on his face with a truly awful thud, and then the falls alarm sounds. Sirens wailing, I leapt to the gentleman's side, poor thing had sustained a rather large scalp laceration and was hosing blood all over the floor, flailing gently on his back and looking confused. Thankfully an army of nurses appeared and together we applied compression to the wound and hoisted him back into bed. I checked over the rest of him - no apparent C-spine tenderness, no bony tenderness over the hips or long bones. No blood coming from the ears. Checked his drug chart to see if he was on warfarin (he wasn't)
- warfarin + head injury = CT Scan. Instructed nurses to start regular neuro obs and bleeped my SHO for an opinion on whether to glue, steri-strip or suture the wound. We glued him back together and all was well. Went back and obtained somewhat delayed digoxin level.
Next job was to certify a death. On examination.. patient looks dead. Actually she kind of looked asleep, but very blue around the edges. I listened for heart sounds and breath sounds, felt for a central pulse, checked pupillary reflexes and response to supraorbital pressure, none of which were present (thank goodness otherwise this may have confused the issue). Told the patient/body to Rest in Peace as I was leaving and felt a little silly. Documented my examination in the notes plus time of death, the absence of a pacemaker and Rest in Peace. Felt a little sad.
Next job was to work out how to hide from nurses on the ward waiting to pounce with additional jobs for me to do, while continuing to carry out the jobs on the ward I already needed to do. Failed, and picked up a review of a patient with high blood sugars (around 27, normal being roughly 3-7). Reason for admission of this patient was.. high blood sugars. Chances of me, the inexperienced FY1, managing to single handedly regulate this patient's blood sugars over the course of one on call shift were slim. Also, I find prescribing insulin a little scary. It's a dangerous drug and can certainly kill people in overdose. There are many many different preparations, all with different durations of action, and I really wasn't quite sure what to do. Cue time spent with the BNF (drug book) and a phone call to my SHO for advice. We settled on a small stat dose of 4 units of Actrapid (short acting insulin) alongside her regular intermediate acting insulin.
Managed to escape the Elderly Care nurses to take blood from an outlying patient near the end of the shift. As most NHS hospitals tend to be on "black alert" due to a shortage of beds, some of the less sick patients from one department can end up seemingly in any other part of the hospital. This chap for example, was parked in Urology. I found another chap in Obs and Gynae on yesterday's shift! I'm not sure what happens after black alert.. must be brown alert!
Tuesday, 13 September 2011
Dr Doctor, maggots in the fridge!
Witnessed an amusing exchange between two of our nurses this lunchtime. One is tall, somewhat rotund female and black, the other is short, seasoned, male and Sri Lankan.
Large black nurse comes out of the kitchen behind the nurses station with much gesticulation at diminutive, elderly Sri Lankan Nurse:
- WHY YOU PUT DEM MAGGOTS IN DA FRIIIIGE HUH?
- dee maggots needs to be keeping cold
- MY LONCH is in da friidge youknowwhaamsayin??
- please, I put dee maggots nowhere near your lunch!
- Oh. Nu-uh. You put dem on da shelf ABOVV my lonch.
- maybe thees is true, but its no problem.
- Oh, I tink it be a problemm - they was in a TESCOBAG
- please, what is dee problem with a Tesco bag?
- My LONCH was in a Tescobag. I open da Tescobag and I tink Oh. Da maggots has eaten my LONCH!
Turns out we have a patient with a particularly nasty sacral bedsore. The NHS, perhaps as part of cost-cutting manoeuvres, has begun to resort to medieval management of such ailments and as such 'maggot therapy' is becoming more widely used within our hospitals. As they only eat necrotic tissue, they are in fact extremely effective at removing rotten flesh without damaging healthy tissue, thus allowing wounds to heal cleanly. Apparently, they need to be kept cool before use.
Large black nurse comes out of the kitchen behind the nurses station with much gesticulation at diminutive, elderly Sri Lankan Nurse:
- WHY YOU PUT DEM MAGGOTS IN DA FRIIIIGE HUH?
- dee maggots needs to be keeping cold
- MY LONCH is in da friidge youknowwhaamsayin??
- please, I put dee maggots nowhere near your lunch!
- Oh. Nu-uh. You put dem on da shelf ABOVV my lonch.
- maybe thees is true, but its no problem.
- Oh, I tink it be a problemm - they was in a TESCOBAG
- please, what is dee problem with a Tesco bag?
- My LONCH was in a Tescobag. I open da Tescobag and I tink Oh. Da maggots has eaten my LONCH!
Turns out we have a patient with a particularly nasty sacral bedsore. The NHS, perhaps as part of cost-cutting manoeuvres, has begun to resort to medieval management of such ailments and as such 'maggot therapy' is becoming more widely used within our hospitals. As they only eat necrotic tissue, they are in fact extremely effective at removing rotten flesh without damaging healthy tissue, thus allowing wounds to heal cleanly. Apparently, they need to be kept cool before use.
Friday, 9 September 2011
Dr Doctor by the way, the patient looks moribund..
Last evening on call and I get completely swamped with jobs from the very start. All the small jobs like reviewing bloods, taking outstanding bloods and checking chest x-rays etc get handed over to the F1 and not to the SHOs because people dont want to bother the SHOs with them. Add to this three new stroke patients to clerk, one catheter to replace, one patient that had fallen out of bed and an abundance of warfarin doses to review the INR and change accordingly, and I was running around like a mad thing, hiding under the desks of the nurses stations on each ward to avoid nurses with yet more fluid charts to fill out.
In the midst of the never ending bleeps came a call from one of the matrons.
- Hello doctor, just checked this lady's bloods and her sodium is 166 [very high].
- Have you got her current obs?
- No, but she looks moribund.
- Er.. I'll come and see her, please start a set of obs and I'll be there.
I figured that matrons by definition have a wealth of experience behind them, and despite the slightly pants referral, if matron says patient looks near death the patient may well need looking at. When I arrived a suitably helpful nurse was halfway through taking the obs and the patient looked sick. Perhaps not moribund, but sick and lying slumped down in bed. She was relatively unresponsive with a GCS around 7 [eek, this could become an airway problem] her pulse was 100, BP 115/80, cap refill 4 secs, apyrexial, RR 30 sats 84% on 2L oxygen [EEK, instructed nurse to please immediately fetch another venturi mask to up her oxygen to 35%] and her chest sounded full of fluid.
So I got her sat up in bed to make it easier for her to breathe, left her on the oxygen (sats were improving to around 94% by now and her GCS came up to around 11 with her being a bit less hypoxic) and rang my SHO who came to see her. Rechecked her bloods, sodium was indeed 166 up from 155 a couple of days before, and on reviewing her fluids chart noticed she hadnt been given any of the fluids she'd been prescribed for the past four days!? Probably why her sodium was so high - she was very dry. Prescribed some Haartman's solution to run in over 10 hours, could have gone for dextrose but after discussing with the seniors we didnt want to correct the sodium level by rehydrating too quickly because this can cause cerebral oedema. Once she was stable the SHO insisted we go for a cup of tea in the doctors mess and divide up the jobs I had left, thank goodness!
I heard the night team diagnosed simultaneous pulmonary oedema (waterlogged lungs) and intravascular depletion (empty circulation) which led them to treat her paradoxically with frusemide (a diuretic that makes wee out more fluid but is also acts in other ways to reduce pulmonary oedema) and fluids to try to get the fluid off her lungs and into her circulation.
In the midst of the never ending bleeps came a call from one of the matrons.
- Hello doctor, just checked this lady's bloods and her sodium is 166 [very high].
- Have you got her current obs?
- No, but she looks moribund.
- Er.. I'll come and see her, please start a set of obs and I'll be there.
I figured that matrons by definition have a wealth of experience behind them, and despite the slightly pants referral, if matron says patient looks near death the patient may well need looking at. When I arrived a suitably helpful nurse was halfway through taking the obs and the patient looked sick. Perhaps not moribund, but sick and lying slumped down in bed. She was relatively unresponsive with a GCS around 7 [eek, this could become an airway problem] her pulse was 100, BP 115/80, cap refill 4 secs, apyrexial, RR 30 sats 84% on 2L oxygen [EEK, instructed nurse to please immediately fetch another venturi mask to up her oxygen to 35%] and her chest sounded full of fluid.
So I got her sat up in bed to make it easier for her to breathe, left her on the oxygen (sats were improving to around 94% by now and her GCS came up to around 11 with her being a bit less hypoxic) and rang my SHO who came to see her. Rechecked her bloods, sodium was indeed 166 up from 155 a couple of days before, and on reviewing her fluids chart noticed she hadnt been given any of the fluids she'd been prescribed for the past four days!? Probably why her sodium was so high - she was very dry. Prescribed some Haartman's solution to run in over 10 hours, could have gone for dextrose but after discussing with the seniors we didnt want to correct the sodium level by rehydrating too quickly because this can cause cerebral oedema. Once she was stable the SHO insisted we go for a cup of tea in the doctors mess and divide up the jobs I had left, thank goodness!
I heard the night team diagnosed simultaneous pulmonary oedema (waterlogged lungs) and intravascular depletion (empty circulation) which led them to treat her paradoxically with frusemide (a diuretic that makes wee out more fluid but is also acts in other ways to reduce pulmonary oedema) and fluids to try to get the fluid off her lungs and into her circulation.
Wednesday, 7 September 2011
Dr Doctor get it yourself!
Now call me naive, but I genuinely thought that nurses are generally helpful beings, willing to assist doctors in caring for sick patients. There was a mixed bag of nurses on duty yesterday evening. I was very much swamped with tasks, from clerking in new patients to reviewing bloods to taking bloods to reviewing medications. I was very much impressed by one nurse who was willing to take a set of bloods for me, from a difficult to bleed patient that she was used to bleeding. She saved me a good 10-15 minutes for which I was extremely grateful. So my faith in nurses was high around the middle of my shift.
When I finally had a minute to inhale some of my "packed dinner" I was sat in the doctors mess when my bleep went off again. Now I had heard rumours that occasionally handovers are very badly done, but had yet to experience it until this moment. The conversation went along these lines:
- Hello, it's the F1 on call.
- Hello this is one of the nurses calling from the ward, I've got a patient with a temperature of 38.5.
[Dead silence, as I wait to hear the rest of the obs and the reason for the call]
- What are the rest of the obs?
- Um, I dont know, we're just doing them.
- Alright, why is this patient in hospital?
- Um, I'm not looking after them so I dont know.
[Silence, while I wait for her to look through the notes]
- Er.. she has a UTI
- What were her last set of obs like?
- I'll just check. I'm not sure where they've been written down.. I think she had a temperature earlier too.
- So you've called about the spiking temperature, is there anything else that's concerning you about this patient?
- Well, yes, the temperature.
- Ok, I need to know if this patient is unwell enough for me to need to come and see her, so maybe you could ring me back when you've done the current obs.
- Alright, I'll do that.
I looked at the phone in puzzled disbelief, still not sure why I had been called. I wasnt particularly concerned, and was expecting her obs to be normalish and that I probably wouldnt need to review her. Five minutes later the nurse calls me back.
- Her temperature is 38.5. Her blood pressure is 147/85. Her heart rate is 98.
[my ears started to prick up at this point]
Her sats are 94%. Her respiratory rate is 33.
[my ears sprang to attention and I sat up rather straighter]
- Is she on any oxygen?
- No
- Please put her on 28 % oxygen and I'll come and see her now.
It took me a good five minutes to traverse the hospital to the ward, and when I arrived there was an abundance of nurses at the nurses station, all of whom ignored me.
- Hello, I'm the on call F1, who was I speaking to?
- Oh that was me [this nurse looked seasoned enough that she ought to know how to give a proper handover] I havent got around to putting the oxygen on yet! [And she laughed.]
- Right. Where is this patient?
I had been mentally running through my approach to the sick patient on my way there.
1 Do they look sick?
2 Assess airway breathing and circulation and treat stuff as I find it.
3 Further investigations
4 Differential diagnosis and plan
So this patient looked sick, she was obviously breathing fast and was quite drowsy. The nurse hovered next to me, not looking like she was in any rush to apply the oxygen. So I asked her again. I was at this point feeling somewhat frustrated, and concerned both about the patient and the lack of understanding of the clinical situation that the nurses here seemed to have. It was the right thing to do to call me, but they'd done so for the wrong reason and were completely unprepared to give me the information I really needed.
I assessed the patient, decided she wasnt shocked but might have a chest infection, ordered a chest x-ray, took blood cultures and decided to do an arterial blood gas sample. I asked a different nurse to please find me a blood gas syringe and she was singularly unhelpful, and flatly refused to go to the next ward over to find one, in fact saying "you'll have to get it yourself'. Here was me thinking that actually, there are about 6 nurses standing around the nurses station doing nothing, and me running around trying to sort out a sick patient, and maybe if I need a piece of equipment it might be logical, helpful, and safer for the patient if one of them were to go and do it. I weighed up the time I would waste arguing with her versus the stability of patient and went myself. I was not impressed, and was disappointed that my idealistic view of us all working as a team for the good of the patients had been slightly tarnished. Had the patient been much sicker I would have insisted that she go, but it's not (yet?) in my nature to pull rank.
Having done as much as I could I rang my SHO for a more senior review. By the time my SHO arrived, the patient's respiratory rate had decreased to 28 and her sats had improved, so I'd at least fixed her a little bit with the (eventual application of) oxygen.
When I finally had a minute to inhale some of my "packed dinner" I was sat in the doctors mess when my bleep went off again. Now I had heard rumours that occasionally handovers are very badly done, but had yet to experience it until this moment. The conversation went along these lines:
- Hello, it's the F1 on call.
- Hello this is one of the nurses calling from the ward, I've got a patient with a temperature of 38.5.
[Dead silence, as I wait to hear the rest of the obs and the reason for the call]
- What are the rest of the obs?
- Um, I dont know, we're just doing them.
- Alright, why is this patient in hospital?
- Um, I'm not looking after them so I dont know.
[Silence, while I wait for her to look through the notes]
- Er.. she has a UTI
- What were her last set of obs like?
- I'll just check. I'm not sure where they've been written down.. I think she had a temperature earlier too.
- So you've called about the spiking temperature, is there anything else that's concerning you about this patient?
- Well, yes, the temperature.
- Ok, I need to know if this patient is unwell enough for me to need to come and see her, so maybe you could ring me back when you've done the current obs.
- Alright, I'll do that.
I looked at the phone in puzzled disbelief, still not sure why I had been called. I wasnt particularly concerned, and was expecting her obs to be normalish and that I probably wouldnt need to review her. Five minutes later the nurse calls me back.
- Her temperature is 38.5. Her blood pressure is 147/85. Her heart rate is 98.
[my ears started to prick up at this point]
Her sats are 94%. Her respiratory rate is 33.
[my ears sprang to attention and I sat up rather straighter]
- Is she on any oxygen?
- No
- Please put her on 28 % oxygen and I'll come and see her now.
It took me a good five minutes to traverse the hospital to the ward, and when I arrived there was an abundance of nurses at the nurses station, all of whom ignored me.
- Hello, I'm the on call F1, who was I speaking to?
- Oh that was me [this nurse looked seasoned enough that she ought to know how to give a proper handover] I havent got around to putting the oxygen on yet! [And she laughed.]
- Right. Where is this patient?
I had been mentally running through my approach to the sick patient on my way there.
1 Do they look sick?
2 Assess airway breathing and circulation and treat stuff as I find it.
3 Further investigations
4 Differential diagnosis and plan
So this patient looked sick, she was obviously breathing fast and was quite drowsy. The nurse hovered next to me, not looking like she was in any rush to apply the oxygen. So I asked her again. I was at this point feeling somewhat frustrated, and concerned both about the patient and the lack of understanding of the clinical situation that the nurses here seemed to have. It was the right thing to do to call me, but they'd done so for the wrong reason and were completely unprepared to give me the information I really needed.
I assessed the patient, decided she wasnt shocked but might have a chest infection, ordered a chest x-ray, took blood cultures and decided to do an arterial blood gas sample. I asked a different nurse to please find me a blood gas syringe and she was singularly unhelpful, and flatly refused to go to the next ward over to find one, in fact saying "you'll have to get it yourself'. Here was me thinking that actually, there are about 6 nurses standing around the nurses station doing nothing, and me running around trying to sort out a sick patient, and maybe if I need a piece of equipment it might be logical, helpful, and safer for the patient if one of them were to go and do it. I weighed up the time I would waste arguing with her versus the stability of patient and went myself. I was not impressed, and was disappointed that my idealistic view of us all working as a team for the good of the patients had been slightly tarnished. Had the patient been much sicker I would have insisted that she go, but it's not (yet?) in my nature to pull rank.
Having done as much as I could I rang my SHO for a more senior review. By the time my SHO arrived, the patient's respiratory rate had decreased to 28 and her sats had improved, so I'd at least fixed her a little bit with the (eventual application of) oxygen.
Tuesday, 6 September 2011
Dr Doctor you're on call.
So it's back to the wards, and I've been thrown back in on the late shift on call. This entails starting at 1430 with my usual ward team, then attending a 1630 handover from the elderly care wards and the medical wards about sick patients and jobs that the day team havent managed to do, picking up the on call bleep and waiting for it to go off. After 1800 the day team have mostly gone so the elderly care wards are looked after by the F1 (me) and two SHOs.
First job, believe it or not, was to do a PR examination on one of the new patients who had a falling haemoglobin level to check that he didnt have any malaena (altered blood in the stools) that might indicate GI bleeding before giving him high dose aspirin. Now my experience of PR examination from medical school is limited to one hour in the clinical skills lab with a plastic model arse, the rubberised arse section of which got stuck on my finger and came off when I tried to withdraw, resulting in the prostate falling out and bouncing around the room. My only previous attempt on a patient ended rather messily with a proctoscope being farted vigorously back out at me (the patient was quite unharmed I can assure you). So of course I didnt quite relish the idea of performing this procedure on the dear little old man in front of me. Despite having never met him before I had to gain his trust, gain his consent, put him at ease and perform the procedure competently and professionally.
My tips - make sure the patient is fully informed about the procedure and why it needs to be done (not only does this build rapport but is a legal necessity), take a nurse to chaperone, talk through what you're doing, be quick but thorough, and for heaven's sake double glove (take the first glove off when you withdraw so that you can clean the patient with a clean gloved hand). Document everything in the notes afterwards, especially that you gained consent, who the chaperone was, and your examination findings.
Other jobs included reviewing an outlying patient on warfarin with an INR of 5.0 (this means she's over-anticoagulated and the warfarin dose needs changing). I went to see her, asked if she had noticed any bleeding from anywhere, examined her and changed the dose according to Trust Guidelines.
I also had to review a couple of x-rays and a heap of bloods (normally this is done by the day team but thanks to the phlebotomists not bleeding the patients on some of the wards till 1600 none of the results were back. I found only one interesting result - a sodium level that had dropped overnight from 133 (normalish) to 126. The patient was well and not confused, and none of the medications she'd been started on recently could have caused the drop so I wrote the results in her notes with a plan to repeat the sodium next day.
Handed over to the night team at 2200, fairly uneventful shift.
First job, believe it or not, was to do a PR examination on one of the new patients who had a falling haemoglobin level to check that he didnt have any malaena (altered blood in the stools) that might indicate GI bleeding before giving him high dose aspirin. Now my experience of PR examination from medical school is limited to one hour in the clinical skills lab with a plastic model arse, the rubberised arse section of which got stuck on my finger and came off when I tried to withdraw, resulting in the prostate falling out and bouncing around the room. My only previous attempt on a patient ended rather messily with a proctoscope being farted vigorously back out at me (the patient was quite unharmed I can assure you). So of course I didnt quite relish the idea of performing this procedure on the dear little old man in front of me. Despite having never met him before I had to gain his trust, gain his consent, put him at ease and perform the procedure competently and professionally.
My tips - make sure the patient is fully informed about the procedure and why it needs to be done (not only does this build rapport but is a legal necessity), take a nurse to chaperone, talk through what you're doing, be quick but thorough, and for heaven's sake double glove (take the first glove off when you withdraw so that you can clean the patient with a clean gloved hand). Document everything in the notes afterwards, especially that you gained consent, who the chaperone was, and your examination findings.
Other jobs included reviewing an outlying patient on warfarin with an INR of 5.0 (this means she's over-anticoagulated and the warfarin dose needs changing). I went to see her, asked if she had noticed any bleeding from anywhere, examined her and changed the dose according to Trust Guidelines.
I also had to review a couple of x-rays and a heap of bloods (normally this is done by the day team but thanks to the phlebotomists not bleeding the patients on some of the wards till 1600 none of the results were back. I found only one interesting result - a sodium level that had dropped overnight from 133 (normalish) to 126. The patient was well and not confused, and none of the medications she'd been started on recently could have caused the drop so I wrote the results in her notes with a plan to repeat the sodium next day.
Handed over to the night team at 2200, fairly uneventful shift.
Monday, 5 September 2011
Dr Doctor there's nothing more we can do.
My last day in ITU was somewhat sad. We had a lady who was day 2 post out of hospital cardiac arrest who we had been cooling (it has been shown that cooling people after cardiac arrest can improve neurological outcomes) and then rewarmed her overnight. In the morning when I arrived she began fitting, which is never a good sign. The decision was made after discussion with the family that she should be kept comfortable and we would let her pass away.
That afternoon I was sat writing in some notes at the nurses station when out of nowhere the monitor that shows all of the patient's heart traces started going completely bananas, flashing red and black and making siren noises and screaming VT! VT! because the patient had gone into one of the cardiac arrest rhythms. It gave me such a fright that I literally leapt out my seat, surprised that I myself had not been sent into a cardiac arrest rhythm.
The consultant sat next me very calmly (ITU and anaesthetic consultants are always calm, without exception, something to do with the vast quantity of experience of very sick patients and superhuman level of knowledge they accumulate) wafted me back down into my seat. "We wont be treating this," he said, "this was expected."
Over the next ten minutes I found it both interesting and extremely sad to watch the wavy lines of this lady's heart trace deteriorate from VT into VF, occasionally back into sinus rhythm and then get gradually slower and slower until the last blip vanished and she was in asystole. It's quite unusual to watch this because in most patients people would be actively resuscitating and those not for resuscitation are not usually monitored.
That afternoon I was sat writing in some notes at the nurses station when out of nowhere the monitor that shows all of the patient's heart traces started going completely bananas, flashing red and black and making siren noises and screaming VT! VT! because the patient had gone into one of the cardiac arrest rhythms. It gave me such a fright that I literally leapt out my seat, surprised that I myself had not been sent into a cardiac arrest rhythm.
The consultant sat next me very calmly (ITU and anaesthetic consultants are always calm, without exception, something to do with the vast quantity of experience of very sick patients and superhuman level of knowledge they accumulate) wafted me back down into my seat. "We wont be treating this," he said, "this was expected."
Over the next ten minutes I found it both interesting and extremely sad to watch the wavy lines of this lady's heart trace deteriorate from VT into VF, occasionally back into sinus rhythm and then get gradually slower and slower until the last blip vanished and she was in asystole. It's quite unusual to watch this because in most patients people would be actively resuscitating and those not for resuscitation are not usually monitored.
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