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.