Dr Doctor can you pull the curtains back?

Some of our patients really are hilarious. Yesterday evening I was taking blood from one gentleman, when the chap in the next bed (which was surrounded by curtains) farted extremely loudly to himself and said "Sorry about that" presumably to the rest of us in the room. When I had finished taking blood I went to leave, and as I walked past the other chap's bed he said "Oh doctor, could you pull the curtains back please?" I drew back the curtains to reveal a middle aged man, spreadeagled on his bed, stark bollock naked with a massive grin on his face and waving at me. Unsurprisingly I pulled the curtains around again!

Had a bleep from a rather stressed SHO on the winter overflow ward to ask me to take blood:

- I'm really sorry, it's just that I was supposed to finish an hour ago and this man needs an INR taking but he's shat all over himself, and the bed, and the floor, would you mind doing it for me?

- Er.. I think I'll wait half an hour for him to be cleaned up, but yes that's fine!

Arrived half an hour later to take the blood to find an innocuous looking (clean) elderly man. First thought - "well you dont look like the type to have recently been entirely covered in faeces". Second thought - "I'm NOT kneeling on the floor".

Pulled the curtains round the bed and started taking blood, when the patient in the next bed started vomiting profusely, much to the dismay of his visiting relatives.

- Bleurgh BLEEUUUUURGH Oh God it's the soup! BLEUUURGH.

Dr Doctor my bleep's exploded!

Entered the doctors mess yesterday evening to find two fellow FY1s in state of panic clustered round the coffee table. There was the sound of a slightly forlorn pager tone mixed in with cries of:

- Quick get it out, get it out!
- I cant get the back off!
- Ow it's really hot!

I joined the commotion to find one of them attacking a pager with a butter knife, apparently trying to prise the battery out of it. The bleep was bleeping continuously in a very odd tone and smoke appeared to be rising from it. My colleague succeeded in prising the back off to reveal a rather melty looking battery! She looked somewhat tearfully at it and said "This is the SAU on call bleep, it hasnt stopped going off all evening and then it got really hot and started smoking! And it made this weird noise and I thought it was going to explode." So this is what I have to look forward to when I get to the surgical admissions unit.

Dr Doctor with pulmonary oedema.

The rest of yesterday's on call shift went rather well. I was called to see a patient I had treated for pulmonary oedema on Friday when he was admitted. He had had a stroke and a proper swallow assessment hadnt been done so he had been made nil by mouth and not received any of his oral medication to stop him going into heart failure again over the weekend, so he promptly went back into heart failure and was feeling awful. It would have been helpful if one of the nurses doing the drugs round had alerted a doctor that he couldnt take his meds.

I examined him and wrote up the same treatment he had had on Friday - 40mg IV Furosemide and 2.5mg IV diamorphine. I repeated the CXR and did an ABG. He was quite tachycardic and said he had chest pain so did an ECG. Asked nurses to do hourly obs and monitor fluid input/output.

I was slightly concerned this chap might also have a pulmonary embolism as the ECG showed sinus tachycardia, the chest pain sounded pleuritic (worse on taking a deep breath),  his ABG had a very low PaO2 [7.6 EEK increase the oxygen!] and I found a tender right calf on examination. Quite difficult to know what to do about this as therapeutic dose clexane is contraindicated with a large ischaemic stroke as it carries a high risk of bleeding. He probably wasnt a candidate for inferior vena caval filters (to prevent a thrombus travelling from a DVT in the leg to the lungs). 

Decided to discuss with the med reg, who came to see the patient. She suggested starting a GTN infusion because the patient's blood pressure was stable at 150 systolic (GTN is likely to drop the BP considerably so should be started with caution.) She also said well done, which gave me some reassurance that I do have a vague idea about what I'm supposed to be doing!

Dr Doctor - a toilet emergency.

So some smart electrician has switched the emergency toilet alarm with the light. We only discovered this after the third little old person was found looking more dazed and confused than usual but otherwise perfectly fine in the doorway to the toilet, blinking at the large crowd of nurses and doctors that had descended en mass when the alarms went off. After the third time the response was a little slower to the fourth, and we arrived to find a little old man floundering on his back on the floor having fallen over in surprise when the alarms went off!

Dr Doctor is it because of my mum?

Interesting consultation with a patient who had had a stroke this week:

- So do you understand that the scan results show that you've had a stroke?
- Yes doctor, I understand that, I just dont understand why it happened.
- Well, you've had high blood pressure for a long time, you have an irregular heart beat and have been smoking 40 cigarettes a day for 40 years, all these things have probably contributed.
- Alright, but was it anything to do with my mother?
- Your mother? Did she have a stroke?
- No, she had a pacemaker.
- I see. Well sometimes things like high cholesterol can run in families and that can increase your risk of a stroke.
- Hmm. So will I get it then?
- High cholesterol? At the moment your cholesterol is within normal limits.
- No, my mother's pacemaker. Is that inherited?
- Not unless she left it in her will..

Dr Doctor - a postural drop of 140!

Really interesting case on the ward at the moment. 80 year old man admitted with TIA type symptoms whenever he stood up. Found to have a postural drop in systolic blood pressure between 90 - 140 mmHg. Just to put that in perspective, postural hypotension is considered to be a drop in systolic BP of more than 15 mmHg. The usual culprit is too many antihypertensive medications.

Trouble with this chap is, his systolic BP usually runs around 200 (normal is around 120). Treatment for postural hypotension (after stopping antihypertensive meds) is fludrocortisone, a potent steroid that acts like aldosterone to increase sodium and water retention. Contraindicated in this chap with such a high systolic BP.

The team is also somewhat baffled by the cause of this phenomenon. Addison's disease is a possibility, but random cortisol measurement was normal, suggesting he doesnt have a steroid deficiency. He doesnt have diabetes, so autonomic neuropathy is unlikely, although there are a few other rare causes of autonomic neuropathy. He doesnt have Parkinson's disease so this cant be multisystem atrophy (a Parkinson's plus syndrome affecting the autonomic nervous system). Maybe he has some sort of baroreceptor problem.

We're also unsure as to why his usual systolic BP is so high, and are considering secondary causes of hypertension. He does have chronic kidney disease (renal artery stenosis or other intrinsic renal disease could cause raised BP). We're awaiting 24 hour catecholamine levels (if raised may indicate a phaeochromocytoma - rare adrenaline secreting tumour). We should check his other hormones for Cushing's, Conn's and acromegaly, and look for coarctation of the aorta.

Oh dear, I seem to have regurgitated a medical textbook.

Dr Doctor - should I say something?

I'll never forget one of my endocrinology lecturers in medical school professing about how he had diagnosed the lady in his local fish and chip shop with acromegaly the first day he laid eyes on her, and that every time he went for his cod and chips wrestled with the dilemma as to whether or not he should tell her his diagnosis.

- I'll have the large cod and chips thanks, no peas, by the way, you know that huge nose of yours, the masculine brow and all that facial hair? yeah well, I reckon you've got acromegaly.
- I beg your pardon!? acrowhat? how DARE you!
- Well it was merely an observation madam, that you have been looking increasingly like a man over the years, and I think I know the reason - you've got a pituitary tumour. [nods smugly]
- A what?
- A tumour, in part of your brain, secreting growth hormone. That's why your hands are like spades and your shoe size has increased 10 sizes in the past five years.
- So you're telling me I look like a man and I have a brain tumour??
- Yes it's probably the reason you sweat so much and your skin is so greasy. You need to see an endocrinologist, and it's your lucky day..!

I suspect he probably still hasnt broached the subject.  I had a similar dilemma myself the other day when I noticed that the bank clerk sorting out my friend's accounts had stage 3 finger clubbing. He was a young guy, around late 20s, looked fairly healthy. What was I to do? It could be normal for him, or he could have some serious underlying disease. I spent a good 20 minutes staring at this chap's fingers, he must have thought I was rather odd. But what could I do? It didnt seem the time or the place to bring the subject up.

Did I have a duty of care to this guy simply because I am a doctor and my level of knowledge allows me to recognise such a clinical sign as being potentially significant? If I was his GP and he were sat in my consulting room I would have no issue with asking him reams of intimate questions in an attempt to screen for any potential serious disease but with roles reversed, such a course of action seemed most inappropriate.

Perhaps I could have asked how long his fingernails has been like that. My most likely differential was something like cystic fibrosis or crohn's disease, which if he had, he would know about and would probably know his fingers were clubbed. This would then be easy, he could smile knowingly and say "a very long time" and I could smile knowingly and say "I'm a doctor, couldnt help but notice" and leave it at that. The problem would come if he had no idea there was anything wrong with his fingernails, as bringing it up then carried a high risk of either causing offence or inciting great terror, or both.

- How long have your fingernails been like that?
- My fingernails? What's wrong with my fingernails?
- Well, they're clubbed, it could be a sign of serious underlying disease. Or it could be nothing.
- What sort of underlying disease?
- Oh many things, lung cancer, TB, bacterial endocarditis, cirrhosis.. how are your bowels?
- Pardon?
- I said how are your BOWELS? [other bank customers turn round to look]
- They're fine.
- Probably not crohn's disease or ulcerative colitis then. Hmm, you do look a bit syndromic, could be congenital cyanotic heart disease.

Hmm.. probably a good thing I didn't say anything, but I am curious.

Dr Doctor - A Day of Incompetence

I had "one of those days" the other day. Almost everything I did seemed to be wrong in some way, and I made a catalogue of (thankfully mostly minor) Mistakes. Now doctors aren't supposed to make Mistakes, we're invincible. And when we do make Mistakes we're not supposed to talk about them because we're just that egotistical. There have been various headlines in the recent press about the instant dismissal of whistleblowers (the people who have seen something wrong and tried to put it right in an effort to improve patient care, affronted a few people's egos and been booted out the door). The airline industry had similar problems a good many years ago and have since invested in Crew Resource Management Training to break down the barriers of hierarchy and allow more junior staff to speak up if they see a problem. Mistakes are considered learning opportunities in a culture that lacks blame. The only part of medicine that has a similar attitude to patient safety is anaesthetics.

So I will tell you about my day, and my Mistakes, because maybe somebody else will get to learn from them, and patient care will ultimately be improved.

The day began with the most ferocious of medical registrars (who also happened to be post nights) striding onto the ward and barking at me that I was on call and therefore should have been at handover while brandishing the on-call bleep at me. I genuinely hadnt realised I was on call, so naturally hadnt turned up. I apologised and willingly took the bleep, hoping that this wouldnt set the tone for my day.

A few hours later, my consultant came to find me, carrying possibly the first TTO (To Take Out - a discharge summary with the patient's discharge medications and further instructions for the GP for continuing care) I had ever written, back when I had no idea what a TTO really was and what meds the patients needed. He gently pointed out that I had failed to write down that the GP needed to start Clopidogrel 75mg after 2 weeks of 300mg Aspirin, which meant that this post stroke patient had had no antiplatelet medication for about 3 weeks. Had this patient had another stroke in this time it could have been my fault. Thankfully they hadn't, but I felt really bad at having made a potentially serious Mistake. The TTOs are screened by a pharmacist before the patient is discharged, so it should have been picked up by pharmacy (note it usually takes more than one mistake to lead to an adverse incident - google Swiss Cheese Model of System Failure). I was glad my consultant had pointed this out (although by now I'd been doing TTOs correctly for quite some time) but what did make me somewhat miffed was our slightly pushy pharmacist (she's the type of person who enjoys bossing others around) butting in, immediately defending herself that it wasn't her that checked this TTO, and turning round to me and in front of my consultant saying "Oh yes, well you remember we had that talk about prescribing medications after discharge." This made it sound as if I had a problem with my prescribing and made me look pretty crap in front of my consultant. In actual fact we had had no such conversation, but she had yelled at me a couple of weeks ago for accidentally signing off an electronic discharge summary before she had seen it. I thanked my consultant, assured him it wouldnt happen again, and left.

Next, I was accosted by the end of life team nurse while ward rounding with another consultant. She wanted to know if I had spoken to a patient's family about deciding whether or not to palliate her. Now, generally I would expect this to be a consultant led conversation, given that end of life decisions are consultant decisions and out of respect for the patient and their family. The nurse had assumed that because I had documented "Discuss with family regards palliation" on behalf of the consultant on yesterday's ward round that I had made the decision and therefore I should have done it. The plan had not been handed over to the afternoon consultant by the morning consultant so neither of them had spoken to the family, and I ended up looking bad again. I probably should have made sure the afternoon consultant was aware of the plan, but things are easily missed when we're all so busy with other jobs.

So I spent the day feeling rather incompetent, but at least it's given me a lot of things to write in the "reflective practise" section of my e-portfolio! I'm well aware that if these are the worst Mistakes I ever make, I will actually be doing rather well.

Dr Doctor the BP is 60/40!

Yesterday I was called to see an 89 year old patient with a blood pressure of 60/40 (my heart rate picked up when I heard this). Details from the nurse on the phone - the rest of the obs were stable, except the sats probe wasnt picking up a reading (this worried me because it might mean the patient is so peripherally shut down that it's not picking up a reading. Patient had been admitted with sepsis (with a resultant acute kidney injury), probably due to her bilateral cellulitis, and was on the appropriate antibiotics for this. Past medical history of note included end stage congestive cardiac failure - this complicates matters when considering fluid resuscitation because if I think she's dehydrated and give her fluids too quickly I could overload her and precipitate massive pulmonary oedema which could be the end of her.

Took stairs two at a time to the ward. Patient looked unwell and SOB (short of breath), and was quite drowsy and confused (not a good sign). On examination she was very peripherally cool, with a peripheral capillary refill time of more than 6 seconds (heart sank a little at this point) central cap refill was 3-4 seconds (hmm, still longer than it should be). Heart sounds were normal, but I discovered she had bilateral crackles throughout both lungs (did she have a chest infection or was this pulmonary oedema?). As all previous chest examinations in the notes had said chest was clear I decided to repeat a chest xray (CXR). Her previous CXR from the day before showed signs of heart failure with no obvious consolidation. The rest of the examination was unremarkable. Managed to make sats probe work for a short period which showed her sats were 98% on 2L oxygen so reassured. Noted patient was already catheterised (important to allow montoring of urine output). Started 24hour bag of fluids, encouraged patient to drink (water, although we could have both probably benefitted from a brandy at this point!), with a view to having a senior review regarding IV fluids.

I decided to check her latest blood results which showed a low sodium 120 and a high potassium 5.9. Asked the nurses to do an ECG (no new changes). Checked her drug chart - she was on spironolactone which could account for the abnormal electrolytes, but with end stage heart failure there was no way I was going to stop this and would need to discuss it with a senior in any case. Also noticed she was on an ACE inhibitor so stopped this with day team to review as this may have been contributing to her renal failure.

Also on the system was a urine culture that was positive for klebsiella that she was not being treated for. Started trimethoprim (having checked the BNF regarding dosage regimen in renal failure).

Decided to repeat a full set of bloods and do an ABG (would be discussing patient with some sort of med reg who would be highly likely to want to know the results of this). Ordered CXR, instructed nurses to do hourly obs and monitor hourly input/output and ran the case past my SHO.

Went back to review the patient a couple of hours later, she hadnt deteriorated and her blood pressure was slightly better. Her CXR showed no focal consolidation (so probably not a chest infection) and worsening signs of heart failure.

Presented all of the above to the senior night team at 10pm handover (included the fact she was DNAR and her past history), and must have placated the previously disgruntled cardiology registrar who said that was a much better handover than the previous night. Gained a sense of achievement for a productive evening's work.

Dr Doctor on call again.

Late shifts on call again this week, and the last two have been a combination of marathon running, fire fighting, patient bleeding, nurse dodging and cardiology registrar disgruntling.

Number of bleeps - innumerable.
Number of flights of stairs traversed at speed - 20
Number of patients spiking temperatures requiring septic screens - 8
Number of times had to run to a different ward to find equipment for taking blood cultures - 4
Number of bloods needing checking according to afternoon handover - 12
Number of bloods handed to me to do by slightly slacking SHO - 3
Number of deranged U&E results requiring action - 2
Number of INR needing checked and warfarin prescribing - 5
Number of bloods needing repeating due to underfilled/haemolysed/lost/mislabelled - 3
Number of cannulas inserted - 3
Number of radiological investigations needing review - 5
Number of patients falling off their perches - 3
Number of times accosted by marauding nurses brandishing drugs charts/incomplete sets of obs - 7
Number of minutes spent in doctors' mess inhaling sandwich and cup of tea - 15
Number of minutes spent regretting such indulgence - 0 (no time!)

Helpfully, one patient decided to fall off their perch around 9pm, 1 hour before handover to the night team. They needed to be examined, septic screened (bloods, blood cultures, CXR, urine dip, microscopy&culture), writing up for antibiotics based on my examination findings (focus of infection probably chest), a cannula inserting and fluids prescribing, handover to nursing staff and handover at handover. In my haste to get on and determine that he was septic and instigate the septic screen and some treatment before handover I didnt have time to look through the notes to determine why he was in hospital or his past medical history or whether he was for resus. My handover to the night SHO as a result was somewhat incomplete, which drew much criticism from the night cardiology registrar (cleverly masked behind the phrase "I'm not criticising..") and much cringing from me who should have done better.