Happened upon one of our junior staff nurses with several towels draped over her shoulders and arms, and a couple of disposable plastic aprons over her head, carrying a couple of wash bowls and some more towels along the corridor outside one of our wards.
Curious (and slightly concerned that maybe one of our patients was fountaining from some orifice), I followed her to find that the ceiling had sprung a leak outside one of the patient toilets and a positive torrent of water was coming out of it. She spread some of the towels on the floor and knelt down to place the wash bowls under the falling water.
No sooner had she positioned them there was a crack and the ceiling tile above her broke and the poor thing was deluged in slightly yellow water of questionable origin, letting out a quite understandable shriek!
I felt very sorry for her and went to find some more towels, but it was rather funny to watch! Turns out the sluice on the floor above had flooded ?cause.
On my way back along the corridor I was stopped by a lost-looking patient who asked for the way to the "maxi failure facial department". Trying to keep from chortling I directed her to Max Facs, wondering quite what she was expecting to find when she got there!
Thursday, 29 December 2011
Monday, 26 December 2011
Dr Doctor - working Christmas.
Everyone grumbles about having to work Christmas. Having never done it I wasnt sure if it would be fun, with everyone in a good mood wearing tinsel and flashing objects and other festive items of clothing, or depressing because in reality we're all trapped in a hospital away from our families. I was on twilight shifts this weekend which at least meant I could make a proper turkey lunch with my housemate before work.
A highlight of the Christmas Eve shift was when a collection of carol singers came round the elderly care wards. They really lifted the atmosphere, and it was lovely to see their number increased by a handful of pink nightdress-clad zimmer frame-wielding little old ladies whose faces lit up as they tottered out of their rooms to join in the singing. One particularly enthusiastic lady knew all the words but couldnt really carry a tune and screeched her way through 'Silent Night' drowning out most of the others. When the song finished one of the other ladies muttered "It's never a bloody silent night with her around!" The singers moved on, and I joined the nurses in fielding our little old ladies back to their rooms.
I was called to see a patient who had dropped their oxygen saturations to 83% (sit patient upright, controlled oxygen as he had COPD, ABG, CXR as chest sounded full of crackles, IV access and bloods). I diagnosed a pneumonia as his inflammatory markers were raised and his chest x-ray wasnt typical of pulmonary oedema and had evidence of bilateral consolidation, so started him on IV antibiotics. Sad thing was he had been due to go home that day, and this would be his last Christmas because he had terminal stomach cancer. It was quite hard to tell him he wouldnt be going home after all.
On Christmas Day I started off wishing my patients a Merry Christmas whenever I went to see them, which usually drew a Merry Christmas in return, but I did reflect that actually, even if it were mid August and I swept into their room with a smile and a Merry Christmas, most of them would probably think it must be Christmas.
Having taken blood from one lady who had just finished her Christmas lunch I offered to pull a cracker with her as she had one on her food tray. She was quite excited at this thought so we pulled the cracker which made a rather loud bang and a nurse come running to find a grinning little old lady and me saying "look, you've won!" The patient insisted I wear her party hat.
The shift remained relatively calm, and my SHO and I managed to sit down for a tea and mince pie break. Every ward had a LOT of food to keep us going. Finished work at 10pm and got back to hospital accommodation in time to spend the last bit of Christmas day unwinding with some mulled wine. All in all not a bad weekend
A highlight of the Christmas Eve shift was when a collection of carol singers came round the elderly care wards. They really lifted the atmosphere, and it was lovely to see their number increased by a handful of pink nightdress-clad zimmer frame-wielding little old ladies whose faces lit up as they tottered out of their rooms to join in the singing. One particularly enthusiastic lady knew all the words but couldnt really carry a tune and screeched her way through 'Silent Night' drowning out most of the others. When the song finished one of the other ladies muttered "It's never a bloody silent night with her around!" The singers moved on, and I joined the nurses in fielding our little old ladies back to their rooms.
I was called to see a patient who had dropped their oxygen saturations to 83% (sit patient upright, controlled oxygen as he had COPD, ABG, CXR as chest sounded full of crackles, IV access and bloods). I diagnosed a pneumonia as his inflammatory markers were raised and his chest x-ray wasnt typical of pulmonary oedema and had evidence of bilateral consolidation, so started him on IV antibiotics. Sad thing was he had been due to go home that day, and this would be his last Christmas because he had terminal stomach cancer. It was quite hard to tell him he wouldnt be going home after all.
On Christmas Day I started off wishing my patients a Merry Christmas whenever I went to see them, which usually drew a Merry Christmas in return, but I did reflect that actually, even if it were mid August and I swept into their room with a smile and a Merry Christmas, most of them would probably think it must be Christmas.
Having taken blood from one lady who had just finished her Christmas lunch I offered to pull a cracker with her as she had one on her food tray. She was quite excited at this thought so we pulled the cracker which made a rather loud bang and a nurse come running to find a grinning little old lady and me saying "look, you've won!" The patient insisted I wear her party hat.
The shift remained relatively calm, and my SHO and I managed to sit down for a tea and mince pie break. Every ward had a LOT of food to keep us going. Finished work at 10pm and got back to hospital accommodation in time to spend the last bit of Christmas day unwinding with some mulled wine. All in all not a bad weekend
Thursday, 22 December 2011
Dr Doctor I think I'm having a DKA!
So ward work this week has been pretty routine. For some reason they've stuck a 17 year old work experience student with me who has been, predictably, somewhat bored having to watch me fill in forms, take bloods, do cannulas, phone the lab and very occasionally interact with a patient. Tried to organise something more exciting for him like watching an operation in theatre but we were told he's too young as you have to be 18. I had forgotten how X-rated our theatres are!
So with nothing exciting to report I'll return to my last shift in MAU and reflect on a patient that actually managed to become really rather sick in the discharge bay. She was a type 1 diabetic who had come in with abdominal pain, nausea, vomiting and diarrhoea. She had been very stable and was just awaiting another speciality to review her before going home. However, she started vomiting late morning and had some more diarrhoea, her obs remained stable so I prescribed some antiemetics, checked her blood sugar (8.5) and routine bloods and decided to keep a close eye on her.
A couple of hours later the nurse called me to see her because she was having chest pain. I asked them to do an ECG which showed a sinus tachycardia at 130 with ST depression in the lateral leads. Patient at this point looked really very unwell and said she felt awful and she (and I) was worried she might be having a DKA (diabetic ketoacidosis, lack of insulin => production of ketones => these are acidic = bad). Put the patient on some oxygen and asked for a urine dip which had ketones in it, rechecked the blood sugar which was 17.5. Decided I needed a senior to be come and review before I took an ABG to check her pH (if acidotic with high blood sugar and ketones = DKA = bad).
Phoned the med reg who was spectacularly uninterested, wouldnt listen to my concerns and ordered me to take an ABG before bothering her again. reiterated that the patient looks Sick and that I was Worried about her but she hung up on me.
So I took an ABG and asked the nurses to repeat the ECG (still ST depression, probably rate related ischaemia).
pH 7.46 (slight alkalosis, definitely not an acidosis)
pCO2 3.58 (low therefore respiratory alkalosis, compensating metabolic acidosis? see base excess)
pO2 7.4 (low, need to increase oxygen)
BE -3.5 (negative base excess means there is a metabolic acidosis, likely lactate or ketones)
HCO3 21.4 (low bicarb, suggests compensating for metabolic acidosis)
O2 Sats 92.5
K+ 4.1 (anion gap = 8.6, within normal range therefore metabolic acidosis possibly not due to
Well I thought that was an interesting blood gas. The med reg didnt, and still wouldnt come to see the patient.
- I am a diabetes registrar. this is not DKA. I have patients to see in resus. Give her some morphine for the chest pain and what else do you want to do?
- I'm going to increase the rate of her IV fluids, increase her oxygen and put her on an insulin sliding scale and continue antiemetics and hopefully get you to see her then?
- Yes do that and I'll come at some point once I've seen the patients in resus.
- Er.. *click*
I was actually feeling uncharacteristically stressed at this point, more because of the reg's dismissive attitude than the patient's condition. Did the above and then was at a loss as to what to do next. Was just considering trying to find an SHO (who more than likely would have said we need the med reg, hence why I called the med reg in the first place) or a consultant when the med reg appeared. She asked the patient the exact same questions I had when I reviewed her an hour before (I know they need their own history but it was like she hadnt listened to anything I had told her) and said they would move her out of the discharge lounge to an acute bed again. Patient looked a little less sick than before so maybe I had done something right after all.
I know I'm 'only' an FY1, but I'm not an idiot and I wouldnt ask for senior help unless I'm feeling out of my depth, which I was. Generally the seniors are very supportive, and this experience was an exception to the norm, and no harm came to the patient, which is the main thing.
So with nothing exciting to report I'll return to my last shift in MAU and reflect on a patient that actually managed to become really rather sick in the discharge bay. She was a type 1 diabetic who had come in with abdominal pain, nausea, vomiting and diarrhoea. She had been very stable and was just awaiting another speciality to review her before going home. However, she started vomiting late morning and had some more diarrhoea, her obs remained stable so I prescribed some antiemetics, checked her blood sugar (8.5) and routine bloods and decided to keep a close eye on her.
A couple of hours later the nurse called me to see her because she was having chest pain. I asked them to do an ECG which showed a sinus tachycardia at 130 with ST depression in the lateral leads. Patient at this point looked really very unwell and said she felt awful and she (and I) was worried she might be having a DKA (diabetic ketoacidosis, lack of insulin => production of ketones => these are acidic = bad). Put the patient on some oxygen and asked for a urine dip which had ketones in it, rechecked the blood sugar which was 17.5. Decided I needed a senior to be come and review before I took an ABG to check her pH (if acidotic with high blood sugar and ketones = DKA = bad).
Phoned the med reg who was spectacularly uninterested, wouldnt listen to my concerns and ordered me to take an ABG before bothering her again. reiterated that the patient looks Sick and that I was Worried about her but she hung up on me.
So I took an ABG and asked the nurses to repeat the ECG (still ST depression, probably rate related ischaemia).
pH 7.46 (slight alkalosis, definitely not an acidosis)
pCO2 3.58 (low therefore respiratory alkalosis, compensating metabolic acidosis? see base excess)
pO2 7.4 (low, need to increase oxygen)
BE -3.5 (negative base excess means there is a metabolic acidosis, likely lactate or ketones)
HCO3 21.4 (low bicarb, suggests compensating for metabolic acidosis)
O2 Sats 92.5
Lactate 1.2 (normal lactate therefore metabolic acidosis not due to this ?ketones)
Glucose 15.2
K+ 4.1 (anion gap = 8.6, within normal range therefore metabolic acidosis possibly not due to
Cl- 106 ketones which would cause a raised anion gap acidosis. ?due to diarrhoea which
Na+ 136 would cause a loss of bicarb.. hmm..)Well I thought that was an interesting blood gas. The med reg didnt, and still wouldnt come to see the patient.
- I am a diabetes registrar. this is not DKA. I have patients to see in resus. Give her some morphine for the chest pain and what else do you want to do?
- I'm going to increase the rate of her IV fluids, increase her oxygen and put her on an insulin sliding scale and continue antiemetics and hopefully get you to see her then?
- Yes do that and I'll come at some point once I've seen the patients in resus.
- Er.. *click*
I was actually feeling uncharacteristically stressed at this point, more because of the reg's dismissive attitude than the patient's condition. Did the above and then was at a loss as to what to do next. Was just considering trying to find an SHO (who more than likely would have said we need the med reg, hence why I called the med reg in the first place) or a consultant when the med reg appeared. She asked the patient the exact same questions I had when I reviewed her an hour before (I know they need their own history but it was like she hadnt listened to anything I had told her) and said they would move her out of the discharge lounge to an acute bed again. Patient looked a little less sick than before so maybe I had done something right after all.
I know I'm 'only' an FY1, but I'm not an idiot and I wouldnt ask for senior help unless I'm feeling out of my depth, which I was. Generally the seniors are very supportive, and this experience was an exception to the norm, and no harm came to the patient, which is the main thing.
Monday, 19 December 2011
Dr Doctor - overworked and underpaid..
I am so very tired. My last four shifts in MAU totalled 52 hours over the weekend. That's already more than the European Working Time Directive allows, in four days! Today I was straight back to the wards, and my next day off is Boxing Day, so I'll have worked 120 hours in 11 days without a day off.
I calculated I'm actually earning less than minimum wage if I divide my salary into hourly pay, and some of the agency nurses are paid more than me to sit and read magazines, drink tea (during their protected break times, a privilege not afforded to doctors) and occasionally do a drugs round.
I find this an interesting observation, especially when the government are gearing up to *ahem* 'amend' our pension schemes, making us pay a higher percentage for a lower return, while raising the retirement age to near 70. No wonder an increasing proportion of our junior doctors are choosing to disappear overseas to practise.
I calculated I'm actually earning less than minimum wage if I divide my salary into hourly pay, and some of the agency nurses are paid more than me to sit and read magazines, drink tea (during their protected break times, a privilege not afforded to doctors) and occasionally do a drugs round.
I find this an interesting observation, especially when the government are gearing up to *ahem* 'amend' our pension schemes, making us pay a higher percentage for a lower return, while raising the retirement age to near 70. No wonder an increasing proportion of our junior doctors are choosing to disappear overseas to practise.
Friday, 16 December 2011
Dr Doctor - last MAU days
Back after 3 days off to my last set of MAU day shifts. Very long day today, I wasnt assigned to a bay so floated between all of them, doing jobs and clerking an endless stream of patients with chest pain, PR bleeding, abdominal pain and jaundice, the ubiquitous collapse?cause and 'general unwellness'.
Clerked a dear old man earlier, thought he might be delirious so applied the Abbreviated Mental Test Score (AMTS) before taking the rest of the history (a consultant once advised me that if they score really badly - as in have no idea where/who/when/what they are - then the rest of the history can be a lot shorter as everything they say is likely to be inaccurate). One of the components of the AMTS is to remember an address. Most questions I asked this chap thereafter were answered with "42 West Street" and there came a delighted screech of "42 West Street!" whenever I approached or passed the bed.
Spent a significant amount of time trying to track down a covering letter for a GP admission which had arrived with a different patient's admission letter from a different GP surgery. Finally got on the phone to the correct surgery:
- Hello, this is one of the doctors calling from MAU at the hospital, hoping to speak to one of your doctors about one of your patients we've had admitted.
- Which GP is it?
- Dr Jones.
- He's dead.
- He's dead!?
- Yes, has been for several years.
- Er..
Wasn't expecting that one!
Clerked a dear old man earlier, thought he might be delirious so applied the Abbreviated Mental Test Score (AMTS) before taking the rest of the history (a consultant once advised me that if they score really badly - as in have no idea where/who/when/what they are - then the rest of the history can be a lot shorter as everything they say is likely to be inaccurate). One of the components of the AMTS is to remember an address. Most questions I asked this chap thereafter were answered with "42 West Street" and there came a delighted screech of "42 West Street!" whenever I approached or passed the bed.
Spent a significant amount of time trying to track down a covering letter for a GP admission which had arrived with a different patient's admission letter from a different GP surgery. Finally got on the phone to the correct surgery:
- Hello, this is one of the doctors calling from MAU at the hospital, hoping to speak to one of your doctors about one of your patients we've had admitted.
- Which GP is it?
- Dr Jones.
- He's dead.
- He's dead!?
- Yes, has been for several years.
- Er..
Wasn't expecting that one!
Tuesday, 13 December 2011
Dr Doctor - MAU Twilights 2
Finished another set of twilight shifts in MAU. One of the SHOs was off sick so I got to cover a bay of patients for two shifts. The first one I ended up with the 3 sickest patients in the unit, all of whom became unwell simultaneously!
The first was a little old lady with sepsis who kept dropping her blood pressure and needed gentle fluid boluses (she also had heart failure so didnt want to send her into pulmonary oedema). She actually remained fairly stable provided she was kept sat upright (the nurses kept putting the bed head "down a little bit to make you more comfy dear" and I kept finding her gasping and tripodding herself on the edge of the bed).
The second was a lady who had come in with confusion and was about GCS 13 on admission. When I went to see her she had dropped her GCS to 7 and wasn't moving one side of her body *Erk*. She was maintaining her airway however. Phoned the med reg who was doing a lumbar puncture so went to find a consultant who said he'd "be there in a minute". Returned to my bay to find some nurses flapping because another patient (admitted with chest pain, probable costochondritis but maybe a PE) was having chest pain again, and she looked very short of breath. *Erk* (15L O2 via non rebreathe mask, urgent ECG(no acute changes), send med student running with an ABG, send nurse to find an SHO, little to find on examination, tachycardic (me, and the patient), attempt to obtain IV access).
Consultant appears and doesnt look particularly interested in this gasping patient, disappears and pokes his head round the curtains 5 mins later to declare that my GCS 7 lady is actually GCS 13 again. Med student reappears with ABG which shows a respiratory alkalosis and a PO2 of 40 (oxygenating rather well then). Patient looks much less short of breath so turn down the oxygen to 35%. Patient says chest pain has gone away and she looks back to normal. Refer for 12 hour troponin and investigation for PE.
My last shift I had one interesting patient who at first was a bit of a mystery. She had come in with shortness of breath on a background of known congestive cardiac failure, with a metallic heart valve, on warfarin. She also suffered with ischaemic heart disease and was rather overweight. It transpired she had been rather tired for several weeks, and suffered with recurrent urinary tract infections for which she had had several courses of various antibiotics. No current urinary symptoms and her stools had been darker but no PR bleeding. No recent fevers or cough. There was little to find on examination, she looked a little pale and a little breathless, possibly had a slight systolic heart murmur (and a metallic click), she also had a slightly firm left calf from where she had a recent haematoma.
So my list of differentials was quite long, anaemia, PE, ACS, endocarditis (suggested by the A&E clerking although she had no peripheral stigmata of this), hypothyroidism.. so I sent a vast array of blood tests FBC, U&E, CRP, LFT, TFT, INR, blood cultures and did an ABG which showed decreased PO2 and an Hb of 6.1. Hmm. Should have sent a group and save. Discussed with the SHO who said wait for the lab blood results to confirm anaemia. Turned out she was indeed anaemic and was transfused overnight. The cause was GI bleeding because the antibiotics for her UTIs had interfered with her warfarin metabolism giving her an INR of 7!
The first was a little old lady with sepsis who kept dropping her blood pressure and needed gentle fluid boluses (she also had heart failure so didnt want to send her into pulmonary oedema). She actually remained fairly stable provided she was kept sat upright (the nurses kept putting the bed head "down a little bit to make you more comfy dear" and I kept finding her gasping and tripodding herself on the edge of the bed).
The second was a lady who had come in with confusion and was about GCS 13 on admission. When I went to see her she had dropped her GCS to 7 and wasn't moving one side of her body *Erk*. She was maintaining her airway however. Phoned the med reg who was doing a lumbar puncture so went to find a consultant who said he'd "be there in a minute". Returned to my bay to find some nurses flapping because another patient (admitted with chest pain, probable costochondritis but maybe a PE) was having chest pain again, and she looked very short of breath. *Erk* (15L O2 via non rebreathe mask, urgent ECG(no acute changes), send med student running with an ABG, send nurse to find an SHO, little to find on examination, tachycardic (me, and the patient), attempt to obtain IV access).
Consultant appears and doesnt look particularly interested in this gasping patient, disappears and pokes his head round the curtains 5 mins later to declare that my GCS 7 lady is actually GCS 13 again. Med student reappears with ABG which shows a respiratory alkalosis and a PO2 of 40 (oxygenating rather well then). Patient looks much less short of breath so turn down the oxygen to 35%. Patient says chest pain has gone away and she looks back to normal. Refer for 12 hour troponin and investigation for PE.
My last shift I had one interesting patient who at first was a bit of a mystery. She had come in with shortness of breath on a background of known congestive cardiac failure, with a metallic heart valve, on warfarin. She also suffered with ischaemic heart disease and was rather overweight. It transpired she had been rather tired for several weeks, and suffered with recurrent urinary tract infections for which she had had several courses of various antibiotics. No current urinary symptoms and her stools had been darker but no PR bleeding. No recent fevers or cough. There was little to find on examination, she looked a little pale and a little breathless, possibly had a slight systolic heart murmur (and a metallic click), she also had a slightly firm left calf from where she had a recent haematoma.
So my list of differentials was quite long, anaemia, PE, ACS, endocarditis (suggested by the A&E clerking although she had no peripheral stigmata of this), hypothyroidism.. so I sent a vast array of blood tests FBC, U&E, CRP, LFT, TFT, INR, blood cultures and did an ABG which showed decreased PO2 and an Hb of 6.1. Hmm. Should have sent a group and save. Discussed with the SHO who said wait for the lab blood results to confirm anaemia. Turned out she was indeed anaemic and was transfused overnight. The cause was GI bleeding because the antibiotics for her UTIs had interfered with her warfarin metabolism giving her an INR of 7!
Monday, 5 December 2011
Dr Doctor "CARDIAC ARREST"
One of the other perks of MAU Nights is that you carry the crash bleep. It only went off twice this weekend.
The night before last we had been sat drinking tea in the mess (I had seized the opportunity after my haematemesis man went to theatre) and had to run to the other side of the hospital (made considerably easier by the fact it was 330am and the corridors were empty). Arrived somewhat out of breath to find one of the surgical patients being subjected to CPR and the usual accompanying flurry of activity. She was in asystole and the ITU and medical registrars made the decision to stop fairly soon after we arrived. Later found out that she had been due to go to theatre for an emergency laparotomy to relieve a probable bowel obstruction but had been sent back to the ward because our haematemesis man was prioritised ahead of her. Chances are had she made it to theatre she would have arrested on induction or on the table and would have died anyway, but had mixed feelings about it.
Last night the crash bleep went off at 630am and I had to run all the way to the same surgical ward (up several flights of stairs). This time I was running on my own and received a few strange looks from porters and cleaners on the way. Arrived to find two nurses performing CPR with rather poor technique, and noted that the one holding the airway had the facemask on the patient upside down! Rectified this and popped in an oropharyngeal airway then took over chest compressions as the med reg arrived. Patient was in pulseless electrical activity and we managed to get a pulse back on him which was a good feeling. Dont know the outcome as I returned to MAU before he was taken for a scan/to ITU.
Sat down to update the handover list near the end of the shift, somewhat tired by this point, and the healthcare assistant (HCA) next to me who was labelling some swabs said:
- How do you spell 'froat'?
- 'Froat'? Do you mean throat?
- Yeah froat.
- Er.. T-H-R-O-A-T.
- Fanks.
The night before last we had been sat drinking tea in the mess (I had seized the opportunity after my haematemesis man went to theatre) and had to run to the other side of the hospital (made considerably easier by the fact it was 330am and the corridors were empty). Arrived somewhat out of breath to find one of the surgical patients being subjected to CPR and the usual accompanying flurry of activity. She was in asystole and the ITU and medical registrars made the decision to stop fairly soon after we arrived. Later found out that she had been due to go to theatre for an emergency laparotomy to relieve a probable bowel obstruction but had been sent back to the ward because our haematemesis man was prioritised ahead of her. Chances are had she made it to theatre she would have arrested on induction or on the table and would have died anyway, but had mixed feelings about it.
Last night the crash bleep went off at 630am and I had to run all the way to the same surgical ward (up several flights of stairs). This time I was running on my own and received a few strange looks from porters and cleaners on the way. Arrived to find two nurses performing CPR with rather poor technique, and noted that the one holding the airway had the facemask on the patient upside down! Rectified this and popped in an oropharyngeal airway then took over chest compressions as the med reg arrived. Patient was in pulseless electrical activity and we managed to get a pulse back on him which was a good feeling. Dont know the outcome as I returned to MAU before he was taken for a scan/to ITU.
Sat down to update the handover list near the end of the shift, somewhat tired by this point, and the healthcare assistant (HCA) next to me who was labelling some swabs said:
- How do you spell 'froat'?
- 'Froat'? Do you mean throat?
- Yeah froat.
- Er.. T-H-R-O-A-T.
- Fanks.
Sunday, 4 December 2011
Dr Doctor he's vomiting blood again!
Last night I only had one particularly sick patient to deal with. A 77 year old gentleman who had come in with GI bleeding with a background of angiodysplasia (abnormal bood vessels in the GI tract that are likely to bleed). His haemoglobin (Hb) was 7.3 on admission and his INR was 5.7 (he was on warfarin for a metallic heart valve). He had been cross matched four units for transfusions which we started running into him.
An hour or two later around 1am he had an episode of vomiting blood. His obs were all stable at this stage but he was a little anxious (which can be one of the first signs a patient is heading into shock) so I got further IV access just in case and made my SHO aware. An hour or so after that he vomited a rather larger amount of blood and dropped his systolic blood pressure to 80 with a heart rate of 128 - scary stuff! He looked really sick at this stage, was clammy, shaky and really anxious.
Put up 500ml of gelofusine stat and called the med reg. She asked me to ring blood bank to get four units of fresh frozen plasma (FFP) and cross match another 6 units of blood before she arrived. One of the other SHOs arrived put in another cannula and took a set of bloods. I ran to A&E with a venous blood gas which showed his Hb had dropped to 6.4. We started running in the FFP and blood stat while the med reg phoned the on call endoscopist and the on call anaesthetist and ITU.
The nurses rang the patient's family and while we were waiting for the patient to go to theatre he got to talk to them. It was quite heart rending to hear him saying his goodbyes as if it might be his last.
In theatre they found several bleeding sites including one of the abnormal vessels that was actively bleeding which they injected with adrenaline (for vasoconstriction) and cauterised. He had a further 7 units of blood in theatre and the rest of the FFP. By the time he came back to MAU around 5am he was much more stable, his repeat Hb was 9.7 and his INR had come down to 2.2.
We saved this man's life.
Saturday, 3 December 2011
Dr Doctor - MAU NIghts Again
Excellent night shift last night. Started off the shift with one patient on BiPAP (non-invasive ventilation) whose blood gas results got steadily worse to the point where the med reg sent him to Respiratory Highcare.
Barely had time to breathe before noticing that one gentleman who had come in short of breath had a rapidly rising heart rate and a rapidly falling blood pressure. He was being treated for a chest infection but his inflammatory markers werent raised and he was apyrexial. He did have a very bubbly sounding chest however. Called the med reg again and we gave him a bolus of fluid. Cue much coughing up of white frothy sputum and no improvement in blood presssure. So having given him pulmonary oedema, we gave him some furosemide and he promtly dropped his BP even further. By this time he had become very confused and just looked awfully sick. Med reg phoned ITU in the end and he was whisked away to a higher place of additional monitoring.
Didnt have time to feel sad about having two very broken patients less than halfway through the shift as the man in bed 18 decided to pick that moment to go into a convincing supraventricular tachycardia with a rate of 160. He had no chest pain or shortness of breath, and no signs of shock so he wasnt compromised. Decided to try some valsalva manoeuvres with him (this raises intrathoracic pressure which activates the vagus nerve, and the parasympathetic stimulation in theory should slow the heart rate). Found myself pondering whether anybody else in the world was spending their time encouraging a 44 year old tachycardic to blow into a syringe at 4 am. Probably just me. Carotid massage didnt work either so called the med reg and we gave some adenosine. The underlying rhythm was atrial flutter, and as he hadnt spontaneously reverted to sinus rhythm the med reg sent him to the Coronary Care Unit.
To add to the fun I also had a 33 year old type 1 diabetic chap admitted with a sodium of 112 (very low) and a potassium of 5.4 (a little high). He was feeling dreadful, nauseus, dizzy on standing and we wondered if he might have Addison's disease (steroid deficiency). ECG showed peaked T waves so I treated his hyperkalaemia with IV calcium gluconate and insulin (with 50% dextrose) and he went hypo! Cue hypostop and more IV glucose.
Regarding his possible Addisons disease, his cortisol came back at 143 (lowish but not diagnostically so). We gave him some dexamethasone, a strong steroid that wouldnt affect the results of the Short Synacthen test (cortisol challenge test) in the morning. He also needed lying/standing blood pressures, an ACTH level and paired serum/urine osmolalities which I handed over to the day team.
I think I might be slightly in love with the med reg after last night. There's a good chance neither I nor the patients would have made it through last night without her!
Barely had time to breathe before noticing that one gentleman who had come in short of breath had a rapidly rising heart rate and a rapidly falling blood pressure. He was being treated for a chest infection but his inflammatory markers werent raised and he was apyrexial. He did have a very bubbly sounding chest however. Called the med reg again and we gave him a bolus of fluid. Cue much coughing up of white frothy sputum and no improvement in blood presssure. So having given him pulmonary oedema, we gave him some furosemide and he promtly dropped his BP even further. By this time he had become very confused and just looked awfully sick. Med reg phoned ITU in the end and he was whisked away to a higher place of additional monitoring.
Didnt have time to feel sad about having two very broken patients less than halfway through the shift as the man in bed 18 decided to pick that moment to go into a convincing supraventricular tachycardia with a rate of 160. He had no chest pain or shortness of breath, and no signs of shock so he wasnt compromised. Decided to try some valsalva manoeuvres with him (this raises intrathoracic pressure which activates the vagus nerve, and the parasympathetic stimulation in theory should slow the heart rate). Found myself pondering whether anybody else in the world was spending their time encouraging a 44 year old tachycardic to blow into a syringe at 4 am. Probably just me. Carotid massage didnt work either so called the med reg and we gave some adenosine. The underlying rhythm was atrial flutter, and as he hadnt spontaneously reverted to sinus rhythm the med reg sent him to the Coronary Care Unit.
To add to the fun I also had a 33 year old type 1 diabetic chap admitted with a sodium of 112 (very low) and a potassium of 5.4 (a little high). He was feeling dreadful, nauseus, dizzy on standing and we wondered if he might have Addison's disease (steroid deficiency). ECG showed peaked T waves so I treated his hyperkalaemia with IV calcium gluconate and insulin (with 50% dextrose) and he went hypo! Cue hypostop and more IV glucose.
Regarding his possible Addisons disease, his cortisol came back at 143 (lowish but not diagnostically so). We gave him some dexamethasone, a strong steroid that wouldnt affect the results of the Short Synacthen test (cortisol challenge test) in the morning. He also needed lying/standing blood pressures, an ACTH level and paired serum/urine osmolalities which I handed over to the day team.
I think I might be slightly in love with the med reg after last night. There's a good chance neither I nor the patients would have made it through last night without her!
Thursday, 1 December 2011
Dr Doctor - MAU Twilights
So the twilight shift entails coming into work around 2pm and working all the way through until 10. You dont look after a particular bay of patients, but instead float between all the bays helping out where needed.
Yesterday it seemed that every patient I went to was elderly, deaf and confused in equal measures. I felt bad that I had to take my histories at shouting volume, which afforded little privacy for the patients.
- HOW ARE YOUR BOWELS, SIR?
- THEY'RE STILL THERE DOCTOR! [cue endearing toothless grin]
It seems this week I have looking particularly youthful. I have had not one, but two nurses ask me if I'm a student. One of them I'm sure did it just to patronise me (unfortunately a fair few of the MAU nurses are lacking a degree of professional respect, which diminishes further if you dare to ask them to do their job). The tally of patients/relatives commenting on how young I look has risen to 24 in the past four months. They often compare me to their grandchildren. I'm getting used to the look of surprise when I introduce myself as one of the doctors.
Pretty harsh MAU shift pattern at the moment, 3 twilights, 1 day off then onto nights over the weekend. Somehow I'm working every weekend in December, including Christmas and my birthday. Social life destroyed. Morale low.
Yesterday it seemed that every patient I went to was elderly, deaf and confused in equal measures. I felt bad that I had to take my histories at shouting volume, which afforded little privacy for the patients.
- HOW ARE YOUR BOWELS, SIR?
- THEY'RE STILL THERE DOCTOR! [cue endearing toothless grin]
It seems this week I have looking particularly youthful. I have had not one, but two nurses ask me if I'm a student. One of them I'm sure did it just to patronise me (unfortunately a fair few of the MAU nurses are lacking a degree of professional respect, which diminishes further if you dare to ask them to do their job). The tally of patients/relatives commenting on how young I look has risen to 24 in the past four months. They often compare me to their grandchildren. I'm getting used to the look of surprise when I introduce myself as one of the doctors.
Pretty harsh MAU shift pattern at the moment, 3 twilights, 1 day off then onto nights over the weekend. Somehow I'm working every weekend in December, including Christmas and my birthday. Social life destroyed. Morale low.
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