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.
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