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!
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