So all this week I'm working the 1630-2300 shift covering two surgical wards with a mixture of upper GI, colorectal and vascular patients plus the Surgical High Dependency Unit (SHDU). Trouble is, the nurses do an obs round at 2200 so I get a flood of bleeps about potentially sick patients all of whom need reviewing so it has been impossible to leave on time.
Monday night I found myself literally juggling four sick patients on one ward. Having been bleeped about two of them, one with post op hypotension and another with low urine output, I turned up on the ward to have two more sets of obs shoved under my nose by nurses with typically foreign disregard for my current state of busyness "Doctor this patient has a resp rate of 44." "Doctor this patient is having tachycardia."
Deep breath. I decided to do an "end of the bed test" on the four patients, decide which looked sickest and start with them.
The chap with a high resp rate I had actually reviewed earlier on having looked at his chest xray which had been handed over to me by the day team to check. I couldnt decide if he had a pneumonia from just looking at the xray so had listened to his chest and thought it was clear earlier. Looking at him now he looked very short of breath and quite unwell so I reviewed him again and thought there were probably a few crackles and reduced air entry on one side, but he was wheezy on the other side. He didnt look fluid overloaded. Plan - ABG, oxygen, senior r/v. Although his ABG result wasnt terrible he actually ended up going to the SHDU.
I had had a handover from the anaesthetist about the post op hypotension chap, who had said if he remained hypotensive to do an ECG to exclude a cardiac cause, and not to give any more fluids as he was at risk of fluid overload. He looked pretty stable with a systolic BP of 88 so I asked the nurses to do an ECG on him and on the tachycardic lady while I reviewed the low urine output patient who looked more sick.
She was apyrexial, her BP was stable with a systolic of 120 and her heart rate was 90. Her inflammatory markers werent raised so I thought it unlikely that she was septic. She looked quite dehydrated and said she was thirsty although hadn't been drinking much. She had had a right hemicolectomy and an ileostomy so I checked her drain outputs and stoma output which werent particularly large. I asked the nurses to flush the catheter, started her on IV fluids and returned to review the ECGs on my other patients.
The tachycardic lady was in sinus tachycardia with a rate around 120. Looking at her obs she had been tachycardic for about 4 hours but her blood pressure was stable at 125 systolic. On examination I thought she was very dehydrated, with a very dry sore looking tongue. I decided to give her a fluid bolus, 250ml normal saline stat and see what that did to her heart rate. She did have some bibasal crackles in the chest which always makes me worry about pulmonary oedema but her JVP wasnt raised and she wasnt particularly oedematous so I thought the chances of me overloading her were low, and the crackles were probably due to post op atelectasis (basal lung collapse, common after abdominal surgery).
While that was running I went to look at the hypotensive chap who still looked very well, his obs were all otherwise stable and he wasnt on any massive doses of antihypertensive meds. His ECG was normal. I asked the nurses to raise his legs and call a doctor if his BP went below 85 systolic.
Back to the tachycardic lady. Her heart rate had come down to 105. I gave another fluid bolus and it came down to 94. Reassuringly it seemed I had made the correct diagnosis. Had another quick listen to her chest to check the crackles hadnt got any worse (they hadnt) and by now it was midnight so I handed her over to the night team and headed for home.
I didnt get a chance to have a break for dinner and was starving. I must have looked somewhat forlorn leaving the hospital tiredly munching on a sandwich.
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