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!

Dr Doctor - MAU Nights 2

Currently spending the weekend recovering from MAU nights. At least I think it's the weekend, have been genuinely unsure of what day it is for some time now. Have decided one benefit of living on hospital grounds is the 30 second commute to work, but you do have to sleep through the noise of all the wailing ambulances during the day.

The last three nights have gone fairly well, with good variety of patients. Some of the most interesting included a gentleman in post renal renal failure with a urea of 50 and creatinine of 2550 (catheterise, IV fluids to match urine output plus 50mls to counteract post obstruction diuresis) whose creatinine had resolved to 250 by the end of the night. Another chap had come in via A&E with chest pain and been treated as an acute coronary syndrome despite no ECG changes. He was anaemic with a haemoglobin of 6.9 (further questioning revealed he had been GI bleeding for a couple of weeks) and actually had anaemia related myocardial ischaemia (stop antiplatelet meds and clexane, X match, transfuse, OGD).

The last night saw my bay turned into a secure unit - two known violent psych patients both admitted with shortness of breath, one from a forensic unit with two reassuringly large psych nurses guarding him was for male only  nursing and doctoring due to his tendency to attack women. He was actually no trouble, but the other one caused issues demanding oxycodone in the middle of the night on top of his tramadol and co-codamol. Given that he had been admitted significantly hypoxic with a blood gas that showed a PO2 of 8 and type 2 respiratory failure I wasnt about to administer any more opiates no matter how loudly he yelled at me (because they can cause respiratory depression and oxycodone and tramadol are both quite strong anyway). The cynic in me wasnt convinced that he was truely in pain, or at least not the sort that would be aided by drugs - "where does it hurt sir?" "all over my body doctor" ..as he sat looking comfortable at rest. 

The patient wasnt taking no for an answer from me so in the end I went to find the biggest SHO I could and got him to talk him down. Was quite reassured when he completely backed me up, explaining to the patient that I was doing the safe thing by not giving him the oxycodone and managed to calm him down.

Further 3am tutorials on liver disease from World's Most Enthusiastic Med Reg were made bearable by tea and cake, and we all made it through our final morning handover, me with three sick respiratory patients to present to a slightly grumpy highly seasoned respiratory consultant, and retired to bed delighted to have finished nights.