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!

Dr Doctor you're on call.

So it's back to the wards, and I've been thrown back in on the late shift on call. This entails starting at 1430 with my usual ward team, then attending a 1630 handover from the elderly care wards and the medical wards about sick patients and jobs that the day team havent managed to do, picking up the on call bleep and waiting for it to go off. After 1800 the day team have mostly gone so the elderly care wards are looked after by the F1 (me) and two SHOs.

First job, believe it or not, was to do a PR examination on one of the new patients who had a falling haemoglobin level to check that he didnt have any malaena (altered blood in the stools) that might indicate GI bleeding before giving him high dose aspirin. Now my experience of PR examination from medical school is limited to one hour in the clinical skills lab with a plastic model arse, the rubberised arse section of which got stuck on my finger and came off when I tried to withdraw, resulting in the prostate falling out and bouncing around the room. My only previous attempt on a patient ended rather messily with a proctoscope being farted vigorously back out at me (the patient was quite unharmed I can assure you).  So of course I didnt quite relish the idea of performing this procedure on the dear little old man in front of me. Despite having never met him before I had to gain his trust, gain his consent, put him at ease and perform the procedure competently and professionally.

My tips - make sure the patient is fully informed about the procedure and why it needs to be done (not only does this build rapport but is a legal necessity), take a nurse to chaperone, talk through what you're doing, be quick but thorough, and for heaven's sake double glove (take the first glove off when you withdraw so that you can clean the patient with a clean gloved hand). Document everything in the notes afterwards, especially that you gained consent, who the chaperone was, and your examination findings.

Other jobs included reviewing an outlying patient on warfarin with an INR of 5.0 (this means she's over-anticoagulated and the warfarin dose needs changing). I went to see her, asked if she had noticed any bleeding from anywhere, examined her and changed the dose according to Trust Guidelines.

I also had to review a couple of x-rays and a heap of bloods (normally this is done by the day team but thanks to the phlebotomists not bleeding the patients on some of the wards till 1600 none of the results were back. I found only one interesting result - a sodium level that had dropped overnight from 133 (normalish) to 126. The patient was well and not confused, and none of the medications she'd been started on recently could have caused the drop so I wrote the results in her notes with a plan to repeat the sodium next day.

Handed over to the night team at 2200, fairly uneventful shift.