Late shifts on call again this week, and the last two have been a combination of marathon running, fire fighting, patient bleeding, nurse dodging and cardiology registrar disgruntling.
Number of bleeps - innumerable.
Number of flights of stairs traversed at speed - 20
Number of patients spiking temperatures requiring septic screens - 8
Number of times had to run to a different ward to find equipment for taking blood cultures - 4
Number of bloods needing checking according to afternoon handover - 12
Number of bloods handed to me to do by slightly slacking SHO - 3
Number of deranged U&E results requiring action - 2
Number of INR needing checked and warfarin prescribing - 5
Number of bloods needing repeating due to underfilled/haemolysed/lost/mislabelled - 3
Number of cannulas inserted - 3
Number of radiological investigations needing review - 5
Number of patients falling off their perches - 3
Number of times accosted by marauding nurses brandishing drugs charts/incomplete sets of obs - 7
Number of minutes spent in doctors' mess inhaling sandwich and cup of tea - 15
Number of minutes spent regretting such indulgence - 0 (no time!)
Helpfully, one patient decided to fall off their perch around 9pm, 1 hour before handover to the night team. They needed to be examined, septic screened (bloods, blood cultures, CXR, urine dip, microscopy&culture), writing up for antibiotics based on my examination findings (focus of infection probably chest), a cannula inserting and fluids prescribing, handover to nursing staff and handover at handover. In my haste to get on and determine that he was septic and instigate the septic screen and some treatment before handover I didnt have time to look through the notes to determine why he was in hospital or his past medical history or whether he was for resus. My handover to the night SHO as a result was somewhat incomplete, which drew much criticism from the night cardiology registrar (cleverly masked behind the phrase "I'm not criticising..") and much cringing from me who should have done better.
Showing posts with label On Call. Show all posts
Showing posts with label On Call. Show all posts
Tuesday, 4 October 2011
Saturday, 17 September 2011
Dr Doctor, the patient has fallen, and is unable to get up.
Just finished my second of three weekend late on-call shifts. This evening has been eventful. Firstly, weekends on call are generally a lot busier than weekdays on call because there are fewer staff on at the weekend so jobs get done later and there are usually more to hand over. So at the beginning of the shift I had a long list of things to do which required some prioritisation. A few of the jobs were things like checking blood levels of drugs such as digoxin and gentamicin, which have to be done at a certain time, others included a mountain of cannulas, a few bloods to take and check and a couple of drugs charts to be re-written.
I was busy attempting to take blood from one chap for a digoxin level, when I noticed the chap in the bed next to him stand up somewhat unsteadily. Now if patients are prone to falls, they often have a falls alarm attached to them and to the chair/bed so that if they try to stand up a siren gets activated and a nurse comes to tell them to sit back down. No such alarm sounded as this gent stood up so I carried on with my attempts to get blood. A split second later and the standing chap turns around and topples forward, landing on his face with a truly awful thud, and then the falls alarm sounds. Sirens wailing, I leapt to the gentleman's side, poor thing had sustained a rather large scalp laceration and was hosing blood all over the floor, flailing gently on his back and looking confused. Thankfully an army of nurses appeared and together we applied compression to the wound and hoisted him back into bed. I checked over the rest of him - no apparent C-spine tenderness, no bony tenderness over the hips or long bones. No blood coming from the ears. Checked his drug chart to see if he was on warfarin (he wasn't)
- warfarin + head injury = CT Scan. Instructed nurses to start regular neuro obs and bleeped my SHO for an opinion on whether to glue, steri-strip or suture the wound. We glued him back together and all was well. Went back and obtained somewhat delayed digoxin level.
Next job was to certify a death. On examination.. patient looks dead. Actually she kind of looked asleep, but very blue around the edges. I listened for heart sounds and breath sounds, felt for a central pulse, checked pupillary reflexes and response to supraorbital pressure, none of which were present (thank goodness otherwise this may have confused the issue). Told the patient/body to Rest in Peace as I was leaving and felt a little silly. Documented my examination in the notes plus time of death, the absence of a pacemaker and Rest in Peace. Felt a little sad.
Next job was to work out how to hide from nurses on the ward waiting to pounce with additional jobs for me to do, while continuing to carry out the jobs on the ward I already needed to do. Failed, and picked up a review of a patient with high blood sugars (around 27, normal being roughly 3-7). Reason for admission of this patient was.. high blood sugars. Chances of me, the inexperienced FY1, managing to single handedly regulate this patient's blood sugars over the course of one on call shift were slim. Also, I find prescribing insulin a little scary. It's a dangerous drug and can certainly kill people in overdose. There are many many different preparations, all with different durations of action, and I really wasn't quite sure what to do. Cue time spent with the BNF (drug book) and a phone call to my SHO for advice. We settled on a small stat dose of 4 units of Actrapid (short acting insulin) alongside her regular intermediate acting insulin.
Managed to escape the Elderly Care nurses to take blood from an outlying patient near the end of the shift. As most NHS hospitals tend to be on "black alert" due to a shortage of beds, some of the less sick patients from one department can end up seemingly in any other part of the hospital. This chap for example, was parked in Urology. I found another chap in Obs and Gynae on yesterday's shift! I'm not sure what happens after black alert.. must be brown alert!
I was busy attempting to take blood from one chap for a digoxin level, when I noticed the chap in the bed next to him stand up somewhat unsteadily. Now if patients are prone to falls, they often have a falls alarm attached to them and to the chair/bed so that if they try to stand up a siren gets activated and a nurse comes to tell them to sit back down. No such alarm sounded as this gent stood up so I carried on with my attempts to get blood. A split second later and the standing chap turns around and topples forward, landing on his face with a truly awful thud, and then the falls alarm sounds. Sirens wailing, I leapt to the gentleman's side, poor thing had sustained a rather large scalp laceration and was hosing blood all over the floor, flailing gently on his back and looking confused. Thankfully an army of nurses appeared and together we applied compression to the wound and hoisted him back into bed. I checked over the rest of him - no apparent C-spine tenderness, no bony tenderness over the hips or long bones. No blood coming from the ears. Checked his drug chart to see if he was on warfarin (he wasn't)
- warfarin + head injury = CT Scan. Instructed nurses to start regular neuro obs and bleeped my SHO for an opinion on whether to glue, steri-strip or suture the wound. We glued him back together and all was well. Went back and obtained somewhat delayed digoxin level.
Next job was to certify a death. On examination.. patient looks dead. Actually she kind of looked asleep, but very blue around the edges. I listened for heart sounds and breath sounds, felt for a central pulse, checked pupillary reflexes and response to supraorbital pressure, none of which were present (thank goodness otherwise this may have confused the issue). Told the patient/body to Rest in Peace as I was leaving and felt a little silly. Documented my examination in the notes plus time of death, the absence of a pacemaker and Rest in Peace. Felt a little sad.
Next job was to work out how to hide from nurses on the ward waiting to pounce with additional jobs for me to do, while continuing to carry out the jobs on the ward I already needed to do. Failed, and picked up a review of a patient with high blood sugars (around 27, normal being roughly 3-7). Reason for admission of this patient was.. high blood sugars. Chances of me, the inexperienced FY1, managing to single handedly regulate this patient's blood sugars over the course of one on call shift were slim. Also, I find prescribing insulin a little scary. It's a dangerous drug and can certainly kill people in overdose. There are many many different preparations, all with different durations of action, and I really wasn't quite sure what to do. Cue time spent with the BNF (drug book) and a phone call to my SHO for advice. We settled on a small stat dose of 4 units of Actrapid (short acting insulin) alongside her regular intermediate acting insulin.
Managed to escape the Elderly Care nurses to take blood from an outlying patient near the end of the shift. As most NHS hospitals tend to be on "black alert" due to a shortage of beds, some of the less sick patients from one department can end up seemingly in any other part of the hospital. This chap for example, was parked in Urology. I found another chap in Obs and Gynae on yesterday's shift! I'm not sure what happens after black alert.. must be brown alert!
Friday, 9 September 2011
Dr Doctor by the way, the patient looks moribund..
Last evening on call and I get completely swamped with jobs from the very start. All the small jobs like reviewing bloods, taking outstanding bloods and checking chest x-rays etc get handed over to the F1 and not to the SHOs because people dont want to bother the SHOs with them. Add to this three new stroke patients to clerk, one catheter to replace, one patient that had fallen out of bed and an abundance of warfarin doses to review the INR and change accordingly, and I was running around like a mad thing, hiding under the desks of the nurses stations on each ward to avoid nurses with yet more fluid charts to fill out.
In the midst of the never ending bleeps came a call from one of the matrons.
- Hello doctor, just checked this lady's bloods and her sodium is 166 [very high].
- Have you got her current obs?
- No, but she looks moribund.
- Er.. I'll come and see her, please start a set of obs and I'll be there.
I figured that matrons by definition have a wealth of experience behind them, and despite the slightly pants referral, if matron says patient looks near death the patient may well need looking at. When I arrived a suitably helpful nurse was halfway through taking the obs and the patient looked sick. Perhaps not moribund, but sick and lying slumped down in bed. She was relatively unresponsive with a GCS around 7 [eek, this could become an airway problem] her pulse was 100, BP 115/80, cap refill 4 secs, apyrexial, RR 30 sats 84% on 2L oxygen [EEK, instructed nurse to please immediately fetch another venturi mask to up her oxygen to 35%] and her chest sounded full of fluid.
So I got her sat up in bed to make it easier for her to breathe, left her on the oxygen (sats were improving to around 94% by now and her GCS came up to around 11 with her being a bit less hypoxic) and rang my SHO who came to see her. Rechecked her bloods, sodium was indeed 166 up from 155 a couple of days before, and on reviewing her fluids chart noticed she hadnt been given any of the fluids she'd been prescribed for the past four days!? Probably why her sodium was so high - she was very dry. Prescribed some Haartman's solution to run in over 10 hours, could have gone for dextrose but after discussing with the seniors we didnt want to correct the sodium level by rehydrating too quickly because this can cause cerebral oedema. Once she was stable the SHO insisted we go for a cup of tea in the doctors mess and divide up the jobs I had left, thank goodness!
I heard the night team diagnosed simultaneous pulmonary oedema (waterlogged lungs) and intravascular depletion (empty circulation) which led them to treat her paradoxically with frusemide (a diuretic that makes wee out more fluid but is also acts in other ways to reduce pulmonary oedema) and fluids to try to get the fluid off her lungs and into her circulation.
In the midst of the never ending bleeps came a call from one of the matrons.
- Hello doctor, just checked this lady's bloods and her sodium is 166 [very high].
- Have you got her current obs?
- No, but she looks moribund.
- Er.. I'll come and see her, please start a set of obs and I'll be there.
I figured that matrons by definition have a wealth of experience behind them, and despite the slightly pants referral, if matron says patient looks near death the patient may well need looking at. When I arrived a suitably helpful nurse was halfway through taking the obs and the patient looked sick. Perhaps not moribund, but sick and lying slumped down in bed. She was relatively unresponsive with a GCS around 7 [eek, this could become an airway problem] her pulse was 100, BP 115/80, cap refill 4 secs, apyrexial, RR 30 sats 84% on 2L oxygen [EEK, instructed nurse to please immediately fetch another venturi mask to up her oxygen to 35%] and her chest sounded full of fluid.
So I got her sat up in bed to make it easier for her to breathe, left her on the oxygen (sats were improving to around 94% by now and her GCS came up to around 11 with her being a bit less hypoxic) and rang my SHO who came to see her. Rechecked her bloods, sodium was indeed 166 up from 155 a couple of days before, and on reviewing her fluids chart noticed she hadnt been given any of the fluids she'd been prescribed for the past four days!? Probably why her sodium was so high - she was very dry. Prescribed some Haartman's solution to run in over 10 hours, could have gone for dextrose but after discussing with the seniors we didnt want to correct the sodium level by rehydrating too quickly because this can cause cerebral oedema. Once she was stable the SHO insisted we go for a cup of tea in the doctors mess and divide up the jobs I had left, thank goodness!
I heard the night team diagnosed simultaneous pulmonary oedema (waterlogged lungs) and intravascular depletion (empty circulation) which led them to treat her paradoxically with frusemide (a diuretic that makes wee out more fluid but is also acts in other ways to reduce pulmonary oedema) and fluids to try to get the fluid off her lungs and into her circulation.
Tuesday, 6 September 2011
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.
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.
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