Cover Shifts Dr Haoming Zhuo - PowerPoint Presentation

1. Cover ShiftsDr Haoming Zhuo6th February 2020Thank you to Dr E Holbeach for providing the slides

2. Learning objectivesHow to manage common cover shift requestsStrategies to be kind to yourself and othersKey times to escalate for senior helpEvaluations:i-phone – just point cameraAndroid – use QR reader appOr use this link:https://forms.gle/DyvjizaEdGy4v8rS7

3. 1. Asking for help is probably the most important thing a junior doctor must learn2. If the patient looks unwell, do an ABG3. Finish the job4. An incorrect initial diagnosis may be copied5. Be nice and have the odd break6. DRUGS & ALLERGIES and DRUGS & ALLERGIES 7. Take a proper social history8. Completed referrals clinch diagnoses9. "Listen to the patient, he is telling you the diagnosis“ William Osler10. Quick brief effective communication is a skill PS have you looked at the observations?http://acutemed.co.uk/v/Thirty+Top+Tips

4. 23. Relationships with Colleagues (some say the hardest part of being a doctor!)Don't play professional games. It's not a competition and it's not about you. Bite your lip. Be straight and be fair. Show respect to colleagues, at whatever level; and they might be the same with you. All of this is true for your relationship with nurses (and porters, cleaners, everyone). Medicine is a small world, don't burn your bridges. If you annoy that colleague today, they may remember this when you meet next time, and he/she is interviewing you, for the job you really want. Reputations stickDo NOT be arrogant, do NOT presume, ALWAYS show respect- to EVERYONE, including yourself.http://acutemed.co.uk/v/Thirty+Top+Tips

5. OKAY… here we go…..

6. Case 1Page: “pls r’v Mrs Wada UnM bed 9. febrile. X29034”What other information would you like?

7. More info:67yo maleSmall cell lung cancer- Rx- chemotherapyAdmitted with vomitingPHX: IHD, OAMeds: dexamethasone 4mg D, omeprazole 40mg, maxalon 10mg QID, Ondansetron 4mg BD What differential diagnoses come to mind?

8. Thoughts?When was chemo?Last Neutrophil count?Other focal signs?Other investigations?

9. neutrophils 0.1, temp 38 degrees= FEBRILE NEUTROPENIA!!!

10. If temp 37.6 and neutrophils 0.1?

11. Febrile neutropenia definitionDefinition:Neutropenia: N/phil <0.5 x109 Or N’phil <1.0 x109 and have had cytotoxic/ anticancer chemo in last 4 weeksFever:Temp >38.3 degreesTemp>38.0 for 1hrAt risk group:CVAD (PICC, CVCs and vas caths)Cytotoxics and Chemotherapy agents

12. Management? PROMPT!EMPIRIC ANTIBIOTICS... When?ISOLATE!Assessment:History:Especially- timing of last chemo, recent proceduresObs- frequency?Examination: FULL?PR for prostatitis?Investigations:Notify Registrar on call- immediately.

13. Investigations:BCultures:1-2 x Peripheral set (2 if no CVAD)1x EACH lumen of central venous access (CVAD)LABEL b.culture bottles as to where it was from!within 30mins of fever/ presentationIF PATIENT REMAINS FEBRILE:Take an additional triple set of cultures for each of the next TWO febrile episodes.Daily blood cultures until afebrile for 48hrs

14. Investigations:MSU: (?in-out catheter?)Bloods: FBE, UEC, LFT, CRPCXRSputum for MCSFaecal MCS+ CDT if diarrhoeaWound, catheter, CVAD swabNose/ throat swab PCR if indicated

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18. What if….Admitted yesterday, started antibioticsOn Tazocin 4.5mg QIDHas just spiked temp 38.4degrees at 5:05pm on your cover shift.Clinically- haemodynamically stable. Nil focal signs

19. What do you do?Investigations?Antibiotics?Call anyone?

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21. What antibiotic dosing if….eGFR 27eGFR 8eGFR 52BM(?body mass?) = weight in kgEg: age 67. Creat 150. weight 45: CrCl 27 eGFR 41 weight 80: CrCl 48 eGFR 41

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24. What if...Also constipated?PR?Enema?also nauseated?IM Maxalon?

25. Case 2Page 2am “pls review Mrs G, post fall”What to do?What other information would you like?

26. FallsI know you know this…. But quick recap!What to NOT miss:Cardiac cause of syncope (VT, CHB, PE)Get an ECG!Acute Hypovolaemia causing collapse:AAA rupture, GI Bleed, SepsisInjuries:HeadSpineLimb

27. DOCUMENTATION: ALL falls will be riskman’d- your notes will be reviewed.What do document:What happened Eg- “Staff report pt found on floor beside bed, sitting on bottom no obvious distress, no witness, pt unable to give history”History+/- presyncopal/ syncopal symptoms/ ?LOC/ CAN’T tell!?How they landed- positionAny painExamination:Neuro- brief: GCS, pupils, confusion/ not confused, U/L power, plantarsIf clear head strike, full motor neuro exam please!Look for evidence of head injury on scalp. Document.Musculoskeletal:HIPS?!– internal/ ext rotation of both hipsExamine anywhere that has painLOOK AT BUTTOCKS- often haematomas missed!

28. Investigation:ECG if collapse/ syncope/ presyncope/ unwitnessed.Bloods if concern about sepsis/ arrhythmia etc.CTB? PROMPT- “head injury”:When to CTB with head strikeFull anticoagulation/ coagulopathic. Consdier if on antiplatelet therapy- esp if dual.Focal neurologyDecreased GCS New Seizure new (especially if prolonged, focal or delayed. Less concerning is the brief generalised seizure immediately following head injury.)Severe or persistent headacheHigher impact fall- (eg: was standing on the bed rails, with the bed all the way up, and head dived into the ground!) in which case- do a c-spine!Consider/ low threshold for CTB if:Over 65yoNormally confused, unable to give historyDifficult neuro assessment- so hard to do regular obsLarge haematoma or lacerationHOWEVERSedation for CTB after hours needs to be balanced with benefitsAlways consider- what will you do if there is an ICH?nothing versus stop anticoagulation versus neurosurgery candidateAlways discuss these considerations with family when you make the decision.ALSWAYS CONSIDER CT C-spine at same time as CTB if Head InjuryEspecially if elderlyEspecially if unable to communicate properly/ confusedNeuro-obs without CTB is often appropriate.For head strike/ unwitnessed:15minutely for one hour30minutely for next hourHourly for 4 hours.

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31. Document planIf arranging CTBDocument plan for neuro obs. Notify if deteriorating.If worried about bones/ joints-Document weight bearing status NON WEIGHT BEAR until XRay reviewed! (and tell patient!)Other:Unit to review meds in am ?review benzodiazepine doseAnticoagulation planHigh visibility roomFalls alarmLow-low bed with Crash mat beside bedNursing ‘Special’ for high risk fallersHANDOVER ALL HEAD STRIKES TO DAY TEAM as allows them to accurately triage if they get a page to say patient drowsy!

32. Mrs P, 87 beign treated for pneumonia. fall on wardOn Apixiban for AF, CVA last year. Nil other PHxFallPlan?

33. Case 311pm Page “ critical result: Mrs W’s Ca++ 3.8”What other information would you like?What are some differentials for hypercalcaemia?

34. HypercalcaemiaCauses?Cancer Boney Mets, PTHrpMyelomaHyperPTH (1,2,3)Others:immobilitymilk-alkali syndromeVitamin D toxicityPost rhabdomyolysisSarcoidMany othersConcerns?Moans, Groans, Stones, BonesTreatment?

35. Mrs W:86 yo admitted post fall with sore hip. Xray- no fracture. ‘Failed’ physio in ED. Admitted for analgesia and physio, possibly needs GEM.Phx: HT, OsteoporosisMeds: Perindopril 5mg D, HCT 12.5mg D, Aspirin 100mg, Atorvastatin 50mg nocte, Calcitriol 25mcg D, Ostelin i D, Protos 2g D, Caltrate i DYou review:Ca++ 3.8 (adjusted)Clinical: Some constipation, mild confusion. Otherwise wellWhat else on examination?Fluid assessment

36. Management?Cover shift:IVT to rehydrate - How much?A LOT!4-6L over first 24 hours is reasonableFluid review regularly if risk heart failure (she’s old- so review frequently!)Send off bloods- which ones?!PTH, VitD, SEPG, FLC, ESR. BJPNo Need to send off PTHrp in first round of investigations- as more likely one of the above. Unless they have a lovely big mass on CXR!Anything else?CEASE- CALTRATE! CEASE- CALCITRIOL! WITHOLD- OSTELIN?StrontiumRepeat Ca++ in amHandover!!Day shift:Continue to Hydrate.They will further investigate:With what?Bone scan, chase above bloods. Then further fishing if needed! Bisphosphonate (pamidronate 60-90mg over 4/24)Salmon calcitonin (faster acting, can be used in combination with pamidronate) Speak to Endo.

37. Case 4“ critical result K+7.2”I know you know this….But lets refresh!

38. Management:ECGIf nasty ECG changes (ie- anything more than peak T waves):CaGluconate/ CaChlorideInsulin/Dextrose (how much?)ResoniumNOTIFY SOMEONE!When to recheck K+?Anything else?VBG!If no ECG changes:Insulin/ dextroseResonium

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42. What if…On Digoxin 125mcg/day and ARI?Admitted today with hypotension, still hypotensive, BSL 2.8 not a diabeticpH 7.09On dialysis

43. Case 59:10pm page: “Please review Mg G with eyes rolled back”What do you do?What other information would you like?

44. Seizure acute management:MET call! Lateral decubitus and protect patient with pillows etcO2 and Yankaur sucker readyCheck BSLPulse oximeter if possibleHigh flow O2 if possibleMedications?

45. MOST seizure self limiting and will resolve in 1-2 mins. Time it!If not resolving (ie- going for more than 5 minutes):IV access:Clonazepam 1mg (0.5mg/minute) repeat x1 after 15minsMidazolam 2.5-10mg repeat x1 after 15minsNo IV accessClonazepam 1mg SCMidazolam 5mg bucally (squirt into side of mouth!)Midazolam 5mg SC If still not resolving, then it gets interesting!options (most definitely a MET call, if they went away, call them back!)Infusions of clonaz/ midaz/ propofol/ phenobarb= ICU!Get IV access x2 (not easy if GTCS)Phenytoin load 15mg/kg IV

46. After seizure resolution…What to do?Patient immediate managementHistoryExaminationInvestigationFollow up

47. Fail to wake up?What to consider:Cx of the seizure: Hypoxia, BSLs, Hypotension, hyperpyrexia, cerebral oedema, lactic acidosis, iatrogenic oversedationProgression of disease: menigitis/ enceph, CVA/ ICH, cerebral hypoxia, drug toxicity Unrecognised continuing statusNon convulsive status

48. PseudoseizuresCAN BE REALLY REALLY HARD TO TELL APARTClues (remember none of these are sufficiently sensitive or specific )Eyes held tightly shut. cryingSide-to-side head turningAsynchronous movementsPelvic thrustingAvoidance behaviour in response to noxious stimuli-tickle nose with cotton wool. Corneal reflex. Drop hand above head and see it falls stright down versus away from head?Absent post ictal confusion. Recall of event

49. If pregnantLEFT LATERAL POSITION!! Why?Check BP, look for oedemaCheck for proteinuriaCALL O+G!Different drugs if preecclampsiaMagnesium IVGet the baby out

50. POINTERS:Sleeping tabletsAntipsychoticsInsulin regimesT1 vs T2

51. ECGs

52. Chest Pain!

53. Prompt guideline: chest painCan give total x3 ½ anginine over 15mins. Aim PAIN FREE. If not, give morphine (2.5mg s/c, or 2mg IV)

54. Prompt guidelines Chest Pain

55. Order ECG/ anginine over the phone if not given alreadyCome and assess patient.1. Look at ECG, compare with old (if STs up code STEMI)2. Take brief initial history- if sounds cardiac and not resolved, start getting IV access, call for help (reg/ MET) and continue taking more history. Ask for more anginine if still has pain and BP>903. Take bloods when you put in cannula: Trop, CK, FBE, Coags, UEC (+/- G+H if possible bleeding) if not sure if cardiac, may also do lipase/ LFTs/ CRP4. others:CXR (portable), +/- ABG5. if CP not resolving MET call, cardiology involvemetn6. if CP resolvedREPEAT ECG- really really helpful to have a pain free ECG to compare- looking for “dynamic” changesChase C.Enzymes. May arrange repeat c. enzymes and HAND OVER to have results followed up with plan: ie- if more than ‘x’, will need anticoagulation. Clarify this plan with your reg before you goMed reg to make follow up plan/ review meds etc/ decide on telemetry etc

56. Angina/AMIImportant point:If the history is consistent with an AMI, you don’t need to wait for troponin elevation to get the patient to CCU/ refer to cardiology

57. ECGs- ISCHAEMIAST elevationST depression (down sloping or horizontal)TWI (T wave inversion) or Twave FlatteningWhich leads is it normal to have TWI?leads III, aVR and V1.Others: - Hyperacute T-waves (eg-flip to positive) - new BBB

58. The following ECGs are all care of Life In The Fast Lane (LITFL) online ECG library, part of FOAMed movement…Highly recommend!!

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67. Other causes of chest painGastritis/ GORD – features from historyTreatment

68. Other causes of chest painGastritis/ GORD – features from history-burning epigastric pain, can radiate upwards into the chest, related to meals etc.Treatment Try mylanta 20ml stat or gastrogel 20ml stat with panadol 2 tablets stat. Pinkmix/ Pink lady (mylanta/gastrogel + lidocaine) 20mL statDOCUMENT if effective! Can be diagnostic if not sure if its cardiac or gastric CP

69. Other causes of chest painPleuritic type chest pain – causes?Pneumonia, P.E, pleuritis, rib fractures as well!Investigations and Treatment? – CXR – consolidation? Wedge shaped infarct?ABG - ?hypoxicBloods – FBE, U+E, LFTs, CRP, COAGSpeak to your friendly med reg if you think it is likely PE re: organising urgent V/Q or CTPA whilst starting anticoagulation – clexane 1mg/kg s/c b.d if renal function is normal (dose reduce for renal impairment to 1mg/kg/day)

70. Key pointsDon’t be afraid to ask for help or activate a MET callKnow how manage common ward calls such as falls, hyperkalaemia and chest painBe able to recognise the deteriorating patient

71. Thank you!Please don’t forget to complete the evaluation:i-phone – just point cameraAndroid – use QR reader appOr use this link:https://forms.gle/DyvjizaEdGy4v8rS7​

72. Learning standardsThis presentation addresses the following components of the Australian Curriculum Framework for Junior Doctors:Clinical Management – H&E; Problem formulation; Investigations, Systems; PrioritisationProfessionalism – Professional responsibility; Professional standards; Time ManagementClinical Symptoms ……….This presentation is aligned with the following NSQHS Standards:Standard 4 – Medication safetyStandard 5 – Comprehensive careStandard 8 – Recognising and Responding to Acute Deterioration Standard