Top tips for surviving your first on call

Dr Maleeha Rizvi Core Medical Trainee

London North West Hospitals NHS Trust

Overview

• Practical points

• The Bleep and prioritising on call

• Cardiac arrests

• Prescribing on call

• Night shifts

• On call scenarios

You are not alone!

Type of on call

Clerking Ward cover

• Clerking on call team

▫ New admissions

▫ AAU ward

▫ Post take ward round

• Crash call team

• Clarify which wards you cover

• Introduce yourself to nurse in charge

• Non urgent jobs list

Survival kit

• Notebook/Handover List

• Useful Numbers ▫ Registrar, SHO, Radiographer, Lab

• Equipment ▫ Cannulas, ABG needles, tourniquet

• Reference book

• Food on the go!

Handover

• Keep a organised list

• Patient name, hospital number, location

• Clinical context

• Chase results – what to do if abnormal

• Document!

The Bleep

• Who is calling, where are they

• Clinical information Background

Last review

Current Observations

• Instructions New Observations

Notes, drug chart

Equipment

Actions – eg ECG, positioning, suction, arrest call

SBAR

Situation

Background

Assessment

Recommendation

Applies to the nurses

and you

NEWS Score

• National Early Warning Score

• Early recognition of the acutely unwell patient

• Based on ▫ Respiratory rate

▫ Oxygen saturations

▫ Temperature

▫ Systolic blood pressure

▫ Pulse rate

▫ Level of consciousness

Prioritising calls

• Clinical urgency ▫ ?Acutely unwell, - ABCDE

▫ Observations – hypoxic, hypotensive, reduced consciousness

• Detailed list ▫ Group jobs

• Too many calls ▫ Site practitioner

▫ Call for help

Who do you see first? 1. 65 year old woman with COPD, saturations 89% on room air, RR 18

2. 56 year old man with a chest infection needs a new cannula for IV

antibiotics

3. 78 year old man with prostate cancer, has not passed urine since catheter removed 2 hours ago

4. 30 year old woman with asthma reports some difficulty in breathing, saturations 90% on room air

5. 60 year old diabetic on metformin, blood sugar is 20, no ketones in urine

Who do you see first? 1. 65 year old woman with COPD, saturations 89% on room air, RR 18

2. 56 year old man with a chest infection needs a new cannula for IV

antibiotics

3. 78 year old man with prostate cancer, has not passed urine since catheter removed 2 hours ago

4. 30 year old woman with asthma reports some difficulty in breathing, saturations 90% on room air

5. 60 year old diabetic on metformin, blood sugar is 20, no ketones in urine

2222

Cardiac Arrest

!!!!

Cardiac arrest

• Pulse check start compressions • ABC approach and get the crash trolley • A – manoeuvres, airway adjuncts • B – high flow oxygen, ABG • C – Defib pads, IV access, fluid bolus

• Clear communication to those running the arrest • ABG, putting a cannula, getting the notes, using the

Defibrillator • How to open the crash trolley and adrenaline!

Assessing the unwell patient

• ABCDE approach • Review medical notes ▫ Current issues from last ward round ▫ Recent blood results

• Initial investigations ▫ ABG ▫ Bloods ▫ CXR

• Re-assess after treatment given • Go with your gut feeling – if something doesn’t seem

right then it probably isn’t! • Ask for help early

Prescribing on call

• Write legible in capitals

• Always check allergy status

• Re-writing drug charts

• IV fluids - ?fluid status

• Local trust antibiotic guidelines

IV Fluids

• Colloid vs crystalloid ▫ 0.9% Normal Saline ▫ Gelofusin

• Maintenance fluids ▫ 3L in 24 hours ▫ 40 mmol KCL ▫ Remember those with poor LV function

• Fluid balance ▫ JVP, skin turgor, Peripheral oedema, crackles on

auscultation ▫ SBP > 90 and UO > 0.5 ml/kg/hr

Case example

• 79 year old man admitted following an NSTEMI 2 days ago

• PMH: CABG 1990, Previous MI, Diabetic, Hypertensive

• On 0.9% Normal saline 8 hourly fluid maintenance due to concerns with swallow

• Asked to see patient – RR 30 Saturations 90% on 4L O2, BP 100/60, no urine output for past 4 hours

What do you do next?

Examination findings

• JVP not raised but patient is lying flat

• Chest – bilateral reduced air entry

• Abdomen – no palpable bladder

• Bilateral peripheral oedema

What would you do?

1. Give 250 mls of Gelofusin STAT

2. Increase rate of fluids to 0.9% NaCL over 4 hours

3. Stop IV fluids, consider giving Furosemide

4. Insert urinary catheter to accurately measure urine output over next hour

5. Slow fluids to 12 hourly and increase oxygen to 8L

What would you do?

1. Give 250 mls of Gelofusin STAT

2. Increase rate of fluids to 0.9% NaCL over 4 hours

3. Stop IV fluids, consider giving Furosemide

4. Insert urinary catheter to accurately measure urine output over next hour

5. Slow fluids to 12 hourly and increase oxygen to 8L

Re-asses the patient

• What is their fluid status

• Response to fluid challenge and further action

• Repeat bloods to check electrolytes

Analgesia • Why are they in pain?

▫ Acute or chronic ▫ ?Change in character

• Regular vs PRN • WHO Pain ladder • Paracetamol

▫ IV route • Weak opiods

▫ Codeine 30-60mg 4 to 6 hourly ▫ Tramadol 50-100 mg 4 to 6 hourly

• Strong opiods ▫ Oromorph ▫ IV Morphine – be weary!

Warfarin

• Indication for warfarin ▫ AF or metallic valve

• Pre-procedure ▫ ?conversion to LWMH

• Trend of last INRs

• New medications started

• Signs of bleeding

Warfarin prescribing

54 year woman with a metallic MVR on warfarin. INR was 1.4 yesterday and is 1.5 today. Warfarin dose was increased from 3mg to 5mg yesterday

1. Continue at 5 mg and check INR tomorrow

2. Increase dose to 7 mg

3. Continue at 5 mg and ensure patient is on LMWH

4. Call the medical SpR on call for advice

5. Recheck INR

Warfarin prescribing

54 year woman with a metallic MVR on warfarin. INR was 1.4 yesterday and is 1.5 today. Warfarin dose was increased from 3mg to 5mg yesterday

1. Continue at 5 mg and check INR tomorrow

2. Increase dose to 7 mg

3. Continue at 5 mg and ensure patient is on LMWH

4. Call the medical SpR on call for advice

5. Recheck INR

Warfarin prescribing

73 year old man on warfarin for AF. Admitted with a LRTI. INR 3 days into admission is 5.6 on 2 mg warfarin, no active bleeding

1. Hold warfarin, recheck tomorrow

2. Give 1 mg of warfarin

3. Hold warfarin and give 10 mg of IV vitamin K

4. Call the Haematology SpR

5. Check the local hospital protocol for high INR

Warfarin prescribing

73 year old man on warfarin for AF. Admitted with a LRTI. INR 3 days into admission is 5.6 on 2 mg warfarin, no active bleeding

1. Hold warfarin, recheck tomorrow

2. Give 1 mg of warfarin

3. Hold warfarin and give 10 mg of IV vitamin K

4. Call the Haematology SpR

5. Check the local hospital protocol for high INR

Night shifts

• Rest well on the day of your first night shift

• Bring food and drink

• Get some rest during the shift, 20 min power nap

• Prioritisation is even more important

• Make use of team around you ‘Hospital at night’

• Review your patient in good light e.g. ABG/cannula

• Handover to day team clearly

You reviewed an elderly patient who was confused and agitated at 3 am. He has been confused for the last 2 nights. You discuss the case with the SpR and he advised a CT head

1. Call the on call radiologist for an urgent CT head 2. Wait till the morning to obtain the CT head 3. Call your SpR again to clarify the urgency 4. Continue neurological observations for now and get CT

head if GCS falls 5. Give 2mg haloperidol then call the on call radiologist

for the scan

?did you fully examine the patient

You reviewed an elderly patient who was confused and agitated at 3 am. He has been confused for the last 2 nights. You discuss the case with the SpR and he advised a CT head

1. Call the on call radiologist for an urgent CT head 2. Wait till the morning to obtain the CT head 3. Call your SpR again to clarify the urgency 4. Continue neurological observations for now and get

CT head if GCS falls 5. Give 2mg haloperidol then call the on call radiologist

for the scan

Case scenarios

A 45 year old man is receiving his second unit of blood for a presumed upper GI bleed. During the transfusion he develops a temperature of 38.5. He is haemodynamically stable. What should you do?

1. Contact haematology team for urgent advice 2. Give IV Chloramphenicol and continue transfusion 3. Start broad spectrum antibiotics 4. Stop the transfusion, take blood cultures and provide

supportive measures 5. Take blood cultures and continue transfusion

Case scenarios

A 45 year old man is receiving his second unit of blood for a presumed upper GI bleed. During the transfusion he develops a temperature of 38.5. He is haemodynamically stable. What should you do?

1. Contact haematology team for urgent advice 2. Give IV Chloramphenicol and continue transfusion 3. Start broad spectrum antibiotics 4. Stop the transfusion, take blood cultures and provide

supportive measures 5. Take blood cultures and continue transfusion

Case scenarios

You are asked to see a 72 year old woman on the surgical ward. She has had a right hemi-arthroplasty for a NOF earlier today and reports increasing pain from the right hip and is very confused. Background of diabetes and hypertension, previously independent. On arrival her GCS 12/15, HR 105, BP 98/45 Sats 98% on 1L O2. Her wound is dressed with no active bleeding. Urine dip is leucocyte and blood positive. She has not had any analgesia. What do you do?

1. Prescribe regular analgesia, re-review following 2. Check the wound, repeat Hb count, inform the surgical registrar 3. Start antibiotics for a UTI, send Urine MCS 4. Prescribe IV fluids and hold morning anti-hypertensives until BP

improves

Case scenarios

You are asked to see a 72 year old woman on the surgical ward. She has had a right hemi-arthroplasty for a NOF earlier today and reports increasing pain from the right hip and is very confused. Background of diabetes and hypertension, previously independent. On arrival her GCS 12/15, HR 105, BP 98/45 Sats 98% on 1L O2. Her wound is dressed with no active bleeding. Urine dip is leucocyte and blood positive. She has not had any analgesia. What do you do?

1. Prescribe regular analgesia, re-review following 2. Check the wound, repeat Hb count, inform the surgical registrar 3. Start antibiotics for a UTI, send Urine MCS 4. Prescribe IV fluids and hold morning anti-hypertensives until BP

improves

Case scenarios

A 45 year old man with a history of alcohol abuse and cirrhosis is admitted with ascites and for alcohol detoxification. The nurse asks you to see him because he is a little more confused. He is on a chlordiazepoxide detox regime. On examination - GCS 13/15. BP 98/54 (130/60 earlier in day) HR 100, tremulous. The nurse also reports he has had some black stool but the patient is on iron tablets. What should you do?

1. Give extra stat dose of Chlordiazepoxide now and increase regular

dose from tomorrow 2. Re-assure nursing staff that patient is exhibiting signs of alcohol

withdrawal and start neuro-obs 3. PR exam, insert cannula and take bloods for FBC and clotting 4. Stop his chlordiazepoxide as contributing to his drowsiness

Case scenarios

A 45 year old man with a history of alcohol abuse and cirrhosis is admitted with ascites and for alcohol detoxification. The nurse asks you to see him because he is a little more confused. He is on a chlordiazepoxide detox regime. On examination - GCS 13/15. BP 98/54 (130/60 earlier in day) HR 100, tremulous. The nurse also reports he has had some black stool but the patient is on iron tablets. What should you do?

1. Give extra stat dose of Chlordiazepoxide now and increase regular

dose from tomorrow 2. Re-assure nursing staff that patient is exhibiting signs of alcohol

withdrawal and start neuro-obs 3. PR exam, insert cannula and take bloods for FBC and clotting 4. Stop his chlordiazepoxide as contributing to his drowsiness

Summary

• Be organised

• Good communication to those around you

• Escalate unwell patients early

• Ask for help

• Handover thoroughly at end of shift

• Stay calm

Questions ???