Top tips for surviving your first on call Dr Maleeha Rizvi Specialist Registrar in Cardiology University Hospital Lewisham
Overview Practical points The Bleep and prioritising on call Cardiac arrests Prescribing on call Night shifts On call scenarios
Type of on call Clerking Clerking on call team New admissions AAU ward Post take ward round Ward cover Clarify which wards you cover Introduce yourself to nurse in charge Non urgent jobs list Crash call team
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 1. 56 year old man with a chest infection needs a new cannula for IV antibiotics 1. 78 year old man with prostate cancer, has not passed urine since catheter removed 2 hours ago 2. 30 year old woman with asthma reports some difficulty in breathing, saturations 90% on room air 3. 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 1. 56 year old man with a chest infection needs a new cannula for IV antibiotics 1. 78 year old man with prostate cancer, has not passed urine since catheter removed 2 hours ago 2. 30 year old woman with asthma reports some difficulty in breathing, saturations 90% on room air 3. 60 year old diabetic on metformin, blood sugar is 20, no ketones in urine
Who do you see first? 1. 89 year old woman, background of breast cancer, admitted with chest infection, new increasing confusion on the ward this evening 2. 46 year old man admitted following paracetamol overdose, reported difficulty in sleeping 3. 59 year old man with gout, reports increasing toe pain 4. 75 year old woman admitted following fall with right tibial fracture, reported increasing numbness in right foot and pain under cast 5. 63 year old woman with suspected PE reporting increased chest pain
Who do you see first? 1. 89 year old woman, background of breast cancer, admitted with chest infection, new increasing confusion on the ward this evening 2. 46 year old man admitted following paracetamol overdose, reported difficulty in sleeping 3. 59 year old man with gout, reports increasing toe pain 4. 75 year old woman admitted following fall with right tibial fracture, reported increasing numbness in right foot and pain under cast 5. 63 year old woman, admitted with suspected PE reporting increased chest pain
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 1. Increase rate of fluids to 0.9% NaCL over 4 hours 1. Stop IV fluids, consider giving Furosemide 1. Insert urinary catheter to accurately measure urine output over next hour 1. Slow fluids to 12 hourly and increase oxygen to 8L
What would you do? 1. Give 250 mls of Gelofusin STAT 1. Increase rate of fluids to 0.9% NaCL over 4 hours 1. Stop IV fluids, consider giving Furosemide 1. Insert urinary catheter to accurately measure urine output over next hour 1. 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/UFH 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 heparin 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 heparin 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 Take a break during your shift 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???