small medic mini-blog

fragments. very junior doctor in the UK. see https://smallmedicsketches.wordpress.com for more

was with the same reg on my last set of on calls! lucky me.

unfortunately one of us is turning out to be a magnet; had plenty of unwell patients. was this the on calls where he decided a very frail patient needed a relook laparotomy? maybe. he seems to have at least one going to emergency surgery every time I'm on call with him.

if you wonder why healthcare staff have such superstition: we have so little locus of control it feels better to blame it on someone saying the Q word or someone being a magnet rather than a strained system.

nonetheless.

have seen many people's bums and carefully squished many people's abdomens. learned a lot. got some pointed but well meaning feedback from said reg.

the ol' career instnct is pointing towards ICU as a way to: * maintain medic diagnostic skills * airway skills * much physiology * learn some surgery-adjacent skills

#surgery #career

UK medics will appreciate: ARCP season is upon us. My ES does not know how to fill the forms in properly. Which begs the question, if there are so many hidden tickboxes, what measure of clinical competence is that?

my registrar and I sat in ED at 3am and he just went “I want to cry” I made an unintelligible sound and we moved on

heck of a night to finish on, first he went to theatre and left his bleep

cue loads of angry referrers leaving passive aggressive mesages in the notes

then the urine analyser stopped working, then the BLOOD analyser stopped working????

then a crash bleep for “cardiac arrest in CT” and the reg thought it was one of our patients

it sure beats the night where three people got unwell the hour before handover tho

or when I went to assess a patient, left the ward, and was bleeped 5 mins later with a much more worrying update

overall still enjoyed it though, much better vibes than medical nights – I guess partly because we know what's going on with each person on the list, the chance to go between the wards and ED, and seeing patients get better...

as a junior

Out of hours, you're most likely to be called for hyperactive delirium, but your workup remains the same.

My finals notes: https://smolmedic.github.io/#Delirium

establish the baseline

  • How do you know they're confused? Has anyone taken a collateral?
  • “patient is a poor historian” just means you don't have enough sources of information
  • Sources of information: NOK, carers (care agencies, sheltered accommodation managers), care home staff, previous therapists docs
  • document who gave you the collateral

approaching the patient

  • usual physical examination and secondary survey – looking for any source of infection, signs that they injured themselves as a result
  • mental state examination (https://smolmedic.github.io/#Mental%20state)
  • can they tell you about any delusions or hallucinations? voices/noises/telling them to do things? seeing people/things/animals? are these frightening? these can contextualise behaviour, help you reassure the patient and risk assessment
  • the last one can help you step into their world for a bit

bedside investigations: aim to rule out reversible causes

  • think U PINCH ME
  • retention – bladder scan
  • hydration/nutrition – fluid status, bloods
  • metabolic – bloods, blood sugars
  • environment – environmental stimuli can sometimes be a focus for a delusion/hallucination (i.e. misinterpreting stimuli) – hearing aids in, glasses on!

bedside paperwork: working with nursing staff

  • bowel chart – they must poo. nuff said. “type 7”/watery stool may be overflow
  • food chart – if not eating, look in mouth (easily missed) – mouth care? thrush? cognition = needs prompting to finish food?
  • behaviour chart – full of incredibly useful information. are they sleeping at night? consultants might like sedatives, but as a junior, making sure they have adequate pain relief can be an easy win

suggestions for management

  • family visits can help re-orient/reassure esp with paranoid ideation
  • 1:1 may be needed if very very hyperactive
  • MHLT can help +/– old age psychiatrists to help with antipsychotic dosing, weaning of psychotropics, follow up/discharge planning e.g. for dementia unit
  • Meds a geriatrician might use (from local experience): risperidone/olanzapine esp with violent behaviour, quetiapine with PD patients (less anti dopaminergic effect I believe), sedatives to even out sleep pattern

Successfully diagnosed viral labyrinthitis in someone who had “failed PT/OT” (therapists declined referral due to no clear indication).

Very interesting conversations about AKI and delirium, as always

Got in touch with [external hospital] and discussed TWO patients in 20 minutes?! (I was once on hold to them for just under an hour)

sometimes I find myself at a loss with a keen med student. I don't want to ignore them, but I don't always (or often!) have a structured tutorial to pull out of the hat

stuff which I found helpful as a student:

at the bedside:

  • examine a friendly patient
  • pt with a rare condition? tell me what you can about it – better, what can the patient teach you about it?

procedures:

  • take a postural BP then talk about risk factors for postural hypotension
  • take and interpret an ABG

prescribing:

  • mock prescribing – antibiotics, gentamicin (grrr)
  • let's talk pain relief...
  • let's talk antiemetics and their mechanisms...
  • let's talk parkinson's meds...

teamwork:

  • write a scan request together → discuss why this modality
  • ask a friendly AHP if the student can shadow them – e.g. specialist nurses, therapists
  • write a referral together
  • calling micro for a specific question

doctoring:

  • chat about on calls
  • do they know how “the take” works?
  • doing a DNACPR? write the “red form” together

investigations:

  • describe an ECG/scan systematically
  • look at some bloods, ask them to tell you what it means
  • parse reports, historical or otherwise (I was asked to look through 6 years of clinic letters once...)

#teaching #meded

  • learned how to flush and remove a chest drain
  • went to a suddenly unwell patient
  • SHO was surprised that I was so calm with the acutely unwell patient, I attribute it to “request a chest X-ray, do an ABG then have a think”
  • spotted a prescription error, carried out duty of candour ** the win not being the error but that I saw it and knew what to do to correct it

#wins

I have two days off after a weekend on call with a steep learning curve, so my brain does need that break.

Just writing some reflections and portfolio sign offs now and thinking

It was pretty fitting that one of my first big learning events was recognising when people were actively dying. That was something I was afraid of, starting off – knowing what was reversibly unwell and what wasn't, and with all the things around that: discussing when people might not survive resuscitation; when to make the call to involve palliative care.

Being in Frailty has helped with making these conversations much more common, and led by seniors used to making these decisions compassionately and sensibly.

Listening to the palliative care team was an education. Listening to how they navigated difficult conversations and family dynamics helped show a way that was calm and clear about uncertainty. In medical school, palliative care teaching was often about generic “breaking bad news” and prescribing. Let's be frank, most of my “palliative care revision for finals” was 80% prescribing, 20% “soft skills”. Learning about palliative care in FY1 has been 20% prescribing, 80% communication skills and styles of patient assessment.... like most other clinical specialties, really!

I have no answers. Coming alongside people and talking about this with them is becoming a bit easier with practice, especially when I know it can be done with compassion and gentleness.

#geris #palliative #death #reflections

small reflections from the other side

I've just finished a run of nights off the delirium ward

I now see delirium everywhere

where before it was “agitated confused” or “drowsy confused” I now recognise “hyperactive delirium” and “hypoactive delirium”... and I see the dangerous transition points where valuable information gets missed, or plans are never actioned.

#geris #reflections

Had a registrar on the ward for the first time since I started – first time in 3 weeks, probably

And she went “I've been on the ward as the only doctor... I'm [grade] and I'm doing all these bloods and NOK updates...”

I feel like I've missed something?? like obv the reg should do the decision making but

idk