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Alcohol Withdrawal

Suddenly stopping alcohol intake in patients who have been drinking heavily for prolonged periods is dangerous and can lead to severe withdrawal. Delirium tremens can occur in about 10% of patients with withdrawal and carries a 5-10% mortality risk. Certain patient will require pharmacological (and non-pharmacological) tools as part of an inpatient alcohol detoxification programme, in order to achieve abstinence safely.

As an FY1 consider alcohol withdrawal in patients with any of the symptoms below or if they are self-discharging.

Symptoms of alcohol withdrawal (think autonomic overstimulation):
TremorAgitationAnxietyHallucinationsSweatingVomitingSeizuresTachycardiaNauseaAnorexiaDiarrhoea These symptoms & signs overlap with those seen in other medical conditions which can make it easy to miss other diagnoses and simply label them as “withdrawal”. Always take a thorough history & full examination including for, particularly to the head. Review when the patient last drank and con…

The Hypoxic Patient

As an FY1, you will be called to review hypoxic ward patients. Here we discuss common causes of generalised hypoxia and not focal hypoxia/ischaemia such as in a stroke or heart attack. Insufficient oxygen carrying capacity due to anaemia, or ineffective use of oxygen at the tissue level (no cyanide management here zebra hunters!) will also not be dealt with here.

Often a patient who is found to be hypoxic will often be referred to you with the following handovers:
"this patient is agitated and confused""this patient has low saturations""this patient is having difficulty breathing"Hypoxia is medical emergency 
you should consider calling for help early (if "should I put a (peri)arrest call out" crosses your mind then put it out!)the patient assessment should be approached with the DR ABCDE system When any patient is acutely unwell, sometimes you need more hands to manage the situation - it isn't a question of your abilities. This might be the w…

Dealing with a complaint

As an FY1, you will receive a complaint. Usually these are informal, "I'm unhappy with the care delivered" from a relative or the patient themselves. I won't address a complaint or issue with a colleague here. Instead I'll talk generally about themes whichwork with the Good Medical Practice guidance & Duty of Candour from the GMC, advice from MDU [dealing with your first complaint & how to respond] and MPS. I recommend you read those documents too as they cover the legalities which I won't cover. 
It is very rare for a complaint to escalate beyond you. Even if it goes to the GMC, most complaints don't reach the threshold for a full GMC review. Your job is to deal with it if you can, but ideally involve your seniors. They have more experience, understand how hospitals work & can therefore direct the person to the right place. They will want to know as the complaint affects them too as complaints are directed to a team not a person regardless o…

Locums as an FY1

Finally earning a wage for all your hard work is great, and locum work can be a great way to up your earnings, whilst gaining more clinical exposure and experience. It may not be long before you start receiving offers for extra shifts, but consider a few really important things before booking in for locum shifts:

Provisional GMC registration
As an F1 doctor, you have provisional registration and limitations on your practice. With regards to locum shifts, this essentially means that you not permitted to work outside of your ‘training post’ - you cannot work in another hospital, trust or speciality.
This acknowledged, internal locum shifts at F1 level are generally accepted throughout the UK, providing it is within an area of current or previous foundation rotation. For example, if you are an F1 in medicine, it would be considered appropriate for you to cover a medical F1 on-call shift in your hospital, because it is within your normal job role and you would be part of an appropriately s…

Neutropenic Sepsis

Please read an overview of the management of sepsis before reading this article.

Definition
Neutropenic sepsis is defined as a temperature of greater than 38°C or any symptoms and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 109/L or lower. It is a common and potentially life threatening complication of neutropenia.
It is important to note that patients with neutropenic sepsis may not always have a raised temperature due to inability to mount an inflammatory response. This is more common in patients who are on steroids as these can mask symptoms such as pyrexia. It is vital that we have a high degree of suspicion in neutropenic patients/ patients with risk factors for neutropenia and assess these patients urgently.

High risk patients
Cancer patientsHIVThose who have had recent courses of chemotherapyPatients on immunosuppressive therapyPatients on steroidsPatients with pathology affecting the bone marrow e.g. myelodysplastic syndromes It is also important to…

Self-discharge

On occasion you will be called by a nurse as a patient wishes to self-discharge. When managing patients with psychiatric conditions, you have the added complexity of considering risk to self and others, and if the mental health act could be considered.

Read the notes for some background information: it’s useful to find out a bit about the patient

What’s their diagnosis and management plan?How long have they been on the ward?Did anything happen or seem to trigger the patient’s request to self-discharge?How did they express their desire to self-discharge? Consider whether there may be psychiatric conditions making the situation more complexCheck if they are informal or admitted under a section Can a nurse provide a handover of what things have been like? How have they been interacting with others?Has anyone been to visit?Consider asking a nurse to come with you, especially if you haven’t met the patient before – it can be more reassuring if there is a familiar face, and they have much mo…

On Call Tips

FY1s are usually most apprehensive about being on call, but it is also the shift you will usually learn the most. Predominantly as an FY1 you will be doing ward cover shifts and so that is what we will focus on below, with templates to improve your documentation.

A brief overview of the types of on calls
Ward shift - bleeped by teams to support ward patientsThis is the majority of your on call commitmentsClerking shift - clerking new patients that are referred to the teamUsually this is led by SHOs, but some places might allow clerking of medical patients by FY1s. Review our other post for tips on clerking patientsDischarge ward round (in some hospitals) - you go round the hospital usually with a consultant discharging patientsEnsure you complete the medication list early as usually pharmacy will close early in the day. Prioritise patients with a blister packCall wards beforehand to ask them to make a list of patients to potentially dischargeOn Call Duties & Handover Usually the on…