Mind the Bleep

Sharps injuries happen when you least expect them. You can’t always prevent them but you can do a lot to reduce the risk. It might be the patient is delirious and moved their arm, or you missed the sharps bin when trying to put the ABG needle into it, and it falls into your hand; it could even be when handling soiled waste and there are blood products on them. As soon as you realise you have been exposed; the key things are to first stay calm, and then think back to your medical school training.

Follow these points below:
Encourage the wound to bleed (applying pressure), while holding it under running waterWash the wound with running water and plenty of soapDo not scrub the woundDo not suck the woundDry the wound and cover it with a waterproof plaster or dressingSeek urgent medical advice from Occupational Health Services (discussing need for effective prophylaxis)Report the injury to your employerBut what happens next?
You will be given guidance by occupational health, or if the injury…

Anaphylaxis is a serious, life threatening allergic reaction that is life threatening. There are two type of anaphylactoid reactions:
Uniphasic - comes on quickly with rapidly worsening symptoms, when treated the symptoms go and do not return.Biphasic - starts with a mild to severe reaction to begin with, then symptoms resolve, then reoccur.Signs and symptoms
Swelling of the throat, tongue and mouth (angioedema)Difficulty swallowing/ speakingUrticarial rash/ hivesSense of impending doomTachycardiaSevere asthmatic symptomsAbdominal painCollapse/ unconsciousnessEmergency Management
Stop the agent causing the reaction & Call for help (ensure anaesthetic support) Establish airwayAdminister IM adrenalineAdults - 0.5ml of 1 in 1000 adrenaline IM (500 micrograms)Children Over 12 years - dose as above6-12 years – 0.3ml of 1 in 1000 adrenaline IM (300 micrograms)Under 6 years – 0.15ml of 1 in 1000 adrenaline IM (150 micrograms)Fluid bolus (crystalloid only- stop colloids as they may cause an…

You will likely encounter an opiate overdose due to the prevalence of opiates for recreational use, in those who have chronic pain or mental health issues & those who may accumulate opiates due to liver or renal impairment. No matter the type of opiate, treatment is broadly the same, although some opiates may require higher doses of naloxone like buprenorphine.

Features of overdose
The life threatening features are of hypoventilation & respiratory depression (i.e. rate of below 12). Other systemic effects of bradycardia, hypotension & hypothermia also exist. Examination features include:

CNS signs
Pinpoint pupils - not always present, particularly in mixed overdoseDrowsiness, Confusion, ComaSlurred speechSeizure Respiratory signs
Respiratory rate less than 12 breaths per minute Short, shallow breathsLate signs: cyanosis and frothy sputum Cardiovascular signs
Hypotension, bradycardia Hypothermia GI signs
Vomiting, decreased bowel sounds/gut mobilityInitial Management
Ventilatory…

Scenario: You are bleeped by one of the staff nurses to review a patient on the orthopaedic ward who is “jerking in her bed” She tells you the patient is a 74 year old female who is 2 days post knee replacement. She is a known epileptic who takes sodium valproate daily but has not taken any for the past 2 days because she has been feeling nauseous from the opioids she has been taking post-operatively and can’t keep anything down.

Arrive at the scene... What do you do to manage the deteriorating patient?

Time = First 5 Minutes:
Ensure you have help. It is difficult to protect the patient from injury & perform an ABCDE assessment & get all the required treatments. Pull the buzzer & strongly consider asking someone to put a medical emergency call out. You will need to delegate a lot of tasks hence even the most senior person will put an emergency call out. Is the patient still seizing? Start a timer.Remove any items around the patient that may cause them harmStart your ABCDEMea…

In this article we focus on interpretation of a CXR. Have a low threshold to request one as they provide a lot of information with minimal radiation. Typically, if the patient is unwell enough to require admission thwn the benefits of CXR outweigh the risks. Common scenarios you might order a CXR include:
Any suspicion of acute/chronic lung pathology (cancer, infection, oedema, effusion)Deteriorating patientsConfirmation of NGT placement (this should ideally be done within working hours)Post interventions e.g. central line, chest drain or pacemaker (to rule out pneumothorax) Always interpret a chest x ray with an appreciation of the patient's clinical assessment. It is difficult to differentiate consolidation from shadowing of pulmonary oedema on CXR but usually much easier in real life.

When to do a portable CXR?
If they are a deteriorating patient or you feel the patient may not be stable enough to be "outside" of nursing/medical care for 30 minutes - consider a portabl…

When I left medical school, I thought my only difficulty would be the actual medicine, which most junior doctors will tell you flies out your head as soon as you walk out of finals (it flies back in when you start working though). I somehow assumed that I would always manage to find ways to swerve leaving late and 'comms skills' my way through any difficult situation with colleagues and patients, just like in the OSCE.

It might seem obvious now, but the reality is that it's quite difficult to leave on time when you're not good at judging what you really need to stick around for, especially when a colleague is guilt-tripping you over a constipated patient. It's easy to feel obliged to forego your breaks and your lunch when it's already noon and you're not even a third of the way through your FY1-led ward round because you've not done one before and the overthinking is making you slow. But stack up just a couple too many weeks of abusive patients, working…

As an FY1 it is likely that you will manage paediatric patients during their admission, often in other specialties like general surgery. Difficult communication scenarios can occur & being prepared and responding to them well can instil confidence in our patients & their parents as well as help us feel more confident in approaching them. Do look at communicating with relatives & dealing with a complaint also.

Communication
In paediatrics, perhaps even more so than most other specialties, good communication is key! Parents are often very anxious (quite understandably so) and it is important to fully explain what is going on and what the plan is. A few extra points to consider:
Work: Parents often have other children at home and have to take time off work to stay in hospital with them. It is important to give a time-frame of when they might be discharged. However, it should be STRESSED that this is an estimate and things can change.Support on discharge: Parents like to know th…