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Deteriorating Patient

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The deteriorating patient is often the worst nightmare for new FY1s.  I remember when I started FY1, I was terrified of coming across a deteriorating patient whilst on call and having to manage them all alone. However, it is important to remember that, although you will definitely come across deteriorating patients, help will always be at hand if needed and it is paramount to stay calm.

So here are a few simple tips on how to deal with the deteriorating patient:

Initial assessment
1. Though the A to E assessment is drummed into us throughout medical school, it remains the most important tool when assessing an acutely unwell patient- it always gives you a good place to start and ensures that you cover all the important aspects.

2. Though everyone has slightly different things they include in the A+E assessment, it is always important to remember:
  • Airway: patent?
  • Breathing: respiratory rate, oxygen saturations, examination of chest and trachea
  • Circulation: warm peripheries, heart rate, blood pressure, bloods and cannula
  • Disability: AVPU, pupils, Capillary Blood Glucose
  • Exposure: temperature, rashes, abdominal and peripheries examination
3. As you work through the A to E assessment, ensure that you tackle each aspect of it before moving onto the next. For example, if a patient is hypoxic, start them on some oxygen before moving onto dealing with their blood pressure.

4. Even after you have finished your initial A to E assessment, continually re-assess the patient using the A to E approach - this allows you to identify if the patient is still deteriorating or if the patient is responding to your initial management.  You can then alter your management accordingly.

5. It is important to ensure that you have briefly looked at the notes for the patient or at least asked the nurse to give you a brief handover when you are asked to see them. This allows you to understand the patient’s background, what has already been done for them and may give you an idea about what is causing their deterioration. For example, if a patient drops their saturations to 86%, you would be less worried about them if they are a known COPD patient with target saturations of 88-92%.

6. Though it may sound simple, it is always a good idea to get a fresh set of observations and bloods when you approach a deteriorating patient. It can normally give you a very good idea about the cause of the deterioration and allow you to act from there.

7. Remember ABGs and VBGs can often be an invaluable source of immediate information; you can get an idea of their pH, oxygenation, haemoglobin, electrolytes and lactate all within a few minutes!

Escalate early
1. If you come across sick patient which you are worried about, don’t be afraid of escalating early! No one will ever be upset at you for identifying and escalating a sick patient - seniors would rather you tell them sooner rather than later.

2. Handover: Try and give it as succinctly as possible over the phone, highlighting early in the conversation that you are worried about a patient and would like an urgent review or advice.  Remember SBAR is an important handover tool particularly if you are stressed as it allows you to clearly deliver the relevant information:
  • Situation
  • Background
  • Assessment
  • Recommendation
3. Often, you just need an extra set of hands. For example, if you are asked to see a hypotensive patient with no access, ask a nurse or another colleague to help you whilst you continue your assessment. Many hospitals have outreach nurses who can come to your rescue and provide another source of advice and help.

4. Before starting on-calls, know whom you can escalate to and make sure you know their bleep numbers! If a patient is fast deteriorating, many hospitals have medical emergency or peri-arrest calls which you can place, or if no such system exists, if the patient is deteriorating quickly and you need immediate help, don’t be afraid to put out a cardiac arrest call!

Trust policies and guidelines 
1. Most trusts have very clear policies about the management of emergencies which makes life a whole lot easier! When you start FY1, I highly recommend you find out exactly how you can access these trust guidelines.

2. Once you have initially assessed the patient, identified the problem and escalated appropriately, you can look up these trust policies and follow the recommended management plan.

Establishing ceiling of care
1. With a deteriorating patient, it is important to be aware of their ceiling of care early on.  For example, check for the presence of a DNACPR form, whether they are for ward-based ceiling of care or for full escalation. This will be important in guiding the future management and it will be a useful piece of information to relay to your seniors.

Updating family
Once the patient is stable and help has arrived, it is important to remember that family members should be updated. Families always like to know sooner rather than later if their loved one is unwell and will always be grateful for the update.

Always remember that you will never be expected to manage a deteriorating patient alone. Help will always be at hand- you just need to ask for it if you are worried about a patient. We have all been brand new FY1s and we don’t expect you to know everything at all, so as long as you start the initial management for the patient and escalate early, we will be more than happy!

Written by Dr Tanya Chopra IMT1

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