Dr Ivor Popovich presents examples of evidence-based decision making during ward calls. We also highlight some recommendations from Choosing Wisely and give an update on death certification.  * The Intern Suppository – Ivor’s EBM blog * The Rational Clinical Examination – JAMA * Plain film in small bowel obstruction  * The gas-less abdomen * Paucity of gas * Non-specific bowel gas pattern * Read more in the blog post here* Plasmalyte in renal failure  * Not contra-indicated * Actually alkalinises plasma, driving potassium into cells * The chloride in NaCl acidifies plasma, drawing potassium into the extracellular space * Read more in the blog post here* Asthma admission  * Tachycardia is not explained by salbutamol administration alone * A large diurnal variation in peak flow (e.g. &gt;50%) is a major risk factor for in-hospital cardiac arrest (not severity of asthma exacerbation at admission). * Severity of wheeze does not correlate with severity of exacerbation * Read more in the blog post here* Choosing wisely * New Death Documents website * MOH Completing the Medical Certificate Cause of Death form (March 2018) * MOH Examples of incorrect and correct cause of death certification (March 2018)

Dr Ivor Popovich presents examples of evidence-based decision making during ward calls. We also highlight some recommendations from Choosing Wisely and give an update on death certification. * <a href="https://internsuppository.wordpress.com" rel="noopener nofollow" target="_blank">The Intern Suppository</a> – Ivor’s EBM blog * <a href="https://jamanetwork.com/collections/6257/the-rational-clinical-examination" rel="noopener nofollow" target="_blank">The Rational Clinical Examination</a> – JAMA * Plain film in small bowel obstruction * The gas-less abdomen * Paucity of gas * Non-specific bowel gas pattern * <a href="https://internsuppository.wordpress.com/2018/01/03/bowel-obstruction-is-a-clinical-diagnosis/" rel="noopener nofollow" target="_blank">Read more in the blog post here</a> * Plasmalyte in renal failure * Not contra-indicated * Actually alkalinises plasma, driving potassium into cells * The chloride in NaCl acidifies plasma, drawing potassium into the extracellular space * <a href="https://internsuppository.wordpress.com/2018/01/22/plasmalyte-is-safe-and-actually-better-in-hyperkalemia/" rel="noopener nofollow" target="_blank">Read more in the blog post here</a> * Asthma admission * Tachycardia is not explained by salbutamol administration alone * A large diurnal variation in peak flow (e.g. &gt;50%) is a major risk factor for in-hospital cardiac arrest (not severity of asthma exacerbation at admission). * Severity of wheeze does not correlate with severity of exacerbation * <a href="https://internsuppository.wordpress.com/2018/02/11/asthma-avoiding-common-pitfalls/" rel="noopener nofollow" target="_blank">Read more in the blog post here</a> * <a href="http://choosingwisely.org.nz/health-professionals/" rel="noopener nofollow" target="_blank">Choosing wisely</a> * <a href="https://deathdocs.services.govt.nz/welcome" rel="noopener nofollow" target="_blank">New Death Documents website</a> * <a href="https://www.health.govt.nz/our-work/regulation-health-and-disability-system/burial-and-cremation-act-1964/completing-death-documents/medical-certificate-cause-death/completing-medical-certificate-cause-death-form" rel="noopener nofollow" target="_blank">MOH Completing the Medical Certificate Cause of Death form (March 2018)</a> * <a href="https://www.health.govt.nz/our-work/regulation-health-and-disability-system/burial-and-cremation-act-1964/completing-death-documents/medical-certificate-cause-death/examples-incorrect-and-correct-cause-death-certification" rel="noopener nofollow" target="_blank">MOH Examples of incorrect and correct cause of death certification (March 2018)</a>

The intern suppository

Cardiology expert Adele Pope returns with an approach differentiating tachycardia and managing atrial fibrillation. We also discuss ventricular ectopics, bigeminy and peri-operative anticoagulant and anti-platelet adjustment. Differential  * Life threatening  * VT * SVT  * AFib * Flutter* Common triggers of AFib  * Post operative state * Myocardial infarction * Sepsis * Anaemia * Hypo- or hypervolaemia * Pulmonary embolus * Electrolyte disturbance* Cardiac dysrhythmia * Non-cardiac  * Anemia * Anxiety * Dehydration * Electrolyte imbalance (especially hypokalemia and hypomagnesemia) * Fever/ sepsis * Hyperthyroidism * Hypoglycemia * Ischemia * Metabolic disorders * Pain * Poisoning and toxic exposure * Pulmonary embolism * Respiratory disease (e.g. pneumonia, pneumothroax) * Shock * Trauma * Withdrawal syndromesApproach  * ECG and new set of vitals before you arrive * Eyeball the patient/ABCs * History  * Old or new tachyarrhythmia? * Chest pain * SOB * Palpitations * Exact time of onset of symptoms * Cardiac history  * Prev AF * Ischaemic heart disease * Valvular disease * Hypertension * Heart failure* ROS* Vitals + Examination  * General inspection + peripheries for perfusion * JVP * Auscultation  * Confirm rhythm * Valvular dysfunction* Wound * Calves/leg oedema* ECG  * Narrow complex or wide complex?  * QRS &gt; 3 squares could be a wide complex tachycardia (call a code) * Concordance (V1 – V6 often point in one direction in VT) * AV dissociation indicated VT* If narrow complex, is it regular or irregular?  * Irregular is probably AFib* Consider investigations  * FBC, U&amp;E (including Mg), TFT * Consider septic workup * Consider troponin* Management  * Consider observation * 500 mL fluid bolus * Metoprolol tartrate 50 mg (not if overloaded or in steroid-dependent asthma) * Diltiazem short acting 30 mg as an alternative* Documentation  * Review past notes * Current medications – has a dose been missed? * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. * Have you eliminated life threatening conditions?  * Why has this arrhythmia developed? * Is there a risk of deterioration?* Type of AFib (first episode, paroxysmal, persistent, or permanent) * Clear and specific plan * Immediate investigations * Fluids * Electrolytes correction * Beta blocker? * Anti-arythmic? * Anti-coagulation? * Consider echo, TOE, CXR, ETT * Consider discussion with senior and escalation, especially if called back to patient again.Concluding remarks  * Get help early for:  * Wide complex tachycardia * Poor perfusion/hypotension * Pulmonary oedema* Main triggers are post operative state, myocardial infarction, sepsis and anaemia. * AF may be the first sign of a significant problem, so a good review of systems is needed. * AF may precipitate cardiac and perfusion problems (ischemia, heart failure, atrial thrombus), so identify patients at risk. * Timing:  * Assume onset of AF to be greater than 48 hours...

Cardiology expert Adele Pope returns with an approach differentiating tachycardia and managing atrial fibrillation. We also discuss ventricular ectopics, bigeminy and peri-operative anticoagulant and anti-platelet adjustment. Differential * Life threatening * VT * SVT * AFib * Flutter * Common triggers of AFib * Post operative state * Myocardial infarction * Sepsis * Anaemia * Hypo- or hypervolaemia * Pulmonary embolus * Electrolyte disturbance * Cardiac dysrhythmia * Non-cardiac * Anemia * Anxiety * Dehydration * Electrolyte imbalance (especially hypokalemia and hypomagnesemia) * Fever/ sepsis * Hyperthyroidism * Hypoglycemia * Ischemia * Metabolic disorders * Pain * Poisoning and toxic exposure * Pulmonary embolism * Respiratory disease (e.g. pneumonia, pneumothroax) * Shock * Trauma * Withdrawal syndromes Approach * ECG and new set of vitals before you arrive * Eyeball the patient/ABCs * History * Old or new tachyarrhythmia? * Chest pain * SOB * Palpitations * Exact time of onset of symptoms * Cardiac history * Prev AF * Ischaemic heart disease * Valvular disease * Hypertension * Heart failure * ROS * Vitals + Examination * General inspection + peripheries for perfusion * JVP * Auscultation * Confirm rhythm * Valvular dysfunction * Wound * Calves/leg oedema * ECG * Narrow complex or wide complex? * QRS &gt; 3 squares could be a wide complex tachycardia (call a code) * Concordance (V1 – V6 often point in one direction in VT) * AV dissociation indicated VT * If narrow complex, is it regular or irregular? * Irregular is probably AFib * Consider investigations * FBC, U&amp;E (including Mg), TFT * Consider septic workup * Consider troponin * Management * Consider observation * 500 mL fluid bolus * Metoprolol tartrate 50 mg (not if overloaded or in steroid-dependent asthma) * Diltiazem short acting 30 mg as an alternative * Documentation * Review past notes * Current medications – has a dose been missed? * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. * Have you eliminated life threatening conditions? * Why has this arrhythmia developed? * Is there a risk of deterioration? * Type of AFib (first episode, paroxysmal, persistent, or permanent) * Clear and specific plan * Immediate investigations * Fluids * Electrolytes correction * Beta blocker? * Anti-arythmic? * Anti-coagulation? * Consider echo, TOE, CXR, ETT * Consider discussion with senior and escalation, especially if called back to patient again. Concluding remarks * Get help early for: * Wide complex tachycardia * Poor perfusion/hypotension * Pulmonary oedema * Main triggers are post operative state, myocardial infarction, sepsis and anaemia. * AF may be the first sign of a significant problem, so a good review of systems is needed. * AF may precipitate cardiac and perfusion problems (ischemia, heart failure, atrial thrombus), so identify patients at risk. * Timing: * Assume onset of AF to be greater than 48 hours...

AF & tachycardia

Deborah Powell

Foremost expert on all things NZRDA, Dr Deborah Powell, explains why RMOs get free meals, what 8.1.2 is, and the RDA’s role in helping members in trouble.  * Meals and the NZRDA Education trust * 8.1.2  * “For runs to which the above paragraph does not apply, any Ordinary Hours which are not rostered shall be counted as hours worked (up to a maximum of 8 Ordinary Hours per day) when determining the category for the run.”* Role of NZRDA  * Negotiating and enforcing the MECA * Informing members * Lobbying * Helping and representing individuals in difficulty * Media * Public relations * All things RMOs* Getting into trouble * Cross cover outside ordinary hours * What happens to membership fees? * Bullying and harassment

Foremost expert on all things NZRDA, Dr Deborah Powell, explains why RMOs get free meals, what 8.1.2 is, and the RDA’s role in helping members in trouble. * Meals and the NZRDA Education trust * 8.1.2 * “For runs to which the above paragraph does not apply, any Ordinary Hours which are not rostered shall be counted as hours worked (up to a maximum of 8 Ordinary Hours per day) when determining the category for the run.” * Role of NZRDA * Negotiating and enforcing the MECA * Informing members * Lobbying * Helping and representing individuals in difficulty * Media * Public relations * All things RMOs * Getting into trouble * Cross cover outside ordinary hours * What happens to membership fees? * Bullying and harassment

Q&A with Dr Deborah Powell

Sam meets some podcasting celebrities and experts in clinical reasoning Dr Art Nahill and Dr Nic Szecket – hosts of the podcast IM Reasoning. We talk cognitive bias and and some approaches to minimising their impact.  Common biases  * Confirmation bias  * The tendency to search for or interpret information in a way that confirms one’s preconceptions, while ignoring information that does not support the preconceptions.* Anchoring  * The common human tendency to rely too heavily on the first piece of information offered (the “anchor”) when making decisions.* Premature closure  * Failing to consider reasonable alternatives after an initial diagnosis is made.* Affective biases  * Letting emotions, pre-conceptions, or stereotypes lead to assumptions that cloud the reasoning process e.g. drug users, chronic pain.* Gambler’s fallacy  * The erroneous belief that chance is self correcting. If the last two patients were diagnosed with serious chest pain, surely the next one will be benign. Remember that each ward call is unrelated to the last.* Posterior probability bias  * Letting recent or past events thats that are independent of the current case, impact on your estimated likelihood of a diagnosis.* Ockham’s razor  * The simplest answer is more likely to be correct. Another way of saying it is that the more assumptions you have to make, the more unlikely an explanation is. Also, that a single diagnosis that explains the patient’s symptoms is more likely, than seperate diseases occurring concurrently.* Hickam’s dictum  * The counter to Ockham’s razor. Patients can have as many diseases as they damn well please.* Larry Weed – The Father of the Problem-Oriented Medical Record  Apps  * Isabel * VisualDX * Diagnosaurus  Podcasts (FOAMed)  * IM Reasoning * Pomegranate Health * EMCrit * ERCast * On the wards

Sam meets some podcasting celebrities and experts in clinical reasoning Dr Art Nahill and Dr Nic Szecket – hosts of the podcast <a href="http://imreasoning.com" rel="noopener nofollow" target="_blank">IM Reasoning</a>. We talk cognitive bias and and some approaches to minimising their impact. <a href="http://imreasoning.com" rel="noopener nofollow" target="_blank"></a> Common biases * Confirmation bias * The tendency to search for or interpret information in a way that confirms one’s preconceptions, while ignoring information that does not support the preconceptions. * Anchoring * The common human tendency to rely too heavily on the first piece of information offered (the “anchor”) when making decisions. * Premature closure * Failing to consider reasonable alternatives after an initial diagnosis is made. * Affective biases * Letting emotions, pre-conceptions, or stereotypes lead to assumptions that cloud the reasoning process e.g. drug users, chronic pain. * Gambler’s fallacy * The erroneous belief that chance is self correcting. If the last two patients were diagnosed with serious chest pain, surely the next one will be benign. Remember that each ward call is unrelated to the last. * Posterior probability bias * Letting recent or past events thats that are independent of the current case, impact on your estimated likelihood of a diagnosis. * Ockham’s razor * The simplest answer is more likely to be correct. Another way of saying it is that the more assumptions you have to make, the more unlikely an explanation is. Also, that a single diagnosis that explains the patient’s symptoms is more likely, than seperate diseases occurring concurrently. * Hickam’s dictum * The counter to Ockham’s razor. Patients can have as many diseases as they damn well please. * <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911807/" rel="noopener nofollow" target="_blank">Larry Weed – The Father of the Problem-Oriented Medical Record</a> Apps * <a href="http://info.isabelhealthcare.com/isabel-iphone-app" rel="noopener nofollow" target="_blank">Isabel</a> * <a href="https://www.visualdx.com" rel="noopener nofollow" target="_blank">VisualDX</a> * <a href="https://accessmedicine.mhmedical.com/Diagnosaurus.aspx?categoryid=41309&amp;selectedletter=A" rel="noopener nofollow" target="_blank">Diagnosaurus</a> Podcasts (FOAMed) * <a href="http://imreasoning.com" rel="noopener nofollow" target="_blank">IM Reasoning</a> * <a href="https://www.racp.edu.au/pomcast" rel="noopener nofollow" target="_blank">Pomegranate Health</a> * <a href="https://emcrit.org/category/emcrit/" rel="noopener nofollow" target="_blank">EMCrit</a> * <a href="http://blog.ercast.org/podcasts/" rel="nofollow" target="_blank">ERCast</a> * <a href="https://onthewards.org" rel="noopener nofollow" target="_blank">On the wards</a>

Clinical reasoning

Vani and Sam give suggestions on how to improve these everyday skills that can otherwise take a lifetime to learn.  Why is this important?  * Decisions will be made based on documentation – we are lazy and tend not to verify information. * Allows you to organise your thoughts, review notes, and identify gaps. * Is a legal record and part of your job description. * Inadequate documentation sinks careers. * You will not remember the details years later if there is a complaint. HDC cases tend to occur years after the fact. * Prioritisation is an art and is learnt through experience. It is however important to know what the expectations are and not cause harm through poor prioritisation.  Types of documentation  * Ward round notes * HO notes * Ward call notes * Plans * Lab requests * Referrals * Clinic letters * Procedure notes * Op notes * Discharge summaries * Sick notes * Supporting letters * Death certificates  All documentation  * Title * Date/time * Reason for review/note * 1 line summary * SOAP (Subjective, Objective, Assessment, Plan) or HEIIP (History, Exam, Investigations, Impression, Plan) * Pertinent info * Solid plan * Your name + pager * Never change a note  Prioritisation  * Let time heal * Trust no one (nonsensical pages, reflux, nebs) * Complete non-urgent tasks ward by ward * Document a plan nurses can follow * Talk to the nurse * Hand over a plan with any jobs * Give a reason for jobs (e.g. fluid review) * Handover on time, handover your jobs * Don’t come to work sick * Perfect is the enemy of good.  Handover  * What makes a good handover? * Concise and objective * Clear plan for pending results * Clear priority * Concise! Most of what you say will be forgotten, so make it count. * Why is it important? * Safety! * Helps with prioritisation * Opportunity to discuss cases with a colleague * Allows you to relax and sleep after you’ve gone home * What is appropriate to handover? * Jobs to be done * Investigations to be chased and plan * Patients to be reviewed * Sick patients * Patients expected to die * Patients for whom you feel additional context would be useful. Don’t just hand over patients the next house officer “might get paged about”. * Go home on time. * Weekend plan * Prepare discharge summaries and referrals

Vani and Sam give suggestions on how to improve these everyday skills that can otherwise take a lifetime to learn.  Why is this important? * Decisions will be made based on documentation – we are lazy and tend not to verify information. * Allows you to organise your thoughts, review notes, and identify gaps. * Is a legal record and part of your job description. * Inadequate documentation sinks careers. * You will not remember the details years later if there is a complaint. HDC cases tend to occur years after the fact. * Prioritisation is an art and is learnt through experience. It is however important to know what the expectations are and not cause harm through poor prioritisation. Types of documentation * Ward round notes * HO notes * Ward call notes * Plans * Lab requests * Referrals * Clinic letters * Procedure notes * Op notes * Discharge summaries * Sick notes * Supporting letters * Death certificates All documentation * Title * Date/time * Reason for review/note * 1 line summary * SOAP (Subjective, Objective, Assessment, Plan) or HEIIP (History, Exam, Investigations, Impression, Plan) * Pertinent info * Solid plan * Your name + pager * Never change a note Prioritisation * Let time heal * Trust no one (nonsensical pages, reflux, nebs) * Complete non-urgent tasks ward by ward * Document a plan nurses can follow * Talk to the nurse * Hand over a plan with any jobs * Give a reason for jobs (e.g. fluid review) * Handover on time, handover your jobs * Don’t come to work sick * Perfect is the enemy of good. Handover * What makes a good handover? * Concise and objective * Clear plan for pending results * Clear priority * Concise! Most of what you say will be forgotten, so make it count. * Why is it important? * Safety! * Helps with prioritisation * Opportunity to discuss cases with a colleague * Allows you to relax and sleep after you’ve gone home * What is appropriate to handover? * Jobs to be done * Investigations to be chased and plan * Patients to be reviewed * Sick patients * Patients expected to die * Patients for whom you feel additional context would be useful. Don’t just hand over patients the next house officer “might get paged about”. * Go home on time. * Weekend plan * Prepare discharge summaries and referrals

Documentation, prioritisation, and handover

Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call. Differential  * Life threatening  * ACS * PE * Dissection * Cardiac tamponade * Pneumonia * Pneumothorax * Oesophageal bleed* Heart  * Pericarditis* Lungs  * Mechanical (foreign body, surgical, chest drain, post-pleurocentesis)* Oesophagus  * Reflux * Oesophagitis * Oesophageal spasm* MSK  * Musculoskeletal * Costochondritis * Rib fracture* Below the chest  * Upper abdominal pain* Above the chest  * AnxietyApproach  * Eyeball the patient * ABCs  * Calling a code  * 777 (or your local hospital emergency number) * This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3.* History  * SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity) * Previous similar episodes? History of exertion chest pain? * Diaphoresis * Shortness of breath * Review of systems* Identify risk factors * Vitals + Examination  * General inspection + peripheries * Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues * Abdomen, calves, catheter and drains (for completeness)*  ECG  * Take your time and be systematic * Look at an old ECG * Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves. * Look for contiguous and reciprocal abnormalities. * T wave change normal variants occur in III, aVR, V1. * A repeat ECG in 15 minutes is useful to identify dynamic changes.* Consider investigations  * FBC, U&amp;E, troponin * CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm)* Management  * Call for help (code or at least registrar support) * Attach continuous monitoring e.g. defibrillator pads * Re-assess stability of the patient * Oxygen only if hypoxic * GTN spray * Opiate analgesia (IV morphine boluses ideally) * Determine bleeding risk  * Identify any anti-platelet and anti-coagulation medicines in use * Post-operative status * Consider loading with aspirin 300 mg PO* Document  * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. Have you eliminated life threatening conditions? * Consider TIMI or HEART score (acknowledging use outside of ED) * Clear and specific plan * Consider discussion with senior and escalation, especially if called back to patient againSpecificity of chest pain symptoms and examination findings [Evidence] Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735  * No single finding rules in or rules out acute coronary syndrome. * The most specific (convincing) symptoms of ACS were:  * Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).

Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call. Differential * Life threatening * ACS * PE * Dissection * Cardiac tamponade * Pneumonia * Pneumothorax * Oesophageal bleed * Heart * Pericarditis * Lungs * Mechanical (foreign body, surgical, chest drain, post-pleurocentesis) * Oesophagus * Reflux * Oesophagitis * Oesophageal spasm * MSK * Musculoskeletal * Costochondritis * Rib fracture * Below the chest * Upper abdominal pain * Above the chest * Anxiety Approach * Eyeball the patient * ABCs * Calling a code * 777 (or your local hospital emergency number) * This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3. * History * SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity) * Previous similar episodes? History of exertion chest pain? * Diaphoresis * Shortness of breath * Review of systems * Identify risk factors * Vitals + Examination * General inspection + peripheries * Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues * Abdomen, calves, catheter and drains (for completeness) *  ECG * Take your time and be systematic * Look at an old ECG * Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves. * Look for contiguous and reciprocal abnormalities. * T wave change normal variants occur in III, aVR, V1. * A repeat ECG in 15 minutes is useful to identify dynamic changes. * Consider investigations * FBC, U&amp;E, troponin * CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm) * Management * Call for help (code or at least registrar support) * Attach continuous monitoring e.g. defibrillator pads * Re-assess stability of the patient * Oxygen only if hypoxic * GTN spray * Opiate analgesia (IV morphine boluses ideally) * Determine bleeding risk * Identify any anti-platelet and anti-coagulation medicines in use * Post-operative status * Consider loading with aspirin 300 mg PO * Document * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. Have you eliminated life threatening conditions? * Consider TIMI or HEART score (acknowledging use outside of ED) * Clear and specific plan * Consider discussion with senior and escalation, especially if called back to patient again Specificity of chest pain symptoms and examination findings [Evidence] <a href="https://www.ncbi.nlm.nih.gov/pubmed/26547467" rel="noopener nofollow" target="_blank">Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735</a> * No single finding rules in or rules out acute coronary syndrome. * The most specific (convincing) symptoms of ACS were: * Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).

Chest pain

Sam and Vani explore the most common requests for after hours prescribing and how to safely and quickly approach prescribing of insulin, warfarin, analgesia, antiemetics, and sleeping tablets. Insulin  * Generally treat any blood glucose of 20 or above. * Target range:  * Inpatient: 7 – 14 mmol/L * Outpatient: 4 – 10 mmol/L * Achieving target 60% of the time is quite good!* Neglecting high BSLs leads to irritating symptoms, opportunistic infections and delayed recovery. * Correct BSLs with a rapid acting insulin (Novorapid)  * Correction doses should be given at meals and no more frequently than 4 hourly. * If correction doses of insulin are required, consider increasing the person’s usual insulin / treatment. * Don’t recheck BSLs too early. Wait until the next scheduled check, unless there is concern of hypoglycaemia. * Don’t use ActRapid – it works slowly subcut so should only be used IV.* Diabetes in pregnancy requires frequent adjustment and tighter control – consult a senior. * Don’t withhold long acting insulin (Lantus and insulin degludec) if NBM, even if on a GIK.  Antiemetics  * Cyclizine (NZF)  * Antihistimine * Classic, old-school, and effective * Great for non-iatrogenic nausea and vomiting * Can give euphoria IV, so avoid in young patients specifically requesting it and in the elderly * 25 – 50 mg PO/IV TDS PRN* Ondansetron (NZF)  * Serotonin antagonist * Newer, but not necessarily better antiemetic * Primarily indicated for PONV and chemotherapy-induced nausea * Can be constipating * Can reduce the effectiveness of tramadol, so avoid co-prescription * 10 mg PO/IV TDS PRN*  Metoclopramide (NZF)  * Dopamine antagonist * Gastric stimulant, avoid in suspected small bowl obstruction * Avoid co-prescribing with droperidol and prochlorperizine * Avoid in Parkinson’s disease * Avoid in under 20 year olds due to risk of oculogyric crisis * 10 mg PO/IV TDS PRN* Domperidone (NZF)  * Somewhat interchangeable with metoclopramide, but no IV formulation * Does not cross BBB, so preferred in Parkinson’s disease * 10 mg PO TDS PRN* Droperidol (NZF)  * Dopamine antagonist * Usually prescribed by anaesthetics for PONV * 0.625–1.25 mg IV Q6H PRN* Scopoderm patch (NZF)  * Nonspecific antimuscarinic * Usually prescribed by anaesthetics for PONV * 1 patch Q72H* Prochlorperazine (NZF)  * Oral: 20 mg initially then 10 mg after 2 hours; prevention 5–10 mg 2–3 times daily * Rectal: 25 mg when required followed if necessary after 6 hours by an oral dose, as above * Don’t confuse with chlorpromazine!Analgesia  * Pain assessment  * Try to get some kind of assessment documented e.g. verbal pain score* Pain ladder  * Simple analgesia e.g. paracetamol +/- NSAID * “Weak” opioides e.g. tramadol or codeine * Titrate up opiates e.g. morphine or oxycodone

Sam and Vani explore the most common requests for after hours prescribing and how to safely and quickly approach prescribing of insulin, warfarin, analgesia, antiemetics, and sleeping tablets. Insulin * Generally treat any blood glucose of 20 or above. * Target range: * Inpatient: 7 – 14 mmol/L * Outpatient: 4 – 10 mmol/L * Achieving target 60% of the time is quite good! * Neglecting high BSLs leads to irritating symptoms, opportunistic infections and delayed recovery. * Correct BSLs with a rapid acting insulin (Novorapid) * Correction doses should be given at meals and no more frequently than 4 hourly. * If correction doses of insulin are required, consider increasing the person’s usual insulin / treatment. * Don’t recheck BSLs too early. Wait until the next scheduled check, unless there is concern of hypoglycaemia. * Don’t use ActRapid – it works slowly subcut so should only be used IV. * Diabetes in pregnancy requires frequent adjustment and tighter control – consult a senior. * Don’t withhold long acting insulin (Lantus and insulin degludec) if NBM, even if on a GIK. Antiemetics * Cyclizine (<a href="http://nzf.org.nz/nzf_2359" rel="noopener nofollow" target="_blank">NZF</a>) * Antihistimine * Classic, old-school, and effective * Great for non-iatrogenic nausea and vomiting * Can give euphoria IV, so avoid in young patients specifically requesting it and in the elderly * 25 – 50 mg PO/IV TDS PRN * Ondansetron (<a href="http://nzf.org.nz/nzf_2392" rel="noopener nofollow" target="_blank">NZF</a>) * Serotonin antagonist * Newer, but not necessarily better antiemetic * Primarily indicated for PONV and chemotherapy-induced nausea * Can be constipating * Can reduce the effectiveness of tramadol, so avoid co-prescription * 10 mg PO/IV TDS PRN *  Metoclopramide (<a href="http://nzf.org.nz/nzf_2384" rel="noopener nofollow" target="_blank">NZF</a>) * Dopamine antagonist * Gastric stimulant, avoid in suspected small bowl obstruction * Avoid co-prescribing with droperidol and prochlorperizine * Avoid in Parkinson’s disease * Avoid in under 20 year olds due to risk of oculogyric crisis * 10 mg PO/IV TDS PRN * Domperidone (<a href="http://nzf.org.nz/nzf_2382" rel="noopener nofollow" target="_blank">NZF</a>) * Somewhat interchangeable with metoclopramide, but no IV formulation * Does not cross BBB, so preferred in Parkinson’s disease * 10 mg PO TDS PRN * Droperidol (<a href="http://nzf.org.nz/nzf_2372" rel="noopener nofollow" target="_blank">NZF</a>) * Dopamine antagonist * Usually prescribed by anaesthetics for PONV * 0.625–1.25 mg IV Q6H PRN * Scopoderm patch (<a href="http://nzf.org.nz/nzf_6936" rel="noopener nofollow" target="_blank">NZF</a>) * Nonspecific antimuscarinic * Usually prescribed by anaesthetics for PONV * 1 patch Q72H * Prochlorperazine (<a href="http://nzf.org.nz/nzf_2147" rel="noopener nofollow" target="_blank">NZF</a>) * Oral: 20 mg initially then 10 mg after 2 hours; prevention 5–10 mg 2–3 times daily * Rectal: 25 mg when required followed if necessary after 6 hours by an oral dose, as above * Don’t confuse with chlorpromazine! Analgesia * Pain assessment * Try to get some kind of assessment documented e.g. verbal pain score * Pain ladder * Simple analgesia e.g. paracetamol +/- NSAID * “Weak” opioides e.g. tramadol or codeine * Titrate up opiates e.g. morphine or oxycodone

Prescribing calls

Most RMOs don’t ever get around to reading the their employment contract (MECA). In this episode, Sam talks to NZRDA advocates Melissa Dobbyn and Tara Martin about what you need to know, and where to get help.  * Key concepts to be familiar with  * Cross cover outside ordinary hours (XXOOH) * Cross cover * Max 2 long days in 7 * 72 hour rule * 144 hour rule * 8 hour break rule * 1:2/1:3 weekend rule + safer roster exception * Sleep recovery days*  Leave  * Entitlement * Leave abutting weekends * Lieu days  * 14 days, undeniable * Abutting rule doesn’t count * Can’t be transferred * Can’t be used on statutory holiday* Leave transfer * Sick leave * Parental leave*   Costs of training  * Entitlements as a house officer * APC application and renewal * Insurance * MEL  * Rarely granted in PGY1, discretionary * PGY2+ entitled to 5 days/year, extendable to 2 weeks for PGDip OMG/Paeds * There is a 12 week total entitlement per vocational pathway, but isn’t something to be too worried about at this stage. Will probably increase. DHBs are required to help you get through training. * Includes interviews, transport, flights, accommodation*  Keep a work diary from day 1  * Leave applied/taken/transferred * Claims made/paid*  Rosters  * Published 28 days before, then can’t change, otherwise after hours shifts are optional * 14 days for reliever, paid 2 categories above * Short notice relief – know the rules * Part of a run desctiption – cannot be changed with 2/3 agreement by RMOs concerned * Run review*  Insurance  * NZMPI  * Provides actual insurance, governed by NZ insurance law * NZ company, NZRDA is a shareholder* MPS  * Provides discretionary cover, not governed by NZ insurance law * UK company* Medicus*  Superannuation  * Entitled to 6% of your salary to superannuation * Can put it all into Kiwisaver or all into a scheme * Or split 3%/3% * There is an NZRDA scheme, but also some others. Just make sure you’re signed up to something to receive your entitlement.*  Where to get help (you need to be an RDA member)  * Local delegate * ask@nzrda.org.nz * MECA and MECA FAQ * Join the RDA * Free for TIs * $40/month by direct debit or $480/year direct debit or credit card.*  RDA membership  * 90% of RMOs are members. * RDA is the only organisation solely representing RMOs. They do not represent SMOs, GPs or anyone in management. * If you run into trouble during your career an RMO, you will be far more likely to have a good outcome if you are an RDA member. RDA will provide extensive help, but only if you were a member at the time the problem arose. This is seperate to medical indemnity cover, that won’t cover professional and industrial issues. * Our working conditions are only good because RDA members before you fought hard for them. Where union membership is low, the conditions erode. Look no further than the UK where the pay is bad, job satisfaction low, expenses not reimbursed,

Most RMOs don’t ever get around to reading the their employment contract (MECA). In this episode, Sam talks to NZRDA advocates Melissa Dobbyn and Tara Martin about what you need to know, and where to get help. * Key concepts to be familiar with * Cross cover outside ordinary hours (XXOOH) * Cross cover * Max 2 long days in 7 * 72 hour rule * 144 hour rule * 8 hour break rule * 1:2/1:3 weekend rule + safer roster exception * Sleep recovery days *  Leave * Entitlement * Leave abutting weekends * Lieu days * 14 days, undeniable * Abutting rule doesn’t count * Can’t be transferred * Can’t be used on statutory holiday * Leave transfer * Sick leave * Parental leave *   Costs of training * Entitlements as a house officer * APC application and renewal * Insurance * MEL * Rarely granted in PGY1, discretionary * PGY2+ entitled to 5 days/year, extendable to 2 weeks for PGDip OMG/Paeds * There is a 12 week total entitlement per vocational pathway, but isn’t something to be too worried about at this stage. Will probably increase. DHBs are required to help you get through training. * Includes interviews, transport, flights, accommodation *  Keep a work diary from day 1 * Leave applied/taken/transferred * Claims made/paid *  Rosters * Published 28 days before, then can’t change, otherwise after hours shifts are optional * 14 days for reliever, paid 2 categories above * Short notice relief – know the rules * Part of a run desctiption – cannot be changed with 2/3 agreement by RMOs concerned * Run review *  Insurance * NZMPI * Provides actual insurance, governed by NZ insurance law * NZ company, NZRDA is a shareholder * MPS * Provides discretionary cover, not governed by NZ insurance law * UK company * Medicus *  Superannuation * Entitled to 6% of your salary to superannuation * Can put it all into Kiwisaver or all into a scheme * Or split 3%/3% * There is an <a href="https://www.nzrda.org.nz/nzrda-member-superannuation-scheme/" rel="noopener nofollow" target="_blank">NZRDA scheme</a>, but also some others. Just make sure you’re signed up to something to receive your entitlement. *  Where to get help (you need to be an RDA member) * Local delegate * <a href="mailto:ask@nzrda.org.nz">ask@nzrda.org.nz</a> * <a href="https://www.nzrda.org.nz/meca/" rel="noopener nofollow" target="_blank">MECA</a> and <a href="https://www.nzrda.org.nz/meca/meca-faqs/" rel="noopener nofollow" target="_blank">MECA FAQ</a> * <a href="https://www.nzrda.org.nz/how-to-become-an-nzrda-member/" rel="noopener nofollow" target="_blank">Join the RDA</a> * Free for TIs * $40/month by direct debit or $480/year direct debit or credit card. *  RDA membership * 90% of RMOs are members. * RDA is the only organisation solely representing RMOs. They do not represent SMOs, GPs or anyone in management. * If you run into trouble during your career an RMO, you will be far more likely to have a good outcome if you are an RDA member. RDA will provide extensive help, but only if you were a member at the time the problem arose. This is seperate to medical indemnity cover, that won’t cover professional and industrial issues. * Our working conditions are only good because RDA members before you fought hard for them. Where union membership is low, the conditions erode. Look no further than the UK where the pay is bad, job satisfaction low, expenses not reimbursed,

Starting work and the MECA

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about reduced consciousness and acute and post-seizure management. Approach to fluctuating GCS  * Eyeball the patient / ABCs  * Calling a code – certainly if the patient is not rousable!  * 777 (or your local hospital emergency number) * This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.* Initial assessment  * Big picture * Vitals * Pupils  * Wide: drugs, alcohol, adrenaline * Constricted: opiates* How does the patient respond to questions?* Assess GCS * Differential  * Intracranial or extracranial? * Surgical sieve * Overdose, head injury, seizure, diabetic, epileptic, previous episodes, medications * Don’t ever forget glucose* Collateral history, including from other patients in the room * Vitals + Examination  * General inspection + peripheries * Neuro exam aimed at identifying localising signs* Consider investigations  * ABGs, glucose, FBC, electrolytes, creatinine, cardiac enzymes, ketones, TFTs, blood cultures, alcohol, coags * ECG, CXR, catheter urine * Consider CT head, LP * Rarely toxicology (urine and blood)* Consider the “3 coma antidotes”  * Glucose: if hypoglycaemia confirmed on BSL give 100mL of glucose 10% IV * Thiamine: 100mg IV/IM (for patients with chronic alcohol abuse or chronic malnutrition) * Naloxone:  * 400 micrograms (1 ampule) in a resus situation (concerned about airway) * 80 microgram boluses for somnolent patients that are just difficult to rouse. Repeat every minute with a 10 mL flush until alert. * Maximum of 10 mg in total. * Note short half-life, so often need repeat doses.* Document  * Basics (date/time/name/reason for review). * Positives and pertinent negatives. * Impression and differential with justification. * Clear and specific plan. * Consider discussion with senior and escalation.Acute seizure management  * DRSABCs * Airway  * 100% oxygen via non-rebreather or bag mask * Recovery position (protect the patient and staff from injury)* Breathing  * Sats probe* Circulation  * Pulse * CRT* Don’t attempt BP during seizure * Duration &gt;5 minutes  * Code code if not done already * IV access (IO if failed IV) * Seizure control:  * Lorazepam (or midazolam) 4 mg IV (give 2 mg, flush, then another 2 mg slowly and flush). * IM midazolam 10 mg is the treatment of choice if no IV access is available. The dose may be repeated if required after 10 minutes. Maximum midazolam dose of 20 mg IM over 24 hours. * Rectal diazepam 10 mg if above not IV and IM access unavailable (empty rectum first). * Lorazepam has a longer anti-epileptic effect than diazepam as it is not redistributed to adipose tissue. If lorazepam is not immediately available do not delay but proceed with diazepam or midazolam. * An anticonvulsant must be started if there is more than one seizure.Post-seizure management  * IV access * Secondary survey for injury and infective causes * History and description of the events surrounding the seizure.  * Who witnessed it? * What situation was the patient in before it started? * Incontinence or tongue biting. * Post-ictal features. * Does the patient remember the episode?

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about reduced consciousness and acute and post-seizure management. Approach to fluctuating GCS * Eyeball the patient / ABCs * Calling a code – certainly if the patient is not rousable! * 777 (or your local hospital emergency number) * This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3. * Initial assessment * Big picture * Vitals * Pupils * Wide: drugs, alcohol, adrenaline * Constricted: opiates * How does the patient respond to questions? * Assess GCS * Differential * Intracranial or extracranial? * Surgical sieve * Overdose, head injury, seizure, diabetic, epileptic, previous episodes, medications * Don’t ever forget glucose * Collateral history, including from other patients in the room * Vitals + Examination * General inspection + peripheries * Neuro exam aimed at identifying localising signs * Consider investigations * ABGs, glucose, FBC, electrolytes, creatinine, cardiac enzymes, ketones, TFTs, blood cultures, alcohol, coags * ECG, CXR, catheter urine * Consider CT head, LP * Rarely toxicology (urine and blood) * Consider the “3 coma antidotes” * Glucose: if hypoglycaemia confirmed on BSL give 100mL of glucose 10% IV * Thiamine: 100mg IV/IM (for patients with chronic alcohol abuse or chronic malnutrition) * Naloxone: * 400 micrograms (1 ampule) in a resus situation (concerned about airway) * 80 microgram boluses for somnolent patients that are just difficult to rouse. Repeat every minute with a 10 mL flush until alert. * Maximum of 10 mg in total. * Note short half-life, so often need repeat doses. * Document * Basics (date/time/name/reason for review). * Positives and pertinent negatives. * Impression and differential with justification. * Clear and specific plan. * Consider discussion with senior and escalation. Acute seizure management * DRSABCs * Airway * 100% oxygen via non-rebreather or bag mask * Recovery position (protect the patient and staff from injury) * Breathing * Sats probe * Circulation * Pulse * CRT * Don’t attempt BP during seizure * Duration &gt;5 minutes * Code code if not done already * IV access (IO if failed IV) * Seizure control: * Lorazepam (or midazolam) 4 mg IV (give 2 mg, flush, then another 2 mg slowly and flush). * IM midazolam 10 mg is the treatment of choice if no IV access is available. The dose may be repeated if required after 10 minutes. Maximum midazolam dose of 20 mg IM over 24 hours. * Rectal diazepam 10 mg if above not IV and IM access unavailable (empty rectum first). * Lorazepam has a longer anti-epileptic effect than diazepam as it is not redistributed to adipose tissue. If lorazepam is not immediately available do not delay but proceed with diazepam or midazolam. * An anticonvulsant must be started if there is more than one seizure. Post-seizure management * IV access * Secondary survey for injury and infective causes * History and description of the events surrounding the seizure. * Who witnessed it? * What situation was the patient in before it started? * Incontinence or tongue biting. * Post-ictal features. * Does the patient remember the episode?

Fluctuating GCS and seizures

Sam talks to Infectious Diseases Physician Assoc. Prof Mark Thomas about fever and the minutiae of microbiological investigations. Cause of fever  * Infection (cytokines) * Atelectasis * Medications including transfusion reaction * Alcohol withdrawal * PE * Malignancy  Approach  * Eyeball the patient / ABCs * History should be directed at identifying evidence of infection across the following systems:  * Lungs * Gastrointestinal * Genitourinary * Skin * Central nervous system * Surgical and cannula/drain sites * Note: eyes, ears, nose throat are rare infection sources in an adult hospital setting* Identify timing since surgery or invasive procedures.  * Dirty surgery may cause early infection, but is rare with routine prophylactic antibiotics. * 2-7 days post-op increased risk of operative infection * 7+ days think alternatives like PE as well as intrabdominal collection and joints* Identify risk factors for deteriorating quickly  * Diabetes * Neutropenia * Immune deficiency* Vitals + Examination  * General inspection + peripheries * Lungs * Abdomen * Skin (including spinal anaesthesia sites) * Surgical and cannula sites * CNS if history supports it (though beware the non-specificity of classical meningism)* Investigations  * Review microbiology for updated reports * FBC, U&amp;E, CRP * ABG for sepsis * Directed culture  * Blood  * At least 2 setsv(4 bottles)* Urine * Faeces * Sputum* Directed imaging  * CXR * CT abdo pelvis * Renal USS for renal abscess in urosepsis* Management  * Fluids * Antibiotics * Oxygen if desaturating * Contact precautions * Investigations/culture* Document  * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives by system * Impression and differential with justification. Have you eliminated life threatening conditions? * Clear and specific plan  * Who will chasing investigations? * Monitoring parameters* Consider discussion with senior and escalation, especially if called back to patient again or there are concerns about source control or neutropenia  Resources  * BPAC common antibiotics guideline (2017) * The Third International Consensus Definitions for Sepsis and Septic Shock

Sam talks to Infectious Diseases Physician Assoc. Prof Mark Thomas about fever and the minutiae of microbiological investigations. Cause of fever * Infection (cytokines) * Atelectasis * Medications including transfusion reaction * Alcohol withdrawal * PE * Malignancy Approach * Eyeball the patient / ABCs * History should be directed at identifying evidence of infection across the following systems: * Lungs * Gastrointestinal * Genitourinary * Skin * Central nervous system * Surgical and cannula/drain sites * Note: eyes, ears, nose throat are rare infection sources in an adult hospital setting * Identify timing since surgery or invasive procedures. * Dirty surgery may cause early infection, but is rare with routine prophylactic antibiotics. * 2-7 days post-op increased risk of operative infection * 7+ days think alternatives like PE as well as intrabdominal collection and joints * Identify risk factors for deteriorating quickly * Diabetes * Neutropenia * Immune deficiency * Vitals + Examination * General inspection + peripheries * Lungs * Abdomen * Skin (including spinal anaesthesia sites) * Surgical and cannula sites * CNS if history supports it (though beware the non-specificity of classical meningism) * Investigations * Review microbiology for updated reports * FBC, U&amp;E, CRP * ABG for sepsis * Directed culture * Blood * At least 2 setsv(4 bottles) * Urine * Faeces * Sputum * Directed imaging * CXR * CT abdo pelvis * Renal USS for renal abscess in urosepsis * Management * Fluids * Antibiotics * Oxygen if desaturating * Contact precautions * Investigations/culture * Document * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives by system * Impression and differential with justification. Have you eliminated life threatening conditions? * Clear and specific plan * Who will chasing investigations? * Monitoring parameters * Consider discussion with senior and escalation, especially if called back to patient again or there are concerns about source control or neutropenia Resources * <a href="http://www.bpac.org.nz/antibiotics/guide.aspx" rel="noopener nofollow" target="_blank">BPAC common antibiotics guideline (2017)</a> * <a href="https://www.ncbi.nlm.nih.gov/pubmed/26903338" rel="noopener nofollow" target="_blank">The Third International Consensus Definitions for Sepsis and Septic Shock</a>

Fever

The NZ podcast approaching ward calls and house officer life

Patient has fallen, please review. Vani talks to Geriatrician and fall expert Dr Cheryl Johnson about an approach to falls and when to order that head CT. Fall causes Common  * Delirium * Visual impairment * Peripheral sensory neuropathy * Stroke/TIA * Joint buckling/instability * Deconditioning * Medication effect or polypharmacy * Enviromental hazards  Uncommon  * Vestibular dysfunction * Gait disorder * Dementia * Depression * Seizure * Subdural haematoma * Syncope * Orthostatic hypotension * Mechanical mobility/gait disorder * Substance abuse * Carotid sinus hypersensitivity * Postprandial hypotension  Approach  * Eyeball the patient / ABCs * History  * Is this a collapse or a fall? * From patient and witness  * What were they doing before the fall? * Do they remember it happening? * Do they remember hitting the ground? * What part of the body hit the ground first? * How did they get back up again? * “And then what happened?” * Any other falls? * Any near falls? * Using walking aid? On their own? * Preceding symptoms? * LOC? * Any injury or pain? * Head injury? * Review of symptoms* Red flags  * Medications * Sleeping tabs, opiates * Head injury/alterered neurological status * Non-weight bearing * Don’t be reassured by a normal plain film* Factors that increase risk of fall in hospital  * Poor lighting * Slippery floors * Equipment in rooms and hallways that gets in the way * Being weak from illness or surgery * Being in new surroundings* Vitals + Examination  * General inspection * Top to bottom – squeeze everywhere and everything * Scalp * Joints * Ribs * Pelvis * Cardiorespiratory examination * Abdomen for signs of intraabdominal haemorrhage (peritonism) * Neurological exam/peripheral neuropathy * Lying and standing BP, can be deferred to next day * Check for injury, such as cuts, scrapes, and bruises. Always visualise and palpate the scalp (a significant injury can be easily obscured by hair).* Investigations  * FBC, U&amp;E, glucose, vitamin B12/folate, TFT, ECG, septic screen (if indicted) * Head CT (if head impact, neurological change, altered mental state/delirium, anticoagulant/antiplatelets, worried)* Management  * Treat skin tears * Dressing/sutures * Analgesia * Hospital fall protocol * Review and withhold meds/flag for team review * Lying and standing BP * Infection/delirium management * ACC paperwork * Risk reduction  * Bed height/remove rails * Hip protectors * Grippy socks * Hearing aid/glasses * Watch or increased frequency of observations* Document  * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. Have you eliminated intracranial haemorrhage? * Clear and specific plan * Consider discussion with senior and escalation, especially if called back to patient againResources  * Health Quality &amp; Safety Commission New Zealand. Falls in people aged 50 and over. 

Patient has fallen, please review. Vani talks to Geriatrician and fall expert Dr Cheryl Johnson about an approach to falls and when to order that head CT. Fall causes Common * Delirium * Visual impairment * Peripheral sensory neuropathy * Stroke/TIA * Joint buckling/instability * Deconditioning * Medication effect or polypharmacy * Enviromental hazards Uncommon * Vestibular dysfunction * Gait disorder * Dementia * Depression * Seizure * Subdural haematoma * Syncope * Orthostatic hypotension * Mechanical mobility/gait disorder * Substance abuse * Carotid sinus hypersensitivity * Postprandial hypotension Approach * Eyeball the patient / ABCs * History * Is this a collapse or a fall? * From patient and witness * What were they doing before the fall? * Do they remember it happening? * Do they remember hitting the ground? * What part of the body hit the ground first? * How did they get back up again? * “And then what happened?” * Any other falls? * Any near falls? * Using walking aid? On their own? * Preceding symptoms? * LOC? * Any injury or pain? * Head injury? * Review of symptoms * Red flags * Medications * Sleeping tabs, opiates * Head injury/alterered neurological status * Non-weight bearing * Don’t be reassured by a normal plain film * Factors that increase risk of fall in hospital * Poor lighting * Slippery floors * Equipment in rooms and hallways that gets in the way * Being weak from illness or surgery * Being in new surroundings * Vitals + Examination * General inspection * Top to bottom – squeeze everywhere and everything * Scalp * Joints * Ribs * Pelvis * Cardiorespiratory examination * Abdomen for signs of intraabdominal haemorrhage (peritonism) * Neurological exam/peripheral neuropathy * Lying and standing BP, can be deferred to next day * Check for injury, such as cuts, scrapes, and bruises. Always visualise and palpate the scalp (a significant injury can be easily obscured by hair). * Investigations * FBC, U&amp;E, glucose, vitamin B12/folate, TFT, ECG, septic screen (if indicted) * Head CT (if head impact, neurological change, altered mental state/delirium, anticoagulant/antiplatelets, worried) * Management * Treat skin tears * Dressing/sutures * Analgesia * Hospital fall protocol * Review and withhold meds/flag for team review * Lying and standing BP * Infection/delirium management * ACC paperwork * Risk reduction * Bed height/remove rails * Hip protectors * Grippy socks * Hearing aid/glasses * Watch or increased frequency of observations * Document * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. Have you eliminated intracranial haemorrhage? * Clear and specific plan * Consider discussion with senior and escalation, especially if called back to patient again Resources * <a href="https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/falls" rel="noopener nofollow" target="_blank">Health Quality &amp; Safety Commission New Zealand. Falls in people aged 50 and over. </a>

Falls

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about differentiating and managing hypotension. Differential  * Life threatening  * Acute haemorrhage  * On the floor and four more* Sepsis * Arrhythmia/cardiac * Drugs (including transfusion reaction) * Anaphylaxis* Dehydration (beware the accuracy of this diagnosis) * Epidural anaesthesia * Heart failure * Pregnancy * Syncope/postural * Neurological  * Positional * PD * DiabetesApproach  * Eyeball the patient / ABCDEF * Calling a code  * 777 (or your local hospital emergency number) * This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.* History  * Why are they in hospital? * Post-op? * Onset, timing &amp; trend of hypotension * Postural * Medications * Associated symptoms  * Pain is very concerning* ROS* Vitals + Examination  * End-of-bed-o-gram is probably the most important * Peripheries for perfusion and pulse * Manual BP  * Both arms * Cuff size* Urine output * Drain output* Consider investigations  * Keep in mind these may be of limited value * ABG (lactate, glucose, Hb) * ECG* Management  * Fluid challenge only if hypovolaemic  * 250 – 500 mL stat* Rehydrate gradually * Transfusion  * Target Hb &gt;70 * Use one unit then reassess* Avoid transfusion outside daylight hours * Catheterise and measure fluid balance * Fix the underlying cause * Have a low threshold to escalate to a senior * Clear observation and escalation plan if cause is unclear* Document  * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. * Have you eliminated life threatening conditions? * Beware an impression of dehydration. * Are they actually hypovolaemic? * Why would they be dehydrated on the ward? * Clear and specific plan * Monitoring * Consider discussion with senior and escalation, especially if called back to patient again

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about differentiating and managing hypotension. Differential * Life threatening * Acute haemorrhage * On the floor and four more * Sepsis * Arrhythmia/cardiac * Drugs (including transfusion reaction) * Anaphylaxis * Dehydration (beware the accuracy of this diagnosis) * Epidural anaesthesia * Heart failure * Pregnancy * Syncope/postural * Neurological * Positional * PD * Diabetes Approach * Eyeball the patient / ABCDEF * Calling a code * 777 (or your local hospital emergency number) * This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3. * History * Why are they in hospital? * Post-op? * Onset, timing &amp; trend of hypotension * Postural * Medications * Associated symptoms * Pain is very concerning * ROS * Vitals + Examination * End-of-bed-o-gram is probably the most important * Peripheries for perfusion and pulse * Manual BP * Both arms * Cuff size * Urine output * Drain output * Consider investigations * Keep in mind these may be of limited value * ABG (lactate, glucose, Hb) * ECG * Management * Fluid challenge only if hypovolaemic * 250 – 500 mL stat * Rehydrate gradually * Transfusion * Target Hb &gt;70 * Use one unit then reassess * Avoid transfusion outside daylight hours * Catheterise and measure fluid balance * Fix the underlying cause * Have a low threshold to escalate to a senior * Clear observation and escalation plan if cause is unclear * Document * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. * Have you eliminated life threatening conditions? * Beware an impression of dehydration. * Are they actually hypovolaemic? * Why would they be dehydrated on the ward? * Clear and specific plan * Monitoring * Consider discussion with senior and escalation, especially if called back to patient again

Hypotension

Sam discusses shortness of breath and oxygen use with Respiratory and General Medicine advanced trainee Dr Cam Sullivan. We also delve into more advanced pneumonia management and investigation as well general expectations of house officers on ward calls. Differential (acute dyspnoea)  * Life threatening  * PE * Infection * Asthma * Anaphylaxis * Pneumothorax * Pulmonary oedema * Pulmonary haemorrhage (TB or anti-coagulated) * Anaemia * Narcosis* Obstruction  * Chronic/COPD * Foreign body* Atelectasis – especially post-op * Pleural effusion * Cardiac  * Heart failure * Arrhythmia * ACS* Mechanical  * Obesity * Sleep apnoea * Flail chest * Blocked chest drain * Ascites* Drugs * Pregnancy  Approach  * Eyeball the patient * ABCs – respiratory arrest code if the patient is having difficulty talking to you * History  * Onset * Previous shortness of breath * Cough/sputum * Inhaler use * Foreign body * Recent new medications * Rash/oedema * Pain * Review of systems* Identify risk factors/respiratory background * Vitals + Examination  * General inspection * Current oxygen flow rate/FiO2 * Talking in sentences, broken sentences, single words * Peripheries/fluid review * Chest wall movements and auscultation * Listen to the posterior chest! * Listen to the entire breath cycle * Heart sounds * Abdomen * Calf tenderness and swelling  * Not sensitive or specific. No negative predictive value* Chest drain – is it swinging?* Investigations  * ABG * ECG * CXR – consider urgent/portable * Consider FBC, U&amp;E, CRP * Pneumonia microbiology  * Sputum sample  * Consider adding on atypical panel* Urinary antigens * Respiratory panel* Consider D-dimer* Management  * Posture!!! * Chest physio if not clearing secretions (mucous plugging or neuromuscular disease) * Analgesia (if splinting) * Fluid restriction * Frusemide * Prednisone * Antibiotics * Consider discussion with senior and escalation, especially if called back to patient again * Consider transfer to respiratory ward* Document  * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. Have you eliminated life threatening conditions? * Clear and specific plan * Specify target SpO2 range and prescribe oxygen including delivery method.Oxygen delivery  * Target SpO2  * 92 to 96 * 88 to 92 for CO2 retainer* Oxygen delivery methods  * Nasal canulae  * 0.5 – 4 L/min* Hudson mask  * 4 – 10 L/min* Venturi mask  * Fixed FiO2 0.21 – ~0.6 (flow rate determined by attachment) * Varies from Blue: 24%, White: 28%, Yellow: 35%, Red: 40%, Green: 60%* Airvo  * Fixed FiO2 with PEEP* Non-rebreather/reservoir mask  * High FiO2 &gt;0.9, set to 15 L/min, near 100% as long as reservoir bag does not empty* Bag mask  * Approximate FiO2 1.0* BiPAP * Invasive ventilation in ICU

Sam discusses shortness of breath and oxygen use with Respiratory and General Medicine advanced trainee Dr Cam Sullivan. We also delve into more advanced pneumonia management and investigation as well general expectations of house officers on ward calls. Differential (acute dyspnoea) * Life threatening * PE * Infection * Asthma * Anaphylaxis * Pneumothorax * Pulmonary oedema * Pulmonary haemorrhage (TB or anti-coagulated) * Anaemia * Narcosis * Obstruction * Chronic/COPD * Foreign body * Atelectasis – especially post-op * Pleural effusion * Cardiac * Heart failure * Arrhythmia * ACS * Mechanical * Obesity * Sleep apnoea * Flail chest * Blocked chest drain * Ascites * Drugs * Pregnancy Approach * Eyeball the patient * ABCs – respiratory arrest code if the patient is having difficulty talking to you * History * Onset * Previous shortness of breath * Cough/sputum * Inhaler use * Foreign body * Recent new medications * Rash/oedema * Pain * Review of systems * Identify risk factors/respiratory background * Vitals + Examination * General inspection * Current oxygen flow rate/FiO2 * Talking in sentences, broken sentences, single words * Peripheries/fluid review * Chest wall movements and auscultation * Listen to the posterior chest! * Listen to the entire breath cycle * Heart sounds * Abdomen * Calf tenderness and swelling * Not sensitive or specific. No negative predictive value * Chest drain – is it swinging? * Investigations * ABG * ECG * CXR – consider urgent/portable * Consider FBC, U&amp;E, CRP * Pneumonia microbiology * Sputum sample * Consider adding on atypical panel * Urinary antigens * Respiratory panel * Consider D-dimer * Management * Posture!!! * Chest physio if not clearing secretions (mucous plugging or neuromuscular disease) * Analgesia (if splinting) * Fluid restriction * Frusemide * Prednisone * Antibiotics * Consider discussion with senior and escalation, especially if called back to patient again * Consider transfer to respiratory ward * Document * Review past notes * Basics (date/time/name/reason for review) * Positives and pertinent negatives * Impression and differential with justification. Have you eliminated life threatening conditions? * Clear and specific plan * Specify target SpO2 range and prescribe oxygen including delivery method. Oxygen delivery * Target SpO2 * 92 to 96 * 88 to 92 for CO2 retainer * Oxygen delivery methods * Nasal canulae * 0.5 – 4 L/min * Hudson mask * 4 – 10 L/min * Venturi mask * Fixed FiO2 0.21 – ~0.6 (flow rate determined by attachment) * Varies from Blue: 24%, White: 28%, Yellow: 35%, Red: 40%, Green: 60% * Airvo * Fixed FiO2 with PEEP * Non-rebreather/reservoir mask * High FiO2 &gt;0.9, set to 15 L/min, near 100% as long as reservoir bag does not empty * Bag mask * Approximate FiO2 1.0 * BiPAP * Invasive ventilation in ICU

SOB and oxygen

Update March 2018 Since recording, a pilot electronic death certification project has launched. See these resources:  * MOH Death Documents website * MOH press release  The MOH has also released some new guidance to completion of the death certificates and including cause of death. See the resources section at the bottom of this post.  Despite its significance, the verification and certification of death are tasks few RMOs excel at. Sam talks to Dr Garry Clearwater, FACEM and Medical Referee, about the practical aspects of verifying death, and completing the paperwork. Verifying death  * Must be done “immediately after a doctor learns of the death” (within reason). * Body clearly in a state incompatible with life (rigor mortis, decomposition, major injury) or; * Absence of:  * Heart sounds, ideally a minute * Breath sounds * Pupil reactivity * Muscle tone* Recheck if in doubt, or do a rhythm strip * It’s okay to backdate the time of death to when you think it actually occurred.  Clinical notes  * If death verified using a standard approach, simply note absence of vitals on examination. * Otherwise, document details that lead you confirm death.  Cause of death  * Part 1 may be a clear underlying fatal condition e.g. metastatic colon carcinoma, severe dementia. * In part 2, list conditions that would modify your approach to further treatment of the primary cause of death e.g. dementia, cancer, severe cardiac or pulmonary disease. * List enough information for the medical referee to understand why the patient died and further treatment or intensive care was withheld. * If the cause was idiopathic, say so, otherwise list the underlying cause. * Remember to state the obvious, and don’t agonise about making a final diagnosis if it remains uncertain. * Importance of cause of death:  * Used to make resource and funding decisions based on death statistics. * May have implications on surviving family members (genetic predisposition). * Clarifies whether or not it should be a coroners case.Referral to the coroner  * Detailed list available at cremation.org.nz * Essentially anyone who dies:  * An unnatural death (violent, suicide), * Or is in custody, or pregnant, at the time, * Or as a result of injury, * Or unexpectedly as a result of medical treatment or anaesthetic.* An exception applies for death by accident in the frail elderly. Patients over 70 years of age who die due of an injury that was primarily a result of their significant underlying medical condition e.g. Dementia -&gt; NOF# -&gt; death. But you must be certain there was no element of neglect or abuse that contributed, and no other indication for referral to the coroner. More detail on the exception here.  Sighting patients  * It is reasonable to ask (or be asked) to sight a patient expected to die after hours. * This is primarily to benefit the family, as it will allow the body to be removed from the hospital. This is probably the most useful thing you can do, while on call, for the patient and their family. * If asked to sight a patient, you should be familiar with their condition, current treatment and sight them such that you can verify they are alive, and will then be able to identify them once they have ...

Update March 2018 Since recording, a pilot electronic death certification project has launched. See these resources: * <a href="https://deathdocs.services.govt.nz/welcome" rel="noopener nofollow" target="_blank">MOH Death Documents website</a> * <a href="https://www.health.govt.nz/news-media/news-items/online-death-documents-service-launched" rel="noopener nofollow" target="_blank">MOH press release</a> The MOH has also released some new guidance to completion of the death certificates and including cause of death. See the resources section at the bottom of this post. Despite its significance, the verification and certification of death are tasks few RMOs excel at. Sam talks to Dr Garry Clearwater, FACEM and Medical Referee, about the practical aspects of verifying death, and completing the paperwork. Verifying death * Must be done “immediately after a doctor learns of the death” (within reason). * Body clearly in a state incompatible with life (rigor mortis, decomposition, major injury) or; * Absence of: * Heart sounds, ideally a minute * Breath sounds * Pupil reactivity * Muscle tone * Recheck if in doubt, or do a rhythm strip * It’s okay to backdate the time of death to when you think it actually occurred. Clinical notes * If death verified using a standard approach, simply note absence of vitals on examination. * Otherwise, document details that lead you confirm death. Cause of death * Part 1 may be a clear underlying fatal condition e.g. metastatic colon carcinoma, severe dementia. * In part 2, list conditions that would modify your approach to further treatment of the primary cause of death e.g. dementia, cancer, severe cardiac or pulmonary disease. * List enough information for the medical referee to understand why the patient died and further treatment or intensive care was withheld. * If the cause was idiopathic, say so, otherwise list the underlying cause. * Remember to state the obvious, and don’t agonise about making a final diagnosis if it remains uncertain. * Importance of cause of death: * Used to make resource and funding decisions based on death statistics. * May have implications on surviving family members (genetic predisposition). * Clarifies whether or not it should be a coroners case. Referral to the coroner * Detailed list available at <a href="http://cremation.org.nz/styled/styled-5/" rel="noopener nofollow" target="_blank">cremation.org.nz</a> * Essentially anyone who dies: * An unnatural death (violent, suicide), * Or is in custody, or pregnant, at the time, * Or as a result of injury, * Or unexpectedly as a result of medical treatment or anaesthetic. * An exception applies for death by accident in the frail elderly. Patients over 70 years of age who die due of an injury that was primarily a result of their significant underlying medical condition e.g. Dementia -&gt; NOF# -&gt; death. But you must be certain there was no element of neglect or abuse that contributed, and no other indication for referral to the coroner. <a href="http://cremation.org.nz/styled/styled-6/" rel="noopener nofollow" target="_blank">More detail on the exception here</a>. Sighting patients * It is reasonable to ask (or be asked) to sight a patient expected to die after hours. * This is primarily to benefit the family, as it will allow the body to be removed from the hospital. This is probably the most useful thing you can do, while on call, for the patient and their family. * If asked to sight a patient, you should be familiar with their condition, current treatment and sight them such that you can verify they are alive, and will then be able to identify them once they have ...

Verifying and certifying death

The Ward Calls podcast dissects common ward calls you will need to confidently manage as a PGY1 doctor and beyond. We discuss practical, safe and comprehensive approaches that are achievable in the limited time available when working on the ward. The podcast is co-hosted by Dr Vani Chandran and Dr Sam Holford, based in Auckland, New Zealand. We hope to provide guidance applicable to hospitals throughout New Zealand, and expect most of the content to apply to Australia and further abroad. Thanks to the NZRDA Education Trust for making this podcast possible. Feedback Please send feedback, questions and suggestions of what you’d like discussed on the show to feedback@wardcalls.com, or find @wardcalls on Twitter, Facebook or Instagram. And remember to leave us a review on iTunes, to help others find the show. Disclaimer Practicing medicine is to make black and white decisions based on grey information. We can’t cover every possible scenario on this podcast and cannot guarantee accuracy. We’ve done our best to bring you useful and reliable advice, from guests volunteering their time to give expert opinion. Our advice does not replace your local hospital policy or guidelines, nor good clinical judgement.

The Ward Calls podcast dissects common ward calls you will need to confidently manage as a PGY1 doctor and beyond. We discuss practical, safe and comprehensive approaches that are achievable in the limited time available when working on the ward. The podcast is co-hosted by Dr Vani Chandran and Dr Sam Holford, based in Auckland, New Zealand. We hope to provide guidance applicable to hospitals throughout New Zealand, and expect most of the content to apply to Australia and further abroad. Thanks to the <a href="https://www.nzrda.org.nz/education-trust/" rel="noopener nofollow" target="_blank">NZRDA Education Trust</a> for making this podcast possible. Feedback Please send feedback, questions and suggestions of what you’d like discussed on the show to <a href="mailto:feedback@wardcalls.com">feedback@wardcalls.com</a>, or find @wardcalls on <a href="https://twitter.com/wardcalls" rel="noopener nofollow" target="_blank">Twitter</a>, <a href="https://www.facebook.com/wardcalls" rel="noopener nofollow" target="_blank">Facebook</a> or <a href="https://www.instagram.com/wardcalls" rel="noopener nofollow" target="_blank">Instagram</a>. And remember to leave us a review on iTunes, to help others find the show. Disclaimer Practicing medicine is to make black and white decisions based on grey information. We can’t cover every possible scenario on this podcast and cannot guarantee accuracy. We’ve done our best to bring you useful and reliable advice, from guests volunteering their time to give expert opinion. Our advice does not replace your local hospital policy or guidelines, nor good clinical judgement.

Introduction to the podcast

Ward Calls

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