First to the crash call

I was on the ward reviewing a complex warfarin/clexane/tinzaparin drug chart.The patient decided to have an ACS as he was being switched from tinzaparin and warfarin to just warfarin following a PE. He was prescribed treatment dose clexane. The second troponin had just come back negative, and the plan documented that morning was to stop clexane and resume PE anticoaguation. My brain was about to herniate attempting to come up with a plan for the evening dose of warfarin/tinzaparin.

Then I heard a bed alarm go off in the ward.

I rushed to the scene, and heard a nurse say “Oh no, she’s aspirated”.

There was vomiting dripping out of the mouth of an elderly, obese woman. There was no way air could be getting in. There was massive seesaw breathing, and her whole body contracted with each inspiration like that vein that won’t release blood during venipuncture as you pull back on the syringe. There was no chest expansion at all.

It really helped to have done ALS weeks before. I asked for the suction, a size 6 nasopharnygeal and all the oropharnygeal airways in the trolley. Whilst the equipment arrived, I did a head tilt/chin lift, and looked inside the mouth. All I could see was the tongue, and vomit.

I asked the nurses to put out a crash call, as I wanted an anaesthetist fast.

I felt for a pulse as I waited for the trolley. I could feel a good carotid pulse.

Once the equipment arrived, I suctioned about 100ml of vomit from the mouth. It was now the tongue that was the main problem. I decided to use an oropharngeal. This was the first time I would do so without any supervision. I was initially confused by the presence of the tongue, as the mannequins do not have a massive tongue blocking the entry to the mouth. I remembered seeing an animation of where the orophrangeal is meant to sit and how it works (in part, keeping the tongue depressed and off the posterior pharynx). I realized it needed to be inserted directly above the tongue and did so, even though this required some significant forcing. It slotted into place and as I applied a non rebreathable mask with 15L/min oxygen, I saw some misting. There was also some chest expansion. By this time, the crash team arrived and the anesthetist took over the airway. After the patient was stabilized, the anaesthetist congratulated me on my airway management.

I can see what they say about confidence coming from experience. I knew how to do that for the last 4 years. However, it is only now that I have done it unsupervised and in a high pressure scenario that I now feel confident of dealing with an airway problem like that anytime, anywhere.

I love being on call.

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When the history was 100% of the diagnosis

It is 3:30am. A 17 year old  girl is referred to AMU for lower left rib/chest pain. The nurses have been unable to bleed her. I was asked to try bleeding her. I decided to take the history and do the examination before taking blood.

I was greeted by a crying girl who keeps saying she just wants to go home. She was referred by her GP to A&E. She is hostile to your questions, and gives minimal answers. The pain has been there for two days, and it anything is better now than it was when it started.  It started gradually over many hours. It waxes and wanes, but never disappears completely. It is localised to the left lower ribs. It is not affected by breathing. She only sleeps on her left, as sleeping on her right stretches the area, which brings on the pain. Lying down brings on the pain. Sitting up relieves it. It is not worsened by inspiration, and there is no shortness of breath at all. There is no cough or fever. There is no leg swelling or tenderness. She has had a similar episode before on her right, when she slept in a funny position. There is no history of trauma. There is no history of long distance travel, and she does not take the COCP.

She has been in theatre rehearsals recently.

On examination, there is nothing remarkable. There is no chest wall tenderness, and she is saturating at 99% on room air with a respiratory rate of 16. The pulse is 78, and BP 108/77. She is afebrile.

The referring doctor from A&E requested FBC, U&E, CRP and D-dimer. He also requested a chest xray.

My differential consisted of musculoskeletal pain, musculoskeletal pain and possibly musculoskeletal pain. I could not think of any investigations that were really needed, as I had no differentials to rule out. I certainly did not want to do a D-dimer, as if that came back positive we would be forced to subject a young girl to a V/Q scan or CTPA.

Not doing any investigations at all on an A&E patient is pretty brave/stupid, depending on your point of view. Still, I somehow felt quite confident in my decision. The patient seemed at risk of becoming disillusioned with medical services the longer she stayed in, especially for repeated attempts at a blood test. I had been clerking a patient in the next cubicle, and could hear her crying loudly at the repeated attempts. I felt that she needed to go home, and the time I saved on not doing bloods/chest xray would be probably be better spent making her and her companions hot chocolates to ensure she has a positive outlook on healthcare professionals.

The father and her brother were with her. I told all three of them what I thought, and explained the very small risk of a clot on the lungs. I explained the consequences of not doing the test. I explained that if we do not do the test, she should come back if symptoms persist more than 48 hours, if they worsen, she develops shortness of breath or generally feels unwell. I asked the patient if she wanted to press ahead. She was well informed, and made an informed decision with capacity to refuse blood tests.

Once she knew that she was not going to have blood tests she became much happier. We discussed her drama production, Family Guy, and how they could make the hospital cubicles for each patient more interesting. I also made sure they got their hot chocolates before they left.

As I double checked my plan with the registrar before letting her go, I felt deeply satisfied. I feel the nature of A&E may make us unnecessarily cautious at times. There was a good chance this decision had saved her a radiation dose and an overnight hospital stay. She was smiling as she left drinking the hot chocolate. I had never felt happier for cancelling a d-dimer.

This lady has taken 1300 units of Lantus. Please manage.

This will probably be the most determined insulin related suicide attempt I think I will ever see: 1300 units of Lantus. That’s 4 and a half pens.

The patient was lying in a foetal position half off the bed, shaking uncontrollably and drenched in sweat. She already had 10% glucose going into the left antecubital fossa.

I called for a nurse to come immediately with the Hypostop kit. The patient was responding verbally to me, but was clearly confused. Her respiratory rate seemed normal. I felt a rapid pulse. By this time, the nurse arrived with the hypostop. Given the history, and the adrenergic (sweating, tachycardia, shakes) and neurological (confusion) symptoms of hypoglycemia, I gave the Hypostop stat whilst the nurse took the BM.

3…2…1…unrecordable [low].

Never had I seen anything like this. Unrecordable BMs, that too whilst on a glucose infusion. We repeated the hypostop and squeezed the bag to give 150mls stat of the 10% glucose. A repeat BM showed 2.3.

This was going to be difficult. Lantus is a long acting insulin. In effect, our patient has an erractic insulin pump inside her, liable to release huge doses at any time. Lantus can hang around for 2-4 days, and given the dose ingested I would not be surprised if peripheral fat and muscle had become further reservoirs of insulin.

We repeated 150ml of 10% glucose. The BM then became 9.0.

I then placed a second cannula in and took a U&E, given the potential effect of insulin on potassium levels.

I then had a think about the plan. This was not like a normal hypoglycemia problem. It was going to be predictably unpredictable and long lasting. I had already seen that a 10% glucose infusion at the normal rate was grossly inadequate (the first cannula and 10% glucose were flowing fine). To top things off, there was no more 10% glucose available in the hospital. Seriously. There were only 20% glucose 500ml bags.

I heard from other healthcare professionals that a similar Lantus overdose in another patient needed 5 days of inpatient treatment. I had also heard that sometimes surgical excision of the insulin source is necessary in long acting insulin overdoses.

The plan I came up with was 500ml of 20% glucose over 4 hours with 15 minutely BMS for the first hour, then half hourly BMs if stable and reassess by the on-call doctor at 4 hours. U&Es came back as normal. We will see on Monday what happened.

I read up on this case report afterwards, and realised that the issues we were having with unpredictable drops were common. I also learnt that you can almost think of it as a case of refeeding syndrome, with monitoring of K, Mg and Phosphate. You would also consider the need for thiamine, although in this case there were no risk factors to suggest thiamine deficiency.

How to improve your QOL and ADLs for £9

I cannot empahsise how awesome the iRefer app is. This app that has been produced by the Royal College of Radiologists to explain exactly which radiological investigation is indicated in various clinical presentations. I have been able to fill in and discuss radiology request forms in seconds and never had one turned down. For example, imagine your consultant has asked for a PET-CT in a 49 year old man with biopsy proven lung cancer. The patient has already had a staging CT. Before you ask the consultant what the logic behind the PET-CT is, he has disappeared. Using the app, you can look up Cancer → Lung → Staging, where it lists the indications for the possible radiological tests. Under PET-CT, you can see the evidence is strong for a PET-CT before any radical therapy is carried out. You can then tailor your request to focus on the patient’s fitness/desire for surgery or radiotherapy as needed, and also use the information from the staging CT to show that the patient is potentially for radical treatment by TMN staging. This is also supported by the latest NICE guidance (1.3.4). Happy radiologist, happy consultant, happy patient and happy you.

The app came in handy when I was asked to review an elderly lady whose INR had come back as 6.4. No big deal I thought. Having been through an INR of 10, I felt confident that I was simply assessing her for any major bleeds, any minor bleeds and hunting for an underlying cause. I knew this patient was on warfarin for PEs and DVTs, and had an INR of 2.8 two days previously. She had been admitted two days ago with confusion following a fall, and a CT done yesterday showed no bleed or any other new problems. Her inflammatory markers were up (CRP, WCC) and a urine dipstick was positive for leukocytes. She was treated as UTI +/- LRTI, despite the lack of localizing features on history or examination.

I knew this patient quite well as a direct result of finding her difficult to bleed and taking 20 minutes to do so. I learnt about her life story. She was still mobile enough to do her shopping alone.  She liked baking apple based puddings.

She also asked me to pass her the cup, and that I could take off her watch to bleed her. She volunteered these phrases. I did not realise at the time how significant remembering this would be.

A few hours later, I was called to see her as she had a new headache that had worsened over the past few hours. In addition, I had noticed that she was different to the woman I got to know when bleeding her. She was much more drowsy, despite it being 6pm. She was not sure where we were. I asked a medical student to do a full neurological examination of the limbs, plus cranial nerve VII, pupils and higher functions.

When asked to name a pen, she said ‘penburage.’

When asked to name a bottle, she said beaker.

Was this new or old? Then I remembered our conversation earlier.

When asked to name a cup (filled with tea), she eventually said teapot.

When asked to name a watch, she just could not.

It seemed like a nominal aphasia. She had fluent sounding speech, if a little distant and drowsy. She followed instructions, but seemed generally more confused. For example, during the Babinski reflex, she denied that the shoes I was putting back on her afterwards were hers.

The Babinski showed an upgoing left plantar. Comparison with the clerking examination showed that this was new.

There were new focal neurological signs, and combined with new drowsiness and a worsening headache made me suspicious of a new bleed since yesterday’s CT head.

Convincing radiologists to re-scan a patient about 24 hours later requires a firm understanding of the guidance and precisely how this scan will change management. Were this scan to show a bleed, what would we do differently? Would we perform neurosurgery on this lady? Perhaps, perhaps not. I felt that a neurosurgeon would be in the best position to make that call armed with an understanding of the nature of the problem from a CT head. Even if the patient were not for surgical intervention, a haemorrhagic stroke is an absolute contraindication for warfarin for life, which would change management significantly.

I discussed the issue of reversing the clotting deficiency before or after the results of the CT head with my consultant. I personally felt that if the CT head could be done within 30 minutes, and there was no further reduction in GCS/evidence of raised ICP, then it made sense to wait for the results. In any case, vitamin K takes 4 hours to act. Prothrombin complex is quick and does not require ABO matching. It does however need a hematologist’s approval and he or she would usually want objective evidence of a major bleed. This is the plan we went for.

I requested an immediate CT head in line with the NICE guidance. An immediate CT is indicated if a patient is FAST/ROSIER positive and on anticoagulation. Immediate is defined in the NICE guidance as the next available slot ideally, and certainly within the hour.

We’ll have to wait till Monday to see what happened.

Edit: Monday’s CT Head was NAD.