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.
Tachycardia is not explained by salbutamol administration alone
A large diurnal variation in peak flow (e.g. >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
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)
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
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.
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.
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.
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.
Waitemata DHB correction of hyperglycaemia guideline (August 2017)
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.
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
It may be necessary to “get on top” of the pain first with some IV boluses, then once the patient is comfortable, some low-dose long acting analgesia may be all that is required.
If possible, please avoid opiates in young patients (e.g. <25 years) as there is a strong link between opiate exposure in the young and subsequent drug and alcohol dependance and abuse. First do no harm!
Sleeping tablets
Very common request on evening and ward calls
Balance benefit with risk
Patients need sleep to recover from the illness, so don’t withhold unnecessarily
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.
$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, and residents are forced to work unsafely.
As an RDA member you have a say on all issues the RDA is involved with, especially negotiating the MECA and rosters.
Getting into trouble
Happens to the best of us
Outcomes often influenced on how the complaint is managed
Contact RDA early
A “support person” should be a RDA delegate or advocate
How to approach problems with RMO unit and supervisors
Wellness
Important to maintain a healthy work-life balance.
The first year as a house officer is probably the highest risk for having a break down. It happens every year.
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 >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?
Alcohol and drug history
Consider EtOH/hand gel if alcoholic or possibly malnourished, consider IV thiamine.
Head injury history
Senior review for workup of aetiology and preventative strategy
Stop gabapentin and tramadol
Diagnosis is clinical and is established on the basis of the patient’s account and on any eyewitness description. A detailed neurological examination is required. Features suggestive of a seizure include:
Absence of syncopal prodrome (nausea, pallor, sweating, dimmed vision)
Period of post-ictal drowsiness and/or confusion
Tongue biting or urinary/faecal incontinence
Note: Syncope can provoke a seizure if cerebral hypoperfusion is prolonged.
CT head: particularly if fever, focal neurological symptoms or signs, or slow recovery
EEG/MRI: selected patients, usually performed as an outpatient
Management
Treat underlying aetiology.
Generally, do not start anticonvulsant therapy following a first seizure, unless a structural brain abnormality is demonstrated.
All patients must be told they cannot drive a motor vehicle for 12 months after a seizure. This is your responsibility. Shortening of this restriction can occur in only very special circumstances (e.g. a provoked seizure). Patients should also be advised of potential risks of swimming alone, SCUBA diving, working at heights and other high-risk activities. Document in the notes that this advice has been given.
Discuss with medical registrar. Generally start an anticonvulsant if benzodiazepine was required.
