Sunday, 8 September 2013

Corridor collapse


Again, I start with an apology for the time since the last post - I will try and remedy this by posting little and often in future. The past few weeks have been very busy - the senior house officer (an F2) in my vascular surgery rotation was off, leaving me to deal with basically everything, and then the breast surgery F1 was off, meaning we had to cross cover breast surgery as there are no other juniors on that rotation, leading to another week of heavy work. All in all, I think that next week, now that everyone is back, things will be a lot easier!

Things have been getting easier as the weeks go by and I get used to things a bit more. I have been working as an F1 for about a month now, and I am getting much more used to not only how the job works but (supposedly more importantly) how my consultants like things done. I can have lists prepared at the correct moment, make sure that surgical lists are in the order that each consultant prefers and try not to get in anyone's way so they trip over me...

A couple of exciting/stressful (they often seem to be both...) things happened to me this week. One of my patients became very sick whilst I was trying to run my pre-op assessment clinic. I was meant to be spending all afternoon assessing a stream of patients to try and tell if they were well enough for surgery or not, but had the surgical 'advanced care' unit calling me telling me one of my patients had a heard rate of 30 beats per minute (very low) and a very low blood pressure. My registrar had gone home for a half day off, and my vascular SHO (year on from me) was stuck looking after a breast based MDT which is a big meeting, so I couldn't contact him. The decision to go to the patient and see what I could do was clearly more sensible than staying in clinic, but once I went to the sick patient, people started queueing up in clinic waiting to see me. I ended up being with the sick patient for about 1 1/2 hours so built up a number of patients waiting for me (who were very understanding, the worst being someone grumbling about the car parking fee after waiting so long). The patient had fluid in his lungs (pulmonary oedema) which meant that giving lots of fluids to try and bring up the blood pressure wasn't such an easy choice to make. In the end I gave him 250ml of fluid over 30 minutes to see the effect on his blood pressure/heart rate/urine output (urine output was basically 0 for the last 6 hours), asked for a bladder scan in case his catheter had become obstructed leading to the poor output, and called the critical care outreach team to help me. Sadly, they took some time arriving (hence why I had to stay there for so long) and my interventions didn't do very much. In the end, when they did arrive, the ended up giving atropine and glycopyrrolate (drugs I wouldn't have dared to give on my own). He ended up going to HDU (a ward which is one step down from ITU) but from there improved and seems well now.

The cause of this profound bradycardia (slow heart rate) isn't really known. At first, the critical care team though that, as this sick patient had been on digoxin then received a spinal anaesthetic, it could be these two interacting to block the sympathetic nervous system and slow the heart. I thought it could be digoxin toxicity. We took the blood to test for dogoxin levels, but the lab only does these once a week (strange and unhelpful).

Later on this week, a person collapsed in front of me while I was hurrying through one of the corridors to request an MRA scan for one of our in patients. I was in a real rush as it was almost 5, and I needed to catch the radiologist before he left the hospital (and my consultant had specifically said it needed to be requested today, so it could be done early tomorrow so she could then leave for dialysis). Obviously, I had to stop and try and help out. This lady was in her 80s, and wasn't a patient at the hospital, but was just visiting a friend. She had started walking down the corridor but had found herself very short of breath. I asked a few library staff who were walking down the corridor to get me a wheelchair, and call the medical emergency team while I took her pulse and tried to talk to her. Being in a corridor was very awkward as people were all walking by next to us and staring. Taking the pulse was much less invasive than trying to listen to her heart in this situation, so that was all I could do, and she was very tachycardic (fast heart rate) with a heart rate near 150. She was also very breathless and seemed hot and sweaty. Added onto the fact that she had had a lot of heart problems in the past, I was very worried! By the time the medical emergency team arrived, she seemed a lot better, her heart rate was more normal, and she wasn't breathless or sweaty anymore. They seemed a bit confused as to why I had got them to run all the way out here to this corridor! In the end, they said that she should probably go to A&E to get checked out, so I wheeled her there in the wheelchair. I wish I knew what had happened after that, but sadly I had lots more to do that day and ended up staying quite late in the hospital, so I didn't get to follow up what had happened. I did feel a bit of a wally after calling the medical emergency team, but I know that it was the right thing to do after she had presented in such an alarming way...


  1. Great read as always. Glad you eren't the one collapsing! I am starting to worry how to handle such pressure. That is plain crazy.

  2. The lab will do them once a week to conserve reagents (which can be very expensive) and analyser time (you can only run so many different tests at a time on the analysers).

  3. I am sure you will do fine peace, it is all about trying to ride the chaos like a wave!

    Thanks for the clarification Skirts&Stilettos, I thought it would be something like that. Isn't it possible to just use a small amount of the reagent for a single investigation, or do you have to use a certain volume for the machine, wasting the rest? Clinically it is quite frustrating as someone can be acutely unwell, you can suspect something like digoxin toxicity but cannot prove it until later that week. This patient's bloods did come back some days later and he had a very high digoxin level in them. I suppose it has to be a clinical diagnosis in this sort of situation?

  4. So much for a quiet start :P

    That corridor story sounds like a nightmare situation of suddenly being put on the spot when you've got a whole load of other stuff on your mind, but by the sounds of it you dealt with it like a pro (i.e. not wallyish at all!). I'm sure the patient was extremely grateful to you. I'm glad that your other patient seems to be improving :)

  5. You certainly have a lot of work to do, keep up the stamina you seem to posses!