As a medical registrar on call, we get referrals from different specialties all the time.
I am going to go through a few bleeps I get when I am on call.
I am going to share some tips in general:
1. Never mock the other person down the phone.
2. Write down whatever they are saying- summarize the case quickly at the end to ensure you have the relevant information.
3. If they are worried, see the patient ASAP
4. Give urgent management advice on the phone - like request them to do an ABG, etc
5. Understand their limitations. They may not have the same medical experience as you do.
6. Be kind and helpful.
FROM ED RESUS
These are the most unwell patients in the hospital and need our input as medical registrars ASAPThey have been assessed by the ED team and have had basic management however our input is crucial.
Cases like
1. CNS infections
2. Stroke ( in some trusts the stroke coordinators manage them)
3. Upper GI bleeds
4. MI
5. Decompensation CCF
6. Chest infections
7. Exacerbation of COPD
8. Exacerbation of asthma
9. Decompensated chronic liver disease
10. Pyelonephritis
11. PE
And a few more medical emergencies.
Here are my tips:
1. Try to go to ED resus ASAP
2. Never request the ED team to sort out things like calling the on call endoscopist to arrange an urgent OGD
3. Take full responsibility of patients referred to yourself - writing a plan like repeat ABG in one hour may not be followed by the ED team as a medical registrar, you should be doing it yourself if you need it done in an hour ( unless you are exceptionally busy).
4. Basing yourself in ED /ED resus helps a lot as you can be referred patients directly and you can help with the initial management - like a patient with chest pain and has a widening of the mediastinum on the CXR - you can request the ED team to request a CT aorta before you see the patient as this might be a dissection which is managed better under care of cardiothoracics.
5. Remember that the ED team does the A to E assessment, stabilizes the patient and then refers them to the appropriate specialty. Things might get missed sometimes and you can request the missing investigations/ give the missing treatment there.
6. Understand how busy the ED team is - they have to see a lot of patients and make plans within 4 hours hence help them.
7. Teach your colleagues if they have missed anything - I usually tell them what a wonderful job they are doing however they could have done this differently ( in a very non-confrontational manner in a way I would expect a colleague to feed back to me)
FROM ED MAJORS/MINORS
These patients are normally stable and do not need an urgent review however we do get nasty surprises. Hence I tend to clerk in ED majors once ED resus is stable.This way, I get a handover directly from the ED team and I am able to provide support and manage these patients.
I also get bleeped by the ED nurse in charge who would like for me to clerk patients in ED directly and if I feel it is safe for them to be outlied to medical wards, they can be transferred directly hence preventing bed blocking when AMU is full.
Tips:
1. Try to go talk to the ED team if they are referring a patient to you. I do not like taking a long history on the phone.
2. Do not interrogate the ED team if you are stuck elsewhere. Open the computer and go through the investigations at the same time
3. Be friendly. Here is an example:
ED team:
'This 40 year old, known ulcerative colitis patient has come with with loose stools - upto 10 times a day since 2 days. His CRP is high, other bloods including magnesium and phosphate are normal. Can you kindly accept him for admission please' You:
Of course. Has he had a Abdominal X ray.
ED team:
No he has not.
You:
Can you kindly request it please, the reason being is that such cases can have toxic megacolon which needs urgent surgical intervention. If we give steroids on top of this, it can worsen his underlying condition.
This is a nice way of explaining why he needs an investigation. Rather than:
' You have been working in this department for 5 years now! And you do not know how to manage colitis flare ups! Do an abdominal X ray and call me once it is done! Idiots!'
( And yes, this was an actual conversation - luckily this was fedback to the registrar and he apologized)
4. Be friendly with the ED nurses. They are trained to work in stressful environments however do not give a list of jobs like doing ABGs. If you are free, do it yourself if you have nothing else to do. And I have worked as a medical registrar in both a district hospital and a busy teaching hospital and trust me, I always get time to do an urgent ABG.
http://omarsguidelines.blogspot.com/2018/01/nurses-in-nhs.html
5. Teach wherever you can - like the example in point 3.
6. Base yourself in ED when you are free. You will learn a lot, teach a lot and make some excellent friends. I am still in touch with ED nurses in charge, doctors and ACPs from my previous jobs.
7. Listen to the ED nurse in charge - they are working hard to improve patient slow, avoiding breaches so work with them. They might sound a bit authoritative but they are lovely.
But do not tolerate abuse either :
https://omarsguidelines.blogspot.com/2020/01/bullying-and-stress-in-nhs.html
GP PHONE CALLS
I have a very soft corner for GPs. They are essentially the back bone of the NHS and play a vital role in avoiding unnecessary admissions to hospital with limited diagnostics. They are the true clinicians who base their diagnosis on the patients history and examination without any fancy tests.
Hence I always listen to their concern and in my opinion, if a GP is worried , then I am worried. I would prefer to see the patient in hospital unless it is a clear cut ambulatory case.
I get called for :
1. Bloods done in the morning. Reported in the evening. Potassium has come back at 7. These patients need to come to ED ASAP for repeat bloods- A VBG along with regular bloods should show an immediate result. Sometimes it is spuriously high as the sample has been sitting on a stand for 5 hours prior to analysis.
2. Hyponatremia - needs urgent admission if it is low
3. Chest pain - needs urgent admission unless it is clearly pleuritic, the PESI, PERC scores are low and the GP has access to giving a shot of treatment dose dalteparin/oral NOAC.
4. ? MI - They need urgent admission
5. ? DVT - can be managed via ambulatory care
6. ? flare up of colitis - need admission
GPs do a lovely, relevant handover in a SBAR manner
https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
This is part of their training and they are very good at this.
I usually request them to send the patient immediately to hospital ED if warranted- They normally book an ambulance and send the patient across with a letter.
My tips:
1. GPs do not have access to fancy diagnostic tests like we do. Hence be compassionate and kind when they are not sure.
2. Listen to them carefully. Whatever you say will be documented. Telling a GP that a sodium of 119 is fine ( with a normal baseline 1 week ago) is pretty risky in my opinion. They will just document this in the notes and when an adverse event happens, you will be blamed.
3. Write down whatever they say. Then summarize everything in the end. It helps to have a NHS number so that you can scroll through previous investigations, hospital management plans, etc to help guide them what to do.
4. GPs are excellent at identifying red flags. So do not brush their concerns away. If I am not concerned, I always ask them what they are worried about. Most of the time, they are right.
5. You might talk to some new GP trainees - listen to them carefully. Do not be rude to them or mock them.
6. They are always willing to learn. I always do a quick 2 minute teaching - like on hyponatremia and what we do as an inpatient.
7. Discuss your management plans with them. Like I agree this patient with hyponatremia needs admission because it seems like she is hypovolemic and hyponatremic so we can repeat her bloods and if it is the case, we can give slow IV fluids , monitor her sodium levels , do tests like random cortisol, serum osmolality, TSH, urinary sodium and osmolality ensuring her sodium levels do not increase rapidly as that can precipitate cerebral edema, etc
8. If the patient needs admission, ensure they send a letter with all the summary care records which helps you go through the patients co-morbidities and medication history.
5. In both points 4 and 5, I request the nurses/junior doctor on the surgical ward to inform the registrar/consultant whenever they are free. I do not wait for their decision. I make the decision for them- unfortunately they are not used to doing this and as a medical registrar ( and former SHO) who has been doing this for a few few years, I feel confident enough to do this. What I do not want is an inappropriate CPR attempt which will prolong the agony/distress of a dying frail patient.
Hence I always listen to their concern and in my opinion, if a GP is worried , then I am worried. I would prefer to see the patient in hospital unless it is a clear cut ambulatory case.
I get called for :
1. Bloods done in the morning. Reported in the evening. Potassium has come back at 7. These patients need to come to ED ASAP for repeat bloods- A VBG along with regular bloods should show an immediate result. Sometimes it is spuriously high as the sample has been sitting on a stand for 5 hours prior to analysis.
2. Hyponatremia - needs urgent admission if it is low
3. Chest pain - needs urgent admission unless it is clearly pleuritic, the PESI, PERC scores are low and the GP has access to giving a shot of treatment dose dalteparin/oral NOAC.
4. ? MI - They need urgent admission
5. ? DVT - can be managed via ambulatory care
6. ? flare up of colitis - need admission
GPs do a lovely, relevant handover in a SBAR manner
https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
This is part of their training and they are very good at this.
I usually request them to send the patient immediately to hospital ED if warranted- They normally book an ambulance and send the patient across with a letter.
My tips:
1. GPs do not have access to fancy diagnostic tests like we do. Hence be compassionate and kind when they are not sure.
2. Listen to them carefully. Whatever you say will be documented. Telling a GP that a sodium of 119 is fine ( with a normal baseline 1 week ago) is pretty risky in my opinion. They will just document this in the notes and when an adverse event happens, you will be blamed.
3. Write down whatever they say. Then summarize everything in the end. It helps to have a NHS number so that you can scroll through previous investigations, hospital management plans, etc to help guide them what to do.
4. GPs are excellent at identifying red flags. So do not brush their concerns away. If I am not concerned, I always ask them what they are worried about. Most of the time, they are right.
5. You might talk to some new GP trainees - listen to them carefully. Do not be rude to them or mock them.
6. They are always willing to learn. I always do a quick 2 minute teaching - like on hyponatremia and what we do as an inpatient.
7. Discuss your management plans with them. Like I agree this patient with hyponatremia needs admission because it seems like she is hypovolemic and hyponatremic so we can repeat her bloods and if it is the case, we can give slow IV fluids , monitor her sodium levels , do tests like random cortisol, serum osmolality, TSH, urinary sodium and osmolality ensuring her sodium levels do not increase rapidly as that can precipitate cerebral edema, etc
8. If the patient needs admission, ensure they send a letter with all the summary care records which helps you go through the patients co-morbidities and medication history.
PHONE CALLS FROM OTHER SPECIALTIES
GYNAE /OBS
These referrals can vary from
1. ?PE in pregnant patients
2. Management of arrhythmias
3. ? Sinus venous thrombosis
4. Headache
There are clear guidelines for all of these conditions available on the trusts websites. The Gynae/Obs team are very good at managing medical issues and sometimes need advice when it gets complicated/ when they are unsure.
Tips:
1. As above, listen to their concerns and be kind.
2. Review the patient in person
3. Be aware of midwives - they are very strong headed however if you are nice and friendly, they will go above and beyond for you ( they get loads of cake and chocolates and can let you enjoy their secret stash for your sugar rush on a busy on call).
4. If you are not sure, talk to the medical consultant on call.
5. Be safe - think about common differentials, discuss management options with the patient and give the relevant information - like CTPA vs V/Q scan in a pregnant patient ( there is guidance on the trust intranet for this)
1. ?PE in pregnant patients
2. Management of arrhythmias
3. ? Sinus venous thrombosis
4. Headache
There are clear guidelines for all of these conditions available on the trusts websites. The Gynae/Obs team are very good at managing medical issues and sometimes need advice when it gets complicated/ when they are unsure.
Tips:
1. As above, listen to their concerns and be kind.
2. Review the patient in person
3. Be aware of midwives - they are very strong headed however if you are nice and friendly, they will go above and beyond for you ( they get loads of cake and chocolates and can let you enjoy their secret stash for your sugar rush on a busy on call).
4. If you are not sure, talk to the medical consultant on call.
5. Be safe - think about common differentials, discuss management options with the patient and give the relevant information - like CTPA vs V/Q scan in a pregnant patient ( there is guidance on the trust intranet for this)
SURGERY
You might be bleeped for:
1. Breathless patients - CCF , HAP, PE
2. Chest pain - PE, MI
3. Fast AF
4. Electrolyte derangement
1. Breathless patients - CCF , HAP, PE
2. Chest pain - PE, MI
3. Fast AF
4. Electrolyte derangement
5. Unwell frail patient who seems to be approaching end of their life.
Tips:
1. Usually it is a FY1 who bleeps you. The registrar is busy in theater, the SHO is busy taking referrals from ED hence they need your help. Go out of your way to help them. They really need your support.
2. When taking a referral, get a quick SBAR and assess the patient yourself.
3. If you feel like the patient should not be for escalation, discuss this with the surgical team and put in a DNACPR/RESPECT form. Some people prefer that the parent team discusses it with the patient/relatives however if everyone is busy, you should not expect a poor FY1 to do this consultation. Hence I either talk to the patient myself or call the family. It takes 2 minutes.
https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html
4. Similarly, if the patient is approaching end of life, I update the family, stop active treatment, prescribe anticipatory medications. Tips:
1. Usually it is a FY1 who bleeps you. The registrar is busy in theater, the SHO is busy taking referrals from ED hence they need your help. Go out of your way to help them. They really need your support.
2. When taking a referral, get a quick SBAR and assess the patient yourself.
3. If you feel like the patient should not be for escalation, discuss this with the surgical team and put in a DNACPR/RESPECT form. Some people prefer that the parent team discusses it with the patient/relatives however if everyone is busy, you should not expect a poor FY1 to do this consultation. Hence I either talk to the patient myself or call the family. It takes 2 minutes.
https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html
5. In both points 4 and 5, I request the nurses/junior doctor on the surgical ward to inform the registrar/consultant whenever they are free. I do not wait for their decision. I make the decision for them- unfortunately they are not used to doing this and as a medical registrar ( and former SHO) who has been doing this for a few few years, I feel confident enough to do this. What I do not want is an inappropriate CPR attempt which will prolong the agony/distress of a dying frail patient.
6. Teach the junior doctor about management of the medical issue they have called you about. A 2 minute teaching session will help them. Of course, always let them know that they should call when they are not sure.
7. If you need to anticoagulate a patient post op, it is best to talk to the registrar/consultant. Usually they are fine with it but it always good for legal reasons to document that the parent team is happy.
7. If you need to anticoagulate a patient post op, it is best to talk to the registrar/consultant. Usually they are fine with it but it always good for legal reasons to document that the parent team is happy.
PSYCHIATRY
These are the cases referred to us:
1. ? Sepsis
2. Electrolyte disturbance
3. ?COVID
4. Seizures
Tips
1. It is best to ask the team to send the patients to ED for further assessment.
2. In my experience, the psychiatry team try their best to keep patients on their ward and when they are worried, you should be concerned as well.
3. Some cases can be managed on the psych unit and hence do not need to be transferred but have a low threshold to bring them to hospital.
4. Usually a mental health worker comes with the patient so let them know to bring all their medical documents like lists of medications, past medical history, etc
1. ? Sepsis
2. Electrolyte disturbance
3. ?COVID
4. Seizures
Tips
1. It is best to ask the team to send the patients to ED for further assessment.
2. In my experience, the psychiatry team try their best to keep patients on their ward and when they are worried, you should be concerned as well.
3. Some cases can be managed on the psych unit and hence do not need to be transferred but have a low threshold to bring them to hospital.
4. Usually a mental health worker comes with the patient so let them know to bring all their medical documents like lists of medications, past medical history, etc
MICROBIOLOGY
A microbiologist might ring you regarding a patient who's blood cultures have come back positive and that patient has been discharged. They usually call in the evening and not at 0300 AM ( I hope this is true for other trusts) hence it is reasonable to bring the patient for a full assessment.Tips:
1. Sepsis kills! Never take positive blood cultures lightly
2. Most of the time, we are expected to ring the patient and let them know. Not the microbiologist.
3. I always ask the patient to come to ED and get a full assessment ,bloods with repeat cultures and then admit them under medicine for observation.
MEDICAL REGISTRARS FROM OTHER HOPSITALS
Patients local to your hospital who have been admitted to a hospital elsewhere may need local physiotherapy and a social work up. Here is an example:
A resident of Scarborough was visiting Leeds and had a stroke. He was treated in a hospital in Leeds however he lives alone, is frail and needs an assessment by social workers in Scarborough to ensure he has the care needs at home prior to discharge. Such cases would be discussed with the medical registrar on call.
I usually hear the summary and let them know that I have accepted this patient. They then let their discharge coordinators know who liaise with the bed managers to arrange a transfer.
Tips:
1. Always request them to send the patients investigations and drug charts
2. Listen to them carefully. Sometimes the patients can be unwell - if they are, then it is best they are treated in that hospital till they are better prior to transfer.
A resident of Scarborough was visiting Leeds and had a stroke. He was treated in a hospital in Leeds however he lives alone, is frail and needs an assessment by social workers in Scarborough to ensure he has the care needs at home prior to discharge. Such cases would be discussed with the medical registrar on call.
I usually hear the summary and let them know that I have accepted this patient. They then let their discharge coordinators know who liaise with the bed managers to arrange a transfer.
Tips:
1. Always request them to send the patients investigations and drug charts
2. Listen to them carefully. Sometimes the patients can be unwell - if they are, then it is best they are treated in that hospital till they are better prior to transfer.
This list is nowhere complete and I am sure you have personal examples of your own which I have not mentioned here. I hope the basic gist is clear to everyone:
1. Be kind
2. Make a decision in the patients best interest
3. Do not be obstructive
4. Be proactive
5. Teach
6. Do what is best for the patient
1. Be kind
2. Make a decision in the patients best interest
3. Do not be obstructive
4. Be proactive
5. Teach
6. Do what is best for the patient
Post a Comment