Your first day as a doctor

What would be a "reasonable" period of time to arrive the scene (for this case) if you're on call?

Sounds like the ortho reg is in deep ****. Is this sufficient grounds to be struck off - that he took 2 hours to get in?

Can the psych team assess his fitness for an emergency section under the MHA? If they did I guess you could sedate him, check his liver function and possibly provide a stomach pump/activated charcoal?

IIRC, most guidelines (not sure how legally binding) are that you should be able to get to hospital within either 20 or 30 mins. 2 hours, unless there was a really exceptional reason (e.g. like back in December when it snowed so much) is unacceptable.

This case is bloody scary, and I've survived 6 months of A&E! Am intrigued why this guy was brought in as a "courtesy call" - sounds more like a major trauma call to me...

The psych team won't help you. If he dies from liver failure then his psychiatric needs don't take immediate priority. Even if they did, it's not wise to sedate someone, especially with all that amitriptyline on board. As for liver function, you need a blood test to check that, and he's not giving you one! And it's too late for activated charcoal/gastric lavage (needs to be within 30 minutes).

Great answer though nonetheless.

What case is that?

Gimme 10 cc's of paaaaaaaaaaain

Well I know they psych won't treat him, but the section would allow you to override his refusal for treatment, no?

As for sedation, well TBH I don't know how something like Lorazepam would interact with amitriptyline and he has had a significant amount of alcohol. Is there a sedative that doesn't interact with either?

The night watchman case! Everyone learns it as part of medicolegal fluffy stuff at UCL.

It's now 1215. Quite a large team has assembled including the ICU consultant and SpR, surgical SpR and SHO.
BP is now hovering around 60/20. HR 50. Pulseless electrical activity. CPR commenced. Adrenaline given. After around 3 cycles output is restored, HR 180, BP around 70-80 systolic.
The patient is log-rolled and the spinal board removed. There is evidence of a significant PR bleed and on examination the prostate is high riding and grossly displaced to the left.
Around 8 units of O negative blood have been given by now
Repeat ABG - pH 6.88, pO2 35, Lac 11, Hb 10.6
FFP and platelets added-on to CM request, with 1:1:1 ratio

It's approaching 1300. The patient has arrested again, but with ROSC after a few more cycles of CPR. He has received 14 units, including FFP and platelets. There is blood everywhere. BP and HR remain very low. You ring the orthopaedic SpR who is still "on his way" having set off from home.

What would you do next?

The night watchman case! Everyone learns it as part of medicolegal fluffy stuff at UCL.
"
A night watchman attended casualty one morning with a history of vomiting. The duty nurse summoned the doctor by telephone but he refused to attend. The man left casualty but died a few hours later. It was found that the death was due to arsenical poisoning. There was no reasonable prospect of an effective antidote being delivered before death. The doctor was found to be negligent, but the man’s death was inevitable and would have occurred even if he had received appropriate treatment. The claim failed because the claimant had failed to establish causation (see Barnet v Chelsea and Kensington Hospital Management Committee [1969] QB 428). "


And sorry it's arsenic not cyanide!

Can you not just sedate him and give him the blood? if he refuses knock him out then do it.

Can you not just sedate him and give him the blood? if he refuses knock him out then do it.

Again, sedation with overdose = bad idea.

He is (was) a lawyer - you sure you want to knock him out?

N-acetyl cysteine (NAC)?

ABC, call ITU reg. If falling consciousness, prep for intubation. Still try the charcoal, then haemofiltration + dialysis, do an ABG and blood monitoring. Thats all i got :/