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    (Original post by electricjon)
    How we getting on with that IV access? Give her some analgesia and tell her to push!
    Still no access, but she has entonox, and you don't really want to be giving opioids at this stage because of the potential effect on the baby. You tell her to push, protect the perineum and with the next contraction the head delivers. Still no madwives/obstetricians.
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    In a baby this small (and presuming that no steroids were given antenatally given the history of labour onset) then there's a high risk of hyaline membrane disease and you'd need someone standing by with all the neonatal resus kit, whoever you can find with the most experience. Realistically this baby id going to need at least CPAP if not tubing and surfactant. Someone needs to be able to give neonatal resus and use the neopuff to ventilate at least until someone experienced comes. if you're lucky, a bit of stimulation and inflation breaths and the baby might start spontaneous breathing.

    I used to hate this bit as a paeds SHO - our mat unit was separate from the rest of the hospital so despite crash bleeping the minute you knew you were running into difficulties, it used to take (what always felt like) a very long time before someone senior came! Using a laryngoscope in such a tiny person and trying to suck meconium out of the cords = distinctly unfun and often requires a change of underwear once the cavalry turn up!
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    Nope, no steroids. And no specialist help yet. Resus has a resuscitaire, but you have only been taught to use the oxygen and the suction. Fun times.

    So, the baby was pretty tiny, being 7 weeks early and with the next push delivered quite easily. It looks quite pale and floppy. What now?

    (Apologies if I'm late in continuing this; I'm off out to enjoy the sunshine! Everyone feel free to post ideas on how you are going to manage this situation - both mum and baby - and I'll get back to you once I return.
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    Ok, someone to look after mum and someone to look after baby. My obstetrics is very rusty so I'd be going with ABC assessment / basics with mum until help arrived (clamp/cut cord, get some fluids running, repeat all obs, prepare for 3rd stage, talk to mum - assume there hasn't been much communication just yet if she arrived pushing. Explain to her that someone else is looking after baby as he/she will need some help as they've been born quite early). Locate some syntometrin I suppose - not exactly the time or place to ask mum if she had a birth plan for 3rd stage, or if there's no syntometrin in A&E then there's not much choice in the matter anyway. Assess perineum / any active bleeding or tears.

    As far as baby's concerned, again ABC assessment. Someone else to get baby onto resuscitaire, dry / stimulate, change towels. Do a mental APGAR score - is the baby breathing after stimulation, weak cry, vigorous cry? Is heart rate below or above 90? Peripheral and central colour? Tone? In an A&E dept there should be someone somewhere who's trained in neonatal resus - if the baby's not breathing within 10-15 seconds of stimulation the red wall buzzer should be pulled. Meanwhile look in the mouth for any debris, but if there's going to be debris causing airway problems it's usually mec in the cords and you can't suction the cords unless under direct vision (laryngoscope if there is one). If there is someone who can use the neopuff, 5 inflation breaths, then repeat until effective, if not working then give ventilation breaths. If heart rate less than 90 give chest compressions as well. Hope to goodness that the neonatal team arrive pronto!!!
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    IM syntometrine for mum to prevent PPH? Get someone to look after mum - get the placenta out, usual ABC's, pain relief... As for baby, I'm stuck. If all you can do is give O2 and suction, then do that until someone more senior arrives.
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    (Original post by electricjon)
    The APLS guidelines are:


    Another pair of pants would be good too.
    Spare underwear always required where neonatal resus is concerned, it should come as standard in the resus box really... *is quite happy to be back resuscitating big people again rather than little people and certainly miniature people in plastic boxes*
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    Yup, that all seems pretty good.

    In real life, my reg arrived just as the woman was being transferred, so I went to switch on the resuscitaire while he delivered the baby. It literally came out in the time it took me to run to the paeds bay, switch it on and run back! He clamped and cut the cord while I wrapped up the baby, which started to move and make some effort to breathe as I rubbed it with the towel. It was nicely pink by the time I got it on the resuscitaire, so I just wrapped it up and wafted the oxygen near its face just in case, at which point the neonatal reg arrived.

    I guess I was a little lucky in that I did some O&G on my elective and did a 3 month O&G job as an F1 so wasn't quite as rusty as many F2s would be, but I was still terrified! I think the learning points here, especially for those who haven't qualified yet, are: -

    • This all happened in under 5 minutes - though it felt like hours. It's all very well calling the consultant, crash teams etc, but if they're not there, sometimes you just have to step up and do your best (within reason).
    • With any obstetric case, you have 2 patients, so get at least 2 doctors.
    • Get as much ready as you can, but know what will take priority. In this case it was so obvious that the baby was on its way no matter what, getting a cannula etc into mum was not necessarily no.1 priority. Don't forget that if this lady had gone to labour ward she probably would not be cannulated or have a CTG or any monitoring put on. You have to be mentally prepared for complications but childbirth is usually natural, so you don't have to completely medicalise it in all cases.
    • Go to lots of deliveries in your O&G attachment, this could happen to any of you and not just in hospital!


    Really, we were very lucky that the baby was in quite good condition and that it was born so easily. If there had been a shoulder dystocia or something things would have got really awful.

    Anyway, that was my happy obstetric story from A&E. I won't do the sad one because it was so utterly awful.
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    (Original post by Helenia)
    Yup, that all seems pretty good.

    In real life, my reg arrived just as the woman was being transferred, so I went to switch on the resuscitaire while he delivered the baby. It literally came out in the time it took me to run to the paeds bay, switch it on and run back! He clamped and cut the cord while I wrapped up the baby, which started to move and make some effort to breathe as I rubbed it with the towel. It was nicely pink by the time I got it on the resuscitaire, so I just wrapped it up and wafted the oxygen near its face just in case, at which point the neonatal reg arrived.

    I guess I was a little lucky in that I did some O&G on my elective and did a 3 month O&G job as an F1 so wasn't quite as rusty as many F2s would be, but I was still terrified! I think the learning points here, especially for those who haven't qualified yet, are: -

    • This all happened in under 5 minutes - though it felt like hours. It's all very well calling the consultant, crash teams etc, but if they're not there, sometimes you just have to step up and do your best (within reason).
    • With any obstetric case, you have 2 patients, so get at least 2 doctors.
    • Get as much ready as you can, but know what will take priority. In this case it was so obvious that the baby was on its way no matter what, getting a cannula etc into mum was not necessarily no.1 priority. Don't forget that if this lady had gone to labour ward she probably would not be cannulated or have a CTG or any monitoring put on. You have to be mentally prepared for complications but childbirth is usually natural, so you don't have to completely medicalise it in all cases.
    • Go to lots of deliveries in your O&G attachment, this could happen to any of you and not just in hospital!


    Really, we were very lucky that the baby was in quite good condition and that it was born so easily. If there had been a shoulder dystocia or something things would have got really awful.

    Anyway, that was my happy obstetric story from A&E. I won't do the sad one because it was so utterly awful.
    I looked up shoulder dystocia and read about the 'turtle sign' which has given me a hilarious mental image...
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    (Original post by Ronove)
    I looked up shoulder dystocia and read about the 'turtle sign' which has given me a hilarious mental image...
    Hilarious...
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    (Original post by Renal)
    Hilarious...
    Mainly because in my mind the head is going in and out and in and out at very short intervals. And now the image has extended to bungee...
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    (Original post by electricjon)
    CASE 8

    It is 3am in A&E. You are asked to see a patient who is being aggressive in the waiting room. She is a final year medical student who is intoxicated and has fallen outside a nightclub, sustaining a head injury and laceration to the face. She is being abusive and aggressive to the receptionists, demanding that she be seen immediately as she is a student doctor and recently finished a placement in your A&E department. As you approach, she recognises you, yelling out your name and shouting derogatory remarks at you.

    What would you do next?
    Ok....I know agression is an indication of a subdural haematoma, but I'm also presuming she isn't losing consciousness or a significantly lowered GCS other than due to alcohol ingestion.

    I have no idea how one assess a head injury past this. If I'm right and she has no clinical emergency, then she should be told to pull herself together (and she really should know better).

    However as she's had a head injury you do have to check to make sure.
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    She has already been seen by the triage nurse, who reported normal vital signs and no LOC/amnesia/neck pain/seizures/headache/paraesthesia/weakness/N&V/visual symptoms. She is accompanied by her two friends, neither of them medically trained, and both sober.

    There is a 3 hour wait.
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    Even with no other signs, a significant change in personality (ignoring alcohol for the mean time) should be a warning sign, right? So stick her on a trolley where you can keep an eye on her and get frequent neuro obs.
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    (Original post by electricjon)
    She has already been seen by the triage nurse, who reported normal vital signs and no LOC/amnesia/neck pain/seizures/headache/paraesthesia/weakness/N&V/visual symptoms. She is accompanied by her two friends, neither of them medically trained, and both sober.

    There is a 3 hour wait.
    Can she be given a ct scan while drunk? If she does have a more serious condition then she gets treated quickly. If not, she waits and gets reminded that fitness to practise applies to students as well.
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    Wow found this thread by accident and it's excellent, I'm really engrossed in the case studies!

    For the last one would you keep checking on her to make sure she's not getting worse / doesn't have a more serious condition and that it may just be the alcohol talking, remind her that there is a wait and she will be seen to shortly. Also alert maybe neuro uncase it does get worse and then there maybe someone on hand uncase she does take a turn for the worse.
    Oh maybe tell her friends to try and take her mind off it and get her to quiet down a little bit?
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    (Original post by electricjon)
    CASE 8

    It is 3am in A&E. You are asked to see a patient who is being aggressive in the waiting room. She is a final year medical student who is intoxicated and has fallen outside a nightclub, sustaining a head injury and laceration to the face. She is being abusive and aggressive to the receptionists, demanding that she be seen immediately as she is a student doctor and recently finished a placement in your A&E department. As you approach, she recognises you, yelling out your name and shouting derogatory remarks at you.

    What would you do next?
    I suppose, as others have already posted, that personality change is a possible indicator of neuro damage. Being intoxicated obviously makes things more difficult though.

    Perhaps the best option would be to keep an eye on her with regular neuro obs watching out for decreased loc, seizures, limb tone, disordered pupil dilation, vomiting etc. Maybe get a bit of history if possible from the friends (e.g. make sure she has no bleeding disorders or anything). I think BMG is also routine for head injury? Inform neuro about the situation and maybe an anaesthetist if the airway is at risk due to decreases in loc? Maybe an IV to sober her up quicker? (although I'm not sure if head injury is contraindicative. Might contribute to intracranial pressure? Dunno)

    If gcs reduces or neuro obs throw up anything weird (or exam shows skull fracture) then get a CT scan to see if a referral is required.

    On the other hand, might be worth trying to get her to tone it down in regards to the "im a student doctor" spiel. I would imagine drunk and disorderly won't look too great especially when in her place of work.

    Stab in the dark really.

    (Original post by electricjon)
    She has already been seen by the triage nurse, who reported normal vital signs and no LOC/amnesia/neck pain/seizures/headache/paraesthesia/weakness/N&V/visual symptoms. She is accompanied by her two friends, neither of them medically trained, and both sober.

    There is a 3 hour wait.
    Oops, missed this update.

    If the triage has cleared all of the above, is it pretty much an indication that she can be sent home, assuming that the two sober friends are happy to stay with her over the next few hours (provided with info of what signs/symptoms to look out for)?
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    (Original post by winter_mute)
    Can she be given a ct scan while drunk? If she does have a more serious condition then she gets treated quickly. If not, she waits and gets reminded that fitness to practise applies to students as well.
    She can be scanned while drunk. The question is whether her aggressive behaviour is because she has a serious intracranial injury or because she's a drunken abusive ****. We can't scan everyone who falls into the latter category.
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    (Original post by Charlottie93)
    Wow found this thread by accident and it's excellent, I'm really engrossed in the case studies!

    For the last one would you keep checking on her to make sure she's not getting worse / doesn't have a more serious condition and that it may just be the alcohol talking, remind her that there is a wait and she will be seen to shortly. Also alert maybe neuro uncase it does get worse and then there maybe someone on hand uncase she does take a turn for the worse.
    Oh maybe tell her friends to try and take her mind off it and get her to quiet down a little bit?
    I doubt the Neuro reg would appreciate being called down to A&E for something the medics there can assess.
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    (Original post by electricjon)
    You call the patient in for a brief chat. She is clearly intoxicated, but appears well, and doesn't fulfill any obvious criteria for CT scanning or neurosurgical intervention - (http://www.nice.org.uk/nicemedia/liv...6257/36257.pdf).

    As she is accompanied by two responsible adults, you doubt that she will require admission for neuro obs. She is however sporting a significant laceration to her face that will need referral to OMFS. You explain to her that she will have to wait.

    "Wait?!? For 3 hours?!? You ungrateful b*st*rds!! When I worked here I did ALL your cannulas and bloods and THIS is how you repay me?!? It's a f*cking joke and you're a disgrace to the NHS!!"

    You usher her back into the waiting room. She is reluctant to wait but understands that her wounds need to be sutured. She is, however, deeply dissatisfied and makes a point of announcing this to the rest of the patients in the waiting room, advising them to all make formal complaints against you personally. To help her pass the time she goes around the waiting room explaining the complaints procedure in detail to each patient, ensuring everyone has written down your name and GMC number correctly.

    Assuming she is seen eventually and discharged after receiving treatment, would you take any further action?
    I would tend to keep in overnight for neuro observations if drunk and head injury as one cannot rule it out.
    This of course because I recall the part of the CG56 guidelines which specifies a GCS < 15 2 hours post injury. And because of my awareness of cases where people have discharged 'drunk' patients who have subsequently died from their intracranial bleed.

    AS for the med student I'm not so much of a **** to report to GMC, but I would have strong words with them and send a formal letter on behalf of the department/hospital advising them that a zero tolerance approach is taken to abusive patients regardless of their background.

    Now, might I be so bold as to enquire what "MBChB MPH Manchester 2008" means?
    Does that mean you graduated MBChB plus a public health masters all together in 2008?
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    (Original post by Helenia)
    She can be scanned while drunk. The question is whether her aggressive behaviour is because she has a serious intracranial injury or because she's a drunken abusive ****. We can't scan everyone who falls into the latter category.
    To be honest I have no idea how a medic goes about assessing that (there are other indications for an intra-cranial bleeds), but how many does the PT need to present before you'd order a scan?
 
 
 
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