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    (Original post by No Future)
    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?
    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...
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    (Original post by winter_mute)
    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?
    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.
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    (Original post by Helenia)
    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...
    Indeed, it should have been a trauma call, which would have saved a lot of time. It was the scariest moment of my medical career so far. I had to squeeze his sticking out fractured humerus back into his arm. Seeing him come in alert and talkative to being a corpse within 100 minutes will haunt me for the rest of my life.
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    (Original post by electricjon)
    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.
    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?
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    (Original post by No Future)
    What case is that?
    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!
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    (Original post by M1F2R3)
    Gimme 10 cc's of paaaaaaaaaaain
    Lol casualty ftw, but it's crap now. Is it even still on tv?
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    (Original post by winter_mute)
    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 short answer is no. If he's taken an undisclosed overdose it's not safe to give him more drugs. If he were to become comatose then you wouldn't know what was causing it.

    And as for sectioning - well he has presented to A&E voluntarily, so would you be able to section him? And also, getting a MH section takes quite a bit of time, and you need this blood test immediately.
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    (Original post by Philosoraptor)
    The night watchman case! Everyone learns it as part of medicolegal fluffy stuff at UCL.
    Gosh, I've never heard of that case. At Manchester all we did was Gillick competence over and over again.
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    (Original post by electricjon)

    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?
    Put him on IV fluids to increase his blood pressure maybe?

    Edit: How stupid, the guy s bleeding out and I think IV fluids. its going to be a long 5/6 years and Ill probably still not know how to deal with this kind of situation for a while longer yet.
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    Can you not just sedate him and give him the blood? if he refuses knock him out then do it.
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    (Original post by Philosoraptor)
    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!
    Ahh. Did the Dr face disciplinary action?
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    (Original post by TomBRFC)
    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?
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    (Original post by TomBRFC)
    Can you not just sedate him and give him the blood? if he refuses knock him out then do it.
    No. You cannot "just sedate" people; there are very strong legal guidelines about this, not to mention the fact we'd rather not screw him over by giving more drugs on top of what he's already taken. And we're wanting to take blood not give it, though perhaps more importantly, get some IV access.

    This case is very dodgy territory and again I'd be getting a senior to help. The fact that he has voices telling him to kill himself suggests his capacity may well be impaired so at some point it may be possible to treat against his will, but I wouldn't be happy assessing that on my own.
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    N-acetyl cysteine (NAC)?
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    (Original post by electricjon)
    Again, sedation with overdose = bad idea.

    He is (was) a lawyer - you sure you want to knock him out?
    You could do it and then say he dreamt it becasue he took an overdose.
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    Obviously with consent - otherwise, the guy is competent so you have to adhere to his wishes and not treat him. Would you discharge him in this situation if he refused everything?
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    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 :/
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    (Original post by 2klthor)
    N-acetyl cysteine (NAC)?
    Can only be given IV. He currently isn't letting anyone near him with needles (same goes for someone else's suggestion of dialysis and ABG)

    You could give oral methionine if he will take it, but that's not going to solve all his problems.
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    I've got 2p. I'll shove it in the ring for this one.

    Can you use a local gel anaesthetic on his arm to take blood. After all, he is blind and won't be looking....

    He presented himself for help so he obviously doesn't want to die. You say nobody can persuade him, but there must be a way? More talking please!
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    (Original post by TomInce6666)
    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 :/
    He's refusing bloods.
 
 
 
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