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    (Original post by electricjon)
    A 46 year old man is brought by ambulance to A&E following a suicide attempt, involving an overdose of an undisclosed amount of paracetamol and amitriptyline, plus two litres of cider. He has no previous psychiatric history.

    Registered blind (secondary to diabetes), single and living alone, and having recently been fired from his job, he decided to take his own life, but immediately after ingesting the tablets, called an ambulance to seek help with the voices in his head telling him to kill himself.

    At 4 hours post ingestion, and after absconding several times, the patient refuses to give blood due to a phobia of needles. The psychiatric team refuse to take over care of the patient until deemed medically fit, but no-one in the department is able to persuade him to allow blood to be taken.

    What would you do next?
    Since he rang the emergency services claiming he had voices in his head that had told him to kill himself, doesn't provide grounds to bypass patient autonomy and go straight to beneficence and non-maleficence?

    Surely you have to assume he's going to suffer long term, irreparable damage to his liver and possibly his kidneys ( or worse, death ) if he's left untreated. Since he actually requested the aid of the emergency services, then you have to promote what is best for patient, since he is currently incapable of doing so himself.

    I'd just restrain him and take the blood. The 999 call should be evidence that he isn't truly in control of his mental faculties at the moment.
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    (Original post by 2klthor)
    He's refusing bloods.
    Just get someone to section him then? Surely you could get an easy psych consult to do it. Or just call the judge who lives down the road from you to issue a court order.
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    (Original post by TomInce6666)
    Just get someone to section him then? Surely you could get an easy psych consult to do it. Or just call the judge who lives down the road from you to issue a court order.
    Have you ever been in A&E at 2am, or tried to get a psychiatrist into hospital (even for a section) at that time?
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    (Original post by Helenia)
    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.
    True. B-blockers be of any use for the TCA overdose?
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    (Original post by electricjon)
    Gosh, I've never heard of that case. At Manchester all we did was Gillick competence over and over again.
    Haha we do a lot of that stuff in the first 2 years - Gillick as well.
    Also Bolam and then the revised version etc.

    All very useful to know - especially once you start practicing!
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    (Original post by No Future)
    Ahh. Did the Dr face disciplinary action?
    You know what - I've no idea!

    The case is very famous , but noone ever talks about the doctor afterwards...

    He was tired and ill at the time I believe (Remember what junior doctors hours used to be like :/ ) so in a GMC hearing he might have escaped being struck off - but might have had another punishment
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    (Original post by TomInce6666)
    Just get someone to section him then? Surely you could get an easy psych consult to do it. Or just call the judge who lives down the road from you to issue a court order.
    I've been over that :P

    OP says psych won't assess him and as he presented to A&E voluntarily he may not be section-able.

    Maybe try to explain to the PT exactly what could happen if he doesn't consent to bloods? Obviously don't be brutal, but if he wants to live he's going to have to set the phobia aside!
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    (Original post by Helenia)
    Have you ever been in A&E at 2am, or tried to get a psychiatrist into hospital (even for a section) at that time?
    I thought most A&E's had an on call Psych reg? Isn't that what Max Pemberton is doing now?
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    (Original post by Helenia)
    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.
    Well, the voices are certainly significant, but they don't automatically mean he doesn't have capacity (don't we all hear voices in our head from time to time?). And your seniors are all stuck in Resus dealing with the RTA from before - so though you might not be happy about it, you're stuck by yourself to deal with it and time is running out.
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    (Original post by 2klthor)
    N-acetyl cysteine (NAC)?
    Yes, that is the antidote for paracetamol overdose.
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    (Original post by electricjon)
    Well, the voices are certainly significant, but they don't automatically mean he doesn't have capacity (don't we all hear voices in our head from time to time?). And your seniors are all stuck in Resus dealing with the RTA from before - so though you might not be happy about it, you're stuck by yourself to deal with it and time is running out.
    I'm assuming someone's tried to reason with him and explain that his liver and kidneys might be packing up? If he hates having bloods taken, he's gonna love Haemodialysis. Not to mention if he does sincerely want to live you need to know how his liver is doing.

    On the other had is there no other way of assessing liver and kidney function other than sending his blood to a Pathology lab?

    Edit: seen you last post, oral NAC and hydration in the mean time. Next step?
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    (Original post by TomBRFC)
    You could do it and then say he dreamt it becasue he took an overdose.
    Sadly, both assaulting and then lying to a patient are not part of the GMC's Good Medical Practice: Duties of a doctor. How would you explain the bruises/lacerations/pain? That's a one way ticket to getting struck off I'm afraid.
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    TBH I'd either go straight for the comforting, 'it's ok you're going to be fine, let me bleep someone who can actually do something about this' lines whilst silently crapping myself and wondering how I even got into med school or just stand there and cry.

    Did he have a hip replacement? What's the t shaped thing in his left hip?
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    (Original post by 2klthor)
    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?
    Good question. However, he isn't refusing everything, just giving blood. He came to A&E because he wants your help, and you have a duty to provide it, as long as it doesn't involve needles.
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    Just seen the low bioavailabilty of oral NAC along with foul taste and adverse affects.

    Actually is there a version that can be inhaled?
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    Oh, onto the OD guy. I'd tell him to man the **** up and let me take some blood, or I'll be holding him down and getting the worst phlebotomist to do it for me.
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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 :/
    No need for any of that just yet. His ABC's are fine. The ITU reg tells you to get lost. He is not unconscious yet, and you aren't willing to wait for liver failure and encephalopathy to develop over weeks. After all, there is the 4 hour wait in A&E to adhere to! And ABGs and dialysis all require needles and IV access.
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    After NAC, if dialysis isn't an option surely it would just be symptomatic relief, i.e. Treating antimuscaric effecs of TCAs, hydration as mentioned. Any arrhythmias?

    EDIT: apols NAC is IV.
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    (Original post by Helenia)
    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.
    That's not a bad idea at all. True it won't solve the problem of the amitriptyline overdose or his psychosis, and it isn't good practice to blindly treat a paracetamol overdose without knowing the blood levels, but it's worth a go.

    Except that this is A&E and we don't keep things like that here. And it's out-of-hours so the pharmacy is shut.
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    (Original post by birduk)
    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!
    Best answer so far.

    Unfortunately, EMLA cream takes a good 30-60 minutes to take effect. And he's refusing to let you take blood because of needle phobia, not pain phobia.

    And there is a way! There are actually 2 ways that this story had a happy ending...
 
 
 
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