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    (Original post by electricjon)
    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.
    :/

    back to reading books i guess :P
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    (Original post by TwilightKnight)
    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.
    Well, he voluntarily called 999 and presented to A&E all of his own accord. Surely that implies he is in control of his mental faculties?

    Most patients are incapable of helping themselves, hence why they attend the health service in the first place.

    And he's a lawyer, and he threatens to sue you for assault if you touch him with a needle.
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    (Original post by winter_mute)
    I thought most A&E's had an on call Psych reg? Isn't that what Max Pemberton is doing now?
    In theory, it's possible they do. I saw one psych SpR in 6 months in A&E. In reality, my understanding is that the SpR covers several A&Es and quite often a psych hospital too. Generally most psych patients in A&E are actually seen by CPNs, specially-trained social workers or at most an SHO. On the rare occasion someone does require sectioning, it takes quite some time to get all the relevant team together.

    (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.
    Oh, I know that - heard of Re C? He needs a proper capacity assessment, so assuming he's still conscious I'd try to do that along with assessing his understanding of what he's done and what will happen if we don't treat him appropriately. Obviously he needs to be on cardiac monitoring, ECG etc, as a tricyclic-induced arrythmia is going to kill him quicker than the paracetamol. However, on my own I doubt I'd be capable of restraining him to try and cannulate him even if it was appropriate.

    I really hate this kind of case. Whatever you do it somehow seems wrong.

    (Original post by electricjon)
    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.
    Normally I wouldn't, this was more an answer to the suggestion of NAC. Though it is reasonable to give it in a mixed or staggered overdose if you are unsure what they may have taken or if, like here, levels aren't possible. However, as I said in my subsequent post, even if you can get hold of some, his arrhythmia will kill him first.
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    (Original post by 2klthor)
    True. B-blockers be of any use for the TCA overdose?
    The bigger problem is his paracetamol overdose. TCA overdoses are generally managed supportively, sometimes with sodium bicarbonate if they are acidotic. Not that you can find out if he's acidotic or give him sodium bicarbonate, as he won't let you near his blood.
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    (Original post by winter_mute)
    Just seen the low bioavailabilty of oral NAC along with foul taste and adverse affects.

    Actually is there a version that can be inhaled?
    No. That's scraping the barrel I'm afraid.
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    (Original post by winter_mute)
    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!
    You have explained that to him. In fact your A&E consultant has also had a go at explaining it to him, to no avail. He wants to live! He just can't set the phobia aside! Haven't you ever experienced a phobia?
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    (Original post by winter_mute)
    I thought most A&E's had an on call Psych reg? Isn't that what Max Pemberton is doing now?
    You ring up Sir Max Pemberton, the on-call psych reg. He says he would be delighted to accept care of the patient as soon as you can declare him medically fit. All that requires is a blood test +/- an antidote.
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    (Original post by kiss_me_now9)
    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.
    Best answer yet. He still threatens to sue you though for assault. Want to proceed?

    Oh and the metal thing is the buckle of the straps used to hold him to the spinal board.
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    (Original post by 2klthor)
    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.
    ECG and cardiac monitor show normal sinus rhythm.

    Admittedly, simple observation would be reasonable, except that if he then died from liver failure, in court the coroner might question why you didn't treat him.
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    I'd start mouth-to-mouth ASAP

    Then all the seniors will come over and ... :bumps:
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    For those who were talking about MHA section, sections only cover mental health assessment and treatment, not any other treatment for physical health. As others have said, the crux here is a capacity assessment (Helenia is spot on with Re C). if you can't get someone to talk the patient round and reason with them and you think they might have capacity to refuse, then you'd be getting seniors in and getting the Trust lawyers / your defence union's advice.

    Not so long ago I was trying to put a chest drain into a patient with schizophrenia who had a self-inflicted pneumothorax from setting off a powder fire extinguisher in his face. He was acutely psychotic, had already had enough IM meds to flatten a small elephant and was still kicking and thrashing round the bed. Time was off the essence, so I had a small army of nurses who were holding him still and at the same time reasoning firmly with him and talking him round, and that did the trick and the drain went in. For about 4 hours. Till the meds wore off and he pulled it out and we had to do it all over again... *sigh*
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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...
    Ok thanks.

    What's a courtesy call?
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    (Original post by electricjon)
    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...
    Tell him to look away/use a drape whilst you take blood so he can't see the needle?
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    (Original post by No Future)
    Ok thanks.

    What's a courtesy call?
    tbh I have no idea in this situation, it's not a term we used.

    A trauma call, on the other hand, is when the ambulance crew pick up a major trauma patient like this and call ahead to the hospital to let them know they're coming so they can assemble an appropriate team (usually A&E, anaesthetics, surgery and ortho).

    In my A&E we only had trauma, blue (medically unwell/unstable) and red (cardiac arrest) calls.
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    (Original post by No Future)
    Tell him to look away/use a drape whilst you take blood so he can't see the needle?
    I'm guessing you're not a person who suffers from phobias...
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    (Original post by electricjon)
    I'm guessing you're not a person who suffers from phobias...
    Haha no, I heard that's what they do for children who don't like the look of needles.
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    (Original post by electricjon)
    Best answer yet. He still threatens to sue you though for assault. Want to proceed?

    Oh and the metal thing is the buckle of the straps used to hold him to the spinal board.
    Ohhh. Thanks :yy:

    **** yeah, why not. I've come this far already!
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    First of all walk in with my stethoscope round my neck so people know I mean business.
    Then scream everybody "SHUT THE **** UP!"
    Take black shades out of pocket, wear them whilst saying "I got this".

    Then realize I have no ****ing clue at what I'm doing.
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    (Original post by electricjon)

    A. an ability to comprehend information
    B. an ability to retain information
    C. an ability to believe the information presented; and
    D. an ability to arrive at a choice based on the above. That is the ability to reason and weigh evidence before arriving at a decision.

    Case 1: In 1994, a gentleman (known as C) had paranoid schizophrenia and was detained in Broadmoor secure hospital. He developed gangrene in his leg but refused to agree to an amputation, which doctors considered was necessary to save his life. The Court upheld C's decision.

    Case 2: Sir Pemberton points out that a patient who voluntarily attends A&E seeking help for a potentially fatal overdose, who is then willing to let his phobia of needles override his alleged desire to live, is contradicting himself, and therefore cannot have capacity.
    Hmm, so does this mean patient C in Broadmoor did not voluntarily seek medical help?

    Or does it rest more on the self contradiction of patient 2 (lawyer)?
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    did you write this as it was happening? and needed advice? :P just told the guy to hang on a moment while you go advice from people on here
 
 
 
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