Your first day as a doctor

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.

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.

I thought most A&E's had an on call Psych reg? Isn't that what Max Pemberton is doing now?

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.

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.

True. B-blockers be of any use for the TCA overdose?

Just seen the low bioavailabilty of oral NAC along with foul taste and adverse affects.

Actually is there a version that can be inhaled?

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!

I thought most A&E's had an on call Psych reg? Isn't that what Max Pemberton is doing now?

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.

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.

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...

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...

Ok thanks.

What's a courtesy call?

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...

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.

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.