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    I have had exposure to a lot as a junior doctor but cardioresp is not one of those things unfortunately. Could someone give a few basic tips? For example on my nights I kept getting bleeped about dropping sats and the patients were all on antibiotics, negs, steroids, oxygen etc and I really didn't know what else to do confidently apart from turn up the 02, get an ABG and speak to med reg about NIV if in T2RF ....;/
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    it is not really my area.

    from what i remember (and my experience) of resus. get help asap. shout and call the crash team. help comes quickly.

    if you are the most senior doctor - delegate jobs to nurses and HCA - you need to 'lead' the call if you are the most senior doctor and its better to get others to do things whilst you think).

    if you are alone i would start chest compressions and ask someone to get the defib (put that on the chest), i think this is most important from experience, as you need to minimise time to shock the heart.

    resus is normally easy in the hospital as you have an aneasthetist that comes and a med reg that normally takes over to lead it.. so in hospital as an SHO often resus is often easy as you get clear jobs to do. i think it is harder for the med reg or other member of staff that leads it.


    low sats. there is no 'rule' for low sats - you need to think what you are treating - just doing an ABG and turning up an oxygen is not a plan. maybe neither is required.

    so if someone how low sats, you need to work out why, the management depends on why. first, you need to read the notes and do an examination to work out why as low sats may be fluid overload, it may be pneumothorax, it may be pneumonia, it may be asthma.

    also, if i remember correctly COPD patients they should have 'low sats' in the range of 88-92% and so turning up the oxygen i suspect would wrong thing to do. (correct me, i may be wrong about that one, but it is what i remember from medicine). often the med reg is locum or gastro so they are not always helpful. normally in these COPD patients, i would normally ask the advice of the respiratory ward nurses as well. i think we used NIV when there was high carbon dioxide in the blood and the patient had respiratory acidosis (?). i dont think i would routinely turn up the oxygen in COPD patients as they normally had low sats. sorry its been a long time since i did acute medicine.

    if you have something more serious when you are alone you have to escalate it to ITU. for example, i had to manage asthma attack a few times on my own in resus, med reg was busy, and as an SHO on call at night you have to manage it. both times i worked up the protocol until nothing was left. but i did call the 'outreach' team early from critical care early.

    sometimes they are not very helpful, as the nurse didnt really add much other than 'ITU is busy and he is not sick enough for us left'. but when i left the patient to clerk the next one, cuz they are on there books, later when they reviewed her condition deterioriated and she was taken to ITU later.

    i remember a time i tried all the things - back to back nebs, steriods, amiotyplline, magnesium, - and in the end she did not improve so they had to take her to ITU. i believe at the end, you have to put in a tube to mechanically ventilate. i think some places have intermediate wards between ITU and the general ward, but they did not have this in my DGH. but it is very important to call ITU outreach team. often the anaesthetist comes but sometimes it is a nurse from ITU at night.

    HTH
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    also...

    dont forget simple practical things if they have low sats. some things i have learnt from my mistakes !

    - make sure they are sitting up

    (very commonly you are called to see patients with low sats and it is cuz they have been kept lying flat)

    - make sure they have kept the mask on properly as often in NIV it is not over there mouth or loose etc.

    (often people 'take off the mask', or it is fitting very inappropriately, dementia patient take off there mask or it is not connected, or the oxygen is not turned fully on etc.)

    - make sure you speak to the nurses / HCAs about the patient

    (you a lot of from this, sometimes people go for a smoke and you would not know unless you speak to the staff )

    dont forget these simple practical things.

    HTH
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    Your role is to check the diagnosis is correct (e.g. pneumonia vs fluid overload is a common one), treat appropriately and escalate their care if needed. If they are very elderly with a DNACPR and their findings are consistent with pneumonia and they're already on antibiotics and they're otherwise stable, then there's potentially not much else to do. In particular, an ABG may not add much to their care if they're not critically unwell - you already know their pO2 is low as their sats are down. Everything else can be got from venous sampling, which is important because you can then get the nurses to help you and protect your time. But again, only if needed. You don't have to do loads of stuff for every patient you see.
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    (Original post by Anonymous)
    I have had exposure to a lot as a junior doctor but cardioresp is not one of those things unfortunately. Could someone give a few basic tips? For example on my nights I kept getting bleeped about dropping sats and the patients were all on antibiotics, negs, steroids, oxygen etc and I really didn't know what else to do confidently apart from turn up the 02, get an ABG and speak to med reg about NIV if in T2RF ....;/
    Assuming the diagnosis is right (and that's part of your job when you're assessing these patients), you're essentially describing a situation where you've maxed out standard ward therapy. So, it's not surprising that you feel uncertain where to go next.

    The important steps would be to confirm the diagnosis and rule out any complications. This may be through getting a CXR or a gas if indicated.

    If, after that, you're happy that it's simply progression of disease, you rightly need to think about escalation. This may be getting an airvo machine, NIV or ITU input if appropriate.

    A few other simple things would be changing patient position, saline nebs and chest physio, depending on what you're treating. Also make sure that they're prescribed their usual inhalers and at the right doses.

    Then at the end of the day, you need to treat the patient rather than the number. Have sensible SpO2 targets in mind and don't get worried about natural fluctuations, especially when it could well be diurnal variation.
 
 
 
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