Dr Ivor Popovich presents examples of evidence-based decision making during ward calls. We also highlight some recommendations from Choosing Wisely and give an update on death certification.

* The Intern Suppository – Ivor’s EBM blog

* The Rational Clinical Examination – JAMA

* Plain film in small bowel obstruction

* The gas-less abdomen

* Paucity of gas

* Non-specific bowel gas pattern

* Read more in the blog post here

* Plasmalyte in renal failure

* Not contra-indicated

* Actually alkalinises plasma, driving potassium into cells

* The chloride in NaCl acidifies plasma, drawing potassium into the extracellular space

* Read more in the blog post here

* Asthma admission

* Tachycardia is not explained by salbutamol administration alone

* A large diurnal variation in peak flow (e.g. >50%) is a major risk factor for in-hospital cardiac arrest (not severity of asthma exacerbation at admission).

* Severity of wheeze does not correlate with severity of exacerbation

* Read more in the blog post here

* Choosing wisely

* New Death Documents website

* MOH Completing the Medical Certificate Cause of Death form (March 2018)

* MOH Examples of incorrect and correct cause of death certification (March 2018)

Cardiology expert Adele Pope returns with an approach differentiating tachycardia and managing atrial fibrillation. We also discuss ventricular ectopics, bigeminy and peri-operative anticoagulant and anti-platelet adjustment.

Differential

* Life threatening

* VT

* SVT

* AFib

* Flutter

* Common triggers of AFib

* Post operative state

* Myocardial infarction

* Sepsis

* Anaemia

* Hypo- or hypervolaemia

* Pulmonary embolus

* Electrolyte disturbance

* Cardiac dysrhythmia

* Non-cardiac

* Anemia

* Anxiety

* Dehydration

* Electrolyte imbalance (especially hypokalemia and hypomagnesemia)

* Fever/ sepsis

* Hyperthyroidism

* Hypoglycemia

* Ischemia

* Metabolic disorders

* Pain

* Poisoning and toxic exposure

* Pulmonary embolism

* Respiratory disease (e.g. pneumonia, pneumothroax)

* Shock

* Trauma

* Withdrawal syndromes

Approach

* ECG and new set of vitals before you arrive

* Eyeball the patient/ABCs

* History

* Old or new tachyarrhythmia?

* Chest pain

* SOB

* Palpitations

* Exact time of onset of symptoms

* Cardiac history

* Prev AF

* Ischaemic heart disease

* Valvular disease

* Hypertension

* Heart failure

* ROS

* Vitals + Examination

* General inspection + peripheries for perfusion

* JVP

* Auscultation

* Confirm rhythm

* Valvular dysfunction

* Wound

* Calves/leg oedema

* ECG

* Narrow complex or wide complex?

* QRS > 3 squares could be a wide complex tachycardia (call a code)

* Concordance (V1 – V6 often point in one direction in VT)

* AV dissociation indicated VT

* If narrow complex, is it regular or irregular?

* Irregular is probably AFib

* Consider investigations

* FBC, U&E (including Mg), TFT

* Consider septic workup

* Consider troponin

* Management

* Consider observation

* 500 mL fluid bolus

* Metoprolol tartrate 50 mg (not if overloaded or in steroid-dependent asthma)

* Diltiazem short acting 30 mg as an alternative

* Documentation

* Review past notes

* Current medications – has a dose been missed?

* Basics (date/time/name/reason for review)

* Positives and pertinent negatives

* Impression and differential with justification.

* Have you eliminated life threatening conditions?

* Why has this arrhythmia developed?

* Is there a risk of deterioration?

* Type of AFib (first episode, paroxysmal, persistent, or permanent)

* Clear and specific plan

* Immediate investigations

* Fluids

* Electrolytes correction

* Beta blocker?

* Anti-arythmic?

* Anti-coagulation?

* Consider echo, TOE, CXR, ETT

* Consider discussion with senior and escalation, especially if called back to patient again.

Concluding remarks

* Get help early for:

* Wide complex tachycardia

* Poor perfusion/hypotension

* Pulmonary oedema

* Main triggers are post operative state, myocardial infarction, sepsis and anaemia.

* AF may be the first sign of a significant problem, so a good review of systems is needed.

* AF may precipitate cardiac and perfusion problems (ischemia, heart failure, atrial thrombus), so identify patients at risk.

* Timing:

* Assume onset of AF to be greater than 48 hours...

Foremost expert on all things NZRDA, Dr Deborah Powell, explains why RMOs get free meals, what 8.1.2 is, and the RDA’s role in helping members in trouble.

* Meals and the NZRDA Education trust

* 8.1.2

* “For runs to which the above paragraph does not apply, any Ordinary Hours which are not rostered shall be counted as hours worked (up to a maximum of 8 Ordinary Hours per day) when determining the category for the run.”

* Role of NZRDA

* Negotiating and enforcing the MECA

* Informing members

* Lobbying

* Helping and representing individuals in difficulty

* Media

* Public relations

* All things RMOs

* Getting into trouble

* Cross cover outside ordinary hours

* What happens to membership fees?

* Bullying and harassment

Sam meets some podcasting celebrities and experts in clinical reasoning Dr Art Nahill and Dr Nic Szecket – hosts of the podcast IM Reasoning. We talk cognitive bias and and some approaches to minimising their impact.

Common biases

* Confirmation bias

* The tendency to search for or interpret information in a way that confirms one’s preconceptions, while ignoring information that does not support the preconceptions.

* Anchoring

* The common human tendency to rely too heavily on the first piece of information offered (the “anchor”) when making decisions.

* Premature closure

* Failing to consider reasonable alternatives after an initial diagnosis is made.

* Affective biases

* Letting emotions, pre-conceptions, or stereotypes lead to assumptions that cloud the reasoning process e.g. drug users, chronic pain.

* Gambler’s fallacy

* The erroneous belief that chance is self correcting. If the last two patients were diagnosed with serious chest pain, surely the next one will be benign. Remember that each ward call is unrelated to the last.

* Posterior probability bias

* Letting recent or past events thats that are independent of the current case, impact on your estimated likelihood of a diagnosis.

* Ockham’s razor

* The simplest answer is more likely to be correct. Another way of saying it is that the more assumptions you have to make, the more unlikely an explanation is. Also, that a single diagnosis that explains the patient’s symptoms is more likely, than seperate diseases occurring concurrently.

* Hickam’s dictum

* The counter to Ockham’s razor. Patients can have as many diseases as they damn well please.

* Larry Weed – The Father of the Problem-Oriented Medical Record

Apps

* Isabel

* VisualDX

* Diagnosaurus

Podcasts (FOAMed)

* IM Reasoning

* Pomegranate Health

* EMCrit

* ERCast

* On the wards

Vani and Sam give suggestions on how to improve these everyday skills that can otherwise take a lifetime to learn.

 Why is this important?

* Decisions will be made based on documentation – we are lazy and tend not to verify information.

* Allows you to organise your thoughts, review notes, and identify gaps.

* Is a legal record and part of your job description.

* Inadequate documentation sinks careers.

* You will not remember the details years later if there is a complaint. HDC cases tend to occur years after the fact.

* Prioritisation is an art and is learnt through experience. It is however important to know what the expectations are and not cause harm through poor prioritisation.

Types of documentation

* Ward round notes

* HO notes

* Ward call notes

* Plans

* Lab requests

* Referrals

* Clinic letters

* Procedure notes

* Op notes

* Discharge summaries

* Sick notes

* Supporting letters

* Death certificates

All documentation

* Title

* Date/time

* Reason for review/note

* 1 line summary

* SOAP (Subjective, Objective, Assessment, Plan) or HEIIP (History, Exam, Investigations, Impression, Plan)

* Pertinent info

* Solid plan

* Your name + pager

* Never change a note

Prioritisation

* Let time heal

* Trust no one (nonsensical pages, reflux, nebs)

* Complete non-urgent tasks ward by ward

* Document a plan nurses can follow

* Talk to the nurse

* Hand over a plan with any jobs

* Give a reason for jobs (e.g. fluid review)

* Handover on time, handover your jobs

* Don’t come to work sick

* Perfect is the enemy of good.

Handover

* What makes a good handover?

* Concise and objective

* Clear plan for pending results

* Clear priority

* Concise! Most of what you say will be forgotten, so make it count.

* Why is it important?

* Safety!

* Helps with prioritisation

* Opportunity to discuss cases with a colleague

* Allows you to relax and sleep after you’ve gone home

* What is appropriate to handover?

* Jobs to be done

* Investigations to be chased and plan

* Patients to be reviewed

* Sick patients

* Patients expected to die

* Patients for whom you feel additional context would be useful. Don’t just hand over patients the next house officer “might get paged about”.

* Go home on time.

* Weekend plan

* Prepare discharge summaries and referrals

Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call.

Differential

* Life threatening

* ACS

* PE

* Dissection

* Cardiac tamponade

* Pneumonia

* Pneumothorax

* Oesophageal bleed

* Heart

* Pericarditis

* Lungs

* Mechanical (foreign body, surgical, chest drain, post-pleurocentesis)

* Oesophagus

* Reflux

* Oesophagitis

* Oesophageal spasm

* MSK

* Musculoskeletal

* Costochondritis

* Rib fracture

* Below the chest

* Upper abdominal pain

* Above the chest

* Anxiety

Approach

* Eyeball the patient

* ABCs

* Calling a code

* 777 (or your local hospital emergency number)

* This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3.

* History

* SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity)

* Previous similar episodes? History of exertion chest pain?

* Diaphoresis

* Shortness of breath

* Review of systems

* Identify risk factors

* Vitals + Examination

* General inspection + peripheries

* Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues

* Abdomen, calves, catheter and drains (for completeness)

*  ECG

* Take your time and be systematic

* Look at an old ECG

* Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves.

* Look for contiguous and reciprocal abnormalities.

* T wave change normal variants occur in III, aVR, V1.

* A repeat ECG in 15 minutes is useful to identify dynamic changes.

* Consider investigations

* FBC, U&E, troponin

* CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm)

* Management

* Call for help (code or at least registrar support)

* Attach continuous monitoring e.g. defibrillator pads

* Re-assess stability of the patient

* Oxygen only if hypoxic

* GTN spray

* Opiate analgesia (IV morphine boluses ideally)

* Determine bleeding risk

* Identify any anti-platelet and anti-coagulation medicines in use

* Post-operative status

* Consider loading with aspirin 300 mg PO

* Document

* Review past notes

* Basics (date/time/name/reason for review)

* Positives and pertinent negatives

* Impression and differential with justification. Have you eliminated life threatening conditions?

* Consider TIMI or HEART score (acknowledging use outside of ED)

* Clear and specific plan

* Consider discussion with senior and escalation, especially if called back to patient again

Specificity of chest pain symptoms and examination findings [Evidence]

Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735

* No single finding rules in or rules out acute coronary syndrome.

* The most specific (convincing) symptoms of ACS were:

* Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).

Sam and Vani explore the most common requests for after hours prescribing and how to safely and quickly approach prescribing of insulin, warfarin, analgesia, antiemetics, and sleeping tablets.

Insulin

* Generally treat any blood glucose of 20 or above.

* Target range:

* Inpatient: 7 – 14 mmol/L

* Outpatient: 4 – 10 mmol/L

* Achieving target 60% of the time is quite good!

* Neglecting high BSLs leads to irritating symptoms, opportunistic infections and delayed recovery.

* Correct BSLs with a rapid acting insulin (Novorapid)

* Correction doses should be given at meals and no more frequently than 4 hourly.

* If correction doses of insulin are required, consider increasing the person’s usual insulin / treatment.

* Don’t recheck BSLs too early. Wait until the next scheduled check, unless there is concern of hypoglycaemia.

* Don’t use ActRapid – it works slowly subcut so should only be used IV.

* Diabetes in pregnancy requires frequent adjustment and tighter control – consult a senior.

* Don’t withhold long acting insulin (Lantus and insulin degludec) if NBM, even if on a GIK.

Antiemetics

* Cyclizine (NZF)

* Antihistimine

* Classic, old-school, and effective

* Great for non-iatrogenic nausea and vomiting

* Can give euphoria IV, so avoid in young patients specifically requesting it and in the elderly

* 25 – 50 mg PO/IV TDS PRN

* Ondansetron (NZF)

* Serotonin antagonist

* Newer, but not necessarily better antiemetic

* Primarily indicated for PONV and chemotherapy-induced nausea

* Can be constipating

* Can reduce the effectiveness of tramadol, so avoid co-prescription

* 10 mg PO/IV TDS PRN

*  Metoclopramide (NZF)

* Dopamine antagonist

* Gastric stimulant, avoid in suspected small bowl obstruction

* Avoid co-prescribing with droperidol and prochlorperizine

* Avoid in Parkinson’s disease

* Avoid in under 20 year olds due to risk of oculogyric crisis

* 10 mg PO/IV TDS PRN

* Domperidone (NZF)

* Somewhat interchangeable with metoclopramide, but no IV formulation

* Does not cross BBB, so preferred in Parkinson’s disease

* 10 mg PO TDS PRN

* Droperidol (NZF)

* Dopamine antagonist

* Usually prescribed by anaesthetics for PONV

* 0.625–1.25 mg IV Q6H PRN

* Scopoderm patch (NZF)

* Nonspecific antimuscarinic

* Usually prescribed by anaesthetics for PONV

* 1 patch Q72H

* Prochlorperazine (NZF)

* Oral: 20 mg initially then 10 mg after 2 hours; prevention 5–10 mg 2–3 times daily

* Rectal: 25 mg when required followed if necessary after 6 hours by an oral dose, as above

* Don’t confuse with chlorpromazine!

Analgesia

* Pain assessment

* Try to get some kind of assessment documented e.g. verbal pain score

* Pain ladder

* Simple analgesia e.g. paracetamol +/- NSAID

* “Weak” opioides e.g. tramadol or codeine

* Titrate up opiates e.g. morphine or oxycodone

Most RMOs don’t ever get around to reading the their employment contract (MECA). In this episode, Sam talks to NZRDA advocates Melissa Dobbyn and Tara Martin about what you need to know, and where to get help.

* Key concepts to be familiar with

* Cross cover outside ordinary hours (XXOOH)

* Cross cover

* Max 2 long days in 7

* 72 hour rule

* 144 hour rule

* 8 hour break rule

* 1:2/1:3 weekend rule + safer roster exception

* Sleep recovery days

*  Leave

* Entitlement

* Leave abutting weekends

* Lieu days

* 14 days, undeniable

* Abutting rule doesn’t count

* Can’t be transferred

* Can’t be used on statutory holiday

* Leave transfer

* Sick leave

* Parental leave

*   Costs of training

* Entitlements as a house officer

* APC application and renewal

* Insurance

* MEL

* Rarely granted in PGY1, discretionary

* PGY2+ entitled to 5 days/year, extendable to 2 weeks for PGDip OMG/Paeds

* There is a 12 week total entitlement per vocational pathway, but isn’t something to be too worried about at this stage. Will probably increase. DHBs are required to help you get through training.

* Includes interviews, transport, flights, accommodation

*  Keep a work diary from day 1

* Leave applied/taken/transferred

* Claims made/paid

*  Rosters

* Published 28 days before, then can’t change, otherwise after hours shifts are optional

* 14 days for reliever, paid 2 categories above

* Short notice relief – know the rules

* Part of a run desctiption – cannot be changed with 2/3 agreement by RMOs concerned

* Run review

*  Insurance

* NZMPI

* Provides actual insurance, governed by NZ insurance law

* NZ company, NZRDA is a shareholder

* MPS

* Provides discretionary cover, not governed by NZ insurance law

* UK company

* Medicus

*  Superannuation

* Entitled to 6% of your salary to superannuation

* Can put it all into Kiwisaver or all into a scheme

* Or split 3%/3%

* There is an NZRDA scheme, but also some others. Just make sure you’re signed up to something to receive your entitlement.

*  Where to get help (you need to be an RDA member)

* Local delegate

* [email protected]

* MECA and MECA FAQ

* Join the RDA

* Free for TIs

* $40/month by direct debit or $480/year direct debit or credit card.

*  RDA membership

* 90% of RMOs are members.

* RDA is the only organisation solely representing RMOs. They do not represent SMOs, GPs or anyone in management.

* If you run into trouble during your career an RMO, you will be far more likely to have a good outcome if you are an RDA member. RDA will provide extensive help, but only if you were a member at the time the problem arose. This is seperate to medical indemnity cover, that won’t cover professional and industrial issues.

* Our working conditions are only good because RDA members before you fought hard for them. Where union membership is low, the conditions erode. Look no further than the UK where the pay is bad, job satisfaction low, expenses not reimbursed,

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about reduced consciousness and acute and post-seizure management.

Approach to fluctuating GCS

* Eyeball the patient / ABCs

* Calling a code – certainly if the patient is not rousable!

* 777 (or your local hospital emergency number)

* This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.

* Initial assessment

* Big picture

* Vitals

* Pupils

* Wide: drugs, alcohol, adrenaline

* Constricted: opiates

* How does the patient respond to questions?

* Assess GCS

* Differential

* Intracranial or extracranial?

* Surgical sieve

* Overdose, head injury, seizure, diabetic, epileptic, previous episodes, medications

* Don’t ever forget glucose

* Collateral history, including from other patients in the room

* Vitals + Examination

* General inspection + peripheries

* Neuro exam aimed at identifying localising signs

* Consider investigations

* ABGs, glucose, FBC, electrolytes, creatinine, cardiac enzymes, ketones, TFTs, blood cultures, alcohol, coags

* ECG, CXR, catheter urine

* Consider CT head, LP

* Rarely toxicology (urine and blood)

* Consider the “3 coma antidotes”

* Glucose: if hypoglycaemia confirmed on BSL give 100mL of glucose 10% IV

* Thiamine: 100mg IV/IM (for patients with chronic alcohol abuse or chronic malnutrition)

* Naloxone:

* 400 micrograms (1 ampule) in a resus situation (concerned about airway)

* 80 microgram boluses for somnolent patients that are just difficult to rouse. Repeat every minute with a 10 mL flush until alert.

* Maximum of 10 mg in total.

* Note short half-life, so often need repeat doses.

* Document

* Basics (date/time/name/reason for review).

* Positives and pertinent negatives.

* Impression and differential with justification.

* Clear and specific plan.

* Consider discussion with senior and escalation.

Acute seizure management

* DRSABCs

* Airway

* 100% oxygen via non-rebreather or bag mask

* Recovery position (protect the patient and staff from injury)

* Breathing

* Sats probe

* Circulation

* Pulse

* CRT

* Don’t attempt BP during seizure

* Duration >5 minutes

* Code code if not done already

* IV access (IO if failed IV)

* Seizure control:

* Lorazepam (or midazolam) 4 mg IV (give 2 mg, flush, then another 2 mg slowly and flush).

* IM midazolam 10 mg is the treatment of choice if no IV access is available. The dose may be repeated if required after 10 minutes. Maximum midazolam dose of 20 mg IM over 24 hours.

* Rectal diazepam 10 mg if above not IV and IM access unavailable (empty rectum first).

* Lorazepam has a longer anti-epileptic effect than diazepam as it is not redistributed to adipose tissue. If lorazepam is not immediately available do not delay but proceed with diazepam or midazolam.

* An anticonvulsant must be started if there is more than one seizure.

Post-seizure management

* IV access

* Secondary survey for injury and infective causes

* History and description of the events surrounding the seizure.

* Who witnessed it?

* What situation was the patient in before it started?

* Incontinence or tongue biting.

* Post-ictal features.

* Does the patient remember the episode?

Sam talks to Infectious Diseases Physician Assoc. Prof Mark Thomas about fever and the minutiae of microbiological investigations.

Cause of fever

* Infection (cytokines)

* Atelectasis

* Medications including transfusion reaction

* Alcohol withdrawal

* PE

* Malignancy

Approach

* Eyeball the patient / ABCs

* History should be directed at identifying evidence of infection across the following systems:

* Lungs

* Gastrointestinal

* Genitourinary

* Skin

* Central nervous system

* Surgical and cannula/drain sites

* Note: eyes, ears, nose throat are rare infection sources in an adult hospital setting

* Identify timing since surgery or invasive procedures.

* Dirty surgery may cause early infection, but is rare with routine prophylactic antibiotics.

* 2-7 days post-op increased risk of operative infection

* 7+ days think alternatives like PE as well as intrabdominal collection and joints

* Identify risk factors for deteriorating quickly

* Diabetes

* Neutropenia

* Immune deficiency

* Vitals + Examination

* General inspection + peripheries

* Lungs

* Abdomen

* Skin (including spinal anaesthesia sites)

* Surgical and cannula sites

* CNS if history supports it (though beware the non-specificity of classical meningism)

* Investigations

* Review microbiology for updated reports

* FBC, U&E, CRP

* ABG for sepsis

* Directed culture

* Blood

* At least 2 setsv(4 bottles)

* Urine

* Faeces

* Sputum

* Directed imaging

* CXR

* CT abdo pelvis

* Renal USS for renal abscess in urosepsis

* Management

* Fluids

* Antibiotics

* Oxygen if desaturating

* Contact precautions

* Investigations/culture

* Document

* Review past notes

* Basics (date/time/name/reason for review)

* Positives and pertinent negatives by system

* Impression and differential with justification. Have you eliminated life threatening conditions?

* Clear and specific plan

* Who will chasing investigations?

* Monitoring parameters

* Consider discussion with senior and escalation, especially if called back to patient again or there are concerns about source control or neutropenia

Resources

* BPAC common antibiotics guideline (2017)

* The Third International Consensus Definitions for Sepsis and Septic Shock