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Surviving the F1 Bleep – Session 1Rachael– FY2 Belfast T rust Med School – QUB FY1 – UHD: Medicine, Medicine, Surgery FY2 – Neurosurgery, ED, Medicine FY3 Year incomingLearning objectives How to cope with your bleep How to obtain the important information How to safely assess a patient and form a management plan When to bleep another speciality Giving and taking a handover SBARWhat is your bleep for?Sick Patients and URGENT tasksDon’t panic You’re on call and have been bleeped! by SN ‘A’ on Ward ’ ’ about patient ‘A’ who has chest painWHA T DO YOU DO?1. THINK • Who are you speaking to on the phone? • Who is the patient? • What is the problem? • Do I need to get there right away? • What else can I find out over the phone? • Hospital Number • Background history • NEWS SCORE • Has the patient deteriorated 2. PLAN Can I sort this out over the phone? Can anything be done on the ward before I get there? • NURSES & HCAs CAN HELP YOU – repeat OBS, IV access, BLOODS (inc troponin), BM, UO • ECG - ask for this to be ready for you arriving • Urine dips • Equipment you might need Tell the staff member on the phone that you are on your way…You’ve asked ah lle important questions and are now on your way to the ward…..WHA T ARE YOUR INITIAL THOUGHTS? Do I have Causes of chest Are they having time to pain a heart attack? pee? Do they have a Start thinking of cardiac history? what investigations you might need3. ACT What do you do when you first get to the ward? • Eyeball the patient!! • Take a handover in person ideally • Have notes and up to date observations • Gather equipment as appropriate • Brief history and A to E assessmentASSESSMENT– CHEST P AIN History HPC PMH Duration of chest pain Cardiac: IHD, MI, HF, ANGINA Speed of onset: sudden / gradual PE RF: cancer, previous PE/DVT/ RECENT TRAVEL Chest pain location: Central / Arm-Neck, Intrascapular GORD Cough: sputum / haemoptysis DH PE risk factors: recent surgery / immobilityTN / Isosorbide mononitrate NSAIDS / Steroids Chest trauma: including surgery Digoxin Recent viral illness VTE prophylaxis ASSESSMENT- EXAMINA TION End of bed-o-gram A – E ASSESSMENT Sweating / pale Airway Increased work of breathing Breathing Distressed / comfortable Circulation Clutching chest Disability Exposure Observations: NEWS score ASSESSMENT– REVIEW NOTES Background - why are they in hospital? Have they had this chest pain before? Check bloods and trends Review notes and observations - what is the trendDIFFERENTIALS ACS PNEUMONIA TACHYARRHYTHMIA MSK GORD PAIN PE PNEUMOTHORAX ANGINAAPPROPRIA TE INVESTIGA TIONS BEDSIDE (ECG, Urine dip, BM) BLOODS (do they need serial troponins) E.G. CTPA / CT AORTA/ANGIOGRAM – DISCUSS WITH SENIOR!! IMAGING (portable CXR) INITIAL MANAGEMENT PLAN ‘Bloods, CXR and senior r/v’ is not always an adequate plan! • Patient cases are a learning opportunity • Practice formulating and writing out management plans • Compare these with your seniors and learn from them (and evidence based research!)CARDIAC CHEST P AIN Patient history– central crushing chest pain, commenced 15 mins ago, nausea but no vomiting, no radiation of pain Examination – Pale, sweating/clammy, hands are sweaty, increased work of breathing, panicking (both patient and yourself) Investigations: 1. ECG – look for ECG changes (ST elevation, ST depression) *REMEMBER there may be NO ECG changes* 2. Compare this ECG to any previous ECGs they may have - if none on admission– give off to ED then check ECR / PRISM / GE MUSE 3. Troponins – each trust has a different guidelines for serial troponins (Belfast TRUST – T0, T1, T3) assessment + the ECG and don’t have a troponin back – they will fax ECG to PCI (trops can take over 1hr to be reported) Management MONA – PLEASE GIVE PATIENT ANALGESIA (they will thank you for it)– you can give morphine / diamorphine as an F1 Respiratory Chest Pain •PE – do not do a D-Dimer in a post op patient (it will always be raised and you may subject them to more radiation) – talk to the surgical SHO if you suspect a PE •Pneumothorax / Tension Pneumothorax (if you suspect tension pneumo – fast bleep your senior – NO ONE will expect you to do a needle decompression on your first day •Pneumonia – CXR may show consolidation – chest infection causes chest pain! Commence Abx if not already on them •GET AN ABG if they have a new O2 requirementMaking a good entry in the notes DATE, TIME, YOUR NAME AND ROLE AND GMC NUMBER ATSP (Asked to See Patient) regarding “Chest pain…” (Brief hx of patient and reason for hosp stay) “Patient A admitted with urosepsis..” Clinical details of acute deterioration A to E assessment Investigations you did and the results of these Your clinical impressionc+/rent differentials A GOOD, LOGICAL, SAFE management plan Referrals / discussion with senior (leave your bleep number in case the ward needs you again)ESCALA TING TO A SENIOR If you’re worried about a patient it’s never too early to get senior help If you need urgent help • Speak to medical / surgical SHO / Reg on call • If they are unavailable you can ring CRITICAL CARE OUTREACH TEAM for advice • Less urgent / unsure where to escalate: speak to your F2/SHO/nurses for advice – they have saved my life more times than I can count! nurse to call 6666 (cardiac arrest number in NI) (think it’s 2222 in mainland UK)est buzzer and ask a **Anaesthetists are not part of the cardiac arrest team in NI** HANDING OVER INFORMA TION Congratulations you’ve made it to the end of your first on call What information do you need to pass on? - unwell patients, patients to be aware of, tasks outstanding What investigations/blood need chasing? - troponins, gent levels, INRs etcF1 ESSENTIALS (not sponsored) INDUCTION THANK YOU!– this webinar will be uploaded toMedAlltonight Webinar ideas: Please scan the QR code on your phones and fill in the feedback form! 1. Doctor my patient is short of breath 2. Doctor my patient has a temperature 3. Doctor my patient is drowsy 4. Doctor my patient’s fluids are finished 5. Doctor my patient needs more pain relief 6. Doctor my patient hasn’t passed urine all day 7. Doctor my patient has had a fall 8. Doctor my patient has a low BP 9. Doctor my patient is having a seizure 10. Doctor something isn’t right with my patient - confused 11. Doctor my patient has passed away, can you verify the death?