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Surviving the F1 Bleep – Session 7Learning objectives How to confidently manage how to deal with a patient who hasn’t passed urine all day 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 handovers SBARHow confident would you feel as an FY1 being called to a patient who has attended ED not having passed urine all day or on ward? A – Yes would know exactly what to do B – Think I would be alright managing this C – no idea where to startDon’t panic You’re on call and have been bleeped! by SN ‘A’ on Ward ’ ’ about patient ‘A’ who hasn’t passed urine all day…WHA T DO YOU DO?1. THINK– * as with any bleep * • 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, BLOOD CULTURES, bloods , BM, UO • ECG - ask for this to be ready for your arriving • Equipment you mightneed e.g catheter set up.. Communicate with 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? Is the patient in Have they Do I have acute urinary spiked any time to pee? retention? temperatures? Any urological history? Has this Fhow much has – happened patient taken in before? vs out3. 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 e.g. cannula/syringe/flush • Brief history and A to E assessmentABCDE criteria…ASSESSMENT– ABCDE ASSESSMENT- EXAMINA TION A – E ASSESSMENT End of bed-o-gram Sweaty/pale Airway ?airway patent ?choking ?Difficulty breathing, visibly distressed – abdohing high flow O2 if patient hypoxic, ?chest pain? Delerious ?Inputs/outputs ? Dysuria ? Painmetrical, rise and fall or erthyema? – try and establish source of Circulation CR <3, HR, Blood pressure infection – is it Chest or Urine?? Disability ?Alert & Orientated ? GCS ?BM Exposure – environment EVERYTHING ELSE – Don’t forget catheter/ Urine output *** spikes? ?Rigid abdomen ?wound sourceny rev temp Observations: NEWS score APPROPRIA TE INVESTIGA TIONS BEDSIDE (ECG, Urine dip, Fluid Balance Chart – I/O, BM) BLOOD CUL TURES, ABG (Do they need bloods e.g neutropaenic sepsis) IMAGING (portable CXR, if patient with complex hx may need further CTAP etc)ASSESSMENT– REVIEW NOTES and brief hx from patient/collateral Background - why are they in hospital? Have they had any previous temp spikes before? Check bloods and trends Review notes and observations - what is the trend Any pain? Is the patient delirious? Are they on any chemotherapy medications?DIFFERENTIALS ?Blocked ?Haematuria catheter ?clots Enlarged Chronic urinary prostate retention Acute urinary retentionHow much urine should the average 70kg patient pass per hour??Normal urine output =0.5-1ml/kg/hour Oliguria = <400-500mls/day Anuria = no urineHow would you manage a blocked cathetherCase Example1 55M admitted with hx bladder cancer, asked to review patient on ward as no urine output from 2-way catheter that was inserted by ED… General inspection you find a large clot obstructing catheter.. GENERAL INSPECTION VERY IMPORTANT – IS CATHETER KINKED?? How would you manage this?Frank haematuria: 3-Way Catheter + Irrigation + Manual bladder washout if clots Consider antiplatelets, NOAC, WarfarinCase Example 2 66M attended ED following not passing urine for 2 days despite persistent intensive effort. One similar previous episode last year. What would you do? How would you manage patient Acute Urinary Retention Rapid onset with suprapubic pain, inability to pass urine What is the usual volume a bladder can usually accommodate? Spontaneous – no trigger event (BPH) Precipitated – trigger event (e.g. GA, Excessive fluid or alcohol, medications e.g anticholinergic or opiates), infection, constipation, cancer, neurological400-600mls HISTORY – any LUTS ?haematuria ? Recent surgery ? Neurological symptoms PMHx – neuro conditions, prev surgery or pelvic radiotherapy? DHX – any recent changes – anticholinergic medication O/E – pre and post catheter PR examination – very important / Neuro examinationInvestigations Bloods Routines (wouldn’t send PSA as may be raised in acute setting, need to wait a few weeks) Urine sample – clean catch for urinalysis and O&S WHEN DISCUSSING WITH UROLOGY– need to know 1. Residual volume 2. PR exam 3. Renal function Usually monitor UO for 4 hours Insert catheter What if it won’t go in? 3 attempts then contact Senior help à tiemann tip catheter à flexible cystoscopy and guidewire insertion à suprapubic catheter DISCUSS WITH UROLOGY … Difficult catheterisation: • Lie patient flat • Instillagel x3 • Tiemann tip catheter, 18Ch two-way catheter, Find in theatres store, Useful for large prostates • Contact surgical reg for ? suprapubic catheter insertion.Reduced Urine Output 1. Context – who is your patient and why are they in hospital? Do they have risk factors for AKI: pre-existing CKD, >65years, co-morbid, septic, hypotensive, medications? 2. Review U&E – Is there an AKI? What is the trend? 3. Review fluid status 4. Urine dip 5. Review Kardex 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!) • Similar approach to most things – never forget hx and ABCDE Making 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 saved my life more times than I can count!eak to your F2/SHO/nurses for advice – they have If you think this is a life threatening emergency situation: pull the cardiac arrest buzzer and ask a nurse to call 6666 (cardiac arrest number in NI) (think it’s 2222 in mainland UK) **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 shift What information do you need to pass on? - unwell patients, patients to be aware of, tasks outstanding - follow up – ambulatory TROC clinic - ?need for commencing Tamsulosin or finasterideF1 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 1. Doctor my patient has chest pain the feedback form! 2. Doctor my patient has had a fall 3. Doctor my patient has a temperature 4. Doctor my patient’s is in pain 5. Doctor my patient’s fluids are finished 6. Doctor my patient has passed away, can you verify the death? 7. Doctor my patient hasn’t passed urine all day 8. Doctor my patient is SOB 9. Doctor my patient has a low BP 10. Doctor my patient is having a seizure 11. Doctor something isn’t right with my patient - confused 12. Doctor my patient is drowsy?