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Surviving the F1 Bleep – Session 2Amy – FY2 Southern T rust Med School – QUB FY1 – UHD: Surgery, Medicine, Medicine FY2 – GP, General Surgery, ED FY3 Year incomingLearning objectives How to confidently manage how to deal with a patient who spikes a temperature on the ward 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 with temperature spike? 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 has just spiked a temperature…RECAP – from the last session Can anyone walk through how you would answer a bleep.. What about if you wanted to bleep senior or other team for help?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 • What ward • NEWS SCORE history • 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 might need Communicate with the staff member on the phone that you are on your way…You’ve asked all the important questions and are now on your way to the ward…..WHA T ARE YOUR INITIAL THOUGHTS? Is this their first temperature Have they had Do I have spike? Are they blood cultures time to pee? Septic? sent already? Are they on any Is it an isolated chemotherapy temperature or cancer tx spike or is rest of (ALWAYS think NEWS high neutropenic sepsis)3. 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 ?Breathing high flow O2 if patient hypoxic, ?chest Delerious ?Inputs/outputs ? Dysuria ? Pain orsymmetrical, rise and fall erthyema? – try and establish source of infCirculation CR <3, HR, Blood pressure – 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 scoreASSESSMENT – REVIEW NOTES and brief hx from patient/collateral Background - why are they in hospital? before?ey had any previous temp spikes 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 SEPTIC WITH POST-OP SEPSIS URETERIC INFECTION STONE TEMP SPIKE NEUTROPAENIC FOLLOWING INFECTION SEPSIS BLOOD TRANSFUSIONCan anyone tell me what the Sepsis 6 criteria is?1. Within what timeframe should blood cultures be taken on first temp spike?? 2. Within what timeframe should antibiotics be administered to a septic patient?? 3. What antibiotics would you prescribe??What if there was temperature spike in a Urology patient with a renal or ureteric stone… **UrologicalEmergency ** Patients with urinary calculi along with fever and other signs or symptoms of infection need emergency urology review for drainage and intravenous antibiotics. Failure to perform rapid renal decompression can perpetuate urosepsis and result in death. Drainage can be accomplished in two ways: - Urologist can place a ureteric stent past the obstruction and achieve drainage. - Interventional Radiology can place a percutaneous nephrostomy tube.Temperature spike during a blood transfusion, what should you do…A patient with appendicitis who had just been admitted.. They have been added to the emergency list in the am… They have spiked a temperature that evening prior to theatre.. What should you do?? Case Example 1 71 y.o. male admitted with 3 week hx of passing urine PR and no urine PU. hormonal treatment.ncer (pT3 N1 M0 4+4) in 2018 for which he had radical radiotherapy and He also had a defunctioning colostomy in May 2020. CT abdo pelvis had shown a colo-vesical fistula with a pelvic fluid collection. At 3pm bleeped from nurse - patient had desaturated and spiked temp. 38.9 & had rigors. the R side.respiratory alkalosis and CXR demonstrated mid and lower lobe consolidation on Sepsis 6 was initiated, senior input was sought and patient was reviewed by ICU for escalation if required.Case Example 2 61 y.o. female presented on Saturday at 4am with left hip pain - at rest. PMhx of metastatic lung cancer (NSCLC) with multiple bony metastases. Had commenced chemotherapy that week and had 1 session of radiotherapy 2/52 ago. Significant deterioration was shown in pelvic films last month with multiple bony mets. Patient was informed she had L NOF pathological fracture. Sunday long day shift - Nursing staff were contacted by labs regarding patient blood tests. handed over reporting Labs were concerned about haemoglobin levels… Her Hb was normal andstaff there was a slight decrease from baseline but nothing significant to warrant phonecall.Case 2 continued. Eyeballed the patient - she was settled in bed, had no SOB or any signs of bleeding etc. Further investigation of bloods revealed her WCC was 0.48 and neutrophils 0.46. Looking at her obs, she had spiked a temperature the day prior. task had documented approx. 1 hr prior to phone call that patient spiked temp – BEWARE OFMS PATIENT’S BACKGROUND – could have been easily missed that this was neutropenic sepsis… I immediately started her on Tazocin and discussed with Haem Consultant on call. What other drug should she be started on?? LEARNING POINTS – always, always, always check NEWS chart and do full ABCDE assessment of patient – could have been so easily missed 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) INITIAL MANAGEMENTPLAN ‘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 impression +/- current 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! 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 What investigations/bloods need chasing? Blood cultures take 24-48 hours to process so don’t handover to chase this..F1 ESSENTIALS (not sponsored) INDUCTION THANK YOU! – this webinar will be uploaded to MedAll tonight Webinar ideas: Please scan the QR code on your phones and fill in 1. Doctor my patient is short of breath the feedback form! 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?