I've had 5 months of downtime since ICU; 5 weeks annual leave, 5 of hospital in the home where I just look at wounds and dose warfarins, and 10 of Kingston nights where I just sleep at work. Now I've been put back to MMC emergency and I'm so slow :-|
I'm happy to report I'm back up from seeing 5 patients a shift to 8/9/10 per shift. Woooot!
Methane gas contributes to the greenhouse effect.
Every time I eat an animal, it is reducing the amount of methane that animal would have produced if it were alive.
If I eat vegetables all the time, I am reducing the amount of carbon dioxide being removed by the plants thus increasing the greenhouse effect. Not to mention the energy needed to produce mock meat for vegetarians who secretly still want to eat meat.
Therefore, if you love the earth, eat more meat! :D
It's frustrating working at Kingston. There is a fine line you must tread when looking after your patients. It is difficult when your patient is sick, but not sick enough to require transfer to Clayton.
Monday night I was asked to review an old lady. She was septic from an unclear source and had a MET call earlier in the day for hypotension. So they gave her a 500ml fluid bolus that propped up her blood pressure and upgraded her antibiotics to Tazocin (she was already on oral Aug DF for a simple E. Coli UTI). When I saw her, she had progressively become more tachycardic throughout the day, now sitting with a heart rate of 110. Because of the IV fluids we were giving her, she was now mildly hypoxic needing low flow oxygen and had creps up to the midzones in both sides of her chest. Because of her hypotension, they were withholding her frusemide and unfortunately the nursing staff had not done a fluid balance despite her MET call so I couldn't tell if she was making any urine. Get the picture? I thought to myself, "If we don't transfer this lady out tomorrow, she will crash... Probably tomorrow night when I'm on."
Now I'm not a big fan of transferring patients during the night. You have to make multiple phone calls to consultants, ED, paramedics, med reg accepting. You have to write what feels like a 10,000 word essay documenting your assessment and exactly who you've talked to. You have to call the family to say, "Your mother is very sick and we can't manage her anymore so I'm passing the buck to Clayton. Because she's so elderly and frail, we should make her NFR and not for intubation. What is NFR? Well..." This is a situation that you want to avoid at all costs if possible.
So I called the med reg at Clayton and explained the situation, asking him to wait list the patient for a bed first thing in the morning. I would get the morning reg to review the patient and if she had turned a corner, they could call and cancel the bed. The med reg agreed and the patient remained stable overnight.
Come morning handover. Yesterday it was a public holiday so only two doctors cover Kingston. The registrar, I don't like. She never comes to pick up the MET pager in the morning when she's on so I have no respect for her to begin with. When I handed over the patient to her and the pre-emptive plans I had made, asking her to review the patient first thing in the morning, her first question was, "Did you talk to the consultant?"
"No. The consultant had already instructed that she would be transferred if she deteriorated. She was stable overnight so I didn't think calling the consultant was necessary. You can see her and if she ends up needing transfer then you can call. I just put her on the list for a bed so she will get transferred sooner rather than later," I replied.
The registrar seemed shocked by this and said, "No, we will not transfer this patient unless she deteriorates then."
"But if she's anuric and we keep giving IV fluids, she will decompensate and probably after hours"
Still not getting through. I gave up at this point and went home. The patient ended up being transferred yesterday in the evening before I started. My goodness...
I saw a patient on Saturday night. He had Parkinsons and I was called to see him because of a low blood pressure. 85 systolic and asymptomatic except for some mild postural dizziness. It wasn't the first time he had a low blood pressure during this admission but certainly it looked like the blood pressure was consistently on the low side for the past two days. At the time I didn't realise they had recently started him on a buprenorphine patch so I thought maybe he was a bit dry or had an early sepsis or maybe it's just from his PD. But he looked well, obs otherwise normal and not tachycardic. So what did I do? Ordered a fluid balance and urine mcs, then altered his MET call criteria to systolic less than 80 or if associated with altered GCS or tachycardia. Sound reasonable?
I didn't hear from him for the rest of the night. However, I just spoke to the reg on yesterday and she had a MET call yesterday morning for the same patient. His blood pressure dropped into the 70s but still asymptomatic. So the reg increased his domperdidone and took off his patch and voila, the blood pressure improved back to 80s. But because it was a MET call, just to be sure she asked for an ECG and the patient was actually having a STEMI. He was transferred but in the end didn't go to cath lab because of his age and his daughter didn't want any invasive interventions.
But looking back at this patient, would I do anything differently? If I had ordered an ECG when I saw him, would he have the ST changes? If he was having a STEMI all night, surely he would be dead by the morning...
Even the registrar was saying to me she wouldn't have ordered an ECG if it wasn't because of the MET call. So how cautious can one be?
I still stand by my decision, there wasn't any reason for me to ask for an ECG and I don't think I'll be asking for one in my asymptomatic hypotension patients in the future if I think there's another reason for it.
Got woken up at 5am because of a code gray. A patient became aggressive because he wanted his doona back. He refused to get back into bed without a doona. When we arrived, he was standing outside his room saying, "My doona please, my doona please."
Of course at the beginning, we were all nice to him, trying to convince him to go back to bed, cajoling him to listen. The nurse offered him more blankets. The security guard offered to call his nursing home if he got back into bed first. Of course he wouldn't listen and all he would say is, "My doona please." In the end we got fed up with him and told him, "Look, this is a hospital, not a hotel and we don't have to follow your orders. You can either stay in this seat outside your room or you can go back into your room and use the extra blankets the nurse had given you already." Then we left.
3 more days! 3 more and then no more agitated patients that I can't sedate!
