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The transferring procedure can vary from place to place cheap zenegra 100mg mastercard, but generally if you are transferring the patient to another ward under the care of another consultant then a simple written summary in the notes of the patient’s admission will suffice purchase zenegra 100 mg fast delivery. However discount 100mg zenegra otc, if the patient is being transferred to another hospital it is customary to provide the features shown in Table 4 order zenegra 100mg amex. Ward Layout/PuttingThings Back Each hospital has a different ward layout purchase zenegra 100mg fast delivery, but generally all wards are the same within a hospital in architectural terms. However, where individual items are stored varies widely and depends on the ward sister who ultimately decides where things go. It is extremely important to be aware where everyday equipment, notes and emergency Surviving the Pre-registration House Officer Post 21 Table 4. Follow-up appointment The patient may need to be seen in the out-patients clinic unless they are going to be followed up at the receiving hospital. Transfer letter A basic typed summary of the patient’s admission outlin- ing the reason for admission,treatment given and course of recovery. This is very similar to a discharge summary but often written by the PRHO or SHO instead. Results of recent investigations Your letter should list recent blood results and any other relevant investigation results. Photocopies of the hospital notes These are sometimes required and you should always ask your seniors before sending this type of confidential information out of the hospital. You should never send originals,as these are the property of the hospital trust. Most juniors need to know the basics such as where the patient notes and radiographs are kept and where request forms and the phlebotomy equipment is. Occasionally you will require equipment for performing a neurological or ENT examination. In theory there should be a tray on all wards containing all the necessary items, kept by the nursing staff. More often than not items are stolen, lost or broken and it is necessary to bor- row these missing items from the relevant specialist ward. When doing so, you will require identification and must return the items when you have finished. I have spent many frustrating hours hunting round wards for something as simple as a tendon hammer in the middle of the night and ended up using the end of my stethoscope instead. Hardly satisfactory when you think your patient may have had a stroke and you need to refer them to the on-call medical SpR. Consent Consent, from the Latin consentire meaning ‘agree’, is defined as to ‘give permission’ or ‘agree to do’. To ask informed consent, you, the person obtaining the con- sent, must be G skilled in performing the procedure for which you are obtaining consent G aware of the reasons for undertaking the procedure G aware of the possible alternatives G aware of the complications G aware of the risks versus benefits, that is the risk of action G aware of the risk of not having the procedure, that is the risk of inaction For this reason, only SHOs who are experienced or more senior staff should obtain consent for the majority of procedures and all operations. Obtaining informed consent for surgery is beyond the experience and skill of the PRHO and is therefore illegal. If you are obtaining informed consent for any other procedure (for example a chest drain insertion) you should fulfil the criteria listed above. If you feel unable to obtain consent then you should not be performing the procedure unsupervised. When performing any procedure to which you have obtained verbal informed consent,which is most often the case (for example a central line insertion,chest drain insertion,pleural tap,etc. This will be at the request of your seniors or you may have decided that it is clinically appropriate yourself. If this is the case,however,it should always be discussed with your senior,unless it is very clear-cut (for example urinary catheterisation for acute retention of urine). Examples of the procedures a PRHO may be expected to perform after proper instruction and understanding of the task (the ‘see one, do one, teach one’ rule is applied with alarming regularity) are listed below. G urinary catheterisation G arterial blood sampling G nasogastric tube insertion G chest drain insertion 2 General Medical Council. Surviving the Pre-registration House Officer Post 23 G pleural fluid aspiration/tap G abdominal paracentesis G central/femoral/long peripheral line insertion G lumbar puncture G simple suturing of wounds G removal of a surgical drain As explained already, the first step is obtaining informed consent. Once the patient has agreed to the procedure you need to set up the appropriate equipment on a stain- less steel trolley. Often for certain procedures a kind member of nursing staff will set up the trolley for you, but do not expect this as it is not the ‘norm’. If the trolley has been set up for you it is vitally important to check you have everything you need before you begin.

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In the presence of a low core temperature a correction factor is required to calculate the true arterial blood oxygen saturation generic zenegra 100mg otc. A falling arterial PaO2 level is a sign of impending respiratory distress syndrome (“normal atrial pressure pulmonary Further measures oedema”) and an indication for assisted ventilation with positive end expiratory pressure (PEEP) generic zenegra 100mg online. The ideal pressure ● Measure arterial gases: ensure low temperature correction setting for PEEP is that which maintains the PaO above 10kPa generic zenegra 100mg fast delivery, ● In case of hypothermia raise core temperature above 28 C 2 before defibrillation with an inspired oxygen fraction (FiO2) below 0 purchase zenegra 100mg fast delivery. Evidence ● Consider plasma expanders and prophylactic antibiotics suggests that aspirated fresh water is more likely than seawater to produce pulmonary oedema zenegra 100 mg on line. Rewarming Extracorporeal membrane oxygenation with extracorporeal warming is the gold standard treatment for patients with profound hypothermia. The Swiss Mountain Rescue Service has recovered the bodies of 46 individuals over the years, all with deep hypothermia from burial in snow. Conscious patients can be placed in a bath maintained at a temperature of 42 C. Shadowing in the left Fluid and electrolyte balance lower zone Plasma electrolyte differences between patients who aspire and right mid-zone fresh water and seawater are seldom clinically important. In represents either situation, the patient is often hypovolaemic and in need aspirated of intravenous fluid replacement, preferably using a crystalloid. The Metabolic acidosis should be corrected by adequate patient is at the risk of oxygenation and plasma expansion; administration of sodium developing bicarbonate should be unnecessary. Water intoxication adult resulting in fits has been reported in infants after near respiratory distress drowning in backyard pools. Embolism of infected ● Chest compression alone for circulatory arrest ● No re-warming for deep hypothermia material from the lungs to the arterial tree may result in brain ● Intubate unconscious patients abscesses or death from systemic aspergillosis. A blood culture ● Defibrillation is unlikely to succeed should be undertaken in all instances in which aspiration has ● Associated trauma may include fracture of the cervical spine occurred. Leptospirosis has been reported after immersion in lakes or reservoirs, possibly due to ingestion of water contaminated with rats’ urine. Outpatient follow-up with a chest x ray taken two weeks later is advisable for all patients who have been immersed in water, irrespective of their clinical state on admission. Prognostic signs Resuscitation in hospital A pH of 7 or less indicates severe acidosis and is a poor ● Aspiration is an indication for admission prognostic sign. A low PaO2 provides an early indication that ● Facilities for extracorporeal blood re-warming should be water has been inhaled with the attendant risk of pulmonary available oedema. The presence of ventricular fibrillation is an adverse ● Correct arterial blood gas measurements for low core sign and responds poorly to defibrillation when the core temperature ● Pulmonary oedema seldom develops later than four hours temperature is below 28 C. The circulation must be supported after immersion by chest compression until further attempts can be made when ● Blood-born sepsis is a late complication the core temperature has been raised above this level. Effects of tonicities of Resuscitation from accidental hypothermia of 13. Circum-rescue collapse, ● Walpoth BH, Walpoth-Aslan BN, Mattle HP, Radanov BP, Schroth sometimes fatal, associated with rescue of immersion victims. Much of the experimental evidence on the role of route, but the intraosseous route is used drugs has been derived from animal work, but the results have occasionally, particularly in children. They include: Current resuscitation guidelines recommend that drugs ● Haemorrhage should be used when scientific evidence shows that drugs are of ● Arterial puncture value, rather than for historical or theoretical reasons, or on ● Extravascular drug administration regardless of the vein used the basis of anecdotal evidence alone. In many cases the ● Pneumothorax if cannulation of the subclavian vein is attempted strength of the evidence of benefit is inadequate to make a Central venous cannulation may be hazardous after the definite recommendation. In most cases, guidance represents administration of thrombolytic drugs, and, if required, in this a compromise between the available scientific evidence and a circumstance the femoral approach is recommended. The routes by which drugs may be administered in these circumstances are also described. Routes of Drug administration Intravenous routes Peripheral venous cannulation is safe, easily learned, and does not require interruption of CPR. A large vein, usually in the antecubital fossa, is the site of choice, and drugs injected here during CPR reach peak concentration in the major systemic arteries 1. This circulation time is reduced if the bolus of drug is followed by a normal saline flush, so once a cannula is in place it should be connected to an intravenous infusion that can be run in rapidly to aid drug administration.

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As con- sultants become more senior their political and economic targets increase cheap zenegra 100mg with mastercard. SpRs order 100mg zenegra with mastercard, on the other hand buy discount zenegra 100 mg on-line, stay for 12 months or more and spend more time with the consult- ant in theatre and clinics order zenegra 100 mg otc, etc buy 100mg zenegra overnight delivery. What You Can Do to Ease the Pressure There are certain things that the junior can do to break down barriers that are very effective. Most surgeons listen to music in theatre when operating and offering to bring in a CD can prove very effective at generating conversation. Engage in conver- sation at appropriate times with any consultant, for example during ward rounds or clinics (as long as you are not in earshot of any patients or their relatives). Once there is trust between you, you will be allowed to practise more freely and be taught a lot more. You will see colleagues trying this approach and notice that it does not work, and furthermore, that they will quickly gain a reputation around the hospital. No-one will explain when you are in medical school that qualified nurses are a valuable asset. They can be your best ally or worst enemy depending on how you treat them. Most often they have been working in a particular speciality (for example orthopaedics, urology, etc. Coming straight out of medical school or house jobs you may have more theoretical knowledge of physiology,pharma- cology, etc. Nursing staff will be able to guide you through the prescriber’s minefield reminding you of times and doses when you are trying to write up drugs on a ward round (a word of caution: always check the British National Formulary if in any doubt whatsoever). The nurses will also know the way each particular consultant likes his/her patients managed. Nurses can be your best friend and your worst enemy,often within minutes of each other if you say the wrong thing at the wrong time. Historically, doctors have always thought themselves more hard done-by than any other medical professionals and as a response to this have always seen themselves as superior to nursing staff,both in their educational/intellectual level or in status. Nowadays more than ever before, nurses and doctors need to work side by side as equals in the workplace although ultimately the overall responsibility and duty of care of the patient rests with the doctor. This respon- sibility can often cause problems,as some junior nursing (and occasionally older) staff do not realise this concept. When giving instructions regarding the care of patients there is often debate between doctors and nursing staff,which can look unprofessional and 41 42 What They Didn’t Teach You at Medical School not be in the best interests of the patient. They have their own role, just as you are not on the ward for their benefit. Nurses and doctors work together as a team for a common goal: the care and treatment of the patients. There are grey areas between the respon- sibilities of nursing and doctoring (for example setting up catheter/central line trol- leys, etc. Nursing staff will often do these things for you if you are busy and they are not, if you ask them nicely. However, always double-check the trolley first, as they sometimes forget small but important items. Pony trekking or horse riding can be dangerous, as can caring for patients. They also have the ability to think, assess situations and come to a decision. When a new rider gets on a horse, the horse will test the rider to see how experienced they are or how in control the rider is by trying to eat grass or wander off the track, going too slowly, etc. The horse needs to have confidence in their rider and once this relationship is established the horse and rider make a good team. Overall you are less likely to fall off and therefore the whole ride is safer. You can see the parallel with nurses: they need to be confident in your actions and judgement before they will let you do things alone without question.

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