Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
DISCHARGE SUMMARIES
Morphine oral solution (10mg/5mL); dose: 10mL/12h PO for
Box 2.6 Examples ofschedule 2/3 controlleddrugs
Morphine (modied release), diamorphine, buprenorphine, pethidine,
fentanyl, alfentanil, gabapentin, midazolam, oxycodone, pregabalin,
remifentanil, methadone, methylphenidate, cocaine, tramadol.
83
Fig.2.5 SampleTTO.
5 days. Total = 100mL (one hundred millilitres)
Morphine sulfate MR 10mg capsules; dose: 10mg/12h PO
for 14 days. Total = 280mg (two hundred and eighty milligrams)
Fentanyl 50 patch; dose: one patch every 72 hours for 15 days.
Total = 5 (ve) patches
Fig.2.6 Sample TTOs for controlled drugs excluding the patient and prescriber’s details.
84 CHAPTER2 Life onthewards
Fitness toworknotes
As the most junior member of the team, the writing of ‘t notes’ (Statement
of Fitness for Work, Form Med 3)will usually fall to you. These notes provide
evidence that your patient has a condition that will impact their tness to work
and enables statutory sick pay and social security payments. You can advise that
a patient is ‘not t for work’ or ‘may be t for work’ under restricted conditions.
Aseparate form (Form Med 0)may be required for periods of time spent as
a hospital in-patient. These forms are available in both electronic and paper formats from the Department for Work and Pensions— ask the ward clerk for advice. Asample is shown in Fig.2.7.
Usage Typical uses include surgical patients who have been admitted rou-
tinely for a procedure and require time o work to recover postoperatively.
Medical patients may also require time to convalesce, while patients with
wounds or injuries may require workplace adjustments during their recovery
period on return to work. Patients can self- certify for the rst week of any
illness so do not require a note if they will be able to return to work within this
time. Never instruct a patient to ‘see your GP for a sick note’ where the need
for this can be anticipated at the time of discharge— the duty to provide a Med
3 rests with the doctor with clinical responsibility for the patient.
Format You should ll in the patient’s name, a brief explanation of their
needs (sickness absence, adjustments to the workplace, or modied duties),
and accurate clinical diagnosis (without mentioning intimate details that might be
damaging to the well- being of the patient for their employer to discover). Sign and
date the form. You need to give an appropriate amount of time for the patient
to recover from their illness as reasonably anticipated at the time of discharge, up
to a maximum of 3mth. If recovery takes longer than you anticipate, the patient
can see their GP, practice nurse, pharmacist, or physiotherapist for a furthernote.
2
Patients can self- certify as ill for 7d.
SAMPLE
Fig.2.7 Example of a Statement of Fitness for Work (Med3). Reproduced from
Mhttps:// www.gov.uk/ government/ uploads/ system/ uploads/ attachment_ data/ le/
34995/ tnote- hospital- guide.pdf. Contains public sector information licensed
under the Open Government Licencev3.0.
2
Useful guidance for completing tness to work forms available at Mwww.rcplondon.ac.uk
Referrals
Referring a patient to another medical team can be one of the most
dicult parts of the job. The other doctor is often very busy and will
inevitably know more about the patient’s condition than you (hence
the referral). At times it can feel like they are trying to make you feel
stupid— this is rarely the case. Consider this from the point of view of
the other doctor—they need to establish:
• How unwell the patientis
• How urgently they need to beseen
• What investigations have already been done and what still need to be
done to assist them in theirreview
• If they are the right person to see the patient.
You will often be asked to refer a patient by your senior. Ask them directly:
• To help my referral and for my learning, why do they need referring?
• What do they want the other team to do (advise over the phone,
formal review, take over care, see in clinic, procedure/ operation)?
• How urgent is the referral?
Next, think about what information the other doctor will want. Many specialties have additional components to history and examination that you will
need to be able to describe, see the pages in the history and examination
chapter (Box 2.7); if necessary, go and see/ examine the patient yourself:
I Box 2.7 Additional components covered elsewhere
Breast surgery
Cardiology
Dermatology
Endocrine
ENT
Gastro
Gynaecology
E p. 39 Haematology E p. 38 Psychiatry E pp. 58–60
E pp. 26–7 Neurology E pp. 30–4 Renal E p. 395
E pp. 36–7 Obstetrics E pp. 56–8 Respiratory E p. 28
E p. 35 Oncology E p. 38 Rheumatolog y E pp. 44–51
E p. 42 Ophthalmology E pp. 40–1
E p. 29 Orthopaedics E pp. 44–51 Vascular
E pp. 54–5 Paediatrics E pp. 62–3
Urology
surgery
E pp. 52–3
E pp. 26–7
85REFERRALS
Before referring Make sure you have the following in front ofyou:
• Hospital notes with patient’s name, DoB, hospital number, andward
• Obs chart (including latest set and trends) and the patient’s drugcard
• Most recent results or serial resultssheet.
Phone the relevant specialist, introduce yourself, and say, ‘My consultant
has requested that Irefer one of our patients who has [medical condition] with the view to [taking over care, advising on treatment,etc.]’.
Oer a brief summary of their condition and management; look up the
relevant condition or referral page (Box 2.7) before calling so that you
know what you are talking about. It is never acceptable to make a referral
for a patient you know little about just because it’s on the jobslist.
Always know what investigations have been performed so far, and what the results
were— sit at a computer with these already called up when you make thecall.
Before you put the phone down determine exactly what action the specialist will do and when this will take place. Write the referral and outcome in the notes along with the specialist’s name and bleep number.
86 CHAPTER2 Life onthewards
Referral letters
You may need to refer a patient you are seeing in general practice for a
specialist opinion or be asked to refer a patient for out-patient follow-up
after discharge.
system, but the basic principles of writing a referral letter remain the
same. In general practice there are often dedicated electronic forms for
sending referrals which may list specic criteria for referral.
The basics Try to make referral letters as professional as possible. It is
essential that the referral contains the following information:
• Who you are and how to contactyou
• Who the patient is (full name, DoB, hospital number, ± address)
• Why you want them to beseen.
Fig.2.8 is an example of a referral letter for you to follow.
Diagnoses List all the patient’s active diagnoses and relevant past diag-
noses; try to put the ones most relevant to the specialty you are referring to
near thetop. When sending a referral from general practice, this information
is usually pulled from the medical record automatically. Nevertheless, it is
worth checking the list of current and past medical problems to ensure it
is accurate.
Presenting complaint Start with a statement telling the other doctor
what you would like them to do (eg see on the ward, in clinic, or give written
advice). Give a brief description of the patient’s presentation and management during this admission as if you were writing a discharge summary.
Medical information This will form the bulk of the referral. Think
carefully about what information will help the other doctor in deciding
when to see the patient and how to manage them; see the relevant history
and examination page (E pp. 22–3). Try to set the referral out like a
brief medical clerking and make sure you include:
• Relevant investigation results
• Latest medications
• Relevant social history (particularly if this will aect how they are
seen in clinic, eg poor mobility, language diculties).
Finishing the referral You should write your name, post, and con-
sultant’s name. If sending an out-patient or inter- hospital referral, you
should also include who the letter is copied to (‘cc’ stands for carbon copy)
which will include the notes and GP. It is recommended practice to send a
copy to the patient though this varies between trusts and doctors.
Sending theletterAsk your ward clerk for assistance. Print o several
copies, sign them, and ensure it is clear where each copy should besent. If
letters are sent by email, ensure you use an NHS email. Never send condential medical information using a non-NHS email account.
3
The referral process can vary depending on the local
3
Non- urgent out-patient referrals to other specialties should go through the patient’s GP, since
payment comes from their budget. If this is required, a note should be made on the discharge
summary with specic details of why this referral is being recommended. Urgent referrals
( especially f or suspected malignancies) can still be made directly. Check with the consultant
recommending the referral.
87REFERRAL LETTERS
Fig.2.8 Example of a referral letter.
88 CHAPTER2 Life onthewards
Being on- call
Being ‘on- call’ occupies an increasing amount of your time and involves
care for a dierent range of patients and specialties than during normal
working hours. Requirements, expectations, and priorities are dierent.
For some common on-call scenarios, see Box 2.9.
At handover Most hospitals have dedicated morning, evening, and
night-time handovers where the outgoing team relays important information to the incoming (or continuing) team. Familiarize yourself with the
location, time, and process of handover in your hospital. It is important
to attend punctually otherwise everyone is delayed. At handover:
• Get to know who is on-call with you and divide out the workload
• Familiarize yourself with how to contact other members of the
on-call team; useful bleeps to write down include the med reg,
surgical reg, critical care outreach teams, and ICU/HDU on-call
• Ensure you have a clear handover about which patients are waiting to
be seen, how urgently they need seeing, and where theyare (Box 2.8)
• If you are asked to chase the result of an investigation, ensure you
know why it has been done and what you are expected to do
• For any unwell patients who will require your input overnight,
establish their escalation and resuscitation status
• At the end of handover, prioritize your workload. Identify and focus
on sick patients.
Being organized on- call You may be in the middle of an important
task when the bleeps come thick and fast.
• Stay calm
• Never rely on memory alone, you will forget something. Always write
things down and keep a clear jobs list. Guard the list with your life. It
will help you to handover to the next team
• Have a means of identifying when you’ve completed a task (ie an
empty box needs doing, a half- full box is partly done, and a full box is
a jobdone)
• Always try to answer the bleep promptly, you do not know why
someone is trying to get hold of you and it may be very urgent
• If you are about to undertake an important task which requires
uninterrupted time, hand your bleep over to someone (you should
not do this if carrying a cardiac arrest bleep)
• It can be helpful to visit the areas you are covering and ask them to
compile a list of non-urgent jobs for you to complete on your return.
TakingbreaksWhile you must not ignore a sick patient, there will be
a constant supply of work that can usually wait. Breaks are not just about
food. They keep you alert and reduce stress and headaches. It is in your
patients’ interests that you recharge. Eat and stay well hydrated—you will
be surprised how much better you feel. Where possible, arrange to take
breaks with the other members of the team on- call— it allows you to catch
up and stops you feeling isolated.
Prioritizing
• Sick patients need seeing rst; if you have more than one really sick
patient then tell your senior. The ITU outreach nurses are your friends
in this situation!
• If the patient’s condition is clearly life- threatening then consider asking
the ward to bleep your senior while you are on your waythere
• Check if a task has a deadline (eg before pharmacy closes)
• If you see an abnormal blood result, check the patient/ notes/ previous
blood results
• Ask if a job can wait until you’re in that area, tell the nurses when this
will be and try to sticktoit.
Box 2.8 SBAR handover
Give and receive handovers in a structured way. The SBAR tool is a
helpful way to communicate.
Situation Why you are
contacting
them
I am a F on ward A. I am calling
about John Smith, hospital number
023456. I am concerned that he
has deteriorated and may require urgent senior review.
Background Brief history of
admission and
treatment
Assessment Observations,
results of investigations, your
impression
Recommendation What you want
to happen
He was admitted 3 days ago and
has been treated for CAP with amoxicillin PO.
His inammatory markers have
steadily worsened and currently his
BP is 98/60, HR20, T35.9, RR 26.
I think he may be septic.
I would like you to please come and
review. Is there anything else for me
to do in the meantime?
89BEING ON-CALL
Box 2.9 Common on-call scenarios
• Chest pain E pp. 254
• Breathlessness/low sats E pp. 284
• Fluid prescribing E pp. 402
• Falls E pp. 464
• Deranged blood sugars:
•
hyperglycaemia E pp. 338
•
hypoglycaemia E pp. 336
• Low urine output E pp. 400
• Hypotension E pp. 478
• Agitation E pp. 245
• Confusion E pp. 382
90 CHAPTER2 Life onthewards
Nightshifts
Few doctors look forward to their night shifts, especially if they are doing
several in a row. Don’t underestimate how tired you feel during and
after a run of nights. That said, on nights you will gain a lot of experience.
Preparing for a night shift
• If you can, try to adjust your sleep schedule in the days before your
night shifts by going to bed later and/or waking up earlier
• Try to sleep for a few hours during the day before your rst night shift
• Sleeping during the day can be dicult. Blackout curtains/blinds, ear
plugs, and an eye mask are all helpful
• If you can’t sleep, try not to panic; remember that time spent in bed
relaxing is still useful rest
• If you have a long commute home, make arrangements in advance
to stay nearby for the duration of your night shifts (the hospital
accommodation team usually keep rooms aside for this).
Things totake withyou
• Food, both a main meal and several quicksnacks
• Stu for gaps in workload— eg books for privatestudy.
Things tocheck (on therstnight)
• What areas and specialties are you responsiblefor?
• The contact details of your colleagues and seniors, what they are
covering, and how best to get hold ofthem
• When and where is handover?
What is expectedofyou
• Turn up on time; your colleague will be late home if youdon’t
• Prioritize work according to urgency— when bleeped to a sick patient
ask for, eg obs, bloods, cannula, ECG to be done while you getthere
• Tour the wards you are covering regularly and delegate simpletasks
• Document all interventions in thenotes
• Remember that your role is to keep patients alive overnight, the
dicult diagnostic workup and discharge letters can wait.
Looking after yourself Your body is not used to working at night;
it is normal to feel nauseous. However, you will feel worse if you do not
eat. Take regular breaks, eat, and keep well hydrated (Box 2.0).
Hospital atnight(H@N)This system is now in place in many hos-
pitals to improve eciency and the standard of care provided by the
limited number of doctors on duty at night. Some hospitals use mobile
phone apps or a night sister to help lter and allocate tasks to individuals
most suited to complete them, eg nurses may be able to cannulate but
you should assess an unwell patient.
Learning atnightNights can be a good learning opportunity. Ensure
the other doctors on at night know if you have particular skills you wish
to learn at that time (eg lumbar punctures). They can then call you to
observe or be supervised.
Pitfalls The potential to make mistakes during night shifts is greater
than during the day. If you are unsure, double check. The following are
some of the common problemareas:
• Poor handover; ensure you know who needs review (Ep. 22)
• Failing to appreciate a sick patient and not calling forhelp
• Fluid prescriptions (eg failing to note renal/ heart failure, DM,
electrolyte imbalance)
• Warfarin prescriptions with INRs coming back out ofhours
• Check you’ve got the right patient when documenting/ seeing results.
After a night shift
• Travel home safely
• Try to go to bed soon after nishing a night shift, external stimuli such
as sunlight and activity can reduce your ability to sleep
• Modern life is busy, but try to give yourself time to recover after a
run of night shifts. Don’t be tempted to schedule exams or interviews
on the days o that follow. The more nights you’ve done, the longer
recovery will take.
T Box 2.0 'The 3am brain'
If you nd yourself unable to string together thoughts in a logical
fashion, or you keep missing that ‘easy’ vein on multiple attempts, then
you are probably suering from ‘the 3am brain’. Think: when did I
last eat? When did I last drink? Providing none of your patients are
peri-arrest, take time to sit down and recharge. Eat, even if you’re
not hungry, and take a power nap if you feel very tired. If a colleague
oers you a hot drink or some biscuits it is a good idea to accept them.
A 20min break may save you wasting 40min through inecient
working. Both you and your patients will thank you for it.
91NIGHT SHIFTS
92 CHAPTER2 Life onthewards
Pain
2Worrying features diHR, diBP, diRR, dGCS, sweating,
vomiting, chestpain.
Think about Headache (E pp. 370–3), chest pain (E pp. 255–61),
abdominal pain (E pp. 303–11), back pain (E pp. 368–9), limb pain
(E p. 506), infection (E pp. 486–95). CommonPostoperative, musculoskeletal, chronicpain.
Wardround Assess daily the eectiveness of analgesia (whether
pain hinders activity, eg coughing, getting out of bed, etc.) and about
side eects (drowsiness, nausea, vomiting, and constipation).
Ask about ‘SOCRATES’: Site, Onset, Character, Radiation, Alleviating
factors, Timing (duration, frequency), Exacerbating factors, Severity, associated features (sweating, nausea, vomiting). PMH Stomach problems
(acid reux, ulcers), asthma, cardiac problems;
NSAIDs, analgesia already taken and perceived benet;
Obs iHR and iBP suggest pain; RR, pupil size, and GCS if on opioids.
Look forSource/ cause of pain, masses, tenderness, guarding.
Investigations These should be guided by your history and examin-
ation; none are specically required forpain.
TreatmentNo patient should be left in severe pain, consider titrating an
IV opioid after an antiemetic (E pp. 38–9). Analgesia prescribing can
be guided by these principles:
• Consider the type of pain the patient is experiencing. Opioids are good
‘all-round’ painkillers, but neuropathic pain may be better treated with
targeted analgesia
• Regular analgesia with adequate PRN breakthrough analgesia is
generally more eective than PRN analgesia alone
• Use the oral route where possible, but consider IV if NBM or
absorption is likely to be reduced (eg nausea or vomiting)
• Tailor your prescription to your patient’s renal function, age, and body
weight. If in doubt, check the BNF
• Use the steps of the WHO pain ladder (Table 2.2). Regular
paracetamol is a good place to start and build from, but if your patient
has severe pain start at step 3 or 4
• Pain is a subjective experience that is inuenced by emotions, stress,
and anxiety; address it holistically.
DHAllergies, tolerance of
SH?Drugabuse.
Table2.2 WHO painladder
Strong opioids
Weak opioids
NSAIDs
Paracetamol
Source:data from Mhttp:// www.who.int/ cancer/ palliative/ painladder/ en
✓✓✓✓
Step Step 2 Step 3 Step 4
✓✓✓
✓
✓