Transcript Out of Hours - My Surgery Website

Out of Hours
Jo Swallow
Difficult cases
1) Unexpected death
• You are called by the district nurse to certify the
death of a 68 yr lady in her home
• On arrival you are greeted by her daughter who
is distraught, although her mother was elderly
and had terminal cancer the death was sooner
than anticipated
• What do you consider, what do you say, what
examination do you make.
??
• There is a syringe driver insitu
• She asks you re the next steps
• She wants to keep the body at the house
for the next 4 days until the arrival of her
sister from australia
• What advice do you give?
• Who else needs to know?
• The district nurses should be informed to
remove the driver and for good communication
• The family may choose a funeral director
• The funeral director will come and collect the
body and may embalm on request
• The death must be registered within 5 days
• If you want to remove a body from
england/wales the coroner has to issue a remval
notice (even if not reported) 4/7 average
• The pts gp should be informed
2) Suspicious Death
• You are called to a nursing home to certify
an 83 yr old man
• He has no known medical conditions, no
recent dr contact and no medications,
• He is bruised in several areas
• What is your next step?
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This is a case for the police,
They will come and inspect the site
Warn the relatives (they will be shocked)
Don’t move anything
Coroner (dr/lawyer) arranges post mortem
The coroner is not 24 hrs the local police
will be in charge
• ********
Coroners
• Death violent/unnatural
• Not seen by dr in last illness or not seen
within 14 days or after death
• Unknown cause/uncertain cause
• During op/anaesthetic
• Industrial disease
• Death in custody/prison
3)Personality Disorder
• You are asked to give telephone advice by
NHS direct to a 34 yr lady who feels
suicidal.
• You call 3 times, the phone is engaged.
• What do you do?
You Visit
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The patient lets you in
The phone is off the hook
The patient has a bottle of sherry by herside
She tells you that she has taken an overdose
Shows you a thyroxine pack with 10 tablets
missing
• She states that she has taken other tablets too
but isnt going to tell you what.
Psychi on call
• You call the psychi sho on call
• She is drunk and needs to go to the
medics
• The medics accept
• The patient refuses to go to hospital
• Psychi sho states crisis team cant come
for 3 hrs, advises call the police
• The police cant arrest on 136 as in own
home
Mental health act
• Obtain all info from records/family
• Inform next of kin, (they can object to
detention + insist discharge unless risk to
themselves)
• Phone Approved social worker agree
whether to call a 2nd dr or police
• If admission likely call psychi duty
• If not admitting pt need care plan, no.s for
family in emergency, follow up in place
Mental health act 2
• Section 136
Allows police to remove a person from a public
place to a police stn/hospital
Section 135
Magistrate
Neighbours? Persuasion
Common law – good faith
Section 4 – dr+ASW/relative (last resort)
Section 4 – dr section12 apprved +other dr +asw
Acute urinary retention
• Elderly housebound patient
• Abdominal pain
• Catheter blocked with blood
• What do you do?
Alcoholic
• You receive a call from care direct to
express concern regarding a confused
slurring gentleman who rang the careline,
he is 67 and named George
• the person who took the call has gone
home but suggested a Dr rang him.
• There is no answer on the telephone.
• What are you going to do?
You visit
• The house is in an alleyway which smells
of urine.
• There is no answer at the door. Several
empty bottles of cider lie in the recycling
bin.
• There is a hallway light on and the tv
blasting
• What are you considering?
Confusion
• You are asked to visit and assess an 82 yr
old man who has hit his evening carer
around the head with his walking stick
• She has called you and is refusing to stay
the evening as was planned
• He is not under the care of any team and
he is on no medication
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Relatives?
?delerium
?risk to you
?risk to self
Oral diazepam?
?rapid tranquilisation
?Needs sectioning
On call social worker
?wait until their arrival
Results
• The biochemist rings with a calcium of 3.2
• The biochemist rings the coordinator to
inform you of a BM result of 34, Gerald
smith age 67.
• The biochemist rings you to advise you of
a potassium of 6.3 in a patient age 49.
• Old biochem results, is the pt diabetic
already/new dx?, ?renal function
• No answer on phone ? Action
• K+6.3
Hyperkalaemia
Hypercalcaemia
• Mild (2.5-2.9)
Symptoms=polyuria, polydipsia,
depression, mild cognitive impairment
Moderate (3.0-3.4)
As above +muscle weakness,
constipation, anorexia and nausea
Severe (3.5 or over)
Vomiting dehydration, ADMIT
• Recommend hydration
• Find out the albumin (if raised ca is really
lower)
• Stop antacids thiazides, lithium,
My Tips
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You are not alone, the hospital Is full
Clutch your oxford handbook
Clutch your green palliative care book
Have a list of phone nos to hand
If you still don’t know ask the coordinator (or the
driver)
• District nurses are also on call
• Patients are genuinely grateful that you are
available to help at all.
Questions?