1STUSIM HOUSE OFFICER

PREPARATORY COURSE
22 – 23 NOVEMBER 2017
Introduction and Welcome
Course learning outcomes
 Prepare participants for their House Officer
posts
 Covering both clinical and non clinical
aspects
The ill medical patient
• Mak Cik S is in the Emergency department
• 56 year old with recently diagnosed rheumatoid
arthritis
• Doesn’t like hospitals
• Admitted with confusion and ? shortness of breath
at 14.00hrs
• Trainee physician thinks “she’s not very well” but
I’m not sure what’s wrong
The ill medical patient
• Mac Cik S is drowsy and confused. She has been
unwell for 2 days. She is peripherally cyanosed and
has cold hands
• Trainee starts to take a history
• Gets bleeped to phone for 10 minutes
• Trainee examines Mak Cik S
• Time is now 14.40hrs
The ill medical patient
• Trainee phones a colleague on the acute medical
admissions ward.
• Mak Cik S is drowsy, confused, cyanosed and has cold
hands. Nurse says “Her respiratory rate is 32”
• They decide to give 28% oxygen “in case she is a CO2
retainer.” (14.50 hrs)
• Her pulse is 120 and her blood pressure is 75/40.
• An 18g cannulae is inserted, no fluids given “in case she is
in heart failure”(15.05 hrs)
The ill medical patient

• Mak Cik S is transferred to acute medical ward where

a “better” assessment can be made
• During transfer to the acute ward Mac Cik S becomes
very agitated
• Diazepam 5mg is given on arrival to the admissions
ward (15.30 hrs)
• Her pulse is 120 and her blood pressure is now 50/0
The ill medical patient

• Mac Cik S arrests

• She is intubated after 8 minutes of CPR as the
anaesthetist has run from the other side of the
hospital
• She remains in PEA despite adrenaline and CPR for
15 minutes
• She becomes asystolic after a further 5 minutes.
What was wrong with Mak Cik S?
• Mak Cik S had a septic arthritis of her left knee
• All her signs were due to this
• Her team were uncoordinated in approach and therefore
ineffective
• We are going to clarify your thoughts and give you practice at
managing these patients!
• Refs :
• NCEPOD report – Emergency Admissions “A journey in the right
direction?” 2007
• NCEPOD report – “An Acute problem” 2005
• McQuillan et al BMJ 1998 316 p1853
How could Mak Cik S’ care have been
improved?
• There was a failure to recognise how serious her
illness was
• The care given should have been logical
• A,B,C,D,E
• Appropriate consultation with seniors
• Transfer only when patient is stable
• This course should help you
House keeping !
• You must attend the whole course.
• Mobiles should be off. Do this now!
• Please be on time