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Essential tips for Surviving as an RMO


									                                       The “RMO” Job
The following information has kindly been compiled by Dr. Ram Thungala, a current RMO.

                     „Dear friends, in this session I will try to explain the following:

                    1) A few common medical conditions that you may come across.

                               2) Some simple tips to survive as an RMO.

                                     3) Do‟s and Don‟ts in your job.

                         4) How to enjoy every moment working as an RMO.‟

1) Common Medical Conditions
Oops….....someone bleeped me again…….

Some common reasons for being bleeped:

            Cause for the bleep/call                              Percentage of bleeps/calls
 Related to drug charts: Rang for writing up drug
 charts, changing drugs, fluids, analgesia, TTO‟s etc     50 to 60%
 Patient is in pain: “Doctor can you please review the    20 to 30%
 patients analgesia….
 Bloods and IV Cannulas.                                  10to 20%
 Low BP/ low urine output                                 5 to 10%
 Constipation                                             5 to 10%
 Low Saturation                                           5 to 10%
 High Temperature                                         5 to 10%
 Chest pain                                               4 to 6%
 Miscellaneous: Examining wounds (for bleeding or         4 to 6%
 infection), for male urinary catheter, etc

Drug charts
Around 80% to 90% of mistakes in the hospitals are due to errors with the drug charts. (About 15 to
20% of these mistakes could be fatal for the patients). Therefore please:
    Double check what you write on whose drug chart. (Identity of the patient and chart, drug
       allergies, dosage, timings, etc)
    Never hesitate to refer to the BNF at all times. (You can actually download the BNF app if you
       have an iphone)
    Be aware of the normal drugs we use day by day and their dosages.
    You can always get help and advice from the hospital Pharmacist.
 My Experience: The only mistake I can remember (since my first job in the UK over the last 5 years)
 is that I have prescribed Flucloxacillin to a Penicillin sensitive patient. (The drug chart was not filled in
 for any allergies at all) and the patient was given the medication by a senior staff nurse without
 checking the patient sensitivity.


 For the Patient: The patient improved from the infection and did not luckily have an allergic reaction

 For Me: I was given a minor warning from my consultant

 For the Nurse: She was given a serious warning and was banned from giving all the IV drugs to her
 patients until further training and monitoring

I encourage you as an RMO to complete the following course in BMJ Learning:

Please see below a guide (tips) to the management of acute pain:
     Avoid two NSAID‟s for the same patient. (Eg: Aspirin + Ibuprofen, Diclofenac + Ibuprofen)
     If you are prescribing Tramadol or Morphine, always prescribe anti-emetics.
     Always consider the Analgesia ladder and try combinations first.
                     Paracetamol (PO / IV)
                     NSAID (PO/ PR)
                     Codeine and Tramadol
                     Morphine (PO/ IM / SC / IV)
     Never hesitate to contact the Anaesthetist if:
             1) The patient is still in severe pain after receiving morphine.
             2) If the patient is suffering from a morphine over dose. (Respiratory depression)
     Always examine the patient if in severe pain before you take your pen to the kardex.

 My Experience: I was asked to prescribe IV Morphine for a patient who had Bilateral Breast
 augmentation 6 hours ago, as she was in severe pain.

 On examining the patient, I noticed that one of her breasts was larger than the other and very tender.
 Expanding breast size with pain post op is the sign of internal bleeding.

 I called the surgeon immediately and as a result the patient was taken back to theatre within half an
 hour. She received a few units of blood.


 For the Patient: Uneventful recovery after her second operation and was discharged as planned.

 For Me: Well what can I say, I was praised by the surgeon and the ward sister (or in other words I was
 very happy that I did examine her prior to prescribing).
Low BP and low urine output
Please follow the guide below on low BP:
         Always review the patient. (Always exclude any active bleeding first)
         IV Fluids to maintain BP (Never try medications to bring BP up without anaesthetist advice)
         Never overload with loads of fluids for someone who has poor heart or lungs. (Also be
            aware that spinal anaesthesia will reduce the BP and also Morphine)

 My Experience: I was asked to see a patient with low BP after receiving 3 litres of fluid over 6 hours.

 On examination it revealed a post spinal anaesthetic patient with wet lungs and mild LVH (left
 ventricular hypertrophy). Diagnosis: Pulmonary oedema

Please follow the guide below on low urine output:
         First try with a fluid challenge.
         Never try furosemide without examining the patient.
         One of the common reasons why you will be called in the middle of the night is for male
            catheterisation. For hernia patients and lumbar spine surgery patients never wait too
            long before inserting a catheter.

 My Experience: I was asked to review a female patient with low urine output. (This patient was
 reviewed by the day RMO and even prescribed furosemide to try increase the urine out put)
 After seeing the patient, I requested the staff nurse to examine the position of the catheter and we also
 tried flushing it. The staff nurse, whilst examining the catheter position, noticed that there is overflow
 incontinence as the urinary catheter was blocked. After changing the catheter, there was more than
 1000ml of urine in the bag.

 NOTE: Low urine out put, please check the urinary catheter for any blockages.

 Imagine if this patient was given furosemide without changing the catheter.

Chest pain
You must review a patient with chest pain ASAP and check the following:
       Always do an ECG before saying “it‟s just indigestion.”
       Please make sure that you know the chest pain (Cardiac) management protocol:
               1. Oxygen
               2. Monitor and ECG
               3. Aspirin 300mg S/L
               4. GTN Spray
               5. Might need IV Morphine
               6. IV access and bloods.
       If you think that your patient had an episode of MI/Acute coronary syndrome, you have to
           speak to the patient‟s surgeon and the anaesthetist ASAP.
       You might need to transfer the patient to the nearest NHS trust where they have CCU for
           further management and monitoring.
       Also a similar approach applies for few cardiac conditions like fast AF and SVT. (These are
           in fact more common than cardiac chest pain in the post op wards)
 My Experience: Very recently, I had to transfer a patient on a consultant‟s decision with fast AF to
 the nearby NHS trust with cardiac monitoring even though the patient was asymptomatic and stable.
 (This happened at about 23:00 hours) Please follow your consultant orders.

 A couple of years ago, I had seen a patient with a similar episode of fast AF post surgery. With
 consultant anaesthetist‟s advice, I had to start treatment with IV Amiodarone as per the protocol. The
 patient responded for a few hours and then landed up in very fast AF (Heart rate of 180 to 200). I had
 to call the on call anaesthetist and cardiology consultant (luckily we had an on call medical/cardiology
 consultant in that particular private hospital). As this patient‟s heart rate was too fast, we tried treating
 as SVT with IV Adenosine as per the protocol. Unfortunately no response. We then took the patient
 to for synchronised cardio version following proper sedation. This patient recovered well and was

 NOTE: Not all hospitals have on call cardiologists or medical consultants so these patients requiring
 further management will be transferred to the nearby NHS trust.

High Temperature
When you are asked to see a patient with a high temperature, the following approach might be helpful:

Days before Surgery                                      Possible Causes
 Day 0 to 2                           Mild fever (T <38 °C) is Common
                                      Tissue damage and necrosis at operation site
                                      Haematoma

                                       Persistent fever (T >38 °C)

                                      Atelectasis: the collapsed lung may become secondarily infected
                                      Specific infections related to the surgery, e.g. biliary infection post
                                       biliary surgery, UTI post-urological surgery
                                      Blood transfusion or drug reaction

 Day 3 to 5                           Bronchopneumonia
                                      Sepsis
                                      Wound infection
                                      Drip site infection or phlebitis
                                      Abscess formation, e.g. subphrenic or pelvic, depending on the
                                       surgery involved
                                      DVT

 After day 5                          Specific complications related to surgery, e.g. bowel anastomosis
                                       breakdown, fistula formation
                                      Wound infection
                                      Distant sites of infection, e.g. UTI
                                      DVT, pulmonary embolus (PE)
    1. Always start with proper aeration to the patient. (open windows, remove blankets, fan control
       room temperature etc)
    2. Regular Paracetamol 1g ivi or po
    3. If there is no improvement proceed with the infection screening policy.

Infection Screening:
    4. Wound examination for signs and symptoms of infection.
    5. Chest examination for lung infection. (Might need an x-ray some times)
    6. Urine dipstick and cultures.
    7. Bloods for culture and sensitivity, FBC, CRP and ESR and U&E‟s.
    8. Please update your interventions to the patient‟s consultant.

If you suspect DVT/PE, you have to speak to the on call anaesthetist and surgeon. Always follow with:
     Oxygen
     Monitoring
     IV access and Fluids
     ECG
     Analgesia
     Specific investigations and management.

Please be aware of local policies for DVT and PE and also the local Warfarin policies.

Most of the private hospitals will not have access to the CTPA or DVT scans. So we have to send
patients to the local NHS Trust for these investigations. Whilst awaiting these investigations, patients
should be started on a treatment dose of fragmin/clexane according to the local policy.
2) Some tips to survive in your job

Please maintain good personal hygiene: Neat and clean dress with your identity badge and
stethoscope is a very good start for your job. I guess most of the hospitals have a dress code of either
scrubs or a white coat. Try stick to this all the time.

 My Experience: In the last hospital where I used to work, I was called the “BEST SMELLING
 PERSON IN THE HOSPITAL”. (Thanks to my collection of good perfumes)

Smile and never argue: Be pleasant and always smile whilst seeing your patients or talking to your
nurses. I am sure there will be a few occasions where you loose your nerves and start arguing with
nurses. The best way to deal with such situations is to speak to your ward manager or the Matron. If you
are still not satisfied you can contact your MSM or anybody from the NES team.

 My Experience: Once I received a racial comment whilst working at a hospital. I then immediately
 complained to the medical director of the hospital. I got an unreserved written apology from the
 executive director of the hospital.

 There is always a proper way to respond for any issue/problem that arise from your work.

 Also using words like “PLEASE and SORRY” will not demoralise your character and in fact they help
 you to survive long and happily in this world.

If you have any issues with your food and accommodation: Like your room is not been cleaned
regularly, your shower is not working properly, you are not getting the food you ordered from the
canteen etc, please try and speak to the matron and explain your concerns.

When the ward is not too busy (over the weekends) why not try treating the small number of
staff with a pizza or try a different take away one night: This will not cost you more than £20, but
will make a few good friends.

The best way to plan your day: Be proactive and not reactive, in other words be a visible part of the
nursing team. For example:
 06.00 till 07.00                              Wake up
 07.00 till 08.00                              Read the Paper/wash/breakfast
 08.00 till 08.30                              Go to the ward
 08.00 till 10.00                              Bloods
 10.00 till 10.30                              Tea/Coffee
 10.30 till 11.30                              Ward rounds with proper notes
 11.30 till 12.30                              Ward jobs/Relax
 12.30 till 13.00                              ***FOOD***
 13.00 till 14.00                              Ward work
 14.00 till 16.00                              Rest in your room and attend to the ward as required
 16.00 till 16.30                              Tea/Coffee
 16.30 till 17.30                              Ward work
 17.30 till 18.30                              ***FOOD***
 18.30 till 19.30                              Bath/shower
 19.30 till 20.30                              Ward work
 20.30 till 22.30                              Read/Relax/TV etc.
 22.30 till 23.30                              Ward work
 22.30 till 07.00 am next day                  Undisturbed sleep if you are organised or if you are lucky.
By being organised with a daily plan, you will have enough rest whilst being available to the ward
regularly. Below are a few more useful tips to ensure your day runs smoothly:
     Try to ask your ward staff to use the RMO book for normal unimportant things. This should
        save you from getting millions of bleeps in one hour.
     Try prescribing fluids for all the post op‟s before you go to bed.
     Try organising your work for the next day. (New patients, discharges, number of bloods to be
        done etc)
     Try carrying a note book or pen and paper to note all the calls you answer.

3) Do’s and Don’ts
   Try answering all your bleeps as soon as possible.
   Patient confidentiality should be maintained at all time.
   Good, clear communication will always show you are a good doctor. Improve your
      communication skills by reading the paper load.
   Never hesitate to ask for help when you are stuck. You should know your limitations at work.

 My Experience: On one occasion, I tried a few times to cannulate a very obese patient who is
 receiving iv antibiotics and fluids for a few days. (She was also marked for daily bloods thus no visible
 veins left). I asked for help from the on call anaesthetist to resite her cannula. The nurses looked
 worried when I called the anaesthetist for help. The anaesthetist tried 4 times and was unsuccessful. So
 if you are stuck, even for a simple thing, don‟t break your head and lose control. Just ask for help in a
 polite manner.

 Here I need to remind you that few nurses are very well experienced in taking bloods and iv

 Don‟t think that you will not be good enough if you do request help from a nurse or another doctor.
 At the end of the day “PATIENT CARE” is very important and we should do what is in the best
 interest of the patient.

      Please do check with the matron if you are bringing someone to stay in your room/flat. (Even if
       you bring your partner or friends)
      Try documenting everything after you have seen a patient. (Good documentation is always better
       evidence in the court and will save you)

   Don‟t leave the hospital whilst you are on call. (For shopping, meeting friends etc)
   Never argue and fight with people at work, try a simple and professional manner.
   If you are a smoker, smoke only outside the hospital and never ware scrubs whilst smoking. It is
    better to inform the ward that you are going out for “fresh air” for 10 min. (Ensure that your
    bleep is always in contactable range.)
   No Alcohol.
   Never ask your friends or family to visit you in the ward. (You can meet them at reception)
   No mobiles on the ward
   Never allow any colleagues into your flat/room. (Except the cleaners)
4) How to enjoy working as an RMO
Everybody knows that working as an RMO can be very hectic and tiring for most of the time.

      TV/Internet/Movies: Try carrying a laptop and a few DVD‟s to enjoy where possible.
      Mobile: Speak to you friends and relatives regularly.
      Gym: Try speaking to the physiotherapy manager to enable you to use the hospital gym. (Most
       of the hospitals do allow the RMO‟s to use their gym out of hours)
      Food: Try to enjoy the food from the canteen. I am sure as a doctor you will be very well fed
       and also try being friendly with the chef. Just a few words will make them happy and you will be
       treated like a king. (Just see the chef after having your lunch/dinner and tell him that the food
       was exquisite and how much you liked it. This should do the trick)
      Courses: Try keeping your CV and CPD log up to date. There are a few interesting courses you
       can do when you are free. For example, course in ECG interpretation, X-ray interpretation, etc.
      Holidays: Try to plan your next holiday and do some research about these places you will be
       visiting. If you plan wisely, you can visit one different country every month with this job.
      Shopping: You could plan what you want to buy with your next salary and try spending it wisely
       by doing loads of research on the internet when you are free.
      Study and long term goals: This job will give you a good break even for planning your future
       and provide you with time to prepare for it. You can even do some part time courses like
       diploma in diabetology, diploma in travel and tropical medicine, diploma in occupational
       medicine, etc.

                                      Enjoy your time as an RMO

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