The “RMO” job

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The “RMO” job Powered By Docstoc
					                               The “RMO” Job
Kindly compiled by a current RMO Dr Ram Thungala

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…..some one bleeped me again…….

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,        50 to 60%
analgesia, TTO’s etc…
Patient is in pain: “Doc can you please        20 to 30%
review this 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           4 to 6%
bleeding or infection), for male urinary
catheter, etc….

A) 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)

      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 all the time (you can actually download
       BNF app if you have an iphone)
      Please 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 for
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.

Consequences:

              For the Patent: The patient improved from the infection and did not had
any allergic reaction

             For Me: I was given a simple warning by 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.

B) Analgesia:
I encourage you as RMO to do the following course in BMJ Learning
http://learning.bmj.com/learning/main.html

Acute pain: a guide to management

Few tips:

      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 is 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.

Consequences:

            For the Patent: 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).




  C) Low BP and Low urine output.

         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


      Low urine out put

           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 have 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….


D) CHEST PAIN

        Please review the patient with chest pain ASAP
        Always do an ECG before say “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 cardioversion following proper
     sedation. This patient recovered well and was discharged.


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

   Days from 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. No improvement proceed with the Infection screening policy.

        Infection Screening:
    1.    Wound examination for signs and symptoms of infection.
    2.    Chest examination for lung infection. (Might need an x-ray some times)
    3.    Urine dipstick and cultures.
    4.    Bloods for culture and sensitivity, FBC, CRP and ESR and U&E’s.
    5.    Please update your interventuions to the patient’s consultant.
F) PE/DVT:

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.

a) 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)

(If something looks and smell good then it will survive even though it doesn’t taste
good.)

b) 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 was commented on a racial issue 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.


   c) 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.

   d) When the ward is not too busy (over the weekends) try treat 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.)

   e) Best way to plan your day: Be proactive and not reactive Be visible part
      of the nursing team.

                   0600 till 0700             Wake up
                   0700 till 0800             Read the Paper/wash/breakfast
                   0800 - 0830                Go to the ward
                   0800 till 1000             Bloods
                   1000 till 1030             Tea/Coffee
                   1030 till 1130             Ward rounds with proper notes
                   1130 till 1230             Ward jobs/Relax
                   1230 till 1300             ***FOOD***
                   1300 till 1400             Ward work
                   1400 till 1600             Rest in your room and attend to
                                              the ward as required
                   1600 till 1630             Tea/Coffee
                   1630 till 1730             Ward work
                   1730 till 1830             ***FOOD***
                   1830 till 1930             Bath/shower
                   1930 till 2030             Ward work
                   2030 till 2230             Read/Relax/TV etc.
                   2230 till 2330             Ward work
                   2230 till 0700 am next     Undisturbed sleep if you are
                   day                        organised or if you are lucky.


By doing so, you will have enough rest and yet available to the ward regularly.

      Try ask your ward staff to use the **RMO Book** for normal unimportant
       things. This should save you from getting million 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
DO’S:
   Try answering all your bleeps as soon as possible.
   Patient confidentiality should be maintained at all time.
   Good clear communication will always show better 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 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 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 way.

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

      Please 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 every thing after you have seen a patient. (Good
     documentation is always a better evidence in the court and will
     save you)

DON’TS:
   Don’t leave the hospital whilst you are on call. (For shopping or
    meeting your local friends etc )
   Never argue and fight with people at work, as there are ways to
    deal with things simply and in a professional way.
   If you are a smoker, please smoke only out side the hospital and
    also NEVER ware SCRUBS whilst smoking. 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 cell phones in the ward (Better keep them in a silent mode)
   Never allow your any colleagues into your flat/room at all the
    times. (Except the room cleaning people)


         4) How to enjoy working as an RMO

Everybody knows that working as an RMO can be very hectic
and boring for most of the time.

   TV/Internet/Movies: Try carrying a laptop and few DVD’s and
    may be a playstation if you want to **KILL** some time.
   Cell phone: Speak to you friends and relatives regularly as this
    will keep you occupied and doesn’t make you feel **ALONE**
    all the time.
   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 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
    few interesting courses you can do when you are free. For example,
    course in ECG interpretation, X-ray interpretation, etc.
   Holidays: Try plan for 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. Think about
    it….
   Shopping: You can 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 brake
    even for planning your future and good 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.

				
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