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.