Out of Hours Jo Swallow Difficult cases

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?

• • • 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 • • • 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 2 nd 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 section 12 apprved +other dr +asw

Acute urinary retention • Elderly housebound patient • Abdominal pain • Catheter blocked with blood • What do you do?

District nurses • • Happy to catheterise Useful to dress wounds after falls etc… Carry a bag of things for syringe drivers Hold the syringe drivers

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

• • • 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 • Mild to moderate is 5. 5 -7 • Check not haemolysed, ? serial results • Stop potassium sparing diuretics, beta blockers, ace inhibitors, nsaids, aspirin • ECG ideally • Emergency treatment if over 7 • (calcium gluconate/resonium) • Concern is arrythmia/asystole

Hypokalaemia • ? diuretics • <2. 5 need urgent treatment • Symptoms, peripheral muscle weakness, polyuria, polydipsia, cramps, tiredness

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

hypercalcaemia • Recommend hydration • Find out the albumin (if raised ca is really lower) • Stop antacids thiazides, lithium,

Acute renal failure • • Oliguria/anuria Uraemia, nausea/vomiting Confusion Fluid retention/postural hypotension/dehydration Immediate referal if suspect ARF on CRF=admit Newly detected gfr<15 ml Risks =hyperkalaemia/fluid overload

My Tips • • • 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? Chemists- which are open until when? Scripts for the rest of the course of abx, Drug cupboards, know what you have and whats in the car, Get your abx in hand before the visit to save hunting in the dark and cold