Two days ago was my Simulation Session; Bleep Day.
All fifth years who are on the hospital block will get a bleep day, and on this day as the name suggests, we will go and collect our bleeps from the simulation suite.
We will be the "on call F1", and we are on call for everything; surgery, medicine, obs gynae or even orthopaedics.
I'll tell you a little bit about our Simulation Suite. Our hospital boasts our well equipped, high-tech Simulation Suite. We have at least two very expensive mannequins and these mannequins talk! They have a speaker attached to them and someone behind the scene will speak. The mannequins can breath (the chest can expand), they can shake like rigors, they may vomit (said the man, I've never seen it yet), they can bleed (I've not seen this too), and they can die. We can attach cardiac monitors, ECG, blood pressure cuff and oxygen saturation device to this mannequins and the readings will appear on the screen. All these numbers will be controlled by someone from the control room. See the excitement?
Well, the concept of this day is, while carrying our bleeps we should follow our normal routine in the hospital ie we stay in our own wards and whenever we are bleeped, we should answer it.
Various cases will be presented to us, we may get a phone call from a "nurse" asking advice about a patient etc.
I am free on Tuesday mornings, I am not sure what my consultant does on Tuesday mornings, but he has clinic in the afternoon.
Anyway, I collected my bleep at 9am and was nervous since then.
I do not know what to expect, what kind of patient will they "give" me and what kind of scenario will they put me in.
I was sitting quietly trying to digest the "Emergencies" section in my loyal Oxford Handbook.
My second bleep was a phone call from a "Staff Nurse" saying that the registrar (a senior doctor, at least 4 yrs ahead of me) said that one of the patients can be discharged if the blood tests came back fine. So I was asked to review the blood test results. Well, everything was quite normal. The FBC was fine, so were the electrolytes. And I said carry on, discharge the patient.
Then only I realised I didn't even ask who was the patient. The most I know was he was a chap who came in drunk last night and is now stable. I immediately recognised my mistake and was really contemplating whether I should call the "nurse" back and asked further details. Heck, I didn't even ask what was the liver function, alcoholic patients might have very deranged liver enzyme.
But I didn't.
My third bleep was a post-op patient having low BP, 90 systolic. Our normal range is about 120-140 systolic, so you can imagine how low it was.
I asked the nurse to administer 1000ml fluid to be given within an hour first, while I get to the simulation suite. As I walked from Education Centre 1, where the library is to Education Centre 2, where the SIM suite is, I flipped through the pages of hypotension in OHCM. I didn't realise I should have given 250ml stat (ie in 15 minutes) rather than straight away 1000ml in one hour, although both of them are the same. I knew I have to, it just didn't occur to me that I knew it. I panicked.
When I get there, the patient was still responding to me. She was desaturating, her BP was low and she was tachycardic. I asked the nurse to give high flow oxygen, and wait to see if the IV fluids brought her BP up. I examined the abdomen as she just had her abdomen open 12 hours prior.
After a while her BP came up again and I asked to continue the fluids and monitor her urine output (ie measure every drop of urine she passed). Sometimes if people develop kidney failure, they don't wee. If after 1000ml of fluid she still doesn't wee, I will be concerned.
Then I left.
My third bleep was a patient who was pyrexic (spiked temperature) 30mins after blood transfusion being commenced. Everything else was normal, said the nurse.
So I ordered the blood transfusion to be stopped and call the transfusion nurse for advice. Truthfully, I don't know what to do. I know I have to stop the transfusion but spiking temperature after transfusion is quite normal, I am not sure if we can recommence the blood transfusion in 30 mins or so? That's why I asked the nurse to call the transfusion nurse. Oh God.
10 minutes later the "nurse" called me back. He said he can't get hold of the transfusion nurse and now the patient has started to be agitated and started to drop her BP.
I had to rush to the SIM suite again. This time, I read the blood transfusion reaction page on OHCM.
While walking from EC1 to EC2, I really hope I bump into a familiar doctor so that I can get a friendly advice on how to tackle this problem. But none passed by. Haih.
When I got there, I had the same page of OHCM opened in my hand, but was unable to understand anything. My mind just went blank.
I've been thinking what is it that this patient is having? Contaminated blood? ABO incompatibiltiy? Simple febrile reaction? Anaphylaxis?
When I got there, the patient talked to me but in a while she quickly deteriorated, she started to wheeze, shakes (yes, the mannequin shook!) and I was like "Oh God...is this anaphylaxis?"
So I ordered epinephrine 500mcg IM, hydrocortisone and chlorphenamine (Piriton) IV and another lot of epinephrine after 5 minutes, seeing the BP has not gone up yet.
I don't know why, I have ABCDE in my mind but I can't remember where to start. The only thing in my mind was the mental image of putting my ears near the patient's mouth and at the same time look at the chest to see any expansion. But the patient has oxygen mask on, how do I assess the breathing? Can I just use the monitor? Her saturation was dropping and respi rate was high. But is that all? How do I assess Circulation God, I forgot! So I just stood there, and then say "Lets call the anaesthetist!". Haih... Anyway I think I could have done much better but being nervous really hit me hard that day. Mike (the SIM coordinator) still say I did a very good job during managing that patient. Nope, I dont think so. But I was too hungry to keep the discussion any longer.
I hope they have more of this SIM sessions. I really do.
-Because life is a test-
-AkMaR- http://nur-akmar.blogspot.com
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