Dr Chris CresswellED PhysicianWhanganui HospitalNew Zealand
BIBA after low speed motorcycle crash after taking handful of sleeping pills Police officer Hx Depression, under psych s/b psych, for OP follow-up, cleared for discharge Alert now ? Fit to work ?
He doesn’t want to take time off, doesn’t want his employer informed. What do you do?
Encourage him to take sick leave Inform NZ Transport Agency – recommend drivers licence be revoked
I spoke to his senior officer Lost his job Suicided
Known to be abusive to staff Police request opinion re gun licence What do you do?
Get patients permission to disclose your opinion to the police! GP didn’t discuss with patient Medical Council not impressed
Patient has a right to privacy of his/her health information unless there is a serious and imminent risk of death to the patient or others Can only disclose information to someone who can do something about it Only give sufficient information to address concern
Agitated, demanding to leave CCU What are you going to do?
This patient can not be assumed to be competent Septic Hepatic encephalopathy Withdrawal Was allowed to leave Found dead in a nearby garden next day
Taken 30g of paracetamol (potentially lethal) She refuses to allow you to take a blood sample What do you do?
We assume this girl is being adversely effected by depression which is preventing her from making an autonomous decision in her best interests We must act in her best interests Usually when we tell them they we will take blood they allow us to Next step: threaten with being sectioned under the Mental Health Act Section Restrain/sedate if necessary
In a fight, several punches to the head In the waiting room, getting stroppy and abusive, throwing things around. What are you going to do?
Talk him down Offer him eg analgesia, a bed, phone a friend If necessary restrain / sedate / scan Call police if necessary Generally safer to do this than to send an aggressive patient to the cells.
In practice: Are they orientated? Do they understand enough to be able to tell you the risks of what would happen to them if the self discharged? Are they free from a mental illness that is making them making a choice that is not in their best interests If so they are competent to self discharge and accept that risk for themselves
A doctor or nurse can restrain/sedate any patient if you have good reason to believe they are not competent and are a harm to themselves or others
Which drug to use Controversial I recommend haloperidol/droperidol rather than benzos Less risk of airway/breathing compromise Exceptions: use benzos for Alcohol withdrawal Stimulants such as cocaine, methamphetamine For the really difficult ones: IM ketamine 5mg/kg IV ketamine 1mg/kg Call in a senior
Demented, double incontinence Should we fix the NOF?
There is no NFR form / advance directive Should we / who should fill in the DNR form?
Difficult area Next of kin / EPOA do not have the legal ability to agree to / sign a DNR. If the patient is not competent and no advance care plan / advance directive -> medical decision We take into account the opinion of the family We inform the family of the decision Sometimes we give into families’ requests, make the patient for resus, to give them time to get used to idea. The conversation can be had again the next day.
Jehovah’s witness child is in an car crash, bleeding +++ into belly and externally, shocked You are struggling to stop the bleeding Do you give blood?