Hi. TW for suicide
21F, with my partner of 2 years in UK
Found out I was pregnant 1 day before turning 21 (4th June) and immediately booked for consultation to do a medical abortion. I was 5 weeks and 4 days when doing it on the 21st June. I did well with painkillers and for the most part didn't feel a thing. I just want some reassurance for the symptoms I have as it's now 10/07/23 and I'm not feeling right still.
I feel like this context may be important as I know stress messes with our bodies so here you go (it's long) and serious TW for suicide.
My partner did not take the news well. He wanted to keep it but I knew 100% we could not be parents at the time. I'm confident in the decision. We have so much family trauma and are not responsible or mature enough for it.
Since finding out his mental health took a huge toll and he was constantly making little comments about ending his life and not being here etc. He would go out on walks that lasted hours and disappear without saying anything while I was asleep. A couple days before the medical abortion it seemed he was at his limit. I tried to speak to him a few times and help him understand his feelings on this as well as mine but he wasn't having it.
The day of my medical abortion, he called his doctor and was prescribed codeine. Then I took my first set of tablets, once he knew I'd be immobilised he told me he is going to use the codeine to kill himself in one of the secluded areas he found on his walk. I called his doctor and 111 and told him he's lying about the reason for the codeine and they cannot prescribe it
He found out his prescription was cancelled, argued with me, cried, threw my phone at me then left saying he will find whatever he can over the counter. I do not drive - he does. I called 999 in tears and police came to my house to take as much information as possible. The situation escalated and escalated and unfortunately I had to tell my mum I was having an abortion (I hadn't told anyone except my partner) because she got suspicious me asking so many questions for the investigation. She came over and was really supportive but I was really upset that I had to tell her.
Police were here for over 5 hours until they found my partner with a drone, the situation with him did not go well and he was told he was being detained under the mental health act...my partner refused and said he will go home on his own but police smashed his window and tried to tase him, then he rammed the cars and sped off. He called me for an hour saying this was it and the call was horrendous. The officer kept asking me to talk to him but I was so broken down and found it difficult saying anything but "please don't I love you" I heard him crash the car and thought he was gone. There was no noise. No car engine, no breathing, no traffic, nothing.
The aftermath is he's okay, went to a mental ward and hospital, police action waiting to be taken, couples therapy booked (he won't do his own) and right now he has actually seemed to have gotten over the baby thing. Yay I guess..?
Anyway back to the topic at hand. He was gone for a day and a night and I took a crap ton of painkillers before I started the tablets 24-48h after the first. I played apex while it did it's thing and my mum, bless her, bought me so many snacks and drinks to keep replenishing me. I started to bleed a few hours after but no pain. My partner came back and all was still okay. Then I got a bit of pain. No Biggie. Heat blanket, keep on top of pain killers and try to sleep. Unfortunately woken up by outside noise and here's where it goes south
I go to the bathroom and I'm bleeding a LOT. I feel sick and call my mum from upstairs saying "I don't feel good please come here" then i start getting weak, laying over the sink next to me and saying I'm going to be sick. I'm not sick but then when mum comes up my vision of her is going black and my head feels static and hot- then lights out
I wake up on the floor and my partner and my mum are there, mum is using a cold flannel and being a great mum as she does but partner is in an anxious fit. I tell him to call BPAS (who I used) and he doesnt explain very well what's going on. He mentions the blood and that I felt faint...not actually passed out. They tell him to keep me cool and comfortable and watch for blood overflow.
I don't remember much from then. But when my mum left a couple days later I just got worse. Everytime I stood up I'd full on pass out or be extremely close to it, the blood loss was constant and I was overflowing maternity pads very fast. Went to hospital for a blood transfusion, IV and scans. Scan showed nothing abnormal. Fine. Go home, same thing happens.
Now it's been 20 days and I'm STILL bleeding heavily. I still feel faint. I still feel generally crap. I still get intense cramp and pain. I've been off work for weeks and I'm going back in 3 hours, but still using strong painkillers to relieve current pain. I've given as much context as I can on how I felt and what was going on in my life so could someone please help me and reassure me this is normal? BPAS has finished with follow ups and my doctor doesn't really wanna know unless I pass out and bleed out simultaneously.
Thank you for reading <3
Clerking the Surgical Patient Well, it’s finally happened. You're on your first surgical on-call. You’re alone in SAU; the only point of call for every surgical nurse in the hospital. Probably the region. You’ve got someone in room one with belly pain, someone in room 2 with a wound issue, and a crying medical student in room 3. Your registrar has gone off to polish his consultant’s car and told you in no uncertain terms to have the patients clerked and ‘sorted’ before he gets back otherwise ‘the bosses won’t be happy man, the
bosses won’t be
happy’.
Only thing – you think back to your surgical rotation at med school and it’s a blur of booze and fried chicken.
Here’s perhaps a helpful guide.
Surgical patients are deceptively simple. I see posts every now and then about surgeons using the CT scanner to diagnose everything, and while it’s got its basis in truth, there’s a lot more to it. Surgical patients tend to present with a set of similar symptoms for most conditions (eg. Belly pain, diarrhoea and vomiting) and your skill is identifying relevant bits in the history to guide you. You’ll likely need imaging, but knowing
what you’re looking for – and
why – makes all the difference.
While they may be simple, they’re usually very sick and can become very unwell very quickly. They will require careful resuscitation and a definitive management plan put in place.
Oftentime, there are multiple unwell patients and your consultants, registrars and SHOs won’t be around to help you. Whatever your feelings towards surgery or surgical doctors, you want to be the foundation doctors who can make a sensible management plan that isn’t just ‘Senior review’. You want to be a doctor and provide good care for your patients.
Step 1 – Introduce yourself. ‘Good evening Mr X. My name is Dr X, I’m one of the surgical team’
Your name is ‘Dr XX’ or “MMs X’.
I can’t get on board with this loss of professional titles. You worked for it, it’s your name now, own it. I make sure to introduce my juniors as Dr XX when we’re seeing a patient together.
Step 2 – Identify the presenting complaint Seems obvious but in surgery things tend to be a little more clear cut than in medicine. Most surgical patients present with pain, or some kind of luminal symptom (diarrhoea / bleeding PR). Even then, it’s unusual for the latter not to be conflated with some kind of pain, especially in the acute take.
Beware extraneous detail. This is a hard skill. I’m not suggesting you try to reduce every symptom to a one line explanation, but there’s a subtle art to taking the relevant bits of history. Now, to be fair – my own methods here might seem a little too simplified to some. But it allows me to rapidly triage, assess and manage patients on my take and I’m good at my job.
For example – Mr Bells is a 29 year old male who has right iliac fossa pain and diarrhoea. He gives you a rambling history that takes five minutes to get through and you’re tasked with writing it down and trying to pick the pertinent points.
An unhelpful clerking: ‘Reports 27 hours of abdominal pain. Initially central throughout the day yesterday; patient moved from living room to bedroom and approximately one hour later, pain moved to RIF. Pain felt like it wasn’t ‘settling’ in right iliac fossa for another few hours. Complains of loose stool since yesterday morning; was unsure if needed to go to bathroom yesterday afternoon but had loose stool. Felt slightly more solid in the evening but the motion after this was loose. Describes some slightly liquid stool but no clear evidence of mucus – cannot be sure. No frank blood.’
A helpful clerking ‘1/7 history migratory RIF pain associated with loose stool (no blood/mucous)’
This is an art and you’ll realise that information is necessary and what isn’t as you present to other doctors and consultants.
Important associated symptoms Diarrhoea - how often? Is it true diarrhoea? Any blood? And mucous? Crucially, *does it predate this acute episode and by how long?*
Vomiting - any blood? How many times? What’s coming up? (Food / bile) have you been having forceful vomiting for a while and now present with excruciating upper abdo pain? (Think Oesophageal rupture)
Weight loss - how much? Over how long? Intentional (and if so, realistic? I'm still scared about a four stone weight loss over 6 months, even if you've been dieting).
Change in bowel habit - generally anything over the last six months to a year is significant; anything older than that is unlikely to be associated to this acute presentation. What I mean by that - the old man who presents with a 6 month history of worsening constipation and weight loss is slightly more worrying than the old guy who’s been having loose stool for his entire life.
Women - any PV bleeding? When was your last period? Any PV discharge? (You May have to prod them on this; understandably it’s an embarrassing topic). What colour is the discharge? Is it new? Does it smell? Any new partners recently?
Step 3 – Relevant past medical and surgical history Not really much to add here – obviously big systemic issues such as diabetes, ischaemic heart disease need to be right at the top. Something very important to note – have they had previous surgery in their belly? If so, please make a note and make it clear – working up a RIF pain who’s had a right hemi for Crohn’s makes it suddenly a lot less likely to be appendicitis, for example.
Step 4 – Drug history What are they taking? Make sure you have their meds and prescribe them in a timely fashion. Yes, the job sucks but it’s yours for the year. Things you need to make sure you sort immediately – PD meds, Diabetes meds.
Are they taking blood thinners? Vitally important – please find out what they are taking (Apixaban, Rivaroxaban and Edoxaban all have different durations of action) and when they last took it. As a general rule please hold any anticoagulants until reviewed by a senior. Make sure that the patient doesn’t take them either!
Alcohol and smoking – both relevant and important to know. Smoking actively gives you crappy wound healing.
Step 5 – Social history This can be brief in younger patients, but for elderly patients there are some things you need to ask. We ask these questions because it gives us a rough metric for their general fitness pre-illness. Using this, we can try to predict how well they’ll do after the immense trauma that is an operation. Here’re some useful questions. Who’s at home with you? Are you able to get about the house by yourself? Do you cook and clean for yourself? Are you able to climb a flight of stairs? If not, what stops you? – We ask this as it’s a rough guide for physical fitness. Patients are sometimes stopped by pain, but we’re really worried about whether they’re stopped by breathlessness – it’s a poor indicator for the physical fitness needed to get through a surgery. Do you have any carers? How far could you walk without getting out of breath?
When you present, you don’t need to include all of these questions individually. For example – ‘Mr Jameson is a 78 year old male who lives alone. He is independent in ADLs and has an unlimited exercise tolerance’ gets all the information to me.
Step 6 – Examination Here we go. It’s time. You’ve gotta use those magic surgeon hands baby. One day, your humble hands will be the ‘could you just have a feel of his belly before we send him home…’ hands. One day, those hands will be in latex gloves, holding a retractor in theatre. It’s time.
So obviously there’s more to it than what’s written down here, but hopefully this will give you the basics.
Palpate the abdomen over the 9 subdivisions. You’re looking for tenderness, guarding (involuntary tensing of the abdominal muscles, secondary to an underlying pathology), and possibly peritonism.
But what does it all mean?! Briefly – organs can either be intraperitoneal or retroperitoneal*. Intraperitoneal organs live within the peritoneal cavity, and are surrounded by a double layer of peritoneum. They are usually somewhat mobile, as they have some flexibility due to their peritoneal covering. I won’t go into the exact anatomy here (maybe a different post…?) but essentially – if an intraperitoneal organ becomes inflamed, then you’re going to get pain that is at first ill-defined and referred to the general area supplied by that portion of the gut.
What I mean by this – your appendix is part of the midgut. When you have appendicitis, you won’t be peritonitic in your RIF immediately. As the appendix becomes inflamed, you have visceral pain referred to your umbilicus, as all midgut pain is referred to the umbilicus / middle area. By the same token, foregut pain is referred to the epigastric region and hindgut pain is referred to your suprapubic region.
After a while, the inflammation will progress to such a point that the peritoneum surrounding the organ (the visceral peritoneum) will become inflamed. This means that should the overlying parietal peritoneum come into contact with an inflamed organ, you’ll get peritoneal pain, and an involuntary tensing of the abdominal muscles over that area. This is what’s known as being ‘peritonitic’.
Therefore, your young gentleman with appendicitis will initially have vague, visceral pain referred to the midgut region – the umbilicus. As the organ becomes more diseased and inflamed, the peritoneum around the organ will become inflamed; and this will lead to the pain associated with the right iliac fossa as the parietal peritoneum overlying it will become irritated.
This also explains why pyelonephritis, for example, cannot make you peritonitic – the kidneys are retroperitoneal. Same goes for a AAA – you will get vague belly pain radiating to the back, but you won’t be peritonitic.
So what’s the difference between locally peritonitic and generally peritonitic? Well, let’s use an example. Mr McCafe has appendicitis. He presents to ED, and the examining doctors notes local peritonism in the right iliac fossa. This is localised because the inflammation is localised to one area. Unfortunately, before he can get to theatre, he becomes suddenly more unwell. Upon re-examining him, you note that he now has peritonism of his whole lower abdomen. This is because the appendix has perforated, and there is free pus irritating the intraperitoneal cavity of the lower abdomen and therefore, the organs within the lower abdomen. He still doesn’t make it to theatre, and this inflammation spreads throughout the entire abdominal cavity. Now, wherever you press on his belly, he’s peritonitic – he has
generalised peritonism.
Be aware that patients often tense their abdomen in response to the thought of pain. This is called ‘Voluntary’ guarding. The trick is trying to distract them so you can elicit what is true guarding, versus voluntary guarding. One represents peritonism, and one may not – be careful! I often find talking to the patients about something or other, or distracting them some other way helps them relax and they stop tensing on purpose.
After examining the abdomen, make sure to examine their groin for herniae. This is especially true if you’re worried about bowel obstruction.
Complete the examination with a PR exam – this will give you a massive amount of information. There’s an argument I always see amongst juniors which is ‘well, the SPR will just do it again anyways…’ which is true, but you need to practice so that one day, when you’re any kind of SPR / GP / Consultant, you know what you’re feeling for.
Special tests
- Rovsing’s sign – palpation of the LIF will elicit RIF pain in a patient with appendicitis. The theory is that palpating the LIF will cause gas within the left colon to move back towards the right colon; this will distend the caecum and stretch the appendiceal orifice causing pain.
- Psoas sign – the patient is lain on their left hand side, while the right thigh is passively extended. Pain on this test indicates a retrocaecal appendix. Not massively useful if I’m honest.
- Sometimes, if you’re unsure, ask them to cough. That will reveal peritonism in a particular area. Asking them to jump up and down can do the same thing.
Nb. Retroperitoneal organs – Suprarenals, Aorta, Duodenum (2nd, 3rd, 4th parts), Pancreas, Ureters, Colon (Ascending and Descending), Kidneys, Esophagus, Rectum, Bladder
Step 7 – Investigations Bloods – FBC, U&E, LFTs, Amylase, Lactate, Clotting and G&S. Order these for every patient and you won’t go awry.
A venous blood gas is excellent to establish a baseline for your patient and will give you their acid-base status and their lactate. These can be taken serially to assess whether your interventions are having the desired effect.
Urine dip & pregnancy test –
mandatory.
Erect CXR – perforations of an intraabdominal viscus will cause a pneumoperitoneum (free air within the abdominal cavity). Beware – a normal CXR doesn’t rule out a perforation! 60-70% of perforations are seen on eCXR, leaving a whole 1/3rd of presentations that will not be adequately identified. Further, retroperitoneal perforations – eg duodenum – obviously will not show a pneumoperitoneum as the air would not enter the peritoneal cavity.
Therefore if you are convinced about a perforation and the eCXR is normal, it’s still sensible to proceed with cross sectional imaging.
Speaking of which…do I need a scan, and if so – what kind of scan?
So, we’ve got a few different imaging modalities to sink our teeth into. These all have different uses.
- CXR – Use to look for lower lobe pneumoniae which can masquerade as abdo pain. Also used tp look for a pneumo. You will never regret getting one; do them as standard for every patient. They must be upright for 20 mins before the picture to ensure that air rises to the top.
- AXR – Use this only if looking for symptoms of obstruction. You are looking for dilated loops of small bowel or large bowel. This is beyond the scope of this discussion, but we only use AXRs to look or obstructive symptoms. Don’t order them for anything else. a. Gastrografin – sometimes if we have made a diagnosis of adhesional small bowel obstruction, we can use an oral contrast medium to try to relieve the issue. Gastrografin has some properties which means that it can gently stimulate the bowel and try to relieve adhesional obstruction. As such, sometimes we try GG x rays – serial x rays looking for the passage of GG into the large bowel. If we see GG in the small bowel on AXR#1, and then in the large bowel on AXR#2, it means that the obstruction has resolved / is resolving.
- USS abdo – Ultrasound is much better at picking up gallstones than CT. Use USS to look for the presence of stones, cholecystitis or to look for biliary tree abnormalities. a. Why not CT? Because gallstones are either cholesterol, pigment or both. These are not kidney stones which are made of mineral. CT is perfect for kidney stones because it shows up metallic elements – eg stones, bone etc. Gallstones aren’t usually metallic, unless they’ve been present for so long they’ve become calcified. b. Pelvic ultrasounds are excellent for looking at the ovaries and uterus.
- CTAP – the donut of truth. Cheap, reproducible and not operator dependent. Gold standard for most surgical diagnoses – gallstones and gynae excepted. There is a concern about radiation risk; approximately 1/400 risk of cancer for women of child bearing age, 1/600 for dudes. These figures might be old; happy to be corrected. Obviously make sure they’re not pregnant beforehand. Get some practice with your reg trying to figure out which cases need a scan and which don’t; there’s no reason you cannot book scans if you feel them clinicially appropriate. a. CT Scans with contrast are the standard. b. CT without contrast is only used for looking for stones. Please do not book them for anything else – they’re difficult to interpret and don’t really help.
There are obviously more, but for your level this is probably enough.
Step 8 – Make a management plan! Right – so you’ve taken a decent history, examined your patient and now it’s time for the dreaded management plan.
Your job in the management plan is to stabilise the patient, advance their treatment
and prep them for definitive intervention. Sounds difficult?
Not at all! Let’s go through bit by bit. Here’s a little framework.
Interventions - Analgesia
- Abx
- IVI
- Ryles tube and oral intake
- Imaging
- Clots
- Theatre
Sepsis Sepsis kills. If in any doubt, activate the sepsis six.
GIVE – IV fluids, Oxygen (maintain sats >94%), Broad spectrum Abx (though if you’re sure it’s a GI pathology, then give them more targeted therapy).
TAKE – Urine output (Catheterise them), Bloods inc. cultures, a lactate (a baseline VBG is excellent).
Step 1 – Analgesia The type of pain relief you give depends on how bad the patient’s pain is, whether they’re ambulant or not, and how sick they are.
Basic guidance – start off small and increase as needed. Paracetamol / Codeine / Morphine. I’m not thrilled about giving NSAIDs to GI patients as a whole; there are some conditions where it’s appropriate (gallbladder stuff / pancreatitis / abscesses). Happy to be corrected on this by cleverer people.
PO / IV Paracetamol – give to everyone.
Codeine – trial 15mg PO QDS if it looks like they can go home; move to 30mg or even 60mg. If they’re requiring 60mg of Codeine however, ask yourself – is this someone safe to be at home? The answer may well be yes, of course. But important to ask the question.
- Codeine slows the GI tract and we use it for reducing ileostomy output as well as analgesia. If you are concerned your patient may have constipation, please don’t use this.
Morphine – if you’re giving morphine to a patient, they probably need to be in hospital. That doesn’t mean that everyone who gets 10mg of PO Oramorph needs admission; that means that If you assess their pain properly and start off on the lower doses of other medications, you can avoid the morphine altogether. If their pain is only controlled with morphine, you need to be a little more concerned that there’s something serious going on.
- PO Morphine is good as a little ‘top up’, but its short acting and wears off quickly. Don’t be afraid of giving it regularly if needed; 15mg/2-4h isn’t an unreasonable regime.
- IV morphine may be needed if the pain is truly uncontrollable. Obviously this isn’t a long term solution; it’s likely the patient will require some kind of operative intervention.
PCA – This is for patients with a proven condition who will require ongoing, regular analgesia – eg. Pancreatitis. Rib fracture patients do well with this, because it allows them to inspire properly and avoid risks of atelectasis. Don’t start by yourself; discuss with a senior (though by all means add it to your plan!)
If they’re going home, what’s the least amount of analgesia you can give to help them at home? This is another reason why it’s good not to just start off with PO morphine; you need to know the minimum that works for them.
Step 2 - Antibiotics Does your patient need an antibiotic? The answer feels like it should be ‘yes’, but let’s hold up for a second.
Why are we giving antibiotics?
You’re trying to treat the very real threat that your patient has bacteria where it shouldn’t be. Obviously, perforations (Gastric, small bowel, large bowel) all require antibiotics.
But what about non-perforated GI tract inflammation? Well, we usually do treat these with antimicrobials, and the reason we do that is that inflammation causes the affected tissue to become oedematous, leaky and more friable. This can lead to bacterial translocation from an area where bacteria belongs (eg your small bowel) to an area where it
doesn’t belong (ie. The sterile intraperitoneal cavity). If in doubt, give antibiotics**.
There are a couple of exceptions, however (lol of course).
- Appendicits that’s been clinically diagnosed, and there’s doubt. Let’s say Mr Cakebox came into hospital with vaguely appendicitis-sounding symtpoms. He’s 25, fit and well, and you’re a little stuck as to whether to take him for an operation or not. Your consultant decides to let him cook for the next 12 hours to see which way he goes – will his pain and inflammation get worse, and therefore declare himself as a true appendicitis? Or will his symptoms improve and turn out to be a simple case of mild gastroenteritis? If you give him antibiotics on his admission, then you’re going to end up partially treating the appendicitis and mask future clinical examination. Therefore;
- a. Unclear history and decision for theatre NOT made = hold off Abx
- b. Unclear history but decision for theatre HAS BEEN made = give Abx
- c. Clear history and decision for theatre HAS BEEN MADE = give Abx
- d. Imaging-proven Appendicitis = give Abx.
- Diverticulitis – there’s some debate as to whether Abx actually help with mild Diverticulitis. Err on the safe side; give whatever your senior wants. This is usually if they’re well enough to go home.
- a. If the patient is septic – give abx.
- Pancreatitis. Pancreatitis is a sterile (at least in the beginning) process. While it will cause a systemic inflammatory response which will mimic the sepsis response, it Is not in itself a septic process. Remember – Sepsis is SIRS in the presence of an established infective focus.
- a. Your pancreatitic who is spiking temperatures of 38.4, is tachycardic and has a low blood pressure is exhibiting organ dysfunction in response to the inflammatory response to their pancreatitis. Antibiotics cannot help them.
- b. Your perforated diverticulitis who is tachycardic, pyrexial and hypotensive is exhibiting a septic response to an infective stimulus. They are septic because they have SIRS with an established infective focus.
The choice of antibiotics will of course depend upon your local formulary.
Step 3 – IV Fluids This is a contentious issue and I don’t pretend to be an expert. I’ll say this; if the patient is complex in terms of CCF or renal failure etc – ask for senior advice before prescribing anything more than a litre or so yourself. We try to use physiologically balanced solutions – eg Hartmann’s. The idea is that it has a composition as close to normal plasma as possible. As a general rule, if you’re admitting someone and they’re nil by mouth, start them on IVI. Approximately 2.5-3L/day will suffice – that’s around 3x8h bags. If they’re septic or fluid deplete, this rate will need to be increased. I won’t go into how to correct various abnormalities here – there’s e-learning which can do it much better than me.
Bottom line – if they’re staying in, give them a 4-8/h bag of Hartmann’s. If they’re sick, put it up on the quicker side. If they’re not, and it’s just because you’re starving them before a senior review – 8h is fine.
If you’re worried about their fluid balance / they’re septic / they’re clearly not going anywhere because of how sick they are – place a catheter and get an accurate fluid balance going.
Step 4 – Oral intake If in doubt, make them nil by mouth. Nil by mouth does not mean that they cannot take oral medications. If you think they might need a Ryles, they need a Ryles.
These are the three main rules you need to keep in mind. When you first start off, keep every patient you see nil by mouth. Worst case scenario? You’ve starved someone for a while before your reg gets to them. No harm done.
Vomiting patients are dangerous patients, because they can aspirate their GI contents and they’ll get an awful aspiration pneumonia. As such, anyone we suspect to be in obstruction, we put a Ryles tube into and leave it on free drainage (though if you put it in, please document how much comes out!). The Ryles will continually empty the stomach and should prevent them aspirating. People who are being sick due to another pathology – eg appendicitis or pancreatitis – don’t need a Ryles necessarily as they’re no hindrance of their GI motility (it may be sluggish due to their illness but that’s not really a need to put a Ryles in).
Even if your SPR comes in and yanks that tube out, you’ve done them no harm – as opposed to the harm that may come to them if they aspirate from a subacute obstruction.
Step 5 – Imaging Do they need a scan and do they need it now? If they do, then certainly feel free to tee them up for it – ie. Have a request planned out, have the renal function ready and ensure they’re not pregnant. If you’re utterly sure – eg. A 65 year old male with raised inflammatory markers and new local RIF peritonism, ? appendicitis ? malignancy – go ahead and book. Back yourself. If it’s a truly wild scan, the Radiologist will (
gently) ask you to reconsider your plan / differential / life.
If they’re well, can the imaging be done as an outpatient? Your ?biliary colic patient who feels much better now doesn’t have to wait 3 days for an inpatient scan – they can be discharged and scanned as an outpatient.
Review any x rays they've had. If they have not had an erect CXR, get them one! As we said, you can do very little harm. Get them an ECG. Worst case scenario - you waste a strip of paper and you get to read a normal ECG again. Best case scenario - you pick up some cardiac stuff that needs to be fixed before slice-time.
Step 6 - Clots Blood clots suck. You don't want your patients to develop them. Unfortunately, the systemic inflammation that is present in septic patients, along with the prolonged periods of immobility that occur during / after an operation gives us the perfect breeding ground for a clot (damn you Virchow).
Every patient admitted to hospital requires thromboprophylaxis in some shape or form.
For a standard patient not taking any other anticoagulant medications and with no particular risk factors,
Dalteparin 5,000units is a standard dose. Use your intranet / Pharmacist's knowledge to increase the dose if your patient is obese.
If your patient has a condition
predisposing to clots - eg AF, or previous unprovoked clots - they're to be started on the
treatment dose of
Dalteparin 18,000units. This is also the case if they've got a metallic heart valve. This can be administered either in a single dose or a split dose. The benefit of a split dose is it means that the anticoagulant effect can be modulated depending on how much we want to stop our patient bleeding. I wouldn't worry about this bit yet.
If your patient is stable on a DOAC, I would move them to Dalteparin for the duration of their hospital stay.
If your patient is on Warfarin, then they will need their INR checked. Depending on their INR and the urgency of the surgical intervention, they will need their Warfarin reversing, and then commencement with Dalteparin.
When do I start anticoagulation? - Essentially whenever gives us the lowest risk of bleeding during surgery. Young, fit and well patients - It's 3pm. You've admitted a young, fit lad to SAU for a ?Appendicitis. Prescribe him Dalteparin from
tomorrow on the off-chance that he goes to theatre tonight / needs surgery in the evening after a senior review.
- It's now 5pm; your plan from the reg is for a CT scan tomorrow. He can have today's 6pm dose of Dalteparin because he's not for a surgical intervention tonight.
Patients taking a DOAC at home - Ask when they last took their Apixaban / Edoxaban / Rivaroxaban etc. Differnet DOACs have different effect times. Eg.
- Edoxaban requires a 24h period from the last dose.
- Apixaban requires a 48h period from the last dose (remember, Apixaban tends to be BD dosing).
- Rivaroxaban requires a 24h period from the last dose.
Do not prescribe Dalteparin while they still have the effects of the DOAC in their system (
https://www.ncbi.nlm.nih.gov/books/NBK557590/)
Eg. Mr Cookbook took his Friday morning Apixaban which he is taking for AF. It is now Friday lunchtime. He is admitted with diverticulitis. Do not prescribe him a Friday evening dose of Dalteparin, and hold off further doses until he either has his surgery, or he is at a point where he can be safely moved onto Heparin. Be guided by your registrar. In my personal experience, I would commence prophylactic Dalteparin on Saturday evening in this patient, though i'm aware some would wait until Sunday afternoon.
Patients taking Warfarin Mr Coaster is taking Warfarin for AF. He is admitted with severe cholecystitis. His INR is 3. When he is admitted, consider prescribing Vitamin K to reduce his INR to <2.
Vitamin K will not make you clot. Following this, he can be commenced upon Heparin. This is because if the patient might need a surgical intervention, it's always better to have them on an anticoagulant you can control (ie Dalteprin), rather than one you are at the mercy of (Warfarin and the INR taking a little while to come down).
Timing of surgery with Dalteparin General rule - hold prophylactic dalteparin 12h pre op. Most patients can therefore have Dalteparin the evening before their planned surgical intervention.
Therapeutic - 24h pre-op. This is usually achieved either by
-
splitting the dose and holding
just the evening dose on the day before surgery and the morning dose of the day of surgery (Eg. Monday AM
PM, Tuesday (Operation day)
AM PM)
-holding the evening dose from the day
before the day before surgery (Eg. Monday
PM, Tuesday
PM, Wednesday (Operation Day) PM)
- Move the dosing to the morning. The issue with this is it tends to preclude decisions for theatre made during the day.
As you can see, it's slightly messy. Don't do anything before taking to your SPR.
Step 7 – Theatre You may be conviced that a patient requires theatre.
Excellent! Surgery abounds. If you follow the previous 5 steps, you’ll realise you have prepped them adequately. You’ve given them pain relief, antibiotics and fluids. You’ve catheterised them and kept them nil by mouth. Their bloods including clotting is done. Your registrar will arrive, realise you’ve done it all and invite you to theatre to take out this guy’s appendix. Or, if you desperately hate theatre, they’ll buy you a coffee and hold your bleep for a while.
Hope this has been helpful.
Next step – common diagnoses!
Hey guys, quick summary of my endo: symptoms from 14 years old, hospitalized at 15 for 3 nights because I violently vomited, and due to the location of the pain they worried about my appendix. Saw a "growth/lump" on my ovary, but no further exploration because it wasn't my appendix. Cried in docs office at 18, got sent to a gyno for the first time, got told they wouldn't do anything because I was a virgin and the hormone pill I had been put on was temporarily helping. At 19 got too sick of it all and went to private healthcare since I had health insurance. Just after my 20th birthday I had my first lap, diagnosed with endo plus a follow-up lap 5 months later.
I was prescribed no pain medication until the date of my first surgery. I was given gabapentin, tramadol, diclofenac and panadol/Tylenol(?).
The diclofenac in combination with panadol would take the edge off on days where I had mild lingering pain, but never really helps in days where I need the help. Gabapentin I took for about 6 months continuously before stopping to see if there was any change. There wasn't. I had been taking it for that long at 2-3 capsules a day for nothing. Oh well, I gave it a try. Tramadol works amazingly. I can take one and be fine for about 24h. However, I can't walk straight for 48h, and doesn't completely go out of my system for 72h. So I have to look at my schedule and decide if it's worth being knocked on my ass for 3 days before I take it.
Since this I have been given codeine, which also did nothing. And they gave this to me very reluctantly.
My family are starting to lose their patience with my recovery, and often seem mad at me when I explain my pain is why I can't do certain things that day. Its exhausting trying to figure out if I should prioritize my mental health and physical health or my family.
I have a heat pad that I use regularly, and get 3 monthly steroid injections in my abdomen.
Tldr: I only have one pain med that works to remove my pain, and I want an option that doesn't knock me out for days. Please suggest any ideas you have.