Case in the spotlight 8 

 CXR for two patients


Question
You are covering medical patients on an extremely busy evening. You have just reviewed on BOSSNET two CXR results of patients recently admitted from the Emergency Department. Both patients had fever, cough, dyspnea, and had some green sputum. They both had blood tests and CXRs and were commenced on antibiotics, and arrived on the ward at about the same time, and have recently received their first dose of oral antibiotics.

The CXR and medication chart are available for your patient. The nurse looking after one of the patients is worried.  At 2030 they ring you and handover their concerns using the following tool

 

CLINICAL COMM REVIEW MO

 You have been asked to go and see this patient. Your registrar asks you to just finish one more task in ED and then to go and see the patient. What will you do in this situation?
(If you are not sure. Perhaps list what options are available and consider them.)

Answer

The first question you might ask is should this be a MET response?

You look at the criteria HR 136 (not >140) RR 28 (not > 30) O2 90% (not <90%... but think of the HbO2 dissociation curve… doesn’t it drop off quickly at 90%?) the patient is a smoker, and just received their first dose of antibiotics, and an allergic reaction and indeed anaphylaxis is the most likely problem.


The nurse has used the appropriate handover tool, and asked that you see the patient now; not in fifteen minutes, and not after reviewing another patient in the ED.

You need to consider the following options

  • Requesting a MET response.
  • Ensure that the medical registrar has all the information just given to you, and suggest that this patient needs to be reviewed immediately, preferably by a senior doctor

A culture of openness, which includes welcoming constructive criticism, will increase confidence in the organisation’s determination to improve quality and safety and we must foster a culture in which all team members can, politely and professionally, speak up.

We should welcome any questions and adopt a philosophy of:  “If you don’t like or are unsure what I’m doing then please ask me”


You are dealing with the medical registrar asking you to not do as requested by the nursing staff. The PACE pneumonic is useful when there is a need to “speak up” without delay to prevent harm.

PROBE – “Are you sure you want to do that?”
ALERT – “I don’t think you should do that”
CHALLENGE – “I want you to stop”
EMERGENCY -  “STOP”
 

In this case you need to escalate to ensure that a senior doctor sees the patient promptly. This might seem difficult. However it is important!

Its 2100 and the MET response is paged overhead. What a lousy time for a MET response, so close to the end of your shift, after a very long day. As you and your registrar head up the stairs, you hope that this is not the same patient that they asked you to see five minutes ago. It was five or perhaps ten minutes, you reckon.

On arrival to the ward you are handed the patient’s chart

ORC MO education chart

What is the likely diagnosis, and what action will you and your team take?

The diagnosis is anaphylaxis secondary to penicillin allergy

  • The MET will manage the situation as a team
  • Continuous monitoring, oxygen, airway support, IV fluid bolus, all without delaying definitive treatment… which is

List any medications likely to be prescribed and their dose and administration

ADRENALINE 1:1000 (1mg/1ml)
0.5ml IMI mid-lateral thigh

Australian prescriber has a wall chart that is accessed here

Further references
http://www.allergy.org.au/health-professionals/papers/acute-management-of-anaphylaxis-guidelines
http://www.allergy.org.au/images/stories/pospapers/ASCIA_Acute_Management_of_Anaphylaxis_Guidelines_September_2013.pdf