You've been bleeped

So this is something we did (used to do) back in the earlies (follow this link to view the bulletin: https://drive.google.com/file/d/1-Ortb7LXvcn_Gu7NmVCHvRnnkNw-SG0A/view?usp=drivesdk) and haven't done in some time.

It was meant to put you (hypothetically) in a simulated scenario that can happen on the ward whilst on call, going down different pathways to see what you should be thinking and how it should be handled, to improve your handling of such a situation as a junior doctor.

That being said, let's bring it back!

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Before we begin, all credit goes to the Student BMJ, you can follow this reference to access the official publication:

BMJ 2016; 352 doi: https://doi.org/10.1136/sbmj.h3890 (Published 06 January 2016)Cite this as: BMJ 2016;352:h3890

Here we go!

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You’ve been bleeped: symptom control in the unwell patient

As a junior doctor you need to know how to recognise a deteriorating patient and to initially manage symptoms that the patient may be experiencing, such as pain, breathlessness, and nausea. This article shows you how to work out the causes of pain in a patient who has gastric cancer and who is deteriorating, so that you can formulate an appropriate management plan.

Scenario

You are a foundation year one doctor (FY1) working a weekend on-call rota that covers the oncology and haematology wards at a teaching hospital. It is 14:30 on Saturday and you have just reviewed a patient on oncology ward A who has hyperglycaemia. You are about to chase up some blood test results that were handed to you before the weekend when you receive a bleep.

Bleep

“Hi doctor, it’s Rob, charge nurse on oncology ward C. I’m ringing you about Mr Lewis, a 65 year old man with metastatic gastric cancer. He came into hospital with haematemesis, although this settled after he received palliative radiotherapy to the stomach. More recently, he has been treated for a chest infection, but over the past few days he has been deteriorating, and now he has worsening abdominal pain. He has vomited once, although I don’t think there was any blood. He is very uncomfortable and looks distressed. Could you come to review him please?”

View from the medical registrar

How would you react to this bleep on the phone?

In this case you need to consider two main points. The first is the symptoms that Mr Lewis is experiencing: abdominal pain and vomiting. You need to work out the cause of both of these symptoms and develop a management plan. The second point you need to deal with is what is causing the patient to deteriorate.

Abdominal pain can have many causes, so you should carry out a thorough history and physical examination. In patients with gastric cancer, it is easy to assume that the cancer is the cause of the abdominal pain, but you should not jump to this conclusion. You should keep in mind other potential causes such as constipation, organ perforation, or bowel obstruction when thinking through the differential diagnosis.

Another important thing to check is whether Mr Lewis has been given any analgesia recently, and if it has been effective. This will help to inform your management plan. If a patient has had analgesia prescribed “as needed (PRN),” but the nursing team has not administered it yet, you should ask them to give Mr Lewis a dose before you review him.

You should also think about the patient’s background before making a management plan. From the history you received over the phone, it sounds as though Mr Lewis may have been in hospital for some time. He has been treated for a chest infection, although his general condition seems to be worsening. Is this because treatment for his chest infection has been inappropriate or insufficient, or because his physiological reserve is severely limited due to his advanced cancer, so that despite treatment he will not be able to clear the infection? Review Mr Lewis’s hospital notes to make a further assessment about this, as well as speaking to Mr Lewis himself, his family, and the nursing team on the ward.

What the FY1 should be thinking . . .

• Mr Lewis is reported to be distressed by his symptoms. I should review him to find out why he has pain and vomiting, but also so that I can try to make him more comfortable

• I’ll need to take down Mr Lewis’s full details (name, ward, bed number) so I can add this review to my jobs list

• I’ll need to find out from the nursing team whether Mr Lewis has any PRN drug available that they could give him for the pain and vomiting they have described. This may need to be given parenterally if the vomiting persists

• Given that Mr Lewis is known to have gastric cancer, this is a likely cause of his symptoms, but I’ll need to keep an open mind about the cause of his symptoms during my assessment

• I will check how promptly the nursing team thinks Mr Lewis needs to be reviewed. I will consider this estimate, the availability of PRN drugs, and the other tasks on my jobs list when deciding how soon I need to see him. I will agree this timeframe with the staff and ask them to bleep again if things become more urgent

Further information from Rob

“He really is getting quite distressed, doctor. He has liquid morphine prescribed, and we’ve given him a dose, but he vomited soon afterwards so I’m not sure how helpful this was. He is on slow release morphine, 30 mg twice a day, and he took this as prescribed this morning. His family aren’t with him currently, but I’m going to ask them to come in to see him as he looks unwell. We have done a set of observations. His pulse is 100 beats/min, his blood pressure is 125/75 mm Hg, his respiratory rate is 20 breaths/min, his oxygen saturations are 95% on air, and his temperature is 37.2°C.”

What the FY1 should be thinking . . .

• It sounds as though Mr Lewis is in some distress. Unless I have other urgent jobs I should attend to Mr Lewis or see if a colleague is able to

• This job is a priority so I can help relieve Mr Lewis’s discomfort but also make sure there is no new acute problem. Mr Lewis’s raised heart rate and respiratory rate may be indicators of his pain or may signify a more urgent acute pathology

• The nursing team has tried some PRN analgesia, but this has not been effective because of Mr Lewis’s vomiting so I will prescribe analgesia to be given parenterally (by another means, not oral or rectal intake) and an antiemetic

• From the information given so far, it sounds like he has become more unwell recently. As well as looking at treating his symptoms and the cause of his symptoms, I’ll need to make sure that he has the opportunity to ask questions and check his understanding of the situation

View from the medical registrar

Walking to the ward

At 14:45 you start walking to the ward where Mr Lewis is located. During this time, think about how you will approach the situation when you arrive. Finding the cause of the pain will allow you to treat the cause accordingly and will help inform your choice of appropriate analgesic and antiemetic.

Mr Lewis is distressed and you should aim to treat his pain and vomiting early on to make him more comfortable and to put him in a position where he’s more able to give a history.

Mr Lewis has already been given opioid analgesia. PRN doses of opioids are calculated with respect to the long acting dose. Mr Lewis is taking morphine sulfate modified release (MR) 30 mg twice a day, equating to a total daily dose of 60 mg. Guidelines recommend prescribing an oral PRN dose of one sixth of the total dose. The dose of immediate release morphine sulfate (liquid morphine) is therefore 10 mg. However, because of the vomiting, intravenous (parenteral) morphine is needed here. Parenteral morphine is twice as strong as oral morphine. Therefore, 5 mg of subcutaneous morphine sulfate would be appropriate.

Although Mr Lewis’s metastatic gastric cancer may be the cause of the pain, other causes need to be considered. It is helpful to consider anatomical structures when developing a differential diagnosis. In this case the following may be helpful to consider:

• Upper gut: gastric malignancy, peptic ulcer

• Lower gut: constipation, bowel obstruction, appendicitis, bowel perforation

• Hepatobiliary: biliary colic, cholecystitis, cholangitis, liver metastases

• Pancreatic: pancreatitis

• Urinary: urinary tract infection, urinary retention

• Vascular: mesenteric ischaemia, aortic aneurysm

• Referred: pneumonia, spinal metastases

• Medical: hypercalcaemia, Addison’s disease.

In a female patient, gynaecological causes should also be considered. Some of these potential diagnoses can be quickly ruled out when you review Mr Lewis. You may need to carry out further investigations to clarify the likely diagnosis but remember that in a deteriorating patient the benefits and burdens of interventions need to be carefully considered. For example, if you suspected that Mr Lewis had a malignant bowel obstruction, you should consider his general condition and possible management options before automatically proceeding to a computed tomography scan.

What the FY1 should be thinking . . .

• On arrival my priority will be a short assessment of Mr Lewis so that I can safely prescribe him both parenteral analgesia and antiemetic. Using these to make Mr Lewis more comfortable will improve his ability to provide a good history of his symptoms so that I can proceed with an in depth assessment

• I need to keep an open mind about what is going on so that on assessment I can come up with a list of possible differential diagnoses. I will need to decide if further investigations are needed to rule out an acute cause that requires attention

• It will be helpful to review Mr Lewis’s notes to find out more information about what has been happening to him while he’s been in hospital. It will also be useful to get more information about his cancer, such as where his metastases are

• An update from the nursing team may be helpful. They might have additional information to aid my clinical judgment

You arrive on the ward at 14:50. You locate Rob and get an update. Nothing has changed since the telephone discussion. Rob has got the notes out ready for you behind the desk, where there is also a computer with access to the hospital pathology and radiology systems. Rob has spoken to the patient’s family and they will come in later this afternoon.

View from the medical registrar

Arriving on the ward

Although it is important to treat Mr Lewis’s symptoms early, you should briefly review him before writing up a dose of parenteral analgesia and antiemetic. You should introduce yourself and make a brief assessment of his pain and vomiting, check for allergies and his recent blood results—especially his renal and hepatic function—to ensure safe prescribing. Assuming there are no unexpected findings, a dose of morphine sulfate 5 mg subcutaneously should be given. Given that Mr Lewis vomited after the administration of a dose of oral morphine, you should prescribe him an antiemetic. Metoclopramide works against both gastric stasis and chemical causes of nausea, both of which can be caused by opioids, but is contraindicated in complete bowel obstruction, which should be ruled out before administration. Although many antiemetics are not licensed to be given subcutaneously, they are commonly administered safely in a palliative care setting. It would therefore be reasonable to give metoclopramide 10 mg subcutaneously in this situation. You can prescribe these drugs after you review the notes and recent results.

What the FY1 should be thinking . . .

• Although I need to get Mr Lewis comfortable, I must get some brief information before writing up the drug regimen, to avoid a prescribing error

• Patients like Mr Lewis are often experts in their own management. It will be helpful to know if Mr Lewis has had this pain before and, if so, what caused it and what analgesia helped. This information could be sought from a nurse or family member who knows him well if Mr Lewis is too distressed to give this information

• Morphine is a drug with potentially serious side effects if given inappropriately, so I must check the dosage carefully when I write it up

Gaining more information

You review the clinical notes, drug chart, and observation chart and find that Mr Lewis has metastases to the lungs, peritoneum, and liver. His haematemesis has settled after the radiotherapy. He has received five days of co-amoxiclav for a hospital acquired chest infection, completing the course this morning. Yesterday’s ward round notes state that Mr Lewis “looks less well,” though this is not commented on further. Mr Lewis has had abdominal pain intermittently through the admission, for which he has used liquid morphine 10 mg orally on occasion. Alongside his morphine sulfate MR, he’s also taking paracetamol 1 g orally four times a day.

You find Mr Lewis’s blood tests from yesterday, which read:

• Haemoglobin—104 g/L

• White cell count—9.8 × 109/L

• Platelet count 205 × 109/L

• Sodium—142 mmol/L

• Potassium—3.9 mmol/L

• Urea—5.9 mmol/L

• Creatinine—75 µmol/L

• Albumin—24 g/L

• Alanine aminotransferase—28 U/L

• Alkaline phosphatase—289 U/L

• Bilirubin—11 µmol/L

• Calcium—2.12 mmol/L

• Corrected calcium—2.44 mmol/L.

View from the medical registrar

Once you have reviewed the notes to gather background information, clarify the likely cause of the abdominal pain and vomiting. To do this, take a history, starting with open questions so that Mr Lewis can tell his own story of events, then focus down to decide on a diagnosis. Remember to take into account the patient’s pain and his episode of vomiting.

You need to find out more about Mr Lewis’s analgesic history and how useful each drug has been for the pain. This will help inform the choice of analgesic in Mr Lewis’s management plan.

You should also think about Mr Lewis’s disease trajectory. The history you’ve been given suggests that Mr Lewis has been deteriorating recently, on the background of a metastatic cancer. Mr Lewis has also had a chest infection, but it has not improved despite treatment. Although other potentially reversible causes for the deterioration should also be considered, there is a good chance that Mr Lewis is reaching the terminal phase of his illness.

You should now form a definitive management plan that takes into account the causes of the pain and vomiting, as well as Mr Lewis’s overall condition.

What the FY1 should be thinking . . .

• I need to examine Mr Lewis to rule out acute causes of the pain such as visceral perforation

• I need to consider the need and appropriateness of further investigations for the cause of the pain

• I need to think about how I’ll manage Mr Lewis’s symptoms from this time onwards

• His renal function is normal and his hepatic function is relatively normal, which makes prescribing more straightforward

View from the medical registrar

Involving your team—do you need anyone else?

Foundation year one doctors are expected to be able to recognise a deteriorating patient and to initially manage symptoms that the patient may be experiencing, such as pain, breathlessness, and nausea. However, they must also be able to recognise the limits of their competence and involve a senior doctor when appropriate, such as when making a definitive management plan.

A deteriorating patient may present in many ways, and it is important to decide on an appropriate escalation plan. The “red, amber, green” classification will help you decide on this.

“What if” scenario A

Mr Lewis is more settled after the administration of the subcutaneous morphine sulfate and metoclopramide. He tells you, however, that his abdominal pain has not resolved completely, and that although he has managed a few sips, he still feels nauseated. He’s not sure he’ll manage the oral drugs he would usually take at the next drug round. Mr Lewis tells you that the pain he experienced was similar to the pains he usually experiences with his cancer, and although he thinks morphine is effective for this, it is becoming less so. The drug chart shows that in addition to his morphine sulfate MR 30 mg twice a day and his recent doses of subcutaneous morphine sulfate and liquid morphine, which he vomited up, he’s also had two further doses of liquid morphine 10 mg in the past 24 hours. He tells you that he opened his bowels this morning, producing a normal stool.

On examination, Mr Lewis’s abdomen is soft throughout. He has mild tenderness in his epigastric and umbilical regions, with no guarding or rebound tenderness. His bowel sounds are normal.

Mr Lewis tells you that he recognises that he’s becoming less well, and that his priority is to be comfortable. He’s not sure how well his wife understands the current situation though, and asks if you would be able to update her later.

What the junior doctor should be thinking . . .

• This is an amber scenario. It does not seem that Mr Lewis’s abdominal pain has an acute cause; the pain seems to be related to his cancer. However, the suboptimal analgesia and examination findings are disconcerting. I would like to run this past a senior colleague non-urgently because Mr Lewis is stable. I want to check that given my description of his case, there is senior agreement on the cause of Mr Lewis’s pain and ask for guidance with his ongoing analgesia

• If I speak with his wife, I would do so with an experienced nurse and aim to discuss the case with a senior before doing so. If I knew Mr Lewis better I might feel comfortable proceeding without this support. However, I have only cared for Mr Lewis for a short time

Action

• I will contact a senior to confirm (or refute) my suspicion that this is cancer related pain, not a more acute problem. If I am confident in my diagnosis of the clinical picture I will discuss rather than request review

• I will discuss symptom control of Mr Lewis’s pain and vomiting with a senior or with a palliative care specialist (doctor or nurse)

• After further adjustments to Mr Lewis’s drugs I will plan to review him later on to see if these have helped. This review is also important so that I can confirm or refute my impression that there is not an acute cause of the pain in need of investigation

“What if” scenario B

Mr Lewis remains distressed despite the administration of subcutaneous morphine sulfate and metoclopramide. He cannot easily give a history because he is becoming confused. He’s pointing to his abdomen.

His observations have deteriorated, showing the following: his heart rate is 110 beats/min, his blood pressure is 100/60 mm Hg, his respiratory rate is 28 breaths/min, his oxygen saturations are 94% on air, and his temperature is 38.2°C. His abdomen is generally tender, with guarding and rebound tenderness over the upper abdomen. Bowel sounds are absent.

What the junior doctor should be thinking . . .

• This is a red scenario. Mr Lewis appears acutely unwell and I need to perform a full ABCDE (airway, breathing, circulation, disability, exposure) assessment

• Mr Lewis’s observations fulfil systemic inflammatory response syndrome criteria and suggest sepsis. Given the examination findings, this may be caused by a visceral perforation within the abdomen

• Firstly, I need to investigate and manage his acute problems but it may be that Mr Lewis is deteriorating, and I’ll need a senior opinion about his ceiling of care

Action:

• Once I have carried out an ABCDE assessment, I will start intravenous fluids, oxygen, and a broad spectrum antibiotic to cover the possibility of sepsis from an abdominal source. I’ll also order a portable chest radiograph and repeat an urgent set of blood tests, including blood cultures

• I will contact my registrar promptly to request an urgent senior review

• Because Mr Lewis remains distressed he requires further analgesia. I’ll advise a further dose of morphine sulfate 5 mg subcutaneously and speak to my senior about further symptom control measures

Before the next bleep

After your review of Mr Lewis it is important to fully document all findings and the management plan, including any discussions that have been had with seniors. Leave your contact details, such as your bleep number, in the notes in case further assistance is needed. You should hand over Mr Lewis’s case to the next on-call team because he is unwell and is likely to deteriorate further.

When approaching a case of a deteriorating patient, both the “here and now” and more long term plans should be considered. Treat symptoms promptly to prevent suffering. When deciding on a definitive management plan, the potential benefits and burdens of any investigations and management should be weighed up and a decision made together with the patient. As a foundation year doctor, it is generally always helpful to involve senior clinicians in decisions about cardiopulmonary resuscitation, and in complex decisions such as setting ceilings of care and withdrawing treatment.

Learning points

On the phone

• Write down details of the case and add this to your jobs list

• Work out how urgently the patient needs to be reviewed and ask the nursing team for their opinion

• If the patient is symptomatic, check whether he or she already has drugs, such as analgesics, available to be given before review

Walking to the ward

• Have in mind a differential diagnosis of the patient’s presenting symptoms

• Think about the important questions to ask during the history taking

• Think about how examination findings will help to elicit the cause of the patient’s symptoms

Arriving on the ward

• Before a full review, it might be reasonable to give the patient drugs to control symptoms if he or she is highly symptomatic; carry out a brief review before prescribing, including checking the patient’s allergy status and recent blood test results. Take a structured history and carry out an appropriate examination to give a provisional diagnosis

• In the setting of a progressive illness, be aware of the features of a deteriorating patient

• Be aware of the limits of your competence and involve seniors in complex decision making

Before leaving the ward

• Ensure you fully document the review and hand over to the nursing team on the ward

• Leave your contact details in case further review is needed

• Hand over all patients who are likely to deteriorate further to the next on-call team

Originally published as: Student BMJ 2016;24:h3890