The ABC approach is one which you will see is prompted towards in nearly every topic in this text. It gives a framework for rapid assessment of the patient’s vital physiological parameters. If faced with the unknown, or you’re not sure what to do next, this will help. This guide is no substitute for hands-on training; many courses exist that will give much greater confidence in handling medical emergencies and flesh out the bones of this brief overview.
A simple premise …
• Airway—there must be a connection between the bronchial tree and the outside world. The tongue, broken teeth, foreign bodies, and secretions are all potential obstructions to this
• Breathing—in this step, we assess both the mechanics of ventilation and the physiological process of gas exchange
• Circulation—is there adequate circulating volume, is it being pumped efficiently, and is it perfusing tissues adequately? Are there any leaks?
• Disability—is there any sign of neurological problems? If so, which part of the system is not working?
• Everything else—once the above-listed steps have been covered, it’s time to begin thorough secondary assessment
• Is the patient talking? Are there any other, additional noises?
• If there are no other sounds the airway is patent—proceed to breathing assessment
• Snoring or struggling to speak suggests total or partial airway occlusion
• Head tilt, chin lift, and jaw thrust to open the airway
• Simple and effective manoeuvres which will give a surprisingly high degree of control
• Practise these at every opportunity on airway manikins
• Is there obstruction evident?
• Suction any vomit or excess secretions ( and remember that the patient has likely aspirated)
• Use Magill forceps to remove foreign bodies
• Airway adjuncts can help
• Nasopharyngeal airways can be tolerated by relatively conscious patients. Size by using the patient’s little finger as a diameter guide, lubricate, pass directly posterior via the right nostril, ensuring that a safety pin is in place at the flared end of the tube to avoid misplacement
• A Guedel airway will likely only be tolerated by a patient with lowered consciousness, and carries its own risk of causing airway obstruction by posterior displacement of the tongue. Size from the distance between the angle of the mouth and the earlobe, and insert flat over the tongue with the curve upwards. On reaching the back of the tongue, rotate through 180° so the curve is downwards (minimizing chances of taking the tongue back with the airway). It has a useful secondary function as a bite block for an intubated patient
• Remember that adjuncts primarily aid oxygenation by holding airways open—this also renders them highly susceptible to aspiration. Manual control is always desirable until the airway is either self-managed or secured by intubation
• 15 L/min oxygen via a non-rebreathing face mask (giving around 85% FiO2)
• While caution is required with patients in type 2 respiratory failure (i.e. with a hypoxic respiratory drive), remember that hypoxia kills before hypercapnia. In this situation, it is advisable to use a Venturi mask and to titrate FiO2 to the patient’s condition. Non-invasive ventilation (e.g. BiPAP) may be required
• ABG sampling gives the most reliable information on gas exchange
• Respiratory rate
• Must be assessed in the context of the clinical condition
• In asthma, for example, a patient with a normal respiratory rate but with poor chest movements after 20 min is not improving but tiring
• Monitor SaO2, again in the context of clinical condition
• If poorly peripherally perfused, the oximetry probe will not give useful information and an ABG is far more appropriate
• Work of breathing (accessory muscle use, subcostal/intercostal recessions, tracheal tug)
• Auscultate chest (assess air entry, any added sounds?)
• Augment ventilation if required, by use of bag and mask
Assessment of circulatory state
• Does the patient have a pulse? If no, initiate basic life support. If yes, what is its character?
• BP—does the pulse pressure suggest under-filling?
• Is there evidence of over-filling? Chest crepitations, pedal and sacral oedema, and ↑JVP are all suggestive of excessive intravascular volume
• Is there evidence of under-filling—dry mucous membranes, skin turgor, sunken eyes, or thirst?
• Does the patient have a fluid balance chart to help with your assessment?
• Is a urinary catheter in situ? If so, what is the urine volume and colour?
• Further guidance on fluid balance and what to do about it is in the next section
• Is there any history of trauma or bleeding conditions?
• Abdominal examination should always be performed as part of circulatory assessment—in the absence of trauma, this is the most likely site of concealed blood loss
• What access does the patient have, and do they need more? Gaining further access once circulatory collapse has started to occur is significantly more challenging
• If giving fluid and drugs regularly, more than one cannula is desirable as it enables intercurrent administration and offers a small degree of redundancy
• Is invasive monitoring required?
• Arterial lines offer beat-on-beat BP monitoring and mean arterial pressure, as well as a portal for repeated ABG sampling
• Central venous lines offer multiple lumens allowing rapid fluid administration, greater electrolyte infusion rates, and monitoring of CVP
• Arterial or central venous lines are usually not used in a ward environment so, if you are considering them, discuss with the critical care team
The Glasgow Coma Scale is reliable, reproducible, and widely understood:
• Eyes (also take this opportunity to note pupillary size and reflexes)
• 1—not opening
• 2—open in response to pain
• 3—open on command
• 4—spontaneously opening
• 1—no vocalization
• 3—incoherent speech
• 4—confused speech
• 5—talking and oriented
• 1—no movement
• 3—abnormal flexion
• 4—withdrawal from pain
• 5—localizes to pain
• 6—movement on command1
Weakness, headache, back pain, new retention of urine, or altered sensation should prompt full neurological assessment with rigorous documentation.
If you have corrected problems as they were identified during this approach, you should now be in a position to consolidate and review information gained so far. If something changes and the patient’s condition deteriorates, go back and start again.
While this approach is useful, it doesn’t solve everything and so don’t delay seeking senior support if the situation is accelerating beyond your control. Identify where help may be found before you need it—medical emergency teams, critical care outreach teams, and, in extremis, cardiac arrest teams may all be appropriate to call.
Around 60% of an adult’s total body weight comprises water—roughly 42L for a 70 kg man. By convention, this water is considered as being divided between fluid compartments (Figure 1.1).
Ionic substances are distributed freely within the ECF, whereas the composition of ICF varies between tissue and cell types, and is controlled by cellular homoeostasis.
Average minimum daily requirements for an adult weighing 70 kg are shown in Table 1.1.
Table 1.1 Baseline requirements for water and ions
In health, renal and endocrine mechanisms ensure maintenance of water and electrolyte homoeostasis, and daily intakes generally exceed the minima shown in Table 1.1 considerably.
Intravenous fluids may be classified as:
• True solutions which may pass though semi-permeable membranes (e.g. dextrose solutions, saline solutions, Hartmann’s solution)
• Homogeneous non-crystalline particles of one substance dispersed through another (e.g. Gelofusine®, Haemaccel®, human albumin solution (HAS), starch solutions)
Crystalloids will tend to distribute more rapidly throughout the ECF, and hence, volume for volume, will have a smaller plasma expansion effect. There is no evidence, however, demonstrating superiority of colloid over crystalloid when measuring outcomes following fluid resuscitation. Crystalloid preparations are considerably cheaper. The electrolyte composition of various intravenous fluids is shown in Table 1.2 (ions in mmol/L; osmolality in mosmol/L).
Table 1.2 Composition of IV fluids
4% dextrose/0.18% NaCl
0.9% NaCl (normal saline)
Potassium is often added to fluids in specified quantities—usually 20 or 40 mmol/L. Concentrations greater than this can cause phlebitis if infused into a peripheral vein.
Choice of intravenous fluid
Maintenance intravenous fluid should provide adequate water and electrolytes. The baseline requirements outlined in Table 1.1 should be set in the context of specific, predictable losses to guide initial prescription. Bear in mind that fluid losses due to burns, pyrexia, or post-surgical drains, among others, may necessitate far greater volumes of maintenance fluid.
Certain disease states will also require larger amounts of electrolytes than those previously mentioned. For example, sodium is lost in large amounts when vomiting or in patients with polyuric renal recovery. Potassium is lost in large amounts in diarrhoea, and in patients with paralytic ileus.
Pathological processes, complicated by the stress response in a sick patient—promoting sodium and water retention—mandate that ongoing therapy must be guided by repeated clinical assessment, alongside serial serum electrolyte measurements, with prescriptions adjusted accordingly.
Assessment of hydration
First, ask the patient if they are feeling thirsty or dry. HR, BP, peripheral perfusion and CRT, JVP, GCS, skin turgor, examination of mucous membranes, and UO will offer further information. Invasive monitoring of CVP may also help, although absolute values are of less use than trends and response to fluid challenges.
The aim of this is to increase the plasma volume, in turn increasing cardiac preload and hence cardiac output. The fluid used should, therefore, be one which expands plasma volume.
Colloids contain large molecules which do not permeate the endothelial membrane and so hold water within the plasma compartment due to oncotic pressure. Fluids containing large amounts of charged ions, such as normal saline or Hartmann’s solution, will distribute throughout the ECF, though will not enter cells so easily. Fluids such as dextrose which contain uncharged particles, will distribute throughout the entire body, and will thus not give rapid increases in plasma volume. For this reason, resuscitation is usually undertaken with normal saline, Hartmann’s solution, or colloid solution. 5% dextrose should not be used as a resuscitation fluid.
Repeated fluid challenges (e.g. 250–500 mL) with frequent evaluation of changes in HR, BP, JVP, CRT, GCS, and UO, alongside surrogate markers of tissue perfusion (e.g. serum lactate), will guide further therapy; a UO of >0.5 mL/kg/h should be maintained.
If the patient does not improve clinically, consider sources of ongoing fluid loss (e.g. drains, third-space losses) or cardiogenic shock, and call for senior help. Further investigations, alongside invasive monitoring and circulatory support may be required, and critical care involvement at an early stage should be sought.
Possibly one of the most frequently reasons for calling junior doctors, this must be approached in a systematic way with anticipation of potential problems. Such an approach gives nursing staff the maximum flexibility without seeking further medical intervention and guards, so far as is possible, against patients being in pain.
A common model is that of the World Health Organization (WHO); a three-step ladder escalates from simple analgesia through to opioid medications (Figure 1.2).
Care should be taken in the choice of agent at each level on the ladder. Particular issues to consider include:
• There is significant risk in using NSAIDs in patients with established renal failure, so non-opioid medication is far better confined to paracetamol
• Any course of NSAIDs should be accompanied by an appropriate gastro-protective measure such as a proton pump inhibitor
• Although a potent and on occasion useful analgesic, it can make patients very unwell, causing disorientation, nausea, and vomiting
• Frail, elderly, or slight patients are at particular risk from this
• Particularly good efficacy for headaches
• Prescription should always be accompanied by a laxative—courses as short as 1 week can cause fatal bowel perforation
Make use of specialist pain services, where available, if failing to control the pain with the ladder approach. Other options that may be available this way include patient-controlled analgesia, capsaicin creams, and nerve blocks.
Remember also that a number of other non-pharmacological options can also help mitigate the negative experience of pain—orientation in dementia patients, optimal splinting, elevation in cellulitis, and similar strategies all play their part.
None of us views death impartially. Our attitude towards it will depend heavily on our beliefs about it, which in turn will form part of the more general and wide-ranging spiritual (often a distinct concept from religion) perspective we hold. Whether we view it as total extinction, or a welcome release from a condition of pain and suffering, or as a transition from one form of existence to another—all of this will have a bearing on how we cope with it emotionally.
It is inevitable that you will be affected by the death of a patient, especially if you have been closely involved with them during their treatment. In my work as a hospital chaplain, I have frequently come across medical professionals profoundly upset by the death of a patient, yet also struggling with the feeling that they shouldn’t be letting their emotions ‘get the better of them’, that somehow such a response was unprofessional. So, in addition to coping with the patient’s death, they also had to cope with their own sense of inadequacy and failure regarding how they handled it.
You are human beings first and foremost, before you are ‘professionals’. What is more, I would suggest that what patients value in you, at least as much as your professional expertise, is precisely your humanity, and your ability to respond to them empathically as one person to another. If that is so, then your vulnerability to an emotional response at a patient’s death will be the inevitable ‘flip side’ to those qualities in you which made you a good doctor for them when they were alive.
So, be prepared to be upset by death; however, rather than seeing this as a weakness on your part, or a failing of professionalism, rejoice in it as evidence of that human gift of empathy which will enable you to be not a medical professional, but a true healer.
In situations like this, remember that you too are a person with needs. Give yourself time and space to work through your feelings; make use of others who can accompany you in this—if your hospital has a chaplain, then you may well find him or her a valuable resource at such times, irrespective of whether or not you subscribe to his or her particular creed.
Consider the patient facing his or her own death, the family of that patient, the loved ones of a patient who has died, maybe suddenly or unexpectedly—all these have in common the fact that they need to grieve. Patients who have lost limbs, or important physical functions, will experience grief; even the loss of independence and control which a stay in hospital can entail, especially if it is a long one, will produce some of the symptoms of grief. Second, as far as death is concerned, grief is not experienced only by others; patients themselves, facing the prospect of the loss of their life, with all that that means, will experience grief too.
It is important for the clinician, who is used to working with a model of illness and cure, to appreciate that grief does not fit this model. It is not there to be cured, but endured; and those who deal with grieving people are not striving to solve a problem, but to support a person who is experiencing a quite natural, and indeed necessary, process. This can induce a feeling of helplessness in those who have to deal with a grieving patient or relative, and that in turn might tempt one to offer quick fixes or facile responses.
Above all, grief is a process; it takes time. A bereaved spouse, for instance, might spend up to 2 years working through this process, before achieving some sort of resolution whereby, though life will never be the same again, he or she feels able to ‘pick up the pieces’ and move on. Though it is important to note that this process is different for everyone, both in its duration and its shape, it does tend to follow a common pattern. In 1970, Dr Elisabeth Kubler-Ross published a seminal work entitled On Death and Dying, in which she outlined the main ‘stages’ of the grief process, namely denial, anger, bargaining, depression, and acceptance.
From this, it follows that you will often see and deal with people—especially relatives—who are in the early stages of the process, particularly denial and anger. Thus it is that a member of the medical professions will get the feeling that the patient or relative has not heard, or cannot have been listening to, what they have been saying. You feel that you have made the situation clear, but it is as if you have not said anything. You may find this puzzling and frustrating, but be aware that this is simply a manifestation of denial by those in the early stage of the grief process. Also potentially difficult is the anger, which may often be directed at you personally, maybe even in the form of accusations of negligence or error. Understandably, this can be distressing for the doctor on the receiving end; nevertheless, bear in mind where it is really coming from, and this will enable you to keep a sense of perspective about such accusations and continue to work with a ‘difficult’ family.
Finally, remember that working with the dying and their families, though it is undoubtedly at times difficult, is also a great privilege, and your approach and attitude to them before and after death can make a significant difference to their experience of the death, whether it be their own or that of their loved one.
‘It is for the patient, not the doctor, to determine what is in the patient’s own best interest.’ Seeking patients’ consent: the ethical considerations2
Practical and legal aspects of capacity and consent vary between countries. This section will focus on the law and guidelines in England and Wales and, although many principles are the same elsewhere, it is important that you familiarize yourself with the relevant legislation where you work. Note that the situation is different when working with children; this will not be discussed here.
Consent is needed for all examinations and treatments. It is the responsibility of the treating clinician to make sure valid consent has been obtained. For the consent to be valid, the patient must:
• Have capacity
• Be informed
• Give consent freely, without being pressured
In most cases it is important to seek explicit consent (verbal or written). Consent can also be implied, when the way someone acts communicates clearly that they consent, for example, to having their BP checked. At other times it may not be appropriate to spend time obtaining consent, such as when immediate treatment is necessary.
Do what you can to make it easier to understand, such as using leaflets, asking if the person would like someone else present, and allowing plenty of time for questions. Individuals differ in how much and what they need to know but, to come to a decision, it is important to know:
• Broadly what the condition is
• The purpose and nature of the proposed treatment
• What options there are
• What is likely to happen if the treatment is not given
• Likely benefits and risks of options
• That the person can withdraw consent at any time
If you have been asked to take consent for a treatment suggested by a more senior doctor, make sure you understand the treatment and that you are able to answer any questions the patient may have. If you do not feel confident doing this alone, don’t!
Capacity is the ability to make a decision for one’s self, and is a requirement for consent to be valid. It is specific to the decision and may change with time. If you find that a person has capacity to make the decision, you must respect it, even if the decision is likely to cause serious outcomes (e.g. death).
The Mental Capacity Act (MCA) for England and Wales replaces common law principles when treating patients who may lack capacity to make some decisions. Professionals caring for people who may lack capacity have a duty to comply with the Act, and need to be familiar with it.
Principles of the Mental Capacity Act
• A person must be assumed to have capacity unless it is established that he lacks capacity
• A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
• A person is not to be treated as unable to make a decision merely because he makes an unwise decision
• An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
• Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
According to the MCA, a person is unable to make a decision for himself if he is unable:
• To understand the information relevant to the decision
• To retain that information
• To use or weigh that information as part of the process of making the decision
• To communicate his decision (whether by talking, using sign language, or any other means)
Take care of yourself!
Use these criteria systematically when assessing capacity, and document them clearly in the case notes. Treatment of a person with capacity against their will is assault, and not giving treatment that is in the best interest of a person who lacks capacity is negligence. In real life, you may also find that there are degrees of capacity, or that you are uncertain about what to do. Ask someone more senior for advice, as a wrong decision may violate the patient’s human rights as well as causing you serious problems with the law, the General Medical Council, or the press.
When a patient lacks capacity to make a decision
Assess whether anything is likely to improve the patient’s capacity to make a decision (e.g. different communication style). If the patient still does not have capacity to make the decision, it is your responsibility to act in the patient’s best interest.
It has been a principle that no one can give consent on behalf of another person, but be aware that the MCA introduces ‘designated decision-makers’ who can act on behalf of a person who lacks capacity (Lasting Powers of Attorneys and Deputies). Advance decisions must also be respected if they are valid and applicable. If neither of these is available, an Independent Mental Capacity Advocate may be sought if there is a decision or review planned of either serious medical treatment or the patient’s place of residence.
This can be a difficult question to answer. Take into account:
• Risks and benefits of options. Which option is the least restrictive?
• The person’s background, beliefs, and values
• The person’s wishes
• Present feelings
• Previously expressed wishes or advance directives
• The views of others
• Family, carers, or others close to the patient
• Any Lasting Power of Attorney or Deputy
• Department for Constitutional Affairs. Mental Capacity Act 2005: Code of Practice. 2007. https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice
• Department of Health. Reference guide to consent for examination or treatment. 2009. https://www.gov.uk/government/publications/reference-guide-to-consent-for-examination-or-treatment-second-edition
• General Medical Council. Consent: patients and doctors making decisions together. 2008. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/consent
• Legislation.gov.uk. The Mental Capacity Act 2005. 2005. http://www.opsi.gov.uk/acts/acts2005/20050009.htm
• The Medical Protection Society. Consent. https://www.medicalprotection.org/uk/articles/consent-uk
An amendment to the Mental Capacity Act, these regulations came into force in April 2009 and apply to those patients who:
• Have a mental disorder as defined by the amended Mental Health Act
• Lack capacity
• Are over 18 years of age
• Have a treatment or care plan involving deprivation of liberty under Article 5 of the European Convention on Human Rights
but are not subject to detention under the Mental Health Act or a court order. They are in place to ensure that any patient in a care home or hospital who is not free to leave has had this situation ratified through a legal process which is subject to regular review. This includes long-term patients in care homes with a progressive process of dementia. It is also crucial to note that the advent of Deprivation of Liberty Safeguards effectively removed the ‘best interest’ principle for ongoing care outside Mental Health Act detention orders.
Defining deprivation of liberty
Although the regulations do not define deprivation of liberty (DOL), a situation is likely to be regarded as so if any of the following are true:
• Sedation is in use
• Staff routinely control freedom of movement
• Access to normal carers or social contacts is by permission of staff
• Discharge to normal carers has been refused
• Autonomy is lost through measures put in place by staff
A hospital or care home should, of course, try to deliver best care without requiring DOL. If it should become necessary, however, the team must apply to a supervisory body for authorization. Two independent assessors are appointed by the supervisory body—a mental health assessor and a best interests assessor. The subject of the assessment has a representative—spouse, relative, carer, or Independent Mental Capacity Advocate to ensure their interests are represented. If the body are satisfied that the DOL is required, authorization will be granted for the minimum time possible. All authorizations are subject to review at 12 months if still in place. The body may also recommend adaptions to care to reduce the degree of DOL.
This is the area most likely to be evident in day-to-day practice for junior doctors in hospital. If DOL must be immediate, the supervisory body will not have time to process the application for authorization. In this case, the organization itself issues an urgent authorization and submits paperwork to the supervisory body. This permits DOL for 7 days, and a further 7 days by permission from the supervisory body. This is a legal process and must be discussed with seniors and ideally the Trust legal team, but from a ward doctor’s perspective:
• Ensure documentation of rationale is clear and contemporaneously recorded
• What is the problem?
• Why can it not wait for a routine DOL process?
• Have any relatives, carers, or representatives been consulted?
• If so, what was their response?
• What steps have been taken to make care as respectful as possible of autonomy?
• What is the next stage in formalizing the arrangement?
• Age UK. Factsheet 62. Deprivation of Liberty Safeguards. 2019. https://www.ageuk.org.uk/globalassets/age-uk/documents/factsheets/fs62_deprivation_of_liberty_safeguards_fcs.pdf
• Care Quality Commission. Deprivation of liberty in health and social care. 2014. http://www.cqc.org.uk/sites/default/files/20140416_supreme_court_judgment_on_deprivation_of_liberty_briefing_v2.pdf
The doctor who can deal with all the emergencies in this book without feeling the strain is rare and probably does not, in fact, exist. Medicine as a career has changed greatly but has not become less stressful. It is inevitable that some days will be better than others—if the bad days start outnumbering the good, take action.
The frightening feeling of not coping is not one you should keep to yourself. Your educational or clinical supervisor will be able to offer you support and without judgement. If, however, you prefer to discuss it outside work in the first instance, there are several ports of call. Your Local Education Training Board should have recommended contacts with counselling services or practitioner support schemes. There is also the Doctors’ Support Network or the Samaritans.
If, however, you feel your performance at work is being affected, informing your clinical tutor or supervisor is wise. If you feel out of your depth, both your patients and you should be protected from potentially adverse outcomes. Also, with the advent of near continuous formal assessment, a sudden drop in performance without explanation has potential to create difficulties in later years.
Simple steps to help avoid this situation arising can be taken. The concept of ‘protected time’ can be applied to personal life as much as to education—ensure that you set aside time to see your friends and to do the things you enjoy. It inevitably takes far more effort to do this around a busy clinical rota, but don’t fall into the trap of not looking after yourself.
Where to turn
Samaritans is available 24 hours a day to provide confidential emotional support for people who are experiencing feelings of distress or despair, including those which may lead to suicide.
08457 90 90 90
Doctors’ Support Network
The Doctors’ Support Network (DSN) is a warm, friendly self-help group for doctors with mental health concerns. These concerns include stress, burnout, anxiety, depression, manic depression, psychoses, and eating disorders.
0870 321 0642
BMA Counselling Service
The BMA Counselling Service is staffed by professional telephone counsellors, 24 hours a day, 7 days a week. All counsellors are members of the British Association for Counselling and Psychotherapy and are bound by strict codes of confidentiality and ethical practice.
The service is confidential, and when making contact you can choose to remain anonymous. It is available to you and members of your family who normally live with you, including children up to the age of 21 even if they are at university.
The counsellors are there to help you deal with a wide variety of issues, including the pressures and stresses of work (and the impact of this on family life), relationship problems, concerns about children and other family members, and issues relating to mental health. The service can also help address alcohol or drug misuse, and provides information about other specialist resources available to you.
08459 200 169