15 episodes

The Ward Calls podcast dissects common ward calls you will need to confidently manage as a PGY1 doctor and beyond. We discuss practical, safe and comprehensive approaches that are achievable in the limited time available when working on the ward.



The podcast is co-hosted by Dr Vani Chandran and Dr Sam Holford, based in Auckland, New Zealand.



We hope to provide guidance applicable to hospitals throughout New Zealand, and expect most of the content to apply to Australia and further abroad. Thanks to the NZRDA Education Trust for making this podcast possible.

Ward Calls Sam Holford

    • Medicine
    • 4.8 • 19 Ratings

The Ward Calls podcast dissects common ward calls you will need to confidently manage as a PGY1 doctor and beyond. We discuss practical, safe and comprehensive approaches that are achievable in the limited time available when working on the ward.



The podcast is co-hosted by Dr Vani Chandran and Dr Sam Holford, based in Auckland, New Zealand.



We hope to provide guidance applicable to hospitals throughout New Zealand, and expect most of the content to apply to Australia and further abroad. Thanks to the NZRDA Education Trust for making this podcast possible.

    The intern suppository

    The intern suppository

    Dr Ivor Popovich presents examples of evidence-based decision making during ward calls. We also highlight some recommendations from Choosing Wisely and give an update on death certification.



    * The Intern Suppository – Ivor’s EBM blog

    * The Rational Clinical Examination – JAMA

    * Plain film in small bowel obstruction



    * The gas-less abdomen

    * Paucity of gas

    * Non-specific bowel gas pattern

    * Read more in the blog post here





    * Plasmalyte in renal failure



    * Not contra-indicated

    * Actually alkalinises plasma, driving potassium into cells

    * The chloride in NaCl acidifies plasma, drawing potassium into the extracellular space

    * Read more in the blog post here





    * Asthma admission



    * Tachycardia is not explained by salbutamol administration alone

    * A large diurnal variation in peak flow (e.g. >50%) is a major risk factor for in-hospital cardiac arrest (not severity of asthma exacerbation at admission).

    * Severity of wheeze does not correlate with severity of exacerbation

    * Read more in the blog post here





    * Choosing wisely

    * New Death Documents website

    * MOH Completing the Medical Certificate Cause of Death form (March 2018)

    * MOH Examples of incorrect and correct cause of death certification (March 2018)

    • 28 min
    AF & tachycardia

    AF & tachycardia

    Cardiology expert Adele Pope returns with an approach differentiating tachycardia and managing atrial fibrillation. We also discuss ventricular ectopics, bigeminy and peri-operative anticoagulant and anti-platelet adjustment.

    Differential



    * Life threatening



    * VT

    * SVT



    * AFib

    * Flutter









    * Common triggers of AFib



    * Post operative state

    * Myocardial infarction

    * Sepsis

    * Anaemia

    * Hypo- or hypervolaemia

    * Pulmonary embolus

    * Electrolyte disturbance





    * Cardiac dysrhythmia

    * Non-cardiac



    * Anemia

    * Anxiety

    * Dehydration

    * Electrolyte imbalance (especially hypokalemia and hypomagnesemia)

    * Fever/ sepsis

    * Hyperthyroidism

    * Hypoglycemia

    * Ischemia

    * Metabolic disorders

    * Pain

    * Poisoning and toxic exposure

    * Pulmonary embolism

    * Respiratory disease (e.g. pneumonia, pneumothroax)

    * Shock

    * Trauma

    * Withdrawal syndromes







    Approach



    * ECG and new set of vitals before you arrive

    * Eyeball the patient/ABCs

    * History



    * Old or new tachyarrhythmia?

    * Chest pain

    * SOB

    * Palpitations

    * Exact time of onset of symptoms

    * Cardiac history



    * Prev AF

    * Ischaemic heart disease

    * Valvular disease

    * Hypertension

    * Heart failure





    * ROS





    * Vitals + Examination



    * General inspection + peripheries for perfusion

    * JVP

    * Auscultation



    * Confirm rhythm

    * Valvular dysfunction





    * Wound

    * Calves/leg oedema





    * ECG



    * Narrow complex or wide complex?



    * QRS > 3 squares could be a wide complex tachycardia (call a code)

    * Concordance (V1 – V6 often point in one direction in VT)

    * AV dissociation indicated VT





    * If narrow complex, is it regular or irregular?



    * Irregular is probably AFib









    * Consider investigations



    * FBC, U&E (including Mg), TFT

    * Consider septic workup

    * Consider troponin





    * Management



    * Consider observation

    * 500 mL fluid bolus

    * Metoprolol tartrate 50 mg (not if overloaded or in steroid-dependent asthma)

    * Diltiazem short acting 30 mg as an alternative





    * Documentation



    * Review past notes

    * Current medications – has a dose been missed?

    * Basics (date/time/name/reason for review)

    * Positives and pertinent negatives

    * Impression and differential with justification.

    * Have you eliminated life threatening conditions?



    * Why has this arrhythmia developed?

    * Is there a risk of deterioration?





    * Type of AFib (first episode, paroxysmal, persistent, or permanent)

    * Clear and specific plan

    * Immediate investigations

    * Fluids

    * Electrolytes correction

    * Beta blocker?

    * Anti-arythmic?

    * Anti-coagulation?

    * Consider echo, TOE, CXR, ETT

    * Consider discussion with senior and escalation, especially if called back to patient again.







    Concluding remarks



    * Get help early for:



    * Wide complex tachycardia

    * Poor perfusion/hypotension

    * Pulmonary oedema





    * Main triggers are post operative state, myocardial infarction, sepsis and anaemia.

    * AF may be the first sign of a significant problem, so a good review of systems is needed.

    * AF may precipitate cardiac and perfusion problems (ischemia, heart failure, atrial thrombus), so identify patients at risk.

    * Timing:



    * Assume onset of AF to be greater than 48 hours...

    • 31 min
    Q&A with Dr Deborah Powell

    Q&A with Dr Deborah Powell

    Foremost expert on all things NZRDA, Dr Deborah Powell, explains why RMOs get free meals, what 8.1.2 is, and the RDA’s role in helping members in trouble.



    * Meals and the NZRDA Education trust

    * 8.1.2



    * “For runs to which the above paragraph does not apply, any Ordinary Hours which are not rostered shall be counted as hours worked (up to a maximum of 8 Ordinary Hours per day) when determining the category for the run.”





    * Role of NZRDA



    * Negotiating and enforcing the MECA

    * Informing members

    * Lobbying

    * Helping and representing individuals in difficulty

    * Media

    * Public relations

    * All things RMOs





    * Getting into trouble

    * Cross cover outside ordinary hours

    * What happens to membership fees?

    * Bullying and harassment

    • 28 min
    Clinical reasoning

    Clinical reasoning

    Sam meets some podcasting celebrities and experts in clinical reasoning Dr Art Nahill and Dr Nic Szecket – hosts of the podcast IM Reasoning. We talk cognitive bias and and some approaches to minimising their impact.



    Common biases



    * Confirmation bias



    * The tendency to search for or interpret information in a way that confirms one’s preconceptions, while ignoring information that does not support the preconceptions.





    * Anchoring



    * The common human tendency to rely too heavily on the first piece of information offered (the “anchor”) when making decisions.





    * Premature closure



    * Failing to consider reasonable alternatives after an initial diagnosis is made.





    * Affective biases



    * Letting emotions, pre-conceptions, or stereotypes lead to assumptions that cloud the reasoning process e.g. drug users, chronic pain.





    * Gambler’s fallacy



    * The erroneous belief that chance is self correcting. If the last two patients were diagnosed with serious chest pain, surely the next one will be benign. Remember that each ward call is unrelated to the last.





    * Posterior probability bias



    * Letting recent or past events thats that are independent of the current case, impact on your estimated likelihood of a diagnosis.





    * Ockham’s razor



    * The simplest answer is more likely to be correct. Another way of saying it is that the more assumptions you have to make, the more unlikely an explanation is. Also, that a single diagnosis that explains the patient’s symptoms is more likely, than seperate diseases occurring concurrently.





    * Hickam’s dictum



    * The counter to Ockham’s razor. Patients can have as many diseases as they damn well please.









    * Larry Weed – The Father of the Problem-Oriented Medical Record



    Apps



    * Isabel

    * VisualDX

    * Diagnosaurus



    Podcasts (FOAMed)



    * IM Reasoning

    * Pomegranate Health

    * EMCrit

    * ERCast

    * On the wards

    • 29 min
    Documentation, prioritisation, and handover

    Documentation, prioritisation, and handover

    Vani and Sam give suggestions on how to improve these everyday skills that can otherwise take a lifetime to learn.

     Why is this important?



    * Decisions will be made based on documentation – we are lazy and tend not to verify information.

    * Allows you to organise your thoughts, review notes, and identify gaps.

    * Is a legal record and part of your job description.

    * Inadequate documentation sinks careers.

    * You will not remember the details years later if there is a complaint. HDC cases tend to occur years after the fact.

    * Prioritisation is an art and is learnt through experience. It is however important to know what the expectations are and not cause harm through poor prioritisation.



    Types of documentation



    * Ward round notes

    * HO notes

    * Ward call notes

    * Plans

    * Lab requests

    * Referrals

    * Clinic letters

    * Procedure notes

    * Op notes

    * Discharge summaries

    * Sick notes

    * Supporting letters

    * Death certificates



    All documentation



    * Title

    * Date/time

    * Reason for review/note

    * 1 line summary

    * SOAP (Subjective, Objective, Assessment, Plan) or HEIIP (History, Exam, Investigations, Impression, Plan)

    * Pertinent info

    * Solid plan

    * Your name + pager

    * Never change a note



    Prioritisation



    * Let time heal

    * Trust no one (nonsensical pages, reflux, nebs)

    * Complete non-urgent tasks ward by ward

    * Document a plan nurses can follow

    * Talk to the nurse

    * Hand over a plan with any jobs

    * Give a reason for jobs (e.g. fluid review)

    * Handover on time, handover your jobs

    * Don’t come to work sick

    * Perfect is the enemy of good.



    Handover



    * What makes a good handover?

    * Concise and objective

    * Clear plan for pending results

    * Clear priority

    * Concise! Most of what you say will be forgotten, so make it count.

    * Why is it important?

    * Safety!

    * Helps with prioritisation

    * Opportunity to discuss cases with a colleague

    * Allows you to relax and sleep after you’ve gone home

    * What is appropriate to handover?

    * Jobs to be done

    * Investigations to be chased and plan

    * Patients to be reviewed

    * Sick patients

    * Patients expected to die

    * Patients for whom you feel additional context would be useful. Don’t just hand over patients the next house officer “might get paged about”.

    * Go home on time.

    * Weekend plan

    * Prepare discharge summaries and referrals

    • 23 min
    Chest pain

    Chest pain

    Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call.

    Differential



    * Life threatening



    * ACS

    * PE

    * Dissection

    * Cardiac tamponade

    * Pneumonia

    * Pneumothorax

    * Oesophageal bleed





    * Heart



    * Pericarditis





    * Lungs



    * Mechanical (foreign body, surgical, chest drain, post-pleurocentesis)





    * Oesophagus



    * Reflux

    * Oesophagitis

    * Oesophageal spasm





    * MSK



    * Musculoskeletal

    * Costochondritis

    * Rib fracture





    * Below the chest



    * Upper abdominal pain





    * Above the chest



    * Anxiety







    Approach



    * Eyeball the patient

    * ABCs



    * Calling a code



    * 777 (or your local hospital emergency number)

    * This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3.









    * History



    * SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity)

    * Previous similar episodes? History of exertion chest pain?

    * Diaphoresis

    * Shortness of breath

    * Review of systems





    * Identify risk factors

    * Vitals + Examination



    * General inspection + peripheries

    * Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues

    * Abdomen, calves, catheter and drains (for completeness)





    *  ECG



    * Take your time and be systematic

    * Look at an old ECG

    * Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves.

    * Look for contiguous and reciprocal abnormalities.

    * T wave change normal variants occur in III, aVR, V1.

    * A repeat ECG in 15 minutes is useful to identify dynamic changes.





    * Consider investigations



    * FBC, U&E, troponin

    * CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm)





    * Management



    * Call for help (code or at least registrar support)

    * Attach continuous monitoring e.g. defibrillator pads

    * Re-assess stability of the patient

    * Oxygen only if hypoxic

    * GTN spray

    * Opiate analgesia (IV morphine boluses ideally)

    * Determine bleeding risk



    * Identify any anti-platelet and anti-coagulation medicines in use

    * Post-operative status

    * Consider loading with aspirin 300 mg PO









    * Document



    * Review past notes

    * Basics (date/time/name/reason for review)

    * Positives and pertinent negatives

    * Impression and differential with justification. Have you eliminated life threatening conditions?

    * Consider TIMI or HEART score (acknowledging use outside of ED)

    * Clear and specific plan

    * Consider discussion with senior and escalation, especially if called back to patient again









    Specificity of chest pain symptoms and examination findings [Evidence]

    Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735



    * No single finding rules in or rules out acute coronary syndrome.

    * The most specific (convincing) symptoms of ACS were:



    * Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).

    • 34 min

Customer Reviews

4.8 out of 5
19 Ratings

19 Ratings

Lownsy ,

Very helpful

TI about to graduate, have found very helpful for knowing where to start and giving confidence before having to be responsible for these situations. Thank you!

NZSarahW ,

5 stars

Great content about common ward calls for junior doctors. Thanks so much for making this series!! Hope it continues

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