Common cases on the acute take - respiratory
I am going to share my experience of management of common emergencies I see on the acute take.
This is no way an official guideline and is just my experience. Please refer to your local guidelines and always escalate if you are not sure.
Read the national NICE guidance here:
https://www.nice.org.uk/
Here is a list of communicable diseases you need to inform Public Health, England about:
https://www.gov.uk/health-and-social-care/health-protection
This is a very helpful link:
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/
PS: I am not going to mention the COVID-19 guidelines as these are changing on a daily basis.
Please read this blog:
https://omarsguidelines.blogspot.com/2020/04/my-experience-of-working-as-medical.html
INFECTIONS
CAP- community acquired pnuemonia
Remember to do blood cultures ASAP, give antibiotics and if the patient has a productive cough, send a sputum C+S.Do a CXR ASAP.
Also read this:
https://www.nice.org.uk/guidance/cg191/chapter/1-Recommendations
Top tips:
Give antibiotics ASAP
Remember your sepsis guidelines - https://sepsistrust.org/professional-resources/clinical/
Usually, when the patient is seen in the assessment area of ED, they have a cannula inserted and bloods taken for FBC, U and E's, CRP, LFTs, coagulation screen, VBG and 2 sets of blood cultures taken. They have a STAT dose of IV antibiotics and fluids - this is becoming very quick now and trusts have improved the patient flow through ED in such a way that they receive prompt treatment.
Do an ABG if they are requiring oxygen - you may have to adjust their target saturations if they have a high PaCO2 - I have seen quite a few patients go into acidosis and type 2 respiratory failure a few hours/days later: So please do not shy away from doing an ABG. I know it is painful and I wish they develop a probe to accurately check the pH and paCO2 reliably but till then, please do this.
Get ITU involved early in a patient with pneumonia and is in type 2 respiratory failure. They might need ventilatory support if they are for full escalation.
If the CXR shows a consolidation, please remember to request an O/P CXR in 6 to 8 weeks to ensure resolution of the consolidation.
Sometimes the initial CXR is normal but you can hear coarse crackles on auscultation - so do not rely on imaging only.
Send a viral throat swab especially in the flu season ( an influenza positive patient in an open bay is a nightmare for the whole team - all the other patients need prophylactic tamiflu and the bay needs to be closed with respiratory precautions).
Think about atypical infections like legionella, mycoplasma - this depends on the history, any significant features ( like hyponatremia, recent travel history to a warm country which has air-conditioning suggesting legionella).
COPD EXACERBATIONS
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/niv/
This can be infective or non infective
If you are suspecting an infection , then do as mentioned above.
Doing an ABG in these patients is very important. If the PaCO2 is high and the patient is acidotic, they need to be transferred to the high dependency area ( like ED resus), have full medication therapy ( ie: nebs, steroids, antiobiotics, controlled oxygen with a target S02 of 88 to 92%, sometimes less if specified by the respiratory teams letters) and then have a repeat ABG in an hour if they are not improving ( earlier if they are deteriorating). If they are deteriorating, then NIV is indicated. Each trust has its own policy ( since I have worked in respiratory medicine as a ST3 trainee in acute internal medicine, I quickly bleep the critical care nurse to let her know , go to the respiratory ward and grab a NIV machine, bring it to ED and along with resus nurse in charge, set it up and initiate it)
Once you have started NIV, you need to repeat an ABG within an hour- if it is worsening, call the ITU team. If the patient deteriorates earlier, then repeat an ABG ASAP and call the ITU team.
Escalation plans are very important here as well. If the patient has severe COPD, on LTOT on home, exercise tolerance of 5 yards, frail then NIV should be the ceiling of care and you, as the medical registrar/SHO should put a DNACPR in the notes after discussion with the patient/ next of kin.
Top tips:
ABGs are the key - you can pick up deterioration quickly and save the patient from an arrest by acting upon the results. Do an ABG as soon as you see the patient with an exacerbation of COPD. Repeat one hour after medical therapy if the initial gas is worrying.
Please read the old correspondence with the respiratory team. In my trust, the respiratory nurses upload a 'COPD bundle' to every patients electronic record who has been admitted with a COPD exacerbation. You will find very useful information there like target saturations, etc
Always check the trend of the PaCO2 - in my trust, you can click on the previous ABG results and then get a cumulative picture of particular values. If it has been high in the past, it is better to give controlled oxygen with a target SO2 of 88 to 92% unless specified in the more recent respiratory letters.
Sometimes, the target saturations may be even lower especially in oxygen sensitive patients. Like anything above 85% or above is acceptable. Again, this will be mentioned in the recent letters from the respiratory team.
Also read the previous discharge summaries - you might find that the patient was started on NIV however could not tolerate it and clearly said that (s)he did not want it again in the future.
Call the ITU team if you are stuck.
NEVER transfer a patient to the ward from ED resus to a medical ward without ensuring that the repeat ABG is improving. The patient is at high risk and should be transferred to ITU if the ABG is worsening ( unless the ITU team suggest otherwise).
PRN lorazepam and PRN oromorph help with panic attacks in such patients however this does not mean every tachypneic patient is having a panic attack - treat the underlying cause but remember this differential.
Do a CXR before starting anyone on NIV to rule out any contraindications, the most fatal being a pnuemothorax.
A pneumothorax, if found needs an urgent CXR and once a chest drain is inserted, then you can put the patient on NIV ( this needs ITU support as it is complex). I would get ITU involved if the patient was in type 2 failure with a pneumothorax.
Review patients on NIV on a regular basis. They can still deteriorate. Hand such patients over to the next on call team.
ASTHMA
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
This can be anything from a mild wheeze to a full blown fatal asthmatic attack.
Remember your basics - a full A to E assessment, doing all routine ED bloods ( FBC, U and Es, CRP, LFTs, coagulation screen, blood cultures and an ABG) and a CXR.
ABG is very important especially if the patient is breathing fast and could possibly tire.
Do not delay treatment - remember the magic drugs: steroids, nebulizers ( back to back), antibiotics, and if the patient fails to improve, start them on the next treatment according to your local policy - this could be magnesium sulfate followed by aminophylline ( with ITU input as per your local policy).
This can be fatal! And the exacerbation is treatable. Hence, treat appropriately and do not delay it.
Tips:
An ABG is essential. You may need to repeat it if things do not improve.
Get ITU involved if the patient is deteriorating.
Back to back nebulizers does not mean one nebulizer - keep giving salbutamol, ipratropium and then escalate treatment.
IV steroids are key!
A wheeze does not necessarily mean asthma - it can be present in CCF as well. Hence, examine the patient, checking for JVP, features of heart failure and look at the CXR carefully.
Read the previous discharge/ respiratory letters - you will find a lot of useful information.
An inpatient can also develop an acute asthma attack - review these patients ASAP!
PNEUMOTHORAX
They may need a chest drain ASAP- especially if they are hemodynamically unstable, are tachypneic or are requiring oxygen. If you cannot do this confidently, ask for help. People who can insert chest drains out of hours are:
1. Medical registrars
2. Medical SHOs who are working in respiratory medicine and are signed off by a consultant to insert chest drains independently.
3. ITU registrars/consultants
4. ED registrars/consultants
5. Interventional radiologist on call
6. T & O surgeons ( they insert chest drains for traumas)
Top Tips:
Do not delay a chest drain in a deteriorating patient just because you cannot insert it. There are plenty of people who can help. Even in a small DGH.
Ensure the platelets, clotting is normal. And they are not on NOACs/warfarin.
PLEURAL EFFUSION
If it is for ?malignancy
They need a chest drain if they are compromised AND after a respiratory/ medical consultant review . If there is no confirmed diagnosis of an underlying condition and a chest drain is going to be inserted, please send a sample for WCC, C+S, LDH, protein, glucose, cytology and an extra sample for saving in case the lab needs more tests.
The samples are then sent to specialist centers for analysis ( ie HMDS, etc) and may take a while to come back.
?Empyema
A chest drain needs to be inserted urgently and antibiotics must given ASAP.
Top tips :
Not all effusions need an urgent drain insertion.
Do not forget other differentials of pleural effusion - especially heart failure.
Always check the clotting, platelet count before inserting a chest drain - if concerned, talk to hematology.
Be careful if it is ?malignancy as insertion of a chest drain can cause subcutaneous seeding of the tumor. I usually wait for a respiratory consultant to make this decision when I am on call unless the patient is very unwell. If the patient is haemodynamically unstable, please do not delay chest drains.
As mentioned above, there are plenty of doctors who can insert chest drains.
PULMONARY EMBOLISM
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Pulmonary-Embolism-Diagnosis-and-Management-of
Top tips:
A high CRP, WCC does NOT mean the patient may not have a PE.
A high D dimer DOES NOT mean the patient will have a PE, especially if there are other causes.
History, Well's score are very important.
CXR may show a wedge shaped opacity- this could be the wedge sign for pulmonary infarction. This may also cause a high CRP.
Get a CTPA done urgently if you are worried that the patient could be a candidate for thrombolysis ( ie, if they are haemodynamically unstable)- get ITU involved ASAP.
Look at the ECG! You may see evidence of right heart strain
Keep an eye on the blood pressure - they will be a candidate for thrombolysis if they are hypotensive/there is a significant drop.
Follow your trusts guidelines for management of PEs as some cases can be managed in the ambulatory setting.
Always think about a P.E. if the patient is requiring a lot of oxygen, is tachycardic and/or hypotensive.
PE can kill ! Please treat as PE if you suspect it, even without any investigations. A treatment dose of LMWH will not do any harm unless there are any contraindications ( in that case, you will need to make an informed decision).
If the patient is short of breath and there is no clear cause, think of PE. This can even be the case for inpatients who are already on prophylactic VTE.
LUNG CANCER
This is a horrible condition. But quite a reasonable number of people do well, thanks to early diagnostic tests- like doing a repeat CXR in 6 to 8 weeks for patients who had a consolidation on their admission CXRs.
If there is any doubt, scan the chest! Usually, the radiologists prefer a full CT chest, abdomen and pelvis to rule out any metastasis at the same time if the history, CXR findings and examination is convincing ( ie smoker- 50 pack years, cough since 6 months, emaciated, CXR shows right lower zone consolidation, weight loss, lymphadenopathy).
There are some excellent specialist teams available to support patients: from respiratory registrars/consultants to cancer specialist nurses to McMillan nurses and oncology nurses.
The pathways may differ from trust to trust but this is what it is like:?
- Diagnosis of lung cancer - bad news broken by doctor looking after patient ( can be SHO/reg/consultant).
- Referred to lung cancer specialist nurses and respiratory team
- Appropriate investigations requested
- Discussed in MDT
- Treatment initiated.
Top tips:
Always repeat a CXR in 6 to 8 weeks if the admission CXR shows a consolidation. If it is still there in a repeat CXR, this could mean there is something sinister going on.
If the CXR looks odd ( as in not a clear consolidation but a ring like lesion), do a CT.
A CT chest abdomen pelvis with contrast is better than a simple CT chest as you get more information in a slightly lengthier scan preventing delays.
Examine the patient thoroughly - a palpable lymph node in the groin can be easily biopsied and will help with an early diagnosis.
Always check calcium levels - they can be inappropriately high in cancer patients.
If the patient has any neurological deficit, even if it is confusion, scan the head to check for metastasis. A plain CT is reasonable to start off with however some radiologists may just do a CT head, chest, abdomen and pelvis with contrast at the same time as that would give more information. But do not delay a CT of the head by assuming this.
Be careful about what you tell the patient
You cannot diagnose lung cancer by looking at a CXR - it will be highly suspicious if it is atypical but you cannot inform the patient that it is lung cancer. Instead, inform the patient that is abnormal and you would need to do a more detailed scan to rule out anything sinister. This decision is usually made by a registrar or a consultant.
Patients never forget the health care professionals face, body language when they break bad news. Hence, ensure you hand your bleep to someone and let the nurses know what you are going to do.
If the patient is well enough, I prefer to talk to them in a private room ( rather than in a bay with 6 beds separated by curtains) with a chaperone ( preferably the nurse looking after the patient).
Everyone has their own way of doing it. This is how I do this ( I have already taken a history and examined them hence developed a good relationship):
"What do you know about your condition"
"As you might be aware, your chest X ray showed an abnormality and we were a bit concerned and hence we got a full detailed scan of your body"
"Has anyone informed you about the results?"
"Unfortunately, it does not look good. Would you like to be with someone before I continue"
" The scan shows you have lung cancer"
Give them time to process this information.
Inform them about the next steps and be slow, ask them if they understand and be very supportive.
There are different ways which patients prefer.
Some want to hear it ASAP, then want the doctor to tell their next of kin privately and then want their next of kin to meet them.
Some do not want their families to know - which is fine, they need some more time to process this and will then ask the team to inform their families.
Some want to inform their families themselves.
We, as healthcare professionals need to respect these different reactions. All of them are natural, none of them are wrong.
It is okay, as a healthcare professional to shed a tear or 2. Remember to be professional but it is difficult not to be human in these situations - especially the young patients who have just been married/become a parent.
Do not blame them - even if they smoke like a chimney. Mention that smoking does increase the risk and to avoid further damage, you strongly advise that they quit and offer nicotine replacement. Be careful about your wording.
Let all other healthcare professionals know that you have just broken bad news - including HCAs, nurses in charge so that they can keep a close eye. The first day/night is the hardest. Prescribe a sleeping tablet ( as required, at night) if there are no contraindications.
If you have time, visit the patient later on. It makes them feel supported and makes them feel at ease. You have no idea what a difference this can make.
There are a lot of other conditions which I have not mentioned here. Please remember to refer to your local guidelines, escalate to your registrar/consultants and your local respiratory team.
This is no way an official guideline and is just my experience. Please refer to your local guidelines and always escalate if you are not sure.
Read the national NICE guidance here:
https://www.nice.org.uk/
Here is a list of communicable diseases you need to inform Public Health, England about:
https://www.gov.uk/health-and-social-care/health-protection
This is a very helpful link:
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/
PS: I am not going to mention the COVID-19 guidelines as these are changing on a daily basis.
Please read this blog:
https://omarsguidelines.blogspot.com/2020/04/my-experience-of-working-as-medical.html
INFECTIONS
CAP- community acquired pnuemonia
Remember to do blood cultures ASAP, give antibiotics and if the patient has a productive cough, send a sputum C+S.Do a CXR ASAP.
Also read this:
https://www.nice.org.uk/guidance/cg191/chapter/1-Recommendations
Top tips:
Give antibiotics ASAP
Remember your sepsis guidelines - https://sepsistrust.org/professional-resources/clinical/
Usually, when the patient is seen in the assessment area of ED, they have a cannula inserted and bloods taken for FBC, U and E's, CRP, LFTs, coagulation screen, VBG and 2 sets of blood cultures taken. They have a STAT dose of IV antibiotics and fluids - this is becoming very quick now and trusts have improved the patient flow through ED in such a way that they receive prompt treatment.
Do an ABG if they are requiring oxygen - you may have to adjust their target saturations if they have a high PaCO2 - I have seen quite a few patients go into acidosis and type 2 respiratory failure a few hours/days later: So please do not shy away from doing an ABG. I know it is painful and I wish they develop a probe to accurately check the pH and paCO2 reliably but till then, please do this.
Get ITU involved early in a patient with pneumonia and is in type 2 respiratory failure. They might need ventilatory support if they are for full escalation.
If the CXR shows a consolidation, please remember to request an O/P CXR in 6 to 8 weeks to ensure resolution of the consolidation.
Sometimes the initial CXR is normal but you can hear coarse crackles on auscultation - so do not rely on imaging only.
Send a viral throat swab especially in the flu season ( an influenza positive patient in an open bay is a nightmare for the whole team - all the other patients need prophylactic tamiflu and the bay needs to be closed with respiratory precautions).
Think about atypical infections like legionella, mycoplasma - this depends on the history, any significant features ( like hyponatremia, recent travel history to a warm country which has air-conditioning suggesting legionella).
COPD EXACERBATIONS
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/niv/
This can be infective or non infective
If you are suspecting an infection , then do as mentioned above.
Doing an ABG in these patients is very important. If the PaCO2 is high and the patient is acidotic, they need to be transferred to the high dependency area ( like ED resus), have full medication therapy ( ie: nebs, steroids, antiobiotics, controlled oxygen with a target S02 of 88 to 92%, sometimes less if specified by the respiratory teams letters) and then have a repeat ABG in an hour if they are not improving ( earlier if they are deteriorating). If they are deteriorating, then NIV is indicated. Each trust has its own policy ( since I have worked in respiratory medicine as a ST3 trainee in acute internal medicine, I quickly bleep the critical care nurse to let her know , go to the respiratory ward and grab a NIV machine, bring it to ED and along with resus nurse in charge, set it up and initiate it)
Once you have started NIV, you need to repeat an ABG within an hour- if it is worsening, call the ITU team. If the patient deteriorates earlier, then repeat an ABG ASAP and call the ITU team.
Escalation plans are very important here as well. If the patient has severe COPD, on LTOT on home, exercise tolerance of 5 yards, frail then NIV should be the ceiling of care and you, as the medical registrar/SHO should put a DNACPR in the notes after discussion with the patient/ next of kin.
Top tips:
ABGs are the key - you can pick up deterioration quickly and save the patient from an arrest by acting upon the results. Do an ABG as soon as you see the patient with an exacerbation of COPD. Repeat one hour after medical therapy if the initial gas is worrying.
Please read the old correspondence with the respiratory team. In my trust, the respiratory nurses upload a 'COPD bundle' to every patients electronic record who has been admitted with a COPD exacerbation. You will find very useful information there like target saturations, etc
Always check the trend of the PaCO2 - in my trust, you can click on the previous ABG results and then get a cumulative picture of particular values. If it has been high in the past, it is better to give controlled oxygen with a target SO2 of 88 to 92% unless specified in the more recent respiratory letters.
Sometimes, the target saturations may be even lower especially in oxygen sensitive patients. Like anything above 85% or above is acceptable. Again, this will be mentioned in the recent letters from the respiratory team.
Also read the previous discharge summaries - you might find that the patient was started on NIV however could not tolerate it and clearly said that (s)he did not want it again in the future.
Call the ITU team if you are stuck.
NEVER transfer a patient to the ward from ED resus to a medical ward without ensuring that the repeat ABG is improving. The patient is at high risk and should be transferred to ITU if the ABG is worsening ( unless the ITU team suggest otherwise).
PRN lorazepam and PRN oromorph help with panic attacks in such patients however this does not mean every tachypneic patient is having a panic attack - treat the underlying cause but remember this differential.
Do a CXR before starting anyone on NIV to rule out any contraindications, the most fatal being a pnuemothorax.
A pneumothorax, if found needs an urgent CXR and once a chest drain is inserted, then you can put the patient on NIV ( this needs ITU support as it is complex). I would get ITU involved if the patient was in type 2 failure with a pneumothorax.
Review patients on NIV on a regular basis. They can still deteriorate. Hand such patients over to the next on call team.
ASTHMA
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
This can be anything from a mild wheeze to a full blown fatal asthmatic attack.
Remember your basics - a full A to E assessment, doing all routine ED bloods ( FBC, U and Es, CRP, LFTs, coagulation screen, blood cultures and an ABG) and a CXR.
ABG is very important especially if the patient is breathing fast and could possibly tire.
Do not delay treatment - remember the magic drugs: steroids, nebulizers ( back to back), antibiotics, and if the patient fails to improve, start them on the next treatment according to your local policy - this could be magnesium sulfate followed by aminophylline ( with ITU input as per your local policy).
This can be fatal! And the exacerbation is treatable. Hence, treat appropriately and do not delay it.
Tips:
An ABG is essential. You may need to repeat it if things do not improve.
Get ITU involved if the patient is deteriorating.
Back to back nebulizers does not mean one nebulizer - keep giving salbutamol, ipratropium and then escalate treatment.
IV steroids are key!
A wheeze does not necessarily mean asthma - it can be present in CCF as well. Hence, examine the patient, checking for JVP, features of heart failure and look at the CXR carefully.
Read the previous discharge/ respiratory letters - you will find a lot of useful information.
An inpatient can also develop an acute asthma attack - review these patients ASAP!
PNEUMOTHORAX
They may need a chest drain ASAP- especially if they are hemodynamically unstable, are tachypneic or are requiring oxygen. If you cannot do this confidently, ask for help. People who can insert chest drains out of hours are:
1. Medical registrars
2. Medical SHOs who are working in respiratory medicine and are signed off by a consultant to insert chest drains independently.
3. ITU registrars/consultants
4. ED registrars/consultants
5. Interventional radiologist on call
6. T & O surgeons ( they insert chest drains for traumas)
Top Tips:
Do not delay a chest drain in a deteriorating patient just because you cannot insert it. There are plenty of people who can help. Even in a small DGH.
Ensure the platelets, clotting is normal. And they are not on NOACs/warfarin.
PLEURAL EFFUSION
If it is for ?malignancy
They need a chest drain if they are compromised AND after a respiratory/ medical consultant review . If there is no confirmed diagnosis of an underlying condition and a chest drain is going to be inserted, please send a sample for WCC, C+S, LDH, protein, glucose, cytology and an extra sample for saving in case the lab needs more tests.
The samples are then sent to specialist centers for analysis ( ie HMDS, etc) and may take a while to come back.
?Empyema
A chest drain needs to be inserted urgently and antibiotics must given ASAP.
Top tips :
Not all effusions need an urgent drain insertion.
Do not forget other differentials of pleural effusion - especially heart failure.
Always check the clotting, platelet count before inserting a chest drain - if concerned, talk to hematology.
Be careful if it is ?malignancy as insertion of a chest drain can cause subcutaneous seeding of the tumor. I usually wait for a respiratory consultant to make this decision when I am on call unless the patient is very unwell. If the patient is haemodynamically unstable, please do not delay chest drains.
As mentioned above, there are plenty of doctors who can insert chest drains.
PULMONARY EMBOLISM
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Pulmonary-Embolism-Diagnosis-and-Management-of
Top tips:
A high CRP, WCC does NOT mean the patient may not have a PE.
A high D dimer DOES NOT mean the patient will have a PE, especially if there are other causes.
History, Well's score are very important.
CXR may show a wedge shaped opacity- this could be the wedge sign for pulmonary infarction. This may also cause a high CRP.
Get a CTPA done urgently if you are worried that the patient could be a candidate for thrombolysis ( ie, if they are haemodynamically unstable)- get ITU involved ASAP.
Look at the ECG! You may see evidence of right heart strain
Keep an eye on the blood pressure - they will be a candidate for thrombolysis if they are hypotensive/there is a significant drop.
Follow your trusts guidelines for management of PEs as some cases can be managed in the ambulatory setting.
Always think about a P.E. if the patient is requiring a lot of oxygen, is tachycardic and/or hypotensive.
PE can kill ! Please treat as PE if you suspect it, even without any investigations. A treatment dose of LMWH will not do any harm unless there are any contraindications ( in that case, you will need to make an informed decision).
If the patient is short of breath and there is no clear cause, think of PE. This can even be the case for inpatients who are already on prophylactic VTE.
LUNG CANCER
This is a horrible condition. But quite a reasonable number of people do well, thanks to early diagnostic tests- like doing a repeat CXR in 6 to 8 weeks for patients who had a consolidation on their admission CXRs.
If there is any doubt, scan the chest! Usually, the radiologists prefer a full CT chest, abdomen and pelvis to rule out any metastasis at the same time if the history, CXR findings and examination is convincing ( ie smoker- 50 pack years, cough since 6 months, emaciated, CXR shows right lower zone consolidation, weight loss, lymphadenopathy).
There are some excellent specialist teams available to support patients: from respiratory registrars/consultants to cancer specialist nurses to McMillan nurses and oncology nurses.
The pathways may differ from trust to trust but this is what it is like:?
- Diagnosis of lung cancer - bad news broken by doctor looking after patient ( can be SHO/reg/consultant).
- Referred to lung cancer specialist nurses and respiratory team
- Appropriate investigations requested
- Discussed in MDT
- Treatment initiated.
Top tips:
Always repeat a CXR in 6 to 8 weeks if the admission CXR shows a consolidation. If it is still there in a repeat CXR, this could mean there is something sinister going on.
If the CXR looks odd ( as in not a clear consolidation but a ring like lesion), do a CT.
A CT chest abdomen pelvis with contrast is better than a simple CT chest as you get more information in a slightly lengthier scan preventing delays.
Examine the patient thoroughly - a palpable lymph node in the groin can be easily biopsied and will help with an early diagnosis.
Always check calcium levels - they can be inappropriately high in cancer patients.
If the patient has any neurological deficit, even if it is confusion, scan the head to check for metastasis. A plain CT is reasonable to start off with however some radiologists may just do a CT head, chest, abdomen and pelvis with contrast at the same time as that would give more information. But do not delay a CT of the head by assuming this.
Be careful about what you tell the patient
You cannot diagnose lung cancer by looking at a CXR - it will be highly suspicious if it is atypical but you cannot inform the patient that it is lung cancer. Instead, inform the patient that is abnormal and you would need to do a more detailed scan to rule out anything sinister. This decision is usually made by a registrar or a consultant.
Patients never forget the health care professionals face, body language when they break bad news. Hence, ensure you hand your bleep to someone and let the nurses know what you are going to do.
If the patient is well enough, I prefer to talk to them in a private room ( rather than in a bay with 6 beds separated by curtains) with a chaperone ( preferably the nurse looking after the patient).
Everyone has their own way of doing it. This is how I do this ( I have already taken a history and examined them hence developed a good relationship):
"What do you know about your condition"
"As you might be aware, your chest X ray showed an abnormality and we were a bit concerned and hence we got a full detailed scan of your body"
"Has anyone informed you about the results?"
"Unfortunately, it does not look good. Would you like to be with someone before I continue"
" The scan shows you have lung cancer"
Give them time to process this information.
Inform them about the next steps and be slow, ask them if they understand and be very supportive.
There are different ways which patients prefer.
Some want to hear it ASAP, then want the doctor to tell their next of kin privately and then want their next of kin to meet them.
Some do not want their families to know - which is fine, they need some more time to process this and will then ask the team to inform their families.
Some want to inform their families themselves.
We, as healthcare professionals need to respect these different reactions. All of them are natural, none of them are wrong.
It is okay, as a healthcare professional to shed a tear or 2. Remember to be professional but it is difficult not to be human in these situations - especially the young patients who have just been married/become a parent.
Do not blame them - even if they smoke like a chimney. Mention that smoking does increase the risk and to avoid further damage, you strongly advise that they quit and offer nicotine replacement. Be careful about your wording.
Let all other healthcare professionals know that you have just broken bad news - including HCAs, nurses in charge so that they can keep a close eye. The first day/night is the hardest. Prescribe a sleeping tablet ( as required, at night) if there are no contraindications.
If you have time, visit the patient later on. It makes them feel supported and makes them feel at ease. You have no idea what a difference this can make.
There are a lot of other conditions which I have not mentioned here. Please remember to refer to your local guidelines, escalate to your registrar/consultants and your local respiratory team.
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