A Acute Internal Medicine (ST4) station on MedMock, start to finish

Thank you for joining us. We'll start with the scenario you've just read: a 32-year-old woman in same day emergency care with pleuritic chest pain and breathlessness, two months after starting the combined pill, with a heart rate of 104. How would you approach her?

I'd see her promptly and start with an A to E assessment. Apart from the tachycardia her observations are reassuring, but I'd recheck her blood pressure myself, look for signs of right heart strain and examine her legs for a DVT. Pulmonary embolism is my main concern, given pleuritic pain, breathlessness and tachycardia on the combined pill, but I'd also consider pneumonia, a pneumothorax, pericarditis and musculoskeletal pain. I'd ask about haemoptysis, previous clots, recent surgery, travel or immobility, family history, and whether she could be pregnant. Initial tests: an ECG, a chest X-ray, a pregnancy test, and bloods including a full blood count, renal and liver function and a clotting screen. I wouldn't use the PERC rule, because she's tachycardic and taking oestrogen, and my suspicion isn't low. On the two-level PE Wells score, if nothing else explains her symptoms, she scores 3 because PE is the most likely diagnosis and 1.5 for a heart rate over 100: 4.5, so PE is likely, and NICE says to go to a CTPA, immediately if possible, rather than a D-dimer. If the scan can't be done straight away, I'd start interim anticoagulation with apixaban or rivaroxaban, which can simply continue if the scan is positive, after sending the baseline bloods but without waiting for the results. If the scan can't happen today and she's well, she could go home on that and come back for it, which is what our ambulatory PE pathway is for. If she were hypotensive, it would be a different conversation about high-risk PE and thrombolysis, with senior and critical care input from the start.

Thank you. The CTPA shows a right lower lobe pulmonary embolism with no right ventricular strain, and her blood tests are normal. She tells you she has two young children at home and would like to leave. What would you do?

I'd see whether she's suitable for outpatient treatment, which NICE supports for low-risk PE, using a validated tool. Her simplified PESI score is zero: she's under 80, with no cancer, no chronic heart or lung disease, a heart rate under 110, a systolic pressure over 100 and saturations above 90%. With no right ventricular strain on the scan, normal bloods, pain controlled with simple analgesia, support at home and no bleeding risk factors, she's a good candidate. I'd start apixaban or rivaroxaban after checking her weight, renal function and other medicines, and ask whether she's breastfeeding, because neither should be used then. Before she leaves she needs written information on what to look out for, a direct number for our thrombosis or ambulatory team, and how to get help out of hours, as NICE sets out, plus a follow-up appointment. She should stop the combined pill today. Because the pill counts as a provoking factor, she'd have at least three months of anticoagulation and then a review; if she's recovered and is no longer taking it, stopping at that point is reasonable. Thrombophilia testing isn't indicated after a provoked PE. And I'd write to her GP the same day.

Thank you. She asks you: 'Was it the pill? And if I stop it, what do I do about contraception?' How would you answer her?

I'd sit down and use plain language, something like: 'It's very likely the pill played a part. The oestrogen in it makes clots more likely, so we'd advise you to stop it today and not to use it again in future. You do still need reliable contraception, because the blood thinner isn't recommended in pregnancy, as it may not be safe for a baby. There are good options without oestrogen that are safe for you: a copper or hormonal coil, the implant, or the progestogen-only pill. Your GP or a sexual health clinic can help you choose, and until then please use condoms. If you think you might be pregnant, contact us straight away, because we'd need to change your treatment. Some women find their periods get heavier on this medicine, so let us know if that happens.' Then I'd check what she's understood, ask what questions she has, and give her the same advice in writing.

Thank you. We'll move on to the second question. Please give us your one-minute presentation: a summary of your experience managing the acute unselected medical take as the medical registrar.

Thank you. For fourteen months, first stepping up as an IMT2 and now as an IMT3, I've been the medical registrar on the acute unselected take at a busy district general hospital, on a full rota of days, nights and weekends. By day I run the take with the acute medicine consultant on the unit; overnight the consultant is on call from home, so I make the first senior decisions and escalate critical care referrals, ceilings of care and anyone I'm worried about. My team is usually two or three foundation and core trainees, an advanced clinical practitioner and a physician associate, working with the nurse in charge and the site team. On a day take I'm directly responsible for thirty to forty new admissions, and overnight I'm indirectly responsible for around three hundred medical inpatients through the ward cover team. Outside the take, I...

I'm going to stop you there; that's the minute. You mentioned making the first senior decisions overnight. Tell us about a night when the take became overwhelming. What did you do?

A night last winter. At midnight there were fourteen patients waiting to be seen, two of my juniors were tied up with sick patients, and I was called to a peri-arrest on a ward. I dealt with the immediate risk first: I led the peri-arrest call, a man in septic shock, and referred him to critical care. Then I went through the whole list with the nurse in charge and the emergency department coordinator, using NEWS2 and the referral details to pick out the patients I needed to see myself, and allocated the rest by my juniors' experience, with clear instructions to call me about anyone scoring five or more. I asked the site manager to open the escalation beds, and asked the emergency department consultant to help with two patients who could be treated and discharged from the department. At two o'clock I phoned my consultant, said we were unsafe and asked them to come in, which they did, and we had seen everyone by the morning without anyone coming to harm. What I learned was to escalate earlier. I'd waited an hour longer than I should have before calling, and now I call when I first see the numbers heading that way, not once we're already overwhelmed.

Thank you. How do you make sure patients move through the acute medical unit safely and promptly?

It starts with an early senior decision: every patient should be reviewed by a consultant within 14 hours of arrival, and the post-take ward round should set a clear plan, an expected discharge date and what needs to happen before discharge. Then a morning board round with nurses, therapists, pharmacy and the discharge team, so blockers are found at nine o'clock, not five. Suitable patients are streamed to same day emergency care so they never need a bed, and we use criteria-led discharge, so a patient can go as soon as they meet criteria the consultant has set, without waiting for a doctor. I led a project on late discharges: for patients expected home that day, we moved writing the discharge letter and medicines to the post-take ward round. Over three months the proportion of our discharges before midday rose from 12% to 21%, and it has lasted because we built it into the junior doctors' induction. And safe as well as fast: frail patients see therapy and social care before they leave, and everyone going home has a plan and knows how to come back.

Thank you. One of the foundation doctors on your night team seems to be struggling: slow, missing jobs, and looking exhausted. What would you do?

Patients first: I'd check nothing urgent on their list has been missed and share out the jobs that night so no one is at risk. Then I'd find a quiet moment with them, away from others, and ask how they are, because being slow and exhausted usually has a reason: illness, stress, something at home, or simply too much work and no break. I'd make sure they get a break and something to eat. If there's a training need, I'd teach on the job and give specific, kind feedback. I'd let their educational or clinical supervisor know, with their knowledge, so they're supported beyond one night, and point them to occupational health or NHS Practitioner Health if their wellbeing is the issue. I wouldn't treat it as a disciplinary or incident-reporting matter unless a patient had come to harm; if one had, it would be reported as a patient safety incident, with the focus on learning. And if I thought they weren't safe to continue the shift, I'd say so, arrange cover and tell the consultant.

Thank you. That's the end of this station.