Tales from the wards: F2 in the Surgical High Dependency Unit (HDU)

Dr Patrice Baptiste swapped from orthopaedics to the HDU – was it the right decision? Read about her day and judge for yourself.

My day begins early at 5.30 am, as I’m in work for 7:30. On the way to the locker room, I walk past the HDU and have a quick peak in. The Surgical HDU is the ‘sister’ ward to ITU, it can hold five patients. ITU has a number of consultants, registrars, senior house officers (SHOs) and specialist nurses, whereas HDU on the other hand only has an FY2 doctor – me.

I grab the sister before she starts the hourly observations and morning washes, there are five new admissions; the first had a right hemicolectomy and was transferred to us for ‘risk of deterioration’. She is currently stable.

Admission two is a gentleman diagnosed with acute severe pancreatitis who needs respiratory support; currently on 50% high-flow oxygen and is in need of an ABG, in contrast admission three is a lady who recently underwent a resection of a sigmoid tumour, but developed a supraventricular tachycardia (SVT) overnight.

Of the final two, one has pancreatitis but persistently de-saturates when his oxygen is weaned down. He has a background of COPD and a recent CTPA was negative for a pulmonary embolism, and the other is a lady with Alzheimer’s disease who underwent a right above the knee amputation, she was found to be in fast AF on admission and not on any anticoagulation.

A frantic ward round

Armed with the nurse’s handover sheet and the knowledge they have equipped me with, I quickly begin a ward round.

I start with the lady who underwent a right hemicolectomy. She agrees to being examined. Before I can remove my stethoscope her team appear from behind the curtains. The registrar bypasses me and explains that the operation went well. After a brief look and feel of her abdomen the team disappear as quickly as they arrived. I return to examining and hear voices behind the curtains. It’s the physiotherapists; they are waiting for a handover from the nurses.

I move on to the gentleman with pancreatitis who does not look well. I see a large number of doctors; the ITU ward round. I edge closer and hear that they are discussing transfer back to ITU. The four consultants leave the ward followed by the remainder of the team. The registrar stays behind to tell the sister in charge “we will arrange transfer”. So that’s that.

Interruptions

I move on to my third patient– the chap who de-saturates on lower oxygen levels, but the curtains are closed. The physiotherapists are behind them. They inform me that they are going to take him for a walk to see how his oxygen saturations vary.

Next the lady with SVT. I manage to see her without any interruptions. She is on metoprolol 12.5mg three times a day; I note that I think this should be increased.

I swiftly move on to my final bed, the lady with Alzheimer’s, but once again the curtains are closed. The nurses are washing her. So I move back to bed three. The physiotherapists are back and say that he did very well on his walk; he did not de-saturate on four litres of oxygen. He looks well, he is not gasping for breath and his observations are stable. As I finish his team arrive and we discuss the plan for him – if he does not de-saturate today he can be stepped down to the ward.

Last but not least I work my way back to bed five and see the remaining patient. All in all she is stable and the team need to review her wound later.

Review and assess

Round done, I start working through the list of tasks generated by the round. I begin by speaking to cardiology about the lady in SVT. They say they will review her later, but increase her meds to 50mg if necessary.

After a frantic morning the ward is quiet except for the sound of the monitors, but not for long. The teams come in move the patient in bed two to the ITU. Bed one has remained stable so she is stepped down to the ward. The gentleman in bed three has not de-saturated so a ward bed is requested. The lady with a SVT is the same, her heart rate has increased from ~100-120 to 150 beats per minute. I call cardiology again and we increase the metoprolol to 50mg.

Treating tachycardia

I get called by the sister who has changed the dressing of the lady’s wound in bed five as she is worried there is a lot of blood. The consultant saw her earlier and removed a few stitches as there was a haematoma at the wound site. I review her and she is haemodynamically stable. I call her team to inform them.

She has become tachycardic, so I ask for a fluid challenge and repeat blood pressure. I check her haemoglobin, it has dropped to 7.7. I inform the team and order two units of blood. Her blood pressure has responded to the fluid challenge, but it is still hovering around 100mmHg systolic. I repeat the fluid challenge. She remains stable and I wait for the first unit of blood to start before handover.

It’s 5:30 already – I’m shattered.

Home time

Before I get ready to go home, I glance at the monitor of the lady in SVT. Her HR is now 85bpm. The cardiology registrar walks gingerly through the doors and I quickly run over to him to tell him the good news!

Pleased that the patients are now stable I say goodbye to the staff and look forward to going home. Moving to this rotation was the right decision, although the HDU is busy and demanding, it’s varied and challenging, all in all a great opportunity.

Dr Baptiste is an F2 in London. She can be contacted at [email protected]