The Med Reg: How to be a Great Medical Registrar in the UK by Chan Rory

Author:Chan, Rory [Chan, Rory]
Language: eng
Format: epub
Published: 2018-02-02T00:00:00+00:00

Reg B/ Managing mHDU, ward referrals and wards

In this section we will discuss managing the medical high dependency unit ; how to approach ward referrals from other specialties and looking after the medical wards.

The disclaimer in this section is that I'm not an intensivist but I can tell you my experience of managing "level 2" patients from a medical registrar perspective. Some hospitals I've worked in have a high dependency unit which is attached to the intensive care unit and thus both are managed by ICU doctors. As a result if you have trained as a core medical trainee in one of these hospitals your exposure to medical HDU will be severely limited.

From my point of view the medicine is exactly the same except the patient is unfortunately a bit more unwell. Different ICUs work differently (surprise!) with some departments being a lot more hands on compared to others. Some ICUs regularly send their ICU registrars to mHDU to touch base with our patients and staff without being asked, whilst others do not take the initiative.

Typically patients should "only" have single organ failure for example isolated severe type 1 respiratory failure OR isolated severe acute kidney injury but as our medical facilities are getting "better" people with significant comorbidities are living longer and thus we are regularly managing people with multi-organ dysfunction in mHDU. However in cases like this, close liaison with ICU specialists is mandatory.

​My advice would be to learn the indications for HDU admission which generally fall into three categories - patients that need close monitoring with a higher nurse to patient ratio than can be provided on a basic ward, patients that need inotropic support and those that need organ support. An example of a patient who needs close monitoring, possibly in HDU, would be someone who has had increasing oxygen requirements and currently sitting on a level 1 ward requiring 10L of oxygen. They may improve but you discover that one of the nurses has called in sick so the ratio of patients to nurses has increased to from 6:1 to 8:1. Your mHDU also has 3 empty beds today so the decision is an easy one.

The most popular inotrope in the medical high dependency unit in hospitals I've worked in is noradrenaline (abbreviated to norad) so I would suggest brushing up on your knowledge of this. Needless to say if you're managing medical high dependency unit you'll be expected to perform central lines under ultrasound guidance and norad would be one such indication. Metaraminol is sometimes used peripherally when waiting for IV or arterial lines to be inserted so that's another one to revise. There should be set protocols that you can use for both norad and metaraminol but if you are not sure, call your consultant or the ICU team. Although you should be respectful of other specialties you should never be shy asking for assistance for fear of appearing silly. Other specialties frequently "silly" questions when I'm on call for medicine or respiratory but the most important thing is patient safety .

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