Monday 8 May, 2006

Get a fax machine and number

Posted in Advice, Michael Tam at 20:19 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Being fax capable is the norm

As a doctor, junior or otherwise, you are a professional and need to present yourself as such. Even if you do not have a permanent practice, you should still have professional contact details. In another article, I highly recommended the use of a post office box. You should strongly consider purchasing a facsimile machine (or service) as well.

Being able to both receive and send faxes is considered part of the clinical and professional norm. All doctors in private practice would have a fax machine. All public organisations have as well. Faxes are great in that they have the relative security of postal mail (i.e., you can send clinical information) but also the speed of e-mail. Furthermore, a fax is much less likely to linger in someone’s (unchecked) inbox like e-mail.

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Saturday 6 May, 2006

Don’t give out your home telephone number

Posted in Advice, Michael Tam at 8:08 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Is it a patient?

For similar reasons of security as explained here, do not give out your home landline telephone number. There is no particular reason why anyone needs to know your home landline number and it is relatively trivial to convert a number back into a physical address.

If you do need to give out a telephone number, a mobile number is always preferable. In the worse case scenario, you can always just get a new mobile number. If you want to give your patients an avenue of contacting you, the practice telephone number or hospital ward telephone number should be sufficient. I once made the mistake of giving my mobile number to a patient’s mum (while I was at the Sydney Children’s Hospital) as she needed a way of contacting me on the weekend. This resulted in being called about 5 times over the weekend for trivial matters. Thankfully, apart from being somewhat anxious, she was otherwise settled so she never called me again.

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Friday 5 May, 2006

Get a post office box with mail redirection

Posted in Advice, Michael Tam at 23:36 by Michael Tam

Original article by: Michael Tam :: Printer friendly

I discovered this in my internship and it is something that you should definitely consider investing in.

There are many good reasons why you should get a personal “post office box”. The main reasons include security, safety, convenience and professionalism.

You will have to trust me on this one, but you do not ever want to be stalked by a patient, particularly a patient with a mental illness or one that has a grievance against you. Considering that over the course of your career (even as a JMO) you will meet literally thousands of patients, even having a very small proportion of “wacky” people being your patients, you will still potentially come to grief (and the proportion of “wacky” people out there isn’t that small). The best way of minimising the risk is:

Never give out your home address to anyone except your family and close friends.

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Tuesday 2 May, 2006

IV rehydration therapy in children

Posted in Emergency Dept., Michael Tam, Paediatrics, Wards at 17:25 by Michael Tam

Index: Intravenous fluid therapy :: Printer friendly

Original article by: Michael Tam

Before you start with intravenous rehydration therapy in children, you should ask yourself the following questions:

  1. Can I use oral rehydration?
  2. Do I need to take blood for blood tests? (if so, do it from the intravenous cannula immediate after insertion)
  3. Do I need to give resuscitation fluids?
  4. Do I need to replace any special / continuing losses for the child?

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“Maintenance” IV fluids in euvolaemic neonates

Posted in Emergency Dept., Michael Tam, Paediatrics, Wards at 12:53 by Michael Tam

Index: Intravenous fluid therapy :: Printer friendly

Original article by: Michael Tam

Baby Beer

Oral intake is always preferable

Neonates (birth to 4 weeks) should be treated as different from other children and have their own needs for fluids. Before you write up fluids for a neonate, you should be asking yourself the following questions:

  1. Why are you writing this up rather than the neonatal team?
  2. Are you actually sure that this neonate is euvolaemic?
  3. Why does this neonate need IV fluids?
  4. Does the neonate have some acute illness or congenital issue that makes “normal” or “usual” fluid management inappropriate?

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“Maintenance” IV fluids in euvolaemic children

Posted in Emergency Dept., Michael Tam, Paediatrics, Wards at 11:49 by Michael Tam

Index: Intravenous fluid therapy :: Printer friendly

Original article by: Michael Tam

This is for children:

IV fluid type

  • 0.45% NaCl + 2.5% dextrose + 10 mmol KCl
  • 500 mL bag

IV fluid rate

4 mL/kg/hr for first 10 kg of body weight

+ 2 mL/kg/hr for next 10 kg

+ 1 mL/kg/hr for the remainder

There is no “autopilot” method for children. Calculate it properly each time. The smaller the child, the more important it is for the rate to be correct. In larger children, you could probably round to the closest 5 mL/h for convienience. If the rate is > 100 mL/h (for maintenance), you should be using adult type fluids.

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Monday 1 May, 2006

“Maintenance” IV fluids in euvolaemic adults

Posted in Emergency Dept., Medicine, Michael Tam, Surgery, Wards at 17:37 by Michael Tam

Index: Intravenous fluid therapy :: Printer friendly

Original article by: Michael Tam

Bag of IV fluids

Bag of IV fluids

The easy (autopilot) way:

Assumptions:

  1. That the patient is relatively “normal
    • normal size
    • relatively well
    • no kidney failure
    • no heart failure
    • no electrolyte disturbance
    • no particular abnormal losses
  2. patient is “nil-by-mouth” (i.e., they have no other sources of hydration)
  3. patient is euvolaemic – i.e., not dehydrated or fluid overloaded.

If any of the assumptions are false, then you should seriously consider working it out properly. If they are all true, then you can use the following regimens (assuming standard 1L IV fluid bags):

Regimen One

  • Bag 1: 0.9% NaCl (“normal saline”) + 30 mmoL KCl (use premixed if available) then
  • Bag 2: 5% dextrose + 30 mmoL KCl then
  • Bag 3: 5% dextrose then back to Bag 1.

Regimen Two

  • Bag 1: 0.18% NaCl + 4% dextrose (“4% and a fifth”) + 30 mmoL KCl (use premixed if available) then
  • Bag 2: 0.18% NaCl + 4% dextrose + 30 mmoL KCl then
  • Bag 3: 0.18% NaCl + 4% dextrose then back to Bag 1.

Intravenous fluid infusion rate

  • Usual sized person: 125 mL/h (or “q8h”)
  • Smaller or older person: 100 mL/h (or “q10h”)
  • Tiny, old and frail person: 84 mL/h (or “q12h”) – though you shouldn’t be writing fluids on “autopilot” for the tiny, old and fail person.

You are hereby warned that imprudent use of “autopilot” therapy with intravenous fluids can (though rarely) harm your patients.

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