Table Of Content

ChurChill’s PoCketbooks of Clinical Practical Procedures for Junior Doctors Commissioning Editor: timothy horne Development Editor: Ailsa laing Project Manager: Anne Dickie/sukanthi sukumar Designer: kirsteen Wright Illustration Manager: Merlyn harvey Illustrator: ethan Danielson ChurChill’s PoCketbooks of Clinical Practical Procedures for Junior Doctors Nisha Patel bsc(hons) Mbbs MrCP specialist registrar in Gastroenterology, Chelsea and Westminster hospital Nhs trust, london, uk Daniel Knight bsc(hons) Mbbs MrCP specialist registrar in Cardiology, royal free hampstead Nhs trust, london, uk edited by Mark Palazzo Mb frCA frCP MD Chief of service, Directorate of Critical Care Medicine and Anaesthetics, imperial College healthcare Nhs trust, Charing Cross hospital, london, uk eDiNburGh loNDoN NeW York oxforD PhilADelPhiA st louis sYDNeY toroNto 2009 first published 2009, © elsevier limited. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from elsevier’s rights Department: phone: (+1) 215 239 3804 (us) or (+44) 1865 843830 (uk); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request online via the elsevier website at http://www.elsevier.com/permissions. isbN 978-0-443-06806-5 British Library Cataloguing in Publication Data A catalogue record for this book is available from the british library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the library of Congress Notice knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. it is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. to the fullest extent of the law, neither the Publisher nor the Authors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher Printed in China Contents Section 1 Airway and breathing 1 1 Airway care with simple devices 1 2 Peak expiratory flow rate measurement and spirometry 15 3 Pleural aspiration (of fluid or air) 23 4 Chest drain insertion and management 33 5 Percutaneous pleural biopsy 45 Section 2 Circulation 53 6 Venepuncture (peripheral and femoral) 53 7 blood cultures 63 8 Peripheral venous cannulation 67 9 Preparing and setting up intravenous medications 75 10 intravenous fluids and commonly prescribed infusions 79 11 Central venous catheter insertion 89 12 Arterial blood gas sampling 105 13 Arterial cannulation 111 14 Performing an electrocardiogram (eCG) 119 Section 3 Abdomen/Genitourinary 123 15 Nasogastric tube placement 123 16 Abdominal paracentesis and ascitic drain insertion 129 17 rigid sigmoidoscopy 141 18 urethral catheterization 147 Section 4 Miscellaneous 155 19 lumbar puncture 155 20 Arthrocentesis of the knee 165 21 subcutaneous and intramuscular injections 171 22 local anaesthetics 179 23 suturing 185 Index 197 This page intentionally left blank PrefaCe After the celebrations of graduating from medical school, the reality of starting out as an inexperienced junior doctor can be particularly stressful. As first year doctors ourselves not so long ago, being left on the wards to do that ‘urgent lumbar puncture’ or ‘quick ascitic tap’ was a dauntingly familiar story. Clinical practical procedures are widely taught on models in medical schools. however, putting this theoretical training into clinical practice in your junior years can be particularly disconcerting. While providing a basic foundation upon which to learn procedures, models can never translate to the reality of performing them on a patient under difficult circumstances, for example, on an acutely unwell patient in the middle of the night. of the multiple factors involved in this stressful time, we hope this book alleviates those associated with performing clinical practical procedures. We aim to provide you with a valuable tool and reference point when asked to perform these clinical procedures. As one of the Churchill’s Pocketbooks series it can be conveniently carried in your bag or pocket. related practical procedures are grouped under the relevant system in a recognizable ‘AbC’ approach, making it easier to find a procedure quickly. each chapter starts with the origins of the procedure, its indications and potential complications to be aware of before you start. After all, you must know what to explain to the patient pre-procedure and what to prepare for should things go wrong. the procedures are outlined in an easy-to-read manner using a step-by-step approach, with abundant diagrams and clinical photographs to complement the text. Chapters finish with post-procedure care, how to process investigations and the basics of their interpretation. Performing the procedures successfully is not the end-point of course; you must know what to do with the cerebrospinal fluid or ascitic fluid you managed to obtain. tip boxes are present throughout the chapters to highlight useful points regarding the procedure, common pitfalls and improvements to your delivery. We hope you enjoy this book and use it to improve your clinical procedural skills, giving you confidence to perform them on the wards and on-call. This page intentionally left blank aCknowledgements We would like to express our gratitude to the patients who kindly agreed to have their clinical procedures photographed. Without their willing- ness to assist, this educational resource would not be possible. We thank Dr Patrick Doyle for his help and expertise. thank you to Chris Priest, Nicola Webster and Philippa hutton at Medical illustration uk ltd for their help with the medical photography. We thank Christopher knight for his assis- tance. We would also like to thank all the staff at elsevier for their help with this project. finally, we would like to thank our parents and partners, kinesh and Amy, for their patience, understanding and support in completing this book.