Factors influencing escalation of care by junior medical officers.

Patients can acutely deteriorate unexpectedly. Junior medical officers (JMOs) are often first to review patients who become unwell. Opportunities to escalate care to a senior colleague may exist prior to the need for a rapid response team review. Little is known about the factors that influence JMO decisions to escalate care. In this study, our objective was to investigate the self-reported factors that influence escalation of care by JMOs in a university-affiliated, tertiary level hospital. We designed a face-to-face questionnaire of JMOs using standardised introduction to minimise interviewer bias. Fifty JMOs participated in the study (a 100% response rate). Most (63.3%) felt that they would be able to identify a clinically deteriorating patient. They would be more likely to escalate care if they were not familiar with the patient's clinical problem. If handover plans were seen to be adequate, JMOs felt it was less necessary to escalate care. Few JMOs (12%) agreed that they limited escalation due to fear of criticism or fear of conflict with senior medical staff. Although 36% agreed that they were concerned about waking seniors overnight, only 6% feared that escalating care overnight would affect their future career prospects. Escalation of care appears to be mostly influenced by the confidence and familiarity of the JMO with the cause of deterioration. JMOs identified clear handover with documented goals of treatment and suggested actions in event of clinical deterioration as the best means by which to improve the process of escalation of care for clinically deteriorating patients.

Deliberate fingolimod overdose presenting with delayed hypotension and bradycardia responsive to atropine.

INTRODUCTION: Fingolimod is an immunomodulating agent used in multiple sclerosis (MS). It is a sphingosine-1-phosphate (S1P) receptor agonist prescribed for relapsing forms of MS to delay onset of physical disability. As fingolimod is known to cause first-dose bradycardia, telemetry is recommended for the first 6 h post-dose. We present the first reported case of deliberate fingolimod overdose requiring atropine administration for bradycardia and hemodynamic instability. CASE REPORT: A 33-year-old woman ingested 14 mg of fingolimod and 2 g of phenoxymethylpenicillin. After presenting to the emergency department 19 h later, she was initially hemodynamically stable (heart rate (HR) 60, blood pressure (BP) 113/89 mmHg). Two hours later, she then developed bradycardia (HR 48) and hypotension (87/57 mmHg). Despite intravenous fluids, stabilisation was only achieved after administration of atropine (300 µg). She was then admitted to the intensive care unit (ICU) for further monitoring where another episode of bradycardia and hypotension required atropine. She was monitored in the ICU for 48 h and then discharged on day 5 with no further episodes. DISCUSSION: Fingolimod is known to cause bradycardia in the first 6 h post first therapeutic dose. Following intentional overdose, onset of bradycardia occurred at 21 h post-ingestion and was associated with hypotension. Atropine was successful in treating bradycardia and associated hypotension.