INTERSHIP SURVIVAL GUIDE

A guide for interns by interns at NSH

Compiled by Dr Francois Uys

(Intern rep NSH 2016 -2017)
Compilation material from:
Dr Elan Milwid
Dr Robyn Meyer
Dr Nicolina Bardou
Dr Micheal Van Niekerk

“The woods are lovely, dark and deep. But I have promises to keep, and miles to go
before I sleep.” Robert Frost
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Welcome to New Somerset Hospital

My name is Francois Uys. I was in your position not too long ago (It literally feels like
yesterday). 2015 end of December I was anxious, nervous, excited, confused and bewildered,
coming to a strange new place in Cape Town. Ready to begin the dreaded internship after 6
years of studying, but all I could think about is; where will I live for the next two years ;). I can
imagine that these are shared emotions of all new interns.

I would like to set your mind at ease even just a little bit as I cannot help with your car
insurance. You have been placed at one of the most awesome internship destinations (just
ask trip advisor), not to mention hospital, in South Africa- and for that I would like to
congratulate you!
Somerset hospital is the perfect blend of experience, exposure, supervision, teaching and
hard work. There are ample learning opportunities where you will be taught correctly and be
asked to perform your new skills repeatedly. I mean we are the oldest teaching hospital in
South Africa, that is why we taught South Africa how to start ARV clinics.

Hard work is a key factor. Hours will be long and times will be tough. Experiencing the
responsibility of being doctor, making clinical decisions that matter has a massive influence
on you and takes time to accept and learn. Be patient, take a breath and take pride in your
work. When times gets difficult do not attempt to go through it alone. Talk to family, close
friends, colleges (most of them will be able to relate) and ask for advice.
Beyond the hours and hard work you will make friends, experience new adventures and be
pushed out of your comfort zone.

Our hospital is situated in the most amazing place in South Africa. If you would ever like to
know what you can do in Cape town, please ask me (I have a list of about 800 possible things
and updating everyday). Try to socialize with your colleagues, (everybody is doctors and are
obviously good contacts to have for the future). Try to avoid making enemies, have a good
attitude towards your work, staff, colleagues and give respect to seniors even at difficult
times.

This survival kit- or basically “the things I wish I knew when starting internship at NSH”. It
started out as a small introduction and developed into a guideline for your 2 years. But it still
remains a guideline which was set up by myself and your colleagues. Please correlate with
textbooks, references, your registrar etc. if unsure.
This guideline is my attempt to help with common problems/questions in our hospital. I
sincerely hope you find it useful.

Good luck.

Dr. Francois Uys

MBCHB UP Cum Laude
0798868966
Fuys24@gmail.com

NSH Interns 2016 year end function

 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Index of guideline
Page Number

Front Page 1
Foreword: Welcoming to new interns 2
Index 3
A word from previous Intern rep at NSH (2015-2016) 4
General tips/ advise/ information 5- 8
- Hospital layout 5
- Intern managerial process 6
- How to get NHLS login code 6
- How to order blood 6
- How to certify death 6
- ARV Clinic 6
- Intern booklet 6
- Door codes 6
- Important speed dials 6
- Important numbers/ emails outside hospital 7
- Call survival kit 7
- Trello/ Listrunner 7
- ECCR/ Discharges 7
- BOOTH/ Conradie referrals 8
- Transfusion reactions 8
- Resus 8
Departmental Breakdown 9- 36
- Medicine 9-15
- Ortho 16-17
- Anesthesiology 18-25
- Surgery 26-27
- Obstetrics 28- 30
- Pediatrics 31-32
- Family medicine 33- 36
References 36
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

A word from the previous intern representative

(2015- 2016)
Well done on getting placed at New Somerset Hospital. Trust me when I say that you are extremely
privileged to spend the next two years at this hospital! Here are some general pointers and tips for
the first two years of being a doctor:

- You have completed your academic studies, so use these 2 years to get as much as possible practical
exposure. You have to become a safe doctor at the end of your internship - something which will
happen at NSH. There is ample supervision and assistance where needed. Focus on becoming a good
clinician - even if you are in another department, if there is for instance an ICD to put in in EC, ask to
put it in!

- NB: Make friends with the nurses, do not for one moment think that now that you have a DR in
front of your name that you are above them. Trust me, if you manage to get onto one of their bad
sides, it will spread like a wild fire in a matter of minutes through the entire grapevine of nurses, and
your two years will become slightly more challenging.

- Make friends with the EC doctors, clerks, cleaners and nurses - basically everyone. This can either
become a safe haven for you, or a daunting setting. They are always keen to help, especially when
you feel like you're in the deep end like on your first medicine call without a registrar at night. Ask for
help.

- Sort your admin out in your very first week of starting work - you don't want to delay your first
paycheck!

- Join SAMA. You don't want to find yourself in any position where you need some external backing
or advice and then realize that you never joined. Look back at the past year and see everything that
JUDASA and SAMA has done for young doctors then you won't need any convincing: shorter
continuous shifts, placement, safety etc...

- Some departments are not as nice as others, try to keep a jovial spirit, you'll see that things always
get better. If you're in a department where you feel like you're doing way too much admin and
getting too little clinical experience like Ortho - do something about it! Insist on doing the reductions,
applying the pop, assisting in theatre.

- In every department at NSH you'll see that willingness to do and learn will be rewarded - you will be
able to cut way more than 10 C/S's! You'll get great experience in surgery etc...

- Don't be lazy, it gets picked up very quickly and will spread. Be proud of your work ethic.

- Lastly, NSH is located in the best area in SA! Enjoy it! Go for lunch at the market next to the
waterfront, go and watch the sunset from the intern room and watch the sunrise from seventh
floor. As said before, you are blessed to be at this hospital, take it in, breathe it, learn from it and
you'll become a better doctor for it.

All the best with the start of your Dr life - it truly is worth all the studying.

God bless,

Dr Michael van Niekerk

MBChB UFS Cum Laude
JUDASA National Secretary General
SAMSA Board of Directors
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

General tips, advise and information

Hospital Layout:
OUTSIDE
Parking Doctor’s parking is at the back of hospital and in front of hospital entrance (Arrange
parking ticket with your department’s secretary)
HR Offices are at second hospital entrance (closest to V/A waterfront). Enter the building and
go up the stairs, your HR person will be allocated to you according to your surname.
NHLS Lab Located next to hospital on the property of the DQ’s.

NEW HOSPITAL
 EC: Includes a clinic area, paeds area, procedure room, x-ray, main area, resus area
(with ABG machine), nebs area, gynae area and isolation area. Very well stocked. The
toilets are available, keys with Sr. at front desk. Always advisable to wear TB mask
(N95) in EC.
 Overflow/ ER: This room is usually for departments overflow so its use changes
frequently.
 Mr George’s office: Across from overflow. He is the man dealing with all death
certificates.
 ICU: 4 bed ICU with ABG machine- Code:2165
 Floor 1: ORTHOPAEDICS and X-ray department. Room 1 usually medical and
isolation rooms for MDR TB.
 Floor 2: SURGERY and MAIN THEATRE
 Floor 3: OBSTETRIC + OBSTERTRIC THEATRE AND ICU
 Floor 4: NICU + ABG
 Floor 5: No one knows ;)
 Floor 6: POST-NATES, OBS AND GYNAE. Some medical
 Floor 7: POST-NATES OBS AND GYNAE.

OLD HOSPITAL (CASTLE BUILDING)

 Below stairs: Offices, SW, Physios, OTs, CEO, Seminar room, Psych
 Up Stairs Right: INTERN ROOM (Upstairs) PAEDS (Barkley, Ebden, ARV cliníc
and paeds clinic).
 Left: MEDICINE (King Edward, Bickersteth and Bailey)
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Intern managerial process:

If you have any complains/ concerns please follow the correct procedural lines
Try to resolve the issue If unresolved take to to intern rep (Francois) with problem Intern
rep will try to resolve If unresolved Intern rep will hand problem to Intern Curator (Dr.
Noor) Intern curator will resolve problem as far as possible.
Dr. Noor is our intern curator. She is also a surgical consultant. Please minimize direct
complains/ concerns to her and follow the procedural lines.

How to get number for NHLS log in:

Complete the form handed to you at the orientation and hand it in to Beauty (the CEO's secretary).
Your username will always be IN followed by your personnel number. Initially your password will
be "P" followed by your personal number.

How to order blood:

Complete the blood bank pink form (Always duplicate). Use pink blood tube (3ml blood is enough).
Mark ‘cross match’ and ‘type and screen’ and select what you need. If it is urgent; request the
porter to fetch the blood @GSH BLOODBANK. The first unit is always initiated by a Dr (You must
prescribe the blood- I.e. 2u of RBC OVER 4 hours each IV, with 20- 40mg of lasix). Patient must
be consented. Platelets and FFP expires very quickly so give them as they arrive.

How to certify a death:

When the Sr phones you and says you must come to certify a death; go to the patient, do a quick
examination and make notes: (I.e. On arrival patient was unresponsive, no respiratory effort or
heartbeat was present. Assessment: Patient passed away. Plan: Death certificate and inform
family. Note TOD). Mr George will come and find you to sign the death certificate the first weekday
or the following day. You are to sign and fill in the cause of death. He is kind enough to complete
the entire death certificate. Check whether the details are correct and complete and always thank
him.

ARV Clinic:
This is located near at the paeds clinic. This is where you will go if you have a needle stick
injury in working hours. After hours’ injuries go to EC for help.

INTERNSHIP BOOKLET:
Get signed off after EVERY block, you don’t want to run around like a headless
chicken at the end of your two years to get your MP number. The page everyone
keeps fussing about at the beginning really is something to fuss about - make sure
everything is in order, that all days from the 1st of January to the 31st of December is
accounted for somewhere.

Door codes:
C1570X (intern room) C790XY (UCT resource center)

Important speed dials for NSH:

Switch board: 9
Physiotherapy 6468
Dietician: 6489
X- Ray: 6243
NHLS green point lab: 2165
Wards:
King Edward: 6208
Bickersteth: 6348
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

1st floor: 6211

6th floor: 6314
ICU: 6215
ER: 6210 6216

Important numbers outside hospital

BROOKLYN CHEST HOSPITAL:
Mr Felton 0215088310 Shaamiel.Felton@westerncape.gov.za
Dr. Te Riele: 0741826726
MDR females: 082 3009744 Nihaal De Vries. Nihal.DeVries@westerncape.gov.za

DP MARAIS HOSPITAL:
Mrs. Sallie 021 7137606
Dr. Scott: 021 713 7688/ 084 7654543
Fhereen.Salie@westerncape.gov.za
MDR males: Dr. Croxford- 021 7137617/ 083 7033442

CONRADIE HOSPITAL:
fax- 0866824679/ 021 3709801

WESTERN CAPE REHAB CENTER:

021 3702371 (McKee). Tertia.Mckee@westerncape.gov.za

BOOTH MEMORIAL HOSPITAL:

021 4654846

Call survival kit

Always remember to pack:
 Food, drinks and small change
for vending machines inside hospital
 Toothbrush/ mouthwash
 Deodorant
 Blanket and pillow
 Desk fan (summer)
 Charger/ powerbank

Trello/ Listrunner
These are awesome apps that can be used to keep track of Jimmy work and patients.
Especially useful in Medicine

ECCR/ Discharges
From the 1st of January every department will use ECCR to discharge patients (Electronic
discharge).
Process:
1. Login: your username and password is your persal number
2. Discharge: print 3 copies of discharges and scripts.
a. Staple only the three scrips together and send the 3 scripts with the
blueboard (WITHOUT THE FOLDER) to the pharmacy. Pharmacy will send it
back with meds and pharmacy stickers on script
b. Make sure the script and discharge copies are signed before sending to
pharmacy.
c. The discharge form: one can be given to pt and two left in the file.
3. If the Dr made a mistake during prescribing the pharmacy will phone you- and they
will correct it. It is your responsibility to correct it on the system (not needed to reprint
corrected ones)
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

4. We are assigned senior clinician status.

BOOTH/ CONRADIE referrals (Ortho, Med, Surgery)

 Booth Hospital is a rehabilitation hospital for a 2/52 stay for physio, relieve or
palliative care.
 Conradie Hospital is a care center for patients with no abode and for palliation

Process of referral:
1. Collect BOOTH/CONRADIE form in ward (Same form)
2. Complete the Dr’s section of the form
3. Notify the appropriate nurse to complete their part
4. Social work referral on ‘pinki’ to ask for them to complete their section (PHONE
THEM to notify them that the form needs to be completed)
5. If patient is referred to Physio/ OT they must complete their section. If not referred
that section should also be completed by the nurse
6. Once the form is complete you can fax it yourself or give to ward clerk to fax.
7. Phone BOOTH every day to ask whether the patient has been accepted
8. As soon as the patient has been accepted then book transport through the ward
clerk.
9. The patient will need a discharge letter (referral) and one month worth of medication
prescribed
10. Phone transport every day until patient has been picked up.

Transfusion reactions in ward

Stop blood, remove line
Transfusion reaction
Return drip set + blood
4 pink top tubes
100-200mg hydrocortisone IV
25mg promethazine IM

Resus:
Activate emergency response team (usually EC team) Ask sr to phone for
them + your reg and Sr. to help with CPR.

Basic algorithm (Do as much as you can before help arrives):

1. Call for Help Activate emergency response team (usually EC team)
Ask sr to phone for them + your reg and Sr. to help with CPR. Tell sr to
ready resus equipment (Emergency trolley)
2. Activate time Dedicated person for keeping time (Pulse and rhythm
check every 2 min)
3. Start continuous CPR (30:2) + Give O2 + attach monitors (Monitor for
shockable rhythms, 120-200J) + obtain vitals
4. IV access + ABG + glucose + administer Resus fluids and
Adrenaline/ Epinephrine (1mg) 3-5 minutes
5. Consider advanced airway
6. Treat reversible causes (5 H’s and 5 T’s)  Hypoxia/hypovolemia/
Hydrogen ions (Metabolic acidosis)/ hypo/hyperkalemia/ hypothermia.
Tension pneumothorax/ Tamponade/ Toxins/ Thrombosis.
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Medicine

General: Three wards- King Edward (Males), Bickersteth (Females), Bailey (TB). Outliers on
floor 1 and 6. You will be divided into a firm consisting of an Intern/MO/Com serve + Reg +
Consultant. There are five firms. This means that you will be on call more or less every 5
days, as you call with your firm. The medical consultants: Dr. Vallie (HOD), Dr. Moosa and Dr.
Bandeker). The medical secretary: Indi (Office underneath big stairs).

Day-to-day: After a call you will have a certain number of patients that you took in. All
patients need to be seen everyday in your firm. You will make plans and do Jimmy work. The
basic principle is that you try to ready your patients for DC before your next call. Every day
starts in ICU @ 08:00

 Monday Antibiotic stewardship ward round at 12:00 or 13:00 with prof. Mendelson
 Tuesday Academic meeting (you must present a patient case of your choice, select
a date and inform Dr. Bandeker.). Echo’s with Dr. Lachman (You will be given dates
to attend on roster)
 Wednesday and Thursday MOPD (dates will be given to you on roster)
 Friday Handover meeting for weekend @ 14:15

Roster: Compiled by Dr. Bandeker. No leave request allowed. If you want to swap go to him
with a solution rather than a question.

Calls: Start at 08:00 with seeing old patients in wards and completing Jimmy work. Then go
to EC, there is an Internal medicine referral book (usually on the table across from the nebs
room). All patients that are in the book need to be seen. You, your reg and sometimes
students will work together. The reg usually leaves at 23:00. After 23:00 you will be alone
seeing the new patients (You can always phone your reg, ask a second year or EC personnel
for help if needed). You will get called for a lot of ward related problems throughout the call-
Drips, patient problems, bloods etc.
I recommend you do an IV round before trying to get some rest at 23:00 to avoid being called
the entire night. You will only see new patients until 05:00, leave a note for the EC guys in the
referral book to please call you only once there is 2 or more patients in book. After 05:00 draw
a line in the book and all referrals received after 05:00 is for the new on call team.
When you are done seeing patients you need to find all your patients from the previous night
and fill in all blood results. Use the admissions book at the reception desk at EC to see where
patients have been admitted to.
Ward round starts in ICU at 08:00. After the ward round Jimmy work needs to be done and
you usually leave between 11:00- 12:00.
Complete all possible work for a patient when you see the patient the first time- this makes
post call and the rest of the week easier. For example TB patient workup (Extensive)- All this
can be done at first contact:
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

1. Will need 2 sputum samples One for gene XP and one for TBMCS; filled in on two
different specimen forms. If a GeneXP has been done in past 6/12 then the lab won’t
do another one.
2. Urine LAM (If CD4 <200, Can be found across from ICU, each urine LAM used must
be documented in LAM book)
3. Blood cultures (If pyrexial)
4. Abdominal US form completed (If hepatosplenomegaly)
5. CXR
6. Bloods- UCE, FBC (RPI, DIFF), LFT’s and CMP (if indicated)
7. Stool MCS and Stool for clostridium PCR (If diarrhea)
8. Start TB referral form DP Marais (Mobile patients, MDR Males)/ Brooklyn Chest
hospital (Non- mobile patients and MDR females). Recommendation; download
Scanner pro on your phone, scan the referral and email directly to email to DPM and
BCH as form is completed. Always attach results with referral (I.E. GXP, Urine LAM,
CXR), it will help with more rapid acceptance of patients.
9. Admit to Bailey ward.

MED Drug Dosages

as compiled by Dr Elan Milwid
(USE ONLY AS GUIDE)

Cardiovascular General

Drug Dose Route Duration

Simvastatin 20 mg nocte PO
Asprin 150 mg daily PO
Clexane ( DVT 40 mg daily Subcut
prophylaxys )
Unstable
Angina
Asprin 300 mg stat 1 month
Clexane ( Post 80 mg bd Subcut 2days
Nstemi)
Isosboride 5mg PRN Sublingual
dinitrate
NSTEMI(
unstable
angina +)
Clopidogrel 75 mg PO 6 month
STEMI acute
Asprin 300 mg stat 1 month
and then 150
daily
Streptokinase 1.5 million IV Indications : If within 6 hours
units diluted in of pain
100 ml NaCl Contraindication: any recent
bleeding/stroke
Morphine
clexane 40mg s/c Initiate only 3 days after MI if
they were thrombolysed
otherwise immediately
Enalapril If low BP : 2.5
bd , if normal
or high BP 5
mg bd
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Simvastatin 50 mg
Atenalol 50 mg daily Oral Unless Low BP or
bradycardia

Resp
Drug Dose Route Duration
Haemoptysis
Pholcodine 10mg tds PO
Morphine 5mg qid IMI
COPD
Salbutamol 2 Puff PRN inhaler
Budaflam 2 puffs bd Inhaler
Formolerol ( long acting 2 puffs bd Inhaler
B2 agonist )
Serotide ( budaflam + 250 mg bd Inhaler Instead of
Formolerol ) budaflam
Fluticasone ( long acting 4 puffs bd inhaler Instead of
steroid ) budaflam
Theophyline 200 mg daily PO
COPD exacerbation
Salbutamol + iptroupium 1:1:2 in saline , initialy 1 hourly Nebs
bromide then 2 hourly up to 6 hourly
or
Berotec 1:2 saline hourly Nebs
Atrovent 1:2 saline 4 hourly Nebs
Prednisone 40 mg daily PO 10 days

Antibiotics
Drug Dose Route Duration
Meningitis
Bacterial : ceftriaxone 2g stat and BD IV 10 days
Cryptococcal : Amphotericin 1mg/kg daily IV 2 weeks
B
TB
Rifafour
Prednisone 60 mg tapering down by 10 after 2 PO 6 weeks
weeks
MgSO4 2g in 200 ml saline over 30 minutes IV

Pneumonia
Augmentum 1.2g IV 5
Augmentum 1g bd PO 5
CAP curb >3: ceftriaxone 1g daily IV 5
CAP curb< 3
Ceftriaxone 1g daily IV
Azithromycin 500 mg bd IV
PCP :
Bactrum 4 tablets QID PO 21
Prednisone 40 mg bd PO 21
Nosocomial
Piptaz 4.5 grams tds 5
Amikacin 10mg/kg 3
Aspiration
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Augmentum 1 g tds PO/IV 5

Haemopholus Influenza
Oseamavir 75 mg bd PO 3/7

Lung abscess
Augmentum 1gram bd PO 6 months

Viral hepatitis
Lamuvadine

UTI: ciprofloxacin 500mg bd PO 5

Bacteraemia
Staph Aureus :
cefazolin 1g Daily IV 14
CLoxacillin
MDRSA( multidrug resistant staph aurus ) : 25 mg /kg stat dose and IV
Vancomycin 20mg/kg bd dose

Anti-Hypertensives
Drug Dose Route Duration
Ridaq 12.5 mg > PO
25 mg
Enalapril 5 > 10 mg PO
Amlodapine 5-10mg PO
Either
Spironolactone 25 mg > 100 PO Only if normal potassium ( enalapril and
mg spironolactone ncrease K
atenalol 25 mh

Psych
Drug Dose Route Duration
Sedation :
lorazepam 2-4 mg IVI
Diazepam 10 mg Iv
Psychosis : 1 gram stat and PO
phenytoin 300mg note
For acute 2 mg IVI PRN
seizures
:Lorazepam
Anti epileptics
First line 300mg daily PO Contraindicated in :
Phenytoin increasing in 50 mg ARV,s and young
increments women
Second line : 20 mg /kg divided PO Max 2.5 g/day
Epilum into bd and increase
by 100

Diabetes sliding scale

Subcut insulin
Glucose action
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

0-4 50 mls 50% dextrose

4.1-8 Nil
8.1 - 12 2 units subcut actrapid
12.1-16 4 units
16.1-18 6 units
18.1-20 8 units
> 20 10 unis

Types 2 Diabetes
 First line :Metaformin
 Initiate therapy with 500mg Glucophage/Metformin Nocte with meals , if
person handles it then 500 mg added Mane with meal , then increase by 500
mg daily > 1g mane 500 nocte > 1 g mane 1 g nocte
 Normal affective dose is 1700- 2500 in divided daily doses
 Maximal dose 850 mg tds
 Metaformin contraindicated in renal impairment ( ie : do creatinine before
initiating metaformin
 Second line : sulphonyureas :
 Glimiprimide : 1g > 2 g >4 g > 5 g > subcut insulin
 Gliclazide / Glibencamide :40 mg > 80 mg > 12 mg bd
Type 1 Diabetes
 Initial dose
 0.6 units/ kg when starting a patient who was in ketoacidosis off
 0.3-0.5 units /kg when initiating therapy in a new onset diebetic
 2 regimes
 Actrophane (mixture of short and intermediate acting insulin)
 Split
 2/3rd mane
 1/3rd nocte
 Better regimen :Short ( actapid ) + long acting/ basal insulin (protaphane )
 40% as basal insulin nocte
 the other half split equally as short acting before each of the 3 meals
 After this patient must test glucose levels before breakfast and dinner for 3 days , add
the before breakfast and separately add the before dinners , if
 more than 20 add 2 units to dose
 between 13 and 20 then maintain current dose
 less than 13 then decrease dose by 2 units

Ketoacidosis Protocoal
 50 units actrapid In 200 mls saline
 If HGT >15 : run at 24 mls/ hour
 If HGT < 15 : run at 12 mls/ hour
 Ringers Lactate
 1 L Ringers Lactate stat
 1 L Ringers Lactate over 2 hours
 1 L Ringers Lactate over 4 hours
 1 L Ringers Lactate 6 hourly
 Obs
 2 Hourly HGT
 Daily Dipsticks
 Daily VBG
 Stop ketoacidosis when all of the following is met
 HGT below 15
 Base excess below minus 5
 PH in normal
 HCO3 is above 15
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Random
Drug Dose Route Duration
Nystatin 1ml qid Drops
Flucanazole 200mg daily PO
Mist morphine 5 mil>10 mil qid PO
DVT
clexane 80 mg stat + bd subcut 2 days
If confirmed DVT : warfarin 5mg daily increasing by 2.5mg to IV /PO 2 days
achieve INR of between 2-3
Eltroxen starting dose 50 mg daily Po
Chronic Alcoholic
Thiamine 100 mg daily PO Forever
DT’s
Diazepam 5mg tds PO
If acute neurology :Thiamine 500mg bd IV for 2 days then taper down 250mg bd for 5
days then 100 mg PO daily
Drug Withdrawels
Methadone 2mg tds PO
Peripheral Neuropathy
Amitryptaline 10 mg nocte PO
Pyridoxine 100 mg daily PO

Migraine ( at feeling of
onset of migraine )
Atenalol 25 mg Po Once
Asprin 900mg Po Once
Metoclopramide 10 mg po Once

Heart Failure
Fursosemide 40 mg IV Contraindicated in Low K
bd
Enalapril 2.5mg PO Contraindicated in low GFR/
bd raised potassium
Carvedalol( if ejection fraction is 3.125> PO Contraindicated in brady cardia
unknown) 25
Atenalol ( if normal sized heart or 25 mg PO Contraindicated in Brady
known good ejection fraction ) bd cardia
Losartan 50 mg instead of ace inhibitor in
daily patient with low GFR

Potassium Abnormalities
Potassium replacement
Kcl 40 mmol in 1 L ringers IV
Mist K+ chloride 30 ml tds PO
Slow k 2 tabs daily PO
Shifting Potassium
Keyexelate 30 mg bd
antrapid 10 u in 50 ml 50 % dextrose
Calcium gluconate 10 ml over 10 minutes
Furosemide 120 mg IV

Other electrolyte abnormalities

Hypocalcaemia
If calcium below 1.9: calcium gluconate 1 amp over 10 minutes IV
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

If calcium above 1.9 titralac 2 tablets bd PO 7/7

Hypomagnesia
Slow magnesium 2 Tablets bd PO 7/7
MgSO4 IV
Hypernatraemia
Hypovolaemic : 1 L Ringers
Normovolaemic : 1 L dextrose + 1 L fluid orally
Hypophosphataemia
Phosphate Sondas 500 mg daily PO

TB
Rifafour Dosage
+pyridoxine 25 mg daily

Weight Doasge
30-37 2 Tablets
38-54 3
55-70 4
More than 71 5

2nd line TB
Kanamycin 500 mg daily IMI
Pyrazinamide 1g PO
Ethionamide 800mg PO
Ofloxacin 500mg PO

Surg
Lansoprazole 30 mg daily PO
Pantaloc (PPI) 40 mg bd PO
Buscopan 10 mg tds PO

Liver
Hepatic failure
Vitamin K 10 mg daily Po
Lactulose 20 mg tds
Nytatin 1 mil qid

Anemia
FeSO4 200 mg daily tds PO
With Vitimin C 1 tablet daily PO

Dermatology
Sebhoragic dermatitis
0.1 % hydrocortisone cream
Aqueus cream

Rheumatology
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Rheumatoid Athritis
Panado+ tramadol
Chloroquine 200 mg PO Monday to Friday
Methotrexate 5 and titrate up 7.5>10>15 weekly PO
Folate 5 mg daily PO

CKD
FeSO4 200 mg daily PO
Titralac 2 tablets bd PO
Vitamin D 50000 units weekly PO

Orthopedics

General: 2 months’ rotation in combination with anaesthesiology. Patients mostly on floor 1,

some outliers on floor 6 and 7. You will be two interns working together. Teamwork is
essential during this rotation. The hours are long and the work is hard, support each other. No
students available. Sometimes foreign students present, teach them early (USE THEM)

Day to Day (Each day starts at 07:00):

 Monday Fracture clinic. All patients need to be seen in ward. One intern at clinic
and one in ward. Afternoon 13:00 Antibiotic ward round. Afternoon ward round. Clinic
can sometimes run till 17:00, if this is the case, the intern that was at clinic should
leave for home and the one in the ward stays for round (set up an alternating roster
for this). Clinic is the time to get stuck in doing reductions and POP’s.
 Tuesday Chronic clinic. Same as above applies.
 Wednesday MO’s will be in the ward with you to see all patients in preparation for
Thursday’s Consultant ward round. All patients will be seen and prepared for the next
day.
 Thursday Consultant ward round. Starts 07:00 in EC. You don’t present patients in
ortho (don’t know why not). Every second week is outreach clinic to Vredenburg/
Wesfleur- These clinics are a great experience to see a bit of the west coast and to see
where our patients comes from. Divide it up so that each intern can go twice
 Friday No clinic. See all patients, make weekend plans, afternoon round. Go home.

Roster: Will be done by a surgical intern. Two requests allowed.

Calls: Cover Surgery, Ortho and Urology. Make sure you know each reg on call for those
departments. Ortho interns cover Saturdays because you can’t be on call on a Sunday. You
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

will never call more than a surgical intern as you are doing cross cover. See Surgery call for
more info.

NOF#
Bloods: FBC, U&E, Alb
AP pelvis, lat of hip, full femur including knee
ECG
Mini mental
Urine dipsticks
GMS (if old, low fluids)
Admit

Pathological fracture
FBC, CEU, CMP, ESR, CRP, serum protein electrophoresis, TSH, albumin, total protein, LFTs
CXR, ECG

Medication: Use surgical meds summary. NB!! All elbow operations need Ibubrufen 400mg
for 2/52 to prevent Hypetrophic oseoarthopathy. All hip operations need to be placed on
150mg of Aspirin daily. Arthroplasty TTO  Aspirin 150mg PO daily x 6 weeks
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Anesthesiology:

General: Day starts at 07:15. Floor 2 (Main theatre) or Floor 3 (Obstetric theatre). If you
arrive a little earlier go and start in the theatre i.e. machine check, drawing up of drugs and
preparing your first patient then your MO will love you!! You have a lot of coffee breaks.
Bring R50 each month for coffee. Bring R65 for UCT Anesthesiology text book (Great guide
and reference book, can be bought from Dr Stonehouse - consultant)

Day to Day: Each day is the same You will do theatre cases with the MO/Reg. You go see
the patient in pre-op area, make sure patient has an IV line, do the anesthetic clark (If not
done the previous day) and take patient to theatre. Do the case- get stuck in- Intubate,
spinals as many as possible. The more enthusiastic you are the better experience you will
get. Around 14:00 the theatre list comes out for the next day in the clerks office. These
patients need to be clerked and prepared for theatre the next day. The anesthetic clerk is
usually short and sweet according to the blue sheet. If something is needed for that patient
(example ECG, bloods) you request it on the anaesthetic chart and the intern in that
department (example: surgery) is responsible for doing that- Just remember to inform said
intern. If you are concerned about a patient speak to your reg and discuss plan for patient.
Learn to formulate own plans.

Tests: In anesthesiology there are three tests (Nothing to panic about)

Machine check test: In 2nd week. Basically the machine check that you will do everyday. Let a
MO show you how to do it a couple of times, then do it yourself everyday before you start
cases. Then this is a piece of cake.
Practical test: In week 7/8. It will be an ASA 1 or 2 case. You will be required to handle the
case from start to finish under supervision of a consultant. The more you practice the easier
this part is.
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Written test: Usually 100 marks. They ask questions that you have repeatedly done over the
weeks. Read one chapter of the book each day in theatre and ask MO for teaching and you’ll
be fine.

Dosages of drugs in anesthesia:

Drug Indication Route Dose Notes
Adrenaline Anaphylaxis IVI 0.5-1μg/kg Titrate to effect
(mild)
5-10μg/kg
(severe)
IMI 0.3-0.5 mg/kg
Alfentanyl (rapifen) Atten. of intubation IVI 10-20μg/kg
response
Sufefentanyl (sufenta) Atten. of intubtion IVI 0.1-0.2μg/kg
response
Atropine Premed SC/IMI 10 μg/kg
Cholpromazine (Largactil) Premed 0.1mg/kg Α-antagonist thus causes
vasoD
Due to hypotension=
seldomly used as a pre-op
drug
Promethazine (Phenergan) Premed IMI/orally 25-50mg Sedation, antiemetic,
atropine like effects
Trimeprazine (Vallergan) Premed (esp. in Orally 3mg/kg Long sedative effect
children)
Midazolam Premed Orally Adults 0.1- Drug of choice for premed
0.2mg/kg
Child(<5)
0.4mg/kg

Essential Anaesthetic Drug Doses

Induction
STP 0.5mg/20ml 4-6mg/kg
Propofol 10mg/ml 1.5-2.5mg/kg
Etomidate 2mg/ml 0.2mg/kg
Ketamine 50mg/ml 1-2mg/kg

Muscle Relaxants
Alcuronium
Pancuronium 0.1mg/kg
Vecuronium 4mg/amp 0.1mg/kg
Rocuronium 0.6-1.2mg/kg
Atracurium 0.4-0.6mg/kg
Cisatracurium 0.1mg/kg
Mivacurium 0.15mg/kg
Suxamethonium 1mg/kg

Reversal Agents
Atropine 10-20ug/kg
Glycopyrolate 10-15mg/kg
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Neostigmine 0.05-0.07mg/kg

Emergency Drugs
Adrenaline 10ug/kg
Atropine 10ug/kg
Ephedrine 5mg/dose
Phenylephrine 1ug/kg/dose
Na-Dantrolene 20mg/60ml 2-10mg/kg

Local Anaesthetic Agents

Lignocaine 5mg/kg TOXIC DOSE
Lignocaine with Adrenaline 7mg/kg TOXIC DOSE
Bupivacaine 3mg/kg TOXIC DOSE
Bupivacaine with Dex
Ropivacaine
L-Bupivacaine

Opioids
Morphine 2.5-15mg/dose
Pethidine 50-100mg/dose IM
Omnopon 20mg/dose
Alfentanyl 0.5mg/ml 1mg/dose
Sufentanyl 0.005mg/ml 1-8ug/kg
Fentanyl 50-100ug/kg
Drug STP Methohexital Propofol Etomidate Diazepam Lorazepam Midazolam Ketamine
Sub-group Barb Barb Non-Barb Non-barb Benzos Benzos Benzos
Class Ultra short acting Methylated oxy-barbiturate. Compiled by Dr Francois
Phenol derivate. Uys (INTERN
Carboxylated Imidazole Rep NSH
GABAa 2016-2017) GABAa agonist
agonist GABAa agonist. Imidazole Phencyclidine derivate –
thiobarbiturate. No sulpur. 2.6 di-isopropylphenol ring structure. Ring opening see action in book.
Sulphur analogue of Alkylphenol phenomenon (pH<4.0).
pentobarbitone. Ring closed at 7.4= incr
6% NaCO3 solub. Most lipid soluble.
Most potent.
Characteristics Yellow powder. Garlicky Powder. Milky white soln Poorly soluble in water. Water soluble. No solvents Partly H2O soluble. 5-10X
smell. Bitter taste Dissolved in 40% prop glyc necessary. fat solb> STP
Package 2.5% soln. Diluted in 20ml 500mg powder in 50ml any 20ml amp with 10mg/ml = 2mg/ml in prop gycol. 10ml 5mg/ml in 2ml amp 2 or 4mg/ml in amp 1 or 5mg/ml in amp 10, 50, 100mg/ml
H2O fluid = 1% 1% amp
1%prop, 10%soy,
2.2%glycerol, 1.2& egg.
Stability Not very stable. Post recon 6 weeks Stable at room temp. Not Not light sens
– 24hrs if clear. light sens. Where opened,
use within 6hrs.
pH 10.5 10-11 (75% unionised at 7 8.1 6.2-6.9 3.5-5.5
phys pH)
Compatability Incompatible with Ringers Compat with 5%DW

Induction Char Where pain on inj= abn One arm-brain cycle. Pain Low dose and slow admin = Pain on inj site. Poorly abs Less pain post IM or IVI During: aimless
on inj. Invol movements + delayed hypnosis. movements: head, arms,
hiccough + cough. legs, torso
Hypesens = rare.
Onset One arm-brain cycle 30-60 sec 60-120 sec 30-60 sec Induc slower< STP. Onset
(20sec). 30sec max at 1min
45-60in decr Q
Emergence Due to redistr 2-3 min after dose Longest action Immediate action Short action Delirium. Dreams+halluc.
Due to redistr Emerg = redistrib Floating. Reduc with
bezo+paed
Distibution Rapid to well perfused Large VD (++females Distrib ½ 3min Plasma prot binding equal. Plasma prot binding equal Plasma prot binding equal Distrib ½ 11-16min
organs. Disrtib1/2 2-8 min Elim ½ 2.9-5.3hrs (related Termination through Termination through Termination through Elim ½ 2-3hrs
Highly lipid soluble= BBB Elim ½ 1-3hrs to hep perf). redistrib from GABA. redistrib from GABA. redistrib from GABA. Large Vd (fat sol)
equilib in 1min Clearance rapid. Prot bind Receptor: 3 Receptor: 1 Receptor: 2
Then redistrib = short action =sig. Cirrh decreases elim
Plasma prot binding = 65-
86% (decreased with
acidosis)
Metabolism LIVER: 10-15%/hr LIVER: conj to glucoronides Process= ester hydrolysis. Microsomal enzyme or Microsomal enzyme or Microsomal enzyme or Hepatic microsomal
KIDNEY: Small % and sulphates = inactive. To: carboxy acid VIA: N- glucuronide conj glucuronide conj glucuronide conj enzyme met VIA: N-
unchanged Clearance> hep blood flow dealkylination. = inactive demethylation TO
Norketamine (20-30%
activity ofK
Elimination Kidneys1%. Faeces 2%. Kidney 85%. Bile 13% Desmethyldiazepam + 5 metabolites = all inactive Rapid ox of imidazole ring = OH-Norketamine via
Lungs. oxazepam= prolonged no active metabolites kidneys
effects
CNS Sedation Similar to STP. Hypnotic. 1 arm brain cycle. Hypnotic in 1 arm brain Sedation. Hypnosis. Sedation. Hypnosis. Sedation. Hypnosis. Complete analges with light
Hypnosis Abn EEG in epileptics Lower dose = sedation + cycle. Mech = GABA Amnesia. Anxiolysis. Amnesia. Anxiolysis. Amnesia. Anxiolysis. sleep – dissoc anaesthes.
Anti-convulsant amnesia. Hallucinations. receptor. No analgesia. Central MR. Less brain Central MR. Less brain Central MR. Less brain Cateleptic state. Delirium
Ant-analgesia Opisthotonus. Ant- EEG = grand mal epilepsy. protect< STP protect< STP protect< STP on emerg
Brain protection analgesic. Epileptic EEG Myoclonus
CSF decreased Decr ICP 30% Decr ICP 30% Not for neurosurg: incr
Blood Flow Decreased Decr CPP 10%. Can> Brain Decr 34%. CPP maintained Decr Decr Decr CMRO2, blood flow, ICP.
isch Petit mal seizures.
CMRO2 Decreased Decr 36% Decr 45% Decr Decr Decr Unwanted phys emergence
CVS Decresed Q, SV, PVR. Slight hypotens Decr Q, SV, PVR. N HR. Minimal depress. Minimal No major changes. Slight No major changes. Slight No major changes. Slight CV stim= noradrenaline.
= Hypotens = Shorter duration 25-40% decr in SBP. =Decr incr HR. O2 supply and drop SBP and SVR. Dose drop SBP and SVR. Dose drop SBP and SVR esp HT, tachy, incr Q. Block
lifethreatening with fixed Q. pre and afterload. Decr demand met. Add opiate to dep BP drop. No intub resp dep BP drop. No intub resp MIDaz. Dose dep BP drop. with barb + benzo. In isol =
Myocard ischaemia. myocard blood flow and decrease tube respons. decr. decr. No intub resp decr. -ve inotrope
consump.
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Resp Depression (Dose, rate, Dose dep depress > STP Apnoea (25-30%)= dose, Post ind Dose dep depress 2 Dose dep depress 3 Dose dep depress 1.Peak Minimal. N CO2. Apnoea
other dep). = temp rate premed dep. =usu hypervent>apnoea. Synergy with opiates. Synergy with opiates. at 3min for 15min Synergy @++doses. Good
Decreased CO2 sens >30sec. Decr RR 2min. Type+dose of premed reln. Smaller dos in elderly Smaller dos in elderly with opiates. Smaller dos in bronchodil. N reflexes.
Decr min vol 4min Cough and hiccough. Decr elderly Silent aspir
CO2
Renal Disease does not affect
elim.
Hepatic Microsomal enzyme induc

Endocrine Inhib adrenal gland synth =

TIVA add vit C
Larynx Sensitised. Laryngo and
bronchospasm in early
tubing or irritation where
anaesth = inadeq
Uterus No effect. Not for foetal
repos. Crosses BPB
Found in breast milk
Eyes Midriasis >> miosis Decr IOP 30-40% Decr IOP 5min. Maintained Pupils dilat midway and
Decr IOP with cont infuse. nystagmus. Retained prot
reflexes
Indications Induction of GA OPD Induction: rapid onset Anxiolysis. Sedation (loss Induction: Midazolam = Short procedures. Poor risk
Control of convulsions Short procedures <STP. Decr BP. Childr of eyelid reflex) choice drug: shortest pts. Fixed Q. Multi anaesth.
Psych analysis Teeth extrac >3=adult rxn. action, less ven Cx incr Accident scenes.
ECT ECT Maintenance: 100- clearance rate. )loss of Analgesia. Asthma. Cong
Basal anaesth in children 200microg/kg/min. TIVA eyelid reflex. heart disease. Cardiac
In head injuries = brain with Alfentanil: 30micr/kg cath. With painful local
protection then 1microg/kg/min. block.
Contraindications Porphyria. Airway obs. BEAPSS HT. MI. Incr ICP. Eye inj.
Fixed Q. Shock. Addisons. Spych. Epileps.
HAALMMM Aneurysms. Catechol
exhaustion
Side Effects Extravenous. Intra-arterial. CV dep. TP. Pain. Resp Pain on inj, myoclonus, ?? Porphyria. Pain inj. Incr convuls threshold. Incr convuls threshold. Incr convuls threshold. Incr lacrimation, saliv, sk
Thrombopheb. Nerve dep. Laryngospasm etc. apnoea, decr BP, TP. Myoclonus. N+V. TP C/S Resp depress. TP. Resp depress. TP. Resp depress. TP. musc tone.
damage. Resp. CVS. Muscl movements. N+V. Accumilation possible with suppress
Anaphylaxis <Extravas SE long time TIVA
Advantages Induct= pleasant + rapid Less CV dep. TIVA. Good tube cond Safe in Asthmatics Haemodynamic stability. No Haemodynamic stability. No Haemodynamic stability. No
No delirium Early LM. Safe malign allergic rxns. No cortisol allergic rxns. No cortisol allergic rxns. No cortisol
Rapid recovery hypotherm and porphyria. supp suppc supp
No N+V No C/s, hep haem or fibrin
Reliable. Previoslu cheap abn. Pleasant ind and
recovery. Good OPD
anaesth
Other Uses Anti-emesis, sed, Potentiates Non dep MR Decr MAC. Ant amnesia.
antipruritis.
Dose IV Induct 4-6mg/kg 1mg/kg Induct:Premed: 1.5- 0.2mg/kg 0.25-1.0 microg/kg/hr Induct: 1-2mg/kg (IM 5-
SE 4mg/kg/hr 2.5mg/kg 10mg/kg)
Brain protect <40mg/kg/hr Unpremed 2.25-2.5mg/kg Analgesia: 0.25-0.5mg/kg
>60 1-1.75 mg/kg
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Inhalational agents
Agent Nitrous Oxide Halothane Diethylether Enflurane Isoflurane Sevoflurane Desflurane
Class Gas Halogenated Ether Ether Ether Ether Ether
hydrocarbon
Colour Blue cylinder and blue RED ORANGE PURPLE YELLOW TURQUOISE
pipes
BGPC 0.74% 2.3% 12% 1.8% 1.4% 0.6% 0.42%
MAC 105% 0.77% 1.6% 1.15% 2% 6%
Liver Met 20% 2% 0.2% 5% 0%
Critical T 36.5
Vapour 5500kPa 256kPa 644kPa
Pres
Char Colourless, odourless, Aromatic, non-irritating, No vaporizer, open Irritating, non- Non-flammable, stable Aromatic, non- Non-flammable, highly
non-flammable, non-flammable, system, bottle plunger, flammable, more flammable, non- irritating, inert, needs
supports combustion unstable> thymol cheap, inflammable stable irritationg, unstable- heated vapouriser
breakdown @6%/hr in
sodalime
Induction Yes, with vapour. Yes No No Yes No
BP Decr Decr Decr Decr Decr Decr – less Decr
N+V Yes – CETZ triggered Yes – CETZ triggered Yes – CETZ triggered Yes – CETZ triggered Yes – CETZ triggered Yes – CETZ triggered Yes – CETZ triggered
Bronchi Dilation Dilation Dilation Dilation Dilation Dilation
ICP Incr Incr Less incr
Muscle tone Decr Decr mm. relaxation & Same as enflurane Dose dependant mm Decr
potentiate effects of relaxation
mm. relaxants
CNS Analgesic ↓Vasomot. & resp. ↓Tº Only vapour with EEG Δ consistent with Non-epileptogenic Same as enflurane @ the start of anaesth:
regulation. ↓CMRO2 analgesic properties epilepsy (eps. If pCO2 ↓CMRO2 & no effect transient ↑in symp
↑Cbf due to vasoD <32) on autoregulation hyperactivity for 2-
↓cerebral autoregul. Increase CSF Less ↑in Cbf 4min.
Post op. shivering production & reabs. ↓ production of CSF
↓symp. + vagal tone ↑Cbf
Met. 20% in liver 2-4% in liver, fluride <1%ofthe +/- 5%is metabolised: Almost no metabolism
1. oxidative:tri- ions excreted by the administered dose is 2 metabolites (1) hexa-
fluoroacetic acid kidneys. metabolised fluoro- isopropanalol =
2.reductive: liver damage,
cytochrome P450, (2)inorganic fluoride =
produce active renal damage
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

metabolites= liver
damage
CVS ↓Contractility ↓BP: direct myocrd. Greater myocardial Myocard suprr with ↓in Mild depressant with Maintains the cardiac
SVR=N Suppres. ↑arrythmias: suppression than stroke volume BUT small ↓ in BP contractility
suppr. cond. & halotahane. ↑HR compensates & Little ↓ in BP
sensitize to ↓myocard. O2 SV stays the same Dilate coronary vessels
catecholamines consump. “Coronary steal” Less dysrrythmogenic
↑HR: symp. Inh. Dilate ↓BP due to ↓HR phenomenon than isoflurane
cor. Vessels ↓myoc. Less dysrythmogenic
O2 demand VasoD:
skin & cerebr. Vessels
VasoC: slanchnic & sk
mm.
Resp Diffusion hypoxia Supress phar.& Lar. Resp depression Same as halothane Dose dependant resp Gas inductions Very pungent
↑Pulm a. resist. Reflexes. preceeds CV depression Dose dependant resp Forms CO in the
Second gas effect Brochodilatation. ↓tidal depression. ↑Secr depression system with the soda-
useful in children vol. ↓MV, ↑pCO2 if pt is lime if left for a period!
ventilated
Liver ↓bloodflow (aa.) = 2-4% met. To fluride ↓PV flow & ↑hep a
halothane hep. flow
Renal ↓ renal blob flow: 40% ↓renal blood flow ↓renal perfusion
Fluoride dep. Leads to
damage
Uterus Miscarriages Uterus: ↓tone As halotahane
&resistance to oxytotic
drugs
Notes BM Suppression. CO by-product in circle
Methionine synthetase system
inhib –B12
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Muscle relaxants
Drug Alcuronium Pancuronium Vecuronium Rocuronium Atracurium Cisatracurium Mivacurium
Trade Name Alloferin Pavulon Norcuron Esmeron Tracrium Nimbex Mivacron
Classification Alkaloid Isosteroid Isosteroid Isosteroid Benzoisoquinolone Benzoisoquinolone Benzoisoquinolone
Chemistry Quartenary Synthetic and highly Monoquartenary Similar to Vecuronium Synthetic Responsible for 65%
ammonium potent Pancuronium bisquartenary action of Atracurium
analogue ammonium
compound
ED95 0.2-0.25mg/kg 0.06-0.07mg/kg 0.05-0.06mg/kg 0.3mg/kg 0.25mg/kg 0.05mg/kg 0.08mg/kg
Description Clear solution Freeze-dried powder, Clear solution
stable
Solubility Water soluble. X cross barriers
Not fat sol> X cross
BBB
Dose 0.25mg/kg 01mg/kg 0.1mg/kg 0.4-1.2mg/kg 0.5 mg/kg 0.08-0.25mg/kg
Onset 3 min 1-2 min 90 sec 60 sec 90-100 sec 0.08 – 3.8min
0.16 – 2.5min
Duration 45min 35-45min 20min 0.6-0.9 – 45min 15-20min 0.08 – 15min
1.2 – 90min 0.16 – 20min
Mechanism Incr eff Incr Eff Incr Eff
Decr T
Histamine Yes Minimal None Minimal Yes – related to
Release speed of admin, dose
and known atopy
Cardiovascular Histamines> decr M block at SA node> CV stable Good haemodynamic
PVR> decr BP> tachy tachy No vagolysis stability
NA reuptake inhib
CI Renal failure Porhyria, MG, Steroid MG, hypersensitivity Scoline apnoea
CU, Tachy
Indications Caesarian sections Poor risk patients Renal and hepatic
disease
Metabolism Unchanged excretion 30% - liver 3OH Vecuronium Not metabolised Ester hydrolysis Ester hydrolysis Entirely renal and
in urine (water 70% - unchanged Hoffman elimination Hoffman elimination hepatic independent.
soluble) Metabolised by
PAChE
Excretion Urine 30% - bile Urine – 10-20% Biliary elimination
60-80% - urine Mainly – bile
Notes PAChE inhibitor Used in modified RSI: No reversal required No reversal required No reversal required
2-3 ED95> can cause
histamine release
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Surgery

Day to day:
Everyday There are discharges, ward work, assist in theatre, cover casualty and see pre-ops.
You work together as a team of interns, so split up the work, get it done.
Tell the pre-ops that you will only be there later when you see them in the morning.
That makes them less restless.
Wednesday You can assist in lumps and bumps clinic in the afternoon.
Friday Urology pre-ops needs to be seen

On call:
Post ward round discharges and ward work. On weekends you have to go fetch medication in casualty
Then: clerk patients in casualty. They are in a blue book called surgery
You must see ortho and urology patients then phone Reg to present.
Respond to calls to the ward for drips etc.
Assisting in theatre on call is the time where you will get excellent theatre exposure, be pro- active.
Usually at 07:00 you will present the ortho patients to the reg. Surgical ward round starts at 08:00 and all patients are seen.
Leave as soon as ward round is done. Help with ward work if still early.

Protocols:
Stab chest
Stab chest form (found @ sr. desk)
If precordial stab: ECG, fast
Pulses/nerves
Ward Hb if big bleed
Post-ICD X-Ray
Blueboard: Admit to chair, ICD protocol, FWD. Analgesia: Tramadol, Brufen, Paracetamol. No fluids
For abdominal stab: Dipsticks
Critical issues: Massive hemothorax >1500ml, hematuria, peritonism
NB! NB! Ask EC to teach you ICD drains and do as many as you can, there are tons to be done.

Upper GIT bleed

Cati score
Lansoprazole 80mg IV stat
Blueboard: Lansoprazole 30mg PO 12 hourly. NPO, fluids

Bowel OBSTRUCTION
Is there peritonitis?
VBG lactate
Catheter
FBC, UE
Erect X-rays, CXR, supine abdo: dilated bowel? Air in rectum?
Blueboard: Keep NPO, NGT. Fluids
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Appendicitis
Always P.V examination and dipstick.
Start on augmentin 1.2g iv tds

Cellulitis:
Cloxaxillin 2g iv 6hourly. Home on flucloxaxillin 500mg po qid

Urology:
If in urinary retention with NA <115 half normal saline, otherwise Normal saline
Urology post-op 3-way catheter, Wash out and irrigation
Post TURP patients blueboard and TTO
Sorbitol/ liquid parafin 10mg po 8 hourly x 1/12
Soflax/Senekot 2 tab po nocte x 1/12
Panado and tramadol

COMMON DRUGS USED:

Augmentin 1.2g 8 hourly IVI
Augmentin 1g 12 hourly PO
Clindamycin 600mg IV TDS
Kefzol 1g 6 hourly IVI 3 days (prophylaxis)
Sennekot 2 tabs PO nocte
Lactulose 15ml PO daily/8 hourly
Paracetamol 1g PO 6 hourly
Tramadol 50mg PO 8 hourly
Morphine 5-10mg PO 4-6 hourly
Ampicillin 500mg - 1g IVI by slow injection 6 hourly
Flucloxacillin 1g PO 6 hourly or 500mg PO 6hourly
Cloxacillin 1g IV 6hourly
Kefzol 2g IV 8 hourly (treatment)
Folate 5mg PO daily
Iron sulphate 1-2 tabs 400mg PO BD
Folate 5mg PO daily
Vitamin C 100mg PO daily
Pyridoxine 25mg PO daily
MVT 2 tab PO daily
Stemetil 12.5mg IM 12 hourly
Cotrimoxazole 2tab 960mg BD Bactrim
Amoxicillin 500mg TDS
Maxalon 10mg 8 hourly PO/IM
Vitamin D 50000 units weekly
HCTZ 12,5mg PO daily
Amlodipine 5mg PO daily
Midaz 10mg PO stat
Pantaloc 40mg IV BD, 80mg IV stat
Buscopan 1tab/10mg TDS
Zinc sulphate 20mg PO daily
Iron sulphate 200mg PO daily
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

OBSTETRICS:

Day to day (depends on where you’ll be working):

Gynae: See patients, round, complete consequent ward work. There is a Reg and a bunch of students.
Beware Thursday's: you are alone, you must see all patients by about ten, then a consultant will round
with you and give you plans
Labor ward: admissions, assist with Caesars
Theatre: get in by 7.30 show your face to theatre, then run up and start seeing post nates on 7. Your plan
will be discharge to 6th floor +\- anti hypertensives +\- hb and group and save. Call Reg for emergency/
pph
Clinic: starts about 8.30. See patients. End of list.

Rosters: Set up by obs intern. The family med interns will do cross cover.

Call
1) Admissions: Clerk new patients. Get their background, go into presenting complaint, examine and
comment on ctg. Decide if they will go home, walk around ward for 4 hours (latent phase), admit to l/w
(active labor)
2) check blood, do drips, assist with red tickets as called by the ward
3) do evacs.
4) assist in theatre if there are no students

Protocols
Analgesia in labor:
Good ctg, sign it, morphine 10mg imi, ondansetron 4mg imi. Tell sister.
PPH:
Call for help, look for cause, rub up uterus, synto in 20u in 1l ringers, consider miso and ergometrine.
Remember ergometrine has many contraindications

GPH:
Bloods: UCE, ALT, AST, LDH, Uric acid, Hb, platelets.
Blueboard 10 mg adalat if bp over 160/110 stat. Magnesium sulphate 4g in 200ml normal saline over
20 min if Reg decides it's indicated. Repeat 4 hourly

Emergency c-section:
Consent signed in book
IV line
Catheter (ask nurse/sister).
Fill out first 2 sections and hb on anaesthetic chart.
Make sure it's booked
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Common Obstetrics and Gynaecology drug doses

As compiled by Dr Elan Milwid
(Use only as guide)

Analgesia

Drug Dose Route Duration

Morphine 10 mg , 6-8 hourly IM
Tramadol 50mg tds PO

Labour

Drug Dose Route Duration

MGSO4 loading dose 4 g in 200 ml over half an hour IV
Aldomat 500 mg tds PO
Adalat ( BP ) 10 mg PO
Adalat (Long tocolysis) 30 mg Stat the 20mg after 90 minutes PO
then 20 mg 6 hourly
Salbutamol ( short tocolysis ) 1 amp in 5 mils and give 2.5 mils slowly IV
Betmetasone 12mg IM Every 24
hours
Ampicilin (Chorioamininitis ) 1 gram daily IV
Azithromycin(PROM when not in 500mg daily IV
labour )
Ampicilin (PROM when in 1 G 4 hourly IV
labour )

Post Op

Drug Dose Route Duration

Senacot 1 tablet daily PO
Clexane 40 mg daily subcute
Ridaq 12.5 mg daily PO
Enalapril 5 mg bd PO
Second line Enalapril 10 mg bd

Contraception
 Noresterate : 2 monthly IM
 Petogen : 3 monthly IM

Evac sedation
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Drug Dose Route Duration

Midazolam 2.5 mg / 2.5 ml IV
Fentanyl 100 ug / 2 ml IV

Antibiotics

Drug Dose Route Duration

Amoxicillin (UTI in Pregnancy ) 500mg tds PO 5 days

Flagyl 400mg tds PO
Cervical discharge syndrome
Flagyl 400 mg tds PO 5 days
Azithromycin 500 mg daily PO 3 days

Random

Drug Dose Route Duration

Jet Fuel :in 1 L Ringers
VIt B co 1ml IV
Thiamine 1ml IV
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Pediatrics
An excellent handout is given by the department when you start paeds, which will serve as your guide.

Calls:

Normal day until 16:00. From 16:00 you will cover C- sections and the wards. It is essential for you to
know how to perform neonatal resus. Ask the MO/ Reg to teach you and act quickly in theatre and
formulate an approach.

Always make sure your equipment is ready

- Neopfuff connected O2 supply and pressure is correct

- Machine is on with incubator working
- Extra blankets (Plastic bag for premies  < 32 weeks)
- Paediatric ambu bag. Check that it works
- Different size masks
- Laryngeal scopes with different blades (make sure lights are
working)
- Endotracheal tubes (different sizes)
- Suction (Make sure suction is functional)
- Drugs adrenaline is drawn up (1 amp of adrenaline in 9ml of
saline, withdraw 1ml in 1ml syringe- dose then 0.1ml/kg)
- IV line prepared with jelco in place.
- Heparin syringes for cord blood gasses on all resus babies NB
NB- ask sister for a loop of cord.

Resus protocol (As adapted form Neonatal guidelines and drug doses 2015)
Most NB! Remain calm, oxygenate ASAP. Call reg immediately. The most NB step is ventilation of the
lungs!!! Remember cord blood gasses!! 1.
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

,
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Family Medicine/ Psych

Common drug doses in emergency Medicine

As compiled by Dr Elan Milwid
(Use as guide)
Acute seizures

Lorazepam 4mg stat

Phenytoin loading dose 1.2 g Stat IV /PO
Sodium valproate loading dose 1.2g stat IV/PO

Conscious sedation
Ketamine 0.5 mg/kg -1 mg/kg IV Stat
Paeds 1mg/kg -3mg/kg IV Stat
Propofol 0.5 mg /kg but titrate IV Stat

Sedation

Etomine 40 mg IVI PRN/8 Hourly

Lorazepam 2-4 mg IVI/IMI/PO PRN/8 hourly

Jet Fuel

1 L 5% dextrose
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Vitimin B CO 1 mil/100 ug
Absorbic Acid ( Vitimin C ) 500 mg /5 mils
Thiamine 100 u g

Hypertensive Urgency / Emergency

Amlodipine 10 mg Stat PO
Hydralazine IV
Labetalol 200 mg in 100 ml saline @ 50 ml /hour and stop when MAP below 120 IV

Common drug doses in family medicine

As compiled by Dr Elan Milwid
(Use as guide)

Minor infections

Abscess / cellulitis
Augmentum + either 1.2g stat stat
Co- amoxiclav 1g Bd
Cloxacillin 250 mg / 500 mg Qid 3-5 days
STI syndromic treatment
Ceftriaxone 125mg Stat IV
Azithromycin 2g Stat PO
Flagyl 2g stat PO
URTI
Amoxicillin 500mg tds 5 days

Constipation

Siena /sneacot 1/2 tablets Daily Stool Softener

Glycerine suppository 1 Daily
Fleet enema Bd / daily for one day For stool impaction
Lactulose 15-30 mls Bd , Tds Increases GIT motility
Fibre Sachet PRN

Gastroenteritis

Buscopan 10 mg Tds PO
Maxalon 10 mg Tds PO
Loperamide 4 mg initially and then 2 mg With every loose stool
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Anal fissure /haemorrhoids

Fissure
TNT paste
Hemeroid
Anusol cream
Stool softner

Panic attacks

Lorazepam 2 mg PRN

GORD

Rinatidine 150 mg bd
Omeprazole 30 mg Daily
Metaclopramide

Eradication

Omeprazole 30 mg bd for 2/52 then 30 mg daily for 4 /52 PO

Amoxicillin 1 g bd 2/52 PO
Either :
Flagyl 400 2/52 PO
Clarithromycin 500 mg bd 2/52 PO

Analgesia

Panado 1g QID PO
Brufen 400 mg TDS 5/7 Max 2 weeks
Tramadol 50 mg TDS PO
Voltaren 70 mg IM Stat
Morphine 0.5mg/kg IV Given slowly mixed with saline

Eczama (with impetigo reaction )

1 % hydrocortisone cream (mylocort ) Bd

Prednisone 40 mg daily 5/7 PO
Phenegran 10 mg tds PO
Cloxacillin 1g QID 5/7 PO
 Compiled by Dr Francois Uys (INTERN Rep NSH 2016-2017)

Bactroban
Aqueous cream /petroleum
Emulsifying ointment

Allergic Skin Reactions

1% hydrocortisone Cream
Antihistamine : either
Allergex ( chlorpheneraime ) 4 mg TDS PO
Phenegram (promethazine ) 10 mg TDs PO

Allergic Rhinitis
Zyrtec ( cimetidine – non sedating antihistamine ) 10 mg Daily
Flomist ( fluticasone ) 2 sprays Daily
Prednisone If severe

Angio-oedema

Phenagren 25mg stat IMI

Prednisone 20mg stat PO

Acute Asthma

BAS nebs 1:1:2 Nebs

Hydrocortisone 200 ug IV
MGSO4 1 g IV stat

Derm
Tinea Fluconazole + Hypo/hyper pigmented
vesicollum Selsun shampoo pinpoint spots most commonly
on back chest and arms

Erythema Red/black macules on legs , Caused by TB , HIV

multiformans panful secondry to drug reactions ,
secondary to infection

References:
1. Jooley, Alan. Horn A. Neonatal Guidlines and Drug Dosages. 2nd ed. Cape Town, South Africa:
Kadima Print; 2015.