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Welcome to On The Wards, it's James Edwards and today we're talking about falls and we have the pleasure of having Associate Professor Mark Latt who's a geriatrician here at Royal Prince Alfred Hospital. Welcome Mark. Thank you James. So falls are a pretty common reason that a junior doctor will get called whereas they're working on an after-hours shift and I think because they're so common we thought we'd start with a probably a fairly typical case that you're a junior doctor, you're working on one of your busy shifts after hours and you're called to review an 80 year old female who has fallen whilst attempting to go to the bathroom. I think the first question I'd like to ask is when you get that phone call from the nurse, what sort of questions would you ask over the phone to help you prioritise how urgently you need to see this patient? I think the first question that doctors need to ask when they get called to see a patient is always what are the vital signs. What is the blood pressure, the heart rate, the temperature, the respiratory rate? And I think for aged care patients they should also ask about the level of consciousness and that should be a vital sign. So you can work out fairly quickly how urgently you need to see the patient. Other warning signs might be if there was evidence of head injury or head strike and obviously where the pain is. If they have pain over the spine or the hip or the chest that might be a relevant indicator that the doctor needs to go to the ward to see the patient quite quickly. So you've worked out that you need to go there reasonably urgently and you arrive at the bedside. Can you describe your approach to this patient who's had a recent fall? It's always a good idea to talk to the nurses and see what they observed and what they thought happened and then to talk to the patient. And the idea is you want to try and work out what are the circumstances surrounding the fall. What activity was the patient engaged in at the time when they had the fall? Whereabouts on the wall did they fall? Was it a slippery environment in the bathroom or were they walking towards the bathroom? And then the next step is to try and work out what the mechanism of the fall is. Was it a trip or a slip or did the patient have problems such as lightness in the head, dizziness, vertigo or syncope? So those would be what I would be trying to work out in terms of the history when I see the patient. And you can get a fairly good idea about what happened in under five minutes. Anything you'd then look for on examination? I think I'm probably harping on a bit about vital signs, but I think that's essential to know what the vital signs are, because that might tell you how urgently you need to investigate and what investigations you need to do. So definitely work out what the blood pressure is, what the heart rate and respiratory rate is. But as always in aged care, we like to know what the level of consciousness is, whether there's any evidence of delirium, in other words a fluctuation in the level of attention or level of consciousness. And then after doing a very brief or very quick examination, you want to work out what injuries have happened as a result of the fall. So this all involves a cardiovascular and neurological examination. In particular, if you've noticed that they've injured their hip or have pain over the hip, you might want to focus on the hip. You mentioned blood pressure. Is this a time to do a postural blood pressure or acutely after the fall? It could be done on a later date. I think with the postural blood pressure, you might warn the nurses that they should check it at a later date. And I think now's a good time to let them know that if the patient tries to walk or tries to get up, then they probably need more supervision than previously. What are your particular red flags after the patient has had a fall? Okay, so going back once again to the vital signs, if there's any hemodynamic instability, in other words, there's a drop in the blood pressure from previously, or if they're bradycardic or tachycardic, that might imply a cardiovascular reason for falling. If the patient is delirious, then the delirium could have contributed to the fall. And also if there's new neurological signs, that might indicate that there's either a complication of the fall, such as intracranial bleed, or else a new neurological event, such as a stroke or a seizure, has precipitated the fall. If you detect hypotension, then I think very close monitoring needs to be performed of the heart. If the heart rhythm is abnormal, tachycardic, bradycardic, irregular, in particular if this is a deviation from what normally is the patient state, then an ECG should be performed. And obviously if there's any evidence of soft tissue injury or bony injury, that might direct your further investigations and management. You've mentioned investigations. What investigation would you consider? I think the investigation should be tailored according to the mechanism of the fall. If it was a neurological event that led to the fall, then I think a head CT would be helpful. If it was seizure or if there was a history of seizures, then an EEG might be required either that night or at a later state. If the mechanism was a low blood pressure or an abnormal heart rate, then an ECG should be performed quite quickly. And I think if there's any signs of neurological disease or new neurological signs, a CT brain should be performed at that point rather than waiting for the next day. How about in regard to blood tests, full blood count, UECs, doing a urine analysis, do they have a role? It depends on when the last EUCs or blood tests were performed. If they were done earlier in the day then I don't think there's a need to repeat them unless you suspect the clinical condition has changed. If the patient is taking a lot of diuretics, then one possibility is that they become hypotensive. Also, they might have acute renal failure. That might be a good reason to repeat the blood test. If you suspect that as a result of the fall, there's been bleeding, then I think a hemoglobin might be worthwhile. But otherwise, if the blood tests were done recently and there's no reason to suspect that there would be a change in the blood tests, they could probably wait till tomorrow. Another blood test that's often considered by a junior is a troponin. Yes. The yield of troponin in this situation without evidence of the chest pain or without evidence of arrhythmia is not terribly high. So I think I would reserve a troponin test if there is evidence of cardiac ischemia, either the patient experiences or has experienced chest pain, if there is worsening heart failure, or if there's evidence of hypotension. And clearly, if there's evidence of an arrhythmia or a change in the ECG, then I think a troponin should be done. And my feeling is if you do one troponin, you've committed yourself to do a repeat troponin in four hours' time. I guess the next decision is do they need a CT brain or not? And I think you've elucidated the reasons why they'd do a CT. Is there any other particular, I guess, risk factors or considerations about when they need a CT? Yes. I think there are a few red flags and a few things that mean you should do a head CT earlier rather than later. If there's any evidence of head injury or there is a history of head strike, then I've got a very low index of suspicion for intracranial disease or trauma. So I would do a head CT in those circumstances. If there's any new neurological signs suggestive of a stroke or an intracranial bleed, then I think the head CT should be performed. And I've also got a very low threshold of doing a head CT on people who are on anticoagulation or antiplatelet therapy, in particular if the anticoagulation is therapeutic. So I don't think I've ever regretted doing a head CT. I can recall two occasions when I've regretted not doing a head CT earlier. And if the test is available, I think if there's head injury, neurological signs, or the patient is on anticoagulation or antiplatelet therapy, there should be a low index of performing the head CT. You say antiplatelet, that includes aspirin? I think that includes aspirin. So you have the choice of thinking, should I disturb the radiologist now if it's 2am in the morning, or can I wait later on when they come back to work? And I think that's probably where the resident needs to talk to the registrar who's on call to see what they think. |
Hi, I'm Josh. I think the real story goes when you really want to ask someone, you ask the other ICU fellow who's actually working this weekend, so then Josh gets stuck. No, I'm kidding. So we're going to talk really, really quickly about blood gases. We've only got 20 minutes. Blood gases are profoundly intimidating, and there's no way that we can get through everything just talking really quickly like this. The best way to deal with it is just to systematically look at hundreds of blood gases over your time. And gases are getting more and more commonly performed, so that's not going to be a problem. So, we're going to start with a quiz. I don't have any technical fancy schmerzy polling stuff. That's going to be old school, hands in the air. You've got someone who's got a pH of 7.4, so a normal pH. a CO2 of 20, so really quite low, a bicarb of 16, again, very, very low, and a base excess of minus 8. We're not really going to talk too much about base excess, but confirming this metabolic feature. So I want to see in the audience, everyone's got a vote, who thinks this person has a respiratory alkalosis? Nobody. There's going to be a lot of nobody, isn't there? Who thinks this patient's got a metabolic acidosis? A few hands. Very good. Who thinks they've got neither? A couple little hands. Anything else? No? Okay. Well, so there's four of you who are willing to commit. That's good. So the first process is to talk about an osis versus an emia. So I think there's quite a bit of what we wanted to highlight in this case. This person has a normal pH, right? So this often gets people a little bit anxious about committing one way or another. So the difference between a metabolic, or not just a metabolic, but an acidosis versus an acidemia, or an alcoholysis, an alcoholemia is quite important to establish up front. So an osis, for example, an acidosis is a process that would make the blood, if there was nothing else opposing that, would make the blood acidemic. An alcohoosis is a process that, if left unopposed, would leave the blood alcoholemic. That sounds really quite simple, but when we go back to this picture, we can see that this person has a very low CO2. If that process were left to go unopposed, this person would clearly become alkolemic. So this person does have a respiratory alkalosis, unquestionably. This person has a bicarb of 16. If that was left unopposed, then that would lead to quite significant pH drop. So this person does have a metabolic acidosis. Those questions are not controversial. The real problem with this interpretation is what the hell is going on with this patient? What is the primary process and what is causing that process? Because only once you've questioned that can you actually start to help to fix this person. And then we'll sort of briefly address talking about compensation. So is there a compensation mechanism working and how adequately is it working? Just really, really quickly, I want to just briefly address the ABG versus BBG debate because you'll get a lot of pushback, particularly from where I live, about people insisting on arterial blood gases as opposed to venous blood gases. I don't think anyone these days really minds that much, and anyone who does mind that much needs to pull their head out of their bum. The CO2 difference between an arterial and a venous sample are going to be really quite small, somewhere in the vicinity of 5 to 10 millimetres of mercury. Similarly for pH and bicarb, you're not going to have uninterpretable results from venous that don't translate across the arteria. Please don't ever mention a venous PO2. It's not helpful. It doesn't assist us in any way, shape or form in decision making about how sick somebody is, unless we're talking about mixed venous or central gases, but that's a completely different topic. So don't insist on an arterial gas and provide a little bit of resistance for someone who does try and make you insist on an arterial gas with a few caveats, right? So if you've got a specific oxygenation question, then that might be a valid reason to do an arterial over a venous gas. But what that's going to tell you over just your satis trace, I'm not sure. If the satis trace is reliable, that's just as good to tell you about oxygenation. Or if there's a reason why you don't actually trust the sample that you've been given. So if this had a very long tourniquet time in someone who is incredibly difficult to bleed, maybe there might be some change in particularly the metabolic parameters. So when we want to think about what our primary process is. We need to remember that there are the four main primary processes. Really simply speaking, we know that arterial CO2 lives somewhere between 35 and 45 in health. So we're going to say that quite simply, if the CO2 is lower than that, chances are they're tending towards a respiratory alkalosis. If it's higher than that, they're retaining CO2, they'll become acidemic, they'll likely to have got a respiratory acidosis. And similarly for the metabolic picture. So if the bicarb is less than that lower range of 22, then this person probably has a metabolic acidosis. Greater than 26, the upper range, then they've probably got a metabolic alkalosis. In terms of determining what the primary process is, the golden rule is usually that whatever pathological processes there are, they don't usually compensate all the way back to a normal pH. So if you're a little bit acidemic, chances are it's the acidosis that's the primary process and the alkalosis is trying to compensate back to normal. But I would really want to emphasize that the way to complete the picture is always with history. So we're going to consider some of these. As fascinating as respiratory alkalosis and metabolic alkalosis are, I've never seen anyone die from these, so we're not going to try and push those onto you, but clearly we need to talk about metabolic acidosis and respiratory acidosis. Respiratory acidosis is probably the easier one. In terms of thinking about causes, then it's quite simple. If your CO2 is high, it's either because you're not getting rid of it or because you're making too much. And that's quite simple. If you're not getting rid of it, that's either a central process, so you're hyperventilating for whatever reason, you're unconscious, you're drowsy, you're narcotized, etc. Or it might be a physiological problem, a respiratory problem. So there's an obstruction to your alveoli expelling the CO2 out. So COPD, asthma, etc. PE would be another reason why you might not get any CO2 out. And too much CO2 production, that's kind of, yeah, you're not going to see that too much. But the sort of things we're talking about are very hyper hypermetabolic processes. So, you know, tremendous, outrageous rigors, malignant hyperthermia, hyperviratism, etc. So that's usually not a particularly common reason for why you'll see someone with a respiratory acidosis, because usually they'll have a bunch of other metabolic things happening as well. When we talk about compensation, then unfortunately there's a whole bunch of complex rules. Don't bother writing this one down. You'll see it written anywhere. I think you should have a cheat sheet enclosed in your little learning package. If not, I've got some resources at the end. But there are equations for this sort of stuff. You know that if your CO2 is going up, your bicarb should go up in compensation to that. So the equation we deal with is your baseline 24 plus some sort of correction factor. And what this equation here is saying is that for every 10 that your CO2 goes up from normal, and normal we can say is about 40, then you'd expect your bicarb to go up by one if it's an acute process or four if it's a chronic process. So let's consider an example. You've got someone who's got a CO2 of 60. Their expected bicarb should be that baseline 24 plus the increase in their CO2, which is going to be 20, divided by 10, so that gives you two inside the brackets. So our expected CO2 is going to be 24 plus either two or eight. |
And if it's in between somewhere, who knows, probably a little bit of maybe acute or chronic or something that's a bit indeterminate. But what you do know is certainly if your bicarb got nowhere near 26 even, right, if your bicarb is still even lower than that 26, then there's some other process that's stopping your metabolic compensation. So that must mean that there's some other reason why your bicarb is being pulled down. This person probably has a concurrent metabolic acidosis as well. Mixed disorders are really quite tricky. We won't dwell on that for too long. So let's say you've found someone who you're pretty convinced has a respiratory acidosis, CO2 of 68 in the context of acidemia. what are you going to do with it? Because this is not going to be particularly uncommon. The most common thing is that the resident for the day team sent a blood gas and nicked off, and then the blood gas result has been called through because the lab took a little while to process it. You've come on after hours, and you're faced with this situation. You don't know the patient, and you don't know what to do. So what are you going to do? Are you going to call the respiratory registrar to see if this person is urgent, non-invasive? Are you just going to push the panic button, call ICU, or even worse, push the panic button and call everybody to come here right now? And the beautiful thing about this is that there is no right answer. The right answer is, what's the right answer always in these situations? You've got to look at the patient. If you see skinny Santa with this blood test giving you the thumbs up, you've got some time to figure this out for yourself. Does he have wheeze? Does he have COPD? Is he having a COPD exacerbation that might be leading to it? In fact, you could go all the way through to, does he always have a CO2 somewhere like this? does he have a metabolic process that's causing this instead? So you've got time to go through that, have a chat to your registrar, have a chat to the people who matter and think about it. But if you come and see Skinny Santa, oh, not so well, then that's the time that you would be activating for more help, okay? If this is the case, if this person's compromised with this picture, then they don't really need too much in the way of smarts. They need some action and some activity, and they need to be in the right place. So that would be my big picture to you guys, right, is that always assess the patient at the end of the bed, and if the clinical picture is concerning, call for help. Metabolic acidosis is a massive beast, and I don't understand it. I'll be up front, but I've got some tools that help me deal with it. So the first picture that we always talk about is a gamble gram. We add up the cations and the anions, and we see that in health, these are the predominant cations and anions in the extracellular fluid, and because we don't walk around zapping things, these have got to be equal. So when we take a traditional approach to acid base, as we already have, and we say that a metabolic acidosis happens when your bicarb shrinks, so when the dark blue shrinks, then we can see that there's two ways that you can end up with a metabolic acidosis. Either the red bit grows, so that gap between your positive cations and your negative anions, either that red bit grows or the light blue bit grows, your chloride grows. And that gives rise to the two types of metabolic acidosis we see, a high anion gap or a raised anion gap metabolic acidosis, a HAGMA, or a normal anion gap metabolic acidosis, a NAGMA. And we're going to consider each of these ones separately. NAGMAs are kind of rare but really quite complicated to go through from a lot of people. There's mnemonics and things that go on forever, but essentially there's only three causes. Either the kidneys are doing it, so that for some reason the kidney's not able to handle bicarbonate in the usual way that it does, and that's usually in things like granotubule acidosis, or in Addison's, where the distal tubule hydrogen sodium exchange isn't working properly. Or it's the gut's fault, so for some reason you're losing tremendous amounts of bicarbonate from bicarbonate-rich secretion as it happens in diarrhea or small-bill bowel fistulae. Or it's the doctor's fault. You did it. So you gave too much chloride. How do we give too much chloride? Usually in the form of normal saline. What's the chloride in the ECF? I don't have a Mercedes to offer you, but if anyone's keen, roughly? 100 and? 10? Yeah, so somewhere around the 100 mark, sometimes even up a range of 90, so somewhere around the 100 mark. And what's the sodium concentration of 0.9% normal saline? 100 and? Yeah, 154. Anyone between 151 and 154, right? So clearly, incredibly non-physiological. This is decidedly abnormal saline. So that's usually, with 5 or 6 litres of that, you can cause a significant acid-base disturbance. Whether that actually turns into a survival difference or not, nobody knows. So how do you treat a nagma? It's really important to know what the underlying problem is so that you can try and fix it. Avoid giving them lots and lots of chloride. That's always a good plan. And at times you might need to supplement the bicarb. But this is usually a chronic process that's not super hyperacute unless you've done it to the patients yourself. So the real big one is the raised anion gap, the HAGMA. It's up to you how you calculate your anion gap. For me, I don't consider potassium as part of my anion gap. I just use the sodium minus the sum of the chloride and bicarbonate, so the biggest cation minus the two biggest anions. and that gives me a number with a usual value of 12 with a range of 8 to 16, but I would really highlight this 12 business. If you do include K, you're going to bump those numbers up by 4, so a usual value of 16 with a value of 12 to 20. I do this for simplicity, other people don't. Once you've found that your anion gap is high, then you've got to wonder, well, what's causing that? And this is where, particularly in med school and preparing for first exams, you get these really long, I mean, another one I was told was mud sleepy, which is, I think it's got 13 things on it. Those are really thorough and important, but I think early in training, there's only really three things that you need to pay attention to. KL and U. So kill you is a pretty good mnemonic, I reckon. Keto acids, probably the most commonly neglected because you actually have to make effort to check them. So keto acids we can't forget about, not just in diabetes, but in alcoholism, starvation, these are really important generators of ketones. Ingestions, which, God, you're going to see this rare as hen's teeth, right? So this is the methanol, ethylene, glycol, salicylates, and so on. You're really not going to see these very much, so I'll put them to the side. But clearly lactate is a massive one, and you can't help but have a lactate measured 15 times during anyone's hospital stay because gases are getting done so frequently and lactate is just a nice cheap part of that. And urea. So we mentioned urea and every mnemonic uses u for urea. Urea is not an anion. Urea does not actually add into that red thing there. What we're talking about is all of those anions that would normally be excreted by the kidneys, all the sulfates and phosphates that when you've got a crappy GFR, those aren't being dealt with and they accumulate. So renal failure is an extremely important cause. So KL and U, okay? KL and U, really important to think about because only by identifying those can you go anywhere in actually fixing the problem. We'll pause for one minute just to talk about the relationship between your anion gap and albumin. And this is something that's a little bit tricky to first get your brain around. |
In normal settings, a good chunk of your anion gap is made up from the negative charge that's on albumin, the most abundant protein that lives in your plasma. So that means that if your albumin drops, that when you're looking at the actual collection of unmeasured anions that you're actually interested in, right, those that kill yous, then if your albumin is lower, even if you've got the exact same anion gap from this case to this case, the actual effective size of your unmeasured anion group is significantly larger. And that might actually take you from a normal gap to a raised gap. So there's got to be some correction factor for albumin. And there is. And it's pretty simple. The way you correct for a low albumin is to take your normal anion gap and add a little bit. How much do you add? You add a quarter of the difference to your normal albumin, where a normal albumin is taken at 40 grams per litre. So let's do that by example. Let's say your anion gap is 12, so plumb normal according to my usual scale, and at albumin that's 20, so about half of what it usually is. So your corrected gap is going to be 12 plus a quarter of the usual difference to 40. So your difference is 20, a quarter of 20 is 5, so 12 plus 5, all of a sudden your normal gap has turned into a possible significant raised gap. And that changes how you hunt for things. Can you have both? Can you have both a raised gap and a normal gap acidosis at the same time? I mean, graphically speaking, of course we can. Both the red and the light blue can grow. So wouldn't it be nice if there was a way of telling the contribution of each one? And there is. So let's consider a pure raised gap acidosis, a high gap acidosis. So in this instance, the size of which the red gap has actually increased, if it's purely a raised gap acidosis, then the increase in the red should be purely matched by the same decrease in the dark blue. Make sense? Yeah? That should be a one-to-one match. So your change in your anion gap, your delta anion gap, should be the same as your change in your bicarbonate. Or, written another way, if you consider the ratio of the change in gap to the change in bicarb, that ratio is one. Okay? Nice and straightforward. But if you consider a normal gap acidosis, so this thing that we have, this ratio here is what becomes referred to as the delta ratio. So if you look at a normal gap, so even if that anion gap has raised a bit, it's raised a really small amount, but your bicarbonate has changed a lot. So when you look at that ratio, the numerator has changed a tiny bit, but this change is quite large. So little thing over big thing, that's a tiny number. So experimentally, what's been determined is that if you find that this delta ratio thing has a value less than 0.4, chances are you're dealing with a purely normal anion gap metabolic acidosis. If it's one or greater, chances are you're dealing with a pure raised gap acidosis. And if it's somewhere in between, then it's probably a mixed picture. Now that seems a bit subtle, but when you're actually going through this stuff, it helps in terms of guiding therapy. I think if you get to the point of saying this person has a normal or raised gap, then everyone's going to be extremely impressed with you as junior doctors, but that's really important. Notice that in the last 10 minutes of talking that we've done, when we've been talking about metabolic processes, we haven't once mentioned pH, and we haven't once mentioned blood gas, which is the whole topic of this talk. So the most useful test when you're evaluating metabolic acidosis is what? Where have we been able to get all of these values from? Bicarb, sodium, potassium, chloride. EUC, right? The EUC is crucial. And probably one of the most, the thing that probably tells you how long you've been in ICU training for is how often you see this happen. That a bicarb on routine bloods just gets ignored because, you know, you use the surgical registrar's but have no clue what it means. And the medical registrar just wants to pass it on until it's not a problem anymore. Because usually these things take it better on their own. So here's a great example, right? Here's a great example. You get your morning bloods. And when I was an intern, I was told when you're documenting on your ward round, get the bloods down, but just make sure you get the important ones, sodium, potassium, urea, creatinine. So you'd actually just get the first two numbers, jump down, and go urea, creatinine. So if you did that, you wouldn't be paying attention to this quite significant result here. So this person very likely has a very severe metabolic acidosis. Does anyone want to add anything on top of that? Anyone want to make an advance? This is just on your routine EUC. What would you go to next? Anion gap, fantastic. Does anyone want to stab at what the anion gap is? So 140 minus 100, that's 40, minus 12, 28. Is that big, small, normal? That's big. So this person, just on their routine morning EUC, you've found a very significant raised gap acidosis. So your brain shouldn't then be, oh my God, what does the blood gas show? Your brain should be, crap, what are the causes of this raise and I get metabolic acidosis? Yeah, I'm going to get a blood gas, but not to tell me about how acidotic I am. I'm going to do it to tell me my... Yeah, lactate, right? You want to get your L out of the way. How are you going to get your renal function? You already know that on your EUC. And the one thing that's left to check is your ketones. So that person should probably get a finger prick or a urine, whatever you've got available to. Does that sort of make sense? So that's without a blood gas. So this session doesn't have to be blood gas as this session is just acid based in general on routine wise. There is a degree of compensation that happens. You blow off CO2 as your bicarb falls, as you become more acidemic. Again, don't worry about this. You'll find it in your handout. Let's just go through a quick little example. If you've got a bicarb of 12, one and a half times your bicarb then becomes one and a half times 12 is 18. So plus eight plus or minus two. So 18, so 24 to 28 if you just very quickly go through these numbers. So, your CO2, you expect your CO2 to be somewhere between 24 and 28 if you had a bicarb of 12 like that in the last example. So, that means that if your bicarb is, so if your CO2 is greater than that, does that make sense? If your CO2 is not as low as you want it to be, there's got to be some other process preventing your CO2 from getting down to normal compensation. So that means that there's probably a respiratory acidosis on top of that. It's another one of those mixed disorders. And if your CO2 is lower than that, then there's something driving you on top of just compensation to blow your CO2 even lower than what you expect it to be. So there's probably a respiratory alkalisys on top. Don't worry too much about that. This is sort of exams, making sure you get all the right answers to download. So to conclude, this was all bullshit. So all of these rules that have been, that we talk about with compensation rules and Boston criteria, all this sort of stuff are derived out of healthy volunteers billions of years ago and I don't think this is the sort of thing that you could introduce now but it's really quite useful. The real reason why everything I've told you is a lie is because bicarbonate is a load of nonsense. So there's a very, this common concept that everyone has is that one molecule of bicarbonate and one, sorry, one bicarbonate ion and one hydrogen ion fuse together and give you one molecule of water and one molecule of CO2 that gets breathed out. That's clearly got to be nonsense. |
Hello and welcome to On The Wards. I'm Sarah Dalton and today we're talking to Mary Dobby about sexual assault as it presents in the ED. Welcome, Mary. Thanks, Sarah. Mary's worked in the day and after hours roster in the Sexual Assault Service at RPA and Liverpool hospitals in New South Wales since 2012. The RPA Sexual Assault Service is geared to provide a joint medical and counselling response for clients reporting a recent sexual assault and sees patients aged over 14 years. Thanks for joining us today, Mary. Maybe we can just start with what is sexual assault? It's actually simple. It's any sexual act that is performed without consent. And that consent has to be freely given. So you can't force someone to give consent or threaten them with killing their dog if they don't have sex with you or something horrible like that. And you can't coerce them into sexual activity. And there are some clients who can't consent. So children obviously can't consent. Anyone under 16 years of age is unable to give consent to sexual acts. And some people may have acute mental health problems that make it impossible for them to consent or things like intoxication, which would give you a sort of a transitory inability to consent. So there are conditions around that kind of free consent. I understand. And certainly in an emergency department, unfortunately, it does seem that we see these presentations relatively frequently. Perhaps you could talk a little bit about how common sexual assault is. It is common. It's probably hard to be very exact because people believe it's widely underreported. But in Australia, the estimates are, the Australian Bureau of Statistics estimates, are that one in five women experience some form of sexual assault, whether that's a rape or other forms like an indecent assault or stalking or interpersonal violence. So it's very common. Worldwide, the World Health Organization estimates one in three women. So that's 35% of women have experienced either physical or sexual violence in their lifetime. It's huge. That's terrible. Certainly, it's something that's discussed a lot in our community. And I know there's some discussion about rape myths. Can you explain a little bit more about that? I think it's really important that you're aware about the myths that exist around any area, basically, but especially around sexual assault, because if you don't acknowledge them, they result in shame and blame for the victim. And they are very common also. So people often believe that only certain types of people get assaulted, you know, that it's the way they dress or it's because they had a drink or whatever, you know, but it's not true. We see a vast range of people in our service and very widespread of ages as well. There's a belief that it's usually a stranger who perpetrates the assault and actually 90% of assailants are known to the victim. So that's only 10% are strangers. So that's a really common belief as well. The other thing that we get commonly is that people are not believed if there wasn't some sort of struggle or physical violence associated with the assault. I guess other people sort of still have that kind of thing that women in particular say no when they mean yes and that that's sort of some sort of gender game. But again, that's not true. There's another belief that men don't get raped. And again, we see more women than men, but men do present to the service. So men certainly can get assaulted. And I guess the other one is that people often don't think that if you're in a marriage or if you're working as a sex worker, that you can't be assaulted. And that's also untrue. Can you tell me more about what the impacts are of sexual assault on victims? Well, sexual assault's a very traumatic and violent crime and really does violate a person's personal boundaries just profoundly. It does have short and long-term effects on the person. It has physical effects, mental health problems, sexual health and reproductive health issues. In some settings, you might be more at risk of acquiring a sexually transmitted infection or even HIV. We've got Australian studies showing that women exposed to sexual violence have double the rate of mental health disorders. So we're talking about women with a history of sexual assault having mental health disorders up to about 60%, which is just enormous. So in an emergency department, they may repeatedly present with depression or anxiety, unexplained physical symptoms, substance abuse, post-traumatic stress. The history of sexual assault is associated with disability, poor quality of life and other disadvantage. And as I said, I know that it is unfortunately a relatively common presentation to an emergency department. And I guess many of us are very aware of the impact on patients and are concerned for them and to ensure that our interaction with them is appropriate. Can you tell me what your advice would be about how we should talk to patients who are victims of sexual assault? I think the one thing that comes out over and over again when you read interviews with women, and again, most of the literature is about women, so I don't mean to imply that men don't present, but overwhelmingly it's women. But being believed is the number one thing that people want from the person who's responding to them. You need to have a private facility or an area to talk to them because you're talking about very personal stuff. It's not possible to do that in an open ward setting. It's not possible to do it in front of other family, friends, support people. Usually it's not helpful to have anyone else there but the patient, the counsellor and the doctor because you need that privacy and you need that safety and you want to validate them for coming to you and seeking help. They might be very stressed. They might be kind of very confused and jumbled and not very coherent. You've got to sort of accept that this person's coming from a very traumatic experience and that that lack of sort of organisation is quite a normal reaction after stress. It's not their fault. Reassure them that sexual assault's a crime. You know it's not their fault. Don't forget to do the simple things like introducing yourself and explaining everything slowly, step by step, so that the person who is already traumatised isn't also confused by what you're proposing. Things like saying, I'm just sorry this happened to you. It's okay now. I'm glad you're here. It must be difficult. It's not okay this happened to you. Those sort of reassuring statements in that sort of private safe setting are really important. So somewhere private, be reassuring, validate their concerns. And, you know, I guess for many of us in emergency departments who aren't expert in this area, it will require calling help. So can you perhaps tell me what happens when a patient presents to a triage desk in an emergency department and what should happen after that. Okay, so patients can come in in an ambulance or with police or they can self-present. So they could walk in the door. But at Prince Alfred, if they tell the triage staff that they've been sexually assaulted, they still need medical clearance, okay? So anyone who presents with a history of sexual assault has to be medically cleared before they get referred for the sexual assault service because medical care is always going to override any of their forensic issues. So that's number one. So there are options if someone presents for triage and needs treatment, medical treatment, and the forensic assessment will be delayed, then there are ways to preserve evidence, which we can talk about if we've got time. But usually the triage assessment is going to ask those sort of simple things like when did the assault occur? Is there any other information from police or from the ambulance officers? Knowing whether the patient's got pain or bleeding anywhere is really important. You want to be managing their pain and distress from the start. History of any pressure on the neck or strangulation history is extremely, extremely high risk assault, extremely dangerous. If you get any history of someone having been choked, they need medical clearance. That's really, really red flag, okay? You can ask about a history or any record of mental health problems. Other thing is whether there's any security risk for your staff. Obviously, that's important. Whether the police are there, whether the patient's intoxicated, because we were talking about consent before, and intoxication kind of goes both ways. You can't consent to a forensic procedure if you are too intoxicated. So that's important to assess. So they need their regular OBS, triage OBS, blood pressure, heart rate, that sort of stuff. So it seems to me that there's a lot of things that you need to consider and the medical clearance is number one. And I guess in emergency departments, we do medical assessments all the time. |
But after that, we're going to need your specialist expertise as a sexual assault service. So how does someone go about contacting a sexual assault service? Well, usually there's a team, there's a dedicated intake person. At Prince Alfred, the intake counsellor is the person who's contacted. So usually SWITCH calls the intake counsellor and the intake counsellor coordinates the response. Usually with our team, they expect to have a short period of time, about 20 minutes with the patient on their own for private confidential counselling issues because you've got to be aware that anything that goes in your medical notes may go to court if this proceeds down the track to, you know, down a legal pathway. So the counselling time is a privileged time. It's a short window and then the medical sort of team is called in and responds that way. So at Prince Alfred it's easy, you get switched to call the intake counsellor and they coordinate everyone else to turn up. I want to say it is a free service because the patients we see are victims of crime so that's something a lot of travellers worry about and travellers are a vulnerable group so definitely there is no charge if you're a victim of crime so even if you don't have card, even if you're a traveller, you can see the sexual assault service and know it's a free service, be reassured. Okay, that's fantastic. Maybe we might just talk about an example case then, and it could well be a traveller, as you've said. Let's say there's a 19-year-old woman who's presenting in the emergency department after she's had a lot of alcohol the night before, and she tells you that she's actually got a really poor memory of the events from the previous evening and in fact has no specific memory of a sexual assault. But she's reporting that her vagina and her bottom are really sore. And she hasn't really thought a lot about what might have happened, but she's coming in for assessment. Sounds like a bit of a challenge and one that I think many people would think, goodness, how will I help here? Where do you start with this case, Mary? You start by introducing yourself and getting some rapport, like we discussed above. The history of memory loss means that you've got to consider what caused that memory loss. Like intoxication, given she's given, you know, she knows she drank a lot, is high on your list, which means you do have to check she's currently not intoxicated before you go any further. But you've got to consider other medical causes for memory loss. So, you know, you could, again, strangulations are really concerning injury that can cause memory loss, a head injury, all those things. So don't forget your medical causes just because this is a sort of a history that will direct people down that sort of sexual assault pathway. It might actually fall to you as the doctor in this case, in this setting, to actually raise with this woman the possibility that some sort of sexual assault might have occurred for the period where she has no memory. She might be unable to kind of go there herself, but she's telling you she's got vaginal and anal pain, so that's going to be in your head. You're going to be thinking about it. And you might have to say to her something like, you know, that when you see someone in the emergency department with a memory loss and with symptoms like the vaginal and anal pain, that you have to consider the possibility that some sort of sexual event might have occurred while she was intoxicated and sort of go from there. So you talked a lot about consent, and I know this might be a big challenge, but say you do get consent in this individual, what do you do next? Okay, so we have a separate area in the emergency department that's completely private and which is not used by any other staff. So it's forensically clean and it's also safe for us to take the patient. So we will take the patient around to our examination area. And my first step is to go through all the medical history. I will make a note about the person's lucidity, I guess. So you want to make a note saying the reasons you think that they're not intoxicated or they're not suffering in any way and unable to get consent. So there's got to be some kind of comment about their coherency and their ability to proceed with the examination. But if you start with the medical history, the general stuff that we're all really comfortable with, it's less threatening for you and it's less threatening for the patient. And that gives you time. So you want to know when their last period was, what contraception they're on, or if any, are they vaccinated, particularly Hep B, tetanus, you know, they're the sort of common issues, and just general past medical and mental health history and any medications. If you're moving then onto the history of the assault, you're going to be starting by asking the patient to give you a history of what's happened in their own words, okay? For this lady, we've discussed in the case, she's telling you she has no memory. That doesn't mean there's nothing you can write down, okay? You want to know when her last memory was and you want to know when the next clear memory is. So you can kind of try and get some sort of timeframe around that window of memory loss. Don't presume she was unconscious in that window of memory loss. Don't write, you know, unconscious for four or five hours, because she could have been walking around quite functioning and talking and walking, but have no memory. You're going to consider drink spiking in this lady, because we're saying we've already ruled out medical issues. But bear in mind that alcohol can cause memory loss and it is the most common drug used in our community. So it may well be that alcohol is the only drug that has been used. You need to keep on checking in with the patient as you go, that they're managing the questions that you're asking and that they're not overwhelmed and just sort of that kind of reassuring them that at any stage if they're tired or exhausted they need to tell you okay so you want her to tell you what happened in her own words but you're going to have to clarify as you go because patients will often give you a really long history about how many drinks they'd had at the pub on the corner of King Street and then they went to Missenden Road and then they went there and none of that really is relevant in the sense except for the number of drinks I guess and then they'll get to the bit where they say and then and then he raped me and they don't want to talk about that at all so that's where you have to then be more directed in terms of what questions you ask And if you were talking to someone who did have a memory of the events that had happened, firstly, if you are asking the directed question, write down what you asked. Because again, we're just thinking that sort of in terms of if this does go to court, which actually is quite unlikely. But if it does go to court, it's good for the legal system to know what you asked and what the patient responded to in their own words and what was the patient's own story without your interference in any context. So if you're asking directed questions, write that down and write their answer. And so then you're going to ask about when the assault occurred and where it occurred. Things like was it in a bedroom, was it in a park, what time that was that the assault occurred. So this is sort of moving into a more general for people who have a memory of what happened. The number of assailants, were there any threats made during the assault? Was there any conversation that the person remembered? Anything that they might have said to indicate that they weren't consenting. It is important that you're explaining why you're asking these intimate questions because they can be really confronting. If there was any weapon or any force used, who took clothing off, how the clothing was removed. And you need to specifically ask what areas were penetrated and by what body parts. So, you know, you can't just say he put it in and leave it at that. You've got to say, look, I'm really sorry to push you on this. But when you say that, do you mean he put his penis in your vagina? And you need to go through and say, was there any other body area? Can you explain why it's so important to ask those specific questions? Because it's important for us in terms of where we take swabs from for forensic purposes. So you want a history of where penetration occurred, so you swab the right areas. There's also timeframes and things in terms of forensic swab collection. So different sexual acts will leave DNA evidence for shorter times. For example, skin cells are only able to be collected for about 12 hours after the event. |
Welcome to On The Woods, it's James Edwards and today we're talking about hearing loss and we're welcoming back Dr Joel Hartman. Welcome Joel. Thank you. Joel is an ENT registrar currently working at the Sydney Adventist Hospital and Joel previously spoke to us about the Sawyer which was a surprise hit for Odd the Woods. Joel were people stopping in the street after the Sawyer podcast? It's been a rock star lifestyle ever since. Fantastic that what I want to hear, Joel. So we're going to talk about hearing loss, which is obviously very common in the community, but I must say probably not something that junior doctors get asked to review or see within the immense number on the wards. But we thought we'd go through a couple of cases, particularly explain, I guess, some of the underlying pathophysiology or a way of classifying hearing loss and then go into some cases. So maybe we'll start, Joel. I mean, we often talk about chest pain, shortness of breath, how we have a general classification on how we should view those conditions. How about hearing loss? How do you look at hearing loss? The most important differentiation for hearing loss is being able to classify it into a conductive loss or a sensorineural hearing loss. And the reason that's important is because it determines, one, the investigation and treatment that you're going to have, but then also the urgency that you need to do both those things with. So conductive loss, the majority of causes are non-urgent, whereas in ENT we treat sensorineural hearing loss as a relative emergency. So in regard to, we may go up how we differentiate those, what are some of the common causes of conductive hearing loss? I think the most common cause that the junior doctors will come across are things like infection, so otitis externa, otitis media, also wax impaction is a common cause especially in the elderly patients that have a bit of underlying hearing loss, foreign bodies, pieces of hearing aids, earplugs, things like that. And since a neural hearing loss is a very broad category, and you've got to keep an open mind, and things that we need to exclude are things like strokes and infections and tumors and autoimmune diseases. So you've got to have a fairly broad mind when you're dealing with these sort of patients. And we did notice that hearing loss is more common in the elderly. Why is that? As you age, the organs of hearing deteriorate, like the rest of the organs in the body, I guess. So you can get what's called presbycusis, which is usually a high- a high frequency slowly progressive hearing loss in the elderly it's usually bilateral and it's one of the more common causes of sensorineural hearing loss okay why don't we go to a case and then we can just explore some of those broad categories in more detail a 67 year old smoker reports three days of hearing loss following an admission with an effective exacerbation of COPD with a benign pneumonia and a UTI. He was given a benzoyl penicillin and also a dose of gentamicin in the emergency department where he became more unwell. He is now just taken as a moral antibody but has a background of some vascular risk factors including diabetes and some chronic kidney disease. The patient really only noticed the hearing loss this morning on the right side, also with a bit of tinnitus, but didn't really mention the consultant the ward round, but has told the nurse and the nurse has asked you, the intern on the team, to come review the patient. Is there anything else you may want to ask the nurses over the phone, maybe before you go see that patient? Yeah, this is quite a common sort of scenario where the hearing loss is mentioned almost incidentally. And something that you'd want to get a sense for is whether there's any sort of other signs of focal neurology, which the nurses may be able to help you with, slurring speech or obvious facial weaknesses or limb paresthesia, things like that. It obviously increases the urgency of your review. So they don't seem to have those things, but you come and see the patient. What are the important positives and negatives on the history for this patient that you'd be particularly asking about? I think the main thing about this patient is that he has a bronchopulmonary infection and we very commonly see lower upper respiratory tract infections resulting in hearing loss and it almost universally fits in with the conductive hearing loss. And the main reason is that almost 100% of cases when you have an upper respiratory tract infection, your middle ear produces fluid, and that impedes the transmission of sound, so you then get a conductive hearing loss. And given this gentleman's history, that's what I'd be thinking for most of my mind, that he's probably got an otitis media. Okay. I mean, we have mentioned bad kidney disease and gentamicin. Yeah. Does that raise any alarm bells? I think most junior doctors know that gentamicin can be bad for the ears, and it certainly is one of the ototoxic drugs. So you do want to have that in your mind when you're going to see them that maybe we have induced a central neural hearing loss. Also anyone with significant cardiovascular disease, you need to keep in your mind that whether they've had a thromboembolic event or microvascular problems within the, which could be contributing to their hearing loss as well. So what other kind of particular things would you ask for in history? So you want to know about the duration of the pain, how it fits in with their current illnesses, whether they've had any discharge, whether their hearing loss is fluctuant or fairly constant. Then you want to ask about other things like dizziness and vertigo, as well as vision changes, changes in sensation and strength. Because all these things will help determine where you go to next. We may talk about red flags a bit later. Are there any particular red flags in this case that would warrant an urgent ENT review? I guess as we sort of talked about, you've got to be thinking about microvascular complications, which probably not so much ENT, but maybe other early specialist review if you are thinking along those lines. We'll go back to the case and I guess when you ask a few more questions, it had been a bit of pain and fullness in the right ear, no vertigo, unsure when it started but probably noticed it only this morning, no discharge from the ear and it's had a bit of runny nose and a sore throat from the coughing. Maybe we'll go into a bit more detail about examination. I mean, what would be the expectation of what an internal resident can do when examining someone with hearing loss? So I think that, as we talked about, it's important to have a broad approach so you don't just focus on the ear. You want to do a general neurological exam with cranial nerve examination, which I think most interns and residents would be fairly comfortable with. In terms of moving on to examining the ear, you want to look for overt signs of infection externally. You want to assess what sort of level of pain and tenderness they have. And then moving on to things like tuning fork tests, I think that most junior doctors could certainly give that a go. No one will hold them to necessarily getting the right answer. And same goes for otoscopy. It's very helpful for us if the junior doctors can have a look in the ear, even if they're not 100% sure what they're looking at, but if they can tell us, look, it's really swollen and red, or there's lots of pus or things like that, that helps us over the phone as well. Maybe we'll go to that, you know, the tuning fork test, which I'm sure I had to know this some stage. is there a special tuning fork you use for this test versus the one you use for determining whether someone's got peripheral neuropathy? We tend to use a 256 or a 512 hertz tuning fork and either is fine, whatever you can find on the woods. I must say finding one on the woods can be quite challenging. Yes, that's often the biggest hurdle. Tell me how you do the test. Alright, so you position the patient so you're sitting in front of them. The Weber's test is the first one that I do and it involves setting off the tuning fork and then placing it in the midline, so on top of the head, on the forehead. And you're looking whether the sound from the tuning fork lateralises to one side or the other. What is normal? So normal is the patient hears it in the middle. So it's neither louder or softer on either side. Now the interpretation needs to be taken into consideration with what the problem side is. The Weber's test is not a good screening test. We use it to help localise. In this gentleman, for instance, his pain was on the right. |
And why would you hear it better in the ear that you've got conductive hearing loss? Yeah, so that's a good question. So the process that's causing the conductive loss actually acts as a bit of a masking. So then your brain is then interpreting that side louder because you haven't actually got the external or ambient noise contributing. So conversely, if you hear it on the other side, or on the good ear, then that's more suggestive of a sensorineural hearing loss. So that's a Weber's test. That's the Weber's test. The Rene's test is, again, you set off the tuning fork, and this time you're comparing between conduction, bone conduction and air conduction. So you're placing the tuning fork tips in front of the ear, and then the base of the tuning fork behind the ear on the mastoid tip, and you're asking the patient whether they appreciate a difference, whether one's louder than the other. And so in the normal hearing ear, the patient should hear the tuning fork tips And if it's sensory or neural loss? There'll be a gap between them and that's part of what an audiogram also looks at, looking at that difference between the air and bone conduction. It'll be reduced on both? Yeah, exactly. Okay, now is there any other kind of test you've found in tunings for, I've heard of kind of whispering tests, hum tests to try and lateralize which side? Have you used any of those? Yeah, so I'd encourage the junior doctors to, in their conversing with the patient, try and get a feel as to whether they think the patient's hearing them well or not. If they're constantly asking them to repeat themselves and things like that, then that's a fairly crude test. And then the whisper test is the same thing. It's looking at speech discrimination. So you stand behind the patient, and then you whisper something in their ear while distracting the other ear. And the distraction's usually rubbing the tragus. And you give them a set of a couple of numbers to remember. And then you ask them to repeat them too. And you can compare sides. Okay. And in regard to doing the otoscopic examination, any tips on how to do that? I think the most important thing, and I've seen a lot of interns get stuck doing this, is that they don't position the patient properly, so then they're trying to bend in to see the ear and making it hard for themselves. It's much easier if the patient's sitting up, so that you have easy access to the ear. You can look around the ear and you can move from side to side. I always tell people to be gentle. If they have infection and things, their ear is very sore, very tender. And then when you're advancing the otoscope, make sure you're anchoring your hand that's holding the otoscope. If patients flinch, you don't want to accidentally be rubbing the speculum against the root canal or giving voice into the tympanic membrane. And don't be discouraged if you don't know what you're looking at. Any sort of information that you can give is good. A lot of people find that when they look in there, all they see is wax. And so what I generally recommend is to move the otoscope around. Sometimes you're actually just looking at the back wall of the ear canal and by changing your angle you get a better view. I generally wouldn't tell people to try and clean the ear. I certainly wouldn't tell any junior doctor to attempt syringing or suctioning the ear if it's not something they've done before. And you kind of pull the tracheas down, up? Yeah, exactly. Again, that just goes in with the positioning. Everyone's ear can be slightly different, but generally I find it easier if you have hold of the helix or the pinna and you pull it posteriorly. Posteriorly, okay. Great, so we've got a bit of chance there looking in the ear and what you can see. If you can see wax, probably just try and get what information you can without trying to remove the wax. Okay, is there anything else in particular that you'd suggest in regard to once you've done an examination, when would you consider that they needed some investigation? So say for instance in this patient the Rene test was negative on the right and the web is lateralized to the right and you've found some fullness behind the tectamic membrane and you're concerned maybe they've got a kind of otitis media. Any other investigations you need or require? At that point for this patient, I wouldn't given that he has got a history of infection and we know that very commonly you're going to have a fusion. So at this point, it would just be supportive management, pain relief, treat the underlying infection. For this I wouldn't request for the blood work or imaging. I would give him time to see that it resolves. Okay. And regard to follow-up, what's the kind of anatomy you should do when it should resolve? It can take up to a couple of weeks to fully resolve but if they haven't noticed any improvement within those couple of weeks then they should be probably referred on for at least a hearing test or plus or minus an ENT assessment as well. And when would you consider referral for something like this? So I think that if you aren't confident that it's infection but there's a conductive loss that persists beyond a couple of weeks then they should definitely be referred to us. If there's someone that suffers recurring infection then it might be worthwhile getting our advice or at least letting us see them in hospital. And if it's developed, or if you're concerned about complications, so otitis media can develop into mastoiditis or intracerebral abscesses and all those sort of terrible things. So if there's any sort of suggestion that it's more than a uncomplicated otitis media, then we should be involved. Okay. And for otitis media, antibiotics, is there any other, what do you normally give? Do they need oral antibiotics okay? So this gentleman that we're talking about is being treated for pneumonia and he's on Augmentin or a penicillin-based antibiotic, which is perfectly fine. If it's just the ear infection, I wouldn't give any antibiotics or antivirals. I would just, it will resolve with time. Okay. And just in regard to, I mean, do they need eardrops for otitis media, or is it really just otitis externa that you consider eardrops? Exactly. I wouldn't routinely give anyone with otitis media eardrops. What we may go on to some other cases and brief cases and just really trying to work out particularly looking at things like what are some red flags for sensor and neural hearing loss. First patient somebody's got a history of atrial fibrillation and it's come as in chest pain and then has incidentally noticed some acute hearing loss with a bit of vertigo and unsteadiness, some of those things you mentioned before. The vertigo and unsteadiness got better but the hearing loss has remained. And you'd examine them, it looks like a set of neural hearing loss. I mean, an arthroscopy look pretty normal. What could be going on here? Yeah, I think the thing that this case demonstrates is someone like this who's obviously a high cardiovascular risk, you've always got to think of whether the patient's had a thromboembolic event that has caused them these symptoms. So you certainly need to think about stroke in your workup and that's certainly the most urgent thing that you need to address in terms of this particular presentation. Okay, and have you seen strokes in your practices in A&T registrar presenting with hearing loss? Yeah, absolutely. Sometimes it's part of a collection of symptoms and hearing loss is just one of them. Occasionally it is the isolated cause. So anyone that came in with a history like this with a sudden sensorineural hearing loss, we would be asking our emergency neurology colleagues to exclude stroke. Interesting, in this case it was a posterior circulation stroke, actually an infarction of the internal auditory artery, a very localized stroke. The next one is someone who presents to the emergency department with sudden onset of hearing loss over kind of a 24-hour period, and ainnitus but no vertigo and otherwise pretty well but it has a bit of a background of Graves disease and you think again it's sensorineural hearing loss. What other things are you worried about? So you've got to keep in mind that the broad set of differentials, if it's not obvious that it's the simple or common things like the infections or the mechanical obstructions and you've ruled out strokes, then you need to start thinking about other causes and one of those will be idiopathic. We sometimes never know the answer. |
Welcome to On The Wards, it's James Edwards and today we're doing something a tiny bit different. This is less on a clinical topic but more of us speaking to someone who's got a very interesting career in medicine. I'd like to welcome Dr Nicola Morton. Welcome Nicola. Thank you. Nicola is a general paediatrician working at Sydney Children's Hospital but also is someone who's worked for Medicine Sof Frontiers and has been on three missions with MSF. So we may just, maybe you can tell us, Nicola, how did you end up working for MSF? Okay, so my start to medicine obviously started in medical school and I was one of those students that loved absolutely everything I did. I'd do a term and say, yes, after doing renal, I want to be a renal physician. And then after doing cardiology, maybe I want to be a cardiologist. So paediatrics was, I guess, the natural progression from that because of the variety. And so I did my training at Sydney Children's Hospital. And when I finished my training, I guess, like anyone, you're at a crossroads of do I become a consultant in Sydney? Do I work rurally? And for me, the areas I found challenging were, I guess, the more independent areas. I loved my time in Darwin Hospital doing outreach. And so for me, working with MSF was a natural, natural step. And thinking that before I settled down with a consultant consultant job now would be the right time to do it so after finishing my paediatric training I joined Medicine Sounds Frontiers and haven't left. So how many kind of trips have you done and trips it sounds like holidays, how many placements you've done for MSF? So I've just got back from my third placement. My first placement was in Pakistan, doing a mixed neonatal, paediatric and malnutrition placement for almost one year, followed by a six-month placement in Afghanistan, just doing neonatology. And then I've just got back from Kenya, where it was just a short-term emergency intervention for a Sari outbreak. So Sari is a severe acute respiratory infection outbreak in young children where there was a very high mortality rate in under ones. And why did you choose a career in MSF as well as your general paediatric? MSF was something I was always interested in ever since medical school. MSF has, I guess, a very big reputation as being the biggest and most independent aid organisation in medicine. And as I said, I wanted to work in a challenging area and MSF being the organisation it is, I believe in their mentality of providing healthcare to anyone regardless of their nationality, religion or circumstance and so joining them was an easy step for me. And what qualities make a good pediatrician in that sort of environment? So I think the first one being adaptability and flexibility. You're going from working in the traditional hospital setting that you've done all your training and experience into to very different settings and even within MSF the variety of the different placements can be from you know a well-equipped hospital to a very basic health facility to a refugee camp. So being able to adapt to those environments, both personally and professionally, is very important. I think also having an interest in teaching and training and coaching is very important. No matter what placement you're in, you're always with staff who want to soak up knowledge and it's really important to be keen to teach them. And then obviously just a sense of adventure, wanting to do something outside the box and see the world while working. What are some of the challenges that you face when you're working as a pediatrician in the field? I think one of the biggest challenges is the limitations in medicine being on the field. Obviously, you're not in a big hospital setting like you are here. You don't have the equipment and medicines at your fingertips that you might have back home and being able to work in that environment and I guess the complications that come with that and the difficulties of sometimes knowing that if this patient was in a different facility, the treatment options would be greater for them, whether it's seeing hemorrhagic disease of the newborn just because they didn't get vitamin K at birth and simple things like that, or lack of immunisation access, meaning they've got a severe pneumonia or they've got measles, I think those things can be quite challenging and confronting. In regard to the environments that you work in, some of them would seem to be fairly dangerous. Is that something you think about? Yes and no. I think particularly before my first mission going to Pakistan, it was something that I thought about, particularly going to a context where the risk of kidnapping was present. That, for me, particularly concerned me. But I guess it's twofold. One, MSF is very good at preparing you for that, so with trainings on how to deal with it. And also they're very good with security and making sure their field workers are safe. It's a priority for them, obviously for their staff to be safe in the field, because if we're not safe, we can't do our jobs. And so that is a priority. But also the practicalities in the field. I'm someone that just gets absorbed in my work and you sort of forget that aspect of it, or it's just in the back of your mind. And thankfully, as a clinician in the field field it's not your job to worry about those things so there's the project coordinators and administrative staff that's their job to worry about the security and you can just focus on on your medical work. In regards to the work can I just ask about things like pay I mean many people have mortgages what happens when you go away for six months or a year yeah so it's definitely not a job you do for the money but msf does support you so unlike a lot of other volunteer organizations they pay all your expenses so your airfares are paid for by msf and any other expenses like your medical checkups beforehand and you're also provided with accommodation and food as well as a per diem living allowance while you're away as well as MSF does pay a very small stipend so it's definitely not comparable to salaries here but it does mean that it is financially viable to do. What are the best aspects of the work that you do? I mean I love paediatrics and I love my job and I think one of the things I love most about paediatrics is although you're dealing with I guess the most vulnerable part of society children also have an amazing resilience and seeing the transformations of children before your eyes whether it's the severely malnourished child that comes in looking like skin and bone that leaves a happy, healthy child, or it's, you know, the mother that's had five neonatal deaths and you sent her home with the first live child. You know, it is the most rewarding work I've done. Although medicine in anywhere is rewarding, I think in the field it's just so much more acute and you see the benefits so much more obviously at the time than I think you do in a society and in a context where medicine is freely available to everyone. Do you think it's in some ways more rewarding because you go back to using your clinical skills rather than within the big hospital, it's about tests and MRIs? Absolutely I think working in the field makes you a better clinician you know you don't have the benefit of diagnosing pneumonia with a chest x-ray you're dependent on your ears and your stethoscope you don't have the blood tests the CTs you are really reliant on your clinical skills and I think it has made me a better clinician for that. Do you come back to a big tertiary hospital and think we waste a lot of money, we waste our resources? Absolutely. I think often we do tests just to reassure ourselves or reassure parents when you know in your gut what's going on but you do the test just to be sure or you get a subspecialist consultation just because they're available even though you know you could manage it without that and I yeah I think we definitely do waste a lot of money and I think we're fortunate to be able to do that and have the health system where we can but yeah definitely we we could be much more resourceful. This one is particularly interesting to me in my role as obviously mentoring junior doctors is what advice would you give someone who wanted to work for MSF because I do get a lot of people who finish two years writing discharge summaries and want to move into working as MSF and I often tell them I don't think there's a great demand for discharge summary writers because really you need some skills to work in MSF so what do they do how do they develop those skills that would be useful for an organisation such as MSF? I think the biggest advice I could give is know yourself both professionally and personally and it will depend on on the individual when is the right time and that they they do something like MSF. For, I decided to wait until I'd finished my training. |
Welcome to On The Wallwards everyone, it's James Edmonds today and today I have the pleasure of speaking with Catherine Spira. Catherine is a neurology trainee. She completed her internship at Residency Liverpool and basic trainee at Prince of Wales and East Coast Medical Network and now she's doing an advanced trainee year in neuroimmunology. Welcome Catherine. Thanks very much James. Now Catherine's going to speak to us today about something that a number of junior doctors have been very interested and told me they'd like someone to do a podcast on and that's vertigo and dizziness, something that many JMOs have difficulty with and a lot of people within emergency medicine when we see dizziness we usually try and run the other way when we see that as a presenting symptom but usually with a fairly good and thorough approach we usually can work out what's going on. So we're going to go through a fairly simple case but also have an overview of how Catherine approaches dizziness and vertigo. So maybe we'll start, dizziness is a very common symptom. What are some of the other words patients use to describe dizziness? Okay so dizziness I a very common symptom what are some other words patients use to describe dizziness okay so dizziness i think means different things to different people so if you as you've said so it can be a code word for a number of presenting symptoms of different cardiac or neurological problems so when some people say dizziness they mean that that they're feeling lightheaded or presyncopal in our language. Other people use it to describe the sensation of a room spinning around them, which is more like what we would call vertigo. And so the important thing if a patient complains of dizziness, actually I've also had someone describe feeling nauseated as being dizzy. And so it's really important when someone uses the word dizzy, you just interrogate that a bit further. So you put it in terms that you can understand and that you can work with. What we do is make sport vertigo in more detail. Before we start, what would you actually, what is vertigo? So vertigo is sensation of abnormal movement. So some patients will describe it as they feel like they're moving in their environment. Others will describe it as the environment moving around them in a particular way. And how do you classify vertigo? So in terms of the symptom itself there are lots of different types of vertigo. The most classical and recognisable one is rotatory vertigo where everything is spinning around you or you're spinning in space and people can experience this on different axes. So the most classic one is that everything's spinning around but I've also met people that feel like they're somersaulting through space and there are some other types as well which are rer. And I just think it's best if you describe what the patient tells you, like, I feel like I've just gotten off a boat and everything's still rocking up and down, or I feel like I'm moving side to side or that everything's moving to the left. And the classification that you're going through in your mind while you're interviewing someone about these symptoms is you're trying to work out could this be a central caused vertigo or could this be peripheral, meaning could it be coming from the brain or is it coming from the vestibular nerve or from the vestibular apparatus? What are probably some of the common causes of vertigo that a JMO may see on the ward? So on the wards, you are dealing with sick patients who are on lots of different types of medications. So anyone who's sick, the risk of vascular events is higher. So stroke is one of the more common causes that you'll see on the wards of the hospital. The other thing that is sort of unique-ish to hospital patients is people that have been on aminoglycoside antibiotics might get vestibular ototoxicity. A lot of people think that those patients get deaf, but the vast majority of them actually just have vestibular issues. And then the things that occur commonly in the community that might be on the wards as well are benign paroxysmal positional vertigo, or BP and vestibular neuronitis. Okay, so now we'll go to a case, Catherine. You are on the geriatric ward as a JMO. It's been a busy day and you're asked to review a 78-year-old female, Mrs M, who has been admitted with an upper respiratory tract infection. The nurse tells you she's complaining of dizziness and the nurse thinks that it's vertigo. What key information would you like to know over the phone before you go and see the patient? So I think as a JMO, triage is one of the most important functions you perform over the phone. So you need to work out how quickly you need to get there for the patient to be safe. And it's important to remember that this is an older person who's acutely unwell from a respiratory tract infection, and so she's at elevated risk of cardiac or neurological vascular events. A lot of people, including medical and nursing trained people, will use the term vertigo incorrectly as well. So you need to interrogate this a little bit further, I think. And you need to make sure that the patient isn't experiencing having an acute cardiac event or an acute stroke. So knowing whether there are any accompanying abnormalities of the ABCs and vital signs of the patient is important. And also whether there are any other things that might hint at an overall neurological problem, such as a patient having a fall or being unable to walk or other problems like that. And there are lots of very reassuring things that can make someone feel quote-unquote dizzy but not vertiginous like being dehydrated, which is common in hospital, or having anemia or bleeding or other problems that will make them feel lightheaded. So I think that just teasing out those things and particularly focusing on the patient's overall health is important. Yes, I mean obviously looking at the context, what the patient's in for can be important. And when you do arrive at the patient's bedside, what is your general approach to a patient with dizziness and vertigo? Okay, again I think the whole format of a neuro consult for a JMO has changed with thrombolysis and thrombectomy being available so one of the most important things when you see someone with a neurological problem is the time of onset because if it's within four and a half hours that person and you think the person is having a stroke they may be eligible for thrombolysis and if it's happening within six hours then they may be eligible for thrombectomy. So what you need to do is firstly you need to be confident that this is actually vertigo. If you feel it is vertigo that's equivalent to saying this has a neurological problem. And then you need to work out how much space and time you have. So if you look at a person, they've got a facial droop while you're talking to them or they're dysarthric, that's already a flag that you should probably be activating a stroke call if this has happened recently. So I'd be looking for sort of flags for acute stroke first up, working out what time this happened. And then if you don't feel that either of those things are active, then you can go on and look at other things about the patient and try and work out what's actually going on. Otherwise, you need to bring in help quite early. So firstly, in terms of the patient's history, if they've given you a history of something that's had an abrupt onset of constant intensity that's continuous or getting worse then that could be due to an acute stroke. There are also benign things that will cause that so again that would put you back on your acute pathway of getting other people involved. In terms of red flags, we've already said she's sick, she's in hospital, she's 78 years old and you've got to find out about her other risk factors for smoke like smoking, ischemic heart disease, diabetes, dyslipidemia and hypertension. And in terms of things you might see when you're looking at the patient, there are obvious things you can see from the end of the bed like facial droop or that they're not moving part of their body as much as the other side. And then when you go to examine them, the red flags for me are not nystagmus outright, but nystagmus that changes direction when you look in different directions of gaze, or torsional nystagmus. Or if there's any kind of disorder of extraocular movement that falls outside that, that would be a brainstem sign. And then you look for other brainstem signs, and you look for other physical signs, focusing probably on cerebellar examination particularly, to make sure that you're happy they're not dysmetric or having other signs that could go with the vertigo. |
So benign positional vertigo very common and can happen in hospital because people are spending long periods of time lying flat and things like that. So the history someone will give there is usually in a hospital situation, either starting with a fall or starting in bed, turning over in bed, and then suddenly getting this overwhelming sense of everything spinning around them. And then that acute, horrible part of the vertigo, the patient might initially say they feel dizzy all the time, but when you interrogate it, they feel terrible for about 30 seconds and then everything subsides, even sometimes less, so 15 to 30 seconds. And then next time they move their head or when they try and get out of bed, they suddenly get the same symptom, trying to reach into their bag to get something, same symptom, but always these short bursts that are associated with head movement. And we'll talk a bit more later, I think, about some of the tests you can do to look for it, but the classic one is the hallpike maneuver. So you're looking for someone without nystagmus at rest who has a positive hallpike test, and then you can be, and no other vocal neurological signs. And if you can fulfil those, then you've probably diagnosed it. You should probably also just discuss it with the registrar, make sure you haven't left anything out, but that's probably a clinical diagnosis that's extremely reassuring. And then there are other things that would be less common in the hospital setting but possible. So vestibular neuritis, again, this sounds very similar to a stroke. And I've actually recently for the first time seen something that I thought was vestibular neuritis that turned out to be strokes. I think you can't be too reassured, especially in a sick patient. But it gives us the history similar, starts usually more gradually than stroke and gradually gets worse over time, but can come on quite quickly. And the signs of that are that you get nystagmus that's only beating in one direction, often present in the primary position beating in that direction. And the further you look towards the fast phase, the more it speeds up. And then there's a test that we do for that called the head impulse test as well. And some patients may have problems with chronic vertigo that's relapsing, such as in Meniere's disease, which is usually associated with a feeling of fullness in one ear or a hearing impairment in that ear that's progressive over time. So I think exclude the scary stuff. Work out if you need to involve other people straight up if it's a stroke or if it could be a stroke. If not, does this fit another pattern of vertigo that I know that makes me feel really relaxed in this situation? And are there any other tests that will need to be done in the ensuing days? Some of the symptoms you occasionally get are vomiting, hearing loss, tinnitus. Are they helpful in differentiating or can they be a bit of an overlap between both the central and peripheral causes? So in terms of nausea and vomiting, usually not that helpful because vertigo is extremely distressing. And if, I mean, imagine if you were actually being spun around and around and around or on an extremely violent roller coaster, there's a high likelihood that you would vomit. And so this sensation that people are responding to is it naturally will induce nausea, which is one of the biggest challenges, actually, when you're assessing someone, I'm sure you'll agree, who's really sick and vomiting and can't really tell you anything because they're too busy doing that. So you need to treat those symptoms. But that will happen from stroke, that will happen from BPPV. So it doesn't really help you differentiate. Tinnitus and hearing loss? Yeah, so tinnitus and hearing loss are helpful in some settings. So if this sounds like a chronic relapsing problem rather than an acute problem that's just happened now and never, ever happened before, then there are symptoms that are associated with Meniere's disease. But you can, with central lesions, also get tinnitus. Getting hearing loss in one ear is quite rare but possible from a central lesion, but usually will indicate that there's a peripheral problem. You've mentioned a bit about your approach to examination, as someone with vertigo, but can we just go in detail? You mentioned nystagmus, and just go a bit about nystagmus and how you assess for it, and then any other bedside tests. Okay. So with nystagmus, the key thing that I'm looking for when I look at nystagmus, and I'm hoping that examining the patient will make me feel less, not more worried, is probably that the nystagmus that you see with peripheral lesions is always beating in one direction. So I have actually, as I said, seen someone just in the last few weeks who had that from a brain stimulation that was just picking off one of the brain stem nuclei. But it's far more common to see that in peripheral nystagmus. Often the patient, when you're talking to them, their eyes won't be fixing on you properly and you'll notice that there's a subtle beating to one side. As you go away from that side, the nystagmus will subside in terms of how fast the fast phase is and as you look towards that side, the nystagmus speeds up. But the real key point is it's only going in one direction. There's no torsional component or very little torsional component, and it's mainly a horizontal beating. You may have a slight torsional component, but the primary component has to be horizontal, and the more torsional component you see, the less you should be reassured by it. With central nystagmus, this is nystagmus that often will change direction. If you see upbeat or downbeat nystagmus, probably central. And if you see torsional nystagmus, that's usually central. And you need to interrogate and investigate that a bit more. You can't just walk away from that. And what other bedside tests would you suggest? Maybe the head impulse or head thrust test? Yeah, so there are a few extra components of the vestibular examination, but I think the most important ones are probably the head impulse test or head thrust test and the Dick's Hall-Pike manoeuvre. Those two are good because they actually are very diagnostically useful and rule things in or out. So how do you do the head impulse test and what's normal and what's abnormal? Sure. So the head impulse test is essentially looking at the vestibular ocular reflex. And this reflex is what allows us to have clear vision when our heads are constantly moving around and as you can imagine that would be vital if you were living on an African savannah trying to hunt down a tiger or well you probably don't eat tigers but you know what I mean it's very important to to be able to actually do this and that's why if you have a broken vestibular ocular reflex on one, it's just so absolutely disabling because you are partly losing the ability to see clearly and also having a sensation of abnormal movement. So the key with this is that you are going to move the patient's head and if their eyes stay, if their eyes can fix on a target while you move their head, that indicates that the reflex is intact and if their eyes move with their head rather than fixing on a target, you know that there's something abnormal. This reflex is so sophisticated that you can move the head extremely fast and the eyes will not move off a target. So you'll be moving the patient's head. Important questions to ask the patient are, do you have a sore neck? You have to know a little bit about the patient's background. If they've got rheumatoid arthritis and big neck problems, you do not want to be doing this test on them. And then you warn them that you're going to move their head very sharply and that it's helpful if they just relax. You ask the patient to fix on the bridge of your nose and you are looking the whole time at the patient's eyes. You rapidly thrust the head either to the left or right and you're watching that their eyes stay on target and then you thrust the head in the other direction and make sure that the head stays on target. So the direction that the head impulse test moves in that is abnormal, so when the patient's eyes move with their head, is towards the abnormal side and the nystagmus will classically be in the opposite direction to the positive head impulse test. So basically, the positive test, eyes move with the head. The eyes will usually then move back because the patient consciously will correct it. And a negative test, the eyes remain fixed on you so you know that the reflexes are intact bilaterally. It's a sign of vestibular neuronitis. So if you have vertigo and you have a positive head impulse test, it suggests a peripheral cause. |
However, if you have vertigo and a normal head impulse test, what does that suggest? So if you have vertigo and a normal head impulse test, it suggests that there's a cause other than unilateral vestibular dysfunction, essentially. So you need to consider... Central causes. In regard to the whole pipe test, can you describe how you should complete a whole pipe test and its significance? Sure so a whole pipe test is a difficult thing to describe on a podcast and we were talking before about how there are so many great resources on YouTube and also you can see step-by-step guides if you just google whole pipe manoeuvre and most of the websites that come up at the top are actually excellent um hall pike maneuver is looking it's a test design specifically to look for bppv and specifically to look for the most common form of bppv which is a problem with the um with the posterior canal so So you basically get the patient to sit up. I've seen violent and less violent ways of doing this test. The important thing is that when you're actually doing the test at the very end of the manoeuvre, that the patient's head is extended backwards about 45 degrees and the head is turned to one side. And you can actually fulfil this just by putting a pillow on the bed and tipping the patient back over the pillow rather than the way that I originally did this which was to tip the patient over the side of the bed in a very awkward position and make them quite uncomfortable. So I now do it with, I just rest a pillow, I get the patient to sit up facing the end of the bunk with their legs straight on the bunk and their back at a right angle. I put a pillow just sort of a little bit behind where their bum is. I tip them back over the pillow and then move the head backwards and about 45 degrees and to the right. And the important thing is before you tip the patient, you have to tell them that no matter how sick they feel, they must keep their eyes open because the typical thing that happens is the patient feels terrible when you activate their vertigo. They slam their eyes shut and they might even vomit on you. So it's also good to have a vomit bag in the patient's hands ready to go and have them full of antiemetics if they need it. So you do that on one side. You're looking at the eyes and what you want to see is torsional nystagmus that's going in a direction towards the floor and that is a positive hall pike manoeuvre. Rarely someone can have it in both posterior canals and so you might get that on both sides. You can also sometimes see it on both sides because you've actually moved around the otoliths that are causing the problem when you do the first side. So you then sit the patient up and tip them the other way. But I'd really recommend having a look at a video and the key things that you need to do. Make sure the patient's holding a vomit bag. Tell them to keep their eyes open. And if the patient's really sick from doing it, you probably should abort the test and let them get better and do it another time. So a positive whole pipe test suggests they've got BPPV? It's diagnostic for BPPV. So if you've got someone, no other neurological signs, you want to make sure also the patient doesn't have nystagmus at rest because that probably is not going to be BPPV and it will confound your whole plaque test because they'll still have nystagmus with their head to the side and you won't know whether or not that means anything. So if you've got someone with either of those things, there's no point doing it. But if you've got a normal neuro exam, you don't have any nystagmus at rest, you do the Hall-Pyck test and it's positive, that tells you that the patient has BPPV and it also tells you what side it's coming from and it's coming from the positive side. Okay, and that's helpful in regard to if we wanted to decide to try and treat it with an ECHOI manoeuvre? Yes, absolutely. We may just go back in regard to BPPV that hasn't been considered or thought to be the most likely diagnosis during an exam or vestibular neuritis doesn't seem the most likely. What further investigations would you do and how helpful is imaging? Sure. So in terms of the more reassuring types of vertigo, often imaging is unnecessary. But if you've got someone like the patient that we're discussing now who's sick in hospital, old stroke risk factors, and they give you a history that's kind of worrying, they may have other signs. First thing, if you want to, you need to exclude acute intracranial pathology and in some centres you also do additional imaging as part of that, as part of a stroke work-up imaging for the patient. So at its most basic, this will involve a non-contrast CT brain to look for hemorrhage, space occupying lesions and stroke. In some centres you'll additionally do a CT perfusion and CT angiogram as part of a stroke workup as well. If you don't see anything it doesn't mean there's nothing there, it doesn't mean it's not a central problem. It just means that you need to look harder for it or that you may be on the wrong track. So down the track, that patient may proceed to having an MRI brain, which will actually detail a lot better what's going on. If you have other vestibular or hearing problems occurring together, such as what we were talking about before, tinnitus and hearing loss, it's actually good to alert the radiologist and radiologist to that in your request because those sorts of patients should also be having more sequences looking at their inner ear and their vestibular nerves. And so they'll actually protocol those differently for their MRI and may give you a good diagnosis. In regard to management of symptoms, so they've got vertigo, we typically use, I said, antibiotics, Stematool classically. It always seems to be a chosen one for vertigo we typically use i said antibiotics stematool classically always seems by chosen one for vertigo um any suggestions on what what antibiotics or are there any medications that help with vertigo and then maybe if they had bppv is the epi maneuver potentially therapeutic sure so if they've got bppv if you've got a positive uh if you've got a plaque manoeuvre and a compelling history of these brief bursts of vertigo that are initiated by head movement, absolutely. The Epley manoeuvre is a fantastic thing and can really make a big difference. Sometimes the patient needs to have it more than once, but you should, I think as the ward jammer with a special interest in vestibular things, you should probably only do it once and then this can be followed days later. So the Epley manoeuvre is one of several manoeuvres you can do for BPPV. It treats posterior... Posterior... Semicircular canal. Yeah, posterior semicircular canal bppv really well and the other you can look up other things for the other canals but honestly you're not going to see it very much so with the athlete i would just google it and do exactly what the google says you can actually start start the manoeuvre at the end of the hall pipe, which is quite nice. So the first step is to have the patient in the position where you've got them with their nystagmus and you wait there till the nystagmus settles, which is horrible for the patient because they feel horrible while that's going on. But that's the first step. You then turn the head, and there are a number of ways that you turn the patient after that. But I would refresh it by Googling it right before you do it the first time. And after you've done it a couple of times, you'll remember how. But, yeah, it is effective. In terms of what antiemetics to use in general for nausea and vomiting with vertigo and vertigo, antiemetics, I just use standard antiemetics that are going to work. I choose them on the basis of the patient's other comorbidities, age, et cetera. And so you can use all your standard antiemetics for that. In terms of things that make the patient feel better, there are some antihistamines that are used, such as CERC. You'll see people on that when they come into hospital. They can be effective, but in terms of the evidence base in different types of vertigo for different antihistamines, it's quite diverse and it's more... But you may see that certain neurologists or other physicians prefer to use that in a number of settings and others don't. So there's a bit of a discrepancy in how we use those drugs as well, just like there is in how we use the antiemetics. |
Welcome to On The Boards, it's James Edwards and today we're having our 100th podcast. It's been a long journey to get to 100. Started here at RPA doing a few small local podcasts and now we've got a On The Wards website where we deliver a podcast a week. I'd like to thank a lot of people on the way, probably Evangeline Polizos, who's our Chief Operating Officer, is the one who probably kept the website going, but lots of junior doctors and clinicians who have helped along the way. And I guess to recognise our 100th episode, we have a special guest today, and the special guest is Professor Nick Talley. Welcome, Nick. Thank you very much for having me. Now, we could go in depth in regard to biography, but I thought maybe I would let you describe a bit of your career to our audience, because they may know you from some areas such as T such as Italian O'Connor but not some of the other things you've achieved. So maybe just give a brief biography of your medical career or you can even go back to childhood if you'd like. Well, I'll do that. Thank you very much. I'll be very brief. So I was born in Perth and then my father moved the family back to Sydney and he was actually an RPA resident here and registrar, yeah. So we have a bit of a connection to RPA. I went to medical school, University of New South Wales, did the first five-year program. That was the time they reduced the medical school from six to five. It was the experimental medical school. First year of that group, it was a very interesting time to be part of an experimental medical school concept. Of course, Sydney did something similar, but it was a very interesting time. Then I did my residency at Prince of Wales. I was a medical registrar there. Then I went to North Shore, did a PhD and my advanced training in gastroenterology, did the professorial registrar job there. So I did an extra year. And then I got a position at Mayo Clinic as a research fellow. Went overseas, did that for a while. They put me on staff at Mayo Clinic. So I got a junior faculty position. I stayed there for a few more years. And then I got headhunted to come back to Sydney. And I became the foundation professor at a very young age at the University of Sydney at Nepean Hospital, which was a very interesting time of my life. Spent nearly a decade there. Then I was recruited back to Mayo, went back there for a period of time, became the chair of medicine for a period of time there. And then I was headhunted back to Australia, where I'm at the University of Newcastle. So I've had an eclectic career, some would say. So how would you describe yourself? Are you a clinician, researcher, educator? So I like to think of myself as primarily a clinician. That's what I train to be i love medicine i like looking after people but i also am a researcher and i feel an educator and certainly my view is my clinical practice is improved by teaching others and improved by doing research and translating that into practice and i i'm a great believer in that triple crown, if you like. I do administration as well. I think of all the things I do, I least like administration. Probably not the only one there. In some ways, that goes against maybe a trend of kind of super self-specialisation that's occurred often within medicine, you know, that you should be a, because we're in research or education or clinician. What do you think about? Well, I know that's the trend and I understand you've got to be narrowly focused when you're in an academic pathway, no matter what academic pathway that is, to some extent. And I think it's fair to say my focus would have been predominantly research with education, something I really am passionate about, but something that I would do on the side rather than as a primary focus. But as I think about it, you know, not to teach, what a pity, you know, why everyone gets well trained, you know, not to pass that on to others, I think is a real pity. And I believe that's part of our mission, no matter whether you're a researcher or not. And I guess I'm a bit old fashioned. I kind of like the breadth. And so it's hard to do, but I believe it's really important to try to do it. And so I've done my best to cover all three areas as best I can. You're definitely demonstrated breadth but how do you balance the clinical versus education versus research versus administrative work? It's actually quite tricky so you work harder than the normal number of hours per week there's no doubt I work long hours but I enjoy it you know most of the time I'm really amazed someone's paying me to do what I really like I mean they're paying me that I really, really enjoy. So that is a great pleasure and I don't find it too much of a burden. I think if you're a very busy clinician with a very large patient load, it is hard to do other things. Although I still believe some of the best clinicians I've ever worked with, I've ever met, have always had some element of teaching and or research as part of their practice. They've all been engaged in that in some significant way. And I've been struck by how good they've been clinically. So I think it's important to have that piece of it, even if you're really busy. And of course, you know, I do my best to balance all those hats, but it is tricky. I'm very fortunate. My clinical load is not too large. It's large enough to keep me, I think, skilled, but not so large that I can't do anything else. But balancing and weighing all those issues up always is a weekly, yearly challenge. Have you had to learn to say no at different stages? I'm very bad at saying no. I can see that. You can tell that from my pathway. But yes, you have to learn to say no. You have to say, look, I really would like to do this, but I just cannot do this. And that's something that younger people, I hope, will be better at than I've been. On the other hand, you've got to be careful. You don't want to say no too often because, you know, if you knock back opportunities, sometimes they never come again. So it may go back to when you worked at Prince of Wales as a junior doctor. Maybe explain, you know, go back through some of your experiences or describe some of those to our listeners who are predominantly junior doctors. Well, I remember my first day of internship. First of all, I couldn't put an IV in. I was terrified. I went to my registrar, who was a fantastic South African, now a general physician in the country, still very good, very good clinician. And I said, look, I'm really in trouble here. Will you please teach me how to put an IV in? And he did a very good job of teaching me how to do that. And I think I got pretty good at it. But I just remember that first day, terror on the wards. And I think everybody has that sort of feeling. So I think medical students, to be fair, are somewhat better prepared today than we were in my day. I mean, literally, you were pretty much left on your own. And if you didn't happen to pick up a certain skill set, you had to find a way to do that as soon as you hit the wards. But I also remember, you know, putting in extra hours. I remember saying, well, you know, I can't leave now. I know I'm finished. I know I'm supposed to go home, but someone's sick and, you know, and the registrar's busy with someone else and I'm going to stick around and do my job. And I remember even then, back then, a few people said to me, you're crazy. You don't get paid for this. And I sort of always felt, well, I didn't do it to get paid. I actually did it to look after people. So I remember that well. I remember some pretty difficult experiences. I mean, hematology, seeing young people die, teenagers die. I found that very hard. I decided if I was going to subspecialise, it wasn't going to be in an area where everyone seemed to die. Now, that was an exaggeration, of course, but it was pretty tough and pretty confronting. And I really admire those people who take on those areas of medicine where that is a daily occurrence and they deal with that extremely well. |
That was my sense of the world and that's how I decided to do the medicine that I wanted to formally practice. But I also recognised it was important to diagnose and make sure you didn't mess things up and that was another lesson that quickly came to the fore. What else? I don't know. First patient who died, you know, I had to do the death certificate, you know, the formal death certification. Well, no one had bothered to teach us how to do that in medical school, had they? You know, and the nurse on the ward calls me up and says, well, you know, you need to, you know, do this job. And I said, oh, that was pretty confronting as well. But as such is the way it is I mean the experiences you describe I don't think are probably that much different to some of the junior doctors who are out there working currently but maybe when we look back at your career you have had a very varied career so what influenced your decision to change direction or take opportunities in different fields or in some circumstances, different countries? So it's a good question. I think it was a combination of opportunity coming up for various reasons. And I can talk about those if you'd like. The sense that I didn't want to be, I always felt, and I think it's got much clearer now, I've always felt that medicine was a bit of a global world and I wanted to experience more than just Australian medicine in my training. I wasn't sure I wanted to spend my career somewhere else. In fact, when I was overseas, I more or less decided each time I went over for a long period, I did want to come back home if the right opportunity arose. But not to have trained elsewhere, not to have had that experience, I think would have been a loss at least for me. And I really believe the world's globalising. I believe the graduates of the future, even our current junior doctors, there's many more of them going to be working internationally for very long periods as the world unfolds. At least that's my view of how it will change. So training and experiencing, that's important. It's also exciting. It's really exciting to go somewhere else. And confronting. You go somewhere else. I remember going to Mayo Clinic and they made me a junior consultant. I mean, you know, I'd done all the training here, but I hadn't trained there. I'd been a research fellow for a period before they did this. And immediately I was on the hospital service looking after the most complicated patients I had ever seen. And, you know, that was very confronting, but steep learning curve, very fast. But you certainly become a very, I think, a very good clinician very quickly in that sort of circumstance. So exciting to have that opportunity. But how I got to, how I became, how I went internationally, it's interesting. I remember towards the end of my PhD and my gastro training, writing to many, many very prominent organisations around the world saying I'd like to come, particularly in the United States. I decided the US is where I wanted to go in particular. And getting lots of lovely letters saying, well, we'd love to have you, but we've got no money and, well, we haven't got any jobs and no thanks. And I wrote to Mayo Clinic and they wrote back a letter saying, thank you very much. We read your papers in gastroenterology and we'd like to offer you this salary if you come. It wasn't a great salary, but it was still enough to live on. And that sealed the deal. It was literally, that's how it worked. So what advice would you give junior doctors if they were faced with similar decisions? Well, I think if you're a junior doctor in today's world, you want to get as much experience as you can and it shouldn't be in one place. At least that's my view. I think the doctors of the future who will be most employable, and unfortunately there will be more competition for employment coming up, there just will, the ones who want to be most employable in the world of the future will have trained in more than one place, will have probably had some sort of international training, will be able, in my view, also to have some skills in educational research, perhaps both. At least in my view, that'll make you much more attractive than the standard model, the current model, which most of us go through, which isn't necessarily that route. And it's exciting, as I said, to go overseas and do things. And it doesn't lock your opportunities away. For me, it opened up doors that never would have been opened if I stayed in Sydney with the traditional path. I basically cut through much of the traditional pathway. Now, that can be good and bad. You can end up in places that you didn't expect and you can end up taking jobs that perhaps you hadn't anticipated, but good jobs, but different to what you perhaps might have planned out many years before. But that often is a good thing, not a bad thing. So really going off from what you've said there, are there any tips for career direction for junior doctors? Well, I think, you know, it depends. The trouble is we've got so many career choices and there's so many options, which is terrific. I think you need to decide reasonably early what your direction really is going to be. That's the hardest decision. Do I want to specialise in some particular area? What is that area? Do I want to be a generalist or a subspecialist or something else and and and and the pathways will differ for individuals in different uh segments of of of the profession but for example if you want to be a specialist physician you know i know that world perhaps the best um then clearly you have to get through, you know, the college exams and you need to go and you need to be in that training pathway. But as soon as you can, my view is you need to be, if you haven't already, you need to be thinking about how do I broaden my skill set? How do I become a better physician and have a more varied career going forward? And that means planning, pre-planning international experience. In my view, that makes you more employable. I'll give an example. You know, there are many gastroenterologists now. We are training. We have not enough positions for all of those people we're training, arguably. There is room in private practice, but even there it's filling up in the major cities. So what do you do? How do you become a competitive gastroenterologist? Well, there are areas in gastroenterology where there's a great shortage of skilled individuals. You know, esophageal disease, looking at it, you know, for example, there aren't that many people who are really, really skilled in esophageal manometry and other testing procedures. Well, you know, you can train in that area, both locally and internationally, and I suspect you would find more of an opportunity if you had that skill set than if you didn't. And there are many other examples. So if you're trying to get the international experience, you send a lot of letters, almost cold letters, we've probably sent emails now. Do you kind of need a mentor or somebody who's on the inside to make those connections internationally? You do need a mentor. You don't need one, but it's certainly easier and better if you have one. I mean, the people I've placed overseas, you know, I've known people in the institutions that they've gone to. I know they're going to get the kind of experience that they will treasure and also it'll be of value both ways. And so you can really help mentor someone and it can be anywhere in the world. They want to go in any area of the field they want to train in, they can be helped with a mentor. So finding a mentor or mentors is critical. And there are many good people who can provide excellent advice. And then if you don't have a local mentor, if you're in the rural sector, for example, but you've still got this ambition, there are opportunities to contact people who will help you. And I think you should be brazen, a little bit brazen, and talk to people and call them up and say, look, I'd really like to go to somewhere and what would you advise and could you give me some suggestions? And most people will be happy to help and certainly I have done that in the past. Eminent clinicians such as yourself often see me infallible, larger than life to junior colleagues, who often feel sometimes they're more criticised and praised at work. Would you be willing to share a story that made you time that you felt uncertain, afraid, anxious at work? And what would you advise junior doctors to do in similar circumstances? |
Certainly no one's infallible. I'm not infallible. No one's infallible. And, you know, everyone makes mistakes, hopefully less than one used to, but they're still made. So certainly don't believe the infallibility story. And actually, I think one of the great benefits of working in a team is it reduces the error rate. And that's why it's so important. The junior doctor member is a very important key member of that team it's not all about um just one person but look you know there have been times where you know i've had difficulties uh you know with with with with a particular working environment hasn't happened very often but i will name one example where i was a more junior person and I had a particularly difficult consultant who, you know, really was difficult with many people, but was really quite difficult to deal with. And that was a little bit frightening and worrying because you felt quite uncertain about your own position and indeed, you know, it can have effects on you. My advice in that situation is to make sure it depends. It depends. My advice is certainly to talk to key people if you need to, if there's any particular serious concerns. If it's less serious, it's about building bridges, good communication, doing your job as well as you can and not worrying about it. It made absolutely no difference to me in the end. It usually makes no difference to people. You know, people who may seem in great power often have not as much or anywhere near as much as you might think or sometimes they think. We might just go on in regard to your career because you took the role as a foundation professor at Nepean Hospital which has just been designated as the new teaching hospital at University of Sydney and those who aren't from New South Wales it's about 50-60 kilometres from University of Sydney can you tell us about that time I think it was 1992 so tell us about that time yeah it was a really interesting time so I was at Mayo Clinic very happy very well settled I had an NIH was I was doing great I was right on the track and I got this out of the blue call about about this job and I was strongly encouraged to come and come and interview and I remember going to see it and look Nepean in those days it was it's a lovely place but you know it didn't even have a registrar didn't even have a training program you know you know, had very few consultants. They were good people, but very few, relatively few of them. So it was a very challenging job. And I remember wondering how I'd feel 20, 30 years later after having taken that job, because I did decide to take it in the end for family reasons and other reasons. There are all sorts of, you know, things enter your mind when you get an offer like this hard to turn back a chair from the University of Sydney I mean it was really quite difficult when I got the job which I didn't anticipate I'd get because I just thought I'd turn up do the interview and they'd send me on my way and I wouldn't have to worry getting the offer was actually the hardest piece of the whole thing but I remember I, I remember, you know, deciding to say yes, deciding I'd like to make a mark and do what I can, turning up on the first day and thinking, oh boy, this is going to be a really challenging time. And it was, it was very challenging. Plus, I had little administrative experience, very little indeed. So it was really a steep learning curve on that side. Anyway, turned up. I think I was lucky. There were some other new academics who were also appointed who were very good, who were collegial, that we could collaborate and talk to and work with. And that was important for the progress. And also there was a lot of goodwill in the place, which helped. And we were able to build Nepean up and do the best job that I think could be done in the time that I was there. And the reason I left eventually was, quite frankly, while my research did well at Nepean, it was a real struggle. It was the hardest period for me to maintain research productivity just because of the resource lack. And I had to be very innovative in the way I did research. I had to collaborate. I had to build new collaborations. Although when I think back on it, some of the most important research projects we set up, I've ever set up, were done at Nepean. And they're still continuing, actually, some of those collaborations. So it actually worked out really well. But it was a very interesting period of my life. I'm very glad I did it. But you could have said I could have taken a much easier road by staying where I was, at least for a longer period, and then coming back for, a different role but I didn't it was a decision I made and I don't regret it so so so I guess you know if you take an opportunity like this you need to understand the you know the limitations the the weaknesses as well as the strengths of doing so and just you have to live with those when we think of Nepeanan, which is again a distance from University of Sydney, it kind of brings to light the increasing number of medical schools within Australia and often the context behind it is that you need a local medical school to deal with the local population, the doctors stay locally. What are your kind of thoughts on that from someone whose University of Newcastle regional has been Nepean? So we've got too many medical schools. There's no doubt about this. I mean, if you look at the numbers, just the raw numbers of medical graduates and the bulge going through, we are in arguably crisis mode. And, you know, the political decisions recently to create new medical schools are political decisions. They're not based on needs of training more medical graduates. I have a number of views on this. There is evidence that training doctors rurally does increase rural doctor workforce, and that's a good thing, a really good thing. And so I don't think we should lose that as we rethink about how we do medical schools. I worry, and I'm going to be controversial here, I worry about really large medical schools. I wonder what the quality of the training is compared to smaller schools. I'm just a little bit concerned that, you know, some of them are a bit too big. And while there may be fantastic experiences those people have, I just wonder about those who could fall through the cracks. They get through, but they don't really get the mentorship that I think is needed today. And the whole reason to go to medical school is to get that mentorship and experience. You know, most of the knowledge stuff can be gained without going to medical school nowadays. I mean, it's a different world. And I think that's important. I think deans of medical schools, and I used to run the school in Newcastle, I don't anymore, I think they need to look at this very seriously and think about, you know, those issues as they're planning their own futures. So too many medical schools, too many graduates probably, and that's going to put workforce pressures on in australia and that's why i was saying earlier you know ensuring you're in a position of strength not weakness that you stand out not part of the crowd when you're a medical graduate in post-grad training yep that's what you need to be if you're thinking about getting the plum jobs or the best jobs anyway in Australia in the future. So, yeah, it's an interesting time for the country. We'll see what happens. I hope there aren't unemployed doctors. That's probably less likely, but you do worry that if this trend were to continue or more schools created, and politicians may well do it, you just wonder if that's really in the national interest. Underemployed, maybe not unemployed. Underemployed, you're right, much more likely than unemployed. Okay, we'll keep on the medical education theme. The website that we've got on the wards is described as a free, open access medical education website. What's your opinion of this foam as an adjunct to traditional medical education well look there's no doubt that you know there's a revolution we're in the middle of it in terms of training um training doctors in fact tertiary education in general and of course how it's going to land is a little less clear. But this concept of open access medical education is, I think, a good one. I know about Foam and the history of Foam, which was founded by people who were looking at new ways of delivering education. These weren't the traditional educationalists who tended to see this as not always a positive move. But, you know, I think information, and that includes, you know, having education by some of the best people in the world available free is the world we're in or in the future. We're probably in actually close to it. |
I mean, why do you need to go and listen to a lecture from so-and-so when you can hear the best person in the world deliver the lecture, you know, any time you want and in a way that you're going to enjoy much more? So a lot of the... And even tutorials can be delivered this way in massive groups, potentially. You know, and people can teach each other. So you could argue our whole traditional models are changing dramatically, and we don't need to provide anything like the current model of medical education that we provide. It could certainly be done very differently. Now, problem-based learning may not be quite as easy to adapt to that model, but some of it is. Some of it clearly is. The piece that can't be replicated this way is the clinical skills, clinical training, you know, the apprenticeship issues, the mentorship. They can't be replicated yet this way. So we're still going to need medical schools. But I think education is going to change. I was just at Harvard at a disruptive innovation program run by Clayton Christensen and the Harvard Medical School. And they were talking about, well, and of course, in the US, they had this very traditional two years of basic science and then two years of clinical. And they're proposing, at least in the business uh sort of uh school of harvard which is where clayton christiansen happens to come from they're proposing well you don't need this first two years that can all be done without going to medical school and it's only this last two years that you really need and in a sense i can see a lot of medical schools in the future going to a completely different model where it's really not delivered, even in the current way it is, with the flipped classrooms, etc. It's changing fast. How would you suggest junior doctors become involved in mental education? It's a good question. There's lots of ways. I mean, if you're an entrepreneurial uh effective person who understands the internet and uh and uh and and and uh can can create new ways of delivering programs that way you can become involved in a very massive way um and i'm sure there's lots of people who have those skills i i don't pretend to have those that depth of skills but there's people out there but i think frankly teaching others and putting your hand up to teach is the first step. It's old-fashioned, but this idea of, you know, when I'm a medical student, I can teach more junior medical students. When I'm a resident, I can teach more junior residents and medical students. When I'm a registrar and when I'm a consultant, I'm going to be committed to teaching, even if I'm a busy clinician. I think that really makes you such a better doctor and broadens you out, keeps you up to date in areas that otherwise you can lose fast. So I think it's really important. And clinical skills, well, it's about practice and part of it's teaching. If you teach other skills, amazing what you learn. We'll go on to clinical skills because many of our listeners will best know you from your authorship of clinical examination. Are bedside clinical examination skills still relevant? Well, it depends who you ask. It's a really good question and I worry about the relevance because I think, you know, and there's multiple dimensions. Patients want contact with their doctor, I think still. There is still this element of talking to patients, hearing their stories, examining patients that I think has, you could argue, you know, some sort of influence on their disease course, a positive influence mostly, hopefully. And we don't want to lose that. At least I don't believe we're in a, you know, I don't believe a computer can take over from us doing that. But a computer can probably take over taking a history as well as we can that is coming that is probably close and um you know it wouldn't be surprising if if there will be innovative ways of better history taking for example that perhaps there's still a physician interaction but it can be done almost or perhaps even better than we than we can do it certainly more in a comprehensive fashion so it's possible possible the roles will change. And then physical examination, you could argue many of the signs that people look for, the things we teach, are a little old-fashioned. They can be replaced by technology. And some of that's true. I mean, I know cardiologists who don't seem to be able to listen to the heart anymore in the same way as they used to. And I realize that's very reasonable with the technology available. But there's still a place for examination, even of the heart, because, you know, again, there can be times where you don't have the technology right at your fingertips and you'll pick up things that otherwise you'll miss that will make a real difference to the patient. And we don't, you know, we've got to be careful we don't throw out the baby with the bathwater with the technological advances that are occurring. So I still think clinical skills will be relevant for the near future. Long term, probably yes, but in a modified way. Yeah, so really going on from what you mentioned about technology, what are your thoughts on teaching medical students use of things such as ultrasound rather than a stethoscope? And I guess I'd take you back to some recent articles in the Medical Journal of Australia, one on eliciting ankle jerks, other ones on them trying to find ascites using shifting dullness. You can argue, at least for the second, that an ultrasound probe is more accurate at picking up ascites or fluid in their peritoneal cavity. But we don't teach medical students these skills, should we? So I think the answer is we probably should start teaching some of these skills. And it's interesting, in Europe, for example, there's more of an emphasis on bedside ultrasound. In emergency departments, there's obviously a big emphasis on consultants learning these skills and registrars learning these skills. So I think there is a place for starting, for example, bedside ultrasound training in medical school. It seems to me that's a technique that probably is applicable in general practice and is applicable in other practices as well. And certainly in emergency room settings is clearly very important. So the answer is yes. Obviously, though, if you haven't got an ultrasound probe or your power goes out and you don't have any other skills, instruments available that will work, then having clinical skills still matters. But you're right, eventually, as technology gets easier and better, and as we can do ultrasound probes where we put it on and the computer tells us there's ascites and here's how much and here's what's going on, you don't even have to be able to interpret it yourself. As that happens and becomes really accurate accurate I think some of these bedside skills will disappear as they should. I mean is it a challenge being a dean of a university medical school to really look how we need to develop or teach the doctors of tomorrow rather than the doctors of today? I think it is a challenge you know because you can also can also be wrong with future trends. You can predict a future trend and you, you know, you change direction. And of course, it doesn't come to bear that that is as important. Some other technology might come along, replace ultrasound that's 10 times better, doesn't require the technician skills. And quite frankly, that's the end of ultrasound and you're doing something else. And you all those years in medical school training in ultrasound which actually didn't help you at all. So that's the real risk. Deans have one advantage, they have a regulator who tells them what to do. So the Australian Medical Council for example will insist that everybody gets trained at a certain level and certain skill sets and that's somewhat conservative in its viewpoint and you can understand why there's some safety in that conservatism but at Newcastle for example we have you know had some medical students getting experience in bedside ultrasound in the past as part of their training and I think those sorts of skills adding them on not over emphasizing them but certainly having some introduction for things that seem likely to retain currency for quite a long time, that does make sense, even if it's not the regulators who are telling us we should do that. You've spoken in other interviews about writing your book Clinical Examination while I was working as a medical registrar and spending all your Saturdays writing with Simon O'Connor. You said that success was due to a good idea, a little luck and a good team. And also that you received some criticism from it from colleagues at the time. There were a lot of pressures on junior doctors to stand out from the crowd, as you've described, but your early decision to write this book in your spare time in the face of criticism from colleagues turned out very well for you. Can you share with our junior doctoral audience what you've learned and what makes an opportunity a good one, even or especially if it seems to go against conventional wisdom? |
You know, you look at those really successful entrepreneurs, they've always gone against conventional wisdom and they've never listened to anybody else. So I think that is a little bit a part of this. If you've got a good idea, don't worry that when you talk to other people about it, you're dismissed or it's dismissed. I mean, if you think it's a good idea and you're passionate about this, it's worth pursuing. At least that would be my first piece of advice. You know, we wrote two books when I was in training. The first book was for physician trainees. And then we wrote the second book, which was even more successful. You know, both times we did have criticisms. There were some people who were very unhappy. We wrote a book about how to pass the physician's exam. We thought it was a great idea. But, you know, a few people I remember saying, well, you can't possibly do this. And we said, but we thought, but people need this. There's no information. And, you know, we just ignored that criticism. And to be honest, there were people who also helped us. I remember a very senior physician saying, this is a great idea. I'm going to help you by at least, you know, looking at this to make sure it's not completely out of whack in terms of, for example, college policies, et cetera. And that was incredibly helpful and also reassuring that we weren't completely off track you know which you always worry about and you know um the medical student book i remember i remember when we wrote it and i had people say to us well well but there's better books from the uk and we surely we don't need to have another book and we thought those books weren't that great that personal view. So frankly, we just ignored that as well. And it's been interesting how the uptake's been, although there are still critics out there. There's one particular medical school that will remain unnamed, where the medical educational group there just don't like the book. And they just don't. Their medical students seem to like it, but they don't recommend it. And I keep thinking, well, there you go. You can still be criticised and you just have to ignore it. And if people like it, it will do well. And if people don't, frankly, it won't succeed. And that's the way it is. I mean, do you think it was easier working in a small team to get through to those criticisms rather than working as an individual? You know, I was keen to work with someone else when I had the idea for the first book. And, you know, really, Simon was a very good choice. And we worked very well together as a team. And I found that extremely valuable, personally. Because, again, when you're having a tough slog, when you're, you know, on your own, it's a tough slog, at least with someone else who's as enthusiastic. It makes you feel like, well, you know, I'll keep going. And yes, you know, I can get through writing the neurology section, which I don't like, but I'm going to do anyway. Yes, it really helped me. But not everybody works that way. Some people are very individualistic and they work better on their own and others work better in even bigger teams and that sometimes can be helpful. On the other hand, working in, I've done some multi-author books, you know, we've edited a book. I find that harder to do. It's much harder to maintain that level of quality, much harder to oversee it when you've got authors in every single bit, some of whom refuse point blank to make any sensible changes, even though they ought to. So I find it much easier to be at least in control of the book when I'm doing it. And I hope books will still last, but I'm sure it'll all be on the internet. Books will be irrelevant, but I think it'll still be on the internet in some form or another. We may go a bit more public health in regard to the recent federal election, there was a lot of talk about Medicare. I think medical students and junior doctors work in public hospitals, but they're not really involved in the details of health funding, and you've worked senior roles here in Australia and overseas. What's your personal experience in regards to the importance of Medicare and in the health of our patients and now and into the future? Well, there's no doubt that Medicare was a very significant piece of legislation when it came in. And indeed, you know, you could argue that it changed the health landscape in this country in a very positive way. And I think we've got a very good health system here. And we shouldn't think of ourselves as anything but as one of the best systems in the world. We have a very good public system. We have a strong private system. There's a strong interaction. I think the public system is critical. I worked in the United States. I was appalled people would lose their house if they got sick and they didn't have enough or any health insurance or enough health insurance to cover them. I was appalled. This was unacceptable. And I think it is unacceptable. And so a strong public system where everyone has a level of cover that's appropriate, I think is really critical. I also recognise the mounting costs of healthcare and that we need to look at this in a very strategic way. And I believe that's something that we need to cooperate with government and with the bureaucrats in doing. And if we don't, we're not doing our job as doctors and as custodians for the community in terms of the health system. So I think that is absolutely critical. But I am worried about some things. I mean, the private system is excellent and has many qualities. But, you know, fees for patients, the gap some people pay, some people cannot afford to pay a gap for a procedure that they really need and they can't wait in the public system because there is no availability. That is absolutely intolerable. I consider that unfair, un-Australian and needs to change. And I don't believe we can allow the system to continue to promote people who need, I'm not talking about things that they don't need, I'm talking about things they need, procedures and other things they need that they can no longer get because the system just has not been able to work it effectively. And that reminds me of the inequalities of the US system, and I hope we repair those over time. Often we're caught up in the daily minutiae of work and we lose sight of the ideal healthcare that we are so passionate about in medical school. So what does ideal healthcare look like to you? And how do we keep that in mind when we're struggling to keep up in the middle of a busy day? Very difficult, isn't it? Look, it's all about person-centred care, at least in my view. So one of the mantras of Mayo Clinic, you know, this is a mantra I've always heard, but they really live this mantra. The mantra there is, and everybody knows this, the patient comes first at Mayo Clinic. So if you've got a patient and you're walking up the corridor and they come up to talk to you and ask you for some directions or some assistance, at Mayo Clinic, the most senior consultant will stop, even if it's in the ward round, turn around and help that person in some way. I remember talking to people who were support staff, you know, people who were, you know, fixing up the wards, cleaning the wards, doing things. And I remember saying to people, well, how do you like working here? And I remember a number of them saying, oh, I love working here. I'm helping the patients and I'm doing my job as well as I can to ensure people get the best care. That's not a health professional. That's somebody else. And I think if everybody took that to heart, and I mean not just said it but actually lived it, we'd actually have a little bit of a better health system. We've got a great health system. It'd be even better. Let me give you an example. There's data that one in three doctors don't wash their hands. They don't wash their hands. I'm sorry. It's a bit like going into the theatre and doing an operation without washing your hands. Can you imagine? Not gloving up, not sterilising. Would anyone do that? Never. But not to wash your hands in the 21st century before you touch a patient, after you've touched a patient, you know, one in three, that's unacceptable, it's unethical, you know, that just can't continue. |
Welcome to On The Wards, and this, the first of a two-part podcast interview in which Dr. Bruce Way discusses an approach to undifferentiated shock. As we know, shock's a complication of a number of different disease states and it presents both a diagnostic and a management challenge. Early recognition and treatment are essential for good patient outcomes. Joining me today is Dr Rob Hislop. Rob's a senior intensivist at Royal Prince Alfred Hospital and does also a clinical lecturer at the University of Sydney and has a strong interest in medical education. So Rob, we might start by, if you can just give us a definition of shock. Well, I guess there are many, but a simple and workable definition of shock would be a state in which there is an inadequate delivery of oxygen to the tissues. There can be many causes of that, but that's probably the bottom line. Broadly speaking, that can be a circulatory thing or sometimes it can even relate to poisons like carbon monoxide or cyanide. But I think we should probably forget about those latter sorts of causes and think more about the common sorts of shock that we think about, which can be classified in terms of hypovolemic shock, obstructive shock, cardiogenic shock and distributive shock. If you think in those terms, you're unlikely to miss much. Okay. We might explore that with a few cases. So the first case is regards a nurse rings you from the operating theatre on behalf of the surgical registrar who's asking you to review a patient for her on the ward. She's stuck in theatre. The message you get is that the patient has undergone a thoracic biopsy that day which was a minor procedure. She is a bit hypotensive and the surgical registrar has asked you to go and have a look at the patient and perhaps chart some fluids. So on reviewing the patient notes you see it's a 43 year old lady who's been previously well. She's being investigated for a fluctuating fever and cough and an outpatient CT of her chest showed that she had a mediastinal mass. So with regard to your clinical review you find that she's got a blood pressure of 90 on 55, a heart rate of 125, and she seems to be unaware that she's in hospital. She's a bit confused and disorientated. So you mentioned before about some of the possible causes of shock. With regard to this particular case, what do you think the causes could be and just sort of go through those in relation to this case? Well, look, I think it could be any of the four classifications that I just mentioned. And as we're talking about undifferentiated shock, I guess most shock states at initial presentation are undifferentiated. And this could be any of the above. She's recently had a biopsy so she could be bleeding even though it was a minor procedure. She could have had an artery could have been hit or something so she could easily be bleeding. She's had fluctuating fever. She could have a septic shock or even a non-septic but inflammatory type of shock with vasodilatory state. She could have had a cardiac event, so she could have cardiac ischemia and be in cardiogenic shock, or she could have even had a PE and have obstructive shock. This tumour, this mass she's been investigating could be a malignancy. She might be in a thrombophilic kind of state. She might have had a DVT and a PE. Any of these things are possible. So, yeah, this is somebody who does represent a problem. Her blood pressure's marginal, her heart rate's significantly high, and that conscious state is of concern. Absolutely. Would you consider any other causes of obstructive shock when she's had a thoracic biopsy? Oh, of course. Yep, of course. So she could have a tension pneumothorax or she could potentially even have a tamponade, cardiac tamponade, depending on exactly whereabouts in the chest that biopsy took place. So absolutely any of those causes of shock could be going on in this patient. And there are some things we can do that can start to point us in the right direction of diagnosis and therefore management. So the JMOs, the doctor who's here assessing the patient, he's a registrar, he's scrubbed in theatre, so what can they do to try and work out what's going on in terms of assessing and managing the patient? Well I think probably the most helpful thing initially on arrival when you see the patient is to touch them, examine their peripheries, feel their hands and their feet. And that can immediately start to point you in a diagnostic direction. There's a fork in the road. And I would hope if you see any good intensivist or emergency physician practising what they do when they're seeing a patient like this, one of the very first things they'll do is touch the patient's hands and their feet. And they'll be assessing whether their peripheries are warm or cold or somewhere in between. Now, we don't really state this, but it's always worth remembering that we're assuming that the patient's being examined in a reasonably, a relatively warm ambient environment. And we all know that if it's a cold winter's day and we're outside, we can get cold hands and feet, but it doesn't mean we're shocked. But if you have a patient in a reasonably warm ambient environment and their blood pressure's marginal or concerning and you think they're shocked and you feel their peripheries and they're cold, then that can head you towards a certain diagnostic pathway versus if you feel their hands and feet and they're particularly warm, that can lead you in another diagnostic pathway. It's more difficult when you feel their hands and feet and they're sort of somewhere in between and that sometimes goes with mixed shock states where there's more than just one thing happening. But if we feel this patient's hands and feet and they're very warm then that's really kind of inappropriate given the clinical status we've already described and that would immediately make me start to think that the patient has an inappropriate vasodilatory state and they're in a vasodilatory shock state. So that would make me start to think about sepsis or even non-infected causes of high inflammatory states that can lead to vasodilatation and hypotension. Things like very, very florid lymphomas with florid inflammatory states can do this kind of thing. On the other hand, if you feel the patient's peripheries and they are icy cold and shut down, you can also look at their capillary refill and that might be very slow. If that's what you're finding, then you're much more likely to be thinking in terms of hypovolemia or cardiogenic shock or obstructive shock. Then you've got some more things to do examination-wise before you can narrow down that field of three. And usually I think it's quite helpful once you're at that point is to start trying to get some idea of the filling pressure or the JVP in that patient. And I know that it's a bit cultural for some of us to forget some of the things we were taught to do at medical school. And there are naysayers out there in the community who say that CVPs and JVPs don't tell you about somebody's blood volume state, and I might go on about that a bit later, but it can be very helpful about telling you whether someone is extremely hypovolemic or perhaps showing signs of some other problem like cartogenic shock or tension or tamponade, in which case their neck veins might be pretty much popping out of their head. So it's more a question of all or nothing rather than it's four or five centimetres? Yes, certainly. So, I mean, I think when we hear people say, oh, their JVP is this many centimetres, I don't think we're that accurate clinically. I think we can tell if it's extremely low, we can tell if it's extremely high, and we can tell if it's sort of maybe kind of sort of middling or somewhere in between. But these are still helpful things. High, low middling can help point us in directions. If the neck veins are standing out of the neck very, very full, then you're starting to think about cardiogenic shock or obstructive shock. On the other hand, if they're very low, you'd be thinking hypovolemia and you'd be starting some volume resuscitation. What about any other, in terms of your focused examination, apart from the cardiovascular system, what other sort of, in this particular case, what other things would you concentrate on in your exam? |
Okay, welcome everyone to On The Wards, it's James Edwards and I have the pleasure today of speaking to Associate Professor Andrew Dawson who's a toxicologist. Welcome Andrew. Hi James. We're going to talk about toxicology and I guess from the perspective of a junior doctor and they're more likely to see a toxicology patient in the emergency department. We'll start as we always do with our podcast with a case. And you're a junior doctor and asked to see a 22 year old female who presents to the emergency department and the triage notes have documented a polypharmacy overdose. She's a bit drowsy and apart from a pulse rate of 110, her vital signs are within normal limits. What's your initial approach to seeing someone like this in the emergency department? Okay, James. Well, the first thing is ultimately you're trying to achieve a really good risk assessment to try and work out where this patient is going to go and what the likely things are to happen with them. And so you do a lot of things concurrently. But the easy thing about toxicology is that much of your physical assessment and the things that you do at the first pass is based pretty well around vital signs. And so the first thing I do whilst gathering in other things that we might do in the assessment is just to recheck the vital signs and get some sort of baseline. And by that I mean really looking at the pulse, at the blood pressure, looking at the saturation, their level of GCS, a very important parameter, and probably quickly looking at their reflexes to check for hyperreflexia. A little later on you might get some other investigations, but the purpose of doing that up front is you want to get a snapshot about where this patient is and what effects the drug has on them at the moment, because sometimes, even in the absence of any other information, if you re-examine them in half an hour and they're progressing rapidly, they can give you a really good idea about prognostically where you're going. So getting that mapped out very early on is pretty important. We could obviously go through a resuscitation approach, but we might just break it down to history exam just for the podcast. When you're trying to get a history, how do you collect a history for someone who may be a bit drowsy? What are other kind of areas that you get history from? Okay. Look, the first thing is obviously you should ask the patient. The vast majority of patients who come in following a self-poison don't want to die, don't want to harm themselves. It is mostly impulsive and they're generally willing to give information if they have it. In addition to asking the patient, they may obviously have things such as empty tablet boxes and all of those things and you need to be able to scope those up. Getting hold of the tablet box is very useful because that often will provide in many patients an entry into understanding who their prescriber is and who's dispensed their medication. So in particular, if they're unable to give you much history, that does allow you to get collateral history from providers. The evidence is that most patients, in actual fact, give a pretty good history. There's a subset which all of us can recognise. So patients who are obviously drunk or delirious or clearly defiant or with a previous history of not giving an accurate history are a small minority and are those you want to go for collateral history. So you see what the patient has. You look at the ambulance form. The ambulance guides will often record information in the ambulance sheet that doesn't always get translated across. And that will give you an idea of their potential exposures. You're also really interested in when they took that ingestion. Now, sometimes patients can give you a very accurate time or there's a bystander who will give you an accurate time. Sometimes the history is a little unclear and you might test them out, ask what they're doing, if they're watching TV, what program it is. These days sometimes we have patients notifying friends using social media, so Facebook and things. So trying to get some idea of the time of ingestion is very useful because once you understand the time of ingestion and the medication they've taken, you can kind of map out what you're likely to expect. So in some ways, if someone has just ingested a whole lot of pills five minutes ago, you're left with a very well patient and you're trying to predict where they go, whereas if they said, I did it all five hours ago, mostly they're survivors and there's little to worry about. Okay, so we're kind of looking at when they took their medications or tablets, what they took, how much, other things like whether they're slow-release medications sometimes. So slow-release, we can come to that a bit later on, but slow-release medications means that their exposure is much later. Once you've got that information, and especially if you're kind of new to the game, if you've been working in the emergency department for a little while, you'll come across a number of tablets that you should be fairly familiar with. But what you want to be careful about is making certain that you do understand all the medications. You shouldn't guess. So you need to be able to think, OK, do I have a good understanding of what this medication does in overdose? If you don't, then you need to look it up or you need to get some further information to inform your risk assessment. But luckily, the vast majority of patients come in with a relatively small amount of exposures. And what symptoms do they come in with? Do they come with drowsiness or nausea? Do they help at all? Or is it really about what the tablets they've taken? In broad terms, James, medications fall into two camps in terms of toxicity. We have a whole range of drugs. This is the majority of the drugs that we see which can cause respiratory depression. And that correlates very well with a depressed level of consciousness, as measured by a Glasgow Coma School. And those patients may require respiratory support. Many of those medications also have some cardiotoxicity and we generally unravel that by looking at the ECGs and by and large statistically these medications are mostly psychiatric medications and so these are direct cardiotoxic CNS toxic or respiratory depressive drugs. The other group of drugs we have which is a bit more of a window is drugs that cause toxic damage to cells and the best example of that is paracetamol. But there are some other medications. And the problem with that is that quite often those patients are relatively asymptomatic when they come in and the toxicity is all a bit downstream. So it's not so much about urgent supportive care. It's about whether or not you have to administer specific treatment. In regard to the examination, you mentioned about the importance of vital signs, but what's your approach to examining a toxicology patient? OK, so in the... This is the bizarre secret of the specialty. The reality is that the examination that you do is really focused on eliciting certain drug effects. So after you've gone through the vital signs, the other things you're trying to pick up in particular is whether or not the patient's got any evidence of anticholinergic effects. And often you will know if they've taken the appropriate medication, but some of the information that I might be asking for when you ring me up is I'll ask, are the bowel sounds present? Do they have evidence of urinary retention? These are things we have to manage, but they're a good sign of a drug with a lot of anticholinergic effect, and it has some implications in management. I mentioned before that we look at the reflexes. Now, in most patients, when they could have come in, if they've got a low GCS, you'd expect that most people, they'd be floppy and their reflexes would be hyporeflexic. If the patients have brisk reflexes, that would normally suggest to us one of two things. Either that they've taken a drug that's pro-convulsant and they're actually quite twitchy and you think, gosh, that reflex is a bit more brisk than I would think. Or quite commonly that they're on a serotonin reuptake inhibitor, which will also give brisk reflexes, even in normal therapeutic doses. But the brisker they are, the more significant it comes. Thereafter, in that brief neuro exam, you would then look to see if the patient has clonus, generally in the ankles. So this is dorsiflexing the foot. And if they've got clonus, especially if they've got more than three or four beats, that strongly suggests they've taken something that's got a serotonin reuptake inhibition. The other thing is to consider is often these patients can be a bit chaotic. And you need to be very clear that as soon as you get any evidence of focal neurological signs that you may be dealing with something else other than drugs. |
Welcome to On The Wards, it's James Edwards and today we're talking about anxiety disorders and today we have Dr. Julian Nasty, Julian. Hi, James. Julian is an advanced trainee in psychiatry, currently working at Canterbury Hospital. And we're talking today about anxiety disorders, which I guess are a very common disorder within the community, and I think all of us have felt anxious coming up to exams. So what's an anxiety disorder? Yeah, so anxiety symptoms are probably the most common of all psychiatric symptoms. And anxiety disorders are probably the most common psychiatric disorders. And as you're alluding to, James, anxiety symptoms are very much on a continuum of normality. It's almost impossible not to have ever experienced anxiety or fear. and the inability to feel those things is probably abnormal in itself. A lot of patients with perhaps more serious diagnoses will almost always identify with having an anxiety disorder or anxiety problem. This can be useful in gaining rapport with patients, for example, who have a psychotic disorder, almost all of whom will identify with having anxiety of some form or another. The anxiety disorders, there's a whole shopping list of them, and I'm not going to go into each and every one today, but essentially they're characterised by excessive or disproportionate fear of a particular object or situation, or fear without an object. And the person who experiences the disorder usually recognises that the fear is senseless or irrational, as distinct from a psychotic disorder where insight into the senselessness of it can be absent. We're going to take a case, and this case is something that would be similar or something that many emergency physicians and registrars or junior doctors would have seen. It involves a kind of middle-aged man who's presented to the ED on a fairly frequent basis now over the last three months with some unexplained physical symptoms, a bit of nausea, epigastric pain has been investigated with ECGs, troponins and no abnormal abnormalities have shown up so far. And he's presented again really concerned about this ongoing chest pain and shortness of breath and he's looking really for an answer. He agrees that he's anxious but doesn't see his physical symptoms as being related to his anxiety at all. So maybe what would be your initial approach to this? Well just in terms of thinking about the symptoms of the anxiety disorders, I find it helpful to divide them into two broad groups which I call the cognitive and the somatic. So the cognitive aspects are the anxious thoughts the patient has, and the somatic aspects are obviously the anxious bodily sensation the patient experiences, which usually relate to sympathetic overactivity. Then beyond that, you have to think about the behavioural consequences of anxiety so basically how the person copes with the anxiety symptoms. That usually relates in some way to avoidance which is a strategy that leads to short-term reduction of anxiety at the expense of long-term worsening. A lot of different behaviours come under the heading of avoidance so you know an obvious example would be something like the person with agoraphobia who avoids leaving the house because they might have another panic attack. But also the use of alcohol or benzodiazepines to avoid experiencing anxiety symptoms in the short term can also be considered an avoidance strategy. So in terms of assessing the possibly anxious patient, it's good to think about the cognitive dimension, the somatic dimension, and the behavioral consequences, which usually relate to some form of avoidance. In terms of considering a differential, particularly in this patient, you do have to think about an organic problem or a substance-related cause, particularly if he were presenting with sudden-onset anxiety symptoms for the first time. You always have to consider the possibility of alcohol and or benzodiazepine withdrawal. There's a huge comorbidity between drug and alcohol problems and anxiety disorders. And anxiety, as I alluded to before, is highly nonspecific. So the presence of anxiety can really signal the presence of any one of a number of psychiatric disorders, including the mood disorders, particularly depression, but also the personality disorders. So if you encounter anxiety, you should be thinking about the possible comorbidities. And really, if you're presented with any form of psychiatric presentation, you should be thinking about the possible presence of an anxiety disorder. Anxiety disorders tend to run together in particular individuals. So in my experience, it's quite rare for people to have a sole anxiety disorder. They usually have bits and pieces of various anxiety disorders or a number of anxiety disorders together. So often people with panic disorder have generalised anxiety and vice versa. If you do see someone in the emergency department with maybe the first onset of anxiety, what sort of investigations would you consider to try and exclude, I guess, an underlying medical cause? I think secondary medical causes of anxiety are quite rare. I think the things to exclude would obviously be a thyroid disorder. I have seen people present primarily with anxiety symptoms who turn out to have a serious arrhythmia. I've seen a couple of people with SVT present primarily with anxiety symptoms. I think that it's always reasonable to do a BSL because the kind of neuroglycopenic signs of hyperglycemia can look like a panic attack occasionally. And any evidence of drug and alcohol use from the investigations, UDS, looking particularly for stimulant use, probably a useful thing to do. But yeah, as I said, the secondary medical causes are quite rare. The things that you see in the textbook like the adrenal disorders, pheochromocytoma, etc. But I think UDS, thyroid function, ECG and BSL are probably reasonable in addition to the usual bloods you would do. Yeah, the other one I'd add that I've seen occasionally is somebody comes in hyperventilated. Yes, that's right. You've got blood gas and they've got a severe metabolic acidosis. So again, you should be able to pick that up from clinical signs, but occasionally that has been missed. Yeah. So I guess we've done some investigations. We think they have got an anxiety disorder. Maybe you could outline treatment, I guess, acutely and then some of the more chronic treatment strategies you could institute or refer to? Yeah. So it's very common for people to present to ED with severe acute anxiety. I think the first step is reassurance, to be quite direct with the patient and say, no-one ever died of a panic attack, despite the fact that it really, really feels like you're going to die, you're not going to die. Deep breathing is useful. The deep breathing technique that I teach patients is to breathe all the way in, as far as you can go, count to 10, breathe all the way out until there's nothing left, pause and repeat as necessary, and that can lead to a very powerful parasympathetic surge from vagal stimulation via the diaphragm. And some people describe that as almost being like a drug. It can be very powerful. Also getting the patient to think of soothing imagery. There is a place for medication, you know, perhaps a stat dose of a benzodiazepine or a low-dose atypical antipsychotic, particularly if it's interfering with essential medical care. So, you know, if a cannula needs to be done or some other investigation needs to be performed, I think I've discussed this in another podcast, but it's quite rare for people to present with, you know, drug-seeking behaviours. I think that, you know, you should err on the side of believing patients in these sorts of situations, particularly if the anxiety is getting in the way of other investigations and management. In terms of long-term treatment, medication, so particularly the SSRI, antidepressants and psychotherapy, particularly cognitive behavioural therapy are the mainstays. Most people with anxiety usually have mild to moderate illness, and this usually can be treated with cognitive behavioural therapy alone. The long-term management of an anxiety disorder is not something that would usually be done by a junior doctor, although if you're working in a GP registrar setting, you might have to deal with that. I think it's just important to understand the available referral pathways. So normally for the anxiety disorders, a GP would initiate a referral to a psychologist. So in Australia, psychotherapy for the anxiety disorders is largely, though not exclusively, done by psychologists as opposed to psychiatrists. The community mental health teams, unfortunately, are burdened with dealing with the severe so-called low prevalence disorders like schizophrenia and bipolar disorder and don't often have good resources for dealing with people with anxiety disorders. An exception to that would be the Headspace organisation for younger people. They have a lot of expertise and resources in dealing with anxiety disorders. And the other useful resource, both clinically and also just as a source of information, is a clinic attached to St Vincent's Hospital called CrewFad, run by Professor Gavin Andrews. So the web address for that is crewfad.org. So that's C-R-U-F-A-D.org. |
Welcome to On Awards. I'm Jane MacDonald and I'm an ONG registrar based in Sydney. Today we're talking about some of the clinical scenarios commonly faced by ONG SRMOs with Dr Becky Taylor. Becky is an ONG fellow at RPA Hospital based in Sydney. Welcome Becky. Hi Jane, thanks so much for having me. Today we're going to be talking about some of the clinical scenarios faced by ONG SRMOs, particularly those on the birth unit. And so as usual, we'll start with a case to illustrate important points to take home. So let's start with the case. A 27-year-old primagravid woman, Amy, presents to the birth unit at 35 weeks gestation with some clear leakage from the vagina since this morning. She has had an uncomplicated pregnancy to date and is being seen by the midwives antenatally. Her last ultrasound was a morphology scan at 20 weeks gestation which demonstrated normal fetal anatomy and a placenta located on the anterior wall seven centimetres clear of the internal os. Becky, how should we approach the assessment of this patient? So I think the approach we take to assessing any patient that presents to delivery ward is first establishing that they're clinically stable and you don't need to initiate any important basic life support. Once you establish that they're sitting there talking to you and you've got time, then what you want to do is to take a detailed history so you know you know that the leakage started in the morning how much leakage has there been has it just been a little bit is it associated with coughing is it associated with a full bladder and getting a little bit more information about the nature of the leakage then you want to ask as with any obst history, whether the lady is having any contractions or tightenings, whether uterus goes hard, whether there's any abdominal pain. And it's really important to also ask always about fetal movements and whether the baby's persisting with its normal pattern of movements that most babies settle into at around 28 weeks gestation. Also, whether there's been any vaginal bleeding, whether there's any vaginal itch or any pain. So in this scenario, the diagnosis that it's important to consider, importantly, whether this is a preterm premature rupture of membranes, that's the diagnosis that we don't want to miss. But other common scenarios are just a heavy physiological discharge. We know that with all that estrogen kicking around in pregnancy, vaginal discharge and secretions increase. Whether there's been any urinary incontinence. So as the pregnancy progresses and you've got a large gravid uterus pressing on your bladder, many women will develop stress and urinary incontinence, which at the first instance, they may well confuse with rupture of membranes. Other considerations include things like vaginal infections with bacterial vaginosis or thrush. So when we're starting, we've taken a history. The next thing is obviously to move on to examination. So as with patient taking vital signs so blood pressure pulse respiratory rate oxygen saturations if required that isn't always done on patients presenting to the delivery ward but it does just obviously depend on on what they're presenting with and you want to always use that opportunity to screen any patient presenting for hypertension which can develop at any stage in the pregnancy you want to palpate the abdomen and determine the fetal presentation and also measure the fundal height of the uterus to assess whether the gravid uterus is an appropriate size for their gestation any patient who you suspect has ruptured their membranes or who's presenting to the delivery ward with abdominal pain or bleeding needs to have a CTG. This is an indicator of the fetal well-being. Certainly from 26 weeks onwards this should be standard. At less than 26 weeks it wouldn't be a standard practice to put a CTG on unless the patient was in labour. And a fetal heart is generally sufficient, but every department will have a different policy on when to use a CTG. And then the next thing that's really important is to test the urine. So do a urine dipstick, assess whether there's any protein or any nitrates or any suggestion of infection. And then you want to perform a speculum examination. So get the patient in a comfortable position with their ankles together and their knees flopped out to the side. I often get women to make fists with their hands and pop them under their sacrum or put a towel under them so that they are in an appropriate position for you to do an easy speculum examination. And then what you want to do when you're doing a speculum is make sure you've got adequate visualization of the cervix and note whether there's any fluid leaking out through the vagina and particularly whether you see any coming through the cervix. And then you want to assess whether the cervix looks open or closed. Many women who are multiparous who had a a few vaginal deliveries before, the cervix may look a little bit open, but this may in fact just be what we call a parous cervix. So the more speculums you do as a junior, the more you'll get used to normal anatomical variations. It's also important to get the patient to cough or bear down, so Valsalva, and manoeuvre to see whether any fluid comes out from the cervix. Great, okay well let's head back to the case then and we find that Amy is vitally stable, her abdomen is soft and non-tender, there are no palpable contractions and on palpation it feels like there's a cephalic presentation. You perform a speculum examination and there is clear fluid in the vaginal vault with a positive cough reflex. So you make a clinical diagnosis of preterm premature rupture of membranes or PPROM. So Becky, how do we manage the patient now? And what are the main risks of PPROM? So the main risks of PPROM are pre-term labor so having a baby being born before 37 weeks and this patient's 35 weeks so what we would term a late pre-termer and so the risks of that baby are you know things such as lower birth weight, issues with breathing on delivery, low blood sugars, increased risk of jaundice. And most of these babies will spend a few weeks in the nursery just feeding and growing and just taking a little bit more time than babies born at term do. Obviously, for women who have pre-prom at earlier gestations and deliver you know before that sort of 34 week mark the risks of pre-term labour are greater and you know they very much sort of correlate to the gestational age in terms of outcomes. The other significant risk is of course of coriomionitis so an infection inside the amniotic fluid and inside the womb and that you know puts the baby and the mother at risk of of severe sepsis so it's something that we need to be on the lookout for in any of these patients and it's because of these two risk factors that we admit patients with PPROM to the ward and usually they'll stay in hospital until they deliver. Some women who have pre-PPROM early in their pregnancy may end up on an outpatient management basis if the hospital offers that, but not all sites are able to offer that sort of program. So in terms of immediate management, so any patient with PPROM, we need to give antibiotics too. Antibiotics have been shown to reduce the risk of chorionitis. And in the Oracle One study, erythromycin alone was shown to prolong the pregnancy, although long-term follow-up showed no significant difference to children's health and development in the long term. In patients that are known to be GBS negative or where there's access to immediate testing, then erythromycin orally alone, normally at a dose of 250 milligrams QID, is the antibiotic of choice. Where GBS, so it's a group B strep status, is unknown, then ETG is currently recommending that patients have 48 hours of IV ampicillin until group B strep is excluded. And if they are group B strep positive, then they should receive at least seven days thereafter of oral amoxicillin and erythromycin. But essentially, each hospital will have their own policy about antibiotic regimes. So just check your own hospital's policy so that you're doing the right thing for your site. One thing to say is Augmentin should certainly be avoided as in the Oracle study, this was associated with an increased risk of necrotizing enterocolitis. It's important when you do your speculum examination that you take a high vaginal swab and a low vaginal swab as well and send those off for microscopy and culture. It may be helpful to ask, particularly in the extreme pre-termers, for them to run additional testing for ureaplasma and mycoplasma, which are not picked up on routine MCNS swabs. It's important that the patient has a pad chart to monitor the volume of losses, any change in the colour of the fluid leaking, such as becoming sort of green and suggestive of infection. The patient needs to be monitored for signs of chorionitis. |
From clinical experience, I often find that a maternal tachycardia is one of the things that first suggests that there's brewing infection. And you're monitoring, again, as I said, for the change in the colour of the PV loss, any development of abdominal tenderness, any fetal tachycardia on a daily CTG and any other signs that's suggestive of maternal or fetal non-well-being. Most centres will perform daily CTGs and then one to two weekly ultrasounds depending on the size of the baby and its growth trajectory. Also looking at Doppler's routine bloods. In general practice, my finding is that in patients with ruptured membranes will have a full blood count and a CRP done twice weekly. There is some controversy about the timing of doing this because we wouldn't necessarily arrange delivery of a baby based on a CRP value alone. And a diagnosis of chorionitis is clinical, but certainly a sudden rise in a white cell can or CRP can be suggestive of early infection and may lead you to expedite delivery. In terms of timing of delivery, again, there's some controversy associated with this. I mean, the most important thing to decide in terms of the timing of delivery is, is there any immediate concern for the fetal or maternal wellbeingbeing in the absence of any signs of coronary anitis and normal ctg and a well-grown baby then most centers would advocate sort of trying to get to 36 to 37 weeks in this particular setting the average sort of lengths of baby staying in utero after p-prom is around nine days, but there's certainly cases of babies staying in for weeks to months after PPROM. In practice in Australia, I haven't seen many centres wish for people to go much beyond 37 weeks. And to be honest, the babies normally take this in their own hands and then start making their way out if they're not delivered by 37 weeks anyways. In this particular setting, there's no strong evidence for steroids for fetal lung maturation because the patient is over 34 weeks gestation, but certainly at less than 34 weeks gestation, the evidence is quite clear that steroids should be administered in the setting of P-CROM. And I think it's really important to remember that, you know, particularly for those patients that rupture their membranes very early, so say 24, 26 weeks, who are in hospital for a long time, not to forget the routine components of their antenatal care. So remembering to do the 75 gram glucose tolerance tests, making sure they've got their vaccinations and their anti-D. From experience, these things are very often, you know, missed on the antenatal ward when somebody's been an inpatient and you're sort of focusing on the issue at hand, which is PPROM, and you forget to do all those things you do on a daily basis in the clinic. Yeah, that's a good reminder. We get caught up in the chorionitis and the preterm labour and forget about gestational diabetes or vaccines. So if we were uncertain whether the fluid in the patient's vaginal vault on the speculum examination was significant or not, are there any other ways to either support or preclude a diagnosis of PPROM? Yeah, so there are a few tools out there which we can use to aid in the diagnosis of PPROM. And I will sort of, you know, caveat by saying it can be really difficult to tell sometimes. Patients can come in with this excellent history of PPROM and then you do a speculum and there's absolutely no fluid at all and you send them home and then they come back that evening with the same history and your examination's the same and it can be really, really difficult. So some centres use bedside tests such as Amnishore. So this is a bedside immunoassay which detects fetal glycoprotein, something called placental alpha-microglobulin 1 that is highly concentrated in the amniotic fluid. Essentially, when you're doing the speculum, you take a swab from the specialised pack that the test comes with, and then you put that into a special fluid which comes with the pack, and you take five minutes to run, and essentially you then put that fluid onto a pregnancy test type system where two lines represent a positive result. Another test is the amnicator. So this is a nitrosine-based test, and nitrosine is a sensitive pH indicator. And that looks like a cotton bud, which is placed in the posterior fornix during a speculum exam. And an immediate color change from orange to black will be seen if the pH is greater than 6.4. Usually the vagina has a pH of less than 6.0. So if the pH is greater than 6.4, that suggests the presence of amniotic fluid. It'll also change color if it's placed on a wet pad where amniotic fluid is present. Actinprom is another similar test. This detects the presence of insulin-like growth factor binding protein 1 in the vagina through specific monoclonal antibodies. Like PAMG1 in the amnesia, this particular insulin-like growth factor is present in the amniotic fluid in high amounts. Now, some of these tests can't be used if there's any history of bleeding as blood undermines the test result or if the patients had recent sexual intercourse and beware of the false positive test result. Many centres actually choose not to use these because of bad outcomes relating to false negative tests and I think it's important to even if you decide that somebody's ruptured their membranes based on one of these tests to always kind of reassess the situation where I work our preference is to do a speculum examination and also to do a bedside amniotic fluid index obviously if there's oligohydramnios or low AFI compared to a recent scan around the baby that's more suggestive of rupture of membranes compared to, you know, if you've got a really good AFI or one that hasn't changed significantly from a previous examination. But it's important to maintain an open mind and understand that sometimes an initial negative or positive examination may not always lead leading to the correct diagnosis. Great. So if we go back to the case, Amy is admitted to the antenatal ward and she's commenced on erythromycin. Her high vaginal and low vaginal swabs demonstrate no growth and an ultrasound later that day shows normal fetal growth, Doppler's and oligohydramnios with an amniotic fluid index or AFI of four. She asks about when it is likely that she's going to have a baby. So Becky, how long do women usually stay pregnant after membranes have ruptured? And I know you alluded to it earlier, but is there an ideal time to organise delivery for Amy? Yes, I guess we sort of touched on this a little bit earlier. I mean, I don't think that, I think in the absence of infection or fetal or maternal distress, it's very reasonable for Amy to try and, you know, continue on until around 37 weeks gestation. The average duration of pregnancy post pre-prom is around nine days, but a lot of women I find that deliver, that rupture their membranes around the sort of 34 to 36 week mark, often in reality go into labour sooner, you know, than those women perhaps who ruptured their membranes earlier, 24, 26 weeks, who may have a longer period of baby remaining in utero. The average duration of pregnancy post pre-prom is around nine days. And essentially time of delivery is always, as with everything, obstetrics going to be based on the balance between, you know, maternal and fetal well-being and whether it is better for the baby to stay in utero versus being ex-utero. Now, in this setting, infection or fetal distress is obviously going to mean that we need to expedite delivery. But there doesn't need to be much to push you in the direction of delivery in a baby at 35 weeks gestation in this situation whereas at 24 weeks gestation due to the extreme nature of a baby being the extreme prematurity of a baby at that gestation you're going to need to have a slightly higher threshold in order to decide to deliver that baby because of the risks of being ex-utero for that baby. Yeah. So when it does come time for Amy's delivery, presumably this will mean inducing her labour. So what does an induction of labour actually mean and what are the different ways in which this can be done? So typically for women who have ruptured membranes who require an induction of labour, which essentially means bringing on the labour through artificial means where it hasn't started spontaneously by itself. So if, for example, for Amy, we noted that she had developed a fever and rising inflammatory markers, then the most common way that we would induce this labour would be to put a cannula into Amy and start an oxytocin hormone drip. |
Now, outside of PPROM, there are other ways of starting an induction. So, for example, if a woman was having an induction for post-dates, then there are other strategies that we will use to get to the point that we can break the waters. So that essentially refers to cervical ripening. So cervical ripening is when we prime the cervix, aiming to soften and dilate it up to a point that it's around sort of two to three centimetres dilated and we can break waters and then start an oxytocin drip we don't really like starting women on an oxytocin drip when the cervix is um is is very closed if we if we can but in the setting of ruptured membranes um what we generally need the only options we really have are to use an oxytocin drip if a woman's coming in for an induction and has membranes which are intact ways that we can ripen the cervix include with prostaglandins so there is a prostaglandin called cervidil which is a little pessary on a string which is placed into the um upper vagina and can be left in for 12 hours. Other options include prostaglandin gel. And then there are also mechanical means of rightening the cervix. So using things like a Cook's catheter, which is a little catheter, which has two balloons, one on the end and one a few centimetres down so that one balloon inflates inside the cervix and one outside the cervix, and that essentially causes a mechanical dilation and can be left in for around 12 hours. Foley's catheter is a sort of more simple version of the same thing, just a Foley's catheter balloon can be inserted and had about sort of 30 mils of water put into that, and that works very nicely to dilate the cervix as well it's important to consider what the indication for induction is so if you've got a very small growth restricted baby then you may not want to use a prostaglandin method which is not reversible because you can't take the gel out once you put it in and things like hyperstimulation from the prostaglandin may cause fetal distress. So for those patients, you may prefer to use a Foley's catheter straight up. Now, lots of different centres have got lots of different ways to run an induction. Some centres outside of Australia will use Cervidil in women who ruptured their membranes. But generally my experience in Australia is that for women who rupture their membranes, we would generally use an oxytocin drip to get things going. Great. So a week later, you're back on the birth unit and you receive a call from your colleague who's covering the wards. Turns out Amy's developed some painful pelvic tightenings and they've not settled with paracetamol and oxycodone. They're now occurring three times every 10 minutes and her CTG is normal, but the tocogram is also detecting some uterine contractions. So Becky, it sounds as though Amy is in labor by this stage, but she's still only 36 weeks gestation. So technically she's still preterm. How do we manage her? Okay, so, yeah, this often happens. It's often in the middle of the night you'll be on your night shift and get called up to assess one of the ladies with P-prime who's started to contract. So I think the first thing is just to go back to basics and do your normal assessment of the antenatal patient. So making sure the midwives have done some observations on her, checking her temperature, heart rate, et cetera. It's also important to put on a CTG to see whether there's any evidence of regular uterine activity and any evidence of fetal distress. What I would normally then do is providing that the CTG isn't you know imminently requiring delivery is to do a speculum. Sometimes you know women with PPROM can can have a bit of a stop start kind of approach to labour and you don't want to subject these women to multiple vaginal examinations. Digital vaginal examinations with increased risk of infection. So my preference initially is to do a speculum examination. You can't determine the exact dilatation, but many a time I've done a speculum examination on a patient with PPROM and seen a head right there. So at least that gives you some idea. If the cervix certainly looks like it is dilating and you can't, you know, it obviously isn't kind of closed or one centimetre, then what I would normally do is to do a vaginal examination to properly assess dilatation. And that will give you a little bit of an idea of how quickly you need to move. I mean if the patient is fully dilated then you want to get down to the birth unit ASAP. If she's three to four centimetres you know you can do that in a timely fashion but do beware the preterm birth can occur very quickly when you've got your back turned. So if you've established that the patient's in labour then you want to transfer the patient to the birth unit. Once they arrive in the birth unit, they need to have an IV cannula cited if they don't still have one from their initial admission. And I would take off some full blood count, a CRP and a group and hold at that time. They need to have continuous electronic fetal monitoring. So a CTG one because they've've preterm second because they've had prolonged rupture of membranes and that will guide you as to how the baby's coping in labor in terms of analgesia then that's going to be dependent on the maternal request a lot of women will start using nitrous gas and certainly a lot of pretermers will deliver relatively quickly and I find in general that they're less likely to require an epidural because the labour tends to be more quick but certainly an epidural would be an option for this patient. We generally tend to avoid morphine for these patients, one because delivery can be quite precipitous and two because of the increased risk of respiratory depression in the preterm baby. And, of course, it's really important to notify paediatrics. So at 36 weeks, there's a high chance this baby's going to need to go to the nursery, although some 36-weekers may be cared for on the ward, but you'd certainly want to have a paediatric doctor or a neonatal nurse specialist in the room for the delivery to assess the baby. So let's say that Amy is transferred to the birth unit following a speculum exam which showed fetal head. You then perform a vaginal examination and she's five centimeters dilated. She requests an epidural and it's cited 30 minutes later by an anesthetics registrar. But then you're on the birth unit and you hear the emergency buzzer sound in Amy's room. You enter and the CTG demonstrates a fetal heart rate of 70 beats per minute. Becky, what do you do? So this is an obstetric emergency. So you want to, particularly if you're junior, you want to get help, let your obstetric registrar know, and then go into the room and initiate basic initial management for a bradycardia. So first of all, review the CTG to establish the duration of the drop in the heartbeat. So whether it's a deceleration or a bradycardia. So a deceleration is defined as a drop in the fetal heart rate of at least 15 beats per minute for at least 15 seconds. Now, these are common in labor associated with contractions. It becomes a bradycardia if the drop in the fetal heart rate is below 100 beats per minute for more than five minutes. If there's a deceleration, then just observe its correlation with contractions to establish whether it's early, variable, late, etc. And it's really important, I think, to say that as an ONG SRMO, interpreting CTGs is something that you need to start learning as soon as you start your ONG term, because you will be constantly pulled into rooms and asked by midwives to assess CDGs. So the earlier you start building confidence in that, the better. If this is a bradycardia, then this isn't an uncommon occurrence following an epidural block sighting. So often there may be a drop in the blood pressure of the patient after receiving the epidural. So immediate management in this situation is to turn the patient onto the left lateral position to reduce aortocable compression. Give the fluid, well, first of all, measure the patient's blood pressure. Give them an IV fluid bolus. If the patient is hypertensive, this can be due to sympathetic blockade and can be treated with an IV fluid bolus or may require ephedrine. I personally don't feel super confident giving things like ephedrine myself. |
Welcome everyone to On The Wards. Hang on there James, you're not hosting this one, I am. This is Paul Hamer hosting On The Wards. Today we've got Dr James Edwards who's our special guest presenter today. We're going to be talking about clinical handover. James Edwards, who usually hosts the On The Wards podcast, is a senior staff specialist in emergency medicine at Royal Prince Alfred Hospital and the chair of the New South Wales Pre-Vocational Training Council and Chair of the Pre-Internship Committee at the University of Sydney. He previously held the position of the Director of Pre-Vocational Education and Training at the Royal Prince Alfred Hospital for six years. Until you took over. Until I took over. And most importantly, he was the Chair of the Clinical Handover Committee at Royal Prince Alfred Hospital. So today we're going to be talking about clinical handover, which James has been doing for a number of years. So James, what is clinical handover? I'm not sure I'm going to go here, Paul. I'm used to sitting in that chair and not saying much. But look, I'm going to talk about clinical handover, something I am passionate about. Look, I'm going to give a definition of handover, which is the transfer of professional responsibility and accountability for some or all aspects of care for a patient or a group of patients to another person or professional group on a temporary or permanent basis. Now, the reason I've given that definition, because I think when we think of handover, we think a lot of it as a transfer of information. But I want to really emphasise that transfer responsibility. Because a lot of time you see a handover from, say, a day team, where you're looking after the patient, to the evening team. And sometimes, although you may be looking at that patient, people don't often take that professional responsibility. This is now my patient. We need to have that instilled within our junior doctors on the wards. So it's not just transfer information handover, it's transfer responsibility. You're now in charge of that patient once you receive that handover. I suppose, I'm going a little bit off script here, but in North America there are some people who feel that clinical handover is dangerous. What do you think about that? Look, it's almost why handover is important and what has led to handover having, I guess, a much higher emphasis than it did when I was a junior doctor. In North America and Europe, they've had a reduction in junior doctor working hours. And everyone thought the less doctors are working, they're not going to be so tired, they make less errors, patient care will improve. But that actually hasn't happened. They haven't had the improvement in patient care they thought. And they may have looked and thinking, well, what's happened is now there are a lot more handovers. Or in the US, they call them handoffs. And maybe that's the weakness in the system. Less hours, more handovers, more communication breakdowns. And that's why handover is important. Because when we look at errors that happen in hospitals, there's nearly always an element of communication. A communication error or something was missed or not spoken about. And handover is, in essence, communication. And what really, when you think about handover, you're trying to give a mental model of the patient you're seeing to another person and often I can't cite Chinese whispers you know every time the more handovers you do you lose that bit of information and that can sometimes be important and lead to poor patient care. So handover is something that is vulnerable to communication failure and communication is associated with most kind of RCA's or errors that happen within the hospital. And I often think about medical school training. You know I did a lot of stuff in medical school training, I think most junior doctors would agree, in regard to speaking to patients. But I don't think I got too much training on how to speak to other colleagues. And that's something that you do as a junior doctor all the the time speaking to either registrars or handing over to your fellow colleagues but that doesn't really get taught in medical school very well. I think also Australia has had a bit of a focus on clinical handover because as part of the World Health Organization Safety Patient Initiative or Alliance that we're the lead for clinical handover and now it's kind of been introduced into our current national standards and accreditation survey so I think handover the last probably five years has been at the focus or much more important for junior doctors. So I suppose it can be safe but just like anything it's a skill that needs to be learned and developed over time. So when does clinical handover occur? When we look at healthcare teams now they're going to work in different areas over different time and locations so we really need those effective handover practices to ensure that there's appropriate coordination and continuity of care and I often think one of the usual reasons that handovers get done is from shift to shift, from the morning to the evening, evening to night. And that can be a formal handover when most people within the hospital get together, run by a senior clinician, and there's a formal handover process. But a lot of informal handover processes, it may not be the big meeting, but you speak to a colleague and say, look, yeah, you need to chase this patient up. Also there's the end of term handover so when you've been in a geriatric term you meet your colleague before they start you give a hand of all those patients and maybe something about the term and similar sort of things on weekends you've been working all week there's a number of things you want done over the weekend, you may need to speak to the Eugene doctor who's covering that ward on the weekend. Again, also that transfer of care between departments. I work in the emergency department, we transfer lots of patients from ED to the wards and that's a potential area where things can get missed, a patient deteriorate, it's important that we do a good detailed handover to that registrar at the other end of the phone who's on the ward, or they come down and do a face-to-face meeting, which we often do in emergency departments. Intensive care to the ward is another area we've identified as potential risk. Sick patient ICU gets transferred to the ward, especially after hours, high risk. I think for the junior doctors probably the biggest one they see is from the wards to the community. So they've been managing the patient in hospital and then they go into the community, looked after by their GP and has that GP had an appropriate handover. Obviously a discharge summary form was part of that but it also should be a phone call to that local doctor about what's happened in hospital and what needs to be followed and what needs to be done. All right, so maybe we can think about what actually happens on the ward with handover. So say I'm a JMO and I'm doing the evening shift. It's my first evening shift ever as a junior doctor. and I've seen a patient on the surgical ward that's developed chest pain that I've seen by the medical registrar and the team and there was a plan for the night team that they needed to review the patient, they needed to chase the troponin results and just you know just check on the patient. How would I go about handover at that meeting? Oh look I think a lot of that stress that comes with going to a big handover, you're getting asked to speak in a group. It helps you've got some structure. And within New South Wales Health and a lot of places within Australia, the structure we use is ISBAR. So ISBAR is actually derived from the US Navy that they used in nuclear submarines. And it's trying to make sure that there's at least a minimum and accurate data set that's transferred from one person to another in regard to that patient. And what does ISBA stand for? You know, there's I, which is introduction. So that really says who you are. They say your name, what your role is. That's important because generalists change roles. So they may actually know who you are, but what role are you doing? I'm working on the evenings. I'm covering these wards. And kind of why you're commuting and where you are, just so they know what ward you're on. It's also important to actually identify who the patient is. So I do that a lot when I transfer some ED to the ward, not only of saying who I am, but I'm also saying the patient's name, their MRN, what ward they're going to. So introduction is important. The situation is kind of what's happening at the moment. You know, a situation that they, you know, I was asked to see a patient with hypotension, what their problem was. |
The background is which is B what are the issues that led up this situation you know they day two post stop a hip surgery what has been happening in the last couple of days that led to your phone call tonight and then there's's the A, which is assessment. And that's kind of what the problem is. What your assessment of the problem, and that takes in your history, your examination, maybe the current investigations that have been back, such as the ECG or for this patient a troponin, what do you think is going on? And last, which I think is most important, which I'll emphasise a bit later, is R, which is recommendation. What should be done? What do you want done with this handover? What's your goal of the handover? So that's a kind of small summary of what ISBAR is. And I think ISBAR is a really good structure and it helps junior doctors plan their handover. But I think one of the areas I think is a potential weakness for junior doctors is that they can include too much information. And really, when we think of clinical handover, it's a clinical skill. Being able to choose the points that are important that they need to know about without filling their handover with lots of information that's not important is a skill that requires learning and also some experience. And that's what some of the junior doctors struggle with. They can't kind of work out what I should include the handover and what can be left out. Okay. So I suppose it can be a system that can be used for very brief things but also very short things. So using the clinical example that we just had, should we just maybe mock up a quick clinical handover and see what it might sound like? Would that be all right? Sounds good. Sounds good. So I'll pretend to be the medical registrar. So James, have you got anything to hand over? Well, partly some of the reasons why I think people do badly at handover is lack of preparation. So preparation, you need to actually spend a tiny bit of time thinking about what you want to get out of the handover. What's the goal? So I'm almost going to go back to, in some ways you look at, oh, so what do I want this medical registrar to do? But in fact, I'm probably, this is more a handover to maybe not the medical registrar, but medical registrar or the junior doctor on the ward, what I want them to do. Do I want them to go see that patient? Do I want them to just chase a troponin on a computer? And what you'll talk about later, what to do with that result. So try to have a bit of a think about what you want to do in regard to the handover will make your handover sound better. I haven't prepared for this one, but I'll give it a go, Paul. So, James, I think it's your turn to hand over, handover shift. What's going on? Okay, look, I was interned covering 8 West 1 and I was asked to see Mr Joe Smith, a 67 year old man who develops some chest pain. Look his background is he's day 2 post right neck and femur fracture, fairly uncomplicated surgery but he did develop some anemia, his haemoglobin was 80 which he hasn't been transfused for. He developed some chest pain and the chest pain was like a chest tightness and his ECG showed some not so much the ST changes that the medical registrar thought and weren't maybe not significant and weren't particularly changed from the last ECG so we thought we'd do a troponin. I'd like you to chase that troponin. If the troponin is normal we'll just need to do another repeat troponin three hours later. If the troponin. I'd like you to chase that troponin. If the troponin is normal, we'll just need to do another repeat troponin three hours later. If the troponin is raised, I'd like you to ring that medical registrar and ask them to come and review the patient because I think they already need to go and monitor the bed and to speak to cardiology and also consider anticoagulation for that patient. Fantastic, that was perfect and you can see that only really took about 30-40 seconds. And it's trying to work out some of those kind of words. One of the things I want to emphasise in assessment, for a handover, especially done within a hospital setting, it's not the same as presenting to the medical registrar or your ED consultant or your physician. You don't have to include every information. And sometimes you can use those, what they call bigger encapsulating words, such as hypercapnic respiratory failure, hepatic encephalopathy, delirium second urinary sepsis. For someone at the other end of the phone, a medical registrar, when they hear those words, they'll start thinking about what the potential problems will be in the future. So some of the common errors I see made by junior doctors is putting too much information, not preparing, not thinking about what they're going to say when they get to handover. And if you've got patients that you will be handing over at the handover meeting, the night handover meeting, when you're walking to that meeting, start thinking in your mind, I'm going to use Isbar. We've got an Isbar app on the phone you can use. Start thinking, using that structure, what you're going to include and what you're not going to include. What I think is the most important part is something I call anticipatory guidance. So this is deciding with the information that you're asking them to chase up or ask them to review a patient, what they're going to do with it. So many times you get asked to chase a potassium, say someone's potassium was 6, had some insulin dextrose, can you just recheck the potassium? Everyone else goes home, you get the potassium and it's 6.1. What do I do with that? Is that okay? Do I need to give more treatment? Do I need to speak to a renal? Do I need to start organising dialysis? Whenever you ask someone to chase a result, you need to tell them what to do with that information. Similarly, if you ask to see someone with blood pressure that may have been low, it went to 90, had a flu bolus, has improved, you go back and ask and review that patient and review that blood pressure. What happens if it drops below 90? Who do they call? Is that someone they need to start calling ICU? Do they need to start calling the team about that patient? So you need to start thinking ahead. It's much easier if people think ahead during the day rather than having that poor night intern on their first set of nights having to make those decisions at four in the morning. If those decisions have been made during the day, who they call and what they do, that information, it makes it much easier for those night interns. And it's actually fantastic learning because part of becoming an experienced clinician is not just working out what's happening now, but almost be able to predict what's going to happen in a day or so. After you've seen it a couple of times, you realise that someone who's developed delirium and ED at five in the afternoon, they're definitely going to have delirium at four in the morning. Or that patient who's got a chest pain, a possible non-STEMI, you realise that once they get some more chest pain, that may be an indication they need the cardiology to see they may be getting a cath, either getting a new ECG change or maybe starting or changing management. So I think anti-spirality guidance is really important. I think that's a really good tip because I think often we see patients who are relatively stable but their junior doctors could foresee that something might go wrong in the after-hour shift and that simple hand handover quiz, like you demonstrated, was only 30, 40 seconds, gives that heads up to the after-hours doctor so that they're not reading through pages and pages of notes. It probably saves them 15, 20 minutes of work by having that 45-second conversation with the afternoon doctor. So I think that's a great tip. I've seen in some hospitals everyone uses ISBAR, but some people also use ISOBAR with O for observations. What are your thoughts? Look, I think it's more important as a hospital that everyone speaks the same language. So I think, you know, having nursing staff using ISBAR, medical staff ISBAR, I think that's more important than actually what the mnemonic is. No, fair enough. |
Welcome to On The Wards, it's James Edwards, I'm the host of the podcast series On The Wards. We're looking at different topics, especially aimed at junior doctors. And our first expert is Dr. Sean Lowe, who's an advanced catalogy trainer here at RPA and also did his junior doctor training at RPA, so he knows the wards well. And we're going to look at post-op arrhythmias. Great, thanks very much. Thanks very much for having me, James. It's a's a pleasure to do this. Great okay we'll start with just like a fairly broad question what are some of the common arrhythmias that you may see that a JMO may see on the wards? Well certainly after hours I think the most common arrhythmias will be encountered in the post-operative setting and for that reason they'll probably encounter tachyarrhythmia, so heart rates greater than 100. And certainly atrial fibrillation and atrial flutter is something that we don't see too infrequently, actually. And that can be precipitated by hypovolemia, anemia, and electrolyte imbalances in that post-operative setting. I guess while they're the most common causes for a tachyarrhythmia or for, in particular, atrial fibrillation and atrial flutter, I think it's very important for the junior doctor to remember sepsis and coronary ischemia as actually being the cause for the arrhythmia. And as always, I think it's important to keep in mind sinus tachycardia in the post-operative setting, which as you know, can just reflect dehydration, but also in someone who's say three to four days post-op, I think you've got to be thinking about a pulmonary embolus when there's sinus tachycardia. Okay. So, I mean, I've often been told that, you know, AS is not just a disease, it can be often a symptom of something. So if you find atrial fibrillation on a patient on the ward, do we need to actively look for underlying causes? I think, yeah, I think you always need to look for an underlying cause and the thing that I use over the phone when someone rings me about atrial fibrillation is I say to them, if this was a tachycardia, like a sinus tachycardia, what would you do? And they most often will answer, well, I'd look for the cause for the sinus tachycardia. I'd look for anemia. I'd look for thyrotoxicosis. I'd look for infection, and I'd look for dehydration. And I say, well, that's the same thing you'll do with atrial fibrillation. It's just in this case, the person's tachycardia happens to be atrial fibrillation rather than sinus tachycardia. So it's very important to look out for those things. I guess the one addition would be coronary ischemia because sometimes you can have coronary ischemia and then you get atrial fibrillation. You can also have it the other way around where someone has underlying coronary ischemia, they get atrial fibrillation, the heart's working a lot harder, and so then they get angina. So it works both ways. Okay, so I guess we've outlined some of the underlying potential cause arrhythmias. So what's your general approach to managing the patient with post-operative atrial fibrillation or flutter? Yeah, I think the first thing you've got to do is obtain a 12-lead ECG and confirm that it is atrial fibrillation or flutter because, you know, well certainly atrial fibrillation you could tell by the, you know, tachycardia and the irregular pulse or the irregular irregular pulse, but a trap often atrial flutter the you know the pulse is going to be regular and you know if you've got a pulse that's dead on 100 or 150 in particular I think you've got to be thinking about atrial flutter so a 12 lead ECG will confirm that and the next thing to do is to make sure obviously that the patient isodynamically stable, and that means that their blood pressure is okay, it hasn't dropped, and that you go through your ABCs, as you always would do in any situation. I think it's important to bear in mind that it is extremely rare for atrial fibrillation or atrial flutter to cause hemodynamic compromise. We'll often get a call about someone who might be having a fever and is post-operative who has a low blood pressure, 80 or 90 systolic, and they also are in atrial fibrillation at a rate of 130. It's extremely rare that the atrial fibrillation would be the cause for the low blood pressure. Invariably, the atrial fibrillation is secondary to the hypovolemia. And the only situation where you may see someone compromised by the actual fibrillation or flutter would be if they had severe heart failure. And here we're talking ejection fractions, you know, 20% or less, so very severe heart failure, then maybe they might actually be compromised by it. But more often than not, the most common cause of the hypotension in this setting is hypovolemia from dehydration, sepsis or anemia, especially after hours on the ward, in the surgical wards. Okay, I mean, I think that's important because all the guidelines say that we should be doing, you know, shocking patients or unstable atrial fibrillation. But, you know, my experience is the same. Most people don't have, I guess, shock from the atrial fibrillation, but the atrial fibrillation is related to whatever the underlying pathophysiological state is. Exactly, and so our first advice with any of those sort of patients is actually not to give any antiarrhythmics at all, but to actually try and look at those reversible factors. So electrolyte abnormalities, in particular potassium and magnesium, and simple things with just fluid. And often giving intraven bring that brings the blood pressure up and slows the heart rate down it still may be atrial fibrillation or atrial flutter but the rate is slow just as you would expect with a sinus tachycardia and only then do we then think about antiarrhythmic therapy once they've actually been filled electrolyte abnormalities have been been corrected, and if there's sepsis, antibiotics have been instituted. I think then we'd look at things like a beta blocker or digoxin to try and slow the rate down. But I guess it's also important to look at whether the patient is symptomatic. So are they actually getting palpitations? Are they presyncopals? Are they dizzy? And of course, do they have chest pain? Do they have angina because of the tachyarrhythmia? But more often than not, the most common thing we would encounter is someone who a JMO is called to see because of the tachycardia and it's atrial fibrillation at a rate of 130 and they've got a low blood pressure because of the reasons we've outlined. So treatment would first be trying to correct that blood pressure and then look at antiarrhythmics. I guess going back to the approach to the patient, I think the other thing then to do is once you've determined if there are symptoms or not, then have a quick look in the notes and just see, is there a past history of arrhythmia or coronary disease? You know, asymptomatic, hemodynamically stable atrial fibrillation or flutter rarely, you know, requires immediate further management other than correcting those reversible factors. But if I was asked, you know, what sort of antiarrhythmic would we use once those factors have been corrected, as I said, beta blocker would be first line, so metoprolol, and that would be oral. After that, you think about things like digoxin or amiodarone if there's a past history of LV impairment. I mean, maybe we should look at what kind of percentage do you think a patient should revert without any antierhythmic therapy or post-op? I often say to people, even when I'm called from the emergency department, about people with their first presentation of atrial fibrillation, that especially if they're reversible factors, they probably have about a 60% to 70% chance of being in sinus rhythm the next morning. So just reverting overnight. Now, there is some evidence that metoprolol will help with that process. I know it's not traditionally seen as an antiarrhythmic that converts someone into sinus rhythm, but there is some evidence that it would help with that. But most commonly people say, oh, I gave them some amiodarone. I gave them one dose of amiodarone and that reverted them to sinus rhythm. Well, more likely than not, it was actually themselves. |
Okay. I mean, in the post-operative patients, sometimes we worry that they may be nil by mouth or may not be absorbing tablets. Would that change your management rather than going for more metocloprolol? I think in that case, again, once you've looked at reversible factors and if the patient is asymptomatic and there's no evidence of ischemia and they're hemodynamically stable, I think you could give some intravenous digoxin. I mean, I don't think it's necessarily safe to be giving intravenous metroprolol on the ward by junior doctors in a setting other than emergency or coronary care. And in fact, you know, rarely do we use intravenous metroprolol in coronary care. So if someone was nil by mouth, I think, you know, moving them to a monitored bed and giving digoxin intravenously could be something to do. Okay, so what would be indications? Do all patients with post-op atrial fibrillation need to go a monitored bed? I think if it's their first presentation of atrial fibrillation and if they're symptomatic with palpitations, presyncope or angina, then they should go to a monitored bed. Likewise, if the rate is very fast, sort of greater than 150, I think it's safer just to put them in a monitored bed overnight and then sort things out throughout the night and in the morning, and cardiology would then be involved. But if it's a simple, someone who has paroxysmal atrial fibrillation and they're post-operative setting and they're a bit dry and the rate's 130 and they have no symptoms, no angina, there is no need for them to actually be moved to a monitored bed. You can adjust the SERS criteria and move on from there and they can stay on the ward. The other thing that, I mean, I guess maybe when we talk about medication, maybe just give some suggestions on dosing for the junior doctors. Sure. So in someone who can take tablets orally, 25 milligrams twice a day of metoprolol is always a good starting point. You can start with 25, wait a few hours and see what happens to the rate, then give another 25. You know, it's not uncommon for people to be on 100 milligrams twice daily of metoprolol out in the community. But in these settings, you always, like with most medications, start low and then titrate up. So metoprolol will be first line. With digoxin, you need to remember to load people. A proper loading dose is actually 500 micrograms, either orally or intravenously, and then six hours later, 250 micrograms, and then six hours after that, 250 micrograms. So you're giving that 1,000 micrograms in 24 hours. You can, in someone who's very elderly and may have renal impairment, you could actually reduce the dose, even though I know there were guidelines that said that you don't necessarily have to reduce the loading dose in someone with renal impairment. It's only their actual regular dose that has to be adjusted. But I think from my experience and from what my consultants have taught me, we would often halve the dose for people who are very elderly or who have renal impairment. And finally, I guess amiodarone would be another medication that is often given. A bolus dose for that is 300 milligrams intravenously, and that's given over sort of about 45 minutes. But in that setting, that would be done either in coronary care or in HDU. And you can give that dose through a peripheral cannula. But if you wanted to, again, give a continuous infusion over 48 hours, generally, or certainly our policy in coronary care is to have a peak line because you can get thrombosis through peripheral cannulas. And I guess when we talk about atrial fibrillation, often the question from the junior doctor is do we need to anticoagulate them? And obviously in a post-surgical patient, what are your thoughts on that, Sean? Yeah, absolutely. So I think once you reach that 24-hour mark, I think you should really be considering anticoagulation. I know probably in most textbooks it says 48 hours, but I think nowadays most of us in a hospital setting would start thinking about it within 24 hours just you know from what I said that if they haven't reverted in 24 hours after looking at all those reversible factors well chances are it may persist for longer so you know why take that risk and wait. Now in the setting of you know post-operative patients the main concern would be post-operative bleeding. So in those settings, I always say, can we please contact the surgical team involved who did the operation and ask what their thoughts are about anticoagulation? And they're generally very good, the surgeons, in knowing exactly what the risks are of giving anticoagulation. So they may only be happy with just some aspirin or more often than not, they're happy for full anticoagulation, which means dosing with either intravenous heparin or clexane at a dose of one milligram per kilo twice a day. So that would be full anticoagulation. So from my experience, the most common thing would be intravenous heparin without a bolus dose. And that way you can aim for maybe a lower APTT. And if there was any bleeding, then that could be reversed with protamine. So would you wait 24 hours to be in an atrial fibrillation before you're starting anticoagulation so give them 24 hours to revert by themselves yeah i i think that's completely reasonable and you know more often than not we will get a call say at 6 7 p.m for someone who's you know post-op and has gone into atrial fibrillation and um we'll say look no anticoagulation overnight revisit it in the morning. Institute all the therapies we've spoken about, including antiarrhythmics if necessary, give them some aspirin, but no anticoagulation, and then in the morning come and see them. And as I said, if they haven't reverted by then, then we can discuss it with the surgical team and institute some anticoagulation and proceed to something like a toe cardioversion, a transesophageal echocardiogram and a cardioversion, that's also an option as well. Maybe we should look at an approach to bradycardias. Is there anything more you want to say? Or maybe before that, anything you want to say on atrial fibrillation? No, I think it's just something that's very common. I think people should just remember it's about 20% of the population above the age of 75 will have atrial fibrillation and treat it like any other tachycardia. Look for those reversible factors and if any concerns then call cardiology and we're more than happy to give some advice. Okay. So how would you approach a new bradycardia on the ward? So I think, first of all, it's very common to find asymptomatic sinus bradycardia in a young, healthy person when they're asleep, and there's absolutely no treatment that is required for that. In actual fact, ventricular ectopic beats and ventricular bigeminy are the most common arrhythmias encountered in the post-operative setting. And again, rarely is treatment required for that unless the patient was very symptomatic. But again, that's highly unusual unless they had severe LV impairment. For a bradycardia, just like with any other arrhythmia, you need to obtain a 12-lead ECG and actually determine what type of bradycardia it is. We'll often get called about people who have a bradycardia and they say, well, this person's bradycardic, but there's different types of bradycardia and that's where the ECG helps you. So is it a sinus bradycardia? Is it first degree or second degree AV block? Or is it complete heart block? So I think it's really important to get the ECG and determine that because if it's a Mobitz type 2 block or complete heart block where there is AV dyssynchrony, then at the very least that warrants discussion with cardiology and moving the patient to a monitored bed because with Mobitz type 2 block and complete heart block, there is a risk of hemodynamic compromise, seeing at periods of asystole or no ventricular escape rhythm. So those people should definitely be in a monitored bed. But an asymptomatic sinus bradycardia, there wouldn't be any need for a monitored bed. Okay, can you just remind JMOs, do between Mobitz type 1 and Mobitz type 2 on the ECG? So the types of second-degree heart block. |
Welcome to On The Wards. This is Sarah Dalton and today we're talking about coaching for performance with Dr. Jules Wilcox and Tony Sloman. Welcome. Jules is an ED consultant, DPET at Gosford and trained as an executive coach. He has a strong interest in coaching and mentoring and a very strong interest in supporting trainees to develop their careers. Tony is the director of Passion and Purpose. He's a facilitator and a coach and he's passionate about empowering people to present the best version of themselves under pressure. Welcome to you both. I'm very much looking forward to this conversation about coaching. I might start with asking you a question Jules and that's just to kind of outline some of the high-stakes scenarios that are common to JMOs and some of the areas where you find your trainees are asking for help? Okay, sure. I think at right now, topically, would be recruitment and job interviews. And that's obviously, we're going through that process right now. So that's a big source of stress for people. And, you know, if you're applying for a competitive position, that's a very high stakes environment, that interview. Also, exams is another one, particularly clinical exams, rather than written per se, but the OSCEs and the VIVAs and so forth. Another very high stakes, pressured environment, you know, if you're a BPT, you only have one shot a year, and other colleges, you have two shots a year. But it's an enormous amount of work, financial investment, time investment, and your career literally hangs on the result of that. So those are the two main ones. But then we also have high stakes, high pressure environments at work on a day-to-day basis, clinical scenarios, team leading in resus, or how do you deal with the difficult personality that you're inevitably confronted with. And often in those situations are less controllable because they happen when you're least expecting them sometimes or when you're distracted by a whole lot of other things. So there's a number of things. I think that's why it's useful to look at these because focusing on how you perform in one area, you can use those skills to translate to perform well in other areas as well. Thanks very much, Jules. I think we all recognise the incredibly high stakes environments that we work in as doctors, both in our clinical and other roles. And I think that the COVID environment we're in now has put even more pressure on people. For some people, they might only have one chance a year, but their one chance is now being changed because of COVID. So it's incredibly stressful environment that we're working in. Tony, I know you have a background in performance and understanding performance under pressure. Can you just explain to us a little bit about what the relationship is between anxiety and performance and why is it so hard to perform when we're under pressure? Yeah, thanks, Sarah. And to echo that last point, being non-medical, I'm not a doctor, I do have great respect and value the work that people do in those high-pressure environments. So relationship between anxiety and performance. We perceive there to be something at stake. As soon as we perceive there to be something at stake, we find it very difficult to relax into ourselves. The thoughts trigger an emotional response. We have the perception of being watched. We can't relax into ourselves. And because we can't relax into ourselves, we create this disconnect. So our mind is one place, our body is another. And that, as all the listeners would appreciate, is fundamentally the fight-flight response. If you're an inward sort of person, and I hate putting labels on people, if you identify as being a little more introverted, the sensation is like being opened up. It's almost like a curtain being opened up into your soul. And suddenly it's like the whole world looking in. That creates a perception of threat. So with that physiological response, we get this imposter syndrome. And as soon as that's triggered, all the old memories start coming up. And these are very likely to be childhood experiences where we might believe we're not good enough. As soon as we get that sensation of being watched and judged, we're not actually in the moment. So those triggers are not about who we are right now in the moment. We're living out an experience that happened to us when we were children, or we might have had an unpleasant experience being put on show at school, perhaps being stuck up at the front of the class. I had a client once, and that was their experience, a very powerful memory of when they were in year eight at school. So what happens is a very human and reasonable element of fear, which is necessary when we are under some sort of performance pressure. It's actually necessary to have that adrenaline rush and be alert. But what happens is a reasonable amount of that quickly becomes escalated because we become inwardly focused. And as soon as our mind starts playing that dance with our emotions, we perceive that it's not a good thing to have that little pang of fear. We think something's not right. It triggers the memory. The memory starts playing games. We become enveloped in imposter syndrome, and it becomes a cocktail of fear. And when it reaches a crescendo, for many people, that's a plateau point where we're actually freezing. And the other thing I'd just like to add, Tony, as well, is that looking at some of the sort of functional MRI studies and things and the amygdala, which is involved in stress response and things, that's a part of your limbic brain. That's a very basic emotional program. So it's not necessarily a conscious thing, which is going to do it. It's an automatic program that's running in the background. It gets triggered. It starts running. When that's running, when your limbic brain fires up and you're running emotionally in stress, you are unable to access your prefrontal cortex and think logically. This is obviously not good in exams and interviews when you're being asked questions you need to think logically on. So you need to be looking at techniques to calm down that stress response and that amygdala. And that's really what Tony and I have spent a lot of time working on to try and teach those to people. Oh, that's great, Jules. I just wanted to say when you talked about opening the curtain into the soul, Tony, it made me remember all those moments where I feel like my curtain's been open and everyone can see my heart beating so hard. And I guess what you're talking about is the head and the heart. And even though your head knows it's going to be okay, you have that amygdala hijack and you just can't get over it and then it gets reinforced for next time as well you know that's why i always say to my trainees do the exam once do it properly pass it don't do this oh i'm gonna just i'll see how i go i'll have a go because it's psychologically so damaging you're setting yourself up for failure later on because these things get reinforced and so then the problems get worse. So Jules, what advice do you give to trainees about how they can prepare to perform better when these things happen? So I think it obviously will depend slightly on the context and whether it's a job interview and so forth. But preparation is key. A lot of the time, and the trouble is for exams and interviews, you can't prepare 100%. There has to be a degree of uncertainty there. You can't know absolutely everything or how it's going to come up. So there is that degree of uncertainty. Getting comfortable with uncertainty is one thing, and that's really useful in medicine anyway because that's what we have to do anyway in emergency medicine, which is my field. So there is that. There are a whole host of techniques and tips and things that you can do. But the one thing I think that people have to understand is that these are skills. So it doesn't matter which one you pick on their behaviors. And they need to be practiced. And they need to be hardwired. Because as soon get stressed Then you're going to revert to type into that behavior and you can't you're not going to think oh now I need to do blah blah whatever it is the thing because you're going to be running on the drone you're going to be stressed and so you have to practice these things well in advance and you have to Hardwire them in because if it's hardwired you don't need to access your prefrontfrontal cortex anymore. Then it's going to run, and you're going to be able to access it. So whatever it is you're going to do, you need to practice it. You need to take it seriously. It needs to be part of your revision plan, your preparation phase. |
The things that I have seen in people who've really had problems passing exams is sometimes it's actually less book work and it's more focusing on a lot of this behavioral psychological stuff. And so we have specific practices that if we have time we can talk about a couple of them. But it's really about shifting that focus and looking at that. And I also, it's not on the bio, but I also training as a professional Forex trader. And one of the things that as I train with who's mental for me is the, you don't trade your, you don't trade the market. You trade the beliefs, your beliefs about the market. And it's a bit like the exams and stuff. You're not taking the exam, you're taking what you believe about. And so all those beliefs come out to play. And it's so important to address some of those. I really like what you said about hardwiring new habits and practicing before you get there, because you're not going to consciously remember that you need to slow your heart rate down or deep breathe when it happens. It's like if you're on recess, you know, and do this, you can do this in sim, you know, if you want to see how what people know, put them in a stressful situation and ask them a question, you know, what's the pediatric dose for blah, blah, blah? And if they can't answer you because they're stressed, you know that it's not hardwired in. I can't help but remember a situation at med school when one of my colleagues was asked a really hard question in theatre by a surgeon looking at an X-ray. And as she was answering the question, her pants fell down. And she could not, for life of herself count how many ribs they were on the test x-ray because she was so stressed. Anyway, I know that's a bit off topic, but it just reminds me we absolutely cannot perform when our body is flooded with those kinds of physiological responses. I might come to you now, Tony, and just ask what would you add to that? Because I know there's a lot of top tips out there about how to prepare and obviously we're going to talk about some of them but what would be your advice to someone who's trying to think of something they need to start doing now to improve their performance? Great what he said um words so much I think it was something Jules said that's really fundamental here is our ability to embrace uncertainty. And with that comes an obsession with perfection. My belief, and having worked with a lot of people from a coaching context and also a group context, when we perceive to be watched and judged, and that's a choice that we make, we don't have to see it that way. Jules was saying, you know, in the Forex area, trading Forex, it's your trading on your beliefs, not the actual situation. Well, it's a situation that's impacted by your beliefs. But when we're under pressure and being watched, any mistake that we make is being magnified. And when those mistakes are magnified, my belief is that we exacerbate the shame response. And that's where all those old stories are being played out. So one of the techniques is to bring yourself continually back into the present. And there's a bunch of techniques that Jules and I run in the workshops around how we keep us present. But there's so many things you can do. Mindful meditation, exercise, good sleep, reasonable diet. Those are things that impact our ability to be present. We also should be getting support. I mean, we're sitting in this room recording this podcast because we're all practitioners who offer people support. There's tons of it out there. And as were talking about before it starts with unconscious unconscious being unconsciously unaware of things in a learning journey you don't know what you don't know then you go to being consciously unconsciously aware is that that's the unconsciously unconscious and you're conscious of how much you consciously incompetent after that so you become consciously incompetent then you become consciously competent then you become unconsciously competent and that's what and that's why seeking support uh you know making things habits habits are incredibly important so it's not like you meditate once and then you're fixed for life. You meditate repetitively. You seek support repetitively. You get coaching over a period of time and you check in with yourself around the habits that you've formed. Yeah. I think it rings true to me and I've heard said before, we all need to develop a meds habit, which is meditation, exercise, diet, and sleep. And that's the basics, you know, and all these things are a hierarchy. You've got to start with that. But if we go to a couple of techniques and just perhaps your favorite, and it's all got to be horses for courses and what person and what situation, but if there was a technique that would be a good kind of catch-all for how do I manage a moment of really like stuck in the lights, deer in the headlights, don't know what to do, I'm interested in what both of your kind of favourite technique would be to help people with that. I'm going to jump in. Yeah, sure. So something that I do across the board, not just with doctors, with leaders in corporate, in government, in all areas, which is fundamental to a model that I developed, which sits right in the middle of the model, is this idea that we own our space. And in fact, that's what Jules and I called our program for the OSCE, Owning Your OSCE. So the idea of owning your space is to use our sensory attachment to the environment to bring us straight into the present. So a great technique, when we feel that our mind is either spinning off into the future, which is what anxiety does, or it's worrying about the past, is to have an object with you. So take an object as good if it's something that's meaningful to you, stick it in your pocket, pull out the object, hold the object, and it's a reminder through your sensory, through your, through touch, which is, you know, and we experience the world through our senses, but it's a reminder through touch, such very powerful sensation, hold the object and, and focus on the object and bring yourself back into the present. And I'll give you an example. There's a gentleman I coached who was an electrical, ran a very successful electrical business. And he had a chronic fear of public speaking, so much so that if he was in a group and he had to deliver a pitch, that's where I met him first, he would hide in the bathrooms and not come out. It was a social phobia. He practiced this and he said to me, he came into one of the coaching sessions one day and he said, I've had a revelation, Tony. I said, what is it? He said, I was in a client meeting. My heart was thumping so loud. It felt like the client could actually hear my heart beating. And he said, I focused my attention on a light switch. He's in the business of lighting. Focused on a light switch in the corner of the room. And as I focused on this actual light switch, gradually I could feel my heart rate coming down. And as my heart rate was coming down, that was the key to being just that little bit more back into balance. Yeah. So there are a couple of things. It starts with mindfulness. You've got to be aware that you're doing this to yourself, that your mind's starting to spin out. Those feelings that you're getting, however, whatever sensory submodalities that it is, you will know that feeling that you get when you are really getting stressed, to be aware of that. And then to have the presence of mind to be able to go, ah, I'm getting really stressed. You need to do that. Otherwise, if you don't do that first step, you can't. So mindfulness practice is really important because mindfulness in other areas will allow you to be more in touch with that. And so there's a lot of stuff, and mindfulness is batted around an awful lot. But in some instances, I think it can be really helpful. So you need that mindfulness to be aware. Breathing is one thing. Breathing and pausing. Taking a breath. It's far better in an OSCE to take a nice deep breath and pause and think and consider your answer for five seconds before going blah, blah, blah, blah, blah, blah, and then saying a complete load of rubbish or something that's, you know, oh, the patient, you know, can you look at this blood gas? And I know oftentimes, I know people who've done it. |
Welcome to On The Wards. It's James Edwards and today we're talking about palliative care and we have the pleasure of having Dr. Bridget Johnson join us. Welcome, Bridget. Thanks very much for having me. Bridget's a palliative care physician here in Sydney and we're going to have a really general discussion about palliative care. I guess it's a really broad first question, but what is palliative care? It's a good question because despite our best efforts as a subspecialty to sort of talk to people about what palliative care is and who should be referred to palliative care, often it's a bit of a nebulous area. So palliative care is the care of anyone who has a life-limiting illness and this can be any way through their trajectory to make sure that we optimise their symptom control, make sure that we give them dignity, and make sure that we give them the best quality of life that they can have. Palliative care looks at physical symptoms to make sure that we address any that have arisen and also trying to make sure that we pre-empt any that might come up, and also looking at patients' emotional symptoms and psycho-spiritual symptoms as well. We work as part of a team, so you'll have working closely together a palliative care specialist, GPs and then palliative care specialist nurses, our allied health team being our social workers, OTs and physios and we often liaise quite closely with chaplain services which can be really important in end-of-life care for patients and we also have bereavement services which can be incredibly helpful and supportive for family members after the patient has died. I'll go to a case, Bridget. You're a junior doctor working in the geriatrics ward and you're asked to review a patient with a reduced level of consciousness. The patient's an 85-year-old male who was admitted five days ago from a nursing home following extensive acute stroke, but also has lots of comorbidities, including ischemic heart disease, atrial fibrillation, chronic lung disease and renal failure. The nurse has been handed over that he does have an advanced care directive, but can't find it in the notes. How would you approach this situation? Yeah, it's a good question, James. I mean, increasingly you're finding that patients are complicated on the wards. Actually, hearing this scenario makes me reflect of when I was an intern, which wasn't that long ago, but in which a 65-year-old with just a handful of comorbidities would be admitted under the geriatrics team and now actually people are dealing with really complicated patients and really complicated clinical scenarios. The question of an advanced care directive, firstly let's define what an advanced care plan and an advanced care directive is. An advanced care plan is when someone writes down either formally or frankly just on a scrap of paper saying these are the things that I would want in my life, these are the things that are important. So often actually strokes are the scenario that is given where it would be helpful to have an advanced care plan. Would you want to be kept alive if you couldn't care for yourself, if you couldn't communicate, if you couldn't feed yourself? And so they're broad statements that someone can write as to this is actually the line in the sand of things that would and would not be important to me and the point in which I would no longer want you to prolong my life. An advanced care directive then spells out specifically what you would and wouldn't want. So, you know, the classic old school not for resuscitation order, being able to have someone actually identify, would you want to be on a ventilator? Would you want CPR? And then on from that, you know, would you want to be in an ICU having IV fluids? And it gives that person a voice when they're then incapacitated and no longer able to have a voice themselves. So when we talk about advanced care plans and advanced care directives, we say to to people this is really important that you discuss this with your family, with your GP and increasingly in nursing homes it's becoming mandatory for people to have an advanced care plan and directive drawn up so that in the case of them becoming incapacitated people would be able to fulfill their wishes. So I would approach it by working down that list of who can I contact to see if I can physically get a copy. So speak to the family, speak to the GP, speak to the nursing home. In an 85-year-old, it may not be the case that he's accessed technology, but in younger patients, we're certainly encouraging people to upload it to the My Health website. And increasingly, we're putting these things on electronic medical records, so there might be a physical copy that's there. I must say that I do it the old school way and whenever someone hands me an advanced care directive I physically photocopy it and stick it in the medical notes. So that's the other place that you can go and access it. What should the goals of care be in this situation and how would you establish these? So the goals of care really depend on the person's clinical situation, their prognosis as to where we are at the moment and then held in conjunction with what the advanced care directives are to try and work out where we go to from here. So in this scenario the goals of care the question is, is this situation curative, is this pallative, or are we in the terminal situation? So I think that one would need to then review, where are we at? We're five days post a stroke. We should have a fair idea now as to how things are travelling. We don't know whether this patient was thrombolysed, but any sort of interventions, we should have a fair idea as to whether they're likely to see any real effect. And given that he's got a reduced level of consciousness, it sounds like actually they're probably, you know, he's not improving and quite probably deteriorating. I would just start from the top. What are his observations? What's his GCS? What does his neurological examination show? What does his cardiovascular and respiratory examination show? Because he does have comorbidities and frankly this might not just be the straightforward or the more straightforward situation of his neurological incapacity. There might be other things that are going on as well. Review the investigations. What were done when he came in? Presumably he's had some bloods and some imaging done. What did they show and how severe was this? How bad is his chronic renal impairment? Do we have acute or chronic renal impairment? Because all of those are showing us a picture now of not someone who had a stroke which may be able to recover from that, but someone who really has got a lot of comorbidities going on and who is unlikely to be able to recover from this. I then would review that in conjunction with what his advanced care directives say because they then help us with the goals of care and I always discuss this with his enduring guardian. So usually in an advanced care directive we ask people to spell out who would they want to be their surrogate decision maker. Often it would be the wife but it might not be, there might be someone else that he wanted to make his medical decisions for him. And I would sit down with them and discuss where things were at. But given our information, I think that this man is in a palliative situation and moving towards needing terminal care. So you mentioned an enduring guardian. Is that different to a next of kin? It is. So the legalities of this frustratingly are different in each state of Australia. But in New South Wales we call it an enduring guardian and that can be someone who can be appointed instead of your next of kin. So someone might think that actually their child or their friend might be in a better position to make decisions rather than their partner and that can be documented and then that person becomes their surrogate decision maker. Your opinion is that this patient is moving to a palliative phase. So if you're a junior doctor, how would you involve the palliative care team in the management of this patient? Yes. So often it's a straightforward situation. The consultant says, ring palliative care, you page them, no problems, done deal. But occasionally you do find things that are actually a bit more complicated. Either the family are reluctant or have concerns or the medical team themselves have some concerns. And I think that you're in a unique position as a junior doctor actually to be able to advocate and explain things in both of those scenarios. So if it's the family that don't understand what palliative care is, there's often an assumption from people, oh my goodness, you get the palliative care team in and someone dies, as opposed to he's dying regardless of whether the palliative care team are going to be involved or not, but they may be able to assist with symptom control and also with being able to make sure that the family is as supported as possible. |
In the scenario of the medical team, I always say to people, is this person who's dying in front of you, are they dying the way that you would want your grandfather to die? So if they're comfortable and things are going well and people are managing it and confident, that's great. The palliative care team doesn't necessarily need to be involved. But if things are unfolding in a way that they don't seem to be comfortable or the family don't seem to be supported and you think palliative care could help, then you might be in a good position just to be able to say to your registrar or to your consultant, do you think it would be a good idea to get the palliative care team involved? Because maybe that's just slipped off their radar. So it sounds like it would be important probably to tell the family palliative care being consulted are going to come. Do you ever turn up somewhere on the palliative care physician and then the family go, what? Why are you here? This is a really common problem and actually it sets up a problem with actually then just starting that rapport and that relationship in this situation. If you can mention to people that the palliative care team are coming, it makes an enormous difference. Even if the family are, you know, confronted and have questions, we right from the get-go can start addressing those, but at least they know then what's coming. So you get the patient's wife and daughter out of the bedside. How would you explain as a junior doctor the role of the palliative care team in managing symptoms? Yes, so I think that checking with them what their understanding of palliative care is, is actually a good starting point. It's really amazing the number of people who have really different ideas as to what palliative care means. So people who think that the palliative care team are the euthanasia team, people who think that the palliative care team are the team who, you know, you meet them and within 24 hours someone has died, or actually I've even had patients think that the palliative care team are there to prolong someone's life. So it's actually surprising just the different ideas from people as to what they think about it. I would just explain to the family that the palliative care team are there to manage and be proactive about any symptoms that might come up. He's got lots of comorbidities so in this situation the palliative care team will be making sure that medications are used properly to address any symptoms that might come up and in particular he's got renal failure. That changes a lot of the pharmacodynamics of medications. So actually just making sure that we get that right. Providing emotional support for the family and also then being able to provide bereavement support for them as well. The other thing is, I think explaining to family members that the palliative care team can have discussions about whereabouts the death would take place. It's interesting as a palliative care consultant the number of people who you come in and talk to them and suddenly they say we had a discussion, we had a deal that if he was ever dying we'd take him home. Can we make that happen? And absolutely as a palliative care team we can try to facilitate that. Even some people will say to you actually they've been in the nursing home for 15 years, that's their home, we're really comfortable there, can you facilitate the death happening in the nursing home? And we can do that. Or otherwise a palliative care unit or in the hospital itself. But I think identifying with the family that there are choices there and the palliative care team will help with that, helps to break down some of those barriers. And the last thing is in terms of resources, often you think to yourself, gosh, I wish I had somewhere to direct people. So if people are younger, you can direct them to the Palliative Care Australia website, which has got really good resources, just breaks it down and explains what palliative care is. And if someone, you know, this patient's wife might be older and not have access to the internet, there are some really good PDF brochures that you can just print off from the Palliative Care Australia website, which just explains what palliative care is and what terminal care is. We've described that patients like this are becoming more common and they're often admitted under geriatric team, maybe respiratory team or the renal team. Look, is palliative care everyone's business or is it something we should be, I guess, outsourcing to a palliative care team to do everything with end-of-life care? I think that absolutely palliative care is everyone's business and actually there are teams in the hospital who do a phenomenal job every day of the week not needing to have the palliative care team's involvement in the case. But if things are more complicated, if family dynamics are more complicated, if the comorbidities and the symptoms are more complicated, then absolutely the palliative care team are always happy to get involved in this scenario just to try and help both the medical team and the patients and the families. Maybe as a junior doctor, are they in a situation where they should be the ones initiating end-of-life care discussions or should it be somebody more senior? I think that it should be someone more senior than an intern. I think it's quite overwhelming in these situations because often you're talking about some pretty complicated and interrelated factors in terms of prognosis, comorbidities, and it's hard for you often as the intern to really work out exactly where this ship is sailing. So I think it should be the registrar or the consultant. But often family members will want to ask you things, so I think just having a general familiarity and comfort with at least being able to you know initiate these discussions and then say listen can I get my registrar or my consultant to come back and talk to you further about this you as the intern do not need to run this show unfortunately it seems that all the patients family always seem to arrive when the registrar's consultants not around. And it's usually the junior doctor who's the one called to say, the family's here, the patient's dying, they want to know what's happening. Any tips for those doctors? Look, I think that's a really valid point. And I think that that is one thing that is inherently flawed about the hospital system, that everyone shows up when they finish work, which is when, as you're more senior, often is when you've knocked off work and left. I think the thing is just to be comfortable with letting people ask questions. I think that the inclination is just to be to shut down the conversation. And I think that actually that's unhelpful for family members. But I think it's totally legitimate to say, actually, I don't know the answer to this question but I will get you an answer. So it's reasonable if someone says you know bails you up an award when you're you know still doing your day work and thinking when am I ever going to get home. It's reasonable for you to say actually I don't know about you know the prognosis and exactly what's going to happen but can I work out a time for my registrar tomorrowrar tomorrow to get in contact with you? This is how you get in contact with us and this is therefore how we can progress things from here. Caring for dying patients can be very confronting for all of us, including junior doctors. How should we approach the emotions that may arise from caring for such patients. I think that caring for dying patients is something which you just expected often to just get on with it and people don't actually sort of put their hands up and say, you know what, I struggle with this, this is really hard. And certainly as a palliative care consultant, I do this every day of the week, but I still have patients that get under my skin, absolutely. And I think that it's often the patients who remind you of yourself or who remind you of a family member that suddenly you find yourself thinking, oh, actually, this is actually a lot more upsetting than I maybe initially had thought it would be. I think it's really important to identify that and to be able to identify it with your team. So to be able to say to your registrar or say to your consultant, actually, I'm finding this quite an emotionally confronting situation because at least then other people in the team can look out for you. I think it's important to have strategies to be able to debrief with people, so debrief with other colleagues, be able to debrief with family and friends. I think you did an excellent podcast with Professor Amanda Walker about self-care, which actually included a lot of really practical tips for that. And I think that if you find yourself in a scenario where actually it is getting overwhelming to be able to just put your hand up because actually it's the strong doctor who actually has the insight to say, actually, this is really upsetting. |
Hi, I'd like to welcome John Saunders, who's a renter physician here at RPA, to our podcast series. As with a lot of our podcasts, we look at common after-hours problems, and this one is, I guess for every junior out there, a pretty common presentation, hypertension on the wards. Welcome, John. Thank you. Now, I guess I'm going to make a statement that I know there's evidence that chronic hypertension is an important risk factor and that good blood pressure control in the community improves things like morbidity and mortality with chronic artery disease and strokes. But I'm wondering is there similar evidence to show that blood pressure control is important in the inpatient setting? I think there probably isn't much evidence to say that it's important. At the very severe extremes of blood pressure then obviously controlling it is sort of important but I think you know there's going to be a big grey area where we probably don't know. As you're aware there'll be lots of different factors that will affect patients' blood pressure, specifically while they're in hospital, and probably manipulating that a great deal is probably not going to be beneficial for them. I'm certainly not aware of any recent published stuff in regards to that. Okay, I mean, obviously, I don't think looking at targets and things like that probably does have some improved patient outcomes, but there may be some special groups that we really need to be careful with high blood pressure. What are those kind of groups that we need to be worried about? I think pregnant women is a special group because the development of hypertension in pregnancy is very different from normal patients who aren't pregnant and really they need to be managed by a specialist team, the obstetric team and the renal team at RPA. And so a normal blood pressure in a pregnant woman is significantly lower than a normal blood pressure in a non-pregnant woman. The other group of patients I think are important are either those that have had intracerebral bleeding or neurosurgery or those that have had a stroke where their cerebral auto-regulation might be disrupted and you should involve the teams managing those patients in regarding treating their blood pressure because they might have different targets that they are aiming for. Okay, well now we'll go back to a case. You asked to review an 80-year-old female who's day one post-op following a hip replacement. She has a background history of hypertension and is on two regular antihypertensive medications. And the nurse is on their routine observations noting her blood pressure is 200 over 110. Can you describe your general approach to the patient with hypertension on the ward? So this is probably a really common scenario that everyone's going to have come across and I guess the first thing that you'd want to do is make sure that the blood pressure is really elevated so it get them to repeat it. If there's any doubt about the automated blood pressure you might want to do a manual blood pressure and just to see if it's really elevated. If it truly is elevated after the second reading then I'd probably want to go and see the patient and have her think why it might be elevated. And the most sort of obvious thing that springs to mind is she's just had hip surgery, maybe she's in a lot of pain, in which case the management should be directed to the underlying cause rather than your treatment of the blood pressure. So I'd want to look at her current medication. Maybe she's missed her usual antihypertensives, which is another common reason that patients may get hypertension. And she's missed her usual medications and simply giving her her usual medications might just be enough. So if we're happy that the blood pressure reading is okay and we're happy that she's had her usual medication and we're happy that she's not in pain or there's no other obvious explanation, I'd probably want to look at the trend of her blood pressure. If it's always been 195 throughout her stay, then going up to 200 is probably not a clinically significant increase and I'll probably be happy to monitor the situation. If her blood pressure's normally been 130 and now it's 200, I'll probably be more interested and I'll probably pay a bit more attention to her and I might consider treating it. You've also got to look at the patient themselves and make sure that they're well, so that they're not having a stroke, for example, because their blood pressure's suddenly become elevated. So if they're clinically well, asymptomatic, their blood pressure's usually elevated, it might be okay just to monitor them. So if you went and saw them, what sort of things would you look for? What would you want, history and exam? So history, so I'd want to know the duration of her blood pressure, how well controlled it's usually been, because it's really the change from her normal blood pressure that's important in this setting rather than the blood pressure right at this second. And if there's been a big change, it's probably more relevant than if there's been a small change. I'd want to make sure that she's taken her medication. I'd want to know about comorbidities. There may be some conditions, for example, patients with renal disease do better with certain types of antihypertensives. Patients with heart failure do better with certain types of antihypertensives. And I'd want to know about medications that she's had in the past, that she's had problems with, that I would definitely want to steer clear of. In terms of assessing her, if she can give me a history and move her arms and legs, that's a pretty good screen that there's no acute stroke happening. And I'd want to check that her heart rate's okay, have a listen to her heart and lungs, make sure that she's not in pulmonary edema, check there's no cardiovascular complications of high blood pressure, and make sure that she's orientated, person, time and place, etc. And check that she's not in fluid overload, which can be another cause. Patients post-operatively get given a lot of fluid, they expand their intravascular volume, and that puts their blood pressure up. Okay, so you have a look at their history and exam. Are there any kind of routine investigation you need to order or is it really tailored to the case? I think it's really tailored to the case, especially sort of in the middle of the night. If the patient's well at the end of the bed and you're happy that there's nothing else going on, you know, don't think there's a real need to order an investigation. If you find something concerning, for example, a short of breath or had some chest pain, then clearly you'll investigate that along those lines. But just the hypertension on its own in a well patient with no other symptoms, that you're not worried about anything else, I don't think you need to necessarily order some tests. In regard to management, you mentioned in some patients they consider an antihypertensive. What is your approach to, I guess, deciding whether they need antihypertensive and what is your usual choice? So that's very patient-focused as well. I think if you think the hypertension is making them unwell in some way, so they've got either some symptoms or signs of a complication from hypertension, then that definitely requires treatment. And the areas that you're particularly interested in are the brain, eyes, cardiovascular system. And so you should ask about headaches, orientation, look for neurological disturbance, check their vision's okay. I don't normally do fundoscopy, but patients will report visual problems if it's severe enough. Make sure they're not in heart failure, they've not got angina. So if all those things are okay, then it comes down to how different their blood pressure is from normal and if it's not that different from normal I might just be tempted to monitor them and if what their current medications are. So if I wanted to treat their blood pressure I would look at their medication and try and choose a class of agent that they're... Well, the options would be to increase their current medication. If there's scope to do that, that might be helpful and easier rather than increasing their pill burden, or add in an additional agent, which should be of a different class to what they're already on. Another option would be giving them a stat dose just to get them through the night and get the team to look at things in the morning. Sometimes that can be counterproductive. You find the blood pressure goes down in the daytime, everyone's happy and it goes up again at night. So that is dependent on good communication between the night and day staff to make sure issues get looked at. In general, treating acute hypertension, I find short acting agents helpful because they act quickly and they wear off quickly and so you can titrate the doses according to the patient's response. If someone's got chronic high blood pressure, you don't want to lower it too much, too fast, that can be quite dangerous. |
Hello and welcome to On The Wards. My name is Faitha Rau and I'm a third year obstetrics and gynaecology registrar based at Liverpool Hospital in Sydney. Today we're talking about infertility and I'm joined by Dr. Louis Angelopoulos, a staff specialist in obstetrics and gynaecology at Gosford Hospital. Welcome, Louis. Hi, Swetha. Thanks for having me and I'm sure it's going to be an entertaining session. Absolutely. So, Louis, infertility can be a tricky topic for junior doctors and even registrars to understand. There are many causes and it can be hard to know where to start, especially when it comes to investigations. However, I guess having a systematic approach can help junior doctors remember not only some of the common causes, but also methods for treatment. I thought we might be able to demonstrate this best by using a case if that's okay. Jenny and John are a couple who present to the fertility clinic after eight months of timed unprotected intercourse without conceiving. Jenny is 37 years of age and John is 40 years of age. They're anxious that the clock is ticking. Neither has any live children nor any significant medical history. So let's maybe kick off first by explaining what actually constitutes a diagnosis of infertility. That's actually a good place to start. Often couples consider themselves to have a problem conceiving if they've been unable to do so after a few months. However, the official definition of infertility is the inability of a couple to conceive after 12 months of regular unprotected intercourse, in which case between 80 to 90 percent of couples will then eventually conceive during this period. However, despite this official definition, we may start evaluating a cause of the infertility sooner than this, should there be other factors which may contribute to reduced fertility, such as maternal age over 35 years, as in the case you just described, women with a history of irregular menstruation, chemotherapy history, radiotherapy history, tubal or uterine disease, such as advanced endometriosis, which we see a lot of. And then not forgetting men, those with a history of groin surgery, also chemotherapy, adult mumps or sexual dysfunction. And so how would you go about approaching a couple who's presented with infertility? In the first instance, it's vitally important to take a good comprehensive clinical history. And this would include questions such as the irregularity of menstruation, which is generally a good indicator of ovulation. Whether either member of the couple has any live children previously, and that's mainly to differentiate between primary and secondary infertility. And then just a general overall past medical history, especially focusing on autoimmune diseases and any cancer treatments involving chemo or radiotherapy. Next on your examination, you would focus on the body mass index, BMI as we refer to it, any clinical evidence of endocrine abnormalities, and this would include hypo or hyperthyroidism, as well as features of any genetic conditions that they may have, for example, Turner syndrome in women or Kleiner-Felter syndrome in men. There's a lot to think about. And so what are some of the commonest causes of infertility? So broadly speaking, we break the causes of infertility into female, male factors, or often it's a combination of both of them. Often they're multiple factors contributing to the infertility. And frequently it's challenging to determine which is the main contributor. What would we classify as the female factor causes? So I'll run through a list of the known female causes, although there will be many more, but just to focus on, so ovarian causes, mainly considering women who don't ovulate or ovulate infrequently and hence don't have an oocyte available for fertilization. And the biggest cohort of patients that we generally deal with are those with polycystic ovarian syndrome. And also not forgetting oocyte aging also contributes to a decline in oocyte quality and quantity. Another group would be those listed under tubal causes, so where the efficacy of oocyte and sperm transport within the fallopian tube is inhibited by tubal disease and pelvic adhesions, especially in those with a past history of STIs, for example, chlamydia and gonorrhea. Adhesions from previous surgery can also affect tubal function and then endometriosis as well. Listing uterine causes, commonly we see uterine fibroids that appear within the cavity of the uterus, which we call submucosal fibroids, and these can have significant impact. There is a lot of evidence to suggest that their removal can enhance fertility rates. Also, uterine abnormalities such as malarian anomalies or septate uteri, both these can interfere with normal implantation. And then not forgetting lesser common causes such as cervical abnormalities due to congenital malformations or trauma, some autoimmune diseases, and then as mentioned previously, genetic disorders, for example, Turner syndrome. Fantastic. And if we look now at the male-related factors, I guess most people would probably only think about the sperm count. But is that the main cause of male factor infertility? I'm glad you mentioned males because they usually run a mile and think it's all due to female factors. But it is certainly one of the main causes. In fact, over 80% of infertile men have low sperm concentrations. And some of the known male factor causes of infertility include testicular defects in spermatogenesis, so the formation of sperm. And we most commonly see this in the group termed idiopathic dysspermatogenesis, so abnormalities in sperm number, shape, or motility without there being an identifiable cause, or genetic causes such as Y-chromosome defects, autosomal or X-chromosome defects, and as mentioned previously, Kleiner-Felter syndrome. They could also suffer from cryptorchidism, which is an undescended testicle or testes, and this produces reduced quality or quantity of sperm or other anatomical abnormalities such as varicoceles, where you have a dilatation of the pampiniform plexus. Infection, as mentioned previously, especially in the form of mumps, can cause male infertility. Environmental factors such as smoking or hyperthermia, hence the advice for men to be wearing loose boxer shorts rather than tight-fitting underwear, and also lesser common anti-sperm antibodies. Endocrine disorders as a group can also cause hypothalamic or pituitary disease as we see in idiopathic hypogonadotrophic hypogonadism or a GnRH deficiency. When this is associated with anosmia, we term this Kelman syndrome. They could also suffer from congenital combined pituitary hormone deficiency, pituitary macroadenomas or other cellar masses which cause hypogonadotrophic hypogonadism, and infiltrative diseases such as sarcoidosis or tuberculosis, head trauma, or intracranial radiation. Conditions affecting the adrenal glands such as congenital adrenal hyperplasia or hypo and hyperthyroidism. Not forgetting sperm transport disorders, such as abnormalities of the epididymis or vast difference, where there's either a motility issue or an obstructive issue. Ejaculatory duct disorders, as we see in spinal cord lesions, and this can cause either decreased or retrograde ejaculation and erectile dysfunction. And then lastly, idiopathic male infertility, just bearing in mind that this is different from idiopathic dysspermatogenesis because their semen analysis is generally normal. Thanks, Louis. There's definitely a lot to consider from both sides there. So I guess if we take it back to the case that we mentioned earlier, after the initial assessment, which we've discussed in terms of the history and examination, what are some of the investigations that you would then like to order? Swetha, many a time you target the investigations based on the couple sitting in front of you. So the commonest that we generally tend to include is, as you mentioned, a semen analysis. And we analyze this for quantity, morphology, and motility of sperm. And we also request a day three serum FSH, estradiol levels, and anti-malarian hormone, also called AMH. And this is mainly to assess ovarian reserve. To assess whether ovulation is occurring, we test for an LH surge prior to ovulation, as well as a day 21 progesterone in a normal 28-day cycle. TSH levels, and then to determine whether the uterus is normal anatomy, as well as testing for tubal patency, we frequently request a hystero-selpingogram or a sonohistrogram. You may want to perform a baseline pelvic ultrasound to rule out uterine myomas. And again, based on her history, especially considering endometriosis, features frequently in infertile women, a laparoscopy. This will also give you benefit to exclude other pelvic pathology. And moving on from there, I guess obviously there are specific treatments that will depend on what the underlying cause is. |
Welcome to On The Wards. Today we're talking about palliative care and crisis medications and I'd like to invite Dr Jessica Bourbassy. Welcome Jessica. Thank you. Jessica is an advanced trainee in palliative care medicine and we're going to, before we kind of get into some of the nitty gritty, we're going to, I guess, put in the context of the case that a junior doctor, those who worked on the wards all this year over the last couple of years have probably seen something similar. And it's an elderly patient who's 89, who's come up from the emergency department with a diagnosis of probably sepsis on the background of metastatic lung disease, has got a fever, tachypneic and back pain, and has been started on some intravenous antibiotics, but't had a not for CPR form completed and you understand his recent CT shows metastatic spread to his spine and his liver. You go see him on the ward refusing to have any tests done, becoming agitated and keeps pulling off his nasal prongs and when you speak to him he says he doesn't want anything done. You kind of review the patient and you feel the patient's competent, understands his prognosis and his request is to be kept comfortable. You have checked with the admitting team and the family members and they're also on consensus. So is this a time we should get on the phone and request a palliative care consult? Well, James, ideally, should we call this man John? John. Ideally, John is already known to the palliative care service and has an advanced care directive in place so that this whole situation can be avoided. We know that palliative care is more about end-of-life care. It's about enabling people to live better with chronic illness or terminal illness before they die. And in fact there's a push in palliative care to rename it palliative care and supportive care. And I don't know if you know this but the landmark trial, one of the landmark trials for palliative care was for patients with metastatic lung cancer who received an early referral to palliative care and they actually not only had a better quality of life but they lived longer. Not that that was necessarily the intention. So certainly it would be great if this man was referred to palliative care at the diagnosis of metastatic lung cancer but nonetheless it would certainly be appropriate for you to call for a palliative care consult on this gentleman. But I would be encouraging you to make sure that you address his symptoms before the palliative care team arrive. So when we talk about symptom management, what kind of the goals for this patient? Well, as you probably recognise, there are a lot of nebulous terms that are banded around, especially when it comes to palliative care and end-of-life care. So, for example, one of my pet hates is ceiling of care, which gives the impression that beyond a certain point we no longer care, which is completely the opposite to what palliative care is. If I was to get a referral for a patient to be kept comfortable I would definitely be clarifying with the patient what exactly they understand this to mean, them as well as their family and it's more than likely that in a patient, in this patient with John, that he would actually be very open to a discussion about what kind of care he does and does not want and that the discussion itself would probably be very therapeutic in acknowledging his wishes and ensuring that he's heard. So in this scenario as the Palliative Care Registrar consulting on John, I'd probably talk to him about the fact that it sounds to me like John doesn't want me to do anything to prolong his life, that he would like me to let nature take its course, and that probably means that he will die during this admission. And I would reassure John that I would do everything to make sure that he's pain free and dignified at the end of his life. Sounds like a lot of talking and conversations. What is the role of medications? Because sometimes junior doctors, it seems a focus that they're called to see a patient to chart medications. Certainly, and treating symptoms is imperative in palliative care. And medications certainly have a role in end-of-life care, but actually they're not always necessary. And certainly I have patients in the community who die at home without morphine and midazolam and without a syringe driver or a NICU pump. And it's also important to know that there is no evidence that prescribing opioids appropriately in end-of-life care hastens death. And sometimes it's imperative that you communicate that with families, that the intention of these drugs are to relieve suffering, not to hasten demise. The important thing when prescribing medications at the end of life is that they are individualised and have clear indications. And I would refer all JMOs to the Clinical Excellence Commission's most recent anticipatory prescribing guidelines, which we can go through if you like. That'd be great. So anticipatory medications I would prescribe for all patients in the terminal phase as well as those patients who are deteriorating and you expect to be in the terminal phase. By terminal phase I mean the patient is unresponsive and you expect them to live hours to short days. In a patient who is opioid naive and elderly with normal renal function I would be starting with morphine 2.5 subcut one hourly up to six a day in 24 hours and the indication would be pain or breathlessness and it's very important that you have a good working relationship with your nurses when you're doing palliative care, end-of-life care, because they are the ones that ultimately give the medications if they are only PRN. And it's the nurse's clinical judgment that is often required to determine whether or not the patient needs the medication. The other medications I would be prescribing would be midazolam 2.5 milligrams subcut two hourly up to six in 24 hours for agitation, terminal restlessness and anxiety and often the anxiety manifests with breathlessness. We know that when you're breathless you get anxious, when you're anxious you get breathless. Metoclopramide 10 milligrams subcut three times in 24 hours, so eight hourly, we use for nausea, first line, and vomiting. And second line, you could consider haloperidol. I usually only use 0.5, but the CEC guidelines say one milligram, four hourly, up to three milligrams in 24 hours. We don't use glycopyrrolate anymore for terminal secretions. Instead, if a patient has what we call the death rattle, we would educate families and probably the nursing staff as well. The death rattle is a heralding sign of death and it can make patients, sorry, patients' families anxious and usually that's because they are under the misunderstanding that the rattles are causing distress. We know that they do not and unfortunately the glycopyrrolate that we used to chart, evidence has shown that it doesn't provide any benefit and so the best thing to do in that situation is talk to families about that the rattle almost in a way suggests how relaxed a patient really is and how comfortable they are because if you or I had those secretions, we would want to be coughing them up. Sometimes people liken it to snoring. You can hear someone snoring, but they don't necessarily know that they're snoring and it's by no means harmful. And then talking to the nursing staff about positioning, sometimes changing the position of patients, which we generally do every four hours anyway, can relieve that noise. And if it's really causing distress, you can even suggest playing some music in the background. So those medications you've described, anticipatory medications, I mean, are they the same thing as what we often describe as crisis medications? I usually delineate between the two. So anticipatory prescribing is for patients who are dying and you do not want them to suffer unnecessarily, you want to be able to treat their symptoms quickly and appropriately. And it's imperative that you assess the adequacy of the medications that you've prescribed. So all of those medications I just talked about were very conservative doses. They're pretty low doses, which is what you'd want, particularly in the elderly population. But then you would want to be talking to your nursing staff and checking on the patient and hearing, did that 2.5 of subcut morphine, did that make a difference to their grimacing and their moaning? And if not, you would have a low threshold then to be increasing the drugs. But crisis medications, I think of as differently. There are certain crises that we're worried about in palliative care. One which comes to mind, which many of us fear, is the patient who has a massive hemorrhage. And there is no consensus about which medications you should prescribe all the doses. As you can imagine, it's very difficult to study. |
Because ultimately, by the time you've determined which drug, how much, checked the medication, got the medication, the patient may well have already died. And it's better that they've died with you being there reassuring them than being alone. You described some of the first-line medications for the anticipatory medication prescribing. Just in regard to the route, you described subcut. If someone's got a cannuline already, they should have an IV and if they're doing subcut, should there be like a butterfly in or do you give subcut injections independently each time? With a case like John, I imagine John and I have had a chat about stopping his antibiotics and so I think we can take that cannula out. Certainly we would be putting a butterfly in which is a subcut line that just stays in and the nursing staff use that to deliver the medications. At this point in time I wouldn't be worrying about oral medications and I certainly wouldn't be giving IV medications. Subcuts we know that they work pretty well so I'd be persisting with those and I wouldn't be prescribing a range of doses. It's important that you prescribe a fixed dose with a good clear indication and you check with the nursing staff frequently about the adequacy of the doses. Even on the palliative care ward we do not prescribe a range of doses. And do you think the doses are the same independent of weight or age? Because within normally morphine prescribing, we do it by kilo. Yes, good question. I only practice adult palliative medicine, so I suspect it's different for children. But normally I do not prescribe based on weight. I certainly take patients' age into consideration. So if someone was 90 or 100, I probably would be tempted to be even more cautious. But the doses I've already mentioned are pretty conservative generally, and I think you'd be relatively safe to start with those. If you have a patient who is not opioid naive, so who's already perhaps on MS-Contin, for example, you would be probably seeking help to change the oral dose into a regular subcut dose so that you're ensuring that the patient's getting that pain relief that they were having orally and then adding the PRNs on top of that. And I would be tempted to also consider using a different opioid if the patient had renal failure for example you'd be more inclined to use hydromorphone but it might be worth seeking help if that's occurring. And is that concerns that the morphine will accumulate in renal fat or the metabolites? That's exactly right. So the metabolite of morphine from metabolized by the liver acts just as much as morphine and so you're more likely to become opioid toxic which I can imagine some arguing does that matter in the terminal phase and I would suggest that you know I always want to practice best medicine and it would be more appropriate to use a drug that's not renally cleared. I guess the only sort of thing from somebody who works within an ED who doesn't use hydromorphone very commonly, hydromorphone seems one of those drugs that is commonly associated with medication errors especially when you're not used to prescribing it. Absolutely. You have to be incredibly careful when prescribing hydromorphone. As you know, it's 10 times more potent than morphine. And so I would probably be seeking advice when you're converting those medications, particularly going from oral to subcut. Jessica, are there any contraindications or side effects that we should be aware of with the medications you've been describing? Regarding metoclopramide and haloperidol, so metoclopramide's a prokinetic, works on the D2 receptors. We use it for nausea that's usually gastric in origin but can also be cerebral in origin. It affects the chemoreceptor trigger zone. You don't use metoclopramide in younger patients and in patients with Parkinson's disease or Lewy body dementia. And the same goes for haloperidol, the atypical antipsychotic that we use for nausea. In those patients, you would have to think about an alternative drug like ondansetron orclozine for their nausea and certainly if you're prescribing those medications you do need to watch out for extrapyramidal side effects and so commonly in my patients who may be in the terminal phase or deteriorating I will check to make sure that they're not rigid. Otherwise most of the drugs are reasonably safe. Midazolam we know is a sedative. If a patient has more anxiety rather than needing sedation perhaps they're not in the terminal phase but deteriorating you would consider using lorazepam instead but they're things that your palliative care consult team can help you with. And I may just ask this question, would you chart the whole list of end-to-end medications that are available for the nurses or you only chart them as required at the request of the nursing staff? Yes, you would. I would chart the whole list. We know that towards the end of life you are likely to experience agitation, restlessness, pain, dyspnea. Better to have medications to relieve that suffering rather than not. And in fact the CEC when they put together their prescribing recommendations found that those patients who did have the whole list charted were more likely to receive the medications and they saw a decrease in these patients suffering. I can see a real opportunity with the mutual electronic medications to kind of have them all as a package if they're normally prescribed that way. Absolutely. And to save some time for junior doctors and prescribing. And some of there are concerns obviously with reduced oral intake, becoming dehydrated. Is there an element or a reason for providing subcut fluids? That's a good question, one that I get commonly from families. So when a patient has advanced disease or a terminal illness and they stop eating and stop drinking, it's more often than not because their disease has progressed to a point that they are no longer able to have oral intake or process oral intake and in fact they don't need it anymore. Their bodies or their metabolism is operating at a level that you or I can't imagine and they don't need the fluid and protein and calories that we do. And it's actually not helpful to give these patients food or fluid. It will not make them feel better. It will not make them live longer. It will not mean that they can go home. And a study done in 2013, a randomized controlled trial of hospice patients, showed that those patients who received a litre of fluid a day compared to those patients who received placebo did not have better symptom control, did not have a better quality of life, and in fact died sooner than the patients who had placebo. And I see this quite commonly in some of the consults I receive. Little old lady who's had a stroke, she's lost her swallow, the team has put up some IV fluids. I've been consulted because she's unresponsive and a bit gurgly. We come along and stop the fluids. Her APO and cerebral edema improves and she subsequently picks up a little bit. So what happens is you give people fluids when they don't actually need them and they go to the wrong places. So you will cause cerebral edema, APO, gastric distension, things that actually cause more symptoms and more harm than you would have anticipated. So we don't prescribe IV fluids or subcut fluids at the end of life. In saying that, it can sometimes be a very challenging conversation with families. I can see clinicians, such as ED clinicians, somebody wanting to do something rather than having that more difficult conversation. And fluids is a, we're providing some type of care. And you've described the importance about communication with nurses in regard to PRN orders versus only making an order when required. Any other comments in regard to that? Just that good palliative care is a team approach. And at the end of someone's life, they're not able to tell you necessarily how they're feeling. And so you have to be in tune with them and their families. And sometimes you have to hand the reins to the families. They know them best. If the family thinks the patient is suffering in pain or anxious, then by all means, encourage the family to talk to the nursing staff about getting some pain relief. And certainly you're looking for things like grimacing or groaning, particularly on movement. That suggests that the patient's not comfortable and would be an indication to give some medication. Okay Jessica, any final tips or take-home points for junior doctors in regard to palliative care medicine or end-of-life care? A few things. Firstly, it takes a lot of courage to talk to patients about advanced care planning, end-of-life care and palliative care and I don't think it's something that's taught very well. |
Welcome to On The Wards. It's James Edwards and today we're talking about ovarian cancer and I'd like to invite Dr. Caroline Ford to On The Wards today. Welcome, Caroline. Thank you. Caroline is the head of the Gynaecological Cancer Research Group at the University of New South Wales. And we thought we'd have the perspective of a scientist in regard to ovarian cancer, a bit about the clinical issues and how they're being interpreted currently from a research perspective. So I'm going to think ovarian cancer for those in the clinical space we see people present and they usually present very late and often in younger females and they're fairly non-specific symptoms and signs that when you speak to them have led up to their presentation their their diagnosis. And this leads to a late diagnosis and a real limitation about the therapy. So we're about to you within your research about looking at something that could help us maybe detecting ovarian cancer early. Yeah, so that's absolutely right. So the majority of women with ovarian cancer are diagnosed at stage three or four. And I think the statistic is about 75% of cases. So it's quite different from other types of cancers in that regard. And we have no early detection test for it. And that is a problem. It's also a problem because lots of women and very highly educated women think that we do. So there's a pretty pervasive myth that a pap smear is testing for ovarian cancer and obviously it's not. It's testing for cervical cancer. And I think there's a lot of confusion in the public about women's reproductive organs and what is what and what we are testing for and that people think they are protected by perhaps now getting an HPV vaccination. So I think there's a kind of broader conversation about having to discuss the stigma and embarrassment discussing women's reproductive organs, but an early detection test for ovarian cancer would be a game changer because if we are lucky enough to diagnose a woman with ovarian cancer at stage one or stage two, the five-year survival rate is well over 70 to 80 to 90% in stage one, whereas it drops to less than 20% in stage three and four. So the biggest difference we could make to ovarian cancer treatment would be just pushing our patient population to stage one and stage two. So it's really important that we develop an early detection for ovarian cancer, but it's also really important that the test is appropriate and that it's sensitive and specific. So there's been quite a lot of press over the last few years on a number of researchers that have used a pan-cancer approach to try to get an early detection test for a whole group of low survival cancers like pancreatic and ovarian cancer. And the research behind them is really strong and these are exciting developments. However, the sensitivity and specificity of those tests for individual cancers and for ovarian cancer is just not good enough. And it's problematic because if you did get a positive test the next step is a very invasive surgery so it's not like the situation with colorectal cancer where you could get a positive test and then do a colonoscopy to explore there's no exploratory surgery for ovarian cancer you're only going in for a major surgery invasive surgery so we need to be really careful about this. So the approach that my group is taking and a number of groups around the world is using technology that now that we can detect circulating tumor DNA in the blood. And so what we and others have shown is that even in a really, really small stage one tumorour DNA is released into the bloodstream of women and so we can look for changes in the genome to actually pick it up much earlier than we would ever be able to see it on an ultrasound or that we would certainly be able to have a woman reporting symptoms and so our approach for that is looking at methylation so we're looking at methylation of the circulating tumour DNA and specific methylation for ovarian cancer. And we've spent a number of years collecting blood samples from both patients with ovarian cancer, but more importantly, healthy women and women with varied gynaecological diagnosis and conditions such as endometriosis or such as just women in a hospital environment having potentially the influence of inflammation and so we're being very careful about what we're looking at there. And in regard to developing a biomarker for a diagnostic tool, how would you see that in a clinical perspective? So I guess with the early detection test, I mean, so that idea is something that you could ultimately have as a blood test that a GP could run and that would be really straightforward. I guess where the biomarker or sort of genetic marker field has moved with ovarian cancer is very much in those patients that have a family history. So BRCA1 and BRCA2, which are the genes that people most commonly think of with breast cancer, also predispose to ovarian cancer. And so that's really critical change in our understanding of family history, women can now be tested for that and therefore it gives them options to undergo prophylactic oophorectomy and salpingoectomy. And it's also given us really interesting sort of perspective on the biology of this disease. So we call it ovarian cancer because we have presumed for many years that it is a tumor that arises on the surface epithelium of the ovary. But what the BRCA1 mutation patients have shown us is when we remove the fallopian tubes and ovaries from these women prophylactically, so before diagnosis of any disease, for over 10 years it's now been noted that there are early changes in the tubes, so in the fallopian tubes of those women and they have a p53 signature and they are by all accounts early cancer that we're picking up and it's in the tubes not the ovaries. So it's really quite radically changed our view of what ovarian cancer is and whether it is organ specific and how it actually arises and what the cell of origin is. So it's a pretty exciting time in the field and that's all come from our understanding of genetic risk. I guess we've gone back to, I guess, the clinical aspect. The kind of concept of personal of personalised medicine is changing that one-size-fits-all approach to the management of cancer patients in general. Although we seem to be still treating ovarian cancer as a single disease, we know it's a fairly complex and heterogeneous disease with multiple distinct subtypes. Tell us a bit more about the advance in molecular profiling into ovarian cancer and how that could possibly inform our clinical decision making. Yeah, and so I, from a science perspective, I moved from breast cancer into ovarian cancer about seven or eight years ago. And I began in this field by reading the scientific literature and I completely sort of drank the scientific Kool-Aid and believed that personalised medicine was happening across tumour types across the world, there was equitable access and that we had one drug, one patient, right dose, right time, all of that sort of stuff. And then I started attending the weekly tumour board at the Royal Hospital for Women, which I've been going to for a long time. And I mean, that was a reality check when I realised exactly what you said. Whatever was happening, they were all getting carbotaxel. And, you know, this very old, old treatment, and they were not getting personalised medicine in any way. And that was quite motivating. It was shocking, but it was motivating. Because I had read the literature, I knew that there's extreme heterogeneity and there's been extensive studies now showing that there are different subtypes of ovarian cancer and that the patient prognosis is very different depending on the groups. Happily, in the last few years, there has been some movement and it comes back to the BRCA1 and BRCA2 patients. So those patients can now receive PARP inhibitors which only work in the BRCA1 and BRCA2 patients. And even though that's a small population of ovarian cancer patients, a number of really important clinical trials quite recently have shown that even in the non-BRACA positive patients, they seem to be responding to these PARP inhibitors. And that seems to be because this is all to do with the homologous recombination pathway, and it's not just BRCA1 or BRCA2 mutation that can make you more sensitive to these agents. You could also have methylation of BRCA1 or BRCA2, and that's something that's not usually tested for in our panels. So there is a degree of personalized medicine coming into ovarian cancer treatment, but it's very early days and it's very different from breast cancer, for example, where there has been individualized treatment for a long period of time and subsequently very positive outcomes for patients. And what do you see on the horizon regarding targeted treatment options for ovarian cancer? Well, I think there's a lot of really solid preclinical evidence of particular pathways that are aberrant in the different subtypes of ovarian cancer and there's been a real movement in this disease for international collaboration. So some of the subtypes of ovarian cancer, which itself is a rare disease, some of the subtypes are very, very rare. |
Welcome to On The Wards, it's Amy Koops. Today we're talking about what makes a good boss with Ria Liang and Ellie Sobels. Welcome Ellie and Ria. Hi Amy. Hi Amy. Great to have you both. A little bit about Ellie. She's a final year medical student at the University of Sydney in New South Wales and she's currently completing her clinical years based at the Royal Prince Alfred Hospital in Sydney. Before embarking on her medical degree, Ellie completed her undergraduate in medical science with honours from Flinders University. She's an avid dog lover and enjoys any beach-related activity as well as playing hockey for the University of Sydney. Welcome, Ellie. We're also joined by Ria Liang, who's a general and breast surgeon on the Gold Coast, a surgical educationalist, I love that word, diversity and surgery advocate and chair of the Operating with Respect Committee of the Royal Australasian College of Surgeons. And I'm Amy Koops, a junior doctor and journalist who swaps news reporting for medicine but continue writing with a special interest in health. I'm a founding editor of Croaky Health Media, which is a social journalism collective for health, and I'm currently a JMO with the Victorian Rural Generalist Program. So let's get started. First question for you both. What is the role of a boss in medicine? Maybe you can start, Ria, being a boss yourself. You know, I mean, that's such a nice, simple question to lead off the interview with. Just a small one. I mean, I don't think you can define it. There's an infinite number of roles. But one of the things about being a boss in medicine is the willingness to always step up and to constantly expand your role. So one of the little strings in my bow is that I am on faculty for the Surgeons as Leaders course, which I deliver for the Royal Australasian College of Surgeons. And that's a really good one to teach on because every time you teach the course, you've got to read up on all your leadership theories and see where we're up to again. And really the whole kind of field is moving more towards versatile leadership. So the idea that we're not looking for authoritative or servant leadership or emotional leadership or whatever, you know, there's all so many different leadership theories that categorize them in different ways. But really what you're looking for is someone who can pivot as required to different roles. So for instance, in a trauma situation where it's very high stress and the blood is hitting the ceiling is not the time to be standing there going, what does everyone feel about this? You know, how's this impacting you? You know, it's not the time. That's the time for authoritative leadership. But afterwards, particularly if the patient, you know, has a bad outcome, that's the time to pivot into how did everyone go? What's your feelings? And let them emotionally debrief rather than kind of going X, Y, Z, A wasn't done, B wasn't done, you know, blah, blah, blah. So when you say what's the role of a boss in medicine, it's not so much can I list the roles, more about what's the philosophy that you should bring into that bossness. Is that a word? That's really interesting. What's your philosophy, if you had to kind of put it succinctly? Just that oftentimes I'm the most senior person in the room and have experienced these things the most. So it's recognising that for some things that are required of me, I'm the best person to do it, but also to recognise that there are times when you're like, oh, that is something I've not had to deal with. And part of my role as a boss is to find someone else who's a boss in that area and not try to be all things to all people delegation Ellie what do you think what makes a good boss in your what in your encounters so far yeah so I think my definition is probably a lot more simplistic than Ria's having probably perhaps it might reflect the time that I've spent, you know, in the clinical setting. But for me, the role of a boss is probably just to make some really very highly complex decisions around patient care and treatment options. And I think this involves, you know, having clinical experience, clinical expertise, you know, a knowledge of the literature and the most up-to-date evidence. And of course, including in that some patient preferences. So I think a really valued skill in consultants is actually the way that they are able to sort of compact all of that information into a way that's easy to understand for the patients and then communicate that in a shared decision-making model. I think that that's a really highly valued skill and definitely something that I've noticed in my times from consultants. I'm interested to hear from you both about, you know, what's defined a good boss that you've had personally, you know, like getting away from the abstract and more into like an experience of a good boss. What's defined that for you? Can you think of someone that's been, yeah, really stood out as a leader for you and why? I think for me, the ones that have really stood out to me are the ones that sort of make you feel part of the team, particularly as a med student in a really busy environment where the focus is obviously patient care, the ones that take the time to sort of say hi and introduce themselves and, you know, ask what year you're in and, you know, ask for your name, those little things that aren't necessarily big, big deals. But to us, that actually does make us feel quite, you know, welcomed and part of the team. So bosses that take the time to acknowledge you and remember your name and, you know, perhaps even delegate a patient to you really makes you feel part of the team. So those are the bosses that really stand out for me. How about you, Rhea? Yeah, I was listening to Ellie answer that question thinking, you know, I was going to say something very similar, but it was about making space, you know, bosses who don't feel that they need to fill the whole space themselves. So they make space for other people. They make space for other ideas and for emotions. You know, they're willing to sit there in silence and listen when there's uncomfortable stuff to be said. I think that's the thing, you know, you do meet, it's perhaps easier to think about good bosses by thinking about bad bosses and basically thinking what you're not going to be and of course unfortunately in medicine we've had some pretty spectacular examples of bad bosses some of which have hit the media but really it's those people who think that they have to be all and end all and fill all the space that that they feel unable to take on the thoughts and ideas of others and I think those are the people who tend to, you know, the medical student tends to be an annoyance in that situation, can't do anything, not useful. You know, that's not, I don't think that's a good model going forward. Do you perceive that being a good boss is different to being a good leader? And if so, how? That's a really tricky one. I mean, a boss is defined. I mean, boss is a pretty generic word, but there are times where your responsibilities as an employer, but right up against your responsibilities as a leader. And I really struggle with that sometimes. My employment requires me to a certain something. But really, as a person of integrity, you're saying, I'm not sure that this is the right thing to do in this situation, if we're going to be truly compassionate, or if it's a specific situation that we've not met before. And God almighty, you know, this last year, with COVID and everything that's gone on bushfires, the whole lot, it's like, I think this is the time for exceptionalism. This is not the time to be following every process and policy. We have to make space for exceptions. What do you think, Ellie? What defines or differentiates a good leader from being a good boss or are they the same thing? I think the two concepts are certainly intertwined. I think in my opinion, a good boss is probably inherently a good leader and for similar things that obviously Ria was saying, but I think that there are leadership qualities when you call someone a good boss. And for me, that's understanding your team's strengths and weaknesses. It's constructing the team around that so that, you know, you have the most successful outcomes as possible. But then it's also, you know, flattening that hierarchy. |
So I think, yeah, it's about allowing that 360 degree sort of feedback with views that are the same and dissimilar to really ensure that, you know, you're making the right choice. Yeah. See, I would be really interested in hearing from you both as medical students and junior doctors what you appreciate in a boss. Well, I reckon it's a lot of the things we've already said for me, but what's really struck me, and I've only been working for a few months, but what's really struck me about, and I've certainly had a few good bosses, really good regs, really good consultants. They're people who they see you, you know, they make you feel valued, but they also see what it is that you do. And they remember what it was like to be a junior doctor and all the kind of, you know, drudgery and, and difficulty at times, you know, particularly I'm on the surgical rotation at the moment. And, you know, you do a lot of the ward work. You carry a lot of the weight of patient care, really, because the surgeons and the registrars are operating, which is where they want to be. And that's fair enough. But the bosses that I've, you know, really valued, one in particular, actually made the effort to call me on my mobile phone to say, I just received one of your discharge summaries into my clinic and I just wanted to let you know. It was really excellent and I really appreciate, you know, your communication and your documentation. And I thought, who does that? Honestly, who does that? But it was so appreciated for me and it really stands in stark contrast to some bosses that you can see a very divorce from what the job is of an intern or, you know, remembering what it was like even worse, even further back being a medical student and how difficult that is. And so, yeah, I think it's people who remember and remain connected to, you know, all levels of the hierarchy, so to speak, and don't consider themselves to be, you know, more than you just because they're much more experienced than you, recognising that you have contributions to make and that you are a valued member of the team and essential, obviously, at times, depending on what you do. Yeah. Ellie, you're even further down the food chain. Yeah. What are your thoughts? I think as I've touched on this before, but, you know, it's the really simple things that make you feel part of the team as a med student. Obviously, we understand, like I said earlier, that, you know, the focus is the patient and, you know, you're just trying to learn as best you can in that sort of scenario. So making you feel part of the team, it's the simple things. It's welcoming you to the rotation, even though you probably already had a new medical student every week still just taking that time to welcome you to it um remembering my name um often you get called student or medical student which is by no means offensive at all but you know I think it's it's really nice to know that sometimes people have taken the time to actually just remember your name um yeah just it's really simple things that just really make you feel part of the team. Yeah. Have you met things that you would have thought that the boss could improve on? I mean, it's difficult to speak up about those things as a medical student, but for any bosses who might be listening, what would you say? I mean, what things do you think they could improve on? Yeah, I suppose in my very humbled opinion, I think that, you know, just acknowledging that you're there and that you are a part of the team, because I think, again, often, particularly in this past year, you know, where things have been moving and wards have been moving to different buildings in some cases and things have, you know, gone from crazy to even crazier. I think that just acknowledging that you are still there and you are a part of the team and realising that, you know, there is an extra person there, how annoying it might be, who knows. But yeah, I think, yeah, just that acknowledgement would be really good. Yeah. Amy, your thoughts? Yeah, I guess it comes back to, I would just come back to what I've already said, which is in a sense, the things you think they could improve on are probably the things that you see other bosses doing well and think, you know, that really should be the rule, not the exception, you know, so people recognising the kind of stresses that you're under as a junior doctor and particularly at the beginning of the year, as we are at the moment, that you're very much still learning. And in fact, as a junior doctor, that is primarily what you're there to do. You're there to learn. Of course, you're there to support the team. But there needs to be space made for that as well. So they need to make themselves available to support you, to give advice. And that's very pragmatic things like when you have questions about managing particular patients on the ward, like you need them to be available for that, but also making themselves available and regularly checking in with you about how you're going, how you're managing the workload, things that you found challenging, I think makes all the difference. Like JMO year requires like a degree of pastoral care, I think. And that really depends probably on the rotation that you're on as to how much that happens. But I think, yeah, I would really like to see that be the rule, not the exception that bosses have a template for how to deal with JMOs. And, you know, it doesn't seem like it's rocket science, but to some people, I think it appears that way, or they just don't really see it as part of their job. When in fact, like every single doctor in the hospital from the HMO upwards to you know the most senior doctor in the hospital isn't should be involved and have an interest in mentoring and fostering JMOs we're the next generation of doctors and the same goes for medical students. Yeah have either of you seen egregiously bad behavior? No comment. I'll take that one alone as well. Unfortunately, like I would say, yes, you know, we see the enduring cultural problems in medicine, like they still happen. I saw a discussion and was involved in a discussion about this recently on social media about, you know, had you ever seen, you know, surgeons yelling at people in the operating theatre and whatever, and surely that's a thing of the past. And like, sadly, I don't think it is. And that thread was certainly testament to it not being a thing of the past. Most people had a terrible story to tell about, you know, some poor behaviour they'd seen. And, you know, I've encountered it myself, definitely people just, I don't know, not necessarily, you know, bullying or being aggressors, but there's a degree of, you know, just a bit of low level kind of mistreatment, people letting the stress of their job and their day get to them. And they sort of forget that you might be making your very first referral to this discipline and you probably don't exactly know what you're doing and you're trying your best. And good feedback goes such a long way. I referred a patient from, so I'm in a rural hospital and I referred a patient to a tertiary centre in my first week as a JMO. And the lovely registrar, the surgical registrar, he was just wonderful. He afterwards, after the referral was finished, he contacted me and said, I just wanted to let you know, well done on referring such a complex patient on your first week as an intern, you did a really good job. That stuff really matters. You know, it sounds really cheesy, but we need to be told when we're doing things well, because not only does it help your morale, but it helps you to keep doing the right things, you know, and not making more mistakes rather than constantly having the emphasis be on, you know, things you didn't do as well as the person on the other end of the phone or whatever would like. So, yeah, I think, I think, you know, we all know there's cultural problems that endurance, lots of it's around overwork and learned behaviors from seniors. And that's why these kinds of conversations are really important to highlight what's a good boss and how do we all become those people in the future? Yeah. And so do you think now that you're a JMO rather than a medical student, what you appreciate in a boss has changed over time? I think so, because I could really relate to what Ellie's saying about, I found being a medical student really difficult. I just felt really superfluous and redundant a lot of the time and annoying. |
And you're constantly torn between like, should I be in the hospital or should I be studying for exams? And should I be, you know, at the clinical school and doing, you know, those kinds of things and striking that balance is difficult. And I think, you know, you have to focus on the here and now really. So I think you do spend a lot more time probably off the grounds of the hospital. And so like, I think then when you get chucked into the job, you have a different kind of relationship with the boss. And I find that, I mean, you can look forward to this Ellie, like it's, people told me that this was going to happen. And I was sort of like, oh, how could it be so different? But you suddenly are a person to the boss, you know, and to everyone else in the team. You're not just like the student. You're a person who's got a name. But I guess your expectations and needs from a boss change as well because, you know, like I said, you need them to be able to answer your questions. You need to go to them for support, you know, whether that's for patient care or other things, you know, complex interpersonal dynamics that you encounter in the hospital, you know, complex dynamics with families and things of that nature. So I think, yeah, the things that you need from the boss change. So your expectations of them probably change. But fundamentally, I think what you think of as being a good boss probably stays the same in the sense that some of this stuff is inherent, you know, like, and it's what, to me, it goes beyond what is a good boss or a good leader. It's like, what's a good person? What's a good kind of, you know, it comes back to some common humanity that you'd hope that we all share. And some people do, and some people don't. And we need to enculturate that as part of medicine, I think, as you know, like, that's a really important dimension of being a doctor too is, and, you know, I guess it's subjective what's a good person, but, you know, it's those characteristics about really caring about other people and seeing other people. And that includes your colleagues. Like I think sometimes doctors are really good at being fantastic people to their patients and then they can turn around and just because the you know your colleague is the closest person and you're you've given everything to the patient just then you just be you can bear the brunt of the you know more poor behavior so I think being able to be that giving person that you are to the patient to your colleagues as well is something that would be really kind of nice or something for me that I've sort of observed and learned over the past few months that I would like to continue or I don't know if I do it yet, but I'd maybe like to do it in future if I'm not doing it already. Yeah. Ellie, because you're a final year now, so you've had at least two years of rotations. from a boss is probably different as I go from year to year. So I'd say, you know, even from last year, my first clinical year, you know, I was very much focused on clinical knowledge acquisition, which, you know, it still is today. But I think this year being my final year, you know, I'm also focused equally on understanding the job of a JMO, which essentially I'm going to be in like less than 12 months, I'll be amy's position so you know i think it's it's it's not so much that you know the qualities in a boss change but i think um i would just say more what you value and what your focus is at that point in time yeah so what i'm hearing is you started off valuing their skills as a teacher you know to convey clinical information and then it's later on that you appreciate their role as a sort of role model or. Yeah. Yeah. So outside of medicine, both Ria and Amy, who are some good examples of bosses and why? I'll let Ria take this one. I need to think about it. No, no, I don't need to think about it. I've been, so I obviously came into, into medicine from journalism. So I had a, I had a whole life and career before, and I guess, you know, I've had exposure to not so good bosses in journalism and some absolutely brilliant bosses as well. And for me, the person that I, you know, probably still think of as the best boss I've ever had, and maybe someone will overtake them in time in medicine, but at the moment, he's just, he was a great, I think role model is the word that you use, Ria, and I think that that's really, that's so important. And I think it can't be kind of overstated enough when you're talking about junior colleagues. Like I really looked up to him. He was such a good operator. He completely flattened the hierarchy in the newsroom. He valued everybody's opinion as, you know, the same. So the chief of staff who had been working as a journalist for 25 years was obviously like a very valued member of the team. me who was like a baby journalist was also valued and I think recognizing like promoting diversity within your teams and valuing that I think is really also something that is done well by a good boss and done well by this boss I remember him you know we just had we had the most diverse team you could possibly imagine. It was an international newsroom. So we had people from like every corner of the world essentially, and had me, who was like this, you know, flaming queer, and then had like some very conservative people in our team as well. And some people from like, you know, very conservative countries and somehow it just all worked, you know, we all just got on and it was absolutely a testament to him though. Like he just, a good boss, like when he, as an example, him as an example of this is just someone who can hang together a group of people and unite people around a common purpose, you know, and we really just, he was just brilliant from that perspective. And I, yeah, I will never forget working working with him and I suspect those values and those kind of attributes are something that you know I'm already kind of seeing in people that I admire in in medicine as well so I think it comes back to yeah values and principles as well as as a way of working and some of it for him was charisma you know and I don't really know if you can teach that to people or, you know, it's not something that money can buy, but it actually does help to grease the wheels of, you know, the social networking. And he just was one of those people that made you feel like you were the only person he was ever talking to and that he never made it feel kind of put on or forced or anything. It just was really genuine charisma. And yeah, I don't know. I think that that's, is it valuable? I don't know, but it certainly helps. Yeah. I mean, one of my great mentors still is the boss of the department when I first came over to the Gold Coast. I'd worked three months as a consultant in New Zealand where I grew up and trained. And I came over having to follow the dearest husband who had managed to land a job here almost without discussing it with me. So I can tell you there was some sort of intramarital discussions about this sudden move. So I arrived on the Gold Coast, you know, slightly uncertain, very fresh in my first year of consultancy. And this particular boss, and it was a woman, I don't think I realized even back then, because this is a decade and a half ago, how unusual it was to have a woman head up a surgical department. But she was just so reassuring. And she was able to put you at ease. But she also gave you wings to fly. You know, she's like, so, okay, we don't really have a fully fledged breast unit, but if you want to develop one, go ahead. I mean, get this, she's saying this to someone who only got their fracks, you know, three months earlier. Go ahead, I'll do my very best to secure funding for it and give you the things you need. It might take me a year or two because that's how the funding cycles go but tell me what you think the women of the gold coast need in a way you go you know it it's that sort of leadership that gets the best out of people you know it wasn't sort of like here's your job assignment here's your employment contract this is what's in your job description go go, you know, your KPIs. |
Yeah. They see, they see potential and they, I think bringing out the best in people absolutely is it. I can't believe it's taken to this point in the conversation for that to be said, but that is one of the main attributes of a good boss, isn't it, is bringing out the best in people, seeing what their skills are and what the things that they enjoy and just like bringing those things to the fore. It's what makes a team work. Yeah. Yeah, so I think you guys have kind of commented on, you know, culture setting almost as well. What's your views on that? I think that's absolutely pivotal. And I think particularly in the context that we were just discussing around, you know, like there are entrenched norms in medicine that are problematic and there are cultural problems in medicine that endure and you need to be changed. And I think it's going to take a generation of leaders to set a new agenda around that stuff. And it's already happening and I absolutely see it. And particularly, I think, like you said, it's really important and valuable to see like a generation of female leaders coming up through medicine. Like I think, and not because, you know, women have all the answers, but because it's a different way of thinking and it brings like all these nuances into work that I think can get overlooked at times under male leadership, like, you know, and around, I hate this phrase, but soft skills, you know, like I think that it's, and around stuff like family and other responsibilities and work-life balance and all those, you know, boring buzzwords that actually really matter to people and matter to longevity in a career like medicine which is you know so prone to burnout like I think setting norms around not just like what's an acceptable way to behave to someone and you know going beyond doing modules around discrimination bullying and harassment into actually like the standard you walk past is the standard you accept like calling calling out bad behavior, modeling good behavior, and also modeling behavior that's sort of like, yeah, people have got lives outside of the hospital. Of course they do. Of course they have children. Of course they have carer responsibilities and they have aging parents and, you know, they have other lives and they have, you know, some people really want to be involved in community work and that's so valuable. And if you want well-rounded doctors who can work for 20 years instead of two years because they're completely burnt out by the end of it we have to model that stuff and we have to kind of at the highest levels say this is what we want medicine to be and this is who we want doctors to be so I think yeah it's absolutely critical yeah no I'd echo that and of course a lot of my work outside of my clinical job is about changing culture and getting people to speak up about it but not just speak up I mean obviously if something unacceptable is said someone should speak up either in that moment or shortly afterwards but actually in the day-to-day it's about starting conversations but it's also that you know principle nothing about. And it's like, well, how can you have that conversation if there is literally no one on your team who is a person of colour or who is queer? Or, you know, like, are you just going to stand around and talk about it without their perspective? And so that's our problem in surgery, which, of course, is one of the most famously undiverse specialties, you know, still 87% male. It's about getting those voices in the room. Otherwise we can't even start having the discussions. And it's really patriarchal and awful to have the discussions without those people. Yes. Given like the timing of this discussion, just after international women's day and all the kind of political fallout around all of the stuff that's been happening in Parliament, you know, like I think, yeah, it absolutely illustrates that point entirely. It's beyond medicine. But medicine is particularly bad for it, I think. Or maybe there's a few professions that are up there with medicine. But, yeah, we're kind of leading in a bad way, I think. Yes. And it's about the patients we look after. You know, it's like our patients come from all walks of life and are diverse. So how do we think an undiverse doctor population is going to understand their needs? And let alone get people to engage with the system, you know, like it's no wonder you see like certain minority populations who get labeled as, you know, non-compliant and lost to follow up. And is there any wonder why that is? No, absolutely not. You know, like Rhea, you and I are both from kind of minority groups in one way or another. And like, I absolutely see how people don't engage with the health system or mistrust the health system really deeply because they've had really poor experiences. And part of informing that not happening is having the voices at the table to be like, have you even thought about how this would look or seem to a person, you know, of color or a trans person or, you know, it's, so I think it's, yeah, it's really important. Just simple things. You know, I had recently a junior doctor come in ranting about Mrs. X and saying, you know, she hasn't filled her prescription. It's a subsidized prescription. You know, the gap will only be $13. And it was really hard in that moment to go, you know, for some people that literally is dinner on the table. You know, you can feed a family of six on $13 if you know how to do it with bulk buys. Clearly the person who's talking is someone who has the privilege of never having had to count their dollars. And that starts really early. You know, we can really delve into selection for medical school and how we select people into medical school. But the essence of it is... How much time do we have? Not today. Part two. But the essence of it is, you know, if we had someone from a low socioeconomic background in their medical school cohort or something, they might be slightly, you know, they don't have to have lived it, but they might have already had that discussion before they ended up in my clinic as a PGY3 or whatever. It's super interesting. I mean, we are going a little bit off topic now, but, you know, my experiences in medical school being a person who, and I acknowledge I have immense privilege in basically most areas of my life. But being a person who's from like a minority kind of population, it's hard because I agree with you, Ria, but I also have had so much of experience of having to do the heavy lifting for people, you know, like educating people constantly around why this is problematic and why you shouldn't talk like this and why you shouldn't hold these kind of views and how damaging it is to do X or Y or say or think whatever. So, yeah, I don't know how we get around that problem, but I think some of that's leadership. It comes back to this conversation that we're having. You know, it's about the leader kind of doing that work and not always expecting the kind of oppressed person to do the heavy lifting, but to kind of call out bad behavior, set the agenda, set a culture and standards of behavior and ways of thinking. And, you know, like, I guess engaging in these conversations, like you were saying, junior doctor comes to you, but doing that in a nonjudgmental way and sort of being like, well, you know, the counterpoint is that $13 is a lot of money to lots of our patients. And, you know, of course, we take our income for granted. It's just astronomical compared to how most people live. But yeah, I think the conversation is where it begins. And we have to call this stuff out really early. Like you said, we've got to call it out in medical school. We've got to call it out when people are junior doctors, because more times that people are allowed to kind of have these, express these views and they kind of just get people can't be bothered to correct them or whatever or people agree with them, then that's how behaviours and thoughts become norms, right? And that's how all of this has been allowed to kind of develop around us over a period of, I mean, I don't even know how long, centuries probably of medicine. Yeah. Yeah. So I think what I'm hearing is, you know, we really need to be more of a reflection of society in our medical profession, which clearly we're not quite there yet. And hopefully this new generation coming through, we can hopefully start to see changes in that. Like you were saying, Amy, you are seeing that. And that sort of brings me to, you know, another question in that if you had some tips for new consultants, what would they be and why? |
Yeah, I think some of it is what I've just said, which is, you know, being a leader is about being brave. You've got to be brave and you've got to call bad behaviour out and you've got to call people on their problematic views. And I think that, I mean, you have to be more careful with this, but it extends to patients as well. Like I've seen some bosses handle like awkward situations with patients really well, you know, and you have to pick your time and place, I think. And some people are obviously not going to change their mind, but sometimes calling a patient out about something problematic they've said about a staff member is just as much about kind of letting the staff member know that you have their back as it is about actually educating the patient. Right. But I think, you know, being courageous, having ideals and values and living those is really important. And I think mentoring is so important and having a role model is so important. I think it's not, I think we talk a lot about it in medicine, you know, like the value of mentors and role models and stuff. But I think being as a, as a lead, I guess if you're an emerging leader or someone who's coming into a leadership role, like really seeking that out and looking for people to mentor and identifying people, particularly people that, you know, like we were talking about diverse people that we, we'd like to elevate into positions of leadership to engender like a generation of such people to kind of come forward. Because I think one of the values of leadership, as you said, Ria, is you can't be it if you can't see it. And I think it's really valuable for people to see themselves reflected in leadership, just as it is for our patients to see themselves reflected in our population of doctors. So I think, yeah, some of it is being unapologetic about who you are. And I think that's really, really difficult when you're a person who's been taught for a long time, whether it's because you're, you know, a person of colour or you're a person of a, you know, different sexuality to the norm or whatever it is. I think it's very hard to kind of be unapologetic about who you are when you've been taught your whole life to internalise the idea that you should apologise for yourself. And that goes for women as well. I think lots of women are socialised to be apologetic about who they are and occupying space and having thoughts and stuff. But it's so valuable to see people like that being unapologetic about who they are. You have no idea how much of an impact you're having being that person in the room who's just sort of like this is me I'm a I'm a leader in medicine deal with it you know so that's probably like very long-winded but values being unapologetic about who you are seeking out you know like-minded people to mentor to to grow an army of feminist queer people to take over medicine would be some of my thoughts real no I would totally echo that and so um all through my training I was I received feedback that you know I wasn't enough of a surgical boss that I had to be more bitch I spent too long talking to people. I was too nice and others would take advantage of me. In retrospect, I've realized that a lot of that was wrong. I mean, it was said from a good place. They wanted me to be able to succeed in the culture. But really, of course, now I'm busy trying to change the culture so that we're not doing that anymore. There is a role for lots of different diverse models. So there's a certain, you know, there are people in society who really like an authoritative surgeon who will just sit there and tell them what to do because it removes that cognitive load. They may not like my style, which is much more collaborative. You know, I'm very, here are some options. What are your thoughts? What's your priorities in life? How can I help, you know, balance that against your cancer treatment. Some people just find it much easier in a very difficult circumstance to have another person decide a treatment plan for them, and that's fine. So we have to provide all of that within our profession. We don't have to expect all of us to each be all things to all people. But the problem historically is that we couldn't be all things to all people. We only had one model. And of course, in surgery, that was a kind of famously undiverse model. So I would say to people coming through, you know, don't be afraid to be yourself, you know, make a new model. That saying you can't be what you can't see is not entirely true. It's harder to be what you can't see. But just make a new, you know, someone's got to be the first. So just make a new one. But the other thing too is harness the early energy. So I'm a bit of a journaler. I write little thoughts in a diary and have done since I was about 13 years old. I'll tell you some of those teenage ones are hilarious reading. But the thing about it is that you have so much on your plate when you're going through medical school and as a junior doctor, you know, just the kind of basics of doing the job, that you'll be full of ideas about what could be done better or this thing has always bugged me. I wonder what could be done about that. I'd encourage you to keep all of those thoughts. That early energy is so important because as you pop out as a boss and start getting some power to change things, change the way you run your clinic or change the way that things are set out in a certain space, then all those ideas can bubble up to the surface. If you've been too enculturated or socialized by that point, you might have had some of those individual thoughts banged out of you. So that's my only kind of bit of advice to, you know, me 10 years ago would have been, you know, write down some more of those thoughts because they're very useful as you go forward. Start planning the revolution now. Ellie, that goes for you too. Yeah. So it sort of seems, you know, not being afraid to trailblaze, you know, a new form of consultant is the message there, I think. Yeah. So changing gears a little bit, you're both considered, you know, leaders in the community as well as the medical profession because you have thousands of Twilitors each, followers online. And, you know, I think the question is, you know, how do we deal with that kind of exposure? And does that change the way you go about your current positions? I don't know. I feel like a complete imposter here. And I know imposter syndrome is something we must talk about as women. But the thing is, I've only been on Twitter for two and a half years now. So I'm a relative newbie and I can only manage one platform. So Amy is definitely much cleverer than I am in this. It's like I'm not on Instagram, Facebook, none of it. I can't manage any of it. So really, I'm a troglodyte who has stuck my head out into one forum and I can only manage that one forum. But so it's been quite a steep learning curve. I think for me it's a space where you can have positive influence beyond your own workplace so of course everyone who works with me has um and so for a whole decade I was the only female general surgeon on the whole gold coast and so of course you know I'm I'm the sort of um oddball you know everyone was like ohia, you know, Ria's always the one who's talking about emotional intelligence, about being warm, fuzzy to the juniors and, you know, talking nicely to your patients. And you can feel a little bit exceptional. And it's really only since getting into the Twitter space that I've realized that actually in almost every department, there's at least one person sharing these exact same thoughts. And that all of us might feel a little bit alone in our departments. But I tell you, I have watched in these last two and a half years that voice growing from all quarters. So I think that's where social media comes into it for me. And I made a couple of early editorial decisions. I decided I wouldn't post identifiable pictures of the kids. So the kids feature, but I wasn't going to kind of disclose their identity online until they were old enough to decide that for themselves. But the other thing was, I wasn't going to separate work and life. So there are quite a lot of people who have a professional account, and they've got a personal account. |
But I thought thought it's important to role model who you are as a whole person because actually in real life those two things can't be separated work is life life is work um and all the things I do outside of my paid work influence my paid work um you know it's fairly well known on Twitter I think that I I'm a bit of a crafter, particularly crochet. And that's a point of connection with a lot of my patients. You know, they know that that's what I do for my social media presence and they bring their projects in and we sit there crocheting through consultations. You know, this is a wonderful thing. I don't think that they would have thought that they could have that sort of connection with a surgeon. So I choose not to separate those two things out. I think it's important to portray ourselves as whole people. I think that is what, I mean, that in a sense is what gets you lots of followers and that's not why you do it. But I think people like to connect with who you are and they like people who are, you know, like I think you have to have boundaries, but I think people who are sort of like a bit real about it all. I think people can relate to that. I reckon I've gone through probably several stages of my life on social media. So I sort of started, I went onto Twitter, first went onto Twitter, like probably 12 years ago or something now, like an early adopter, was on there as a journalist. And I think, you know, you use it as a journalist to connect with other journalists, to kind of also get stories or information. And I don't know, I was always just like very public facing about kind of who I was as a journalist. And then I got really burned by that one time, like got news limited kind of columnists going after me with flaming torches type styles. And that was like very kind of, it was a good wake up call for me. And my boss at the time, who's this wonderful man that I was talking about was talking about earlier sort of said to me you know don't say anything on social media that you're not prepared to say in front of a TV camera and I guess everyone's kind of limitations around what that might be are probably different and I probably don't necessarily agree that I would put that strict limitation on I don't think they're comparable I don't think you talk in front of a camera like you do behind the anonymity of a keyboard, which is probably part of the problem, but sometimes it's liberating, right? And allows people to kind of have conversations that they might not otherwise have. But I kind of, you know, sort of, I guess, moderated myself a little bit and curated my thoughts a bit more carefully. And then when I was a student, again, it was sort of like the reins are off a little bit. I wasn't kind of like in a professional kind of space. And so I then found Twitter in medical school to be like a fantastic place to kind of learn heaps of stuff and connect with doctors and yeah, connect with like-minded people. I think one of the things I found really difficult about, you know, being quite a kind of lefty person going into medicine was that it was very conservative in lots of ways. And it wasn't just kind of senior doctors that I encountered that were like that, but it was, and it was students. And it was also just like the institution. It was like, it really reminded me of, I grew up in a military family and sometimes it really reminds me of the military. Like it's very kind of hierarchical. It's very like do this because I told you to, and this kind of thing. I really found that difficult. And Twitter was amazing for me because it opened up this whole world of like, there are so many doctors out there who are actually like-minded, you know, who are lefties and do amazing things like working with refugees. And I don't know, I was great for me from that perspective and then I think I'm in another phase now and so like I've started working and I started talking a little bit like probably a few weeks back now about and nothing like I didn't think it was kind of anything really out there I was just sort of commenting on problematic kind of things that I'd encountered. And people started coming into my DMs and saying, you need to be careful about what you're saying. Like you're going to get yourself in trouble. And, and I really think they meant well, like there weren't people trying to censor me. They were genuinely kind of saying, and people were telling me stories about things that had happened to them where they'd kind of been speaking out about problem, you know, problematic culture in their hospital or whatever. And then because it's identifiable where they work, they got hauled before like, you know, ethics committee at their hospital and asked to explain because they'd kind of put disrepute on the hospital and this kind of stuff. And they were just sort of like, you need to be careful not to let that happen to you. And part of me was like, so angry about that, you know, because I was like, this kind of silencing is how this behavior is allowed to continue, you know, and it's like, oh, there are proper channels for kind of doing this. But we're in a different position to like being a journalist or another kind of profession when we're doctors because the profession itself can't, we have to be careful not to bring it into disrepute because there are actually consequences for that, right? You know, patients perceive that doctors are, you know, fast and loose or, you know, problematic in some way. It undermines trust and trust is at the center of the clinical therapeutic relationship. So yeah, I kind of just went offline for a bit. I just kind of shut down my, deactivated my Twitter and went away to think about it and talk to some, you know, I guess I talked to some role models or some people who I really respected who are doctors and who had, you know, navigated this in one way or another to kind of be like, you know, I don't really know how to approach this. And I think I just benefited from having a bit of time out. And then I don't know, I guess I've come back to curating my thoughts in some way and not censoring myself. But I think, yeah, just being careful about how I word things and the implications of how I talk about things. And not really for myself. I don't care about that. I'm sure I'm going to get in trouble many times before, you know, before I even finish this year. Because, you know, I'm an outspoken person. And that is probably, I don't think that's like a, because I'm a journalist. I think I became a journalist because I was an outspoken person. So I think it's like a chicken and egg sort of thing. But I think, yeah, you have to be careful. You have to understand what social media, you know, like who reads social media, like who is the audience because it's your colleagues, of course, but it's the general public as well. And I think, you know, in the past year in particular, we've come under lots more attention, right, because of COVID. Like I've picked up lots more followers in the past year because I have written about and spoken about COVID and I think it's been a good reminder that we need the public trust in our profession because that's how we defeated this pandemic and I know it's not over yet but, you know, the vaccine's rolling out and we really have escaped anywhere near the kind of suffering that we've seen in other parts of the world and that's because people kind of went, okay, this is what we need to do and we're going to do it. And so much of that is down to, I think, you know, how it was communicated and how people understood the importance of it. And that was through voices like not just Brett Sutton, the hottie, but also all of the doctors on Twitter who are out there kind of having these conversations. So yeah, it's a really tricky one. I don't think I know what the answer is about how to do it properly and how to do it well. I think it will just continue to evolve. And I think social media itself is evolving too. And I think the audience is evolving. When I first went onto Twitter, like, yeah, there weren't that many people on there. And now it's just like this insanely noisy place where there's also heaps of bots and trolls and that's a whole other thing. And conserving your energy around those kind of conversations is an important part of it too. And I think you have to exercise self-care around using social media for everyone. |
Welcome to On The Wards. Today we get to talk on cross-cultural communication with Dr. Alan Giles. Welcome Alan. G'day, lovely to be here. Alan is a fellow emergency physician and a medical educator based in Sydney. He also hosts podcasts. It's a podcast I've been on once or twice, EMcast. You can get that on an app. And he's also the hospital school director for the Sydney LHD and the SSW LHD. Why are they so long? You don't get out west very much, do you? No. Sydney's southwest. Okay. We're going to talk on an interesting topic of cross-cultural communication. We have a couple of cases and then we'll just talk around it. Alan, how's that? Yeah, I think that sounds like a good idea. Let's see how it goes. You're a junior doctor working on the ward. An 80-year-old Vietnamese-speaking male has been admitted with shortness of breath under a respiratory team. You've been asked to admit him to the ward, but he doesn't speak much English, but fortunately his grandson, who does speak English, is with him. Kind of what techniques or how do we obtain the most accurate history in this case? The most accurate history you get by the best communication you have with the patient as a general principle. So there are things that you can usually get before. If you look up the electronic medical records, you can get a lot of previous history so you don't go in there blind. And that helps with your communication with the patient and with the grandson. And you might find things in that history that your grandson's unaware of anyway. So that's the medical records. You'll also get some information if they came in by ambulance, the ambulance might have some additional information and via say triage or before they've come to the wards. So all that information primes you to know where you're going and so walking in with that you can go in more confidently as a junior doctor to start addressing the components of the history and examination you need to do. I think that that initial time that you go into the patient and with the family there, in this case the grandson, is pivotal to what sort of history and examination you're going to get. If you go in there and you look dismissive or you look like you don't really care or you've got something else on or you're checking your phone, all those things, they're going to read those prompts, whether they speak English, don't speak English, and you will never get the respect and you'll never get the history and examination you desire. So I would say that initial time that you walk in, you should be using eye contact, you should be looking around the room and introducing yourself personally to everyone and telling what your role is. And even the people, in this gentleman, if he speaks no English, he probably does speak some English, but he speaks no English, then use eye contact, go to his level and shake his hand and say, lovely to be here, you know, let's have a look at you. Now, if he's on the wards, it's likely there wouldn't have been resuscitation. So we have a little bit of time to work through history. And then if he speaks a little bit of English, you can explain that you're going to go by the grandson. That there's a few other just a few other practical things that I just want to bring up before we move on your body language determines also what they perceive your level of interest is so I know that medical students are told they're not meant to sit on the bed as part of their training I must admit I do do it, so that I'm at the level of the patient. And I don't have defensive body language, I don't cross my arms, I don't cross my legs, I will lean forward towards them and if appropriate I would touch them on the side of their arm or something like that. And this doesn't disarm, but it makes them feel they're out of their comfort zone. This is your place you work. They don't work here. They don't want to be there. They want to be back in Cabramatta. They want to be back home. They want to be out of that place. So making them comfortable means that you'll be able to make them feel you care and make them feel that you really do give a stuff about them and that you're not just ticking them off as yet another one on your respiratory round. Starting with that, they will respond. Appropriate communication at that level, a lot of it's non-verbal, will mean that you will get the response that you want and you'll be able to do an appropriate and rapid examination. Certainly any data about this is quite interesting that when people do, when they look at literature on it, does it take longer to do that? And this is from the emergency department. It actually doesn't. It doesn't take any longer because you get a much more directed history and your examination is much more directed. And patient satisfaction is much higher when you're doing these simple things. So you can be not the greatest clinician in the world and be loved by your patients if you have good communication. You can be the best clinician in the world and be despised by the world, by the patients, because you might be giving quality, in inverted commas, care, but you're not getting overall quality care. So that's what my initial thing would be. That's the important thing. That's where your money goes. And that will determine your relationship with the patient for the next week they're in hospital, four days they're in hospital. You will go in there and they will try and tell you what's happened in Vietnamese. may not be able to understand Vietnamese but this relationship that you establish initially will determine how your communication in your relationship and their quality of care goes so some real time that's a bit of a soliloquy wasn't it was the first question it just went on didn't it it was a bit you know the idea a bit of a time investment to start with will repay you. Absolutely. And also, that's what you're employed to do. It's old school, but aren't you going to be a doctor? And that isn't your caring profession. And you will get a lot more back and learn more about the patients and therefore become a better doctor and enjoy your day if you invest in them. If you don't and they find them, it's number three in bed eight, that's not being a doctor. That's being just a dreadful robot to the system and you will hate your job and you'll wish you've done plumbing. Okay. We've talked a bit about general sorts of communication, but they don't speak English. What are, I guess, the options for interpreter service in this case? Yeah. Interpreter service is an awkward area because it's always an imperfect art, isn't it? You always have to go via a third party to impart your information and get it back. So it's a bit like a Chinese whispers. There are times when you need to use all your available interpreting options as soon as possible. So someone comes in and they're having a respiratory arrest or near respiratory arrest. And you've got a grandson that speaks English. And to get an interpreter on the phone is going to take some time. So you will use your available best English speaking person. And that also may be one of the nursing staff, maybe one of the medical staff. So that's the imperative one. If you then step back and say, well, what am I using this interpretive service for? If I'm using it to clarify the history, to clarify the medications, to clarify what brought them into hospital this time and what they're feeling, then often the grandson might be entirely appropriate. Now, there is a question about whether this is breaking confidentiality with the patient. My personal feeling is that I think it's simply using the family to assist you to gain an appropriate history. And in many ways, the family want to be part of the problem and the solution. They brought them in often so they want to tell you their story. They want to make sure that it's not mixed up, you know, that you think he's great at home but in fact he's hopeless at home. He's demented. He's falling over. Please let me tell you this. If there is a more important decision that needs to be made, I suppose an acute appendix that's got a guarded abdomen, something like that, and you need to consent them for that operation and you need to tell them specifics of what the risks are, what the advantages are, I would then want to have an interpreter there. |
But that becomes more awkward, but I think that's certainly where the interpreter service is required, is essential. Along the cultural aspect, you know, sometimes as a doctor you'll be asked by your patient to see a doctor of a different gender to your own. Yes. I've come across this before, and many people in emergency have. And as an example, if you've got an Arabic lady and they're brought in and the family comes with them and they have some vaginal bleeding or something like that, and they've requested to see a female doctor, I think that rather than being arrogant and judgmental and saying, listen, I'm the doctor, you're the patient, this is the way it's going to happen, we're in Australia. That sort of aggressive, Caucasian dominated way. Have a reflection and say, look, I actually don't understand that culture that well. I have my own biases and I've got my own which have not come from living in that area. And I think you should accommodate such a request, if it's not a resuscitation, where you can. So in most emergency departments, and certainly that's where I work, this is something that we would accommodate. And it's not just something like that. It might be potential testicular torsion in a 14-year-old boy. You've got an option of who would go to see them. We would titrate it to the appropriate person. Saying that if you're taking all these patients, if you're getting someone else to say to see your patient, you should take their patient so they don't feel like you're being a lazy bugger in the background. But I think that's, I think it's reasonable. Yeah, I think it's a reasonable approach. It's not an aggressive approach. It's not a confrontational approach. And in the end, what you're looking for in the end? In the end, you're looking for safe, good, quality care for this patient and the other patients that are in the department or in the system. And to do that, sometimes you have to tailor your things. In some ways, it's no different to tailoring who should see a cardiac arrest. The best person who should do an ultrasound on the person, the best person for it should do it. So I don't think it's significant of an issue to be a problem. You've been continuing on with this case and they came with shortness of breath and ended up in the next couple of days had a CAT scan. It showed a lesion, highly suspicious from a lymnocyte. And you have actually told the grandson and the grandson's asked that you don't tell the patient the result of the CAT scan. How would you handle this request? It's an awkward situation, but one that I think certainly turns up fairly commonly. I think that the way it's going to go actually goes back to what your established relationship with it. This is now a couple of days down the track. If you have a good relationship with the patient and with the family, you can have a conversation saying that the patient, it's their body, and they should be aware of what's occurring. That's my general feeling. This is not really to do with confidentiality per se, but they own their body. And the family will, for good intention, not want them to know. But you don't know their agendas either. They might have guilt. He wanted always to go back to Vietnam and we stopped him. Who knows what their backstory is? And implying that you should acquiesce to their desires with the clinical care of the patient like this, I think just smells morally wrong. And I've never actually not told a patient. One important part of it is that you don't know what it is. So if you've done a tissue biopsy and it comes back, you've got SCC. Well, that's a discussion that you need with an interpreter. You need to have the senior of your team involved there because that's a discussion about well what now so that's something that your team needs to get together and then have a time that all the players can be together and explain it but when it first comes back you've already mentioned oh by the way geez it looks like that look at that or they've noticed it what's that you've Then you don't know what it is. And I've come across one situation where I've said to someone, I reckon it's a glioblastoma multiforme. And in fact, it was a cerebral abscess. And so she sends me letters every now and again saying, I'm still alive, feeling good. How are you going, Alan? And I'm going, no, not so bad. So without a tissue diagnosis, you do have to be cautious about it too. It's an awkward one, but that relationship is really important. Any final thoughts on communicating better with patients and families from a non-English speaking background? I think people like mankind, people generally respond to your body language and your tone and your sincerity. They can see through all this other crap. They can see whether you're a pompous sort of doctor that doesn't respect them. And establishing that whether you're a junior or a senior doctor when you see a patient is really the basis to communication try and be the best you you can okay so they there are lots of different use and some of them aren't as good as other use that you have but with the patients try and be the best version of yourself you can, the caring one, the reason you went into medicine. If you think like that with every patient you see, then they will respond inside because they only want to get better. They just want to have someone who's got empathy towards them and explains what they're doing in simple terms. So if you do that, I think that's really the essence of it. Now, we're going to go to a different case, and this is... That bloke survived, didn't he? Yes, it was a three-point... No, it was a lung abscess. It was a lung abscess, okay. I think they're fine. I feel better now. Now, imagine you're working as an intern on a surgical ward. Your registrar always seems frustrated with your work. So I'm working on the wards? On the wards. You're a surgical intern. Your registrar doesn't seem to like your work much, but you're finding it really difficult to understand what they want from you because the ward rounds don't last too long in the morning. A typical surgical ward round, then they're off to theatre. Right. But you understand also the registrar trained overseas and was a consultant in that country is now reacting as an unaccredited surgical registrar position and you kind of know wow that you even think yourself that would be a difficult transition so when we talk about cross-cultural communication we talk about cross-cultural communication with patients but many of our colleagues we work didn't train in Australia so how do we better communicate with our colleagues who possibly trained overseas and possibly our language is not their first English is not their first language yeah it's um you're right that as soon as you you know even in this magnificent RPA there there would be large number of people who have trained overseas and come in as consultants here or worked as registrars and become consultants. And certainly as you move to the outer metropolitan and outside Sydney, a higher and higher percentage of your junior through to senior doctors have been born overseas or trained overseas and are working. If we go back to this particular case that you've said, it would be difficult and it is difficult. When you're a doctor, say as a surgeon, in many countries or areas of the world, South Asia, Middle East, you've got an exalted position. I think more, if you've travelled overseas and you've seen them, they really are the top of the pile. And whatever they say goes. And that hierarchy also extends through to junior doctors and to the nursing staff. We, for good reason, have had a flatter hierarchy where people can bring up concerns about people's attitudes at all levels. And I think part of that will continue going through things like bullying and harassment, et cetera. So for this gentleman, I gather it's male, I'm not sure, but most commonly they've left where they are, where they are the top of the tree, and they are coming out and they're trying to transfer what they translate, what they do before, into this area. And often the two of them go at right angles. So as soon as they, and often with not having accent-free English, it can appear abrupt. So their attitudes might be left over from being in South Asia or somewhere else, and their physical physical and the way they speak might actually slightly sound abrupt. But they're making a transition that is much harder than your transition. They're going from the top to having to work their way up again. It varies. |
Good morning and welcome to On The Wards. It's Amol Merrick today and we're talking about end-of-life care with Professor Imogen Mitchell. Welcome Imogen. Hi. Imogen is an intensive care specialist at Canberra Hospital and the Dean of the Medical School at Australian National University. So today we're going to be talking about end-of-life care. So end-of-life management in hospital setting presents a number of clinical communication and management challenges. This is especially true for junior doctors who may be unfamiliar with the disease progression and the process of dying. These challenges will continue to become more prevalent as an increasing proportion of patients with multiple comorbidities die within hospitals. Imogen, I understand that you have a bit of an interest in end-of-life care in an acute care setting? Yes, no, that's correct. It's essential. I don't know if you'd agree with this, but I think it's essential for junior doctors to be able to contribute to the best possible end-of-life care for patients. Junior doctors do have the ability, in my experience, and I don't know about yours, to improve end-of-life care for patients and their families. We've been sent a case here from one of our colleagues on the wards, a 77-year-old male, Imogen, who was brought in by his family to the ED for drainage of ascites. The ascites are on a background of pancreatic cancer with extensive liver metastases. On presentation he has jaundice with a GCS of 15 and a heart rate of 70. The respirator is 16 and the SpO2 is 97%. His BP is 105 over 60. He is admitted to gastro for further drainage of the side ears and assessment of surfaces. So Imogen, before we launch into the case, I wonder if you might tell us a little bit about your background with what spurred your interest in end-of-life care for an acute patient? I think you probably started twofold. One, working in intensive care, you are exposed to dying patients probably more frequently than, say, on the general ward. And I've always been passionate about having the time to speak with families such that they have a clear understanding of what is happening in terms of their loved one dying. And the second aspect, having worked in terms of research in the arena of patient deterioration, probably about 30% of deteriorating patients are actually dying and they don't seem to have appropriate goals of care which directs with great clarity as to what should then next happen to them. So I guess I'm on a little bit of a mission that patients who are dying have a much better experience than they are at the moment, particularly in the acute care setting. So for a patient like our patient, a 77-year-old man who's brought into ED and admitted under gastro, if there was a junior doctor reviewing this patient and on a mission on the rounds, they notice that there's no advanced care directive or resuscitation plan, when would be the most appropriate time to discuss end-of-life care with the patient? I think all patients, as soon as they are seen or certainly admitted into the hospital environment, need a very clear plan as to what should happen to them, whether it be around end-of-life care or just more generally so that you've actually got a diagnosis and that you have a treatment plan so that everyone is clear about what's to happen. In respect to end-of-life care, I mean in this particular patient you'd be very concerned that they have a trajectory of a poor outcome in the not too distant future. So I think you would want to make sure very early on, and that I think would still be in the emergency department, that there is a clear direction of what both the patient, their family, and the treating team believe should be the pathway for the next day or so. So I would include in their discussion is had in emergency? Yeah, I mean, it is clearly not the most ideal situation, but I feel very difficult about patients being admitted in the middle of the night and then suddenly having a MET call when, in fact, there's no clear direction in the notes as to what should have happened. So I guess I think early on we need to make a plan. When a patient such as the one we're talking about here today deteriorates, say they become hypertensive, febrile, positive urine culture, they have worsening liver and renal function, what would be the appropriate point for a junior doctor to advocate for a palliative care review? And would this be an appropriate juncture for the junior member of the team? I think in an ideal situation, this patient should have an early palliative care review because of the complexity of the patient, but particularly in relation to the fact he seems to have a terminal disease and he's getting worse. I think the challenge always is whether the admitting consultant is on the same page as well. So I think ideally you'd want to make sure that they were aware that you were about to do this. I think secondly, the resources in regards to palliative care are very limited. I mean, if you think about it across the nation, we have 200 palliative care specialists. So that makes the referral quite difficult and particularly out of hours. But again, I go back to patients who would probably be better treated if they had earlier palliative care review. Unfortunately, we seem to leave it right up until the last moment, until they get the palliative care review. And I think that probably diminishes the experience that both patients and families have as the patient is dying. In my experience, and certainly in a lot of people's experience, there are those difficult situations where the initial conversations have been had by the senior physician or at the time, but the family either don't understand the context of the discussion or disagree for whatever reason. How, in your experience, do you bridge that divide between the desire for all care and resuscitation to be given and knowing, as we might do, that this might not be in the patient's best interest? So as you rightly say, I mean, this is a difficult situation where the treating team feel one way and the family feel another way. And often what happens is that if you have enough time, and I guess this is where it's difficult for junior doctors having time, I have the luxury in intensive care, I probably have more time, to sit with the family and get a really good understanding of what their understanding of the current situation is. So walking them through right from the time the diagnosis was made, and preferably with the patient if they're obviously conscious enough, to get an understanding of where their understanding is up to. And I think a real understanding of where do they see the journey headed. And then that gives you a really clear idea of what you're now trying to deal with and trying to maybe correct them in terms of their understanding of the disease process, but also starting to get them to really start to distill out what the prognosis is likely to be and the symptoms thereof that might come with it. And I think I'm honestly, in all my time talking to patients and families around such difficult matters, once you take it very slowly, they often, I mean, may not be on the first visit, but certainly very quickly can see that they're not getting better in spite of all the active treatment. They're getting worse. So really, what are we actually trying to achieve? And I think you then start to reach out that maybe, you know, things aren't going to get better to the point of cure, that actually this is really starting to be a situation where we're really taking away the things that don't help and allow them to have a more peaceful and symptom-free death, if you like. So it's a very slow but considered conversation about the story beforehand and where we're going into the future. And within the context of a junior medical officer on the wards, if they were to be confronted with the conversation where a family member might advocate for intensive care omission. What are the sort of things that need to be described or discussed with the family around the limitations of that care? Yes, I think probably these conversations are best had once perhaps talking to your consultant. I think it's very important to make sure that they are on the same page as where you want the conversation to go. You may also want to talk to someone from intensive care to perhaps get a clear idea of what their thoughts would be. And then having gained some, I suppose, if you like, expert advice, you feel better armed to then go and talk to the patient and their family such that you're making informed discussion rather than talking in isolation. So I think it is important to get some information beforehand and also to get some information if you can about the family, what the situation is, who's who and who doesn't like who and making sure that really you're then going to reach onto the same page. For the junior medical officer within the ward environment, sometimes it seems that one of the challenges is managing the expectations of the medical and nursing team. |
So I think, again, I mean, it goes back to I've just mentioned talking to the medical staff. I think probably one of the other discussions that you need to have is particularly with the equivalent of the nursing team leader or the nurse manager. Make sure that they are also on the same page. I mean, I think it's incredibly important that when you are starting to go down this pathway that everyone is on board, be it the nurses, the physiotherapists. There's a very good understanding of what the treatment expectations are and then this probably isn't going to get better and that really, as a medical team, you're thinking, no, this is more appropriate for palliative care. To be honest, often what happens is that nursing staff will come to you with concern that you are being too active with treatment and so they are raising the concern almost on behalf of the patient that this is not the right thing to do. And you have to be, I guess, comfortable for that. And whilst you may feel threatened that your actions are being questioned, I think you need to reflect and think, well, hang on a minute, if they are experienced and you're not, and they've seen probably more of the patient than you have, then you have to take note and consider what they're saying. And I think then you talk to your consultant to see where you should take the family next. I think it's just trying to get everyone acting in the same direction as a team, which I guess I am passionate that everyone considers themselves as part of the team. In different cultural contexts, junior doctors may find themselves in a position where the family are very passionate following a discussion around palliation or end-of-life care to take that patient home to provide family care as they see fit. Is this appropriate or is it even possible? And if not, should it be? would like to do and what we can do. I think one just has to be realistic. I mean, I think certainly within the intensive care unit, when we've got patients or particularly families saying we want to take them home and they're strung up on a ventilator and inotropes, clearly by detaching them, they will probably die en route and that would be a little untidy. But I think if there is an environment where they can be safely looked after at home, I think people underestimate how difficult it is to care for the dying and the care that's needed 24-7 and that, you know, furniture needs to be moved and things need to be put in place in terms of medication to alleviate symptoms. It's not a small task, but it's equally not an impossible task. So I think if there is that desire, then one should try very hard to make sure it happens. But it will need everyone pulling very hard and fast, particularly to get them home and have the right support. So I think, yes, I do think it's appropriate. But equally, one has to be pragmatic and recognise that sometimes it's not possible. For the junior doctor, I'd like to talk about a situation that I've certainly been in with junior doctors before. Sometimes, and say our patient here becomes more and more hypotensive throughout the night, but yet they're experiencing pain. The nursing staff may call at 1, 2 in the morning, send a page and request fervent morphine for pain relief. Now, the medical staff might be aware that this would potentially exasperate hypertension, potentially affect respiratory drive. How do you balance that discussion? for the patient and the family is that symptoms are relieved. So if the patient is in pain, they need pain relief. I think I've heard too often where the junior doctor is reluctant to give pain relief for the reasons that you may state, and then the patient dies in pain. I think, for me, that's completely unacceptable, and that if the patient has pain or the patient is breathless, then the patient must have those symptoms relieved. Now, there may be the unintended consequences. They stop breathing. But at the end of the day, patients must not die with extremely awful symptoms. So I think for me, it is about being patient-centered and ensuring that the patient doesn't have the symptoms and you treat the pain or breathlessness or whatever is the issue that's troubling them. For our patient, they pass away through the night and you come on, the junior medical officer comes on in the morning and is informed that the patient's deceased by the nursing team leader. They request, the nurses request that you certify the death, that is a junior medical officer certifies the death. How is this situation best handled? So I think, you know, you're going to have to certify the patient dead with the family in the room. So I don't think this is a situation where if they want to stay, then you should allow them to stay. I mean, obviously, that's the first question, if they want to be there, because they may not want to be there. The second issue, obviously, in talking to the family, you need to acknowledge that something very sad has just happened, that their loved one has just died. So I think it's important to recognise that and the meaning that might have for them. But I think, you know, if they want to stay, then you will have to certify them that with them in the room, as confronting as that might be. Are there any specific things that you would like to communicate to junior doctors around end-of-life management in the hospital? I think, I mean, we're all a little bit afraid to talk about death, but I think if there are patients who fill certain criteria and there are now tools out whereby patients, if they have metastatic disease or stage four cardiac failure or equivalence of chronic disease deterioration, then these patients need a goals of care conversation. And it needs to be very clearly stated what those goals of care are. So I think it's not to be afraid to talk about it, whatever time of night. It needs to be very clearly set out in a plan. And most hospitals these days will have a goals of care plan as to what the most appropriate action is. And that has been talked with and decided by you and the patient or you and the family. And I think the other aspect before you're going to do any of that is you make sure that the treating team who are caring, your consultants are caring for the patient, that they also agree with what should be their goals of care. So I think, yeah, don't be afraid. Must be clear plans. And that before making those plans and talking to the family, you need to make sure that you've spoken to your consultant or whoever is actually admitting the patient. I think those are probably the three take-homes for me. You mentioned the goal care documents. Are there any resources that you might recommend for anyone interested in this topic? I mean, there's multiple websites around that talk about advanced care planning. There's also education packages, particularly out of Flinders University, the End of Life Essentials. That's actually quite an interactive program, which I think junior doctors would find very helpful. And I guess the Australian Commission on Safety and Quality Healthcare also have a sort of tab, if you like, on end-of-life care, and there's a toolkit that hospitals might want to engage with. So, I mean, I think there is a lot of material. I wouldn't say there's only one particular website, although I say the Flinders University End of Life Essentials Package is, I think, quite helpful and, thankfully. But equally, when it does happen, you have to make sure that you do it right in terms of talking to the family and taking the time that you're not rushed. And I guess for me, it's not about leaving decisions to someone else. I mean, I think whilst we run an out-of-hour system, we still need to make decisions out of hours so that it actually benefits the patient from being clear, but it also benefits the teams that might be involved, particularly in intensive care, when faced with a deteriorating situation. And the other thing in trying to help the distress, it's important to debrief. And I think we probably don't do that enough to try and desist what can be a very anxious situation. When you say debrief, does it involve going to the pub and having a conversation or is that a more formal process? I mean, I think that, to be honest with you, it's really any mechanisms which allows you to feel better at the end. And now, obviously, if you're not doing it within the health environment, you know, there's a structured episode that when you're talking to someone, it always needs to be de-identified. I think that's really important to remember. But certainly in the old days, yes, going to the pub would be a good mechanism, but I'm not sure I should advocate that these days. Thank you so much. |
Welcome to On The Wall, it's James Edwards and I have the pleasure today of having Dr. Ian Katerson, an endocrinologist who's been an endocrinologist at RPA since 1982. Is that right, Ian? That's right, John. Okay, well, you must have seen a number of patients with diabetes and almost the epidemic of type 2 diabetes. So we're going to go through, I guess, some reasonable, simple kind of blood sugar management of patients who've come with diabetes. I guess a common case that most junior doctors will see or get a call from the nursing staff is somebody who's an elderly patient who's got a history of diabetes and the nurse has checked and found a BSL of 26. But they've actually come in following a fall at home and the nurse brings you up as a junior doctor and says, can I have an order for insulin? What would your response over the phone? My response would be, look, she doesn't need insulin. She has known diabetes. Please check that she's had her medications. Make sure that she gets the appropriate diet for someone with diabetes. At 26, we will adjust her dosages over the next few days and bring it down. She doesn't need an acute drop in blood sugar, particularly at age 65. Is there anything over the phone that would make you go and see the patient more urgently? Certainly, if it was a new diagnosis in a young person with high sugar and if there were ketones. So when you say ketones, are you on ketones? Urine ketones are generally the easiest ones to do and done on the wards. And so let's say somebody came in who was in their 30s, was feeling crook, vomiting, blood sugar 35 to 40, three plus ketones in the urine, and even better if the emergency department does ketones, then you can come in and say they actually need a blood gas to see if ketoacidosis. The other thing would be an elderly person dehydrated with a really high sugar and thinking about hyperosmol and non-ketotic coma. They would be the ones you'd see. So in this one we go back and the patient has some type 2 diabetes normally controlled with metformin and glycoside. However, these weren't given on the morning when they were in the emergency department because they were concerned about dehydration. Doesn't normally take her sugars at home and doesn't know what they usually are, but had type 2 diabetes for eight years and it's usually managed by her local doctor. And a reasonably common story, but doesn't know what her sugars are and managed probably reasonably well by the local doctor. So what you're very interested in in this lady is the control of her diabetes overall. And the simplest way of doing that is to get a glycated hemoglobin. So that's part of your blood collection. But also you want to know in this lady who's had diabetes for eight years, does she have any complications that are causing issues? And really what you need to know is kidneys, blood pressure, heart, and then you would look at eyes and so on. Are there any particular investigations you would routinely do? You mentioned doing HbA1c. I would do HbA1c and in this lady in CAS who's got a blood sugar, say, in the 20s but doesn't have any urinary ketones, I would then look at renal function, electrolytes, and I probably in this lady wouldn't do a blood gas first off because there's no real indication. We're looking for pH because here it is, type 2 diabetes. Very unusual to get a ketoacidosis in these. Unlikely to have hyperosmola with a blood sugar of 26. The only trap now for young players is with the new SGLT2 inhibitors, which this lady isn't on, the ones that allow people with diabetes to keep passing glucose in the urine, that there have been reported some cases of ketoacidosis in those. So that would be a rare case in an elderly person. What are some of the common trade names we've known of those class of drugs? Giardians is the one that I would remember. So in regard to further management, we mentioned in an inpatient, they're on the ward now, the glucose has been high for a day or so. Is there a role in the insulin for these patients on the wards? It depends on their state, right? So that if this woman who's had a fall is eating well and is taking her medications, then you would look to adjusting her medications and what she's eating. When she gets home, it'll be a different story, of course, because hopefully at home she'll be more mobile and then she'll go back to whatever pattern of eating she had previously, which could either make her blood sugar better or worse at home. So in these ladies, we try to get their sugars in hospital in the range of 5 to 12 or so because we know then that they're not going to get a hypo, which we don't want. And if their sugars are in that range, they're not going to run into too much trouble with dehydration and so on. Yeah, I mean, are there particular concerns about having hyperglycemia in the wards, especially if you're going to have an operation or something like that? Particularly in an elderly person, hypoglycemia is the big issue that we're trying to avoid. And it really happens quite regularly because people do still get medications, then they're put on nil by mouth. And with the sulfonylureas in particular, that's one of the issues that you need to think of if you have an elderly patient on sulfonylureas. Either make sure they're fed or if they're not going to be fed, stop their sulfonylureas. Metformin's okay to continue, though we also do like to stop it 24 hours before a procedure. In contrast to hypoglycemia, about hyperglycemia, the sugars being high, is it a worry if they're in the kind of 12 to 24 region? Not really, because that's what we would say is, okay, let's look at the medications, increase the dose if necessary, and so on, make sure they're eating properly. In these older people, it's not really necessary to rush into insulin. However, let's say that staying in the 20s while they're in hospital, then you might think of a basal insulin. What are some of the common causes of high sugars on the ward? Infection, lack of medication, progression of diabetes. So they've come in over the years because diabetes is a progressive disease and it does get worse year by year. So ultimately, probably if you've had diabetes 10 years or more, then insulin is hovering in the future. So those would be the things that we would worry about. So I'm asking steroids sometimes. Yes, well, steroid treatment. So certainly in patients coming in for chemotherapy and oncology patients, we have a big issue with steroid-induced diabetes. But in a woman who's had a fall, probably no probably no but in other wards like renal wards, transplant wards oncology it's an issue This person's been placed on some appropriate management and you're asked to see them on a Tuesday night because she's being made a nil by mouth for an orthopaedic operation the next day. What changes to her oral hypoglycemia agents would you make? I would, because sulfonylureas can cause hypos, I would cease the sulfonylureas in the morning of the operation. And we like, because of issues, potential issues with metformin, to stop at 24 hours before. So I see her and say, okay, she's had a sulfonylureas this morning, none tomorrow morning, pre-op, and let's stop the metformin now. And then I would inform the anaesthetist that this woman has diabetes and that they need to take appropriate precautions, which would be IV fluids and glucose in the morning. Okay. Early operation, even though she's not an ancient, I always try and get my diabetes patients an early operation. Yes, okay. And in regard to fluids overnight, do they need to have some dextrose in them or depending on when their operation is? It depends on when they're allowed to eat. So if they have their evening meal, not really, and they can drink up to a certain time. It's only in the morning and particularly in those who've been treated with insulin that you would like to have a drip in. What are the indications for asking the endocrinology team to see a patient with type 2 diabetes who's been admitted to hospital? |
Welcome to On The Wards, it's Jules Wilcox here and today we have a real treat for you because we're talking about the AstraZeneca vaccine-induced clotting disorder with Professor Marie Scully, the person who made the link between the vaccine and these extremely rare unusual cases. Professor Scully is a consultant hematologist at UCLH and professor of hemostasis and thrombosis at UCL in London. Her particular interests include platelet-mediated disorders, specifically ITP, TTP and AHUS, and acquired bleeding and thrombotic conditions. Her primary publications include TTP and, in particular, treatment of clinical subtypes in conjunction with an understanding of the pathogenesis of the underlying disease. She's the clinical lead for the National TTP Service, UK TTP Forum, and patron for the TTP Network. She supervises postgraduate doctorates and is involved in undergraduate and postgraduate teaching and regularly reviews for haematology and related medical journals. So welcome, Marie. Thank you so much for participating in our podcast program. I mean, I really appreciate it. I'm sure you must be really busy now that you're world famous. No? I was busy anyway. Well, yeah. It's just a new level. I can imagine. I mean, for those listening, Marie and I were at medical school together and we're part of a sort of class of 87 WhatsApp group. So that may make some of you feel rather young. And there's a WhatsApp group that regularly posts messages about things that are going on. And I thought we might touch on that a little bit before we go on to talk specifically about the clotting disorder stuff, because it's quite clear that we're very lucky here in Australia with what's happened with COVID compared to what's been going on in the UK. And I thought to give some people some context, could we take a step back and could you tell us what it's been like working in the nhs and living in the uk for the past year or so so from a hospital perspective because obviously there's loads we could talk about and the impact of people being isolated pretty much for 18 months now but from the hospital perspective we've had two big phases in the uk the initial one last march and that went on a number of months and that was like a bus that hit everybody you know full speed overnight so we were presented with all these cases nobody really knew what they were doing with you know it was it's a new disease yeah um so it was tough but you know the NHS is the NHS and like all medical fraternities everybody pulled together so sort of came out of that uh it was a pretty gruesome time really very very traumatic for everybody and they worked very hard and then we went into phase two and that literally again happened overnight just before Christmas. And where I am at UCH, it's one of many hospitals in London and obviously in the UK. And it replicated what many hospitals had. So we had five large ITUs full of intubated patients. Five in the one hospital? Yeah. So there was 120-something patients intubated and they could have made more room. So we were kind of retrieving where other hospitals were just overflowing. That was only the intubated and essentially the whole hospital was COVID. So there were wards of CPAP patients. We did a of CPAP over there and then those that you know just needed high flow oxygen a few days in and weren't as bad thankfully but the second phase was very different it was it was worse but it was just so organized at UCH anyway it was just everybody knew where they had to be and what they had to do. But the disease itself was really very traumatic. Nobody quite knew, you know, ventilatory-wise what to do, COAG-wise what to do, definitely not inflammatory-wise what to do. And they were the two main components of COVID-19. So I'm glad you didn't experience it. Hopefully to that extent, I'm sure different areas will have had different levels. Yeah, Melbourne had the worst of it at one stage. Brisbane for a bit. Didn't Brisbane have a bad amount? Yeah, well, I mean, the thing is they go into lockdown here if you get two cases or three cases and they just shut everything down. So it does, but Melbourne had, I think it was about 20,000 cases in total and they got pretty slammed. But yeah, and talking to family and friends over there as well, the lockdowns, I'm going out for dinner in Sydney tonight and that's just not possible in the UK, is it? And that's been like that all year. Well, it's opening up next week so we can actually go to a restaurant next week and sit in a pub, not sit outside in the cold or rain. Again, unimaginable to you guys. The cold and the rain or just sitting outside? The cold and the rain, yeah. Not sitting outside, you're very used to that. It's just been very weird and, you know, there's a lot of people who literally haven't been out for 18 months. Everybody been working at home from my perspective I've worked the whole time so I can't appreciate it um in fact it's been worse than ever you know there was a lot of good things there's no traffic getting to work was easier you know all the selfish things in life yeah but people have really really suffered and the kids have suffered not going to school so my daughter who is just doing her a levels now she's essentially had her whole sixth form period covid yeah it's all online it's yeah it's not pleasant that interact you need social interaction yeah you need special interaction absolutely yeah yeah i mean i was talking my mom i didn't actually realize my mom hadn't actually seen younger sister for 18 months. I just thought they'd been catching up because they were not allowed to go around. So, yeah, really crazy. And were you seeing a lot of plotting issues with COVID patients? Yeah, yeah, yeah, yeah, yeah. It was a big issue. So the two big components was thrombosis and inflammation. And there was a very high thrombotic risk. So all our protocols, you know, in the UK, everyone gets standard thrombop and inflammation and there was a very high thrombotic risk so all our protocols you know in the uk everyone gets standard thromboprophylaxis when they come into hospital i don't know if you do it that in australia um out the window you know itu was all intermediate dose lomelic weight heparin the patients were too sick often to bring down for a scan or if they had to go for a scan, you know, the logistics of getting them from the third to the second floor was such, you know, it would take a whole massive team out. And so they weren't always scanned, particularly in the first phase. The PE rate probably wasn't as high, but they had really high right atrial pressures because of their lungs. So often they were going just empirically onto treatment dose, low molecular weight heparin for weeks on end, which they needed. So it was a big, big problem. And of course the histology is that of a microvascular thrombi, which is kind of my thing. But we don't normally see that in TTP in the lungs. We see it with other thrombotic macroangiopathies. But the lungs, the heart, the livers, brain, all of it had these small blood clots. So, you know, they had to be on more blood thinners than you would normally give. Okay, that's interesting. And then monitoring. Monitoring, because then they went into renal failure and, you know, sepsis from whatever lines or whatever. So, yeah, it was tough. So you're always just juggling dosing and based on how they were that day or over a few days. Yeah, it's really weird because, you know, up until last year, I felt, you know, I could work pretty much anywhere in the world. But now I don't think I could. I've got no idea about COVID. There'll be a lot of upskilling that I would need to do, you know, to develop that sort of clinical nuance and expertise that everybody else has around the world now, which we don't have here. So it's just bizarre. So I guess moving forward, you know, the vaccine got developed. And then you started getting case reports of weird clotting disorders in previously healthy patients who received the AstraZeneca vaccine is that right is that how it sort of came about so there was um there was certainly evidence from Europe of a problem where they stopped giving AstraZeneca um saying that there was blood clots, atypical blood clots in young people who'd received it. And the EMA were looking at it, the MHRA were looking at it. |
In UCL, came into your hospital? At UCLH, yeah. And a low platelet count was sent to us, you know a blood clot in their head in ucl came into your hospital at uclh yeah um and a low platelet count was sent to us you know low platelet count you look after low platelet counts must be itp uh and she just deteriorated even though there was no good reason for it she was completely fit and healthy um we found that she had a portal vein thrombosis. Again, very uncommon. You find a cause for portal vein thrombosis out of the blue. And all of our standard testing and rare tests were completely negative. And, you know, so you have someone with a low platelet count who's got progressive thrombosis, despite giving them standard good therapy, who was completely fit and well. And then we had an MDT for another reason with intensive care because she started having multiple fits. So she was on ITU and somebody just, my ex-chief executive just passed a very, kind of flippant comment so contacted the lab ran the PF4 antibodies no reason for me to have done them or to even consider they were going to be positive they were positive but so were those of a lady that had died about five weeks before so we run the ADAMS 13 for TTP and hers were positive. And all I remember about her was she had a very low platelet count and she had neurological disease that they couldn't explain. And then she died. And then my colleague and I, I told him he had a case in. He ran his. His was positive as well. So that was over a couple of days. Then confirmed it on another test to prove they were PS4 antibodies, not just some funny, you know, pre-analytic odd result. They were. And so then we informed all the people we had to inform. So the MHRA chief medical officer, chief scientific officer. Yeah. Okay, good. I'm really curious as to how you made the link between the cases and the vaccine. What do you think? Oh, I didn't. I didn't. No, I didn't put the link together. I tried to avoid linking them in some ways. Yeah. What, subconsciously or consciously? Yeah yeah because there was no reason for it to be linked to a vaccine so we kept getting texts going is it the vaccine is it the vaccine i said no definitely not it's just itp and we'll find the cause of thrombosis but once all those three patients who'd all had astrazeneca had these funny results that they should not have. You don't see it other than if you have this other condition hit, pepperine-induced thrombocytopenia. So the penny dropped. And then the floodgates opened. In fairness, the Germans confirmed the antibodies on the same day that we did. In Europe, there were two groups considering the same thing and found the antibody on the same day. What was the chances? Yeah. So moving on to this new syndrome then, it's got two names, vaccine-induced thrombocytopenia and thrombosis, and vaccine-induced immune thromboticytopenia are they just different names are the same thing or are they actually two different no they're the same thing and it depends where which country you're in and what time of the day it is as to which one you use right so to keep it equal i put both in but it's probably had more acronyms this condition uh them i won't say them patients because that's not true but it's had a lot of acronyms in the last eight weeks. Yeah. Surely we should be calling it Scully's disease, shouldn't we? No, because then my German colleagues would get very upset. Yes, but we always upset the Germans. But they would be very upset. Yeah, I know. I can imagine. Cool. All um how does how does this sort of vit thing work what's what causes it yeah you get the thing you get the vaccine i mean we haven't got how many cases have we got now of this so in the uk we've got over 200 oh it's obviously yeah okay and there's many more around the world obviously I saw your previous podcast interview thing that's gone up a lot yeah yeah I was reading this morning actually that in the US they've got a number coming from the J&J vaccine J&J yeah so they're both adenoviral vaccines. So that's the difference. Yeah. And that was during their trials. They found some. Of course, the benefit with the J&J is it's just one dose. Right. Where all the other vaccines. You've not seen this after the second dose of the vaccine. No. It's only after the first dose. So if you get it, you're good, you're fine, you can carry on. To date, but of course the second doses are far behind. Yeah, yeah. Okay. And it seems to be mainly in people under the age of 50, is that right? Yes, yes. Certainly in our cohort, it's about 70% of patients are under the age of 50. And when it affects young people, it really is quite severe. And more in females or not statistically? No, so in Europe it has been, but that was based on the vaccine rollout. So they more likely did their healthcare workers first, which a lot of countries have done. But with AstraZeneca in the UK, we got Pfizer first. So all the healthcare workers got Pfizer. And then they started in the UK, giving it to the older population. So it was over 80s and over 70s. And so it wasn't really until February, March, that younger people were starting to get it for very different reasons if they were in high-risk groups. Whether we've missed a load in the elderly is absolutely possible because, you know, if an elderly person who has multiple comorbidities comes in with a stroke or a sudden collapse or a bleed in their brain, but on a basic CT, they'll just say, well, it's because of X, Y and Z. But that look back is being done. Okay. All right. And I mean, what we're seeing over here, what I'm seeing in the emergency department over here is getting a number of people coming in you've had the vaccine who then come in with a headache who are then worried that they've got um sort of clotting sort of um I don't know the last shift I did I had somebody come and she'd had the vaccine you know two days before and came in saying I've got this headache for two days and I'm really worried that I've got this thing but looking at your your your data it takes a few days to come on if you're going to get this, is that right? Yeah, so you don't really see it within the first four days. The problem is there is a lot of symptoms in patients with headaches, not feeling well, temperatures in the first 48, 72 hours. Yeah, we've had a heap of sick leave because they started vaccinating all our healthcare all our health care workers with with it and i i had my first dose as well um in march um and march april march um and yeah and i had you know two or three days really of just really feeling very flu-y it was like a bad flu jab um and i was able to get a word but we've had a heap of sick leave from people who had sweats i mean they can be really really unwell and in the data that i sent you uh with a well all of them can cause headache but with az it was significantly higher and of course we don't know yeah at what time point that was recorded so it could have been after the five days so you know the first four days first four days, it's not, it's not fit. I mean, you never say never, of course, but it, based on the immunological response of an IgG formation, you know, it's going to be day six that they start getting really symptomatic, but the headaches for the severe ones, it's like the worst they've ever had. Yeah. They can't sleep. How are you seeing these patients presenting? What are they presenting with? Well, so the lion's share present with extensive cerebral venous sinus thrombosis such that you then get a secondary intracerebral bleed. So they will have collapse, severe headache, you know, some have strokes, fits, whatever, wherever it's irritating the brain. They come in critically unwell. And clearly it's not, I've got a bit of a headache because I've had the vaccine type thing. They are clearly unwell. They're clearly unwell. |
So what they are in the morning with a very severe headache, never one like this they could be tubed in the afternoon it can be really very progressive okay so the usually so what we've done is develop uh pathways for all the specialties including ed so please do share that with your colleagues if it's any help the one i sent you yeah and what we ask for we've suggested is because you get a low platelet count is to check the platelet and if that's reduced do a d-dimer which will be out off the scale it'll be much higher than you would get with a normal dvt it's a bit like our snake bites over here we get this consumptive gynecology uh that's the dimer is it's not just you know it's not just a little bit raised like in a pe it's off the charts yeah yeah yeah and they were the sort of d-dimer levels we were getting during covid so everyone's trying to put the clots of covid you know is it similar with this it's not similar at all and you get them in a typical site so the main sites of the brain, the portal vein system. We've had about 10, 20% arterial events. So that's peripheral arterial blockages requiring amputations. MIs in otherwise clear arterial systems, massive MCA infarcts, intra, what do you call it, the carotid arteries can be just blocked off in young people. I mean, it's crazy. Yeah. Types of clots that you don't normally see. Yeah. Older patients do seem to get your good old standard DVTs and PEs. Right. So in the older age groups, it seems to be just the standard thrombosis, which with all respects, at least we can sort of manage those ones, you know, the kind of common gardener ones. But I think you still need to be mindful. And the median day is about, you know, it's between 12 and 14 days after the vaccine that patients are presenting. Yeah. okay. That's really interesting. And the mortality rate you're saying is like 30%, 50%? I think it's huge. Yeah, so it's 20% now for us in the UK. Originally, the European data showed it was 50%. Yeah. It's massive. Yeah, yeah. and presumably a big morbidity associated with the people who do survive as well yeah so that hasn't been looked at but there will be so for as long as the platelets are below 150 they just keep clotting so if they've clotted in their brain they would just keep clotting in the brain and the venous can then turn into arterial clots right and then you know you can scan them do ct caps and then they've got p's you know um bowel ischemia venous ischemia and infarction it just keeps going until we get the platelet count up wow okay um so yeah so how do you treat it then? How do you get the platelet count up? Yeah. So the first thing is to avoid platelet transfusions. Now that can be quite difficult if patients need to go for neurosurgery, which is not uncommon. So there's a lot of them needed cranial decompressions. Thrombectomies have been done, a bit of thrombolysis. But it's preferable to try and avoid them otherwise, just as top-ups. We give non-heparin-based anticoagulation. Now, the evidence for this is still a bit 50-50. It's probable that standard heparins are okay. But if we look at it like a hip type process we avoid them and immunosuppression so everyone started on IVIG as quickly as possible but for those really severe cases we just plasma exchange them now okay it works much quicker yeah and a and steroid given you know high dose steroid so you are going to steroids as well now because I know that this time when you my first are you, are you talking about this? That was sort of a bit like, Oh, maybe not sure, but that was any, a few weeks into discovery. Yeah. Yeah. Yeah. Yeah. No, we definitely, we treat them like a TTP. Yeah. Okay. Um, does anybody know why it's the vaccines causing this? No, not yet. Um, obviously no, not yet. Everyone's obviously very busy trying to find out. I mean, what we do know is it's unlikely to be the spike protein because we're only seeing it with the adenovirals primarily. Even though the spike protein is very immunogenic, it doesn't appear. Otherwise, we'd be seeing more cases with the other vaccines, the mRNA ones. Now, whether it's the AAV or if it's a constituent of the vaccine is unclear. So there is a lot of other human proteins, certainly in the AstraZeneca ones, that need further investigation to see if they may be related. So that's where the work's looking. I mean, if you can find the cause, we can fix it. Yeah, yeah. And it's just the AstraZeneca and the Johnson & Johnson vaccines that are doing this. The other ones aren't doing this, as far as we know, at this stage. No. So we've had two cases of Pfizer in the UK, but it's much longer. It's eight weeks out. That hasn't been published. You're the first to know. Fantastic. An exclusive, an Australian exclusive. There we go. Yeah, exactly. See the media pick up on this. You'll be getting phone calls in the middle of the night. Oh, God. But going back to the vaccines, though, I mean, so how many have we given around the world now? Over a billion, something like that? Yeah. But it's only 7% of the population. And we've got to do, what, 75% of the population? 75%. To clear the disease. Yeah. That's a lot of vaccination. Yeah. And looking at what's going on around the world, India and other places, if we ever want to go travelling again, it's really important to, we've got to do this. Absolutely. I think what we forget is that we've been vaccinated all our lives for various different viruses primarily. So we kind of, we don't take too much notice of it, do we? We just do it and we have our kids vaccinated. So from that point of view, we got to remember it's a really really important public health issue and benefit however we have identified this condition which is rare but it exists and we're giving it's you know it's an iatrogenic cause isn't it yeah so young people are having something to prevent a condition and and's a 30% to 50% chance of dying or having significant morbidity. Yeah. And I think that's how people see it. I mean, we're generally pretty bad at judging risks and all that sort of stuff. And I think a lot of people sort of see it as a, although it's extremely rare to get it, if you get it, it's bad. And so people really just see it as a case of, well, it's either 100% or nothing, you know. And which if you're in the UK, and I mean, you know, as you know, from the WhatsApp group, a whole lot of our friends caught COVID and some were in hospital on oxygen and things. Fortunately, no one's died, but members of my wife's family, extended family have died, friends have died. But in Australia, we don't really see that. And so there we have this issue of life is pretty normal here at the moment, except for the travel outside of Australia. And yet to be able to do that, we've got to vaccinate. And then people are saying, but you're putting me at risk of this thing. And I can kind of live normally here. So unless you want to leave Australia, you don't really need it at the moment. And obviously, if we're going to open our borders, they're not going to open our borders until they've vaccinated enough of the population that it doesn't then overwhelm the health service, which is, you know, it's really worried about, isn't it? Yeah. Oh, yeah. I mean, you would not want to have a hospital full of covid patients it's it's honestly absolutely soul-destroying it's so awful however i suppose the benefit of what we are saying is we have found this condition we know how to diagnose it and we know how to treat it and all specialities are aware so we don't know what causes it, but that will come. You know, in 16 months, we've had a new virus. We've now got the vaccines. |
Hi, it's James Edwards. Welcome to On The Wards. Today I'm speaking to Dr. Cherry Koh, a colorectal surgeon at RPA. Welcome, Cherry. Thank you very much for inviting me to come along to this podcast. Thank you. We're going to talk today about PR bleeding. And we'll start with a kind of scenario that some junior doctors may face in the ward. They get a phone call from a nursing staff and they want to review a patient who's had some rectal bleeding. This is actually a very common problem that the colorectal unit gets asked to consult about, both sort of from emergency department as well as for inpatients who are currently admitted under a different unit. So the sort of information that a colorectal fellow or surgical registrar or consultant will want to know would be, you know, to be, I guess you can break it down into a few sort of broad areas. The first thing that we want to know about is some of the patient factors. So for example, how old they are, whether they're actually in hospital with, are they in hospital because they've recently had a, you know, a stroke or diabetic foot ulcer. And then then along with that we want to know about the medications that the patient's actually on and then you pass surgical history so in terms of medication we'll be interested in anti-platelet therapy particularly Plavix, Lasso, Aspirin but obviously they're both relevant and Warfarin and I guess in this at their age whether or not patients are on the sort of special anticoagulants such as the Gibetran or anything else like that, because there is no specific reversal agents for those agents. The other things would be heparin and Clexane. So that's part of the sort of the medication history that comes along with the patient. Other surgical history that's relevant to us, so things like previous laparotomies, bowel resection or any haemorrhoids history. Haemorrhoids, I have to say, is a very common sort of thing that is blamed for, but it is so common that I think that if a patient in hospital is in the hospital, you have to almost not assume that it's haemorrhoids. You have to assume that it's something more sinister, and hemorrhoids is almost a diagnosis of exclusion, if you like. And I guess more importantly after that, after knowing a little bit of background about the patient, would be about the onset and the type of bleeding we're talking about. Are we talking about someone who's just had a very small episode in a setting of being constipated in a hospital, having had some opioid analgesia, not sort of reduced mobility, or we're talking about someone who is bleeding in association with hemodynamic instability. We're talking about low blood pressure, being tachycardic, looking pale and just unwell. The other thing that a lot of junior doctors unfortunately don't get the opportunity to look at is actually the blood itself. Whether it's true melina, as in black, tarry, very offensive, once you smell that you do not forget about the smell. Or are we talking about bright red, small volume bleeds, which is more typical of anal canal type bleeding? Or are you talking about something that's really rapid, fresh looking, not offensive? And I think smell is actually a very important characteristic to any rectal bleeding because if something is offensive, you can almost be sure that it's been in the colon or the rectum or in the gut somewhere for quite a while. Okay, so that's a good kind of start that you speak to the colorectal surgeons about. But maybe in that first one you're on the ward, what kind of particular questions do you ask the nursing staff? So you want to know about whether or not the patient's stable I think that's the most important thing are they well unwell are they looking pale are they tachycardic are they hypotensive and you want to know the specifics if you can you want to know how much the patient's actually passed in blood wise and are they passing sort of lots of small lift frequent stools or are they passing a very large amount and it's now looking very pale and sort of flat on the bed. And I think if that was the case, then you want to get there as soon as possible to review the patient. Those would be the first things that I want to know. Okay, what are some of the common causes of rectal bleeding? Hemorrhoids, again, are, as I say, very, very common. They do. They do they are unfortunately get blamed for a lot of things and I guess even hemorrhoidal bleeding in a hospital setting because they're on because patients are on clexane or any other anticoagulation can become magnified into much more significant amount of rectal blood loss compared to normal bleeding. That will be common, but in terms of outpatient, so patients that actually require an admission simply because of rectal bleeding from emergency department, the common causes in elderly patients, I would say, are diverticular disease-related bleeding or alternatively angio-dysplasia. Other causes are much less common common but things that we have to consider are things like ischemic colitis or any other forms of colitis such as Crohn's or ulcerative colitis, not common but certainly can occur. And the other things would be things like malignancy and much less frequently rapid transit from say upper GI source of bleeding such as peptic ulcer or a small bowel cause of bleeding such as a small bowel adenoma or gist tumour or something like that. And what sort of questions would help you differentiate between those common causes? The common causes are as I said again so anal canal type bleeding which would be fissure or hemorrhoidal related bleeding. Those sort of bleeding have a very, they're very characteristic in the sense that they are almost invariably associated with a bowel motion. They occur typically at the end of a bowel motion. They are bright red, they're small volume, and they don't tend to occur independently of passing a stool. I think that's a very, very important thing. If you have someone who actually passes just blood, and we all have to remember that blood is a very good cathartic and it's a very good laxative. So if patients have blood in their colon or rectum, they will have what we would call diarrhea, meaning to say quite frequent bowel motions, not watery stools, but just frequent bowel motions. And patients with diverticular bleeding or angio-dysplastic bleeding being sort of a colonic source of bleeding tend to pass blood by itself, which may be clotted or unclotted, typically dark red as opposed to the bright red causes of anal canal type bleeding. And I think that's very important. and if you have a right-sided angio-dysplastic bleed or a right-sided diverticular bleed patients tend to get a little bit of abdominal discomfort just simply because of the rapid transit they get that sort of rumbling it's not pain per se but it is sort of a rumble and they feel a little bit uncomfortable and because blood can make because of rapid transit and a distension of the colon it's actually not uncommon for some patients to become a little bit vasovagal at a time of passing emotion they might feel a little bit faint on a toilet which then can become a trap for young players because you think that patient is actually passing a lot more than they are actually passing. A big question for gene doctors is trying to work out is this upper GI bleeding or lower GI bleeding because in our hospital we speak to the surgeons for lower GI bleeding and the gastroenterologist for upper GI bleeding. How can we differentiate between the two? For an upper GI source of bleeding to actually present with rectal bleeding without hematemesis at all is relatively speaking uncommon, but it can happen. Patients like that have very rapid transit. So if the blood comes out pretty red, then you know that it's pretty rapid transit. transit and invariably this is associated with tachycardia or hypotension. The less rapid bleeds would present with melina which is very very different from the rectal bleeding and the other thing that I find very useful is obviously a patient history is very relevant. History of alcohol, recent sort of vomiting, making you think about malaria-wise tears, or risk factors for peptic ulcer disease, such as non-steroidal use or previous history of peptic ulcer disease. The other thing that I find very useful is a high elevated urea, which can actually give you an indication that they've actually been breaking down some of this blood and absorbing it in the system. But if they have such rapid transit, invariably patients are hemodynamically slightly unstable or unstable. We've kind of gone through some of the historical features. How about examination? What are the features you particularly look for on examination when someone presents with PR or rectal bleeding? |
So if the patient is hypotensive, tachycardic, and we're talking about not just hypotensive or lying down, sometimes I actually sit them up and see what the blood pressure is. Just looking at them from the end of the bed, you can tell that if someone has lost a significant volume of blood, they just look shut down and pale and just a little bit anxious, a bit not quite right from the end of the bed. That's a very important end of the bed eyeball test. So that's the first thing I look at. Also, while I introduce myself, I normally put my hand on their hands because if they're cold and clammy it gives me a very important clue that they've actually lost quite a significant amount of blood. The other thing that I then look at is have a feel of the abdomen. I just want to make sure there's no areas of tenderness or peritonism. It's not common for patients to have peritonism, but tenderness, particularly to indicate underlying colitis, that could be very helpful. Very rarely you might get sort of an aorta or enteric fistula. We're talking about very rare stuff. You might be there in a very skinny patient, you might feel something that is pulsatile, but that's very rare. Examination is, generally speaking, unrewarding apart from vital signs. Very important to pay attention to a good digital rectal examination, looking for obviously any perianal pathology and obvious fissure, which might actually make it very difficult for digital rectal examination simply because of the pain associated with that. Any obvious haemorrhoids. Haemorrhoids in general are not palpable. So sometimes it's very common for me to get phone calls from residents saying they can feel haemorrhoids. I mean, I can't feel haemorrhoids, so I find it difficult that residents can then tell me that they can feel haemorrhoids. The other thing is looking at the nature of the blood when you're on the glove itself, whether it's melina, which I think is a very different kettle of fish compared to red blood if it's anal canal type bleeding it's not uncommon that you don't get any blood at all because obviously your finger is beyond the anal canal if there is actually blood and it's dark red then i think you're pretty sure that you're dealing with something that's colonic sort of a little bit more proximal to the rectum itself. The other thing that I forgot to mention on the historical side of things as well is that diverticular bleed and angio-dysplastic bleed typically have a very sudden onset and they switch off equally rapidly. And it typically, you know, patients, by the time patients come in, they've actually typically stopped bleeding. When we come to management later, that probably impacts on that. So we've done an exam. What investigation would you routinely order? And especially when do you think they need a group and hold? I think that it all depends, again, on a history. I have to say, patients, it's very difficult to quantify the amount of rectal bleeding simply because a drop of red blood goes a long way in the toilet bowl. All you need is a drop of blood, just like urine. It's very difficult to quantify how much blood you've actually lost in urine or in the toilet. But if patients are telling me that they've passed a lot of what they thought was runny stuff, and when stood up and they looked down it was just clots. That's probably significant. It is actually very difficult beyond that to try and quantify anymore but the because the one thing that I did mention before is that blood is a very good cathartic. So the frequency of bleed or passage of blood emotion is actually a very good indication of how much blood they have in a colon. If someone has had a significant bleed, that presents a very high osmotic load into the colon itself. That draws a lot of fluid in, that distends the colon, which is why it gives them that mild discomfort. And that's why it gives them a large volume of blood sort of very quickly sort of in quick succession. So if a patient is telling me that they're going to the toilet every half an hour every hour I would know that that is a much more significant bleed than someone who tells me oh yeah the last time I passed a little bit of blood or blood was about three or four hours ago. Because that simply means to say that the speed, the rate at which they're bleeding is a little bit lower, is not drawing in fluid into the colon as rapidly and therefore not coming out as ferociously. So I think the characteristic of the bleed itself is very important for me to try and determine what I do next. Sorry, I think I digressed a little bit. Your question was? About investigations. Investigations. So I think every single patient who comes in requires at least a coagulation, liver function test, electrolytes, and full blood count. Full blood count, obviously, we're looking for hemoglobin, bearing in mind that it could actually be very normal in someone who is not resuscitated. The coagulation study purely is for patients who are on aspirin, undiagnosed sort of coagulopathy or something else. And if patients have lost a lot of blood and they've been staying at home, or if they've got liver dysfunction, that is very relevant as well. Because if patients have been bleeding at home, you find that they actually, the INR can be just mildly deranged. We're not talking about very high, possibly 1.3, 1.4, typically not very high. Electrolytes are very useful because, again, upper GI versus lower GI bleed, looking at the urea, how dry they are, how much they've been impacted by this, and liver function tests, because in a tertiary hospital, we find a lot of patients who do not necessarily come up to you confessing of alcohol intake. In terms of group and whole I think it all if a patient looks unwell I will just group and hold them. It's not very common that we have to cross match patients straight away but I think a group and whole just after looking at them and just based on the history can give you a very good idea which ones you need to group and hold. In regards to management, what are the kind of management priorities for someone who's got some rectal bleeding? I think one of the most important things to say is that 90 to 95% of rectal bleeding stop by itself. Most of patients, I think it's very important for the junior doctor to decide, first of all decide, does this patient need an admission? Most patients do not come to the hospital unnecessarily, I think it's an important thing to say. There are obviously patients who come in wanting the reassurance, but the majority of patients do not want to come into hospital, particularly emergency department, unnecessarily. So in that sense, I think majority of patients actually warrant an admission. For minor bleeding, so if the history is consistent with that of anal canal type bleeding, so we've covered that previously, then I think that patients do not necessarily need an admission unless they are old, they're frail, there are any other social reasons as to why they might be concerned, or for example, if they are on anticoagulation or the gibbetran, or if they're frail, there are any other social reasons as to why they might be concerned, or for example, if they are on anticoagulation or the Gibbetran, or if they live in a remote area where they may not be helped. I mean, it's uncommon for those patients to obviously present here as the first port of presentation. So it all comes down to history again. If the history is suggestive of anal canal type bleeding, then I think that they can be very safely discharged unless there are any other social or other patient factors that decides otherwise. And all these patients can be very safely followed up with a colorectal surgeon in rooms on a sort of very elective basis. Everyone else with sort of more sort of bleeding that is not anal canal, meaning small bowel or colon or other rectal causes, I think require an admission for observation. The patients invariably stop and therefore end up being discharged for subsequent follow-ups such as a colonoscopy. The patients who require urgent interventions are patients who bleed heavily, patients who have a hemodynamic instability associated with the bleeding. In regard to upper GI bleeding, nearly all people with bleeding get a gastroscopy. We often find that colonoscopy, how useful that is in someone who has recently had a bleed or maybe actively bleeding? It depends on the expertise of the institution. Maybe we should talk about it now. I tend to think about bleeding as dividing bleeding into three different categories. So we're no longer talking about anal canal type bleeding, which can be safely managed as an outpatient. |
In patients like that they require what we call, what we would do in this institution is a CT angiogram. The reason for that is because we have a very good CT angiogram, we have a very good interventional team. So a CT angiogram, we know that one of the problems is that it only detects bleeding days rapid enough. We're talking about a mil a minute. And that becomes relevant, and I'll talk about that later, as to when you actually order a CT angiogram and a pickup rate with a CT angiogram. So patients who are bleeding interstitially need a CT angiogram because if they are actively bleeding and continue to bleed, we can actually get in our interventional team with a plan to then do a proper interventional angiogram with a view to embolising. Or if the bleeding has stopped, there is the option of leaving behind a catheter in the region of the bleed, such as inferior mesenteric artery or superior mesenteric artery, and it restarts again, we can then have the option of rushing them off to radiology again for a repeat angiogram and a view to embolization again, or alternatively, infusion of vasopressin so that that would stay stopped. So that's the first category of patients. Then we've got the second category of patients who came in, they seem to have bled quite significantly. Sudden onset, painless, clots frequently. So they pass, say, a bowel motion between every half an hour to every two hours, either prior to them coming in or when they just came in. But by the time they get seen, they seem to have not passed the blood now, a blood emotion now for about two, maybe three, maybe four hours. And in patients like that, what I would do is I would admit them and observe them. Most of these bleeding, as I've indicated before, are related to diverticular bleeding or angio-dysplastic bleeding, and the majority of them will will stay stopped and they do not require any further investigation apart from supportive treatment such as withholding warfarin, withholding aspirin, withholding clopidogrel and all these patients require ease and outpatient colonoscopy just to confirm that it is truly an angio-dysplasia or the presence of diverticulosis because that pattern of bleeding is not typical for colorectal malignancy. So there is no real urgency for us to try and do it. And the other reason for not doing it acutely as well is that the thought is that there is now a clot that is sitting on that vessel that's bleeding. In order to have a good view, so even though blood is a very good laxative, it actually coats the entire colonic wall with red. If there is blood, there's actually very poor views. So patients still require bowel prep, not because of the faeces, but to get rid of the blood, so there's still good views. So the concern is that by bowel prepping the patient, we could disrupt the clot and actually trigger bleeding again, which is obviously causing unnecessary morbidity. So that's the second category of bleeding. And then we've got the third category of bleeding, which is patients who basically don't bleed that much. And they might bleed, you know, sort of a small amount, maybe 100 mils once or twice or three times a day. That we know definitely will not show up on a CT angio. As I talked about before, for a CT angio to detect anything, you need a minimum of a mil a minute. So a lot of residents would say, you know, you get called on the ward to see someone after they've passed 200 mils of blood with nothing prior to that, and you don't know what's going to happen after that. If you order a CT angio at that point in time, you're probably not going to find anything simply because to have a mil a minute over an hour, you need at least 60 mils, at least. Remembering that blood is a very good cathartic, you know, 60 mils could end up being sort of 80 mils, potentially 100 mils. So if you're not passing at least sort of that amount every hour, you simply will not have a positive CT angio. And all you've done to the patient is subject them to contrast load and potential nephrotoxicity and a trip down the radiology expands to the hospital with no real gain. You're probably much better off checking some blood, putting them on a stool chart just to observe them. Anyway, I digress again. So the third category of bleeding are patients who just continuously have a slow boost but are just not bleeding enough to either have it detected on a CT angiogram. For those patients, we have two options to try and localise the bleeding. The first option is a red cell scan. The problem associated with a red cell scan is that patients have to be stable. So obviously these patients typically are, because the patients have to lie in the scanner for anywhere between four and six hours for that slow bleed to be detected. There might have been changes in technology since I've been a surgical registrar, but that's my understanding. So some departments I understand they actually do the dye and they keep bringing patients back and forth, back and forth, but that again is also very disruptive to the patient and quite tiring as well. But the problem with red cell scan is that patients have to lie on that cold hard table for anywhere between four and six hours so that they can actually detect bleeding. A red cell scan is actually a lot more sensitive. It can detect bleeding of as slow as 0.1 ml per minute so that's actually quite sensitive but. But obviously, for it to detect anything, you need to be very patient and watch the blood leave the colon. And the other problem with the red cell scan is that it's not very specific. How it tells you that it is bleeding in a colon versus small bowel is that it looks at the pattern of blood. So when you have bleeding in one spot, blood can either go forwards as in sort of anti-grade or it can go retrograde. And what it relies on then is basically colonic or GI motility to try and propel it in a forward direction. So you end up with a small dot which becomes a slightly brighter dot and you then rely on the direction that the colon or the small bowel is propelling it in to then define the outline of that bit of bowel so that you can know whether it's right colon, left colon or some other part of the bowel. It makes it very tricky for small bowel bleeds because small bowel obviously does not follow any particular configuration. So if you have a bit of small bowel that is lying on the left side of the abdomen that is bleeding, that blood can potentially go forwards or backwards and apart from telling you that it's in small bowel, it really hasn't told you anything else. So you're still responsible for trying to pinpoint which particular spot in the small bowel you're talking about. The colon, I guess, fortunately or unfortunately, is relatively fixed in that the ascending colon is on the right-hand side, the transverse colon is sort of across the top of the abdomen, and the descending colon is on the left side of the abdomen. So in that sense, the blood or the contrast within the bowel lumen will kind of indicate to you roughly whereabouts that is, but it's not true for small bowel bleed. The second option in this group of patients who basically have a very slow trickle is to then do a colonoscopy in a semi-elective manner, actually bowel prepping the patient with a fair bit of bowel prep. We're talking typically about four litres of glycoprep because blood is very sticky and we're not trying to prep the bowel of faeces at all, we're talking about blood. And that then allows us to inspect and then try and clip or to inject the spot of bleeding. These colonoscopies should not be underestimated because it's typically quite difficult and normally requires someone who's experienced and patient to actually stay there with the colonoscope looking for bleeding, washing things out and then injecting areas. As a final resort for this patient, sometimes we have a combined interventional and colonoscopy approach. So what we do is that me and Dr. War would have a patient in somewhere like the radiology suite or the interventional, the hybrid theatre in Theatre 17 in RPA. What we then do is that he would get access to the IMA via the groin, and I would have the patient in front leg position with a colonoscope into the colon and rectum. What we then do is that we actually inject the IMA territory with provocative agents such as vasodilators, heparin, potentially even urokinase, provided there's no other contraindications for urokinase such as recent surgery or stroke, to try and provoke and to trigger the bleeding to start and to bleed more ferociously so that we can then clip it or embolise it. |
Welcome to On The Wood, James Edwards, and today we're talking about something really important. We're talking about medical students' mental health, And today we have Professor Gavin Andrew with us. Welcome, Gavin. Thank you. Gavin is a professor of psychiatry at the University of New South Wales and at St Vincent's Hospital and has a long track record in web-based treatments for anxiety and depression. And so we thought it was a perfect opportunity to speak to Gavin today, especially about a website that he has, which is www.med.thiswayuplinic.com, which we'll talk about in a bit more detail. Gavin, maybe we'll just start. I mean, how common is mental illness in medical students? Well, it should be rare, but it's not. Anxiety and depression and probably substance use, meaning alcohol, are three times more common than they are in the general population who are not at uni. So something's going wrong. Okay, and why do you think that is? We don't know, that's for sure. It occurs around the world, nothing about Australia. It probably, all the data's on medical students because obviously people in medicine know how to measure things. But it probably is in all high-stress courses. And I think it's probably the pressure and the competition. That's what I think it is. I mean, we all select medical students into, I guess, our programs differently. Do you think we self-select some people maybe who maybe have some obsessive-compulsive traits, which is sometimes a bit good as a doctor? Yeah. Well, hopefully we don't select the psychopaths. Yes. But yes, there's something in that, and someone argues that the sort of selection procedures we use favour highly competitive, compulsive, perfectionistic characters. But I don't think that's the full explanation. I mean, obviously you've mentioned the pressure and the competitiveness that may be making students more susceptible to mental illness. Are there any kind of protective factors that maybe reduce a medical student's susceptibility to mental illness? Yes, the obvious, the desire to get never above 55 and the notion that life is for living and playing and especially in UNSW which has an undergraduate intake, these people are 18 to 24, and there's a lot of things to be done when you're 18 to 24 that have got nothing to do with study. So the protective factors are being a bit cooler about the whole thing. After all, they're almost all going to graduate. Yes. The dropout rates in medicine are extraordinarily low. And despite all shock, horror, outrage about jobs going, jobs in medicine, jobs in health are not going. And therefore, all our graduates will get jobs. I think that, yeah, there's that thought about they're all getting jobs as internal residents. I think there's a lot of stress within the junior doctor community about whether there will be the next jobs, the training program and then the consultant jobs. Sure. I mean, but that's part of their sense of entitlement. After all, they were the pick of the crop they were very bright very capable and they feel entitled to follow the specialty of their choice but it's a real world but they'll all get jobs and they won't starve and I don't think you can ask more of life than that okay that's always's always a positive thing to look at. In regard to recognising medical students who may be experiencing a mental illness, what sort of things should we look out for? What sort of symptoms should we be looking for? Well, look, all the anxiety disorders and the depressive disorders and the substance use disorders are dimensional. So they move smoothly from someone who's a bit too anxious, a bit too sad about things or drinks too much through to being a case. There's no sort of magical clue. It's as flat as that. And being anxious in the face of exams, of course, is normal. When is it abnormal? When it disables you. But there aren't any big signs. There are lots of good screening questionnaires. There's a thing called the PHQ-2 with two questions. It's a very reliable and valid measure of people at risk of depression. And there's the same sort of questionnaires for anxiety. And if only people would be honest, there's the same sort of questionnaires for alcohol. In regard to getting help if a medical student is concerned about a mental illness are there any barriers that are preventing them of getting help at the moment? Yes of course the stigma and the fear that somehow it will become known that they sought help and therefore when they graduate they won't get taken on in ophthalmology where they'd make the most money because they were known to have a history of depression. I mean that is an enormous fear across the board in medical students and in junior doctors. They'll do anything rather than turn up for treatment where they could be identified. And you think that sticker is more for mental illness rather than say physical illnesses such as diabetes? Oh yes. Yes, diabetes is not your fault. A broken leg from skiing is a mark of approval. Mental illness is never a mark of approval. And so they guard against ever seeking help, which is really very, very difficult. I guess you could argue how, given how common mental illness in society that maybe doctors have had I guess a lived experience of some mental illness may better be able to relate to their patients. Yeah you could argue all that but when you're being selected competitively for a specialty training program you'll be selected on the notion that you're an Olympic athlete who also played rugby league. I mean, that's really what will happen. So the notion that you were kind and sensitive and had a lived experience of anxiety and depression will go against you because medicine's tough. I mean, work is hard. The hours are long. You have to be stoical under pressure. Sure, you have to be compassionate when it's required, but most of all, you just have to work and don't complain. And that doesn't fit with a history of anxiety or depression or substance abuse. No. So, I mean mean that's what people are worried about. So if they are worried about it, where should they go for help? Well that's exactly why we created our website of med.thiswayupclinic.com. It's exactly why we did it. It's totally anonymous. We don't even know their names. We don't need to. We need a valid email address, but it can be Donald Duck at Big Pond. We don't care. And that overcame the sort of problem of stigma and rumour that they were in trouble. Can you maybe tell us a bit how or how it was developed? Well, over the last 15 years, we've been developing this website for ordinary people. And the main site was developed for doctors to prescribe for their patients. We've got about 8,000 doctors registered to prescribe it for their patients. Any doctor in the world can prescribe it and any resident in Australia can use it on the self-help basis. So there are 26 courses on it or in test and half the coupons cost 60 bucks for a complete course and half the courses are free. So, you know, it's pretty, been very successful. About 32,000 people have registered to use it one way or the other. So we just took that established course. We took the anxiety and depression courses and just put them on a website as a clone, if you like, of the main site. And it's completely free. So there's no charges if you go to what we said, med.thiswayupclinic.com. And what's your target audience and I guess who can sign up? Well, medical students from New South and Sydney and young doctors. Do we vet them to make certain that they're bona fide? No. And so far, we can't tell. It doesn't look like we've got a lot of strangers in there. If it looks like it's being abused, we'll create some sort of way forward so they have to answer some medical questions. But otherwise, it's pretty available. We've had 150 med students use it so far this year, which is about the right number. So we're pretty pleased with the way it's functioning. And for those who, I guess, are in Greater New South Wales and across Australia, could they also use the website? Yeah, we've got no written agreement with their university, which will make us a bit nervous but we wouldn't block them like we're we've got a written agreement between with Sydney and obviously with our own university so they the powers that be in both universities know that this is up and working. The course we put up, we've got nine courses for anxiety and depression and three well-being courses up there for stress management, for mindfulness, and for insomnia. |
Welcome to all our listeners from On The Wards with a discussion with Jonathan Brett who's one of our Addiction and Toxicology Fellows here at RPA And we're talking about something I think scares most junior doctors about, that's really dealing with the agitated, aggressive patient. Welcome, Jonathan. Thank you. So we'll start with a case. You're asked by the nursing staff to review a 30-year-old male who's become agitated. He's admitted with an overdose the night before and has a background of drug-induced psychosis, borderline personality disorder, alcohol and methamphetamine abuse. What will be going through your head as you walk to the ward? Well, this isn't an unusual situation at all will be going through my head. So I suppose, you know, preparation is the key in this situation. And you'll already hopefully have had some training on this. I think the first thing you want to think about is you know where is the patient exactly you know are they in a ward that's in emergency or are they in a ward that's you know in the hospital building are they in a dermatology ward are they in you know general medical ward and that will tell you something about the level of staffing you have and the training of that staff and what resources you have. I think the second thing is would be checking myself and what experience I have in this area and wondering whether I do need to call for help relatively early. And then I suppose you can have some of the potential causes of what could be going on running through your head, just so you're a bit prepared for the situation. I think the main problem that people face going into this situation is their own anxiety. And I think the last thing you should do is check your own pulse and make sure you go into it in a calm way because you can transfer your anxiety, project your anxiety to patients and staff as well. So I think it's very important that you remain calm. Sounds easier said than done. Indeed. Facing someone who could be potentially aggressive and I think we always worry about ourselves as well as our patients in this situation. Yeah, absolutely. So, I mean, the primary sort of approach, the primary sort of objectives when you're approaching the situation is, as you say, really, you know, safety for yourself and the staff and then safety for the patient. Determining causes and instituting management is really secondary to all that. So, depending where you are, you may have we've got a code black team that you can call would you call that before you arrive or maybe go and see what the situation is before calling for that help? Yeah sure so the first thing to say is you know the code black team code black which is our sort of security crisis code in this hospital, can be called by any member of staff. So if the nurses make a judgment call before you get there, they may have already called the Code Black team. But, you know, you don't necessarily need to call them straight away. It sometimes helps for you to go and make an assessment. And if you feel that you can't deal with the situation, then you can call the Code Black team in. And perhaps, you know, we could talk about what that comprises of and so on as we go along through the assessment of the patient. Okay, so you arrive there, patient's pacing up and down the ward, what's your initial approach? Yeah, so as I said, you know, safety for yourself and the staff. And if there's obvious safety concerns, the patient has a weapon or is being aggressive and threatening to attack people, then I think that's time to call the co-black team early. If that's not the case and they're just appearing agitated, then I think you can go in and make a bit more of an assessment first. And so I guess the approach is a non-confrontational approach and expressing empathy. But really what you want to get down to is, first of all, what's your legal standing in the situation? Does the patient have capacity or not? And we can talk about that in a moment. And secondly, is there some of the medical issue going on that's making them agitated so you really want to do a as fuller medical assessment as you can to determine underlying medical causes and thirdly you know is is there or is there just you know is this just a wound up patient or relative that needs to needs to be reassured and verbally de-escalated? If you were thinking that they could be verbally de-escalated, do you have any kind of hints on how the gymnauts can do that? Yeah, absolutely. So, look, if you've done your assessment, which we can talk about if you like, and are happy that there's no other medical causes and this is just a sort of an angry patient or relative or anxious. Actually, the first thing to say really is, you know, fear and anxiety are the biggest causes of anger, I would say. And then having an understanding of that yourself can help deal with the situation. But verbal de-escalation, I mean, what studies have shown is about 50% to 60% of people who are in a code black situation can be verbally de-escalated. So you don't always have to reach for medicines. But as I said, non-confrontation approach, give the patient space, express empathy, so an understanding of the situation. The key is listen to what the patient or relative wants, because often things have escalated so much that they aren't able to get their needs across. So then you can, once you know what their needs are, then you can attempt to resolve any conflicts and reassure the patient. But at the same time, providing very clear boundaries on what is acceptable behavior and what's not. And then I guess the last thing is to offer the person choices so they don't feel like they're backed against the wall. Choices of how we can proceed. You mentioned assessment. What would be your assessment of anticipation? So assessment starts as soon as you walk in the room, really. And it's an assessment of, you know, I guess the most obvious thing is cognition. So you want to assess whether there are any obvious disturbances in cognition. And if they're talking nonsense, that's probably a good start. But simple things like orientation are useful once you've engaged with the patient. I guess you'll also be able to tell whether there's any serious or life-threatening issues going on as well, hopefully. And to assist that, just a simple set of hopes is a good idea. And you can ask the nurse to do that even before you reach the ward, if possible. Sometimes it's not always. And so it's very much an observation thing. I suppose the other thing you want to be observing for in this patient is you know hopefully they've been assessed in ED but are there any external signs of injury, in particular head injury and yeah are there any other signs of things that could cause delirium? So like withdrawal states from typically alcohol, benzos or opioids or intoxication. Sometimes patients do either go out from the ward and use drugs or have drugs brought into the ward. So I suppose those are the things, those are the sort of obvious things I'd be looking out for. And along those lines, you could look for fresh track marks and things like that. In regard to things like past medical history, how important are they in trying to work out what the underlying cause of the possible agitation are? Yeah, very, very important, actually. I suppose, you know, any cause of delirium could be exacerbated by underlying medical comorbidities. In particular, if they have a pre-existing brain injury or something that's going to cause cognitive impairment like alcohol brain injury or something like that. But also, cardiorespiratory things, probably not in this patient, but in older patients, could predispose them to delirium as well and so make them agitated and difficult to manage. In regard to doing vital signs, are there any other examination findings that you think are particularly helpful in trying to work out what the cause, the underlying agitation are? Well, I think, you know, as well as the vital signs in particular, well, they're all important, but I guess, you know, the most important ones are breathing and circulation because those are the things you're going to have to do something about straight away. Temperature is important because infections are another cause of delirium, particularly intracranial infections. And then really, I think probably the next most important thing is a neurological exam, if you're able to do it, because that's going to tell you a lot about what's going on with the brain. |
Welcome everyone to On The Wards, we're doing a podcast on febrile neutropenia and we've invited Dr. Ibrahim Tahidi Esfahani to speak with us. Welcome. Thanks for having me. So Ibrahim, we've actually just had a podcast on transfusion reactions and I guess we're doing another haematology topic because Ibrahim's a haematology advanced trainee at RPA and Concord Hospital and a clinical associate lecturer at the University of Sydney and he graduated from the University of Newcastle with distinction and has a special interest in cellular therapy and blood banking. And we're going to talk about a topic that most doctors who work in a tertiary centre where there's oncology and haematology patients is the possible febrile neutropenic patient. So neutropenic sepsis is a potentially fatal complication of anti-cancer treatment and mortality rates between 2 and 21% and junior doctors are often called to these patients after hours. It's important they know how to recognise the patient with febrile neutropenia and how to act. Maybe we'll start with something simple. What's the definition of febrile neutropenia? So essentially, while on PowerChart, neutropenia will be shown as less than 2, for the purposes of the diagnosis of febrile neutropenia, neutrophils of below 1 is what would be considered neutropenia. Moderate neutropenia would be between 0.5 and 1, and severe neutropenia would be below 0.5. And with regards to the temperature, there's two things. The main thing is that once they hit a temperature of 38, they're generally considered febrile neutropenic. But the strict letter of the law is they need to have the temperature of 38 for one hour or to have reached 38.3 at any point to be considered febrile neutropenia. And what causes the neutropenia? So in this patient population the most common cause is their treatment for their malignancy and the chemotherapy is what is the main cause. Radiotherapy can sometimes affect bone marrow and cause suppression and lead to neutropenia as well. And sometimes the malignancy can affect their bone marrow as well and cause neutropenia. So after chemotherapy, when does it most commonly present? So all chemotherapies have different myelosuppressive effects. For the junior medical officer, the thing they should keep in mind is that the most common period where it will occur is between the 7 to 11 day mark after chemotherapy. If we give an example, that you're called by nursing staff on the ward to see a patient who's developed their first fever eight days after receiving their first cycle of chemotherapy. What information would you like to know over the phone before you see the patient? So I guess the first thing that would be the responsibility of the junior medical officer would be to determine the hemodynamic status of the patient because that's the most concerning feature with development of septic shock. And so obviously they'd ask the nurse for their vital signs and how that's changed from their baseline to have an understanding of the significance of that number. They'd also want to determine whether this is the first febrile episode or whether there's been several and whether they're on any therapy for it at this current point in time. When you arrive, you see the patient, they're looking a bit sweaty and unwell, just outline your approach and what sort of things you look for on history or ask on history and look for an examination. So as in any situation that a junior medical officer faces with a patient, they should first and foremost assess the ABCs of the patient. And airways, breathing and circulation, typically it's the circulation that's affected. And once they have the observations, they should make a quick assessment of the circulatory status of the patient as the timing of the management of shock and sepsis can be crucial to the survival of the patient. Once they've established that the patient is not in any immediate danger, then they can take the time to try and find the source of the infection and to give specific therapies. However, there are guidelines of broad spectrum empirical therapy regardless of the source of the therapy. So with regards to history taking, the first thing you would ask is just to get a general understanding of how the patient feels because they can present with any number of symptoms. And so you would ask an open-ended question initially to gauge what their most pertinent symptom is. Then you would be systematic in determining the source of the infection. And one trick that I've learned is to just go from top to bottom. So I start with the head saying, do you have headache, photophobia, neck stiffness, any sore throat, runny nose? And then I just move my way down till I get to whether they have dysuria or whether they have diarrhea. And the most important thing is not to forget the skin and whether they developed any rashes, most commonly forgotten question. With regards to physical examination, you would reflect your examination to the questions you've just asked looking for the source of infection. And so essentially you would go through the bulk of the systems. Obviously you wouldn't do an extensive neurological examination unless that was warranted by the history or earlier examination. The key, I guess, despite everything I've just said, the key would be to be quite timely in this regard and initiating antibiotic therapy as soon as possible. Okay, is there anything you don't do on examination, PR exams, out of doing examinations, if someone is possible feb everyone with neutropenia? Absolutely. So all invasive forms of examination should be discussed with the haematology registrar. And as a rule, the JMO should consider a PR exam as contraindicated in neutropenia, as well as implements such as a nasogastric tube or other indwelling catheters, although these should be discussed with the haematology registrar prior to application. Okay, so what are the common cause of infection in a hospital oncology patient or haematology patient? So with regards to a patient who's had chemotherapy, the most common source of infection tends to be the gut, which is a result of neutropenic colitis. And the organisms involved tend to be gram-negative organisms, which can cause septic shock very quickly. The other frequent source of infection is the skin and access lines. The patients within these two departments often have long-term access, which can be colonized with skin flora, which in an immunosuppressed individual such as themselves can be pathogenic and potentially cause septic shock. When you go see the patient, what investigation would you do? So after doing our history and examination the most obvious and important investigation would be to perform the blood culture and it's quite important to perform both peripheral and central blood cultures and if they have a triple lumen PICC line for example you would take a culture from each of the lumens. And the importance of this is to not only be more sensitive, it also can help determine the source of the infection if it's the access. So when you say central, you mean like a Hickman's? A Hickman's line, a central venous catheter, a peripherally inserted central catheter, portaca-catheter. There's several different types of access that these patients will have, all of which are ending up in the central venous system. Okay, so the blood coaxes, what other blood tests would you take? So if you already know they're neutropenic, that will dictate early empirical antibiotic therapy therapy but if this isn't known and it's suspected you would repeat the blood count and you'd also do a full range of tests not only for determining the source of the infection and the nature of the hemodynamic compromise you'd also do it as a baseline prior to starting antibiotic therapy. So you would want to know their renal function, their electrolytes, their liver function, their calcium, magnesium, phosphate, as well as in these patients, because of the risk of tumour lysis syndrome, you'd also perform a lactate dehydrogenase test and a uric acid test as well. Is there an indication for taking blood culture in someone who's already on antibiotics? Absolutely there is. These patients have the susceptibility to multiple infections and for example if they've been on antibiotics for three days and they haven't had a temperature for 48 hours and now they've spiked another temperature, it could very well be a different organism that isn't susceptible to that antibiotic. We'll talk about antibiotics, but would you start antibiotics just with a suspicion they have neutropenia or would you wait till the full blood count comes back to confirm neutropenia? In this situation, in this patient population, particularly if they're in the right time frame, of that beyond six days mark after chemotherapy, you would start empirical antibiotics, which can be stopped if you've determined they're not neutropenic. Okay, what's the choice of antibiotics that you would give this patient? |
Welcome to On The Wards, it's James Edwards and I'm here again speaking to the junior doctors of Australia and beyond. I guess I'd like to start off, this is a podcast in 2017 and we've made lots of changes for On The Wards with a new website and I'm really encouraged by how many people are visiting the website so I know we're doing something right. I think we're going to talk today about paediatrics and I have the pleasure of welcoming Dr Chris Elliott and Dr Kylie Yates. Welcome. Thanks James. They're both consult paediatricians at Teaching Hospitals here in Sydney and we're really going to go on to a topic of pediatrics, a fairly general one of how to assess a pediatric patient and I think when I consider looking after children I do find it daunting and I think junior look find it scary especially early in their career. I guess we've all been taught that children are not simply small adults, but how exactly does the assessment of a pediatric patient differ from that of an adult? So maybe I'll start. So what are some of the key differences for a junior doctor to consider when approaching an assessment of a pediatric patient? Thanks, James.. James, Dr Arjun Rao, who's an emergency physician colleague of ours, a paediatric emergency physician, has done a great On The Wards podcast about the approach to a sick child. So I really encourage people listening to this to go and have a listen to his podcast as well. And we're going to pick up a few of the themes that he touched on, but expand upon. So just to go back and remind people, you know, kids are different to adults. They're physically different. They're physically smaller. They have different kinds of injuries and drug doses. They're physiologically different. So, for example, they can maintain their blood pressure for a long time, even when they're critically unwell. it's a poor indicator of illness. They increase their heart rate. They have different kinds of conditions like bronchiolitis and croup, which tend not to affect adults. And they're psychologically different. And that's the pit that I want to really focus in on today because approaching children, recognizing the fear and uncertainty that they have in unfamiliar environments and understanding just some strategies to deal with that can make the world of difference for junior doctor's assessment. Now speaking for myself, I'm a consultant pediatrician with children and so I have a lot of experience with kids now but for most of my training I didn't have children and I really was baffled by this mystical child whispering ability that some people seem to possess and I spent a long time trying to break it down. And so one of the key messages that I want to convey today is that the skills to examine children are just skills. You can learn them. You can have a bag of tricks and I'll tell you some of my favorite ones today so that even if you're an awkward 20-something tall male who generally terrifies children, which is what I was as a junior doctor, you can get on to their level and have a really positive experience. I'm really excited to hear about how to be a child whisperer. I think that's a fantastic attribute to have. Well, I would like to dispel the notion of child whispering, actually, and just say you can be a great junior doctor. So for me right when you first approach a child and they're usually sitting with their parents you know children take all their initial cues from their parents and so we'll talk about it a bit later but addressing the parents concerns and building credibility with a parent is the fastest way to build credibility with a child. So when I enter a room, I might just ignore a child initially because they don't want my attention. That's what they're terrified of, the doctor paying them attention. So I might just speak directly to the parent. And if I can cut to the heart of what is worrying that parent, I can maybe sit down, demonstrate to the parent that I take their concerns seriously, that I have the time and the skills to manage their child, and that parent can start to feel comfortable in the interaction, then the child's going to pick up on that immediately. If I'm dismissive or combative or judgmental with the parent and that parent starts to become defensive and hostile, that kid's never going to allow you to do a thorough examination. So I'm there talking to a parent, taking history, why did you come to hospital and so on. And then I might just employ some non-verbal communication strategies. So it might just be a glance or a wave or a smile and then that's enough and go back to talking to the parents. It's like acknowledging that the child's there, you've seen them, they've seen you, but you don't need anything from them right now. They're still safe, they can sit with their parent in the bed and not have to engage with you. And if you do that over the first few minutes of the history, then you start to become someone who's part of the social group in the room, not a stranger, but part of the social group. And then it might come to the time when it's time to examine the child, right? And I think it's really important to recognize that because children are physically smaller than us, they're quite familiar with the idea that their personal space can be invaded without their consent, right? Because, you know, whether it's bigger kids in the playground who push them over or adults who pick them up and put them in the bath and they might tolerate that from a parent, or my children don't always tolerate that, but they might tolerate it from their parent, but they're not going to tolerate it from you. So you have to actually ask permission to enter their space. And that's not going to be talking permission. That's going to be non-verbal permission. So I have a few tricks which sound naff and can go, you know, don't work in all situations, but are generally good. So firstly, kids are usually wearing clothes that have brands or colours or logos on them, and you can often interact with them about something completely non-medical. I notice you've got a My Little Pony T-shirt on. I notice you're wearing Thomas or Spider-Man. How cool is that? And I even then particularly like to use an undermining strategy where I undermine myself. They might be wearing a Thomas T-shirt and I might go, wow, Lightning McQueen, how cool is that? Which is clearly wrong. And if you don't know what Lightning McQueen is, don't worry. You can pick anything from your own childhood that's clearly wrong. And if you're wrong and they're right and you can encourage them to say to you, that's wrong, doctor, this is Thomas. You've put them into a situation of control. And so I'll often undermine myself a couple of times. You know, look at those great blue shoes you're wearing. Are they really blue? No, sorry, they're pink, of course. So silly. Thanks for telling me what's right. I find the same thing works really well when you get to examining with a stethoscope. I often hold it and say, does it go on my nose? Does it go on my knees? And again, they think it's hilarious. No, it goes here and helpfully put it straight on the chest for you. Right. So I think, you know, it's kind of silly but with a purpose. So undermining yourself in a way that gives them control. And then if they've got a toy, it's a wonderful opportunity i might ask them straight up why did you bring your toy yeah what's their name and even if they don't respond to you which they often won't because they're too scared they might look at the toy they might be prepared for you to examine the toy and so you might say i really need to look inside their ears i wonder what we I wonder what we're going to find. Do you think we'll find lollies? You know, just really simple stuff like that and all of a sudden you can get them to help you. Could you hold the toy so I could look? Would you like to have a look in their ear? What do you see? And they're a part of it. Yeah. Is there, I mean, I'm sometimes concerned if I, you know, often come to the end of an exam and want to look in their throat, and you say, can I look in your throat? And they say no. Yeah. So just not ask the question. Yeah, I think avoiding asking a question where the no is not an answer you'll tolerate. And so, again, giving the kids some control, which is I need to look in your ears, I need to look in your throat. So I'll say, which ear should I look in first? |
And then they're closer, do you want to look in mum and dad's ears? And usually they'll warm up to it after that. Exactly. And so I talk about preparation, examining, and then like explanation or debrief, because it's really common for kids to become distressed. No matter how great your rapport building skills and how kind you are and how good of a person you are in your real life, not when you're examining sick children, they'll often cry and become upset during the examination. And, you know, it is a finely judged balance between being silly and building rapport and recognising when the role of that opening explanation is finished and actually you need to do the examination part as a medical professional because at the end of the day, family have brought the child to you for a medical assessment. So that's okay if you get stuck in a situation where you can't bond with a child and you have to just examine them while they're crying. So that might be auscultating their back while they're cuddled into their parents, which is a great way to listen to the back of the chest. They might be looking in their throat while they're crying. That might be having the parent hold them tightly while you look in their ears. And that's a particular skill which isn't well suited to a podcast, but which someone can demonstrate to you how you have the child sit on their lap and the parent hold them tightly. That's okay. Get your examinations done. And then at the end, finish off with an explanation for the child. So I always think it's important to frame distress as a sign of courage. And I'll often say for the older kids, you can't be brave unless you're afraid. So being brave, if you're not afraid, is not a thing. And what you just, you're obviously afraid of that and you did it anyway. That means you're really brave, basically like a superhero. Like not your mum and dad, not me. You're the superhero in the room. What a great job you've done. And for the littler kids, it might be just like a well done or even reframing it for the parents so that the parents can use your language at a later point. And I think, again, that's a really important way of accessing children is through the parents. So I might give them the words, what a great job, you know, Danielle did. You know, make sure when I leave you give them a big hug and a reward. Definitely a treat is in order, you know, and then the parents can do that later and that might just make the child process the experience in a way that's a bit more positive. Yeah, and helping them hold on to the bits that they did well rather than often the parents will get embarrassed and frustrated and, oh, come on, you know, and giving the child permission that it's OK to be scared and it'll be over soon and you did well for the bits that you let me do. Well, I think why don't we go to a case and then from there we can expand on some of the, I guess, the comments and tips you've already provided. And we'll go to a two-year-old girl who was brought to the emergency department by her father with a three-day history of a cough, runny nose and some fevers, bit off their food, and dad thinks maybe passing some less urine than normal. The father's worried and, you know, quite rightly feels a bit anxious about what could be going wrong. So maybe just outline your initial approach to this young two-year-old girl. So again, I think Arjun's podcast goes through the whole assessment of a sick child in some detail. It's great. But just briefly, so I have two parts to my initial assessment. So there's always airway, breathing, circulation, disability. That's your standard primary survey for any resuscitation. So she's coughing, so she's got an airway. She's breathing. I can make an assessment whether I think she's having difficulty breathing or not, and I might use some objective measures like respiratory rate and saturations. Her circulation relating to her heart rate, capillary refill, blood pressure, recognising that's a late sign if it goes down, and disability. So that's just, I guess, an assessment of how engaged and interested she is. But then actually most children you see pass ABCD, that in the primary survey quite easily. And so I do then a second ABCD, which is about toxicity. So are they likely to be septic or not? And that ABCD is activity, breathing, color, and drinking. So activity, breathing, color, and drinking. And there's a tool that I use myself, I teach my junior staff, I even teach to parents. Because if their activity is grisly, irritable, or their normal selves, then that's better than if they're lethargic, unresponsive, really not interested in the things that they would normally be interested in in this day and age, usually like iPads or smartphones. Breathing is, from the end of the bed assessment that a parent can do, do you think your child has trouble breathing? If you think they have trouble breathing, then that's really important. Even if their obs are normal, that's a really important sign that they could be sicker than you think, and that would be particularly relevant in this case. Colour is straight up and down. You can be flushed and red, you can be sweaty and miserable, but if you're blue around the lips or tongue, that's a really serious sign, sign and you've got to take that seriously it's a reason to come to hospital if you're at home it's a reasonable reason to have another close look if you're in hospital when you talk about color one thing i often find difficult is that kind of mottling you know some especially winter it's cold you know and they sometimes look a bit mottled and um but they look otherwise well, I find... Any tips on mottling? Yeah, absolutely. I actually find asking their parents, is this normal for them? Are they always like this or is this different? And you're absolutely right, a lot of neonates or young babies look a bit like that and the parents are usually able to say, no, no, that's new or, oh, yeah, he's always a bit like that when I put him in the bath. And the same with pallor, that kids come in all different colours. I don't know what they were like yesterday. And so the parents can tell you, no, no, this is pale for them and that makes a big difference to me. I think exactly right. The point of these sort of end-of-bed initial assessments are just a triage level of concern. None of these in isolation are sufficient to say yes or no. And I think modelling and P power are really good ones. So if you see them, then you've got to go further. And it would be to something objective like a set of odds, heart rate, respiratory rate, and probably measured over time based on the context of the child and their history. So in and of itself, it's not enough, but it's a trigger to look further. And then the one that I find particularly useful in the activity, breathing, color, drinking algorithm is drinking. And quite simply, it means that if you can drink at least half of what you normally would and pass urine at least three or four times a day, then you're safe enough, you're not dangerously dehydrated and you're safe enough to be at home. And the flip side, of course, is if you can't drink at least half of what you normally would and you can't pass urine three or four times a day then you're probably not safe enough to be at home and we should be thinking about ways to augment your oral intake. And so the two systems that are particularly important in this case are obviously respiratory examination and a hydration exam. And I think all the things that I spoke about earlier about building rapport and settling the child and approaching them with the stethoscope are valid for the respiratory exam and obviously as all exams, you want to expose the area. So a two-year-old's really going to worry about having their T-shirt taken off, and that's terribly important. You're going to want to, you know, inspect palpate, percarsus, and auscultate, like we do for all exams. And particularly for this child, we're looking for signs of increased work of breathing or accessory muscle use. So tracheal tag or suprasternal recession, intercostal recession, subcostal recession, expiratory grunts, nasal flaring, head bobbing in the littler kids, and then collating that with your observations, particularly your respiratory and your saturations. |
And we might call them 3%, 5% or 10% dehydrated. And that's probably a great topic for another podcast, James, if you can find another pediatrician to come in and talk about it. But, you know, we are looking at things about how much they've had to drink, whether their mucous membranes are dry, whether they can produce tears, whether their eyes are sunken, what their urine output is like, and if they've been weighed recently, and often they have been in the course of an illness. So this child's had a three-day illness. They might have gone to their GP on day one or day two and had a weight there. We can weigh them again, and that gives us some idea about what percentage of body weight they've lost. So I think that those are the two systems that I'd examine here. And always in my mind, I'm thinking, what's this likely to be? And what's really serious for me not to miss? So this kid, a two-year-old child with a fever, a cough and rhinorrhea, they probably either have a cold, the flu, bronchiolitis and it may not be that bad. That would be common wintertime presentation. But we really don't want to miss those kids with severe bronchiolitis who need oxygen or fluid support or kids with pneumonia who need antibiotics either in hospital or out of hospital. And so I always think what's it likely to be? What mustn't I miss? And what's rational? What's reasonable for me to do to make sure I don't miss those important things? And really, it all comes down to history and examination. Investigations don't have nearly as big a role in children as they do in adults. Do you ever kind of set examination order, kind of examine the chest first while they're quiet and go through, or is it really fairly intuitive, whatever happens? Unlike in adults where you might be sort of taught a very set structure, in kids it's much more important to be opportunistic. And so with the things Chris said before about rapport building, if they're cuddled up to their parents' chest, that's a great time to listen to their back. You mightn't listen to the front until they happen to turn around and do something else. So, yeah, much more opportunistic. And it's always tricky. Sometimes listening to the back is great because the kids aren't really aware and that's easy. And sometimes it's very threatening because the kids don't like to let you out of their sight. So sometimes you need a lot of permission to examine the front of their chest and listen to their heart because you're right up in their face, whereas sometimes they're okay with that because they can watch you and if you approach in a cautious and gentle way, and I think that's really about individualising your approach and making it opportunistic. But generally, I think we touched on this earlier, I mean generally I look at their ears and the throat at the end because you basically cash in all your credibility, trash it and you just want to be able to walk away with it and say, well done, you were very brave. And a much younger baby, like a very young baby who's obviously going to have less fear, you know, if they're asleep, then rather than undressing them completely, try and examine as much as you can with them settled and then leave the things where you've got to undress them until the end. Any other kind of tips and tricks on examination to try and improve your ability to get great examination findings and get the most out of your examination? I think it's working out how much you can do without touching the child. As Chris was saying, a lot of the information we get, we're relying on the parents. So while you're talking to the parents, it's not threatening you. You've still got a little eye on what the kids are doing. And so that will give you a lot of information about their work of breathing, about their colour, about their level of interaction. And I find that 10 minutes I've been talking to the family, I've got a lot of background information on the kids' examination already. Are there any suggestions or good props to have to try and help with the examination? I think something that whatever the kids have brought with them, obviously. And I confess I find it's not practical to carry too much around with me all the time. And I have the luxury of having a clinic where I can have toys available. But if you're in emergency, you mightn't have stuff with you. Torches are quite popular. Bubbles, of course. But yeah, it's something the kids are happy with. So it's usually their own toys work better. Yeah, I've moved from a high prop environment to a low prop environment as I've become more confident and experienced. So I used to really carry, you know, bubbles, maybe some stickers. You know, you could always just give kids lots of stickers for whatever that they've done and you can buy them at the $2 shop and that's totally fine. But I must confess that now it's about using the things they brought and, of course,'t beat a smartphone yep parents will have their own smartphone I'll just say what could you put their favorite whatever on yeah and you know and and so I've done that for a long time and then last year one of my children had an operation and I was stunned that the anaesthetist came out into the waiting room and my son was anxious but very brave and she just carried ahead of her her own smartphone playing Peppa Pig and he just followed it into the anaesthetic bay, sat on the thing and went to sleep without even blinking. He was so happy to be locked into something familiar and friendly that he wanted it and it was great. And so now I do that a lot myself, I think. And kids watch videos of themselves that their parents have. Even if you don't have an internet connection, there's always something to look at for a few minutes while you examine them. And it's absolutely stunning how much information you can get from simply observing children if you know what to look for. Because there's a lot of difference, obviously, between looking and seeing. And seeing and so you know really keeping that a b c d whether it's airway breathing circulation or activity breathing color drinking in your mind will help you focus on your observations and then come away with useful information otherwise you tend to hear a lot of people say um they're sort of sitting on their lap sort of just like looking around and that's not as helpful as saying different to well actually when the child heard the name mentioned they turn to look to see what we were talking about or they heard something else outside and they responded to it or I heard the parents talk to the child and they didn't react at all it's quite different when the parents pulled up the peppa pig they sort of turned their eyes but they made no other acknowledgement and they made no attempt to restart the video when it finished. That's telling because most of these kids are highly tech savvy. That's completely different to a kid who's taking it off and moving it around and engaging, right? There's a qualitative difference into the level of activity and you get all of that just by observing. We'll go on to communication at a later stage, but I think especially as Peter Hitchens over the phone, if you've got someone experienced out there and he says the child looks well, you could probably... But I think if a junior doctor says, look, well, I haven't seen many children, you'd probably prefer more detailed actual comments on their behaviour and then you could probably make a better assessment. Yeah, and that's when some more background information is said. Using the structure like Chris has given, including the vital signs, the observations can be really useful, and so then that helps me form a picture over the phone and even a description of exactly what they're doing. Okay, we've kind of gone through examination. We're going to move to investigations. In this case, you've had a chat to the paediatricianian or the ED physician you decide you do need some investigations. Any tips on I guess what investigations you would probably do with a child like this and any ideas on how to best achieve and get those investigations done? That's always a challenge. I still like Chris said I remember being an intern in emergency and being told a child needed a cannula and being completely horrified by the prospect. But it's about making sure that you've got the right support around you and planning beforehand so you get as much as your organisation done before you get the child into the room, preferably taking the child to a separate space so that their bed remains a safe space and nasty things happen in other places. And I think it's about being honest with both the child and the parent about what's going to happen. |
It might be uncomfortable and here's some things you can do. So giving the child some power over it. And then again all, all the distraction things we talked about before, thinking about which of those distraction things you can use to keep the child comfortable. So smartphones are fantastic, thinking about how you position the child for procedures. Classically, you see a lot of children are sort of wrapped up and held on the bed, which is a very disempowering position for them, whereas most children probably prefer to be cuddled and think about how creative you can be if the child's being cuddled, facing their parents with the arm out under the parent's arm so you're actually behind the parent. Sometimes that works. It's a bit more awkward for you, but it might help the kids a lot with that. And then talking them through what's going to happen, giving them a little bit of power of, okay, do you want to count to three before I start or control the things that they can control. That's right. I think the key, I guess, message that I always remember is that being traumatised comes from being out of control. So resilience is built when you go through an experience where it's sufficiently appropriately graded to your ability to tolerate it and you can put it in some context and you can understand it and that builds resilience. When things are foist upon you unexpectedly that far outweigh your ability to contain them and then you're kind of left with no context, that's when you get traumatized. And I think as junior doctor, I was very focused on my boss wants a full blood count and a blood culture. That's my job. And as a pediatrician, I recognize that the kids who are wrapped and held the first time they come to an emergency get harder and harder and harder to investigate, examine everything because they've been traumatized and quite rightly they don't trust anyone. So the two take-homes I have for investigations in children, particularly to have blood investigations and cannulas, are about control and context. There's a great algorithm or mnemonic called One Voice and there's a resource which we'll put at the end of the podcast on the website. And it's One Voice for Kids. And this is developed by a nurse who's come up with this really great way just to remember what's involved in helping children survive investigations in the kindest possible way. So it's O-N-E-V-O-I-C-E. And you't have to remember it because it's on the website but I'll just take you through the elements of it, right? So O for one voice. So you'll often see whether it's in emergencies or investigations or blood taking or even deliveries that there are six people talking at the one person all at the same time. People going, it's going to be fine. Just keep going. Where's the tonic? And it's chaos. And it's very distracting, disorienting and upsetting. So just one voice. It's usually the clinician, but it could be the parent if they're the one talking to the child, reading a story, talking about them, but without lots of babble and auditory confusion. So one voice happening during the procedure. You need parental involvement, right? The overwhelming, and I remember this too, the overwhelming inclination is to ask the parents to leave, hold the kid down, do what needs to be done, protect your own ego from embarrassment and fear. Pretend it never happened. Pretend it never happened. But there's really good evidence that having the parents involved, even if you fail the cannula or don't get the blood, is a more positive outcome for them and for their child. And then ultimately that means it's more positive for you because they're much less likely to be defensive, anxious, worried or whatever. And so it does put more pressure on the clinician to behave in a calm, professional way. But that's probably not a bad thing. That is a standard we should all aspire to anyway. And I think that comes really important about the truth. And the truth is hard because it's scary, but it's also very liberating in a way. So if you say to a child, this is going to hurt, a bit like when you fall over and scratch your knee, but it's only going to last 30 seconds and then it's going to feel okay, that gives you much more credibility and gives them the context to avoid trauma than if you say, it's probably going to be fine, don't worry about it. And then it hurts. And then they think, what on earth was that? I can't trust this joker. So I think being honest and having the parents there usually keeps you honest because there's no secrets. And I like giving the kids strategies for it's going to hurt, but here's some things you can do to help. So if you hold your hand really still, that really helps me. It might mean it hurts less. Yeah, and I'll often say, I'm going to do it on the count of three. So I'm going to say one, two, three, and then I want you to take a big breath in, and that's when the scratch happens. So I don't know we talk about needles and pain and blood. I might talk about scratches and sharp, you know, and I'll often, for having a cannula, for example, I'll get a cannula or I'll take the needle and throw it away and just show them the plastic straw bit. And I can show them, look, it's soft, it's flexible. You can hold that for me. we're going to have a straw in your hand, it's like a drinking straw, like a milkshake or a soft drink, we're going to use it to give great medicine to you and so that's about, that's the third part of One Voice which is educating the patient, so showing it to them. So we're going to put a drinking straw in your hand, there's going to be a scratch, it only lasts for a few seconds and then it's going to feel okay, we're going to put your hand on a pillow and we're going to tape it down so your hand's nice and relaxed and we can give all the good medicine that's going to make you feel better and if you show them the pillow and you show them the cannula and you and you don't lie to them about how much it's going to hurt or how long it's going to take then then they can process that and the next time you come back to do bloods or spree up the cannula it's much easier i think really matters. And is there an age group that you maybe don't do that the younger they are or do you just tend to do it to all and if they don't understand it, then you haven't really lost too much? I think even babies are still going to benefit from their parents' presence. I mean, neonates still feel pain and so we need to manage their pain as well. I suppose the very young baby then being held by the parent might be more difficult and but you know still thinking about using things like breastfeeding during procedures or certainly sucrose is important yeah and I'll think about the education oh yes okay I agree with you so a newborn baby doesn't care yeah a milkshake straw and you talkhake straw, and you talk about pillows, but the parents will. Right? And remembering that parent children, even newborn babies, take their cues from their parents. If you can show the parents what's going to happen, because, you know, a five-year-old is, you know, a parental relationship with a five-year-old is a bit more complex than it is with a baby. I mean, parents of newborn babies or young babies, they live their baby's lives, things that happen to them that they feel themselves. And so you can, it's still a great reason to show the parent what's going to happen, even use that language. And yeah, again, there's really, I agree with Kylie, there's great evidence to show we underestimate the pain that newborns feel and we tend to dismiss it. And that's not right. So still going through this procedure i think is terribly important so then very quickly that the rest of the the one voice algorithm talks about validating the child with words or the parent we've talked about that i i'll often say parents um it's really unpleasant like great work i'm so glad you were here talking to your child that made the world of difference you know so even if they're too young too young or, as we said, you know, that was really brave, nice work. Offer a comfortable position. So exactly what Kylie talked about, things that we think will suit us, wrapping them and supine on a bed, pinned down by four nurses, doesn't really suit us for all the reasons we talked about, follow-on trauma, losing faith with the family, making it more difficult next time. |
Okay, I would like to welcome our listeners to our next podcast series and it's about the opiate dependent patient in hospital and we've got Jonathan Brett who's a advanced clinical pharmacologist and addiction specialist. Welcome Jonathan. Yeah, thank you for inviting me. So what we'll do is we'll start with some scenarios and I guess opiate dependence in hospitals seems to be much more common now. Obviously, ejecting drug use has always been an issue, but a lot more people come in with chronic pain to hospital. Indeed. So I think it's really relevant for junior doctors and I'm sure many of them have faced patients with chronic pain and on some medications. So let's say that we've got a patient who comes to hospital, they've gone to the ward and when you're doing their medications they mention they're on maintenance methadone but they haven't, you know, they're wanting, the nurse is wanting to prescribe that methadone. What are some of the practical things that you need to do before you can prescribe that methadone? Yeah thanks, this is, this can be a daunting area because these patients often have multiple and complex needs but it's often something that comes up quite early in the admission. So the first thing and always the thing to think about with these medications is medication safety. So you've got to be as safe as possible. So with people on methadone the two really important things you need to, or any substitution therapy, the two really important things you need to know is who is the prescriber and where do they get it dispensed and what are the most recent dispensing details. So I guess you can think about it as this happening in hours and this happening out of hours. So in hours, the best way to do it is to phone up the Pharmaceutical Services Branch, and there's a number available online for that. They have record of all authority prescriptions for methadone and buprenorphine, and they have records of the prescribers and where they have it dispensed as well and they'll be able to give you phone numbers for them. So then what you do is you phone up either the prescriber or where they get it dispensed which is usually either a public clinic or private clinic or a pharmacy and get the most recent dispensing history so the last five to seven days you really want, in particular the last dose. And that will help you decide on what dose of methadone you can prescribe. Now ideally, we'd like that done in consultation with drug health services, and that may be the clinical nurse consultant or it may be the registrar on call. After hours is a lot more tricky. I suppose we like to believe the patient, but thinking of safety first, you're in a tricky situation if you can't get in touch with either the place where they have it dispensed or their prescriber. So the situation we're left with there is to really go on clinical features of withdrawal. So what we do then is start them on a withdrawal scale, which we'll discuss I think in a moment, and then dose methadone or buprenorphine based on clinical features, objective clinical features of withdrawal. And a typical thing we may do is say something like if you have a clinical opiate withdrawal scale score of six or greater, then usually you get about 20 milligrams of methadone or up to four milligrams of buprenorphine as a start dose. All of that after hours should definitely be done in consultation with drug health services or addiction services. Okay, so we've got someone who can give a dose of oral methadone, but say they come with pancreatitis or some surgical problem that they can't have oral methadone. What kind of analgesic strategy would you suggest? Yeah, so these, a big problem in this group of patients is often under treatment of acute pain because of the worry of, you know, fueling opiate dependence or whatever. And I think we've got to be really conscious of that. So I would say that you shouldn't withhold intravenous morphine or even a morphine PCA in these patients who are clearly in acute pain. And you can do that if you only anticipate them being nil by mouth for a shorter period of time, so 24 to 48 hours. If you suspect they're going to be nil by for longer than that there are parenteral ways of giving methadone. You can give it IM or subcut. But that has to be done through pharmacy and also through drug health because it's not exactly equivalent to the oral dose so you really need to get some specialist advice if you're going to do that. The beauty of buprenorphine is it's a sublingual medication, so even if you are nil by mouth, you can still have buprenorphine sublingually. And regardless of whether you're in acute pain or not, the dose of that really shouldn't change, you shouldn't stop that. And I think we're going to discuss that in a second. Okay, so we've got another scenario. In regard to say a patient gets admitted with infective endocarditis, they've got a history of injective drug use and heroin use, and the patient seems agitated and wants to discharge himself from hospital, and some of the nurses can say they may have opiate withdrawal. What are some of the clinical features of opiate withdrawal? Yeah so this is a really good question I think it's something that junior doctors encounter a lot and have to deal with. So thankfully there are some objective measures and some scales you can use similar to the alcohol withdrawal scale and they are available on the wards and the one we use in our hospital is the clinical opiate withdrawal scale and that's a scale that includes things including heart rate, sweating, restlessness, pupil size, joints, bone aches, GI upsets, things like diarrhea, tremor, yawning, and irritability and goose pimples. And yeah, you'll see on the scale that it's rated mild, moderate, and severe depending on what score you get. So it's not exactly like the AWS in that we can then determine exactly what dose of methadone and buprenorphine they should be getting. Really, that should be done in consultation with drug health services. But a safe dose of methadone to start on is 20 to 30 milligrams if there's features, objective objective features of at least mild to moderate withdrawal. And buprenorphine, it's a bit more complicated because you have to figure out how recently they used opiates. But if they have clinical features of withdrawal, then it's usually safe to give a two milligram test dose just to make sure you're not precipitating withdrawal and then to give another four to six milligrams after that, about an hour after that. Okay. So when do they start developing symptoms and signs of opiate withdrawal? Yeah, so that's a good question as well. So that really depends on the opiate they've been misusing and the half-life of that. So, for example, if they've been injecting methadone or OxyContin, that has a much longer half-life. So methadone, for example, has a very variable half-life as well, but people may not go into withdrawal until 24 to 36 hours after they stop taking it. With OxyContin, again, 12 hour half-life, so you expect withdrawal symptoms around that mark. With fentanyl, which we're seeing more and more abuse of, the half-life's much shorter, and people get very severe withdrawal with that. And you may see withdrawal within hours of the last dose used. So how do you decide between giving them methadone and ripponorphine for someone who's similar to this case in hospital? Yeah, good question. So it depends on a number of things. As always, you want to have the patient involved with the decision. And so often they will come with some kind of prior knowledge of one or the other, and you find some people are really adverse to one or the other. So it's really important to ask them what they want first. This is talking from a drug health perspective. The second consideration really is ease of starting it. So people where it's unclear how recently they had an opiate, opioids I should say, then methadone is probably a bit safer to start because you're not going to precipitate withdrawal because it's just an agonist. With buprenorphine, because it's a partial agonist and it has a very high affinity for receptors, what you can do if there's opioids already in the system, you can displace the opioids from the opioid receptor by the buprenorphine binding and that can precipitate withdrawal. So if there's any worry that there's any opioids hanging around from previous use, you've got to wait until they're out of the system and the patient's in significant withdrawal before you can really start that. |
Methadone's probably slightly more effective for the users that are very heavy users or very unstable socially, psychiatrically or medically. Buprenorphine is preferred by some people because it's more flexible, so you can do things like second daily dosing because it has such a long half-life. And it's much, it's probably much safer in overdose because of the dose-sealing effect. Okay, and what that means is because it's a partial agonist, you get to a point where no matter how much you take, all the receptors are occupied and you have maximal effect. So, you know, even if you take more, you can't get more effect and more toxicity. So in patients who are at risk of overdose, we would prefer buprenorphine probably. Okay. Are there any other problems with buprenorphine? Are there any other concerns about, say, co-prescribing things like benzodiazepines with buprenorphine? So not as much as probably methadone. Buprenorphine is quite safe. The only theoretical concern is the issue of management of acute pain when a patient's taking buprenorphine. Okay, we may go on to ask that. So what about someone who's on buprenorphine and so they come with acute pain from a fractured tibia? Yeah, yeah. Again, another quite common scenario. So what we used to do was we used to be really worried about the buprenorphine blocking the action of any morphine or short-acting opioids that we would give the patient. And we used to stop the buprenorphine. What we're seeing now, actually, from very recent trials, is that if you compare the group of patients on methadone and buprenorphine, and you continue it throughout the acute pain episode, their analgesic requirements are exactly the same. They're not significantly different. So what we recommend doing now is, if they're on buprenorphine, continuing the buprenorphine, but just giving larger than normal doses of short-acting opiates like, you know, IV morphine and so on. Now, the other important thing I must say and people must never forget is to think about non-opiates, analgesia, and people with acute pain. So these are often very effective. So simple things like paracetamol and a non-steroidal anti-inflammatory like ibuprofen or napritin or something like that. That's definitely one of the first things I would think about doing because that's going to act via a different pathway of analgesia. So that's really, really important. So you mentioned you may need increasing doses of morphine when someone's on buprenorphine, and that's because they've got tolerance? Yes, exactly. So they've got tolerance, and they've actually got a degree of receptor occupancy of the methadone and buprenorphine. So getting the opiates in there, you need a higher dose to overcome that competitive effect of the methadone or buprenorphine. Now, it's a bit of a puzzle why, because buprenorphine binds so tightly to the receptors, it's a bit of a puzzle why we can't actually achieve good analgesia with IV morphine. And it may be for some complicated reasons, such as different downstream receptor effects from buprenorphine compared to other opiates. But the jury's still out on that. So what's the difference between, we mentioned tolerance, but there's also addiction. What's the difference between tolerance and addiction? Yeah, good. So tolerance is a feature of addiction. The other word I guess we use for addiction is dependence. And that's probably the term that's used more in DSM-IV, certainly. They're starting to use the word addiction more in DSM-V, which is the new diagnostic criteria. But yeah, so dependence is you need to meet at least three of the seven criteria, of which includes tolerance, withdrawal, salience, so focusing on the drug to the detriment of everything else, continuing to use the drug despite you know physical, psychiatric, social harms and I think that yeah that sort of covers most of it. So tolerance is just a feature of that and tolerance is probably a composite. We just figure out really what tolerance is and it's probably to do with fact that you have, your body tries to adjust to the opiates being around by down-regulating opiate receptors, but also up-regulating the stress part of the brain. So the glutamate system and the NMDA receptor system. so yeah that's that's why you get tolerance okay I guess we occasionally see complications from the long term opiates of people on for say chronic pain and maybe a case that came into hospital not not a fairly recently so it was on 5-step down 20 milligrams three times a day for chronic pain. They had a chest infection, admitted to hospital, and one of the JMOs was asked to see them after hours and they were drowsy. So, I mean, I think this is, the way you'd approach this patient is the way you'd approach any patient on the ward. That would be to do airway breathing circulation and to determine whether they had any immediate resuscitation needs. It's always worrying in this case for people on these long-acting opioids and I guess what you want to know is are there any features of opioid toxicity. It may of course be related to a deterioration in underlying medical conditions such as chest infection but certainly you'll be able to tell that from doing basic observations as well as an examination. But features of opioid toxicity you're looking for in particular are small pupils and decreased respiratory rate. So we see this happen sometimes when patients come into a hospital and they're on a dose of methadone, biseptone, which is the oral tablet version of methadone, where they may not have been taking what we thought they were taking before they came in. And then we restart the medications as we understand this. But that's often much more than they used to, and they don't have the tolerance to be able to deal with that medication. So the important thing to know about methadone and fiseptone, which is the same thing, is that it has a very long half-life, but it's also very variable. So often we don't see the peak effects of a dose adjustment until about two to three days after that's occurred. So often when patients are starting on methadone, you don't see the toxicity until about two to three days afterwards. So it may be that this patient, and it sounds quite familiar, that this patient hasn't been taking what he's been prescribed at home and then has come in and a couple of days down the track has got opioid toxicity from the methadone because of the long half-life. So what you do to treat that is firstly to recognise it, secondly to try and reverse it with naloxone. Would you like me to go into the details of that? Yeah, maybe just some naloxone and how we would reverse it. Yeah, so the two things to know about naloxone is it's different if you're reversing someone who's opioid-naive to someone who's opioid-tolerant. So if they're opioid're opioid naive, you can go for complete reversal, in which case you might give 400 to 800 micrograms IV. The only risk there is if they're hypercapnic, so if they've got high CO2 and they have some other reasons to have cardiac problems, you may precipitate an arrhythmia. And that's sometimes what we see in kind of older people with cardiac disease, particularly if they've got high CO2. If they're opioid tolerant, then what you have to do is really ideally titrate the naloxone in slowly so you don't precipitate a horrible withdrawal. And usually what we do is we put 400 micrograms in a 20 ml syringe with normal saline and titrate just a couple of mls at a time and wait five minutes between them. The exception to that is life-threatening toxicity, so whether the peri-arrest, in which case you give a lot more a lot quicker. And for this person who's on something slow acting like methadone, just giving some boluses, they may wake up, but there's obviously a concern that they may require an infusion. That's absolutely right. So long acting opioids like methadone, OxyContin, MS-Contin, so on, MS-Mono, often they'll need a naloxone infusion. And a good rule of thumb with that is, so it always should occur in either HD or ICU. So by this point, you're really wanting to get some more critical care involvement. But a good rule of thumb is to start the dose per hour at two-thirds of the dose that are required for reversal of their malcosis. |
Welcome to On The Water, Jules Wilcox here again. This podcast was created in conjunction with our sponsor Global Medics, your career solutions recruitment specialist in permanent and local medical jobs across Australia, New Zealand, United Kingdom and Ireland. Today we're speaking with Dr. Hina Moa Elder, a leading New Zealand child and adolescent psychiatrist and author of two best-selling books. Today we're speaking about racism and institutional issues with medicine and various other aspects of societal norms and pressures that we touched on in the last podcast. All the themes discussed in her first book, Aroha. Hinamau Elda is Ngati Kuri, Te Rarawa, Te Opuri and Ngapuhui. She is a New Zealand child and adolescent psychiatrist and a fellow of the Royal Australasian and New Zealand College of Psychiatrists and works at Starships Children's Hospital in Auckland. And she's a deputy psychiatry member of New Zealand Mental Health Review Tribunal. She has a PhD in public health as well. She has received the Member of New Zealand Medal for Services to Maori and Psychiatry in 2019, and she's an invited member of the Bussara Circle, which is a group of senior international women leaders, which forms a critical support for the Homeward Bound Project, a global leadership programme for women in science. She's a board member of the Howard Clark Foundation, a non-profit, non-partisan public policy think tank, which generates public research and debate and a board member of the RANZCP Foundation. And she's also the patron of Share My Super, a charity aimed at ending child poverty in New Zealand. She's written two best-selling books published by Penguin Random House, Aroha, Maori Wisdom for a Contented Life Lived in Harmony with Our Planet. And that was named on the Oprah Winfrey book club in 2021. Wawata, Daily Wisdom Guide by Hina the Maori Moon was the number one best-selling non-fiction book in New Zealand and currently number three. She is also regularly invited to keynote presentations. Hinema also has a background in theatre and dance. She performed at the Edinburgh Festival as a past chair of the Auckland Theatre Company Trust and the inaugural chair of Te Tā Mata and Iwi Arts Foundation. Hinemoa also worked in New Zealand's children's television in the early 1990s as well. So Hinemoa, kia ora, welcome back again. Kia ora, lovely to be back Giles. Nga mihi nui kia koutou katoa. Thank you so much. So I really enjoyed our last conversation about well-being and how we can try and look after ourselves. But at the end of the day, we're also trying to look after patients. And I read a report that came out recently, and I don't have the report, but I'm sure you're aware of it, saying that despite all of the advances in medical care, despite all of the things, Maori are referred less for tests for tests less for treatments and their health outcomes are significantly worse in New Zealand which in this day and age is quite shocking and I thought we could talk about that and perhaps why that might be happening in the effects of colonization and systemic racism because that's a subject which is certainly present in Australia. I work in Alice Springs now, and the difference in life and spectancies between Indigenous patients and Caucasian or non-Indigenous patients here is in the region of something like 20 years. It's quite staggering. So, yeah, perhaps we could just start off with that and your thoughts. Sure. It's lovely to be back. And to talk about some of these nitty-gritty issues that actually impact on us on a daily basis. So one of the salutary experiences I remember from being a medical student was the number of doctors that were coming to Aotearoa New Zealand to see children with acute rheumatic fever and rheumatic heart disease. They had never seen cases like that in the UK or in the US, in Germany, and yet here in Aotearoa New Zealand, they would come to learn about these conditions. Sadly, 30 years or so down the track, I was reading just this morning that we continue to have between 40 and 80 times more rheumatic heart disease in Māori and Pacific children than in the non-Māori, non-Pacific community. And that is because this, in part, the authors of this report were saying because of racist contracting, which is a barrier to all the confluence of all the things that need to happen together changing. So it's an illness of poor housing, overcrowding and poverty. And when we don't, we've got lots of research about this condition here, but we haven't had a robust mechanism for all that evidence to come together and make a difference for our children's lives and their families' lives. We have exactly the same problem here as well. It's absolutely heartbreaking. I see rheumatic fever every week. We have 400 rheumatic fever patients in our caption area. We have a population of 27,000. And then the out-of-line communities. We have higher rates than India and Africa and things. It's quite unbelievable. Yeah, same. Same here. And it should be a national disgrace. It absolutely is. And yet, and we've had great advocates saying this for years I remember since medical school and what's changed so I think what you know I could give you other examples from mental health for example Maori compared to non-Maori who are treated under compulsory treatment orders Maori are much more likely to be treated in that way and in fact under indefinite orders we're much more highly likely to be treated in that way with the same severity of illness so there's all sorts of ways that racism plays out in in healthcare systems there's there's an enormous body of literature from all around the world which articulates very clearly the the healthcare user experience of racism, the team's experiences, the importance of anti-racist training. We also know that there's a lack of organisational support in managing racism. In general, there's a racial bias that, you know, healthcare systems tend to think about our healthcare as impartial. So we don't always discuss racism in the workforce. So we need to change that. One of the things that's happening here, as you may know, is we've had a major restructure of our health system, which really kicked off in the middle of last year. And so we have a Maoriori health authority called Te Aka Whaiora, and that's a really key structural element to leading, monitoring, this kind of transformational change that we need to create the differences that you've touched on and similar for Indigenous peoples all over the world. We really need those mechanisms to be robust, the contracting to be different and to indigenise the health system itself. You know, the key job, I remember, is a registrar in the hospital. And, you know, the hospital is populated by lovely people who come to work every day who want to make a difference but there's something else that goes on there are all sorts of covert and overt messages to our Maori patients in their whānau that say basically leave your Maori stuff at the door pick it up on your way out we're not interested in anything about you as a human being we're just interested in your symptoms and your diagnosis and a very narrow biological approach and we all know that that is not the way that contemporary medicine needs to be practiced that is so antiquated and is not fit for purpose yeah it's interesting isn't it there's a few things i'd like to try and touch on on there again going back to what we were talking about in the last that connectedness you can't treat a patient i wasn't with william also i think it was he said so it's not it's not important what sort of disease a person has it's what sort of person um has has the disease because you need to look at people's values and and what's important to them to be able to treat the whole person. And on other podcasts in the past, there's a book, which in addition to your book, I reckon everyone should read, is Compassionomics. And this is a literature review on the effects of compassion in healthcare. And there's one study in there where they looked at HIV compliance and so forth in America. And the question they asked was, do you feel that your physician knows you as a person? And if the answer was yes, because that physician treated them with compassion, took time to get to know them and so forth, the compliance was something like 30% higher in taking their medicines and their viral load was undetected. And the effect was just quite, quite incredible. And this is just something that we as doctors can do. This is not a pill. This is your approach to your patients. And I think I would imagine that in psychiatry, particularly that compassion, that listening is even more important potentially. |
How do you avoid labelling people? Like you say, there's so many covert things through medical school and through society. If you look at the Harvard Implicit Association test, which I recommend to my registrars, they all take it and do it because a lot of them are coming from places where they haven't seen Indigenous patients before. We now have 70% Indigenous patients, very different culture. Absolutely. So, you know, unless you know what your biases are, and interestingly, my wife, whose family is originally Pakistani, when she did it, I did it, she had a stronger preference for white than I did. But she grew up in Scotland, grew up being called a dirty Paki and being spat on when she was a child. So no wonder she wanted to be white. Yeah. It's complex, isn't it? It's very complex. We need to listen with really well-informed ears. I think that listening is an underrated skill and listening with the ears that have been informed by the histories of the original people of the land. And I think that is a missing piece in medical education is the historical and the politics of the histories of the lands where we work. As medics, we travel around the globe. We may end up working in different hemispheres. And so I think it's really important that we remember to listen in to the nuances of the people who are the original owners. So in the place we currently call Australia, you know, you've got hundreds of nations around Te Whenua Moi Moi Ya, as we call it, where the histories, the philosophies, the value systems are very different and unique. The languages are unique. doctors that come and work in Aotearoa New Zealand absolutely need to be au fait with the the at the very least the tiriti of Waitangi the history of colonization here and how that impacts in health and then how they can apply that practically on a daily basis these are not things that are some sort of theoretical nice to have kind of knowledge that you hold or that sits in a book on the shelf. This is knowledge that we operationalize as doctors every day. And actually, I wanted to touch on something that you mentioned there before about as doctors, we listen and we provide the psychosocial counselingselling because actually this brings in another layer that I think we need to talk about which is the differences between the genders. We know that female doctors face a whole lot of discrimination. We know that about 50% of our medical students have been sexually harassed by the time that they finish their medical training. That's an appalling statistic isn't it? It's absolutely unacceptable and we know that women doctors have been shown to be more likely to adhere to clinical guidelines, promote preventative care, use more patient-centered communication and provide more psychosocial counseling and in fact there's a really interesting JAMA internal medicine paper, which found that when they looked at more than a million hospitalisations, the 30-day mortality and readmission rates were much, much better for those that had women doctors. I saw that, yes. So, you know, I think on one hand, we've got a whole lot of discrimination going on for women doctors. We know that women who have babies during their training are discriminated against. There's all sorts of really interesting, troubling findings about the layers of discrimination that women doctors face. They're not put up for promotion, not given options, family-friendly options around training programs, not given the same kind of feedback and positive feedback, much less likely to be described with superlatives than male counterparts. And yet there's this other evidence that shows that female doctors are actually getting better outcomes. Yeah, absolutely. I was just, I got on my medical WhatsApp group thing, a friend of mine who I was in the anatomy study group with her in the first year. And she's a GP and she's a leader as a GP back in the UK. And she was saying, and there's a whole thread here about culture and, you know, bullying and stepping up and all sorts. And she said, with assertiveness, it's 200 times worse if you're a woman. We are always accused of being aggressive when we are stating our case. My conference feedback was that I should resign for telling someone to stop arguing with me from the floor whilst I was trying to chair a national conference. So it's going on at all levels and it's still going on. That was this morning. Yeah, I think it's trying to totally change the toxic culture. And how do we get over these biases? Well, you know, one of the things that I do, I'm interested in pursuing is why are our male colleagues not standing up for us more? And there was some interesting recent research in the BMJ last year. There was a review of 425 consultants, GPs, SMOs, looking at UK male doctors' perceptions of sexism. And what they found was that, so there was about half and half female to male in the study, but what they found was that male doctors were overestimating the representation of female doctors across a range of specialty areas, and that that overestimation actually predicted the fact that they were less willing to support gender-based initiatives. So I think we've got an opportunity here to get our male colleagues on board, educate our male colleagues, because we know that they're likely to have this bias and think, oh, well, there's no problem with gender disparities. There's no problem with gender bias. Of course, we know that women doctors also get paid less than male doctors in general. So we need to educate our male colleagues because our male colleagues don't see themselves as sexist. I think that they want to be good allies, but they just don't have the information. We need to make it socially unacceptable for our male colleagues to discriminate against us because they will have the evidence and they will have practice-based evidence of how brilliant their female colleagues are to work with. So I think we can create a fait accompli here for our male colleagues and get rid of that kind of toxic, biased way of thinking about female representation to the betterment of our patients as a whole. Yeah. I see when I hear these things, I think it's just that people seem to be scared or they feel like they're under threat. Maybe that's because deep down they know that they don't practice as well or they don't they've got some issues I don't know I don't see it smacks to me what are you going to be scared of why would we why would we not want this it seems like it would be a good a good thing it's an interesting it's an interesting one isn't it is it sort of crucible around different facets of life one of the areas that I've got really interested in lately is online misogyny. And so, you know, we recently, our prime minister stood down, resigned in part because of that kind of exposure. And the questions she had to deal with that a male prime minister would never have been asked. Exactly. And there's been a senior Scottish woman politicians also stood down. And I think in general, we know there's lots of good research coming out now showing that women in public life and women in general still face this absolutely disgusting online vitriol, which is very much targeted at us us as women and so my question is why what's stopping the male colleagues the male politicians for example in our prime minister's case from actually standing up and saying no no no this is unacceptable we've got to stop doing this as men we need to work on ourselves and prevent this make it make it absolutely unacceptable but I haven't seen that and I was interested in your views about what's what are the barriers for our men doing that and and preventing misogyny from happening online I think it needs to start at a very young age with education and role modelling. And I think there's a lack of a lot of that role modelling in society. If you look at our domestic violence rates here in Australia, they're horrendous. Women are killed every week in Australia. And for Indigenous women, it's much, much worse. We have the highest rates of domestic violence and exploitation in the world. And a lot of that is related to the effects of colonization and past traumas and the ongoing issues of poverty and health and loss of culture and so forth. And, you know, as you were saying, you've got the new Maori body now for health and that's so important. Well, this year we've got the voice happening and it's not even a definite that will go through that the First Nations people should be recognised in the constitution and that they should be engaged with for conversations about what happens to them. So we've got an awful long way to go over here. But I do think a lot of it is education. Like I think with racism as well, a lot of it's education. It's often that sort of, it's not my group. And so therefore it's a threat. |
I saw a quote the other day, which I quite like, which said that every time you hear an attack, you see an attack, it's a cry for help because actually they're scared and they're afraid. Not that I think many people would admit that, but I do think it comes from a sense of threat and that education is the way to go. And then, yes, you need to have role modeling. And one of the things I think that Jacinta Ardern was very good at was displaying empathy as well. I think we could do with more kindness in the world and more empathy. And I think if we had a journey, you know, the base, if we came from that basis of kindness and connectedness, going back to your book again, that would go a long way, I think, to including people and not discriminating. So I think it will take time because there's a lot of societal norms, so they're covert, I think, that people don't even realise. And to go back to the racism thing, I was curious as well in your journey, as you have been able to embrace your own Maori heritage more, have you become more aware of those covert racist structures, do you think? Because I think one of the problems for people like myself is from a dominant culture is not realising and not seeing how something might discriminate against somebody. And so trying to open up that awareness is also absolutely key for dismantling some of these racist structures. Is that something that you have found over the years? Oh, yes. I mean, racism, white privilege is ubiquitous. It's everywhere. And the fact that many white people, Pākehā people don't see it is evidence of that because it's designed in a way that Pākehā people, white people wouldn't see their privilege because that is their normal way of going around in the world. So look, it comes up all the time and, you think you're in a group of people who are aware and equipped to have difficult, awkward conversations about race. And you suddenly, you know, begin to realize, oh, there's a lot of sensitivities here. There are some things that the signaling is we can't really talk about that. That's a bit too hard. Don't go there. And I'm sure you've been in meetings where you can suddenly, you can sense the temperature in the room changes. And as doctors, I think we have a very particular responsibility to be sensitive to those things. We are advocates for the most vulnerable people in our societies. We have license to stand up for those people who haven't got the kind of voice that we have because we're doctors. And so I think the onus is really on us to understand the literature about racism and to understand the lived experience of racism of our patients and to find ways that we can feel confident and comfortable to talk about racism at work. We know that these sort of no-go zones are the way that those systems perpetuate themselves. So I do think that as doctors, we have a very particular role in recognizing the damage to their whole being, you know, the whole cultural, biopsychosocial, historical beings that we look after, that racism is damaging those people all the time. And it's part of our job to know about that. Yeah. Another great book, I don't know if you've read it, is The Body Keeps Score. We've heard of that one and about how the trauma then manifests in disease later on, which goes, and, you know, if you there's a fantastic ted talk by nadine burke harris about how the traumas of childhood then cause worse health outcomes later on in life and you know it is that isn't through no fault of the individual because it's very easy to blame people for things oh well this and that and so forth i think think i'd add one thing i think that we need to do and that everybody should do and particularly in australia is do you need to educate yourself about the history of what actually happened because what is taught in schools or has been taught in schools is getting better over but what has been taught in schools is is not a true history in general um and it's very much a dominant white culture story used to justify terra nullis because the terra nullis thing which is the land along to no one because to therefore take it you you have to justify that so that we don't classify the uh the people as people uh up until the 60s um and you don't give them rights or anything like that because you have to otherwise otherwise your whole basis for occupying that country is false. And so there's a whole history there which isn't taught in schools that well. And it's very interesting being in Alice now and talking to Indigenous patients and especially some of the older ones who've been, you know, grew up here since the 40s and so forth. And they've got stories of family members who were hunted and shot. And the statue of the guy who did it is still in Alice Springs. You know, that I think would have been torn down in most black lives matter protests around the world. It's still up here. And, you know, things like that. And you wonder why we still have some issues, you know. And going back to the national disgrace, you know, I can't remember the exact statistics, but I think it's something like if you have a chronic, subdued ear disease in your population of over 5%, the WHO says it should be treated as an emergency. We've got 40 to 50% rates in some of our communities. You know, again, that should be a national disgrace. Why isn't it? You know, it's almost as if there's a bit of poverty and the overcrowding and all these things which haven't been addressed for decades and decades and decades. We've had a lot of media presence on Alice Wings because of crime and other issues with alcohol and things. And unfortunately, the media has sort of sensed a stereotype and sensationalized things. But so they put in some alcohol bans, but that that hasn't that's not going to change the underlying problem of colonization dispossession poverty lack of investment for years and years and years and years you know we've got people living 20 people in two-bedroom house hence the rates of rheumatic fever which i see every week scabies you know higher than you see in africa and we see scabies every day multiple times times a day, but it's hard to treat things if you... That advice of, oh, you take all your bed sheets and you borrow them in the washing machine. What if you don't have a washing machine? So it's... You can actually just put them in a black plastic bag and leave them in the sun, but it's just those concepts that we have of how we are and how our health systems work and all that sort of stuff, you just have to radically change things and be open-minded. And there's so many issues. And it's heartbreaking when you say, as you say, we go into medicine to try and help people, and yet there seem to be these large government-type structures or historical structures that want to perpetuate these inequalities. Do you have any advice for women? Sorry, go on. No, I was just going to say, I think one of the issues too is, you know, Indigenous people, we need to be in charge of our own healthcare systems. And so often we are infantilised and have been infantilised intergenerationally with the idea that, oh, you know, we couldn't possibly sort out the problems which have been created by colonizing societies. So in fact, sometimes doctors, well-meaning doctors actually need to get out of the way and ensure that the succession plan for the local Aboriginal peoples, the local Māori communities, that that's in place because that's where the real solutions are going to come, the robust solutions that come from within those communities that are going to work. And that's what The Voice is about. It's like, you know, you've had all this money chucked at these problems over the years, decades, and the problems are worse than they were. So stop making up things in Canberra and maybe talk to the people who actually, you know, have to solve those problems. And I do hope that will happen. Just going back to the book again, I know a couple of the things that chapter 42 of these, where one chief disappears, another one is ready to appear. No one is indispensable. You indispensable you know just sort of getting back to that you know maybe step out of the way let some other leaders come through champion other leaders absolutely and I think that's a big part of what we do with our medical teams who are at different stages of their career is to champion them you know know, they are our retirement plan. They are our succession plan. And I want them to feel really good about what they're doing and really empowered and educated and challenged because we need them to be strong. |
Welcome to On The Wards, it's James Edwards and today we are talking straight mimics. I'd like to welcome back Dr. Catherine Spira. Welcome back, back Catherine. Thanks James. Catherine's a neurologist working at Prince of Wales Hospital also privately and stroke mimics is something that is concerning as an ED physician also I assume as a neurologist in that we do have lots of stroke calls, not all of them end up being strokes. So we'll talk through a case and then we'll try and bring up some of the pertinent points around stroke mimics and how common they are and how important they are to diagnose. A really interesting story of a 35-year-old G3P0 who was brought in at 25 weeks pregnancy with some left-sided weakness with an obvious facial droop. At the onset, there was a severe stabbing pain in the ear, which is now gone. Had a history of smoking whilst, but quit whilst trying to conceive, but has a TAMPAC here prior to that. But she's always interesting. Her first two pregnancies culminated miscarriage before weeks. And her father died of a stroke at 50. So you put lots of things, lots of things in this case. And what is your initial response when you hear this presentation, such as I called you over the phone? Okay. So concerning things are that this woman has had two pregnancy losses previously, which is sometimes a marker for thrombophilias and vasculitides. So that would be something that would be concerning. She's got other stroke risk factors in that she's got a history of smoking. She's pregnant, which is a prothrombotic state and also a state of increased vascular reactivity. But we're now finding that the association with stroke is much greater in certain subsets of women than in the general female population during pregnancy. The other thing is that she's gotten pregnant. So even though she's got these risk factors, she's essentially probably living a very full and active life and would like to be there for her baby. So you're very concerned about disability. The other things that I put in there a bit more subtle. So she's had this stabbing pain in her left ear at onset, which is sometimes actually seen with Bell's palsy. Bell's palsy becomes more common in the third trimester of pregnancy. But unlike other entrapment neuropathies, it's not that much more common earlier in pregnancy. And it may even be less common in early pregnancy. So I'm getting a sense of I'm worried that she's having a stroke. But also, there are these other clues that maybe she isn't. And I'm very anxious because it's a healthy young person. I'm anxious about anyone having a stroke and getting disabled. But it's a bit of an emotional situation where you think, gee, the stakes are pretty high here. She's going to have to be looking after herself and Evie. And we don't want to stuff this up. And Catherine, you do have two children out of three. It's true. I am very proud of being pregnant and having children. So that definitely biases me towards caring a little bit more. Should we activate a stroke call? And many major tertiary and master departments have stroke calls and often some smaller ones do. But should we do a stroke call now? Yes, I think so. And that would probably happen even at the triage of that patient that they would become a stroke call. I'd be very disappointed, I guess, if someone came in with a very mixed picture like this and we weren't called. But the key is, well, there are a few things. If it's in hours, a lot of the time you think, oh, thank God, I can just call a neurologist right now and they'll come and they'll check this out, which is always great. If it's nighttime, you're faced with doing a lot more before that person gets there. And then there's also, I think, the most important thing about being a junior doctor, which is that you actually think through the problem. It's very easy to get caught up in, oh, I'm the person that takes all the bloods and puts in all the cannulas and does the notes for everyone else. But really, one of the great things, particularly about ED, is that you get to do medicine. So you need to be thinking, what would I do if I was in charge of making the decision about whether to treat this woman for stroke? So you've actually got quite a detailed history, which is good. But the great thing about facial droop is that there's a lot you can see from the end of the bed. And that's why often there's a stroke call and the neurology team gets there and they just walk in and say it's a Bell's palsy and everyone just breathes and relaxes. The other thing is often when there's facial droop for another reason like Bell's palsy, patients often complain of weakness in that side because they recognise it as a sign of stroke and they become very anxious about it. And so that often will confound the presentation of Bell's palsy and it's also why Bell's palsy ends up in ED, not as much as it ends up with a GP in the waiting room. So I guess the things that I think about with the Bell's palsy that I can see straight away is actually I look a lot at whether the eye can close and at blinking specifically because blinking is something the person is doing all the time. And there aren't very many strokes where you get weakness and the inability to actually fully close an eye. So that's my key end of bed program. I know people talk a lot about whether the forehead is sagging because if it is paralyzed, it's more likely to be a lower motor neuron facial palsy. But I find the eye really useful. There are things you can do that make it easier to, there are a couple of tricks that can make it easier to work out whether the patient has a Bell's palsy when you examine them. One is looking at the corneal reflex because if you don't blink on that side, then there could be a problem with the efferent arm of the corneal reflex, which is controlled by the seventh nerve. So that also will be down in, you won't have a corneal at all in a Bell's palsy. And also, if you're feeling really excited, and you can actually test taste on the anterior two-thirds of the tongue, and that's great because that's going to definitely be a Bell's palsy. It's a really hard sign. I can talk about how to do that well in the ED, but basically you've got saline, which tastes salty nearby, and that's a really good one to use on the tongue. And usually in the tea room there's some sugar, so you can make something sweet as well. And I just get a piece of gauze, hold the tongue between my fingers, I test on the – and then I have a – I put a piece of gauze in, put it on the tongue. They can't tell what it is. I put it on the other side of the tongue and they can, and that's pretty good, I think. And because they can't talk to you while you're holding on to their tongue, I just write sweet, salty, sour and nothing on the piece of paper and they just point to it. So, yeah, that's sort of a very reassuring thing when you find that. And they tend, if they do have a Bell's palsy, have a problem with the anterior taste of the two-thirds of the tongue. Does that mean they can't taste anything at all? They have trouble. So they would say for salty or sweet, nothing? Yeah, that's the normal thing. So they have a total absence of taste there. And on the other side, they've got normal taste. I'm going to do that next Bell palsy. I know. It's kind of, you feel like a bit of an idiot but it just confirms it beautifully and then you can just relax and of course yeah when you're when you're when you're doing a physical exam on a patient like this you're obviously looking at a power the the NIH SS examination is great for doing it for being quick yes but it's not great for looking at subtle things. So, you know, say that you're waiting for the neurology reg to get there, it's the middle of the night, you examine the patient with an NIHSS and you score it, and then you go and you actually properly look at power. And you might find, you know, if power's down on that whole side of the body, that's very concerning for stroke. |
Sorry, it's more Bell's palsy, less concerning for overall systemic or neurological issue. So we mentioned Bell's palsy as a mimic for stroke, but what are some of the other conditions that can mimic a stroke? So I've made a little list. I guess I was thinking, what do you get caught about that? Or what do patients leave the ED with that I'm not comfortable with as well? So one thing that patients often mistake for a stroke in themselves is a migraine sensory aura. So first of all, you want someone that's had a migraine before, preferably, although not always. So when you have a vascular occlusion causing a deficit, like in a stroke, you have a sudden loss of power or a sudden loss of sensation or sudden onset of altered sensation in that side of the body or face or whatever it is. When you have a migraine, a sensory aura, often you get a history of it, again, developing over about a 12 minute, 15 minute period and slowly tracing around the fingers of one hand and then slowly traveling up the arm. And then, and the patient can describe the onset. There are some, there are some seizures that also have a sensory aura that's very similar to that and it's called the Jacksonian march of tracing that pattern. So that's quite a good one, especially if you have someone who's got normal power and they've got a really bad headache at the time and they describe that slow sensory march. That's actually quite reassuring. There are a couple of serious things that can mimic that, like a surface subarachnoid hemorrhage in an older person in certain situations, but almost always it's quite good for saying, okay, well, this actually doesn't sound like a vascular onset at all. The other things, well, the thing that's to do with headache that I don't like being diagnosed in the emergency department is hemiplegic migraine, especially in someone who's never had one before and never had hemiplegia with their migraine before and where there's no other reason to suspect that this may be the case. It's usually the patient who comes in and they're hemiplegic, they get better in the emergency department, they get a bit of a headache, and the temptation is to call it that. But it's actually usually not. And either way, we only really diagnose hemiplegic migraine clinically if it's happened a couple of times at least, and where there's a very typical onset and offset. So I think in general, not something that you should be you know especially as a JMO saying this is what the patient has you always have to treat it seriously and look for stroke and usually admit the patient even if they get better because they may have had a TIA. I think also short TIAs are you know a great stroke mimic but they indicate aensity to stroke. But they're very challenging in the ED as well because you have someone who might even be better by the time they see you, and that's difficult. The other thing that can be confusing is an antalgic gait versus a neurological gait. So people present with all sorts of orthopedic issues as well. And often the patient themselves is worried they're having a stroke because they can't walk properly. And they don't recognize that the pain element is actually the problem. And I've spoken with you before many years ago about vertigo. And that's also a classic thing. When is it stroke? When is it not stroke? And usually the nystagmus itself gives you a clue and the presence of other cranial nerve findings. So do they have vertical nystagmus is always concerning for a central cause or any direction changing nystagmus. If it's always been in the same direction, it's often but not always peripheral. So that can be another one that tends to throw people and be difficult. But I guess as a neurologist, I'm always happy to see any of these patients. It's always frustrating when you get up out of bed and you get to ED and it's a Bell's palsy, but I would never be comfortable either with that kind of story that we've talked about, someone just going home. And I think if someone's getting cranky, that's really their problem. And we all come in and see Bell's palsy all hours of the day and it's absolutely fine. Yeah, I mean, another one we probably see more commonly, maybe we don't, is probably a totsiparesis. Oh, absolutely. So sometimes I have, and sometimes it's just a good seizure story, but sometimes they come in post-ictal and it's the first thing you see and they're just waking up and examine them and you kind of go, could it be something? And probably one more common way to have a stroke calls for is delirium. So we have an elderly person who comes in, you know, and whether it's a speech issue and, you know, I guess it's one of those things. Yeah. It's, I actually sat there one night and I thought, how can, like, is there any really great thing I can say about dysphasia versus delirium? And there isn't. I mean, it's really hard. If that's the isolated neurological finding, you just don't know. So, yeah, I think both of those are really important ones. So what are the dangers of diagnosing a stroke mimic? So I guess if you're a stroke core, stroke person, you get shunted down this imaging pathway, you have lots of fabulous investigations. And if you are diagnosed as a mimic, then you don't. So really the big problem is that I guess in ED in particular, you're really focused on what's going to kill the person soon and you don't want to miss anything that's vitally important and the whole system is stacked in that direction. But there's also a tendency to forget people that have been shunted to a sort of less acute tier of your mind when you're looking after multiple people. So I think the biggest problem is, yeah, is forgetting about the patient and forgetting that there may be another really serious issue that's causing the presentation or contributing to it. So, yeah, the hemiplegic migraine person in your mind is not going to get treated like a stroke patient, but they probably are a stroke patient. And the Bell's palsy woman with all the vascular risk factors is pregnant and probably shouldn't be getting Bell's palsy at the moment. You know, she's someone that, you know, will go, oh, you know, she's got a bit of overlay. She's not really, you know, trying hard in her power examination, but I've gotten five on five power in her limbs. I think it's a Bell's palsy. So I'm just not going to deal with that right now. Or maybe she can go to the labor ward and be evaluated by her obstetrician. So that's the problem. So I guess it's very good to be an astute clinician that can tell the difference, but I guess always maintain a degree of scepticism and try and think of things other than stroke that could be causing the problem as well. I mean, I think this is something that I would, from experience, there's a thing within MSP, the location is destiny. If you're seen with your symptoms in the resuscitation day with a stroke team, nothing would get missed. The same presentation gets seen in a waiting room, you would immediately think this is a more or less serious pathology, even though the symptoms can be almost the same. It's just where they were placed. And I think sometimes we have a cognitive bias that they're in a waiting room. They can't be serious versus a resus babe. I guess, but on the reverse of what the danger of diagnosis stroke mimic, I mean, we are thrombolyzing many people with strokes. Many of those people whose strokes end up not being strokes. So is there a particular danger that we'll end up thrombolyzing people who don't have strokes and have other pathologies? Absolutely. And we do it all the time. And thankfully, if you select the patient carefully, as you always should, it doesn't result in morbidity most of the time. But of course, there will be people where it does. I think you need to... I think the stroke evaluation tools we have at the moment and the checklists that we have are actually very good at selecting patients that are unlikely to have a massive hemorrhage and be more protected from that. |
Okay, welcome everyone to On The Wards and today we're doing a podcast on chronic liver disease. Now I've invited Dr. Anastasia Volovets, who's a second year gastronomy advanced trainee here at Alpine Salford, which is a liver hospital, liver transplant hospital. So experience with chronic liver disease is something you must see all the time. Correct, all the time. So we're the only transplant hospital in the state of New South Wales. So we're probably lucky in that we get more referral for end-stage liver failure from across the state and we probably see more end-stage liver failure than anyone else does. So junior doctors who work at RPA but also who work at other hospitals will probably have to deal with people with chronic liver disease because it's a fairly common underlying problem in the community at the moment. And I'm going to give a couple of cases that may have presented on the wards here or presented on other wards. You're a junior doctor on the ward and you're awake in the evening, you're asked to see a patient who's got some alcoholic cirrhosis, who's become confused. When you speak to the nurse over the phone, what sort of information you may want to get to the nurse before you're deciding when you're going to come and see the patient? Yeah. Okay, so I guess the first, I mean, I think the basic rules of resuscitation apply to these patients as they do for everyone else. And any confused patient, I guess I would be triaging them on the phone based on the level of their confusion, how quickly they have deteriorated, how new this confusion is, and based on the rest of their vital parameters. So certainly the first thing I would be asking the nurse over the phone is a full set of their observations and also the trajectory of their observations, trajectory of their Glasgow Coma Scale, and also what exactly is meant by So you know a little bit of context about the patient is very important here and the most common kind of I get called a lot about patients with you know presumed hepatic encephalopathy because they're cirrhotic but it's important to remember that our patients are just as prone to delirium as any other patients. And of course, anyone who's got underlying alcoholic liver disease, you have to worry about things like withdrawal from alcohol or other psychotoxic medications. So I guess if I was the junior doctor, the first thing I would do would be try to triage how urgently I had to see this particular patient. On arrival, I would first have a quick glimpse through their notes and try to see exactly what we're dealing with, how long they've been admitted. Certainly, it's uncommon for people to go into alcoholic withdrawal within the first 24, 48 hours of admission, but at 72 hours, three days to five days, that's probably the time that it's going to manifest. It's important to recognize that hepatic encephalopathy presents very differently to delirium. So patients with hepatic encephalopathy are usually more slow than anything else. So they'll be a little bit confused. They might not know where they are. They will be very slow in talking. They'll be more drowsy than anything else. They might be slurring their speech. Different to patients who are frankly delirious. So, you know, overt psychosis features are very rare with encephalopathy. So if your patient is appearing paranoid, if they're climbing out of bed, if they're throwing things, if they're seeing things, all of that is more likely to be an organic delirium or a psychotic episode. So I guess if a patient, however, has sort of been getting more progressively drowsy and more confused, and at the same time, you know, you notice a hepatic flap, which must always be assessed for in our patients, then encephalopathy is more likely. And certainly patients with chronic liver disease who have had encephalopathy before, who are a bit more constipated, those sorts of things, I'd be thinking about that. In terms of what the right thing is to do, so the first thing I would always do is you have to try and find the precipitator for encephalopathy, whether on the ward or whether you're seeing them in the emergency department. And I guess the most common precipitants that we would see would be the non-compliance with medications. Lactulose is the most common drug used, but it has side effects and people don't like taking it. It tastes very sweet and you have to take it multiple times a day. So non-compliance would be your biggest issue. And the second most common precipitant will be sepsis. And in a chronic liver failure patient who's got known alcoholic cirrhosis, you know, spontaneous bacterial peritonitis would be the most common source of sepsis. But any kind of sepsis, pneumonia, urinary tract infection, anything like that will be a good source of that. And then the third most common cause would be a commencement of some sort of new medication. So benzodiazepines and painkillers that are building up in people who have impaired renal and liver function. So those would really be your three main differentials for a confused patient with encephalopathy. So the best way to work them up is just like anything else, these patients on the wards or NAD need a full septic screen. And if they have clinically obvious societies, they need a diagnostic tap as well. And they need a careful review of their medications, including any kind of psychoactive medication. So benzodiazepines and opiate analgesics need to be sometimes withheld, sometimes reduced, looking for any other medications. And then we would usually treat them with lactulose. If I was convinced that the patient had a hepatic encephalopathy, if they were really constipated and hadn't opened their bowels for a few days, I would usually start them on hourly or two hourly lactulose. If they're very confused, if their GCS is sort of borderline on the time of, you know, to the point where they can't take oral medications, they need a nasogastric tube. But really, if that's the case, you should be discussing them with a senior and even contemplating referring to ICU. I usually continue the lactulose on an hourly or two hourly fashion until they have significant bowel motions, aiming for at least five on the first day, and then I would be cutting it back to Q4 hourly, QID, TDS, aiming for three bowel motions a day. That's usually the optimal amount. That's how you titrate sort of the success of the lactulose. And patients who do not respond to lactulose usually require an addition of something called rifaximin, which is an antibiotic which also decontaminates the gut. And our usual protocol here is to commence these patients on some antibiotics as well. So if they spend most of their time out in the community and haven't got any multi-resistant organism, we would treat them with Keftriaxone. If they're in and out of hospital and they're at risk of resistant organisms, then we would give them Tazacin just to treat for any underlying SVP that they might have as a precipitant. Are there any investigations that are helpful in diagnosing some with hepatic encephalopathy? Look, an ammonia level is something that we do. It's a difficult blood test to get on the weekend. It has to be sent on ice. It's not something that can be added on to routine bloods. And it is something that we do in our chronic liver failure patients. I think it's not a particularly useful test for a JMO because it'll take a few days to come back. It's difficult to send. And the reality is that the relationship between a high ammonia level and encephalopathy is not linear. So people can have quite high ammonia levels but still be walking around fine, you know, not clinically overtly encephalopathic. And I mean, I've got a young patient in ICU at the moment who came in with full minute liver failure, an obvious flap in encephalopathy and had an ammonia level of 30. But initially it was less than 10, so normal. So the relationship between these two things are not linear. And certainly I wouldn't be doing ammonias on every single patient. It's an expensive test and a bit of a hassle to do. It's really more of a clinical diagnosis. If you have a patient who's got chronic liver disease, they're really slowing down and slurring their speech and they have a flap, it doesn't matter what their ammonia level is. I would just give them lactulose and go from there. The ammonia level becomes more useful in really diagnostic dilemmas. |
So we would use that, but probably for a JMO, I wouldn't bother. Do any of these patients need a CAT scan? Look, I think anyone who's got an acute drop in GCS always should be investigated with a CT of their brain. Especially a lot of our patients are coagulopathic, thrombocytopenic, and their potential for bleeding into their brain is large. And I guess it depends on the clinical situation. Certainly if someone drops their GCS acutely or has any focal neurology, I will scan them. Or anyone who's ever had seizures, I will scan. Patients that are just slowing down and don't have any obvious focal neurology, I think that's very low yield. Okay. Look, along a similar frame, you asked to see a patient with abnormal distention and peripheral edema in the setting of heavy alkaline tape, but they have no documented history in the notes of liver disease but whilst there are any patient-genomic recentia marked ascites what's the significance of ascites in someone with chronic liver disease and should we give other causes of ascites and other liver disease? Yeah look that's a really good question. I think it's important to remember that ascites has a really wide differential diagnosis and decompensated liver disease is only one of them. Certainly any patient who has a history of heavy alcohol disease, sorry, heavy alcohol abuse, cirrhosis, cirrhotic liver disease is a consideration, but you also need to worry about, you know, other things like alcoholic cardiomyopathy, which we do see commonly. You know, other problems people do get, you know, nephrotic syndrome, and certainly we have patients with hepatitis C or hepatitis B who get a vasculitis and end up with nephrotic syndrome or nephritic syndrome. There's an association. These patients can also have malignancy and can have problems with, you know, mental deposits from malignancies, or they can have, you know, an undiagnosed tumour in their liver which is blocking off their portal vein. So I think it's important to remember that even though someone might have a history of alcohol, that alcohol doesn't necessarily mean cirrhosis and even cirrhosis did not necessarily mean ascites secondary to decompensated liver disease and portal hypertension. So a few tricks of the trade here would be that, you know, if you've got a patient with chronic liver disease who's got other evidence of portal hypertension on imaging, for example, a large spleen, a low platelet count, things that are suggestive of portal hypertension, they have a low albumin, you know, and a higher NAR suggestive of synthetic dysfunction of the liver, then, you know, then ascites is more likely to be related to chronic liver disease. Whereas if they've got no other evidence of portal hypertension, so normal platelet count, normal spleen, the ultrasound is reporting normal flow, you have to start thinking about something else. So certainly when I see a patient with new diagnosis of ascites, I would go through the whole workup. So, you know, the most important test here is going to be an acidic tap, a diagnostic tap, which can be done on the ward quite easily. And what I would do then is I would make sure that I would get enough of a sample to send for both biochemistry as well as cytology and as well as microscopy and culture and perform a whole range of investigations on the acidic fluid that's going to be your most high yield investigation to determine what the ascites is due to. So there is you know the concept of a serum to ascites albumin gradient which we use quite a lot. So basically what that means if your serum albumin is less, sorry SAG, so S-A-A-G is something we would use. And so if the difference between your serum albumin to the albumin that you get from your acidic fluid is more than 11, then you know you've got a very very high chance of this being due to portal hypertension, therefore due to chronic liver disease. So if you're doing a diagnostic tap, you should really send it for a protein level, an albumin level, microscopy culture and sensitivities. If your patient's from a high risk area such as Southeast Asia or the Middle East, I would always routinely send it for TB, PCR, as well as AFB staining as well, because you never know. And cytology is really important. And so then, you know, there's algorithms available through the literature that based on a person's albumin level and protein level, you can decide whether it's an axodate, a transudate, and whether it's due to liver problem, cardiac problem, et cetera. These patients all need formal kind of sonography and having a good look at the flow through their portal veins, hepatic veins, looking for slightly stranger things like, you know, bud Chiari and portal vein thrombosis. And of course, a good look at the liver parenchyma. It's important to note that cirrhosis can be really difficult to diagnose, especially well compensated cirrhosis on imaging. It's It's very operator-dependent, and the outline of the liver is not always immediately coarsened on ultrasound. And so sometimes just because someone's got a normal ultrasound, that does not necessarily mean that they're not cirrhotic. But if you've got a patient who's got a normal liver or an ultrasound, a normal spleen, normal platelet count, and large amount of ascites, it's unlikely that the two things, that the chronic alcohol history and that picture is linked. So I would look for other causes. Certainly having a look at a patient, it's important to check their jugular venous pulse as well. Cirrhotic patients usually do not have an elevated jugular venous pulse unless they also have some sort of cardiac problem. So I would routinely screen all my new kind of patients with alcoholic liver disease. I would always do an echo looking for an alcoholic cardiomyopathy and I would always do a urine protein creatinine ratio trying to get how much albumin they're losing in the urine. They're probably, you know, the echo, the ultrasound, the diagnostic tab in a urine protein creatinine ratio I think are kind of baseline tests that you need to diagnose anyone with new onset ascites. What are some of the long-term management strategies for someone who has ascites? Yeah so ascites due to chronic liver disease it really so a lot of it the management of it is really initially with medication alone and lifestyle changes. So the most important thing that people with chronic liver disease can do is cut out their salt. And I think that's a part of advice that is quite often not given and often ignored by the patients because they don't understand the importance of it. But really, if they completely minimize their salt, a large volume of patients with mild to moderate ascites will actually resolve on their own. So you don't necessarily need to fluid restrict these patients but you do need to aggressively salt restrict these patients. The ones that have mild to moderate ascites we would usually manage with diuretic therapy and we'd start it usually with spironolactone, 50 milligrams daily is my starting dose and then then basically I would titrate it to their daily weight. So it's important to anyone that you're trying to diaries in hospital that you weigh them daily and sort of monitor your progress from there. So, you know, you'd increase your spironolactone by 50 every 48 hours. So, you know, 50 milligrams, then 100 milligrams of 200 BD is probably the maximum dose I would use and when that wasn't successful I would add in some frusamide escalating it up in you know 40 milligram doses so and if your patient starts to lose weight which is really what you're aiming for then I would aim not to lose more than a kilo a day because you want to avoid worsening their renal function and precipitating hepatorenal syndrome. If the patient's extremely hypoalbuminemic because they're very malnourished, then I'd usually give them a few bottles of albumin, not because I think it will improve their synthetic function, but because it will help you diurese them a little bit. So I usually give people a few bottles of albumin as I'm trying to diurese them a day. So two bottles of concentrated albumin, 20% albumin a day while I'm trying to diurese them to prevent, you know, that kind of cardiovascular collapse from drying them out too much, protect their kidneys, help shift the fluid out. I only fluid restrict patients if they become significantly hyponatremic. So in our patients, we will tolerate a sodium of as low as 125, but anything lower than that, I'll start to aggressively fluid restrict them. |
So they'll be coming into clinic and getting taps of up to 10 litres of fluid removed at a time. And really, if they've reached this point, they're either heading towards a transplant quickly or they're heading towards death quickly. Once you develop, you know, diuretic resistant, large volume ascites that need a weekly tap, your prognosis is probably only about six months. In regard to doing those large-volume taps, one of the issues that we sometimes find in ED is platelet count and what their INR is. Is that a contraindication to doing the tap? And do you need to give the concentrate album when you give the tap? So I think it's important to point out that the relationship between the INR as a number and patients actually propensity for bleeding in chronic liver disease has not really been clearly established. Certainly we know that an INR of two in a patient due to synthetic dysfunction and chronic liver disease is very different to that to a patient who's got an INR of two because they're warfarinized so a lot of our patients are actually prothrombotic despite having an INR of two or even three and they're more likely to clot than they are to bleed and the problem is we don't really have good tests to determine which patient is sitting on which side of the coagulation problem. So the other important thing to remember is although a lot of our patients have low platelets, they're not necessarily, it's not the same as having a patient who's got low platelets because their bone marrow has been wiped out from chemo. Our patients have low platelets because they have very large spleen due to portal hypertension, and the spleen is sequestering a lot of the platelets. And the theory is, is if you need more platelets, your spleen will, you know, release them. And so it's not, the numbers look worrying, but they're not necessarily implying that the patients will bleed. So a lot of the times we give blood products to make ourselves feel better without necessarily knowing whether that's the right thing to do. Certainly if a patient was having, you know, an operation of some sort, which had a high risk of bleeding anyway, then we would correct their numbers. But for things like diagnostic or even therapeutic taps, I think unless someone's platelets are less than 20, I wouldn't give them platelets. And unless their INR was less than three, sorry, was more than three, I would not give them FFP. So we routinely do taps on patients with INRs of 2.5, platelets of 30 without any blood product cover, and they do well. You know, the chances of someone bleeding post an acidic tap are very low. In the last two years that I've been in AT, I've probably only seen two patients with large volume bleeds post a tap. And it's not even, in both of those cases, we're not related to the procedure itself, as in what I mean, it's not like we put a needle through a varix, which can happen sometimes. People get varices in the anterior abdominal wall. But in both of those times, what tends to happen is because people have lots of intra-abdominal collaterals, which are tamponaded effectively by large volume of ascites, when you drain that large volume of ascites, veins can, you know, sort of spontaneously pop. So both of these patients actually had bleeds, you know, the next day or many hours after their tap. So even if someone does have a bleed, it's not necessarily, you know, secondary to the procedure that was done by the GMO. So I think, you know, overall, unless the patient has platelet count of less than 20, I wouldn't give platelets and an INR of more than three, I wouldn't give FFP. And you warn the patients always about a potential for bleeding. And if you have evidence of avert then you should replace their factors but prophylactically I wouldn't having said that if that same patient needed for example a tooth extraction or a central line placed or something where we knew that they had very high risk of bleeding I would correct their factors not really knowing whether that was the right thing to do or not but just because because it would make everyone feel better. In terms of albumin replacement, it is, again, really, really important to give people albumin. If you don't give people albumin and you take off 10 litres, they're going to go into cardiovascular collapse and hepatorenal syndrome and die. And we've learned that the hard way over many years. So the general formula is for every two to two and a half litres you take off, you give them a bottle of albumin. So our patients who are getting their 10 litre taps, we give them five bottles of albumin and that should be uniform practice. Are there any take home messages generally about the management of chronic liver disease that would be important for the JMOs to know? I think it's important to realise that patients with chronic liver disease are much more sicker than sometimes they appear. And patients certainly with decompensated liver disease have actually a really terrible prognosis, which I think a lot of people don't really appreciate. So, you know, if you have decompensated liver disease or child's PC cirrhosis, you know, if you're that patient who's in hospital with, you know, gross decompensated ascites and jaundice and an INR of two from your liver disease, you're looking at anywhere from six months to two years. And I think that's a lot of things, you know, sometimes get done to them in terms of surgical procedures, et cetera, without realising how poor their prognosis actually is. The big take-home message is, you know, sometimes get done to them in terms of surgical procedures, etc., without realising how poor their prognosis actually is. The big take-home message is, you know, a person can have really impaired liver function but be well compensated for quite a long time until something happens to them. So it's really important if you do have a patient with known diagnosed cirrhosis and your team is planning any form of surgery or treatment or, you know, chemotherapy or whatever it is to get the gastro service involved early. We may not be able to prevent a decompensation, but we will be able to manage them. And certainly I've seen many patients who have come in for an appendix or a hernia repair who were fine preoperatively and then deteriorated significantly postoperatively, you know, with their liver function completely decompensated and they died. So it is really, really important if you have a patient with known cirrhosis to involve the gastro team early. The second point I'd like to make is that, you know, patients who have impaired liver function don't tolerate medications and don't metabolise medications well. So anyone who's an alcoholic and anyone who's malnourished prior to coming into hospital should not be receiving high-dose paracetamol or even regular-dose paracetamol because they don't metabolize it as well. And they can get significant paracetamol toxicity on much, much lower numbers. So in these patients, you know, opiate analgesia at small doses is appropriate. And always re-evaluate the medications. If you've got a person with impaired liver function, you know, you should be checking all of your antipsychotic medications, you know, your opiate analgesias, your anti-epileptic medications, your antibiotics. You know, a lot of those things are not, you know, even something as simple as endocentron is high dose endocentron is contraindicated in people with significant liver impairment. So check your drugs, same as patients with kidney problems, you know, just always check your drugs. And I guess the third thing that probably doesn't get paid enough attention to in probably most patients, but especially in chronic liver failure patients, is nutrition. So our patients come in and they appear overweight because they're carrying 10 litres of fluid in them, but they're actually extremely protein malnourished and they all need to sort of really, really aggressive nutrition support. So if you ever come to the transplant ward, you'll find that most of our patients who are waiting for a transplant have nasogastric tubes inside you and they're being fed 24 hours a day with high protein supplementation and so you know we do that because we're trying to build up some protein stores to help them survive big operations so if you're an intern who just happens to be looking after a chronic liver disease patient you know just automatically put all of them on a high energy high protein no salt diet don't don't wait for a dietician to come and tell you that. Just automatically all liver patients should be on a liver diet. |
Welcome to On The Wards. It's Jules Wilcox here and today we're going to be talking about indigenous health and how to relate to indigenous patients and some of the specific aspects that you might need to consider when you're dealing with indigenous patients. We have a panel discussion and I'll let them introduce themselves but we have four indigenous doctors from around the country who've very kindly agreed to be involved in this panel discussion and bring their own unique perspectives and insights to this so perhaps Tilia might get you to introduce yourself first. So my name is Talila Milroy. I'm an Njibundi and Pauku woman and GP registrar living and training on Noongar country in Perth. Welcome to the podcast today. And I'm just going to go in order of who I've got on the screen here. Tom, Tom Henry. Hi, thanks for having me. My name is Tom Henry. I'm a proud Wurundjeri man who grew up in Mudgee in the central west of New South Wales. I've completed physiotherapy in the past and am currently a RMO at Gosford Hospital on the central coast. Okay. And Jess? Hi, my name's Jess Johanson, formerly Archie. I'm an Arundhya Yakanja woman from Alice Springs on my father and grandmother's side and on my mother's side, she's a Bundjalung woman from New South Wales. I originally grew up in Alice Springs and now I'm back here. Went away for boarding school for a little bit and did some study in Adelaide and now I'm back working here in the Alice Springs Hospital as an RMO and I'll be doing GP training next year. Great thanks very much and I've just realized that I can't count because I said four people but that was because I was looking at screen boxes and I'm including one of those people. So my name is Jules Wilcox, I'm an emergency physician at Gosford Hospital and also the DPET there and I've been going to Alice Springs on and off for about 10 years now and before that, I worked in Darwin. And that's how I know Jess and asked her to be involved with this. So I think I'd like to start perhaps, Jess, do you want to explain why you introduced yourself in that way? Because it's slightly different to how we would normally do this. Yeah so yeah sure so we thought it was important for us to sort of introduce ourselves in this way because at the root of our culture is our ability to share knowledge through storytelling and yarning in a conversational way that helps us talk about important topics and life lessons and to be able to that, we need to know and trust the person that we are giving that information to. So it's always important to identify with who we are and where we come from as it's a part of our belonging, our identity and our strength. And by listening to your Indigenous patient's story and their identity, I think it's the first step in engaging in a therapeutic relationship, because they can tell that you care and that they can invest their trust in you. And if you generally invest your time and attention in them, that goes a long way for Indigenous and non-Indigenous people, I think. So I think it's really important to sort of always gauge, you know, their identity at the start. But obviously read the room and the situation, as unfortunately there are many people, and it's a vulnerable topic for a lot of Aboriginal people, as some may not have the privilege and luxury of actually knowing their culture and their identity due to past generational traumas, and that can actually be quite upsetting too. So, yeah. Yeah, I think that's one of the things when we had some preliminary conversations about this, we're sort of talking about that, how it's not a one size fits all, one rule fits all this, is it? It's part of the problem, I think. It's a very difficult thing to gauge because there are so many different experiences. And Tom, I think you said at some point about how in Gosford, where we both work, the Indigenous patient you come across there is likely to be highly different to the one you might meet in Alice, for instance. Oh, absolutely. I think, and that's when it comes back to not making any assumptions about someone's level of Aboriginality or how connected they are to culture because it is such a varied and diverse group. Our people are spread across this great nation and experience things in a variety of different ways and come from a variety of cultural backgrounds as well. So I think there was an interesting show on the SBS a while ago that said it's a bit like a cup of tea. We can't make any assumptions based on the colour of the tea. And really, we just need to be good people, treat people with respect and kindness and go about things on a very individual basis whilst keeping all that intergenerational trauma and history at the back of our minds so that we're not stepping on sensitive topics in an unnecessary way. Yeah. Tilly, do you have anything else that you would like to add into that aspect before we move on to the next part? I think that was very well articulated already. Okay. All right. Okay. So, I mean, I think one of the things we spoke about before when we were talking about doing this podcast was that there's a lot of, everyone seems to be aware of the disparities in health between indigenous and non-indigenous people, but perhaps what is less understood is how to communicate effectively with indigenous people to optimize the healthcare delivery. And as you say, Tom, with those caveats of not bringing up past traumas necessarily and things, how do we navigate through that minefield? Tilly, do you want me to go? I'll go to you first. Then you get a chance to test so they can say that back to you this time. So I think that the important thing to remember is to, you know, be thinking about, still have knowledge about Indigenous concepts of health and wellbeing and the historical impacts of kind of past policies that are still impacting on Indigenous people's health today. So for Aboriginal and Torres Strait Islanders, good health is more than just the absence of disease or illness. It's more of a holistic concept that includes physical, social, emotional, cultural, spiritual and ecological wellbeing. And it's important to remember that Indigenous people think about these factors in the context of both the individual self and their community. And this concept of health emphasises the connectedness between these factors and recognises the impact that social and cultural determinants have on health. And, you know, these concepts of health were really disrupted completely by colonisation and the repeated historical mistreatment of Indigenous peoples and has had pervading and ongoing impacts on our health status, as I said. said and historically Aboriginal people have been subject to discriminatory and damaging policies that have caused mistrust of the health system, a perceived sense of lack of control and disempowerment and perceptions of doctors and hospital staff for example as authority figures and these are just some of the factors that contribute to barriers in healthcare delivery. So if you were going to go and engage with an indigenous patient how are you going to start to get around that? Jess, what things should you already know before you walk in to see that patient? What should you prepare to do? What mindset should you be trying to go in with? Yeah so I think think like you would do with, you know, with Indigenous and non-Indigenous patients, first do a little bit of research before going in. So I think it's important to look at, you know, their past medical history, their comorbidities, previous presentations and whether or not they're recurrent. And especially with Aboriginal people, if English isn't their first language, I think finding out that information prior to the interview is helpful on two fronts. Firstly, it reduces the burden of trying to get that information out of them because you're already fatiguing them from that point of view rather than getting to the crux of the information. And what's really important is why are they here and also what are actually their priorities for this consultation outdoors. Secondly, by already knowing their past medical history, when you ask them, I think it's still important to ask them because it actually helps you gain really important information on their health literacy. And this is important as it helps tailor the way the interview will go. Depending on their health literacy, it will determine how you give the information and also how you discuss management. For instance, a lot of patients might say, oh, doc, like it's all on the system there. It's all on my file. Like I'm sure you have it all there. And that kind of gives a clear picture that maybe actually they don't know much about their chronic kidney disease or where they're up to with their heart disease. As opposed to a lot of other Indigenous patients who will know when their last benzothine, benzopenicillin injection was. |
So I think it's really helpful to sort of gauge that health literacy. And I think also in terms of before you go into an interview, remembering sort of what, like touching on what Tilly was saying about having empathy and compassion before you even go in there and remembering that for a lot of Aboriginal people that come into hospital, they are already in a very vulnerable position. They're in a Western setting where the most prominent language is English. Perhaps people don't understand them culturally, there's systemic mistrust, there's prior sad and traumatising experiences with losing family members, but also on an individual level, they might be coming in over and over again. And remembering that, you know, these Aboriginal people, when they come through our doors, they might feel like they're out of place, but in their community, they're strong, prominent elders. They carry a wealth of knowledge. They're depended on and they're respected and pillars in their community. So that kind of juxtaposition of then coming to a hospital where all of that is kind of ripped from under them, it can be really destabilising. So just sort of remember that when you're going into a consultation as well. Yeah, I remember that in Alice last time I was up when I saw you going through that old lady in HD2 with the chest pain. And I really remember the interaction that you two had. And it was really evident to me that you were treating her with respect and you had genuine concern and empathy. And the whole nature of that conversation and that encounter for her, I think was a good one. And English obviously wasn't a strong language, wasn't a language for her by any means. But it really shone through in the way that you were talking to her and dealing with her, that that respect and empathy was there. And are there any, because I was thinking about it quite a bit, and I was thinking, oh, how did you, why was it so obvious to me? What was it that you were doing? Are you aware of any of the things that you were specifically doing, or was it just something that you just... Yeah, I think it's almost a natural thing, because it's almost familiarity for me. You know, it's like, you know, when I see that older lady, I think of my grandmother. I think of my grandmother's sisters or brothers. Do you know what I mean? It's that. But also I think it's the, which I think we'll touch on a little bit later as well, it's those non-verbal cues, which are so much more important for Aboriginal people, especially if English isn't their first language, it's sort of stripping that back and making it a little bit more informal so that it isn't so confrontational for them. So, you know, if I'm comfortable, I'll sit at the end of the bed and if I can see the patient is comfortable with that, then that's fine. And, you know, if I feel that I've sort of touched on a vulnerable topic, especially I think as an Aboriginal female doctor, it might be easier. You know, I can, you know, do a comforting touch to the shoulder or to the leg just so they can see that I'm caring and I'm listening. So I think the non-verbal cues are really important. Yeah. Tom, anything that you would add to that in terms of things that you would specifically do? Well, I think it is often a lot easier for us that have grown up with a bit of a cultural attachment and understand a lot of the underlying importances of community and community interconnectedness. But I find something as simple as having a bit of background knowledge about certain sports or interests that people bring up and exploring that as part of the healthcare journey, sort of delve deeper into other social and cultural issues that they're experiencing can be really useful. There's a lot you can uncover just by having a conversation with someone in a kind and respectful manner. And I find particularly in our people, it's really important. Yeah. Tilly, anything from your point of view that you want to add to that? Am I not going to make you say what they said again? Yeah, no, I think they've made really good points. And I think in terms of like non-verbal cues, something that kind of comes into that is being comfortable with silence. And silence can be a really powerful form of communication for Aboriginal people. So those silences are more comfortable if they feel like you have the time to spend with them. So you are sending verbal cues if you're looking rushed or, as Jess said, not kind of sitting down and feeling like you're getting comfortable with this conversation and having the time set aside to do it. The other thing that was touched on by Tom was asking them about things which are non-medical like sports or interests and I think this comes into the concept of clinical yarning with Aboriginal people so the concept that you might commence your consultation with more of a you know informal conversation a social conversation or a social yarn and then you will more progress into your you know clinical yarn clinical yarn, asking about, you know, what the medical reason is that they've come in today. I think for me as well, like Jess said, you know, there's a lot of this that comes naturally with just having, you know, your own family experiences and how you interrelate with other Aboriginal people. But I think you, I'm more comfortable asking about, you know, spiritual aspects of their wellbeing as well. And so I think that that can make a difference for Aboriginal people as well if you're comfortable broaching those kinds of topics with them because these things do play a role in their wellbeing overall. Yeah, yeah. And I'm just reflecting there a little bit about some of the things you were saying about treating with kindness and respect and things. But those should really be universal as well, shouldn't they? I mean, there's a lot of things that we should be doing for all patients. And I'm not sure that we actually do them for all patients anyway. Sometimes we've just been recording a podcast on compassion and the effects of compassion and how powerful it is. And just touching back on what you said about silence and listening and that in studies, and these are studies from the US, so there won't be any indigenous patients in those, but 85%, the most most important thing was they just wanted to be listened to. So there are some universalities across all patients but then you can just tweak them. I think you have to feel you've got to be completely different and when I go to Alice to work there I'm cognizant of the fact that I need to slow down. I can't go in and go and start talking and ask a question and then five seconds later ask another question and then another question because I'm just not going to get anywhere at all. But if I take that back to Gosford, I find I often get further doing it there with an elderly patient there who is white from Scotland type thing originally. And so I think there's some universalities that we can take those skills that we developed in one area and then just have the confidence to apply them in another area as well. So I just wanted to move on now. We've talked about sort of the nonverbal cues and storytelling and things. What about sort of privacy issues, cultural issues, elders, seniors, other family members and anything there? Jess, I might come back to you again on that. Any of those particular issues that you would think we need to be particularly aware of? Yeah, so I think this is also universal, I think, in the sense of when you're setting up the interview, like thinking about if you're going to be discussing anything that is potentially private or sensitive to make sure that they are in a room where they feel comfortable, it's a private area, it's a quiet area. And obviously with Aboriginal people, you need to then think, well, is this going to be a men's business or a women's business discussion and other sensitive topics? And then, you know, finding the appropriate doctor who can discuss that, female or male. And also I think it might be different in Gosford, perhaps not, but I have to be conscious of the fact where I work in Alice Springs, it's not a big town. And a lot of the surrounding communities, a lot of community members know each other or at least know of each other. So I think we have to be quite mindful of that with sensitive topics. Like I know that we had a patient here in the past, was kind of burnt in the past where he was in a cubicle where sensitive topic, like a sensitive conversation was kind of overheard. That got back out to the community. And that was obviously very detrimental and traumatising for him. Yeah, I mean, that's a huge issue, isn't it? That's absolutely going to impact his life so much. |
No, that's exactly right. It affects his personal life, but it also affects his health care too, because it's a a barrier now for him to access healthcare because he has that fear of his personal information sort of becoming public knowledge. And like I was saying, when we share a story, we're trusting that person with that story. So I think it's really important that we keep that in mind. Yeah. Yeah. I think that's one of the things I think to go back to what we do is we are being entrusted with people's health and their experiences and when they come into hospital they are entrusting us and we we need to have that respect to to have earned that trust it's hugely important what about shared decision-making Tilly in your role as a a primary care GP registrar, that's going to be a huge part of what you would do, I would imagine. Could you touch on how you approach the shared decision-making? Yeah, I think that, as we've talked about so far are you really need to get to know your patients really well, their social situation, their cultural situation and their, you know, the kinds of things that are going to be barriers or enablers with your kind of plan for them. So discussing with them really the management plan that you have in mind, but also what their goals are, as Jess said, you know, what is their agenda? What is their reason for being there? And what are they hoping to gain from having come and seen you, especially when we're thinking about all of these, you know, barriers and potential fears of even having come and stepped foot to see you in the first place. So, you know, laying all that out on the table, discussing, you know, what kind of goals they would like to achieve. And then, you know, making these decisions together is really important. I think, for example, like I've seen like young Aboriginal males with, you know, drug and alcohol problems. And so when you're thinking about that, yes, you've got your, you know, pharmacological approaches or your non-pharmacological approaches, but you've also got to be thinking about things in a cultural framework as well. So thinking about your cultural approaches as well. So I will ask them about, you know, what family members do they lean on for support? Do they have, you know, elders they can go to or people that they can trust with helping them in their kind of healthcare journey? And how do these factors impact on your management going forward. So I think, you know, family connections are another factor that are really important to kind of broach with your patients with that shared decision-making and how they, you know, want to proceed. Okay. Thanks for that. We're getting on a little bit with the podcast. I might move on now. What would you say the main things that you've learned about communicating with Indigenous patients? If we had to sort of distill it down a little bit, what would be a take-home message? We'll go for some different ones. So Tom, I might start with you this time. What would be a take-home message for you? Well, I think one of the most important things for me, especially considering most of my practice has been in an urban setting, is to never make assumptions, you never know whether somebody is or isn't Aboriginal or Torres Strait Islander and how they identify or how involved in the community and connected to the local community they are. So these are things that you need to explore as a part of the consult and, you know, likewise, you need to try and take these opportunities, which are few and far between at times, where you're a doctor seeing a patient, to make it a positive healthcare experience as much as possible. And, again, that all comes back to tailoring each interaction to the individual and making sure you're respectful and kind throughout. Yeah, respect and kind goes a long way. There's a thing in coaching that we did, an exercise we did, where it was called meeting people for the first time. And the premise behind it was the fact that our minds are always judgmental. We're always making judgments quicker than you can blink when you meet somebody about this, that, and the other. And it just cut away in the background. And the meeting people for the first time thing was to be really mindful of when you meet a person to be almost watching your mind like a cat watches a mouse hole so that when those little thoughts start bubbling up which you can't control they just bubble up you can go ah okay you're aware that you're doing it and you don't have to engage with those thoughts you can just let it float off and so if you can do that you are not then meeting people with their expectations and judgments and things that you may have or may be coming up through there and because they'll be doing the same thing to you as well and and so they're meeting people for the first time is that you that suddenly you're truly meeting somebody for the first time and you can do it with people you've met for a long time because you have these little judgments and biases and history coming up. And you can get a much deeper connection by doing that. And you can get past an awful lot of the egos knocking into each other by doing that. And it's a technique that I found quite useful in the past, that sort of curious, nonjudgmental, open-mindedness, which is, I think, what you're talking about there. 100% rules. You've articulated that perfectly. I've been struggling to practice it for a long time. And it is hard work, isn't it? You know, these things, you go in to do things and you can have the best of intentions and things suddenly start spiraling. So sometimes you're not even sure why. And it is, it is hard work and it's just constant work I think to, to try and pick up. And certainly, you know, when I met, when I first went to Alice, I found it very difficult as a, as a white person, white English person coming in to that and not really understanding some of the nuances and sort of feeling a bit of an imposter. And even now sometimes I sort of, it's not my comfort zone. I love going to Isle of Springs, but I find that I don't have that innate knowledge and I need to rely on, I need to talk to, you know, other people who do have that knowledge. And as a, as a person who's coming from completely outside of this get involved with your Aboriginal Liaison Officers in the hospital you work in. Ask some interesting questions what you're interested about or what you don't understand because I think that can be real eye-opener and can get through some things as well but Jess perhaps go to you what's your take-home message? I think my big one would be time, that with Aboriginal people we should just be taking our time and knowing that the initial consult might actually be a little longer than you expect. It's actually, you know, what Tilly was talking about, having a yarn, hearing a story, and I think most importantly, actually, their priorities and trying to either compromise or match up at what our expectation is as the treating practitioner and what the patient's expectation is of what they're going to get out of it as well. So it helps build that sort of therapeutic relationship. So, yeah, just take your time. Yeah. Well, we've had that one. Do you remember that lady with the infected knee? Who, again, I think was an HD2 last time I was up. And she had sorry business that she had to go to. And we knew that. And we knew that she wasn't going to stay in. So it was, well, I'm not going to just say, well, you've got to stay in and this and that. And then, okay, we'll sign this piece of paper, discharge against her medical advice. It was, okay, well, we need to load you with IVs right now, debride and clean as much as we possibly can. And also respect her choice. I think that was the other really important thing. So when the surgeon came down and it was great to see the surgical reg walk in and just go, first thing he said was, look, I understand that you need to leave and this is really important for you. We need to try and make sure you don't get sick so that you can go to your sorry business and you will be well whilst you're there. And so we try and change that care. |
Welcome everybody to On The Wards. It's James Edwards. I'm here again talking today about a pediatric topic, febrile convulsions, and I'd like to welcome back Dr. Arjun Rao. Welcome. Thanks, James. Now, Arjun has spoken to us before. He's a pediatric emergency physician from the Sydney Children's Hospital, and we're going to talk about a pretty common topic, febrile convulsions, especially within the emergency department. And we're going to give you a case just to kind of paint a picture of what a junior doctor may see when they're working in ED. A 14-month-old was brought in by ambulance and they've had a seizure at home that probably lasted from the parents about three minutes and now the child is known to have a fever and is a bit sleepy. So maybe you have a broad outline of your approach when you see this child. Yeah, sure, James, thanks. So I think, like with everything, I always start with an overall approach, an ABC approach, an airway, breathing, circulation, and I won't go into the details of all those assessments, but I do that global assessment first. And probably by the time you're seeing them, in most places, the child would be in a bed, ideally monitored, and they'd be triaged to a fairly high credit category, especially if they were still sleepy. So once you're sort of happy that they're stable from an ABC point of view, I'd start with a history from the parents. And I'd always start open-ended and asking the parents to describe the event. And I actually just let them speak without interrupting them because they'll be quite traumatised. They'll want to describe this event to you. And I actually think it's really important to acknowledge how scary that event was for them and to understand that they'll be quite traumatised, they'll want to describe this event to you. And I actually think it's really important to acknowledge how scary that event was for them and to understand that they'll be really distressed and actually not interrupt them, just let them speak. Once they've given you the history, then you might go back and clarify some specific points about the history. I think it's useful to try and work out whether the onset of the seizure was witnessed or not, because often isn't but sometimes it is and trying to work out whether it was the whole body that was shaking initially and were they actually hot at the time or did they feel hot as far as the parents know so just asking them was the whole body stiff or shaking and it's often useful to go through it one limb at a time and and give them time to actually remember so don't keep interrupting them again just Just let them think about it and answer your question. One tool that's quite useful is actually asking the parents to demonstrate what they saw physically so that that can sometimes help you decide whether you think based on their movements it was truly a generalized seizure as opposed to a rigor. I often specifically ask them what the eyes did. Was there any color change? And I get them to try and estimate how long they think it went for. That can be a really difficult question for parents because, you know, it's pretty scary and they're obviously not looking at the clock and timing it. And they often think it went for longer than it actually did. And for anyone that's been in an emergency when a child or adult has been fitting, 30 seconds can seem like a long time when someone's fitting. Another strategy that I use to help them try and remember and get as much information out of them as possible is to actually, rather than ask them directly about what the child was doing, get them to tell you about the environment that the child was in. So for example, if it was in their bedroom, I get them to tell me about the bedroom, where the bed's located, what other furniture there is. And I find what that does is it puts them back in their environment and they can then visualise what was happening and give you a lot more information. And I think finally it's good to ask what happened when the seizure stopped. So were they limp and floppy? What was their colour like? Were they sweating? Did they think the heart was racing? And importantly, have they been normal? Have they come completely back to normal since the episode? So that's for the seizure itself. I think it's also important if they're febrile to remember to ask about things relating to the cause of the fever. So anything's on history to suggest a cause of the fever, like runny nose, vomiting and diarrhea, or any sick contacts. And lastly, just asking about a family history of seizures or febrile convulsions can be important. Can you maybe just describe to us that classic history of febrile convulsion? Yeah, sure. So usually, actually often the parents don't know that the child is unwell or has had a fever before it. So it's often the first sign of a fever is the child has a convulsion. Usually you get two sorts of situations, one where the parents aren't with the child and they are drawn to the child from a noise in the bedroom. And often in that situation, when they get there, the child's already floppy and have the fit. But if they do see the fit, what they often describe is the child becoming less conscious, their eyes might roll back. And then they have a stiffening phase where the child goes stiff and there might be some subtle color changes around the lips. And then it's usually a generalized convulsion. So a generalized stiffening. And there might be a clonic phase as well where the arms and legs are both shaking. And it's usually overwhelmingly short-lived, so a couple of minutes. And then after that, the parents will often have them in their arms. So they describe the child being really stiff and then going floppy and being floppy and unresponsive in their arms. And many parents will say they thought their child was going to die when they see that. What specifically would you look for on examination? Yeah, so I think the approach to examining a child who's had a febrile convulsion is twofold. So one is assessing them neurologically from the seizure point of view, but also examining them for a potential cause of the fever. So I always start with a general observation. So stand at the end of the bed, get as much information as you can, or if they're with the parents, leave them with the parents, but get as much information as you can by observation. So you can decide if you think they look well or unwell. Are they alert? Are they sitting up eating or drinking? Or are they sleeping in the parents' arms? If they're on monitoring, you can note the heart rate, the saturations. You can count their respiratory rate without touching them, with them on the parents. And then, like I said, then you divide it into assessing them neurologically, so their neurological status, and then assessing them for a source of the temperature. So if they're alert, I would just start by engaging with them, playing with them essentially. And the best way to do a neurological examination on a child is by playing with them and observing their hand movements and how they're moving. Specifically, I'd look at their eye movements, their pupils, feel their fontanelle. So in a 14-month-old, there may still be an open fontanelle that you might be able to assess. If they're asleep, then try and do as much of your examination with them asleep as possible. So the examination of a child is the same as any examination. So you've got your inspection, palpation, percussion, auscultation, so for the chest, for the abdomen, but you might do things in a different order. But you should do a thorough examination of the chest, the abdomen, listen to the heart sounds. Very important to do an ear, nose and throat exam because there's many times with children with febrile convulsions or just even fever where people haven't looked in the throat and I've had a look in the throat and you then get a source of the fever. Expose them fully and look for signs of a rash. And also examine bones and joints in terms of trying to pick up an occult or osteomyelitis or bone and joint infection, which people don't always do. So I think that's my overall approach to examining. And if we go into more of the neurologic examination, do you do a GCS score or how do you kind of... Yeah, so I think... I don't remember GCS, so I'd need to refer to something. |
And if they're sleepy, trying to gently rouse them and see what they're like. If the seizure's just recently finished, it wouldn't be surprising that they're in a postictal phase. And if it has just been a generalized seizure in their postictal, then I would expect them to gradually get better. So close monitoring is really important. And similarly, we sometimes worry about things like underlying meningitis. So things like neck stiffness, a valuable examination in a 14-month-old. I think if it's there, it's useful. But it can be subtle. And I think the most useful thing in terms of trying to work out whether to be more worried about meningitis or encephalitis as a cause for the seizure is how they wake up after the seizure. So your typical child who's had a simple febrile convulsion from a viral illness will, within half an hour or so, wake up and the parents will say they're back to normal and they'll be really reassured by that. Any child who's not, after a period of observation, back to normal, you need to think about could this be encephalitis or meningitis and need further investigation. Okay, that's a good kind of summary because it leads into our next question. What's your list of differential diagnosis in a typical febrile convulsionle convulsion yeah sure so the first thing is to decide that you think this was a febrile seizure that this was actually a seizure and not rigors and that cannot not always be easy but things to include on the differential even though they're rare are as we said meningitis or encephalitis thinking of other causes of seizures with fever something metabolic so if a's got an underlying metabolic problem, has an intercurrent illness that's caused a fever, but that's made them become hypoglycemic. So if the child's not awake, just checking the BSL. And often if they've come by ambulance, they will have checked that already. And then thinking of all the differentials of the cause of the fever, so the viral versus the bacterial causes. So do you think this is a likely febrile convulsion or febrile seizure and what criteria need to be met to decide it's a febrile seizure? So I think from the description, there's a lot that would suggest this is a simple febrile convulsion. So the typical febrile convulsion is something that happens in young children. It's in the definition from one month to six years of age, but mostly between three to five months up to six years of age, not caused by an infection of the central nervous system. So if the child's woken up and looking well, that would fit. They need to be neurologically and neurodevelopmentally normal, ideally not have a family history or first degree relative with epilepsy and it needs to be a generalised seizure, usually of a short duration. The current criteria says up to 15 minutes but I think that's quite a long time. So they're the broad categories that you'd need to satisfy and I think this child does satisfy that assuming they wake up normally. Okay so you think it's likely to be a febrile convulsion do they need any particular investigations? Yeah sure so overwhelmingly in a simple febrile convulsion children don't need specific investigations over and above what you would do to investigate the cause of their fever which may be nothing So most of the children that come in having had a febrile seizure that we see recover fully and don't require investigations, especially if they have a readily apparent viral cause for the fever. But you typically want to see them return to their normal self. And if they haven't returned to normal, then you might think about some investigations, both for investigating the cause of the seizure, but also for the cause of the fever. So you might start, if you thought you needed to, with some baseline blood cell, full blood count, looking for evidence of raised white cell count, some electrolytes to make sure that there's no derangement of sodium potentially causing a seizure, a BSL. And if they're febrile, we'll do a blood culture and a urine culture. In terms of a lumbar puncture, that's always a difficult decision. And I guess if you're really worried that a child is encephalopathic or encephalitic, you might not do a lumbar puncture because there might be contraindications in terms of level of consciousness to do that. And we shouldn't delay treatment for the lumbar puncture if we're worried that the child's unwell. But if the child is well enough and there are some worrying features or as you mentioned signs of meningism then we think about a lumbar puncture. In regards to treatment would you treat them with intravenous antibiotics and antiviral medication? So I think different places will vary in their protocols for empiric treatment of meningitis or meningoencephalitis. If it was purely meningitis and we didn't think they were encephalopathic or encephalitic, I would just start with broad spectrum antibiotics and recommendations will vary depending on where you are, but a broad spectrum antibiotic. If you're worried that they were encephalopathic and they were very drowsy and they hadn't returned back to normal, then I would add an antiviral such as acyclovir. So kind of in, I'm just trying to summarise, so if you're investigating a febrile convulsion, is it different to the investigation of just a febrile child? So are they at a high risk of a CNS infection by having a convulsion or really the risk is similar in both groups? So if you took a whole population of children, if you took a whole population of febrile children and a whole population of children with fever who'd had a febrile convulsion, the chance of the children who had the febrile convulsion having a meningitis as a cause would be higher than just the children with fever. But the risk in both those groups is exceedingly low. So the risk of meningitis in an otherwise healthy 14-month-old child who comes in just with a fever is far less than 1%, and it's similarly low in a child with a febrile convulsion. So I can't remember the last time I saw a child with a febrile convulsion that ended up having meningitis. And is that a bit of change with change in immunisation status? Absolutely, yeah. So 20 years ago, it would have, certainly the American Academy of Paediatrics were recommending lumbar punctures in children with febrile convulsions, and they've changed that recommendation as a routine investigation. And we've certainly seen a drop-off in the rate of bacterial meningitis with immunisation. Do children who have had a febrile convulsion need admission to hospital or paediatric review in the emergency department? Yeah, so most children, well I should start by saying it depends where you work and depends on a lot of other factors apart from what's happened to the child, but most children with a febrile convulsion won't need an admission. Whether or not they need paediatric review in the acute sense will depend on where you work and what expertise around the illness is. And paediatric follow-up is also not routinely required. But if there are complex features, which I'll talk about in a moment, if there are complex features, then they may warrant paediatric follow-up. But my overwhelming message would be, depending on where you are, to always err on the side of caution. So if you're unsure, it's better to ask for help or a second opinion. And if you're unsure, it's better to admit and observe a child than sending them home. And it depends on the time of day as well and how worried the parents are about this. Yeah, I mean, it seems most febrile convulsion convulsion children I admit is usually late at night. That's right. First convulsion. Absolutely. Worry the parents. Absolutely, and we'd be the same. Where I work, we have the capacity to admit them in emergency department to an observation ward, so we would do that. So you do desire that the child is safe for discharge home. What are you going to tell the parents? Yeah, so I think it's important, whatever you tell them, to give them written information as well as what you say to them. And there are some good fact sheets depending on where you work. So in New South Wales, we have the three children's hospitals have produced fact sheets that parents can access and I'll give you the link to them to put along with this podcast. |
So welcome to On The Wards, it's Jules Wilcox here and today we're going to be talking about self-efficacy with Kirsten McKenna. Welcome Kirst. Thanks so much, Jules. Kirsten is a corporate leader turned entrepreneur, the founder and principal consultant of two purpose-driven businesses, Cortex Consulting and my favourite, Winefulness, in Sydney, Australia. Kirsten focuses on igniting and cultivating curiosity with individuals, inspiring teams and engendering positive change in organisational cultures. She's an accomplished leadership and performance coach, a well-being expert, and author of the book, Lead Well, How to Show Up Consistently Well in Leadership and Life. Kirsten is passionate about human potential. She's got degrees in psychology, education, and physical and health education, and she translates science into practical tools to help individuals, teams, and organizations thrive. As a transformational coach, she supports others in sifting through the overwhelmings in order to cultivate clarity, confidence, and grit. She's a soccer mom, an avid runner, a triathlete, an insatiable reader, a yoga teacher, and the free time that she does have is all about family, friends, fitness, and personal growth. So, Kirsten, let's talk about self-efficacy. Before I met you, I had never heard of this term. What is it? It's exciting to introduce you to something. Self-efficacy is essentially one's perceived ability to perform an action or learn something. And so it's essentially around the concept of if you believe in your ability to do something or to learn something, it actually influences your ability in regards to that performance and that achievement. Okay. So how is that different from confidence? So confidence can be considered more general of a term. And it also has a negative slant to it. So you can be confident you won't be able to do something, whereas self-efficacy is positively geared and oriented in that the higher your self-efficacy, the higher your belief in your ability to do something in a designated area. Okay. All right. As a sort of a tool or as a measure for people performing in teams and, you know, what's the word I'm trying to say? So high performance endeavors, which medicine certainly is. Well, because within the definition itself, it examines how self-efficacy is directly related to performance and achievement. People who decide to focus on self-efficacy and decide to nurture it and cultivate it will consequently have a higher rate in their performance and in their achievement in a designated area. And so the fact that we know that if you can focus on your experiences, if you can focus on your vicarious experiences through others, and if you can focus on social modeling and verbal persuasion and physiological states, those are all the things that can influence it. And we have direct control over those things as individuals. So they're within our internal locus of control. And so if we place emphasis on those, it will have an impact on our motivation, on our goal orientation, and on our ultimate sense of achievement. And it's also strongly linked with our self-regulation. Okay. So once self-efficacy isn't fixed, then you can improve it through training and practice. Definitely. And we do start growing our self-efficacy at a very young age. So it's experience-dependent. And it gets influenced by our own performances, by our own experiences, but also by those around us, such as our parents, our teachers, educators, our coaches. And so there are a number of people that contribute to our individual self-efficacy, but we also have a strong internal locus of control over that. Okay. And for this audience audience why is it important for doctors? I think junior doctors don't necessarily feel prepared when they start their postgraduate training and to have a tool and a process that they can go through that will help them develop their self-efficacy means that it'll help them in their performance as a junior doctor and it'll help them receive feedback and take it on board. It'll help them develop a growth mindset as well. And that's with regards to junior doctors. If we're talking about experienced doctors and clinicians, it also helps them in the same ways. However, quite often, the senior clinicians are the ones who are training our junior doctors. And if they can then focus on the four areas of influence when they're training the junior doctors, they can have a significant impact. So, for example, mastery experiences, if the senior consultant can provide opportunities for junior doctors to have as many mastery experiences as possible through deliberate practice and through observation as well, that also incorporates the modeling aspect of self-efficacy. And then with regards to verbal persuasion, feedback is essential and ongoing feedback and support and encouragement, which hasn't necessarily been the path to success, let's say, when it comes to junior doctor training. And so if... My strongest educational memory is being absolutely shat on by a surgical registrar for not knowing how to define a lump properly when I was a student. I can still remember every single word of that. gears and providing that positive reinforcement that then encourages others to do more and increases their motivation and their performance. And it also gives them that higher sense of self-efficacy, which is key because we know the link to performance and achievement. And then lastly, with regards to the physiological states, the fourth influence of self-efficacy, if our senior consultants can ensure that the junior doctors are in the right frame of mind, if they're stressed, giving them opportunities to get into the right state because we know that positive states also influence performance and we want to encourage that. Yeah, for sure. Okay. So you've mentioned some of the sort of components of self-efficacy. Do you want to just sort of drill down on those a little bit more? Yeah, definitely. So the first one is through task mastery or mastery experiences. And that's essentially talking about the more you practice, the more you apply deliberate practice, the more you take part in a task or a learning experience, the better you're going to get at it. And so exposing yourself to as many experiences as possible, whether it's through actual practice or through observation, will contribute to your self-efficacy. Number two would be vicarious experiences. And this is social modeling. And based on the fact that if you observe others who are similar to you doing the task and achieving and performing well, that has a tendency to increase your self-efficacy. So watching others be successful, essentially. Next, we have the verbal persuasion or the feedback, and that we just spoke about with regards to senior consultants providing that feedback but as a junior consultant or junior doctor going out and seeking as much feedback as you can on your performance so that then you can refine and repeat the performance and continue to do that. And then we need good feedback as well. Yes. Trying to give Yeah. Although one thing I came across, I think it was in a different podcast, actually, about feedback. And I think this is a really good one, just to sort of deviate slightly. And what they were saying in that was that when you get feedback, don't ask yourself, is it true? Because that sets you up for a right, wrong, I didn't do it, so forth. We like to tell ourselves a narrative that makes us feel good about ourselves. So if anybody says, oh, well, you know, you could have done that better type thing, we tend not to listen. So the thing to do when you're being given feedback is not to ask yourself, is it true? But to ask yourself, how is it true? And that then reframes that into, you know, I could say to somebody, you know, when you were having that conversation, as a general thing, your conversational skills or your communication skills, you could work on this, that, and the other. If that's a how is it true, then you can say, well, that gives you the option to say, well, actually, I'm really good in this situation, but maybe in breaking bad news, I haven't had a lot of experience and I feel really uncomfortable, and so I could improve there. It's's not so adversarial. And so you're far more likely to listen to it. You're far more likely to take things on board. And that feedback, therefore, is far more likely to be effective. And I thought that was a really, really good way of framing things. Yeah, that's exceptional because it also plays to our internal response to just hearing the word feedback. And this is across all careers and domains, but within the medical profession, with all the high achievers, as soon as you hear the word feedback, you don't even know if it's positive or negative, but just the word activates our stress response and we feel threatened. |
And you're then switching on your relaxation response, which puts you in that good physiological state that was number four for influencing self-efficacy for receiving that feedback because people do even though feedback is common when it comes to medical training I think that people don't seek it out as much as they could. Because it's uncomfortable. Yes, yes. That's partly because you're approaching it as, oh, what have I done wrong? Exactly. As opposed to a more of a positive thing. Exactly. It's interesting, actually, when you lay out the four different things, I think a lot of that, a lot of those components are done unconsciously by people without really realizing, without thinking, oh, actually, I could make this a deliberate practice to provide this environment for the juniors. And that's the consultant who's doing it unconsciously, who then you really enjoy that term. Or you think, oh, you know what? I never thought I wanted to be an oncologist, but after that, you know, now I might because I had such a good time and that was so good seeing that person. And I think that it's providing that environment, providing that positive feedback, that safety and so forth. And perhaps if we could make it more commonly known about self-efficacy and say, well, actually, you can create this environment and it's going to be such a more powerful learning experience. Exactly. Then that will be just so much better. Yeah, because you're also pulling in that growth mindset concept that Carol Dweck talks about with regards to looking at challenges as opportunities looking at the success of others and and getting an understanding of what contributed to their success and I'm believing that you're not fixed in your abilities, that you can improve over time and you can change as opposed to the fixed people who then don't. And then you take on greater challenges as well and you push yourself because you have that belief that you can do it. And failing is good, which we had in the simulation podcast we recorded this morning as well. Failing is good. It's an opportunity to learn and it's an opportunity to get better. It's not a threat. Yeah. Yeah, and that's hugely important. We ran some sessions up at Gosford, didn't we? Yes, we did. We ran a few sessions with the junior doctors out there. And we collected some data, which I can't remember the details of it, but can you just take us through a little bit of that and why I've then asked you to then do this we felt that it was it was something that would be useful for for genius based on what you were seeing in that data that we looked at definitely so I think with regards to junior doctors self-efficacy comes at a really vital part of their careers because they need that internal dialogue that provides them with that belief that they're going to do well. And so what we did was we ran an assessment with the junior doctors to determine where their self-efficacy was at. And there are a number of assessments that you can do in terms of self-efficacy. If you look it up, there's the new general self-efficacy scale. There is the academic self-efficacy scale. So these are validated tools? Yes. Yeah, they're all validated tools. And we'll be able to provide the information after the podcast if anyone's interested in going out and finding out what their self-efficacy is. However, with regards to what we did with the junior doctors at Gosford is we provided them with the assessment and asked them questions such as, I will be able to achieve most of the goals I set for myself. And when facing difficult tasks, I'm certain that I will accomplish them. I believe I can succeed at almost any endeavor to which I set my mind. Even when things are tough, I can perform well. And so those were the types of questions. There were only eight questions that we asked. And what we found is that overall, across all of the groups, that there was room for improvement in terms of... Compared to the general population, you mean, that they were scoring lower? Yeah, compared to the general population. Yeah, that's interesting, isn't it? Definitely. And I think certainly, you know, you go through a huge amount of change in that first couple of years. Going from medical school to intern is obviously the biggest one. And you really sort of get thrown in the deep end. And I think the trouble is with medicine, it's such a vast subject. There are so many potential scenarios out there that you cannot cover them all. And I've been doing it for 30 years and I still haven't seen them all. And I still have to go and go, I don't know what this is, I don't know what's going on. That happens on a daily to weekly basis. So getting comfortable with that and believing in yourself is an enormous part of what we do. Experience is what you get just after you need it most. So they were scoring lower than the general population, and yet they're having to perform these sorts of tasks and are put into an environment when they're far more likely to need it than the general population, I would imagine as well. Yeah, and I think what we also have to consider is that these individuals we've mentioned, they're obviously high performers. They hold themselves to a really high bar. And so when you compare them to the general population, perhaps it's not necessarily apples to apples because their bar is so high. Yeah, type A perfectionists. And so I think just acknowledging that it's something they're not necessarily aware of because it was new to you, and it's something that they can control and that they can influence through the way they think, through the way they feel, through the way they behave. And because of its influence on performance and achievement, it's important to recognize and acknowledge that it also interplays with our ability to establish a sense of agency in order to achieve goals. And so it also draws on the hope theory in terms of being able to look at alternative pathways if we do fail. So if we plan to achieve X and we get Z, then we need to have a Y path. And being okay with that, as you said, accepting that failure is a part of learning and growing and we need to do it in order to progress. Yeah, okay. So, you covered the sort of the components of it, so what are some of the ways that dramas can deliberately try and increase their self-efficacy? I think first and foremost comes down to that experience in the deliberate practice. So just being willing to throw yourself into any situation to learn with that as the main objective and applying that self-compassion when you don't necessarily get it right. Yeah, I mean, self-compassion is a hugely important part of this, I think. And again, that's something that I've seen seems to be really lacking in doctors as a whole, that ability to be kind to yourself. And the things we say to ourselves, we wouldn't dream of saying to other people. And I've run workshops on this at conferences, and we do some regular teaching with our JMOs about this. And it's something that I've had to work on over the years as well. Yeah, but hugely, hugely powerful part of this, I think. It is, it is. And we all have that negative inner critic. And, you know, we need to become our own best friends and our own fans and our own supporters and remind ourselves that we're all human and we're all under pressure and we all have stressors. And everyone's going through the same thing. Yes, exactly. And even though it may not seem like it because we all exhibit the stress and the pressure differently, as you said, everyone's going through the same thing. And I see that time. Literally, I have had DPET meetings when the new intern will come in and they say, oh, I'm struggling and I'm really struggling and I just wish I was like so-and-so because they're so good. And then I get so-and-so coming in and they're going, oh my God, I'm just falling apart. You know, and just, yeah, just carrying on a brave face. Everyone goes through it. Yeah. Yeah. It's really, it's really eye-opening when you see, when you see it from the other side like that. Yeah. I often show an image of the duck on the water and, you know, the legs paddling underneath because we're all like that. We try to put on a brave face, but it's important to recognize and acknowledge that we're going to have times and moments where things don't go well. And so how do we talk to ourselves? And what can we do to learn from that experience and harness growth out of that situation? |
Number two is observe. Yeah. Okay. I'd say next is placing yourself in that optimal physiological state prior to embarking on a task or learning experience. Because if we go into that task or experience in a negative state, it influences our performance negatively. Versus if we go into it positively, if we've taken two minutes to ground ourselves, do a few diaphragmatic breaths to establish that sense of calm, then when we go into that challenging experience or learning, we're more likely to succeed and have a positive experience. Yeah, I think there are some functional MRI studies that show that if you are, well, if you're stressed, you can't access your prefrontal cortex particularly well anyway because the limbic brain kicks in. But also, I remember even reading a study saying that if you have your arms crossed, so in a defensive body posture, not just because the hospital air con's freezing, but if you have your arms crossed, they did one study, and you were far less likely to remember the content of the lecture because your brain takes on a defensive body posture as well. So it also sort of closes down, shuts itself down to protect itself from an outside threat. So being in that negative state of mind, you can't learn nearly as well as if you're... I've heard that because it activates that threat response again, which compromises blood flow to the areas of your brain that are needed for learning. So your hippocampus and your anterior cingulate cortex, they're needed for learning and for memory. And so it also plays to the fact that when we're stressed, we have a more difficult time learning or remembering things. Yeah, absolutely. And I suppose the last thing that I believe JMOs can do is to genuinely make their own well-being a priority because we know that when you are well and when you are focusing on your physical, social, psychological well-being and you make it a priority, it positively influences your self-efficacy and your own belief in your abilities to accomplish things and perform well. And quite often, well-being tends to go out the window because of all of the other demands that are being placed. Absolutely. And there was a study that came out of looking at some traders who, you know, trading is another very high performance, lot of stress sort of thing. And with people who perhaps don't necessarily live the most healthy lifestyle either, you know, walk on the wall street type things. Coming from a trader. Yes, me too. Yes. I'm trying to reverse that. I did get to bed at five on Saturday morning. What they found was that the people who did something that made them happy, something that stimulated them mentally or physically, something that made them feel fulfilled, and I always forget the last one, which I'll come back to in a sec. They were able to perform at a really high level for a really long time. And the way to do it is to schedule it in. So that you do, you know, so you phone a friend to say, hey, let's go for a surf in the morning because then you have to get up and go, not just go, oh, it's a bit cold this morning. I'll stay in bed. Because otherwise, those are the first things that go. And I've done a number of things on well-being saying that it is as important as learning the medicine because if you are not well, you cannot look after somebody to the best of your abilities. Exactly. Exactly. It's an imperative. And with regards to scheduling it in, I get made fun of quite often because I now schedule everything in. I have no white space on my calendar, and it's because this author recommended, his name's Nir Eyal, he recommended having no white space in your calendar so that you don't get distracted. Because like everyone out there, there are a lot of things vying for our attention. And I found I was getting distracted by emails, by phone calls, by the white fluffy dog that walked past. And if I didn't have any free time in my calendar, then I was okay. I stayed focused. And so well-being is one of those things that you need to have yoga in your calendar. You need to have, you know, breathing practice if you do that, or meditation, or going for a run, or whatever it is that you do for your own well-being, including the social connection. I think that's something. That was the fourth one, was social connection. Yeah, it's been compromised this past year for a lot of people. And I think what we're finding is that they're missing that social connection. Or in the case of a lot of JMOs, they're too busy to make time for that social connection that offers a form of psychological detachment. Because you get social connection at work. Yeah. But what are you doing outside of work to nurture that social connection? Yeah. Because what the research tells us is that having low-quality social connections is actually worse for us than high blood pressure, smoking, and obesity. Yeah, that was that Harper's Men study, wasn't it? It's amazing what... We are social animals. We are. We need it. Yeah, absolutely. All right, so are there any resources then for anybody who wants to go off and try and improve their self-efficacy or learn a bit more about it? Are there any resources that you would recommend? There are a number out there. I suppose I'd start off with Banjura, who came up with the theory of self-efficacy. It was based on his social cognitive learning theory. He has a talk out there on YouTube. I'm sorry, what was his name again? Banjura. Albert Banjura, B-A-N-D-U-R-A. So he's kind of the godfather of self-efficacy. That would be a good starting place. If you want to find more about your own self-efficacy within yourself, you can go to positivepsychology.com. They have free assessments on there, which can give you some guidance and at least give you a bar of where you're starting at. And just by educating yourself about what it is and knowing the four factors that influence it, you can start focusing on it and paying more attention to those things. Yeah. Once you become aware of it, then suddenly you start noticing it. Exactly. When you're thinking about buying a certain car, you see the cars everywhere. Exactly, exactly. So I think there is a lot of research out there, and it's started gaining momentum in the medical field. So we're going to provide a couple of articles post-podcast that people can go to. There's some links, yeah. Yeah, and some links, because it's something that started off in learning. It's moved to performance. It's moved to business. And it's in medicine at the moment. And they're demonstrating how both the individual and those that teach them have a big influence over it. Yeah, yeah. Okay. The other thing I'll probably add in for resources as well is that for the self-compassion aspect, if people want to do that, then if you look up Kristen Neff and just go to selfcompassion.org, all the stuff on there, she's the lead person in the world on that. And you need that as well, I think. Definitely. You can't really have one without the other. No, you have to be be your own fan you have to have that positive inner voice you know that gives you a boost when you need it versus yeah cuz it's tough and it's done for many many years so if you don't do that you can have a pretty miserable life but you want to stay happy and focus and you'll be a better doctor if you do that. Patients will like you more. Yeah, it's not all rainbows and unicorns. No, no, absolutely. All right. So I guess if you had to say to anybody what were they going to do from now, what would you recommend the first thing they would do then, the next sort of baby steps or to take it further? Baby steps is get those master experiences under your belt, as many as you can. Find practices that can put you into those positive physiological states quickly. So as I mentioned, the diaphragmatic breathing, meditation, things like visualization, applying a self-compassion practice, as you were discussing, those would be two things that people could start doing immediately. And just reading up on the articles that we'll provide and the links will give you that additional insight into what can be done in the future. Because self-efficacy is something that's also future-oriented. Confidence is more so in the moment of your ability, where self-efficacy is your perceived concept of your ability to perform in the future. Okay. Yeah. Great. |
Welcome to On The Wards. It's Abhi Pal, a medical oncologist based in Sydney. Today we're talking about human factors in medicine with Dr Ranjana Srivastava. Ranjana will be a name that is familiar to many of our listeners, but for those who don't know, she is not only a very successful medical oncologist, but also a very successful writer and media personality. In 2017, her contribution to the field of doctor-patient communication was recognised with an Order of Australia. She's a widely published writer and public speaker and is the author of six books, in addition to being a steady contributor to the extremely popular magazine for doctors, the New England Journal of Medicine, and she's also a regular columnist for The Guardian, with a fortnightly column where she's published many essays on medicine and humanity. So a real pleasure to have her on for this series on the human factors in medicine. I've personally been a huge fan of Ranjana's work and I followed her closely over my career, particularly as a medical oncologist myself. The stars continue to rise and I'm really excited about this opportunity to chat more about how she has got to where she has, where she's up to now and what she's planned next. I think this podcast will hopefully be of a lot of interest to all doctors, but particularly those who are interested in doing something more than just medicine in their career, those hoping to combine their creative energies with medicine, those hoping to reach the public with their message. So welcome, Ranjana. Thank you very much for taking the time out of your busy schedule and these fairly extraordinary times we're living in right now to speak with us. Thank you, Abhi. It's a real pleasure to join you on this podcast and anything to do with junior doctors is particularly close to my heart still. Wonderful. We're all junior doctors once. Yes, yes. You never forget those times. I think the first thing I just wanted to start with, that's one of the experiences I've written about recently in your Guardian column, is a Master of Public Administration that you've completed through Harvard University, funded by the Fulbright Commission. I was reading about the extraordinary nature of how you've done that during a pandemic. I was just wondering if you could talk a little bit, since it's so close to at the moment, I guess, why you chose to do that, what you've taken away from it, and what you're hoping to do with it and how you're going to do that. Yeah, thank you for that, Abhi. So I've now spent more than 20 years in medicine. And for the last few years, I have really been grappling with this idea that bedside medicine can only affect change one person at a time. And while that's incredibly gratifying and so important and so precious, I think, to every oncologist, sometimes I do wonder about broader societal change. And I think anybody who has worked for any time in the hospitals sees that, you know, that there can be a frustrating realization that you can only do so much for one person. And so really, I felt that a master in public administration would give me the tools to recognize how to move the levers of policy and government. And, you know, and as I have done periodically through my medical career, I sort of look beyond medicine to say, well, what else is out there? The world is a really interesting and a large place. And I think sometimes one of the pitfalls of any career, not just medicine, can be you become so stuck in what you do that you fail to look beyond. And so that led to some really interesting conversations with the Fulbright Commission because I'd been a previous Fulbright winner. It's quite rare to both apply and to receive a second Fulbright. And so I just had to compete. I mean, and I did, and I was very fortunate to win a second Fulbright award, which allowed me to pursue this Master in Public Administration at Harvard, which is a one-year mid-career course. We were packed up to go. We had schools lined up for our three children. I rented an apartment by the Charles River. It was all looking great. And then, of course, the pandemic happened. And I kept hoping that the pandemic would happen and go away. Like all of us. Exactly, exactly. So in the end, to cut a long story short, I had the option of either deferring and trying to get on to campus in the next few years, or doing it online. And you know, it's an interesting sort of decision and a choice. And I've always been a believer in making the best of the situation you are confronted with now. And in retrospect, that decision turned out to be right because Harvard remains closed. So I just joined online like the rest of the world, took a sabbatical from work and had a really nice experience studying with 150 people, none of whom was a doctor. Oh, wow. Right. That's interesting. And it was amazing. And so meeting people from the armed forces, for example, or consulting sorts or non-profit sorts. There were a couple of public health people. But it was really interesting. Just to clarify something, this isn't like a master of public health, which a lot of doctors are familiar with. This is actually just public administration. So more general than just health. Correct. So the doctors who want to do sort of will often do an MPH at the Chan School at Harvard is very famous. And there are many people who go on. But I wanted to do, I wanted to get away from health and look at broader systemic change, you know, in health, but maybe in other areas too. So, you know, I studied a lot of international relations and diplomacy and one of my classes was on climate change. And I sort of thought, you know, I read all these things about climate change and you sort of go, well, I'm an oncologist, how does that matter? But of course, as a citizen of the world, it matters. And I think, you know, one of my most gratifying moments about studying at Harvard actually happened to be I was driving my kids to school, I was listening to the radio. And there was a long form interview with a climate change scientist on the ABC. And I think generally I would have tuned out at some point going, I don't understand this. This is not a language that I'm familiar with. I should, maybe I will one day. And as a byproduct of having done a term's worth of climate change from one of the prominent sort of climate change academics at Harvard, I listened in. I listened to the whole interview. I understood it. And I thought, you know, that is the benefit of a broad education. Learning the language. I think so many things are like that. Like science, for example. If you don't know the language of science, you can't participate. And if you understand the language. So, yes so yes so the graduation so i studied for a year i graduated uh just recently and and it's done and it you know i feel i feel the richer for it and now i'm back back it does clarify something so were you doing this in american time then correct for a whole year so this is like you would you're on night shift and uh and And my heart goes out to people who do a lot of night shift. It really discombobulates you. So some of my classes are at 3 a.m., 4 a.m. Sometimes they would end at midnight. And then there were other classes that were sort of, you know, a very respectable time of sort of 7 a.m. or 10 a.m. It was was difficult, but again, I think those were the choices. You either do that or you don't, and I decided it was well worth pursuing that line. Sounds great. Thank you, Ranjana. I guess just moving back a bit now, I suppose what many doctors would know you best for is your writing. And that's, I just want to explore a little bit. I know a lot of junior doctors are listening today. And I know a lot of doctors have a lot of creative interests and not many manage to combine them in their career. A lot of doctors just go down specially training or go down. But you've managed to do both. Can you tell us a bit about when your interest in writing started? And also just related to this question is how you were able to sustain your interest in writing? Because the way medical training is, there's not much room for doing things that aren't papers or publications or directly related to your progress. Thank you. That's a big question, Abhi, and I'll try to answer that. And if I become long-winded, you can always edit it out. |
I started writing at a very young age and I wrote all sorts of things. I was always an avid reader and, you know, entered little kiddie poetry competitions and little story competitions, etc. My first foray into publishing as a doctor, as a medical student, I went back to India. I was studying in Melbourne and I went back to India to do my elective. And I was very surprised and I guess shocked by being removed from the first world bubble of medicine and going back to India where I had grown up and seeing things like rife tuberculosis and people who could not get basic imaging. And I had this and this experience continues to stand out in my head and it will resonate with all doctors. So a man came in with excruciating abdominal pain, and he had been brought to this doctor on a cart. And this doctor was a surgeon who had trained in the UK and decided that he would come back to India to serve his people. So he was a surgeon, physician, social worker, psychologist, everything combined. And everybody came to see him with all kinds of things. There was no triaging. This man came in and the doctor sort of looked at him and said, and examined him and percussed his abdomen. And on, you know, percussion, that thing we don't do anymore, except for clinical exams. Did you say CT scan? Did you say CT or percussion? Yeah, exactly. So percussed the abdomen, which was extremely hollow, and said to me, this man has a perforated viscous and we are going to take him to theatre now. And I said to him in my sort of naive medical student way, I said, hang on, how about the bloods and how about getting a scan? And he said to me, the man has come to us by cart. By the time I send him for a scan, which is not easily available in the town that we were in, and this is, you know, we're talking about 20 years ago now. He will have died. And so without the help of anything but percussion and the stethoscope, this man went to theater, had a perforated gastric ulcer, had his surgery, recovered, and walked out some days later. Wow. Isn't it extraordinary? So I came back and I wrote about my experience. And one of my mentors in medical school said, this is very good. You should send it to the Lancet. And I remember looking at him and going, you're crazy. I'm a fourth year medical student. I don't send things to the Lancet. And he said, no, no, you really should. And so I sent my essay to the Lancet. The Lancet said it was too long and they would publish half of it. And I went back to my professor and I said, isn't it amazing? The Lancet is going to publish my essay. And he says, no, it's not amazing at all. They're cutting out half of it. We should argue for them to publish it in full. And I said, I really am a fourth or fifth year medical student. I don't think I should be arguing with the Lancet. And he said, no, no, you should always be willing to put your point forward as to why your essay needs to be published in full. So with the help of my professor, I argued my case back in those days via snail mail. And my professor, I'll never forget, he's now 90. He lent me his fax machine to fax the Lancet to say, you really do need to kind of look at my essay again and please publish this essay in full. And so to cut a very long story short, the essay was published in full in the Lancet and it was called, Am I My Brother's Keeper? And it was really sort of an ethical debate about doctors like me and migrant doctors, where should they work? Should they insert themselves in the first world medicine world, which is where we have trained, or do we have a duty of care to the world at large? And, you know, and the final sort of irony about that essay, I have to mention this is because, again, this will resonate with students particularly, is so when you go on an elective, you have to report back to the faculty, right? So the faculty has a form, you fill that form out and you submit your report. So instead of writing an additional report, I thought, how cool is this? My report actually got published in The Lancet. And so I photocopied The Lancet article and I attached it to my report and the response came back from the university. The essay doesn't fit the form. I knew you'd say that. I was waiting for that. Yeah, write something else. Yeah, fill out criteria. Yeah, perfect. And, you know, fill out criteria. The computer says no, basically. And what really killed me about that is that I was a struggling medical student and there was an award for the best report. And I kind of went, if your report gets published in the Lancet, I think that is good. And that is deserving of the $200 award. But of course, I was out of contention because my report wasn't right. It wasn't filled out on time. Ineligible, invalid. Yeah. That's it. That's it. So that was my first foray into writing. And then secondly, you mentioned the New England Journal. So several years later, I had just come back from my fellowship in medical ethics at Chicago, which was on a Fulbright. And the New England Journal had a call for writers and readers who read the New England routinely will say that, will see that there are often ads and they will say something like, we're looking for an editorial fellow. We're looking for a writing fellow. And this one said, we are looking for a writer on kind of social affairs or something like that. And, you know, interested candidates should submit a piece of their writing. And so by this time, this was in the early 2000s, I had a few pieces of writing here and there. I had won a few awards for short writing. So I sort of had a little body of work. And so I picked something that I had written about my experience of treating refugees in Melbourne, because I thought that did count as social affairs. And I sent this piece in. And the New England responded by saying that I didn't meet their criteria for who they were looking for, but they liked the piece that I had sent. And would I consider submitting it to perspective, to the perspective section? And so that was my very first essay published in the New England Journal. So, you know, life works in really funny ways. I didn't actually send it to them. I was applying for a job. I thought, wouldn't it be cool to write for the New England? I ended up writing for them in a different way. And then, you know, it continued. And I've now had sort of more than a dozen pieces published in the New England. And one thing I would say about the New England or the Lancet or any of these sort of peer-reviewed prestigious journals, is I've always found that they keep me honest in terms of writing because they're still very rigorously reviewed. And the people who reject your writing will be these people, but you always learn something from those rejections. And so I have continued, despite my busy schedule, to have a goal of writing, say, one essay a year for the New England, because I love the rigor of writing for the New England. Sounds fantastic. So an early experience in medical school, and you started building a portfolio. And I think failure has probably been a part of your career that people probably don't know as much about. I'm sure you've had rejections. And I think a lot of people get deflated. I got rejected. I'm a terrible writer. I mean, how did you handle rejection? I'm sure you've had that. Yeah, I think part and parcel of applying to anything, whether it's residency, becoming a specialist, trying to find a job or writing or playing a sport. Rejection is an inevitable part of life. And really, I always sort of thought that the rejection made me better because especially when I started writing for the medical journals, they wouldn't just say, we don't want to publish your piece. They would say, this is why we don't want to publish your piece. And I always thought that as free advice. I mean, free editorial advice. That's a nice way to think about it. And so I would work on that piece and then publish it somewhere else or send it back to, often not send it back to them because they had rejected it and it's unusual. |
So I think the key here is to be interested in writing for writing's sake and to be interested then in improving oneself. So my metric was never how many publications. And my metric was never how many publications can I get into the New England? My metric was, gee, I love to write. I love getting high grade free editorial advice because I don't have the time to go chasing someone and paying someone to read my piece. How do I become a better writer? And I think that's what's, I think that would be the key to why I have continued to write, because I didn't see this as a rejection that would affect my career. It was always, it was a side interest, but an interest that increasingly, I think, is really important for the mental health of doctors, whether it's writing, whether it's music, whether it's art, something creative. So, you know, I kind of started off writing thinking, this is cool, this is interesting, I bump into stories at work, I should write about them too, this is actually good for my well-being. That's really interesting. So actually, the writing was a protective thing as well, where you got to process those experiences and articulate them for a broader audience. I mean, I would say that as an oncologist, you would be particularly aware of the need to process things. You come home and, you know, the dinner table is not a place to have conversations about what happened at work and how awful it was to look after a young patient who was dying or the juxtaposition of life and death that we see all the time. And oncology in particular can be very sad and very confronting. And I always thought that my writing was my catharsis. Sometimes other people could benefit from it and that's great, but many times they didn't need to. It was my catharsis and anything that was published was an icing on the cake. I think my experience is that a lot of the difficult things at work we kind of box or put away or squash and don't think about and it kind of very try and not process it even. And we kind of, because it's so difficult to deal with, we just don't engage with that material so it's that's really interesting so maybe i mean burn out something we'll talk about a bit later as well but that's tough can i just ask you one thing so i guess in your career when you were younger i am sure you were thinking about specialty training and the kind of medicine is a very military kind of very um the rules are very narrow you have have to have these publications. You have to do this. You have to do that. And you don't get rewarded for doing things outside that necessarily. I mean, and how did you make that decision as to how much time to invest in your career as a medical oncologist, which is apparently your, people might say your main profession, and then your writing career, which is so important as well. I mean, and time, and we all have 24 hours. So how did you, where did you start being confident about saying, look, medical oncology is great, but I also really want to focus on my writing. And I suppose that comes with seniority where you have a bit more flexibility, but just those junior years, what happened there? Yeah, I think that's a really important question and something that I see many people grapple with. And to be honest, you know, despite 20 years in medicine, I continue to grapple with it. And I think we should pay it sort of due justice. I will say at the outset that I think things are becoming apparently harder for junior doctors now and trainees who I see stressing much more about building credentials and sort of, you know, I often, well, not often, but I've been involved in enough medical interviews and hospital interviews to look at a wide range of CVs. And I can say that the CV of today's average intern or resident does not resemble the CVs that came out 20 years ago. A PhD, many papers, what's happening? It's everybody has done a project, everybody has done something or the other. And that's fantastic. But what worries me is that when you look closer, many people have done these things in order to get ahead, in order to find a job. And what worries me is that that doesn't always pan out. So I will be very honest in saying that when I was a trainee, there was quite a bit of pressure on me to do further training because getting an FRACP was just the beginning of your qualifications. It's not enough. It's not enough just to be a specialist. It's not enough. And by that time, I was at a place where I wanted to have a family. And my first decision was, do I have children or do I do a PhD or a master's? And I know that there will be people who can do both. But for me, that was a decision point. And I took it seriously. And I said, what matters to me is having children, is having a family. And yes, I love medicine, but I'm not sure that I am committed enough to doing research because my heart lies in clinical medicine. And so firstly, to somehow shake off the feeling of shame or somehow inadequacy, that if you are not pursuing a higher degree, then you're not cut out, that you are less. And I do feel that academic institutions, unfortunately, make you feel like that and make you feel that if you are not doing something else, then either you're a disappointment to yourself, to the institution, or more pragmatically, perhaps, that you can bid goodbye to getting a job. Yeah, unfortunately, that's more and more. And I see this repeated all the time where I have to think back to a person who said, I'm doing a PhD because I really, really care about this aspect of medicine, which would be amazing. And, you know, many people begin to like what they do, but many people are also not happy. So I think that was, you know, that was a decision thing for me. And then I would very openly say that the decision to take a different path does come with consequences. And there are people who went on to do higher degrees or who went on to really establish themselves as a specialist in a particular branch of oncology or, you know, the left lung or the right breast. And that came with its own rewards for them. So whether they are successful in the public hospital system and are leading sort of lights, people who are obviously doing very well and informing us clinicians about how to treat our patients, which is excellent, people who have gone on to do very well in private practice. And, you know, let's not forget, there's nothing wrong with studying very hard and then having a lucrative career. And one should not judge those people either. And so I had to make a conscious decision to say, A, I really like working in the public hospital system. And B, I think there is value in doing something different and in writing about medicine from a doctor's perspective to educate patients and to inform the wider public. So this kind of ties into this whole issue of bedside medicine is one patient at a time. How do you effect change on a broader platform? And I felt constantly frustrated sort of talking to my colleagues or hospitals about the need for change. And then one day I thought, you know, I should just speak to patients directly. And then I worked on it. And I started writing for various newspapers, Fairfax Media, other publications. Because at the end of the day, the New England Journal is read by people like us. So it wasn't really reaching out to the public. And that's how I decided that I was going to write. I was lucky enough then that The Guardian came to Australia and they sort of road tested me and then gave me a job as a columnist. But it's been a bumpy road. It's been a bumpy road to establish credibility. Many doctors have questioned whether I'm really a doctor or whether I'm really a writer. Really? That's awful. Well, and, you know, I think it, again, is a demonstration of the narrowness with which we can begin thinking. We have such a narrow definition of success. What does a successful doctor look like? You know, a super specialist in a quaternary hospital. Exactly. And I've tried very hard to both break that mold, but also live that and try to be comfortable with it. And I would, you know, I would openly say that it hasn't been an easy process, but I think at the end of the day, I'm content with how I have ordered my life. It's allowed me to be an active parent. It's allowed me, it's probably allowed me longevity in medicine, I would say, which is something that's a real worry for a lot of people. |
People end up not doing things they don't like and they're not having a good time doing it. Thank you. That's really, so I think the take-home message of that is doing something different in medicine is not simple because it's such a conservative and very hierarchical and just having some confidence, being creative. So another example of somebody who has done things differently in medicine is a radiation oncologist that some people may have heard of. Many people may have heard of. Name is Bronwyn King. Bronwyn King was a young radiation oncologist who was one day struck by the fact one patient at a time by treating their lung cancer. But what about tackling the root cause? So then she realized that even her own superannuation fund was investing in tobacco. Yes, that's right. And so she went on this, you know, kind of crazy idea as a very young specialist to go, I'm going to change that. And I'm going to lobby for large companies to divest from tobacco, from big tobacco. And I mean, people who are interested can read on about her really superb career, which has been now recognized nationally and internationally. But yet, you know, again, that is an example. And she was told many times that she was just being silly. You know, why doesn't she just stick to her specialty, do what she knows how to do? Give radiation, give radiation like that. Exactly. And she said, well, hang on, there is a bigger picture here. So this is another example of somebody who worked very hard to become a specialist and then sort of took a creative route to effecting bigger change. I think those stories are really helpful. And having those role models for junior doctors that, you know, Ranjan did this, Bharmah did this, that I can do something creative as well and not be punished necessarily for it is probably key. Just quickly, you talked about The Guardian. I guess one of the things I was going to ask you is what do you think the key principles are when you're communicating with the public versus communicating with doctors? Because I think doctors tend to speak in a particular way and would become unintelligible. Did you have to consciously work out how to get your message across effectively or is there a particular, any tips for that to become a good public communicator? I think one of the keys is that I read a lot and then I try to discern what was it about this reading that struck me and what was it about this reading that was not particularly cogent. And I think it is true that the more you write for public consumption, the better you become. Just like anything else, writing is a muscle. But I've always been cognizant, and I think particularly in oncology, where you are trying to explain such complex principles to hapless patients who are generally health illiterate. I work in a particularly health illiterate community in Melbourne, where there are lots of migrants and refugees. Almost nobody speaks English as their first language. And I think almost, I mean, this is a good example of your primary profession becoming a training ground for something else. And so I'm just very cognizant of how to communicate with the public in understandable terms. And then, of course, you know, writing for a mainstream publication means having editors and readers who will tell you when they don't understand you. So there's a lot of feedback. But, you know, it's a process of continuous improvement. And I think if you care to step away from sort of the ivory towers of medicine and listen to the average person, you listen around the table to how people talk about their health and things that matter. If you just keep your ears open, you realize what it takes and the levels, the notches you have to come down. And that's not meant to sort of discredit the average person, but the notches you have to come down to actually communicate with the average person who may be very intelligent in another field. My father is a professor of physics, but it doesn't mean that he understands medicine. Health literacy. How does health work? Exactly, exactly. So, you know, in a way, it's a really kind of nice challenge, and that's why I've never understood sort of this criticism of, you know, should you be a doctor, should you be a writer? Because I think medicine is the perfect profession from which to reach out to people because illness is so universal. And I don't think simplifying communication is one of our main priorities. We don't go to work with, I wonder how I can simplify my message. It's often really important to do that. And finally, I've noticed that a lot of your writing is fairly ethically motivated or morally motivated. A lot of your writing comes from this place of where you've noticed an inequity or an injustice and you've felt a consent in your writing. You've felt compelled to articulate your response to that. And I know you did an ethics fellowship as well. So just talking, if you could just speak briefly about that fantastic experience you must have had in Chicago as a Fulbright scholar, and perhaps just how do you kind of enact those moral feelings into your writing? Because I think a lot of doctors share your feelings about these inequities and injustices. Yeah, I think that you're absolutely right in that our discomfort with many things we see and are part of can be quite acute. And then, as you said before, we sort of package it away and we often feel that, you know, helpless in the face of a large system, or we feel that, you know, we just need to kind of protect ourselves, protect our well-being and not speak up unless it is absolutely imperative to do so. And I think some of that comes with seniority. I would say that an ethics fellowship for me was, again, a chance to step out of the hurly-burly of clinical medicine to reflect on broader issues in medicine, such as ethics, such as doctor-patient communication. And one of the things that I got to do in my ethics fellowship, which was, again, a very sort of tangential thing that landed, is that I got a chance to accompany a palliative care social worker to people's homes in the States. And she would pick me up in her car and we would drive around town. Wherever she went, I went. Because it was a non-clinical thing for me, I had the time to do it. And sometimes I used to wonder in that year in Chicago, you know, whether I was sacrificing my time to become a better clinician or to do a master's or a PhD. But then, you know, I was there and I decided to make full use of it. And one of the things that really struck me is that the number of people whose homes we would go into who spoke very good things about their oncologists' understanding of treatments and chemotherapy. But the moment they became terminally ill, their sense of abandonment, complete abandonment, to the extent that they had very harsh words for that same oncologist and a real sense of being let down. And of course, these people didn't know that I was an oncologist. And it was quite profound for me to watch people sort of shed tears over these relationships and their sense of being let down. And ultimately, regarding many doctors as failures, because they hadn't held their hand, not because they didn't have access to great treatments. And it was kind of a light bulb moment for me as a fairly, I was then a trainee. I was on the brink of getting my letters. And I thought, oh my God, that's just not the kind of doctor I want to be. And I would hate for people to talk in the privacy of their homes about, well, she was really clever, but she really let me down. Or, you know, she didn't have sympathy or empathy. And I think this whole experience of studying ethics and looking at patients from another perspective sort of really grounded me in ideas about sort of patient justice and equity and fairness and also about speaking out. And one thing I've tried to do, and I hope I've tried to do through all my writings, is not be an armchair expert to say every doctor has got this wrong and I know the answer. And so I think what I try to do in the columns is also accept personal responsibility to say, hey, I'm part of the same system and I make mistakes too, but I'm going to reflect on these mistakes and see how we can collectively do things better. That sounds, I mean, That experience for us today is really common to oncology. When you're in active treatment, I'm going to see you. If you're not, see you. I think part of that is the fragmentation of how we separate palliative care. That sense of abandonment is awful. In the last couple of minutes, you've talked about being a full-branched a few times. |
It's just completely like that's beyond me. I don't know. It's a big question, but in a couple of sentences, what are the key steps in a Fulbright scholarship? Are there key eligibility, key timelines? Is it possible? Yeah, I'm glad you brought that up because everybody I meet, I sort of try to encourage to at least have a look. So many doctors apply for Fulbright scholarships and many doctors are successful. So a Fulbright scholarship is essentially offered. It's an American scholarship that allows recipients from around the world to study in America. And then Americans come to different countries. So it's an exchange program. The Australian American Fulbright Association, and there'll be one, there'll be an association, wherever your listeners are listening from, you can jump on the website. One of the things I like about it is that it has no age limit. So you can apply for a Fulbright at any age. Now a Fulbright, you can apply for to study a number of different things. So for me, it was the study of doctor-patient communication the first time around, the second time around public administration. Some people apply for a Fulbright to fund a PhD or part of a PhD, or you could just go away for, say, three months and be part of an institution that is doing something innovative. So one of the criteria is that you have to demonstrate how this will create public good and how you will come back and contribute to your country in whichever field that is. And one of the wonderful things about the Fulbright is, you know, so I wrote an article about this in The Guardian for anyone who's interested, but there are people who might be studying, you know, rice. And there are people who are studying blindness. And then there is AI and somebody else wants to study space. So they pick people from, and there are Fulbrights in writing. And there are people who go and do, you know, you obviously have to make a very strong case. So you fill out an application, which is a long application. But I think I have applied for the Fulbright four times, by the way, and been successful twice and failed twice. So just to put it out there. Each time, I think the process of filling out the application really helps you crystallize your thoughts. And either it makes you believe in what you're doing or it tells you to reform your project. And I will say that the two Fulbrights that failed to make the cut appropriately failed to do so. So, you know, they taught me something. So you do that. The first round is a paper application with some references, followed by an interview. Again, the interview is, I mean, many doctors will be used to interviews. It's an interview by a panel. Many of them are academics where you talk a little bit more about your project and then there is a decision made. And I think, you know, sometimes again in medicine, we are not always exposed to other ideas and there is this fixed sense that you do your residency, you get into specialty training, you become a specialist, then how could you live now that you've become a specialist? Shouldn't you be setting up shop somewhere and so on? But I would really encourage people who are listening to sometimes take a pause and think about what else is out there because it enriches you. So I guess just to cap off your kind of where you are, where you've come from, where you are now, what are you thinking for yourself for the next five to 10 years? What would you be on your wish list? Or what would you, especially with the MPA, I can understand, is there a particular aspect that you think is, I mean, there's so many things to deal with. What's number one, two, and three on your list of things to try and advocate? Oh, that's a tough question. And I think I've always been someone who has not had an answer to where do you see yourself in five years? Because every five years that I look back, I think I couldn't have seen myself in any of these situations. So maybe that's saying something about sort of not preparing too much and not forecasting too much and being open to possibilities. And that's kind of always been my key. I often say to people that eventually the Guardian may decide that there is another columnist they want to bring on board. And that's great. And hence, for your listeners, there are many people who will ask me for advice about writing for the Guardian, who will ask me, I hope this doesn't lead to a tsunami of op-eds being sent to me, but people will send me articles and say, can you help me publish this? And I have always adopted the view that it's kind of silly to feel that those people are my competition. There are many good writers and writers deserve to be heard. So I will always help someone who says, I want to publish where you want to publish. And I never see that as some kind of competition because ultimately people are replaced all the time. And so I try to enjoy what I do and try not to say, well, in five years time, I will do this or that. Having said that, I think it is important to have some goals. I would say that studying at Harvard and studying a degree that is non-medical does change you. And it makes you think about systemic issues, about broader issues in medicine. And so one of the things that I would like to do is to somehow pivot to being part of that change. And especially in the pandemic era, when I think there will be so much that will need to be, that needs a rethink. I'm also, and particularly in oncology, where I run a geriatric oncology service, by the way, so that eventually became my specialty, but after sort of 15 years, not, you know, not at the outset of my specialist life. So I'm very concerned about an aging population and how we look after an aging population and maintain an excellent healthcare service. And anybody who works in the hospital system sees the fragmentation of care, sees the frustrations, the enormous amount of waste that goes on in healthcare that will need to be curtailed and looked at, not just by bureaucrats, but by clinicians who have been at the call phase. So maybe something in government or policy setting or administration? Yeah, I think so. I think so. And, you know, I think that to be able to take 20 years of bedside experience and harness it and experience in communicating and harness it elsewhere would be a nice thing and another way of public service, which I'm strongly committed to. So, you know, sometimes after you have done a course or you have done something, it's not immediately apparent how that will sort of manifest itself. I am advising the health department, the federal health department on COVID communications with culturally and linguistically diverse populations. And that seems again, like a good thing to be involved in and harnessing my experience to do something different. And so, you know, I think one of the important things is to not be so set in your specialty that you forget to think about other stuff. Like I would hate to be the oncologist who says, what would I know about COVID or what would I know about atrial fibrillation? It shouldn't become like that. It's so tough, isn't it? I mean, specialization the way it is. Like a lung cancer oncologist might not know what's happening in ovarian cancer, let alone what's happening in AF. It's just like we've become more and more focused. Yeah, and I think there is a difference between not knowing the nitty gritty of something. But I think to be broadly aware and to be conversant with the language of broader medicine is really important. And that's something that I feel is increasingly disappearing. And I think it's to the detriment of medicine and it's certainly to the detriment of patient care. You know, you end up having a doctor for every organ and that's not how medicine should be. I don't think so either. Final question is more for myself. I'm always interested. What are your three favourite books, if you've had a chance to think about it and i can see you know i'm you you are talking to me from your library and i'm trying this is this is a jpeg this is okay okay i'm like what books are there i do like books but i you know i read widely and it's very difficult to think about. I will say there is a particular book I read as a teenager that really struck me. And it probably, it was a very fictionalized version of studying medicine at Harvard Medical School. It's called Doctors and it's by Eric Segal, who wrote Love Story, which many people would have heard of, which was made into a film. Doctors is just a storybook. |
Welcome to On The Wards. It's James Edwards and today we're talking about a problem that every junior doctor would have seen on the ward, heart failure. I'd like to welcome Dr. Sean Lau. Welcome, Sean. Thanks, James. Thanks for having me. Sean did one of our first ever podcasts for On The Wards when he was an advanced trainee, but now he's a clinical academic, cardiologist at Rupert and Salford and the University of Sydney. He trained at University of Sydney RPA and Harvard Medical School and has clinical research interests in heart failure. So, shall we, we may start, I mean, heart failure is pretty common within the community and on patients we see on the wards. Maybe she's over you about the definition because it can be often confusing with some of the terms that are used. That's right, and I think the easiest thing for a junior doctor to do is think about heart failure as either heart failure with preserved ejection fraction or heart failure with reduced ejection fraction and they're probably more used to dealing with heart failure with reduced ejection fraction. So this is systolic dysfunction of the left ventricle and most commonly thought of as an ejection fraction that's below 50%. We would regard an ejection fraction between 40 and 50% as actually just mild systolic impairment, but certainly once you go below 40%, that is significant systolic impairment. So that's heart failure with reduced ejection fraction. But in actual fact, what is becoming increasingly more common and probably from a public health point of view in the future will be one of the biggest problems with heart failure is heart failure with preserved ejection fraction. So this is where the systolic function is preserved. So the ejection fraction is usually 50% or above, but the left ventricle is stiff and non-compliant, and there is diastolic dysfunction. So it doesn't feel as easily as it should. And your classic example of such a patient would be somebody who has left ventricular hypertrophy, maybe because they've got a bit of aortic stenosis. They've had hypertension. They're usually obese. They also usually have diabetes as well. So it's this cluster of symptoms which you can already see is extremely common in the community. So it is possible for somebody to have heart failure symptoms, so shortness of breath, or to have pulmonary edema, who when you look and see or look at their past medical history, say, well, their ejection fraction is normal. But in actual fact, when you delve deeper into that and look at some of the characteristic echocardiogram features, you see that they actually have diastolic dysfunction. So what is diastolic dysfunction and why does that cause heart failure? Yeah, it's really interesting because if you look at as we age, there's a natural physiological tendency for the left ventricle to stiffen, which means that when the mitral valve opens and the left ventricle fills with blood, when we're younger, it should fill nice and easily, nice and quickly because the left ventricle is nice and compliant. It's similar to like a balloon that's easy to blow up. But then as we get older, the left ventricle stiffens a bit. So it's not as easy. It's that balloon that's a bit harder to blow up. So that's physiological stiffening. That's physiological changes. But what can actually happen is you can get an exaggerated response of that. And things like hypertension, diabetes, obesity, sleep apnea will stiffen that left ventricle, make it non-compliant. So when the mitral valve opens, it takes longer for it to fill. So the diastolic filling time is reduced. And because it doesn't fill properly, you can get a backup of pressure into the left atrium. So the left atrium will often dilate. The left atrium dilates, then you can then start to get a buildup of pressure in the lungs. So you can get pulmonary venous hypertension, which can then give you shortness of breath as well. And of course, if the left atrium stretches, that makes you prone to arrhythmias such as atrial fibrillation. So that's why that's another common comorbidity with people with heart failure with preserved ejection fraction. The mitral annulus might stretch a bit as well. So you might have some mitral regurgitation too. So it becomes a very common cluster of things we see with aging, obesity and metabolic syndrome. Okay, we may go to an occasion example, we may just come back to see whether those two syndromes you described present differently or are the same. Yeah, sure, absolutely. But the case is a 60-year-old you asked to see on the ward, and they've been down to the respiratory team with a kind of some cough, early-type symptoms and sort of shortness of breath. But I'll take a bit further history. You do note that they have had some difficulty waking up of shortness of breath at night and have had trouble walking up stairs. And interestingly, he's a non-smoker. He's been admitted for some IV antibiotics and some IV fluids and when you go to see them it's because they've been short of breath. Maybe what would be some initial conversation you may have with a nurse over the phone when you're getting called to somebody who's got shortness of breath or that kind of story? Absolutely. So I think that's a very common scenario, particularly around wintertime and people admitted under the respiratory teams with pneumonia, that in fact may set off some heart failure or even lead to a new diagnosis of heart failure. So I think when you're called over the phone, you should ask how long have they actually been admitted for? What treatment has been administered? Do we know if they have any cardiac history? Just so that when you're walking to the ward in your mind, you're thinking about, is this a patient who has known heart disease and the pneumonia has just precipitated an exacerbation? Or are we potentially dealing with something that's not related to the pneumonia and there may be a new diagnosis here? So I think whenever you hear about shortness of breath, obviously you're looking at a respiratory cause for somebody who's admitted under respiratory, so is it an exacerbation of their pneumonia? Have they been in hospital for a long time? Could it be a pulmonary embolism? But then third on the list might be actual, well, is this heart failure? So now you're at the bedside. Just take me through, I guess, your bedside initial look at the patient, but also what you particularly ask for on a history. So always the bedside test is to make sure that the patient is not in an extremis. So particularly with shortness of breath, is this acute shortness of breath which is going to require immediate intervention or are they a bit more short of breath from their baseline and they need some oxygen supplementation and you can take it from there. So hemodynamics are really important here. So I'd want to immediately know about their blood pressure. Are they hemodynamically stable? Has there been a drop in their blood pressure? Along with that, are they tachycardic, which can be a stress response, or it can happen with new heart failure. But obviously with sepsis, we would see that too. You don't want to miss that if for some reason they've got a bradycardia as well, that's commenced and that can sometimes give you shortness of breath or presyncope.. So really it's the blood pressure, the heart rate, have they changed from baseline? Then looking at your respiratory rate, which I think is an underutilized tool when you're looking at acuity. Really you want to have, how hard are they breathing? And then of course, which you probably would have been told over the phone would have been oxygen saturations and how that's changed. Presumably, they may have been on some oxygen from the onset of their admission. Fever as well. Are they spiking fever? So really trying to answer the question, is there shortness of breath related to a sepsis, a worsening of their pneumonia? Or is there something new here? Do I need to consider a pulmonary embolism? And then thirdly, is this something completely different? Is this an exacerbation of heart failure or new onset heart failure that has been unmasked by this infection? So from there, I would then move to, assuming that they are stable on those respects, I'd start speaking to the patient to see, is there another possible cause for this? And what particular things on the history would you be asking about? So in relation to heart failure, I mean, I would first of all ask, is there any history of known cardiac disease? |
So I think it's better just to ask an open-ended question and ask, do you have any past medical history, cardiac related history? Because if you have somebody who says, well, look, I see a cardiologist as an outpatient and maybe they've got some coronary disease and they think about the fact that they've got coronary disease but not necessarily that that's led to heart failure. So I think any sort of history related to the heart is important. So that may include valvular disease, hypertension, your risk factors, hypertension and diabetes, smoking history, whether they've been investigated for coronary disease and whether they've actually been investigated and have their heart looked at with an echocardiogram. And they may then know if they have some impairment. Previous admissions for heart failure is a big prognostic factor so that might be a simple way to ask them have you ever been admitted to hospital under a cardiology team and that would straight away alert you to a cardiac history. So in things in regard to their shortness of breath things like orthopnea, PND, how kind of valuable they are baseline because everybody has a level of breathlessness and that depends on their fitness. But I think a patient who says, I've become progressively more short of breath within three to six months, as opposed to the patient who says, look, I've been getting more short of breath over the last one to two years and that has corresponded with less exercise and I've put on weight, that's less alarming than the patient who says, I don't know why, but I'm becoming more short of breath. When you talk about shortness of breath on exertion, you then want to say, is it on the flat or is it up a hill? Is it up flights of stairs are useful as well, just to get an idea about the type of shortness of breath. If they can say, I can walk on the flat without any problem, but one flight of stairs is now causing me a problem. That's the start of something going on here as the cause of the breathlessness. Then you want to ask for associated symptoms. So you want to say, are they getting chest pain with that breathlessness on exertion? Are they getting lightheaded, so presyncope, palpitations as well? That's sort of the more, if you like, stable and outpatient workup that you would typically get. What you're worried about is the patient who is now short of breath at rest, and that comes back to what you were saying about orthopnea. So the patient who's waking up short of breath, who is now sleeping on two to three pillows having slept flat, you're then really pointing towards pulmonary congestion, and that really then puts heart failure on the table as a cause. So maybe proximal internal dyspnea, I mean what is that and how is that different to orthopnea? Yeah, so I think it's really and it's a very sort of, it has a high positive predictive value for heart failure. It's a patient who wakes suddenly in the night gasping for air and they feel claustrophobia because they're so short of breath as opposed to the orthopnea which is sort of, you know, more gradual sort of thing where you would, sometimes without even knowing, putting extra pillows or sitting a little bit more upright which with gravity would then help, you know, with pulmonary congestion going to the bases of the lung and allow you to breathe earlier. I mean, with paroxysmal nocturnal dyspnea, you do worry about precipitating factors that are waking them early hours of the morning would be a classic example. So sleep apnea may be a factor that is driving that. Coronary ischemia as well, particularly in that early morning when you're getting the surge of your adrenaline, noradrenaline and cortisol to wake you up. That's where you can also, there's stimulants to the heart. So I think the patient who has that, you really need to then look closely at sleep apnea and coronary artery disease. You mentioned some of the background such as sleep apnea and coronary artery disease. What other background or social, in regard to alcohol, that we should particularly look at in regard to people with heart failure? Yeah, absolutely. So, I mean, and the other point would be palpitations to an atrial fibrillation just because that goes together with that. And, you know, there was a recent study that showed, you know, 50% of patients with atrial fibrillation sort of above the age of 60 have some form of coronary artery disease. So it's alerting us to actually look at that. And whether it's chicken or the egg, it's unclear, but it's an important thing to look for. Otherwise, social history, smoking obviously is important as a vascular risk factor. And that goes also with peripheral vascular disease and claudication. So that's something else to ask on your history about exertional shortness of breath. But alcohol is very important to ask and quantify how much they are drinking, whether it's regular drinking or binge drinking. I think the point there is you can get an alcoholic cardiomyopathy, so you can get an alcohol-related dilatation of the left ventricle, dilated cardiomyopathy that is due to alcohol, but it's an extreme amount of alcohol that you would have to be drinking. It's something like 7 to 10 standard drinks per day for a number of years. Having said that, it's a very important thing not to miss in the patient who presents with new heart failure where you have an echo evidence of a dilated heart. And I've had patients exactly like this where they have actually stopped drinking and had a complete reversal of their heart failure, complete reversal and actually gone off medication. So it's one not to miss. So alcohol history is important. Otherwise, alcohol is then related to other aspects. It might make their sleep apnea worse, for instance, particularly if they're binge drinking. So I think that's an important aspect of the history to get. And if we go to examination, just describe especially examination, focusing on those probably related more so to heart failure. Yeah, so actually I should say, James, one of the other points in history would have been family history, of course. So not just of coronary disease, which is what we typically ask, but the other, of course, is is there a family history of heart failure? So then you're talking about genetic forms of heart failure, which can sometimes manifest to your 50s or 60s where you've got a dilated cardiomyopathy or hypertrophic cardiomyopathy so you want to ask is there anyone in the family who's been diagnosed with heart failure a very specific question but another open-ended question would be well has there actually been someone who's died unexplained and particularly dying young and if there's a history of that you'd start to think of a genetic cause like a dilated cardiomyopathy but going back to point about physical examination, so as we said initially when you turned up at the bedside you wanted to make sure all the vital signs were within normal limits or hadn't changed dramatically and you made that assessment about acuity. So as we said low blood pressure, tachycardia are cardinal signs of new heart failure and And I think with that, when somebody has lower blood pressure, you then want to assess a simple test of looking at their peripheries and whether they're warm and well perfused is a very good sign about perfusion and what cardiac output is. Urine output is also very important. So they may not have a catheter in, but it would be good to ask the nurse about what the urine output is and has that been recorded. So essentially you're looking for signs of a low output state, which is a more acute form of heart failure, of systolic heart failure, where the cardiac output is down, you're not able to maintain an adequate perfusing blood pressure. As a consequence you get a reflex tachycardia that's actually trying to drive your cardiac output, and then your vital organs are being under-perfused, and a classic example would be a low urine output. And then when you look at, you know, if you looked at bloods, you know, the creatinine might be going up. Otherwise, if blood pressure is quite stable, then, and urine output is good, then you want to focus then on your chest examination. You take pulse first, obviously, and look for rhythm and look for atrial fibrillation and tachycardia, as mentioned. But then you'd want to look at the jugular venous pressure. Now, I think that's a very difficult thing for junior doctors and specialists alike. |
So anatomically when you're looking at that internal jugular vein if you look from the angle of the jaws below your earlobe and start down, that's pretty much where it would run in most people. I say to people, look, take what you can get. So if it's the external jugular vein that's prominent and you can see that and it's elevated and it's halfway up the neck, well, that's giving you a clue that the right axial pressure is up. But classically, what you should be looking for is a very elevated JVP. Start from the top, work your way down. And if you get to the base of the neck and then you see it, then just make the comment that the jugular venous pressure was not significantly elevated. I think after hours, no one's expecting you to get a ruler out and start quantifying it. I think you just want to know, is it significantly elevated or is it at the base of the neck or do you not see it? And the transmission of the carotid pulse is something that can trick you. I think if you use the back of your index finger with some light pressure and you feel pulsation of the carotid pulse, but then if you put a bit more pressure and you get rid of the pulsation, that's suggestive that it's the jugular venous pressure that you're actually looking at so I like to use that sort of bit of pressure let go quickly and look for the flicker to come back as a marker so I think the important point is is the filling pressure of the heart elevated that's what you want to answer with the jugular venous pressure you then move on to to the chest, you know, and as junior doctors would have been taught in medical school, so, you know, feeling the apex beat, looking for a heave. I mean, they're really quick things sort of to do after hours, I mean, because if you're finding there is a heave over the sternum, you'd be thinking about right ventricular overload, pulmonary hypertension, and things like that. The apex beat, again, can be difficult to feel in people who are bigger and also you don't know how much extremist the patient is in and getting them in the right position and things may not be easy. So I think a quick feel just to see look is it grossly over to the left or inferior so is it a grossly displaced apex, which would alert you to possibly a dilated cardiomyopathy. But I think then really what you want to do is put your stethoscope on there and hear are there any significant murmurs. So what you're really looking for is significant, new, perhaps undiagnosed valvular disease, because that will make you short of breath. It can give you pulmonary edema. So you're looking for your classically, you know, your mitral regurgitation, loud pan-systolic murmur going into the axilla or your aortic stenosis or your systolic ejection murmur that can be heard throughout the precordium. If there's only a light or soft systolic ejection murmur, then listen over the carotids because it might be aortic sclerosis as opposed to stenosis. And, you know, it's not uncommon to get calcification of all your heart valves, particularly the mitral and aortic valve with age and all those other risk factors we just talked about. But what you're really doing is, is there a, you know, valvular disease here that's been undiagnosed? And then all you need perhaps is a tachycardia and a bit of a chest infection, and will set you off into pulmonary edema and then on that note you want to move to the lungs and listen then you want to hear you know are there any signs of pulmonary edema so just want to go to the heart third heart sound yeah a bit cold or fur yeah often they're tachycardic yeah often find it difficult i mean what's your experiences i mean the third third heart sound, if you hear it, is helpful. Absolutely, yeah. Look, I think if you hear it, then, again, it's one of those real sort of positive predictive values. But the likelihood of hearing that is very low. But obviously when you're listening at the apex, you're going to hear for it. It's classically with the tachycardia. So you'd be alerted. It's already in your mind to really hone in on it from the bedside when you've said, well, this patient is now, blood pressure's low, heart rate's up. They don't look so good. They're not well perfused. Almost invariably, you'll then hear the third heart sound. I think, but if you've gone through and everything's quite stable and it might just be a bit of case of some pulmonary congestion that's been set off, your yield of hearing the third heart sound is low. So I think it's the tachycardia is the one that you want to, because it does have that galloping rhythm and it does, if you close your eyes and you hear it, it does sound like the horse's hoofs. It really, it is an apt description of it. And it's just one of those things as a junior doctor that your seniors, if there is a patient that has it, you just, you need to hear it. And once you've heard it, you'll remember it. It's sort of like aortic regurgitation. I think I struggled with that as a junior doctor until I heard quite a few clear cut aortic regurgitations. And after that, it was very clear to me. So I think the third heart sound is one of those. But if you hear it or you think you hear it, that is strongly suggestive of new onset heart failure and usually a marker of someone who's quite sick. So we've gone to the chest, we're listening for pulmonary edema. What's the classical finding? So I think you're looking for perhaps reduced air entry at the bases where there might be some pleural effusion that started, but classically you're looking for, you know, crackles. You're looking for crepitations and it's in both lung fields and it may be more towards the bases, just above the pleural effusion and in the mid zones. But, you know, in general it will be bilateral as opposed to, as you know, I mean, the patient with pneumonia may have very, you know, classic bronchial breath sounds and crackles in a discrete area that's in keeping with their chest X-ray findings. But I think with the pulmonary edema, you're looking for symmetry in what you're hearing. And sometimes when they come to ED, we can even hear wheeze sometimes. Yeah. When they've got bad fluid overload. Absolutely. So there's that notion of cardiac wheeze. I think I always say to the junior doctors on the ward round, you know, with cardiac, with wheeze, I think you just, you have to take it on its merit and say, well, you know, does it fit with the picture of heart failure or is it an exacerbation of some airways disease in someone who's a smoker as well? At the end of the day, it's a clear-cut pulmonary sign. And I think we spend a lot of time trying to tease out, you know, is it some pulmonary congestion or is it an exacerbation of underlying lung disease? And in the end, there's a lot of common risk factors there. And when you've got somebody who's older with both sets of risk factors, in the end, it's probably both. And it becomes academic trying to really tease it out. You need to treat the patient probably for both. And so that's why we do work closely with our respiratory colleagues. And I guess we're predominantly looking, I guess, at left ventricular failure. But in regard to looking to signs of right heart failure, a lot of people have swelling of their ankles. Is that a reliable sign of heart failure or can it be lots of other different things? Yeah, I think out in the community, as our patients and GPs will refer to cardiologists with new onset peripheral edema, and they're rightly asking the question, is this heart failure? I think as we get older, there's venous insufficiency that can occur. And so just due to the elasticity in the veins, and that can be a common cause. I think you've got to put it all together. So with your right heart failure signs, really it's the raised jugular venous pressure. The heave is a really late sign. |
Welcome to On The Wards. It's Carly Castamento and today we're talking about the infant refeeding difficulties with Dr. Chris Elliott. Welcome, Chris. Hi, Carly, thanks for having me. It's all right. Chris is a general and developmental paediatrician. For the past seven years he's worked at the Paediatric Multidisciplinary Feeding Clinic at St George Hospital in Sydney and he leads the Succeed Research Group supporting children with complex feeding difficulties. He's also the father of three healthy young children of his own. All right, Chris, so tell us why we need to know about infants with feeding difficulties. So I reckon infants with feeding difficulties, and we're specifically going to talk about kids who present to the emergency department with feeding difficulties, because of course there's lots of other ways they can present, but most junior doctors won't come across them unless they're doing a peds term so i recall when i was a junior doctor and someone with a feeding difficulty would show up to emergency i felt really uncomfortable about that particularly this was before i had my own children and it feels really different talking about breastfeeding and bottle feeding little tiny babies which is is a really common presentation. So my messages today are that it's okay to feel uncomfortable, but you don't need to because a lot of your basic medical skills and knowledge are all that you need. And the thorough history and examination will take you there. And that it's really, really common for parents to worry about feeding difficulties. So it's something you should know something about. Yeah, so we know from the research that between one in three and one in five parents worry about their child's feeding when they're really little and that if you have a child with a disability it's much higher you know three quarters of those kids will have difficulties feeding at some point so feeling confident with at least an assessment and knowing when to ask for help is really important and uh yeah and the good news is you can do it with what we're going to discuss today. Great. Let's start with a case. So three-week-old Abby has been referred in to emergency by her GP because she still hasn't regained her birth weight. She's very unsettled and the GP is concerned that her mum, Lauren, isn't coping. Lauren's been treated for mastitis and she's got cracked nipples, but she continues to exclusively breastfeed. So, Chris, how would you approach a presentation like this? So this is not that uncommon, even if you haven't seen it before. And having a mum stand in front of you and tell you about their cracked nipples, particularly as a young male doctor, can be really challenging. So a history and examination is all you need. And with feeding in particular, I always think about what the end result is going to be because it helps keep me oriented. There's so much detail when it comes to feeding, volumes times and durations and so on that it's easy to get lost. So just like any other emergency presentation, you're often thinking about admit or discharge. For feeding, I think, why are we going to end up here? And there are three things I think about. Do the family just need reassurance that things are going fine? Do they need information to help them get on their way? Or do they need some kind of support? And if so, what support do they need? So reassurance, information and support. That's where we're going to end. And that helps us keep us oriented as we progress through. And then like with all presentations, I always think about what's common and what's dangerous. So the thing about any child who presents with feeding difficulties or parental concerns about feeding is that it can be the first presentation of really dangerous things. So, you know, this instance, Abby's three weeks old. So could she have a really nasty infection? She sure could. Could be urinary tract infection or meningitis or blood infection or anything. Could she have, you know, she hasn't regained her birth weight. could she have a neurological problem? So low tone or cleft palate or, you know, kind of horrible neurodegenerative conditions? Like, yes, of course she could. Probably she doesn't, right? But there are things we should talk about. And other things like metabolic conditions, pyloric stenosis, inflicted injury, cardiac disease, really scary stuff can present as parents concerned about their child's feeding. But a good history and a thorough examination will get you to most excluding most of those things. The common stuff, so breastfeeding things, bottle feeding things, reflux, constipation, parent skills, mental health. These are the things that, you know, 19 times out of 20, that's what you're going to face. So when I start my assessment, I always think, what's common, what's dangerous and where are we ended up? What am I going to need to come to the conclusion the family just needs some reassurance? Or what am I going to need to provide them some support? And then we go from there. Okay. So in your assessment, what do you do first? Yeah. So whenever we see a child in emergency, it's really useful because a lot of the time they're category three, category four, category five kids, right? They're pretty well at triage. It's really useful to remember why a family has brought them. And, you know, these babies, all babies are the result of, you know, like a nine month pregnancy and a labor process, which is really involved and scary. And like, it's a huge life event for most people. So this was just three, three weeks ago for this family. And they're sent home with this precious bundle to care for and raise. And so people don't bring their babies to hospital lightly. They only bring them if they think something could be seriously wrong. And when you really get down to it, most people worry that their child is going to die because of something that they've done or haven't done. So when you pick up a category five healthy baby who's fallen asleep in their mom's arms, the triage and has no more arms, you've got to think that the family is not at a low level of concern they are maximally concerned about the situation and when you remember that it makes the first thing to do really easy which is you just find somewhere quiet you sit down you don't stand you sit down and you just listen to what the parent tells you and that might take oh my goodness a whole two or three or four minutes where you don't talk, you don't interrupt, you just ask them what's going on. But that two or three or four minutes is so well invested because it starts to bond a relationship. Because if you're going to subsequently tell this family, everything is fine, you can go home, you've got to bring them down from being worried their child is going to die to happy to leave hospital without any tests or intervention. And the only way they're going to manage that is if they trust you. So that's it. Just listen to what they tell you and you'll get a lot of useful information. And then you do a structured history, right? And it's the same with all pediatrics. We also just want to know past medical history and history of any illness. We also want to know about pregnancy and delivery and what happened after birth and what the usual feeding pattern is. And feeding is like many other symptoms like pain, for example, you know, how much do you feed? How often? How long do you feed for? Things like how did they grow? So we know, for example, that Abby still hasn't regained her birth weight. She's three weeks old. And really a baby should regain their birth weight by 14 days so something hasn't worked well with the feeding here and in feeding growth is like the big headline if you're growing well then that's extremely reassuring if you're not growing well then there's something you know you're immediately not at reassurance you're either information or some kind of support um And then so as well as the history and then the feeding history, then we sort of screen for some of the indications for those serious things we mentioned. So fever, lethargy, vomiting, diarrhea, rashes, abnormal movements, you know, all that sort of stuff. So these are questions that you would be familiar with from asking about other stuff, right? Other presentations. And then really important at the end to make some very courteous and respectful inquiries about how mom and dad are going and what kind of supports they've got at home. Because of course it takes two or more parties to feed a baby. There's the baby stuff and then there's the parent stuff. And postnatal anxiety and depression is really common. It's very underdiagnosed. |
you know you can't manage the child's feeling without having teased that out right um so how much and how often chris should a baby feed in the first month of life okay so this is where you come down to you've taken your history and you've heard oh so she feeds 60 meals a day you know 60 mils per feed and it takes 20 minutes and she feeds, you know, four times a day. And you think, oh, that seems like a lot or not much. And so on average, right, and bearing in mind that if you're growing well, then you're feeding enough. On average, you would expect a baby in the first few months of life to feed six times a day. The younger they are, they might feed more, seven or eight or more times a day, particularly if they're demand fed. A little bit older, they might feed less. And you want a wet nappy with every feed or at least three or four wet nappies a day. So that's for a breastfed baby. And for a bottle fed baby, you'll often find that some of the fluid calculation formulas, which are on the back of your fluid charts, are quite handy. So, you know, 120 mils per kilo per day or something. But as long as you get a sense of, for breastfed kids, how often and how long they're feeding and how they are afterwards. So this comes to whether they're feeding enough. Are they settled? Do they fall asleep? Are they happy? Do they sleep for a good period of time? Or are they still cranky and grumpy and miserable and whatever? Then if they're growing and they're settled and they're feeding six or seven times a day, that's fine in my book. I mean, Carla, you've got kids. How often do your kids feed when they're little? It's really variable. Yeah, how long is a piece of string? It's true, right? And, you know, it's so interesting. It wasn't until I had my own children I realised this idea of, you know, three or four wet nappies a day is like totally dependent on how often you change their nappy. It's completely arbitrary. If you leave them all day, they have one wet nappy, but it's got half a kilo of urine in it. Not that as a father I've ever done that. All right, so we can tell if they're getting enough, if they've got wet nappies and all of those things. But how do we know if they're getting too much? Can they get too much? Well, babies, yeah, babies are not good, particularly under three months. They're not good at regulating how much they take because feeding is a reflex. So if you put a bottle or a breast in their mouth, a healthy baby will have a brainstem reflex to suck and swallow and breathe. So I think certainly you can be overfed. I mean, you're gaining weight very quickly. You're vomiting a lot. The kids, particularly kids who are fed, you know, six or seven, eight times a day, large volumes via bottle, vomiting a lot, gaining weight really fast, there is a risk that they could be overfed. But you don't want to reach for that as the first diagnosis. You want to really be clear in your own mind that there's nothing else going on before you say, well, you're overfeeding your baby. Because, and we'll come to it later, but sort of crummy advice from lots of different places is one of the major challenges when feeding your baby right so every person in the world has an opinion about how you should feed your baby and they're all slightly different so that's really um you'll be really clear in the advice you give and overfeeding is a very specific thing that you want to um i wouldn't say that to a family lightly, but it certainly can happen. I think we've all seen those kids who've really chubby kids who've been overfed and vomit all the time. The parents say they vomit all the time and they don't wake up overnight, but they've gained, you know, they doubled their birth weight in two months. And you think, well, that's, you know, more than they need, probably. You can safely back off. Yeah. So the weight is a really good indicator that you keep coming back to right that's i really if you're growing well my whole level of suspicion goes down for feeding but if you're lethargic and you know in abby's case there's some suggestion that um uh oh she's very unsettled right so that's red flag. Yeah. And do you go by growth charts or is there a formula that you use for kind of a rough guide to appropriate weight gain? Yeah, I mean, so roughly you would expect a healthy newborn baby to gain 150 to 200 grams a week, 100 to 200 grams might get away with. But I always chart on a growth, put on a growth chart because, you know, there's incredibly rapid growth in those first few months of life, but it does sort of peter out. And if you're sort of guessing, you know, every child in New South Wales has a blue book and other states have other newborn health records where you can plot it or your electronic medical records will have growth charts appropriate for newborns. Just put it down there and you don't have to worry. and it's so useful to have documented it because then the next time the family come in with a concern you can see how things track over time whereas if you haven't taken the time to measure you know height sorry length and weight and head circumference it's very hard to be reassured you know two to four or six weeks okay so for baby abby we've talked about a history but what would you look for an examination so with all pediatric examination just remembering that observation without so meaning just standing looking at the baby in the mum's arms or on the bed or wherever without touching them is incredibly important way to start an examination to get so much information when they're calm and settled so once you've riled any baby up and they're crying and they're miserable it's really hard to listen to their heart or to get a blood pressure or a pulse rate or whatever so my examination is always you know i'm a pretty pragmatic simple guy it's like sick or well common and dangerous i'm always thinking what don't i want to miss here so there's a arjun rao did a great on the woods podcast about you know how to assess a sick child and i think you should have a listen to that if you're still figuring out how to determine between sick and well but that's really important so if you're sick if the child looks unwell dehydrated tachycardic febri lethargic, then you want to go and get a senior member of ED right away. Say, excuse me, I've got this three-week-old baby. She doesn't look very well. If she looks well, then you're going to end up doing your growth assessment and a thorough top-to-toe with the baby fully undressed, including looking inside their nappy. Yeah. So it's a mistake to think that it's hard to undress babies. Sometimes they don't always like it, but the parents can help you. But you really want to start at the top with the fontanelle, come down looking at their facial expression and the way they move their tongue and their mouth, which is kind of like an observational cranial nerve examination, just the way they're symmetrical when they cry, come down to their chest, listening to their lungs and heart, their abdomen, palpating their abdomen for masses and lumps and tenderness and whatever, looking at their groin for hernias, testes if they're down, looking at the skin, their tone and their muscles, flipping them over, looking at their back, looking at their bottom. And, you know, any person is capable of doing those things, even if you're not very experienced with children. And you just have to record what you see. So we're really looking at excluding dangerous things so that if we do come to the point of reassuring parents, listen, everything is fine, we've got a lot of good evidence to back that up because the stakes are really high for these little babies. A little baby can't go a long time being underfed and stay healthy. So we want to reassure ourselves that that's the case. Great. What investigations would you do, Chris? So, again, I have these two categories, sick and well. So if you're sick, you may need lots of investigations, blood tests and urine and whatever else. And you will definitely need senior guidance in what to ask for? Because we want to do the right number and the right type of examinations on babies. They're usually invasive. We don't just do a sort of a scattergun approach. |
Well, that's holding baby down, doing a very technically challenging procedure or putting a catheter into their bladder to get a sterile urine sample. So sick, senior help, investigations are needed. Well, you may not need any investigations, particularly if they're growing well. If they're not growing well, as Abby isn't, then you're going to need to have a hypothesis about what's going on. And investigations can sometimes help there. So I often think about what's going in, what what's coming out and what people's requirements are. A bit like fluid balance, yeah? So how much is Abby getting? How much is she losing? And does she have any increased requirements through cardiac disease or anything else? And that's going to guide your investigations. But basically, a well-looking child who's growing, I think you should err towards not doing investigations. The kind of common investigations that would get done for pretty healthy kids, and maybe I'd consider with Abby, would be, I would consider blood glucose. Yeah, particularly if you've lost weight recently. I'd consider looking at the full blood count and electrolytes. So I worry if she's dehydrated, she might have hypernatremia, which can be dangerous. I would consider urine, looking for occult urine, tract infections, which can affect young babies and can be a reason for poor feeding. But again, I would always, if I was a junior member of ED, I'd always expect someone to come and ask me about that because it's a big deal to collect those things. Yeah. What management would you instil for baby Abby? Okay, so baby Abby, is she, let's talk about sick or well. So we haven't got extra information, but we know she hasn't regained her birth weight. So she gets a red flag on growth. She's very unsettled and the GP is concerned that mum Lauren isn't coping. So there's three, there's sort of two red flags that you can be unsettled for lots of reasons as a baby, but putting that all together and thinking about, are we going to give this mum reassurance, information or support? I'm already thinking we're in the support category. I'm probably not just going to give this mum extra information and send her on her way without providing some additional support. There's the last sentence of the case, Lauren's been treated for mastitis and has cracked nipples, but continues to exclusively breastfeed, which I just point out is very, very good. We should be really careful about advising breastfeeding women to stop breastfeeding. And I would say it's never a junior doctor's role to ask a woman to stop breastfeeding without really seriously getting advice on that. Yeah. For a range of reasons, not the least being breastfeeding is wonderful for women's health and baby's health. And it's also not based on my personal experience, but certainly observation. It seems really hard. And, and, and, you know, I really, for people who have never breastfed a baby like myself, just listening to women talk about it, it's kind of trivialized in a way in contemporary culture and even the health system. People just assume it's natural. The baby will get it. You'll get it. And, you know, but I watched my own children really struggle to breastfeed for a long time we need a lot of support to get there particularly our first so to to just say casually to mom change what you're doing with breastfeeding i think is um is a mistake and not in in their best interest unless you've got really good reasons okay so um you can breastfeed with mastitis it's important you don't ask the mom to stop so let's go back to what kind of support so i'll I'll take it in order of the sorts of things you can do. So for reassurance, recognising that we're going to get to support for Lauren. So for reassurance, we said right at the top, parents come fearful for their baby's lives. So to reassure them, you've got to have some evidence. You've got to have built some rapport. And if you know already the family are highly unlikely to believe you when you try and reassure them and discharge them, if that's your intention, then go and get some senior support early because there's nothing less rewarding than forcing a family out the door who don't believe that you've done a good job. They're not reassured. They will, you know, if you were a parent of a child and you weren't reassured you'd had good service at a hospital you would be obliged to go find some other person to help you right and we don't have to wedge families into that situation it's not an admitted discharge kind of a way so um but if you are going to reassure them i always start by reminding families they're doing a really good job and i'm really glad they brought them to hospital they they're trying to hospital for a check. And there are a few people more vulnerable in our society than young babies. So it's always like good work. Parents rarely hear that they've done a good job and they should. And then if you're gonna reassure someone, I always talk about safety netting. So there are breastfeeding association hotlines, there are nursing hotlines, there's a family doctor, you can always come back to emergency if they're not right. Give people permission to seek other healthcare after you let them go. So we're not going to just reassure Lauren and safety net her, we're going to think maybe about whether she needs some information. So I don't have any more information from Lauren, but let's think about the hints and the clues in the presentation about postnatal anxiety, depression or fatigue. So she might be very exhausted or she might have some anxiety and depression. The weight loss means there's something not working with feeding, whether they're breastfeeding or bottle feeding. And so is it sufficient to give information? Well, you could say, again, family doctor or the early childhood nurse or their lactation consultants. you might be able to refer to a paediatric clinic in the hospital. And in the links, I'll give you a couple of really useful links to talk about structured approaches to feeding and some websites which we sometimes refer people to like raisingchildren.net.au or paediatrics.online. There's a feeding section there. So there's useful places you can give families information. But for lower end, we're talking about support. So again, what's it going to be? Outpatient support at home or an admission? Outpatient support, remember in this area, I mentioned early childhood nursing. We don't do much of it as doctors, right? But there is a whole primary healthcare sector out there that's sort of targeted at this. And it very much depends on where you live and what the access is. But the families will have been told when their children were born who their early childhood services in New South Wales, they'll have had a home visit. So they'll have some contacts and connections and they're really great places. Those services have pathways back into the health system if families want to follow up there. But then you can admit the child and there's a range of reasons why you might consider that in Lauren's case. It doesn't say what time Lauren presented, but probably, what do you think, Kylie? Probably it's like nine o'clock. Usually, yeah. Usually they've seen the GP in the day and then by the time they've waited four hours in ED, it's getting to nine o'clock at night, isn't it? Right. So, you know, before we discharge someone home, we've got to make sure they're safe to go. And I don't have any information here that she's necessarily safe. She could be. It could be that we've got the wrong end of the stick. She's got a really supportive partner or parent who can come and help. And one of my primary hypotheses here would be that the baby's not getting enough milk. It might be an opportunity just to offer an extra bottle or some more breastfeeding with follow-up in 48 hours or 72 hours as an outpatient. That is an option if everything else is more reassuring after your assessment. But I will admit children, or rather I'll ask, I would ask the pediatricediatrician or the paediatric team about an admission. If you don't have enough information to make an assessment, if you don't have enough information to reassure yourself that the child's safe to go home, there are two good reasons to admit, even just overnight. And you ask the nursing staff to document what happens with feeding. And the next day you can ask for some lactation support from your obstetric service or midwifery service. And you might then in the morning be reassured that, oh, the baby's completely healthy and feeds well and just needs an extra feed and we'll follow them up in a couple of days through the early childhood service. |
Okay, welcome to On The Wards. It's James Edwards, I'm here again and today we're talking about graded assertiveness and we have the pleasure of welcoming back Dr. Sarah Dalton. Welcome back Sarah. Thanks James. Sarah is a paediatrician working at the Kids Hospital at Westmead, also worked for the Clinical Excellence Commission, has a senior role within the RACP and about to move to the ACI. That's right. So perfectly posed to speak about graded assertiveness which is something that has probably popped up in the literature especially over the last probably five to ten years. So what is graded assertiveness? Well basically graded assertiveness is a way of talking about talking, a way of getting a message across when you're not quite sure how to say something that might be a difficult thing to say to a senior person. So where does the concept or where did the concept arise from? It all came out of the aviation industry and we know a lot about crisis management has come out of the aviation industry. I believe that in the origins of it, it was about the crew working together and pilots working together. And in particular, giving the junior crew an opportunity to speak up to the head pilot, trying to challenge what they thought might be wrong in a way that was manageable for everybody. So why do we need it? It's really about giving junior people an opportunity to speak up. And I say junior in terms of of hierarchy people who might not be as high in the hierarchy but are often the people whose eyes are open and can see things that the person in charge might not see. Sometimes the people who are more junior in the team have better situational awareness about seeing different things and knowing different things and it's about bringing that information to the conversation. Okay I mean we can obviously say having hierarchies in health may be bad and you say that people with the perspective of a gene doctor can see things that a senior person can't but do hierarchies in themselves serve a purpose within medicine? Oh look absolutely everyone has to have a approach to decision making and problem solving and ultimately one person is responsible for a decision. It depends on the decision to be made and the situation. Obviously in resuscitation or crisis environments then an urgent decision is needed, in which case a hierarchy is really important. But it also is important to be able to capture feedback from everybody on the team and this is one way of doing that. Okay, so we may go to a case and we can explore some I guess methods and ways to look at and use greater assertiveness. You're working as an intern on a busy orthopaedic team. The morning ward round, the registrar marks a patient's left leg for a hemiarthroplasty. But you admitted the patient last night and believe they have a right neck femur fracture for operative management. What would be your approach to the registrar? I think that's something that everybody can relate to who's been a junior member in a team. You see something happening and you don't quite know what to do. I think the first thing is a matter of considering how important it is to act on it and when is the right time to act on it. This question is a difficult one because this has arisen in the team in front of a patient, which may not always be the best time to bring something up if it's not urgent. So I think the first thing would be, do I need to do something now or can I do it later? But if this is a marking going on a patient that will go with them to theatre, and if you know the patient's about to go to theatre and you don't have another opportunity, it might be something that you have to speak up for at the time. Okay, so speaking up's got a bit to do with, I guess, the seriousness of the incident as well as the timing? Yeah, that's the way I would see it. I mean, is there a concern about one of our embarrassing the registrar in front of the team but also in front of the patient? I think it's both. Absolutely nobody wants to make their registrar look bad but also you don't want the patient to feel like they're in the wrong hands, that they can't trust us, that we were about to make a mistake. So it is a very difficult issue. But sometimes you can use some techniques to get away with having a short conversation that can put it out pretty quickly. Maybe can you outline some of these greater assertiveness techniques that are available to junior doctors? Sure. So there's a lot of different ways of going about it, but there's just a couple that I thought I'd outline today. There's one that's a pretty easy kind of two-step technique. It starts with what we call advocacy with inquiry. So advocating for what you see and inquiring as to why that might be the case. It usually starts with something like, I notice that you just put a mark on the left leg when I know that the problem's on the right leg. Have I missed something? So it's just making a statement about something that you see. And sometimes, in many times, that's enough, just the first step. If you don't get the response that you want from that, then you can go to the next step, which is more challenging, which could be something like, I see that you've marked the wrong leg. I think we need to fix that now. But that's much more confrontational and difficult to do in front of a team. So you said you've got more than one technique. Have you got another one that you'd like to identify for our listeners? So one of the things people talk about is CUS. It's easy to remember and it's easy to talk to your friends about cussing your registrar. CUS stands for concern, uncertain, safety and stop. And so they're the four steps of escalation. I can speak through some examples of how you could do it in this case, if you like. Yeah, I think it'd be really valuable for our listeners. So expressing concern is a little bit like the first step that we just discussed. It's saying something which is kind of a, you know, I'm, excuse me for interrupting, but I just always like to double check things. Mr. Brown, was it your left leg or right leg today? Sometimes you don't get a response or you don't get what you expect and you might need to up the level a bit. The next level is uncertain. So it's just being a little bit more aggressive and saying something like, you know, I'm not sure, but I thought your fracture was on the left side. And so you're actually being more specific about what the problem was. If that doesn't get the response required, you can move to the level which is safety. And that's really saying, you know, we've got a problem here. So something like, you know what, I'm sorry, but I don't think it's safe to proceed until we confirm which is the correct side. You don't usually get to that point and hopefully you won't get to the next point, but the next point is stop. And that is pretty much what they say, stopping the line, stopping things going forward. And you might say something like, can we just stop, please? We need some time out to confirm which is the right side. Okay. When I look at this case, this is fairly unambiguous. It's obvious that they've chosen the wrong leg. But sometimes you may think the decision by the registrar consultant was the wrong decision, but you also may be, I guess, concerned about maybe your lack of experience or lack of judgment and not want to raise a potential issue. How does a junior doctor cope with that, I guess, concern about maybe your lack of experience or lack of judgment and not want to raise a potential issue. And how does a junior doctor cope with that, I guess, uncertainty about their own knowledge when really trying to speak up with somebody who's more senior than they are? I think actually that the first step of both these techniques is the excellent way of going about that. Because it pretty much says, say we were to take a different example, like you were about to use the wrong antibiotic. You could say something like, oh, I noticed that you've chosen gentamicin. But in my experience, all the other consultants use something else. For my information, can you explain to me why we're using gentamicin today? So putting the onus on them to explain to you why with the way of suggesting that it's your own knowledge that needs to be improved. And sometimes the reason that this technique, particularly advocacy with inquiry, exists is sometimes you get an answer back that is a very good answer. And you might have the consultant say, look, there's been a paper released recently. I've just reviewed the evidence. |
Welcome to On The Wards. My name is Eloise Sobelz and today we're talking about after hours care and safety with Dr Sonia Chanchlani. This podcast is produced in collaboration with MedApps, a proud sponsor of On The Wands. Welcome Sonia. Thank you, thanks for having me. A little bit about Sonia before we begin. She's currently balancing clinical forensic medicine and training in the Royal College of Medical Administrators across WA, New South Wales and Queensland. She completed a dual master's in health management and public health alongside research interventions to promote clinician wellbeing. Advocating for junior doctors and enabling a safe working environment led her to being appointed as the Director of Clinical Training at the Royal Brisbane Women's Hospital prior to her current role as the Chief Medical Officer at MedApps, working closely with organisations to ensure governance, clinician engagement and wellbeing are prioritised. That's quite impressive resume, Sonia. And as you know, it links in quite well with what we're talking about today, which is After Hours work. So for those who are like me and are nearing the end of their medical school training, or perhaps those junior doctors who are yet to do an after-hours shift. What is after-hours work? So just going back to the basics, I guess any work that's conducted outside of what's considered normal business hours of a hospital, which normal is usually considered between 8am and 6pm. So after-hours would include evenings and nights on weekdays, all day weekends and public holidays. Okay, great. And so obviously, I know that future me will be doing some kind of night shifts and after hours work. But which doctors are likely to be doing these shifts? Is it just juniors? Junior doctors make up the majority of the on-site workforce, looking after most of the general wards, with more senior clinicians also rostered to be available for phone advice. And then again, it's differentiated between units. So the emergency department would have a range of different roles, as well as units like ICU. But generally, the ward doctors are junior. Yeah, it's good to know that perhaps there's more people around than just juniors, because I think I probably speak for not only myself, but also like some of my colleagues that we're probably most nervous about doing the night shifts by ourselves so it's nice to know that there's probably some other doctors around to help us which would be great. Around and under the phone as well. Oh good yeah of course. So what is the role of a junior on a night shift or perhaps more poignantly, what is the expectation of a senior doctor that they have on the juniors who are on that night? Yeah, so I mean, it's well known that most of the roles and responsibilities are reactive as opposed to proactive clinical management. So kind of waiting around to get called to respond to acute issues, including acute patient deterioration, any patients of concern, admissions, or even things like minor ward-based procedures. They're usually kind of the roles and responsibilities of the juniors after hours. So what are some of the benefits working after hours as a junior? I'd love to hear what you think. I guess word around town is that some of the benefits working as an after hours junior is increased autonomy, exposure to like a diverse cohort of acutely unwell patients, good learning experiences and opportunities, including in procedural skills. But these are all based on the caveat that these environments provide the right type of emotional and physical support for all of the clinicians involved. And having that type of support is obviously quite important for the juniors who are just starting. But what are some of the limitations to working after hours that, you know, juniors should be aware of? I guess we just have to keep in mind that healthcare is a resource-constrained environment. And my experience, as well as the experience of many of my colleagues and some of the project work I've done in this area is that juniors can feel quite busy, commonly talking about feeling run off their feet, having limited kind of handover and communication opportunities, dealing with patients that aren't their own, so unfamiliar patients with unfamiliar conditions. And overall, I've heard feedback about it being quite an overwhelming and stressful shift type of work. I guess in general, there have been many studies about shift work disrupting healthy and positive work-life balance and kind of the effort required to maintain positive emotional states after doing a lot of shift work. And one of my experiences and one that I hear quite a bit is the lack of a team environment, limiting that concept or sense of community that clinicians, especially nowadays, are craving. So it can feel quite isolating. Yeah, that's actually really interesting to hear. And particularly since, you know, I haven't had the experience yet, it's really good to sort of get that perspective of how others feel. Do you think that there's a higher mortality rate for patient admitted as emergency cases on weekends. And so this is combined with the trend of hospital staffing being reduced after hours. So I guess the combination of fewer doctors on site in the evening and the weekends that are more junior working with less experienced medical staff on the ward and access to, you know, limited support services can all be compounded. And so like based on my experience, as well as the projects that I've worked on, key elements have been missing in some of these organizations or in the processes to kind of create the optimal environment for patients and staff. Some of them are based on unclear roles and responsibilities of the clinicians on the floor. Again, limited handover and communication of patient management, unclear escalation strategies or maldistribution of workload. So some doctors having really busy wards and some doctors just having kind of not as busy wards in their portfolio. And then all of that combined with kind of limited onsite skill mix to support and supervise any complexities or complex deteriorating patients or procedures can all have an impact on patient care. Yeah, so you've identified some really important issues there. And I guess as well, then that kind of indicates how important it is to have resources that help junior doctors as well as other staff in during their after hours work. So what are some of the current resources out there that support those working after hours? When I was a junior, we had our after hours on call book, our like trustee clinical Oxford guidelines, or in Australia, they, you know, most people are familiar with On Call by Tony Brown, which is now an app. And it's like our security blanket kind of running around our first few night shifts with all of the bookmarked pages, easy access to common calls and presentations. Some hospitals have developed local guidelines, like after our survival guides with more specific local details of escalation strategies. But then this is an area, this concept of after-hours and access to resources that the organisation that I work with, MED-APP, has a lot to contribute to in terms of ensuring that the right information is at the fingertips of the clinicians that need it the most. Yeah, it's great to hear that there are people like you working on initiatives like this to make things easier. But speaking on MedApp specifically, what information does it contain? And can you give us a real life example of when it can be used? Yeah, so for those unfamiliar with MedApp, it's basically a blank slate. It's a repository for local resources that hospitals can purchase the app and then populate it with all of the relevant clinical and organizational guides that your clinicians need to do their job. So specifically in the after-hours environment, the app is populated by the medical education unit with after-hours common calls, escalation strategies, clinical procedures and protocols. There might also be a section for contact information for other members of the after hours team, after hours theater management, bed managers, as well as the rosters outlining who's on site and who's on call from home. And then again, local organizational resources like hospital maps, when you're running around a new hospital that you're unfamiliar with the landscape, where to park after hours is something that most people don't think too much about until it comes to the night of, how to access taxi vouchers if you're fatigued and don't feel confident driving home. And also things like where you can find healthy treats at 3 a.m. So a really resource kind of heavy app, especially in the after hours tile, is of crucial benefit to all of the clinicians and the patients. Yeah, that's great. I actually didn't even think of the parking thing until you just said it. So it's really good to know that you guys are really thinking outside the box of things that we need to know, not just ward-based issues. But I guess now we want to speak, I'm speaking to you more generally as a senior doctor who's gone through training. Are there other factors away from digital health which could ease the strain on our junior doctors? |
Hi, it's James Edwards. Welcome to On The Wards. Today is the first day of October 2014 and we've got Dr. Oliver Warren, who's a colorectal fellow at RPA. Welcome, Oliver. Hello. Thanks for having me come along. Today we're going to talk about something I know little about, stomas. So many of these podcasts I ask inquiry questions questions but i often know the answer to the questions but some of these questions i don't know the answer so i'll be very interested in your perspective on stomas because it is something that junior doctors will occasionally get called about especially after hours yeah and especially they are not doing a surgical term could be quite challenging so'll start with a case. The junior doctor on the ward covering the colorectal surgery ward after hours. Been asked by the nursing staff to review a patient day two post-heartless procedure with a dark-looking stoma. So it may go right back to the beginning. What is a stoma? Can you maybe define what a stoma is? Well, yeah, I think stomas can be quite challenging. And people who aren't used to looking after patients with stomas, they can actually initially be a bit frightening because you're not quite certain what you're looking at and why it's suddenly there on their abdominal wall. So if we just start by considering why a patient might have a stoma, and really there aren't that many reasons for a patient to have a stoma. I tend to like to think about them either as permanent stomas or temporary stomas. The only true permanent stomas that patients have are patients who for nearly always malignant reasons have had to have their sphincter mechanisms removed. So they no longer have an anal canal. They don't have an internal and an external anal sphincter. So they have a truly permanent stoma. They have no mechanism by which they could be continent and be joined back up. So those patients tend to either have had that done because they've had a cancer of the low rectum, they've had a cancer of the anal canal, although the majority of anal cancers are now treated non-surgically, or they've had severe Crohn's disease of the anal and rectal region, which was so bad that they had to have that area removed. There are of course even rarer reasons but they're the most common. They have permanent stomas. For all other patients their stomas are temporary. Now for some of those patients they are truly temporary and they are awaiting a reversal. For other patients although they are temporary by nature of the fact that they still have a bottom and they could be connected back up, they, for whatever reason, in all likelihood and reality, will not go on to have their stoma reversed. So an example of that might be a patient who has an inoperable pelvic malignancy. So they've still got their bottom, but they've had to have that pelvis what we call defunctioned. They've had to have the bowel brought up proximal to that nasty pathology. And that could be for symptom relief, pain relief, because they'd become incontinent, because there was infection that was being driven by the passage of faeces through that area. So whilst they have, in theory, a temporary stoma, they never actually go on to have it reversed. So for those patients who are reversible in the truest sense, they tend to have had a stoma created upstream, normally from a surgical join or what we call anastomosis. So something has been removed either a cancer or diverticular disease or a Crohn's stricture or other pathologies. The bowel has been joined back together but the surgeon at the time is concerned enough about the healing of that join that they wish to give that join a period of not working. Now, it's commonly said that that is to rest the bowel, but that is a slightly misleading concept. What we know from large randomised control trials and meta-analyses is that whilst defunctioning an anastomosis, so stopping that joint from having to work on faeces, does probably reduce the chance of that anastomosis leaking. It does so by only a small percentage, perhaps within the order of one or two percent change in the chance of a leak. What it does do more importantly though is it reduces the severity of any leak. So in a scenario in which you feel a leak is either possible or probable or that the patient is so frail that they wouldn't survive a leak you then elect to defunction that patient by bringing up a stoma for a period of normally three to six months. So I hope that that just gives a little bit of an overview of why these patients might have stomas on their abdominal wall. We were talking about what is a stoma. So a stoma is where you bring into continuity with the surface of the body an endothelial lined lumen. So tracheostomy is where the trachea is in continuity with the skin. A colostomy is where the colon is in continuity with the skin. An ileostomy where the ileum is in continuity with the skin. The commonest stomas that you will see on your internships or on the sort of general surgical wards and so on will either be a piece of colon brought to the surface, a colostomy, or a piece of ileum brought to the surface, an ileostomy. It's quite common in examinations that you are asked to say what the stoma you're looking at is and there are a few little general tips for that. An ileostomy tends to be placed in the right lower quadrant of the abdomen. It tends to have a spout so to stand slightly proud of the skin. This is because the contents of the ileostomy are caustic. People often say they're acidic. They're not actually. They're alkaline and they can irritate the skin. So by having a spout, a bag is more easily placed and there is an avoidance of effluents hitting the skin surface. An ileostomy tends to have contents that look more like mint sauce or mint jelly, a sort of loose porridge-like consistency, because of course the colon hasn't had the chance to remove all the water, which is the main job of the colon in forming a normal stool. Colostomies on the other hand tend to be placed either on the left side of the abdomen or another way of thinking about it is in the sort of general lie of where the colon is which is on the outside of the abdomen rather than located centrally but most commonly on the left side they tend to be flat to the skin and they tend to have a content that is more like normal faeces. Brown, more solid and obviously the more distal the colostomy the more like normal faeces the contents will be. Finally before we sort of come on to the cases and some more specifics I would say that people get a little bit confused or concerned about this concept of a loop colostomy or ileostomy or an end. Really this is only of sort of technical interest in terms of managing the patient for the vast majority of scenarios. It all depends on what you do with the tube. A colostomy or an ileostomy is bringing a tube to the surface. As you then open that tube, you're left with two ends. Those two ends can be left in continuity, thus forming a loop or a double-barreled stoma is another way it's sometimes referred to or the distal end can be left inside the abdomen or tucked under the skin or attached to the fascia you can do all sorts with it but you won't be able to see it so you only see one end and this is then referred to as an end ileostomy or an end colostomy. To be honest in most of the scenarios that junior doctor would encounter, this makes little or no difference to the way that patient is managed. It just gives clues as to what the future plan is and what surgery has already happened. Great, thanks for that. That's an excellent summary of stomas and why stomas are created. But we'll go back to our question. The junior doctor has asked a reviewer patient and they they're worried that the stone looks dusky. What sort of things they look for in the history, maybe examination, look at the patient's notes, observations that will be important for that patient. Yep, no problem. So that's, it's a really good scenario. I think it's the commonest scenario that we get junior doctors calling us about and being concerned about. So as with all clinical scenarios be it revising for your finals examinations or actually just making sure that you present well to your bosses and care for patients well you've got to go right back to the beginning and go through all of the standard approach of taking a history and examining the patient first. So the nurses ask you to come because they don't like the look of the stoma. |
And there's all sorts of different pieces of information gathering you can do. You can talk to the patient who most often will know why they've got a stoma and what operation they had. Look at the operation note. The operation notes are now nearly always digitally available so they're there on PowerChart. And often the good surgeons, and there's lots of those at RPA, will write down exactly what the stoma is, why it was formed and whether or not they had any concerns with the stoma at the time of surgery because sometimes we do, sometimes as we're making the stoma we're not 100% happy but for whatever reason we have to settle for what we've got. Then find out from the nurses whether or not they feel that the stoma looks the same as it did when the patient first came up, better or worse. And the commonest scenario, as you describe, is where they're concerned about the colour. All that reflects is a concern about the blood supply normally. The blood supply to the bowel comes through the mesentery, as you all know, and that mesentery is stretched up to the abdominal surface has to come through the fascia of the abdominal wall and it has to supply the mucosa and the bowel wall all the way up to where it meets the skin. The fatter the patient the more that has to be stretched. Furthermore the more that the patient's vascular system perhaps isn't working properly they might be on noradrenaline or other vasopressors, they might be septic, they might have a repeated low blood pressure because they're on an epidural infusion or on a PCA and all these sorts of issues, the more that you can put at risk the blood supply to that mucosa. And like any mucosa that's suffering slightly, you'll then start to see changes. So after you've found out about the general condition of the patient, are they sick or not sick, getting better, getting worse, is there a problem with their blood pressure, are they a very large patient, was there a problem with creating the stoma, there then comes a point at which it's best to look at the stoma. And it's important to talk to the nurses who will be experienced nearly always in looking after these types of patients. You cannot look at a stoma adequately through a stoma bag unless the bag is clear and at other points in the day or previously you've looked at the stoma. To properly assess it, take the bag off, make sure that there's a bag available to change it afterwards. Take the bag off and look at the stoma. And there are three key tricks that I tell every junior doctor who's assessing a stoma. The first is to feel the stoma. It should feel the same temperature as the skin around it, so it should be warm. If it feels cold, that's a concern. The second thing is to take a very fine needle, like a blue needle or an orange needle that you use for taking blood, and to prick the mucosa of the stoma. It should bleed. I've seen perfectly healthy stomas that will bleed nice, bright red blood, like you've pricked a finger doing a blood sugar level. Then you tend to get the sort of slightly venous congested stoma which will still bleed but you get a darker venous type ooze from it. And then when you have a truly dead stoma you'll tend to see a sort of blackish purple or no bleeding whatsoever. The final thing to do is to shine a light on the stoma and to do that with the passage of a blood specimen tube down through the stoma. Now the reason for this is that it is not uncommon for the final one centimetre or so of the mucosa of a stoma to slough off and to become either ischemic or fully necrosed. But actually the rest rest of the bowel wall and the mucosa to be absolutely fine. And that's a situation that can normally be managed conservatively. And if you're just looking at the end of the stoma, you get a misleading picture. So by applying a small amount of KY jelly to the end of a blood specimen tube and passing it into the stoma you can shine the light of a torch or the torch on your phone down through that blood bottle and you can visualize the mucosa beyond and if within a centimeter or so there is pink healthy mucosa then you can be less concerned about that final one centimeter or or so of stoma. So when anyone rings me, those are the three things that I ask them to have done. The other really great thing that we have now is the technology to not only record things like podcasts, but also to send photos. And I would take a photo of the stoma in question and I would send it to the surgeon who's looking after the patient so that they can get a good idea of what it looks like. Okay there's some interesting ways of assessing stomas. Is there any concern, I know it's a dirty error about introducing infection or concerned about putting a needle into a bowel? No, no there's not. So you can rest assured, I mean if you're using a very fine needle like that there's nothing to be concerned about in terms of infection we do see cellulitis around stomas why some patients get that and others don't isn't entirely clear to me we know that you're stitching dirty bowel mucosa onto skin and in theory I would expect probably more patients to get cellulitis but the the vast majority of patients don't. That wound, what we call the mucocutaneous junction between the mucosa of the bowel and the skin of the abdominal wall, heals really nicely. If the patient's stoma is a little bit dusky or has a slightly poor blood supply or there's another problem because they've been on something like high dose steroids or something like that, we sometimes get separation of the mucocutaneous junction. Again, most of the time that can be managed without further operation. But that's something that you tend to see a good few days after surgery. So if you see a cellulitis around a stoma, the thing to do, as with other cellulitis, is to draw a dotted line around the boundaries to speak to a senior and to start antibiotics. And those would be antibiotics that covered gut flora as well as skin. In regard to once you've done an assessment and you think there is something wrong with the blood supply of that stoma, what's the urgency of having something done about it? Is that something they need to go back to theatre that night or something can be more assessed over time? So that depends slightly. If you have a fully dead stoma, so we're talking about it's gone black, it's icy cold, you prick it with a needle, no blood at all comes out, you pass a tube in, it looks black all the way down. That is emergency. It doesn't have to go back to theatre within the hour, but it needs to go back to theatre within a few hours. So if that was, you know, three o'clock in the morning, you might say that that could be the first case on the list at 7am, 4 hours later, but it's not the sort of thing that you can leave for 24 hours. It's a relatively urgent scenario because dead bowel will make the patient septic and also you worry about how far in that that is going. You can only see maybe 2 or 3 centimetres. It might be that the patient has 10 or 15 centimetres of dead colon and the rest of it's inside the abdomen. So it's something that you'd want to be operating on within a few hours. Probably the next reason that a junior doctor may get called to assess a stoma is the stoma's got, say, high output. So maybe you can tell us what's a normal output of a stoma, and especially about the different types of stoma that have different outputs. Yeah, of course. So the high output stoma is not an uncommon event. It's far, far, far more common in ileostomies because, as I mentioned earlier, the colon's main job is to extract water from small bowel contents and solidify the effluents into what we recognise as a more normal stool. And even patients with most of their colon removed but say 15-20 centimetres of colon left in place will do much better in terms of their stoma output. The residual colon is able to adapt and to perform a lot of that absorptive function. So most of the time that we get a high output stoma, we're talking about ileostomies, or even if the patient for whatever reason has had to have a lot of ileum removed, jejunostomies. So it might be worth just revising the fact that most people have something in the region of three to four metres of small bowel. |
So again, the operation note can be a source of great information because if the surgeon has noted that, for example, only 150 centimetres of small bowel exist proximal to that stoma, then we know that that patient is going to have a high output stoma in the post-operative period and that we're going to have to do something about it. The flip side of that is that in a patient who's had no small bowel resected at all and who has an end ileostomy, the majority of those patients, even if they have a transient high output stoma, will be able to get the situation under control and dealt with before they leave hospital. So what's a normal ileostomy output? Well, that depends, as with lots of things. But what we would be aiming for to ensure that a patient is able to have correct fluid balance, not become dehydrated, and to be able to have the appropriate electrolyte balance as well, would be something under one litre per 24 hours. Most patients in the first few days after surgery, as things get moving, start at a level beyond that, but we normally wait a few days to see if things settle down before introducing certain medications to try and slow the stoma ourselves. So what's the role of the junior doctor in all this? Well the most common thing that they will be called to help with isn't about reducing the stoma output but managing the sequelae of a high output stoma. So just yesterday we had one of our patients who had a 2.3 litre ileostomy output. She had had a pouch operation and for the first few days after surgery had had an ileus and had not passed anything from her stoma. So it wasn't particularly surprising that when it finally started working she had a high output because this ileus was resolving and all the fluid was pouring out. So in terms of her stoma output, we did nothing. And sure enough, the next day, her output fell to 1.3 litres. And then this morning on the ward round, it had fallen to 900. And that's without the addition of any medication. That's just with her settling down. But what she did run into difficulties with two days ago was that she had a low potassium, a low magnesium and a low sodium. And that's because her ileostomy output would have been rich in all of those. At its most extreme, patients can actually become somewhat acidotic because they also lose a lot of bicarb. So they can a hypochlorimic acidosis but that's quite unusual. So what the junior doctor did quite rightly in that scenario was he fluid resuscitated the patient because she'd become quite dry and in fluid resuscitating her he made sure that she got fluid that was rich in potassium and he also gave her a magnesium supplementation. So we then checked her bloods and sure enough they had corrected. It's really important to note that people increasingly I think compared to when I qualified are slightly frightened about giving potassium. We probably used to give it a little bit too aggressively but now we seem to to have rebounded the other way. And potassium is absolutely vital to cardiac function and also to gut function and pretty much the function of all cells, particularly muscle cells, skeletal or smooth muscle cells. So being potassium deplete is a very bad state of affairs. So please don't keep giving these patients when they're resuscitated simple normal saline which as a lot of intensivists will tell you isn't normal at all or use Hartman's and if you aren't using Hartman's use potassium supplementation like 30 millimole bags. So once fluid and electrolyte replacement has taken place if an ileostomy or a colostomy doesn't slow down, what are the other things we have to consider? Well, a high output stoma can be caused by a number of other things. It sometimes isn't a sign of just normal gut function. So intra-abdominal sepsis can cause an ileus but it can also cause a high output. So we need to make sure that the patient's inflammatory markers are normal or are normalising and if they're not or we have any concerns then a CT scan of the abdomen and pelvis will likely be performed to make sure that there aren't any intra-abdominal collections that are driving a high output. The other thing that we must do is send the effluents for culture and the common things that we worry about are things like C. diff, so Clostridium difficile, which can infect both the small bowel as well as the more well-known large bowel colitis type picture and also things like CMV which can also cause a high output. So that's cytomegalovirus. So a stool culture would be sent, blood tests would be performed, and we would consider imaging to ensure that there's nothing else that's causing the high output. If, however, all those things are okay and we still have a high output, our attention will then turn to two things. The first is what is the patient eating and drinking? These patients need expert advice from stoma therapists and dietitians regarding what they eat and drink. They often will feel thirsty and will be driven to drink water but in so doing will actually perversely make the situation worse. Water is hypoosmolar and as the patient drinks water it will suck more electrolytes and solutes into the lumen of the small bowel thus depleting them further of sodium, potassium, magnesium and bicarb and things like that, worsening their output making them more dehydrated. So you get this paradoxical dehydration, which worsens the thirst and the patient enters a vicious cycle. So patients must be encouraged to drink things like gastrolyte or diurelite, or even some of the over-the-counter things like Powerade are better. So all water should have in it salt and sugar. This can even be made up. And if you Google things like Who Solutions, a World Health Organization solution, or St. Mark's Solutions, St. Mark's is a colorectal hospital in the United Kingdom, these places and organizations have created really simple electrolyte drinks that you can make up in third world settings or on a ward using simply teaspoons of sugar, teaspoons of salt, the addition of cordials or squashes to give it a nice flavour and sometimes a small amount of bicarbonate of soda. So if you're ever in a situation whereby you don't have access to the more complex stuff, a simple Google search of Who Solution or St Mark's Solution will allow nurses or yourself to make up the drink there and then on the ward. The patient should also try, where possible, to eat because eating food will thicken the contents of the small bowel, give the small bowel something to work on and thicken the output and slow transit. And there are certain things that patients should avoid and certain things that are really good. And to the delight of some patients, these are often the things that you're not supposed to go around eating if you've got a normal healthy bowel. So, for example, potato chips are excellent for thickening ileostomy output and they also contain lots of sodium and potassium. So you'll see patients with ileostomies munching away on big bags of chips. Also things like marshmallows and jelly babies which have gelatine in them thicken the ileostomy output are an excellent source of sugar and calories because often these patients struggle to get calories in. They should avoid high residue, by which we mean high fibre diets. And things that will often cause them the most trouble are things like raw vegetables. So salads, tomatoes, apples, things like that can be sources of lots of fibre, difficult to digest and will often give them a little bit of difficulty with their stoma. So they go for a low fibre diet. Then, after we've done that, we need to consider adding in anti-motility agents. And the most common one that is used is loperamide, which is often called in Australia, I think, gastrostop, also called in other countries imodium. It's all brand names, but loperamide works on opiate receptors to slow the gut. You will often see that the maximum dose that is quoted is something like 24 milligrams in one day but actually once you've worked in an intestinal failure unit you know that these can be far far exceeded and I've seen patients on 64 milligrams 72 milligrams a day. You can get loperamide toxicity it's not a serious condition it's something that by simply stopping the loperamide goes away and it tends to be that the patient gets sort of central nervous system type symptoms like agitation or drowsiness. Some surgeons and physicians who work with these patients prefer once they get to a certain level of loperamide to stop and try other things. Others are more comfortable with using high doses. That's not really something that a junior doctor will need to make a decision on. They should certainly be aware that loperamide is certainly the first line agent for the use of a high output stoma. |
Welcome to a thought-provoking discussion. My name is Dr. James Edwards. Today we'll be discussing diagnostic error and this is an initiative of our partnership between On The Wards and Avant and I have the pleasure of welcoming today Dr. Mark Graber. Good morning James. Mark is a leader in the field of patient safety in the United States. He's published widely in the area and has been a pioneer in efforts to address diagnostic error in medicine. I'm also joined by Dr. Owen Bradfield. Owen enjoyed university so much he's both a lawyer and a doctor and has been working in medical legal claims area with Avart Mutual for the past six years. So I think for the next part we're going to look at responding to diagnostic error. I think within this era of open disclosure for clinicians there has been some concerns about how we respond to diagnostic error. So how should, I guess, a clinician respond if they know they've made an error? Well, I think honesty is by far the best policy. We need to be honest and forthright with our patients. They know that we're human. They know that medicine is complicated, that diagnosis is not a certainty. And if there is a diagnostic error, I think we just need to tell them this is what happened. To the extent that we know why it happened, we should tell them about that. We should communicate that we still have their interests foremost in our minds and we're going to try and make it right. We're going to try and understand what went wrong so that we can fix it. It doesn't happen to the next patient again. So I'm a big fan of early disclosure and honest disclosure and trying to make it right for the patient. Yeah, what do you think? Absolutely. I mean, I think, you know, a big part of when we at Avant we have a 24-7 medico-legal advisory service and a frequent reason for people to call and use that service is because there's been an adverse event and whether that, you know, to some extent includes a diagnostic error or not, the doctor may be considering open disclosure. And so I always say to doctors, get advice. So that's why they're calling us. We would always encourage doctors to practice open disclosure. But if they've not done it before, then talk to people that have. Seek advice. I mean, very often in hospitals these days, they have sort of an open disclosure response team, so people within the hospital who are practised and proficient at open disclosure, they've done it before, and they're able to think about some of the finer points of how to do it. But I'd certainly encourage people to seek advice and certainly at Avant it's a frequent reason for people to call and seek our advice. One thing people are often concerned about and rightfully so is this idea of an admission of liability, this concern that if I say sorry to a patient for something that's gone wrong, if I apologise that I got the diagnosis wrong, is that an admission of liability? And I think, look, absolutely the laws throughout Australia are very clear that an apology does not amount to an admission of liability. But the other thing as well is that very often when we say sorry and when we talk with patients about what's actually happened and what's gone wrong, what we're talking about and what we're admitting maybe is the facts rather than liability. We're actually just saying, look, this is what happened, this is what I thought the diagnosis was, it's now transpired that perhaps there were some other factors that we didn't consider and now we've arrived at a new diagnosis. They are the facts and generally if you look at the records that's what you'll find. But I always think it's important to get advice before embarking on that process and ensuring that you have a good idea, good understanding of what you're going to say and that you have somebody there to support you through that process. Yeah, and you know, Owen, it's a scary thing to do, these disclosures. It's an awkward conversation and physicians are uncomfortable doing that. And it gets to the opposite of the thing we don't want to see, which is to try and keep the error a secret. A lot of physicians, I think, sometimes assume, well, nobody will ever find out. And you're probably wrong. Probably it will be discovered and it's the worst thing you can do to try and keep it under the carpet. So absolutely, these things need to be discussed. And just to take off on a related issue, so we'd like to be open with our patients. It would also be great if we were more open with our peers and the people that we work with. It's still an awkward conversation. But at a time when we're not doing autopsies and we're not getting good feedback about our errors, discussing errors internally would be a very powerful way to, I think, improve the diagnostic process. It would make us more alert to the possibility that we might be wrong once in a while. Absolutely. I gave a talk recently to some medical administrators and that was one of the points that I made in that presentation is we do spend a lot of time thinking about how we communicate after the event with patients when something's gone wrong and we put a lot of time and effort into thinking about how the patient will perceive that conversation and thinking about their thoughts and feelings and emotions and I think look, we need to treat our colleagues in the same way as we would treat our patients. If we think that maybe one of our colleagues has made an error, we need to have that conversation with that colleague. And I think, again, very often people worry about the medico-legal implications of doing that. But I think we also have to balance that against what that means for that organization's culture, if we're able to have those open and frank discussions, and also what it means for patient safety and for the community. Yeah, and there's some tricks I think that would be very helpful in this regard. One is to give permission. For example, I work in a teaching hospital, so there's the senior attending physician, there's a more junior person, there's trainees going down. It's a very awkward thing for a junior person to criticize or raise the possibility that the more senior person made a mistake. But if the guy in charge openly at the start of the rotation says, listen, we're a team. You know, if you, if anybody has a suspicion that there's something that we may be doing wrong, just don't be afraid to bring it up. If you give people permission, you're more likely to get that feedback that will prevent that harm from taking place. And not just on teaching services. We'd like to see this happen in the hospital for example if you're in the emergency department james your patients get admitted the guys on the ward are going to be reluctant to tell you if there was a diagnostic error because it's an awkward conversation they don't want to compromise their good relationship with you sometimes they're too willing to tell me no either way i mean i think we do focus on diagnostic error but i think i know when i give feedback to junior doctors about a case it's nearly always about something they've missed yeah i rarely tell them about the incredible diagnosis they made all the all the all the right ones they made great point just focus so much. So any discussion about diagnosis is normally always called into the office, what's this about? This is not a good conversation. So I think we have so many, those conversations are difficult because they're always negative on an error. We should be much more focused on what we do well. So we'd like to see more feedback, both good and bad. Yes. And giving people permission and encouragement to give you feedback is the trick. So tell the guys on the ward that you'd like to get feedback and you'll get more of it. And that's how experts become experts. They get really good feedback that's relevant to what they're doing. And we need a lot more of that in medicine. I think more junior doctors, but also maybe new consultants, they're worried about their reputation among their peers if they admit error, thinking that they may not be as good as their other clinicians. How do they overcome that? Yeah, that's a good point. But I think if you dedicate yourself to excellence and to trying to be good and trying to get better and trying to be expert, people will appreciate the fact that you want to get both good and bad feedback. Nobody's going to be perfect. And unless you hear about the things you're not doing right, the things where there were problems, you'll never get better. And I guess when we do focus on looking at errors, we use, I guess, things such as root cause analysis, which really predominantly look at system errors, but don't really look at Diagnostic error what are ways that I guess reviewing diagnostic error that people could use within hospitals within their their departments? |
Welcome to On The Wards, it's James Edwards and I am speaking to Lauren Troy today. Lauren is a respiratory physician here at RPA. Welcome, Lauren. Thank you for having me. Lauren did one of our first ever podcasts on the approach to shortness of breath on the ward, but today we're talking about pneumonia, particularly pneumonia that develops on the wards. And we're going to start with a case. You're called to review a 58-year-old male with a history of diabetes and peripheral vascular disease who presented earlier in the week with leg pain and was found out of critical limb ischemia and underwent an endovascular revascularisation. Tonight, four days following admission, he's known to be febrile to 38.5 with a respiratory rate of 24 and the nurse tells you that he's been coughing a lot. What would you like to know over the phone when you get this phone call from the nursing staff? Yeah so I think really the same rules apply to any phone calls that you're getting after hours so a very similar approach should be taken whenever you have this sort of call that should be what are the vital signs of the patient? So is this a patient that's very, very unwell as evidenced by hemodynamic instability? So is the blood pressure low? Is the heart rate very fast? Are there any other features that the nurse can tell you quickly over the phone that will help you triage the urgency of the situation? So things like the level of consciousness can be really important, particularly in a septic patient, but also the oxygen saturations and the respiratory rate will give you an indication as to how compromised they are from a respiratory point of view. Well, you go and see the patient and you do a history and examination. On the examination, you notice that their pulse rate and blood pressure are okay, their SATs are a bit lower, 93%, some reduced air entry in the left lung, and you order a chest X-ray which shows new left low-lobe consolidation. So my question is, Lauren, what are the clinical and radiological features that are required to make a diagnosis of pneumonia? So it's really the same no matter whether or not you have a hospital acquired or a community acquired pneumonia. You need to have at least two or four features. So an elevated white cell count on a full blood count, a fever over 38 degrees, new possible purulent cough and also new infiltrates on a chest X-ray that either are progressive or persistent. So we did discuss, when we discussed the approach to shortness of breath, that lots of surgical patients may have a bit of a white or low-grade fever and have some atelectasis. And how would you differentiate that between pneumonia? Yeah, it's a good question because sometimes that distinction can be quite subtle and it will come down to your clinical suspicion in some cases. Particularly in this case, the history of coughing is a good clue that there is something that's new and that's developing. The dense consolidation at the left lower lobe on x-ray, it will be obviously sometimes very distinct from an atelectasis pattern, which can be quite subtle and really just looks like a little bit of volume loss rather than consolidation. So there can be distinct features on the x-ray. And of course, the presence of other features such as respiratory compromise, hemodynamic instability, all those other things I mentioned earlier, may point towards a more serious condition than simply atelectasis. What other important differential diagnosis should we consider? Well, obviously atelectasis is number one, absolutely number one, particularly if it's happened shortly after a procedure, a surgical procedure. But other possibilities aside from a hospital-acquired pneumonia is aspiration pneumonia. In fact, aspiration pneumonia and hospital-acquired pneumonia are very, very similar and share a lot of overlapping clinical features. But other things that may mimic this condition may be a left lower lobe effusion. So a left side of pleural effusion may mimic consolidation on an x-ray. And if that's an infective effusion, that may also present with some of the similar clinical features. And then, you know, you always have to consider other causes for respiratory compromise, such as pulmonary embolism, which may cause a low-grade fever and may cause a leukocytosis, as well as those other things that we've talked about, and can, if it's large enough, cause some infarction of the lung, and that might be what looks like pneumonia but is in fact pulmonary infarction. So that should always be considered. Congestive cardiac failure may be a complicating factor on top of the pneumonia. There may be infiltrates that look a bit like pneumonia but may in fact be congestive cardiac failure. So you just need to be considering the patient as a whole and considering what the most likely differential diagnoses are based on their background information and risk factors. So we've done a chest x-ray, but what other investigations would you perform? So always some routine full blood counts, biochemistry can help you determine the severity of the situation. So the other tests that may be really useful in the after hours are an ECG to make sure that they're not in an arrhythmia or having any compromise in terms of coronary ischemia, which can happen in some patients, particularly this patient who's clearly a vascular path. So you'd need to make sure that wasn't happening. You might also perform arterial blood gas in this situation. And there's quite a bit of information that you can gather from the ABG. Aside from looking at the pH to tell whether or not the patient has acidosis or not, you can also look at their PaO2 to see how hypoxic they are, PaCO2, which may be elevated if there's a background of COPD or heart failure. And then, again, going back to the pH, if there is an acidemia, is it metabolic or is it respiratory? And if it's metabolic, there are a number of things that may be the cause, such as acute renal failure, lactic acidosis from a sepsis and various other complications. We've talked about this, I think, before on podcast, but should you do the ABG on air or on oxygen? Again, another good question. We'll come down to the severity of their respiratory compromise. This guy's saturation's at 93% on air. So in this setting, it would be probably okay to get away with an ABG on air. But if the patient needed oxygen to preserve their saturations, then it would be dangerous to take them off oxygen to simply prove that they're hypoxic. We know they're hypoxic because their saturations are low. So doing the ABG on oxygen is not going to give you any further additional information there. Really the more important elements to be looking at in that situation are the presence of acidosis as well as the presence of hypercapnia or not. So yes and no is the answer, but in this case I think it would be okay. What is the role of blood cultures and sputum cultures in patients you think have got nosocomial pneumonia? Yeah, there's a good role for them in this setting. So all of our culture mediums are limited by sensitivity. So we will often never get an answer on culture in terms of positive blood cultures or sputum cultures. However, if we do identify an organism, it's incredibly useful in directing our antibiotic therapy as well as duration. So the role in this situation is that the blood culture and the sputum culture should ideally be taken prior to the initiation of any antibiotics, which is going to maximise the diagnostic yield. And hopefully in two to three days' time, if those cultures return positive, it will then help point to the direction of antibiotic therapy. How do you assess the severity of pneumonia? Well, we don't... So in the community-acquired patients, there are a few well-validated tools for assessing severity, the SmartCop, the Corb, the CURB65, and the PSI, the Pneumonia Severity Index. But these are probably not as applicable to the hospital patient. And so really the severity is judged based on their hemodynamics and whether or not they need greater ventilatory support than can be supplied on a general ward. So if you're concerned that they're severe based on very severe hypoxemia, hypotension or any other derangement, then a high dependency or intensive care setting is most appropriate for these patients. Do you want to just outline what your management will be because I guess including consideration of appropriate empiric therapy? Sure so there are really well written guidelines on e-therapeutic guidelines which are accessible to all junior doctors on the ward so if anyone is faced with this situation and they're not sure what to do then the first thing to do would be to go to e-therapeutic guidelines. So in this situation, there are recommendations for antibiotics, empirical antibiotics, based on the likelihood of having a multi-drug-resistant organism. |
Welcome back to Key Lime, where the number needed to listen is one. We keep track of all the medical education literature for you and tell you cool things that you need to know as a clinician educator. It's Jason Frank. Today, I am once again down under. This is our Keyline podcast, Takes to the Road. We've recorded previous broadcasts in the Middle East, and now we're in beautiful, sunny Sydney. I am joined by two Aussie MedEd gurus. I have with me Mary Louise Stokes from the RACP. Welcome back, Mary Louise. Hi, Jason. And today, Anthony Llewellyn from HETI, who's the MedEd director there, has chosen a really heavy but very important paper for all of us. So welcome, Anthony. Thanks, Jason. It's great to be back. And just for listeners who may not know your famous history as a medical educator, can we just ask you a few questions about your pathway to become the Meta Director of HETI? Sure. So I understand you're a psychiatrist by training, so how did you end up in this job? Well, I understand a lot of people in medical education either come from a psychiatric or emergency medicine background, so I feel like I'm in good company. I trained as a psychiatrist, but as a psychiatrist, I was always interested in human behavior and what makes people tick and motivates them. And I was drawn at an early stage into medical management and medical education. And like many people in MedEd, I had a bit of a tortuous journey through to a medical education job. And I've been really happy to do the Hedy job for the last four years as the medical director, which is a really cool job to do. And yesterday I got to visit Hedy and all the staff, and I can tell you that Anthony is beloved by his staff. Makes you wonder what he's saying to them, but he clearly is a well-respected medical educator and director. So, and you have an exciting team. I want to compliment you on them. Thank you. Now you've chosen this paper. It weighs about 10 pounds. I lost weight reading it. It was so heavy. It has a lot of words, which is hard for my emergency physician brain, since my short-term memory is only about five seconds. However, I do get why you chose this, but maybe you can introduce the paper and tell us why it's important. Sure. Thanks, Jason. Look, maybe some of our On The Wards listeners might be wondering why I've chosen this paper as well, but perhaps to address that issue first, I think the whole issue of how people are selected into medical school and then after medical school into training positions is very preeminent in terms of a trainee's mind. I think it's very important as medical educators we actually justify our selection practices. So I actually blame Marie-Louise for this paper because Marie-Louise contacted me a few years ago from the college because they were interested in actually looking at this issue of selection into specialty training and we've been participating in a best evidence medical education review group looking at selection into specialty training and we're just about to publish that paper and there's some really good findings out of it but one of the findings we found really if I can sort of without giving too much, say is that I think there's a whole lot of selection techniques that haven't even been looked at in the medical education literature. And I think med ed's a little bit better than other parts of medicine, but we're still guilty from time to time and not looking at other fields of research. So if you go through some of the papers from some of the better authors like Patterson around how to select people into various training programs or medical school, you'll find these authors, Schmidt and Hunter. It's a very well cited paper in the human resources and organizational psychology literature as well. It's a little bit dated, but I think it's still valid and it's the most up-to-date reviews, if I can call it that. So the article I've picked today is entitled, The Validity and Utility of Selection Methods in Personnel Psychology, Practical and Theoretical Implications of 85 Years of Research Findings. It's by Schmidt and Hunter, published in the Psychological Bulletin in 1998. It is a classic psychology study, but I think, as I said, it's got relevance to the medical education audience. And it's just for readers' benefit. It's also heavy because it's so old it's been typed onto stone so you have to use a wheelbarrow to carry it around. No, no, I'm just joking. It's actually entirely apropos as you're about to tell us. So what's it about? Well, if you spend a bit of time as I do worrying about the best way to select doctors for jobs and looking at the medical literature, you'll come across this article. And these days we're spending a bit of time thinking about that. Many training posts in Australia are becoming quite competitive. As I said, our On The Wards listeners really love the podcast that we give them advice on how to prepare for that next job in medicine. Yet often, we still see the standard type of approach to job selection happening for our training posts, by which I mean, put in your job application, someone reviews it, maybe there's a paper culling process, the interview panel forms and some sort of interview process ensues and a reference check. But many lead authors in this space, such as Fiona Patterson, are suggesting there may be better approaches, such as the use of assessment centres, the multiple mini-interviews and situational judgement tests. This paper is, as it says, it's a meta-analysis, or actually a meta-analysis of meta-analysis of 85 years' worth of research into selection methods from the psychological literature. And the paper actually looks at 19 different types of selection tools, some of which will be familiar to the key linemen on the wars listeners and media researchers and many of which I suspect will be much less familiar. The authors start out by suggesting that the most important property of a selection method is predictive validity and that the use of hiring methods with higher predictive validity leads to substantial increases in employee performance which can be measured in a number of ways such as the increased learning of job related skills. They then go on to look at the performance from the literature of the 19 various types of selection tools, as well as looking at how some of these tools work in combination. In the paper, which I do have to confess is quite heavy and long and contains some rather complicated statistics, the authors start off by giving what I think is a very nice history of the research into personal selection, which is interesting because it goes back to the early 1900s. So very early on in the 20th century, researchers had realised that not all selection methods were the same in outcome, and there was often noted variability in the outcomes in studies, some of which was often attributed to the size of studies, which is, you know, not unsurprising. But once they started to apply meta-analysis techniques, they found that the techniques were far less variable and actually, surprisingly, not only less variable across common jobs, but in fact, very small in variability across different jobs as well, which then allowed them to look at the various selection techniques using quite powerful numbers. So this is actually a paper that summarises the various personnel selection meta-analyses conducted between the 1970s up to and through the 1990s. Marie-Louise, Jason, what did you think of the methods? Well, actually, they didn't describe their methods terribly well. I was thinking if you were wanting to reproduce this paper, they didn't really have a methods section at all. I agree. The acknowledgments footnote is probably longer than the method section. And it basically says who made the graph. So there's some really powerful analyses and meta-analyses in this. And clearly the authors have put some thought into how they're comparing apples and apples. And I think that's appreciated if the reader really cares about some of the numbers. So they use some, what we would consider today, non-contemporary validity measures for stats. If you treat these papers that they identify and the methods they identify as a diagnostic test, just like we would with any test we would use in medicine, then we want to see areas under the curve and we want to see sensitivity and specificity or likelihood ratios. and that is not even in the vocabulary of the papers that they had to choose from at the time so from 1901 to 98 nevertheless there are some really cool findings from all of these papers even though they're very heterogeneous yeah so i agree they don't actually tell us how they got the papers and i think that probably partly reflects the fact that it's not a medical article and also it's from the 1990s. But that is still a gap in understanding this. |
Because what I often have seen, not having read this article up until recently, but seen reference to it, is people quoting the findings and treating them as said. Yeah. So shall we move on to the findings then? Yeah. So what do you think the implications are for medical educators? What stood out to you? The authors present a range of findings for the 19 different selection tools, and I'm not going to go through every one of them for the listeners, but perhaps the most useful of the paper and as I said the one that's most probably cited are the tables that rank these tools. Now they do this by firstly presenting the results in ranking order in combination with what they call the general mental ability as a tool. So the suggestion here is in the research the most valid predictor of future job performance when hiring someone when they haven't done the job before is an assessment of their general mental ability. Now, we might want to pause and talk about that in terms of medicine. What do we think about that, Marie-Louise? Well, it's interesting because by definition, the population of people who are in medical school and postgraduate training, they're already selected on mental ability. And we use in Australia the UMAT and the GAMSAT for a lot of medical school selection. So we're already dealing with a group that have high levels of mental ability. So my question would be how applicable would it be to that group of selected people? I have to admit, I've never heard of the GMA before reading this paper. I don't know if there's a version of it that's still in use, but it's certainly not used in medicine. And I agree with your point that the populations that we're selecting from are already highly selected. They are a 0.01% of a population that we live in, and they've already gone through millions of tests to get as far, to actually meet us. So the question is, should we really select on academic ability? I think every director of training who's listening says, hell yes, I need to select, because there's still heterogeneity within the medical learner population. I don't know about locally here in Australia, but in Canada, for our entry to postgraduate medicine match, people do look at licensing exam scores. They do look at the transcript from the school, which puts pressure on deans of schools to make sure that all those marks are buffed and polished and look their absolute shiny best. So, you know, cognitive measures, marks probably matter, especially if it's relevant to a subject area, like what's your mark in psychiatry or whatever. Yeah, and so one could probably argue that if you've made it through medical school, you've got a fairly high GMA, whatever that is. And so what we then see after graduating from medical school, the selection techniques, at least in Australia, generally more about the other things on top of accepting that you've made it through medical school that we can apply to selecting the best candidate for the job. So the other tools that are presented in a format that suggests how much more valid they are in combination with this concept of a GMA. And this is what I find very interesting because if you work your way through the first table, some of the tools that are seen as really being more powerful add-ons, if I can say that according to statistics, are things like work sample tests and integrity tests along with something that our listeners would probably be a little bit more familiar with which is the concept of a structured interview. These are things that are seen as being additionally powerful of the level of somewhere like 24 to 27% according to this study. The usefulness of the tools then reduces with things such as job knowledge and things like job tryout ranking in the 12% to 14% range, and then going down to really troubling percentages of around 8% for an unstructured interview. And surprisingly, the statistics for reference checks were 12%, although the authors do explain that you need to understand the context of the study and that perhaps if you'd gone back a little bit in time, reference checks were a bit more powerful. And that's explained by the fact that at the time of this study or around the time of this study, there was a lot of litigiousness going on in the research and people were less comfortable about providing a reference that might prove to backfire on them. It might be helpful for people to understand a little bit more about some of these non-well-known techniques. So the authors mention work sample tests. So what that's about is essentially a hands-on simulation of all the parts of the jobs. So you could envisage, for example, in a surgical training selection process, as part of your assessment, you might ask someone to tie a surgical knot. That would be an example of a work sample test. I think that happens here, doesn't it, for some of the colleges? It's starting to, but again, when we did our review of the literature, there were very few articles looking at this concept of asking people to demonstrate job skill or job ability. Essentially, in Australia, a lot of selection is, as I described, put in your application, get a written reference or two written references, go to an interview, which is usually the questions are now set, sometimes behavioural, and then the decision is largely made on the day. And there's none of these other additional techniques thrown in. I was just interested, Anthony, because the authors present two tables. One is looking at predictive validity for job performance and the other is predictive validity for performance in job training programs. Now you could make the argument that we're about selecting people into a training program so the job of the training program is to teach them how to do these things and I notice in that table the work sample tests were not really relevant because that sort of defe little bit ahead of their colleagues. I just want to jump in there. I think that there's a variety of selection methods all over the world. So given that it varies so much all over the world, that sort of tells you that there is no one way to do this well, or we haven't figured it out yet. I'm struck by the fact, even within my own country, how much it varies. So yes, we have a match that standardizes these placements in postgraduate medicine. It's called CARMS in Canada. And we tend to look at marks and cover letters and reference letters. That sounds familiar to all of us. And then we have this really important one-day interview by a program site. So the trainees travel all together. They pretty much should just charter a plane because it goes from coast to coast. And that interview is so important. It actually determines our final rank list. Our super secret scoring tool in my program in emergency medicine in Ottawa involves sort of impression about their academic ability, impression about their interpersonal skills, and our impression about how, quote, trainable they are. So that's a construct created by our director of training. And it basically means, you know, is this person going to come here and be able to take feedback and adapt? And does this person look like a lifelong learner? Does that sound familiar to you? Yeah, I think that concept of trainability or teachability people do talk about. And they're looking, you know, they don't expect people to come in at the expert but can they learn and take feedback and it's interesting in the paper they sort of alluded to that and the closest I guess test for that would be the conscientiousness they mentioned about the conscientiousness test and that people who score highly on that which is correlated with the GMA score, perhaps do better. The predictive validity is higher because they are more able or more keen to take on feedback and learn. So there's something about this conscientiousness testing. And I'm wondering, do you do that in Canada? We do it with, if you have the term secret shoppers here, do you have that? Yeah. Where there's somebody who's sort of disguised we we all of the staff in the hospital are in on the job so on the day of the interview anybody that they interact with will report back to our selection committee and we have every year we have people who exclude themselves because they're bright shiny and enthusiastic in the interview room they step out and then are really rude to a program secretary and that is is absolutely scored and tracked. So we do a little bit of the secret shopper. It's not conscientiousness, it's more professionalism. I think that's what they describe in the paper as an integrity test. So this concept that you can exclude people that might demonstrate bad job performance down the track by using testing mechanisms. And I know there are medical schools also that do this. They invite the students in for the day and have everyone around campus observing them and reporting back if they see someone doing the wrong thing or being rude. And I think that's important because we have issues in medicine where we do have people doing the wrong thing and bringing the whole profession down. |
It's actually something that does something completely differently and therefore adds a lot more into your selection process. Just before you go on with some of these other things that they pulled out of the literature, I'm also aware of some surgical programs that bring all the candidates together to one site and do some standardized testing, like the idea that you said, tying a knot, or the one I've heard of is actually suturing on a standardized trainer. Another one, this is very controversial that I heard about, was actually measuring people's ability to perceive depth or whether they're colorblind because they felt like in their discipline, a lack of both of those would actually impair their ability to be that type of surgeon. And you can see how that might lead to, at least in our legislation, a human rights complaint. And that leads to a whole other world of selection issues like, is a medical student who is blind able to be a dermatologist? Somebody who's deaf are able to do cardiology, whatever it is. And in Canada, there's a number of precedents where programs are asked to accommodate a trainee with a disability. That's a whole other world of admissions conversation. But back to these tests. So some of the other things that they looked at were this concept of training experience, what they call the behavioral consistency method. Now, a lot of our listeners would have experienced this in an interview when they're asked to give an example of past work that demonstrates their ability to do the job. That really does, and actually in combination with how you think about your structured interview, increase the validity of that tool. So that explains why we talk to our listeners about this concept of behavioral interviewing, that when you go to the interview time, you'll be asked a series of questions and some of them will be about, can you tell me or give me a good example of how in the past you've worked through conflict in a team, for example. So that comes out in this study. Another interesting thing is this is however the concept of training experience by the point method being not so good. And we see that quite a bit in medical selection, this idea that essentially you can look at all the things the trainee brings to the table and allocate a point. And we can all speculate why that may not work. But my theory on that is that if you tell trainees what the point system is, they will all go and get those points. And therefore, you get no discrepancy between trainees. And it's hard to select out those that are perhaps better than those that are not so good. Can I just ask, for all three of us are physician executives to some extent in our week, so how are your staff hired by the non-medical organisations or the administrative staff? How are they hired? What's their hiring procedure? Very good question. How do you hire your staff, Marie-Louise? I think it varies by role, but I know, for instance, that they do, for some roles, skills testing. So they'll give information, say, construct an email that you would send to a physician, a fellow, and they'll give them a bit of information. So they're testing their ability to gather that information, put it together in a courteous email and that sort of thing. So we do actually use that for some roles, but I guess mainly it is the traditional CV interview reference combination. How about you, Anthony? My team knows that I've got a bit of an emphasis on getting the right hire. I do know, though, even though you can use all these best techniques in the world, you'll still get some non-successes and it's important to acknowledge that and talk to that through with the new people you hire and so in my organisation we have a concept of a probation period which is kind of an opportunity for both the organisation and the person to try out the job and see whether it's a good fit for them and that's mentioned also in the literature and in this article but the other things I like to do I like to really review the position description and make sure the selection criteria are appropriate candidates have to sort of show how they feel they address those criteria we do generally in our interviews include a work sample test it might be giving them a scenario or asking them to present on something that mimics current work. In one job interview, we even set up an out tray for the candidates to sort through and had one of the team come in and interrupt them and try and throw them off their game and see how they performed in that role. You guys are tough. So we do the same at the Royal College. We have an HR department headed by somebody named Bonnie Seidman, who's very good at her job. So everybody obviously goes through a screen. Are you eligible? Do you have the background for the job? Then there's a scoring around the CV and some examples of work, reference checks, and an interview. And the interview, despite my ability to throw them off, is always anchored around objective questions and a scoring scheme. So that sounds familiar to medicine. We always do an assignment. So we always have something that is exactly drawn from that week's work. So if we're writing a briefing note for a council and this person's going to do that in the future, we give them the same assignment, same box of papers. We have the probationary period. And incidentally, that's one that, you know, we don't really do in medicine, except for some of our international trainees have also a probationary period to see if they fit in our system. You might say that in medicine, we have more evidence of them being already in the system or something like that. But, you know, lessons for us around, you know, this work sample, maybe my emergency medicine program should say, hey, we're going to go to the simulation center today, and all of you are going to be in this room, and maybe there's a really difficult family simulated or something. I don't know. But that just makes me hesitate that maybe our methods are not optimal. And do you do reference checks before or after? Depends on the job. So if it's a very senior job, there's a lot of screening before we get to reference checks just to save time. I often find it's a bit of a trade-off but if you can do the reference checks beforehand I think they're much better because once you've had the interview people are already biased towards who I think the preferred candidate is and so when you check the references you're looking to confirm your impressions rather than getting true data. But in the Canadian residency match the references are part of the the application package. And I have to tell you, there is something about name recognition that we have to be careful about our bias. Canada's a very small medical community. There are certain people who tend to write more letters. People get electives with them on purpose. And I read their letters, and it has a lot of strength in my opinion. If that person says, I work with them for a month and I really have trust my family with them, that person's hired. On the other hand, somebody I don't know, I put less weight in it. So we have to be careful. And unfortunately in New South Wales, there's so many jobs come up at the same time and so many people are asked to give references multiply. We've had to come up with a compromise where the same reference is given for one person for a number of jobs and so you have to wonder and think about the utility of something like that and it's all done online. Well I notice that reference checks doesn't score all that highly does it in the predictive? No but as they say that may be biased by the fact that at the time people were concerned about giving out information in a written form and that might backfire on them and they say that in the 90s there was a change around the legislation in the US but I prefer to take verbal references and I think I find people if I can more honest I find people are more honest and again I ask them behavioural questions about the person my question to you both is do any of you analyze people's handwriting? Because I was fascinated to see graphology as a legitimate or a tool that is used. Well, but the authors discount it. They say it's got 0% increased validity. Well, there goes my palm reading that I've been doing. Nevertheless, it is being used, they say. In some countries, France and Israel were using graphology. It sounds like something out of Sherlock Holmes. It's crazy. It's probably a little bit like phrenology. It's gone the way of the dinosaurs, but as I understand it, at the time, people felt that, and there were people that made good money out of this, interpreting people's handwriting, and it wasn't just about the clarity of handwriting, but it was inferring personality characteristics and other things into it. But that's been totally discounted as a selection technique. |
So maybe we should add that into the list too. I immediately held my hands. So, Anthony, are there any other highlights you want to give for medical educators out of this very thorough paper? Some meditators probably don't need to read this paper, but we can get to that. But just in terms of limitations, look, the study is a little bit old, but it is, as I said, one that's still referred to in the current literature. It's limited to studies of combinations of predictors, so I didn't look at individual studies. And the authors recognize that researchers also opened up further questions about combinations of selections. And as we've discussed, I think we've probably maybe learned from some of these techniques and evolved them over the last two decades into things that sort of encapsulate some of these things. So they talk about, for example, the selection interview might be assessing across multiple domains, including mental ability, past experience, conscientiousness, etc. The authors conclude by saying that the cumulative findings show that research knowledge about these techniques make it possible for employers to substantially increase the productivity output and learning ability of their workforces by using procedures that work well and also by avoiding those that don't work very well. They suggest a combination of assessment of mental ability plus an integrity test or a structured interview depending on the type of role you're interviewing for. And maybe things have gone past that a little bit. But I think the take-home message is that employers are currently using sub-optimal selection techniques and can save themselves a bit of time and save themselves, more importantly, a bit of pain by using better ones. And I honestly don't think things have changed in two decades. Mary Louise? Well, I think in the context of medical education, selection into the program is the highest stakes assessment of them all. And people may think that doing an exam is high stakes. It's not as high stakes as about selecting into the program. So we need to be applying the same rigor in terms of the validity of that assessment. So I think it's great to have papers that attempt to look at that by looking at things like predictive validity. I agree. It's critically important. Can I just ask, if you can give us 30 seconds, you just did a beanie review. You read dozens of papers. They were all methodologically amazing, I'm sure. So do you want to tell us just a couple of impressions? Maybe this is going to drive traffic to your review when it's published. I'm not the lead author on this, so I'm not sure I should give it away. But as I said, one of the things was the surprising thing was the lack of papers looking at certain techniques. There's certainly some good papers that are looking at, you know, essentially taking your time, working out what it is you're actually trying to select for, and then what's the most appropriate test for doing that, and moving people away from the standard approach of, you know, non-structured interview and some reference checking and putting in a letter of application to things more like assessment centres where we're using a combination of selection methods. And none of that will be surprising to, I think, listeners in medical education as a better way to think about these things. It does come with a trade-off. Obviously, there's a bit of time and effort put into rejigging your selection techniques. But even then, some of the papers we've looked at show how that actually can save you time in the end. For example, one of the papers I looked at was around structured letters of reference. And even if all you did that for was to save you the time of going through unstructured letters of reference, it saved the person time. But actually, there was some suggestion that it was a better way of assessing people's application as well. Some of these techniques can actually save time. And if we think about running a money clock for all the people that get involved in selecting people into training, it's a big endeavour pulling together all these panels for the day. It takes people off service. It takes trainees off service. We want to get it right first time and we want to get our best return on investment. Marie-Louise, any other teasers to add? No, I think I follow on from Anthony's comments there. I think it is. It's a hugely resource intensive. I think there was a recent review in New South Wales. It was multi-million dollar investment of people's time. So if you're investing that time, you want to be investing it in techniques that have some validity. I think the challenge is that trying to convince people in terms of a better way is hard because everyone wants to have a personal stake in the selection choice. So what you often find is resistance to these changes coming from the people that own the jobs, i.e. the supervisors or the directors of training. They all want to be on the panel. They all want to eyeball every person that's applied for that job and trying to convince them that that's not necessarily the best way to do it involves change management and a debate. But I do think trainees should be challenging some of these current processes and saying, well, why is this the most valid way of selecting me into training? Doctors resisting standardization, never heard of it. Okay, so I think that was a really fulsome discussion. I do feel more informed about the theory behind this. And I think, if anything, the two biggest things I took from your selection of this paper was, one, there's a whole world of tests and techniques out there that medicine is often quite naive to, and maybe we need to look a little bit further afield. The other is, we should really be talking to our HR professionals for whom they're trained to do this kind of thing, and maybe their techniques have some utility for us. And if there's a third one, it's we have more medical education research to do. So of all of you listening to the podcast and you're thinking of your future career as a medical educator, clinician educator, you're doing a graduate degree, well, here you go. We have your thesis for you. don't actually tell us how they got all the papers. So you have to sort of use a bit of eye of faith around that. But I think the techniques they've applied, again, were valid for the time. If you're doing it again, you probably use different statistics and ways of analysing. Fair enough. Mary Louise? I agree. I think a three. Okay. And at the risk of being agreeable, I would also give it a three. I think it comes across as very comprehensive, given that it's 10 pounds of papyrus, but how they select it is not clear. The analysis is a magical and wondrous thing. Okay, so a one to five, should all medical educators have this beautiful tome in their library, Anthony? Well, I'm a bit biased, Jason. I think at the very least, all medical educators should have the table that shows them the ranking of techniques, maybe updated by the HR department, as you say, but I'd certainly give this at least a four out of five. Okay, all right. I'm going to agree again. Really? Because selection is so important and people rely on papers such as these to be able to actually check that you've got the source paper for what are high-stakes decisions. I would say in medical education, selections are a really important things. So I would say yes. Oh, you guys. Well, you guys did the Be Me review, so you'd think I'd be more respectful, but I'm going to give it a two. And my rationale is not only is it an extensive paper, but I just didn't think it was one-to-one useful for contemporary medical education. So that's my concern. I get why it should be in your library. You should reference it. It's like you start with the Bible and then you add in Shakespeare. But I just don't think that I'm going to use the GMA. And I'm not sure that their validity stats are actually something I can quote. So maybe it's an awareness thing, but I'm going to be tough today. So that was the Key Lime and On the Wards Conjoint Podcast for today. Thank you so much to my colleagues, Mary Louise Stokes from the Royal Australasian College of Physicians and Auntie Louie Lewin from HETI here in Sydney. Thank you for bringing me to Sydney and I love the sunshine. It is their winter and it's just as warm as my Canadian summer and I enjoyed this discussion. If you have any comments on this paper, we would welcome your comments. We want to know if you agree or disagree. We want to know if you love very large old papers. |
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