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Welcome to On The Wall, it is James Edwards and today we're going to be talking about acute pain. Acute pain is a very important topic for junior doctors and we have the pleasure of welcoming Dr Tim Sahato. Welcome Tim. Thank you. Tim's an anaesthetist at Nepean Hospital here in Sydney. We're going to give a few cases and really explore some of the issues around the management and prescription for acute pain and we'll start with a case and you're a junior doctor on the ward and a seven-year-old female who has sustained a neck and femur fracture and is due to transfer to the ward whilst awaiting surgery under the orthopaedic team and you've been asked to chart some analgesia for them. Maybe we just start very broadly, why is it important that we treat pain? Well, I mean, you know, obviously pain is something that a lot of patients experience. We want to be compassionate and we want to relieve their suffering. So that's, you know, probably the primary reason. But there are other reasons why we treat pain. In different contexts, for example, pain may be something that can lead to complications for patients down the track. Fractured ribs, for example, leads to hyperventilation, pneumonia, etc. So there are multiple reasons, but we need to think about the patient holistically. Maybe you can just try and classify the different types of pain and I guess how they relate to what analgesia may prescribe for them. Okay. So I suppose when I think about pain, there are different types of pain or concepts related to pain. We've got acute non-cancer pain. There's obviously cancer-related pain. And then there are patients that have chronic pain. Again, not necessarily cancer-related. And then there's another concept called neuropathic pain. These are sort of different types of concepts in pain which have different approaches. And I suppose whenever we're thinking about prescribing something for a patient, we think really about the context. As I've just mentioned, or just alluded to the different types of pain, we think about what type of pain is it. We think about the patient, and we also think about the infrastructure surrounding the patient. Is this something that's going to be in hospital? What kind of ward are they going to be in? Is this a patient that's going home? What kind of community services are going to be available? Who's at home with them? That type of thing. And know, in 1986, the WHO put out a statement with regard to, you know, an approach to analgesia, this sort of stepwise approach. And although I think that's still relevant, we've sort of, you know, moved on to a more mechanistic approach with these different types of pain. But still, we think about simple analgesia that you want to have on board, potentially use weak opioids for pain that's more mild to moderate, and then opioids with more significant pain. So I put the medication chart in front of you and ask you to chart some analgesia for this patient who is going to the ward whilst they wait on operation and would like to be nil by mouth. What's your approach? Okay, so this is a, so we'll need to find out a bit more information about this patient. So we know that she's an elderly patient who has got a neck ephraema fracture that obviously can be very painful. We need to know a little bit about if she's got any other comorbidities, whether there are renal or hepatic issues that we have to consider. What medication she's on, consider, you know, potential drug interactions. Another, I suppose another aspect is looking at to see if she's been on pain medications in the past or currently, you know, whether she's on a regular non-steroidal, whether in the past when she's been in hospital, whether she was put on any other pain medications and whether she had any problems with those pain medications in the past. And of course, with any patient, you're looking at allergies and things like that. Okay, look in this patient she's got normal renal function, normal hepatic function, not on any regular analgesic agents apart from some paracetamol for possibly osteoarthritis. So maybe just go, what medication would you be likely prescribing this patient? We can go into some more details about that. Okay. So she's going to be nil by mouth. She's awaiting surgery. And I guess we want to do some basic things first, if we can. You know that there's, she's had a neck of femur fracture that we put her in a position, so non-pharmacological stuff needs to be looked at initially, you know, traction for the hip, things like that, that'll make her a little bit more comfortable. We would want to continue her paracetamol, paracetamol, you know, obviously we're considering different routes in this situation. You know, in general, I mean, obviously we're awaiting surgery. Usually, you know, you're still able to have oral medications two hours preoperatively. I mean, unless she was, you know, just about to go to surgery, that might be an issue. But in general, we can, in most cases, we're still able to give oral medication. But if she was nil by mouth for other reasons, like she's been getting opioids in the emergency department and had lots of nausea and vomiting and we wanted to avoid the oral route, we could prescribe opioids such as morphine, for example. Subcut morphine would be an approach to go to the wards. In a lot of hospitals that I've worked at, IV opioids is contraindicated. The nurses won't support that primarily due to the types of observations that needs to be done on the ward and they just don't have the manpower for that. So if we decide to use subcut morphine, what dose, and how do you write it on the National Inpatient Medication Chart? Can you write a range of doses or just write one dose? Look, we can, so on the medication chart, the subcut can do a range. Usually in an elderly patient, we're going to start at very low range to something that's appropriate for that patient's weight. But we really want to err on underdosing slightly rather than overdosing this patient. So in terms of this, for this 70-year-old woman, she might be a little old woman who weighs 50 kilos, you might be thinking of 2.5 milligram subcut to 5 milligram subcut every four to six hours, depending on, providing there's no other drug interactions. Okay. So every four hours, and then do you need to put a maximum dose for 24 hours? Yeah, for the 24 hours. And again, you know, you're looking at this, the other considerations in this patient, you know, is she from home? Is she cognitively intact? You know, those types of things, that baseline thing is really important and that needs to be, you know, handed over. Now, so when you describe your dosing, is it based on their weight or their age or both? Both. There's considerations certainly for extremes of age. Elderly and kids, there is certainly less ability to deal with particularly respiratory depression. So certainly they will hyperventilate and become apneic a lot quicker than a young adult, for example. So if I had a 30-year-old with a similar hippie jury from Pratchett playing football, weighs 100 kilos, you need to write the subcut morphine up for that. Absolutely. What kind of dose would you use for that? So, I mean, somebody like that. I mean, the first thing we would need to do is obviously get them settled in the emergency department with acute IV morphine. In that situation, that patient will probably need a PCA rather than subcut doses. And again, there is significant inter-patient variability with opioids. What's appropriate for one person is going to be very different for another person. What doesn't, you know, what's underdosing for one person could be apnea for another person. So that's the thing that we have to be careful about. So in general, when they're on a ward, it would be likely subcut either an emergency department, intensive care centre or in the theatres, intravenous. Intravenous, yeah, would be the approach to gain, this is we're talking about acute pain, where we need to get on top of the pain relatively quickly. Is there a role for intramuscular opiates? Well, certainly when I started off in training, intramus was, you know, you'd write up either subcut or intramuscular. |
Okay, welcome everyone to On The Woods and we have Dr. Andrew Keynes, a ophthalmologist at RPA. Welcome Andrew. Thanks James, actually, I know Andrew reasonably well. Andrew did live together. So if I call you Keynes-y halfway through, don't, for people outside, think I'm being rude. Just don't repeat all the stories. Okay, we won't. We won't do that. We'll stick to the script, which is acute visual loss. So this is probably not a common presentation at Junior Dr. C, but I know from my experience working in the medicine department, I do get scared when I hear acute visual loss because I'm thinking, are they going to lose their vision if I don't make the diagnosis right? And how time critical is to make that diagnosis? So I really kind of value your expertise in this area. So when we talk about sudden visual loss, can you just give a kind of general overview of how you approach that patient? Yeah, look, there's a couple of diagnoses you don't want to miss. And there's also a system you want to go through so that you cover all the rare things. So some of the really dangerous things are things like giant salatoritis, retinal detachment. We'll come to a couple of others in a minute. But you really don't want to miss those ones. And then after that, you want to just go through a system of most of the diagnosis can be brought out through just history predominantly and a little bit of examination. So the things that I'm looking for on history are things like primarily does it affect just one eye or both eyes. If it's one eye then you're really thinking that the eye is the cause. If it's both eyes that are affected with their visual loss, then it's really the brain that you've got to be thinking of much more importantly. That's really important because I often, once I go through my exam and history, I'm usually wondering who do I ring, the ophthalmologist or the neurologist? But that's probably a good start. It's one eye, ophthalmologist, two eyes, neurologist. That's exactly right. And it just puts you, it makes you think about the pathology, where the pathology is. It's possible that both eyes can be, you know, an eye-related cause, but it's very unusual. You need to have it affecting both eyes at the same time. And that usually doesn't happen. Then after that, you really want to just go through what is the normal history. So, you know, when did it happen? And acute visual loss for some people is a few minutes and hours, but for some people it happened a while back. So just find out how long ago. And that also will give you an idea of how quickly you need to ring somebody. But so how long it happened? Usually sort of 24, 48 hours, the sort of classic time that people will come in for. And then some recover and some don't. So that's important as well. So if it recovered, it could be an embolus that's come through or it could be giant salatoritis, which is just giving that warning. Or it could be a migraine that's come and gone and the vision's completely recovered. But there are lots of diagnoses where the vision doesn't recover and things like a vascular disease or macular degeneration or retinal detachment. So there are a lot of things that the vision doesn't recover as well. So it's important to know which one of those two groups it fits into. After that it's things like the age of the patient. The diagnosis will be quite different between patients who are young and old. If it's a young patient you may be thinking of conditions like optic neuritis or migraine. If it's an older patient, you'd be thinking conditions much more vascular disease or once again, giant salatoritis. So they're fairly straight, you know, fairly simple questions which you can really come up with on the day. You don't have to, you know, I think if you take a normal routine history, then you can come up with a lot of those things. There's more than that as well. So you should take a history of their presenting symptoms. A lot of people will come up with other symptoms as well. For instance, they may say, I came in and I had a lot of flashes and then floaters and How do kind of word the floaters are more variable and they usually don't say that word so they may say I saw an insect or I see it saw some dirt and I kept on trying to clean it and it wasn't I realized it wasn't there so that's the way they describe those so we think of those other symptoms what other kind of symptoms do you think would be associated with some of the eye some of the patients um so um i mean things like pain was it pain or painless does that help at all look it doesn't some of the things that can be associated with would be headache would be a fairly common one um so that would be of use, once again, for, say, migraine or for giant cell arteritis. And if you go through the history, you can usually get a fairly classic history out of most of these people. So if it's giant cell arteritis, they'll come in usually with a temporal pain, and you can ask, you know, is it tender if you press anywhere? anywhere and you press on different parts of their head and some people will say everything's tender all over them and you press their shoulder and it still hurts and that's not particularly useful but if you if you're pressing around the head and nothing hurts and then all of a sudden you get to that temporal area or descending down in front of their ear and those parts are very painful then that's much more specific and you can really press on it fairly lightly people say that just by combing your hair you can get the pain so it is a quite a severe pain in that distribution and then they will come up with other symptoms of giant salatoritis it it you know they get jaw claudication and the underlying pathology of giant salatoritis. They get jaw claudication. And the underlying pathology of giant salatoritis, which I know you know, but it is that you get vascular insufficiency. So the wall of medium-sized blood vessels gets thicker, so the lumen of the blood vessel gets very small, and the amount of blood flow decreases. So the reason they get transient visual loss or acute complete vision loss is that a lot of the blood will be getting through and then at some point it becomes critically low and their vision blanks out. But there may be just a continuation of flow and so it comes back again. So for giant side rhinos, they usually get a couple of episodes where the vision blanks out and then two or three days later it goes completely and doesn't come back. But that system of, or that pathology of really reduced vision, of really reduced blood flow, sorry, it happens throughout their body. So it, for their jaw muscles, they'll chew and everything's okay, but they've only got enough blood supply to last for a few mouthfuls of chewing, and then their jaw muscles become sore. Same for their heart, they get angina. They often get peripheral claudication as well. So they can get abdominal claudication. It's a whole series of things. They can get polymyalgia, so they get weakness in their hips and also in their shoulders so it's it usually goes that they get fevers and sweats there's a whole usually a large number of symptoms that go with that diagnosis and you can usually make it on history one more thing with with giant slide or honest because that's such an important one a couple of things aren't the age of onset patients. This usually happens in older people and there's always this debate in ophthalmological and other societies of what's the youngest person that can ever get giant salatoritis and practically probably about 55, maybe 55 to 60, somewhere in that age group. If you've got a patient younger than that, it's very, very unlikely. But above that, you really need to do an ESR, CRP and platelets to help give you diagnosis, give you information about that. Okay, so we've gone through some of the historical features. Any other things in past medical history that are important or medications? Yeah, look, it is, I think the history is really important. So past medical history can include other things. If it's a younger patient, well, if you just ask a nice detail, tell me about your past medical history and sit there and listen, you can usually come up with it. |
Someone may also come up with the past history of, say, diabetes. Diabetes, you're much more likely to get vitreous hemorrhages in diabetics because part of the pathology of diabetes is that you grow new blood vessels and those blood vessels bleed, so vitreous haemorrhage would be common. And there are other vascular risk factors like hypertension, hypercholesterolemia. Those things would go with expecting that person to be a vasculopath. So those patients would be predisposed to getting retinal vascular disease. and that would be things like a blocked artery or a blocked vein. So either if you occlude the blood supply in any way to the eye then the thing that they'll notice is a reduced vision. And then the other things for history, once again a patient may come up with, well I've got atrial fibrill And if that's the case, then they may be at higher risk of having a mural thrombus, throwing off an embolus, and you're getting embolic disease and, say, amyrosis fujax or an occlusion ischemia. So there's a lot of stuff in the history, the past medical history, that will give you pointers as to which of the diagnoses it is. Also another obvious one is trauma. So I know it's a bit dumb, but if someone comes, I was punched, and that's why my vision went down. But it's a bit obvious, but it's there. Okay. So in regard to any more on history, or are we ready to move to examination? No, there's a little bit more. So another one I haven't mentioned is macular degeneration. And wet macular degeneration is a cause of reduced vision. They won't come through so much to the emergency department, I think, because most of these people will be plugged into an optometrist, an ophthalmologist, but they would be on the wards and you will see them around. So those patients, if you say, have you ever been to an optometrist or ophthalmologist? Do you have any eye disease? They'll say, yes, I've... Wet macular degeneration always follows dry macular degeneration. And so you'll have had dry for 10 years and then they'll turn into wet. And wet is when you get the sudden loss of vision. So if people may say, you know, is there anything wrong with your eyes? Yes, I've been followed for dry macular degeneration for the last five years. Then it may spark that, okay, this patient could easily be a wet macular degeneration. So that gives the majority of the stuff that you'd go through in history, I think. Okay. So how about a kind of focused physical examination, especially in regard to an eye examination? Yeah, okay. So the most important, one of the most, probably the most important thing when you ring an eye, an ophthalmologist, a registrar, a consultant, is to get the visual acuity. We love the visual acuity in each eye separately and also with a pinhole. So when you start off you do your vision you have to the first thing you write down is the number of meters you are away from the chart. So if for a standard distance there will usually be a line in a room and then it will go to a mirror and then back to the vision chart and it'll be about three meters to the mirror and three meters to the vision chart so you're six meters from the vision chart so you write six and then back to the vision chart. And it'll be about three metres to the mirror and three metres to the vision chart. So you're six metres from the vision chart. So you write six and then a big slash. Now, if you're in a smaller room or it's a different vision chart, it might be a three metre chart, but you always start off with what is the distance you are away from the chart. So almost always that'll be six and then you write a dash. And then you get the patient to read down with one eye, read down as far as they can and there are little numbers next to the letters. So if they read right down the bottom, there'll be a little number six next to those letters and then you just write, you know, whatever they read. So if it's six, it'll be six, six or if they made the line above, it's usually a six, nine line. So you write that and that's your vision for the right eye and then you repeat it for the left eye. You also do the pinhole vision and the importance of that is that it gets rid of the need for wearing glasses. So if someone's either just not had enough money or for some reason haven't got a new pair of glasses or they've left them at home, then you think this person's got terrible vision, it's just they haven't got an updated pair of glasses. So you put the pinhole in front and that will get them the effect of having a perfect set of glasses. So you can get a much, you know, it's an important and common thing that people often say, well, vision can be reduced, but it's actually just you're not wearing the right pair of glasses. After that, I would check pupils. Okay, so with pupil examinations, pupils are a bit tricky. There is the simple one which is the direct test. So you shine light in one eye and the pupil you shine the light in will constrict and the consensual will constrict. And that's the most straightforward one. And if you've got a complete destruction of the optic nerve so that no light is, no signal is getting through, that will be definitely positive. But there is a more subtle way where you can pick up if there's a partial defect in the optic nerve, there's partially the signal images getting through, or a relative problem would be another way of describing it. And that is where you do a swinging flashlight test. And what you do then is if you've got, say, the left eye is normal and the right eye is abnormal, you shine the light into the right eye and the pupil will be constricted. You quickly, with a bright light, go across to the right eye. And because only, only say half the signal intensity is getting back to the brain compared to the full signal intensity the pupil instead of being constricted because half the signal the intensity is getting back to the brain of saying how much light is coming through the pupil instead of remaining constricted will paradox dilate. And then you shine back to the correct eye and both eyes will constrict. Once again, you shine back into the eye that's got a weakened number of signals going back to the brain and the brain says there's only 50% of the light intensity coming through and instead of remaining constricted it'll dilate. And that's called a swinging flashlight test or a relative afferent pupillary defect. So it means there's not a complete destruction of, there's not no signal going back to the brain, but it's just reduced from what it normally is. Okay, so the abnormal optic nerve on that eye will rather than constrict, will slightly dilate. That's correct. Okay. Yeah, that's something I must say I do all the time, but I'm never that confident that I've got the right in my head. So thanks for explaining that. It is difficult. And the trick with it is to have a bright light. You can't elucidate it if you don't have a bright light. You need the light. You need to be shining, you know, on the normal eye, it's got to be 100%. And then when you, you know, you can then pick up if there's a 50% reduction on the abnormal eye. If the eyes, if you don't have a really bright, intense light, and when you flick it across, you've got to be really fast so that there's not enough time for the eyes to equivalent out to normal. You know, dark room, normal room, does it make any difference? It doesn't make too much difference, but if you have a too darker room, then you won't be able to see the pupils. Good, okay. So we've gone pupils, visual acuity. Yep. Look, after that, it starts to become tricky. It's difficult to... Hopefully, by the time you've done your history and got the... The history hopefully will be on a pathway of almost knowing the diagnosis. But there will be a few conditions where you won't be able to see what's in the eye. And at that point,opy or looking at the eye is the best option. |
And I believe there's one in the emergency department or if it's not, I believe it's on its way. I can't, I've never used it, sounds great. Look, I think that is the, you can either use the, to look at the fundus, to fundoscopy and look directly, but if your emergency department's got access to a colour camera, then I think this is a much easier way to do it. Do they need to be dilated to use the colour camera? They don't have to be, no. So these new colour cameras don't have to, but it's not dangerous to put dilating drops in as long as you've checked the pupils first. You need to have had a reasonable go because once you put the dilating drops in for up to 24 hours, you're not going to be having any meaningful pupillary information. And if it's a potentially neurological patient where they've been in a trauma, you want to have got permission of either neurosurgery or some other group before you put dilating drops in but if it's a well patient there really is virtually no contraindications to putting dilating drops in I think glaucoma doctors will be happy if you put it in just about everybody is happy if you put in dilating drops. In terms of a white non-red eye. Okay. And which drops do you use for the short-acting ones? Tropicamide is the shortest acting, but you can use whatever you've got in your department. Phenolephrine is fine, but most places will have Tropicamide, which is the bottle which has got a red top on it. One thing in terms of avoiding, and this is something I perhaps could have come back to earlier, but if you've got a patient who's got acute visual loss and their eye is red, then that could be a whole series of other diagnoses. That could be acute glaucoma or it could be a contact lens wear and they've got an ulcer or a lot of uveitis. There's a lot of things that could cause that. And that's a different diagnosis, a different differential diagnosis. So if you've got a red eye and visual loss, then don't go down the pathway I've been describing today. Go down the red eye pathway. Red eye kind of trumps a visual loss in a white eye. And what we're talking about today is a completely normal looking eye from the outside, but just they can't see. Okay. Now that's important, I think, just to clarify which way you go. Because once you go down one route, you don't want to be stuck down that route if that's the wrong differential diagnosis. Yeah, that's exactly right. That's exactly right. So I would then look at it, if you can, whatever way you've got of looking at the retina, assuming it's, say, one eye, it's not in both, the visual loss is not in both eyes, it's just one eye, so you think this is the eye that's causing it. You've done your pupil examination, so perhaps put drops in it or take a photograph if you can get a good image. And then after that, when you're looking at the retina, some of the more common things would be a vein occlusion. And a vein occlusion will give... There are four main veins coming out of the optic nerve and it could be one of the four veins that are blocked. And if you block the vein, you stop blood getting back into the eye and then it spreads out into the surrounding retina. So you get this very hemorrhagic looking retina. They could be in one quadrant if it's one of the veins or it could be if the central retinal vein is blocked it could be affecting all four. So that would be one of the most common causes of acute visual loss is either a branch retinal vein occlusion or a central retinal vein occlusion. And when you take that colour photograph or you look at the eye there'll be blood all over the retina. Another common would be wet macular degeneration. And that will be a different picture. So when you're looking at your photograph, basically the macular is the bit next to the optic nerve. It's the bit that you use for central vision. It's the highest acuity bit. So whatever you're looking at, you're using your macula. And usually there'll be hemorrhage or bleeding, or there'll be bleeding in the macula itself. And there'll be a whole lot of yellow dots around it, which are drusen, which is parts of the dry macular generation that you had before. So there'll be, what you'll notice, a whole lot of yellow dots plus some hemorrhage in the middle and the whole surrounding retina will be completely normal. So that would be a wet macular degeneration. And the other one probably to mention there would be an artery occlusion. And artery occlusions are important because we generally like to treat them if we're going to within the first 24 hours. Basically, the retina is a bit like the brain in that once it's had its, it's got a time when it can recover, you have an ischemic event, it can recover within, say, the first 24 hours. But after that, it's not going to really recover if you've depleted enough blood supply. So it's, artery occlusions are more difficult because when you take a photograph of the back of the eye, everything will more or less look normal. They do describe some features. So they may say there'll be a cherry red spot in the middle. But cherry red spots are somewhat, unless you've had a look at a whole lot of retinas, they're quite subtle. And the idea of a cherry red spot is that all of the retina goes a bit pale, but the centre of the retina, the macula, is quite thin, and so you can see the blood supply from the choroid coming through. So even though there's, you know, the whole retina is a bit pale and white, but because the macula is so thin, you can see the redness coming through from the choroid, so it gives us this red glow in the middle. You may see an embolus somewhere in the vascular system, which will cause the blockage, but sometimes you don't see an embolus as well. So if the patient's vision, the vision in patients with central retinal artery occlusion will be reduced. It'll be 660, which is the top letter on the chart, or worse than that. And so you'd have severe vision loss, but a relatively normal-looking retina, and that would be suspicious that it would be a central retinal artery occlusion. So in regard, we've done the history, we've got a fairly detailed examination, but something I think most junior doctors could do. Are investigations helpful, blood tests, ESRs, or just in a certain population? It really is within a certain population because hopefully you'll have got down a pathway where you'll have known which one you're heading towards. So hopefully you will have got to a point where you have a fair clue this is flashes, flutters, a curtain, it's a retinal detachment. So there's no investigations that are really necessary for that. You know, that's probably a retinal detachment. You've got to bring up the ophthalmologist to get a review of that. The one, if you're going to do any more general investigations, the diagnosis you don't want to miss is giant cell arteritis. So a patient older than 60 with sudden visual loss, they may have all those symptoms we talked about, they may not. Then the investigations would be ESR, CRP and full blood count. The reason this is such a significant disease is firstly the vision loss in the eye that's affected almost never comes back. So that's bad. But what is really bad is that we know that the second eye, their normal seeing eye, will also go and become blind within a few, it can be just hours or days or weeks, and the other eye will be affected. And so you don't want to send that patient home because it's terrible if they've lost vision in one eye, but if they've lost vision in both, you're in all sorts of trouble and it's irreversible. So, look, CRP is the one that is the most important because that almost is invariably raised. |
Welcome to On The Wards, it's James Edwards and today I have the pleasure of speaking to Professor Steve Chadbound, Arena Physician here at RPA. Welcome Steve. G'day James. Thanks for having me. I should also say, Steve is a very good opening batsman for our cricket side. But today, we're not talking about cricket. We're going to talk about acute kidney or acute renal failure. And as we normally do, we start with a case. So, Steve, you imagine the junior doctor covering the orthopaedic ward on the weekend, and when you get a call from the nurses, and they about one of the patients, a 30 year old male who 24 hours previously had an intramedullary fixation of a fractured femur which they sustained at a high speed MVA but they've noticed the urine output's been trending down steadily over the last kind of 6 hours and only 70 mils in the last 6 hours. So you get the phone call. Are you concerned about this patient and what would you want to ask the nurse over the phone? James, it takes me right back. My first ever term as a doctor was the orthopedic intern. So I say to the situation, yes, I am worried about this fella. It sounds like he's oligarchic. He's certainly passing less than 30 mils per hour. And the nurses, particularly on the orthopedic wards, are often very helpful. I'd want to know about this guy's vital signs, his blood pressure. Has that too been trending down? Has his pulse been trending up? Has he had a fever? Is he conscious and well and drinking and eating? Has he got a drip in? So is there anything else you'd ask the nurse to do before you go and view the patient? Sure would. So I want to know if he's got a catheter. He probably hasn't. And if he hasn't, it would be really handy if the nurse could look at his bladder with a bladder scan. Key to know if that oliguria is real or if it's spurious. And if we think of this as an acute kidney injury, what does that mean? You define it for us? It's a tricky one to define. It's when your kidney stops working from any cause really, James, and it's different to chronic kidney disease, although you should bear in mind that people who have chronic kidney disease, which are pretty common, 10% to 15% of the general population, are more likely than others to get acute kidney injury. Acute kidney injury implies that there's been an acute insult to the kidney, it's not working properly, it's potentially reversible. And obviously when we think of a kidney injury we often look at our blood tests and we look at creatinine. Is that the most used tool or should we look at estimated glomerular filtration rate? The tricky thing is that if I took you to the operating theatre just now, which would be extremely dangerous in my hands, if I tied off both of your renal arteries and made you effectively anephric and then did a blood test on you, your creatinine would probably be normal, but you would have zero kidney function. So the problem is that creatinine takes a while to rise. So typically in someone who's anephric, their serum creatinine will rise about 200 micromoles in a 24-hour period. Serum creatinine is the key driver of EGFR. EGFR is a more sensitive measure, but it too is hindered by that delay in recognition. That's why oliguria is so important to detect, which isn't always present, but when it is, it's telling you something that those kidneys aren't working. What are some of the most common causes of kidney injury in hospitalized patients? This chap's a classic case, so pre-renal factors are the most common causes. This is a young man who's had a major injury. He may have had an unappreciated other injury. For instance, he might have ruptured his spleen and he's quietly bleeding away and is hypovolemic. So hypovolemic shock is a key one. Two, sepsis is another key pre-renal factor. And then three, drugs are probably the other most common. This man may have had some contrast studies to look at his abdomen. Radio contrast is a common cause of acute kidney injury, as are some of the antibiotics such as gentamicin. So this man has several potential risk factors that we would like to know about. Do you have a way of classifying acute kidney injury? I still think that the pre-renal, intra-renal, post-renal is very valuable both in figuring out what's going on and giving you a structured approach. So the pre-renal factors, you and I have just gone over several of them. Is this patient clinically dehydrated? Second, exclude post-renal factors with an ultrasound. And then if you've excluded those factors, you're into the intra-renal things which look like nephrotoxins. Is there an underlying kidney disorder that's just suddenly happened? So in that context, both the blood test, but also what's in the urine is key. Are there red cells? Are there white cells in the urine indicating bleeding or inflammation in the kidney? And you mentioned ultrasounds. We've done the bladder scan, but you were saying a renal ultrasound to look at the kidneys as well? Renal ultrasound is probably the best way to exclude obstruction to the kidney, which is a consideration less commonly in a 30-year-old, although he may have fractured his pelvis and gotten an obstruction. But particularly in older men and even older women, obstruction is quite a common cause. So to look at the kidneys, you can both determine whether there is hydronephrosis bilaterally, but also an ultrasound gives you an idea of how big the kidneys are and how meaty they are. Do they look like there's chronic kidney disease with scarring or reduced volume, or are they normal size, or in fact, are they expanded, suggesting some inflammatory disease going on within the kidney? And in regard to the severity of acute kidney injury, is there a grading system, or how do you look at severity? There are a couple of potential grading systems put out by various people, including the RIFLE classification, KDGO, and a number of others. And they use a combination of oliguria and rise in creatinine because they're our two clinical tools. To be honest with you, I think that if someone's oliguric, or particularly if they're anuric, then it doesn't get any more severe than that. That's bad. And it doesn't matter so much what the creatinine is. It's going to go up 200 points per day. Besides that, the rising creatinine over a 24-hour period does give you a feel for severity also. You arrive on the ward and note the bladder scan has only 10 mLs in it and also the routine blood test seems to have spiked with the creatinine increasing to 180 mLs per litre. So what do you look at now? Has that changed your initial approach? It suggests to me clearly that there is acute kidney injury present. The creatinine confirms the oliguria. The fact that he's risen 80 to 100 points in just 6 or maybe 12 hours suggests to me that this man has virtually zero kidney function at present. I want to very thoroughly assess his pre-renal factors, what's his volume status like, what's his blood pressure, his pulse, where's his JVP, and institute some very prompt fluid resuscitation would be the first measure. Then think about the other things we mentioned. Is there sepsis? Is there a nephrotoxin present? Let's get some imaging of those kidneys. It's probably less difficult in a 30-year-old, but often we need to try and work out is this acute kidney injury or is it a chronic kidney disease, especially when you don't have previous blood results to compare to. What would your approach be for that patient? There are some features of acute kidney injury, such as electrolyte disturbance, often acidosis, hyperkalemia, predominate the picture. And typically the kidney sizes are preserved in acute kidney injury. There's been no time for scarring or loss of volume. In contrast, when there's chronic kidney disease, often longer-term complications of chronic kidney disease are evident, such as anemia, hyperphosphatemia, low calcium and high PTH, indicating renal bone disease. Acidosis and hyperkalemia can also occur in those settings, though they're more frequent in acute kidney injury. And the ultrasound will commonly show a loss in kidney volume, so typically smaller kidneys in that context. |
Hi Dave, welcome to On The Wards, it's James Edwards and I have the pleasure of having Natasha Andriada speaking with us today. Welcome Natasha. Hi James, thanks for having me. Natasha's a gynaecologist and a certified reproductive endocrinologist and an infertility specialist. And today we're going to talk about pelvic pain. And I guess we're going to talk about it in the context where most junior doctors will see people with pelvic pain, and that's in the emergency department. And it's interesting, I did this script, a case, you know, last week, but then I saw a similar patient yesterday. And that's a young female who presents to an emergency department with kind of rightly at foster pain, maybe a bit of nausea. When you see a patient like that, what's your initial approach? My approach to all patients, I always have holistic in mind, meaning when I meet a patient, my questions don't go straight to the pain. I like to know a bit about the patient and I think we all can afford that time, a couple of minutes to actually say, hey, what's your name? Where do you live? Where do you work? Who do you live with? And to take a very brief general medical history. And I have an acronym. I've always had acronyms. I've used acronyms all my life. And I've tried a doctor, which enables me to never leave out a single important question. And that enables me to cover everything before I then focus on the pain. So focusing on that pain is probably the last thing I come to. And that enables you to establish a rapport with the patient because at the end of the day, we're dealing with people. And in an emergency department, when it's very rushed, I think it's important not to forget that. And you can easily forget that, especially when there's so much going on. And if you don't have an idea about the whole patient, you're not going to be able to understand the pain as much and as well. So my pain history is obviously important, but it's not the first thing I actually approach in that patient. Okay, so tell us your approach then. So my approach is just striking up a conversation and asking them, obviously, what their general life history is. Have they been in hospital before, et cetera, et cetera. I'm also asking the patient what they think the pain is. What do you think the pain is? Why do you think you've got this pain? And it's amazing how much insight patients do have around their own pain. And then when I go into the pain, I go through the basics, onset, severity, when the pain came or what brought it on, has it been present before, etc., etc. And then collaterally, you're making sure that the nurses are attending to the patient, that their obs are being done, that they're being kept nil by mouth, that they've got a cannula in, in case the patient needs to be admitted. And pain relief is really important. So not forgetting that the patient needs pain relief. And I don't believe that giving someone pain relief is going to stop you from making a diagnosis. So making the patient comfortable is the main priority. And at the same time, coming to, you know, trying to figure out what's going on, but doing all of these things at once. So using the resources you have in your emergency department to facilitate that is really important. Yeah, I'm interested. So many people come with pain and doctors are so focused on finding out what the cause of the pain, they forget to actually treat their presenting complaint. The person. You're treating a person, not a symptom. Yes. Yep. And not forgetting that patients have a lot of insight and asking them, what do you think it is? Okay, so any questions on history that would be valuable in someone who presents like this? Yeah. So obviously, you know, with any woman, you obviously want to also focus on a gyne history, a gynec history you want to ask her when her last period was is she cycling where is she in her cycle because then that will perhaps change your differential diagnosis is she using contraception is she having intercourse and asking these questions in a very sensitive kind of way and of course you know asking other questions about vaginal bleeding, that's abnormal for her, any discharge, and, you know, other histories such as obstetric history, medical history, are they on any medications at the moment? And then again, asking in a sensitive way, there's a history of sexual abuse, etc. Previous incidents that have brought it to the emergency department for a similar reason. It's not unusual to have women who have recurrent hemorrhagic cysts who present to the ED. And, you know, you also find that people who live alone may present to the emergency department more often because there's no one at home to actually look after them. So all of these things come together. So a very focused and detailed gynaecology history is a part of a holistic view, I would think. Okay, what specific things do you look for on examination? On examination, you're obviously going to just look at the patient and by looking at someone, you can tell what kind of pain they have. And I always ask someone before touching them, how bad is your pain out of 10? And then they will usually say a zero or, obviously I'm not going to be zero, unless I've had some great pain relief, but a nine out of 10. So you're going to be obviously very cautious. Focusing on the abdomen, you are going to obviously inspect. Is there any obvious distention, any scarring? Then you're obviously going to gently palpate and then try and elicit where the pain is. Does she have any guarding, any rigidity? And then onwards, yes, depending on the clinical scenario, you may perform a speculum so that you can take some swabs if you're suspecting she has pelvic inflammatory disease. And we'll talk a bit about PID a bit later. And gently performing a vaginal examination, of course, after someone's permission, both for the speculum and for the vaginal. And know you will get some information from a vaginal examination a digital vaginal examination and that could be she could be quite tender at the intra-oitus upon insertion of your fingers into the vagina she might have a long history of dyspareunia and that may give you a hint as to perhaps something higher up is going on like endometriosis for example and then on deeper palpation you might feel nodules of endometriosis you might elicit cervical excitation or tenderness around the uterus or the adnexa so basically you're you're looking for an obvious cause and you're going to explain to the patient as you before you do all of this why you're doing it. So I'm doing this examination because I'm trying to find a cause for your pain. And once someone understands that, then they're going to be a bit more relaxed. And before doing a speculum or vaginal examination, it's really important to set up the patient appropriately, to make sure that she's not up in stirrurups so that if someone draws the curtain, they can see everything. Get her to face the wall so that she feels a lot more comfortable. And if she's more comfortable, then your examination is going to proceed in a more comfortable way for both you and the patient and you're going to get more information from that examination as well. So again, not forgetting about the patient. And, you were a patient, what would you want in that scenario? You'd want to be covered up. You'd want a towel over you. It's those little things that make a big difference. And I believe that you can still do that in an emergency setting or even on the ward. You mentioned several excitation. Can you just describe what that is? Because it's something we talk about a bit, but I'm not quite sure everyone understands what it really means. It's basically when, upon insertion of your fingers into the vagina, you basically find the cervix, and everyone knows what the cervix feels like. What it does feel like, if you're not really sure, is the tip of your nose. So it's quite hard and firm. And once you've found where that cervix is, you try and put your fingers into the posterior fornix, which is the posterior part of the cervix, and wiggle it around gently, just very gently, nothing too vigorous. Now, normally, if there's no inflammation there, that shouldn't cause the patient discomfort. But sometimes even just touching the cervix gently or performing that cervical motion causes a significant amount of pain. So that's what we're looking for there. |
How do you frame your differential diagnosis for a young female with, say, right iliopsoas pain? So I would recommend that any doctor, before even seeing the patient, have a differential diagnosis in mind because then that will frame your questions and also keep you kind of focused on what to ask for. So it's either non-gynecological or gynecological. And I explain this to the patient. I say the cause of your pain may either be related to your gynecological or your reproductive system or it might be unrelated like you know urinary tract infection or appendicitis gut related and then of course for your differential for your gynecological system you're going to talk to her about things like you know PID, ectopic pregnancy, you know general infection, torsion, hemorrhagic corpus luteum that's ruptured. So I think it's really important to outline that and to actually verbalise that to the patient because then that actually helps, again, you become, be focused on the history and the patient knows what you're talking about. How this doctor is explaining things really nicely to me and that's really, really important and it doesn't take long to do. No, okay. So we've got a differential diagnosis. We've done a history examination. What initial investigation is going to be helpful for a patient like this? So simple things that you can do on the water are a urine analysis, for example, and then you can send that urine off for microscopy culture or for chlamydia screening. And then when you're taking bloods, you can ask the person putting in the canner whether it's yourself or the nurse to take a blood for a full blood count, EUC, LFT, beta-8CG if she's sexually active. And if she's febrile, also checking her temperature, sorry, checking her blood culture if she's febrile. And of course, you would have assessed that as part of your initial examination, all those things so blood pressure heart rate and temperature of course so there are a few things yeah you mentioned about doing some also some possible specimens of escapation when you're doing the speculum examination just to describe which ones you do and how you do those so you would if she's got if she's got any discharge or even if she doesn't have discharge and you're suspecting PID, you would do a high vaginal swab and send that for microscopy culture sensitivity and an endoservical swab, I'm sending that for PCR for chlamydia. And depending on if there's anything else, you might do a low vaginal swab and send that off for microscopy culture as well. And I always send the urine off for chlamydia and gonorrhea PCR. Okay, and those swabs are different for a high vaginal swab and an endocervical swab? Yes, endocervical swab has to be a PCR swab. And the low vaginal swab is just a general microscopy culture. Okay. So probably one of the biggest ones that comes up is someone's rightly at phosphopain. Is it appendicitis or something gynecological? What are some of the things that help you decide which way it's more likely to be? Well, obviously, if she's had an appendix, it's not an appendix. I always ask about previous surgical history. And yes, you want to know where she is in her cycle. Because if she is in the luteal phase, that is, if she's in the phase of her cycle after she's ovulated, and you know she's regularly ovulated, she could have a corpus luteum that has become quite hemorrhagic. When a woman ovulates, the corpus luteum is formed. And that's quite a vascular structure. And being so vascular, it can become hemorrhagic and it can actually rupture. And that can cause quite significant pain. And it's a very common finding. Of course, there are other things such as, is there a cyst? Is there a big dermoid cyst that could be predisposing to ovarian torsion? Could she be pregnant? Could there be an ectopic? An ectopic could be in the tube, but it could also be on an ovary. It's rare to get ovarian ectopics, but they do happen. So there, you know, things like tubo-ovarian abscess, for example, so an exal PID is also something to consider. We're talking a bit about PID. Is that a diagnosis you make clinically or do you need to wait for the laboratory test to come back to prove that it's PID? I wouldn't wait for any laboratory test to come back. And the reason why is because there's no one clear historical investigative test that you can do to actually say this patient definitely has PID. And I think we need to clarify PID, what is it? It can be sexual or non-sexual. So sexual being secondary to Neisseria or chlamydia is more common. And then of course the non-sexual, and it's important that we don't forget that that so non-sexual causes are things like ascending infection and that's what PID is in the reproductive tract from perhaps IUD insertion or a termination of pregnancy or post-pregnancy or even an appendicitis can cause a type of PID so it's really important to keep those two differentials in mind, those two separate groups, because then what you do is you collate all your findings, both on investigation and through history. I would never let a woman who I thought may have had PID leave the emergency department without some antibiotics. And the reason why is because there is no reliable test to indicate any ascending infection. And so you want to minimise the risk of any chronic PID leading to tubal damage and infertility down the track. So you should have a low threshold for prescribing antibiotics in these women. So, you know, I think it's a bit like a syndrome. You have to perhaps look at not just your history, examination and investigation, but everything put together. And if you're unsure, give her some antibiotics. That's my recommendation. Okay. We may go, we've actually done some blood tests and the BDACGg has come back negative it's got a white cells a bit up at 11 the urine's clear where would you go to next um look i would just be really keeping my differential in mind and in terms of going where would i go to next i would still give her some antibiotics. And I, of course, would manage her pain. So what's happening with her pain? I mean, you know, got to look at the pain. Does she need admission? How bad is it? And often with these women, we do have to admit them for further investigation and pain relief and also observation. Does the pain get worse? Does it get better? What, you know What further tests does she require? Does she need an ultrasound? Does she need an operation? If I'm the general registrar or resident in the emergency department, I'd want to know, okay, who do I need to see this patient? Do I need to get the surgical registrar involved? Do I get the obstetric and gynae registrar involved? Perhaps involve both of them. And I think that's quite important. So even though she doesn't have significant leukocytosis and she's not pregnant, I mean, obviously that excludes a lot of your differentials there, so she's not pregnant, so you know it's not an ectopic. So that really helps you focus on other things. So what is the indication for a pelvic ultrasound? And which ones would you do as an inpatient, which ones maybe could be done as an outpatient? I think any woman coming into an emergency department should have a pelvic ultrasound. It's a very useful tool. Having one as an inpatient, obviously if you admit her, she'll need an inpatient scan. And if you discharge her, then you should organise an outpatient scan. Obviously you discharge someone when you think they're stable, when their pain's under control. And you may still discharge someone not even knowing what's going on. And that's, again, very important to actually explain to the patient that often patients come in with pain and we don't know why. These are our differentials, but you don't clearly fit into one box. We haven't forgotten about you. We need to follow you up. And so giving them clear instructions on where to go for that scan is really important and also making sure that they go to an ultrasound service that does good quality pelvic ultrasound and not, I believe, all centres are equal in that way and actually explain that very carefully to the patient. And what are you looking particularly on the ultrasound? What are the likely diagnoses you're going to make based on an ultrasound? So you might see an obvious cyst on an ovary. It might be a dermoid. |
Welcome to On The Wards, it's Jules Wilcox here and today we're talking about simulation with Jessica Stokes-Parris. Welcome, Jess. Jess is an ICU RN and Assistant Professor of Clinical Practice at Bond University. She's worked as an educator in a variety of settings and holds a PhD in medical education, where she explored authenticity in simulation. Jess has an interest in social media as a means of science communication and equity in healthcare. She's also a co-producer of Simulcast, a podcast all about simulation. So Jess, I think we probably better just start off perhaps by saying, what does simulation mean to you in a medical education context? I think for me, it's an opportunity to fail safely, firstly, and it's also an opportunity to learn. But more importantly, it's an opportunity to provide patients with the best care possible. And so from a medical education standpoint, whether that's undergraduate or postgraduate, it's an opportunity to grow, reflect and improve practice. Okay. And I think nowadays most people have had some exposure to simulation, whether it's, you know, lo-fi or hi-fi. Do you want to touch briefly on sort of the different kinds of simulation that people use? Yes, for sure. So there's lots of different modalities of simulation and they can range from using actors, what we call simulated patients or simulated participants. And then there's also mannequin based. So, you know, the really high tech fancy sim man three G's that have eyes that blink and things like that, right down to task trainers for practicing pelvic exam or venipuncture, etc. It's, of course, expanding even more than that now with augmented realities and virtual realities. And it even goes to serious games and all sorts of things. I guess it depends on what your learning purpose is, depending on which one you choose, but there's a huge variety out there. I think that's really important when trying to put together a simulation program is to try and work out what your learning goals are first to then get the most out of the simulation equipment and setups that you have. It's not a panacea for everything. Oh, absolutely. Do you have any advice for in terms of if somebody was going to be involved in simulation and was thinking about how to set up a simulation program, what sort of things do they need to think about? How would what you're doing? What could the potential negative effects be? And have you adequately prepared a safe space to learn? Okay. I actually want to touch on that a little bit. Where do you see people going wrong with simulation? Because I think when it first come out, everyone's like, oh, we've got to do this, do this we've got to do this but then some simulation sessions as I'm sure we've all been involved in them some are perhaps less educational than others or maybe not not education the right way I was in a simulation recently where someone went off script and decided to change the scenario midway through unbeknownst to the person that was running it because they wanted to crash the patient and so you know number one rule in simulation it's not all about cpr and it's not all about a deteriorating patient um so i think you know't go, don't automatically assume that your simulation is all about crashing patients. It's actually about bread and butter skills. It's about building teamwork. And I think don't bite off more than you can chew. Don't go for something that's going to take a lot of time, a lot of investment and actually could have a detrimental impact on your team. Start slow and go from there. And build over time. So you can start off with a basic skill and then add it in rather than... Yeah, because, you know, like if you think about it, you know, if you put you and I in a room together, we're both clinicians, we're both skilled, we're comfortable in the workplace. But if you put us in a simulation where we have to perform in front of our peers, that can be really uncomfortable because we are both thinking, oh, I don't want to make a mistake. What's Jules going to think about this, that and, you know, vice versa. So you actually need to give your staff and your team opportunity to get used to learning in that space before hitting them with something really hard. Yeah. Yeah. And I think that having that, having that safe space so that like you said, it is okay to fail. Yeah. It's really important. I mean, I think I say to my juniors anyway, it's okay to fail and make mistakes on a day-to-day basis because we do. But as long as you're learning from them, that's okay. And I think there is a real stigma in medicine about making mistakes and things which we should try and get away from, which I think simulation allows people to feel that it's okay. It's more okay at that point to do that. Do you think you can have too much simulation? Yes, of course. Just like you can have too much of anything. Yeah. So you think it should really fit into as an overall, as part of an overall educational program? Yeah, definitely. You know, I think, again, it comes back to what's the purpose of what you want to achieve. And if you are trying to teach something that would work better in more of a journal club or a reflective group practice or if you're just trying to get information across that your team may not actually have, then simulation is not the right place because you're actually going to set up your team to fail. Yeah. And do you find that sometimes, I think I'm trying to think of in the past, I've sort of had some people who seem to be simulation experts, but then when it comes to being on the floor, they struggle to translate some of the things they've learned across to that. So they seem to be able to perform quite – you see it both ways. You see some people who can perform rewound simulation and then don't manage to translate on the floor. And then you see some people who are really good on the floor and they really, really, really struggle to make it real. That's probably more common, I would say. Yep. Yeah, and look, we have found that simulation is a pretty good indicator of how somebody will perform in the clinical workplace. But you're right in the sense that you get that sense that someone's watching you. So then you become a little bit more uncomfortable. It's an artificial environment. And then again, so how are you setting up your environment? My PhD was looking at authenticity and how do the visual cues contribute to your engagement in a simulation? And when we have less accurate visual cues, we have to mentally work a lot harder to engage in a simulation, which then means we've got these two processes going on in our head where we're thinking, hang on this real is this a simulation or what am i supposed to learn here so you can feel this tension in the actual simulation itself yeah and how how do you get around that um i think when you set up what the expectations are for the simulation in the first place, what it is and what it is not. You let your participants know what the limitations are. So you might say, look, we are in a really fabricated environment. We get that. Don't, you know, these are the parameters of that activity and let's just carry on with that. You can do things to help set up the environment to look more realistic. So, you know, making it look as much like a ward or a unit as possible and giving your participants repeated times to participate in the simulation will help them move past that inability to suspend disbelief. Okay. Yeah. If we were to, I'm thinking about sort of some of the JMOs who are going to be listening to this and they're probably listening to it from one of two angles, either somebody who is using simulation to learn, but there will also, I think, be a cohort of people who are interested in becoming teachers and trainers in simulation what what sort of key skills do you think you need to be a good simulation educator so simulation is very different to other kinds of teaching and that is that you have to say less and do less so what I mean by that is it's not like a problem-based learning tutorial where you're sitting and someone's facilitating a discussion. Often there's more power in silence in a simulation and just allowing an individual to process through it. So I think the first thing is to identify whether you feel comfortable to just watch and let someone learn and to whether you have the skills to debrief. So I would say get an understanding first of what simulation is and what it isn't. And there's some resources out there around that. And then I would look at developing your debriefing skills. Okay. All right. Yeah, that will be good advice, I think. |
Okay, welcome to On The Wards, it's James Edwards and today we're going to be talking about anemia and I'd like to welcome Shaka Inam who's a Haematologist Registrar at Concord and Royal Prince Alfred Hospital. Welcome. Good to be here. So look anaemia is pretty common in hospital patients so we'll start fairly generally. What is anaemia? So anaemia is a reduction in the number of red cells and haemoglobin concentration of blood. This is clinically important because haemoglobin is the main carrier of oxygen in the blood. Haemoglobin ranges are different for males and females and for children. And it's important to recognise that anaemia is not a diagnosis in itself, but a manifestation of an underlying disorder. Okay, so maybe we'll go to a case, and we're going to make it a case of somebody you're seeing on the ward and you're an intern, it's a busy surgical term and you're reviewing a newly admitted patient and the haemoglobin's at 92 so they're anaemic and your registrar says well we want to try to optimise this haemoglobin before surgery. What would be your initial approach when you notice someone's got a haemoglobin of 92? So the first step with any abnormal blood test is to confirm that the test result is actually correct and it's from the right patient. And this is particularly the case for unexpected results. So potential sources of error might include incorrect patient, dilution from the administration of intravenous fluids. So make sure you check the other blood test results, such as the electrolytes, to exclude this. Another cause of anemia in a patient who's been admitted from emergency might be dilutional anemia from intravenous fluid administration which is physiological. My approach to this patient would be a comprehensive pre-operative history and examination. I would ask for any symptoms of anemia or clues to etiology. It's important to review the rest of the blood test results as well as previous hemoglobin results if available to get a sense of the tempo of the anemia. Okay, so do you think it's useful to have a classification of anemia? It's very important to classify anemia to try and work out exactly what the cause is. The most practical way to help determine the cause is to classify by the size of the red cells or the mean corpuscular volume, MCV. The normal range for MCV is 80 to 100 femtolitres. Common causes of anemia with low MCV are iron deficiency and thalassemia. High MCV should make you think of vitamin B12 or less often folate deficiency. And normal MCV anemias include anemia of chronic disease and acute bleeding. Another important classification is to consider whether this anemia is acute or chronic. You noted there will be some questions you'd want to ask about someone who's anemic. What sort of important questions are there? So in the history, ascertain whether there are any symptoms of anemia present. These would include fatigue, dizziness, shortness of breath and palpitations. This is more common in acute anemia as chronic anemia often causes minimal symptoms until it becomes quite significant. In the patient's past medical history, ask about any potential causes of anemia. This might include chronic kidney disease, liver disease which may cause bleeding, any known blood disorders like thalassemia, as well as a medication history for medications like warfarin or antiplatelet therapy which may predispose to bleeding. Also ask about any cardiac disease which might affect your threshold for transfusion. Are there any other things you want to make sure you try and find in the history in addition to identifying the etiology? So in addition to the etiology, try and work out how compromised the patient is. In addition to the symptoms mentioned above, look for acute signs of bleeding and ask about any previous diagnosis of anemia and any previous investigation for anemia as well. Okay, what should your examination focus on? So on examining the patient, look for signs of anemia and its potential causes. So of course you'll be guided by the specific clinical situation. Signs of anemia include palmic crease or conjunctival pallor. Heart failure with pulmonary edema may develop in severe anemia and in older patients with poor reserve. Vital sign assessment is important in new acute anemia as hypotension might indicate significant bleeding. Look for clues to etiology. So things like koilonychia or spooning of the nails and angular stomatitis are uncommon signs of iron deficiency anemia, but helpful if they're present. If you suspect gastrointestinal bleeding, look for proof or stigmata of liver disease. Examine the abdomen carefully. Examine for bruising in a patient on anticoagulation, as it may suggest super therapeutic anticoagulation. In many cases, the examination may not actually be helpful in identifying the exact cause, but can exclude very obvious ones. Before we go on to what test you consider ordering, what are the common types of anemia in the hospital setting? So there are multiple causes of anemia in the hospital setting, and anemia can often be multifactorial too. The common causes you might see include acute anemia in patients with bleeding, long-standing anemia in patients with chronic disease, say liver or renal failure, primary hematological diseases or patients receiving chemotherapy treatment, as well as post-operative anemia from blood losses during surgery. Remember, there may not be only one cause, particularly as our hospital patients are often older with multiple comorbidities. For example, an elderly lady who has fractured a hip and is awaiting surgery with a haemoglobin of 85 grams a litre and MCV of 80, you would consider iron deficiency, possibly contributed to by antiplatelet therapy and occult bleeding, poor nutrition, multiple chronic diseases, as well as the acute blood loss from the injury. What blood tests would you consider ordering someone who's got anemia of hemoglobin, let's say 90? So further testing will be guided by your clinical assessment of the patient and what you think the likely cause might be. In cases of acute bleeding, ensure the patient has a valid group and whole in case they need a transfusion. Depending on the clinical scenario, electrolyte and liver function testing may guide you towards, say, gastrointestinal bleeding, a raised urea to creatinine ratio is quite specific for upper GI bleeding. In microcytic anemia, check iron studies, and a thalassemia screen might be appropriate in the right age and ethnic group. You may see a blood film comment made by the laboratory hematology registrar suggesting some of these tests. In macrocytic anemia, consider testing for vitamin B12 and folate levels. In a patient with normocytic anemia and hypercalcemia or renal failure, an electrophoretogram or EPG might be useful to exclude multiple myeloma. Hemolysis can also cause a normocytic and occasionally a macrocytic anemia and its diagnosis can be confirmed with a hemolysis screen. Be mindful not to order all these additional tests routinely but be guided by your clinical assessment of the specific patient scenario. You mentioned a hemolysis screen. What's included in that? So hemolytic anemia is caused by the shortened survival of red cells in the peripheral blood and has a number of causes. Congenital disorders of hemoglobin like thalassemia or sickle cell anemia, autoimmune hemolysis and certain medications. We make a diagnosis of hemolysis on a set of investigations called a hemolysis screen. This includes, in addition to the full blood count, a reticular site count, which we expect to be increased, a lactate dehydrogenase, or LDH, also increased, total and indirect bilirubin, increased, and haptoglobin, which will be low. Finally, a direct antiglobulin test, or DAT, is sent to test whether the hemolysis is immune in origin. So what about a Coombs test? Coombs is the same as a direct antiglobulin test. What blood feature would suggest an iron deficiency picture? So an iron deficiency anemia would be microcytic, with microcytic hyperchromic cells seen on a blood film. Another suggestive result on the blood count would be a high RDW, or red cell distribution width, which you might have noticed, which suggests increased variation in red cell size. On iron studies, deficiency is confirmed by a low ferritin. However, remember ferritin is also an acute phase reactant and may be high in states of inflammation. Therefore, look for an increased transferrin level and a low transferrin saturation. Iron deficiency anemia should lead you to think carefully about its cause. It's frequently present in younger females who may have heavier menstrual bleeding. However, in adults, you must consider occult blood loss from a polyp or bowel cancer, and these patients need further investigation, usually with endoscopies. |
Well, welcome everyone to this latest podcast for On The Wards, and this one's entitled Heart to Swallow, an approach to esophageal disorders. My name is Bruce Way and I'll be interviewing today and joining me for the conversation is Dr. Reg Lord and Reg is a upper GI surgeon at St. Vincent's Hospital and also at Macquarie University Hospital, both of those in Sydney. He's also a professor and head of surgery at Notre Dame University School of Medicine, and he's head of the Gastroesophageal Cancer Research Program at St Vincent's Centre for Applied Medical Research. Welcome to On the Wards. Thank you, Bruce. So we're going to talk about swallowing problems today, and we're going to start just by talking about dysphagia and what dysphagia is and how it differs from adenophagia. So do you want to start with that? Yes. Well dysphagia is a very important symptom for esophageal disorder is arguably the most specific symptom, and dysphagia is essentially difficulty in swallowing. More specifically, it's the sensation of difficulty in the passage of food or liquid from the mouth to the stomach. And the primary objective in anyone who presents with dysphagia, we'll mention right at the front, is either to diagnose or exclude esophageal cancer. Adenophagia means pain on swallowing, and these two symptoms, dysphagia and adenophagia, often occur together, particularly in patients with obstructive lesions, when there's some food stuck at the level of the obstruction. And typically the pain will be relieved by passage of the bolus that is obstructed. But with motility disorders, which we'll come to discuss, I'm sure, you can also have a combination of dysphagia, which is the classic symptom of a motility or motor disorder of the esophagus, with pain, usually due to inflammation from the food sitting there in the esophagus. So cancer's the big one in terms of diagnosis that you're trying to explore? Yes, this is why it's so important whether you're an intern just taking a regular history for a presentation for something else, a GP, anything at all. And actually anyone who has an esophageal history at all, even something like reflux, you should specifically ask about dysphagia. And remember when you're taking a history for dysphagia, it's not only asking about what sort of foods get stuck and how long has this been occurring and is it getting worse, liquids versus solids, et cetera, which we'll come to, but you also have to take a dietary history because patients will even subconsciously adjust their diet. So you have to ask, what did you have for dinner last night? Because you may ask, do you have difficulty with swallowing? Which, as I say, should be a routine question. And the patient, particularly elderly patients, may say no. And you say, well, could you eat the classic sort of foods that get stuck, which are bread, rice, and meats like steak or chop? Oh, no, I haven't been able to eat them for months. What did you have for dinner for dinner last night? Oh, soup. Have a lot of soup? Yes, I have soup. It goes down well. Yeah. Okay, so apart from cancer, what other causes could there be for dysphagia? How do you sort of group them and think about them? Yes, there are two main ways of classifying dysphagia. One is according to the anatomy. So there's oropharyngeal dysphagia in the cervical esophagus and the neck. This is also called transfer dysphagia. So it's a problem with transferring the food from the oropharynx into the top of the esophagus. And then getting the food and drinks through the esophagus, the tubular esophagus, is called transporter dysphagia. And so these are quite separate. And transporter dysphagia is, like I say, involving the cervical esophagus, and it's usually in patients with neuromuscular disorders. Most common one would be stroke. And this is generally dealt with by the physicians. Every now and then there'll be a surgical role, but not often. So for the esophageal surgeon, it's really this transport esophageal dysphagia involving the tubular esophagus and the chest. The other main classification is into obstructive or mechanical dysphagia due to some sort of a lesion compared to non-obstructive dysphagia where there's no lesion. And this is due to esophageal motility or motor disorder, of which the commonest one is achalasia by far. And with the mechanical or obstructive lesions, as we've mentioned, the main thing is to diagnose or exclude esophageal cancer, remembering that dysphagia and weight loss is the commonest presentation of esophageal cancer. And the esophageal cancer, including in Australia, adenocarcinoma is increasing at a faster rate than any other cancer. So it's increased more than six times in the past several decades. And the classic question on the history is whether the difficulty in swallowing is with solids or both solids and liquids. Solids, particularly progressively getting worse with solids, suggests a mechanical or obstructive cause, whereas difficulty with both solids and liquids suggests a motility disorder. Okay. We might move on to a case now. So we've got a 56-year-old obese man who's been sent into the emergency department by his GP and he's complaining of being unable to completely swallow food. He says that a piece of food has been stuck in his chest since last night and on further questioning he reveals this has been happening on and off for several months but this is the first time he hasn't been able to actually clear it. So what would your initial approach be to this patient if you saw him in the emergency room? So this patient is a little unusual in that he seems to have a food bowl of obstruction where he thinks it's absolutely stuck. And so you have to assess how completely obstructed he is. It may be that he's unable to swallow his saliva, for example, in which case he really needs to go fairly rapidly to the endoscopy suite or theatre, have an endoscopy, and remove the food bolus. And then we have to deal with the underlying cause. And in this patient, you've mentioned he's middle-aged, he's obese, he's a male. So these are all the classic risk factors for esophageal adenocarcinoma, which develops from Barrett's esophagus, has the same risk factors. And Barrett's is further is a consequence of reflux disease so we're already starting to think that this could be cancer. Could be cancer yeah. Can I just ask you with regard to the initial management I mean you know you need to go on and work him up and think about cancer. But in terms of the initial management, we get told a lot of things in the emergency department about different ways to relieve bowel obstruction and they talk about, you know, Coca-Cola or equilibrium and all those sort of things. Coca-Cola does work, actually. You probably remember those stories about you can drop a dirty coin in a glass of Coca-Cola in the morning, it's clean. Those stories, unfortunately, when you think about the worldwide ingestion of Coca-Cola, are basically true. So in the esophageal surgery world, we have people who will struggle with dysphagia as a result of our operations for months. And we tell them to get a can of Coke or Pepsi, open the can that the bubbles go a bit flat and then drink that and that is often successful. Okay. Does it have to be Coke or could it be any sort of carbonated beverage? No, it seems to have to be Coke or Pepsi and I've heard that Diet Coke is even better than regular Coke. Okay. What about other things? There's other drinks. So pineapple juice contains an enzyme. And pawpaw contains an enzyme. So these are things to remember. One of the other things they talk about is glucagon. I suppose I try. I'm not sure. I couldn't say for sure. Okay. But certainly the Coke and Pepsi do work. If he's got a piece of food really stuck there on top of a can, so he's quite likely to need a scope to retrieve it. Yeah, yeah, yeah. He needs a scope anyway, this guy. Definitely. It's just in terms of, you know, trying to symptom relief, I guess, as much as anything. Okay, so past medical history, what are the sort of things that might concern you when you're taking history from this guy? |
So whatever it is, it's getting worse over a relatively short time period and that's also concerning for cancer. You can get a food bolus obstruction with achalasia and motor disorders. But I think it's his general presentation with risk factors, esophageal adenocarcinoma and this progressive food dysphagia that's telling us that we probably have a mechanical obstruction. Of course, we want to take a detailed medical history, and we're assuming here the patient hasn't had a missing fundoplication that could be too tight. He doesn't seem to have a long-standing history to suggest a motor disorder. And achalasia can also develop quite rapidly, but we'd take a history of all those things. And as we've discussed, we'd talk about whether it's solids versus liquids. Okay. Has he had any weight loss? So any other body systems or any other questions you'd ask in trying to work out what the cause might be? The other body systems would be of interest in relation to that transfer dysphagia, the neurological, neuromuscular type of illnesses. We would be taking a reflux history, and reflux involves the potential for other body systems. Approximately half of non-cardiac chest pain is due to reflux. Some of the Barrett's cancers may have a reflux history. Interestingly, patients with long-standing reflux often have an improvement in their reflux symptoms when they develop Barrett's. So they feel as though things are getting better, whereas in fact they're getting worse. So it's something to be aware of when you're taking a reflux history. Reflux of course is so common that as an intern you're going to meet many people with reflux and if you can pick up the high risk patients for reflux which are the middle aged with central obesity. And if they can be diagnosed with their cancer before the onset of dysphagia, then their likelihood of survival is much better. As an intern or a GP, it's worth reflecting on that when we see patients in surgery for the first time with esophageal cancer, very often they've been to the doctor at least several times beforehand with this history of dysphagia. So it's a really critical symptom. And what, in terms of trying to differentiate between medical and surgical causes, can you do that just on history? You can get a good idea from the history, and sometimes it's quite apparent. And there are symptom assessment scores which have got a high accuracy for the patient being likely to have esophageal cancer. But the history alone is not reliable enough. So the golden rule is that everyone with dysphagia should have an endoscopy. And that even includes young people. Young in the esophageal world, we sort of think of as less than 60. But people with motor disorders can present much younger in life. And even people with esophageal cancer. They may be from a Barrett's family, for example, where the Barrett's is more likely to progress to cancer, and these people can present quite young. Just for those people who might not know, can you just tell us what you mean by Barrett's? Barrett's esophagus is the condition in which the lining of the distal or lower esophagus just at the end of the esophagus where it meets the stomach is replaced by its normal lining which is pale appearing on endoscopy with flat squamous cells to a more columnar looking mucosa with goblet cells, which defines the presence of intestinal metaplasia. So the type of cells you would see normally in the small or large intestine, but when they're seen in the esophagus, are a diagnostic of Barrett's esophagus. Barrett's esophagus appears as a consequence of severe long-standing reflux disease, remembering, as we've mentioned, that the symptoms may not be particularly severe, even though the underlying disease is severe. And Barrett's is the main risk factor for esophageal adenocarcinoma, which we've also discussed is increasing in incidence at a really alarming rate. Right. facing a significant problem with Barrett's which currently can't be diagnosed without an endoscope. There are some problems with the pathology interpretation of Barrett's. We can't endoscope the whole population. It's just not realistic in terms of cost effectiveness. So if you found Barrett's what would you then do with that? If we find someone with Barrett's esophagus, then we currently put them into Barrett's surveillance, which involves an endoscopy with the interval between the surveillance endoscopies being determined by the severity of the Barrett's. So the Barrett's would be staged according to its length. And here we use the prior classification. Right, okay. above the circumferential, this person would have a C1 circumferential one, M3 maximal 3, C1 M3 Barrett's esophagus segment. Okay. And then the second part of the classification staging would be the microscopic evaluation, where we're first of all confirming the presence of Barrett's esophagus by seeing these goblet cells, intestinal metaplegasia. And then we're also looking for dysplasia, where the cells are more irregular. Right. And this is a binary classification into low and high grade dysplasia. Okay. So it's basically a continuum process from... Yes. If we see high grade dysplasia, then we intervene because then we know the risk of developing cancer within a year is high enough to warrant you doing something about it. So we would either do endoscopic mucosal resection if there's any nodules and we may do also some type of ablation so the aim there is to completely remove the Barrett's esophagus. Right, okay. Alright, we'll move on with our patient. We'll say the patient gets admitted, they get a CT scan of their chest and abdomen. The working diagnosis is carcinoma. Are there any special considerations for junior doctors who are looking after the patient on the ward? One of the things that comes up is, in terms of is it safe to put nasogastric tubes in if they need need it or can that cause problems? So if you're the intern looking after a patient with a significant esophageal disorder in the ward such as a cancer or large hiatus hernia, severe reflux, the cancers that you're going to see in Australia are more likely to be adenocarcinomas in the background of reflux and Barrett's. So firstly, these patients have got a high risk of aspiration, and aspiration pneumonia is not a good workup for esophagectomy. They may be malnourished. And in these days where the patients can easily look up their diagnosis, they'll quickly find that esophageal cancer has got a very poor outlook, so there's sort of supportive elements for the intern to consider there. Nasogastric tubes, so if the patient's fully obstructive, it's better to have a nasogastric tube than have them aspirating. And it can be placed in the normal fashion. Yes, but you wouldn't, if you were having any difficulty, I think if you were the intern, you'd call someone a bit more senior. The chambers are fr friable it is possible with excessive force to cause an injury okay we've talked a bit about endoscopy and Barrett's and how that's staged and progressed are there any other investigations that might need to be organised in terms of this patient's now got got a cancer. So we're now staging the patient for cancer. The intent of therapy, whether it's curative or palliative, unfortunately often palliative, especially in patients who present with dysphagia. And we're looking as to whether the patient should receive chemo or chemo radiotherapy first, whether they can have surgery, etc. So we've discussed that all these patients with dysphagia need to have an endoscopy and a biopsy and they would have a chest x-ray. The chest x-ray sometimes shows an air fluid level in someone like this with high-grade obstruction. If there's any suggestion of airway invasion, such as from cough or aspiration, then you'd get a bronchoscopy. And nowadays, the PET would also be augmented with... The CT would be augmented with a PET scan, which is usually a combined CT PET. And the PET scan has been shown to be more accurate for lymph node involvement than a regular CT. Endoscopic ultrasound is also part of the staging. It's being used less and less. It has little benefit for the most superficial type of cancers, the T1 cancers, it's very good for T3 and invasion of adjacent structures. Right, okay. Alright. You'd also, if the patient's being considered for surgery, want to do a work-up because the esophagectomy is one of the biggest operations a patient can undergo, so they would routinely have a stress echo, lung function tests, and of course the anaesthetist will be interested to review the patient. |
Okay, welcome everyone to On The Wards, it's James Edwards and I'm here with Jenny Liu who's a resident here at Royal Prince Edward Hospital. Hi Jenny. Oh, hello. Jenny's also part of our On The Wards team. We're going to talk about something today which I think is very important for junior doctors and it's discharge planning. Often on The Wards we talk about medical topics, chest pain, shortness of breath, and there are lots of things on how to do those within textbooks, but it'd be hard to find something on discharge planning. So how have you learned about discharge planning, Jenny? So I've mainly learned about it through on-the-job experience, through my colleagues, mainly more experienced registrars, and just by doing it. Yeah, so I think that's how most people do it. So we're going to try and give other gene doctors some tips and tricks on discharge planning, and we'll start with a case. You are rounding on your first week of internship on the respiratory team and you are seeing Mr Thompson, a 75-year-old man admitted with haemoptysis and found to have a new diagnosis of metastatic lung cancer. He's had a complicated 30-day admission and received palliative radiotherapy for bony meds, had an episode of delirium and urosepsis, and despite his pain improving after palliative care team stuttered on multiple opioids, he was still needing oxygen to maintain his saturations. The consultant tells you, aim for discharge in a few days. So Jenny, what are the potential issues do you need to address for Mr Thompson to ensure safe discharge? So first of all, it's quite clear from this case that this patient has a lot of issues going on. And the most important thing to stress is ideally that discharge planning has started from the very beginning and not when the consultant says to aim for discharge. So the things that have been pointed out from the case history, the fact that he's on multiple opioids started by the palliative care team, so his discharge medications is definitely going to be complicated. He's quite an elderly man. He's been in hospital for 30 days. We don't know much from the case history about his social history, but it's likely that he may not be able to cope living at home if he was from home. And it's important to look into whether or not he needs additional support at home, what his ADLs is like, and whether or not he needs assistance with that. His discharge summary is probably going to be quite complicated. Multiple teams have been involved. And so it's important to get the story correct for ongoing continuity of care. Perhaps the fact that he's been in for 30 days, his mobility might not be at baseline. And it's possible he may need rehab versus things like home modifications if he was able to go home. So at that point, important to involve physio and OT with the discharge planning. And sadly, the fact he's got metastatic lung cancer, his prognosis may not be very good. And in terms of the fact that PAL care is involved, we may need to look at things like long-term end-of-life care planning, perhaps even talking about advanced care directives. And if this gentleman was to become unwell again, is an acute hospital the most appropriate place for this patient to come back to or would he and family prefer to go directly to a place like hospice? So liaising with the palliative care team who have already been involved in his care would be very important. An important point that's mentioned is the fact that he's still requiring oxygen and for many new interns organising home oxygen is quite a daunting task and sometimes it requires a bit of logistics and it varies from hospital to hospital whether or not the patient can afford it out of pocket or whether or not they need to fulfil certain criteria And this depends whether or not they're known to a respiratory team or a palliative care team. So it's important to find out. And there's probably more state-specific and hospital-specific sort of requirements for organising home oxygen. It's likely he'll need further follow-up, both from oncology and palliative care, possibly from the respiratory point of view and so it's important for the JMO to liaise with those teams and find out what sort of follow-up appointments are required. And finally educating the patient and the family with all of this information prior to discharge. Hi Cass, there are lots of issues there that you've noted for Mr Thompson. Which members of the multidisciplinary team may be able to help you discharge Mr Thompson in a safe and timely manner? So we've mentioned a few of those already, but the common members of the multidisciplinary team, including physiotherapy, which is important for assessing mobility, perhaps providing mobility aids or guiding the patient in terms of what kind of aids are required, as well as defining potentially rehab goals if the patient was to go to rehab prior to going home. Occupational therapy is very important if his patient was to go home and perhaps looking into home modifications, rails and extra bathroom equipment to prevent falls if this patient's got back pain and reduced mobility from his long stay. In terms of social work, particularly in an oncology case, there may be a need for emotional or psychosocial support or even perhaps organising home packages. This may include things like compacts or other community care packages, organising help in terms of finances or even transport to ongoing appointments, whether that be with radiotherapy or with palliative care. Social worker might be an important person to contact. Dietitian is quite important in many patients, particularly oncology patients who can be quite cathetic. So important to involve dietitians early on and provide advice about optimising nutrition in the setting of advanced cancer. And also the pharmacist, the ward pharmacist may be very important to advise on the safety of medications and medication interactions. And some hospitals may have a discharge liaison pharmacist who may be able to come and speak to patients, particularly those perhaps on warfarin or multiple S8 medications and educate the patient and the family about taking those medications, when to use breakthroughs and that sort of thing. Finally, palliative care teams often have community palliative care nurses. So that can be organised via the palliative care team and it's an important member of the multidisciplinary team, particularly for Mr Thompson. And lastly, given the fact there's multiple allied health members, sometimes what's beneficial is organising a family conference and this can bring all the members together with the treating teams and with the patients to ensure, I guess, everyone has a common understanding of what the patient's going to be going through and what's needed following discharge. Jenny, as an intern, you're having lots of difficulty coordinating all the logistics and installing home oxygen for Mr Thompson. He doesn't seem to have any family or friends who could be at home to receive the oxygen tank for installation. Who can you speak to about helping to arrange discharge element as issues on the wards? Yeah, so this is actually a situation I was involved in last year when I was doing medical oncology. And sometimes these little logistical glitches, say if a patient has no one at home and oxygen has to be delivered, ideally to home to be set up so that it's ready for the patient once the patient gets home. It can be quite tricky. I think the best port of call initially is the numb on the ward because they're very experienced with coordinating discharges. They've had many years of experience on the wards and they may be able to refer an intern in difficulty with discharge planning to someone else in the hospital. Other people who might be good to talk to, particularly for issues like home oxygen, could be the palliative care team or if they weren't involved, even contacting the respiratory team or the respiratory ward to find out if there's anyone that has information. And as the intern, you're never alone, so never feel afraid to ask the registrar or the consultant on the team that you've got this issue and hopefully it can be sorted out. What are some of the common issues that usually delay patient discharges? I guess what's the role of the intern in making sure this discharge process is nice and smooth? Yeah, so in terms of the common issues, so things that we have addressed already are things like medications. It's important to organise medications ahead of time. Pharmacy especially can be very busy on a Friday afternoon understandably with over the weekend discharges so it's important to try and order medications ahead especially if you know a patient's going to be discharged the next day and also ensuring the patient and carer are educated about any new medications involving people like the ward pharmacist or a discharge liaison pharmacist. Other things include ensuring that a discharge summary is accurate and complete. It can be difficult when starting a new term and it's always courteous when you're leaving a term to try and update discharge letters so it makes it easier for the next person starting and hopefully they'll return the favour as well. |
Okay, welcome to On The Wards. It's James Edwards and I have today Dr. Ed Aberdeer, who's a Haematology Registrar at Concord and RPA and this is part two of our anti-correlation series. We've spoken about warfarin and today Ed's going to talk about the heparins. Welcome Ed. Thank you Jack. We will start with a question in regard to the heparins. You're asked to heparinise an inpatient who's got a pulmonary embolus. Outline your approach, especially what influenced your decision to use either low molecular weight heparin or unfractionated heparin. Yeah, so heparin, either low molecular weight or unfractionated, is almost always the first therapy given these days, though the direct oral anticoagulants are making inroads to that. And the two options that you have are the unfractionated version and the low molecular weight version. I'll just discuss the pros and cons of each briefly. The unfractionated version is more difficult to administer as you need a continuous IV infusion. So it's important for junior doctors to make the distinction that unless it's a continuous IV infusion, it's not a therapeutic dose of unfractionated heparin. All these subcutaneous injections are prophylactic doses of unfractionated heparin. So you need to maintain a continuous line and it needs to be monitored as in the, with the pharmacokinetics, it's quite difficult to maintain a steady state on a single dosing. So you need to do regular APTT monitoring tests, which initially start six hours after any change in duration in one stable for a fixed period can be lengthened to up to 24 hours. So it does require more monitoring and difficulty to administer are the cons. But the advantages of unfractionated heparin is that it is probably the most reversible of any anticoagulant that we have. It not only has a very short half-life, and you can stop it, and its effects will cease relatively quickly, but you can also reverse it with protamine quite effectively. So it can be terminated very quickly. The other advantage is that it's not dependent upon renal function. So many of the other oral anticoagulants, including low molecular weight heparins, accumulate with impaired renal function and unfractionated heparin is not a concern. So they would have an advantage in those groups of patients. The low molecular weight heparins, of which claxanes or noxaparin is the standard one that we have available, have the advantage in ease of administration. The therapeutic dose is either 1 mg per kg twice a day or 1.5 mg per kg daily, and it's a subcut injection, which most patients tolerate, especially for limited periods, quite well. And the monitoring, there's no monitoring required, except in some situations, which we'll talk about later. So for most patients, they don't have to be monitored. As we know, it has good, stable pharmacokinetics in most patients. And in some scenarios, it's thought to be more effective than unfractionated heparin, though this does not appear to be a huge advantage. The major negative is that it accumulates with impaired renal function. So patients with impaired renal function will have to either have dose monitoring or are not eligible for it. Generally, dose reduction in monitoring with anti-10A levels can be done in patients with an estimated glomerular filtration rate of greater than 30. And EGFR of less than 30, it's not absolutely contraindicated, but most clinicians wouldn't feel comfortable giving noxaparin at that level. The final disadvantage, I guess, is extremes of weight, which we do encounter more commonly, especially with obesity on the rise, and that there's less evidence and not very good evidence in patients greater than 100 kilograms and certainly greater than 150 kilograms. There's almost no evidence for pharmacokinetics and levels. So generally, with all of this being said, unless the patient has severely EGFR less than 30, anoxapar and a low molecular weight heparin is a preferred agent due to its ease of administration, and it might have a slight advantage in reduction of progression of VTE in this scenario. Okay, so we've identified most circumstances low-medicine white heparin would be the preferred option, and that's what we'd probably stand to use in someone who has pulmonary emboli. If you were deciding to use intravenous heparin, I think you mentioned before, when would you check the APT initially? After six hours after starting or six hours after any dose change. And another question, do you need to check their currents beforehand? If there's a concern leading into it that they would have underlying coagulopathy, some of these patients you might be concerned for a lupus anticoagulant, if there was reason to suspect that, which would raise their APTT prior, then I would. Otherwise, I don't think it's required, generally. And if the APT comes back higher, say greater than 120, what would be your approach then? Yeah, so every hospital, local area health district will have their own guidelines, so I would consult whatever guidelines I'm working within. I believe our local guidelines suggest stopping for two hours and then repeating and checking the APTT again in six hours when you repeat it, I'm sorry, when you recommence it at a lower dose. Okay, okay. So there should be guidelines at most hospitals to tell us what to do. Yeah, it's nearly impossible to use without guidelines because the variability is so great within the range that you're aiming for, depending on individual patients, that I certainly would always use it with the local guidelines. We mentioned a few before. What situation would you monitor your enoxaparin treatment with anti-10A levels? Yeah, so anti-10A levels I think are useful if a patient has impaired renal function. So if, you know, say the EGFR is 45 but you still feel clexane is the right drug for this patient, you would take an anti-10A level. And the best studied times and way to do it is to do a peak level, which occurs between four to six hours after administration. Generally, we say aim for four hours. And the dose can be adjusted based upon those peak levels by interpreting that. Another situation where you take anti-10A levels, again, all these cases are to check peak levels, as stated before, would be extremes of weight if you choose to use Glexane in those patients because we know body weight does affect the dosing and you may have a sub-therapeutic anti-10A level in someone who's very heavy or have a high anti-TNA level in someone who doesn't weigh much at all. In regard to the weight, say when he's obese, I put them on the scale, it's 140. Do I chart them for 140 milligrams, subcut BD, or do I look at the ideal body weight? So after 100 milligrams and you would have to dose either 100 kilograms minimum or 150 milligrams if you're doing the once daily dosing. As soon as you start dosing above 100 milligrams we know there's an increased risk of bleeding and some of the studies that were done into people up to 150 kilograms show that there's an increased risk of bleeding. But in those people, there's also an increased risk of clotting because they're often underdosed. So if you go above 100 milligrams of clexane, you know you're giving the patient a higher risk of bleeding. But between 100 and 150 milligrams, if you underdose them, you then have a higher risk of clotting. So this is an individual judgment that would have to be made based upon that patient. After 150 milligrams dose, there's really no evidence, so it'd be hard to comment on that. So for a junior doctor, if you've got someone who's 120, 130, the consultant says over the phone, start them on Clexa, that would be somewhere they may need to... I would confirm that they're happy to start on a dose of greater than 100. Okay, perfect. What if they do have a significant bleed whilst on heparin? What would be your management then? Yeah. |
Okay, welcome everyone to On The Wards, it's James Edwards and today I have the pleasure of speaking to Angela McGilvray, a neonatologist at RPA. Welcome Angela.. Thank you, James. Look, we're going to talk about neonates, and I know as a consultant, I get very nervous when I see a triage that says two-week-old baby, so I can imagine the residents are also a bit nervous. So we'll go through a case, and we'll just go through some general principles in management of a neonate. You're working in a emergency department when a two-week-old baby is brought in by its parents with a fever of 38.5. The parents say the baby has been more irritable today and is refusing feeds. As a general question, are sick neonates just small sick children? Thanks for your question, James. I think that's a kind of really common question that people have, and I completely understand why people get so concerned about looking after tiny babies, because obviously they're not just little children, and there's every reason to be concerned about a two-week-old baby with a fever of 38.5. So, no, they can't be treated as just small children for a number of reasons, which include that they have relatively immature immune systems compared to older children. So therefore, they tend to not localise signs of infection very clearly often. And they also often don't show the typical signs of severe infection or illness. So, for example, the temperature might be very high, like in this case, but it also may be a child may also present with a low or hypothermic temperature as well. And the other thing to bear in mind as well is because their immune systems are so immature that they can deteriorate very quickly. So what other ways are they different? So different immunity, what other sorts of things that particularly when you're about to manage an innate come to mind? Oh, well, obviously their size is different to older children. And particularly in this group of children who this child is only two weeks old, this baby may also be affected by congenital infection, for example. So it's always important to take the pregnancy and perinatal history into account as well. Okay, so maybe what's your initial approach to managing a, it sounds like it may be a sick neonate? So I think like any sick patient, you need to sort of take the ABC approach to a baby and does this child need to have any resuscitation? So I would be looking at whether this baby is maintaining its own airway, what is the breathing like, are there any signs of respiratory distress, is the baby breathing up, so is the baby tachypneic, is the baby got any intercostal or subcostal recession, is there any grunt for example, grunt is a sign that we pay a lot of attention to in neonatology because it's a sign that a child may be just about to fall off its perch, for example, and need to maintain its own expiratory pressure. In terms of cardiovascular signs of a baby like this, I think heart rate is a really important sign. So a baby who is tachycardic or got a slow heart rate can be of concern. Perfusion is not a brilliant sign in small babies, but it's also just worth bearing that in mind if a baby's really shut down so it's got poor central perfusion so capillary refill times greater than three seconds centrally then I would be worried about that too and also just feeling what the baby's pulses are like and what are the peripheral pulses like in particular and then I'd also be having a look at the child's neurological status. So using the AVPU scale, for example, is quite a good measure in this sort of circumstance. So does the child, is this child as irritable, which is a concerning sign, but is the child settled by the offering of feeds, for example, is the baby consolable or not at all? So that would be my initial approach. So AVPU, what does AVPU stand for? So AVPU is just simply the child is alert or the child is responsive to voice, is responsive to pee for pain or used to stand for completely unresponsive. And obviously when we talk about tachycardic and tachypneic, the normal respiratory rate and pulse rate for neonates is different to adults and children. How do we work out what's normal? Well, that's a very good question as well. I'm not going to give you a normal range in this interview, but I think it's important to find out where you have those, where are those resources available for you. There are cards that can go around on your lanyard, for example, and you need to be able to find a resource that gives you those reference points for a baby like this. So we've done the kind of initial resuscitation, and I guess as we're doing resuscitation, we're thinking what could be the cause of why have we got a sick neonate? What are the common causes of a sick neonate? With a temperature like this? I guess a temperature is pointing towards sepsis, but maybe in this case, and there may be some other cases, there wasn't a temperature, but they were just the irritable and refusing pains. Yeah, yeah. I mean, I think with a baby like this, when you've got a temperature, the answer is infection, infection, infection until proven otherwise, and therefore you would just always entreat empirically, and probably we'll come on to that down the track. But it's important to think about other issues related to the baby's system. So this could be a cardiac condition, for example. This could be a baby whose duct is closed and has a duct-dependent congenital cardiac defect. So worth thinking about that. Worth thinking about other congenital abnormalities as well that you might find on x-ray, such as a diaphragmatic hernia. They're the things that sort of spring to mind particularly. Okay. So when you're taking a history from the mother or father and trying to get other history from other sources, what are some of the kind of key historical features you'd be asking for? Well, I think in the immediate history, you're looking to see how long has this illness been going on for? Has it just been hours or has it been days? Has there been a prodrome leading up to the presentation today? Has there been a carousal illness? Are there any infective contacts in the family? What has the baby's intake been like over the last 24 to 48 hours? What's the output been like, so how many wet nappies has the baby had, has the baby had a normal stool pattern or has that been increased or decreased. And I think going back a bit further then, obviously as I've mentioned it's important to look at the perinatal history as well, so was mum well during the pregnancy, was the baby born at full term, was any need for resuscitation at that time um did was mum gbs positive for example um and all of that should be available um on the local um electronic health record for mum it's also always important to go back and see what was going on with mum so did she have a uti in pregnancy for example was there any colite uti there that you need to think maybe this is now this child, it's been inadequately treated in the newborn period? Did the baby get any antibiotics in the early few days because of concerns about infection? Has the baby been immunised? Have the other children been well or unwell? Is there any recent history of travel? So a lot of the, I guess, the symptoms or signs are going to be fairly nonspecific in an innate. So what are the ones that are commonly present with mention of their food, maybe a temperature or other kind of symptoms that they may, parents may bring in an innate with? Often you'll get the unsettled baby, which is a really difficult one to try and work out is the baby unsettled because the baby's unwell, stroke, irritable or is the baby just unsettled because they're a newborn baby who's unsettled and that's a normal developmental phase that babies go through. So that's often a difficult one to work out and that's why it's important to go through a really detailed history with those things in mind that I've mentioned. The lethargic baby is a baby who I would always really be worried about and babies don't get described as being lethargic unless they are unwell and so beware of that. The irritable baby like in this case is definitely a red flag that needs to you know this baby really needs to have a full workup to work out whether the baby's got meningitis or not and you may not get the answer to that for a few days down the track. That's why we treat empirically. |
Are there any other particular words or descriptions that parents give that make you particularly worried? Really, if a parent is worried, you've always got to take that seriously. Trust the parents really. Don't try and second guess. If a parent is worried they're just not right, not feeding well, not latching on well, not taking their fees, I don't know, doesn't seem to be waking for fees quite as well as he or she has been, looks pale, those sorts of things. Even if it sounds kind of vague, I would always take it quite seriously. I often hear presentations at nursing staff say, well, this is a first parent. We probably don't need to worry too much what they say. Or sometimes, oh, this one's had four children. They say this one's different. We're worried. Does that make a difference or is that something you think's important? I don't think it's important. It's easy to be led down that path. And I have definitely made that mistake myself. But the opposite can be true. Sometimes the first parent can be more appropriately concerned than the busy parent of multiple children. So I would ignore any of those sorts of comments really and just take the history on face value and if a parent is concerned take it seriously. You can make those mistakes very easily. Good, I think it's an excellent point. So we've mentioned a bit about resuscitation but what's your approach to examination of an ENA? So, yeah, obviously it's important to go through the ABCs that I've mentioned to start with, and it's a really head-to-toe systems examination of a baby. So this baby, as I've mentioned, I'll be looking to see, I'll try and examine the baby and the parents' arms, for example, where they're most comfortable, where you can really get the best assessment of their neurological condition and also the best chance of actually being able to elicit some useful signs. So I would be looking at the vital signs, as I've mentioned already. I'd be looking at the child's perfusion, looking to see if the child appears to be meningitic or not, so looking to see if the baby's irritated by putting the head back, for example, or stretching the knees out. And that's even, because I mean, I've always kind of, adults, we often do those kind of tests and sometimes they work, but I've always kind of thought the younger they are, they barely bother. Well, kind of. I mean, it's difficult to kind of give, you know, clear advice about how to manage, but I think that, does the baby settle in a normal circumstance that it should settle and being being cuddled by their parents and being offered a feed and if yes that is no then you've got a child who's irritable um again i've mentioned perfusion i do look at perfusion although we know it's not a particularly useful sign in terms of um getting an idea as to whether how septic a child is or not um Tachycardia is a concern. Grunt, as I mentioned, is a concern. So you're trying to work out where this potential infection is coming from. So obviously having a listen to the lungs, is there any differential air entry? Does it look like the child has any pneumonia, for example? But in many ways at this stage, it doesn't really affect what you're going to do because you're going to if a baby's only two weeks old and there's this fet bar you're going to this baby should be admitted and should be fully investigated with a full septic workup and have empirical antibiotics and important to look in the ears and the throat to look for any signs of an EMT infection urine Urine infection will only really be able to work out once you've got a urine sample. Chest, as I've mentioned. And to try and listen, I mean, I find it hard listening to an innate heart because they go very quickly. You hear murmurs. And when you feel the pulses, do you feel the femoral pulses as well as peripheral pulses? Does that help? I would feel both. The femoral pulses are probably the most useful out of them all because you're most likely to be able to feel them. So if you know they're decreased, then you've got an unwell child, whether that's cardiac or septic. Often a septic baby will be tachycardic and they will have relatively good peripheral perfusion and will be in a sort of high output state. So that can give you a bit of a guide. But the peripheral, the radial pulses or the pedal pulses can be quite difficult to feel in a child anyway, so they're not really that helpful. What kind of initial investigations would you order? Yes, I mean, as I've mentioned, the baby needs to have a full septic workup, so lots of investigations. So in terms of blood investigations, I would make sure we've got a blood culture, a full blood count, a CRP, really just a track change. It's not going to influence my initial management. I would get a gas on this baby. A venous gas would be absolutely fine, and a lactate as well. Electrolytes would be a reasonable thing to add. And then I would make sure we get a urine sample from the baby. So it needs to be a clean sample. So a bag, people sort of argue about it, a bag urine is okay if it's negative. If you haven't got a negative bag urine or you want to get, sometimes it would just be quicker to do a cathetereter sample or a super i prefer to do a catheter sample myself um or you can do a super pubic and sample but that obviously requires a bit of expertise um around um a sugar i meant to mention a bsl is a good is a good baseline test as well to do um in terms of respiratory investigations it's pretty much always worthwhile doing a chest x-ray on a baby like this and also trying to get an MPA off as well so that in time you can narrow down the differential. Again, as I've mentioned, I'll be looking up to see what maternal biological investigations are available. And then lastly, you've got to think about doing a lumbar puncture. It is important that a cerebral spinal fluid sample is sent off on this baby, but it doesn't necessarily need to be done at the initial presentation. What's most important in this situation is to get treatment activated for this baby. So you can do it, and an LP does need to be done because it will guide the duration of your treatment, but it's not necessarily something that needs to happen there and then in the emergency department, as long as it's on the list of things to do. Okay. So they get a cannula in, blood, including blood clot just come off. Yeah. Urine's kind of getting sorted. The antibiotics can be given. Yeah. Even though you haven't done the L-blubber push yet. Yeah, absolutely. So time time to antibiotics, we often think about that's really important in adult patients. Within an hour if you can. Okay, so it's equally important. Absolutely. I think it's the one thing that will make a difference. Doing a lumbar puncture on a baby like this requires expertise and because the baby needs to be curled up quite tightly to get a sample, it can be quite distressing. 's obviously very distressing for the family, but it also can compromise the baby as well if they're already unwell. So I wouldn't be doing it as part of my initial assessment. OK. So, yes, similar blood tests, what they're doing with steps as an adult. Yeah. So some similarities there. In regard to management, obviously we can talk about this case and then general management of neonates what's going to be our management initial management for this neonate well initial management i actually just meant to mention as well that um whilst you know we were doing full septic work upon the baby and we want to exclude meningitis it is obviously important to look at a baby's skin and just check the baby has a rash or not. So it won't affect your initial management, but it's important to kind of put the pieces together. So in terms of the management, these babies need to be admitted. I would never take a watch, wait and see approach with a febrile two-week-old baby. So they need to be admitted initially to ED and then to the paediatric ward. Antibiotics, so empirical antibiotics are important and there are very helpful guidelines out there from Sydney Children's Hospital for example the Royal Children's Hospital for empirical guidelines. But I think if you're worried about meningitis in a baby who's two weeks old I think that the the recommendation is to give cefetaxime and benzoyl penicillin. |
Welcome to On The Wards, it's Jules Wilcox here. Today we're talking about orientation and handover for junior doctors when starting their internship with Rob Perlman and Sonia Chanchlani. And this podcast is produced in collaboration with MedApps, who are a proud sponsor of On The Ward. So welcome, Rob and Sonia. I'll give you a quick background. Rob taught himself to code whilst he was an intern, because he wasn't busy enough, and he built MedApp. His response to the inefficiencies that a junior doctor experiences whilst rotating through different hospitals and terms. And since launching in 2015, the platform is now deployed in 50 public and private hospitals across Australia, New Zealand, the UK, and Canada, with over 20,000 clinicians using it to access site-specific hospital information. He's passionate about health tech and improving doctor mental health. And outside of MedApps, continues to regularly assist in theatres and enjoys cycling, swimming and sci-fi. Sonia has been balancing clinical forensic medicine and training with 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 and interventions to promote clinician well-being. Advocating for junior doctors and enabling a safe working environment led her to being appointed as 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 well-being are prioritised. Hey, Jules. Hi, how are you going? Good. Excellent. So I think if we just dive straight into the orientation thing and then we'll come on to the technology aspect and why MedApps can help with this. But do you want to just cover, you know, what orientation and handover is and why is it so important? Because we are seeing an increased focus on this and certainly as part of the accreditation, HETI is very keen on that each term has a proper orientation and with something that we review at our GCTC meetings. And I think there's been an increasing recognition of how important it is. So Sonia, do you want to perhaps just touch on why it's so important? Yeah, so although orientation and handover are similar, they both involve communicating the right information to succeed at your job. There are differences between what an orientation is considered and what a handover is. So in terms of a handover, the Australian Medical Association guide defines or considers a handover to achieve efficient communication of high quality information at any time when the responsibility for patient care is transferred. And so the goal of a handover is usually task relevant information between shifts, between teams, ensuring continuity of care. And I guess in practicality that that can happen between clinicians changing shifts or changing terms, or patients moving between wards or being discharged from the hospital, whereby the discharge summary is a handover document to a GP. Yeah, there's a number of different ways there, isn't it? And it's just a real, I mean, so many complaints or so many issues and RCAs and things, because there's so many errors that come up during handover. It's one of those periods where things can go badly, badly wrong. Rob, what's the difference between handover and orientation then really as you see it? Because there are similarities as well, aren't there? Yeah, well, so I guess there's the clinical and there's the term handover. I think something that really stands out to me is orientation is, even though we're doing it maybe four or five times a year in training, we're really most of the time starting a new job, even if we are inside the same four walls of the hospital. And that creates, you know, it's a new environment. It's a new opportunity for mistakes. And I think, well, hopefully things are beginning to change, as you mentioned, but often the term orientation can be brushed over and that leaves doctors in training flat-footed with regard to process. On the clinical handover side, obviously there's the importance from a patient safety perspective and from a term orientation perspective, I think that there are some really important aspects around doctor in training well-being and cognitive load and that also has a flow on into patient safety. So, you know, briefly a bit of an anecdote. So Jules, when I started on the Central Post and really this is, I guess, sort of a little bit of the impetus for where we started with MedApps. I did my week-long orientation down in the lecture theatre there and we were given a 120-page handbook of how the hospital works. And then a week later, I went on to the wards and one of the first things I was asked to do by my consultant was to order a CT for a patient. And I stuffed it up because I didn't know that I was meant to put through a contrast consent form. And I didn't find out until the next day. So as a result of my mistake, I caused a delay for that patient by an entire bed day. So that's $2,000 to the health system. I'd caused obviously an increased risk of hospital-acquired infection. There's all of the backup around the hospital. You know, radiology's got this piece of paper they need to somehow feed it back to me. I'm wondering what's gone on. My consultant's wondering why the patient hasn't had their scan. And all of those elements of process are backed up because when you move to a different hospital or if I shift to a different term, say now I'm at hospital X and we've got outpatient bone scans and I need to know how to do an outpatient bone scan and I've never organized one. And that's a problem. It's cognitive load, it's inefficiency in the hospital and it's, you know, hopefully not, but occasionally it must be patient harm as well. Yeah, yeah. The, the, the orientation has changed somewhat since, since, since your days, Rob, I hopefully for the better, I think so. I think we've, we've we have a lot more buddying time because I found that, you know, it's, it's all very well with orientation, giving people lots and lots of information, but if they haven't got context, it's useless. And if you give them too much information, it goes in one ear and out the other. But yeah, but I totally get what you're saying. And we've just had term changeover now as well. And that cognitive load thing's really interesting, I think, and the well-being aspect that you touched on there, Rob, because, you know, we've just had people, they've just finished their first term and they were getting comfortable and they were thinking, yeah, I've got, I kind of got this. And now I've had people come in going, oh man, I'm back at square one again. You know, I just, I feel really uncomfortable. I don't know, I feel like I don't know what I'm doing. It's all unfamiliar. Yeah. And like you said, it's within the same hospital and there's a large amount of jobs that are similar, but there's still that thing. And that, that, I think that really, and you know every time you go back to thing and you get that that discomfort and you get that cognitive load and so you slow down and then you're you know big big cognitive load well you can't learn as much because you haven't got the cognitive space to take things on so it's not as good for junior doctor development as well i believe that you know if you've got a if you can mitigate some of that cognitive load and if you can, if you can make people feel less or say more comfortable, less threatened, then I mean, there's functional MRI studies and things on that, looking at how much brain you use when you're trying to solve problems, depending on how threatened you're feeling. And if you're feeling a bit threatened or a bit uncomfortable, then you can't use nearly as much of your brain. And so therefore you're less able to problem solve. And so therefore you're having more issues. So it is actually, it's a huge problem. And the volume, I know the AMA is looking at going to four terms a year rather than five. And actually, I think that'd be a great thing because it's one less orientation, slightly longer terms get familiar yes you're not going to um be able to have experience of doing five different terms but i think there's there is potentially a big payoff there as well um so and we kind of touched on the um sort of the poor poor orientation handover affecting work performance there and you that i think that's a really useful anecdote, that saying it is not just that one patient. There are so many flow-on effects throughout the hospital. |
But do you think the difficulties with handover and stuff only apply to JMOs or do you see problems in other areas as well? Well, I think, you know, I know that basically it's not just JMOs, but I would say it's not just in medicine. We've recently run pilots using MedApp to help with orientation and engagement amongst allied health and nursing staff. And the reality of the situation is the issues in those areas are actually not exactly the same, if not significantly larger, because you're dealing with a much larger workforce. And I think that that's really interesting because we as doctors can have a tendency to view the problems as only doctors facing them. But the reality is that in every every other aspect of our work life we're engaged in multidisciplinary teams and thinking about it as a hospital-wide problem I think is very important. Yeah yeah I think we have sorry excuse me I think we have some issues sometimes where certainly the central case with patients being strewn all across the hospital because it's so bed-blocked, you just try and find their bed somewhere. For the nursing staff, when they're doing their handovers, they're on the one ward, and that allows a little bit of consistency. But as a doctor, you're often spread across four or five different wards, which lends a whole other layer of complexity to things as well. And having the tech to back some of that up and to make those things a bit simpler is kind of invaluable, I think. Sonia, is there any research? We've talked about poor orientational things impacting on wellbeing and things and sort of the mental things. Is there any research about any of that or is there any data that you're aware of with some of the well-being aspects of orientation? Yeah, I think an Australian study a few years ago concluded exactly what we're talking about, that effective orientation and handover is more important nowadays as junior doctors are faced with more complex patients with multiple comorbidities. There's a rising demand in services because of the workforce shortages all across Australia and that there is a growing kind of need and responsibility to teach students and undergrads as they move through the system. So essentially the handover ritual is estimated to occur at least 7 million times a year in Australian hospitals. And so that goes to your point of maybe reducing the terms to four terms a year to reduce those high risk periods of handing over and orientation. Although it is important to be set up for success, if it's done poorly at the start of a term or a shift, then the psychological impact and the impact on patient care can be higher. Yeah. Yeah. And then again, linked to handover and orientation, the research shows that handovers are a key point of communication and error and whereby any breakdowns can have serious consequences for patients. Yeah. Knock-on effects to then clinicians, kind of known as the second victim complex in doctors involved in unanticipated adverse events can have secondary trauma as a result. Yeah, I mean, that's a hugely stressful thing for people when they get involved in RCAs and complaints and all that sort of stuff, isn't it? And medical error, hugely stressful. In terms of, we're talking about there, you touched on undergraduates and being taught about this process and when they come through as juniors, medical school is obviously quite difficult, quite different to working as a junior doctor. I think we see this a lot. Do you guys have any sort of things, Rob, perhaps, you know, when you make that step up from undergraduate to intern, any of the sort of the issues to do with that process and how the orientation can help with that? Yeah, Jules, well, you know, there's a whole bunch of differences between, you know, the final stages of medical school and shifting into internship. Obviously, there's a step up in responsibility. I think what I sort of found a little bit surprising shifting over to internship is that it's much more important to know what doses of a pari-amps to use. And I guess, you know, those logistical details, like how do I get this patient to their scan as quickly as possible? How do I organize the scope then you know knowing the four different types of renal tubular acidosis and and that aspect of being proficient in in driving the EMR is unfortunately becoming one of the more important skills at the moment and I think there's a real cost there in terms of our skills as clinicians because we're spending less time at the bedside and undertaking assessment or observing our registrars doing it where we can undertake more learning. Now, I'm not sure if there are some, I've got some takeaway messages from there around orientation, but maybe if there are any medical students listening to this, I hope I haven't reality checked you too much. Well, something I say in the orientation is that, you know, yeah, you've learned all this stuff at medical school, but it's generally irrelevant. And now we're going to try and teach you to be a doctor and you're going to feel slow and you're going to feel like you don't know anything. And that's normal. You've got all this theoretical knowledge and actually what you need is practical knowledge. And then you try and bring the two together. And I see the intern year really as an orientation to being a doctor. The whole year is that. It takes you probably about nine months to get to that plateau phase where you're now cognitively not overloaded because you've got all these processes in place and you've learned all the basic stuff and then you can start to layer on top that clinical knowledge combined with the practical aspect of things. It was definitely at least nine months. You go around feeling like you're an imposter for the rest of the time. Yeah, absolutely. Yeah, don't worry. I still do that now. You talked about EMR there. And I think this has been a big thing in the last five to 10 years, really, hasn't it? In how technology has changed the way we're practicing medicine. This is obviously something that's really key to what you're doing with MedApps, Rob. Do you want to talk about that a little bit and how technology is changing what we're doing? Yeah. Well, you know, medicine and technology have always operated pretty closely together. Obviously, there are some pretty strong advantages to better technology. We've got the benefits of better diagnosis, new treatments coming online. I mean, you only have to look at what medical research has been able to produce in the last 12 months from, you know, sequencing the COVID genome to having a mRNA vaccine in the space of a few weeks, apparently even before there'd even been a death on US soil, is remarkable. And we're going to see the flow and effects of that and all of those amazing things over the next few years. But I guess getting down more to the nuts and bolts of it in the hospital, I think that the digitisation of hospitals is increasingly leading, particularly junior clinicians, to being really glorified data entry clerks or secretaries. Our job is to keep people moving around the hospital. And, you know, there have been a number of studies looking at the amount of time that clinicians are spending with a patient in emergency over a, you know, hopefully sub-four-hour stay. I sort of recall it as 10 minutes. Julie, you might actually remember the number. And also in terms of, you know, what I noticed as we've shifted into full EMR in a lot of New South Wales hospitals, the amount of time that people are sitting there typing and entering information in notes, whereas, you know, still when I go out to a rural hospital or a place that doesn't have a full EMR and you've got a two-page sheet to do your full assessment for an emergency patient as opposed to the amount of typing that you might do, a lot of it potentially that useful on some of the systems that are involved. And Jules, I'm sure that you've seen this around people copy pasting notes and sometimes there's no, it's not being run through the thought processor. I found somebody who was told that they had something like leukemia of the nose or something and this thing had been documented for about two years in their notes. I was like, what the hell is that? It was a typo that haded. And it just, and it just kept on facing all the way through. And it's like, you know, yeah, really bad. And, and I think that thing about the, the amount of time that you're now spending on the computer versus there's a lot of evidence. And that'll go one day is written about that in the New Yorker about how it's destroying our interactions with patients and it's reducing empathy. It's reducing compassion, it's reducing patient satisfaction because you're actually not sitting there and looking and talking to patients. You're on the computer constantly and there's this barrier between you and the patient. I think it's a big issue. |
Yeah, going back to the orientation then and the handover though, how can we... Because there's undoubtedly benefits to technology as well. So how can we utilise the technology in a good way, in a positive way for the orientation and handover then? Yeah, well, I mean, speaking specifically about MedApp and how it works in hospitals, what we're intending to do is, and what we've been able to accomplish in lots of places, is a way to reduce the administrative overheads to ensuring a smooth transition. And so this ranges from ensuring that rovers can be kept easily up to date. So instead of medical education officers having to send an email to everyone and have someone sit down, update it, open their email, open words, make a paragraph change. The radiology meeting is shifted from 9 a.m. Tuesday to 4 p.m. Thursday. Save it, close it, and email it back for it to be reviewed where you've got eight or nine steps and points of friction in order to keep these important pieces of information up to date. You can edit it inside the app and change the paragraph and hit save and it can be reviewed by the MEO. And we've seen that to really great effect in a number of hospitals where 70-80% of their rovers have been updated in the last six months, which obviously has fallen effects in terms of accreditation and workload for really busy hospital, you know, the medical administration, medical workforce teams. And so they're not getting burdened around times of accreditation. And also ensuring that, you know, all of the hospital handbook and the other information i guess the implicit knowledge um that people are generally finding out from either asking questions of their registrars or um you know maybe reading that 120 page handbook that's set on the back seat of my car is really easily accessible and we're not talking accessible like buried seven layers deep on the intranet um yeahApp has a high signal-to-noise, so everything's only two clicks away. It's easily searchable and it's highly, highly consured. And, yeah, so we've found that there have been a huge number of benefits there. And interestingly, looking at the data, so I point out that we collect, we've got a blog page post on our website talking about how we anonymize data so we can't review, you know, link information to a particular person because the amount of tracking that goes on on your online profile has gone way too far. So we've got a very strong stance against that. But we take a look at aggregate analytics and so we can see very clearly for example that at hospitals where we've implemented at the start of you know intern orientation and you get good uptake with the residents but you know exceptional uptake with the interns in year two those interns have now become residents have a much higher baseline level of engagement and a different way of accessing information compared to those residents who have gone on to be registrars. So you're actually changing, I think, what the dominant paradigm is for how we as doctors generally access information, which is make the mistake and then find out when someone tells you that or have to ask someone. And I'm sure, Jules, what I have heard a lot of when I'm running around in different emergency departments all over the place is that emergency consultants are spending a huge amount of time having to deal and communicate with procedure and how to do things to locums who are rolling through. And I'm not sure if that's been your experience. Well, we had a situation with e-meds where on the Central Coast, locums were told that they had to do local e-meds training four hours, even though they'd done e-meds training in Sydney. And they weren't going to get paid for that for us so and we couldn't get any locums so we were really short-staffed you know it's like come on um i think i think the the benefit i see with the med app thing is that you know you're you know you are first and foremost a junior doctor and then you put this together as opposed to a lot of what we see with EMR which is it's developed by people who are not doctors and so they have this thing and I'm sure you I'm sure you remember your your first net training Rob of you know and you're going through every single every single sort of tab on the thing and people go but we don't We don't use this. Oh no, but we've got to tell you about it because yeah, we've built this function and you can do this and you can do that. It's like, we don't do that. What we do is this, you know, e-meds is a classic case. I now have so many clicks to do stuff when I just want to write up something quickly, you know, patient medication has not been documented. And, you know, you know, you write, you write up a dose of dexamethasone for a kid with croup and it's like, you know, or now how often do you want the blood sugars? And, you know, what kind of diabetes is this? And it's like, it's just not fricking relevant, you know? Well, yeah, there's the context switching there is remarkable as well. Last year, I triggered an incident when I incorrectly transcribed syringe driver medications for a palliative patient. And, you know, because it was my fault, obviously, and the error was unfortunately discovered. But it took me half an hour to transcribe a syringe driver medication changes because i had to go from one tab to another and then i had eight interruptions and how are you supposed to deal with that cognitive overhead compared to i guess the simplicity of the paper chart which i think is something that you really miss and i'm sure that i'm not alone in getting to mistakes. Yeah, yeah, no, absolutely. But they don't get rid of mistakes. They just create different mistakes, I think is the issue. And there are efficiencies in some sense, but they're also not in the other. And I think that's- Yeah, it's great to be able to order medications from the other side of the hospital, but it's- Yeah, I do telehealth as well for Western New New South Wales and it's very useful for me to be able to write up stuff for patients in Bourke and Lightning Ridge from Avoca. But I think that functionality is so important about how we, because just because it's technology doesn't mean it's necessarily better, I think is the thing. It's got to be. Yeah, absolutely. And so I guess what we're really talking about now is user interface, user experience, which is really in terms of the systems that we're using, not even even really a field of study when the programs that were in widespread use were actually put together. And now they're entire fields of research. And I guess one of the elements that we've got the benefit of as well is that for the MedApps teams team have come together with a very strong focus around user experience and usability. Whereas the experience with a lot of the systems that are implemented has been, you know, 1990s Windows 3.1, add another button if you need another functionality. And so we've got modified accounting systems that have millions of buttons and millions of functions that are not designed for smooth clinical flows. And they're not built around how we actually work. Yeah, no, absolutely. I think that's why I was so impressed with MedApp when I first saw it. It's obvious that it was built by clinicians for clinicians. I have been practicing in clinical as well as medical administration for over 10 years across multiple states in Australia. And I was introduced to MedApp when Rob actually pitched it to me when I was the DPET at the Royal Brisbane Women's Hospital. And as soon as I saw it, I thought, oh, my God, where has this been all my life? The challenges that I had faced in my training, as well as now in a medical administration position, the challenges that we were facing with orientation handover technology in our hospital I just immediately saw the benefits and the supports that MedApp could provide to clinicians before they even stepped into the hospital for the first time all the way through their training and hospital experience so I think it's really incredible how far MedApp has come and the benefits that it can provide in the world of technology in healthcare. Yeah, and has that been the experience, you think, Rob, across the, with introducing MedApp into other hospitals? Positive and useful? That's the feedback you've been getting? We've always found that people have found it positive and useful. We think it's clear that, I guess, the implementation resources and hospital capacity are probably limiting factors. There are sites where we've implemented where I think it's absolutely evident that we've changed the nature of the interaction between medical workforce and hospital administration and the clinicians. |
Welcome to On The Wards, it's James Edwards and a pleasure today of speaking to Associate Professor Kate Wyburn. Hi, thanks for having me. Kate's a Senior Staff Specialist and Nephrologist at Royal Prince Edward Hospital and a Clinical Associate Professor at the Faculty of Medicine at the Central Clinical School at the University of Sydney. Now we're going to speak about something today, the approach to the dialysis patient. This will be probably most relevant to those who are doing renal turns, but many people after hours will get asked to go to the renal ward. So maybe we'll start, Kate, with just an overview of dialysis. What are the different types of dialysis? So the two main types are hemodialysis and peritoneal dialysis. Hemodialysis basically is removing excess fluid and toxins, extracorporeally outside the body on a dialysis machine, through an AV fistula or the use of a VASCAS central line. It can be done at home, in centre, at a satellite unit or nocturnally. The other way of doing dialysis is peritoneal dialysis, which is basically using the peritoneal membrane as your dialyser. So fluid through a catheter is placed in the peritoneal cavity and then again excess water and toxins are removed down the gradient across the membrane and then drained out. And PD peritoneal dialysis can be done at home overnight or intermittently throughout the day. And how do you determine which dialysis method you choose? So neither one is probably absolutely more superior than the other. It's based on a few medical contraindications for one or other plus a large part involves patient preference and lifestyle. So it's important that I suppose anyone who's approaching end-stage renal disease has all that information to help be part of that decision. Hemodialysis means you're only dialysing usually three times a week but they're for big chunks of time and if they're in centre it's not particularly flexible time-wise. The advantage of doing it home is it can be flexible. The disadvantages are you use needles and there's chances, there's obvious risks of infection. Peritoneal dialysis I guess is usually more flexible. You can do it at home and again you can do it overnight. There's no needles. The problems with it are sometimes the glucose in the bags can cause problems if you're a diabetic. If you've got a really large abdomen, sometimes the peritoneum isn't going to be sufficient. And similarly for hemodialysis, sometimes if your vessels are all terrible, you can't actually form an axis. So it's based on some medical decisions, but a lot comes down to patient preference and lifestyle. When we discuss dialysis, dialysis in intensive care seems to be dialysis is different that you deliver. What are the differences? So someone that's having regular routine dialysis and isn't established on dialysis is usually relatively stable. Someone who's in ICU obviously is much sicker, often needing inotropic support and usually in much more complex medical situations. So in ICU we can do intermittent hemodialysis and we can do normal peritoneal dialysis, all else being equal, but the majority of patients that are in ICU for acute events usually don't have the cardiovascular system to support hemodialysis and need to have a continuous gentle form of dialysis so usually that's CVVHD continuous venous hemodialysis which runs 24 hours a day and there's much less dramatic fluid shifts, so it's more gentle, and you can titrate that as to how much fluid you want off on it, and it's more gentle. There are some other kind of letters that come up, CCRT, what do they all mean? I get confused. CCRT is continuous renal replacement therapy, So they're all basically saying the same thing. CVVD is just where you're doing dialysis. There's also CVVHD, and you can haemofiltrate the dialysis. So it's just whether or not you're isolating the ultrafiltration, which is really just taking off the water. So UF is the term you'll hear. If you just ultrafiltrate, it's really just taking off water, not the solutes. So it depends, I guess, on the clinical situation in which you'd use. But really, most of the words we'd see in front of it is continuous. What are the most common indications for dialysis that you see and the kind of underlying pathologies that end up requiring dialysis? So the commonest cause for people reaching end-stage kidney disease is hypertension and diabetes these days and I guess with the increasing incidence of diabetes that's only going to blow out further. They're the commonest causes for needing dialysis in terms of the pathologies, if that's what you mean by pathologies. The commonest indications really are acid-base issues, fluid removal. So if someone's becoming aneuric, you can't remove fluid, the dialysis is your only way out. Electrolytes, so in particular it's potassium, so high potassiums, you can temporise that with insulin dextrose, but really you can't get it out of the body if someone's aneuric unless you're doing dialysis. Anurimia. Anurimia is the other one. So a simple way to remember it is A-E-I-O-U, A for acid, I is for ingestible, so toxins might be, sorry if you've taken an overdose of some sort, sometimes that's helpful. E, sorry for electrolytes, I for ingestibles, O for overload, so fluid, and U for uremia. Okay. We're going to go back to a case now that you are on the wards and you're asked to review a patient in the dialysis unit with a low blood pressure of 80 over 40. What is your kind of initial approach maybe over the phone and then when you go and see the patient? So it's a common occurrence that people develop low blood pressure on dialysis so it will be a common call. The initial approach I suppose is not too different from a normal someone with hypotension. So don't be too put off by the fact that someone's next to a big machine. In fact, in some ways, it's an advantage. You've got good access, venous access. You've got specialised nurses around you and you've got a bed that you can lie flat. So the initial things, which you'll often find the dialysis nurses have done as well, is to lie someone flat or head down and you can give small boluses of normal saline as well. When you're assessing a patient, obviously you want to make sure that they're not obviously bleeding or they're not in significant distress with chest pain or something else that's going to alert you to another cause for someone being hypotensive. But the commonest cause will be too much fluid or too rapid fluid removal. So lying someone flat and either slowing dialysis or stopping if it's severe and giving a fluid bolus is probably your initial approach. And when you say small fluid bolus, give me a... 200 mils, 250 to start start with and I guess it's a situation that you're continuously reassessing. You might actually find that this patient normally has a blood pressure of 90 and so 80 is not such a big deal. If they're normally hypertensive with a blood pressure of 160 then it is a really big deal. How do you assess fluid status in a patient with end-stage renal failure? One of the most helpful things to use is what their ideal body weight is, what their interdialysis weight gain usually is and how much fluid is being pulled off. And that is recorded for everybody who's doing dialysis. Dialysis patients all know their dry weight. And that gives you a really good idea of where someone's at with their fluid. You can be caught out a little bit if someone's putting on lean body mass and their actual lean body mass is going up and you're still trying to pull a lot of fluid back to get them down to a dry weight that is probably too low for them but really using their dry weight and their changes in body weight so what their last dialysis was weight was other than that it's all your usual assessment so it's the pulse the blood pressure you can look at jvps they're often difficult sometimes people often have lines in them look at edema, but sometimes particularly if someone's got lots of problems with edema or they've got a nephrotic syndrome or anything like that, that can be difficult as well. But I think weight and blood pressure is probably your main keys. You've identified, I think, what the common causes of low blood pressure are, maybe too much fluid off. Are there any other particular ones that are specific to a renal patient? So the commonest will be too much fluid off, so too much ultrafiltration. |
Welcome to On The Wards. I'm Rebecca Taylor. And I'm Emma Watson. And today we're talking about COVID-19 and pregnancy. Emma has worked as an antimicrobial stewardship pharmacist for six years and excitingly she has just started her maternity leave and is expecting her first baby later this month. Rebecca is a fifth year ONG registrar who was working in the Solomon Islands until the pandemic brought her back to Australia. She is now working at a major tertiary hospital in Sydney. Emma, thanks so much for chatting with On The Wards today. So I think we can all agree that the last few months have been a bit of a roller coaster for everyone. But what has it been like being pregnant in the midst of all of this? To be honest, it's been a little bit scary. There's so many unknowns associated with COVID-19. And at the very beginning, information was changing on a regular basis. Being pregnant was kind of scary enough, but then when you threw COVID-19 into the mix, it really just kind of ramped up the fear. And has your care changed significantly during all of this? For me personally, not a huge amount. I do have a pre-existing health condition, which means all my appointments have still been face-to-face, which has been quite reassuring. But I do have pregnant friends who have told me that a lot of their appointments are now via telehealth and the face-to-face has become a lot less frequent. Probably for me, the biggest change is that I haven't been able to bring my husband to scans and to some of the appointments. It'd be really, really nice to have had him there for support. And particularly for the scans. I feel like he's missed out on a lot because he hasn't been in the room to see the scans. I've had to take photos for him to be able to experience it. So I feel like he's missed out a bit on some of the experience as well. Yeah, I think there's probably a lot of dads out there that are feeling the same way. So you're due to have your baby in the next few weeks. What are your main concerns about coming into hospital to give birth? They kind of keep changing on a regular basis, to be honest. One of my biggest worries is that things are going to change and that I won't be able to have my husband there for the birth, or there'll be limitations on whether he's allowed to visit or how long he's allowed to visit when I'm on the ward. I'm worried about support following the birth. If I'm having trouble feeding or having issues, will I be able to contact someone and get in touch with someone? Will I be able to have midwives come out and visit me on a regular basis? I'm quite sad that probably mother's groups may not go ahead because they're probably just too risky. I'm also really worried about a second wave occurring and what that might mean. My mum, for example, she lives two hours away. So if we get a second wave and they start saying, again, you're not allowed to travel out of your area, does that mean I won't be able to get my mum to come down to spend time with me to help me should I need that? So they kind of oscillate between all of those worries. Yeah, it's a difficult time for everyone. And I think a lot of pregnant women are sharing the same feelings that you've just expressed there. So I guess sort of part of this podcast is to try and answer some of those or allay some of those concerns that you have and answer any questions you've got. So if you want to fire away and ask me anything you'd like to know about COVID-19 and pregnancy, I will do my very best to answer them. Excellent. I've got a few questions for you, Rebecca, so I'll just start firing them away. Are you more likely to get sick from COVID-19 if you are pregnant? So that's a really good question. And I think one that I can give a fairly reassuring answer to. So pregnant women have been deemed an at-risk group during this pandemic. And that really reflects a number of physiological changes that occur in pregnancy, particularly relating to the respiratory system. So things such as an increased oxygen requirement. And those changes increase a woman's susceptibility to severe infection and what we call hypoxemic respiratory failure. But a lot of our concerns have been born out of influenza, pandemics, and a previous coronavirus infection, so such as MERS and SARS, where pregnant women seem to be disproportionately severely affected. However, the data that we're seeing coming out of some of the countries where there's been a significant number of infections, such as China, are actually really reassuring for pregnant women in that the majority of women who contract the SARS-CoV-2 virus during pregnancy will experience mild to moderate cold flu-like symptoms and that only a very small proportion appear to get significantly unwell. And that's much more reassuring than the data sets from other coronavirus outbreaks. So I think people should be reassured by that. That's good to know. So what are the risks to my unborn baby? So again, another really good question that I think a lot of people would like an answer to. I think the first thing to say is that due to the recency of the pandemic, we've got very little evidence of outcomes for babies when mums are infected in the first trimester. So during that period that the baby's undergoing embryogenesis, and that's going to need close ongoing research and follow-up of women that are infected in the first trimester just to make sure that it doesn't cause any harm. There's no significant concern from the SARS and MERS outbreaks that it causes congenital abnormalities, but we want to be following that up closely. Reassuringly, there's no evidence that it significantly increases the risk of miscarriage in the first trimester. Looking at some of the case studies from China, there does appear to be an increased risk of preterm birth in women that are infected with coronavirus in their second and third trimesters. But it's a little bit difficult to work out whether that's partly iatrogenic in nature and that the babies were delivered early because mum was unwell and the doctors wanted to deliver babies so they could treat mum. There is also some suggestion that in babies that stay inside after mum's been infected, that there might be a slight increased risk of growth restriction and that all that hypoxia caused by the virus to mum may cause damage to the placenta. But we need to do more follow-up studies to ascertain that clearly. In terms of vertical transmission, so I guess the concern that the coronavirus may be passed through mum in the womb to the baby, that's certainly theoretically possible. And there have been some studies which suggest, based on immunological blood markers, that that can occur. But there certainly doesn't appear to be a significant cohort of unwell neonates that are born to infected mothers. So it appears that in the vast majority, vertical transmission doesn't occur. And I think it's really important to say that in babies that have been infected normally by acquiring the virus after birth, that most of those babies, like the rest of the general pediatric population, do really well and the vast majority have very mild symptoms. So I think parents should be very reassured by that. Awesome. So you mentioned things with the different trimesters. So should people be taking different levels of precautions based on how far along they are in their pregnancy? Or should the recommendations for keeping safe be pretty much the same for everybody? So I think we all need to be following the government advice and practicing good social distancing. I think that women in their third trimester of pregnancy, so that's when you're going to have the most significant impact from those respiratory changes, those physiological changes I was talking about earlier, are probably wanting to be a little bit more mindful and making sure they're very, very cautious about their social distancing and avoiding unnecessary travel or exposure to large numbers of people. You know, I'm thinking if I was in my third trimester and looking at certainly New South Wales relaxing of the rules this coming weekend, I probably wouldn't be having a different person around for dinner every night, but I might be willing to open up my bubble a little bit and maybe see close family members. So I think it's about being sensible and limiting the number of people you have interaction with and probably taking a more cautious approach than you would do if you were 20 and not pregnant. But I think at the moment, fortunately, Australia has a very low prevalence of disease. So the risks to you by going out or going to work are still very low. So in regard to work, I'm already on maternity leave, so I'm quite fortunate. But people that are a couple of weeks behind me, say late 20s, early 30 weeks in their pregnancy, should they stop working to reduce their risk of getting infected? |
And obviously that makes sense. The less people you come into contact with, the less risk of contracting COVID-19. But obviously there's a large number of people who aren't in jobs that can be done from home, such as yourself, such as myself. So, you know, you want to make sure that your employer is helping you to maintain good social distancing, good hand hygiene at your workplace. And if you have any concerns regarding any of those, that you raise them with your line manager. If we're talking specifically about healthcare workers, RANSCOG has recommended that from 28 weeks onwards, so going into the third trimester, that women avoid face-to-face contact with patients where possible and certainly don't work in high-risk COVID areas. So that would be something like the COVID ICU. But they fall short of following the RCOG, so the UK ONG College's guidelines, which is that healthcare workers should not be working in the hospital at all or in face-to-face settings in the third trimester. But I think that that reflects that the UK has a much higher prevalence of disease and therefore any face-to-face encounter is going to be inherently more high risk than it is in Australia where the prevalence is much lower. But I think Ranscock also encourages women to raise any concerns they have with their employers and acknowledge that, as you said already, that pregnancy can be a scary time as it is. And if you feel unsafe working in your workplace or if you just feel like the thought of going to work and putting yourself at risk is too much, then they want employers to support their employees to work from home or find other arrangements so that they feel safe and supported in their pregnancy. So should mums-to-be and other people who are living in the same household as the mum-to-be self-isolate for 14 days prior to their due date to try and minimise the risk of coming into contact with someone who may be affected with COVID-19? Yeah, so I don't think that that's something that couples or mums need to do, providing that they're being sensible about social distancing and avoiding close contact with other people. I think, as we just discussed, you probably want to limit the number of people coming through your household, but I don't think you need to act like you're actually in quarantine. Just be careful and sensible about things. So if mum or a member of the household has been diagnosed with COVID-19 or they have come into contact with a confirmed or suspected case, what sort of plans are in place on the ward and during delivery? Yeah, so that's a really excellent question. So if one of your household members has been diagnosed with COVID-19 or you've been in contact with a confirmed or suspected case, then public health will be issuing guidance to you as to what you need to do. And usually that will be 14 days of quarantine from the time of exposure. And during that time, getting tested if you have any symptoms or if indeed the public health team asks you to. During this time, hospitals are asking if you are in quarantine. So that might be if you've, as I said, been in contact with a confirmed or suspected case, or if you've just recently returned from overseas and you're in one of the quarantine hotels. we ask that you don't attend your routine antenatal visits until you're out of quarantine just to reduce the risk of exposure to other people in the hospital and to staff members. But obviously during that period, if you're unwell or if you're in labor or you're not feeling your baby move or anything that you would normally come to the hospital for that is not a routine antenatal appointment, we want you to come in. So we don't want people in quarantine sitting at home not feeling their baby move and not coming in. We want to see you, but we ask that you give us a heads up by calling ahead, so whether that's the emergency department if you're a little bit earlier on in your pregnancy or the delivery ward, if you're over 20 weeks so that we can get ready and make sure that we've got the right rooms that we're seeing the COVID-19 patients or suspected patients in and we can get PPE ready and just so that we're a little bit prepared. And we'd also ask that if your household is in quarantine or there's a confirmed or suspected case at home, that your partner doesn't come in for that episode until they are also cleared. Yeah, no, that makes sense. There were reports at stages in the media from particular countries. There were some from New York in the US saying that only the mother was allowed in the room during the birth and there were to be no other support people. I know that freaked quite a few people out here. It did certainly worry me. How likely is it that something like that would happen here and what kind of things would need to happen for us to get to that level of separation? Yeah, I was reading that in the media as well and I just thought what a horrible thing for everybody to be going through to not be able to have your loved one or your support person with you during labour. Now, I can't speak for every unit around Australia, but where I'm currently working, each woman is allowed one support person throughout the labour and throughout their inpatient stay. But we're asking no children under 16 to come in to visit and that it's the same person throughout the labour and postnatal period. I think in terms of what would we have to see to change that, I think we'd have to be seeing very high prevalence levels of COVID-19 in the community and significant overload of hospital resources for us to stop partners or support people in the delivery ward. The only caveat to that is, as I sort of alluded to in the last question, is that we do ask that if a person is unwell, if the support person is unwell or has traveled overseas in the past 14 days that they don't attend and that you choose another appropriate support person. But I think if we manage to keep things under control as we have done, that is unlikely to change and women will be able to have their support person with them in labour ongoing. That's very reassuring. So what other precautions have been put in place to keep both mums and staff members safe during the delivery and also on the ward? Yeah, so there's lots of changes that people will probably notice when they come into the hospital. So I, for one, having been away overseas for a few months and then coming back, have noticed them. So apart from limiting visitors, everyone who enters the hospital is being screened to ask if they've travelled overseas in the last 14 days, whether they have any symptoms. I'm also doing temperature checks as people walk in. We've got really low thresholds for testing anybody who might have, who may have been exposed to coronavirus or who has symptoms. And we're in close discussion, you know, with our infectious diseases and respiratory colleagues, if we have anybody who's had a fever in labor or antenatally, and then taking appropriate, you know, precautions until we've tested that patient if that's appropriate and we have a result. In terms of what you'll see on labour ward, which is different, so a lot of our staff, well, in the clinics, a lot of our staff are wearing masks. And then on the actual delivery ward when we're caring for women in labour, the RANSCO guidelines are that in the second stage of labour, which I guess is the time of labour where there's the biggest risk of infection between healthcare workers and women because of the close contact and the nature of bodily fluids, which we see in the second stage, staff are wearing face masks and surgical masks, goggles, gloves and aprons. So that's a little bit different, you know, to what you would have seen before in terms of people having masks on, but it's to keep everyone safe. And if the mum is suspected or a confirmed COVID-19 case, then we're asking the mum who's in labour to wear a mask throughout the labour and we're also aiming to use one of the negative pressure rooms if those are available on the labour ward but not all units will have a negative pressure room. And of course good hand hygiene for everybody that's coming through the hospital so there's ample supplies of alcohol gel and the soap and soap and water, obviously. And I think, you know, in terms of staying safe during the delivery, I think, you know, we want women to know that we are looking after you. Although there are these changes within the hospital, we're still looking after you the same way we always were. And COVID-19 shouldn should impact on the way, the mode of delivery for your baby. There may be some changes around the hospital to keep everyone safe, but in, you know, babies keep coming even when there's a pandemic and we'll be supporting you through your labour and delivery or your elective caesarean section, however your baby's coming into this world, just the same as we always have been. Yeah. |
Hi, it's James Edwards, welcome to On The Wards. This is a podcast for supervisors, so not for junior doctors, and the podcast about assessment. And we're going to talk about assessment today because there has been some changes in assessment within Australia. There's a new national intern framework, new national intern outcome standards, and a new assessment form. Given that much of the audience is from New South Wales, we'll talk about the junior doctor assessment form, but it'll probably be known in other states as the National Intern Assessment Form. I'd like to welcome Paul Hamer to On The Wards. Thank you, James, and thanks for joining us. So I think we're going to swap positions, Paul. That sounds a bit weird, but we'll swap positions and maybe you can interview me. All right, so I'll introduce you. So James is the current chair of the Pre-Vocational Training Council for Health Education and Training Institute in New South Wales and he's also a member of the Australian Medical Council's National Intern Assessment Evaluation Group. My name is Paul Hamer. I'm the director of Pre-Vocational Education and Training at Royal Prince Alfred Hospital. So James, let's talk a little bit about assessment as a principle. So why should junior doctors be assessed? I think the first point is about patient safety. I think it's important that supervisors know how they're interned and do not stop performing. Because if they're not performing, there are concerns about performance and patient safety that is critically important and that may need an urgent discussion with someone such as yourself to either reallocate them to a different area or to change their levels of supervision. So I think patient safety is everyone's responsibility and that's an important part of assessment. I think also assessment does drive learning for junior doctors, so if you're not assessing them, they may not have that same drive to learn. The most important part of assessment for supervisors to understand is your feedback. What the gene docs want is feedback and the forms which we'll talk about later are about providing feedback, they're not about ticking a box. Finally we need to think about I guess our responsibility to the public. The public expects supervisors and their medical profession to ensure that all people who reach general registration have the appropriate skills and attitudes. And that may require, as a supervisor, you not passing somebody for a term or addressing somebody's weakness within the term because the responsibility is on that supervisor to make sure that intern is safe to practice. So at the end of the term, you know, how does, well at the end of the year, how does registration relate to internship? Yeah, so look, internships is a foundation year of work-based learning and it's that key kind of area from a medical school student to an independent practitioner. And medical graduates must complete internship before being eligible for general registration. And whilst they're undertaking their internship, they're granted provisional registration by the Medical Board of Australia. So interns need to do 47 weeks of practice, and of that, 10 is medicine, 10 surgery, 8 emergency care and once they've completed those satisfactorily then they can be eligible for general registration. It's important that the medical board will look at the whole year in deciding about suitability for general registration. So the failure in one term will not necessarily mean that junior doctor will not pass the year, will not get general registration. So you've got somebody you're concerned about early on, it is much better not to pass them for that term. That will probably not affect their future career, but it will at least address to that junior doctor and the supervisors and director of clinical training or DPET within your hospital that this junior doctor needs more remediation for them to continue. So that's quite a new and big change because I think previously if you'd failed a term you would have had to make it up the following year but that's not the case anymore. If you're satisfied that by the end of the year that they've met the standards then they'll pass their intern year. Is that right? That's right. So it allows us to better identify those junior doctors who may be underperforming, allows to put in place a plan to remediate them earlier without any fear that it's going to have any effects later. And I think that's what supervisors often identify junior doctors they don't think are performing, but they're maybe afraid that by failing for that term their future career is going to be affected. In most times it isn't and it should not affect their future career prospects. It would actually improve their career prospect because if a junior doctor is floating under the radar not performing well then they will struggle to move on to a vocational training program better address problems early and then there should be hopefully with some remediation improvement and it reinforces that when we think of assessment education is a kind of like on your continuum and we should see assessment on it as a longitudinal process and not just a snapshot right then and there i suppose another concern of some supervisors is if they fail the term that they'll have to repeat the term in their term and they may not want that underperforming doctor in their term again and they fail to fail them. Is that necessarily the case? Yes, that does happen. A lot of people will almost the reverse when they know there have been issues within the term and they kind of say they've just passed them. And then when you go back to supervising and say, oh, well, you passed them, they must have done OK, they can go back and do your term next year. They say, oh, no, this person's never coming back to our term. If that's the case, then they shouldn't have passed them in the first place. So I think that occasionally happens. You really, which we'll talk about at the end when you make a global assessment, you're really saying you're happy with that person's performance and that performance at a certain level such that you'd be happy next week for them to come back as an intern. So I suppose it's sort of similar to what has gone in the past where you're making assessments on junior doctors. So what are the new changes in intern assessment currently? Look, I think one thing is national. A lot of different states have their own assessment forms or junior doctor assessment forms. This provides some conformity throughout Australia, which I think is important because we all should be looking at the same things for junior doctors. They all align to a degree with the medical school graduate outcome standards, and we've developed some new intern outcome standards, which have got outcome statements. Now, these also link with the Australian Curriculum Framework for Junior Doctors, which I think is important. And as part of this is a new things are required to assessment, which include a new assessment form and a new assessment review process or committee. All right, well, let's start talking about the new forms. So what's new about the forms? It seems every couple of years we're filling out a new form and every time it's a little bit longer. So what's different about these forms? Look, the forms are, I guess, criterion-based assessment forms in that they provide intern outcome standards and then they measure the intern's performance against those standards or the junior doctor. Now, to make it easier for the supervisor, they've given some behavioural anchors or descriptors to help the supervisor determine what the performance has been of the junior doctor. They use a five point scale and using these descriptors should improve the reliability of assessment and it really tries to kind of make sure that the rating you give them is authentic and valuable for that junior doctor. So I had one supervisor in my hospital who didn't want to use the new form, he just wanted to stick with the old forms. Can he do that? No. I mean, because this is now a national form brought in by the AMC, isn't it? Look, you can have a different form as long as it meets the broad intern outcome statements. So all of those domains need to be assessed? Yes. You can make the form slightly different, change the colour, change the wording slightly, as long as it fits within generally those domains and it's reasonably similar. So you can't change it, kind of carte blanche, but you can make subtle adjustments. Okay. So on the form, there is a box in there which I know is called the not observed. When should I use that? Yeah, I think the not observed box is something a lot of us are concerned about, that maybe people will have a lot of not observed throughout their maybe assessment. And this would obviously make their ongoing assessment for the end of the year with a reach gender registration difficult. Given that, not every term will be able to assess every area and I predict the areas that most supervisors find most difficult is what is domain three, which has some stuff on health advocacy, interaction with Aboriginal and Torres Strait Islanders and probably other ethnic groups and that communication interaction. And they can be more difficult, but I think you'll need to think about how you can observe those areas. |
So not saying you can't use it, but we'd like to limit the amount that boxes use because if somebody happened to have five terms in a row where they're not observed in one domain, then they would not be able to get general registration because there'd be no evidence that they've met that intern outcome statement. Okay, so that's quite interesting interesting so it is important to try fill out those boxes if possible. Yes. Okay so at the end of the year the junior doctors are collecting all these assessment forms how does that fit in with the certification process at the end of the year? Yeah so there's something there's now an assessment review group which will determine whether that intern has met the intern outcome standards and your hospital, your network will support their application for general registration. It's reasonably broad on how each hospital network could run that. It should be run by, have some senior clinicians within that group. It provides some support for the DCT or DPET so they're not the only one making that decision. I think that sometimes it's difficult being the person who is the supporting person and also the one doing the assessment so it provides some more people around and you may actually not have that DPET or DCT in that group but they will obviously see their information be valuable for that group to make a decision. I think it's important because you need to have a fairly robust, transparent process because if you make a decision and it could be the correct decision that this intern has not met the intern outcome standards and they need further time or further remediation then that needs to be a fairly robust process because it needs to be defensible. I think most people would understand you may not be happy that they don't pass their turn and maybe they will not always be given that extra opportunity to remediate and that they could take that through different pathways to try and get that decision overturned. So having a robust, transparent process should make that easier for hospitals, especially if they make that decision to fail a junior doctor. I suppose keeping an open dialogue between the supervisors and the director of training is important to make sure that things are discussed early. Yes, and I think the intern assessment group could be seeing if something happens at the end of the year, but maybe if there are issues earlier in the year, maybe that's a time to do an intern one, address the problems early. And that thing with everything to do with assessment and supervision, if there are problems early, you don't have to wait till the end of the term to address them. We'd rather, if you know there's a problem in term week two, address it there, speak to the intern, give as much time for them to remediate, to improve their performance, rather than telling what often happens a week before their end of term, which is often their midterm, and say, your performance isn't good enough. If you don't improve, you're going to fail the term. I mean, I suppose it sort of takes us to what is a supervisor's role in assessment. I mean, very often the junior doctor just presents in the last week of term with this form that the supervisor feels that they need to fill out. But, you know, sometimes they've been working with a junior doctor. Sometimes they haven't. You know, if they're on a big, busy team, they might be working with other consultants more than the other person because of rosters and things like that. So what's the supervisor's role and assessment in all this? So it probably does need some planning. So I think importantly, the team supervisor plays a key role in the national medical registration process. So don't just think this is local. This is really any decision you make on that intern is at a national level because you're saying they get general registration. I think it's important that there's a big responsibility on supervisors to make sure they take assessment seriously. I think it's important as part of the orientation to have fairly clear goals of what you expect of that intern and how you're going to do the assessment, what you base the assessment on. It's great to have that discussion as part of the orientation and then then you can determine when the assessment will happen. Nearly always they should have a midterm assessment and if it's a 10-week term that should be five weeks and an interterm. And often you'll need to organise a meeting and the one thing the supervisors need more than anything else to have a good dialogue with a gene doctor is time. Probably the most valuable thing as a supervisor to have some time to sit down and chat to them and the more organised and the more you can plan a meeting that is not just after the ward round in a separate room sit down and allow that junior doctor to have some self reflection and we've spoken about the role of the junior doctor in their forms and they should spend some time reflecting on their performance. Within New South Wales we ask for them to self-rate. They need to do that beforehand. You need to have enough time to gather information. So where do you get that information from? I think it's important to get the information from as many people as you can. Multi-source feedback or 360 degree assessment are buzzwords for really just asking lots of different people about performance of that junior doctor. It's important not just to ask medical and not just senior consultants. You may ask registrars because registrars are the ones who probably have the best idea about the performance of that junior doctor. They spend the most time with them. The other people are really important are nursing staff. The NUM or other senior nursing staff on the ward will probably give some excellent feedback on what that junior doctor skills are like, especially in regard to communication, discharge planning, some of those other things that may be harder for a senior consultant to view. They should also look at some of the documentation, look within the notes, how the notes are written, is there a plan, can you see evidence of the gene dogs are thinking about what's wrong with the patient. You can look at discharge summaries, they're really important. It gives a summary of what the patient's admission to hospital was like and make sure that's accurate and clear. You may be able to observe procedural skills, such as in theatre, or putting lines in or something, or doing procedures outside of theatre. And there could be other kind of work-based assessment models, and I think work-based assessment is where most of assessment's happening, and whether that's within the junior doctor level, medical students, or vocational, things like mini-CXs, case-based discussion, DOPs, and like that, are common education methods that many supervisors would be aware of and use in their other areas. So as we move through the form, the domains are pretty clear and the outcome statements are fairly self-explanatory, like professionalism, prescribing, things like that. But at the end of the form, it asks us to make a global assessment of the junior doctor. How do you come to that? Yeah, I think you just need to consider everything. And I don't think it's a set formula of they get a two here, a four there, a three there. There's no kind of magical mathematical formula to work out where their performance is. But to be satisfactory, you need to be generally happy that they're able to practice safely, they can work with a bit of increasing or decreasing level of responsibility, comply, knowledge and skills. And although the guidelines here don't measure trust, and trust is something really big in education at the moment, my feeling is that if you're giving satisfactory, you trust the intern to do their role and although when we look at is this an outcomes-based assessment form because really the form is linking with outcomes-based assessment which is again reason we think in education that they need to meet outcomes I think most people look at the form although they read the outcomes I think also supervisors use their experience of seeing many other gene doctors at a similar level or a similar time within a term and make a judgment whether they're at appropriate level within the appropriate norm so although it's a kind of outcomes based assessment I think most people recognize that a first term intern, you'll be a bit easier regarded with their satisfaction or not versus a term, a fifth year intern or fifth year PGY2. And I suppose one of the new things in there is that there's, previously it was just satisfactory or unsatisfactory, but now you've got a borderline assessment too, which I think is quite useful because I suppose in the past, some supervisor might have feared failing someone or giving them a completely unsatisfactory mark. But the borderline, I think, would flag to the junior doctor and also to the director of training that this person needs some remediation and is probably on the way there but needs just that little bit of extra help and I think that flag is important. |
Welcome to On The Wards, it's Jules Wilcox here and today we're talking about rational test ordering with Dr. Deborah Leach and Dr. Paul Bunting. Deborah is the clinical director of the ED at Box Hill Hospital for the last 21 years, Eastern Health Director of Emergency Services from 2003 to 2009. She's director of the medical student programs, Eastern Health Clinical School, Monash and Deakin Uni students since August, 2018. She holds a number of college roles at ASIM, was in examination committees and is a recent ex-college examiner and senior examiner. And her career interests include leadership development, teamwork, not doing unnecessary tests, quality and redesign, patient-centered care and teaching. Paul is the director of emergency medicine research for Eastern Health in Melbourne and a clinical face at Box Hill Hospital. He's got a particular interest in rational medical test ordering and reducing low value interventions and is the clinical lead for the Eastern Health No Unnecessary Test Project. More often than not, he'll ask his junior doctors and registrars to justify why they're ordering a test or performing a particular intervention rather than why they're not planning to do it. So welcome, guys. That is music to my ears because I find myself doing similar things, much to the annoyance of my juniors, I'm sure. So perhaps we could start, Deborah, with a bit of sort of history and the background on this. What are the issues with test ordering as you see it at the moment? Well, I think test ordering is something that's a little bit like an avalanche that I've seen happen over the last 20, 30 years of my career. We used to not have that many tests and, you know, like when I started, there was no CT scanner in the hospital. And over the years, we've got more and more gadgets and more and more tests. And it just seems that people are applying them without due process and without due thought to what they're ordering and the utility of them. And I think that a few years ago, when Paul and I suddenly realised that this was happening, that we had an opportunity to just put the brakes on a bit and think, no, there has to be a better way to teach how to order tests and to consider how we're all using these things. Because obviously tests are very important and very useful, but they have to be applied in the correct setting. Okay. So, Paul, I might go to you then and ask, from your point of view, what's wrong with ordering heaps of tests then? Yeah, look, that's a good question, and a lot of people ask me that. And my main concern is really around efficiency, to be honest, of running out of apartments. We have access to all these tests they're often just second guessing what we already know and there's plenty of research that shows that we're pretty good at getting it right by taking a good history so we're just backing up what we already know and it's a really really expensive thing to do there are also issues with finding stuff that we don't really understand which can lead to more tests and more tests and all sorts of issues along with that. It can lead to anxiety for patients when we find an incidental finding that we don't really know how to interpret or when one of their biochemical values is a little bit out of the reference range. It's quite difficult to explain that to a patient to say, look blood tests are not quite normal but i'm not really worried about them a lot of anxiety there and then there's issues obviously with sticking needles into people and exposing them to radiation and all the actual risks that come with doing the tests themselves yeah yeah absolutely i remember reading a really good article by atol gawande in the new yorker about the morbidity of the secondary morbidity of test ordering and how, which we don't see. You order some tests and you say you order those LFTs for some spurious reason and they're slightly abnormal. And so then they end up with an ultrasound of their liver and then they end up with something else and then they end up saying, well, they get liver bops and then they bleed from it. And you don't see this because it happens days, weeks to months later, or even in a different hospital and enormous expense and actually significant morbidities, he was saying. And if anybody listening hasn't read that article, I encourage you to do it. So, okay. I think I have a thing as well that I seem to notice is that sometimes the test ordering seems to be related to a lack of confidence. Is that something that you've come across as well? I think we've all, as Paul said, we second guess ourselves. We don't trust our clinical judgment. And I think that people think if you order a lot of tests, you've got your sort of somehow spreading a safety net for yourself and that you're keeping patients safer. And I think that they've forgotten how to just take a good history and learn how to be a bit critical of their practice. So I think underconfidence is a big part of it, not just in juniors, but also in seniors. We've forgotten how to live with clinical uncertainty. Yeah, and look, we've all been there. I can remember being a registrar and the only registrar overnight and had a patient come in with just the most obvious AMI you can possibly see on an ECG. It just, you couldn't get more textbook than this is this patient, but there's no way I was speaking to cardiology until I'd run that troponin in our troponin machine and got the result back, which was ludicrous. And for that month, our daughter cath lab time was, was, was all pretty good except for that one patient that was a, an order of magnitude longer wait than everybody else, because I was waiting for that test. I did that patient a massive disservice because of my lack of confidence. Yeah, yeah. And going back to the history taking, I mean, it's the crux of what we do because if you don't have a good history, you don't come up with a sensible or a realistic differential diagnosis that may include the patient's diagnosis. And so you can order all the wrong tests, which are not going to get you any closer to where you need to be. And I've seen that a number of times with, say, a patient with a headache in ED, you know, who comes in, who ends up with a CT scan for looking for a subarachnoid. Now, if you'd taken a proper history, there was no way that patient had a subarachnoid. I mean, even the demographic is, and it's rare and people are scared of missing that, that big diagnosis. And yet you can often rule these things out with a really good history and a little bit more time spent on the history taking. So, you know, I think we seem to be inundated with technology. And so we've got all this stuff now. It's like, oh, we've got to use it. We've got to do stuff with it. How do we get away from that? Deb, I'm going to ask you first about that. Well, I think it is tricky because these pieces of technology are very glamorous and exciting to use and it almost becomes the norm that the first thing you think of is tests. So I think it's really got to be pared back to reorientating our thinking to history taking, history is king. And I really liked what you just said before about a realistic differential diagnosis, because it's all too easy to just, you know, have a scattergun approach to differentials and put in all these crazy things. But a realistic differential will aid the patient far better, I think. Yeah. I actually reckon that goes back a little bit to the way we're taught medicine or historically where we're encouraged to throw out bizarre differentials in our exams back in medical school. You can almost see the examiner with their little pen giving you ticks when you mention things like atrial myxomas and so on. The most esoteric thing you can put on, it will still be worth a mark. And they're never putting a cross if you say something ridiculous. So I think right from the start we've created this system where we encourage doctors to think really, really broadly rather than really, really accurately and cleverly. They memorise these big lists but they don't perhaps put a lot of effort into being realistic and practical in their application of those lists. I do think, though, that nowadays, particularly in our clinical school, we are putting a focus on clinical reasoning. |
And they've looked at that with doctors and given them a certain amount of information, and then given them more and more, and rated the confidence of their diagnoses when they have a lot more information, and the confidence goes up hugely. And yet the diagnostic accuracy does not. And I think that's got a real issue for patients if you've got somebody who is starting to become a bit closed-minded and subject to perhaps more of those cognitive biases because they're very confident that they've got the right ideas because they've done heaps and heaps of tests rather than thinking rationally about it. So that's, which is again, yeah, another problem. So if we were to go forward from here, what advice would you give to the juniors? How do you start on this process of pairing back the tests, especially if you've got a consultant as an inpatient team who wants you to do a million different tests and serum rubups and this? How do you deal with that? I think it's very tricky for the juniors to deal with that situation. What I generally advise them is to just keep challenging, keep challenging and keep asking people, why are you ordering things? And sometimes that has a really good effect that the seniors can learn from the juniors. And that's really nice to see. Yeah. And there's evidence to show actually that if you have just come through medical school or say as a registrar, you've just done your exam, you know, your BPT exam or something like that, your knowledge is actually better than your seniors. The seniors are relying on pattern recognition and experience, but they're often not as up to date as the juniors on certain things. And so we do have to go, hang on a minute, I can recognise the patterns quickly, but if it's sitting outside of that or if it's a specific bit of knowledge, then actually the evidence is there that unless you're robustly engaged in a CPD program, you're probably a bit behind the juniors. I think another thing, and this may be more applicable to juniors working in ED than on the ward, but I think a junior who's spent a lot of time talking to a patient and taking that good history and getting a good grasp of this particular patient often allows their knowledge that they've just picked up to be overturned in a 30-second phone call by somebody who hasn't seen the patient, has only half listened to what they've said. And I find that really a little insulting almost that someone over the phone will completely disregard everything they've heard and then ask for all of that to be confirmed with a bunch of random tests. It's very, very easy to water things over the phone on patients that you haven't seen, especially when you don't know and perhaps don't fully trust the doctor that you're listening to. But for the junior making that phone call, I think it's worth reminding themselves that they know that patient better than anybody else. And if they're getting advice over the phone that sounds a little bit off centre, that they probably should encourage that doctor to come and see the patient and take these through themselves rather than order those tests remotely. Yeah, yeah, absolutely. Because I think you get into this, the cascade syndrome then, don't you? You had a plan and then they want a load of tests and then it shows up. And I do think there's still that sort of be a bit of a wall sometimes from the inpatient teams. I'll attest to use as a weapon. There's no doubt that they're a fantastic delaying tactic or decision deferral tactic. You know, cardiology always want to see TPA. Shorten some breath. Yeah, that's another thing that I... The spiritually always want to BMP. I encourage my junior doctors to sort of filter the advice they're given also by the specialty of the person they're speaking to. If a cardiology doctor over the phone gives them advice regarding a cardiology specific bit of information, they should listen to that a little bit more closely than if the cardiology registrar gives them advice on, you know, excluding heartburn or something like that, that they don't perhaps know so much about. And we get this quite often where inpatient doctors are over the phone. Once again, this is fairly ED specific, but they'll have less confidence in excluding differentials than ED doctors do, for example, because we do this all day long. We know a little bit about everything. Most inpatient doctors are super good at what they do and perhaps a little bit more cautious about the areas that aren't part of their specialty. And I think part of our job in ED is to filter that information a little and to take more notice of the specialty-specific information than the perhaps broad differentials that we're asked to exclude with tests. Yeah, and it's that dealing with uncertainty again, isn't it, a little bit? I think people get very uncomfortable dealing with something that might not be in their speciality, especially the way the hospitals work these days. If they end up admitting somebody who doesn't actually have something under their speciality, it's a nightmare for them trying to get the other team to then come and take over care and to get the consults. So I think we're set up in a little way with the silos that people operate in sometimes that promote this sort of thing as well. It's interesting that, though, Jules, because our organisation, the actual organisation, has made enormous efforts to break down those barriers. And at an executive and program level, there is no issue with admitting the patient under the wrong unit and getting the bed kit changed. And yet that message, despite being an official Eastern Health message where we work, it still hasn't really filtered down to the junior levels of staff. And there's still a lot of fear over getting a unit wrong, even though the hospital itself doesn't care. Yeah. So can I just ask you then, Paul, with the No Unnecessary Tests project, what did that involve? Yeah, look, so we, I think, approached this the way a lot of other people approach it. We looked at some areas of testing that were clearly over-audited and it does involve a lot of auditing to start with. These were either high volume sort of low yield, sorry, high volume tests that didn't really help very much or they were low volume expensive tests that had big implications. So a high volume test might be something like a CRP, for example. It's not particularly expensive, but it actually really helps. A low-volume expensive test might be something like a CCPA, which we don't actually order that many of, but there's a lot of radiation involved and there's a lot of resource involved and it's $400, $500 a pot. So we did a bunch of auditing first, worked out what areas to target, and then introduced a multimodal behaviour change package, I guess, with publicity, some gamification, some education, a lot of education, getting clinical champions, getting junior staff involved as clinical champions, creating a little bit of hype and more auditing and then feeding back results. We introduced a little bit of electronic decision support, which was very effective for some things, some paper decision support for other things. And then once we had shown that we could actually make these changes, we then had the challenge that, once again, most people doing this work have of maintaining sustainability with rotating doctors and new people coming and going all the time. It's actually very challenging to keep these sort of processes in place long term. That's probably where we're at now, just trying to keep the momentum going. And how was it accepted by the senior staff and the junior staff? Was there a difference between the two? Broadly speaking, my experience has been that junior staff are very receptive to this sort of thing and actually quite like having having some testing guidelines to be honest senior staff uh are often a little bit more set in their ways um a little bit more uh you know what this is what i've done all along this is what i was taught when i was an intern and i'm not going to change that now that i've been sold for 20 years um So a little bit more resistance from the senior staff and Deb and I found that we were in putting our resources into the junior staff we got better bang for our buck. Okay. Senior staff who you know weren't really on board with this we could just ignore to some degree. Having said that a lot of senior staff were very supportive as well. The pockets of resistance tended to come from senior staff, not junior staff. Right. Okay. Yeah. I think that there have been more pockets than a global experience. So I think there are some people who have been swayed along the journey. You know, if you keep at it long enough with the right messages, they do come on board. Yep. Did you, I presume you would have saved a bucket of money doing this, reducing test ordering? |
It's very easy to, look, it's all observational research and it's not particularly robust, but it's very easy to say, look, you know, we reduced, you know, CTPAs by 30 percent and we did x number and we're now doing x number and they cost four or five hundred dollars each on the medicare rebate schedule and times that by a year and three hospitals and you end up with hundreds and hundreds of thousands of dollars and this is another educational message for the the junior staff that i try and tie in with this that hospitals have a finite amount of money and sure it goes into all those those different pots, but at the end of the day, there's a little bit of fluidity between them. And if all the money's being spent on things that the hospital can't really control, like your test ordering patterns, then they have a little bit less money to spend on things that they can control, like hiring more doctors. Yeah, yeah, which is exactly the spot we're in at the moment. Yeah, we stopped doing blood gases. We made it a consultant-only decision to do a blood gas in ED, and we saved $100,000 in three months. And this is it. The money saving from this stuff is phenomenal. The expenses associated with medical testing in a big organisation like a hospital are just phenomenal, and just one little thing like that and you've got a couple of couple of extra doctors really i mean it's yeah i mean that's 400 000 a year you know i mean that that's four rmos so you know it is it is huge um and it doesn't change if anything i'd say it improves the the care of the patient because it speeds things up and you're not getting all this extra information. Certainly, I don't think it has diminished the care of the patient because if we feel they need it, sure, they get it. It's not a problem. One of the things that I do and I'd be interested in whether you use this tool with the Choosing Wisely website, using that as a thing saying to my juniors, go and look at this website. Go and look at that. When the surgical reg wants coags on the 24-year-old appendix, for instance, I don't know. I don't know. We need to know. And I said, no, no, you need to go to this website and you need to look at this. It's been agreed by the various colleges and all this sort of stuff because I find that way, you know, that I just have to listen to me. There's a bit more backup. Do you use that as a resource at all? Yeah, we use it a lot. We're very involved with Choosing Wisely and have been since they arrived in Australia four, five, six years ago. I think they carry, like you said, a bit more clout than just one mad, raving ED consultant who just keeps going on about this stuff. So, yes, that's a very, very useful resource. We also had the Choosing Wisely five questions in each of the patient cubicles, so trying to get the patients more involved as well in their care. Okay. Can you just quickly recap those? Do you think they've gone off the top of your head or just in people haven't seen that? Yeah. So just broadly speaking, it's encouraging patients to ask, you know, why am I getting this test? What value does it have for me? What will the outcomes be? How useful is it? Are there anything that you can do that's less invasive? That sort of things. Unfortunately, with COVID, we had to sort of strip back the cubicles a little bit to prevent fomites, but no doubt we'll be putting them back soon. Yeah, yeah. Okay. One of the interesting things that I came across recently in this book, Compassionomics, looking at the effects of compassion on healthcare in all sorts of different ways. And they looked at test ordering and they found that doctors who are rated independently, raters having higher compassion, ordered far fewer tests. And I can't remember the exact number, but it was, it was certainly not less than 40%, I think. And it could have been as high as 60 to 80%. I can't quite remember the study, which is just incredible. But I think it goes back to what we were saying before about getting a good history. And if you're really leaning into your patient and listening and setting up that rapport, they tell you a better history. You're taking a little bit more time, but I think you save that time later on. And the healthcare economics of that, let alone anything else, would be quite incredible. If you could bottle that and sell it as a pill, you would be a billionaire. And our hospital is 20, I think 24 million in the red this year. We're not allowed to hire anyone else. We've got all sorts of issues. And yet a day-to-day basis literally i see people burning hundred dollar notes left right and center oh it's extraordinary isn't it blood cultures on a patient who's got an abscess you know it's like swap the abscess um you know or you a uti you know we'll test the you know it's not going to pick anything You're going to get a false positive. Then you're going to chase the false positive. And it's very frustrating to see it again and again and again, day after day after day. And you tell somebody and then the impatient teams and it just comes overriding. And I guess what I'm saying is we've been trying to work on this for a while and it still seems to be going on. And for the people listening, what would you suggest that they do in terms of take home messages for where should you go now? Obviously there's things that you should do for yourself in terms of, am I feeling uncertain? Do I need to, am I doing this test? Cause I don't quite know what's going on and it's going to make me feel better or, you know, have I specific question I'm trying to answer I mean that's one of the things we often say is that you know what are you trying to answer with this test ultrasound for instance you know what are you trying to answer with this test because you can't come up with a specific diagnosis or that you're trying to confirm or refute you probably shouldn't be ordering the test um but above and beyond what you can do about yourself and sort of calling yourself to account on that, where do you think juniors should go in terms of if they wanted to, for instance, do research into this area or try and institute a policy in their hospital to get this movement going in their hospital, dealing with their consultant colleagues who are still insisting on this test and the serum re-rub test and thing and deb might ask you first just pick one of those obviously it's a big big topic but what would you suggest to the jmos who are listening there could be an effective thing that they could do going on forward from the here having listened to this so i think that the juniors can be very effective change agents. We used our juniors a lot when we were putting in interventions and we used them to do auditing. Some of our juniors were really wedded to VBGs. We got the person who was the VBG champion to do an audit and that completely changed his ordering and all of his peers almost overnight. However, from an organisational perspective, I think it's really important to have champions and to really nurture those people who are on board with you and to seek out seniors who can influence the hospital executive because that's where we really got our momentum from was when we had organisational backing to do this work. They saw that it was important and it helped us with it. So although a lot of the grassroots interventions we put in place were utilising junior staff and their enthusiasm and their momentum for change. Without having that backing of the organisation, I don't think we could have done nearly as much as we did. I don't know, Paul, if you agree with that. Look, it's very easy to get the organisation on side and any organisation is going to be on side with this because as we've discussed a clear financial burden associated with it so yes you'll always have a friend in your organisation and there'll always be a Jules or a Deb or a Paul in your department who you know will want to get involved in this there's there's I think a lot of senior staff who've been frustrated with this for a long time. And as a junior doctor, if you find the right person and go and say, look, this is something I've noticed, they'll support you in this. |
Okay, welcome to On The Wards, it's James Edwards and I'd like to welcome Dr. Ken Liu. Hello. Ken is a liver transplant fellow at RPA. He did advanced training in gastroenterology at Concord after doing his junior doctor training and BPT training at RPA. So for all the listeners out there, today we're going to talk about an approach to the abnormal LFTs. This is something I think junior doctors are faced with on the wards because they're usually the ones who order LFTs. So we may start at the beginning. When should they order LFTs on patients who are on the wards? Well, usually, actually, they come in with LFTs already ordered. It seems a pretty common thing to do in emergency. But I would think anyone who is sick enough to be admitted in hospital should have an LFT at some point in their admission. The next question is how often should we do it? And I think if someone came in with normal LFTs with a disease that you don't think will affect the liver, I think it's wasteful to do daily LFTs or even regular LFTs. Whereas the population I see in gastro and liver, people who come in with cirrhosis, who have decompensated or with liver failure, then they need daily LFTs. So it sort of depends on the situation. But I think certainly people with liver disease need LFTs. People who have biliary issues like biliary obstruction, cholangitis, cholecystitis should probably get LFTs. And occasionally if you want to start medications that might impact on LFTs like statins, you might just want to do a baseline check. Yeah, and once you've done the baseline check and they're normal, as you said, maybe in a week's time, two or three days, depending on what their presentation is. Yeah, I mean, I think anything more than once a week is wasteful if their condition has nothing to do with the liver or bowel tree. Okay, so the LFTs were ordered in ED or on the ward and you get them back and you have a look as a junior doctor and they all look a bit abnormal. So what's your approach to the patient with abnormal LFTs? Yeah, I guess there's a lot of questions I usually ask. Durang LFTs probably after GI bleeding is the most common consult we would get. I think people don't realise that history is quite important. I think a lot of people make the mistake of calling me and think that by just looking at the LFTs, I'll be able to figure out what's wrong with them. And they're often surprised that I ask them about their admission and what's gone, what's happened, what it meant to their own, et cetera. I think surely, Ken, you can just do it just by the button. It's a history exam. Okay. So my approach is generally to ask about the history to begin with or what's going on at the moment because you might not realise but someone with sepsis will have deranged LFTs or someone with heart failure can get deranged LFTs. Drug history is a big one and especially drugs that have newly been commenced and people, I think, often miss over-the-counter drugs or herbs that patients might not be really forth-willing in telling you. And I also want to know how acutely deranged they are. Have they been deranged for a long time or have they recently gone off while they're inpatient? And the severity of them. So how many times above the upper limit normal have they gone? And so those questions sort of allow me to piece together what's going on. Okay, so you've kind of mentioned things on history, a good medication history, finding out the underlying medical problems. Any other particular thing on history? I guess it's also useful to know, obviously, if they have underlying liver disease, so if they drink alcohol, if they have a history of cirrhosis, and what the examination shows. So if they've ever presented with jaundice or dark urine or ascites and capillopathy. And I guess sometimes pain sometimes helps differentiate between surgical causes and medical causes sometimes. Yeah, so right upper quadrant pain is very useful in knowing is this cholangitis or is this for example drug related liver derangement? Okay, so you've taken a bit of a history. What should the junior doctors specifically look for in examination? I think they should know if the patient is jointless or not. That will help them think of ordering LFTs and also look for signs of chronic liver disease, all the peripheral stigmata like palmar encephalitis, spider nevi, signs of decompensation like ascites and cephalopathy. And further examination, anything else in particular? I mean, vital signs, we talk about vital signs a lot. Do they matter much as some of the abnormal LFTs, or is that something that would normally routinely be usually normal? No. So another common cause of deranged LFTs is hypotension, and the liver is quite sensitive to ischemia. So you can get elevations, particularly in your transaminases, if they're particularly hypotensive. Going on to that, you can also get derangellative tears from liver congestion, so if you have right heart failure, so elevated JVP, peripheral edema, but a cardiac failure patient with right heart failure, it's often not surprising that they have Duran-gelifatase. So I guess, yeah, thinking outside of the abdomen, you need to look at the hemodynamics and also the cardiovascular system as well. And when you think about the abnormal LFTs, do you group them into kind of a cholestatic picture, a palosalial picture? What's your approach? Yeah, that is something I have in the back of my mind, but after seeing lots of deranged LFTs, I often find that nothing fits into the box quite as neatly as that. So, for example, I've had people come in with cholangitis but have sort of what you would expect more, cholestatic enzymes, but their transaminases were higher. Or similarly, someone comes in with a hepatitis, but their cholestatic enzymes are high. So yes, it is useful that it provides you with a general framework that you have a hepatitic picture where the transaminase is mainly high, a cholestatic picture or a mixed picture. But just don't get so fixated on that and not be able to think outside those categories. We may need to go back one thing. So when you say cholestatic picture, what blood results would suggest a cholestatic picture? So your ALP, alkaline phosphatase and gamma-GT and usually with an elevated bilirubin as well. And often they would talk about things like an alcoholic hepatitis, the differences in AST and ALT. Do you find them useful? I do. Try to look at ratios. There are not many causes of deranged ALTs or transaminitis where the AST is higher than the ALT. So classically, alcohol can do it. But the other thing which I learned along the way with alcohol is it's rarely very, very high. So the transaminase is rarely above 300. And if it is, it doesn't mean it's not alcohol, but there's maybe another component. Maybe there's panadol on there or maybe there's ischemia, etc. So alcohol is one of the causes of AST higher than ALT. The other cause is ischemia. So a lot of people who come in with ischemic hepatitis have transaminitis in the thousands and AST is generally higher than the ALT. So what other investigation would you consider apart from the LFTs if they were abnormal? I guess it sort of depends. If it's predominantly colour static and you've got suspicion that it's a biliary problem, then you would order imaging like an abdominal ultrasound to assess the bile ducts. And if your suspicion is strong and the ultrasound's not that conclusive, you might go on to order an MRCP. Whereas if it's predominantly a hepatitic picture, the history will guide you, but you can do tests looking for viral hepatitis, take a history for alcohol, and perhaps order some of the rarer blood tests like for autoimmune hepatitis, primary bilirucerosis and all of those other things. What's the role in a disease of blood such as coags or albumin? Yeah, I mean liver function tests are a misnomer aren't they? Most of them are markers of liver damage whereas the true liver function tests are like coagulation, albumin, and to a certain extent bilirubin. |
Welcome to On The Wards. This is Eli Matter. I'm the Vice President and Co-Editor of On The Wards, and I'm also a neurologist working in Sydney, Australia. Today's podcast was created in conjunction with Global Medics, your career solutions recruitment specialists in permanent and local medical jobs across Australia, New Zealand, United Kingdom, and Ireland. There are many reasons locum work may appeal to doctors who are looking for career flexibility or want to fill gaps between jobs or explore different parts of Australia whilst earning an income. Each year our healthcare system relies on locums to fill roles in rural and remote areas as well as provide emergency relief and hospital for all grades and specialties. Today we're going to be talking about the benefits of locum work with Robert or Bob Gerber, who's the leading cardiologist, physician and interventional cardiologist currently working in regional Victoria, Australia. A little bit about Bob. Bob graduated from Guy's, King's and St Thomas' Medical School, which is part of King's College London. He holds dual accreditation in cardiology and general internal medicine and is currently working in Wongaratta Northeastern Health as a physician and general cardiologist and in Bendigo Health as an interventional cardiologist. He has expertise in hypertension, heart failure, heart rhythm disturbances and dyslipidemia. Bob has performed over 2,000 cardiac procedures, over a 25 career in cardiology and general internal medicine in Australia, New Zealand and the United Kingdom, where he maintains and holds accreditation. Bob has had some extensive experience and insight in locuming and is here with us today to talk about what he's learned and what you may want to consider if you're contemplating a similar career path. Bob, thank you so much for joining us today. Thanks, Eli. Thanks for having me. It's great to participate in this podcast. It's great to have you. I'm going to jump straight in and maybe ask you to tell us a little bit about your career journey and where locuming fit into that journey. Yeah, I think like with most people, you've got a career and you've got your aspirations. And I was finished medical school in the UK and did most of my training in the UK and locumed intermittently in the UK, which we can, we can talk about as well. Did all as we do as most cardiologists do, do your research and your fellowships. I actually did my fellowship in, in Italy, which was a nice year. And then after sort of working in the NHS for, I guess, about 25 years, did a sabbatical in New Zealand. And that then led me to decide to stay on and work in New Zealand and Australia. The advantages of working in Australia and New Zealand are great in terms of the different working environment and maybe slightly less pressurised in the NHS systems. And that's also one of the reasons why it's been quite useful to Locum. And I have to say Global Medics have been excellent for that, both in Australia and New Zealand. I've also maintained my credentialing and maintained my expertise intermittently which is nice and so that's where it's led me to Victoria mainly in rural Victoria where we can deliver sort of heart attack services services because my subspecialty within cardiology is interventional cardiology. And then because I do want to maintain my interest in general medicine, general cardiology, I'm doing that in Wangaratta in Northeastern Health at the moment as well. That's great. I guess, so locuming kind of fit in various parts of your career. Could you maybe expand on when and why did you decide locum work was right for you all the way through to, you know, when you were a junior doctor? So I remember, you know, when I was training, one of the professors in London said to us as a group that our generation are going to be a generation where we'll be working a bit more flexibly and also a generation where we'll be working in different roles, more so than ever before previously. And I think the models of certainly within the medical professions across the world has always been, you kind of go into one hospital, you work there, you work there for a period of time, 20, 30 years, then you retire, you get the gold watch or whatever, and then you retire. And actually, I don't think that fits for the sort of modern contemporary life. And it also doesn't fit for a lot of people trying to gain clinical experience and also um a way of gaining career progression and being paid well as also so all of these factors are quite useful and so locuming um um can fill that need in terms of introducing you to different subspecialties and specialties introducing you to different colleagues different parts of the world that you wouldn't necessarily consider as in my case and also maintain your your sort of direction of travel and intermittently you will have some substantive role like i do in bendigo albeit part-time that gives me the option to do the other things so um i think that's um that's useful i think people in their lives things change their families are you know families you may uh as as as i i've done i do a period of research where you're doing less clinical work uh you might want to boost income because research incomes not as much as you'd have if you were doing clinical work um and also um you don't want to you know kind of de-skill uh and and doing that's quite useful. The other thing is as well is that you can, what's quite nice is you can elect certain global medics, you can elect to go to various places where you might want to explore the culture or understand a bit more about the medicine in that part of the world and see different types of pathology. So I mean, overall, it's actually a really good experience. And it's one of those things that I think before you do it, you kind of go, oh, you know, you want to sort of stay at home as usual. But actually, it's very enriching and um it helps actually when you're when you're back at base doing your other work as well so it it's um it sounds almost um you know is quite prescient of your of that man that mentor to talk about the fact that you know it'll be a know, the future of working will be a lot more flexible. So was it quite a premeditated decision then for you when you were a junior doctor or were there any specific reasons of those that you listed that sort of made you jump into locuming at the time? So I think my first time I started locuming was as an SHO in London and with young family and between the SHO jobs, usually I think it's still the case to this day, you know, in Australia and New Zealand, that you have these periods where you're working on rotations that may be up to a year or 18 months and then you may have a gap before the next one starts and it can be that people are like oh I can't have a gap I've got to try and sort of fill it but actually you can fill those gaps with intermittent sort of short or long-term locums. And it doesn't look in any way bad on your CV at all. In fact, I, and I've been on interview panels and I have also seen CVs where there's been people that, for example, in my case, wanted to do cardiology, but I went off to the Royal Free and did a locum with them, med-ax doing dermatology. Now, training in cardiology, having experience in dermatology, that's sort of unheard of. But actually, you know, there are lots of cardiac meds that cause dermatological complications. And if you haven't ever seen that because you've never done dermatology then um you know and i would say most cardiologists have never done dermatology but i did a stint there and actually the royal three is one of the big dermatological centers in london so that was really useful and so um i had a patient the other day that was um on the ACE inhibitors which are we know, are used in cardiology and they got late angioedema. And I saw it and said, that's your drug. That's the medication we put you on. |
And then when you're writing, that can be a bit heavy because it's just sitting at a computer or in a library or whatever. And so low-coming periods of that is quite good. Definitely. I think some of what you've said touches on my experience in that a lot of junior doctors I was mentioning offline come to me and they sort of are concerned about, they want to locum, but they're a bit concerned about, you know, coming back onto the conventional career pathway or applying for the next job. I think your experience as an SHO, a senior house officer, I think that's sort of equivalent to our resident medical officer, senior resident medical officer level. And in fact, my experience, if anything, has been that what it provided for some of the people that I've met that have locummed alongside me are that it actually gave them a more diverse clinical skill set and experience that then they used as an advantage when they were applying for their next role, just as you were sort of saying. And certainly the other point about the ability to do some locuming whilst maybe you're doing some research would also help you keep your skills up and keep your credentialing up in certain cases, which has certainly been my experience. So I think a lot of pearls in there. I guess what I want to ask then is sort of what are some of your favourite destinations to locum in and have there been any kind of positive surprises about locuming that you hadn't considered? Okay, so just at the moment I've been locuming up in the Wangaratta in the northeast part of Victoria, which is an area of the world that I guess I sort sort of knew of because we do know about it but did i actually know that area of the world well i know i didn't and it's a really beautiful part of victoria and australia i mean it it spans the sort of alpine region and at the moment you can even you can ski if you want but my passion is getting out cycling and there's a corridor of towns and villages that run from Wangarata all the way down to a town called Bright which is some beautiful mountain scenery and some lovely villages areas it's a wine area as well Bright's famous for holding these alpine classic cycle races which obviously had never been heard of i cycled up mount buffalo at the end of one day in the summer and um bumped into another cyclist said oh if you like cycling you can you should you should join you should do this and that and and and one of the things i did which I really cherish, the last year was the Seven Peaks Challenge, which is in Victoria, but it's trying to cycle up these seven big, sort of really gnarly peaks, basically, is the only way to describe them. And the thing is, once you start ticking them off, you're like, well, I've got to do the next one. You tend to do the easy ones. And then the last two, there's a mountain called Mount Baw Baw which is huge that was the most exciting bit I mean other things in New Zealand I was posted up to up in the Northland which is where you have the 90 mile beach which is really memorable as well and you know, when you look and quite often you're surprised at the kindness of people where I was speaking with one of the clinical managers and they said, well, I said, I've never been up to the right of the top of New Zealand to Cape Granger. And she said, oh, it's so amazing. You know what I'll do'll do if you see a few extra patients in the morning I'll let you slip off at sort of 2.30, 3 o'clock and just jump in the car go up there because I'd love you to go and see it and I went up to the top of Cape Granger where you see and literally you just see this amazing beach and the next continent probably I think is probably the Philippines but actually the whole of that area and the environment and the flora and fauna, you never see any of the native bush. It's really nice. So there are a few things that I do remember. And then obviously, you know, it's like coming in the UK. You get to, as you quite like, rural parts of the the UK because you get little village country pubs and those kind of things and that atmosphere and the walks in the country as well. So, yeah, this is actually really nice. It's really nice. You're transporting me away from my more everyday dimly lit corridors and fluorescent lighting of the Sydney hospitals that I'm used to. So it sounds great. Look, I guess there are probably doctors out there right now that are listening to you, that are interested, that are excited by what you've said, and they want to get going and do some locuming. So how do you think they should get started? So I think you've got to be comfortable with your agent and the agency you're with. I started by actually just speaking to colleagues that have done locuming before and just saying, you know, what sort of things are you doing? Where's a good place to locum? Actually, it's interesting that in the locuming world, if somewhere's not very good in terms of how it looks after its doctors then locums don't tend to go there uh and as we know as trainees or as you know as if you look at the college there are some uh doctors that are posted in in roles where they have to as part of their training they're actually probably um worse than locuming in the fact that you know it's more service and less kind of the balance between clinical provision, service and training. And so that's, what's quite good about the locuming is that you can, you can find out through your agent and also through the two or three people that maybe worked in various places, you know, is it a, you know, do you want, do you want to go to the hospital and it's it's less likely in fact it's unlikely because i guess it's there's a market forces thing with locuming because if it doesn't work out you're not going to go there even even if they you know pay really really well you just don't want to go and get exhausted and feel bad about the work you're doing. So that's the first thing. And that's actually relatively easy to find that because most people know that. And then, and then just doing the right, just, you know, getting the right shifts in the right balance. I mean, I actually found when we had our second child, I was low community because I I preferred to run my shifts back-to-back and have a rest. And that's the thing that we couldn't do. I think you can now, but at that time, this was in the UK, because of the European Working Time Directive, if I was a normal trainee, you'd have to have, they'd say you'd have to do that. But because I was low-coming, I could just do a shift, have a rest, then and do another shift and then have a day off. And that was much better for me to have a day off with two young kids, you know. It would help my wife and it would be also nice to have a day when they're awake, you know. So they're the sort of things to do. You get, when you register with the agency, you should get regular updates with your specialities and then you can look and approach them I would say that you've always got to be honest so I would never take a locum role and then say not show up I think that's very bad and even when I work you know in my permanent role if a locum doesn't show up then I will most people will cop that I would say that's a rare thing that happens and if you for whatever reason you can't then just you just need to let people know because usually they're relying on the locum to fill in the gap for either a holiday or sick leave or something and that's really how I would start most of the hospitals that are on the list are actually well vetted in terms of they've been used or they use open agency regularly. So we know that they look after their junior doctors. It's interesting that you'll find that some regions in Australia and New Zealand never use tokens. And when they try to, it always tends to be sort of an internal thing. Don't know why that is, but you might notice that as well, Eli. And it may be that they're the ones to kind of maybe potentially think about avoiding because obviously they're trying to make it more profitable for them. But then that's at your expense, either whether that's the accommodation isn't quite as good or the working role week is a bit more arduous and less supported. So these are the things to just think about, depending on what stage you are in your career as well. Those are all really helpful. |
Yeah, so obviously this is a broad audience. I would just say in general that you just don't want to be vulnerable. And that's fine in terms of what most people understand. So if I was to go off and do a local role and they would say, can you do this procedure, which I can do as a cardiologist, and it wasn't an emergency procedure and it was something that carried some risk and there wasn't the right facilities, the right backup or the right connections, so to say, so if you're in a rural situation situation say a tertiary center or a secondary center that you can bring back up that's like then i just wouldn't i wouldn't do that and i do think that's the same for for anyone at every stage you're at if you find yourself where there's a desire for you to do a procedure or a clinic or something that you think it's either it's above your sort of clinical skill level then just say look honestly I'm happy to do this but it needs to be supervised or this is something that I need more training with because what you don't want to do is find yourself in a situation where it's uncomfortable where you're seeing patients and you're like I'm not really sure how to tackle this the one thing I would say though is that you will see an rural pathology that you may have never seen before that's different that's different to being asked to do you know so let's say if you were a fellow in cardiology and you ended up being asked to be a consultant interventionist, that's clear, there's a clear mismatch in skill level and that would be wrong. However, if you're a, you know, a trainee or a fellow and you're doing, let's say, a physician and you come across a patient that's got some really weird heart murmurs that's fine actually you just need to use your you just need to use your skills which is part of locuming either phone a friend or speak to someone and diagnose that patient it would be same and the same um you'll see all sorts of weird neurology i mean i know you're a neurologist and i've i've seen that and it's like what is that but you can describe it you can you can you know you can go through the the correct methodology um the one thing that is really nice, particularly about Australia, is that you have access to practically every diagnostic test. Who interprets them and how you put it together, that's different. So you can always get an MRI, you can always get imaging, and also you can always bring someone. So that would be the only things I would say to to be mindful is to kind of stick stick to your guns know what your clinical limitations are but also be open to kind of new avenues and and you'll find that much richer as well and financially it can even help because what happens is you may be asked to do on-calls. On-calls are, on the whole, something that the hospitals don't tend to want you to do. Sometimes they do because, obviously, they're paid higher. But they're actually nicer things to do as well if you're there because you're away from home. And so it's like, well, I do the on-call, I get to see more clinical cases and you get paid a bit more. And usually that's if you're a local that rolls up your sleeves and gets stuck in. So that's another thing to say as well. That's really great advice. I mean, you know, just recapping it, sort of knowing your limitations, maybe inquiring about the role ahead of time to know, you know, say if you're a resident or a trainee, what level of supervision you would be expecting and then being open. And in that process, I think that's the expertise that you get by going out somewhere different and seeing some new pathology and maybe bringing that back. So I think that's really helpful. I guess coming to the nuts and bolts of it, what are the sort of things you need to be eligible to do locum work in Australia? Just sort of the more, you know, nitty-gritty detail sort of things. Is there anything unusual out of the blue or is it just some of the standard things yeah so if you're um not australian uh trained then you do need to go through the apra process i would forewarn everyone going through the apra process it's not easy um in that there are lots of, and I think that's right. I think that APRA needs to make sure that everybody is trained and working and operating at a certain standard. And I actually think that was great to see that. So you will have to prove that you've done your various rotations, your various skills. You'll have to get references. In my case, because I'm an interventionist, I had to prove that I could do certain procedures. I was fortunate to work in countries where there was a regular audit, a government audit, an independent audit, peer review, so on and so forth. So the APRA process can take a while. You'll need to have referee checks, obviously police checks, all these sort of things. It's very thorough. I mean, for example, I did my fellowship, as I mentioned earlier, in Italy for about 18 months, a year to 18 months off and on, it was in in 2007 and even the police checks you have to include places like italy even though you know that was so long ago and but they will do all of that which is great because then when you get your certificate to practice within your specialty what you're doing everyone knows that you're at that standard but yeah i would i would give at least six months. I've heard it's faster now, but I would bear that in mind, particularly if you're coming from outside of the Australian, New Zealand, or the Anzac kind of region. Medical Council New Zealand, I've gone registered with them as well. That is also quite rigorous, but the process is slightly faster. And again, you've got to maintain your credentialing for both. And that can always be done. I would say to anyone, particularly if you need to locate them for a bit longer, and when I mean a bit longer, say more than a year, if you're, say, in between work or you've got children or something, that you could always do an audit. It's very useful. They're like both APRA and medical council link into the Royal college in terms of the credentialing. And one of those things is audit and good clinical practice and clinical effectiveness. That's actually easy to do. It's so easy. It surprises me. People don't think about that. So you could just audit, for example, your patients you've been seeing in clinic, you know, how many have got, I don't know, chest pain or whatever you're doing or how many patients you'd see on ward rounds and some of the outcomes. That's very useful. And you can often forget about that as a local, because I think as a trainee, you're encouraged to do a little bit more academic type of work and also some more clinical effectiveness but you can do that for yourself and that's also good for your own personal clinical governance if you're not an Australian citizen or a permanent resident you'll also need in parallel to do I would do it in parallel because it takes time to get a visa, working visa. If you're from Europe or the UK, it's not automatic that you can just, you know, work in the hospital setting or just work in general. If you have a skill that's needed within the area, then you can get an essential skills working visa. And there's all different types of subclasses, 5.8 to 5.5 to millions of them. But you can also, so my, my visa is actually it's through the hospitals I work with because, you know, you doing an essential skill in that region. And usually those, you know, if you hold that for a period of time, then that can convert to permanent residency. I would say at this stage it is important to think about that, and that's something I'm thinking about. Not necessarily because of your eligibility to reside in Australia or New Zealand, because that's actually not an issue. Usually if you're working in the hospitals in the roles you do, it's just that practically it can be difficult to do things like buy a house or to get a credit card or something like that, as I've found that's just a practical thing because obviously as you locally or wanting to live somewhere it's nice to not necessarily have to rent and so on and it's just really to do with the banks they're not very keen to give you a home loan or something or even a car loan if you're not a permanent resident in Australia. In New Zealand they're not so fussy actually. But still again that's also something to bear in mind. |
Welcome to On The Wards, it's James Edwards and today we're talking about teamwork and the role of patients in the team. I'd like to welcome Dr. John Samet. Welcome, John. Hi, James. How are you going? Look, John's a senior emergency physician who I've known for a long time, a mentor of mine, but we've got him to speak today predominantly because of his role in the Clinical Excellence Commission where he kind of led an investigation of the In Safe Hands program. So maybe it'd be worth, as a start, just give us a bit of an overview of the role of teamwork in healthcare. I know it's a very general question. Yeah, look, I think teamwork's everything, isn't it? I mean, teamwork is what makes healthcare work. I don't think it's an exaggeration to say that without teamwork, there can't be effective healthcare healthcare. No one service or a kind of phrase I like to use, no tribe provides all aspects of care. We're all dependent on each other and I'm talking of course about nurses, doctors, various allied health members, ATs, physios, social workers, the administrative staff that help the wheels turn, they're all integral to good, effective patient care. If I can just kind of set the scene, if you like, James, time and again, when you look at where major incidents go wrong, poor communication is seen as always one of the root causes of major incidents involving patient care. Teamwork is about addressing this issue of poor communication. George Bernard Shaw, I think, said it best. He said the single biggest problem in communication is the illusion that it has taken place. So I think I've said something to you. We don't use closed-loop communication a lot in health And so you hear something different and we walk away with different understandings of what's been said. And teamwork is all about having a format by which you can break down these illusions because you have explicit conversations, particularly in a multidisciplinary team meeting, about a patient's care. That's what generates good teamwork. You know, the people who study these things tell us that teamwork relies on three key elements. It's a so-called shared mental model. What do we know about what we're talking about in relation to this person? Situational awareness. What are we aware of are the risks for this person in this environment? And mutual support that comes from having these conversations and talking to each other. Once you've got those three elements, you'll be in a well-functioning, highly communicative, multidisciplinary team that's all about good patient care. You mentioned a multidisciplinary team. I mean, how do you define that? Yeah, look, I think you can define it fairly basically. To me me it's the sum of the various professionals that are contributing to the patient's journey to good health and I've mentioned them already that the doctors, the nurses, allied health, pharmacists, these are all elements of what constitute a multidisciplinary team but the nuance that I think is important is to say they're not just a multidisciplinary team, they have to be an interdisciplinary team if they're going to be good communicators for better patient care. I'm going to talk about a few different types of team. And the first case involves an intern, respiratory medical term, and you're attending a multidisciplinary team meeting where you participate in a discussion about the patient's care that's under your team. What is the kind of goal of one of these meetings? Well, as I've kind of alluded to, the goal is to be interdisciplinary. That is, to improve communication by improving the flow of information between the various tribal elements, doctors, nurses, allied health, all of whom have the ultimate goal of improving patient care, both in quality and in safety. The purpose of a multidisciplinary team, it's all about recognising that your service is busy, my service is busy, but we need to take time out as caregivers to regroup and link with each other so that we know what's going on for the patient from our various perspectives and we make sure we're all on the same page. I call that in brackets situational awareness and a shared mental model. And by doing that, we reduce the risks for an individual because we're clear about what we're doing and we're aware of the risks. So how are these kind of meetings or conferences or case conferences typically structured? Yeah, the structure of them varies around the world. Part of that work I did in the Clinical Excellence Commission was exploring how these multidisciplinary team meetings could be conducted. I think it's fair to say the traditional model most interned junior medical officers would see is the multidisciplinary team meeting held in a staff room with a representative from each of the various disciplines, usually the nurse unit manager, the senior medical officer, the admitting officer and their medical team and then a representative from the various allied health members and they're all sitting around case by case discussing individuals and what their contributions to their care are. I'd like to put to you that if it were done in a Rolls-Royce style, if it was done in other words to the best of our ability, it would be done in a way in which it was by the bedside. We would move that meeting to the place that matters most, and that is to the bedside where the patient and their family are invited to join in and be part of a multidisciplinary team to ensure that the communication is open and free. So really including patients and their families as part of that team? Yeah absolutely. I mean I truly believe you don't function well as a multidisciplinary team without involving patients and their families because at the end of the day patients and their families know what the issues are from their perspective and they know what their concerns are and if we're about meeting their needs need to know what their issues are. And doing that in a room away from them misses the opportunity for new information or to cross-check that the information we're discussing is accurate. It also affords a really important concept, and that is the opportunity to park a concern. Families often say we were worried about dad coming home, we were worried about what was going to happen but we didn't know who to ask. For us it's familiar, we work in it every day, we understand the hierarchies, we understand the interplay between the tribes. Imagine you walk into a health system as sophisticated as it is and you have none of that knowledge. You're often left anxiously wondering, who can I tell I don't think Dad's ready to go home yet? I think the mobility issues are significant. When we survey patients and their families, they tell us this is a real issue for them and you can take that issue away by involving them in that multidisciplinary team communication so that they feel relieved and they feel confident those concerns have been heard and by the way the team can be reassured all those concerns are addressed so everybody's satisfied at the end of the day. And who kind of leads these meetings? Is there a particular model that you think works? Yeah I think when it it's done at its best, it's led by the medical team because it is still a reality that it is the medical team that tends to determine who gets admitted and who gets discharged and when. But that's not to say we don't show due respect and that we don't recognise the contributions of all the other team members without whom we couldn't make the patient better. So to answer your question, it still should be led by medical staff, but it should be done in a way that everybody understands what's coming and the conversation is predictable. We're going to go around, we're going to hear from each of the caregivers, we're going to do it in a structured way so that we each contribute our perspectives on their care. So how can a junior doctor really optimise his or her contribution to this meeting? Yeah, by understanding what the purpose of the meeting is and understanding what your role in that meeting is. You, as part of the medical team, are expected to bring what I call your tribes knowledge. You've got information from your perspective, you know the results of tests, you know what tests are forthcoming, you know what treatment adjustments are being made, you know what the desired outcomes are and what the probable outcomes are. Other caregivers have other bits of information. Bedside nurses have an enormous amount of information around how stable patients are, how they're improving with the various treatments we're implementing. They have information about the concerns that aren't expressed in any other format. Physios have information about how people are improving from their perspective. And so the thing you should be aiming to do as a junior doctor is being prepared to bring that information forward so that when other caregivers say to you, so what tests are you planning on doing and when? Or what was the result of that angiogram? What did that CT show? |
Partly you've answered this question if the patient was within the meeting, but if it's more the traditional model where the patients aren't there, whose responsibility is to liaise with the patient following the meeting? Yeah, I think I can answer this two ways. It's everybody's responsibility, but I know that in saying it's everybody's responsibility, we're all concerned everybody's responsibility is nobody's responsibility. So what do I mean by everybody's responsibility? Well, all of us as professionals have a responsibility to be talking openly with our patients and their families around the things we're doing with them and to them to improve their care. Having said that, there's no doubt it is the role of the medical team to ensure that that's happening and that all their concerns are being addressed to the satisfaction of everybody concerned. So the way we get around everybody is nobody is to ensure quite clearly, and I state it clearly, it is the medical team's ultimate responsibility to keep patients and their families informed of what's been decided and what's going on. So we've kind of described a meeting and we're going to move to a different case where you're working within the colorectal unit, but this time you're actually in a weekly ward round, multi-sensory ward round. I guess how does a ward round differ from a meeting and I guess what is the typical role or goal of that? Yeah so in a meeting as I've alluded to it's often done in a staff room and it's often done by a representative of the various services. The value of a ward round is you have the opportunity to get the direct caregivers involved in that patient's care and I can't emphasise enough the role of the bedside nurse. So a multi-disciplinary ward round gives you the opportunity to speak directly with the nurse caring for that patient, to ask them, the person who probably knows best what's happening, what's happening in the care of the patient. It also brings that conversation forward to the bedside and truly does give the patient the opportunity to see and hear and hopefully contribute to the conversation around what's happening in their care. And can you describe a structure of a typical ward round? Yeah, so it can be a bit daunting, I have to say, both for junior medical officers and for patients and their carers, because you can imagine it often involves a lot of people. If you add up the contribution of the nurse, the multiple medical team members, an allied health member or more, usually a social worker, and then usually the numb because they want to see what's going on overall in the ward as well, you can envisage, you can picture it's quite a large number of people. And that has its own issues in terms of privacy and being able to hear clearly what's happening. And it also runs the risk of intimidating people who are junior and not so familiar with the structure. And so my advice here is, as it always is in a team, you need to be familiar with the team and you need to make sure you know who the team members are. You need to introduce yourself to them and you need to ensure everybody feels comfortable in their role in the interest of facilitating best communication flow. So what's typically the role of a junior doctor and how should that junior doctor prepare for the ward round? Yeah, again, the role of the junior doctor is multi, several roles. So one is they're going to be the person who documents the conversation. And that's a really, really key element. It's a topic of another conversation, but it's an art to good communication to be able to document clearly, succinctly the key elements of what's been discussed and the decisions that are made. So that's a role. The other role is to bring information. I look at this, I would encourage junior doctors to see this as the tribes coming out of their tents and meeting and each of them bringing information. So it's information sharing. I've got medical information, you've got nursing information, they are different by nature of the different jobs we do and the role of a junior doctor is again to have that information at hand that others are going to want from you, patients, their families, other caregivers, so that they are clear about what their role is and they're better informed about where the overall care is heading. And in regard to the preparation and how they can get the most out of that ward round or contribute best to the ward round? Yeah. So they'll get the most out of it if they understand its structure and they understand, one, the information that will be asked of them and, two, they take the opportunity before the round to think about what do I need to know from a physio point of view, from a social work point of view, from an OT point of view, from a pharmacist point of view if you're lucky enough to have a pharmacist join this multidisciplinary meeting and many units do but not all. So what I'm saying is there will be questions that you will have as you're doing your medical ward rounds. I wonder what the physios are thinking. You know, how likely is it going to be that the IT assessment's being done at home and what are they going to tell us about when we can get this person home? I wonder, you know, if there are other issues we haven't thought about. We made that consult with the social workers. I wonder if they've explored how we can transition this person home. have those questions ready to go because this is your golden opportunity to save yourself a lot of time and to get a really rich communication going by being able to turn to them and say, so from a medical point of view, we're anticipating this, but I'm really keen to hear from you because you might remember we left that consult with you and we were concerned about this. Could you tell us now what you've determined and from your perspective, are we on the right track? Is the trajectory going the right way? Are we likely to be able to get this person home on an expected date the way we planned it from the start? You mentioned time, I guess one of the criticisms maybe with these ward rounds, won't they just take too long? Yeah, you know, we've done some studies on this and I'd encourage your listeners to go to the Clinical Excellence Commission website and look at our In Safe Hands program in which the cyber rounds are discussed, which is structured interdisciplinary bedside rounds. And I've been kind of describing them in the way they're structured. People come armed with knowing what they need to provide for the multidisciplinary round because it's been agreed by the team long before they start the rounds. It's interdisciplinary, not just multidisciplinary. It's bedside because it deliberately involves patients and their families and it's a round structure. What we've shown is if you do these well to a template that you as a team decide you want answered in that meeting, you want to know. So you plan your meeting and you say to the physios, what do you want to know when we meet? And you say to the AT, what do you want to know? And they say to you as a doctor, what do you want to know and what do we want to get from you? So it's all determined. And when it's done, you actually save a lot of time. Because imagine, you know your cyber round is occurring at a certain time each day and you advertise it. You put your hand on your heart and you say to patients and their families, please come, we invite you to be there. What have you done? You've eliminated all those disruptive pages, other families just arrived, could you come back to the ward and explain what's going on. You've told them when you're rounding, they will be there, I guarantee it. You've eliminated those disruptive calls for predictable events. Nurses tend not to call you when they know there's a round that's happening at a certain time. They bank their issues up and they discuss them on the round. You don't get asked, can you come and do that medication chart that's expiring? Can you renew that fluid order? Because they know, oh, we're meeting at 10. I'll bring it up at that time and I'll sort it out then. So we've studied this. It's not just in concept, but we've shown when a team functions really well with a cyber round, the satisfaction for every element of the team goes through the roof. It's such a rewarding experience and they save time. The time you commit to that round saves you in bucket loads because you're not going to be disrupted for things that are predictable. Of course you'll always get a page for something that deteriorates or changes but that's a whole different conversation. We can also show in fact that those deteriorations are less frequent when you meet in this rounding structure because you nip things early in the bud. It's a win-win. And do you think what have been the barriers for maybe being more widely adopted? |
Welcome to On The Wards, it's James Edwards and we are going to continue with Professor Andrew Dawson talking about the management of the toxicology patient. Resuscitation we won't really mention now but maybe we'll talk about decontamination. What's the kind of rationale behind decontamination and I guess activated charcoal is the most commonly used and who should get activated charcoal? So the rationale of decontamination is that if you can get the tablet out or stop it being absorbed you're going to minimise toxicity. So the first thing you want to ask is, is the patient likely to have toxicity that I'm going to be worried about? So, for example, if someone has just taken some benzodiazepines and it's got no real cardiac toxicity, for most patients it does have much respiratory depression, there's not much there to treat. So what you're really interested in is saying, is this a medication that can get the patient into serious trouble where maximal supportive care might be pretty aggressive and sometimes fall short? And so these are generally drugs with major cardiotoxicity or sometimes major cellular toxicity. Now, the way charcoal works is it's called activated charcoal, James, because they burn some coconut husk and then they cook it up under a high-pressure steam environment and it punches lots of little holes through the charcoal. And these holes are tiny, 100 to 800 angstroms. They're really tiny holes, but in the mid-range of that space, it's about the size of many drug molecules. And if those drugs are carbon-based, which most drugs are, when they squeeze in next to all that carbon, you get sort of weak van der Waals forces that cause that drug to effectively stick to the charcoal. And so it can dramatically reduce the absorption. And in order to do that, it's got to be put close to the tablets. And so there's a time factor. So clearly, if the tablets are all still in the stomach, you pour all the charcoal in, that's probably your highest rate of picking it all up. And so the effectiveness of charcoal drops off for appropriate drugs as the time stretches out. So for many drugs in low doses, when people rapidly absorb them, there's a drop-off after an hour. For those situations where people have taken highly toxic drugs that bind to charcoal and taken big doses, the efficacy of charcoal is probably much longer. So you'll want to think, in particular if you're thinking, this patient's going to need to be intubated, it's quite likely that they may still have a considerable amount of tablets in the stomach. So for example, they may take a sedating neuroleptic with a bit of anticholinergic effect. They might absorb 20 or 30% of it. That's enough to make them unconscious, but it slows down the gastric emptying, and these people will often have a lot of tablets there. And so a single dose of charcoal in those patients is very useful. There are other circumstances that we mentioned before, controlled release medications, where we would give charcoal because those tablets won't often stick in a big glump in the stomach, but they continue to release. And the other situation is we have a number of drugs, things like phenytoin, carbamazepine, theophylline, where repeat doses of charcoal will enhance the clearance of the drug, either by sucking it back across the gastric mucosal wall back into the lumen or interrupting biliary excretion. So some drugs have biliary excretion. So there are some circumstances where we would give repeat doses of activated charcoal to try and also enhance the clearance. But there is a range of drugs charcoal is not much good for and they're mostly drugs that sound like they're on the periodic table. So think iron tablets, lithium tablets. These are all, although we often bind them up with some other compound, the toxicity is about the iron, it's about the lithium and they bind very, very poorly to charcoal and that's generally not, it's just not recommended. We would normally proceed with some other intervention and that intervention is often something we call whole bowel irrigation, which is not going to win your friends amongst the nursing staff, but this is a bowel prep polyethylene glycol, euphemistically called Go Lightly or Colon Lightly or whatever. it doesn't really get absorbed. So it's got all the sophistication of flushing the toilet. You pour about a litre or litre and a half every hour down the top end until it comes rushing out the back end. It's very, very effective, but that would be something you'd normally be seeking advice on or the nurses will not speak to you again. In regard to charcoal, often they're a drowsy patient with thinking about charcoal. Is there any issue with that kind of drowsy patient? It's a delicate balancing act. The bottom line is any form of decontamination, you've got to have reasonable confidence that the patient can protect their airway. And so at the extremes, life is pretty kind of good. That is, if they come in and you're clearly going to intubate them, then it's not a problem. And in fact, you'd almost think most of those patients are probably going to be candidates. The real problem can come when the patient comes in very acutely, let's say within 10 minutes, and we will see this, with a drug where you think they're highly likely to lose consciousness. And in those circumstances, there is an argument for giving activated charcoal, but the judgment, and this is probably where you need to get some senior advice is do I think even though the charcoal might be effective that they're still going to lose consciousness in half an hour in which case many experienced people would just get on and say no let's intubate first however there are patients and this is the advantage I think of looking at why you should examine people up front and be able to, because if you think, OK, here I am 45 minutes later or something, I've gathered myself and everyone around me and they're not progressing, they're cooperative, they might be a GCS of 14 or something, but it's not progressing very much. It turns out that it's a drug that might cause a big confusional state, but then you may make a judgment to say, look, on the basis that they're not progressing and cooperating, we can move forward. But this is often the difficulty. The single examination is a point in time and you're hoping to think, okay, they've done this within half an hour of the over-ingestion. But repeated examinations, especially when you're not certain what's going on, you know, that you're doing, that you come back will be the most reassuring thing. But yeah, you do need to be confident that protect the airway. And in the old days, as you know, people used to induce vomiting and all sorts of things. Well, that was a bit of a copout. It's the same thing. Regardless of what you want to do, it's the same thing. You think, I shouldn't be doing any decontamination unless I've got reasonable confidence about the airway. And by and large, I think you've got to think about decontamination in the sense of, do I think this is important enough that I would do it, and if it needed to be, I'd protect the airway. And for most things, the answer should be yes. There's a couple of things where we've got alternate treatments, such as paracetamol. It's difficult to describe management without knowing what the initial drug was, but maybe you can tell us some of the general principles of management in a toxicology patient and when we consider an antidote. Thank you. down to normal but not to put them into withdrawal and then we just need to consider what opioid they've taken and what the likely duration of effect is to what we will do so for example if someone has just used heroin the vast majority of those patients once we reverse them once don't require further treatment if however they've taken large doses of methadone with long action or controlled release morphine then many of those patients require repeated treatment and sometimes when you ring up for advice, someone will say, okay, now you've reversed them, you probably should just give them a low-level infusion of naloxone. Other than that, we would be looking at just doing standard supportive care. The other, the supportive care, as I mentioned, controlling pH is very, very important. The other antidotes that we would see probably most commonly in the emergency department being started is making an assessment in a paracetamol overdose about whether they're going to need N-acetylcysteine, which supplies the substrate that the toxic metabolite requires to go down and be metabolised to non-toxic things. And that decision, firstly, it's a decision that we make, it's very, very conservative. Our treatment guidelines are very, very conservative. We over-treat lots and lots of patients. |
And because our issue with giving N-acetylcysteine is the longer we delay that treatment, and particularly if we delay it after eight hours, the more, the greater likely the patient will get organ damage, specifically liver damage or renal damage. So they're the two most common antidotes. Then there's a range of other antidotes, but most of you should be probably calling a friend to get some advice about how you would use them or whatever, because they're very rarely used. You mentioned calling a friend. So who should the JMO call and what are some of the different avenues they can get access to a toxicologist? Look, obviously it depends on what your environment is. And I get calls from all around the country from people doing a locum in a tiny hospital where they're in, which is possibly why they're calling me. Whereas at the other end you might be in a tertiary teaching hospital on the floor with some very senior staff in the emergency department who are going to be familiar with a large number of these poisons and also have the skill set to address the acute resuscitation. But wherever you are in the country, at any time you can ring the poison centre. And if you ring the poison centre, you call it initially it's going to be answered by what we call a spy, a specialist poisons information officer. And these people are predominantly pharmacists or scientists, but they have very extensive training in risk assessment and poising and they take thousands and thousands of calls, so they have a lot of expertise. They also have predefined thresholds for referring on to a clinical toxicologist, so any clinician can ask to be referred to a clinical toxicologist. That perhaps shouldn't necessarily be your default position. You should actually listen to what someone's saying. But they have predefined thresholds, so you might be thinking everything's comfortable. They might say, I'm going to give you this information, but you are going to be put through to a toxicologist regardless of what you think. But you can ask to speak to a toxicologist. Sometimes people will speak to a toxicologist because of clinical uncertainty about saying this is unusual, is there something else going on? There are other good resources online. On the CF sites, there's a toxicology and wilderness handbook. There is Micromedics, there's Toxins, there are a range of defined internet resources. And they're generally extremely good, in particular when the patient's taken a single agent, because then it's a little bit more of a recipe book, and then you just need to be aware when you're looking at it to say, is my patient just fitting into this general scheme of things, or have they done something really outstanding? So there's a big difference between someone, say, taking 14 grams of paracetamol, which is what we might commonly see, to the odd patient who arrives with 100 grams. So you want to think, OK, here's the recipe, but, boy, I'm really way out of the end of the spectrum. And that spectrum, they're the ones, like in everything in medicine, where something aberrant can go wrong. When you get someone such as a polypharmacy overdose, which is not a diet, you want to tease out all of the drugs. And there are circumstances there where people can take drugs which interact with each other, that might interact with your potential treatment for another drug. The true horror story is when someone's taken an entire Webster pack. Those Webster packs normally contain a range of drugs which are bad news. And at that sort of setting, that's probably where you want to seek early consultation. Do your essential primary assessment because that's the information someone will want. But it's at that sort of point where you look and say, okay, I think I understand three or four of these drugs. There's a couple I don't understand and I'm not sure about the interplay. And so we, as I said, I think you look at your local resources. But as soon as it gets complicated or as soon as you're getting major complications, you should ring early. The other thing that you should definitely get early advice is when someone has an overdose and they have a cardiac arrest because in that situation there are things that are done at high level emergency care or toxicology which are not quite in the normal ACLS guidelines that are not necessarily familiar to even experienced people and yet the outcomes from a cardiac arrest from a drug overdose is much more analogous to the outcomes from drowning or electrocution and so you're often in young people with better prognosis and we're often just needing to figure out some way to support the patient to get them over a bit of a hump for one or two hours to wait for their drug levels to drop, mostly due to redistribution. In regard to disposition, where do these most patients end up? On a tox unit, a psych unit, monitored bed, ICU? Okay, it depends on your hospital and it also depends on patient needs. Clearly, a patient who requires cardiac monitoring or respiratory support needs to go to a HDU or an ICU or be transferred to a hospital that has one. There will be a subgroup of patients who in addition you might signal or figure out early on may be likely to require additional stuff, in particular if you think they're going to need to require things like dialysis, whether that's available in your hospital or not. Then we have a group of patients who are clinically stable, relatively lower risk toxicity, or often their clear risk of toxicity is passed after four or five hours, and then their issue is that they need to come into hospital to have their underlying psychosocial stresses sort of addressed. So if you're in a hospital where you've got clinical toxicology, they might go there. In some hospitals, they may stay in an EMU. In many other hospitals, they may go to a general physician if you have them or the physician of the day. In some hospitals, people seem to argue over whether this is liver or whatever. But primarily, they're probably going in to be sat upon and to have their hand held so that psychiatry can come in and make a proper assessment. And the psychiatry assessment in these people is difficult. Mostly people have a complex social situation kind of going on. It's probably unreal... If it's bedlam at home, it's probably unrealistic to think that a quick patch-up and a pat on the head in ED and sending them back to that shambles is likely to come with a good outcome. In fact, we know that in Australia, when people self-poison, about 30% of patients will represent within a year with another self-poison, but 80% of them do it within the first month. So allowing a little bit of time for everything to settle down and for the psychiatrist to be able to get proper collateral history and to assemble a bit of a plan is probably still a lot more efficient than sometimes sending people home. Nevertheless, sometimes we will have people, it's kind of clear that this was very impulsive, that they don't have great suicidality, that they may leave hospital and they're probably not scheduled. We may not think it's a great idea, but there's a large number of the population making decisions that aren't great ideas already out there. But the ideal thing is to try and make that assessment and to try and acknowledge to the patient, look, clearly things haven't been travelling well for you because this is not the way to meet people. You've been under stress and what we want to do is, I would normally tell you, look, we just need to check out and make certain that you're going to be physically okay and there's no consequence of that. So we're concerned about that. But we are concerned about how you've kind of got here and that you're all stressed and we think there might be some things we can do to help you with that. So, you know, the patients often already feel a little bit beaten up or under siege. You need to try and say, look, we're not planning to keep you in here for a long time. We are planning to help. And we're offering a little bit of refuge. And just, as you know, Dan, for the vast majority of patients, these are one-offs. We do have individual patients who are much more chaotic. We see much more frequently. Many of those patients have or should have really specific management plans that really addresses their needs, much more like a chronic illness rather than this is just this episode. You've got to see it in a bigger context. And if that's the case, you want to make certain that you tap into that and kind of make sure you're doing stuff that's consistent with the bigger plan. Well, thank you, Andrew. It's a fantastic summary of toxicology in a short period of time. Any other take-home messages for the junior doctors before we finish up? Well, to quote one of my colleagues, the best thing you can do is don't guess. |
Welcome to On The Wall, it's James Edwards and I have the pleasure today of introducing Dr. Ryan Downey, who's a licensed here at Royal Prince Albert Hospital, so at Lifehouse. Welcome, Ryan. Thank you. Hello. Now, Ryan used to be one of my interns, but now he's now a consultant. And what we're going to talk about is something that every junior doctor does often during an evening shift, a night shift, and also during the day, and that is inserting cannulas. We'll start with a case, and really it's not a case. It's a nurse ringing you on the ward and asking you about a cannula that needs to be replaced. You're actually not on the ward, Ryan. What questions would you ask the nurse over the phone? So, I mean, I think it's pretty important to ask why they want the cannula changed, what's wrong with it, is it tissueed? So get a reasonable idea about what they want you to do the cannula for. The urgency of the cannula replacement. Do they have something like an antibiotic dose that's pending or do they need a blood transfusion or what's the reason? And then also, yeah, what the cannula's for. So, as I said. Yeah, I mean, sometimes they don't maybe need another cannula. That's true. Or they can wait and change to orals tomorrow anyway. But you agree that cannula does need replacement. Any suggestion on how you prepare equipment for cannulation? Yeah, so I always draw absolutely everything up before I go. And that gives me a chance to put the tourniquet on and leave it on for five or ten minutes while I'm getting everything ready. So I draw some saline up in a syringe, I attach the bung, I get it all lined up on a sterile tray. Then I start looking for a cannula or a cannula site. I start prepping the skin and then I go for it. Yeah. One thing that often comes up is about what size cannula you'd select. So how do you make that decision? So it depends on the indication. If you actually look on the back of the cannulas, they've got little flow rates. So a 22 gauge has a flow rate, I think, of about 60 mils an hour, whereas a 14 gauge has a flow rate of something like 300 mils an hour. So if it's just going to be for IV hydration or antibiotics, probably a blue cannula is going to be adequate and you need to think about how long it's going to stay in. If they're seriously hemorrhaging, you might want to start thinking about a 16- or a 14-gauge cannula, but that's normally a problem in the emergency department. We need to think about it. And the blue gauge, that's 22? 22. Pink is 20, 18 is green, 16 is black, and 14 is orange. Okay. Now, in regard to incendiary cannulas, do you routinely put local anaesthetic in? I do, but that's because I'm nice. It certainly makes cannulation more difficult because it'll make the vein actually vasoconstrict. So if you've got a nice big vein and you're going to put a reasonable size cannula into it, so probably a 20 or an 18, I always put local anaesthetic for elective sort of cases. For an emergency, I wouldn't. And to do it, I try and use the smallest syringe that I can and smallest needle that I can. The technique is to probably use a 27 gauge needle, which is on the end of the insulin needles, draw up the local anaesthetic. You don't have to inject it on top of the vein. You can put it next to it, inject a reasonable volume, and then just rub it down with your finger so it spreads, and then start getting your vein ready for cannulation again. And how long would you need to take before the anaesthetic will start working? The anaesthetic will work by the time you've picked up the cannula to try and insert it, so you don't need to worry about too much time. So we've decided the size of the cannula. How do you decide what the preferred location for insertion of the cannula is? So again, you try and think about what's going to be comfortable for the patient and the reason they're having it. In anaesthetics and lots of other sort of elective reasons, we put it in the hand because it's easiest to access. The other reason to start in the hand is as you start putting holes in the veins further up the arm, if you eventually get a vein in the hand, whatever you're giving is going to leak out of the hole you made upstream. Probably the most comfortable spot for a patient is in their non-dominant hand in the forearm. If you put it over a joint, they're going to kink it every five minutes and their infusion alarms are going to go off all night and they're not going to get any sleep. And if you put it in the hand and it's taped really poorly, they're not going to be able to use it to eat. So just think about the ergonomics of the patient. I see a lot of cannulas put in the cubital fossa for even fairly elective, just some intravenous fluids. Why do you think that is? Look, it's really easy. That's the main thing. And certainly in ED, it's probably because it's such a big vein, it's easy to draw blood out of. So you can do two things at once. But probably for the patient, it's going to be really inconvenient. The cubital fossa veins aren't really straight where they go in. If you put a 22 gauge in there, it's just going to kink for them all night. They're not going to get any sleep. I think it's really best avoided if you can find somewhere else. What other factors do you consider when sleeping in your vein? Like past history of having exudate dissection, maybe requiring dialysis in the future? Yeah, so if they've got, so things like, say a DVT, if they've got definite swelling of that arm, you really shouldn't put a cannula in. It's a definite contraindication because any infection or any extra fluid you're putting down there is probably not going to get to the target anyway. Lymphedema at risk, so patients that have had an axillary dissection, is a relative contraindication. Occasionally, when we can't find anywhere else, we'd consider putting it in, but that is an absolute last resort and you should probably speak to a surgical doctor before you do that. And then with Vasquez, if you think they're maybe going to someday have dialysis, they'll probably try and ask you to avoid forearm veins, particularly the cephalic, which is the one that runs over the radius, because that may be a fistula someday. So what other approaches are you going to regard to, I guess, ensuring you get the canyons in, like tethering the skin, making it easy for yourself? So, I mean, so start with ergonomics. So I try and be directly in front of the vein that I'm going to cannulate. I set up all my stuff on the bed. I have the patient usually, so if I'm going for the arm, I have the patient lying down at 45 degrees with their hand and arm hanging down. I inspect the arm really thoroughly, pick my vein and try and get a straight one without too many kinks and of a reasonable size. If you stick a 22 gauge cannula in a vein that only supports a 22 gauge cannula, chances are it's going to get blocked and stop working pretty quickly. But if you can put a cannula in a big vein, it's less likely to block and be a problem for you. So select something that's of reasonable size. Tether the vein by pulling in front of the vein, not across the vein on the sides, and that will straighten it out for you. And then go for your cannulation. I try to make myself comfortable and make sure I can reach all of the bits that I need. Sometimes with elderly patients, they've got very mobile skin and the veins are immobile. How do you kind of combat that? Yeah, I mean, it's difficult. You can't. You're going to have a difficult time with older patients anyway. One of the tricks is at some point that vein will be attached to the skin and you can find out by just rubbing your finger across the vein and seeing where it is actually tethered to the skin. |
Hi, it's James Edwards. I'm here for On The Boards. It's February 2015. We're going to do something different today. Everyone's sick of my voice and speaking to other consultants. What junior doctors really want to know is how to manage on the ward and really hear from some of their colleagues on some tips and tricks on surviving. So I've asked two of my junior doctors who were interns last year, Jenny Han and Nathan Trist, to come and speak to us. Welcome to both of you. Thanks, James. So I'm not going to be here. I'm moving out. They're going to have a bit of a discussion about some of the, I guess, survival tips that they learnt during their intern year. So, Jenny, I guess we'll start off with talking about surgical terms and surgical rounds. They're some of the more intimidating and busier parts of our job. So, I don't know, tell us how you found your surgical terms and how you coped with the speed of your ward rounds. Yeah, I generally felt that I was struggling to keep up with ward rounds, especially when consultants were present. They go speak to the patient and by the time you find the notes, they're already done speaking to the patient with the plan in place. So generally what I do is your list is of paramount importance, and you basically write the pertinent points, what the consultant just explained. On your own personal printout list? Yes. So there's usually a gap or you just flip the page and you write BT brain or MRI brain results discussed, patient blah, whatever plan has been in place, and patient has consented to a procedure for the following day, plan nil by mouth. But typically I like to grab a pile of progress notes before I go and just scroll, seen by consultant name and then whatever they've had discussed and then a plan sort of on one page per patient. What do you do, Nathan? Yeah, it depends on the term. So on my colorectal term, I found it really useful to get there 15 minutes before the round started. And most of your patients are on the one ward on 9 West 1. So I'd get all of our patient files and just pop them outside each room so they're ready to go. So you're not trying to carry around a whole stack of files and writing them. I found that really useful because you could just jump in and see the patient, write a quick note. And I found if nothing else, on a really quick consultant ward round, you just write the plan. As you said, seen by this consultant, plan, blah, blah, blah. You often don't have time to write, observe blood pressure of this and, you know, patient's settled in bed, none of that. Just really, really get to the point. Yeah. Generally, I use my medical students as well. I ask them to collect the ongoing files of the next few patients. Yeah, that's great. It's great to have medical students. That can be useful. But often, yeah, I really think you've got to be very concise and very quick. I found when I did an orthopaedics term, I really didn't have any time to go back to the patient notes and write in them because often as soon as ward round finished, I'd be called to theatre. I might be there until after lunch and then you're trying to do your jobs, your consults and your investigations. And it was really, really difficult to then go back. So I think your idea of writing in blank progress notes is really good and I've seen other people do that. The other thing I think is that's very important in the surgical ward round is to go back after the whole round's finished and whether you've got it written in front of you on your list or just some little shorthand, is to go back and discuss with the numb on the ward about the plan. And I find that it cements it in your mind what the plan is. The numb often adds, oh, what about this? We talked about this earlier in the week. And they can jog your memory. And that way everyone's on the same page pretty early in the morning and things can start happening. So straight after ward rounds, you tell the NUM and then how do you sort of figure out what to do first, Nathan? Yeah, that's a question of prioritisation, I guess, once you've generated a list of jobs from the ward round. I think the first thing you've got to do is anything that's time precious. So if you have to order a CT that has to happen that day, any sort of test, you have to chase some bloods. If someone's going for a procedure and they urgently need some outpatient cardiology letters, I think those things have got to come first. And then hopefully you don't have too many of them and then you can get on to your day jobs, I guess, your other jobs. Next up I think will come people imminently leaving. People might have heard of the whole hospital program where it's everyone's responsibility to make sure the patient flow is optimised through the hospital. So it's our responsibility to make sure our end of the discharge, the meds are ready and the patient can leave the hospitals as early in the morning as they can to allow someone else to come up from ED. So that would be my next job. Hopefully if you were able the day before and you knew someone was leaving, you've already done their discharge, ordered their meds and all you have to do is sign it off, which really doesn't take very long. So that's what I'd do. And then thirdly, I think any consult you have to do, to be fair on the med reg that has to do the consult, you have to order it as early as possible. And I think lunchtime really is the cutoff. If you're given a consultant in a morning ward round, and they'll know that when they come and see the patient because you've most likely written, you know, cardio consult in your plan in the morning. And so they'll know when you knew about the consult. And if you call them at 3 p.m., they're not going to be very happy. So I generally take lunch, you know, 12.30 as my absolute cutoff to get a consult in. Got anything to add to that? Well, if everything's been done by, say, 1pm, what do you do after that between 1 to 5? If everything's been done, it's a rare event. But I guess you've got to work out who discharges. So for the next day is probably the priority. At the very least, getting your meds into pharmacy because that can be a big, big holdup. So I start writing my discharges. And if I can get all my discharges ready that are going to be leaving in the next couple of days when I've got an opportunity, then it makes it a lot easier. Is there like a speed-up process that you do with discharge summaries? Because they can take a while. How do you sort of make it fast? Within PowerChart, I use a few shortcuts like auto text and I think that'll just come with practice using PowerChart. Like I've got a couple little, I think it's like I put DD in and it comes up with a big, dear doctor, thank you for continued care of the XX patient. And the first part of my discharge summary comes up. Do you read page by page progress notes? Try to. I definitely try to. And on a medical term, like a geriatric term or something, I think it's really important to go back and if they've been there for a long time, because you often forget issues, on a surgical term, if they've come in at a relatively simple procedure and a short stay, then yeah, not always. But definitely that is my goal, is to read through every page. What about you? So I like to make my discharge summary process a little as fast as possible because we've had patients who stayed there for months. And basically I go during the ward round when the registrars are discussing amongst themselves what they should do, I'd like to write an issues list. Yeah, for sure. Yeah, so whatever the patient came in with and then going through what the complications were so far and then our management plans. Yeah, that's really helpful. If at one point in the admission you've had the time to go back and do a full issues list, and I sometimes find on medical terms the consultant will sit there on their ward round to help them sort of think through the patient. They'll say, oh, this is this issue, you know, and you just write them down. Also very important for activity-based funding, I guess, because that's what they look at after the discharge. |
You write how many days worth of IV and then how many days worth of PO they've acquired. Don't fool yourself into thinking that you're going to remember when you started them, because you won't. But yeah, so just at the bottom, like right, day one or, and that's, so when people reach out the meds and if you're, if you're recharging the meds, make sure you continue the days because yeah, I've definitely seen incidences of people being on, you know, three and a half weeks of Augment and Duo Fort and everyone's like, what are they talking? And then you click back in the notes and no one's ceased it. So, yeah, it's a great tip. In terms of after hours, after you've finished all your ward jobs, maybe at like 6 p.m., how do you prioritise what you're going to do afterwards on after-hour shifts? Oh, so if you're on an evening shift? Yeah. I think the most important thing to do when you start an evening shift is to go and talk to the team JMOs at five and always I'll still be there on their wards and if not, you can page them and just find out if there's any sick patients on the ward, any issues they foresee during the night, during your evening shift and that sort of set the tone for your shift in a certain way. So do you generally track down the residents or interns? Yeah, I try to. You? Generally, if they're around, I go, any issues? Yeah. Generally, they say no issues. But if they do have issues, they will generally either call you directly via mobile or they will pay you. Yeah, that's true. Yeah. Yeah, because often, yeah, on your shared wards, like, you know, I've just done seven. So seven is two. It's like surgical oncology. It's urology. There's breast. There's ONG. There's so many different teams. You can't contact all the residents. So, yeah, you're right. You might just wait for the page. But I do the walk around and find who I can and then check the jobs boards and just see what's outstanding on those. How about, like, say you forget to hand over something, what then do you do when you're already home? I think you've got to gauge how important it is and if you think it's important enough, you've got to call back, don't you think? How do you contact them? I just ring switch and just say, so if you're on an evening shift and you need to contact the night person, you will get used to remembering who it is or you might know them later in the year. But early in the year, it's sort of a bit of a blur. Just call switch and just ask to be put through the night in turn and they'll put you through and hand it over. So let's talk a bit more about after hours. Generally that's when shit hits the fan, if you will. Literally. Yeah, on Jerry's ward, literally. How do you deal with when you've got two SIRs, an ICU assist, you know, nurses are asking you this, this and this on the ward? How do you sort of settle everything down and work out what you've got to do next? Yeah, I've had a lot of that happen to me after hours, especially like on Jerry's ward because nursing staff are asking you, can you come review this patient? There's an arrest pager going off and you've got another SERS on your regular pager. And that's when I run to the arrest call. You should never walk to an arrest. You should always run to an arrest. And you go, I'm really sorry. I have to go see a patient who's arresting. But once you arrive and you're happy that there's enough team members helping out with the arrest, you can ask either the ICU staff or the med reg just on the sidelines whether it's okay and if the situation's under control, you can go see the clinical emergency response school. Yeah, I'll just add to that. At the moment, the arrest calls don't actually go to the intern after hours. We get the service calls but not the arrest calls. Hopefully that'll change because I think it's very important if there's an arrest on the wall that you're covering that you go because often you're very useful taking bloods, taking your gas, putting in the line, running tests, ordering tests. So I think it's very important that you attend those. Anyway, keep going. So I then go to if there are multiple SIRS on and there's no ICU assist or ICU arrest calls, the med reg will generally delegate who goes where because obviously you want to minimise the kind of lag between SIRS because otherwise it'll be escalated to ICU assist. Yeah, so you get half an hour with the SIRS to see the patient. Otherwise, it gets escalated to an ICU assist where ICU have to attend within 10 minutes. So otherwise, the MedRidge can start delegating treatments over the phone to the nursing staff. So, for example, I think this patient's got an asthmatic attack. They're usually on salbutamol. Then the MedRidge will let her go. I'm happy to give a stat dose. Do you give phone orders for that sort of thing? No, because the SERS always has to be supervised by MedRidge. So the MedRidge always sort of has to approve, especially as an intern. What about surgical SERS? Surgical SERS, generally the surgical registrar will call you up directly. Really? I've had to hand over, yeah, via ISBA. I've found more, not more often than not, but pretty often if the surgical reg is operating after hours, then they haven't got their pager on them to get a surgical SIRS. So often you're the only one there and you talk to them afterwards or escalate as appropriate. If it's a SERS, you should technically need supervision. So if the surgical registrar is not answering the page, I generally got turned to the medical registrar and just say, I'm really sorry to have to do this, but I need your advice regarding a patient who may be deteriorating. They're more than happy to help out. But typically if the surge ridge cannot see the patient, it's the surge ridge's responsibility to hand over to the med ridge to ask them to see the patient. Yeah, I generally go if there's that situation. And even with medical patients, often you're the first one to a surge. I think it's really important just to go there and eyeball the patient, get the OBS and see what the SIRS is for and decide whether, you know, does this need immediate escalation or can I just talk to the med reg on the phone and do it from there. And I usually, I'm pretty happy instigating treatment there, whether it's, you know, a bag of fluids for hypotension if it's appropriate or a simple antihypertensive for someone who's got a systolic of 200 and something. Generally, I'll do that and then hand over to the med reg rather than wait for them to come if they're caught up, if it's something you're confident with. yeah, definitely. On week one, if you're not confident doing that stuff, then I wouldn't do it. But by the end of the year, I think you'll be instigating that really simple treatment and then running it by the med reg and they'll say, oh, have you thought about this and add this in. And they have to see the patient, you're right. The registrar has to see a SERS. So let's say you're on your day job and you're in surgery doing your surgical term and you have a patient you're worried about but they're not technically breaching a SIRS criteria. Your registrar's in theatres not answering their pager. What do you do? So I've had this situation a couple of times. On my ortho term, I had a patient who was not for ICU, who just had a hip replacement, and they're back on the ward and they had new ST elevation on their ECG and some chest pain. And they were 90-something, you know, NFR and not for ICU assists. And I tried to call my team and they were all in theatre or in clinic. No one could come and see the patient. And I didn't really feel comfortable managing this, you know, without some input from a registrar. So, yeah, you're faced with what do you do? So my first port of call was to call another registrar. |
So my first port of call was to call some registrars from other teams, and although it wasn't their patient, to see if they could come. Unfortunately, they couldn't come either. Yeah. But that would be my first port of call. Second, it happened that we had a pre-op cardio consult on this patient, so I thought, you know, I'll call the cardio reg who saw the patient. Got on to him. He was rounding with his boss and said, there's no such thing as an urgent consult. Can't come straight away. I said, okay, all right, fine, which, you know, I think that's reg dependent. I think a lot of regs would come. And so, yeah, in the end I was a bit stuck because I was in hours. I couldn't call the after hours med-reg. There weren't a lot of people I could call. And I ended up, what I ended up doing is getting one of the other registrars from the other team, other orthopaedics team, to then to call that cardio reg and have a reg-to- reg conversation and say, we're all busy. Would you like sort of ask a favour? And then the cardio reg came and it actually came with his boss and they, they saw the patient and sorted it out. But I think, yeah, it's, it's a, it's a tough situation to be in when you, when you can't find help. Have you had anything similar? I've had it just after hours actually though. But the surge ridge was caught up in theatres. So then luckily the surgical consultant was actually rounding on the patient at the time. There you go. And his advice was call ICU. Yeah. I mean he's not going to entrust the care of his precious patient to an intern who is unsure of themselves, unsure of how to manage a potentially serious life-threatening complication. So your safest bet and the bet that no one will ever refuse help is ICU. Yeah. Yeah, definitely. There is actually a SERS criteria for worried. Oh, yeah, for sure. And I think, and that's for nursing staff, and I think if you're worried, then you're always justified to call an ICU assist as long as your patient is for ICU. And if you don't think they imminently need an ICU registrar there, you can always page the on-call ICU registrar and speak to them over the phone and they can give you some advice over the phone. If you are imminently worried and you happen to have the contact details to your consultant, I like to generally ask the consultant if they're approachable. You mean if it's one of your day team patients? Yeah. Yeah. I think in a big hospital like RPA, and I think it sort of gets drummed into pretty early, that the consultants are very happy to hear from you if you can't find anyone else and you've neglected to call the consultant and something bad happened. And I think that the consultant will say, why didn't you call me? So I think, you know, even if you think they don't want to hear from you, yeah, ultimately it's their patient and you just have to call them. But I don't think I've had to do that yet. I think there's always someone in between that's been able to come and see the patient for me. Yeah, definitely. But if it came to that, I would definitely do it. Yeah. So are there any particular strategies you use when you're going to call someone senior? Is there a particular way you speak on the phone or something you say to really get your point across? Well, I start off the phone call, say, to an ICU registrar, and I go, I'm very sorry to bother you. I have a patient who is not really breaching a criteria, but I am certainly worried about this patient, and I would really appreciate your input. And they'll understand. Yeah, I think they're the words, like, I am worried about this patient, sort of twig something on the other end of the phone. And if you say that in your opening sentence, then I think, you know, you've got their attention and they know, you know, if my intern's worried about them, I've got to see them. You know, there's no two ways about it. There's always something about an intern in distress that is quite imminent. Oh, gosh, something's off. Yeah, I think most registrars will come and see the patient themselves. Otherwise, they'll ask you a thousand questions about the patient and give you some really good specific advice over the phone and you can go from there. Yeah. How do you kind of balance between appropriately asking for help and showing your registrar or your consultant that you can act independently? Okay. That's a good question because I guess, you know guess we all want to impress our superiors and our consultants. So, yeah, we want to, and you've graduated from medical school, we want to prove that you're able to now work as a doctor. But I think the first consideration is patient safety, right? I think the worst thing you can do is go out there and try and act independently and make decisions above your pay grade because that's what will probably look the worst for you if something goes wrong. And I think it's inevitable if you're making too many high-level decisions that it probably will do. So I think you look for other opportunities to show your independence and your ability to look after a patient rather than making specific medical decisions. So I think coordinating patient discharges. So, you know, on a surgical term, no. As an aside, every medical patient that comes into the hospital has a medical registrar see them and do a full admission. That doesn't happen with surgical patients. Often they just come up from theatre and they'll be on the ward and you'll see them after hours and there'll be no documented thing. So I think if you're the team intern, it's your responsibility to a certain extent to document their social history or especially your older patients, start thinking about where they're going to go. And I think that will really impress your consultant. If on the ward round they come and see them the next day and you say, you know, this person's from home, I don't think they're going to be recovered in a week, so I think they're going to have to go somewhere else. I've looked into it. They've got private health. Perhaps private rehab's an option. Otherwise we can think about sending this patient to Balmain. I think that's the sort of thing that will impress you, impress your consultant. Also pre-empting, pre-empting things they're going to ask. If you get an old patient, old surgical patient that comes in that has a history as long as your arm, I think starting to chase a few outpatient tests, like if they're known to a cardiologist and they've come in pre-op, you know you're going to have to chase that stuff. So before the consultant asks you, you know, get a cardio consult or find this out, you've got their letters there and say, you know, they had an echo in January and it showed their LB function was this. And the same goes when you speak to a cardio reg on the phone. If you've done all of those things, then it'll make you look better. Definitely. Anything else? I think as long as you sort of make a recommendation such as I've got a patient, if you're worried about a patient, you shouldn't just give the problem and then expect them to sort it out. You go, my impression is blah. Would you be happy with this recommendation such as giving IV fluids and then rechecking their observations in half an hour, et cetera? So I think by making some sort of recommendation, they know you have the initiative and have sort of thought about the issues that could be going on and will therefore appreciate it more. And they will sort of guide you if it's not correct towards a certain way of thinking. They won't berate you for it. They will certainly go, what is the hemoglobin? Yeah. They will be like, oh, I didn't think of that, but I'll just check for you. The hemoglobin is 80. And then they'll go, okay, so we need to think about giving blood transfusions, et cetera. Yeah. Yeah, no, I agree. I think it's good to put yourself out on a limb and say, my impression is this. My impression is the patient's in APO and they need fruzomide and an urgent chest X-ray rather than just saying, oh, can you come and see this patient who's desatting a little bit? I agree. |
Welcome to On The Wards. It's Jake Edwards and today we're doing a bit of a different topic and I've got Dr. Claire Hooker who works at the University of Sydney Health Ethics. She's going to talk about a play. We are. A verbatim theatre play. The play is called Grace Under Pressure. Maybe tell everyone a bit about it and why did you try to develop a play? So Grace Under Pressure, first of all, is performing next week, October 25 to 28, at the Seymour Centre in Sydney, quite close to the University of Sydney campus. But more interesting is the question, why did we make a play? And the answer is that we were strongly motivated by our direct experience of watching junior doctors especially deal with mistreatment in the workplace. And I am struck as someone who works in the medical humanities where doctors are, especially doctors in training and nurses, are routinely exhorted, told they must show empathy to patients. And empathy is transformative. It affects quite literal physiological benefits. We see all sorts of health outcomes for patients from it. But doctors are treated with the reverse themselves. So I have never understood why we would expect doctors to show empathy for patients when no one is modelling it in their treatment of them themselves and where they are so routinely exposed to exactly the opposite in their workplaces. So what will people see if they go to see Grace Under Pressure? Describe what the play is about. Grace Under Pressure, one of the wonderful things about art is it doesn't make anything simple. So this is not just a play about teaching by humiliation and about bullying and harassment, although it also talks about those things because people experience them. Grace Under Pressure is an exploration of what health workplace cultures are like. Sometimes they're exhilarating. I'm sure that you've experienced this yourself. Sometimes you remember how much and why you're compelled by or really love the work that you do. Sometimes it is so privileging and enchanting to be involved in people's care at some of the most extraordinary periods of their lives. And then it's about all of the other things, the ways in which systems place pressures that are literally impossible to manage sometimes, how workplace hierarchies can reinforce cultural habits of mistreatment that no one should ever be exposed to, least of all in a health workplace where care should be something that we extend to colleagues as well as to patients. So whose story does it tell? Verbatim theatre is a theatre form that is known as a form of what's called documentary theatre. So in verbatim theatre, you solely use the spoken words of real people gathered typically as we did in interviews. So we did interviews with many, many doctors and nurses and a few other people involved in healthcare systems. Some were young, some were older, some were early careers, some were late career. We tried to take as wide a sample as we could. And we had long interviews exploring what got people into their workplaces, into their professions, what they were interested in, how things have changed, what their wonderful, what their terrible experiences have been, and threaded through all of it were those themes, what generates pressure in healthcare workplaces, what and where is grace yeah so you mentioned that Grace Under Pressure explores the perspectives of nurses and doctors what can doctors learn from placing their experiences and experience of nurses side by side well we learned a lot about this so I hope that our learning gets transformed to the audience because Because even though we had nursing voices on our team, it nevertheless became obvious to us halfway through that nurses' voices were somehow still sort of secondary, without anybody intending for it to be like that, as if they really only are there to help a system that's mostly about doctors. But actually nurses do healthcare on quite different terms and struggle with the way in which their voices get sidelined or are placed in secondary ways. So actually wrestling with that problem and doing the juxtaposition in the text reveals the times where the voices come together, like harmony. In harmony, voices are not the same. It's not unison, it's harmony, but you need them both to get the full music. And that's collaborative care. It's a great model for collaborative care. They're different, but they're all necessary. Sometimes they're put aside. There's a struggle for which voice might be actually heard or even hearable in that situation and where it's most uncomfortable is perhaps where it's most important because I think people want to work together. Everyone sees that it's important and everyone feels the pressures that drive people apart so making that more visible in the play is also quite compelling. Obviously there'll be some challenges faced by the narrators that are described but maybe are there particular parts of the play that celebrate what it is great about working within health? Yes there are. This is a good piece of theatre and I don't think that's going to be a news to anybody who's a clinician because you work in circumstances that generate awesome theatre, the highs, the lows, the moments from the sublime to the ridiculous in 30 seconds or less, the times in which there is a real possibility for something that is more than simply good workplace culture but is true privilege or generosity where people work together. And I think we pick up those moments and hilariousness in the script. And there are also moments of desperate sadness. And that's not just about patients. In fact, the desperate sadness, I think, are all the places where people feel betrayed by the huge gap between healthcare as it should be including their role and the way they are treated within it and healthcare as it is sometimes experienced, sometimes come at well. We know healthcare takes the lives sometimes of people who work in it and that's also something that occurs in the play because people said it to us. I mean, you don't witness that, but we're not shying away either from noting that this can be an extremely punitive workplace at times. Amanda, what have you identified about junior doctors that seem to make them so vulnerable within the health system they work in? Junior doctors, we know from research that some of our team members, including Professor Louise Nash at Brain and Mind Centre, have done extensive studies with Beyond Blue about mental health of doctors and junior doctors especially, that there's a kind of perfect storm of factors of inexperience on the one hand and a lot of pressure that comes just from that to often managing close to absurd working hours and working conditions purely from that perspective and when you put on top of that a significant situation of mistreatment in the workplace, which commonly does occur, sadly, sometimes through the stresses and pressures that are placed on other people. Sometimes it's from patients, perhaps increasingly so from patients, but also because of behaviours routinely found in the healthcare workplaces. Then you have poor sleep, and we know that fatigue is extremely damaging and maybe a multiplication of pressure if that puts an enormous amount of strain on so for example an intimate relationship or perhaps being a new parent and there you have conditions where people find it impossible to sustain their working that their normal selves and we should take burnout seriously I think burnout is one of those words that many of us use loosely. And it's not maybe until you've watched someone close to you or experienced yourself that you can understand that it is an incredibly serious multiplication of conditions. It's not just overwhelm. It's not just fatigue. It's a literal cessation of functioning. Some people describe an inability to regulate emotions so that you react with fury to simple requests, completely disproportionate, or a sudden inability to even draw on your brain at all, that becomes literally a form of illness. And those moments, we need to be able to find places where people can stop and seek help and be supported and not be punished for it. Look, I've noted within this space over the last couple of years, there has been a lot more conversations about junior doctor wellbeing, burnout, but solutions are much harder to find. Yes. What ways should we change the culture of medicine, of our workplace to try and prevent some of these issues that we know are occurring? Well, this is going to be a long, slow process because we know that anything that creates significant change will require changes in structure and some aspects of workplace conditions, some of which are told in stories in the play, and some of it will require culture change, and culture change means you need multiple points of entry. There's not going to be one simple solution. It'll probably take a generation to occur. But our hope is that we can contribute to that with theatre by helping people do two things. One is helping a new generation of doctors hold on to seeing how enormously economically as well as ethically constructive it is to retain that commitment as they move into senior management positions themselves so that they eventually become the people who the next generation of junior doctors can go to and feel safe in saying that they are now experiencing trauma to a degree that's interfering with their work and know that what they will get is support and not some kind of denigration. So that's long term. And in the medium term, it gives people an ability to do what we call holding on to yourself. |
So all of the advice that people are given about how to use their social networks, their pleasures, their play, the things they love, and to reprioritise some time around that, even at the expense of maybe a little bit of steady state in their careers, can sometimes be a survival mechanism in the short term if you view resilience as the maintenance of core function over a long-term survival period. I mean, that's the challenge that doctors have, so little control over work, sometimes work hours, sometimes they work in different cities or different towns for rotations. They've got so little control over work, so how do they control things outside of work? Yes, with extreme difficulty is I think the answer that most people find. But that reprioritisation, I think it helps people to reprioritise around core, that sense of what is truly core to me because that's all I may be able to hang on to in this situation. And then people will find multiple ways in. And we know some of the basic ones. We say them over and over again. But again, you only understand this at a gut level when you do it of course your physical functioning is the place to start it's exercise exercise and as much healthy eating and as much maintenance of fatigue as can be done and then the next level are things that are about your core values because people are motivated by their values more than anything else. So the things that you love most or that give you pleasure will be ways of survival until they can return again to a circumstance where they can become something closer to ways of flourishing. And we mustn't ever forget that in our work, which often uses working with acting skills, theatre skills, not role play. We take two steps back from that in the other work that we do. But working with acting skills to allow people to use their voices and their body to identify more about who they really want to be and want to hang on to. But we use those aspects to let people see what their core values are and to work towards flourishing in those domains. There seems to be so much focus on currently on mistreatment in the workplace but often a lot of the focus is on junior doctors I mean is it fair to us there to be standing up to bullies or is it really about I guess the bystanders theers, the other senior consultants? That's what I was going to say. Thank you for reminding me. So in that work, what's emerged so much, and this is from the voices of junior doctors themselves, by accident we discover through the theatre-making processes that bystanders can have very active roles to play. They can be small and no one needs to do more than to offer support. There are so many occasions when that small offering of, I see that this is real, you are not insane, you're actually just dealing with an impossible circumstance. And if you really need me to say that, then I can affirm that what's happening here is that you are not failing, you are caught in an impossible situation and I can support that. Sometimes that's all you need to say. The choice between ignoring and standing up to bullies is always terrible and never successful. Both those things are terrible. And no one should expect the least powerful person to do the work of standing up to someone. That's not how it works. What we hope is that those people who are victims of mistreatment can start to not re-become perpetuators in the future. The cycle has been that you reproduce eventually the negative behaviors to which you've been exposed. Breaking that cycle is where we hope that the creative arts can help support culture change in medicine over a generation. In the meantime, maybe we can use theatre to invite people who don't want to look but who might have an inkling that maybe they haven't always behaved as beautifully as they would like themselves to to their colleagues, to have a way of being able to look at that without it being so awful that they can't bear to see that in themselves because we all have room to improve in that respect. I mean Claire you work within health and medical humanities program at University of Sydney I mean why and how do arts and health work together? I love the creative arts because sometimes when places are stuck in health, arts offers us safe and positive ways forward. It's a relatively new field that has begun to explode in Australia and overseas. And it is precisely because when people are at their sickest or when any of us as humans are dealing with some of the most difficult aspects of our lives, and often that does occur in our workplaces since we spend so much of our lives there and we really need to find a way of valuing ourselves in those contexts, then arts provides conversations that are not reduced to one or two factors. And they are attentive to the things that mean the most for us. So little things. If you have patients with multiple mental health issues, for example, who are experiencing a lot of difficulty in health systems because they're frustrating patients to work with, often they come to be defined mostly in terms of their problems, the things they're not doing, the things they can't do, the things that need to be fixed. But if you make art with them, all of a sudden you see what they can do. You give people autonomy back by giving them a mode of expression that allows them to own their story more. Often you see more in their story and it's a positive one. You begin to find joyful forms of interactions that open the space for much more productive conversations with healthcare teams who can now understand maybe that's why you are not able to be compliant with your medication routine or now I understand why that thing is painful for you or whatever it happens to be. In workplaces, it opens up a space for us to no longer measure ourselves against the kinds of efficiency regimes that are imposed with us and to own and uncover the things. In this play, what comes through so much is how some of the greatest joys in healthcare are where people connect to patients, where care happens. I think people want that so much. We know patients want it. We know patients thrive on it. We know patients show lower levels of cortisol, lower levels of pain medication, increased capacity to engage in shared decision-making. All the good stuff with that occurs. And we know it's heartbreaking where it doesn't happen. Everybody in this play speaks to that somehow. So art lets us see that and understand the mechanisms by which we can redesign systems so that that happens more in ways that will show better health outcomes and therefore better financial outcomes, both for clinicians and for their patients. Wow. I hope I've convinced you James. You've convinced me and you've convinced me to go to the play. What's next after the play? The Sydney Arts and Health Collective who are the team of people I have the privilege of working with to create this play are a multidisciplinary team that draw from psychiatry, nursing, public health, myself, health, medical humanities, Sydney health ethics, and of course theatre and performance studies. And we want to continue using theatre and performance studies techniques to work around these issues both I'm quite passionate about people being happy at work because I had the true privilege of an incredibly supportive boss and when that's modeled to you and you see what it's like to be given wings because someone values what you does and has your back then you want other people to experience that in their workplaces most of all the people who give so much of their lives with such dedication to providing care on the ground. So I want people to be able to be more effective advocates for positive workplaces and generating ethical workplace processes that enable better workplace cultures for everybody. But I also, and I want to use theatre skills to do that because we've been watching how much that can open up for people in terms of their insights into how the micro aspects of human communication works. But it does happen. You can hear we're having a pleasant conversation with enthusiasm and enjoyment of each other's company, but it wouldn't take much for an interview to become defensive on the one side and perhaps aggressive on the other. And those things happen in half a sentence in healthcare and can be the difference between what a patient experiences positively and can do positively with their provider and what they can't. So I want to continue to use theatre and I think all of us do as a team to explore more about how we can help that happen to everyone's advantage in healthcare through workshops, through working with performance professionals, through exploring some of the edgier aspects of new performance approaches. I've never liked modern art before and now I am in love with what I can see from it happening in these healthcare domains. Well, thank you for speaking to us today, Clare. Just a reminder, it's at Seymour Theatre. It starts October the... Wednesday, October the 25th at 8 o'clock and runs Wednesday, Thursday, Friday and Saturday nights. That's October 25 to 28. There are matinees on Friday at 4 and Saturday at 2. |
Welcome everybody to part two of non-invasive ventilation. We have Paul Hamer, a respiratory and sleep physician from Wilkerns Alfred Hospital who spoke to us in the first session on non-invasive ventilation, the difference between CPAP and BiPAP and how to use CPAP and some of the tips and tricks on introducing CPAP. But now we're going to talk a bit more in detail about BiPAP. So maybe we can start Paul what are the indications for using BiPAP? Yeah so I suppose there are four main indications for commencing BiPAP. The first is in chronic obstructive pulmonary disease COPD where there's a respiratory acidosis. So they need to be both, have an acidosis, that is a pH less than 7.35. And I think it's important to end that they need to be hypercapnic. There are a lot of patients with COPD who are hypercapnic, but are not acidotic. We term them chronic, people with chronic type 2 respiratory failure. But if they have acute type 2 2 respiratory failure and that's anyone with a ph less than 7.35 that's abnormal generally the body maintains very good homeostasis to keep ph in a very tight narrow band and i think a lot of people casually see a ph of 7.30 and go oh it, it's not that far below normal. That's fine. It's actually a really dangerous warning sign that something bad is going on. That person is not able to breathe adequately. They're not able to blow off their CO2. And as a result, they've become acidotic. So it's not good enough usually to say, I will just watch and see what happens. You need to act on that acidemia and do something about it. So that's the main indication for COPD. The second type is chronic respiratory failure due to a whole raft of reasons. And these people are on it for life. So these people might have neuromuscular diseases, they might have chest wall deformities or severe kyphoscoliosis, they might have what's called obesity hypoventilation syndrome where they're so obese that they actually developed a respiratory restriction and that causes respiratory failure and hypercapnia. So that's another indication. The third indication is in pulmonary edema which we discussed a little bit in the last case but you might occasionally see pulmonary edema who are also hypercapnic. Generally you'd start them on CPAP but if they're not responding it's fair enough to to trial bi-level ventilation as well and lastly is use in the ICU when you're weaning people from tracheal intubation so it's becoming more common now that if someone is coming off intubation they'll be put on bi-level ventilation as the next step down and it has been shown to decrease re-intubation rates in the intensive care. How about asthma as an indication for NIV or BiPAP? So asthma is not a recognised indication for BiPAP. There's evidence, or there's not much evidence at the moment. I think they're trying to gather evidence and they're doing some trials in it. The trouble with bi-level ventilation in asthma and in other disorders which you might be thinking of using BiPAP for is that it may delay intubation. And so as you're sitting there playing around with BiPAP, the patient's getting sicker and sicker and sicker. And if you sort of heard my last talk, applying BiPAP is not easy. It takes 15 to 20 minutes really to get someone established on bi-level ventilation or non-invasive ventilation. So if you've got someone who's particularly sick and you're thinking, oh, we'll just give it a go to see if we can avoid intubation but really the question you should be asking yourself is should this person be intubated right now and are we messing around doing something when we really should be controlling this person's airway right now. So that's my worry about using BiPAP in severe asthma that until we have good data to show that it is useful, and I think from a pathophysiological mechanism, there might be some situations where it may be useful. In very severe asthma, I'm concerned that it'll probably delay intubation in those patients who might need it. Okay, thanks, Paul. I mean, there is some thought that you could almost use a BiPAP as a as a I guess a bridge to getting to intubation so you can improve their oxygenation with always the plan to intubation but it's that kind I guess that mindset to make that decision yes this person's needs intubation rather than persist with NIV when it's not probably going to work. I suppose it depends on how good your service is at setting up bi-level ventilation quickly for people who are in trouble. You don't want it to delay appropriate therapy for people. So probably the most common reason that a junior doctor be called to somebody in the ward who may need NIV is somebody's been admitted to the ward with an exasperation or COPD. They get a GASH result back and it does show some acidemia and a raised PCO2, what would be next for them? What does she start thinking of? I suppose my approach to type 2 respiratory failure in general is not just to think of it as COPD as necessarily being the cause. There are a lot of causes of hypercapnia with acidemia. So the first thing you want to think of is, say you find them on the ward and they've been in hospital for a few days and they've got COPD, is it an exacerbation of their COPD? So is their ventilation worse? And is that causing them to become hypercapnic and acidotic? We see that less on the ward. Generally, you hope that people have been on appropriate therapy when they come into hospital, they're on bronchodilators, they're on steroids, and hopefully they're getting better. But you will see it from time to time and their COPD will get worse. But it's also useful to think of other things that might be co-contributing to their ventilation. So coexistence of APO. So if someone has come in with COPD, for example, but they've been put on too much IV fluids, they've got diastolic heart failure, and they get a bit of fluid on the lungs in combination with the COPD then you know they'll develop worsening type 2 respiratory failure so it would be worth just checking that see if their lungs look congested and if they do you could give them some Lasix that will improve the situation. The third thing is of course opioids so if someone comes into hospital and they have a little bit of pain and they're given regular endone or something like that, it will depress their respiratory rate. And a lot of people who are already in type 2 respiratory failure, chronic type 2 respiratory failure, if you give them some opioids, it will depress their breathing even further. And that could send them into type 2 respiratory failure with hypercapnia and acidosis. So the treatment for those patients might be NIV, but it might just easily be giving naloxone as an opioid antagonist to reverse the effects of whatever opioid they've been given. Lastly, people who have COPD are very dependent on their respiratory muscles to breathe. So if they've got anything in the abdomen that restricts their ability to expand their chest, that might cause them to have a reduced respiratory ventilation, minute ventilation as well. So if someone's on the surgical ward, for example, who's got COPD with a distended belly, then the treatment might be more urgent because you can't fix the surgical thing straight away, but that might be the underlying cause of why they've deteriorated with their respiratory drive. So it's not always just an exacerbation of COPD, I suppose, is what I'm getting at. You want to look at all the possible causes of type 2 respiratory failure, and there's a differential list. You just need to go through one by one and check. Okay, I think it's really important Paul. One of the other situations I occasionally see is that somebody has got borderline hypoxia on maybe two or four litres of oxygen. The gas comes back and they have hypercapnia and maybe a pure 265, there's sometimes a thought that the junior doctor should take that oxygen off because that will make their CO2 better. Can you make a comment on that? That's wrong. But you're right, it's a commonly held belief that giving too much oxygen causes hypercapnia. And in some senses it does. but hypoxia is going to kill you faster than hypercapnia does. So generally if someone has saturations between oxygen saturations you can measure this by a finger probe you don't need an ABG to do it. If the oxygen saturations is between 88 to 92%, then that's adequate to oxygenate someone. |
And certainly in someone who's already hypercapnic, the oxygen level shouldn't be that high. Aim for a level between H8 and 92. If they're hypercapnic with a level of 88% or 90%, you don't turn down the oxygen further. The treatment is to give them non-invasive ventilation or refer them to intensive care because they will need some other support. The mechanism is actually quite interesting and debated amongst respiratory physicians. You know that in the lung when an area is hypoxic, the circulation, the microcirculation tends to close off. It's called hypoxic vasoconstriction in the lung. And there's a thought that when you give oxygen, it actually opens up those blood vessels to areas of the lung that otherwise wouldn't be ventilated. And that causes the patient to become hypercapnic because that area of the lung is not ventilating properly. So that's one thought of the cause of hypercapnia. I think a lot of junior doctors think it's because of a suppression of respiratory rates centrally. And there are some physiological studies that suggest that as well. But I think most people think that it's due to the release of hypoxic vaso... Well, it depends on the underlying disease process. But at least in COPD, it's thought to be the release of hypoxic vasoconstriction in the lung by the delivery of more oxygen. Okay so I think it's a really important point for junior doctors to take home that if someone is hypercapnic but they've got their oxygen saturations are really within 88 to 92 do not remove the oxygen. No no the oxygen level should not go below below 88%. That's an indication for giving oxygen if the oxygen's less than 88% and won't help the situation. It'll probably just make it worse. And similarly, you don't need to do an atrial blood gas off oxygen? No, there's never a circumstance in an acute situation to do an ABG off oxygen. The only indication for doing an ABG on room air is for home oxygen because they need to qualify for the government to prove how bad they are. The better way to do it is to record what the exact level of oxygen they're on, and that might be one or two litres by nasal prongs or Hudson mask or a non-rebreather mask, you record that faithfully on the ABG and you calculate their AA gradient. So you need to look up your textbooks and look at that again. It's not that difficult to calculate and there's even a lot of apps on your phone you can get to calculate it for you. But generally if someone is having borderline oxygen saturations despite uh supplemental oxygen they're going to be hypoxic so i don't think an abg necessarily helps where an abg does help and we don't have any other way of detecting it is looking at hypercapnia and acid-base status that's why you need an arterial blood gas not a ven blood gas, because venous blood gas is confound by so many factors, including metabolic rate, the blood that's circulating at the moment. Arterial blood gas is the best way of detecting whether someone has true hypercapnia and acidemia. Okay, we've seen them gone off route. Sorry. But I think they're really important points because there's stuff that comes up all the time um on the wards with junior doctors so maybe we'll get back to the niv so somebody who is hypercapnic and acidemic on the ward you looked at what the potential causes are you want to start niv maybe some of the practicalities about starting that i think it depends on where you work um so generally if someone is hypercapnic and acidotic you should at least raise it with your medical registrar and they will hopefully know that the policies and protocols within your hospital of what can be done. In some hospitals the provision of NIV in very mild acidosis and usually the requirement is for a pH between 7.25 and 7.35, in an experienced service where they're used to the provision of NIV on the ward, in patients who have just COPD as the cause, it's generally safe to give NIV on the ward. But your institution has to be comfortable with that and have policies and protocols in place. In some places there's a high dependency unit, sometimes a respiratory high dependency unit, where they're used to dealing with patients who are on non-invasive ventilation. But I'd say the bulk of the country would actually, these patients would go to the intensive care department who will be able to monitor them for their NIV, are able to intubate them in case they deteriorate, but also take regular blood gases in the monitoring of these patients to see whether they're improving or deteriorating. While we're on that, I suppose, is how do we monitor these patients after we start NIV? But we'll probably get to that once we start therapy. So how do we start therapy? So we work out where they need to go in the intensive care on the ward and I guess the junior doctors don't need to know, may not be the ones starting it, but it's nice to them to have some concept of what the commencement of BiPAP would look like. Well let's say they go to respiratory HDU because I suppose junior doctors might have a bit more of a control of what goes on there. So say they get started on some pressures. So when I see a patient with COPD I'll look at how high their CO2 is and how acidotic they are and I'll set some pressures based on that. Remember last time we were talking about the EPAP which is the expiratory positive airway pressure, that's the lower number and the IPAP which is the inspiratory positive airway pressure. So in patients with COPD, there's a concept of intrinsic PEEP. They need a certain amount of pressure to help them with their expiration. It's probably something too complicated to go on to talk about in the podcast, but be aware that you want the pressure at a minimum of about five or six centimetres of water to overcome that intrinsic PEEP. Then you set the pressure support depending on how high their CO2 is and how much minute ventilation you want to deliver. And generally between six and eight centimetres of water is a good start. So starting at pressure zone, say an IPAP of 14 and an EPAP of six, isn't probably such a bad place to start for someone who's got an exacerbation of COPD. Similar to the last talk that we gave, when you apply the mask for the first time, you want to be talking the patient through it, checking the seal of the mask and the fit of the mask and looking for air leaks. And then with the supplemental oxygen that you give, because you're recruiting more alveoli, you might find that their total oxygen percentage that they need becomes a little bit less. But because of the volume of air that you're delivering through the non-invasive machine, you might find that you need to actually turn up the oxygen at the wall tap a little bit more. So it depends where you're working, what your machine displays you as a graph. Some will display you as a percentage, FiO2. Others, you'll just need to plug in the oxygen at the back of the machine and turn it up to whatever. And you titrate the oxygen, like we were saying before, to 88% to 92%. You don't need anything more. You don't need anything less. 88% to 92% is that perfect sweet spot. After you've commenced NIV, you want to repeat the blood gas in about an hour. That tells you two things. It says whether you're winning or losing, essentially. If you're losing, you really, and you're in a respiratory HDU, you need to get intensive care involved, or at least let them be aware of the patient. Because if they continue down that trend, then you could be in a lot of strife and they might need intubation so it's important that they're aware. If you aren't winning you need to make some changes to the setting so you need to look at the patient. Have they coordinated with the machine properly? One of the things with bi-level ventilation is when you put the mask on because there's an in-spirituary pressure as well as an an expiratory pressure, the patients have to trigger the machine. Now if someone has such poor breath, inspiratory strength, that they can't trigger the inspiratory pressure to turn on, then that'll be a problem. So you need to look at that and on some machines there's a trigger sensitivity that you can turn down if they're not triggering in the machine. So that might be one reason why the NIV fails. The second reason which NIV fails is there's a small setting within NIV which is usually there on the front display of all the machines but people don't really look at it called the rise time. |
Welcome to On The Wards, it's James Edwards speaking to the junior doctors of Australia and beyond. Speaking about technology and healthcare, I'd like to welcome Professor Tim Shaw. Welcome, Tim. Thank you. Professor Tim Shaw is Australia's first professor of e-health at the University of Sydney. So maybe we'll start, how did you come to take up this role? I guess I've been working in e-health and technology and healthcare for a long time. For anybody that studied at Sydney University, I guess one of the first things I did was actually digitise the Wilson Museum of Anatomy when I was a PhD student and turned that into an online resource which let me develop basic surgical training for the College of Surgeons in 1999 when they were the first college that really looked at how digital information could be used in education. I've then gone on to use technology in implementation of behaviour change within organisations, a wide variety of them, hospitals, community practices and so on. So that kind of led me to take on this role. But this role is more substantive in terms of kind of trying to guide where the university goes in e-health across research, education and practice. Is it just within health science or is it more than that? Well, look, I think you can't really look at technology or e-health without going more broadly than health sciences. I'm not particularly pointed in health, but I'm very much reaching out to colleagues in engineering and IT, for instance, that do human factors work with data. I think often when people think of human factors they think of pumps being put into the right socket and things like that but there's a whole discipline of human factors around how we actually interface with data and use information so certainly drawing on those aspects as well. How do you define e-health? Yeah well look I think it's when I was given this role of professor of e-, so I kind of had to redefine it. It's certainly not studying ecstasy, which a lot of my younger cousins might think it is when I asked them. But I guess, look, I see three main domains of e-health that we've actually defined over the last year. The first one I call health in the hands of consumers, which is the use of apps, mobile devices. And this is probably the one that's really getting away from healthcare in a way. It's kind of everybody's got them now and everybody's using them. The second domain I talk about is what would traditionally be called telehealth, but it's really how we transform the way healthcare professionals and patients interact using technology. So how consultations have changed, how distance is no longer a problem, although there's no reason why I have to visit my GP in Annandale when I can communicate in different ways with them. And then the third domain is how we store and manage data, which is traditionally looked at the electronic medical record, but it's kind of the whole lot now. It's how do we incorporate fitness data into the way we practice health and so on. And I guess what I'm really interested in is the overlap between those three domains. So how do we start to incorporate how you might use an app as both a patient, a consumer, and as a health professional? And then how does that influence the way you're going to interact with your patients? Then how do we actually store that data so it's meaningful? So I think everybody's madly going off building apps, but really as a clinician, what does that mean to incorporate that into your practice when you're working with your patients? Or in fact, any of us as people that want to just be fit and lose a bit of weight or reduce chronic disease and so on. So what are your main research interests currently? Look, I work across a wide range of areas. I work a lot in oncology. so I've been working on projects that look at how technology can, say, support patients that might be in rehabilitation for cancer, maybe have surgery at RPA, and then go back to Orange, and how do we actually maintain rehabilitation programs for them. So it's that kind of health in the hands of consumers, but supporting them in their home base. I guess I guess more though that where I'm really interested in is how we really use health data. So not from a pointy-headed epidemiologically driven space but how do we actually make health data meaningful to clinicians. I don't think it is at the moment. I think that we're just at the beginning of a revolution in how we use health data. At the moment it's largely painful for clinicians in terms of having to put stuff in an EMR and there's a big pushback against that. But I think that in five years' time we'll look back and go, well, how do we actually manage without this massive amount of data? I actually say we're at the beginning of a new reformation in a way. It's a bit like in the 1400s, just before they produced the printing press, when most of the information was locked in monasteries with monks writing in Latin that nobody could access. Now, where much of our data is locked in CERN or in EPIC and other large databases that clinicians don't really get access to, it's controlled by technologists and the only people that can really understand it are epidemiologists. It's a very similar place now but I think mobile technology and this kind of revolution is going to take that over and make that data really accessible to you as clinicians. Many other registries have embraced the digital revolution. What are some of the challenges to implementing digital health projects in the health system? Look, I think there's lots of problems. Some of them are real and some of them are imagined. I really don't understand often why healthcare has been so resistant to disruption. I mean, you look at travel, you look at banking, you look at other industries that totally, you've had Uber, Airbnb, you've had some massive game-changing technology shifts. But we're really still using medical records that were developed 15, 20 years ago for accounting purposes. And we haven't had a revolution in that yet. So I don't understand why. Obviously, privacy is a concern. But I think often that's some people hide behind that rather than being real. And I think most health consumers and patients think that we're using data in better ways and that people can access it and so on. But obviously it is challenging. But then I think health is complex. I think we've obviously got these complex interrelationships between lots of different systems and organisations. But again, I think there's more opportunities than there are problems if we can just kind of get over this hurdle of the barriers that we're encountering at the moment. Yeah, I mean, I see within health that most... Well, most organisations outside of health are all about how to share information, and within health it's how to stop information from getting out into the wrong hands. Yeah, I 100% agree. And I think that's because's because the premise of again it's going back to that kind of reformation period almost where really when you look at the medical record it was built around billing um and now it's largely been used for accreditation and reporting requirements which i'm not saying aren't important but it's certainly not been the system you design for health care professionals to have access readily to data that can impact on their on their cares. You know I really hope that's something that we we have happen shortly but I'm not sure it's going to come from I think it's going to come from the the mobile technology device space I think there's a whole pile of organizations out there they could probably do the data really well that are not yet in the system. I think most union doctors will complain that the quality of the electronic devices they have or any mobile device they have outside of health are far better than what they have to deal with when they go to work. This is a real problem. Again, I think it's because we're having that disruption of technology to come in and kind of wipe that out. And often when we have kind of devices that are built along the best possible reasons for improving people's health often come to it without thinking about how it's the usability and the function and the form and so on, which tends to drive when something is built around a business model externally, then that's their whole focus is actually how the end user is going to do it. Whereas often many of the programs I've been involved in, the emphasis is on functionality perhaps rather than form and how it operates and how you're actually in usability. And I think that's one of the problems we've got. Again, we've had this kind of restricted access to some of this. Does Australia have any particular challenges in relation to e-health compared to, say, the US or UK? Look, I think we do have our own particular challenges. |
We've got the federated system and we've got states and we've got the federal government and then we've got, within the states, that means got people controlling different aspects of care obviously the hospitals being state largely and primary care being federal and I think that's made it really challenging to get unique systems in place and even though we have a public system there's still not a lot of cohesion perhaps across those systems so in New South Wales we've got seven versions of Cerner I think and then two other mainframe operating systems and even the seven versions of Cerner that drive our EMR are kind of different applications. So we've got real problems in terms of how we integrate and then what we do in New South Wales is not necessarily the same as Victoria and then what's done in primary care. So I think a lot of that makes it particularly complex. I think where I'm seeing internationally some of the exciting things, even though everybody is often negative about the US, but if you look at something like Kaiser, which is a single billing service or single service from primary care through to specialist services, that means we've got, you know, within that system, you've got kind of control. So if you want to have data flow between them, they can just make it happen. We can make these kind of things work much better together on this fragmented system where you're always pushing uphill to actually make things work together. Yeah, I mean, information's available at my hospital. I can't access the hospital that's only one kilometre away. Local doctors, private hospital, all that information is separated and sometimes I'm still doing faxes. Oh no, look, and I use the analogy in healthcare that I think we can do some of the most amazing things with technology. I mean, you've only got to walk into RPA and you'll see there's amazing things being done. But to me, it's a bit like if you look compared to the space race, it's like we can fly rockets to Mars, but we have to tow them to the launch pad with a horse and cart. So some of the real fundamental basics that we have in the health system around data and flow and connectivity just aren't there yet. Although, in a positive note, there's lots of people working on that, and I think we've got some new organisations and revived organisations like eHealth NSW and others that are really trying to understand this and grapple with it. What does the establishment of the Australian Digital Health Agency mean for this country? Okay, so that's the kind of latest group being put together to help with the eHealth space, and I've certainly been engaging with them. They're an enthusiastic group of people. I think they're really charged with making My Health Record work. So for those of you who don't know what My Health Record is, it's a universal record that we'll all have. It's taking the old personally controlled opt-in method and making it one that we all have and we have to opt out of if we don't want it, which basically means the whole country is going to have this record. So this is going to be such as you were complaining about, the lack of coordination between specialist services, primary and public and private. So I think we're assuming that the horse has bolted in having one system that we all use. Therefore, hopefully My Health Record will be the repository that all this data will flow into that we can then use to coordinate that care. I mean, I think the real hope is that we don't just create another filing cabinet in the sky. I think the real opportunity is how do we use My Health Record to really drive changing the way care is delivered to mean that we could have general practitioners setting goals within My Health Record that patients can access and that can be shared with other providers and so on. So it becomes really something that says the data actually, the data The data's boring. And it's actually, you know, only people that love data get excited about data. It's what you do with it that's important. So it's actually not my health record. It's kind of my health, I think we should call it. And then the data's actually going to drive the way we transform different aspects of care. How is e-health going to impact on a junior doctor's practice? Look, I think in lots of ways. I wish I was a young doctor starting out now because I think it's really exciting. I think probably the doctors that are in practice at the moment are the ones that happen to struggle through this kind of teething problem of getting stuff to really work. I think over the next five years we're going to get lots of really different ways of working. So I think a doctor in five years time is going to be able to access lots of information about the patient they're delivering, they'll easily be able to access their colleagues, there'll be a whole kind of shared database of how you can work together. I think the key area that I'm researching at the moment is actually about understanding the outcomes of the care you're delivering. Because I think clinicians of all types at the moment are flying really blind in terms of the outcomes. There's no performance measurement. And I mean that in a positive way. I'm not meaning in terms of a punitive way, but just so that clinicians can actually see what's happening with their patient outcomes. So I think we're going to have a revolution where they'll easily better access what's happened in my last 10 patients, my last 100 patients, and how does that compare and how do I use that to actually change the way that I really practice. So I think there's going to be a real transformation in terms of that aspect. I think there'll be massive connectivity across devices and things like that. So I think you won't, you know, hopefully we'll remove manual entering of data so that clinicians just kind of can spend more of their time, I guess, actually on delivering care rather than actually entering the data. And that has been some of the criticism about electronic health record is that we spend less time with patients and more time at computers. Yeah. And look, this is a reality at the moment and it's something we've really got to deal with. I think we really have to start to look at how we can reduce that time spent in data entry. But we also have to get people to start to understand that it's the quality of the data that goes in, it's going to be the quality of the data that comes out. So I think at the moment we've obviously got lots of examples of really busy people cutting and pasting and just putting data in because they don't actually see any value. I often say electronic medical records suck, they don't give information out. So I mean I think we, you know, people like me who are involved in projects trying to get data out need to start to give that back to clinicians so they see the value of putting it in and actually see the value of spending that time so you don't feel that time's just being spent for reporting requirements that don't really do anything much for your practice at all. I've outlined some of the frustrations you may have in regard to e-health, but if they want to become more involved and improve things, how can they become more involved and be innovative in this area? Look, I think it's vital that junior doctors get involved in this and don't just kind of sit back. I know that most of the agencies that I'm dealing with, eHealth New South Wales and the Digital Health Agency are really keen for participation. In fact the Digital Health Agency's new motto I think is we listen. So I mean I think it's really important that young doctors get actively involved in projects that are going on. I think they start to look to see how could you incorporate this into your practice, depending on where you're going in your own practice. If you're going to go into primary care, what does that mean to have apps as part of your business? How do you actually work with how you might transform the care, the way you're interacting with your patients and things like that. So lots of different things in those kind of ways. I do think there's an emerging specialty which is really exciting which is kind of, I don't want to call it health informatics, I think it's much more than that, but in terms of actually being a clinician that specialises in how we use technology in healthcare delivery. So at Sydney we have a new Masters of Innovation in Health Technology where this isn't taking people out and turning them into programmers. This is actually saying how do we really get clinicians that understand technology to be partners in this development process. So if people have interest I'd be really encouraging them to look at that. My experience of many doctors as they move through is they look for something different when they start to hit 30 and 40 and I think this is an area that you can really have some value in now. |
Okay, welcome everybody to On The Wards, it's James Edwards and I have the pleasure today of speaking to Penny Gordon, one of the advanced trainees in urology here at RPA. Welcome Penny. Thank you very much. Look, we're going to talk today about headaches and we're going to talk more from a headache perspective of one that a junior doctor may see on the ward rather than when they see the emergency department, although the principle will be fairly similar. Yep. So we'll start with a case. You're a junior doctor on night shift and you're called by the nursing staff about a patient on the haematology ward with pancytopenia who has developed acutely a severe headache and blurred vision. Whilst you're on the phone to the nurse before you go see the patient, what sort of questions would you ask? Okay, so I think your questions really need to be directed towards, you know, what's the clinical urgency for this patient. I quite like this example because, you know, clearly this is a potentially very sick patient and there's some serious possibilities as to the cause of this headache. So I think establishing, you know, the clinical urgency is important. So how quickly do you need to attend the patient? So I think firstly, starting off with, you know, talking about, you know, is the patient alert? Are they or are they drowsy? So what's their GCS? Then looking at some other sort of objective measures, such as their vital signs. Has there been a history of them having had a very, you know, rapid increase in their blood pressure? Are they febrile? So those are the kind of things that you want to initially find out about. Then I guess also knowing what the patient's been like otherwise on the ward, what the current treatment is,elet counts, have they, are they currently being treated for an infection, things like that, I think, over the phone. Okay, so you ask a few questions over the phone, but you decide you need to go see the patient, and you see them reasonably quickly. What are some of the most sinister cause of headaches on the wards that can't be missed, and probably also within this patient. Okay, well, with respect to this patient in particular, I guess the sinister causes that would come to mind first up is, with them being pancytopenic, is I guess particularly the platelet count. If they've had a low platelet count, they're at risk of some sort of intracranial hemorrhage would be one of the first things that comes to mind as well as with the history of pancytopenia potentially neutropenic and may or may not have another sort of nidus of infection but I'd be thinking of a meningitis. Other things would be sort of rarer things but you know possible in hematology patients who are on cytotoxic medications are things like posterior reversible encephalopathy syndrome, which is uncommon but possible again in this kind of patient population. I think looking at other patient populations around the hospital, I suppose, I guess pregnant women are the other patients that we worry about with new headache, and that can be a number of things like, you know, pituitary apoplexy, again, a rare thing, but something that needs to be thought about. Cerebral venous thrombosis. And I guess the same goes for any patients who have some sort of, in some sort of hypercoagulopathic state or in sepsis with DIC, those kind of things. Subarachnoid hemorrhages, I suppose that's probably a less common thing to have as a presentation on the ward, but again, possible. And I guess particularly if you're seeing a patient who was admitted with a trauma and there may be a delayed presentation for a subarachnoid hemorrhage. Subarachnoid, there may be rarer causes of a subarachnoid on the ward in, say, a cardiology patient who's got infective endocarditis and they could have a mycotic aneurysm as a cause. So I think they're probably the main sort of things. And then other, you know, subdural hemorrhage, I guess, if you're looking at the elderly, you know, geriatric population or alcoholic population. And there may or may not be a history of, you know, having had a fall in that setting. So those are probably the most serious ones that come to mind. Okay. What's your initial approach by the bedside? So I guess with any patient, the initial approach at the bedside is, you know, what are the vital signs? Do you have to act on any of the ABCs promptly? How well or unwell does the patient look? Is this, you know, the end of the bed test? And then I guess if those things are all okay, then I suppose you need to start then with, you know, a history. And in particular, I think, you know, important question to ask will be those red flags about headaches. So, you know, a new or unexpected headache in a patient or the first or worst headache of a patient's life. And I think those kind of features are probably age over 50 are more important and more useful. If they've got any, again, you know, if they've got an infection at the time, which could be a nidus for, you know, for cerebral infection. So either lung infection or sinus infection. I guess the pattern of the headache is quite important too. If there's sort of an accelerating pattern to the headache, you sort of think about subdural hematomas or an enlarging mass lesion. And then headache, I guess, associated with postural change, which might suggest raised intracranial pressure. And so you can ask questions about bending bending the head forward coughing or sneezing things like that um yeah so okay in regard to some of the important questions to ask what signs would you also look for okay so again looking at the level of consciousness of the patient so it's important to sort of evaluate their gcs I'd also look again at the vital signs as we've already talked about. Examination of the pupils I think is quite important too. So looking at pupil size, looking for asymmetry, reactivity to light. So that can sort of point you towards different types of lesions. So I mean pinpoint pupils can occur in pontine lesions and also in certain overdoses, of course. But sort of fixed mid-sized pupils can occur in a brainstem lesion, mid-brainstem lesion. If you've got, you know, one pupil that's dilated, that could suggest like a cranial nerve 3 compression externally and that might raise the possibility of raised intracranial pressure could be related to intracerebral hemorrhage or posterior communicating aneurysm something like that. Then I think it's important to assess for meningism as well if you're thinking along the lines of, you know, CNS infection. And then just a general sort of neurological examination, looking for any focal neurology. So in regard to looking for meningism, looking for the kind of pupils and cranial nerve size and looking for focal signs, I guess is will be what we'll talk about soon in which are the indications for getting a CAT scan. One thing that does come up occasionally is should we be looking at the fundi and does doing fundoscopy on the ward help? I know lots of junior doctors aren't confident with fundoscopy. Is this appropriate to fundoscopy? Look, I would say definitely. I think anyone who presents with a headache needs to have a fundoscopic examination. And I agree, I think junior doctors are not used to having to do this. It's often hard to find an ophthalmoscope on the ward, but I would definitely encourage that being done, at least an attempt at doing it. I know it's difficult. Some of these patients are going to be photophobic too, which might impede your ability to actually perform fundoscopy. But I think the important features to look for on fundoscopic examination would be for signs of papilledema, so swollen optic disc, blurring or loss of the disc margins, engorged veins. And you may also see retinal hemorrhages in the setting of a subarachnoid hemorrhage, for example. So I think it's a vital examination. It depends on, I guess, your level of confidence as to whether you think that you may be able to interpret things that you may find. But I would suggest definitely needs to be attempted. So we've gone through some history examination. Now we think you want an investigation and we should order. What sort of investigation would you routinely order and also what are the indications for a scan of the brain? Well I think probably the most accessible scan especially after hours and in this particular case in the middle of the night would be a non-contrast CT scan. |
Any patient with new headache age over 50, and I guess that will also depend on the clinical scenarios to the urgency of that being done. And then another group, it would be HIV or immunosuppressed patients. So I think, you know, those would be the main indications. And we haven't mentioned space-occupying lesions in our differential book. Yeah, sorry. What are the risk groups for who may get a space-occupying lesion as it causes a headache? Well, I guess, again, those immunocompromised patients who may have another nidus of infection somewhere else that might seed up to the brain. So, yeah, definitely those patients and they should have contrast, of course, in that setting. And people with history of cancer or they're on the ward being managed for cancer, is that a common presentation of someone who's got a known cerebral met or can it be a first presentation of a headache with somebody who's got cerebral mets? I'm not sure that I probably have enough experience with the oncology patients to know about that, but certainly I think, yeah, if there's a history of malignancy, definitely that needs to be thought about too, that they've got cerebral metastases and, again, a contrast scan in that setting should be arranged. Are any blood tests helpful? Often we sometimes think of the older patient doing ESRs in CRPs and the ED. Is that something that is helpful in the ward? With respect to just headache in general? Look, I think probably in certain groups it may be helpful, but I think probably the history and the examination would be more helpful. We tend not to rely too much on any one particular blood test to sort of help tease things out, unless, of course, you think there's an underlying cause such as a vasculitis or something like that that might indicate checking ESRs and doing a vasculitic screen. But generally speaking, it's not particularly helpful. I think the main things are getting a good history and a good examination and then following that up with some imaging. We may talk about LP later because I don't think many junior doctors will go and do an LP without getting help. So when would a junior doctor should contact the medical registrar or the neurology registrar for help or advice? Well, look, I think that if you find any of those red flags on the history that you've taken, or indeed if you find any sort of focal neurological abnormalities, then I think you have to, you know, speak to somebody about that. And depending on how sick the patient in front of you is, you know, depends on how urgently you need to discuss that patient with somebody. I think other things would be if there's an associated fever with the headache, because clearly a diagnosis needs to be made as to whether those two things are correlated and there's a possibility of an encephalitis or a meningitis because you need to initiate management or further investigation and management for those patients. And I think if you decided that you needed to perform a CT scan on a patient, then you absolutely should be speaking to somebody. And not only, you know, just to let them know that you're worried that the patient's unwell, but also just to sort of help determine whether you're ordering the right scan to start with, because that may be, you know, your only opportunity to get certain tests done and also just to determine whether you think the patient's safe to go down to the radiology department, particularly this patient in the middle of the night. You know, you probably want to let someone know that that's what you're doing. And I think particularly those where we have a little consciousness that may be decreasing or changing, we don't want it to drop particularly when they get a CT scanner. When they do do the CT brain, it shows intracranial hemorrhage and the patient does start to drop their GCS as they return from radiology. What would you do now? Okay, so this, I mean, clearly this is, you know, looking bad for this patient. So I think the thing is that you need help. You cannot possibly manage this patient alone now. So I guess depending on which hospital you're in, you need to either activate a MET call or, you know, an ICU assist or whatever your sort of options are for getting people to help you quickly. I mean, this is representing a patient who's at risk of, you know, brainstem herniation and death if things are not attended to quickly. They may require urgent intubation and ventilation and certainly they, you know, they need urgent referral to the neurosurgical team. So obviously you need, you know, multiple hands on board, you know you know to stabilize the patient and then to decide what needs to happen next for them. Okay that sounds very sensible Penny. We're now going to change tacks slightly and we've gone from someone who's very sick and worried about with a very sinister headache to a probably a more common scenario for a junior doctor that you're asked to chart analgesia for a 65-year-old female who's on the renal ward, who's got a bit of a dull frontal headache, but she reports of having this headache many times before. So what characteristics would help you differentiate the different causes of headaches, and especially working out is it one of the kind of chronic headache subtypes? Yeah. So I guess, again, I mean, the temptation, I guess, in these these patients when you just ask to chart some analgesia is to chart the analgesia without actually seeing the patient so I think it's probably important to go and address the actual concerns from the patient and what they're describing with the headache. So I guess the primary headache disorders are migraine, tension type headache, and then there's your cluster headaches and other trigeminal autonomic valges. I guess migraine and tension type are much more common. So I think it would be important to establish that in the history. So I mean, for example, migraine typically is like a unilateral headache. There's usually a pulsatile quality to that headache. It's usually moderate to severe and patients typically don't want to continue performing their usual activity. So walking, climbing stairs, even those minor things can aggravate the headache and people tend to prefer to go and have a lie down. There's often nausea, possibly vomiting, and then photophobia and phonophobia is a feature of those. As opposed to that, I guess a tension type headache is usually episodic headache, often generalized, but again, it can be unilateral. Typically, patients will describe a tight band around their head. And they can also get, you know, the headache can either arise from the neck or refer down to the neck. So I guess another important feature in the history to ask about is how often they're getting the headaches. Has this now turned into chronic daily headache? And the other thing I think that's common and often overlooked is the medication overuse headaches. So often there's a history of accommodation analgesic use. So either analgesias containing caffeine and codeine is probably the most common ones, but it can also occur with simple analgesics such as aspirin and paracetamol so it's important to ask you know how much medication people are getting because you know potentially a migraine or tension type headache has now turned into a medication overuse headache and that would certainly change how you're going to manage that person. So it does make a difference. My next question was what analgesia would recommend for a headache. I guess it depends on what type of headache it is. Are there any things to avoid? I mean, we're often concerned about maybe the use of opiates or codeine in headaches. Do they have a role or should we be looking for other treatment? Well, I think if in primary headache disorders, I don't think that there is a role for opiates and especially codeine. So I don't think that they actually help the headaches. They can contribute to nausea and they also have the additional addictive potential. So I think avoiding those altogether. I think simple analgesics in the first instance, especially if it's, I guess, a tension type headache. I think, I guess, in the example of the patient that you've provided with the renal patient, you know, I would avoid using non-steroidals in that setting. And I guess even, you know, potentially avoid aspirin, especially if they're end stage renal failure without, you know, I guess a discussion with the team as to whether they'd be happy for those types of medications to be given. But I think, you know, you're better off just using something straightforward like paracetamol. Okay, no, I think that sounds very sensible. Any other take-home messages on headaches and approach for junior doctors? I guess getting a good description from the patient. So getting them to describe the headache in their own words. |
Welcome to On The Wards. This is John Scott and today we're talking about financial wellness with Dr. Jules Wilcox. Welcome Jules. Hi. Jules works at Gosford as an emergency physician and is also the DPET. So welcome, Jules. So today we're going to talk about financial wellness. So I guess, what is financial wellness and why is it important? Yeah, I think this is a topic I've become gradually more interested in over the last 10 years or so. It's something I found that we were given no training on whatsoever in medical school or in my subsequent postgraduate years. And I think to me, financial, I think financial wellness can mean lots of different things to lots of different people. It's not being rich. It's, I think, allowing you to do the things that you want to do and structure your life in a way that you want to be able to structure it so that money isn't an object for achieving goals and doing things that you want to do. For me, financial wellness is time because if I don't have to work all the time, I can do other things, spend time with family, go surfing, do other projects and so forth. So to me, being financially well means that I don't have to be out there, you know, earning a living, slaving away because I have investments and passive income coming in that will freeze me up to do the things that I enjoy. And one of the things I really enjoy, in fact, is going to work, but I'm doing it on my terms. And I'm not doing it because I have to go to work. Because if you're like that tend you're kind of a slave and you start to resent it yeah and i think you become a worse doctor because of that it's funny you're saying that actually when you as you were saying at first i was disappointed because you're not going to tell me how to be rich today but also took me back to when i first arrived on the coast and i rented a house i had no financial outgoings turned up to work which paid me what seemed pretty well and I went surfing and that was it that's probably the happiest in a way I've ever been because I didn't have all these other burdens over my head that sort of change the way you look at life. Yeah absolutely I mean I remember going traveling when I actually met my wife when I was traveling in New Zealand and you know I had I think when I met her I had five surfboards and 500 CDs it was a long time ago and I had no money no savings nothing I'm incredibly happy though. So money is not the source of happiness. Yeah, because we think when we become a doctor, we get a good career, or that'll be it. We've got a good income, so we should therefore be happy. Yeah, but you find as you go up and you assume more responsibilities and you get kids or a mortgage and all these other things, it doesn't matter how much you get paid, you can always spend it. It's working about what your goals are and what you really want out of life and then having the finances to allow you to do that, which is the thing that's important, I think. Excellent. So why are we talking to you, Jaws, then? What sort of skills have you learned that have enabled you to hopefully achieve that outcome that you want to be sort of time rich, I guess. Yeah, so I think the first really important thing to say is that I'm not a financial advisor. So none of this is financial advice in terms of specific what you should invest in and this and that. This is more about sort of general principles and practices that perhaps you could think about incorporating and looking at so that you can then make up your own mind and form your own ideas about things. Because at the end of the day, I'm a sort of 50-ish-year-old white guy who's had my own life history and things, and I could give advice out all over the place. But if you're 20 years younger than me and you're not married, what's right for me isn't necessarily going to be right for you. Plus, one of the main things with investing, we can get on to that later, is really that you have to have the same, you have to have the right beliefs. It has to fit with your beliefs, otherwise you're not going to be able to do it. We'll talk about that. We'll come back to that later. So I got quite interested in some of this, partly because I think it's just the way I am. If you look at my Myers-Briggs, I'm ENTJ, which is the one that is most like, most traders are of that makeup. I think I think that one explains a lot. And, you know, over the last 10 years, I've done gradually more and more reading and things. And I was looking at ways, you know, I have my own self-managed super fund. And I thought, well, I'd rather, if I lose money, it's my fault. I don't want to pay somebody who then loses money because most fund managers do lose money over the long term. And so I figured, I thought, well, I need to educate myself. So I started getting interested in that sort of thing and it's kind of gone on from there to the point now that I guess some important things, I looked at doing the financial advisor training and things. I actually did a lot of the reading. I didn't go through with it because I didn't think it was actually that useful. I thought it was going to give me a lot of insights into why I should invest in this and how it doesn't. It's really about how you construct a portfolio for your clients and cover your arse. There's a whole lot of stuff in there about conflict of interest. Yes. And some of the resources they're saying in the thing was the daily newspapers and things. And so when I started reading that, I thought, you know what, this probably doesn't have a lot of value for me. This is a conflict of interest in itself. Yeah. So I went through that. I got involved with some people that run a managed fund and things and spoke at some trading conferences on the psychology of it. I've been training with the Van Tharp Institute in the US to become a professional Forex trader. And that's been an interesting journey because they believe that it's all about psychology and you don't trade the market, you trade your beliefs about the market. And the first step of any investing thing is really taking a good hard look at yourself and your goals and so forth. So I've come through this sort of very circuitous thing. And I used to play professional poker for a living, as you know. So that obviously took the speculative bit, but there's a lot of money management rules in there that you need to master and things as well. So yeah, it's something I've had an interest in. And I think over the years, I've managed to surround myself with some really good people that I trust who are very smart, who know a lot about this stuff. And I can perhaps pass on some of their ideas and their thoughts about things. Because I think that's one of the hardest things about financial management is who do you trust? Yes. Because most of the time, and I have friends who run this managed fund, they say, you know, financial school, he says, we are taught to look for you guys. Is it because you're really time poor and you earn lots of money over your lifetime, so you've got a big target on your back because you're just like, yeah, we'll give it to them to manage. It's too hard. It's too hard basket. I don't understand it. It's not medicine. And they said, so you're the ideal clients for us and we are taught to aim for guys like you. So you've got to be very aware and doctors are overrepresented in scams and things. We are targeted. Absolutely. My financial planner said the same. Most doctors, they're the worst with their money of anyone. They take on all this debt, then they finally get some money, and then they go and blow it on a sports car. And I'm one of those. I was going to say, that sounds very familiar. I'm sure I did tell you not to buy that. Yeah, you did. So Jules, you're someone who's well on your way to, I guess, financial freedom or your money working for you and being in the situation that, looking back 20 years ago, you'd probably be pretty happy to be where you are now. And it's been quite a journey for you to get there and a lot of personal education and investment in yourself and everything that you're just discussing about. |
I think before we move on to anything about investing and all that sort of stuff to do that you've got to put yourself in a situation where you can invest. So you need to sort out your finances on a sort of day-to-day level, first of all, on a week-to-week and a month-to-month thing, and end up with some savings and a lack of debt that you can then think about investing. And there's different types of debt. We can talk about that later as well. But I think one of the best things you can do if you want to sort of start with some good principles is get the barefoot investor and read that and do what he says. It's really simple, good advice. And, you know, it's, what, $30 for the book or something in the bookshop. And I would thoroughly recommend you do that. It's very simple. I know a number of people who have done it. And I've recommended it to people before. And they said, you know, it really makes a difference. Because it'll set you up with good financial practices for the rest of your life. If you win the lotto, most lotto millionaires, a couple of years later or five years later, they're no happier. And they And they've usually lost it all as well. Yeah. Because they come to it quickly. They haven't got that good financial management which you need if you're going to make money in the end, if you're going to make it work for you. Okay. So simple principles over time pay dividends essentially, isn't it? Yeah. And is it worth us discussing what those steps are or should we just read it? I think just go read the book. If we start discussing they won't go by the book. Okay. So, all right. So do the simple things, do them well. Make them a habit. Yeah, make them a habit. So that's things like minimizing your debt. What about investing then once they've got those things under control? Yeah, actually, before we do that, because one thing he doesn't touch on the book so much is insurance, particularly for doctors. If you're listening to this, please get income protection. Over your lifetime, you're worth about $15 million. More if you're going to do something like ophthalmology. This is like an ED consultant over their lifetime. Yeah, a lowly ED consultant. Working in the public system. And I put it to you that if you owned something that was worth $15 million, you would insure it. You are your most important asset. And every year we have horror stories that somebody has had a horrendous accident and then can't work. Somebody has got cancer or leukemia, things like that. And what they don't need when they're trying to get better is financial stress as well. If you're just on your own and it's just you, well, yeah, sure, you don't need life insurance and things, but if you've got family and kids, you want to make sure. Yeah, and a mortgage. My wife and I, I have pretty good income protection and life insurance so that I know that if something happens to me, all of the mortgages, all my mortgages will be paid off, all my properties in various countries that I own. And my wife will have an income that will mean that the kids can go to university and she won't have to go to work. There won't be no hardship in the family. And that is an immense source of security and comfort to me. Yes. And part of my role, I see it as a husband and a father, is to provide for the family like that. If you don't have dependents and things, obviously you don't need the life insurance, but you need income protection. Something could easily happen to you. We were trying to get here today, weren't we, to do these podcasts. There was a crash on the Harbour Bridge. And I've heard that apparently a woman was killed today in that crash on the Harbour Bridge and they shut the Harbour Bridge and it took us three and a half, four hours to get down here from Gostin. But you don't know what life's going to do for you. So it's really important and it's really important to get the right sort of insurance as well. So you want insurance that will pay out if you can't work as a doctor. Now you have to look into the companies that do that and things and get proper advice on that. But you don't want something that just says, well, if you can work in Coles, we're not going to pay you. And that is not my retirement plan. No, definitely not. So I think insurance is really, really important. So it should be life insurance. Yeah, or income protection, definitely, and life insurance if you've got other dependents. And if you decide not to take it out because you think, well, I'm pretty healthy and everything, and I'm prepared to roll the dice for a year or so, that's fine. It's up to you. But make it an active decision so that in a year's time, you then revisit that decision and go, what about now? Don't just forget about it until suddenly something happens and then it's too late. And you get it when you're young and you're fit and you're healthy and it's easy. You haven't got any exclusion criteria. But if you get that cancer, you can't claim on it then after you get it set up like that because they're going to exclude it or you have an MRI or whatever it is. And at that stage, it's pretty cheap, isn't it? It gets more expensive as you get older. The risk goes older. But also at that point, you're earning more so you can cover that. Yeah. So it all way up the risk and benefits and things, but just make it an active decision and an informed decision. Okay, so we've thought about insurance. We've made some decisions there and got that in place. So what should we be doing once we've got the basics and we've got some savings? What then? Well, I think you need to work out what your goals are. The Van Vliet guys talk about your financial freedom number. And what that is, it's how much money do you need a year to live on, to do all the things that you want to do. Go traveling, fly business class, whatever it is. Join golf clubs. It doesn't matter what it is. But how much is that money going to be? How much do you need? What's the figure? What's the figure? Yeah. Because that's the figure you need to get in impassive income through either rent from properties or dividends from shares or whatever. Once you know what that is, then you can structure an investment plan as to how you're going to get there over what time period. Yeah. If you don't have a strategy, you won't achieve anything. Absolutely. Yeah, absolutely. Or you don't have a figure. Yeah. And if you don't know what you're doing, you're not going to get there. You don't know where you're going, you're not going to get there. So I think that's a really important thing. And so part of that is working out what your goals are. When do you want to retire? At what age? When do you want to go part-time? Do you want to work full-time until you're 65 and then stop or whatever? These are difficult concepts when you're 25, just hit the wards when you feel young and fresh and you can do nights forever and do evenings and life changes, doesn't it, once you hit 35? Your stamina for that stuff suddenly changes. I'll tell you about it. Last week I got called back in. I ended up getting like two hours sleep for the night. I had stuff before that evening shift. So I started work at nine in the morning and I got home at two in the morning, got sleep at three, got a call back in at five and had to go straight from one thing to the next and got home at four in the afternoon. And normally I would have just gone for a surf, had a couple of beers, carried on. Yeah. Oh, I was absolutely buggered for two days. For two days. Yeah, exactly. So your stamina for those things changes as you get older. It's probably worth for the JMOs, interns and residents listening to have a chat with some of the guys who are a bit further down and see what their appetite and what they want, how they respond to those challenges as you get older. |
And plans can change, but you just need to think about it. Write your plan down as well. Write it out. You're far more likely to achieve things if you write them down, even if you don't necessarily stick to them. But, you know, it may not be that it's that that's the thing, but maybe in fact you've got kids and you want to spend a bit more time at home with them. Yeah, I do have. I've got a 13-year-old and an 11-year-old son. And those are crucial years. I want to be able to spend a bit more time with them. So I've cut my hours down. Now I can do that because I've structured my life in such a way that that's okay. But if I was indebted up to the hilt and had an extravagant lifestyle and all this sort of stuff, then I wouldn't be able to do that. Yeah, and that's the danger of taking on too much, of having a huge mortgage that now you have to actually think about picking up extra shifts to pay it off when you actually want to be phasing back and spending more time with your family. Yeah, and we're in, we're in an era of incredibly low interest rates. But when I was back living in New Zealand and we did, we got some investment properties in New Zealand. At one point, the interest rates went up to 10%. And I was suddenly working most days to cover the mortgages on the investment properties because we got in when, you know, the interest rate was 5% or 4% or something like that, you know. And so suddenly our mortgage repayments had doubled. Now, one of the reasons I took those on was because I knew that if that happened, I could cover it. It doesn't necessarily mean that I want to do that again. So having a really structured plan as to how you're going to get there and over what time period, because the bigger returns that you you want the more risk you need to take on generally and the only thing that would diminish that is the amount of time yeah so if you want to make 20% in a year that's a massive return if you want to make 20% in 10 years that's not so it's hugely important to think about what you need and why and what you know what what to want and what to need you know in terms of in your plans and things yeah what you make a necessity will happen, but if you just, it'll be nice. Yeah, but also, do you really need that European car? Can you make do with a Mazda? Is it a want or is it a need? And only you can answer those questions. But I think sitting down and really having a really good hard look at yourself and what your goals and what your values are. Why are you doing what you're doing? And a lot of the things you ask yourself, if you came up, let's say you came up with a number of 200,000. And you say, okay, that's the amount. So what will that give you? And you just keep asking the question, what will that give you? And you write it down. And when you get back after you've done it four or five times, you find out often that you get back to principles often. You know, 200,000 a year, that'll give me fun and that sort of stuff. And then what will that give me? That'll give me happiness. Okay, and what will that give you? And you go back. Time with the family. Yeah, it's time with the family, security and all that sort of stuff. What will that give me? That will give me happiness. Okay, and what will that give you? And you go back and so it's... Time with the family. Yeah, it's time with the family, security and all that stuff. What will that give you? And it will give me probably peace and contentment. Okay, so my underlying goal is to feel peace and contentment. Well, how do I need to go about that? Well, it's not buying a European car that's going to do that. It's going to be... And it's not buying necessarily properties and working... So you can structure things and you have to look really deep into what you want and why and over what time frame. And only then can you get your investment plan sorted. And then you need to look at the different avenues you're going to do that. Yeah. Yeah. So, okay. So having a clear strategy, being very clear about why you're doing it. Yeah. And then... And trying to find good people to do it. do it as well is really important. We can talk about perhaps some of those resources that we use, that you and I have used. I was just wondering if there's any particular pitfalls you think that people commonly, and we kind of mentioned the one about the European sports car. I'm taking very personally. Any other things that you think people should be careful of? Yeah, I mean, 97% of traders lose money. Okay? So don't bother trying to trade unless you're really going to put a lot of work into it. You're going to lose money. Most people, because people, you know, people and friends, I get phone calls from people saying, oh, hey, I wonder if I could pick your brains on some investment advice. I had one the other day, actually, and a guy friends with me says, oh, just, you know friends with me says, which broker would you recommend? And I'm like, okay, for what? What do you want to do? Well, what timeframes are you trading? What markets are you trading? Are you going to be doing Forex? Are you doing equities? Are you doing US stocks and things? What is it? I'm not'm not really sure at the moment. Okay. So, well, let's draw down to this a little bit more. What's your entry criteria for buying a stock? So you're going to do stocks. Okay. And what's your exit criteria? When are you going to get out? What's your plan? Oh, yeah. I don't really know yet, but I just thought I'd, you know, I'll probably start just trying to trade a few and buy a few here and there. I said, just don't. You're going to lose money. You've got no idea what you're doing. You haven't got a plan at all. And Van Tharp, who I'm doing all my trading work with, says, whether you make money or not on a trade, that doesn't matter. It's whether you follow the rules or not. And if you don't follow the rules, that's a mistake. If you follow the rules and that trade doesn't work out, well, that happens. But if you don't follow the rules, that's a mistake. And if you don't have any rules, then everything you do is a mistake. It's just luck. Yeah, absolutely. And just to give you an indication, so I'm just starting this Forex trading now. I spent the last 18 months to two years so far working on this. I have written probably something in the order of 300,000 words in terms of systems and other bits and pieces, beliefs, looking into my own psychology of things, working out worst-case contingency plans and all this sort of stuff. I put as much work into this as I did becoming a consultant in ED because I want to be successful. I know that only 3% of traders are successful. That's why they make it so easy for you to open up trading accounts and things because they want your money. They know you're going to lose money. If it was really easy, you would be working for them. They would make it really hard to open a trading account. So that's probably not for everyone, is it? The trading? No, absolutely not. Investing is slightly different because I think that's a long-term time frame. But the commonest thing that people do, I find, is they find, hey, what do you think of oil? What do you think of this stock? Or what do you think? I say, it doesn't matter what I think of it. It's irrelevant what I think of it. That's just my opinion. What do you think of it? Why are you buying it? Why are you thinking of buying it? What's your goal? When are you going to get out? Getting out is the hardest thing. There are actually a couple of strategies. I could show you them. |
So it doesn't matter when you buy. It's all about the position sizing and the exit strategies. So people have got to, but people don't want to put that work in. They want the quick tip that's going to get them rich and make them money and all that sort of stuff. And it just doesn't work like that. So really for our GMOs, they probably should try and avoid those kind of things. Yeah, don't do it. Or if you're going to do it, put a lot of work into it. Yeah. And what about ETFs and things like that? But again, what's your plan? When you're getting in, when you're getting out, what's your exit strategy? How much are you going to position sizing? How much are you going to buy of that? In terms of your overall net worth, there's all sorts of things. You talk about diversification of portfolios and things. I think you and I would both agree that we, and Australians in general, I think we like property as a way of generating passive income. But there's times to do that as well. And there's ways and means of doing that. You need really good tax advice. If you get the tax wrong, you're going to lose a whole heap of cash or not make as much money as you could. There's gold and there's bullion that you can use if you want to go down that thing as a store of value. There's cryptocurrencies, you know. And, you know, disclosure here, John and I are both really keen on various cryptocurrencies, but not all of them. But it's part of a well-thought-out strategy that we've talked about over a long period. But if you took my wife and got her to invest and do stuff, she would be so different to what I do because that's got to fit with her beliefs and her strategies and so forth. So it's a very individual thing. That's why I say I can't, I'm not going to try and even give advice. But I think you just need to think, know yourself well, know what you're trying to achieve and then construct a plan to achieve that yeah and I guess yeah consistency to your plan over time generally pays dividends but do it because that's what's going to that's what's going to allow you to cut your hours down in the future that's what's's gonna allow you to retire or retire early. That's what's gonna be a source of strength if somebody in your family has a really bad illness or an accident or something, you need to take time off and things. Because that's where the financial wellness aspect comes into it. It's being able to ride out those shocks because who knows what life is going to throw at you. And there's a myriad different ways of doing it. You know, if you change the rules of the game, you know, at the moment a lot of the rules seem to be, well, if I've got the biggest car and the biggest house and this and that, then I'm successful. Well, why don't you just change that rule? Yeah. You know, why don't you change that rule to, you know, well, if I get to sit on my sofa to have coffee in the morning because i don't have to go to work today then i'm successful yeah you know um it's up to you what you play by the rules that you want to make not what people try and dictate to you yeah yeah exactly i was having a discussion with a chat with a mate who's not even 40 yet um and he's pretty much paid off his mortgage he also had a house in germany which he owned outright and he's just sold that so now he's in a position where he's got his house that he owns and he's pretty much paid off his mortgage. He also had a house in Germany, which he owned outright, and he's just sold that. So now he's in a position where he's got his house that he owns, and he's got all this money from the house he's just sold, and he's deciding whether he takes redundancy so he can go to Japan to see family out there for six months, or he takes the promotion. That gives him a lot of luxury, that sort of being in that position. Absolutely, and I think, you know, when you look at decision-making, the more options that you have, the better the likelihood is that you're going to be able to make a decision that's right for you. If you've only got one option or two options, you know, your decisions are really limited. Yeah. If you've got 10, it may take you a little bit longer to make that decision, but the chances are that decision will be one that suits you a lot better because you've had more options and you want to give yourself as many options as possible when you're going through life with that. That's right. Yeah. I always struggle because I always want a bigger house with a better view. I'm sorry, a bigger house, but I definitely want a better view, but I've got to got to pay a lot of money for that. And then I struggle because that means I now have to work for the next 20 years to pay for that view. But you just change the rules of the game. I hadn't done it, but it's always that little green-eyed monster sort of rears its ugly head every now and again. Or go buy some land in Costa Rica and save like $30,000 for half an acre. And you've got a great view. Who says you have to have the view in the central coast? That's right. Change the rules of the game so you can still achieve things that you want. So I guess that's, to summarise all of this, the point of taking care of our finances now is so that our money can give us freedom and we don't end up a slave to it. Yeah, absolutely. And I think, again, this all relates back to what we do, the core thing. You're going to be able to look after patients better. You're going to be a better doctor. You're going to be a nicer person to work with if you enjoy going to work because you don't have to because you want to do it. So I think that's sort of one of the underlying drivers to go back to that thing of why are we doing this? What are your goals? If all my investments in crypto and things came off and I had ridiculous amounts of money, would I still go to work? Yeah, I reckon I would because I enjoy it. I really enjoy being with the people that I work with and stuff. Some of the patients that you see and the things you get to do and all that sort of stuff. But I would do it on my own terms completely. Yeah. And that'd be interesting, wouldn't it? Because I think for me, I would actually enjoy work more in a way because it's a choice I've made to go there. I've been having that discussion a bit with people actually. And when you actually really think about why we do medicine and you think about that concept of Ikigai, you know, the job that we do does tick all the boxes, you know, so I'd be hard pressed to find something that had more meaning for me. So, yeah, if I had no debt and had however much money in the bank, I'd still be there. Maybe not be quite as much, but it's still something I'd want to do. I wouldn't want to be there at 2 o'clock in the morning, you know, and not getting sleep because that's not healthy for me and so forth. But teaching and seeing patients and doing stuff like that, yeah, absolutely. I would say one of my friends was saying the other day and I said, oh, you know, this and that and I would say hopefully I'll be able to be in the position where I can retire and not need to work again in the next few years. And they laughed at me and said, you'll never retire. I said, no, I don't think I would. I've always got 101 things I'm doing because I enjoy them. And that's the point. Not because I have to go in and do it. It's a big, big difference. And I think the other thing I would say just for JMOs who are listening is that that's the other thing, is that once you get out the other end and so once you become a consultant you are in charge of your destiny but you don't want to start planning that once you get there absolutely you want to start it before because the biggest thing that you guys have that I don't have is time you've got to give your investments time unless otherwise you have to take on more risk, huge amounts of risk. The seventh wonders of the world is the miracle of compound interest. |
Welcome to On Rewards, it's James Edwards and today we're speaking about the medical issues in pregnant patients and I'd like to welcome back Dr. Nhi Nguyen. Welcome back, Nhi. Thanks, thanks, James. Nhi's an attentivist at Nepean Hospital and has previously spoken on the wards. In regard to this topic, because you really have a special interest in this area, Nhi. Yes, I do. So I do obstetric medicine as an interest, mainly in the critical care, but obviously I also look after them in the antenatal and postnatal period. So hence the sort of the, I guess, the expertise around it. Because I think we all see pregnant patients with MS, but we're on the wards, and just by being pregnant somehow freaks us out because they could have the usual medical problems that everyone gets, special problems that only people in pregnancy have and also makes the assessment often more difficult. Absolutely and I think even in the most seasoned players it can be pretty scary at times and it's around the concept of two patients and the risk of getting it wrong feels like such a high burden of responsibility, which I think is why we're all a little bit, you know, sort of really mindful about looking after these patients and making sure we assess them properly. Okay, so look, in the setting of that, you know, that's really good for the junior doctors to kind of get a bit of understanding about what some of the issues are and we'll start with the cases we do every week and this is a 30 year old female who presents in the emergency department with a three-day history of shortness of breath and a bit of right upper quadrant pain and maybe a pleuritic component. She's 32 weeks pregnant and this is her first pregnancy and everything else has been pretty well from an antenatal history and she hasn't got any too many other medical problems. So we've got a very broad stem, so what sort of things are you thinking of if you're going to start seeing this patient? So first thing to say is if you ask every 32 week pregnant patient, at some point they feel short of breath and they get niggly pains and often it is sometimes in the right upper quadrant. I think that an approach to this is that it's the balance of patients who normalise their pregnancy and think that it's just niggles and they ignore it to a patient who on advice or has been troubling them long enough that they would take the time to present to hospital. So in your assessment, you need to think about those, balance those two things. On the other hand, the risk of missing something is really significant. So therefore, it is really important to make sure that you have a structure to go through the symptoms in order to elicit things that might be worrying. There will be some things that you can dismiss and others that you can't. And because of the implications of a whole lot of investigations which we'll go through, sometimes it's a balance of those risks and benefits. For a patient at 32 weeks pregnant with this sort of history, things that you need to worry about, just as you've talked about, there will be problems which occur even when they're not pregnant and those specifically in pregnancy. So the list of differentials for all patients would be things like pneumonia, for instance, is a good example of someone who's short of breath. Particularly for the pregnant woman, they have a much higher risk of pulmonary embolus because of their clotting tendency. So you need to worry about that. You need to think about specific things like preeclampsia, particularly at 32 weeks, and the elusive peripartum cardiomyopathy, which absolutely is rare. However, if you don't look for it or think of it, then you can't diagnose it. So they would be my top four differentials. So you describe a structured approach. So we go back to, I guess, history and exam. What particular things on a history are you going to be asking about? So the history would be standard for any person who comes in. So a little bit to do with how did the pain come on, what are the features of it. I think this should be seen with the caveat, though, that pregnant patients don't present classically. And if you say to them, do you think it comes on when you take a deep breath? And they'll go, well, maybe sometimes. So I think that although the history will contribute somewhat, I don't think that any component of the history can be used as the reason for you not to investigate. And it comes down to thinking, it very much is getting some help with some senior decision making when you can and not ignoring little bits that might not fit in with the story. But there's no doubt the specific things is in relation to preeclampsia, for instance, would be if there was a family history of preeclampsia with either the patient themselves may be born prematurely, if there has been any hint of clotting disorders in the past in the family, although this particular patient herself doesn't have a history, it may be in her sisters or maybe in her mum. I always am really mindful if they have had recurrent miscarriages, if they have an assisted pregnancy with IVF, twin pregnancies, all those sort of features may sway you to say that they're at higher risk of developing preeclampsia and therefore you would put that higher on your differential. I guess thinking through the risk factors for DVT would be, and pulmonary embolus, think that absolutely physiologically third trimester patients are more prone to clotting in general for who are pregnant. However, sometimes the source of the clot may not be in the legs and may actually be in the pelvis. So there is a little bit of clinical decision making in the absence of history of travel and even in the absence of unilateral leg swelling, you would still need to consider the pelvis as being a source, particularly from the third trimester onwards. And when you do an examination of a pregnant patient, is there anything in particular you'd look at in addition to what I guess we'd normally do, or any changes in, I guess, their vital signs? Yeah, so an acknowledgement that in the physiological changes of pregnancy will mean that the patients will have a resting tachycardia often. They have a physiological, so they tend to feel warm and vasodilated. Patients are often hypotensive or relatively hypotensive. So those features, for instance, if you were worried that these were features of sepsis, for instance, or presentation with infection, they can be masked by its normal physiology. And then if you're worried that a sinus tachycardia is a reflection of pulmonary embolus, it actually may be arresting tachycardia. So I think that those, you know, I think when you see these patients, examine them as you would normally do, anticipate that it may very well be relatively normal exam and these patients may actually look relatively well. And it's listening to the features of the presentation and how troubling or how worrying it is to the patient. And that then allows you to have some joint decision-making because they are guided. Sometimes they come in wanting reassurance that it's nothing. At other times, it genuinely is, you sort of say, based on your examination and the history that you've taken, that you genuinely feel like it's worth ruling out because the potential to miss a diagnosis such as pulmonary embolus is such a high risk. Are there any other areas that you particularly examine in a pregnant female that you may not routinely do and someone else you were concerned about a pulmonaryimbalance? So what in what way do you mean? I mean do you routinely look for things like making sure if you're worried about preeclampsia, do you test for reflexes, do you always examine the baby, the baby heart rate? So I always, know, I think if I'm worried enough, I will ask for a CTG and get the midwife to come to do that. And just explain what a CTG is. Oh, sorry. So it's to look at the baby fetal heart rate, okay, and check on baby movement, which is over time. Now, in general terms, in my history taking, I would say to the mum, have the baby been moving normally? They'll say yes. They might sort of say, oh, look, actually hasn't moved as much, but I sort of put that as a sort of a bit of a history of the thing. Okay, well, I'll need to make sure about that. Okay, so that examination. You can do an examination that has an estimation of fetal growth. I don't think as the general clinician we're not as good and trained in that. So I think that if you ask the mum, you know, have your babies, the tests so far been normal? Have they told you growth's normal? |
Okay so that's really an indication that the fetal growth if it's impaired at all occurs over a period of time and it's usually about placental insufficiency. So in a setting of someone with a three-day history, it's unlikely that there's been any issues with that. From the point of view of clonus and reflexes, patients who are pregnant will be hyperreflexic and in general, very easy to elicit reflexes without the tendon hammer. But pre-clampsia, you will then see sustained clonus. And that, if you haven't seen a lot of examination of women with clonus, that's sometimes not something that you would easily know how to interpret. But certainly, you know, check to see what the reflexes are like. I mean, you mentioned getting a CTG, which you can do if you've got obstetric service in your hospital. Is there a role for checking for, I guess, a fetal heart rate, either using auscultation or many of us have ultrasound for the RED? Sure. So I think a quick ultrasound would be... It was readily available. I don't think that it should distract from your examination of an assessment of the mum. So we've done a history and exam and I guess we'll be stratifying what we think this is, whether this could be a problem with the emberless and we're considering what investigations we would like to do. What investigation would you consider in this patient? Okay, so I would do the routine, what would be considered to be routine observations and also investigations like blood tests. Now I would do these tests mainly to help rule out big red flags like a white cell count that's grossly elevated, hinting towards an early pneumonic process rather than pulmonary. It's unusual that the blood tests come back to be grossly abnormal. You will have the uric acid or urate in particular points to preeclampsia. So that's worthwhile doing. The urine dipstick is mainly to see whether you've got proteinuria. Because often these patients will say that, yes, I'm a bit edematous and a bit puffy, but didn't realise they've got two or three plus. And that would certainly hint towards preeclampsia. An ECG will most likely demonstrate a sinus tachycardia. However, you might find some, you know, there's certainly been times in the past where I've looked at it and thought, oh, look, I can see a pattern that might be consistent with right heart strain. However, it is rare, okay? But it's not to say that you shouldn't do it. The reason you would do a chest X-ray, for instance, with appropriate shielding of the foetus would be to make sure that there is a pneumonic process and they don't have gross pulmonary edema, which might hint at a cardiomyopathy, for instance. I mean, often chest X-ray, we consider chest X--ray and they'll be concerned about radiation for the fetus. How would you counsel a young woman who's 32 weeks pregnant? Yeah so I think the radiation dose with appropriate shielding is minimal and when I speak to patients about this I will say that that helps me to, if the test stops me from doing another test, which involves more radiation, then it's a worthwhile one. So patients think that because there's such a heightened awareness of it, there's lots of concerns. About 32 weeks where the baby's actually grown and developed, the risk to fetus is minimal. I mean there are many baseline or routine tests you describe we're doing, but sometimes you get the normal findings may differ from a non-pregnant patient. Can you kind of describe some of those? Sure. So the physiology of pregnancy does mean that patients have a respiratory alkalosis. So you have to be mindful of baseline venous blood gas. The PaCO2 will be around 30 or 32. You have an elevated alphophos because of the placenta, so that's going to be completely normal. Your white cell count may be marginally up, and it's very, very nonspecific. At the third trimester, you'll have the physiological anemia of pregnancy, which is a dilutional anemia because of increased blood volume. And the increased filtration rate in the kidneys means that urea and creatinine are relatively low. So not uncommon to see a urea of 2 and a creatinine of 40 or 50. So that leads to the fact that if you have a creatinine of 70 or 80 or 90 in a pregnant woman, then that means that there's moderate renal impairment. You also mentioned during an ECG, are there any particular variants that you see in pregnancy? I don't think so. You know, I don't think there's anything in particular. I think apart from the sinus tachycardia, you wouldn't see much else. Now, we've mentioned preeclampsia as a potential differential dose for this patient. What particular things would point to the diagnosis on your history and investigations? So keeping in mind now that preeclampsia is really part of a spectrum of disorder. So it ranges from gestational hypertension all the way through to preeclampsia and eclampsia. Classically speaking, the definition of preeclampsia is it must occur after 20 20 weeks and there are features of organ dysfunctions which can occur which allows you to grade pre-eclampsia. There are guidelines in regards to the elevation of blood pressure readings. I think we really need to be mindful of this because if you want, classically speaking, more than 140 systolic on 90 on more than two occasions or a 20% increase in baseline. Now, a one-off blood pressure reading, if it's really elevated, then that contributes to the clinical picture. But we will often do blood pressure profiles rather than a single blood pressure reading. So I think if a junior doctor comes and assesses this patient in ED, they've got a blood pressure of 180 on 100, then absolutely, together with protein diphtheria, proteinuria, and a few other features, you start to put the picture together a bit. But the absence of hypertension does not preclude you from having the diagnosis. OK, so you don't have to have the full deck, in a way. There are absolutely other things to look for in all... Because preeclampsia is a disorder that affects multiple organs, and in doing so, it can then help you to classify the severity. So we've talked about the blood pressure changes. We've talked about proteinuria. You can have haematological changes with a low platelet count. The thrombocytopenia, which can occur as a result of preeclampsia, could be part of a spectrum of help, which is the elevated liver enzymes and thrombocytopenia, which can occur, and hemolysis. So that in itself may overlap with the features of preeclampsia, but that's its own entity. You can get abnormal LFTs mainly in the ALT and AST rather than the obstructive enzymes and the neurological findings which is a manifestation of cerebral irritability can be as mild as a headache which is persistent and not amenable to any simple analgesics, to visual disturbances, visual loss, and of course the other spectrum is eclampsia. When you have pulmonary edema associated with it, it's often part of the clinical picture of edema elsewhere, and the history of fetal growth restriction as a marker of placental insufficiency can mean that they have had preeclampsia developing over weeks and then present acutely rather than the acute severe type, which you might see hit at 38 or 39 weeks. So if we go back to the case, it's a bit of a review of preeclampsia, but really things are pretty similar to what you said. Like you do lots of investigations, doesn't show much, X-ray looks okay. You had some fetal monitoring, looks fine. Blood's unremarkable. A bit hyperreflexic, but no clonus. You're considering now pulmonary embolism with the pleuritic chest pain and no other obvious cause. What should we do next? Okay. All our ways to risk stratify patients who aren't pregnant have not been validated in the pregnant patient. So things that the doctors would have heard of in regards to the WELL score don't apply to pregnant patients. So it really is genuinely a case where you have to be clear what your pre-test probability is based on the history and examination you've gathered. And often these patients will fit in that intermediate risk. |
It's this grey group in middle okay where they fall into the intermediate groups and I think that at 32 weeks it would be unusual for me to say that there was a they were absolutely low risk okay so I think that for a patient like this I would be stuck thinking about what's the next best investigation there really isn't a blood test that is is going to help you because D-dimers can be elevated even in the absence of clots. So having a negative D-dimer, maybe, but the likelihood of a negative D-dimer is going to be very low. But if it's negative, then it could be helpful. I think in the vast majority of patients where I've gone to assess them or I've had a request to say what next, I've recommended some sort of form of imaging. Now the imaging modality that you choose very much depends on where you are, what time of day it is because the reality, because if you think about the two options the two options we've got or to investigate is either a VQ scan or a CTPA. So they both have pros and cons to them and there are practicalities in regards to when you can have them done. So we think through and I guess just before I leave those two modalities the other modality that I always try to get at some point in the next 24 hours is an echo. Now, the echo is mainly around, rather than looking for signs of right heart strain as a marker of pulmonary hypertension or pulmonary embolus, it's more for me to exclude peripartum cardiomyopathy as a cause for the shortness of breath. So let's think through the options of VQ or CTPA. Maybe before we do that, I mean, what's the role of Doppler? You know, the idea of, as a low risk, if you've got a DVT, you wear a keg late, you may need to go and do it, if they're scattered at all it all yeah would you do it routinely only they've got some leg swelling uh again um i think that if you have the skill set available um and i know that now a lot of ed physicians in fact do have the skill set to look at at lower limbs i would do that. I find it's very much organisational. If you can get a Doppler quickly, obviously that's a great modality because if you see it, you've got your answer in regards to not needing to do a next investigation and anticoagulation. It's the important message, though, is that even if you do it and it's negative, it doesn't rule it out. Okay, so sometimes if the history is such that my clinical suspicion is high enough, the Doppler almost isn't enough because if you think about a patient anti has it even if they've got a dvt and you have then a reason to anticoagulate them anyway you want to get a bit of a sense of what the clot burden has been in the lungs okay so um in the degree of mismatch in the lungs, because it might just help you think through planning a round-clot load, thinking through maybe an IVC filter. I think there's a whole lot of things that come into play when you're talking about a 32-week pregnant woman who may go into early labour, for instance. How are you going to plan that? So if you can buy yourself a few days and know that you're anticoagulated and you're anticoagulated therapeutically, it helps, but it's switching off the anticoagulation in preparation for labour or in preparation for planned delivery. So in practical terms, I will generally still go ahead with doing some sort of investigation. Maybe we'll go through those two, you mentioned the VQ and the CTPR. So I think the advantage of the VQ is obviously it's sort of a lower dose, and if you skip the ventilation component, you can minimise the radiation to the mother. Oh, sorry, to the baby. It does give you a sense of how much mismatch there is. And if it's available in daylight hours, which most services... If the service is available, that's only the time you can do it. So I would do that as a first if it was available. The alternative is a CTPA. Now, CTPA in most centres, it's probably more readily available than a BQ. The radiation dose can be done at a lower dose than what is believed, and it's almost on par with a BQ. The only, I guess, consideration is that you're giving that radiation in an area that's concentrated around rapidly dividing tissue like breast tissue. So that, and I don't think we know the answer to that. Okay. I don't think we know whether there's an increased risk of problems associated with irradiating breast tissue, but it certainly gives you a very, very clear picture. You know exactly what the clot load is and allows you to plan pretty well. And in doing so, will help you find other diagnosis that you might not have been expecting, like sort of consolidation that wasn't sort of clear on initial chest x-ray. Well you've gone ahead and done a VQ scan after discussing respiratory and radiology and it does show a significant VQ mismatch in a large segment of the right lower lobe consistent with a pulmonary embolism. So treatment, what next? Okay, so I think that therapeutic dosing of low molecular weight heparin is the mainstay. You don't have any other options really in a pregnant patient, okay? So you can't use warfarin, you can't use the oral anticoagulants. The advantage of a noxaparin or something like that is you can then ask the patients to time it in a way, because at 32 weeks, the anticipation is that you would hopefully still get this patient through to 38, 39 weeks and have a normal delivery. So you can counsel them. they're able to do it at home, twice a day dosing, and then counsel them that if they go into labour to make sure they don't give the dose that they were due to have, and then you have some time up your sleeve in order to make sure that it's not still sort of in therapeutic range when they go into labour or have to deliver. So I think that that's been the safest mechanism to anticoagulate. Sometimes if patients have had a really high clot load, just say they come in at 37 weeks with a pulmonary embolus and you need to deliver them in the next week or so, you might transition them to a sort of heparin infusion in hospital for the 12-24 hours before delivery or planned delivery. And you say for the twice BD dose versus occasionally use once a daily dose? So you can do 1.5 milligrams once a day. I think that the recommendations are difficult in pregnant patients because of the concept around ideal body weight versus total real weight because of the increase in total body water and the volumes of distribution are different. So we genuinely do sort of pick a roundabout dose, make it convenient, and depending on the patient and the risk factor, we might say actually we want to push on the side of making sure that they're well anticoagulated, so you'll do BD. Otherwise, for convenience, it will be single dose, maybe having established it for a little while. Great. Well, thanks for a really good summary of some of the issues with your pregnancy that we're likely to see as physicians. Any take-home messages? When you look at maternal mortality reports, maternal mortality in Australia is the lowest rate that we'll ever get it to. So under 10 per 100,000 deliveries. So we're the best in the world from that point of view. However, if you look at the deaths and the theming around the deaths which occur across Australia in those reports, pulmonary embolism or a sort of thrombolic disease is still a very significant diagnosis. And these patients, when you look at those deaths carefully, it's patients who've had the diagnosis missed. So I think for junior doctors or anyone who sees these patients, have a high index of suspicion. Be really, really careful with your history taking and the risk stratification and err on the side of doing some sort of investigation rather than not for peace of mind of yourself and the family, okay, and the patient because of those who have died of those who haven't, you know, haven't had it investigated or haven't had it treated. So I would be my, and, you know, there's no doubt the physiology of pregnancy is that a hypercoagulable state. And the hypercoagulable state exists beyond delivery, okay. So the pregnant state is present for about six weeks postpartum. So remember that patients, particularly those with preeclampsia as well, or proteinuria, will have a higher tendency to clot. So get the diagnosis and be mindful about prophylaxis postpartum. |
Okay, welcome to On The Wards, it's James Edwards and today we're having a talk about improving communication between hospital, secondary care, community care and general practice. I'd like to invite Associate Professor Sharla Hesby. Welcome. Hi, thank you James. Associate Professor Sharla Hesby is a general practitioner working in the inner city of Sydney in Glebe and also is very passionate about patient-centred care and that's why we invited you along because I think communication between the hospitals and the community is often identified as a bit of a weak point within our system. So we just want to see how junior doctors can be involved and how they can do better. Yeah, thanks James. I mean, from my perspective, it is most of the time one of the weak links in terms of how we deliver what I would call seamless patient care, because it's very easy for us to silo care and we sort of live in little systems. So we think of primary care as this sort of separate entity of a system and then we have the sort of the secondary care as another system and then the hospital operates as a sort of a system completely separated from often both of those. But the patient doesn't. The patient actually has to move across those systems and they don't get that everybody is sort of living in a different system and then the care that they have delivered sort of gets a fractured, because not everybody knows what's going on, those things. So as a junior doctor, from my perspective, I can remember not really getting it because the patient came to me and I was told, you know, so you know, admit so and so and you would admit them. And then you'd look after them. And then you'd say, well, we we're discharging them and sort of splat they're they leave and so for me as the junior doctor they didn't really exist again unless they were readmitted for some reason for something going wrong so although I had the job of doing a discharge summary and I do inverted commas around that because and I'll come back to why I say inverted commas. So I didn't really understand the importance of all the information about what had gone on in hospital in terms of what that might mean for the ongoing care of the patient once they left because it wasn't something I had any real understanding about. And I think that luckily that's changing, that I think we're better at getting that patients have to transit between care. And that's why I'll come back to that discharge summary concept, because I think if we actually use the same wording that we use in hospitals when we talk about clinical handover from one ward to another, that really that's exactly the same thing that happens when you're moving them out of the hospital back home, that it's really a clinical handover that has to happen. And so we actually sort of, it's another of the transitions of care. And so we need the same diligence of making sure that everything that means that we can safely move them into that next ward or primary care space home etc is actually sort of all signed sealed and delivered and actually done so that they can safely move from one to the other and everybody knows what's going on and I mean mean, I hear lots of reasons why, you know, discharge summaries aren't good or aren't good. Certainly when I was doing them, we had to do these triplicate, you know, handwritten things and they were appalling. Now we have these, you know, wonderful electronic discharges. But again, sometimes the information is still not always done in a way that's actually saying, well, what are the key things for this patient in order to be able to move from here? These things have happened, but these are the most important bits and these are the most important bits that need to be followed up so that we can make sure that they continue to heal, get better or have all the things that need to happen. Yeah, I mean, I think that's a real challenge. And we've had lots of discussions in my different roles about how we can improve discharge damage or the clinical handover from hospital to community. I think one of the real challenges is that depending on what the goal of that summary is, because in some ways as a hospital document, there's a whole bunch of pressure to make sure everything's written down to get the most amount of money from coding. And then there's another kind of goal to have a detailed summary for when they come back to the emergency department. And then there's usually a more short and abbreviated with really the key factors for a general practitioner to understand. And sometimes it's hard to meet all those needs. You almost have to write three separate dishar summaries, which no one's going to do. So sometimes it's for what's good for somebody doesn't meet the goals for somebody else. I think that's one of the challenges doctors find. Yeah, absolutely. And I suppose that's where I sort of go back to the patient, because if we can at least have the patient at the centre of all of those goals, then probably you can sort of, the sort of the most, the clarifying points will come out. A bit like writing a good essay, isn't it? Sort of, you know, there'll be those summary topics. These are the things that have happened. And then this means this, and then that means this. And then you hopefully would cover off on all of those goals at the same time. It's the challenge, isn't it? It's sort of understanding, well, what is important? And yes, you're right, what's important to you might not be important to the person next door to you. So hence, everything sort of needs to be there. So in regard to, I mean, you mentioned handover, which is really just a way of communicating. I mean, what are the, you think, the essential parts of good communication for junior doctors? I think the essential part is actually thinking about, well, what, you know, they don't need to be in hospital anymore. But a lot of the time, particularly now, we actually want to try and move them out of hospital as quickly as possible and move them back into home where a lot of the things that still need to be done are being done and we sort of need to sort of safely manage that. So it's about what are those key things and I think that's really good for our clinical reasoning too. If we actually sit back and go okay you know I might be interested as the surgical junior medical officer in the reason they came in for the surgery that they've had done today. But the things that are actually impinging upon that patient may actually be, you know, well, what does that mean for his diabetes? Or what does that mean for his, you know, the medicines that have been changed by the endocrinologist? And what have they meant for X, Y, and Z? Which sort of starts getting complex. But I mean i mean for me that's the joy of general practice because i love the complexity that we often have to oversee um but just being able to actually get that how complex some of our patients are and being able to sort of do a nice little crystal clear summary and think about well you know who have i got what all the things that are really important? What are the goals that we need to achieve for them in order to safely transit them there? So I'm probably have sort of said the same things again from the junior officer's perspective. It's saying, OK, do I think if I was the person who was going to read this document, would I actually understand, A, what's happened, the key things that have happened, B, what are the key things that then need to happen, and C, what are the things that we need to make sure that, you know, medication-wise and appointment-wise are actually also sort of documented so that no mistakes can happen, so that we don't fail to follow something up or we don't fail to make sure that the medicines that have been changed actually get changed. Well, you've really emphasised to me that, you know, these handover discharge summaries are really a clinical document because I think sometimes you get in your own mind when you're writing these, it's really just some paperwork, but it's much more than that. Oh, yeah, it is. you know it tells the it tells the story and i mean a good discharge summary um is just just so wonderfully helpful but it's not just the written document sometimes so it's also those phone calls so um again if i go back to my days of being a junior officer and certainly the junior doctors that i talked to today I think feel like that as well is that sometimes you you lose sight of the fact that for a lot of patients for them their GP is actually the person who's overseeing their overall care and when they're in hospital it's when they're acutely unwell and they may be very vulnerable and all sorts of things are out of control. |
And so the GP is this sort of ongoing link and the person who might know them when they've been extremely well, as well as then can take them through all of the other things that go up and down. I've been a GP long enough now that I've got this wonderful group of patients that I've been able to look after for almost now 20 years. And so therefore in in that 20 years, a lot of things has happened to them. And so they'll come and say, they know that they're sort of safe, they don't have to retell the story. But at the same time, they know I know their story. And that's where the phone conversations are often so good. Because you know, you can, you can ring up and go, look, I've got mixed Mr. X come in, and this has happened.. Can you tell me anything more? And I can, you know, fill in the stories about the social details, about, you know, what are the other complexities that have actually impinged upon why maybe they're not coping when you might think that they should be. And they may not want to volunteer that because they are feeling too vulnerable. And I start to get quite passionate often about, particularly when the socially vulnerable patients, because they're the ones that are least likely to tell you stuff often. And things are most likely to go wrong. So and the health literacy of them understanding what's going on, they might tell you or look at you in a way as if you think they know what's going on, but really they don't. And so sometimes I might know that. Classic example, one of my darling patients can't read. Now, he doesn't like anybody to know he can't read, and he would never admit to anybody that he can't. And so he came once, you know, for a consult with a dietician and was given all of this stuff to read and quite complex sort of stuff. And he came home and he had to bring it all to me so that we could sit down, read it, and then put it into a way in which he could actually then make some choices about the foods he eats. And he gets away with not being able to read because, you know, there's so many labels and stuff that people do. And so you can hide that sort of level of illiteracy. And so that obviously impinges on your health literacy. And I can tell you that without it being an embarrassment so that you can then care for them in a way that you might otherwise you know you hand them the documents and we make assumptions that everybody can read what's in those that documentation. So I mean how do we improve that dialogue between general doctors or junior doctors and general practitioners I mean when should those phone calls happen like early within the end of admission, both? Well, I always say the earlier the better. It's sort of like, you know, one of the things that we do know when someone gets admitted to hospital is that we are going to send them, well, hopefully going to send them home again. And so we should be planning for that to happen earlier on, you know, when they come in, than on the day that you go up, setting your home and at that point it's just like, well, but nobody knows and, you know, well, make an appointment and see a doctor in 48 hours or this, that and the other and that might not be possible or they can't get onto them or, you know, those sorts of things whereas at least if you can sort of plan for it. I love it when I'm phoned up by the junior medical officer in the ward and they say, look, we're going to be sending so-and-so home in two or three days and these are the things that need to happen. Can you make sure? And then we can proactively make the space, whereas if they rang, they might not communicate to the front desk staff that why or what, you know. And I'm dying for the day when I get a list in the morning of all my patients who've been admitted to hospital so that I can actually plan from that day that we need to be communicating with you and then planning to have appointments and access for them as soon as they're home so that it's sort of a bit, you know, seamless. That happens in a number of health systems around the world. And you sort of look and you think it just makes so much sense, doesn't it, to actually be told easily that you've got this list of patients. I mean, we used to do faxes of admissions. That sort of doesn't really happen so well now. Discharge summaries are so much better. Like I get them, generally speaking, within six to eight hours electronically. And it's so helpful because as soon as I get it, I can get my front desk staff to actually ring and make the appointment. But again, it's nice sometimes to know even before then. And so if you can say, look, you know, they're going home to be on their own. They really need some services that are actually going to help with this, that and the other as well. I mean, you've described some, I guess, some of the more technological ways that we could improve and make a more seamless transition. What are some other technology available do you think could that currently works now or looking towards the future that we could improve? Oh look there's I mean there's all sorts of things I get quite you know excited about the future in terms of being able to communicate electronically seamlessly between systems which still doesn't really happen happen very well. But the My Health Record, I think, is going to make a big difference because once we get the access to, in primary care space, access to pathology, radiology and all the investigations that get done in the local health district space, as well as the discharge summary, we're really going to be able to sort of understand and follow and do things better. I love the fact that we've got this sort of medication reconciliation ability now. So I know what I think I'm prescribing. I can see what the discharge summary has thought that is necessary and I can see what's been dispensed from pharmacy all in the one look now and that's just fantastic it makes such a difference but what's really interesting is I think now that I've got better access electronically I'm not I'm actually also seeking phone calls more proactively I'm much more likely to ring up say accident emergency and, and say, look, I'm sending in so and so, this is their stuff, you can access a good summary on the My Health Record. But you know, this is why I'm sending them in. And hopefully, that will facilitate better care. But by doing that, then you establish some relationships as well, so that we can trust each other. You know, you go, oh, yeah, Charlotte's not silly. So if she's sent them in, there is a reason why she's worried and maybe I then need to take this patient a little bit more seriously than I might have otherwise taken them. Yeah, I mean, I think it's my role as a emergency physician. I mean, my general rule is if a GP sends someone in, you've over sent them home, I think it's always important and polite to make sure you make a phone call to that GP because they've sent them with a good reason. If you've decided to think there's another reason, and you may have very good reasons why not, but I think you should always make that phone call. I mean, similarly, if they do come in, often people get sent in with a presumed diagnosis. I think it's always nice to ring back at that date, possibly and say, yes, that person you thought had an acute chronic disease, yes, they've had a non-STEMI, they're in the cath lab. I think people appreciate that. So I think communication, I know from the ED perspective, could always be better, but it's something I think whenever I ring GPs, they're very appreciative of. Yeah, well, it's nice too. I mean, sometimes when you're ringing up about a new patient, you can also say, and by the way, the patient that you saw in accident or emergency is now home and doing really well. So you can get that follow-up as well. Because I think that's sort of one of the really nice things is about being able to understand that the journey is all around the place. We can share those stories and it makes it so much better. So when do you think my health record will really start to kick in? Because it's been a fairly slow burn and I think it is more an opt-out. |
So from a doctor perspective this is I think a great opportunity to be able to really take hold of what this means in terms of actually having sort of good documentation. I think it puts an onus on the GP to actually make sure that there is an up-to-date, relevant, accurate summary available in the My Health Record. It puts it in the patient's area of responsibility and make sure that they say to their GP, make sure that what you put up is the right information and when things change that we actually upload a fresh document. And in the same way as the hospital sort of sector is that you know you can start to look at it and actually trust it and go, okay, it's only a summary but at least it's a really good start in terms of, yep, these are the medicines and, you know, these are the really key important other bits of data as well. And increasingly all the discharge summaries. Yeah, I mean, we've kind of, you've explained the role of, I guess, the general practitioner in the hospital. I mean, where does the patient fit in there? What ownership do they have over this medical record? Well, and that's a really good question because that's sort of where this whole sort of privacy and should I have a My Health Rec, should I opt in or should I opt out? Clearly, my big argument is that you should definitely stay in and have one, but you do have an ability to sort of have levels of control. If there are things that you don't want people to be accessing, from behind the scenes you can actually say, I don't want just anybody looking at it. It'll only be, say, the medical people that I give special permission to or X, Y, and Z. And I think that's really important because otherwise people, we've got to sort of learn to trust how people use it. The biggest argument against it I've heard is, you know, that paranoia about, well, I don't want just anybody accessing it. It's like, well, not anybody's, just anybody can access it. You know, there really are levels of, you know, as a doctor, we are absolutely bound to not access a record that we, A, don't have explicit permission to do so. And, you know, really what's the point? The reason for it is to make sure that we actually deliver really high quality, up-to-date, accurate care for our patients. That is about the patient. And as the patient myself, I want that information there. If I get hit by a bus tomorrow, I want you in accident and emergency to be able to access the important things about me. I mean, what are some of the common pitfalls you see when the communication process does break down and you don't get a great handover? Well, there's a number of issues there. So I'll go first for the patient. So for the patient, it's that classic thing of A, doubling up on unnecessary investigations where they're put through having tests that don't need to be done because that's already been diagnosed or excluded or this, that and the other. There's the errors that can happen when I might not remember that I have a certain, I had something happen to me. Classic example is allergies. You know, when someone has a major allergy to something, back we had a patient who had an allergy in 1990 something at St. Vincent's Hospital. Now that got lost in time somewhere and she forgot what it was that actually she was allergic to and because there was no sort of continuity of care or sort of handover she moved, she changed her piece and she couldn't remember any longer what actually happened so she actually then ended up being re-exposed to that drug and it went okay. It was a Keflasporin. So it was that classic thing of she'd been 20 years of not being, having had it, and then she had it again and then ended up dying of the anaphylaxis from that antibiotic. You know, with my health record, hopefully that won't happen again because we actually do have you know this ability to actually take with us those key significant allergies, those key significant things that actually happen and you know so it doesn't matter so much if I can't remember it myself personally it's there on my record for me. And I guess responsibly for patients care when they've left the hospital I think there's that period between they've left the hospital and seeing yourself in general practice there's often things that need to be done sometimes they seem to get lost on whether that's still the hospital's responsibility until they see you or once they leave hospital it's now the general practitioner's responsibility or does the patient have some involvement as well? Yep. You know, all good questions. Yes, who is responsible? You know, because as a junior officer, I've written on it, GP to do, does that mean therefore the GP must do? And what if the GP never gets it? You know, I must say it's one of those sort of classic two is when i get a letter directed to me by the patient which is to doctor doctor no name um where you know the the well-meaning junior doctor has written this really nice letter but hasn't actually checked that there is actually a name of a doctor there and again it's that you know that you know, that, well, who am I actually handing this over to? So if I'm writing a letter that says, GP, you're responsible, who is that GP? And, you know, should I make sure that I actually am doing that clinical handover? It's really funny. The Americans call it a warm handover. A warm handover. A warm handover is when I actually speak to you and say, these are the things I'm actually handing to you and making sure that you know you're responsible to, rather than this sort of cold, I suppose, just on a piece of paper. And then no one really knows, well, who is actually responsible for it. And I sort of, I warm to that idea of saying, well, if these are really important things, then we do need to take responsibility of making sure that it is properly handed over to someone else to take responsibility for. Yes. And one of the first blogs written on our website was from a general practitioner who I think, I think their title was GP to Chase, you know, whatever pet hates was, you know, in the final part of the discharge, GP to Chase, a whole bunch of things. Well, yeah, GP to Chase. And then as I said, often the letter is to Dr. No Name. And I think, you know, we've got to build up, as I talked about this sort of sense of trust. If we actually are handing over someone's care, you know, who are we handing it to? And we all need to take responsibility for that. You know, as a GP, I need to send you a bloody good letter, you know, and it needs to be actually with all the information that's relevant, up to date, and about what I think and why I'm sending them. And so I'll stand up and say, you know, there's no doubt we can always do better on that front. But in the same way, the importance of the letter back to us needs to do the same thing and take hold of, well, who am I handing that care to? Not just this vacuum of space that's in primary care, but actually to somebody to actually follow it up properly. And I think when we look at training systems of junior doctors, they're all hospital-based, you could say that they should understand primary care, but until you've worked in primary care, it's very difficult to understand what the difficult challenges are. I think most probably people who have done a couple of years in hospital and then worked with the general practice probably change their opinion, I can imagine, within weeks of working. And really it's a shame that we've lost some of that opportunity which we used to have with the PGPPP. I believe that might be coming back so let's hope it does because I'm with you completely. I think that we are far more respectful of what we each do in our own specialties I think when you've actually've actually done it, rather than it being, you know, this sort of, oh, you know, what possibly, you know, could be hard about that or whatever, and then you go and you go, okay, I get it, about what we have to do and how it gets handled. And the same, I mean, it's in all the spaces that we do. Are there any particular resources in regard to why we can communicate better with general practitioners you think would help junior doctors? Look, I think really it's about one of the things that I think is really good sometimes is actually doing tracing a patient's journey and actually getting why it's so important to have that clinical handover. |
Okay, welcome everybody to On The Wards. It's James Edwards and it's March 2015. We have the pleasure today of having Dr. Bethan Richards with us. She's a staff specialist rheumatologist based here at Royal Prince Edward Hospital and is also the Network Director of Physicians Training. We're asking you to speak about activity-based funding today and she has been extensively involved in the implementation of activity-based funding in New South Wales. So welcome Bethan. Hello James. So junior doctors are probably wondering, look activity-based funding, that doesn't have much to do with me. What is activity-based funding and why should I care or they care as a junior doctor? Well that's a really important question. I think to understand activity-based funding, which essentially now means that hospitals get funded for the activity that they actually do and also for how efficiently they do that activity. So to understand this, you need to have a historical perspective a little bit. So prior to 2012, when this came in in New South Wales, the government funded health in New South Wales through what was called block funding. So essentially, there was one pool of money and hospital services were given a block amount of money based on historical needs and context. So there wasn't a lot of transparency in that system. And because there was no patient level data, we weren't able to identify with that system, whether that money was being used in an efficient way or not. I think you'd agree, James, that we have one of the best health systems in the world. And certainly from working overseas and coming back here, that's the feedback that I get from junior medical staff. Unfortunately, though, with an ageing population, with lots of great but very expensive treatments coming through, with a more obese population with lots of comorbidities and an expanding number of people to treat, at the moment our health costs when we project forward are unsustainable. So we need to look at a system and we had to change our system to look at if we've only got a fixed amount of money, how can we make each health dollar go further? And that's what this activity-based funding system is essentially based on. So what it will allow us to do is actually gain patient-level data about how we are practising medicine, how efficiently we do that, and then with that data we can use it to drive resource allocation. So we can see what's going well, we can see what's not going well, and try and fix those processes. So it's a much more transparent way and fair and equitable way of giving money to various health services. So that's basically the background, I guess, for activity-based funding. In terms of how it actually works, so for those looking at a very basic overview, the junior doctors obviously provide a service to a patient. So anytime you you see a patient be it as an inpatient or as an outpatient that is an occasion of service and that will now be documented and junior doctors are the key people in this process in terms of what they write in the notes about what that service contained. At the moment now, for inpatients, all that information is then sent down to the coding department, and the coders then go through the notes and look at the documentation, and based on that, they form what's called a DRG, or a diagnosis-related group. And essentially, that just means that all diseases are grouped into a DRG which reflects the cost of care for that patient. So that information, these DRGs, are then sent back to the government and the government then pays the hospital based on that information for the amount and the complexity of the patients that they've then treated. So you can see already that junior doctors are a critical part of this process because they're the ones doing the documentation. At the moment now that information is then put into a performance report and the consultants of the hospital will receive these performance reports on a quarterly basis and that will allow them to see how well they're going against their peers in other hospitals. And then that information is analysed and we can use it to try and improve the quality of patient care. So that's sort of the background and a key, key step in the process and really an important take-home message is that junior doctors as the primary documenters of all this information are critical to the success of this whole process working. And valuing documentation and some tips that we'll go through shortly will become a really important part of day-to-day practice. Hi there Beth, and we've got lots of junior doctors who listen to our podcast who aren't from New South Wales. Is this just something we see in New South Wales or this is in other states within Australia? Yeah, so no. New South Wales is actually a bit behind the game compared to the rest of Australia. So many people, particularly if they've come from Melbourne, this was implemented in Melbourne about 20 years ago. So they are already seeing this as part of day-to-day practice. And so certainly we're catching up to the rest of the states. We are looking at activity-based funding now with a national perspective. So this is part of a larger agreement at a national level that all of health across all states goes to this activity-based funding model. And what that's going to allow us to do in time is actually to compare how efficiently we're treating people and what important clinical outcomes there are at a national level. So we're going to have a really useful set of data granularity that's going to allow us to answer some really important questions in this database of information. We'll go back to the role and the practice of a junior doctor. What impact does activity-based funding have on them? So in terms of the day-to-day practice of medicine, that is not really going to change. I think activity-based funding gives a focus that hasn't been there to as great an extent on the quality of documentation. And at the end of the day, we all know that that's a significant association and marker of the quality of patient care. So I see activity based funding as actually a great way of highlighting the importance of highquality documentation. That's going to have benefits for the patient themselves, for their GPs, for their healthcare team that are seeing patients after hours. And at the end of the day, because there is a cost value associated with this, it also has implications for the hospital in which we're working. So I think one of the biggest changes, I guess, for juniors will be the focus on documentation. Senior staff will be valuing this and so it will form part of the feedback process. So I think when you're doing your term reports and things, part of the conversation will now be in regards to this important skill about how well you're going with your documentation. So that might be another slight way that things are changing. In terms of the broader perspective and looking at how efficiently we do things, the better that our junior doctors are at this process, the more efficient care we'll be able to deliver. That means there's more health dollars to invest in areas that we perhaps as clinicians see as important. That may also mean there are more job prospects long term. And that's obviously a key thing to juniors looking forward. It really emphasises how important junior doctors are within the hospital system. And let's hope that they're valued as much by their staff specialists, not for any of their clinical work, but also some of the other work they do and how they contribute to, I guess, the funding for the hospital. Can you give an example of some of the differences that may occur for someone who has very good documentation versus someone who may have had documentation that's not so good? Yeah, so if we just take a very basic example, to show the impact of good documentation but also in the context of the activity-based funding environment about how big a difference junior doctors can make to this process. So if you consider you've got two ladies, Jane and Mary, they both have unstable diabetes and they're both admitted to hospital to investigate their identical chest pain. Jane and Mary are both diagnosed as having a non-ST elevation myocardial infarction. They receive an angioplasty and stent and both of them during their admission develop a urinary tract infection and hyperkalemia which require treatment. Both ladies stay for exactly the same length of time, they undergo exactly the same tests and they receive exactly the same treatment. When we look in the notes the documentation in their files is identical except in Jane's file the JMO has documented the hyperkalemia and the treatment that was received with risonium and in Mary's file this is not actually recorded. So if we look at the implications of this basic example in the activity-based funding environment the first thing and the most important thing I think to point out is that with inadequate documentation, so by Mary not having the hyperkalemia and the risonium treatment recorded, her medical record at the moment is incomplete. |
So clinical handover in that way suffers. Mary herself in her discharge summary that she will read is not aware that this has happened. Mary's family won't know this has happened. Importantly, Mary's GP won't know that this has happened. So you can see just with a small error with clinical documentation that there can be big impacts in terms of the flow of information to a large variety of people. The other thing is in the activity-based funding environment that Jane, with her adequate documentation, meant that the hospital received the appropriate funding for that admission. And in this case, this is funded at $18,573.97. Unfortunately, with Mary's admission, just by a minor admission in a condition that may have potentially been serious and required some treatment, her admission was only funded at $10,755.04. So you can see that this is an $8,000 difference for one single patient in the hospital. Now that might seem like a lot of money and essentially what it means is that our hospital has been underfunded $8,000 and that $8,000 pays for the length of the admission so it's likely that someone with this stayed a bit longer. It pays for the bed they stayed in, it pays for the nursing staff that sees the patient, the doctors that see the patient, it pays for the extra blood tests, the drugs that we're given. So that's why small changes in documentation can actually have a really significant financial impact at the end of the day. So this is a very simple example, but hopefully the take-home message is with accurate documentation, there's actually a really significant impact on funding for the hospital at the end of the day, as well as the quality of patient care. Are there any tools out there that can help the junior doctor improve their documentation, ensure the funding's appropriate for the team's care that they provide? So it's, yes, there are certainly tools. So we know at the moment that the way the health system works and some of these skills aren't necessarily taught in medical school. And as a critical part of the process, our districts are working towards trying to support junior doctors with this documentation skill. So there are resources available and there are also some very basic things that junior doctors can do that at the end of the day I actually think are a good way to learn medicine. So in terms of the resources available at the moment at RPA, we have both case mix guidelines. So essentially, these have been developed by coders and clinicians at Royal Prince Alfred, and they give advice about the most common conditions for each specialty and what are the key things that junior doctors should think about that are clinically important but also important in documentation sense for funding. So these are available on the intranet homepage under case mix guidelines. They're also being made into little tags that go on with your ID tag and are given out at orientation. So if you don't have these, you could always see your director of pre-vocational training. And it's likely that other hospitals would have similar things within there? Other hospitals are working towards the same goal and you would have similar sort of initiatives in place. And certainly if they're not available at yours, you could always share the resources between districts, or you could look as a junior doctor at taking the initiative and implementing a project like this so that you can have a quality assurance initiative that leads to, you know, great outcome for your patients at your individual hospitals. The second thing that's in development and many of you will have road tested is the activity-based funding iPhone application. So we know that it's difficult sometimes to access terminals and that you need information quickly. So that is currently undergoing a phase two of development and the junior doctors here at the hospital have been integral in helping design that. That will hopefully be released in the next few months on a state basis and that will be available across the district. HETI have also developed in association with clinicians, coders and management staff, a really high quality activity based management learning tool. And you can certainly access this on their intranet. And the New South Wales Health Government also have a website with many links to educational resources and presentations if you're interested in knowing more about activity-based funding. And we can provide some links to those when we release this podcast. That would be a great idea. In terms of what you can actually do on a day-to-day basis and maximise the quality of documentation and at the end of the day your clinical handover and patient care, there's six tips I think that are really important not only for patient care but actually for learning medicine at the same time. And I think junior doctors should really think about. So the first and probably the most important thing that doctors at all levels should be thinking about doing for each patient is to do an issue list for that patient on admission, but also every few days that summarises their entire problem list going forward. So that's everything from their clinical issues that need sorting out, but also their social issues. And it really helps junior doctors to think forward about what needs to be done to help get this patient home? So issue lists are a really simple process that can happen on a day-to-day basis. The second thing that I think is very useful as a junior doctor and helps ward rounds, in particular the next day, is to make sure that every day you record the investigations in the notes and not only just write them down but interpret them. So for example when you write a potassium level of 3.2 in the notes the coder that looks at that isn't allowed to interpret that that's a low level of potassium. So it requires the junior doctor to interpret what that level of 3.2 means. So by writing the word hypokalemia, that's a really important interpretation because that has an implication that may mean you've needed to recheck that blood test level or to treat that level. And so that's why there's a cost associated when the level is low. And Bethan, can I just write an arrow down for hypokalemia? Is that enough or do I need to actually write the word? Yeah, so in an attempt to make this as user-friendly for all staff, you can just write an arrow down or up so the coders can interpret that as being low. Importantly, if you then treat that condition, actually recording that you've done that is also important. So we know sometimes on ward rounds junior doctors are really busy and that the registrar or senior staff ask them to chart medications at the bedside and sometimes that's not then translated into the notes and so as part of the admission that treatment is never recorded. So again the importance of trying to document any results and interpreting them and then recording any treatment required. The other good thing, medically speaking, is to try and think about why has the patient got that condition. So for example, if you take the hypokalemia again, why do you think as the junior doctor that they have that? Is it due to the fruzomide that they've been taking? Is it because they've been on treatment for hyperkalemia and now they've gone too low? So thinking about and putting a differential diagnosis for each of the values becomes really important. This also applies to imaging tests. So it's useful to write down, for example, the results of a chest X-ray that says there's some consolidation. But if you only write consolidation, that doesn't actually say or tell the coder why that consolidation is there. So it requires your clinical expertise to interpret that. And if you think it's pneumonia, you have to actually write the words pneumonia or that won't get funded. So again thinking about not just symptoms and signs but what's actually causing them is a great way to learn medicine and force you to think about differential diagnoses for all of these things and at the end of the day is a great documentation tip as well. So aside from the issue list and recording the investigations each day, the other thing that often happens in medicine is that sometimes when we treat things, we're uncertain that the patient absolutely has that problem. So for example, someone comes in with a fever and they might have some red cells in their urine. We think they probably got a urinary tract infection, but we're not absolutely sure because we haven't cultured anything. At the end of the day, to investigate that, we send off a urine. We prescribe antibiotics often if they're symptomatic with a fever. So we've done some costly tests and treatment. And it's fair to say that if you thought it was there enough to investigate and treat it, then the cost would reflect that in the notes. So it's useful to write the words possible or probable if you're actually treating for conditions that you're not absolutely sure that you've proven at the end of the day and that's fine in this environment. So just by writing the word probable UTI that would be included and costed into that patient's admission. Other tips that I would suggest, particularly for the discharge summary. |
Welcome to On The Wards, it's James Edwards and today we're talking about a really important topic, recognising and responding to domestic violence. I'd like to introduce and welcome as a guest Dr Rosemary Isaac. Welcome Rosemary. Hello James, great to be here. Rosemary and I both work together. Rosemary is a forensic physician with a background in general practice and was until very recently the director of the sexual assault service within our district. Yes that's right, of RPA. And obviously domestic violence has got a lot of media recently and I think it's increased recognises such an important topic for everyone to know about but I guess what we're really looking at the role of a junior doctor recognising and responding to domestic violence. Maybe you can just give us a general introduction about domestic violence and what I guess one of some of the challenges that you guys face in recognising and responding to domestic violence. Okay, well we're really talking about violence in the home and there are other specific topics, child abuse, elder abuse that we won't be going into today, though they're very important. Our focus today is more on interpersonal violence or partner violence, and that includes violence by an ex-partner. In fact, where there's been violence in a relationship, the time of separation is actually often a time of crescendoing and increasing violence. So ex-partners are very important in this too. Okay, look, as we usually do with Honour Awards, we often have a bit of a case just to stimulate some discussion. And this one you're working with in the emergency department as a junior doctor, and you see a 33-year-old female teacher who presents with a bruise and swollen nose, and she's requesting an X-ray of that nose, concerned that there may be a fracture. In the room, when you go to take a history and examine the patient, you notice that she's holding the young child and also there is a partner who seems concerned and also keen to support her. When you go through a bit of the history, it seems like they, yesterday evening, tripped over a child's toy and then fell into the door. The swelling's got a bit worse and they're worried that the nose may be broken. So look, in this case, should a junior doctor consider the possibility of domestic violence? Yes, James, I'm afraid they should. Most adult fractured noses would be from sports injuries or from a fight. But with any injury, the thought of domestic violence should be in the doctor's mind. Are there any particular red flags within this case that you'd want to highlight? Perhaps not. It might be, it is a delayed presentation, but that could be accounted for in other ways. Tripped and fell into the door, you'd want more history. It sounds like a red flag, but it might be quite plausible. The thing is, this is a teacher, and often we think that competent people who seem to have a nicely presented family and the partner seems attentive, I don't need to ask about domestic violence and in fact we do. But I think as doctors we often find it difficult or challenging to ask about domestic violence. Can you give us some advice on how we can ask about issues such as this? Yeah, there'll be situations where you can start with a broad history. For example, you're seeing a patient with depression or abdominal pain or pelvic pain and you're doing an admission or a long history of headaches. You can say, how are things at home? Does it get out of hand sometimes? And take a general history first. But in every case, and usually with an an injury you have to get straight to the point and straight to the point is to actually ask did anybody hurt you with her because she's already given you a sort of an explanation you might say I'm wondering if anything else was happening which softens it up and then did anybody hurt you in some way. So I mean our concerns are we may offend people by then raising the issue of domestic violence is that a valid concern? I can fully understand why doctors are concerned about that but in fact it doesn't need to be a valid concern if you give some context for the question. So the context you would give is to normalise the fact that you're asking it. You don't want the patient to think I'm asking because you look suspicious, I'm asking because you're unmarried, because you're indigenous, because your clothes are a mess or whatever you want them to think, we ask every single patient. And so you say either, for all injuries, as a doctor, I ask this question, or you say domestic violence is common in Australia, so we ask. If you're stuck and it's a sensitive topic, the easiest thing to say is, I need to ask you a sensitive question that works for a lot of things sexual health all sorts of things I need to ask you a sensitive question I need to ask did anybody hurt you whatever the question might be and I guess the kind of the logistics of the partners there how do you deal with that you need to be a bit creative it's no asking in front of the partner. It's actually a worry asking in front of a child who can speak. There'll be people who come to art patients. Let's say this is a follow-up with the same fractured nose in the ENT art patients. When they get home, Dad might say to the four-year-old, what did Mummy say to the doctor today? So you really need the help of your colleagues to make a situation and a situation like this one creative option might be to wheel her to x-ray yourself or to take her to x-ray yourself but you may have to go and talk to the nursing staff and you need to really reassure the patient there is someone standing outside that curtain which is not a great barrier and they'll let you know if anyone's approaching. I wouldn't even assume that a female relative is supportive. They may be there as a spy. If you possibly can, ask the patient on their own. Okay. So you go and try and get some further history, and you do state that you're concerned about her and ask what else was happening at the time of the fall. And she does state that she was stressed as her partner was angry about some bills. She was also upset about the argument and trying to leave the room when she fell. What should the doctor ask now? Well, now you've got to ask the direct question. And again, you need to not have the partner in the room. You to say okay I need to ask you did your partner hurt you she might say no did he push you or shove you you've got to be specific most patients the first time won't recognize that being pushed is a form of domestic violence they'll think if he thumped me in the middle of the face, yep, that's domestic violence. But if he pushed me and then I tripped, oh no, that's just normal. So you're actually helping the patient to identify that what's happening is domestic violence by asking that question. I mean, you say often in the first time they may not recognise. Is looking through their past history with things like electronic medical records helpful? Well, it could be, but most of the patient's history isn't in there and they're likely not to have it on their electronic medical record in Australia. It's the sort of thing that, for confidentiality reasons, people may remove. I was more thinking there would be previous unexplained injuries. Well, there would be, but a lot of... There will be in some cases, and the sort of cases that get highlighted in the emergency department, yes. But there are a lot of assailants who are quite careful. They might inflict injuries on the soft parts of the body, the abdomen, which you can have a lot of force and very little bruising or no injury on hidden parts of the body there are a lot of people out there suffering DV who haven't actually had a fracture and they haven't presented to the emergency department before but by all means I would support going through the record I'd look for other chronic illnesses headache migraine that of thing, which could be a sign that things are not well, and look around the room. If that kid has got a bruise on its face, who's present, that's a real red flag to you. So you've mentioned now examination. I mean, what sort of things should we specifically look for when we're thinking about domestic violence? Well, it's a great advantage if you can do a head-to-toe examination, even if the patient, so if you can get them into a hospital gown, you can see other parts of the body. I've talked to domestic violence patients who for example presented at our service, I noticed there's a baby present, I say oh what happened during the pregnancy? She will say things like, well, they asked you in screening. I said, no. Then I came to visits. I would wear long blouses or long shirts to cover up the bruises on my arm. |
So really good advice to think about a head-to-toe exam because otherwise if you don't look, you won't find. That's right. So when the patient discloses some violence has occurred within the home, what are some helpful responses from the doctor? Well, the most important thing is to validate. Even if you're on the cardiac arrest team and the beeper is going off, you can say, gee, I'm so sorry to hear that. My beeper's going off. If you just say, I'll call the social worker, it sounds like you don't want to talk to them. The beep is going off, I'm really sorry to hear that, I've got to go, we'll ask the social worker to come, puts across a really different message. So the first thing is, in a sense you're representing us all as a community by saying, I'm sorry. The next message is, it's not your fault. Now the patient, they may very well love the person who may have some other fine points for their character, and they will be making excuses. Oh, he'd had a hard day at work, he'd lost his job. And I'm going to interrupt myself here to say, I'm referring to a female victim and a male perpetrator. That is the more common pattern, but by no means the only pattern. It can be the other way around or it can be in a same sex relationship. For simplicity, I'm using he and she. And in fact, there's also a higher injury rate when it's a male perpetrator and a female victim. And that may just be differences in physical strength or other reasons. Anyway, sorry, I diverted there. What was your question? No, it's really about your responses. So you've made a, I guess, validating their... I'm sorry it happened. Nobody should suffer this. Nobody should have domestic violence inflicted on them or should be hit or punched or whatever the thing is. And then the next thing is either I need to ask them more questions or how can I help? Or in some cases, I need to involve another member of staff. But normally, you're going to get a little bit more history before you refer because the patient may disappear if you just go off for the consultant and it's two hours later. At least let's get a bit of history to get started. Okay so you've done the further history any other particular features on history? Well you want to know what happened on this occasion and in my next podcast I'm going to talk about documentation but it's really helpful if you can document what happened not your assessment but as much as possible in her own words and that might be relevant years later to a child custody case or something. You don't know where it's going to be relevant. Secondly, you want to ask, has anything like this happened before? Or maybe a more broad question, have you been hurt in the home before? Find out what's going on there. Emotional abuse, financial abuse and other forms of abuse are very important and certainly if a person's been made to do sexual acts against their will but that is part of a broader history which the junior doctor may not be in a position to take time-wise. And you mentioned about documentation, what are other sorts of strategies that you'd go on from following, taking a bit more history and exam? Okay, it's very important we find out if there are any children involved or present. In New South Wales and in Australia witnessing domestic violence is considered a form of child abuse and when there's domestic violence in the home about 50% of the time the children have witnessed it. People say, oh it's not affecting my. And maybe a doctor who knows them better, their GP, is sitting there thinking, gee, you didn't let yesterday because your eight-year-old's wetting the bed. Other children look scared. Somebody's got school refusal. I think it is affecting the kids. It's not that that victim is lying for you. The enormity of the thing, they haven't had a chance to process and take it in. I guess it's a form of denial like we see with cancer and other things. Okay, so to identify them as a child and I guess escalation referral, how would you approach that? So then the next part really is to say it would be very beneficial if we can get you to talk to somebody with more, who can help you. And that's usually the social worker. Now that may not be the case. It might be the senior doctor because we're assessing a situation now. But some patients are going to refuse that referral. They may be telling you this now, but they may know that if their partner tweaks what they're talking about, they're in increased danger. There may be other people they're worried about and they may not be free to talk. So the junior doctors, we can't force the patient to stay, so the junior doctor's got to do a quick risk assessment. And these are sort of things that are risk obviously if there's a serious injury and serious injury includes strangulation which we're talking about in the second podcast if there's a firearm present in the house so that's going to be a bigger issue in rural areas but we need to ask or if any sort of weapon was used every house has got knives in it but were the knives used as a weapon or threatened? If the violence is escalating that can happen for all sorts of reasons. So some violence I'm afraid grumbles on over many years and it's a chronic pattern but if it starts to escalate it may be worse tomorrow that's a pattern of risk of death and can the patient get help when they need it now if this lady goes to work every day that would be a sign she could probably talk to somebody make a phone call access someone some people are very controlled in in domestic violence situations their car keys are taken, their phone is taken. They may get phone calls monitoring them all day at work. The person says, why were you five minutes late home from work? It was just the traffic. And they actually can't get to help. Other people have kind of got a plan. You know, my sister lives down the road with her husband, blah, blah, blah. You know, they can get away and they are much safer going home so there will actually be times where talk to you can talk to your senior but you may even have to call the police if a perpetrator nobody else is going to respond quickly but if the perpetrator is trying to remove someone out of the emergency department and there's a weapon in the house that that would be a time to call the police. But do talk to a senior colleague if you possibly can, if it's not crystal clear, before you call the police in because only the police can respond immediately to a crisis situation. I guess we could debate within New South Wales, is there a kind of mandatory reporting for things like domestic violence like there is for child abuse? Absolutely. It's slightly different from the child abuse situation. But in New South Wales, there is now mandatory reporting for serious injuries or when firearms might be involved and in certain other situations. We're just, the hospitals and New South Wales Health are working on making it a little clearer when we have to report that. So I'd really advise people to get advice unless it's crystal clear it's a serious injury. And then it should be reported straight away because the police can make a crime scene. If you tell them the next day, the perpetrator may have cleaned up all the mess at home and that's going to make quite a difference to the police situation. Is there any particular information that you can provide to the victim if they do, may want to leave, you've made a referral but they may not want to stay for the social work review? Yeah. It's great that they know that the hospital is interested and the very fact you ask, even if they totally deny it, might make them get their courage and tell the next time. So it's important that you ask. In Australia, we've got a national phone number, which is 1800RESPECT. That's really easy to remember. And they can give advice by phone. And if the person's on their mobile, they'll phone them back because they might be worried about the cost of the credit. They've also got confidential email services and so on to give a national counselling service for domestic violence, sexual assault, that sort of thing. Actually if a doctor goes home really stressed after listening to something like that they could phone the service to debrief or if you just want advice. There are other local state services. Most hospitals have a social work department and there's a lot of kind of women's health services and other services. Police have domestic violence liaison officers. There's a lot of stuff out there. |
Welcome to On The Wards, it's James Edwards and today we are talking about liver transplantation and we have Anastasia Volovets who's a hepatologist and gastroenterologist at Royal Prince Alfred Hospital, which is a centre that does liver transplants. So we're very lucky that you're able to speak to us today. Obviously liver transplantation is not common and many junior doctors have limited experience with it, but we thought we might just go through some general questions about liver transplantation. Maybe we'll start. What are the most common indications for getting a liver transplant? Yeah, thanks James. Look, I am very aware of how limited people's exposure to liver transplantation is, and that's because we are the only centre in New South Wales that performs them. And really, there's not very many transplants that are done in New South Wales. We do probably more than any other centre in the country, and we would do 100 a year, thereabouts. It's actually increasing now. And some of them will be children, although children are done mainly at the Westmead Hospital. So I guess the most, there's two main indications for liver transplantation, and they both make sense. One is acute liver failure and one is chronic liver failure. And really acute liver failure is a talk all in itself, but it's a pretty rare condition, but usually in the setting of some sort of drug toxicity, such as paracetamol, occasionally due to some sort of viral infection. And really when people go into fulminant liver failure, they need transplant pretty quickly because otherwise they'll be dead within a couple of days. So that's a condition kind of we probably do about 10 transplants a year for that. But much more commonly, we transplant people for end-stage disease and you know I think all junior doctors across all hospitals in New South Wales would have had patients with advanced liver disease that they will be familiar with so you know most common reasons for end-stage liver disease would be either hepatitis C infection although we're hoping to see less and less of that now that we've got fantastic hep C drugs, alcoholic cirrhosis and fatty liver or NASH cirrhosis is a really rising indication and really we start to consider that a patient should be worked up for a transplant when they have significant complications and when they decompensate and we know that their prognosis without a transplant is poor. You know these are the patients who present with severe hypertension, so variceal bleeding and ascites. They're yellow, they're confused, encephalopathic, they're malnourished and muscle wasted, they're unable to work, and they have a poor quality of life. And we want to get people kind of early in that process and work them up for transplant so that they don't get so sick that they actually will be too sick for transplant. And the important thing to understand is that advanced liver disease is an irreversible and progressive disease for most patients for which there is no alternative therapy but transplantation. That's important to understand because the morbidity and mortality associated with the liver transplant is significant. So it's a treatment that's only done when there is no other way to prolong a patient's life. The decision making has to be multidisciplinary. So it's never down to just one person who should have a transplant or who should isn't. We have a very big team that's made up of hepatologists, also transplant surgeons, you know, anaesthetists, psychiatrists, social workers, dietitians. It's really very much a multidisciplinary process and the patient has to be fit for a transplant medically. They can't have too many other comorbidities that will prevent them surviving this, but also they have to be kind of socially and psychosocially and emotionally able to cope with it, but their liver disease has to be bad enough such that they will benefit from it, and selection at the right time can be really difficult. To make it a little bit easier, we use the concept of a MELD score, which is basically when we calculate the patient's synthetic function, which includes their bilirubin, their INR, and their creatinine. And patients with a MELD score of higher than 14 is our average cutoff for patients that should be thought about transplant and worked up if there's no contraindications. There are some patients who don't fit that for a liver failure indication, so such as patients with liver cancer who may be transplanted despite having normal liver function, but if they've got multiple tumors and we know that they'll die from liver cancer in the next couple of years, they can be worked up for transplant as well. So what does MELD stand for? Yeah, so it's basically, it's a model of end-stage liver disease and it's a logarithmic formula that helps you estimate patients prognosis. So once your MELD score is particularly high then your chances of being alive at three to six months are virtually zero. Okay and what are the contraindications to getting a liver transplant? Yes, so look the contraindications there's few absolute contraindication but probably the biggest one is uncorrected cardiopulmonary disease. So if you've got a patient with severe triple vessel disease and, you know, left ventricular failure, they're not going to survive a 14 hour operation and severe hemodynamic changes. And similarly, if they have really severe COPD and, you know, they're oxygen dependent. So if they've got some sort of medical problem, that means they'll not be able to survive the transplant or the associated recovery, you can't go ahead. Patients who have either active infection or a malignancy that's not curable or metastatic are also excluded. And the reason for that is as soon as you do a transplant, you have to put patients onto immunosuppression. And so anything like a chronic infection or malignancy, you know, that process will be accelerated aggressively with immunosuppressant medication. So those patients are excluded and patients who won't be able to, you know, look after their liver, such as patients with severe brain injury. So those are the ones that basically absolute no-nos. And then there's kind of a number of relative contraindications. So again, patients with malignancy that can't be easily treated, you know, and I'm not talking about things like small skin cancers that can be removed, but, you know, patients with bowel cancer, really, unless they can have a colectomy at time of transplant, or patients with very grade hematological malignancies such as CLL, you know, that they're going to live with for another 10 years and isn't going to be accelerated with immunosuppression, those patients are probably okay. Technical reasons, sometimes it can be very difficult to do a transplant if patients are morbidly obese or if they've had previous abdominal surgery or even a previous liver transplant or complex liver surgery. It can make it very difficult for the surgeon or if there's problems such as, you know, that portal vein is all clogged, etc. And then patients who have complications of end-stage liver disease that make it difficult for them to have the transplant. So things like hepatopulmonary syndrome or a cirrhotic cardiomyopathy. So that's when the heart and the lungs are also affected by end-stage liver disease. And again, they may not be able to survive the operation and thus benefit from a transplant. It's good to know that HIV is no longer a contraindication for liver transplant, as long as it's well controlled and patients are established on antiretroviral therapy with a suppressed viral load and a good CD4 count, there's no reason why patients with HIV can't have a transplant and do very well with it. And the issue of alcohol dependence really comes into it a lot. So we do transplant people for alcoholic liver disease and really anyone who is actively dependent on alcohol and who has a high risk of relapse post-transplantation cannot have a transplant. And so we, you know, kind of across the whole world, there's a standard that patients have to have at least six months of alcohol abstinence before even being considered for transplant. But, you know, really the assessment about how likely people are to return to drinking is much more complex than that and usually requires involvement of an addiction specialist and psychiatrist. Patients who are on stable doses of methadone are fine and we do, you know methadone again is no longer a contraindication for transplant. And again one of the things that we probably struggle with the most are patients who are poorly socially supported. So you know as we'll go through the risks and long-term outcomes of transplant, you'll see that it's not an easy life and people really need to have social support and emotional resilience in order to go through all of this. And a lot of the time we tell people what's involved in a transplant and they say thanks but no thanks. |
Okay, so for most of our patients we work them up as outpatients provided their liver disease is stable and that process can take several weeks or even months if they're from far away and really that's probably a good thing for us because we get to know the patient really well and identify what extra help they'll need to get through the process and same as the patients get to meet us and get to know the transplant team and figure out how they're going to function within it. But occasionally some of our patients are met at very advanced stages of liver disease and their prognosis without a transplant is less than three months and we't have the time to do this extensive workup. So we actually admit them and get through it all in a week or two. And there's really quite a lot of tests that they need, which again, all makes sense. Basically, if you think about all the contraindications just to a transplant. So the first thing we need to do is we need to work out is their heart and lungs going to be able to withstand it. So they get, you know, at least a transthoracic echocardiogram, but anyone who's of higher risk of heart disease may need to do an stress echo or even a cardiac angiogram. We test their carotid dopplers to make sure they don't have severe plaques that may lead to a stroke with big changes in volume during the transplant. We check their lungs, so we do arterial blood gas, pulmonary function tests. If there's any indication that they have right heart impairment due to either liver disease or primary lung disease, then they get a right heart cath. We test them for a liver cancer, which is very common in chronic liver disease and can influence whether patients can or can't have a transplant. So everyone has a multi-phase CT scan of their liver, plus minus a CT of their chest. If you do identify cancer and if also patients have had a long history of alcohol use, we also do a CT of their brain. We do blood tests. We basically repeat their entire liver screen to make sure that there's no other possible cause of their liver disease that's been missed and do serology, especially if patients are from high-risk countries, things like tuberculosis, strongyloid issues, schistosoma, all these patients that are immigrants from countries where these infections are endemic and they're not routinely tested for, but with immunosuppression they can become a problem. Post-transplant we're gonna give them steroids and most serotics are osteoporotic, so we we need to know where their bones are up to so we'll do a DEXA scan and a skeletal survey and if we identify osteoporosis we'll try to treat them with bisphosphonates before transplant or very soon after to prevent fractures. We usually like to do an extensive dental review again because if patients have poor dentition and car, that represents a significant infection risk. And then there's all those kind of multidisciplinary team involvement that we've talked about. So if patients have had issues with substance abuse or alcohol abuse in the past, they need to be seen by addiction psychiatry, by our social workers. A lot of our patients are malnourished, so dieticians are very heavily involved and we even nasogastrically feed patients who we think are really frail to try and give them more reserve to survive the operation and the recovery. And we always do a gastroscopy for variceal surveillance, which hopefully all chronic liver disease patients are up to date anyway, and we assess their cancer risk. So colonoscopies, pap smears, mammograms, skin cancer checks, all those things should be sorted before transplant because as soon as you start giving people immunosuppression, tiny cancers can blow out into big problems. And after all of that has been completed, the surgeons and the anaesthetists need to be happy that they can go ahead. And that's not even including the, you know, patients have other comorbidities, their own relevant specialists need to be involved as well. So it's a really full-on process. So how long do patients typically spend on the list? And once they've had their liver transplant, how long do you follow them? Yeah, so look, time on the waiting list is really variable. And it really depends very much on how sick you are and how likely you are as a patient to die of your liver disease in the next three months and that's where the MELD score comes in. So it's not a first come first serve. It's not like you get on a list and then you just patiently wait your term, okay? So the list basically fluctuates based on how many people are on it and how sick they are and people who are most likely to die go to the top of the list and people who you know have okay liver tests and can wait longer they wait longer. So on average people will wait about six to nine months on a list and that's because liver disease is progressive. So once you've sort of started down that spiral that your liver is starting to fail, unless we can do something to eliminate that insult, such as treat your hepatitis C and stabilize your disease, most patients will continue to deteriorate and their liver disease will become such that they will move up the list and be transplanted. So some people, we put on the list that morning and they get done that afternoon. Some people wait only a couple of weeks if they're very unwell. Most people wait months. Some people do wait years and that's if they're very stable and have small tumours that are easily controlled with local regional therapy. Obviously, we have to do the patients that are most at risk of dying first. So the waiting lists really vary. And whilst the patients are on the waiting list, we usually see them if they're outpatients every six weeks or so, just keeping an eye on how they're going and what their symptoms are in recent events and medical reconciliation, making sure that nothing's happening that can prevent them from being called in for a transplant at any point. And again, monitoring them for complications of end-stage liver disease. Once they're post-transplant, we see them for life. Yep, I can imagine. Does everyone who goes on the list eventually get a transplant? No, no, not at all. And that's for multiple reasons, and sometimes the reasons are sad, such as patients have something happen to them, such as a new cancer or some sort of catastrophic infection or something happens or their tumour or their liver cancer progresses and they're not able to be transplanted, they grow outside of criteria. Sometimes something good happens, which is that, for example, we list patients with advanced hepatitis C because they're really unwell and then we treat their hepatitis C and their liver improves and they no longer need a transplant. So not everyone who's listed eventually gets to transplant. The numbers quoted in the literature is probably a quarter to a third will never get to transplant. Our own numbers are probably only about 10%, which I think means we're choosing patients really well. Maybe just give us a brief overview of actually what happens at the operation. Okay, so it's a pretty big operation. I'm not a surgeon, I'm probably not the right, and I'll probably get it all wrong now. But from what I understand is so initially we so it's a very complex logistical exercise and there is always a liver transplant coordinator on service who basically receives what we call donor offers and that's when we identify that there is a patient somewhere in New South Wales who may be suitable for organ donation and usually what happens is there is between, you know, the medical team to make sure that that donor is appropriate and for the patient that's on the list. And then there's a surgical team will actually go out to perform the operation and, you know, they'll dissect the hepatic structures and they'll remove the liver and they'll pre-cool it with a special solution and they'll store the liver on ice basically and a good liver can last up to 18 hours on ice and that will allow us to transport the liver to as far as it has to go and we do occasionally even take interstate donors if we can. And then while all of that is going on, the coordinators will call in the recipients. They'll come in from home. They'll have another medical assessment to make sure that they're right to go on the day and that the anaesthetic team is happy with them. And then they'll go to theatre for what is anywhere from an eight to 20-hour operation, although I think the fastest I've ever seen it done was in four hours, which is amazing. But on average, it's probably about an eight-hour operation with massive blood loss. You know, people can have up to 10 to 15 litres of blood loss. So there's a lot of resuscitation done by the anaesthetic team. And we also use a machine called the CellSaver, where you can actually save some of the patient's blood and recycle it back into them. |
So the veins, the portal vein gets reanastomosed, the IBC, the hepatic artery and the biliary tree. And sometimes you can't form another biliary anastomosis and the surgeons need to bring up a little bit of bowel called the roux loop. So basically there's much, much stitching involved. Fantastic description for a non-surgeon. Much stitching involved to get the little bits joined together. I like it. What's the immediate management post-transplantation more from a medical perspective? Yeah, so immediately patients go from the operating theatre to the intensive care unit. And, you know, if the operation's gone well and there's no complications, they can be extubated in a couple of hours and awake and ready to go the next morning when you come to see them on the ward ramp. Go to the ward. No. Not go home? No, no, no. No. No. We have had, you know, usually our patients stay in ICU because of occasional bird block in winter. But, you know, if everything goes well, patients can come out of ICU in two or three days time post this really big operation. Occasionally there's some sort of complications patients are kept kind of in intubated and sedated for example if they need to return to theatre for the next day for further reconstructive surgery or removal of packs etc so sometimes patients can stay asleep for a couple of days but most of the time they're extubated pretty quickly. Everyone has to have an ultrasound of their hepatic artery the next day to make sure that that artery is not blocked. And we start immunosuppression then and there. So usually on arrival to the intensive care unit, patients will get some methylprednisone, and then we will start things like tacrolimus the next day or the day after, depending on their renal function. About 10% of our patients will require dialysis in the intensive care, during the operation actually and also in the intensive care unit and usually that stops in a couple of days and that's done as CBVHD continuous dialysis in the intensive care unit. And as I've already mentioned, a few of them surgery you know if there's a some sort of leak or a biliary problem or the abdomen needs to be closed. You mentioned some of the medications that these transplant patients are required can you just go into a bit more detail especially about that immunosuppression? So that's probably the most complex part for that of patient care that the junior doctors will come across. So patients are on large doses of immunosuppression immediately and so most of our patients will get high dose steroids so they'll get pulsed methylprednisone for about a week before being converted onto oral prednisone. That's not for all patients. Sometimes we do run them steroid free, but most will. And then we'll be looking to start a calcineurin inhibitor the following day, which is these days usually tacrolimus, although it can be cyclosporine if patients don't tolerate tacrolimus. Sometime over the next week, if indicated, we will also probably add in a third immunosuppressant, what we call an antimetabolite, so either mycophenolate or azathioprine. And occasionally, if there's some sort of complication, you can't give tacrolimus too early, we'll also give an IL-2 receptor antibody, which is called basaliximab. So there's a lot of immunosuppression and the protocols really depend on how the patient's going and what their tests are and what complications they're having. So it's not the same for every single patient and it's very much a balancing act because every one of these medications has significant toxicity and side effects and so sometimes you need to back off on one and give another and can be really complex. So I mean the junior doctors probably one of their roles will be when they've gone from intensive care to the ward and writing a medication chart that seems like a difficult job in those kind of places. Yes it would be and it's just so so so important that they get the medication chart right because in transplant medicine your immunosuppression really dictates whether the patient will live or die. So you know and the typical drug chart for our patient you know so you've got these immunosuppression that I've mentioned on the ward so prednisone, mycophenolate, tacrolimus. Because these patients are immunosuppressed we also have to give them antimicrobial medication to prevent them from getting infections. So all our patients will be on a couple of days worth of intravenous broad spectrum antibiotics such as Tazacin. If they're at risk of CMV disease, which most of them are because they've had previous exposure, they'll be put onto valgancyclovir for three months. Our protocol is also to put patients onto Bactrim for a year to prevent PJP, and occasionally there may be increased risk of fungal sepsis, so they'll end up on fluconazole or even more powerful antifungal agents. Because we're giving high dose steroids, a lot of our patients will be made diabetic and will need to have a complex insulin regime or an oral hyperglycemic regime. And then on top of that, it's a big laparotomy and patients will have pain. So you'll need to give them long acting opiates and plus short acting PRNN opiates. So all of that is just for the transplant. That doesn't begin to include their regular medications. Exactly right. So their med charts can be really long and complex. Once they've had their liver transplant, sometimes medication will worry about liver disease. Once they've had their transplant, is the assumption their liver's working? Perfect. If their liver looks good good then there's no reason why they can't have whatever they need to have. Including paracetamol actually quite, this is probably an important thing to mention, quite a lot of the times I'd find patient on the ward and the junior doctors and the nurses would be afraid to give them paracetamol because they're a liver patient but if you've had a liver transplant and you've got normal liver tests there's absolutely no reason why you can't have a healthy standard dose of paracetamol, which is four grams a day. Great. And what's the hospital management of these patients? Immunosuppression's key. What else do we need to be doing? Yeah, so we do a lot of blood tests, okay? So we check their liver tests and their kidneys and their full blood count and the level of tacrolimus, which is their immunosuppression every day. And patients do not go home until all those tests are normal, appropriate, and stable as well. There's really, really big fluid shifts that happen. So it's really important that we review their blood pressure and their fluid balance and their weight. And what happens is once your liver kicks in, patients just start to lose their water weight at an astronomical level. And then they become too dry and so that's why it's really important to keep an eye on that. We've already mentioned the liver ultrasound and the immunosuppression and the pain relief. Sometimes if they were really malnourished pre-transplant we'll actually continue to aggressively nasogastrically feed them for a week or so post-transplant again to improve their strength and we have to have good glycemic control and then of course their mobility has to be improved as they were very sick or if they've had a long operation or long recovery they may need quite a bit of time and then we have to educate them about all of these drugs that we're now putting them on and also all of these complications that we're worried about and all of the monitoring that's going to happen and that can take several days. That's done by our nurses and pharmacists and there's Webster packs and all that sort of stuff and we have to educate not just them and their family. So all of that can take quite a bit of time. Mind you, a simple straightforward transplant patient can be out of hospital in 10 days. Something that's complex or difficult that people need more time, it can take several weeks. And what are some of the complications a junior doctor should be worried about post-transplant? |
Welcome to On The Wards. 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 interns and residents in a two-part podcast series with Dr Becky Taylor. Becky is an ONG fellow based at RPA in Sydney. Welcome Becky. Hi, thanks for having me. I know you were really keen to record this podcast Becky, why was that? I really wanted to do this podcast because I think sometimes it can be really challenging starting as an intern or resident on your ONG term. I still remember my first few weeks on labor ward as a resident in the UK and albeit that was more than 10 years ago now, but I felt totally overwhelmed. Everything was so alien and it was completely different to all my previous medical and surgical terms. The OBS charts were different. They wanted me to put 16 gauge cannulas in everyone. It was a lot more blood than I thought there would be. And I was constantly being pulled between theatre, delivery suite and the wards. And I found it all quite stressful. And I thought that a podcast, which just teaches JMOs what they need to know to be an effective internal resident on delivery ward would be a helpful thing to have out there. So I did a little survey on our current RMOs and they suggested that the topics that we'll cover in this podcast and the things that they thought would be most helpful to start your ONG term well. And I hope that this podcast can shed a little bit of light on what's expected of you when you're an internal resident in ONG term and how to make the most of your time in the role. So Becky, what do you think interns and residents should be aiming to get out of their ONG term? So I think this totally depends on the individual. So some GMOs will be wanting to pursue a career in ONG or GP obstetrics. And so for them, they may be seeking to learn skills such as perineal suturing or fetal blood sampling performing you know normal deliveries whilst others will be wanting to pursue a career in general practice so they may have more of a focus on antenatal and postnatal care but whatever it is you want to do even if you want to do neurosurgery there to be learned. And I promise you that whatever you do, someday a pregnant woman will turn up in your practice and you will feel much more comfortable with that if you made the most of your time in ONG. So what are these essential skills that your JMOs have told you we ought to be achieving in their ONG rotation? So having heard some of the RMOs I work with, they came up with five essential skills that they thought GMOs ought to achieve by the end of their term. And we're going to cover these over a few podcasts. So the first three things that we'll cover today are the initial assessment of the sick pregnant woman. The second is a cannulation in obstetrics. And the third is the postnatal assessment. And then in separate podcasts, because they're slightly longer topics, we are going to cover how to assist in a cesarean section, which is a really important skill that you will need to learn as an internal resident in ONG. And the second is a podcast on common medications that you will be required to prescribe in your ONG term. Great. So let's start with the three we're going to tackle today with the initial assessment of the sick pregnant woman. Let's do it. So let's start with assessing the sick pregnant woman. I'm sure you remember when you started in ONG, but everything just felt so alien when you were examining pregnant people. And yeah, so this probably required its own podcast, but let's just get started with that. So you may often be the first person to assess a sick pregnant woman, especially if your seniors are caught up in theatre. So first of all, don't panic just because they're pregnant. Be methodical in your assessment, just as you are in other areas of medicine. Much is in fact the same when you're assessing the sick non-pregnant patient, but there are some key differences. So we'll focus on those. So the first thing is observations. So due to the physiological changes that occur in pregnancy, women over 20 weeks gestation require a maternal observation chart in which the between the flags parameters are recalibrated for the pregnant state. So particularly of note is blood pressure. So a blood pressure of 140 on 90 or greater is abnormal in pregnancy. And a BP of 170 on 110 is classified as an obstetric emergency. This is a big shift from adult medicine where you wouldn't normally bat an eyelid at an inpatient who had a one-off blood pressure of 150 on 90. So the key message here is to get used to your centre's maternal observation charts and their differences so that you know when to act. The second thing is symptoms. So, you know, as always, tailor these to the patient's presentation. So if they've got chest pain, when did it start? Where does it radiate? Do they have any shortness of breath, et cetera? But you always need to ask about specific symptoms that we want to know about in obstetrics. So those are, have there been any abdominal pain? Is the patient having any uterine tightenings? If they are, are they painful? How frequent are they? How long do they last? Many women have praxen and Hicks, but they're not painful. Women who've got painful tightenings may be going into labor. Do they have any vaginal bleeding? If so, was it spontaneous or was it after intercourse or a vaginal examination? How much is there? Pads soaked I find is a really good measure. So did they soak a maternity pad or a panty liner just to get an idea of how much blood that's been lost? Is there any vaginal discharge, any watery losses to suggest rupture of membranes or offensive discharge to suggest infection? How are the baby's movements? So movements are usually felt by around 18 weeks and babies settle into a pattern by around 28 weeks. So has this pattern changed? Is there any headache, visual disturbance, right upper quadrant or epigastric pain? These symptoms may be associated with preeclampsia. Are there any urinary symptoms? Are there any other things that you typically ask, Jane, or that you think that the RMO should add to that? No, I think that the main thing that is often forgotten is about the fetal movements. I think when you've been doing, you know, other type of rotations in your junior years, you just forget that there's another patient that's often invisible when you see a pregnant woman. And fetal movements is something we really stress in obstetrics and gynecology. It's not something we're able to really measure objectively. So the mum's the boss of whether the fetal movements are normal or not. Yeah, I think that's a really good point. And I think when you're starting, it's really challenging to know, you know, you see a lot of women with abdominal pain and who do you need to worry about? Who can you send home? Who's got pubic synthesis dysfunction and who's in labour? So until you're gaining confidence, I think it's really important to always run any pregnant patient with abdominal pain past your senior and you'll quickly gain in confidence in assessing these patients. Then moving on to examination, again, tailored to the patient's presentation, but should include as a minimum blood pressure, pulse, respiratory rates, temperature and saturations if there's a respiratory concern for the patient or they are significantly unwell. An abdominal examination, so determining the fetal lie, which is essentially impossible at very early gestations, but as the baby gets bigger, you will start getting better at determining whether the baby's catholic or breech or transverse, although sometimes we get it wrong and the ultrasound is often your friend there to confirm your suspicions. Whether the uterus is soft, tender, whether there are any palpable contractions. Also really important to measure the fundal height to assess whether the uterus is growing appropriately with gestational age. And then do a fetal heart rate or a CTG depending on the gestation. And if relevant to the presentation, you may also consider additional examination. So if someone's presenting with abdominal pain or vaginal loss, of course, a speculum examination is essential. And when you're doing that, consider doing a high vaginal swab and low vaginal swab for microscopy and sensitivities and culture. And you may also at the same time do other testing such as a fetal fibronectin if you're concerned about preterm labour or some of the amniotic fluid testing bedside kits if you're worried about ruptured membranes. |
Like this is your chance to get the experience in that examination and you will take that to ed and to other specialties and whilst you're starting get your senior to supervise you initially but i really think that anybody who has done an ong term as an internal resident should be confident to do speculum examinations by the end of that a bedside ultrasound ultrasound may be performed by a senior colleague. You may do a cardiovascular respiratory examination if the patient's presenting with relevant symptoms. Do a calf examination if there's DVT concerns. And if there's concerns around blood pressure or preeclampsia, then test the patient's reflexes. So you will typically see hyperreflexia and preeclampsia. also assess for clonus and also assess whether there's any upper abdominal tenderness. So in the right upper quadrant or epigastrium, which may be indicative of liver involvement from the preeclampsia. Is there anything else that you would sort of say in terms of examination? No, I think you've covered it all. Just the difference in maybe when you want to do a CTG versus fetal heart rate, depending on the viability of the fetus. But, you know, that's the sort of thing that I think your registrar would probably advise you on or a senior would give you advice on after you'd assessed a patient who'd presented. Yeah, I agree with that. And most places will have a policy about when it's appropriate to put a CTG on. So the midwives will almost always know that. So ask them if you're in doubt. And then basic investigations, again, like everything, just depend on the presentation. So many women come to labour ward and don't require any additional investigations and can be sent home quite confidently with a history and examination. But if you have specific concerns, so if someone's been having issues with blood pressure, you want to do a preeclampsia screen on the bloods. So take a purple top tube to check their full blood count and then a gold top tube to check their EUCs LFTs and urate and you may also need to consider doing coagulation profile if they're very severe blood pressure and if you think the patient's going to be admitted their blood pressure is really high and it's not looking like they're going to go home and potentially delivery may be indicated take a group and hold at the same time it's annoying to kind of have to go back and do that again. So if there's anything which makes you think they may be staying in or needing delivery, I'd normally take a group and hold. So it's in the lab and it's there if needed. Obviously, if they're bleeding, you need to take a full blood count group and hold and also take a fetal maternal hemorrhage or a Klyhauer QFMH. That's really important and essential for any bleeding in women who are rhesus negative, but can also be helpful in rhesus positive women to suggest whether there's been any mixing of maternal and fetal blood at the placental interface. If a woman's got a fever, so particularly in labour, if they've got a fever two or more of 37.5 or above or one temperature of 38 and above, then take blood cultures. And I normally also take a full blood count and CRP and a VBG, particularly to look at lactate as a marker of severity of sepsis in women who have fever. Really should do a urine dipstick on pretty much everyone who walks through labour ward. It's an easy test to do. And if it's positive or there's concerns about infection, then send it off for a urine MCNS or a urine PCR if you're worried about preeclampsia. If the patient's got chest pain, do an ECG and be aware of some of the normal changes that you can get on ECGs during pregnancy. And if there's concerns about fetal wellbeing, then your registrar may order a formal fetal ultrasound. Anything else that you think we should add to that, Jane? The only other thing I would say is that when you see someone on the birth unit, you assess them, you can always present some sort of safeguard. You always reassure patients that if they're worried for any reason, even if it's as soon as they get back home, they can always call up the birth unit again, or they shouldn't feel as though there are too many times to present to the birth unit. If they're worried that trumps everything or if their pain is getting worse or they're bleeding more pronounced, then they should always just come back. And I think giving patients that safeguard is really important. Yeah, I think that's such an excellent point is that, and like I've said before, you know, things can change so quickly in obstetrics that if they feel that anything's changed or they're still worried just come back we always yeah absolutely and the next essential skill that you think jmos ought to achieve oh my gosh you think you've mastered it just as you've done your intern and residency rotations and then you're asked to put a 16 gauge cannula which looks like you're torturing women just as they're about to be in labor. Tell us about that, Becky. Yeah, I remember the first time I saw a 16 gauge cannula, I was like, are you serious? But the reality of busy labor is that you're frequently called cannulas in women in labor. And in fact, you're asked to put cannulas in everybody. Sometimes I used to feel like all I did was put cannulas in as an intern, and I couldn't believe how many women needed cannulas. So whether that's women in labour who need augmentation with oxytocin or want an epidural or they're being admitted to the antenatal ward with an antepartum hemorrhage, they all need cannulas. And in almost all cases, it's going to be a 16 gauge. Now, the reason for this is that they allow a volume to be infused more quickly in the setting of postpartum hemorrhage. Now, as we sort of alluded to, they are big and they are slightly daunting to put in until you get used to them. So watch somebody put a few in before you get going. There is a bit of a technique to them. And the good news is, is that most pregnant women are really really vasodilated so they normally have good veins and you will get the hang of it important things to say make sure that you and the patient are in a comfortable position and you've got all your equipment with you including local anesthetic if you use this which it's kind to use given the size of cannula in terms of where to place the cannula ultimately wherever you find a vein that you will get lots of people will have have opinions on labour about not putting it here, not putting it there. And sometimes they used to say, well, where is left to put it? But ultimately you are using the cannula, so put it where you think you've got the best chance of getting it. But if you've got some choice, then often a really good place to use is where the vein sort of crosses over the wrist or the hand vein. So for women in labour, that allows them a little bit more freedom to move than if they've got a cannula in the antecubital faucet. But if they're having a postpartum hemorrhage, just put it wherever you can get it. Nobody cares. You just need the access. If you're new to this 16 gauge IV cannula business and you haven't had success after two attempts or you can't see any good spots to try then try and get help from one of your senior doctors or the anesthetic reg there's almost always an anesthetic reg um allocated to delivery ward um and they are very good at getting cannulas in and almost always very happy to help you do that um another caveat um or another thing to say is that whenever you do put a cannula in in delivery ward always take a full blood count and group and hold unless this has already been done and the group and hold is in date. Most people assume that once a woman's got a cannula in labour ward that they've had these bloods sent, which we should never assume, but make sure you do that. So any woman having an epidural or having an augmentation should have a full blood count and group and holds and also take off any additional bloods that may be required as we've just discussed in the first section. So then the next thing that the JMI said would be really helpful to go over was doing a postnatal check. So as the ward internal resident, you'll often be asked to perform a postnatal check. So general principles include asking questions about the following areas so patients questions about patient's pain so patient reported pain and also based on the analgesia that they've used on their drug chart their blood loss so number of pads and the color of the lochia and whether it's any offensive smell to it. Bowel and bladder function. |
Welcome to On The Warts, I'm Becky Taylor, an ONG fellow based in Sydney, and today we're going to be talking about spinals and epidurals with Dr. Blake Kesby. Dr. Kesby is a consultant anaesthetist at Royal North Shore Hospital in Sydney. Welcome Blake. Hi Becky, thanks very much for having me. So today we're going to talk about spinals and epidurals and obstetrics and so as usual we'll start with the case to illustrate important points to take home. So a 30-year-old primogravid woman Annie is in spontaneous labor at 39 weeks gestation. Her last vaginal examination was performed three hours ago and she was four centimeters dilated. She has been using nitrous gas with good effect but the pain is increasing and she is now requesting an epidural. She has a pre-pregnancy BMI of 30 and no other medical issues. So Blake, what exactly is an epidural and what are the differences between an epidural and a spinal anaesthetic? So a spinal anaesthetic or an intrathecal injection involves using a very fine needle, preferably with a pencil point tip, and inserting it into the intrathecal space. We do this at a level below where the spinal cord terminates or the conus, which in most adults is at around about L1, L2. So we'd normally insert our spinals at the L3, L4 space or a space below this to minimise any risk of damage to or potential damage to the cord. When we reach the intrathecal space, we see a flow back of CSF through this very fine needle, at which time we inject a mixture of local anesthetic and often opiates. The needle is then removed. So this is a single shot technique. And therefore the spinal only lasts for the duration of the drugs which are injected, which is normally a couple of hours. An epidural, on the other hand, involves placing a catheter into the epidural space. Now, the epidural space is what we call a potential space, and it lies between the ligamentum flavum and the dura. We do this using a loss of resistance technique with what's called a tui needle, which is a much larger needle than the spinal needles that we use. And the reason that we use a larger needle is one, because it helps us find the epidural space through this loss of resistance technique. And two is because we need to insert the catheter that remains in the epidural space and enables us to give long lasting analgesia. So unlike with the spinal, we do not want to puncture the dura or enter the intrathecal space. This is what's called a dural puncture and it is an unwanted event. When we do reach the epidural space, we insert through the large needle, the very small catheter, and we then fill up through this catheter, the epidural space with local anesthetic and other opiates, similar drugs to what we use in the spinal. And these nerve roots that are passing through the epidural space then become blocked. Okay. So how are epidurals and spinals used in obstetric anaesthetic practice? So there's pros and cons to both spinals and epidurals. And for this reason, we tailor them or use them for different obstetric needs. Spinals have a very fast onset and produce a very dense and reliable block. This is often associated with quite a significant motor block as well. And this makes them ideal for use during cesarean sections. They also have a greater effect on the patient's hemodynamics due to the denser block and sympathetic blockade. And therefore, they're much safer performed in an operating theatre environment where we can, A, monitor more closely, and B, we have the ability to give vasopressin agents such as metoraminol or phenylephrine. Due to their single-shot nature and the fact that they only work for a few hours, they're not really appropriate for labral analgesia. Epidurals, on the other hand, are not as fast in terms of their onset. We gradually top them up over a period of sort of 15 to 20 minutes, and for them to achieve their maximum effect, it normally takes around about half an hour, depending on the drugs that we use. But they have the benefit of us being able to infuse agents through the catheter over a long period of time. And this means that we can keep women comfortable during their labour, regardless of how long the labour lasts. And outside of obstetrics, for example, when we do thoracic epidurals for analgesia post-op from major abdominal or thoracic surgery, we can sometimes leave these epidurals in for up to five days if they're working effectively. So the big advantage in obstetrics is that we can provide analgesia over a long period of time while women are labouring. Epidurals can also be used for a C-section, in which case we have to use much higher concentration local anaesthetic agents to achieve a denser block which is appropriate for surgery. But in most cases, when we're using it just for labour analgesia, we use lower concentration, local anaesthetic agents. Okay, great. Thanks. And what is a combined spinal epidural? So sometimes if we were doing a caesarean section where we feel that there was a potential for the surgery to be prolonged, whether this may be that the woman's had previous extensive intra-abdominal surgery or any other sort of complication that we feel may lead to a longer duration requirement, we'll sometimes do what we call a CSE or combined spinal epidural. This is where we do an epidural. We get into the epidural space and then through the epidural needle before we feed the catheter, we actually put a spinal needle through the epidural needle and into the intrathecal space. This gives us the benefit of being able to do the spinal, which gives us that really good, fast-acting, dense block, but we still have the epidural catheter in the space should we need to use it if the spinal starts to wear off. So what are some of the considerations you take into account when a patient requests an epidural? So like any other anesthetic that we give, we always start with a history. So we often have to be quite brief and tailored in terms of our history for epidurals because women are often in quite a bit of distress and also sometimes their ability to give an adequate history is quite difficult. So the first things we want to know about is has there been any significant gestational issues and in particular has there been a history of preeclampsia or any other issue that may cause an increased risk of bleeding? So for that reason, we'll often also check the patient's platelet count to make sure that their platelet count is adequate before performing the procedure. Similarly, we want to make sure that they haven't had any requirement for any sort of anticoagulation because again, this may preclude us from doing an epidural. We want to know, has there been a history of any infection such as chorioamnionitis during labour? Because we don't want to seed an untreated systemic bacteremia into the epidural space because this could potentially cause an epidural abscess. This is really rare. And most of the time, once the patient's received adequate antibiotics, we'd be happy to put an epidural in, but it's another consideration. There's a big focus, I think, from a patient and other medical practitioners on previous back issues for insertion of epidurals. From an anaesthetic point of view, we see this really commonly because most people have had some form of lower back pain in their life. And really for us, patients that have just had really nonspecific lower back pain issues, it's not really an issue at all in terms of inserting an epidural. It doesn't make it more difficult. It doesn't increase their risks at all. There are some back problems that we do like to know about. So in particular, patients that have had previous spinal surgery, because this distorts the anatomy of the epidural space, as well as some of the other landmarks we may use. Obviously, patients that have a history of spina bifida, we want to know about, again, because of that anatomy, and it would often be dangerous to insert an epidural in some of these patients, depending on the type of spina bifida they have. The other one is sometimes scoliosis, if it's a severe scoliosis, can make things more difficult, but certainly doesn't preclude us from attempting an epidural insertion. Finally, the last thing is really how much or how far a woman has progressed through her labour. Again, this doesn't stop us from offering an epidural, but it's a discussion because it takes a bit of time to put the epidural in and then to establish analgesia. |
Thanks, Blake. I think that's an important point that you make about a woman's progress in labour. So it's always important for the obstetric and midwifery team to do a vaginal examination before a woman has an epidural. One, so that the team know how she's progressing in labour. Two, because it may change the woman's mind about whether she does indeed want an epidural if she's progressing really well. And I think it's important to say that it's a common misconception that if a woman's fully dilated, that it's too late for her to have a spinal, sorry, rather an epidural anesthetic. And that's not the case. Obviously, if she's progressing very quickly in the second stage and the head's about to crown, then it's too late probably at that point to put an epidural in because the baby is about to be born imminently. But sometimes there may be slow progress in the second stage, their head may be high and epidurals can actually be very useful in that sort of circumstance to allow a woman to have adequate pain relief which may then allow an augmentation to help progress in the second stage and even potentially help if the woman does eventually need an assisted delivery. So, Blake, there are some situations in which we actually encourage women to have an epidural block. Do you want to talk about those a little bit? where the strain and the increased blood pressure, heart rate, et cetera, of labour may worsen pre-existing conditions. And commonly we see this with severe cardiac conditions. So putting an epidural in early, one provides adequate analgesia for these patients during their labour, which reduces all of these sympathetic drives. And the other thing is, should these patients run into trouble during their labour and require an emergency caesarean section, it means that we've already got a well-established working epidural in. That means that we've got a bit more time to safely top up in these more complex patients. The other patient group that we encourage to have early epidurals are our sort of increased BMI patients. And the reason behind this is, one, they do have an increased requirement of intervention during labour. So whether that's going to caesarean section or some other form of assisted delivery which often obviously requires some form of analgesia and two because these patients are often quite difficult in terms of insertion or should I say it takes us longer often for insertion of a spinal and epidural so by putting an early epidural, this means that should we have to rush to do an emergency caesarean section, that we're not limited by the time to put a spinal in or the potential risks that come with a general anaesthetic should we fail putting that spinal in. So it's a bit of a safety net for these patients. I think that's really good points that you're making about those cohorts of individuals with underlying health issues that can benefit from an epidural. And there's also obstetric indications, of course. So often women who are having a twin pregnancy or twin vaginal delivery, you know, certainly sometimes, as we all know, the second twin may require additional maneuvers to be delivered. So things like internal pedallic version and having an epidural on board can certainly help the obstetric and midwifery team to perform the necessary maneuvers that are required in these sort of circumstances and ensuring that the woman is comfortable throughout. And also for women who have gestational hypertension or preeclampsia, epidurals can also be a benefit in labour because by reducing the level of pain that they're experiencing, we're able to control the blood pressure better because the woman's not in pain and also because of the lowering effect that having an epidural has on the blood pressure from a physiological perspective. So tell me, Blake, are there any anaesthetic contraindications to an epidural or a spinal? So yeah, like most procedures, there's absolute and relative contraindications that we have in regards to the absolute contraindications, so patient refusal is obviously one of the big ones. We'd never force someone to have a neuraxial technique. Obviously, we always speak to patients in regards to the risks and benefits of any technique. But if a patient had a refusal to have one, we'd never insert it. Allergies in terms of local anaesthetics are very rare, but they do occur. So this is a potential absolute contraindication. If the patient has a local infection, so if they've got some sort of a skin infection over the area that we would be inserting the epidural or the spinal, this in itself would be a contraindication because obviously we don't want to drag any potential bacteria into those neuroaxial regions. If patients have an uncorrected hypovolemia, this is another consideration in regards to epidurals and spinals. Certainly spinals have a greater effect hemodynamically than epidurals, but we'd be proceeding with a high degree of caution in any patient that's hypovolemic in terms of putting in uraxial just because it has that profound sympathetic block. So particularly patients that have had any form of significant bleeding, this would be something that would probably move us towards doing another form of analgesia or anaesthetic. Coagulopathy, so patients with either low platelets or an increased INR or other base coagulopathy, are patients that we may consider unsafe in terms of potential for an epidural hematoma. So these patients, it's a longer discussion what we have time for today, but there are guidelines that we use in terms of deciding whether we feel that they're unsafe from a coagulopathy point of view. As I said before, there are relative contraindications as well. So untreated systemic infection. So as we said, if a patient had an infection elsewhere that hadn't yet been treated, so they hadn't had any antibiotics, we'd probably wait for them to have some sort of antibiotic therapy prior to placing a neuraxial. axial and similarly cardiac disease. So epidurals, because we can top them up quite slowly, are actually reasonably safe and sometimes are anesthetic of choice for C-sections for a lot of the significant cardiac diseases. But we just need to proceed with caution and know what we're dealing with before inserting either a spinal or an epidural into these patients. Okay. So what are the risks of having an epidural or a spinal? So this is a really important discussion to have with our patients. There's a lot of, I guess, misinformation in the community in regards to a lot of these risks. So it's important for us to go through them with patients. And we do this before any time that we do any kind of a neuroaxial spinal or epidural. So the big thing that most patients want to know about is, is there any risk of permanent neurological injury? So permanent weakness, permanent numbness, because these are the things that people hear about in the media. And even though they're incredibly rare, they can happen. The general risk of this is very, very small. And depending on where you're reading the literature, it's somewhere in the range of one in 20,000 to one in 100,000 insertions that we do. So it is very small. There's risk of temporary nerve injury, which is about one in five to 10,000 people, again, small number. These are probably the two big things. Epidural hematomas are very rare. We're talking about one in half a million. Similarly, epidural abscesses are very, very rare as well. So less than one in 100,000. So those are all the kind of the big neurological things that people want to know about. There's a risk of what we call a dural puncture, which we'll talk about a little bit more later on. Dural punctures where we inadvertently, so in a spinal, we always want to be getting into the intrathecal sac. That's how it works, but we use very, very small needles for an epidural. We don't want to go as far as going through the dura, but occasionally that can happen. And when it does happen, there's a risk of having a very small leak of CSF that comes out and that can create headaches. And the risk of dural puncture is generally about one in every 200 epidurals that we do. And patients that then get headaches afterwards, about 50 to 70% of these patients that have had a dural puncture will get some sort of a headache so that can happen there's also a risk if we go in as i said too far and go into the dura there's a a couple of different things that we do to test for this so it'd be very unusual that we didn't pick up that we're actually in the intrathecal space not the epidural space, but it can happen. |
And very rarely, this can give us a very high spinal anesthetic. So that can sometimes mean that it can be potentially unsafe and that patients may need to have further intervention. Okay. So one of the things I've noticed is that we not infrequently see a fetal bradycardia just after an epidural has been cited. What are the reasons for this? So there's really kind of two major reasons for this. The kind of traditional reason was very much because we do get a degree of sympathetic blockade with an epidural, which obviously causes a degree of vasodilatation and can drop the patient's blood pressure. For quite some time now, we've been using what we call low concentration, high volume epidurals, meaning that we use low concentration, local anesthetics and larger volumes of them. What this means is that we get less sympathetic blockade and in fact, less motor blockade as well, which we can talk about a bit later, but also means that we get far less hypotension. We always make sure that patients have a cannula in before they have an epidural, and we'll often give them some fluid loading before we place the epidural as well, which again reduces this risk. But in a large number of patients now that we see that have any sort of fetal bradycardias following an epidural, the blood pressure is often completely unchanged. And one of the things that we do with an epidural is we actually top it up very slowly. So we'll give a very small dose of the local anesthetic. We'll wait five minutes. We'll check the blood pressure. We'll give another dose, et cetera, et cetera. We'll often do this three or four times until we're happy that the epidural is established. But one of the other reasons, even if the blood pressure doesn't change, is that pain during labor causes release of adrenaline. Now, adrenaline acts on beta-2 receptors on the uterus and causes uterine relaxation. So following an epidural insertion, the woman's pain is significantly reduced. That's the whole point of the epidural. And therefore, there's less circulating adrenaline. And this causes a temporary imbalance or a shift in the uterine tone. So there's increased uterine tone, which can cause fetal distress. Now, ephedrine is sort of our drug of choice for both of these problems. One, because ephedrine obviously increases blood pressure should there be problems due to hypertension. But ephedrine also acts on the uterus at beta-2 receptors, the same way as adrenaline does, and causes relaxation until the uterus finds its new balance point and hopefully the baby becomes happier. Thanks for that. It's quite a complicated set of factors at play there. So tell me, what drugs do you use when you're using an epidural or a spinal? And how do you test the effectiveness of your block? Sure. So we'll talk about epidurals first. The drugs are actually similar for both. As I said before, for epidurals, what we really want to achieve is analgesia. We don't really, we'd much prefer that the patient doesn't have any sort of motor block and that we minimize sympathetic blockade as much as possible. Fortunately, as humans, we're built so that our pain fibers are actually very small fibers and our motor and proprioception fibers are much bigger nerve fibers. And this works in our favor in the case of epidurals because we can use low concentration local anesthetics that will block those small fibers, but don't block the larger fibers. And as I said previously, we do this by giving a large volume so that we cover a large number of dermatomes. Generally, we like to cover up to about T10 or around about where the belly button is. And that should give us good analgesia for pain during labour. And we do this using, most commonly in Australia, Repivacaine, which is a longer acting local anesthetic agent. And we'd often top up with 0.2% Repivacaine to get it established, so to make the epidural work. And then we change the patients onto 0.1%, which is a very dilute solution of Repivacaine. And in most places, we give this, the patient will receive a dose of this via a pump every hour. But because patients are different in terms of their size, their epidural volume, and the amount of analgesia that they require, everyone's slightly different in terms of the volumes that they require. So often we'll give them a patient control button that we set so that if they need more analgesia, they can push it. And obviously if they don't, they just don't push it. We also use some opiates as well. The most common one being fentanyl. And this also has analgesic properties in the epidural space, as well as in the intrathecal space and reduces the amount of local anaesthetic we may need, but also speeds up the time for the epidural to work or to start to work. And how do you actually test how effective your blocks have been? Yes, that's a really good question. So as I said before, the pain fibres are about the same size as our temperature fibres. So to check the adequacy of both the spinal or an epidural, what we do is we actually often will do a sensation test to cold. So we'll get some ice and we will place it on the different regions. So from the patient's legs, up the different dermatomes, up to their abdomen. And in the areas that the spinal epidural is working effectively, they should have a reduced or loss of sensation to cold. And this tells us where exactly the epidural is working, how effective it is. We obviously check bilaterally because sometimes depending on where the catheter is placed, some patients can have a block more effectively on one side or the other. So this is the major way that we check. We can also check using like a sharp prick through a blunt plastic needle. But we find that temperature testing is pretty much just as effective because it's all the information that we need and is much nicer for patients. Yeah, I think that's an important point to make is that a lot of patients think that they're not going to be able to feel anything at all at a caesarean section and get a bit surprised when they can feel pressure and pushing and pulling. And I think it's really important to reassure them that they won't feel any sharp pain, but that we don't completely remove all sensation because I find that patients who aren't aware of that can sometimes get a little bit unnerved when you start the cesarean section. I think similarly in epidurals, now that we're using dilute solutions, a lot of people expect that they're not going to be able to move their legs or have much control of their lower limbs. But now that we're using low concentration solutions, a lot of people have almost no motor block. And in some institutions in Australia, we do walking epidurals as well. So the patient has good analgesia, but can still get up and walk around. Interesting. Okay. So let's now go back to our case of Annie who requested the epidural. So she got her epidural. It's working well. Her contractions tailed off. So she was started on oxytocin and four hours after the oxytocin was commenced, she was re-examined and remained four centimetres dilated. There were now some complicated variable decelerations seen on the CTG. And so the decision was made to proceed to an emergency category two caesarean section. So Blake, we now know that Annie's going to need a bit more in the way of anaesthetic cover to actually have a caesarean performed, even though her epidural has been working well. So how do you proceed from an anaesthetic point of view at this point in time? Sure. So the first thing that we do, our options obviously for going to theatre, if we're happy with the epidural and it's working well, we can top up that epidural and make it adequate for performing a caesarean section. If it's not working adequately, then we could take it out, place a spinal anaesthetic, which would be our next preference. And finally, if we're really rushed, which it doesn't sound in this case we are, it's a cat two. But if it was a cat one and the epidural wasn't favorable and for whatever reason we couldn't get a spinal in in time, then we could do a general anesthetic. But in this case, in this patient, it sounds like she's had a working epidural. |
Welcome to On The Wards, it's Abhi Pal. Today we're talking about human factors in medicine with Dr. Kirill Musa. Welcome, Kirill. Kirill is an ICU senior registrar at Royal North Shore Hospital and worked with Medicine's On Frontier in 2020, and he was deployed to Yemen and Iraq as part of the COVID-19 response. Apart from that, he's classically trained in ballet and performs freelance work and also does ballroom and Latin dancing. Welcome, Kirill. I'm very happy to have you on the podcast with us today. Thanks, Abhi. Thanks for the invite. That was a very, very nice message from you because we went to medical together and I think it was really nice to hear back. We did. After a really long time. Was that last year, maybe, Kirill? No, it wasn't, was it? No. It's a lot longer than than that. I reckon it's a bit longer than either of us would like. So that, so I think that that's how this started. I, we had not talked for quite a few years, obviously. And then I saw this blog and I was like, I recognize that name. That's someone I went to vet school with. And it was was on the MSF page and it was a really wonderful blog um it's called where the light enters reflection on the fight against COVID-19 war-torn Yemen and it's a wonderful blog and I'd recommend it to all our listeners and we will provide the link at the on the website uh for when this podcast is released so I suppose um suppose the place where I might talk about a few things today, but the place I might start at is what got you interested in MSF? When did you start thinking to yourself, I want to work for MSF in your medical career? Yeah, so the story I always tell is that my love for it kind of got ignited, I would say probably more than a decade ago. I think it was either late after undergrad or early med school years. There was this info session and there were people from MSF that presented about their work. And I remember sitting in the audience and just hearing about how cool I thought they were and just like hearing about the stuff that they got to do in some of the most forsaken places in the world. And I thought that that was something I wanted to do. And I think I've always had a curiosity about life outside the bubbles that we find ourselves in. And I really, really kind of thought to myself and said to myself that at some point in my career, when the time is right and when I have the skills and the experience, I like to do something like that. So I think that's sort of where it started. And thankfully, I managed to do it because it took a lot of time and building courage, I guess, to get there. That sounds good. Why don't we jump to the front then? So maybe just talk to us a little bit about... So did you go to Yemen first or Iraq? Yemen first. Yemen first. That was at the start of 2020. Yeah, so I joined MSF, I guess, officially late in 2019. And then my first field deployment to Yemen was early in May 2020. By 2020, yeah. So I think like getting there wasn't the easiest in the sense that as part of the process for MSF recruitment, you do have to go through a few different sort of stages, which include an application process and an interview. And then after that, there's a period of waiting essentially for deployment. Yeah. So I first got matched to go to Iran quite early in 2020. And then that mission fell through because of some political issues and then Yemen came through and then finally once visas and things got sorted I got sent to Yemen yeah kind of first week of May I think first or second week of May. Sounds fun and were you traveling with a group of Australians or a group of other MSF volunteers? Yeah so I'm not a bit of a unique situation in the sense that we all congregated in Paris. So we got sent to Paris to get our briefings, just medical checkups and bits and pieces and our visas sorted. And so I went to Yemen with about 10 other people from all over the world, basically. And because we were setting up the first COVID-19 treatment center in the whole of South Yemen at the time. So it's a bit of an unusual setup. MSF doesn't usually operate in this way, but it was just very early in the pandemic. I think we're still trying to figure out how we're going to basically support patients with COVID-19. Sounds fine. And how long were you in Yemen for? I was there for almost three months. Three months. And I'm just, I guess, what were your highlights from your time in Yemen? Was it everything you had thought MSF work would be? And maybe we'll start with that. I mean, what parts of the experience matched up to your thoughts of how MSF would be? Yeah, okay, such a big question. So the parts I guess that matched up was the ability to go to really hard to reach places and help people in extremely dire circumstances. I thought that was pretty extraordinary, especially considering at the time the whole world basically had their borders closed and there were so many flights grounded. So even getting there was a huge challenge. And I knew that there was quite a few other NGOs that struggled to get into Yemen, despite like how much help they needed. So I thought that was pretty extraordinary that MSF could mobilize a group of clinicians and other support staff to get to a place like Yemen and provide the help that they needed. So I thought that was cool. And other parts of it as well, I think just being part of an organization that has worked for more than 50 years in the medical humanitarian sphere was pretty extraordinary. I think that the infrastructure and the system that they've created to be able to help people, it's pretty amazing to be part of. And their ability to basically create something out of nothing. It's pretty awesome just to see how that works. So I think those are a few of the highlights. And of course, being able to be part of different cultures and just to help the people that are in need and be part of their journeys, I guess, and helping to support them. I thought that was pretty amazing. Sounds extraordinary. I can't even imagine what that might feel. Is that simple? Was language a problem in terms of talking to the other volunteers or talking to the patients you were treating? So I think it really depends on where you're going. So I think a lot of the Middle Eastern missions, they take English speaking field workers because we do have quite a well-established network of local staff who can speak both Arabic and English. So I think that's where the translation happens. In some of the MSF missions, for example, a lot of the African missions, they do expect you to to be able to speak French so I think it really does depend on where you're going and the missions that you're doing so even though I didn't speak much Arabic I had a little bit of Arabic but not very much communication wasn't generally too big of an issue so you don't speak French so English French. So English was fine to get it? Yeah, English. Yeah, English was fine. Most of my colleagues were from French-speaking backgrounds. So a lot of them are from France and Belgium. But we all mostly conversed in English. And what parts were a bit unexpected? Or what did you find surprising on your trip in Yemen? Yeah, so I think there were a number of things that I found particularly challenging. I think seeing war, I think that was especially hard. I think that we all have probably imagined idea of what war means and what it looks like based on what is presented to us through the media. but really seeing it for the first time in my own eyes, that was really confronting. And I think a lot of it was just trying to come to terms with the disparity in the way people live their lives in places like Yemen compared to where I was coming from, Sydney. And that was hard, I think. When you say war, what do you mean? What do we think the effects are for or injuries? Yeah, I think a bit of everything. I think so like my mission in Yemen, so I did two missions in Yemen. So one was COVID-19, the other was working at a trauma hospital in Yemen. And that was almost exclusively treating patients from the battlefields. And also other civilians who were injured as a result of the civil war that's been ongoing for almost seven years now in Yemen. |
I thought that was really hard to sort of come to terms with. And then, of course, seeing other vulnerable people, women and children, who were also being hurt from landmines and IUDs. And I think that that was just like a taste of humanity that I never really, I guess, seen before beyond what we saw through lenses of the media and other ways we sort of learn about places out there. And I think having to see that firsthand and just see that there is a really, really quite dark side to humanity, that was hard, I thought. That's extraordinary, Kiril. I don't think, I think few of us would ever have that insight or ever have that experience. I mean, that's, that sounds pretty, yeah. I mean, a couple of questions in my mind. I mean, I guess one question, probably quite practical, is at this point, were you worried about your personal safety at any point during these times that's a very complicated question I do get asked that a fair bit so so I think there is there is a there is an element of risk that you need to accept if if if you're you're hoping to work with MSF and and that's something that we are briefed on quite extensively even before you join join and before you go to the field. If I were to say I didn't feel unsafe at points, that would be a lie because there were moments where we were in quite dangerous situations. And my mission in Yemen ended because of a terrorist threat. So we to be evacuated so there are pretty significant things that come as part of the work but I will say that MSF as a whole takes security extremely seriously and as part of our sort of organization that we have security advisors whose job is literally just to take care of your security. And as much as they can, as a clinician, they try to take away that worry you might have about your own safety. So I think it exists, but I guess in the most okay way it can be. So it's a very, I don't know, it's kind of hard to sort of simplify. simplify. I can understand. It is a complicated question. It sounds exactly what I thought you might say. It's a complicated question. Just moving on to your experience in Iraq. So you spent from May to about August? Yeah. So I moved. So actually between Yemen and Iraq, I had a bit of time off. So I went to KL, which is where my family lives. And I spent a bit of time there, which is strangely lucky because you couldn't really travel anywhere else. And I traveled a lot in 2020. And so I spent a bit of time in KL and then I went to Iraq in November so that was a bit of a big gap and that was deliberate because I struggled a lot after Yemen ended like I had quite a lot of difficulties adjusting back to life and did you come back to Sydney at all? I stayed in KL. Partly strategically because I think Sydney and Australia have such strict rules about quarantine. I think it was a lot easier for me to get back out to the field. I knew I wanted to do more field work but I just needed a bit of time I think to sort of sorry I'll just explore that that's what I was going to ask you so there's the personal safety but also I mean it sounds like you were exposed to like an incredible amount of trauma that most doctors in Sydney would never would might see over a year or years, you saw in a very short span and you saw a lot of just really difficult. So how, yeah. So what, what did, I guess, how did your colleagues deal with it? How did you deal with it? I don't, I'm not sure it is possible to deal with, but it sounds, what happened there? Yeah. So I think that's a really great question. And I think we all dealt with it differently. And I think, I guess part of that is just the way you process things and maybe your personality. And then I, it being my first mission, I really struggled. A number of my colleagues were much more experienced than I was having done similar work in the past. And others were in the same level as I was too. Also new missionaries who have never really done that work before. And I think for me personally, it was hard because it wasn't just the war bit of it. It was working in an extremely resource-limited setting. Looking after, at the time, the first part of my mission, looking after COVID-19 patients when we didn't really know what we were doing. And I meant that as a global thing. Like, I don't think many places... Not many people did know what they were doing. Yeah. And I think the other bit of the challenge was just that we had seven ICU beds in a city of about almost 2 million people and trying to look after, we had hundreds and hundreds of COVID-19 patients come to us because we were the only place that would treat them at the time because other hospitals just basically didn't want anything to do with anyone with COVID-19. They were just really quite scared of it. And I think just being part of that and trying to help as many people as you can when you have really limited access to oxygen, to PPE, to drugs and all the stuff you need to treat patients, that was tough. So basically um you're just surrounded constantly with death and suffering like that was literally all we sort of like had to deal with for for many many parts of of the mission and so i think that was really challenging especially like coming from a place like sydney where you're resource rich and and you can treat basically anyone you wanted to wanted to and just go into a place where even like insulin was hard to come by and we had patients die from DKA. And that's some of the stuff that I found really hard. And I think after that, after COVID, then I did trauma work and that was seeing the effects of war. So like, I think I came to very traumatic I mean that's really traumatic yeah it was and and I think I'm just to sort of answer your question like how I dealt with I didn't I didn't deal with it like I dealt with it really poorly and I knew that that was to the expense of my own health both physical and mental like I lost 10 kilos after three months working in Yemen and that was like one of the well yeah and and beyond that as well like I like I I suffered quite a lot I think um and and like you talk a lot about burnout and I think for the first time I in my career in my life I suffered it and more like it was it was almost beyond that level and I was wondering about burnout because I think sometimes with extreme trauma and large volumes of trauma people's depersonalize or don't process what they're saying in front of them maybe yeah and that's exactly what happened the last month of work and I mean again like I was working every day for almost three months and and being on call 24 7 so I think I think like sleep deprivation, witnessing trauma and having to make really big level decisions. So a lot of things that I've never really had to deal with before. So like, yeah, I got rent out and I think I needed that time afterwards to just basically feel like a person again, because yeah, yeah, yeah. Because like like and especially in the last few weeks I like of of my job in Yemen like there were some really horrific things like we had children dying in a really terrible ways and in our ICU and I just couldn't really feel anything I think that was really that profound sense of depersonalization that you were saying and like talking to people after coming back they're like that's probably the only way I knew how to protect myself and be able to still do the job and and I really don't think I ever want to get to that place again and that's like a big lesson that I try to teach my colleagues and my juniors now is that if you if you do lose your humanity that's probably a time when you need to pause and just read the other way yeah and and that as important as the job is, it's not so important that you should lose yourself to it completely. And that was a really important lesson for me to learn. Thanks, Kirill. So it sounds like it took a few months off and then you went to Iraq for another mission. What was that mission focused on? So that was just purely COVID-19. So I was deployed to Baghdad, which is the capital of Iraq, to help. So we were supporting a ministry of health hospital in the capital and we then opened our own MSF board and yeah, just part of this public COVID-19. So interestingly, Iraq had a much better infrastructure than Yemen. Wow. Yeah. Relatively resource richer. Richer. Yeah. Richer. Definitely. |
So a lot of them were very educated. Like a number of our patients and family members could speak English, which was different to Yemen where basically no one beyond our own kind of national staff spoke English. So they were more educated, they were more aware, and which kind of gives slightly different flavor to the work. And similarly, the doctors and nurses that we worked in in Iraq were much more at a higher level of experience. And many of them were training in anesthesia or interested in surgery. So I think, yeah, it was kind of a different mission and I really enjoyed it for a very different way to Yemen. And how long was that mission for? So that was just under two months. Two months, yeah. Sounds like a bit more of a different experience, but not as kind of confronting perhaps. Yeah. And I think, I think like part of the, like part of it, I think it's related to the geopolitics of Iraq. And, and I don't think many people know that over the last kind of year or two, they've reached quite a, quite a nice level of stability and it's a bit of a fragile stability. So there's actually a lot of like development happening there's a lot of infrastructure that are sort of being put in place and when i arrived in baghdad they were building a new sort of like separate covid-19 treatment center next to the hospital which was beautiful like it's one of the really positive kind of activities so clinical stability kind of makes a big difference to health care like oh man i like i yeah it's funny right because i feel like that's some of the stuff that we're insulated from when we work in in our kind of hospitals and we assume political stability we assume we're in a safe government and that's right that's right and i think that's that's what we like some of the many things we take for granted how important leadership and governance is right to to a functioning health system. And it was interesting for me because I really saw it just like that difference. And despite being in the same region, despite- In a matter of months, you would like to go one-on-one. That's right, that's right. And like Iraq still has, like they still have troubles with war and things are still not the way- Perfect. Yeah, that's perfect. But despite that, I think they've managed to reach a certain level of stability, which means that their healthcare that they can provide is to a higher level than in Yemen. Well, Kirill, thanks for talking to us. I mean, I think they both sound like extraordinary experiences. And I suppose just some practical questions for the medical students and junior doctors listening right now. So if we had a student right now or a couple of quick questions, when is the best, I think people get asked this all the time, when is the best time to apply for MSF work in your training? Wait, let me wind that back. So what specialties are particularly valuable in MSF training? So at the moment, ICU is exceptionally valuable. ED is. And always throughout, even before COVID-19 times, the surgical and anesthesia specialties have always been in high demand. That was my thought, the critical care specialties. That's right. And also if you're from a pediatric background, that's also really highly valued. So it really does depend on what you want to do and how long you have time to sort of commit to doing the work. And that will determine whether it sort of fits in your kind of circumstance. Okay. So next question is, so what stage of training is the kind of optimal time to put that application in? Do you think? Yeah. So, so there are two schools of thought. So MSF as an organization are willing to take anyone who's PGY2 and above. PGY2 and above, above. But I personally think that you're better off going very senior. So whether that means towards the end of your training or when you're qualified as a specialist. That's right. Because I think that's when you will be most valued and you will have the most impact in what you're doing. But I think that the trouble though, is I know many people who are at that point in their career are, that's when a lot of them have young children and have other sort of obligations that might make it a bit more challenging. It's a bit of a tricky thing. Okay. Can you just, you know, in a nutshell to tell me what the application process looks like-wise? Is there a particular time interviews open or something like that? Not really, no. So they sort of recruit throughout the year. And I would say from the time I applied to the time I was deployed, it took about six months. Six months from application to deployment. But that's pretty unusual. So it usually takes a year. So I think it's just because of my ICU profile that was sort of just fitting at the time. Yeah. So the application process is like, so you have to go to a recruitment drive and they have it throughout the year where they just give you a lot of information about the work and other bits and pieces. And you hear from people that just returned from the field which is always really interesting you put in an application online and then you wait to hear back and that might be six weeks to two months that it takes for them to process it and then once you're through then you come in for an interview which takes about two hours it's the longest interview I've ever done so it's a two-hour interview that How many people? Just one-on-one. It's not quite the way you would think an interview is. It's more like a chat. They make it reasonably informal. I think a lot of it is to really understand whether you're the right candidate to do the work because as we sort of discussed before there's a lot of different facets to it that's important to consider and then after you've gone through the interview then it's the waiting and that the waiting is sometimes the hardest bit because some people wait for up to a year before they get unpredictable managing your that's right like life and exactly exactly and that's the hard thing as well because like I took the year off essentially to do MSF. So like I paused my ICU training to do it. And that's what was with the support of my department and my supervisor training. And I think that really depends on where you are and who you're working with and whether that's the right thing to do for you. I was going to ask you, so does the college, do people, can you count MSF as part of your training to a fellowship? Is that possible? So yes, yes, for some colleges. So it wasn't possible for mine. So I know for ED and for PEDS that they can. And my friend of mine who was an ONT fellow managed to get some of that time accredited as well because she did obstetrics work overseas. So it really depend on which college but at this state there are not many that will accredit that time unfortunately this is a just a practical question in terms of money I guess do you get paid it's a silly question but do you get paid it's an important question I think and because it's not like people think it's volunteer work, but you do get paid. You don't get paid a lot. I'll tell people because all this information is online. You get paid about $1,500 a month. It's not very much. The upside to that is that you don't spend a single cent when you're being deployed. I was going to ask, are your travel costs and your insurance, is that all covered? Literally everything is covered. So flights, visas, accommodation, meals, everything else is covered. So I didn't spend. So you won't be left out of pocket. No. Yeah. Like if you've got like a massive mortgage, it might be a bit tricky to navigate, but otherwise, yeah, you're pretty sorted when you're out there. And I do know many people who do the work, don't do it for the money. So I think, but that's an important consideration. Yeah, that sounds fine. Thanks so much, Kirill. So I think that about covers it for your MSF experience. I just had a few more questions. We had a brief chat earlier. Moving forward, I guess one question, do you think you'll go back to MSF work in the future? Do you think you'll do more missions? Yeah, yeah. So I think I'm doing my two missions. So Yemen, after Yemen, I wasn't sure if I wanted to do more of it because it was so challenging. |
I think the work that they do is really important. And now that I've had a taste of it, I do feel like I can continue to work and contribute to the great things that they're doing. And so that is my hope. Let's continue doing it. You mentioned you're completing a diploma of palliative care. And I found that quite surprising because I think a lot of medical students, junior doctors, see palliative care as oppositional or quite the antithesis of intensive care with all its lights and sirens and tubes and excitement. People tend to think about palliative care as a fairly, you know, this is not my thought, but some people might view it as a specialty where not much is done, perhaps in a medical sense where less is done. But I've known quite a few intensive care people who do palliative care. And I think there is a real closeness there that people don't realize always um what do you what are your what are your hopes there do you hope to uh and how does it fit into your msf experience does that are there any synergies between palliative care things what medicine can and can't do and where you are now uh okay like i so i just did six months of palliative care uh which which part of ICU training, not palliative care. We have to do medicine. And I chose palliative care specifically because of some of the things that you sort of mentioned, I guess. Despite the work that we do in ICU, and I think we do do a bit of palliative care, I just feel like there was still a lot I wanted to learn from the palliative care physicians. And I really do feel like they're an undervalued and misunderstood specialty. And I think that the term was probably one of the best terms I've ever done in my training because I really saw a side of medicine which really reaffirmed my love for it in many ways. And I think that, like in some ways talking about the MSF work, I think what I found really devastating was feeling like I couldn't do much, feeling that helplessness that we often feel sometimes and understanding that even holding a patient's hand can sometimes be the most powerful thing you can do. It's not, it's not the vents. It's not the, you know, the dialysis machine. It's not the ethanol, right? It's like, despite those things being really important things and then part of our tools, I think sometimes it's that, that human aspect of caring for others, which I think is the most profound and powerful lesson that I learned myself when I was overseas last year. And I think that's what the palliative care physicians have and the clinicians have in spades. Like they have so much humanity and so much love. And I was really inspired by that because I think that I really love ICU because of the bells and sirens and all the cool stuff we get to do. But sometimes the more, the more important thing perhaps is figuring out where, where it all fits in and a patient's sort of like a patient's journey, right? Because sometimes we do get to a point where maybe those things are not the right things anymore. And you need to be able to, to, to figure out like, like how you, how you can keep caring for them in a meaningful way. And I think that's where palliative care becomes very important. And I think understanding that a patient's beyond their disease and beyond their organ that fails, that they are a person. I think that's the key. I think medicine tends to view people as organs or like it's very technical. But I think in disciplines like palliative care, humans have used as subjects with emotions, hopes, dreams, family, friends, and you tend to have more time to think about that. So, yeah. And so I think, I think I'm like, I, I, I am very, very, very in awe of palliative care physicians. I think they've got so much, so much love that they give the people that they care for. And I think that's, that was incredibly inspiring. And I think I hope to sort of carry that with me, even in the work that I continue to do in the future. Sounds like you've had a very interesting set of experiences, from one range to another range. And finally, we've talked about this and we've kind of talked about this already, is that ultimately we're doctors and we need to look after ourselves to have a long and sustaining career and to be able to do these things for other people. But we can often come to, a lot of doctors can come to harm in various number of ways because of the work we do and especially types of work you've done. From your experiences so far, what are your thoughts on, particularly maybe suggestions to junior doctors and medical students about as they go into their career, what things they could look out for or start doing about protecting themselves? Yeah, I think a really important lesson that I had to sort of face and learn was that medicine isn't everything. And I think that I was very focused just before I went to Yemen. I had this kind of mentality in mind that I'm going to save everyone and help everyone. And that's why I'm there. And I think that that's great to have that in mind. But I think it also is dangerous because oftentimes it's at the expense of your own safety and your own well-being. And I think I'm seeing a bit of that sort of anxiety now with a lot of my junior colleagues, because I teach medical students and I've got a group of first year medical students at the moment who told me how anxious they are about being competitive and what specialties they need to go into. I got asked do they need to do PhDs to be able to get into the specialty they want. And I think that anxiety worries me a lot because I think that as important as it is, the work that we're doing, you also have to remember that there's more to this. You have family, friends, a life outside of the work that you're doing. And I think it's important not to ignore those things as I did when I was in Yemen and completely focused on my work because it really cost me a lot. And it took a long time and a lot of work for me to sort of get to the other side of it. And I just wanted to say to the junior, like to the junior doctors, trainees, things work out, right? Just like take time and go at your own pace. It's not a race and it's not a competition. You don't get any sort of prizes by finishing your training and becoming a consultant. That's sort of the start of a new journey, isn't it? And I think if you can do it in the most healthy way and in the most fulfilled way that you can, I think that's the way you should take it. And I do sort of like encourage people as well to do take time off training and the way I did, maybe not necessarily to do MSF, just explore the other things in life because the lessons that you will learn will be so valuable. And I learned so much in this past year, I think more than I would have learned if I just stayed and continued my training in ICU. And I think that it really opened my eyes to what is possible and what great things, how great things are outside the work sometimes. And I think that's the important thing to remember. Great message, Kirill. I mean, totally. A lot of medical students, junior doctors, and I guess training is competitive in a way as well. And some, and probably some people you do need to do a PhD. Yeah. So it is, it is reality. And I think they see it as a, it's, I can, I remember myself, it's, it feels like a tunnel that just have to get to the end of, but there isn't really a real end to this tunnel and you can get on this train for forever and taking time off the training conveyor belt was quite valuable um definitely there's a lot of pressure that it finishes finish but there's no real finishes here is there there isn't there isn't and and like like one thing that i sort of like carried with me like from from one of my mentors, who's a senior intensivist where I work. So he, he taught me when I was in SRMO. So this was years ago now that to, to do the work well, you need to balance everything that you're seeing and doing with all the beauty in the world. And I think that's a really important thing to just remember that, that you should be invested in your work and you should try your best for your patients. But sometimes there are moments that we sort of miss or things that we don't value enough because we're so focused. As you said, like you have this tunnel vision, but you're missing the sky and the things around you that make life so meaningful. |
Welcome everyone to On The Wards. This is Tony Sloman. Today we're talking about coaching with Sarah Dalton and Rita Holland. Now Sarah is a paediatric emergency doctor and she's also a professional coach who's passionate about supporting junior doctors to be their best. Rita's director of Capstan Partners and she's also a professional coach from the International Coaching Federation. Now Capstan's a bespoke coaching organisation and they support healthcare professionals. So let's get underway. First question for Rita. Rita, can you describe what coaching actually is, perhaps debunking common myths about coaching, and how is coaching used in sectors outside the healthcare system? Thanks, Tony. Love to. Coaching really is a concentrated, structured conversation that helps explore where you are today and where you want to be tomorrow. But it also takes the coachee to a place that allows them to build some steps to get them where they want to be, where they want to go, that aligns with their passions and their beliefs and provides meaning and purpose. So it's a space to focus thoughts and really bring out conversations that perhaps you would never have had and may never have on your own. It is what's called solution focus. We're not going to solve the woes of the past. It's really about bringing creative, thoughtful, meaningful solutions. And it's also very future focused and where you want to be to be at your most fulfilled. And it's driving meaningful goals. So we're not there to fix things. We're not there to tell you what to do. And coaching can bring those conversations to life. Outside of healthcare, it is used fairly commonly in corporate environments where leaders come either as entry level with high potential to bring them to better places and also to mid-career and late career opportunities for their professional development. Some of the myths I would love to very quickly debunk is firstly, it's sometimes seen to for remedial support that is you're not performing you're a problem child how can we fix it send you to coaching. That is clearly not what most people are attracted to coaching for. It brings the best and the brightest. A second myth very quickly is coaching is for the elite I'm not good enough I'm not special Yes, it does attract bright and the best, but it is about providing a safe support for a whole range of career development conversations from entry-level people to senior leavers and subject matter experts. And the third myth I'd love to debunk is that it fixes every problem. It doesn't. Coaching doesn't change the systemic issues, under-resourcing and problem children in organisations, but it does change your approach to what might be a challenging organisational issue. Wow, it sounds like a really powerful approach. Rita, thank you. So question now for Sarah. Sarah, why would medical trainees want coaching and what value can it bring? Great question, Tony. And I think we've already heard a bit from Rita about how coaching helps you get places, how it helps you reach a goal. So goodness knows there are a lot of goals that trainees are working towards. And, you know, they don't have to be professional. They can be professional and personal. But professional coaching is really about achieving things that matter to you in your career or in your training. And there's a lot of things that JMOs may wish to reach out around coaching. Exams are a really common area. Preparing for interviews is a really common area. But really anything that you want to spend some time working on, that you want to talk to someone in a safe space without judgment, where you can be very honest about what you care about. And sometimes I find those conversations are really important around career directions and career choices. And for some doctors, there's a conversation about should I even be in medicine? So there's a lot of really deep and personal and valuable conversations to have. And coaching can provide a really safe place to have that conversation. Well, it's just really up to the individual. Yeah. Thank you, Sarah. Rita, question for you now. What would a trainee expect from a coach and a coaching session? I have to laugh when I hear that because I'm reminded of a conversation and a quote from one of the world's leading coaching psychologists, a fantastic academic researcher and practitioner, Associate Professor Anthony Grant. And he, as the person who trained me and hundreds of well-trained coaches, would say that coaches are trained to afflict the comforted. And by that, we had a laugh. He's got a wicked sense of humor. And he kind of said, look, we're not there to inflict pain on our coaches. But what is really critical about a well-trained coach and a coaching conversation is it will take coaches in a safe and, as Sarah said, supported, nonjudgmental way to a place where it might be mildly uncomfortable. It'll be a place where maybe they've never had this conversation and the vulnerability becomes exposed. It's a place where there might be silences, questions that might reflect some of the patterns that haven't actually served you well but have kind of been there but haven't really been brought to the surface. And to that point, there is the affliction, the slight degree of discomfort in facing some of those really useful and often transformational aha moments that go, wow, never thought of it like that. I feel I can be creative, I can be vulnerable, I can be supported. And if you're not having that sort of experience in coaching, then you're probably not benefiting to the potential that what coaching can bring. So in terms of what to expect, it's okay to be in that place of supported discomfort because it's likely to bring you the best aha moments that you may ever have. Wow. So what I'm hearing there is that if we can focus on the benefits, if we can focus on the outcomes, then it's worth that discomfort. And we know any growth process, we have to go through a period of discomfort. I think that's right, Tony. And I can jump in there maybe and tell you a little bit more about what coaching is and how it's different to mentoring. Because I think that that check and challenge process that we do in coaching, where we actually stop and talk to someone and probe them a little bit, make them a little bit uncomfortable, is actually where the growth comes from. And one thing that's clear in medicine is that there's a long tradition of mentoring. And I have some amazing mentors and many, many doctors do. I think the thing about mentors is that what we often go to them for is advice. And we go and say, what do you think I should do? Or what did you do when you were in this situation? And that's brilliant when that person's very aligned with your thinking and very like you. But sometimes someone else's solution is not the best solution for you. So if you were to talk to me about how I could exercise more, for example, you could say, well, what works for me is getting up at 5.30 every morning. That's what you should do. You should just get up really early and get your exercise done for every day. Whereas I might think, whoa, I am so not a morning person. I am not going to make that work. But I might be too scared to tell you if you're my mentor. I might say, thanks very much. That's great advice. Really appreciate it. Whereas in coaching, if you set the goal, I want to exercise more, a coach will flip that around and challenge you a bit and say, well, how could you do that? And they might say things like, what works for you? And that's what I think is the power of coaching. It's coming to a point where the coachee themselves is the expert on themselves and they know what's going to work for them. So a coach's job is to work with the coachee to understand what their solution is, what is it they need, and to challenge a little bit to push you out of your comfort zone and perhaps to challenge your thinking a bit, but to then empower the trainee to come up with their own decisions and their own goals for how they're going to move forward. Great. Thank you, Sarah. So in thinking about the difference between coaching and say other interventions like mentoring as you say, a supervision, I'd love to hear an example of a coaching journey that you'd be happy to share with us. Yeah it's really interesting because I have coached a number of trainees around exams and that's why I think it's top of mind for me about the difference between mentoring and giving advice and coaching because I have passed exams. |
Where's the hardest part for you? What things could work for you? So for example, I remember asking a trainee, how did she think through how she was going to answer a question that she didn't know the answer for? And she said, I've never thought about that before. And so then I said, well, how do you think other people do it when they're asked a question that they don't know how to answer? And she said, I don't know, I haven't asked them. And so that became something that we then went to talk about and she thought about and she asked other people. And she came back and she said, I know what I'm going to do. Next time I get a question like that, I'm going to take a brain break. She came up with her own idea that she was going to take a brain break, which was taking a deep breath in, thinking about the fact that she knew what she was doing, pause for five seconds, and then answer the question. And she came up with that herself. So that is actually what got her through the exam, she told me afterwards. And she did pass a good story but she came up with that solution not me I'm going to pass that technique on to my son who's sitting HSC next year if you don't mind I'm sure she'd be delighted brilliant brilliant Rita Rita benefits and skills so what benefits and skills will coaching actually give trainees? And also what other areas can coaching help in? For example, as Sarah was saying, could be interviews, exams, problem solving, leadership even. Yeah, Tony, absolutely. So look, the benefits and skills, it's hard to distill all of them, but I've kind of tried to theme some of where the patterns are and what people actually do come out with in the process of the coaching experience. Firstly, it's a no-brainer. There's an increased awareness. Self-awareness comes clearly under one of the benefits and skills and as we've mentioned before, yes it's vulnerable but it's pretty exciting too. So there's an absolute focus and being brutally honest with yourself that coaching can actually take you to explore perhaps for the first time what is really going to be meaningful and fulfilling in making the decisions that you've allowed yourself to be intentional about your future. And it's really this safe place to say things that, and certainly when I've coached trainees and mid-career doctors who say, I've actually never had this sort of conversation before. The only person that might know a little bit about this is my partner, but my boss certainly doesn't know and actually my partner doesn't know either. So there's a place that brings an awareness of self with honesty and safety and courage that is often not had in the loneliness of other parts of our world. And that is often the feedback we get from people who have had a coaching experience. So that's increased self-awareness. The other common experience where people benefit is around having a heightened understanding of the patterns in their thinking and their thoughts and their behaviours that perhaps have served them well and to largely they are successful high achieving individuals and have served them well but invariably there are other conversations that coaching brings out which is where perhaps there are patterns that actually haven't served them well there's some of the self-talk that's been self-sabotaging. There's assumptions on beliefs that actually are a little bit irrational that come out. And so the ability to identify patterns in thinking and thoughts and feelings have been some of the benefits that have been really powerful in allowing people to change and disrupt patterns to bring them to a better place. So certainly understanding those patterns have been one of the other benefits. And my only other key way of explaining some of the benefits of coaching is around commitments and consequences. And I kind of go the C's. And that's really saying, where else can you be held accountable for, you know, those really good ideas, those New Year resolutions that you think, oh, yeah, I should, I could have, might have, could have, but actually don't actually translate to action. Coaching is about bringing big, audacious, amazing thoughts and goals to action. So chunk it down, bring it into small steps, make it achievable. And as Sarah said, you are the expert of your choices, so let's make it happen. And it's really holding that accountability and commitment to making that happen. And that can happen whether you're doing exams, whether you're doing interviews. Often, you know, at crossroads of, I want to take this leadership role, but actually I feel so underprepared. So how can I actually, you know, amazing examples of where people have said, I want greater presence in the way I turn up at this meeting. I have a seat at the table, but I don't feel I'm at the table. I want to be more proactive in how I actually present myself. And that comes with, you know, am I worthy of being at this table? Discussions around that are often underpinning why I don't speak up. Actually, I need to put time in my diary to prepare because I can't go into meetings without preparation. I need to plan what I want to be and what I want to say. And they're amazing conversations to have when it's within the scope and the capability of individuals who are prepared to commit to making those decisions and then executing those decisions. It's almost crazy that we wouldn't do it, that we would go through a journey in life without actually investing in this kind of process. It's really helpful, Rita. Thank you. And Sarah, Rita, it is, of course, used as a developmental process in all sorts of areas outside of the medical profession. Can you give us an example of a journey that you took someone through in a non-medical area? I feel absolutely privileged to have worked with many, many doctors and trainees. And it's hard to distill one particular story, but one I'm kind of working with at the moment, it comes to mind. And it's really about the fact that this person has come through in a clinician in a non-clinical role that has struggled to deal with very imposing personalities that have made feeling heard and feeling present difficult. They are conflict averse. They're not into and sensitive to the culture of hospitals and hospital environments. So we are working really closely with bringing the confidence and the skills to have a voice, to choose to be assertive, to choose very carefully the language and the ways in which they are approaching very big personalities in their department. And with that, there are many layers that this coaching journey will take, starting from are they worthy of having a voice? Why would they not feel more confident in speaking up? And what are the risks in doing that? Risks in the pushback and the challenges for the others to accept that this person is going to be creative and going to be proactive and working in the interests of the organisation and trying very hard to dispel the sensitivity of the fact that to be a great leader, you can't always be liked. To be a great leader, you have to be courageous. To bring people to make organisational change in the interests of patient care and the interests of working efficiently as a department means that not everyone's going to like what you do. And for people pleasers and carers and for people who are trained to be carers, that is culturally and sometimes personally very, very difficult. So it's an incredible part of the support in working with this individual to be saying, I actually approach this conversation, this meeting differently. And I ask different questions. I ask questions in different ways. I'm listening differently. And I'm coming to the meetings and the conversations with that difficult personality in a way that's actually causing a bit of discomfort, but I'm doing something different and we're getting different results in the department and that's one where I go wow okay and they're going I just never did that before I'm trying something new and that's part of coaching is to try new things and having the courage to do that and assess the risks before so that's just one of. It's a pleasure. Pleasure. Sarah, could you give us a sense of how coaching can actually help build a career path for trainees? Look, I don't think I can put it any better than Rita just has. And the reason I say that is that it's about taking you out of your comfort zone, finding something you want to work on and really progressing with your professional development. And it can be a technique based thing like how to pass exams or how to pass an interview. But it can also be about your professional development in your non-technical skills like leadership or communication or any of the areas that we all think about as doctors, which are not just our technical and medical expertise. I think there's a big piece around career decisions as well. |
Welcome to On The Walls. It's James Edmondson. Today we're talking on a really important subject, how to care for yourself as a doctor or as a medical student. And I've invited Associate Professor Amanda Walker to speak to us today. She has previously spoken to all first year students at the Western Sydney University and is a specialist in palliative care medicine. And she is going to speak to us today on some tips and tricks on how to care for yourself as a junior doctor. Welcome Amanda. Thank you. We'll start with I guess an opening statement that we realise that there is still an existing stigma around mental illness and it seems in many studies that it is common in junior doctors. So what is the prevalence of mental illness amongst medical students and junior doctors? Really, really high. Scarily high, in fact. In 2013, Beyond Blue did a really big survey that was incredibly extensive across all of Australia. And it looks like about 20% of interns have been depressed. And similar rates of medical students. 6% are currently depressed at any one point in time and 12% have had suicidal thoughts in the last 12 months, which is really scary because that's 1 in 10 have been suicidal. And is that higher than, I guess, the general population or similar people outside of medicine? It is high in the general population. What's a little bit scary is the results don't seem to drop as we continue in medicine. So being a medical practitioner puts us at much greater risk of depression and also anxiety. So about 9% have anxiety. Do you think mental illness is becoming more common amongst junior doctors? Or do you think they're just more forthcoming and identified themselves as suffering from mental illness? I think we're getting better at talking about it and I think we're talking about things a little bit more openly. I know that the Postgraduate Medical Council in New South Wales was founded in the late 80s and early 90s because there were three intern suicides in a year. So I think the problem has always been here. I think we're just starting to talk about it. And I think some of that's a reflection of society. So last night I was just watching the television and there was an ad about supporting women with postnatal depression. Now, when I was younger, you never acknowledged that women got depressed after babies. And so I think we're now starting to talk openly about things that we didn't talk about so much. I worry that this is much worse than we realised it was, though. I mean, why do you think the problem is so prevalent? Look, I think there's a lot of stigma about mental health issues generally. I think we like to believe we're the doctors, we're not the patients, and so we see ourselves on the other side of the equation and that we should be the ones who fix other people, not be in need of fixing ourselves. I think there's also a really strong sense that if we are good doctors, we just cope and we are okay and we don't show our cracks and we don't show our weaknesses. And I think there's also something in when we learn to be clinical and professional, one of the things we have to learn is how to separate our face from our feelings. And so we get good at hiding how we are on the inside. And that's a good thing with patients. So when someone shows you their fungating breast lesion, you't have your chin hit the floor and go oh my god that's disgusting that's a really good skill but if it means that your family and friends now struggle to know when you're not in a good space that becomes a problem for us is there anything intrinsic in the role we have that places at a greater risk of mental illness look i don't don't know whether it places us at a greater risk of mental illness. I think it places us at a greater risk of hiding our mental illness. And I think it places us at a greater risk of thinking that if we are good, we can't reveal our weaknesses. And so we cover up when we're struggling. And I think the biggest thing I realised later on was that everybody struggled as an intern. But I thought I was the only one. I went through my whole internship feeling like I was completely useless, like I was flying by the seat of my pants. And then I got Intern of the Year, and that was the most unexpected thing because I thought I was barely making the grade. I kind of felt like an imposter and if anybody had pricked the bubble they would have realised that here is a faker who somehow flicked her way through med school and I realised in hindsight that everybody felt the same way but none of us talked about it because we were so nervous that if anybody scratched the surface we would unravel so i think those hiding skills are a problem because our thought processes are actually impaired when we're depressed or anxious and that's not good for patients if we can't think clearly yeah no we've we've actually written i think within a number of blogs it's kind of underlying imposter syndrome and I think we've all we all feel that at some stage almost you did mention anxiety as being an issue yeah do you think the kind of people we attract to medicine that may almost play into that that obsessive compulsive I was going to say obsessive compulsive I think you know to be a good doctor you have to have a little streak of it and i think it's definitely i think we shift towards one end of the curve i think there are certain personality traits that work very well in medicine but they're ones that struggle with uncertainty that don't deal very well with doubt um we don't like the shades of grey, we like black and white, I think. And we also don't want to be seen for not hacking it, you know? And so it gets really tricky. I think we are built a little bit that way. So I think we've identified that it is a problem within medicine and it's much more prevalent than we realised. Maybe going to some of your experience being involved in medical education, you have become a port of call for medical students at your university and junior doctors who may come to seek you in their time of crisis. Have you got any stories that you might want to share with our listeners that have maybe particularly touched you? Look, I suppose the first thing is just how incredibly common this is and how people who are objectively awesome, you know, they are in the top 1% of the state, they are bright, engaging, funny people, can think that they are worthless. You know, they think that they are the only one who is struggling, that everybody else around them is fine, and that somehow they are not enough, and they intrinsically are not enough. But the thing that touches me the most is probably the fact that when they get past that space, they realise that suicide is a permanent solution to what was actually a temporary problem. Those feelings pass. They're not permanent and they're not because you are intrinsically worthless. They're because for a little while you felt worthless. And the realisation that they nearly did something that would have changed everybody around them forever. And so I suppose, like I'm in palliative medicine, so I don't get to save lives. I'm not in the business of saving lives. I'm in the business of giving people the best death possible. But I've had more than 20 students come up to me at different points and share things about how things that we talked about in lectures or in sessions, in tutorials or in personal conversations had changed what they were planning to do. And for me to look back on that and know the amazing things that they have since gone on to do and the things that they will continue to do in their careers, that's incredible. And what astounds me is how amazing each one of those individuals was, but how little they felt. And I think when you're in a bad space, you can't be objective about who you are and what your value is. And so I suppose I can't think of any individual stories that wouldn't compromise the individual and I would hate for someone to hear their story coming out live in a blog. But I suppose it's just there's a lot of people out there and people who I look at and go, you are so funny, you are so self-deprecating and amusing and bright and intelligent and you see the world from an incredible perspective, but you can't see that you do. Do you think there's a role for their colleagues to maybe see if they're having issues or problems maybe before they do? Yes, because in fact some of the times I get contacted by the friends of people who are struggling to say, I'm worried about my friend, what should I do? Or I'm worried about my friend, can you talk to them? Or I'm worried about my friend, how should I approach them? |
Any comments in regard to that? Look, I suppose the first thing is, yes, there is mandatory reporting if a student is seriously impaired, but APRA isn't there to try and take away your registration. It's actually about making sure that you get the help you need. You know, ARPA has a responsibility to the community to make sure that impaired people aren't practicing and to make sure that patients won't be harmed. But it doesn't do that by aiming to kick you out. It does that by working to get you better. And so people are very scared that ARPA is punitive, but it's not. It's actually supportive. And AR opera is there to help you, not to kick you out. And in fact, it can speed things up and it can make the situation much better for you. It can get all the support you need within your course and it can also get you special consideration, which is awesome. So I would strongly support people to declare and not be scared of APRA and not to think that APRA is out to get them. The Doctors Health Advisory Service has found that less than 40% of doctors have an identifiable GP. Can you give some reasons or explain to junior doctors and medical students the importance of having their own GP? The older I get and the more I understand how we think as human beings and how we think as clinicians, on a good day we have a whole bunch of cognitive biases in play and we cannot be objective about ourselves. You know, we can't separate ourselves well enough to think clearly. And every major body, you know, the colleges, the College of Surgeons, Physicians, Psychiatrists, ONG, all of them, APRA, the Medical Benevolent Society, Doctors Health Advisory Service, they all say, don't try and be your own GP. Get a GP and they can be paid to do that thinking for us. Partly because the further we go from a medical student training, more often we lose a lot of the general skills. So I'm completely disconnected from ONG and I'm completely disconnected from ICU and a whole bunch of places and really disconnected from dermatology. So the last thing I need to do is diagnose my skin lesions but the important thing is you're accountable to someone else you know you tell them your story like a normal person and they work out what's happening and our job is just to be a normal person for a little bit and be the patient not be the doctor I can give an example of my own experience. Yeah. And it's not to do with mental health, but in regard to a difficulty hearing in my ear. I'd had a history of having an effusion. And I went to, my GP said, I just need a referral to an ENT surgeon. Please write me a referral. She goes, fine. I may have a look in your ear. I looked in my ear, full of wax. The wax went, my hearing got better. So I was convinced that I just needed an ENT referral and oh, it took somebody to look into my ear and tell me, no James, you've got wax in your ear. And in that, you'd catastrophised. So you'd imagine the worst possible thing, that you were going to need a serious operation, you know, there was going to be a great big drama and all it needed was a simple point out yes yes yeah i completely get that you often teach first year medical students about an acronym known as nita to maintain their well-being over the course of the medical practice what is nita and could we apply that to junior doctors within their career yeah absolutely so nita So NITA stands for Nutrition, Exercise, Avoidance of Toxins, Tranquility, Enjoyment and Relationships. Okay. So simple things like eat well. And these days it's actually easy to eat well in a time-poor environment. You can get things delivered to your house that are pre-cooked if you are struggling for time or if you're doing shift work and that kind of thing. Exercise, getting out and about and clearing your head. Avoidance of toxins is really important. So doctors are at risk of depression, drink and drugs. You know, there are three greatest risks. It's not SARS, it's not Ebola, it's not exposure to all sorts of horrible bugs. It's actually depression, drink and drugs. One of my colleagues recently was sharing that they'd had a serious incident in their intensive care unit and they arranged for employee assistance scheme to come in and support the registrars who were involved in this serious critical incident. But the consultants were at the table at the same time and in the course of reviewing the critical incident they realised that the coping strategies of all of the bosses was to dream to excess. So we often don't have really good strategies and we often do turn to things that aren't particularly helpful for us. Then in terms of tranquility, I think one of the big things is meditation. And I'm not good at meditating. We're here at Prince Alfred and Chris O'Brien was a famous head and neck surgeon who developed agrioblastoma multiforme. And one of the things he talks about in his book was that he'd never been good at meditating. And he realized that all he needed to do was actually practice. And the moment he started practicing, he got better at it. And one of the problems is that we call on it just before exams or in periods of really great stress. But if we don't practice it, we can't do it when we need to do it. So it's a good idea to make a little bit of space. Now, I'm not good at meditating. And in fact, I've found that those colouring books that are in all the supermarkets now, I find that it gives my brain just enough to do that I can zone out a little bit. I'm kind of an overthinker. And so I actually find that works for me. But there's lots of people who can just focus on a flower, who just focus on the sound of wind in the trees, that kind of thing. So find what works for you and practice it so that when you need it, it works. I've been to a couple of conferences and mindfulness has been a theme at many of the workshops I've been to developing mindfulness as a strategy. So I think that's going to go very similar to meditation. It's sort of the same strategy but slightly... Yeah, and I think good mindfulness actually helps you be present in the moment with patients. I think it's actually a skill that you can bring to your clinical work. So then in terms of enjoyment, I think it's really important to think about what are the things that make you you? Because often as you transition from being a medical student to being a doctor doctor you leave some of your youthful pursuits behind or you lose them in med school and we forget the things that make us happy and that may be simply walking on the beach that may be playing basketball with your mates we stop doing the things that lift our spirits and I think it's really important to stop for a moment and work out what are the things that lift you when you're feeling flat. Like I've worked out for me the song Walking on Sunshine by Katrina and the Waves. And yes, it dates me firmly as a child of the 80s. You know, if I put that on repeat, by the fourth time, I'm dancing around like a loon in the kitchen because it just makes me happy. But I like listening to 1980s French music because that's again a thing of my teenage years. Then Monty Python songs, if I put on Monty Python albums, that makes me laugh. But my personal favourite is I have a Jane Austen playlist and I'm sure this is going to make you grimace, but I have audio books and I've taken the chapters from the end of Emma, where Mr Knightley proposes, and then it moves to persuasion, when Captain Wentworth proposes in the letter, which is just awesome. I must speak to you by such means as are within my reach, you pierce my soul. And then it moves on to Elizabeth Bennet and Mr Darcy and his proposal. And it takes 40 minutes and it's easy and it's there. I have it on my iPod and my iPhone. And so if I've had a really crap day, I'll put that on in the car. And by the time I've reached home, I feel awesome. I feel in love with my husband. I'm happy with the world and everything that was annoying me is left behind. So that works for me. But I imagine if I made you listen to my Jane Austen playlist, you would not be a happy camper. No, I listen to On The Woods podcasts. Oh, there you go. Exactly. Listen to your On The Woods podcasts. |
Welcome to On The Wards, it's Chris Elliott. Today we're talking about Croup with Dr. Daniel Wurzel. This podcast is produced in collaboration with Therapeutic Guidelines, publisher of ETG Complete, who are proudly supporting On The Wards. Welcome, Danielle. Thanks, Chris. Danielle is a paediatric respiratory physician. She has appointments as a consultant physician in respiratory medicine at the Royal Children's Hospital, research fellow at the School of Population and Global Health at the University of Melbourne, and Honorary Research Fellow at the Murdoch Children's Research Institute. Her clinical interests include a broad range of respiratory problems with a special interest in respiratory viral infections and childhood cough. Danielle has a PhD in chronic wet cough in children and bronchiectasis with an ongoing research program to investigate the early origins of bronchiectasis with the aim of developing interventions to prevent chronic lung diseases in children. Danielle is also a contributor to and co-author of the newly released therapeutic guidelines on croup and is the perfect guest to discuss things with us. Let's start by talking about croup. Croup's also known as laryngotracheobronchitis. It's a respiratory illness that usually occurs in children aged six months to six years, typically self-limiting, lasts two to five days. Boys are a bit more commonly affected than girls, and in Australia, when we're recording this now, we're in croup season. It's a bit more prevalent in autumn. Croup is characterized by an acute onset of inspiratory stridor, a barking cough and a hoarse voice. It's usually associated with parainfluenza viruses and most importantly it's a clinical diagnosis. Laboratory or radiological investigations are usually not required. What we're looking for is a careful assessment of the child presenting with acute stridor and we're looking to not only confirm or consider croup as a diagnosis but to exclude potentially serious alternatives such as other causes of upper airway obstruction. Danielle, I've sort of covered a bit about croup there. How do you define croup in practice? Oh, thanks, Chris. Yeah, croup is basically caused by inflammation of the larynx or the voice box and the trachea as well, which is the windpipe. And it's a fairly common condition in children. Generally, it's associated with a viral infection. As you say, lots of viruses around the autumn season that can trigger croup. And it generally presents with a hoarse voice, a barking cough, and breathing difficulties. Yeah, and often kids have had a day or two of runny nose or something, haven't they? And then the parents report, or this really typical cough can come in and their voice goes that's my experience anyway does that sound reasonable yeah i think that's a really crucial point that it is triggered by a viral infection which often is preceded by as you say a sort of runny nose and some viral symptoms let's think about a case to try and make it really concrete So let's imagine that we're both emergency doctors on a night shift and we're asked to see a three-year-old male presenting with acute stridor and a barking cough. So a bit like we discussed, when you ask his mom, she says, yeah, his symptoms began a few days ago. They're worse at night. He has no significant past medical history. And when you go and see him, he looks really unsettled. He has an inspiratory stride, also a high-pitched noise on inspiration. He's breathing a little bit fast. His respiratory rate's 31. And his heart rate is fast, too, 153. Danielle, I'm a general pediatrician. I'm in ED a lot. You're a specialist respiratory physician. Between the two of us, hopefully we can come up with a sensible assessment. Talk about how you approach kids like this. Yeah, thanks, Chris. So in this child's case, he's clearly presenting as a sort of unwell three-year-old child. And I think the crucial approach here is really to observe the child, to carefully assess him, looking at the pattern of his symptoms of his stridal, look at his work of breathing and try and limit, I guess, your interaction so as not to further distress him, giving the parent and the child a sense of confidence and calmness and limiting any sort of formal examination of him in the first instance while you obtain the crucial information to really ascertain how unwell the child is. It's also important to mention that whether the child looks sick and toxic is very important in determining the cause of his presentation and the potential differential diagnoses. So I think you make a great point, a lot of great points there. But this idea, you know, people who've been in emergency departments, junior doctors and the rest of our audience, you know, a lot of kids show up with respiratory illnesses and they have bronchiolitis or asthma, and that's quite a common thing. And the instinct is often to go quickly and auscultate the chest. And my advice is exactly as you said, with these kids who are distressed and with stridor, just take a deep breath before you go and approach them, because you can learn most of what you need to know by observing them. And if you upset them, it can actually make things a bit worse, can't it? Absolutely. I've certainly seen that happen many times. And as you say, the temptation is to run in and, you know, assess them, put the oxygen probe on, et cetera. But there's really valuable information you can obtain just purely by observing prior to initiating any sort of assessment of them so I definitely can't emphasize that more yeah so let's say we're assessing them what are we actually looking for so how do you sort of describe this different severities of croup and how do you assess those they're trying to figure figure out how bad this kid might be. Yeah, well, look, there are various components, I guess, to the assessment that, you know, and if you break those down, they really give you a sense of what category this child perhaps fits into, whether they're considered mild, moderate or severe in their croup. And some of the components we look at are, firstly their overall appearance and behavior are they sitting up normally and happily and interacting as they normal would are they a little bit agitated or unsettled as this child clearly is that would put them in the moderate category for that component or are they really agitated are they drowsy are they of, do they have very altered behavior? Then, of course, we're looking at their respiratory effort, you know, their respiratory rate, their accessory muscle use. Again, that's divided into sort of the three categories. If it's normal, then they would be considered mild. But if there's any evidence of increased respiratory rate or chest wall intercostal muscle use, moderate use would be obviously in the moderate category, but marked use would indicate severity. And then thirdly, and perhaps probably the most important is actually the pattern of the stridor. So in order to diagnose croup, you know, the stridor is a key component. And again, categorizing them according to severity, if they've got mild croup, you won't hear stridor. You may not hear stridor at all. You may only hear it when they're upset or when they're running around. Children with moderate croup tend to have some intermittent stridor at rest, whereas those with severe croup will have persistent stridor at rest and usually they're self-limiting their activity. I should mention, however, that how loud the croup is is not necessarily an indicator of severity. It's more the presence or absence of croup and the pattern of the stridor. Thanks, Danielle. I mean, that discrimination between stridal when you're distressed or active and stridal at rest, that to me is a really important pivot point when you're sort of considering management of diagnosis and whether they're mild, moderate or severe. And yes, that loudness of stridal. And I always think to myself, you know, what's causing stridal is a critical airway narrowing. I mean, that airway has to be really small to act as a whistle. And I think that keeping that top of mind really informs a lot of the things you do. So it's really easy to remember not to distress someone whose airways are a few mils wide and they're struggling to breathe. And yeah, and just like in many other conditions, it doesn't have to be loud to be bad. You know, quiet is really bad as well, but that's a great point. Yeah, no, I definitely agree. And if you upset a child with croup, they will invariably develop more significant strata and may actually need a higher level of intervention. So one of the key points is to try and keep, and part of keeping the child calm is keeping the parents calm. |
And that can, you know, I guess, make the child more worried. So keeping the parent as well as the child calm is really important. And I mean, I'd be really interested in your experiences, actually, Danielle, but in terms of keeping a parent calm, often just projecting a sense of confidence that, you know, even if this is severe croup, and by the end of this podcast, you'll have a bit of an idea about your management options, and you can always go and read the therapeutic guidelines. And of course, this is a really serious illness in a child. So I would be expecting junior staff to be accessing senior help early. But it doesn't matter. You can be confident that there's a pathway of what you can do. And if you project that confidence, yes, there is help here. We do have options that can really help to settle a parent who's really uncertain about what's going on, particularly if it's their first time. And the other thing that you mentioned about distressing things we didn't say explicitly is, you know, I would say never do a throat examination, never put a tongue depressor in the mouth of a child with stridor. That's a really dangerous thing that, you know, you must never do, you know, ever really, but certainly not without senior support or insistence. Absolutely agree. Now, a lot of childhood stridor will be croup, but not all of it. What are the differential diagnoses that we need to be thinking about in the back of our head? And you sort of, you know, signposted this when you talked about toxicity and kids looking really sick. What other things do you think about, Danielle? Yeah, so I think that's a really good point is just being just being aware as you say that most causes of stridor particularly the vial prodrome are you know croup however there are a number of differential diagnoses just to be aware of when the picture or the pattern is not completely typical of croup particularly need to be considered in a child that appears septic or toxic, more unwell than you would expect with a viral infection. And some of those other causes are other causes of upper airway narrowing and particularly bacterial causes of upper airway narrowing. And there's a list of those which range from, you know, epiglottitis, which can be a life-threatening condition we don't see very often, but certainly does still occur, a peritonsillar abscess or a retropharyngeal abscess, which often can present with a toxic, drooling child who is refusing to move, refusing to talk, clearly looks extremely unwell. And these children are basically a medical emergency and, you know, senior help needs to be enlisted and they're treated obviously very differently to croup. Another common cause is bacterial tracheitis as well. So these need to be considered in children who present with a slightly atypical presentation and perhaps in children that haven't been immunized and when they don't you know fit the the classic description of viral crew yeah that's right and these you know they talk about the tripod position which you know it's sort of more subtle in my experience, a bit more subtle than it's made out in the books, but this rigidity, children who refuse to move their airway because they're holding it in just that position to keep it open, that is clearly an emergency and something that when you're standing back and observing the child rather than rushing in with your stethoscope, you'll get a notice. And the next thing you do after you see that is you go and get someone senior to help you out would that be fair absolutely the other thing we can sometimes see is kids who don't have a viral prodrome particularly those sort of mobile kids you know 12 to 12 months to two but it can be any age really so then don't have a viral prodrome but they do have a stride or they're not febrile, they haven't had a snotty nose. And sometimes then we're always thinking, could this be a foreign body? Could they have picked something up from the floor and stuck it in their mouth and breathe it in? And of course, keeping an open mind about those sorts of things in that appropriate age group. It's not as likely in babies who aren't mobile. It's not as likely in five and six-year-olds, although never say never. But that's another thing to consider. What about kids who present for a different reason but you notice they have stridor? So I guess, and the parents say, yeah, they always breathe like this. This is normal. This is a kid's sort of a chronic stridor. It can be a little bit different as well. Danielle, what do you sometimes consider with that? Look, absolutely. And, you know, the pattern, as you say, is so important in determining what the differential diagnoses are. And so, for example, if you have a young child who's had a stridor present perhaps since, you know, the first week of life and they've had persistent sort of stridor and it's not clearly related to a new onset viral infection, other causes need to be considered. This would be considered sort of a chronic stridor rather than an acute onset stridor. And certainly in these instances, we'd recommend referral to a pediatrician or respiratory pediatrician or ENT specialist, because there are other conditions such as laryngomalacia or subglottic stenosis, subglottic hemangiomas that can present in this more insidious chronic fashion. Yeah, really helpful. So just, you know, not all stridor is croup and you'll learn a lot by listening, you know, like with all pediatrics, history and examination, predominantly observation, that's going to get you a lot of the way all of the time. Now, let's back to our case. So this three-year-old has the viral prodrome. The stridor is a bit worse at night. He doesn't, you know, seem on the history we've been given to have any signs of any other differentials. So we're thinking this could be croup. What investigations might we need to do to confirm the diagnosis or reassure ourselves or exclude other things? So I think this is a good opportunity to just remind that croup is a clinical diagnosis. So it's based upon the clinical observations and the constellation of symptoms of stride or the horse voice, the barking cough, the viral prodrome. So there's actually not any specific investigations that are indicated in the assessment of croup. Right. I think that's, you know, another key take-home home message and we'll come back to these at the end, but don't distress a child with stridor because they've got an AOA problem and don't do investigations. You don't need to do any investigations to diagnose croup. It is a clinical diagnosis. If you've got that typical picture, very helpful. Now we've kind of without all the information that we'd normally like to see, we're kind of thinking that this child, because they have been spiritually astride or at rest, might have moderate croup at least. What are our initial management options then, Danielle? What can we do to help this child? So in addition to the sort of conservative measures that I mentioned about keeping the child calm, in terms of what medications we would administer to the child, in the first instance, we would give them an oral steroid. And this will help reduce some of that upper airway swelling and actually starts acting quite quickly. So the two main options that we use in this setting would be either prednisolone, so a one milligram per kilogram oral dose up to a threshold of 50 milligrams as a single dose. Alternatively, if oral dexamethasone is available, then we would offer 0.15 milligrams per kilogram orally up to a maximum of 12 milligrams as a single dose. And the vast majority of children will take the oral therapy. We would then observe them for a minimum of 30 minutes after the steroid dose with the expectation by that time at 30 minutes, if they're going to respond, you would start to see some response. So, Danielle, there are two options for oral steroids there and you sort of lightly mentioned if the dexamethasone is available do you have a preference in clinical practice why are there two options I think the JMOs might be really interested just to hear what's going on there. Yeah so the reason why there are two options is that dexamethasone is not universally available in settings, community settings. Within hospitals generally, it is available. Hospital pharmacies can provide an oral dexamethasone solution. But outside of the hospital setting, it's not universally available. And there's no clear evidence that one is better than the other. So either of them are fine. Some parents will say dexamethasone works better for their child. |
Okay welcome to On The Wards, it's Dr James Edwards and today we're talking about a very challenging topic of the assessment and management of suicide risk. And we have Dr. Joanne Ferguson back with us today. Welcome. Thank you very much. So Dr. Ferguson is a star-spatial psychiatrist in addiction medicine and works with the Croix de la Comunité Health Centre. We've spoken a number of podcasts with Joanne in regard to depression and psychosis. This is, I guess, closely linked with the assessment management of suicide risk. We're going to start straight with a case. And it's a fairly simple one that you've been asked to review a patient on the ward who has told the nursing staff that he's having suicidal thoughts. And we really just want to have, I guess, a general approach over the phone and then initially, once you go go and arrive how you approach the patient when you see them on the wards. So talking about suicide is regarded as one of the most stressful discussions that people that staff have with patients. It's very challenging emotionally and intellectually. It can be very challenging to your idea of yourself as a doctor and particularly to your idea of patients and what they should be doing, what their role is in this interaction. So it can be a really difficult discussion to have. If somebody has acknowledged or mentioned to another member of staff that they're having some thoughts about suicide, they're often quite ambivalent and expressing some fear about the thoughts and some concerns about what it might mean or a sense of powerlessness with their thoughts. But they are open to some discussion because they've mentioned it. So it's a really good opening. So you shouldn't really be afraid as a junior doctor to ask about it. Asking most patients about whether there's ever been times where life's just been too hard and the suffering that they've been experiencing has been too hard to go on with is a really good opening question. In this situation the person has mentioned to a member of staff that they're having suicidal thoughts and it's an important assessment. You need to know how risky they are right now and so that's the sort of thing you'd ask over the phone. Tell me a little bit about the patient, tell me about who they are, have they done anything right now and is this this something I need to come up for immediately? Or can I come up in 15 minutes because then I'm going to have the appropriate amount of time to talk with them? So that's your sort of initial approach. Is it safe? How am I going to put this into my day? And do I need to make another plan straight away? You arrive down, you sit down and you've got an opportunity and strangely enough on an evening shift you actually have got 30 minutes to have a chat to the patient. We can dream but in this scenario they do. So what would you be approaching when you arrive? You might ask the nursing staff if things are okay and whether you could perhaps see the patient in a more discreet place. Sometimes being in a four-bed ward with curtains around you and visitors in there making a noise is actually very difficult to get someone to talk with you in a way which is going to be helpful. You might take them to a quieter space if you've got one. And yes, in this situation, we do have about 30 minutes to talk and it might be an unusual thing. So you might work out where is best to do the interview and hopefully there will be some space. You shouldn't really be afraid of approaching someone for your own safety unless there's been some suggestion that in fact they're hiding a weapon or they're feeling hostile and frightened which is a little bit of a different referral. The nursing staff in that situation might have said they're feeling suicidal but we're really like there's something edgy about them. So in that situation you'd approach with other staff members and you wouldn't be necessarily in a private space. Assessing a risk of suicide is quite a sort of simple but complicated thing at the same time. There's no general consensus that there's a reliable way to predict suicide and an assessment has a very short period of time in which it's valid. So there's no sense that a risk assessment for suicide carries forward for very long. The assessment that you do is valid at the time you do it and for a little bit around that time so you're going to have to keep going back and talking to people about that sort of thing. The way to assess it really is to look at the risks and the thoughts and to have a sort of hierarchy in that discussion. So if someone has had an occasional fleeting thought that life's really very hard and they'd be better off dead, and they've made no other thoughts about it, but they're perturbed by that thought, then that's a different level to someone who feels that life is definitely not worth living and that they would much rather be dead and they are going to, and they have a plan perhaps. You can then make a guess about the lethality of their plan and of course the details in that plan. If people have made preparation for this event, if they've started to sell their things, finalise their business, write a note, those sort of things are much more telling and obviously require a much more acute response than a sort of more general or simplistic sort of thought. Often people who have a general sense that life's very difficult will be quite reassured when you talk with them about their suffering and how hard it is and what they have as resiliences or strengths. Sometimes people can't see their resiliences and bringing out some of their protective factors is a really valuable part of this. It helps predict whether people might act on it. So being Catholic where you are, or another religion, where suicide is against your religion and you're a strongly religious person will usually be a significant protective factor. If somebody has experienced suicide in their family and noticed the effect on their family, that's often a protective factor actually. If people are isolated and feel that they have no friends, that nobody will miss them, that they have no future, that's a risk factor, not a protective sort of thing. Young men are more likely to use more lethal methods. They're more likely to use methods that are impulsive, for example, jumping of heights or jumping on the train line. So that's also one of those things that you might consider. Okay, so I guess you've provided an overview of their risk of suicide. I think one of the challenges that I find as an emergency physician is that many people come into the podcast and talk about history is everything. And we say that, yes, history is everything, but usually we have another test, a blood test, an X-ray to help us. Really, this assessment, it really is just on the history. There's not too much else to help us. That's true, but there's also something else which is a little bit useful, and you should perhaps think about this as we develop our skills as doctors. We have feelings about things. When you're with a patient, you can sometimes get a very prominent feeling about them. It's a transfer of subliminally information. It's a constellation usually of information that you're seeing, that you're reading, that you're hearing and you're thinking. And those things often come across very strongly. That feeling can be one of despair. And if you walk out of that interview completely despairing, knowing I understand why they're going to suicide, you think, uh-oh, you know, there's something about this which is really profound. And that would be a really, it's a subtle sign, it's something that you can develop, but it's actually something we ignore to our loss. Look, it is one of the things I tell every junior doctor, probably not always to say to a psychiatrist, but sometimes your gut feeling is really important. And you see your gut, there's something not going right here and you shouldn't, every time you ignore that gut feeling, it usually ends badly. So I think it's an excellent point. Any other particular underlying disorders that are associated with suicidal thoughts or ideation that we should consider? So there's some groups which are particularly associated with suicidal thoughts and with suicide. People with psychosis, with schizophrenia, about 15% of people with schizophrenia will suicide and about half of people with schizophrenia have tried to take their life. Not just thought about it, but tried. About somewhere between 5 and 10% of people with bipolar, and about 10% of people with a serious substance use disorder. Of course, any combination of those increases the risk. People with a significant severe personality disorder of the borderline type have a significant ongoing suicidal ideation, and many of them have made significant attempts on their life. So that's a group of people who are often severely distressed in their mental illness. Most of them can be well for long periods of time. So it's not a persistent behaviour. |
Welcome to On The Wards, it's James Edwards and today we're talking about Toxicology with Dr. Zef Koutajanis. This podcast is produced in collaboration with Therapeutic Guidelines, publisher of ETG Complete, proudly supporting On The Wards. Welcome, Zef. Hi, James. How are you going? Well, Zef is an emergency physician and clinical toxicologist with a strong interest in illicit drug use, critically ill poison patients, acid-based disturbances, dependence, addiction and management of pain. And we're going to go through a case with Zeph and kind of really explore a really interesting and evolving area. And the case is that you're working in an emergency department. So a 90-year-old male who's been brought into the emergency department with pleas from a dance party, agitated, acting bizarrely, after taking what he thought was ecstasy. He was one of three people taken to hospital with a similar presentation that night. Others at the scene are worried that there's a bad batch of ecstasy out there, that he may have had a novel psychoactive substance, NPS, such as an N-bomb or flakka. So, Zef, maybe we'll start. What are, I guess, novel psychoactive substances or NPS and what's an N-bomb or flakka? Yeah, well, NPS is they're designer drugs, essentially, that are produced and designed to mimic traditional recreational drugs such as cannabis or ecstasy MDMA or even heroin, for example. And they're novel in a sense that they might be novel because they've been newly made and produced or they're novel in terms of it's an old drug, but it's got a new novel use out on the street about it. And it's in terms of legally, different countries have got different legalities with respect to them. So some of the, for example, say NBOB and FLACA, they may not necessarily be NPSs in the traditional sense of the word now because they're illegal, but when they first started, they weren't illegal because they were new substances. But it's that sort of thing. And they're designed to, like I said, mimic the traditional recreational drugs. And there's been an explosion in these substances over the last 10 to 15 years. And the broad categories are stimulants, novel stimulants, synthetic cannabinoids, which are designed to mimic cannabis, hallucinogens, and even sedative agents such as designer opioids and designer benzodiazepines. So, I mean, the stimulant group are the most common of the ones that we see, particularly in the dance party, party drug sort of scene, because they're designed to mimic the effects of what people would take at those places, like the amphetamine type of substances like MDMA. And it's all about a lot of receptors, but the main ones are dopamine, noradrenaline and serotonin. And depending on how you're built and your receptors and how those neurotransmitters are released or reuptake inhibited depends on what effects you have from them. And the common stimulant ones that we see are the cathinone group, which involves their stimulants, but they also involve hallucinogens as well. And they're basically substituted amphetamines. So you put different chemical structures on these different... The basic phenylethylamine chemical structure is the basic building block for our own neurotransmitters, and then you add all these different chemical groups to them and they have different effects. So things like bath salts and flacor and Enbon, they're just street names to suggest certain cathinones. I mean, I can go into what they're meant to be, but they're quite long chemical names, which is not that important because the important thing is what they say it is and what it actually is may be two different things. And on that, yeah, sorry, go on. No, yeah, I mean, you've mentioned how much they've really proliferated over the last 10, 15 years. I mean, why do you think that is? Why has that happened? Yeah. Lots of reasons. It all started mainly in the mid-2000s, you know, 2006, 2007 in the UK. It's like the summer of 2008, 2009 in the UK mainly and lots of things. It was like the Swiss cheese model. All the holes lined up and all the planets lined up that year that things happened. So ecstasy became like a category A type of banned substance in the UK, which everyone was up in arms about because it's relatively, well, I won't say harmless, but in terms of recreational drugs, it's not that bad compared to some others. And because it was given such a high grade with a criminal record, if you get caught with it, then people started looking for other things that weren't as illegal to use. There was that. There was the GFC that happened. There was billions of tonnes of saffron oil in Asia that was seized by border police, which is a chief ingredient in MDMA production. So MDMA wasn't available. Cocaine was less pure and more expensive. So it was sort of rife to start playing around with these substances. And in those days, mephedrone was the first cathinone, which was the poster child of all these substances sort of emerged, and it was legal because it wasn't illegal. And it was marketed as plant food or pond cleaner. So you would order your plant food and these vans would rock up to your house in the middle of the night and give you food for your plants. And it would clearly say not for human consumption. And that's how they would bypass this. As the law caught up with them saying, actually, methadone's bad. We're going to ban it. Then they produced another substance, which wasn't illegal, but methadone was and so forth. And same goes with synthetic cannabinoids. You remember K2 and Spice and they were, you can get them at head shops and those bong shops and you can just buy pot puree, not for human consumptions, but people would buy it and smoke it and have the effects of cannabis, essentially. And then as the years go by, there's just hundreds and hundreds and hundreds of them, just explosion. Yeah, and all available on the web somewhere through the dark web. Yeah, absolutely right. And you can get it straight through with cryptocurrency and the dark net. You can just order it online and it just gets delivered to your house. Okay. So there's obviously a downside because these are pretty obviously dangerous drugs. So maybe when we think about, I guess, the initial assessment and management of these kind of new NPSs compared to traditional drugs, obviously like methamphetamines and MDMA, how does our management differ? It doesn't really differ because one is you don't really know what somebody's taken and you basically just treat the clinical scenario in front of you. So methamphetamine or ice, as we all know, can produce a variety of effects and so do these, say, you know, Flakor or Enbom or synthetic caffeinones. So it doesn't really, you don't need to know what the drug is to treat the patient. So essentially, like I said before, it's a ratio between what your dopamine, serotonin, noradrenaline is doing will depend on how you present. MDMA, for example, is mainly a serotonergic type of drug. So it makes you feel nice and warm and fuzzy and, you know, close to people. And sometimes you can have mild hallucinations. Whereas Flaka, for example, is a very potent dopamine and neurodegenerative agonist, which gives you quite marked agitation and neurotoxicity. And the N-bomb is essentially a substituted amphetamine with very potent serotonin 2A agonism effects, which is hallucinogenic. So they can get very agitated and hallucinogenic. And essentially the syndrome that you see clinically is a spectrum from mild to severe of sympathomimetic or serotonergic toxidromerome, for example, behavioral disturbance and what kills them essentially is hypothermia. So you can get really bad hypothermia. You need to get onto that pretty, pretty fast. So it's all quite variable. Some people might come in a bit agitated, not feeling quite right, and they can just settle down. Other people are at the other end of the spectrum and they've got an excited delirium and they really need to be, it's a medical emergency rather than a mental health emergency, if you know what I mean. So the management is a case by case and you don't really need to know what it is. But when they say bad batch of ecstasy, it's not a bad batch of ecstasy because it's not ecstasy. |
It's something else that's been sold as MDMA and that's why you get the runs like this. And the media love it because it gets a lot of media attention. So when they arrive in the emergency department, can you just describe what kind of assessment we should provide and what are the key important things to look for? Yeah, so like any patient, I guess, in the emergency department or mainly toxicology patients, but particularly these ones, you need to know what all their vital signs are, including temperature, because like I said before, hypothermia and the degree of how hot you are has got more morbidity and mortality associated with it. Try to get a sense of whether they've got a serotonergic or a sympathomimetic toxidrome and looking for autonomic effects, excitation, CNS excitation and how severe that is. And essentially they're all, like I said, there's a degree of from mild to severe of agitation, tachycardia, hypertension, hypothermia, and sometimes they even have seizures. Because if you can just imagine all your body systems are ramped up. So your CNS and cardiovascular system just sort of ramped up. So that's basically what the initial assessment should be. And an assessment of what their mental health's like, yeah. And just in regard to things like temperature, do you just do a normal temperature or do you have to rectal temperatures? Oh, look, initially you just do a normal temperature and you'll get an idea. And a lot of them run a little bit hot anyway, like 37.5, 38. Once you start getting above 39, now 39 degrees, you're getting a bit like too hot. But sometimes they present like 41, 42, 43. You've only got half an hour to cool them. Otherwise they cook from the inside and they die. But they don't tend to do that in the ED. They present like that pretty much. Yeah. I mean, I think we've seen a tiny bit of that, especially within New South Wales and some of the dance parties, stuff like that. Hot days plus drugs has been a bad combination. Yes, and not only that, it's the dancing and you've got, you know, psychomotor agitation in terms of your movement, you've got exposure, then you've got the drug as well and, you know. So what are the management priorities for this patient? Well, the management priorities in general with people who take recreational substances, they sometimes don't get a fair go with doctors and health professionals because, you know, they're drug users and they get judged. So I think the initial priority would be to be respectful and caring and calm and not being judgmental and just treat the patient that's in front of you with the problem that they have just as a going in that way. And the manager priorities in a nutshell is controlling their behaviour and calling them if they need calling. Basically, that's it. And to do that, it depends on the severity. Sometimes if it's mild, you can offer them. Benzodiazepines are good for these sort of stimulant type of scenarios because they calm everything down. Like your body's ramped up, so you need your mind soothed, you need your body soothed. So tachycardia, hypertension, agitation all respond well to benzodiazepines. Sometimes if they're really, really bad, they need to be taken down with pharmacological management and therefore you may need a dopamine antagonist like droperidol or something, or even ketamine sometimes they're using pre-hospital. And would you usually use diazepam or Bidaz? It doesn't really matter. We like diazepam as toxicologists because it's smoother, it's long-acting, it's lipid-soluble, gets into the brain better, whereas midazolam is more water-soluble, sort of quick on, quick off. And midazolam is probably maybe better to take somebody down if you want to use a benzo to do so. But if you just want to just chill somebody out for a bit, diazepam is good because it's got active metabolites as well and it lasts longer. You mentioned about cooling. What kind of cooling techniques can you use? Well, again, it depends on the severity of the cooling. If it's basically just stripping them is one way or fan and misting is another way. But if they're really, really bad, then sometimes they need to be taken down, intubated, paralysed and cooled that way. Two Panadols probably not enough. No. It's a thermoregulation problem. It's not a fever, basically. It's hyperthermia, not fever. So what are some of the complications associated with stimulant NPS intoxication? Well, again, depending on, there's a spectrum of severity. So if we go in the most severe aspect, they can have multi-organ failure from extreme agitation and lactic acidosis and rhabdomyolysis and coagulopathy and all the things that go with severe and acute renal failure with severe hypothermia. But in the more milder sort of sense, they can present with maybe a seizure. They can have hyponatremia from SIADH because a lot of these drugs have SIADH effects or water intoxication because a lot of dance parties, they're told to drink a lot of water so they tend to maybe overdo it so they don't get dry, for example. The other important thing is there's also the acute and long-term sort of mental health and psychiatric effects. You can have like a psychosis, acute psychosis and hallucinate and not be quite right. And that usually settles, but sometimes it doesn't. And that's a bit of a problem. And another problem that people forget is, excuse me, the cardiovascular complications of these drugs, not just these drugs, but even the traditional amphetamines and MDMA, they cause vasospasm and thrombogenesis. So anything goes in terms of ischemia. We've seen 19 and 20-year-olds have MIs and we've seen strokes in 23-year-olds. So the message there is don't ignore chest pain or headache or things like that in a young person who's taken these drugs because the concept, a lot of doctors think I couldn't possibly, a 22-year-old couldn't possibly be having an infarct and they just sit there in the cubicle complaining of chest pain and people are ignoring them. So take it seriously. And just in regard to, you know, I guess assessment, are things like urine drug screens helpful for this group of drugs? No, urine drug screens are not particularly helpful for anything really in the emergency department. I mean, they're good for say surveillance out in the, you know, drug and alcohol world if you want to see whether somebody is compliant with their medication and so forth. But in terms of the emergency department, there are a lot of false positives and false negatives. And the urine can stay positive for, say, amphetamines for three or four days. So your presentation today with a positive urine drug screen does not tell me that that's what you've taken today. You may have taken that drug three days ago and what you've got today is a completely different thing. So it's not that helpful. It may be helpful in children, like young children who may have gotten into their parents' drug stash and therefore they're acting a bit bizarrely, maybe in those. But generally in this scenario that you've just presented to me, a urine drug screen, one may not even come up with anything, two, it's not particularly helpful. Okay. Well, thank you so much for that. Can you just give us any, I guess, take-home messages? About NPSs in general? Yes. Yeah. Well, NPSs, novel psychotic substances, are designed to mimic the traditional recreational drugs that we're all familiar with, such as MDMA and cannabis, the main ones. The main syndromes that they get are varying degrees of combination of the serotonergic and sympathomimetic toxidromes. It doesn't really matter. You shouldn't get caught up with the names and the street names and what they may have taken because it's not that important. What's important is what's in front of you and how you're going to deal with that patient, which is basically control their agitation or their behavioural disturbance and cool them as required and get on to severe hypothermia early because it's life-threatening because that's all the deaths that happen at music festivals tend to be hypothermic deaths. Some of them are arrhythmia deaths, but a lot of them are just hypothermic deaths, so you need to cool them quickly. And that's about it, really. |
Welcome to On The Wards, it's James Edwards and today I'm talking about combat medicine and blood preservation with Brigadier Michael Reid. Welcome, Michael. Thanks very much. Michael's biography would literally take me 15 minutes to read. He's an anaesthetist, an intensivist. He's the Australian Defence Force Professor of Military Medicine and Surgery. He's got PhDs from Oxford and a bunch of other incredible accolades to his name which will all be available on the website. But we thought we may get into talking a bit about combat medicine and blood preservation, but maybe really going back to the start. Why did you decide to join the Australian Defence Force? Well, that's a good place to start. I joined when I was a first year medical student at Sydney University. And I think I primarily joined to do something a little bit different to just being a standard medical student, maybe also for a sense of belonging to something bigger than just being one of 250 medical students as part of the medical course. And I had an eye on the future maybe as well, to practice medicine in a way different to what I knew I would be practicing as a hospital doctor as well, to add something to the practice of medicine, which has certainly proved to be the case over the subsequent 31 years. Okay, so in that 31 years, tell me a bit about that career. Well, I spent the seven years, I did a BSc Met as well, seven years at university becoming a general service officer in the Australian Army Reserve. So I learnt to be a troop commander lieutenant and I spent the rest of the time as a medical student, well, driving around New South Wales with a troop of trucks actually. We used to go on four-wheel drive weekends through New South Wales. But more importantly, I learned to lead a troop of 30 soldiers and, I suppose, take command of an infrastructure of a troop with people who were much older than me and who knew much more about the technical requirements of driving trucks around country New South Wales than I would or ever would. And I thought that was actually, in retrospect, enormously beneficial preparation for being a junior doctor because when you walk onto the wards as an intern, well, you know a little bit about medicine, but the practicalities of being an intern, a lot of that you really learn from the nursing staff and allied health professionals within a hospital and although technically speaking a lot of the medical decisions are yours to make as an intern or maybe as a junior doctor, you really rely on the expertise of those people around you and I'd overcome many, you might say, psychological issues as a troop commander maybe three or four years before in the Army Reserve. So I thought that was terrific preparation for being a junior doctor. Anyway, so I graduated as a junior doctor and then I became a battalion regimental medical officer for an Army Reserve unit. And I did that through really all of my training as a Specialist and Aesthetist and Intensivist. I went to the UK to do my PhD and I was attached to a British Army Unit while I was there. I did my first two deployments to Bosnia and Kosovo with them, with the British Airborne Brigade and then I came back to Australia as a Specialist and Aesthetist and did a few deployments with the Army Field Hospital and really have, I suppose, progressed up the rank since then. And for a time I was the Director of Clinical Services of the regular Army's deployable field hospital in Brisbane, which would definitely be a career highlight. And then when this academic position became available in 2011, I transferred to that and I've essentially been working full-time for Defence since then. So what sort of opportunities has the career within the Defence Force provided you? An enormous opportunity to combine both a civilian and a military practice in one. So I've done all the civilian training that any other anaesthetist or intensivist would do without question. But I've also had opportunities to command US soldiers in the California desert. I've been the director of clinical services of a small field hospital in Afghanistan. I've been the Commander of Australian clinicians deployed to a very large field hospital in Afghanistan during one of the busiest times during our deployment in Afghanistan. I was the Director of Clinical Services of the hospital that we deployed to Iraq in 2015, which was really quite a challenge from a logistic point of view. So a whole lot of, you might say, non-clinical things, but I guess I'd argue things that required a lot of clinical insight to establish hospitals in those environments. Sometimes technical things. So, for example, when we put up the tent that was going to house the operating theatre in Iraq, I looked at the anaesthetist and she looked at me and we thought, yeah, electrical safety in an operating theatre. We learnt about that in the primary, but we've never had to worry about it since. And those little knobs on the back of the anaesthetic machine, they're there for a reason. That's for the common rail. We'd better do something about this. So from that very technical side of things to very non-technical things of, well, for example, and again, in Iraq having to integrate clinicians from five countries into a functioning hospital and not that there were many things like complaints and so on, but when there were little wrinkles in the organisation of that hospital, which country's regulations were going to be followed, how were we going to sort out those problems that essentially fell to me to work out the protocols. So challenges that you wouldn't normally expect in conventional civilian anaesthetic and intensive care practice. That's an incredibly diverse and interesting career. Any particular highlights that stand out? I think two really. One, being the commander of the Australian contingent at that Royal Three Hospital in Kandahar in 2013, which was really very busy clinically. It was war surgery like you see on TV, which was clinically challenging, but that wasn't really the highlight. The highlight was keeping that team together and focused and bringing them back in one piece mentally such that we all got on the plane, I think, psychologically stronger coming home than we were when we went over. That's what I consider my biggest achievement in defence. And maybe the other highlight was the four years that I spent as the Director of Clinical Services of the Regular Army Deployable Hospital, a really big organisation, 350 people. I wasn't the commanding officer, so all of the administration was done by somebody else, but coming up with the clinical policies and building that team of clinicians was a challenge, but a really rewarding challenge. They'd be my two highlights. Okay. So broadly speaking, what opportunities do you see there for medical and health professionals within the Defence Forces? I think the opportunities are really limited only by what you want to make of it. I think if you want to put your head down and do good clinical work with soldiers, sailors and airmen, you can do that. It can be a busy practice, a practice that has a lot of overlap with civilian work, but equally has a lot of elements that you would never encounter in a civilian population. A lot of occupational medicine overlay to whatever practice of medicine, nursing, allied health that you're embarking upon. But at the other end of the spectrum, if you want to combine a clinical practice with many of those what we would call command and leadership aspects of clinical practice, then the military gives those opportunities, both training and opportunities to develop those skills as well. So clearly I've benefited from both of those opportunities. But, you know, I think really for someone contemplating this as a career, it's a matter of choosing the path that is most suitable to that person. Who should they go talk to? So they're interested in it, they've got an idea, but is there some ways of what someone that should contact or? Yeah, that's a really good question. I mean, certainly you can talk to someone like me, but I'm an old brigadier now. I don't think I'm that old. I'm only 49. But you're always a little bit sceptical that you might get the party line from someone like me. I would be sceptical if I was a young 25-year-old looking at all of this as a possibility. Unquestionably, to get the nuts and bolts of what's required and commitments and so on, the Defence Force recruiting people have all of that information current and they would be the place to start. But the other thing that the Defence Force recruiting people will have on hand is a list of people who are currently doing the job at that level or maybe just a little bit beyond that level. And that would be the place I'd send someone. So, you know, let's say you're a 29-year-old PGY-1 who's contemplating doing this as a PGY-2. I would find a PGY-3 in the Navy, Army and Air Force and I'd get the truth. |
So I'd probably find two or three people and get a bit of a group average about the opportunities that might be available. And they'll tell you the truth. They've got no vested interest in telling you anything other than the truth. Maybe we'll go on to combat medicine. I mean, what is combat medicine? I think combat medicine is really good medicineised in slightly unusual environments, sometimes with some rules around it that don't exist in civilian practice, and sometimes with some pathologies that are uncommon in civilian medicine. So we teach our people in the army in particular about blast and ballistic trauma and chemical, biological, radiological casualties and so on. But actually the majority of our casualties, even during the intense conflict phase in Afghanistan, weren't blast and ballistic trauma. They were routine primary care presentations but in an environment where we couldn't just send someone for a cardiac stress test very easily and we had to weigh up the pros and cons of sending them out of the country. Or we were dealing with people who had been severely injured but who for one reason or another weren't able to be rapidly evacuated from the country and so had to be treated as best as we could in that environment. So there are differences compared to civilian practice, but I go back to where I started, that really combat medicine still aims for the highest standard of practice within those limitations. So, yeah, so you've kind of contrasted, I guess, some of the differences with combat medicine to conventional civilian medicine. You joined the Army in 1919. Over the course of your esteemed career, you have been deployed to Bosnia, Kosovo, East Timor, Somalia, Afghanistan, Iraq. Over your time in the Army, how has combat medicine changed? That's, I think, quite a perceptive question. When I first joined back in the early 90s, I think we were setting up hospitals in, and not even really what would qualify as a hospital, in tents and we were just saying, well, look, we'll do the best we can, but we accept that it's not really going to be very good. But, you know, war's war and we'll just accept that standard of care as being lower than what we might accept everywhere else. And there's been a real shift in our approach to what we think is acceptable now. So although inevitably, if you're in the middle of nowhere at the end of a nine-hour flight to anything that you or I would recognise as a hospital, sometimes clinical outcomes are just inevitably not going to be as good. I think our mindset has changed to the point that we've embraced all the civilian concepts of continuous quality improvement, of evidence-based medicine and so on. And that's led us to lead in some areas. So in trauma care in particular, that I'm most familiar with, the things that we have innovated with in Afghanistan and Iraq have been brought back into civilian practice. And the idea that something could have been developed in a military environment in the 1990s and brought back to civilian practice just wouldn't have happened. We wouldn't have had the ability to generate that evidence. And now there's a whole infrastructure to do just that because we're holding ourselves to that higher standard. So I could list for you a whole lot of technical developments, but they to me are a consequence of this fundamental shift in our understanding of what it is to do medicine well in this environment. That to me is the fundamental change. So you really see now the Defence Forces innovating, leading the way within combat medicine? Very much. Now we'll go to the Australian Defence Forces has been working with the Red Cross Blood Service and National Blood Authority since 2010 to develop and supply frozen blood products that are suitable for deployment to remote and austere environments. Can you tell us a bit more about this collaboration? We have indeed. We've developed a very fruitful partnership with what is now Lifeblood, which was the Red Cross blood service until late last year, to operationalise a technology, first of all with frozen red cells, so red blood cells we encountered when we worked with a Dutch field hospital in Uruzgan in Afghanistan. The red cells are frozen at minus 80 degrees in glycerol as a cryopreservative, and then through a process of deglycerolisation, they're prepared for transfusion. We found that a very effective technology in that Dutch field hospital and under certain circumstances we recognised that that would be very useful for the Australian Defence Force as well. So we approached the blood service with that as a proposition and they've been our partner throughout the last 10 years in bringing that online. So that technology is now available for Australian soldiers, sailors and airmen, if we deployed our field hospital. The other thing that we encountered with the Dutch is frozen platelets. Frozen platelets have less evidence to support them. And we think, as do the Dutch and some other countries, that when there's no alternative, there's enough evidence to support their use. But certainly in Australian civilian practice, in a lot of cases, certainly in big hospitals, there is an alternative, we have conventional platelets. But really the trial evidence for frozen platelets is pretty thin. And so for the last four or five years, we've been working with the blood service on a clinical trial program. We finished a pilot study in four hospitals around the country 18 months ago and then last year the NHMRC funded us with nearly two million dollars to do a definitive study of frozen platelets around the country and we're in the early stages of operationalizing that trial. We'll recruit the first patients into that trial in 12 Australian civilian hospitals starting this year 2020. We anticipate that trial will run for 18 months to two years and all being well, of course if I knew the answer I wouldn't be doing the trial, but all being well, in about two years' time we'll have sufficient evidence to have frozen platelets registered for use in Australian civilian hospitals by the TGA and also for use by the Australian military. And we imagine that's going to have international significance as well. Yeah, I mean, as an emergency physician, you know, a lot of the ratios we use for blood products have all come really from some military data over the last 10 years. I have a talk actually that talks about platelets specifically. You're absolutely right that based on military experience from really a landmark paper back in 2007, I think it was, that we started giving much more plasma to red cells. Almost as an afterthought in both that and some subsequent papers, people have thought about platelets as well. Turns out, platelets are actually probably really quite important and possibly even just as, if not more important than plasma. A lot of the coagulation cascade happens on the platelet surface and a lot of the enzymes in the cell surface receptors on platelets are required for coagulation and may well be the rate limiting step in coagulation, much more so than factor concentrations per se. So it is actually a little bit early to say that definitively, but there is some observational evidence looking at platelet ratios that shows mortality benefit from high ratios of platelet transfusion that's probably stronger than high ratios of plasma transfusion. So that's something that our group's also pursuing in parallel with our frozen platelet work. Okay. And any other sorts of things, I guess, the Board of Mecklenburg can learn from this project that you're doing with the frozen platelets? Well, in parallel with the clinical trial, we're also working with the Blood Service in investigating a health economic analysis of where these platelets would be useful in Australia. So we're very mindful that as a defence force, we need to work in partnership with the civilian healthcare agencies around Australia, because we're a very small defence force. And so if we're going to fund our research, it needs to be done in partnership. And so the question is, really in a very large hospital that has a good platelet supply, these are probably not going to be terribly useful, although sometimes those hospitals do run out of platelets, so maybe that won't be true. And in a tiny hospital, it never gives a platelet transfusion. They're probably not going to be relevant. But somewhere in between those two extremes, there's going to be a sweet spot where you would want to invest in a frozen platelet, but rather than just making that guesswork, we're going to rigorously investigate what size hospital should have this. My intuition says that it's going to be something with an emergency department and that has maybe 200 odd beds, so a country hospital with around 200 beds. |
Welcome to On The Woolwoods. It's James Edwards and today we're talking about rhombocytopenia, which is a low platelet. And we have one of our favourite podcast presenters and that's Shafqar Inam, who's a haematology registrar at Royal Prince Alfred and Concord Hospital. Welcome back. It's good to be back, James. So we've spoken on lots of different topics with you, but this one's about thrombocytopenia. We're going to look at a fairly, I think a fairly common finding. We'll start with a case that you're reviewing the routine blood results of your ward patients. And you know one of the patients who was admitted overnight through the emergency department had a fever, had a prosthetic valve and the background of some indefinite drug use and alcohol dependence. And the platelet count is 40. Maybe we'll start, how do you define thrombocytopenia? So a normal platelet count is usually between 150 and 400 times 10 to the power of 9 per litre. And thrombocytopenia or a low platelet count is any count below that, obviously. You can sort of classify it into mild, moderate and severe thrombocytopenia. So mild would be between 100 and 150, moderate below 100, moderate to severe below 50, and more severe thrombocytopenia below 20. Remember that you have to exclude artifactual causes of thrombocytopenia as well, because occasionally you can get clumping when you collect a platelet count, or you can get clotting on the end of your collection line. So be careful of that. The lab should usually flag that. So is it common in ward patients? Thrombocytopenia is surprisingly common, particularly in the hospital setting. And that's because the bone marrow, like the rest of the body, can be quite sensitive in acute illness. And so, for example, in this patient who presents, there's probably a number of causes for thrombocytopenia. So maybe can you describe your approach to a patient with thrombocytopenia? So how I conceptually think about thrombocytopenia is pathophysiologically, what are the ways it can happen? So platelets can be low for a number of reasons. There can be a bone marrow production problem. There can be a destruction of platelets in the peripheries, for example, autoimmune or consumption, as well as sequestration, most commonly in the spleen. And that can be for reasons like splenomegaly, commonly in the setting of chronic liver disease. So how I approach a patient with thrombocytopenia is to look at a number of things. First of all, the degree of thrombocytopenia, the trend and the tempo of the counts. Is this acute? Has this happened overnight? Or is this a long-standing, slow, grumbling thrombocytopenia? You take a thorough medical history, looking at all these various causes that we mentioned, as well as examining the patient. So specifically, I'd ask about things including previous bone marrow disorders, recent medications, in particular, antibiotics or antiplatelet therapies, as well as risk factors for chronic liver disease and other autoimmune and infectious etiologies. So in patients who you see in the hospital setting, what are some of the common presentations of thrombocytopenia? So thrombocytopenia can present in a couple of ways. One is just incidentally on a full blood count because pretty much all our patients come into hospital to get a full blood count. So someone might pick up that their platelet count is 88, say for example, or this patient, say 40. Another way it can be picked up is if a patient presents with bleeding and someone does a full blood count or thinks to do a full blood count and they're found to be thrombocytopenic. Now, you did mention medications that are important in investigating whether they cause thrombocytopenia. What medications particularly cause thrombocytopenia? So medications that specifically cause low platelet counts in isolation are not that common, to be honest. You can get an idiosyncratic reaction to a number of drugs, most commonly antibiotics like penicillins, drugs like vancomycin that can result in acute thrombocytopenia. Other medications that generally cause bone marrow suppression, so things like chemotherapy or amylose suppressive drugs like methotrexate can also cause a thrombocytopenia. More commonly though are actually drugs that interfere with platelet function and don't necessarily cause a thrombocytopenia. So things like aspirin or non-steroidals which are commonly withheld prior to surgical or sometimes withheld prior to surgical procedures because of their effect on platelet function and aggregation. So if they're on aspirin and have a normal platelet count you could still still be worried about their bleeding? Certainly, particularly if they're having neurosurgical or, say, ocular procedures where hemostasis is very important. Sometimes aspirin can be withheld prior to it. Okay, and what kind of timeframe do you normally withhold the aspirin for? So aspirin or other antiplatelet therapies like clopidogrel can last up to a week in terms of their effect on platelet function. So if we necessarily want that effect completely to not exist, then usually we withhold the agent for about a week. Now you've described some of the features you look for in history. Anything particularly you look for in examination as well with someone who has got a low platelet count? Of course. So we are trying to assess both the etiology of the thrombocytopenia as well as any bleeding complications, which is what we clearly worried about in patients with very low platelet counts in parallel. So in terms of bleeding, in thrombocytopenia, it tends to be mucocutaneous. And what I mean by that is regions of the body like the gums, the oral mucosa. Often young females might complain of menorrhagia. You often see on examination petechiae or purpura. And this is in contrast to bleeding that you see in factor deficiencies, so in patients with hemophilia, which is more commonly joint muscle. You do look, of course, in patients with low platelet counts, particularly those who've had, say, trauma, for more serious organ dysfunction. So ask about and examine for GI bleeding and potentially, if they've had a head strike, CNS bleeding. To complete the examination, I'd also look for underlying causes. So you'd examine for splenomegaly, features of chronic liver disease, and lymphadenopathy for underlying hematological disorders. What kind of platelet count do you worry about bleeding occurring? So this is a bit of a vexed question because bleeding can happen at platelet counts ranging from mild to more severe but typically we start to worry when the platelet count drops below 50. So even though a platelet count of 80 is significant thrombocytopenia, generally patients don't bleed. We do get quite worried when the platelet count starts to drop below 20 and in particular 10. For procedures, again, we do have a different threshold. So generally a platelet count above 50 is safe for most procedures. But for certain procedures, in particular, neuraxial anesthesia or ocular procedures, sometimes we aim for a higher threshold of, say, 100. Okay. And at what platelet level would you consider doing investigations for thrombocytopenia? So in terms of the exact level, generally we sort of consider the platelet count in the context of the patient. So have they had bleeding? Are there any other blood count abnormalities? And is this progressive or just a single isolated finding? But certainly if the platelet count starts to fall into the moderate to severe range and is associated with other blood abnormalities is when we would certainly start to look at investigations. Okay, I want to talk about investigations. What are some of the investigations you would consider doing? So I'd be guided by the complete assessment of the patient, including the history and examination. In a patient with a, say, moderate to severe isolated thrombocytopenia, you would do a few other screens to try and look for underlying causes. So what I would do if I followed up a patient in clinic, for example, is order hepatitis serologies, hepatitis B, C and HIV, nutritional studies, vitamin B12, folate, as well as an autoimmune screen, sometimes a serum electrophoretogram. Now none of these have to really be ordered in emergency or in inpatient hospital patient. These are more specialised tests for cases that present through a clinic for example. |
Other tests we might progress to might be something like a bone marrow barb, see if we're worried about underlying haematological causes. And if you do identify platelet count as such as 40 in this patient, how often do you need to monitor that platelet count while they're in hospital? So generally, a patient like this will often get fairly regular blood tests. I would say that our inpatients do tend to get too many blood tests in hospitals, so it's more a question of whether we need to really track the platelet count. I would say a patient like this should get a platelet count at least once every couple of days to wait for recovery. But once the platelet count is on the way up and we're confident we have a clear reason for it, in this patient I would say probably multifactorial from sepsis and bone marrow suppression from his alcohol dependence, possibly liver disease, I don't think platelet counts need regular monitoring at all. And before we go on to a few cases, what are some of the indications for a platelet transfusion? So there can be a number of indications for giving platelets. One is if the patient has a low platelet count and is bleeding, then it is reasonable to give platelets. Platelets are sometimes given as part of, say, massive transfusion protocols in combination with red cells and fresh frozen plasma. We also give platelets routinely, and there is evidence for this, when the platelet count is below 10 or below 20 if the patient's febrile, as well as prior to procedures. As mentioned earlier, we do sometimes have a high threshold. The best time to give platelets prior to surgical procedure or another intervention is just prior because platelets are consumed fairly quickly. One pool of platelets tends to rise the platelet count by about 25 to 40, so go by that rule of thumb. Remember, there are certain cases where it's not safe to give platelets, and they're very specialised diseases, in particular something called thrombotic thrombocytopenic purpura, as well as HITs, which we'll talk about later, which although cause low platelet counts, don't need platelet replacement. We may go on to a few specific cases in regard to who had thrombocytopenia. The first one's an ED presentation of a 26-year-old female who presents with a particular rash on the shins, feet and ankles and also describes some recent bruising and menorrhagia and on the full blood count, the platelet count is only 12, but there's a normal white or normal hemoglobin. What's your initial approach to this patient? So in this patient, I would assess bleeding complications as well as try and find the etiology of this patient's thrombocytopenia in parallel. This involves, as mentioned earlier, a thorough history and physical exam. I would focus on particular triggers for this acute thrombocytopenia, in particular looking for recent viral infections, any risk factors for transmission of viral infections, any prior haematological problems and recent medications. I'll try and chase down any previous blood counts she might have had, as well as on examination looking for any more concerning features of bruising or bleeding. So it's described that she has easy bruising. I would look at the oral mucosa to look for wet purpura, which in particular are quite a sensitive indicator for bleeding tendency. With a platelet count of 12 and an otherwise reasonably well patient with a normal full blood count, the most common diagnosis would be something called ITP or idiopathic thrombocytopenic purpura. And I would go down that track in terms of further investigations. So what investigation would you do if you're considering this as ITP? So not many others, to be honest. I mentioned some of the other screens we would do, and they're more to look at other potential causes of thrombocytopenia. In this patient, in emergencies, you should also have a set of EUCs, LFTs, just as a baseline, given we might use certain other medications for this condition, as well as a group and hold, because any patient who is significantly thrombocytopenic is at risk of bleeding, and I think that's important to have on standby. And what is ITP? So it's a condition which is essentially an autoimmune clearance of platelets from the peripheral circulation, most commonly occurring in young females, but occur at any age and is generally treated with immunosuppressive medications. Are there any particular features on history examination that are particularly suggestive or diagnostic of ITP? So it's really just a typical presentation as described in this case, an otherwise young well person presenting with acute thrombocytopenia. There can be a form of chronic ITP where the platelet count does drift down slowly over time. And often in acute flares, there can be a viral trigger. In terms of other risk factors, these patients do sometimes have an autoimmune phenotype. So for example, they might have rheumatoid arthritis or SLE, and that sort of indicates they have an autoimmune tendency, and they often get ITP as part of that spectrum. Okay. Is there anything you'd want to know over the phone if someone from ED was ringing you up, any other definitive tests they need? Not particularly for ITP because there aren't any diagnostic tests. It's really a diagnosis based on the clinical presentation and exclusion of other potential causes. So I wouldn't order anything else like antiplatelet antibodies, which have been done in the past but haven't really been shown to be useful at all. And regard to treatment? So in terms of the treatment of this patient, in the acute setting it usually involves immunosuppression with corticosteroids, often prednisone or dexamethasone. If this doesn't work, then patients sometimes need intravenous immunoglobulin or IVIG. In the long term, sometimes we use steroid sparing agents like azathioprine in addition to steroids, and occasionally we progress on to splenectomy, which can be curative in some cases. So would you give this person platelets? So I wouldn't, because in ITP, platelets are rapidly consumed and are generally not useful. So this patient would be started on prednisone at a milligram per kilogram. Given her fairly low platelet count, she might be admitted for observation to make sure she doesn't bleed and probably be discharged with a weaning dose with follow-up in clinic. Okay, let's move on to another case. You're now looking after a 72 year old male who's day 8 following elective CAGs for coronary artery disease and he's been treated with tri-stati heparin for DVT prophylaxis and when reviewing his blood results you notice the platelet count has dropped to 80 from 190 which was prior to surgery and on your examination you notice his left calf is swollen compared to right, despite receiving DVT prophylaxis. What do you think is going on here? So this clinical presentation of a surgical patient who's had bypass surgery and has had a relatively quick drop in his platelets is concerning for heparin-induced thrombocytopenia, and the fact that he's got a swollen left calf is concerning for the fact that he's developed a deep venous thrombosis along with that. Obviously, in any patient, you would entertain the full differential of thrombocytopenia like we talked about before. A sick surgical patient might have an infection as well. For example, you would check a fibrinogen D-dimer to make sure he's not in DIC. But certainly I would strongly consider the differential of HITS. In regard to investigating HITS, are there any particular blood tests you should do? So what is useful in HITS, which is an immunological condition where an antibody develops against heparin and a part of the platelet called platelet factor 4 and causes removal of the platelets as well as paradoxically thrombosis. The most important part is actually the clinical history and the timeline of when they received heparin and the trend of the platelet count. It is a clinical pathological diagnosis and the pathological part or the testing really does depend strongly on your pretest probability. And so we tend to use certain scoring systems and the most common is the 4T score to work out how likely it is the patient has hits. And this includes the timing of the platelet drop, so generally between five and 10 days after heparin exposure, the degree of thrombocytopenia, so usually more than 50% and a count between 20 and 100. The presence of thrombosis, as well as the lack of any alternative causes for thrombocytopenia. There are laboratory assays that confirm your clinical suspicions, and they're usually immunological assays, which I won't go into the details of. |
Welcome everybody to On The Wards. It's James Edwards and I have the pleasure today of welcoming Dr. Dane Chalkley. Thank you very much. Dane is an emergency physician who has worked within the UK and Australia and is a current ED physician here at Royal Prince Alfred Hospital. He's also a good mate of mine and this idea of a podcast came at a conference. It didn't actually come in the standard conference part, but actually over a few years later on. We were talking about the language that we all use within an emergency department, and we thought it was probably a good idea to maybe reflect on some of that language, especially for junior doctors who are coming through. So, Dianne, welcome. Thank you very much. So, maybe you want to start. We started talking about language within the emergency department. What are some of your thoughts about that? Well, I think the emergency department is quite a stressful environment and some of the language reflects that. It's stressful on staff. But unfortunately, I do feel that sometimes that language comes across as almost adversarial, something that separates us from our patients, maybe to protect us in the context of the environment. It's a very stressful place to work and we sometimes, I feel, treat our patients with the way we speak about them and to them, not as the customer that they are, because we work in a service industry, albeit a very difficult service industry industry but we treat them as people who are there to make our life more miserable which I think is if you summarize it like that is obviously wrong yeah and I think what we really want to kind of emphasize is the the language we're using and some of the terms that Dan would describe I think I have said said all of them. Absolutely, and I have too. So it is not saying, oh, you're a bad person if you said this, and I think there are people saying that right now doing ED shifts. So we're not trying to stigmatise a group, but really just kind of, I guess, shine the light on some of the language and maybe give a chance or reflect on how our terminology may be viewed from outside the inner circle of nursing medicine. Absolutely. And maybe perhaps how that language affects, as I call it, the way we feel about our patients when obviously we'd all want to be sharing a love and a want for them to get better and for them to leave smiling rather than what happens sometimes. So maybe we'll start with some of the more kind of litigious kind of comments that often come through. Yeah, I think probably the commonest one that I hear and also I see written in notes, albeit good notes, is the term denies. And when I first heard that, and it's not something I'd used historically in the UK and this may be a sort of a reflection of geography but denies to me is a litigious term it's an adversarial term they denied that they had any chest pain almost as if you were accusing them of having chest pain and they were in the dark I say to you so you had chest pain no no no I deny that it does to me sounds very litigious and that has a potential to separate us from them and make them feel like well you should have had chest pain why didn't you have chest pain I don't know maybe I'm that's the one I think I get the most debate about when I discuss this with other doctors. But I certainly think the term refuses is definitely a term which I think separates us from our patients. And it's most commonly in the context of pain relief. They refused pain relief. Well, I think the only thing that really refuses anything is a horse when you try to make it jump over, I think. And that's a sensible't want any pain relief they declined the kind offer of some pain relief or refused a scan refused observations there's something behind that and that's what needs to be gotten to and the reason why they declined to have the pain relief why did they and sometimes that's a communication issue and sometimes it's also they have their own perceptions or ideas that they brought. I don't want to have pain relief because I don't want to, in case I get worse and I hide it. That's very common. So I think when we see patients who decline something, it's not that they refused it, because I think that's a negative word, but they declined it and we need to have a conversation as to why do you think part of it is that when we say refused analgesia we're almost implying that whatever pain they've got is obviously not severe enough to really come into our department and if they had true pain then that except our kind of analgesia absolutely and we we very much objectify pain in our patients when it's a subjective experience and objectifying it does the patient no good. Patients are allowed to tolerate various amounts of pain and certainly we have awful stereotypes about which kinds of patients are more likely to be able to, in inverted commas, man up or not be quite, in inverted commas, a wussy. But at the same time, it is a subjective experience and we should be there to offer them help with that. And if they refuse analgesia for their pain, then we're saying, oh, why are they here then? Why are they here? Allegers? Yeah, I think allegers is a strange one because I remember being taught that if someone came in and they'd been bashed, then you should always write down alleged assault, almost as if you were going to become a material witness and called into the stand. But I think that history is something that the patient says. And if they say that they were punched in the face, then you write the patient states they were punched in the face. And that's on the basic level of the alleged assault. But I think that sort of bled into other parts of our language. And they alleged that they had some chest pain. They alleged that they vomited. It's a very strange terminology. They just said they had it. Apart from the fact it's an extra word to write in the notes, you don't really need to. It's just a very strange word to use, I think. And I think when you reflect that many of these patients go home and read what you've written in the discharge summary and they've given you a quite detailed history about what's happened and maybe it was an assault and they see alleged assault, the perspective of the patient is that this person did not believe what I said and they've written alleged. Absolutely. And if it's used in a different terminology, not just assault, then I think it's very confusing. And it can certainly create the thought in a patient that they didn't believe me, that they didn't take what I said as the truth. And the foundation of a doctor-patient relationship is truth from both sides and you should assume, unlike Dr House, you should assume that the patient's telling you the truth and then what you give them back is the truth and that's the only way to get a doctor-patient relationship where you get what's right for the patient at the end. So any of these terminology I think can get in the way of that and can make the patient feel that they weren't believed, that they may have had something to hide and perhaps as a result of that the doctor didn't give them the credence and the treatment that they deserved. We'll move on to some ones that are often mentioned, especially within the emergency department environment and asking for, I guess, a transfer of care from the ed team to the say medical team there's often that terminology around selling selling a patient or i sold a patient i need to sell a patient the hard sell in inverted commas i think a lot of that did perhaps originate from the house of god it's not something i have read but um certainly i know there's a lot of terminology that's leaked out of that book and I think the cell implies that the patient wasn't really worthy of an admission but you couldn't think of anything better to do with them than to offload them onto another team which again I think doesn't give the patient the due respect for their. And it certainly doesn't give the inpatient teams the respect they have for continuing their specialist care. So I think it's maybe a difficult one because there is this terminology, the selling the soul, but it's about the correct disposition, not about who you sold it to. Because the implication is that you've told some fibs, maybe sexed it up a little bit, well, the pain wasn't as bad, well, you know, I sold it to them. It's a little bit, you know, we're distrusting our inpatient colleagues to appreciate how sick the patient was and do what's right by the patient, which is to continue their care in hospital. |
Yeah, and as we know, the initial diagnosis that's made in the emergency department in the vast majority of patients sticks even for quite a while even if it's not the right diagnosis because once all the the front loaded treatment and investigation has been done things do get slow on the walls by due to resource management and resource availability and i think leaving stuff out is what's hard to do is turn around to say someone and say I just don't know I haven't really gotten to the bottom of it but they do need to come in and I think you're the best person for it and I think that's a harder thing to do because everyone's expecting the patient to be you know packaged in inverted commas not a great word I like either but packaged correctly and had everything done for them yeah so I mean yeah I think package is also a word that's not ideal and it's the same on the reverse side that the feeling from some of the teams that are being dumped yes ED dumped a patient on me I mean again dumps yeah not a word that you'd like to describe about your grandma's admission to hospital that they were dumped onto your care. And they're referring to a sick patient who's been dumped on them. It's sort of, yeah, it's not fabulous. Look, one of my pet hates is I often get asked, you know, to see a patient that is ready for discharge. And it is, you know, off the terminologies,ologies yeah i think we can get rid of this patient yeah get rid of again it's depersonalizing the patient and nobody comes to a hospital because they've got nothing better to do so if we start with that premise that they have come to the hospital because they want our help irrespective of whether we perceive that that's the appropriate place our job is to smile and make sure they get treated and investigated and shown the right path and if that's a mission or finding the appropriate healthcare resource for them whatever it may be they don't work in emergency departments so they don't know what's appropriate for a patient to be seen in an emergency department. So whatever they have, they should be seen and treated as that. Yeah, I find that one very difficult too. Yeah, I think you imagine if you just try and put yourself in the patient's shoe or you brought your daughter into an emergency department, it's five years old, you're concerned, and you overhear one of the senior doctors say, which one of these patients do you want me to get rid of? Yeah. You'd feel like a number just rather than a person and a patient that needs care. Yeah, absolutely. And, you know, emergency departments are stressful for the staff and they're used to it, being paid to be there. Who knows how awful it is for a patient. It's confusing, they're in pain, they feel sick, they're worried, they're concerned, they've got loved ones who are worried and concerned. They wouldn't have come unless they wanted help. And yet we seem to try and put this wall between us and them where it suggests that they shouldn't really be there and then use terminology that makes them feel unwelcome. Going along that same theme, a therapeutic weight. I think the therapeutic weight is probably one of the most hideous things you ever hear, and I find it utterly so difficult to deal with. So most people who work in ED don't know what therapeutic weight is. Can you just explain what, I guess, the background behind when someone sees somebody, oh, I think they need a therapeutic weight. Well, so the Australian triage scale suggests that patients should be seen within a certain time frame because depending on their physiology, their pain, their symptoms, et cetera, if you were to leave them longer than that, they might become more unwell. They may have needed treatment and you've not gotten it to them in time. So patients who are then perceived as being the higher triage numbers, so can wait longer, the triage fours and fives, if they come in with what is seen to be inconsequential or not important enough for us to look after, then they should have a therapeutic weight. So patients who are seen after them should be seen first, irrespective of whether their triage category is the same or this patient was here yesterday and they've come back with the same thing, so we should give them a therapeutic weight and teach them a lesson. Teach them a lesson. They should wait a bit longer because they're misusing the system, etc., which is just not right. It's not fair and it's not our business to do that in any shape or form. We'll come to other kind of things that I often see written in notes, such as being a poor historian. This patient is a poor historian. Yeah, I was always taught there's no such thing as a poor historian, there's only poor history takers. And whereas that's not 100% true, the objects, everything we do is the history, and everything after that is directed by the history. The examination rarely turns up surprises, the bloods rarely turn up surprises. Imaging narrows down maybe a differential, but the history is everything. So it's important to get the right one. Not speaking English is no excuse. You can get language line very easily. And what we do know, especially in emergency departments, is that where all of the root cause analyses that show patients who've done really badly, quite commonly one of the main reasons was not allowing the patient to talk at the beginning and interrupting and not using open-ended questioning but using directed questioning. And that's difficult. That is difficult. And whether someone, whether there's a language barrier who may be confused or maybe have a cognitive issue or just doesn't speak our language, it's our job to speak their language. Or if we can't find someone who can, whether that language is just due to education or etc., there's no point using medical terminology with patients ever unless they understand it, unless they've been educated in medical terminology. We may leave the last one to kind of wrap up. Maybe you can explain what's often said in regard to patients who have presented to the emergency department and some concerned by the doctor that's seen them that maybe they should have maybe gone to a different path, such as going to a local doctor. Yeah, I think the one that does encompass all of this and encompasses our attitudes toward patients and separates us from the patient and therefore hampers the doctor-patient relationship, which will ultimately only result in the patient not being treated as they should be, is I don't know why they are here. And it doesn't matter why they came. The point is, is that the lights are on, that the doors are open, and there's staff there to look after people who feel that they need to come to an emergency department. And that is the reason why they're here, because they want to be there. And to say anything else doesn't really understand the basic premise that we're a public service and we're here to look after people who are sick, worried, ill, or anything else. I think it's a really good way to kind of finish up, Don. I guess maybe the challenge for everyone out here who's listening and the challenge for me is one, I guess, not just to say these words because I think you can probably fairly easily change your terminology to not mention these words. But I guess what you do about the other people within your community who are saying these words? It should be something, I guess, from a leadership point of view as consultants, whether we should really be stamping down and saying, stop the inappropriate words, rather than kind of going, I wouldn't say those words, but somebody else is saying them. I kind of think the challenge for us if we're going to change the culture in a mental department is actually not to walk past people saying these words and actually kind of step, stop and just say, look, what are you saying? What is that saying about what you think about this patient? What do you think if you were the person on the other side, would this be how you'd like to be spoken to? Yeah, no, I think sometimes we treat our work environments and our patients worse than we would if we worked in McDonald's or worked in a car dealership, etc. There you get fabulous customer service and there's nothing more important than the patient's body or mind and we should reflect our language on that and just think, oh, they're worried and they're worried about their health, their safety, their mental health and we should try and think how we would want to be treated if we were just ordering a Big Mac. I must say the car mechanic is something I think about quite often. I'm not great on cars or whatever. I kind of drive in and there's some really good questions and I just, no, I haven't changed oil. No, I haven't done any of that. No, I haven't even thought about doing that. And, you know, that slight raise of the eyebrows, but there's a thank you. |
Welcome to On The Wards, it's Abhi Pal. Today we're talking about research and medicine with Dr. Eli Matar. This podcast is produced in collaboration with Avant, a proud partner of Underwards. Welcome Eli. Thanks Ali. Just to introduce you, Eli is a neurology advanced trainee and a NHMRC postgraduate scholar based in Sydney, Australia. He is a clinical lecturer with the University of Sydney and has a strong passion for medical education and clinical research. Having co-founded a hospital clinical redesign committee, Eli believes junior doctors have an important responsibility in pioneering innovation to improve the healthcare systems within which they work. So just to start off, could you tell us a bit about the decision to interrupt the traditional pathway of training and pursue research? Did it feel scary to leave the conveyor belt? Yeah, thanks Avi, and it's great to be here on the podcast. So just to give a bit of context, so I finished my basic physician training back in 2016. And what I did at that point is usually the standard model is that you go directly into your advanced training. At least that's the standard model now. It wasn't always this way. And what I actually did was I actually stepped out of my training program to pursue a few years of full time research. I mean, I think initially the first year was a clinical research and clinical fellowship year in which I did both clinics and started on my research. And then that kind of went into full swing in the second and third year as a PhD. So I think that that's where I diverted and I had a lot of people look at me in a funny way saying, what do you mean you're going off to do some research and you're not continuing on advanced training? Especially because at the time, I think that it was, I was quite confident that I would get an advanced training role. So stepping out of that seemed a little bit perplexing to some people. But I guess the reason that I made that decision was that I was at that point already quite passionate about research. I'd done a lot of research in my undergraduate days and even throughout my medical degree, my postgraduate medical degree. And I've really thought about research as a conjunction to my clinical career. And I wanted to explore that as a potential career option, explore the area that I thought I was interested in a bit more. And also it just so happened that the opportunity came up where I was thinking about going back into research and exploring what I wanted to do and then the opportunity came by with funding so I took it. I was also at that point having done some research quite mindful that when you take a clinical academic career you're really taking on a dual career pathway and I really didn't I didn't want to start a second career at the end of my medical training in my early to mid-30s. What I wanted to do is to get a start when I was quite passionate, when I was motivated, when I was feeling creative. And I really wanted to dip my toe into that to see if that's also what I really wanted to do. So I think leaving the conveyor belt on that point, I think it did feel a little bit disconcerting. And I have to admit there were times, at least in the first part of the sixth month, where I woke up in a sweat in the middle of the night and was like, did I make the right decision? Especially, I think that was a reaction because I think we all become quite secure throughout our training. But at the end of the day, everyone at the end of their training gets let loose into the world and there's no one looking after you anymore. And I've actually had some colleagues describe this as pretty unsettling. So you're going to have to meet that juncture at some point and where you're going to have to finally fend for yourself. I think having this exposure earlier on for me encouraged more of a sense of self-sufficiency. It gave me perspective about the breadth of clinical practice beyond the training period. It also made me feel more secure in my ability to actually make a career out of myself in a number of ways and also to see the value of my own training. I think applying it to where I am now, I actually already have made changes to my life and made strategic decisions about, you know, particular research papers or conferences and so forth that I've visited or done specifically because I know where it's going to fit in my future career beyond my medical training. So yes, it felt scary initially, but in fact, now I look back on it and I'm glad that I made that decision. Sounds like a courageous decision and you followed through and it's working out for you now. So I guess the second question I had was, it's a big shift to go from medical training to full-time research. A lot of doctors do research on the weekends or part-time. So you did full-time research. And what did you find was the most beneficial thing about just dedicating your complete time just to research? Yeah, so there's actually a lot of advantages. As you said, I think a lot of people, including myself, I was doing research part-time on the weekends or after work, having been doing full-time clinical work and doing the reverse was quite a change. I think speaking broadly, I think people can think of a number of advantages by doing it this way. I think that first of all, there's flexibility in terms of how you spend your time. As we'll talk about later, my son was born over this time and I was able to take care of him and also work around that, which was extremely rewarding. I think it gave me the time to travel, to go to conferences, to network with people, go to research events, present my work both locally and abroad, which I think was something that I couldn't do before when I was working full time. As I said, that time also gives you time to think, to plan, to get perspective about where you want your career to go. I think we often don't get enough time to just stop and think about where we're heading when we're on this conveyor belt, on this medical training conveyor belt. And sometimes I think people find themselves far out from where they initially wanted to be or at least not having thought about where they wanted to be until the end of their medical training. And I think people realize also quite quickly that when you start applying for basic physician training or advanced training or surgical training, whatever it is that you want to do, you kind of have to be a few steps ahead and have decided where you want to be to begin with. And I think people get confronted when they show up to an interview and someone's asking them, well, what do you want to do in five years time? And people haven't thought about that question well. So I think that that time of doing full-time research even gives you time to plan what you want to do with your career, whether it's your academic career, or even if it's just deciding that, you know, you've done full-time research and it's not really what you're into, I think that's extremely valuable. As I said, you know, you're really building a dual career. And I think that you need to be full-time to master technical expertise. I think things like neuroimaging, in my case, you know, complex statistical analyses, whether it's machine learning or other things like that, I think that needs dedicated time where you're hitting your head against a wall for hours and days and weeks. And I've definitely spent that just, you know, trying to debug a piece of code. And I think that that's just what it takes. And I don't think that you can develop that mental concentration when it's all fragmented in and around your clinical work. I think that the other benefits of pursuing full-time research is that you get really acquainted with how to interpret the findings from the medical literature, and you become extremely knowledgeable about the boundaries of knowledge in medicine. And that's because you're sitting there pushing those boundaries. A lot of my research got me thinking about diagnostic boundaries and really gave me an appreciation of the fluidity of what we know about medicine and how it might change in a few years' time. And also, when you really come across all the limitations of a particular type of research, you also see the limitations in other people's work and you'll know how to interpret their findings in that context. And then I think finally, the thing I like about full-time research is that it allows you to exercise your creativity more freely as opposed to you know medicine which can be quite algorithmic and heavily regimented so those are all the I think quite general benefits of pursuing full-time research and as I said I think you really need to dedicate some time to full-time research if you are serious about academia as as a part of your career. |
What did you personally find was most difficult or challenging? And what do you think other doctors might find is difficult about research as well? Definitely. Look, research is very tricky and it's very different to medicine. I think the thing that you need to realize is that the time scales of reward are very different in research than they are in medicine. You don't get that immediate satisfaction. You don't often get to just tick that box and feel happy and done with it by the end of the day, which is the routine you kind of get into when you're an intern or resident and a registrar even. Research is incremental. You have to spend a lot of time sometimes, as I said, hitting your head against the wall, trying to get a piece of code to work. Or, you know, you might go and do a whole paper that will take you months and then only to have reviews come back that points out some little flaw that you have to go back and reanalyze. There's a lot of time overcoming those challenges. And there's a lot of other challenges too. You know, sometimes they're technical challenges, as I've alluded to. Sometimes they're logistical challenges. You know, we're sitting amongst a COVID-19 pandemic and I've got a lot of friends who are currently or are supposed to be currently recruiting patients for their research and they're just unable to because of the restrictions. There are logistical barriers in getting patients in for research in general as well. You know, if you're doing research in patients with dementia or other kinds of diseases where they're quite symptomatic, that can be quite challenging. Even recruiting those patients is challenging to begin with. And there's also, you know, there are called bureaucratic challenges. You know, people can spend a year of their PhD just getting ethics through if you're not onto it already. So I think that those type of challenges are very different to the type of challenges you see in medicine. And making that switch is quite tricky. I think also sometimes you, you know, a lot of us go into medicine because we like the interaction with people and patients. You get, you become part of a team. And sometimes research can be a little bit dissociated from those factors, in particular, even dissociated from other people, depending on how your research is conducted. So I think that that was something I found tricky, sometimes finding myself in my own head and trying to pursue this singular path, even though I had lab members, but they're all working on their own individual aspects of the project. So I think having that reward taken away from me made more of your own motivations internally guided. And I think that that's a skill to develop in and of itself. Medicine's quite social, and I suppose research can be lonely at times. Yeah, I mean, you know, it also gave me the appreciation when I came back into medicine after that of my team. I just loved interacting with my residents, my junior registrars, you know, even my consultants and the patients. It was a very different dynamic, which I'd kind of missed. Good one. So that sounds like there's some hurdles to think about as well with research, as long as with the benefits. So I guess a key question for some of our listeners who are at different stages is going to be what, at what point in the road along medical training is it best to diverge into this full-time research possibility? Is it better to do it early, middle, late? And I suppose there's pros and cons. What are your reflections after your experience from doing full-time research after BPT? What you've seen? Yeah, so I get this question a lot. And I don't think that my, even though I guess my views could potentially change once I'm even a little bit further down the track, because I sought advice as well just before I went into it. And I had quite varying advice from a lot of encouragement to people discouraging me from doing it. And I think having done it and also seeing other people who've done it differently, I could say that that question is very much tailored to the individual. I think that it really depends on why you're pursuing the higher degree. In my case, I really wanted to explore academia quite seriously at an earlier stage when I still had a lot of passion for it and I knew what areas of research I was really interested in. And part of me exploring that area of research was because I was, I didn't, you know, when people finish the medical training, they start to have to establish themselves in terms of a subspecialty or even an academic niche. And most people fall into whatever niche they just decided to at the end of their training. Whereas I felt that if I did it before my advanced training, even if I went into an area that I wasn't that interested in, I had time to pivot away from that by the end of my medical career, my medical training, sorry. So I had a lot of those particular reasons. And I also had a research background. And I knew kind of what I was getting myself into. And I think people who are extremely motivated about science purely from that perspective, I think that they can and should do it earlier. I think, though, there are also people out there who are not that sure about what subspecialty they're interested in or even specialty. I think that there are people who want to do research as a means to secure a clinical job or maybe even just to familiarize themselves with research and become more literate in research, which is an essential skill as a clinician. And I think in those circumstances, it's better to maybe do it at the end of your medical training, when you've figured out what subspecialty you might be interested in, when you've developed rapport with some mentors who might have a good research track record that you might want to take some opportunities to work with them, where maybe your clinical interests may dovetail into your research interests so that you can see patients in a particular subspecialty. So I think that those are all reasons to maybe think about doing it at the latter end. What I did actually, just to be a bit more specific, was I actually took up a clinical fellowship role where I was seeing patients in clinic and getting a lot of clinical expertise. And I was actually able to count that as part of my advanced training because fortunately neurology allows you to have a non-core year, which you can prospectively count once you get onto the program or retrospectively count once you get onto the program, provided you prospectively registered for it. And I know not a lot of training programs do that. But I think it is essential if you are, you know, going down a clinician pathway that you do some research that still exposes you to some clinical medicine, which it did for me. And what I did was I started off as a master's degree, which meant that I had a one year out if I really wanted to. And then once I started developing the research and knew that I was interested in it, I converted it to a PhD. So I think that that's also an option for people to consider when they think about higher degrees. But it is a sacrifice and you really need to be serious about why you're doing the PhD in the beginning before you leap into it or a master's before you leap into it. And I think that's going to dictate when's a good time to do it. Whether you do it before internship or in the middle of your internship or even earlier as a medical student, I think a lot of the listeners already passed potentially that point. I think that you will always learn something from a PhD and it'll always give you some kind of perspective that's novel. But I think that if you can tailor it to the specialty that you're interested in, the subspecialty expertise that you're interested in, you also get a whole bunch of benefits that I don't think that you would have gotten as a medical student or as an intern. And that's the actual benefit of networking and making yourself known amongst the community that you're going to continue to work in in the future. It's very hard to do a PhD, I think, at the end of your internship or before your internship or even as a medical student and then pick up the threads of that research 10 years later when you finished your career. I think it's more doable when it's sort of you're a few years out and the continuity is there. But I think earlier on, it's not so feasible. So my overall answer is that it depends on why you want to do your higher degree and what it's for and what opportunities are available to you. I'm just going to go off script for a second because you brought something up which I think is a really key part of research. In about in a couple of minutes can you summarize for our listeners what do you think the key things they should think about when thinking about a research mentor or research supervisor? |
So I think that there are some general things and specific things that I would look out for. General things are that you get along well with your supervisor, that they have time for you, that you look up to them in some respect. You know, not all mentors are perfect, but certainly that there are aspects of the way they practice, the way they maybe handle themselves around patients or even the research acumen that you respect and that you get on with them at a personable level because it's a relationship that I think that you will keep for the rest of your life in some way and they will be critical for the next stages in your career and supporting you for that grant or that next scholarship. So I think it's important that you do get on well with them and that they have time for you. The other aspect is maybe a little bit more practical and something we may be talking about before the show or podcast is that, you know, I think it's important that they have a good research track record and that they are well connected. I think that research careers are often built on the back of other people's research careers. And so you need to look at someone whose research career is actually successful, you know, that they are actively publishing papers, that they are part of a network of people that they can link you in with so that, you know, you can move beyond that particular research lab if you wanted to. And I think it's important to also be in an environment where there is technical expertise around you, because sometimes the mentor may not be the person that's there doing the research. And I know that's particularly true in the clinical research realm, because often the clinician scientists are so busy between the clinical work and the research work that often what they do is they lead, but they aren there to handle the nitty-gritty with you so you need to make sure that there is an infrastructure there that's supportive of your technical needs so i think yes get get along well make sure that they have time for you make sure that they're there to support you i think from a clinical perspective it would be nice if they um if they had some access to you know patients if that's something that you're interested in seeing so you want to make sure that they have that and that they're good at what they do because i think that one thing that i liked about my research experience is that i complemented that with learning new clinical skills and exposing myself to a particular subspecialty of medicine that I now feel very comfortable with thanks to the clinical mentorship that I received from the people around me. So those would be my suggestions. That's really excellent. Good summary of the key characteristics. Just to get into some concrete details, a lot of doctors I know are worried about this. So we get a reasonable salary in medicine, but it's not always the same in research. And most of us are aware of this. So going into full-time research, how did you deal with this? And what strategies did you have to support your income during this period? Yes. So this is something that's just obviously a bane of every researcher's existence, which is that you actually have to apply for grants or scholarships and you have to seek out your own money. You have to self-promote. You have to look around and figure out where the money is and where the pools of money are so that you can apply for these things. They don't just come to you by some centralized process, which is really, really painful. And it is, in fact, what spends at least a third of the time, a third of researchers' time is spent sort of applying for grants. And the higher up you go, the more people you have to support and the more time you spend writing grants and applying for money. That's a common misconception. It's not just at entry. It's the entirety. It's the whole time. And of course, you know, with a failure rate of somewhere, you know, with an acceptance rate of somewhere between 5% to 20%, depending on where you're applying, you know, you're often writing grants over and over again that don't get accepted. So that's also, that's also crazy. But look, I think that there are actually a lot of options for people to get into research. And I was extremely fortunate because I sought out one of those opportunities and I got the Avant Doctors in Training scholarships. And that was actually quite a substantial scholarship amount because it recognises, I think, that there is an opportunity cost for junior doctors and doctors in general who do research. You know, there's a lot of cost that they are missing out. There's a lot of financial gain that they're missing out on when they step out of a clinical role, which is much better enumerated than in an academic role. And so I was very lucky that they have those scholarship schemes. And in fact, similar scholarship schemes exist in other companies. And I'd say that my advice would be to look very broadly. There's definitely government-sponsored scholarships. So there's the NHMRC. And we're lucky as clinicians in that there is a specific pool of money that they try to give to people who have a medical background because they recognize that we need clinicians who have a clinical background to go into research because they know where the important questions are. They know how to recruit patients. They know how to deal with patients. So they want to encourage people into research, medical people into research. So I'd say look at the NHMRC, of course the APA, the universities individually all have a whole bunch of scholarships and top-up scholarships. So often the government scholarships will be a good base to start with, but then you kind of want to supplement that with your you know, your additional top-up scholarships, which of which there may be named scholarships associated with the university, which you kind of have to go individually and look at. Other things that you'd look at is, you know, your individual society. So I was also fortunate to be supported by the Australian New Zealand Association of Neurologists, which is our governing body of neurology. So often they have funds aside for that. The RACP, or if you're in surgical courage, the RACs and so forth, they all, all the specialty colleges potentially have funds aside for starting, for startup research projects. And also even just patient advocacy societies. So for instance, Parkinson's Australia, which relates to kind of my research, or dementia, fight dementia and so forth. Those things tend to have also scholarships for junior doctors. And if all that fails, and I know we're not going to go into it now, and it might be covered in another podcast, but there's also the fact that you can take advantage of your clinical skills to locum and top up whatever scholarships you need. And that can be quite a lucrative avenue to supplant your financial status during that time. Okay, so plenty of avenues to obtain funding. And if you're ever lost, just speak to people around you that have done it. And that's often the best way to figure out what's around. Speak to your supervisor, speak to their researchers, and then speak to people around you that have done it. Yes. And that's often the best way to figure out what's around. You know, speak to your supervisor, speak to their researchers and then speak to your colleagues, because there's often someone who knows a bit more about this. Many doctors have done PhDs. Yeah. And doctors have found their way through it. Okay. And I guess you just mentioned this briefly at the start, but you had a child during this period, a son named Leo. He's three years old. And I suppose, Eli, what's your secret? I mean, I've known you for a long time. You've got two university medals. You've done a PhD. You're doing neurology training. You've got a child. I mean, you are doing a lot of things at once. I know how busy you are. What's your secret? Tell us what it is that is driving you on and how you organize your time are there any apps or software you use what's going on or do you just not sleep uh definitely don't sleep that much i think uh but look i don't know about the secret i'm i was very lucky you know that you know i have a very wonderful wife angela good answer who, you know, that, you know, I have a very wonderful wife, Angela, who, you know, obviously supported me. She's a general practitioner. So she was a lot more flexible with her time, but also doing research, I was quite flexible. |
Welcome to On The Wallwards, it's James Edwards, I'm here again and today we're going to be talking about gentamic prescribing with Kate Cleasy from Prince of Wales Hospital. Kate's an infectious disease physician at Prince of Wales. And I think before we get started into gentamicin prescribing, I just wanted to plug that we are available on iTunes. And please, if you could also rate us on iTunes, it would be fantastic. So we'll get started into a case, Kate. You're a junior doctor, working nights, and you review a 70-year-old female who's post-op and has now developed some urosepsis. You confirm she doesn't have any allergies, but you're considering starting some antibiotics and you're thinking prescribing gentamicin and ampicillin. Before you prescribe those antibiotics, what additional information would you like to obtain from the history and examination? So really the most important thing with aminoglycosides, of which gentamicin is the one that we use most commonly, is that we know that gentamicin can cause problems with the ears, or ototoxicity, and can cause renal disease as well. So other than allergies, which are pretty rare, you'd want to know about whether there are any other nephrotoxins which can potentiate that problem, whether they'd ever had aminoglycosides before that might have caused ear problems or if there's any family history of aminoglycoside-induced ototoxicity. So they would be really important things to try and establish. So we may go back to, I guess, some pharmacokinetics. What's a mechanism of action of aminoglycosides well they're quite interesting drugs because they they inhibit bacterial growth by impairing protein synthesis by binding to proteins on the 30s subunit of the ribosome and then that that makes the organism have incorrect amino acids inserted into protein or peptide chains and if those peptide chains happen to be in the cell membrane then the cell membrane no longer functions correctly and that's how in fact the cell then doesn't divide properly and the organisms actually die so that's there are a couple of other mechanisms but that's the principal one okay i remember from pharmacology that's the pharmacodynamics i should have asked what about the pharmacokinetics but we we will go on to a few things in regard to gentamicin. How do we administer gentamicin? Is it always parenteral or can you give it orally? So gentamicin is given mostly parenterally. Sometimes it's nebulised in patients with bronchiectasis who require treatment of pseudomonas and other conditions such as those. There are a couple of oral aminoglycosides, but they're used for their local effects on the gut. But they have pretty rare indications. So gentamicin is typically given intravenously. It may be given intramuscularly, but intravenously is the preferred route. And what is gentamicin spectrum activity? What sort of organisms should we use gentamicin for? Okay, the best way to think about it is that it has good activity against most of the gut gram-negatives, so what we would call the enterobacteriaceae, and it also has mostly good activity against pseudomonas. It has some gram-positive activity, but typically it's gram-negative with some synergism for some of the gram-positive organisms. So good for gut-related conditions and good for urinary tract because in the urinary tract they're the organisms typically. Yes, so things like E. coli. That's correct. Klebsiella pneumoniae, proteus and so on. Yes, absolutely. And prior to administering the intravenous antibiotics, would you require any further investigations such as renal function, testing of creatinine? Yes, so really the most important thing in terms of looking at factors for patients in terms of safety is you want to know what the creatinine clearance is or at least the creatinine and then figure out the creatinine clearance and clearly if someone was septic you'd want to do urine and blood cultures to see if you could find the organism before you in fact started the antibiotics. Not that you should wait for those results to come back, but if those tests are done before the antibiotics are prescribed, it means you've got a much higher chance of identifying what might be causing the infection. And now you need to decide what dose you're going to write up for this patient who's got urosepsis. What factors determine the dose? Is it their weight, what their sex is, or do you also factor in what their renal function is? So this is a kind of it depends answer. So in general, the initial dose is between four to seven milligrams per kilogram ideal body weight, not actual body weight. And as we know, lots of patients are not at ideal body weight. So that requires some calculation, but it does depend on the indication. So patients with severe sepsis or septic shock have altered volume of distribution so in fact they need higher doses around the seven is recommended around the seven milligram per kilogram mark which very rarely gets given but you should go slightly higher in those patients if they're not septic then the lower dose of say four milligrams per kilogram is completely appropriate patients Other patient groups have altered pharmacokinetics, and that includes patients on renal replacement therapy, patients with severe burns, those with significant ascites, and so on. So all of those things need to be taken into account, and maybe you need higher doses in those situations. So if you're prescribing gentamicin in those situations, it would be reasonable to ask for some advice because that then becomes quite complicated. Renal function is important. We would recommend caution if the creatinine clearance is less than 40 mls per minute, which is not that low. So that would be important. And in patients over the age of 80, I think you need to be very cautious about giving gentamicin. And most of us would not recommend that unless it was life-saving. So there are a number of considerations in prescribing gentamicin. And you mentioned that probably doses are probably lower than recommended. Why do you think we probably underdose with gentamicin? Oh, I think people are scared of giving big doses. It comes in a certain ampule size and people give multiples of the ampule and then when it gets to 760 milligrams or 720, if it's 240 by 720, people get very concerned about that. So I think you've kind of answered the next question. Is gentamicin contraindicating in patients with poor renal function? And if so, kind of, you know, is it, as you said, creating clearance around 40? Yeah, less than 40. I think that you need to have significant caution in patients with impaired renal function. If it was clear that it was going to be life-saving, then you would administer it and then you'd clearly then monitor the patient's renal function. But often there's an alternative agent that could be given in that situation. Any particular tips on charting of genomycin? Because we all use the National Inpatient Medication Chart. So where should you chart it on the chart? Is it something on the regular medication on the once only medications? So best to chart it on the variable dosing section of the chart because then that allows it to be a prompt for ongoing dosing make sure the indication is actually written and the start date so they would be the most important things on the National Inpatient medication chart now obviously you want to start antibiotics promptly in someone who's doing like urosepsis yeah are there any time of day that is best to chart gentamicin um in terms of so so there's two ways of uh prescribing gentamicin so it's empiric treatment which is principally what we're talking about now in this particular patient. And it doesn't really matter what time you chart the drug because you don't need to do levels if you're using empiric therapy because generally you'd only give two doses or 48 hours worth depending on how frequently you were dosing. However, with directed therapy, which is where you actually want to measure a number of trough levels or levels in relation to the dosing, you would then want to chart the drug in a way that allowed that to happen with routine blood collection. But we're not really talking about directed therapy here very much. So we'll go back to the patient who we think has uricepsis and you're thinking about gentamicin ampicillin. Why is that often a combination for urinary sepsis? So gentamicin covers many of the urinary pathogens, but one common, it's about the second or third most common urinary pathogen when you look at urines over a large population is enterococcus. And so gentamicin doesn't provide cover for that, whereas ampicillin does. And in fact, those two drugs work synergistically against enterococcus. |
Welcome to On The Wards, it's James Edwards and today we're talking about gastrostomy feeding tubes and I have the pleasure of inviting Dr An Anastasia Volovets who's a consultant gastroenterologist and hepatologist to speak to us today. Welcome Anastasia. Thanks James, it's really nice to be back here again. Yes, we have spoken before on chronic liver disease and this time we're talking about gastrostomy feeding tubes and maybe we'll go to a case just to set a bit of context. You're a junior doctor, you work in the neurology team and a 65 year old male who is a known vascular path has had a large stroke. It hasn't been feeding because it can't swallow properly, but on some fluids and there's a thought well maybe we should put a gastroscopy feeding tube. So why can't they just stay on IV fluids? I mean what's enteral feeding? Yeah, no, that's a really good question. I guess the important thing for all junior doctors to remember is that IV fluids is a very short-term temporary measure and really does not provide the patient with the caloric support and the vitamins and the nutrients that the patient needs. And really if your patient is going to be not able to swallow and has been on fluids for more than 48 hours, you need to be thinking about some sort of enteral feeding. The short-term enteral feeding is done via nasogastric tube and provided that the patient doesn't have an obstructing lesion somewhere in their throat or in their oesophagus that actually precludes the placing of such tube, that is a perfectly appropriate and reasonable way of feeding the patient. That decision is usually a multidisciplinary decision, so you need a speech pathologist, but also a dietician to assist with feeding regimens. And that is usually what needs to happen to ensure the patient's health is continued to be maintained while they recover from the stroke. So that's what we mean by enteral feeding. Enteral feeding really just means assistant feeding of actual calories and fats and carbohydrates rather than just IV fluids with a bit of electrolytes in it. It's important to note that nasogastric feeding is not a long-term solution. It's a temporary solution only and that's because nasogastric tubes are very flimsy. They fall out easily. They block and they cause a lot of pressure necrosis on the nose and can cause large volume kind of hemoptysis. Sorry, large volume epistaxis. So if your patient has a chronic swallowing problem and you're anticipating that it will not recover after six to eight weeks, we need to be thinking about long-term access, which is where you really need to think about a percutaneous gastroscopy tube, or what we call a PEG. If the PEG is put in by an endoscopist with an endoscopy procedure, then it's a percutaneous endoscopic gastroscopy is a PEG. In some hospitals, they may be put in by radiology and they would be called a radiologically inserted gastrostomy or a RIG. But in both times, what you're asking for is a feeding tube that's inserted directly into the patient's stomach through the skin. And that can be their long-term access for nutrition for the rest of their life. Okay, so you've given us a bit of an overview of the different types of enteral feeding. What are, I guess, the most common long-term indications for enteral feeding that you see? Yeah, so any patient that's basically lost the ability to safely transport food from their mouth to their stomach. So the most common would be a neurological problem that affects some patients swallowing. So a big stroke like you mentioned, but other debilitating neurological disorders such as multiple sclerosis, motor neurone disease, patients that have had a traumatic brain injury and have an uncoordinated swallow. They're the most common patients. We also see a fair amount of patients who have either an upper GI malignancy or a head and neck or an ear, nose and throat malignancy and they're patients who may actually have curable disease but they're going to be undergoing a prolonged course of chemo and radiotherapy and so their mucosa will be really, really inflamed and it'll be very painful for them to swallow and so we know a large number of those patients lose their nutrition and therefore lose reserve they need so actually in those patients we put feeding tubes in prophylactically for the duration of their treatment before the treatment actually starts once the chemo radiation takes effect they transition with the help of the dietician in the oncology services, they transition to predominantly peg feeding and then after treatment's completed and everything's recovered and they're back to eating normally, the tube can come out. So a gastrostomy tube can be permanent but can also be a short term for the duration of treatment. We do occasionally, although I'm pleased to say more and more rarely, get referrals from patients who are unable to swallow because they're quite demented or they're too, you know, deconditioned and too weak to swallow because they're in the last stages of life. And that is always a really difficult and contentious topic. And we're hoping to see less of those referrals because we know that although gastrostomy feeding tubes can be really helpful, they really don't do very much for patients' quality of life in these kind of situations. So you did briefly mention some of the different ways that gastrostomy tubes can be inserted, but can you just go into a bit more detail? Yeah, sure. So the most common ways that people would get feeding tubes from major teaching hospitals is through a referral to a gastroenterology service and they'll put in the peg in during an endoscopy. So what happens is the patient goes down to the endoscopy unit, they're sedated, they're placed on their back and then an endoscopist will perform just a standard upper GI endoscopy, make sure there's no complications in the stomach, and then identify a spot from inside the stomach where the feeding tube can be placed. And then their assistant will put basically a cannula from the skin directly into the stomach and pass a wire in, which the endoscopist will then use the feeding tube to be attached to and then pulled through. So that's called the pull technique, which is the most common one. It's a pretty good technique. It's pretty safe. You know, because you are doing a blind puncture through the skin, there is always a risk of damaging, you know, another organ, perforating the colon if the colon's in the way, causing a large volume bleed if you hit an artery. The risk of something pretty catastrophic happening and a patient actually dying from a pig insertion is less than 1%. But we have to remember that the subset of patients that gets a feeding tube like this are already sicker and frailer and have lots of comorbidity. So that needs to be considered when you're asking the patient to have the procedure. The whole thing takes about 30 minutes and does require a sedation. So again, a lot of the patients who need feeding tubes, as the case we discussed, are vasculopaths. They'll be on antiplatelet therapy. So they'll have increased risk of bleeding. So all of these things need to be thought about when you're requesting the gastroscopy and PEG insertion. Occasionally in some teaching hospitals it can be inserted by a radiological team as well. And what they do is they basically ask for the patient to have a nasogastric tube placed the night before and they give some contrast through that tube to eliminate the colon. Because the following day they do the procedure under fluoroscopy and so you can do x-rays and see where the contrast is in the colon to try and avoid a perforation of the bowel. But again they do a blind sort of insertion of dilators kind of like Zeldinke technique through the stomach until they put the tube in and secure the tube in percutaneously. So again, there's a risk of damage to a bleeding vessel or something like that. If the patient has no stomach because they've had a gastrectomy, for example, in the past, then you can also do what we call the jejunostomy, so a feeding tube directly into the jejunum. More often than not, that's put in by the upper GI surgeons and that can be done laparoscopically. You can also actually put a feeding tube into the stomach, so a gastrostomy by surgery with a laparoscopic technique, but that's done less and less because obviously you want to not do a large general anaesthetic if you can avoid it. So those would be kind of the most common ways that people can get a feeding tube. Okay, so and in regard to once the tube's been in, you've created a tract, you know, how long does it take to form? |
So the stomach is in a bit of a strange position. And then eventually, with all the inflammation around the side, then internal adhesions form. And so then what happens is that anterior wall of the stomach becomes stuck to the anterior abdominal wall and kept tightly there by adhesions. And so that's what we call the gastrostomy tract, is that entire process of having a stoma, if you like, going from the skin into the stomach, but having everything stuck down together. And that process usually takes six to eight weeks for it to mature. And it's a really important concept to understand, because if a patient inadvertently removes the feeding tube in the first six to eight weeks, so before the adhesions are formed, before the tract is mature, then the stomach will fall away from the anterior abdominal wall back into the cavity because there's not enough adhesions. So what happens is when you then go and try and put a feeding tube back into the same hole, you're not going to end up back in the stomach. You're going to end up in the peritoneum and you're going to cause significant peritonitis. So it's really important whenever we're trying to figure out what to do with a tube that's displaced, we know how old the tract is and how long it's been since the feeding tube is put in. If it's been more than six to eight weeks and the feeding tube falls out, you can be pretty confident that the tract is secure and on the ward without needing to do another procedure, you can quickly put in another feeding tube to keep that tract open. Okay, we'll go into some of those things a bit later, but I think in regard to a junior doctor, you've been asked to organise for a percutaneous gastroscopy tube to be inserted. What are the usual contraindications we need to think of? Yeah, look, it's really, really good for junior doctors to be aware of how feeding tubes are put in because understanding how they're put in is where they can derive logically what the contraindications would be. So as I've already said, we're taking sharp needles and scalpels and poking them blindly through the anterior abdominal wall into the stomach, so there's a significant risk of bleeding. So obviously any patient that's got uncontrolled coagulopathy, elevated INI, severe thrombocytopenia, those patients in general should not be having a gastrostomy tube placed unless those factors can be corrected. Patients with chronic liver disease in particular do not do well with feeding tubes and that's because they have chronic ascites. So as soon as you put a feeding tube in, what you're going to set up is persistent leak of ascites out of that tract permanently. And the other thing is patients with liver disease and poor hypertension, you know, hopefully everyone knows about the varices in their gullets, but you can actually also have intra-abdominal varices and varices in the anterior abdominal wall. So the risk of causing a big bleed when you're putting in a feeding tube is really high. So we don't ever put feeding tubes in patients with advanced chronic liver disease. Obviously, if there's any active sepsis going on in the abdomen because there's a perforated viscous, it's not a good idea to be putting foreign objects back into that area. And also, if a patient has significant cellulitis across their anterior abdomen, putting a feeding tube through that is a bad idea. So that makes sense. I've already mentioned that if patients have had surgery such as a gastrectomy, obviously putting a feeding tube into the stomach is not going to work. But also if there's some sort of mechanical or structural problem with the stomach itself which stops the stomach from emptying, such as they have a tumor causing a gastric outlet obstruction or they have gastroparesis so the stomach doesn't empty, putting a feeding tube directly into the stomach is a bad idea because what you're going to do is fill the stomach up with feed. That won't go anywhere and the patient will have a vomit and aspirate. So again, those are patients that usually require jejunostomy feeding rather than gastrostomy feeding. And, you know, as I've already mentioned, if a patient's really unwell or debilitated and there's no decision makers for them who can give an informed consent, obviously that's a contraindication. There's also kind of relative contraindications which make things a bit harder but not impossible. So patients who have, you know, and unfortunately that's a lot of stroke patients and older patients. So when you have significant debilitation and kind of the muscles of swallowing are weak, you know, patients will aspirate their food. And that's a lot of the reasons that we get asked to put feeding tubes, but they'll also aspirate on their own saliva as well. So it's really important when you're talking to the patient's family and having realistic expectations about a feeding tube, we all know that a feeding tube, a gastrostomy tube, will decrease aspiration because patients are not swallowing, but it won't completely eliminate aspiration. Patients will continue to aspirate their saliva and actually also if they're lying flat in bed because they're bed bound, they can aspirate the gastric feeds as well. So people with persistent oropharyngeal dysphagia, patients with severe reflux disease, you know, you need to think carefully whether a feeding tube is going to benefit them and what the realistic expectations are. Anything that's going to make the procedure technically difficult, such as morbid obesity of a patient or significant hepatosplenomegaly, anything that's going to increase the risk of the procedure failing probably should not be referred to a gastroenterology registrar, but maybe to a surgical team for a laparoscopic procedure where you can have you know direct visualization and to minimize complications there's some thoughts the patients who are on peritoneal dialysis or patients who have a neurosurgical VP shunts place so shunts that goes from their brain to the peritoneum if you also add a feeding tube that there may be you know increased risk of sepsis I don't think that's been proven by long-term good quality data, but it's something that we need to think about and be concerned of. We've already sort of mentioned bleeding risks, so obviously patients who are on antiplatelet therapy and anticoagulants. So on average, most gastroenterologists and radiologists will put in a feeding tube if a patient's just on aspirin. We don't think the risk is very big. If the patient, however, is on clopidogrel or if the patient's on dual antiplatelets or anticoagulants, whether it's, you know, warfarin or the newer agents, in general, we would think that that would increase the risk of catastrophic bleeding by quite a lot. And we would like clopidogrel or antiplatelet agents stopped for seven days prior to the procedure and for the anticoagulants for two to three days prior to the procedure. Now that may not always be possible because patients can have unstable cardiac disease, you know, high-risk mitral valves, etc. So what's really important is that in these kind of high-risk patients, there is a lot of discussion between the team who's going to be putting the tube in but also the team who are coordinating the patient's care and also the patient the family are aware of the risk. Sometimes people are just in a hard spot you know it's high risk if you do this slightly lower risk than if you do that and we make difficult decisions but as long as there's of organisation and forward planning, that's the most important thing in these cases. And then of course, you know, a gastrostomy tube is put in usually under a sedation or sometimes a general anaesthetic. So again, if you have a really frail patient with advanced cardiac disease, severe lung disease, then, you know, those patients may not survive the anaesthetic they need for the feeding tube, so you'll need to really think about whether they're going to benefit from this. The last patients that are really difficult are the ones that have poor prognosis from their underlying illness, whether it's an advanced malignancy or dementia. And really the thought is that in these patients the feeding tube is not appropriate. We know that feeding tubes, despite the fact that they allow us to give patients nutrition, don't actually prolong survival of the patients. And I think that's really important for both junior doctors and family members to understand. A lot of the time family members say to doctors, but you know, I don't want my father starving to death. And you know you know that's a very normal very human emotion and we need to be supporting families in that situation but there's no evidence that putting in a feeding tube in a patient with advanced dementia will actually make them live longer and there's no evidence that it will make their suffering less or make them feel more comfortable and there's good evidence that the complications can actually shorten their life even more. |
I mean you've really brought into some of I guess the ethical considerations about long-term enteral feeding. Obviously severe dementia is one. Any other pretty ethical issues that you've noticed come up in your practice? Yeah, look, probably patients with advanced neurological conditions such as really severe Parkinson's disease or severe multiple sclerosis and motor neurone disease. You know, patients who have a pretty poor quality of life. It's always a very difficult topic and really something that junior doctors should definitely have an opinion on and advocate for their patients, but always involve senior members of the team and, you know, and have lots of conversations about this. Sometimes we say, you know, as gastro registrars, we used to say to junior doctors, there's no such thing as an urgent peg. And that's true for multiple reasons. One is because sometimes swallows improve and people don't need the procedure, but also because you need that time for these complex patients to have these discussions and make sure that everyone understands the realistic outcomes that are going to be. So there is good evidence that an early insertion of a feeding tube in patients with motor neurone disease will improve their well-being and improve their nutrition, whether it improves their survival, I don't think anybody knows that. And patients who have ongoing chronic aspiration in the geriatric setting really do not benefit from a PIG because as I've mentioned they'll continue to aspirate on their own saliva and will end up with aspiration pneumonia anyway. So these decisions need to be multidisciplinary involving the neurologist, the geriatrician, the palliative care physician, also the people who are going to be doing procedure, the technician, the anaesthetist is going to be providing support, and most importantly, the family and the patient, because the expectations need to be realistic. So I guess what can go wrong, I guess in the short term and maybe long term, but we'll start with short term with a peg or rig insertion. Yeah, so when I consent patients or their families for a feeding tube, I go through the immediate complications that can go wrong as part of the procedure. It is an interventional procedure, not surgery per se, but definitely invasive. So the most common thing we have is because people have to lie flat on their back for 30 minutes if they're not intubated with an anaesthetist, and there is a significant risk that they can aspirate their own saliva or some of the gastric content and then have a severe aspiration pneumonia you know post the insertion of a feeding tube. Anytime you give sedation there is a risk of cardiovascular collapse, hypotension. There is as I said a small chance that we can hit a big blood vessel on the way in and cause catastrophic bleeding, which can be stopped with clips usually, but if it's really big and it requires a huge laparotomy to stop the bleeding, again, you know, the underlying subset of the patient may not tolerate that, so you need to think about it. Because we're going blindly, there is a risk that we can damage the colon or the liver or any other organs and you know the direct mortality associated to the procedure itself is quite low it's about 1% but actually if you look at studies in patients who've had these feeding tubes put in up to 25% of them die in the next 30 days anyway from anyway from whatever it is that's caused them to need these tubes in the first place. So again, that's a really important thing to remember. Patients with advanced cancer, advanced dementia, or severe ongoing oropharyngeal aspiration, they're on borrowed time, and so putting this feeding tube may actually hasten their demise and not bring them a lot of comfort. We've covered some of this stuff to a degree, but what should a junior doctor do before, I guess, they're putting in the order for a peg or a rig and making sure that the patient is optimised so they can, with the procedure, it all goes okay? Yeah. So I think the first thing is the JMO, with the supervision and advice of their registrar and consultant, needs to be really happy that a feeding tube is the right way to go. So does the patient, should the patient just have nasogastric feeding for an extra couple of weeks? You know, what is the prognosis of the swallow? And that comes back kind of to the multidisciplinary decision-making. You know, what is the speech pathologist saying and how necessary is this feeding tube? If the feeding tube is definitely necessary, then we need to make sure that from a bleeding and anaesthetic point of view the patient's optimised as possible. So are they on dual antiplatelets or anticoagulants? If they are, you know, when would the team that's inserting the tube want them stopped and how does the patient's cardiologist or neurologist consultant feel about that and what are the risks and does the patient understand them basically is the patient able to take part in the consent process and if not who is the next of kin or power of attorney or decision maker and do they understand what is going to happen to the patient during the procedure and all these complications that we've outlined. They're probably the most important thing. So it's just like any surgical procedure, you know. You really need to make sure that the patient's bleeding risk is optimized, that their cardiovascular and respiratory status is optimized before an anesthetic, and that both they and their family understand what's going on. So when the patient arrives back on the ward, what kind of immediate complications should be looking for when they arrive on the ward? Yes, abdominal pain is quite common, and that's usually mild, but can sometimes require more than paracetamol, can require endone for a day or two. And the reason for that is we make a cut in the anterior abdominal wall as we drag the tube through and that's quite painful. And although we insert local anaesthetic at the time of the procedure, that wears off. And also because we're insufflating air into the stomach to dilate it and some of that air escapes through the hole in the stomach, patients can have a little bit of kind of right shoulder tip pain or referred pain, the same that one gets post a laparoscopy. Quite a lot of the time people can do an x-ray and then see air under the diaphragm and will panic that it means it's a perforation. That's not the case at all. Having said that, if the feeding tube was placed into the wrong place or a bit of bowel got caught or, you know, the patient has really severe pain out of keeping with, you know, just mild discomfort or something that you would expect post a standard laparoscopy, then you have to be concerned about peritonitis and patients need a CT scan to make sure that the tube is in the right place. Quite commonly, you can have a little bit of ooze of blood just from the site. That's quite normal, but if there's a large volume bleeding, JMOs need to call for help. The most important thing is that patients who've come back to the ward, I mean we don't always do this as an inpatient procedure, quite a lot of our patients are outpatients, but if you are an intern who's looking after someone who's on the ward, they need a regular abdominal wall assessment, so the nurses should really do their OBS every 15 minutes for a couple of hours and also check their belly and see how much pain there is and if there's bleeding. And if there's any kind of question that the pain is extreme, then it needs to be investigated and looked at properly. Okay, maybe we'll look at some of the more longer-term complications of feeding tubes. Yep. So a lot of problems that patients have with feeding tubes refers actually to how the tubes sit and how tightly they're fitted. So all tubes have what we call an external bolster or a flange, which you kind of sit right up against the skin to keep the tube in place. And actually, if that bolster is really tight and digs into the skin, then it can cause pressure ulcers and contribute to cellulitis and really nasty infections. However, if that bolster is too loose, then the tube is loose and then patients will have leaking of gastric content and sometimes feeds onto their skin, which can then irritate the skin and cause really severe excoriation and can be really uncomfortable. Also, if the bolster is really loose or not present at all, then the tube can actually migrate inside the stomach and cause a bowel obstruction if it blocks the pylorus. So it's really important that the bolster sits in the right place, which is two to five millimetres off the skin. So you should be able to very easily take the tube, rotate it 360 degrees with absolutely no block and have that two to five millimetres space between the skin and the bolster and that's a good bolster. |
Welcome to On The Wards. It's Chris Elliott here and today we're talking about the unsettled infant with Dr. Carly Casamento. Welcome Carly. Thanks Chris. Dr. Casamento is an advanced trainee in general paediatric space out of Sydney Children's Hospital, Randwick. She is passionate about anything to do with the health of babies and children and is committed to improving junior doctor education, mental health and wellbeing. She's currently undertaking a research project on virtual learning environments with the University of New South Wales and dedicates most of her time to chasing around her two energetic young boys and trying to get them to bed on time. That is a thankless task Carly, good luck. Carly, we're talking about unsettled infants, what do we mean when we say the unsettled infant? Thanks Chris, it's really hard to define but essentially the problem is that a baby that cries a lot can be extremely distressing for new parents and it's a common cause for presenting to their ED or GP. It goes by other names like infant colic or wind, but essentially it's a baby that parents are having difficulty settling. They present to the doctor usually because they're concerned that there's something medical underlying all the crying. And it often comes to that junior medical officer in emergency to discern normal baby crying, which even the experts struggle to define from about a thousand different conditions that can cause a baby to be irritable. And it's really difficult, which is why I thought we should talk about it today i think it's a great idea i love uh you know the honesty there uh people don't really know how to define normal baby crying do they let's start with a case so imagine you're working in an emergency department and mrs jones brings in six week old baby johnny because she's concerned that he just won't settle generally cries a lot, but today he's been particularly irritable and hasn't stopped crying for the last three hours. However, he's had a good feed in the waiting room and has since fallen asleep. Mrs. Jones tells you that Johnny's otherwise had a normal course. He was a normal vaginal delivery. There were no issues after birth. And he mixed feeds, meaning he has breastfeeding and bottle feeding. So talk about some of the red flags. What are you looking for in your history and examination that really might worry you? All right. So the differentials at this point are really broad, but there are life-threatening ones that you don't want to miss. Serious bacterial infection, congenital cardiac disease, neurological causes, metabolic disease or non-accidental injury. So I always start with weight gain because poor weight gain is one of the first symptoms in all of those serious congenital conditions and if it's normal it's immediately reassuring. It's really simple to plot a few weights in the blue book on the charts and it can really reassure parents as well. I think a feeding history is the next most important thing. Baby that's feeding well is again unlikely to have a serious underlying condition. Over or under feeding are also common causes of an infant being irritable. So in our case, little Johnny is mixed feeding with breast and bottle. Is he getting enough? Does he stop crying when he's fed? They're important questions. It's really complicated, but there are lots of right ways to feed the baby. Just a really quick guide because you've already given us a great podcast on baby feeding. Cross promotion. Yes. Listen to the other podcast we just did. Exactly. But a very quick guide is that a baby should be getting kind of between 120 to 180 mils per kilo per day in a bottle fed baby. They should be able to stretch generally three to four hours between feeds and have a wet nappy with every feed. If they're feeding very frequently or they're having a lot of dry nappies or they're not gaining weight, it might be a feeding problem and it might be able to be fixed. It's important to ask about vomiting and stalling. Small milky posits are normal as are mild reflux symptoms. A gastroenterologist that I used to work for would always quote a study that came from the 1990s and they took 500 normal babies and measured their pH in their esophagus and they found on average normal healthy babies reflux 30 times a day. A lot of parents can sense that their child is refluxing too and I think it's really important to acknowledge that they're right and tell them that really the best way to cure reflux is for the baby to get older and bigger which is what the parents are doing by feeding them and comforting them. We can do some small behavioural changes like propping up their mattresses or we can suggest kind of prolonged burping for kind of 15 to 20 minutes after a feed. Again, as long as the baby's gaining weight, then reflux symptoms on their own are not something that's likely to be causing them to excessively cry and certainly doesn't need treatment. There's also a lot of anxiety about poos in new mums and I often say to parents that stools can be any colour of the rainbow for me except red, black or white. So you also want to ask though about mucus because if there's mucus and blood, for me that might indicate cow's milk protein intolerance that can be treated but I wouldn't treat for cow's milk intolerance unless there was a lot of blood mucus eczema rashes around the bottom some really solid signs I really wouldn't recommend a diet for the mum unless you had strong suspicion for cow's milk allergy and I would be talking to a senior. Can I ask about that? So I love that. Any colour of the rainbow, because poos, I always ask if parents have taken photographs of the poos because that's like a real, yeah, a lot of people sometimes will have a lot of photographs of poos that's so shows that they're important so red black or white are the colors they can't be why is that what are those three colors mean so red and black blood um fresh blood and fresh blood and old blood um so upper gi blood for the black um and that that's after the first couple of days so in the first couple of days, a baby will have black meconium stools and that's okay. And then white chalky stools, we're thinking about problems with the bile ducts. And that would be in the context of having a jaundiced baby as well. So they're kind of rare things that you want to look out for. But green, mustard, yellow, the babies are developing the microflora at the time and when you're adding in formula or changing, their guts are changing. So the colour of their stools change a lot and I don't think it's something to be concerned about. Yeah, cool. In terms of the frequency of stools, that's also another source of anxiety for a lot of new parents. The normal frequency in a newborn less than three months can range from anywhere from five times per day to once every five days. So you can reassure mums that they might look uncomfortable when they're passing poo. It's usually them just reacting to a strange sensation. We don't usually treat for constipation unless the baby is passing hard pellets. And again, you wouldn't want to start any medication unless you had seen your advice or you had a good way of following up. Likewise, WIND, there's a lot of talk in mothers' groups about WIND and it's a strange sensation for the baby and they might look distressed, but there are hundreds of different products on the market and the best treatments are non-pharmacological. So they can do things like rotating the baby's knees, like the babies on a bike. They can massage a baby's tummy. Things like improving the baby's latch on the breast or changing the teat of the bottle can help them swallow less air. And again, prolonged burping techniques and holding the baby upright after a feed. Next, most important thing to ask is about the pattern of crying. So crying that lasts for several hours and doesn't settle even with a feed is very concerning. But crying that settles easily or is intermittent with the baby showing periods of being awake and comfortable in between is a lot more reassuring. Other red flags on history might include temperatures especially and the temperature is 38.0 or above in a less than three month old baby. And then you want to screen for social issues like postnatal depression, which is underdiagnosed, domestic violence, drug use or mental health problems that might indicate non-accidental injury in the child. Okay, so this is on history. You've got a really structured assessment of a couple of things. You've talked about weight gain, feeding history, vomit and stalling, wind, the pattern of crying and then these red flags specifically around particular conditions. What about when you come to your examination? How do you approach that? So again, there's a broad differential. |
Okay, welcome everyone to On The Wards, it's James Edwards and it's March 2015. We've had a couple of questions on our website in regard to downloading the podcast. Just a reminder, you can download the podcast on iTunes, which may make it easier to access when you're at work and it is sometimes difficult to get internet access. Today we're talking about end-of-life care and we're the pleasure of inviting David Anderson back. David's an intensive care fellow here at Rockport Southwood Hospital and has a special interest in end-of-life care as well as medical education and pre-hospital care. Welcome David. Thanks for having me back James. So David did one of our first ever podcasts on sepsis but today we're talking about end-of-life care. I guess from the junior doctors, they do, especially after hours, often have to review patients who are dying or offer some support and counselling to families who have loved ones who are dying. And it's something that I don't think they particularly get taught well in medical school. And often a lot of those conversations happen between consultants and registrars and family and patients. And sometimes you don't want to miss out. So we're going to kind of talk about a couple of different scenarios and maybe get some of your expert opinion. Sounds good. We'll start with a scenario. You're on the ward. You're asked to come and see a patient by one of the nurses. Someone has been admitted to hospital with end-stage COPD. The nurses call you because the patient has a respiratory rate of 50 and looks unwell. But they do tell you that while the patient was in the ED, it was decided the patient wouldn't have any medical emergency team calls or arrest calls, but this wasn't documented. And she says, can you complete a not-for-CPR order? Otherwise, you'll have to make an arrest call. What would be your approach as a junior doctor, David? Well, Jay, this is a difficult, but unfortunately, not that uncommon scenario of a patient who is probably coming to the end of their life and who has had some degree of goals of care or advanced care planning but perhaps it hasn't been as complete or in this case as well documented as we would like. I guess the first thing to make clear is that in any circumstance where there's a lack of clarity around what the patient's goals of care are or around what is or isn't appropriate in terms of the limitations of medical treatment then the correct approach is to manage the patient's goals of care are or around what is or isn't appropriate in terms of the limitations of medical treatment, then the correct approach is to manage the patient with curative intent until that's been clarified. And so the answer to the immediate question is, as the junior doctor, I wouldn't be completing a not-for-resus form in the absence of any other information. I would have a quick look at the patient and see if there's anything I can do immediately to relieve the symptoms. But based on the quick description, this sounds like someone who either needs to be intubated or palliated in the not too distant future. And look, it may be that putting out an arrest call is not an inappropriate thing to do and that it will immediately get you at least two doctors, probably three who are more senior than you are, one of whom may even know the patient and will be able to assist you in decision making. But look, it may be that you just have to give the patient a bit of extra oxygen and some nebulized salbutamol, make sure they've had some steroids and then get on the phone pretty quickly to someone who knows this patient and clarify what the goals of care are and what discussions have taken place. And look, that may be the registrar who was involved in admitting the patient, or it may be the patient's AMO who hopefully would know the patient. And if they say, yep, look, I've known Mrs. Jones for years. She's really come to the end of the road. We've had an end of life discussion. We've been waiting for this to happen. Go ahead and just make her comfortable. that's entirely appropriate to fill in an op for recess form and focus on palliation but if there's any indecision and especially if there isn't consensus amongst all the doctors involved in her care then it's it's not inappropriate to refer this patient to ICU and and let us take over the high-end decision making stuff and and from my point of view if as as as a fellow in the intensive care unit, if one of my registrars called me about this patient and there wasn't consensus, I would say, look, put on some non-invasive ventilation, intubate the patient if you need to. We'll give them a 24-hour trial of ICU and see what happens. Bearing in mind that this sounds to me like a patient who's really distressed, who's really uncomfortable and who's probably in a high state of panic and anxiety. And giving them an anaesthetic and intubating them isn't necessarily the worst thing in the world to do. Having said that, ideally the best thing would be if several weeks or months ago goals of care were set and the patient knew that this was coming. In regard to goals of care and decisions about end of life, they're not often made or discussions aren't with junior doctors, but maybe you can tell us in your role as a fellow and as a registrar how you approach those discussions with the patient and their family. Well, that's a good question and it's actually two questions, isn't it? Because there's a difference between the discussion that could be had with the patient and a discussion that could be had with the family as surrogate decision makers in the case of a patient who's not competent to provide their own information on what their goals of care might be. Let's say I was in this situation with this patient, seeing them in the emergency department, for example. You could have a quick look through the notes, and that would give you a pretty good idea to say, look, you know, this person's had COPD for five or six years. They've now had six hospitalizations in the last six months. They're getting worse every time. They're on home oxygen. They don't leave the house. You know, this is clearly someone who's coming to the end of their life. And that's clearly apparent to anyone who's seen enough patients with COPD. I would sit down with the patient if the patient were competent. And by competent, I don't just mean conscious. I mean, this, you know, the patient in this example with a respiratory rate of 50 who looks unwell, this is not someone who's competent to have an end-of-life discussion. But let's say the patient is, I would first of all establish from the patient what their understanding of their illness is. And sometimes just saying, you know, sitting on the end of the bed and saying, hi, my name is David. I'm one of the doctors. I want to talk about how sick you are today. Can you just tell me, you know, what your understanding is of what's going on with your illness? Look, nine times out of 10, you're the first person to have asked them that. And the answer will be, look, doc, I know I'm really sick. I know the treatment's not working. You know, what can you do to relieve my breathlessness? And that makes it a lot easier. If the patient isn't aware of how sick they are, then you have to, you know, broach the issue gently. And you have to say, well, look, you know, I want to talk about something that's a bit serious and I might have some bad news for you, but I just want to tell you that I think you're a bit sicker than that and I'm really worried that the treatment that we're giving to try to reverse or cure your disease isn't working and I'm really worried that any more treatment that we'll give you to try to cure your disease will make you worse and I think that the right treatments to give you now are treatments to make sure that we can relieve your breathlessness and focus on making sure that you're comfortable and and i'm really worried that that might mean that that at the end of your life might be coming soon and again often might be the first person to have told them that and that that can be really distressing and that's something that hopefully you'd have the family around when you have that discussion um but it is an important discussion to have. But I guess the important thing is to be honest without being blunt and to prepare the patient that bad news is coming and to make sure that they're aware that there's a plan in place to provide ongoing treatment. Just the focus of that treatment has changed. Now, look, all of this is assuming that there's medical consensus that this is a patient who is definitely coming to the end of their life. |
Either there isn't medical consensus or it's genuinely not clear. This is someone who does have bad COPD, but it's not clear that they're end stage. And in that case, it might be appropriate to get into a discussion with the patient about what their goals of care are. And this can be really tricky because the last thing you want to do is give the patient a plethora of options to choose from. This has been referred to as the tyranny of choice. You know, you say to the patient, well, we could intubate you, we could give you non-invasive ventilation, you know, we could send you off to St. Vincent's for a lung transplant. We could do this. We could do that. And the patient or the family are just totally bewildered. Your job as the doctor is to decide what the best treatment is for the patient. And if there's genuine indecision as to whether one treatment would be better for the patient or the other, then you put that to the patient. But often you can do that with your recommendation as well. You could say, look, Mrs. Jones, you know, your emphysema is really bad. We know it's been getting worse over the last months. You're in and out of hospital all the time. I think we're getting to the stage where together we have to make some hard decisions and we need to decide if things get really bad. Do we have another try at going to intensive care? And might mean being on a breathing machine or do we want to focus on making sure that you're not breathless and that you're comfortable and accept that that may mean that nature takes its course. And most patients in my experience will opt to go down the palliative route. But for those who opt for one more crack at intubation, that's not necessarily a bad thing, so long as it's clear to all involved that this would be a trial of intensive care. And increasingly in intensive care, we will give someone a trial of 24 to 48 hours of aggressive treatment and then pull out and provide aggressive palliative care. The discussion with the family is a bit different because with a family discussion, we use the term surrogate decision makers. That's not entirely true either. What we're doing in the family situation where the patient's not competent to talk for themselves is we're sitting down in the family, outlining the situation to them, and then saying to the family, I need to make a decision about what's best for your mother. And I can't make that decision without knowing her the way you do. So what I need you to do is to bring your mother's voice into the room and let me know what she would say if she was sitting here with us. What course of treatment would be appropriate for her? What would she want to do? And again, nine times out of ten, when you word it like that, the family will say, oh, she's spoken about this for years. She's told us that if we put her on the breathing machine again, she'll come back and haunt us. So a lot of times it's very clear. But this again implies that there's some indecision. If it's clear that the patient's dying, then it's okay to say that. It's okay just to sit the family down and say, look, I've got some really bad news. Your mum's really sick this time. I'm really worried about her. I think she's dying. And there's no choice to be made. You've diagnosed the patient is dying. That's a medical decision. You've got consensus. It's clear from the patient's history that that's what's happening. And any further treatments would be not in the patient's best interests. So, you know, these are really hard discussions to have. And I think of having these discussions as a clinical skill like any other. And, you know, we don't let very junior doctors put in central lines without having been shown how to do them and seen people do them a few times and done them under supervision a few times. Having an end-of-life discussion should be no different. It seems often the end-of-life discussions I'm involved with in the emergency department is about things they can't have or won't have, not for CPR, not for ICU, not for analysis. Is that the right way to frame things or we should be more, maybe more positive what sort of things we can do for you? I think it's important. You're right. A lot of it is how you sell it and you sometimes feel like a bit of a used car salesman. But again, it depends on the scenario and I think you can broadly broadly split patients into three groups. There's one group of patients who come into the emergency department who clearly there's no choice but to resuscitate them. There's no doubt. You know, a 25-year-old who's had a cardiac arrest on the rugby field, who's brought in, who's got return of spontaneous circulation. If this patient re-arrests, of course, you'll do everything. They'll end up on ECMO. That's fine. No one would argue with that. And then there's a group of patients at the other end who are clearly dying. And in that case, you don't have to tell patients or families what you're not going to do. If CPR is not going to alter this patient's outcome and is not in the patient's best interest, you don't even have to mention it to the family. And it is legally and ethically and morally acceptable to fill in a not for resus form, say not for CPR. You have to say you've discussed it with the family, but that discussion would go along the lines of, like I just outlined, I'm really sorry, I've got some bad news, you know, your mother's dying and this is what we're going to do to make her comfortable. So you are focusing on the positive things, but you're not going to tell them what you're not going to do. The tricky people are the ones in the middle who have a chronic illness, CHF, COPD, cancer that's, you know, responding well to treatment. In that case, you do have to get into a bit of a discussion about whether or not, you know, some advanced resuscitation techniques are appropriate. And that's a situation where, again, I wouldn't say, do you want us to do CPR? Or if your heart stops, do you want us to restart it? Because no person in their right mind would answer no to that question. I would say, look, if you got really sick, you know, we need to decide together what would be best for you. Would it be to make you comfortable or would it be to have a try at, you know, fixing things that we can fix, but understanding that there may be some things that we can. So you are having a discussion about resuscitation, but it's not a formulaic. Do you want us to ventilate you? Do you want to be bag masked? Do you want adrenaline? You know, because then you end up with this sometimes farcical situation, for example, of a patient who's documented as for CPR, but not for ICU. And, you know, well, that just doesn't make any sense at all. For this scenario that we've had the discussion with the family, and they were in agreement and the patient had previous wishes that they didn't want ongoing intensive care resuscitation. But the daughter asks the question, which often do nurses get, she knows her mother's dying, wants to know how long it will take. Should I get the family in? So that's probably the question that palliative care doctors get asked most commonly. How long, doc? And it's a question that I wish we were able to answer. I think the most important thing is to start out by telling the daughter that this is a question that no one knows the answer to. But in your experience, this is the range of periods of time that the patient will have left alive. And in this situation, this is looking very much like someone who's got hours to days. And so that's what I'd say to the daughter. I'd say, look, thank you for asking this question. It's a really hard question to answer, but looking at your mother and having seen similar patients in the past, I'd estimate that this process is going to go on for hours to days. And yes, you should get the family to come. I would never say 12 hours or, you know, three weeks because that's, you know, that's when people say, oh, you know, you see on today, tonight, the doctor said, I've got six months and here I am two years later. |
The question of should I ring the family? Increasingly, I just say yes. And the only thing I can say to that is that no one ever regrets being there. People regret not being there. You can tell the family that in most cases, dying is a process that occurs over time and it's rarely a sudden event, but obviously anything can happen. You know, while she's there in the bed dying of COPD, she could have a PE and have a sudden cardiac arrest. You know, it's unlikely, but it could happen. And so I would always end with that. So my answer is always to give them a range of times. Say, yes, people probably should come if they want to see them. Remember to offer spiritual support at that time as well. And then say, but look, you know, this is what I think, but things could always change. Okay. No, thanks there, David. We're going to change the focus slightly and we'll have a different scenario that we'll ask a few other questions about. In this time, a nurse calls you to see a patient who's under the care of the medical oncology team and the nurse says that it's a diagnosis of stage 4 melanoma with brain mets and the team has documented in the notes that the patient is for comfort care only with a valid not-for-CPR order in the front of their notes. But the patient's now unresponsive, but the family distressed by his noisy breathing, grimace-faced and frequent groans. Can you outline your approach if you've gone to see this patient? Yeah, well, this is, again, a not uncommon scenario for junior doctors on the ward. This is a patient who's clearly dying, and I guess there are two things that you need to do. One is that you need to manage the dying process as a doctor and make sure that the patient is comfortable. The other is that you need to provide education and emotional support to the family. So my approach to this patient, first of all, from a medical point of view, I would still examine the patient just to make sure there's nothing obvious that could be making the patient uncomfortable. And then I would look at charting some medications to make sure that the patient is comfortable. And, you know, looking at the symptoms that we've described, I think the grimacing is the thing that worries me the most because that does indicate that the patient is in pain or uncomfortable. And this is something that in end-of-life care we tend to manage with opioids. I'd have a look through the patient's notes and see if they were on any opioids before coming to hospital. And then I would transition those opioids to a subcutaneous or an intravenous route. Now, people often ask, why do we use subcut meds in palliative care? Very simple. It's because it means the patient doesn't have to have their cannula changed every three days. That's all. There's no other reason. And in America, for example, they use PICC lines. So it's just a route of administration that's easier for the patient. Let's say, you know, I mean, I don't want to get into the intricacies of opioid conversion. You can look it up on the internet. There's resources available. But let's say, for example, example you know the patient was on 20 milligrams twice a day of OxyContin in Australia we tend to use a 1.5 conversion for OxyContin to morphine so that's about 60 milligrams a day of morphine we would have that for sub-caps that's 30 milligrams a day we'd give that dose every week make divide that by six and give the dose every four hours that's five milligrams four hourly and then i would give the same dose hourly prn and then each day you tally up how much prn was used about three prn doses is acceptable that probably means we're getting it just right because you can overdose these patients at the end of life and they can end up with troublesome symptoms from narcosis. But, you know, it's important that our opioids are targeted. And there's a bit of controversy in end-of-life care about terminal sedation and about are we hastening death with opioids. I think so long as you're clear that the opioids are being targeted to a clinical effect of a respiratory rate or the patient's seeming comfortable, then you're doing something that's medically entirely appropriate and in keeping with good medical practice. If the opioids weren't doing the trick, and for example, if the patient was moaning or groaning or agitated, then we'd normally add in some haloperidol. Sometimes in palliative care, we use a drug called levomipromazine, which is an old, old antipsychotic that's very sedating. It can be quite hard to get your hands on sometimes. But alloperidol is a good place to start. And fairly hefty doses, five milligrams every hour or two is probably not unreasonable. And only then would we think about adding in some midazolam. And again, starting with very low doses. The only other thing I would say about the opioids is obviously there's a whole bucket load of opioids to choose from. If a patient was on one to start with, it's probably reasonable to continue with the same one. Morphine's my favourite, seems to be the best, but sometimes people are intolerant and increasingly we use a drug called hydromorphone, which is very important to be aware that that's much, much, much more potent than morphine, so much smaller doses. As far as the noisy breathing goes, this is probably reflective of what's called the death rattle. Very common, it's just secretions pulling in the back of the mouth. The first thing to do is to say to the family, look, this is just his saliva pulling in his mouth. It's not distressing him, but I understand it's really distressing to you guys. We can give some medicine that may be able to stop this, but it may not. But it's important you understand that it's not worrying the patient. And increasingly in palliative care, we use a drug called glycopyrrolate, which is similar to hyacinth, which was used in the past, but glycopyrrolate doesn't cross the blood-brain barrier, so it's not going to make the patient more agitated. And we'd use a dose of about 400 micrograms every two to four hours. And those are probably the only five medicines that we tend to use in end-of-life care in this patient, who's clearly in the last few hours or days of their life. Sometimes we use a syringe driver, but really the only benefit of a syringe driver is it means the nurse doesn't have to come into the room every four hours to give an injection. It's probably good to have the nurse going into the room every four hours, though, just to check on the patient. So there's a lot of geographical variation. That's the medical side of things. The next thing is to sit down with the family. I tend to sit on the end of the bed, have everyone in the room talk with the patient there as though the patient can hear, explain to the family, you know, reiterate that the patient's dying and that it's likely to be ours today. These are the things we're doing to make them comfortable and, you know, ask if there's anything else we can do to support them. What other resources are there actually for the junior doctors? Let's say this patient, you know, who can they call? Are there other resources you suggest for them? Yeah, I think first of all, you know, obviously there's a palliative care service in most hospitals and they're always happy to be called with questions and advice. Having said that, however, my personal opinion and the opinion of most of my colleagues, I think, is that the provision of end-of-life care to a patient who's in their last few days of life is a basic core skill for any doctor. And in a patient like this, who sounds relatively uncomplicated, this is bread and butter general medicine as far as I'm concerned. I'm not saying you shouldn't be asking for advice, but this is not someone where we'd want to get specialist palliative care involved to look after the patient. But there's no reason why you couldn't ring them and ask them a question. Having said that, this patient's under the oncology team, and oncologists are also experts at managing patients who are coming to the end of their lives. So the oncology advanced trainee would probably be the first point of call. In this case, plus or minus the palliative care registrar or any of the SMOs involved in the care of the patient. Also remember, palliative care isn't just about medicine. |
Hello, my name is Ben Nguyen and I'm one of the Respiratory Advanced Trainees. I'm here with Mikey Shear, who is our basic physician trainee who was working on the COVID team last week. Today we'll be talking to Mikey about his experience as the COVID registrar to hopefully give everyone a better understanding of what's happening here at RPA. So Mikey, to start with, can you explain to our listeners how patients with suspected COVID-19 are being managed in our hospital and what the role of the COVID team is? Yeah, thanks for having me, Ben. Look, this is a situation that's continuously evolving and I imagine in a month when some of our listeners might be listening, this could be completely different. At the moment, our suspected COVID patients are showing up to ED or they're coming through via the COVID clinic. As the COVID team, we're sort of a multidisciplinary team who involves respiratory doctors, infectious diseases consultants, and the intensive care specialists. What might happen is a patient comes in through ED, the ED doctors might give us a call and ask whether or not they should swab someone. This is one of our jobs that we're sort of helping them with. The next step that we're involved in is deciding where the best place to manage these patients would be if ED think they do need admission. And the sort of third thing that we are mainly involved with is managing patients with either confirmed COVID or suspected COVID. So where are patients with COVID-19 currently being managed at RPA? Yeah, so I guess we can divide patients with suspected COVID or confirmed COVID into sort of three groups. At the moment, we have one, the patients who are very well, there might be a suspicion of COVID and they meet the criteria for swabbing. Unfortunately, they can't sort of self-isolate at home because they either live with someone else who's immunosuppressed or they're living in a share house. These patients were sort of currently getting admitted to 10 West 1 overnight. The second group of patients are unwell people who have respiratory illness or other symptoms who do, again, meet sort of the criteria for swabbing. These are the group of patients that the respiratory team and the intensive care team meet up about and talk about. We sort of decide whether or not they should be managed in green ICU or 10 West 1, depending on how well the patient looks and the bed situation. And finally, the third group of patients are critically unwell patients who are in respiratory failure. And these patients at the moment are going to green ICU or red ICU. Subsequently, if patients have negative tests, we then sort of try and reallocate patients out of these COVID areas. So out of 10 West 1, Red ICU and Green ICU to the other areas of the hospital. At the moment, we've had fantastic uptake from the rest of the hospital in helping us take over care of these patients. And we've been very appreciative of that. Obviously, it's very important that we sort of keep these COVID areas to patients that do have suspected COVID or confirmed COVID. Currently the plan is to have a COVID team available on site at RPA 24-7. The shifts will be divided into day, evening and night shifts. Mikey, can you give us an idea of what the COVID shifts will be like for the registrar? Yeah, so starting as of this week, we've been very lucky to have a lot of support from the different training units and we've had now 24-7 cover of the COVID ward and ED. So at the moment we have a morning shift that goes from 8.30 to 5 o'clock. We have an evening shift that goes from 3pm to 10.30pm and we have a morning shift that goes from 8.30 to 5 o'clock. We have an evening shift that goes from 3 p.m. to 10.30 p.m. And we have a night shift that goes from 10 p.m. to about 9 a.m. This gives us an opportunity to have overlap between all three teams. And it lets us sort of do a good handover so that everyone knows what's happening. Again, this is a situation that I imagine might change and might be completely different in a few weeks, but that's what's happening right now. Just to give you sort of an idea of what our normal day might look like, we start with sort of seeing all the patients on 10 West 1, and these are sort of the stable, relatively well patients who either have suspected COVID or do have confirmed COVID. At 11 o'clock, what we're doing is we're calling the ICU team and we're actually discussing every patient who has been admitted to ICU because that's currently where the majority of the patients are. We discuss a few things, namely, one, do we think this patient is likely to have COVID? If we don't think it's COVID, what might an alternative diagnosis be, such as heart failure or bacterial pneumonia? Three, if we think it's not likely to be COVID, or sorry, if it is likely to be COVID, how much more testing do we need to do? So do we think that one test is adequate, or do we think that a second swab might be needed or maybe even further investigation? That's sort of happening at 11 o'clock. At 3 o'clock, we hand over all of our patients that have been seen in 10 West 1. Mikey, can you tell our listeners what a typical COVID ward round entails? What do you do on a COVID ward round? So look, it's not completely different from a normal ward round. There are just a few caveats. It's obviously very important that every time we see a patient, we strictly adhere to PPE. We're trying to limit the number of doctors that are going into each of the patient rooms and currently the setup that we have is for example a registrar will go into the room and then using the patient's phone we'll call so that the JMO sitting outside can hear what's being said and they will sort of document what's happening on the round. We try to limit the number of times that we have to go into a patient's room. So if, for example, we think that someone might need bloods today, when the registrar is going into the room to assess their symptoms and do an exam, they also bring in all of the blood taking equipment and they do it at that time in sort of one visit rather than having two separate visits. We try and limit the number of times that we have to do a physical examination of a patient and sometimes for a patient that is very well we might even just call in using the phone and see how they're going and ask about whether or not they feel any better or worse or any other symptoms. What sorts of investigations have you been performing on COVID-19 patients and what's the rationale for these tests? So first of all I guess I'll speak to who we're swabbing and again this is something that's constantly changing. At the moment the criteria that we're following are from the New South Wales health guidelines. So one, if you have international travel or have close or casual contact with a suspected case within the past 14 days and you have a febrile illness or acute respiratory symptoms. Two, if you've got bilateral community acquired pneumonia that is severe with no other cause identified. Three, if you're a healthcare worker who sort of presents with fevers and respiratory symptoms. And four, in addition at RPA, we are now testing patients who present with fever above 37.5 and respiratory symptoms, and particularly if they're from a high-risk setting, so nursing home or other facility. In terms of the other investigations that we're doing, these haven't changed from what we normally do. We do a full blood count to assess for any evidence of lymphopenia, which is a common sort of finding in patients with COVID. We do the EUCs, LFTs and a CRP. These help to sort of give us prognostic information in terms of their LFTs. Some of the sort of more unique tests to COVID that we're doing include an LDH and D-dimer. These have been described in the literature to be associated with more severe disease potentially and increased mortality. For all patients with COVID, we're trying to do a chest x-ray. And again, in the literature, there have been sort of descriptions of the typical findings being ground glass changes with or without consolidation in the bilateral lower lobes. So for patients admitted with COVID-19, what are some of the important symptoms, signs and investigations that we should be monitoring? Yeah, I mean, this is something that is similar to any normal ward patient. And I guess this hasn't really changed from our clinical practice. We look at our patients from the end of the bed. Do they look well or unwell? |
Okay, welcome everyone to our first podcast for 2014. We're doing a podcast on fever and we've invited Andy Lee, an infectious disease physician from RPA. Welcome Andy. Thanks James. So this is a common after-hour scenario that our junior docs will face. We'll start with a scenario. You're asked to see a patient with fever. He's day four post-anterior section of a colorectal carcinoma. What question would you ask over the phone to the nurse? As you mentioned, this is a very common scenario. So I think every intern on ward will be asked to see a febrile patient at some point, usually early on in the year. And I think it's important to bear in mind the context in which you're getting called. So this is a post-operative patient. So it's someone who's been in hospital for at least four days, and I'm assuming from the history that this is a new fever. So I think when you get the call, there are a number of important questions that you need to ask. So one of the questions that I'd ask is how high is the temperature? I know the height of the fever is not necessarily indicative of whether or not someone's got an infection but post-operative patients often do have a fever and if it's been a low-grade fever and it's been present since the surgery, then it's less of a concern than, say, someone who's got a very high new fever. So I'd ask about how long the fever's been present and also how high the temperature is. I'd also ask specifically about the vital signs, and this is a good way of triaging whether or not you need to see the patient straight away or whether you can wait and look at other patients who might be higher on the priority list for you. So I'd ask about the heart rate, also the blood pressure in particular, and also look at the respiratory rate and oxygen saturations. And I think these basic vital signs will give you a good idea of how sick the patient is. Obviously, if the patient is tachycardic, you'd probably expect the patient is tachycardic if they have a fever. But if they have a very high heart rate, then it might suggest they've gone into an arrhythmia, say, because of sepsis. And that, particularly if the heart rate, say, gets to about 140, 150. If their blood pressure is low that would be a major concern because it might be a sign of septic shock. So that would be someone that you would prioritise to see early. At RPA if the blood pressure is low that would obviously trigger other emergency calls such as a medical emergency team may be called in that circumstance. Now respiratory rate and oxygen saturations are also important because these sorts of patients are at high risk, so post abdominal surgical patients are at high risk of hospital acquired pneumonia so it might give you an early clue as to the potential focus of infection. So I'd ask about the vital signs and I'll help you triage how urgent it is to see the patient. I'd also ask in this circumstance you know the patient's come in for surgery but in other circumstances they might have actually come in for some other reasons so I would ask for the initial reason for admission and also if the nurse hasn't told you that the patient's had surgery recently then I would certainly ask about that as well because that would put them at increased risk of a post-operative infection. And if you have time and the nurse knows if the patient has any associated symptoms that often helps you decide whether or not this patient's likely to have an infection or not. So these would be the six questions that I'd be asking on the phone. Okay, so you ask them on the phone, you get some notes, do some observations, you arrive to see the patient. What is your approach when you actually go to see the patient? Yeah, so I'd probably first of all walk past the patient, have a quick look at the patient, see if they're looking well or looking unwell. I think the end of the bed test is actually quite a good initial test as to how sick the patient is and whether they're likely to have sepsis or not. So if they're comfortable sitting up in bed, reading a book, then I think it makes you much less worried than someone who looks anxious or lethargic. These features might be a stressed early infection or sepsis. So I'd probably do that and then grab their observation chart just to have a look at the pattern of the fever and what their blood pressure's been doing as well. So I'd do that and if they don't look too unwell then I think you have time to have a quick look through the notes and see what the patients come in with and what the team's written say in the last few days. So you've documented that they've come in with a colorectal carcinoma say and that they're now day four post-op. Sometimes you can get a bit of a clue from the operation notes that it might have been a very difficult procedure, so there might have been some bowel leakage, which might make them at increased risk of infection, or they might have had a very prolonged procedure, which might suggest that they had some, they might have only had one dose of say, prophylaxis intra-op, and they might be at increased risk of surgical site infection. So these sorts of things are very helpful. Then obviously you can look at the progress in the last few days and see if there are any concerns about infection that the team had already documented or whether this is just an acute event. So that's what I'd be looking at the notes when I initially come and see the patient. Okay so I guess when you go and examine patient, we're probably thinking in our mind before we see the patient, what are some of the common sources of fever in a post-operative patient? Could you outline some of those causes? So common causes of fever, I suppose in the hospital setting, infection is high up on the list, but it's not always the case. So sort of broadly categorize them into infective and non-infective causes. Infective causes are the ones you don't want to miss. You can get other causes of fever which you don't want to miss either in a post-op patient they include pulmonary embolism. Other non-infective causes include things like drugs, sometimes malignancies or other inflammatory conditions, but I'd put those down the list and make sure you've excluded infection and pulmonary embolism first of all. So in terms of infective causes in a post-op patient, you always think of things related to the surgery, so things like surgical site infections. Post-operative patients often have urinary catheters in and so that increases their risk of urinary tract infection. They often also have intravenous access which might be central access in someone who's nil by mouth for a long time post-operatively and these invasive devices always increase patients risk of healthcare associated infection. So I'd be thinking of surgical site, I'd be thinking of intravenous catheters and indwelling urinary catheters. In post-abdominal surgery patients, as I might have mentioned earlier, pneumonia is also a risk because patients might have a lot of post-operative pain and they might have some diaphragmatic splinting and they might not be clearing their secretions as well as an ordinary person. So I'd be looking for signs and symptoms of a respiratory tract infection as well. So I think they would be the big things in terms of post-operative infections in this clinical setting. And surgical site is not only superficial surgical site, so the wound itself might be infected, but the wound might look perfectly fine, but they might have a deep surgical site infection, and that's always something to bear in mind, particularly in someone who's had abdominal surgery there is a risk of a wound or dehiscence of the anastomosis and intraoperative or intra-abdominal collections. Obviously if that wasn't a concern that would be something that you'd be speaking to the surgeons about but that's always something to bear in mind. When we think about fever is the kind of time onset of fever important in kind of working out a cause? Yeah, no that's really important. So a lot of people have fevers perioperatively. So usually in the first, say if you're febrile the day of the surgery could be related to an infection at the time of the surgery. So if you've had, say if you're having an anterior section for a perforated bowel, you might have an intra-abdominal infection at the time you have the surgery, so you'll likely be febrile at the time of, for the first few days after the surgery. The other thing that can cause fever around the time of surgery is drug reaction or transfusion reaction. |
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