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In the first couple of days postoperatively, it's not unusual to get a fever. Often that might be related to some tissue breakdown, but it can also be related to what some people term as atelectasis. So you can get some collapse in the basal segments of the lung related to, say, having the anaesthetic or splinting of the diaphragm after abdominal surgery say and that can cause a bit of a fever as well. So usually in the first day or two if you're febrile it's not necessarily related to infection. After about three or four days infection becomes much more likely because the causes of fever around the time of surgery are no longer an issue and often you get infections related to invasive procedures or invasive devices and they usually take a few days to incubate so you might not actually develop an infection that's been incubating around the time of surgery until about two or three days down the track. So people who have fevers say three or four days after surgery are much more likely to have an infective cause of their fever. And say if you have a fever a week down the track, you'd be thinking of things like pulmonary embolism because the patients have often been bed bound post-operatively and the increased risk of developing a deep venous thrombosis and subsequent pulmonary embolism. Any tips on doing an examination or looking for those underlying causes? Any other things we should be doing for looking on a clinical examination? Yeah, so in a febrile patient in hospital, so this is a patient who's developed a fever in hospital, it's really important to have a look at their skin, so particularly cannula sites because one of the leading causes of hospital-acquired bacteremia are line-related infections. So cannula sites, if they're peripheral cannulas you might see some erythema and potentially discharge around the side of the cannula. If it's a central line the actual entry point might look fine but the infection might be at the tip of the catheter in which case you might not see any signs on the outside. It's still worth looking at the entry point to see if there's any signs of local infection. So urinary cath is a very common postoperatively and so you can have a quick look at the urine bag and see whether or not it's draining properly. There might be obstruction and that might be a cause of you might get a urinary tract infection because the catheter is not draining properly or you might see cloudy urine in the urine bag. So these are all important things and of course you want to have a look for signs of deep venous thrombosis as well in the legs to see if that might be contributing to the fever in this patient. Now often once we've seen a patient especially speak to our registrar over the phone they'll tell us to do a septic screen. What is a septic screen? Yeah so I don't like the term septic screen because it's very nonspecific. I think septic screen, in my mind, I think a septic screen would, at the minimum, be at least one set of blood cultures. I would recommend taking two sets of blood cultures if you're going to start antibiotics. I think anyone in whom you suspected infection, in whom you're going to start antibiotics, should have at least two sets of blood cultures collected prior to commencing antibiotics. If you suspect endocarditis, then I would expect three sets of blood cultures prior to commencing antibiotics. If this patient has a new fever and hasn't had blood cultures collected, and you suspect infection, I would take two sets of blood cultures from different sites. And when I say sets, I mean two bottles in each set, so an aerobic and anaerobic bottle. And if you're taking two sets, then you're taking an aerobic and anaerobic blood culture bottle from one site and then an aerobic and anaerobic bottle from another site. And the reason why we do this is because one set of blood cultures picks up bacteremia probably in somewhere between 60 and 90 percent of cases. So in potentially up to 40 percent of cases you might miss the bacteremia because you're only taking one set of blood cultures. So taking two sets increases your yield probably to 90 to 95 percent. The other reason why we take two sets of blood cultures is sometimes you can get organisms that are common skin commensals and if they're present in one set of blood cultures and not in two then it makes it less likely to be a significant pathogen than in a patient where you have skin commensals positive in multiple sets of blood cultures. This is particularly important if you've got say prosthetic infections of catheters or prosthetic intravascular or joint prosthesis. So in this circumstance, it's really important to take multiple sets of blood cultures. And this also applies to certain organisms that cause endocarditis. So the virudan strep group is a classical group that causes subacute bacterial endocarditis. But having a virudone strep in one set of blood cultures doesn't necessarily mean it's a pathogen because it's often a skin commensal as well. So I would suggest taking at least two sets of blood cultures. And you say different sites. Do you have to do them over a different time or you can take them one after another? Yeah, so that's a good question. It depends on the circumstance. So if you're going to take blood cultures and you want to start antibiotics straight away because the patient's unwell, then I think it's reasonable to take the two sets at the same time prior to starting antibiotics. Often we space them out over time, say in someone who's not too unwell and you're putting off starting antibiotics and you suspect endocarditis, then we would space them out over say 24 hours if we're going to hold off on antibiotics. But I think it's important to note that you need to take them prior to starting antibiotics. So if you need to start antibiotics straight away, then you take two sets straight away. The other elements of the septic workup include, I would collect a urine sample. It's easy to do and it gives you a lot of information about the potential for a urinary tract infection. So I would include that in my septic screen. Other samples are really dictated by what you see clinically. So if you see pus pouring out of the wound, then obviously you want to take a swab of the pus. If the central line site looks oozy, then I would swab the central line site. If you think the patient has line sepsis and the line needs to be removed, I'd be doing that in consultation with someone more senior, then I would remove the line and send the tip off for culture. If someone has signs or symptoms of a respiratory tract infection then I would include doing a chest x-ray and a septic screen. I think the chest x-ray sometimes, I think junior staff sometimes are not sure whether to do a chest x-ray. I think if you have signs or symptoms related to a possible respiratory tract infection then that would be the time to do a chest x-ray. Obviously patient has no respiratory tract symptoms at all then it may not be necessary after hours to do a chest x-ray. Okay so we've looked at the septic screen and looking at taking bloat cultures. Obviously, starting antibiotics would be something we'd be discussing with somebody more senior. We may leave that maybe to another podcast on antibiotics, which will be coming up soon. Another common scenario is that you're asked to see a patient with fever, but the patient's on the haematology ward and has a low neutrophil count. How does your approach differ compared to the patient we described earlier? Yeah, so this is a special group of patients. They're obviously immunosuppressed. Their ability to fight infections is much lower than the average person. So they're neutropenic, so their risk of bacterial sepsis is very high. So usually in this circumstance, you need to assume that someone's got an infection until proven otherwise. So if this is a new fever in a neutropenic patient, I would again do the septic screen. So you need to prioritise this patient very high on your list. So these patients can become unwell and go into septic shock very quickly because they're immunocompromised. So fever in this group is infection until proven otherwise. If this is a new fever, then obviously you need to go up and assess the patient and do the blood cultures and urine culture and other cultures as necessary based on your clinical picture. So I would be doing at least two, I would obviously go up, make sure the patient doesn't look unwell, look at their vital signs, look at the history. These patients are often already on antibiotics, so it's often, as you mentioned earlier, it's important to discuss these patients with someone more senior.
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Welcome to On The Wards. It's James Edwards and today we talk about anaphylaxis and we're actually welcoming back Associate Professor Roger Garcia who's an immunologist at RPA and I think many of you remember one of our first ever podcast was on anaphylaxis and Roger spoke then so welcome Roger. Thanks it's lovely to be back. So anaphylaxis is actually a fairly common presentation to med departments and also seen on the ward and obviously can be if not diagnosed or managed correctly can be fatal. So what we thought is do a review of anaphylaxis and allergic reactions and we'll start as we always do with On The Wards with a case. And this case is a four-year-old female who presents to the meds department with facial urticaria and angioedema, a swollen tongue and widespread wheeze. Obviously it's a bit upset with some respiratory distress and actually brought in by a friend's mother from a birthday party because the mother's actually away. Not sure if she's got any allergies and goes straight to our resus bay and one of the doctors is looking after the patient with you, a junior doctor. Maybe we'll start, what signs and symptoms suggest anaphylaxis over maybe a less severe allergic reaction? Well, thank you. So this is a young girl in whom we only have part of the history at the moment, but clearly she is showing signs of bronchospasm and also cutaneous signs of allergic reaction. And that combination together should make you suspicious that you've got widespread histamine release or high levels of allergic mediators in the system. So in her really the key things are to look for signs of shock and in young children this is obviously difficult to be clear about sometimes because first of all their four-year-old's normal blood pressure is going to be much lower than an adult's and one needs to be age specific in assessment. The child obviously can't readily tell you about whether she's experiencing abdominal pain which might might be another feature to be concerned about. But quite clearly, she's got angioedema of the tongue. She's got bronchospasm and she's got cutaneous manifestations of histamine release. So she's got enough features there to say she's got anaphylaxis, although she hasn't yet got the most severe sign, which is shock. And in regard to things like anaphylaxis, what other things should we think about? You mentioned angioedema, so often you get confused about angioedema and anaphylaxis. So the key thing is that angioedema is common and there are multiple causes of angioedema and not all of those will be associated with cardiovascular decompensation or risk of that. So angioedema can be caused by abnormalities in the complement system, there are granulomatous causes, it can be a local manifestation of allergic reaction which has not become systemic. So in terms of severity it's a very important indicator that there is a risk and there's obviously a local risk of airways obstruction. So one is trying to assess whether the airway is going to be compromised but also what is the evidence or not of a systemic reaction. So if we're concerned about, as in this four-year-old, imminent anaphylaxis, should we really get a go ahead and start treating or should we take a bit more time and ask a few more questions? Look, she is in trouble. You know, she's got significant bronchospasm and we don't have any prior history, I believe, of asthma. And so she's very much at risk of rapid deterioration in this setting. So I think there's enough there in this child to warrant giving adrenaline in this child in this situation. So adrenaline would be the urgent intervention whilst one gathered more information and this is a team obviously at work, we're usually not talking in the emergency department of one person managing this sick child by themselves. This is a time to harness some additional help and for people to be doing things simultaneously. So, lying the patient down is crucial. Positioning is really important, particularly in children. They're at high risk of vomiting, so being aware of that risk is important. Oxygen is important and one wants to have the appropriate dose of adrenaline available and all the evidence points to it being best delivered intramuscularly and the appropriate dose for children is 10 micrograms per kilogram up to really we say up to the age of about five or up to about 20 kilograms. Beyond that, then, a 300-microgram intramuscular dose, which is the adult auto-injector dose, is appropriate for most children, even if they're sort of in the school-age group. Nebulised Ventolin can be helpful in this situation. And also when we want to have glucagon at hand. Not so much in a child, because it's highly unlikely a child will be on beta blockers. But in an adult, particularly an older person who might have had anaphylaxis, glucagon can be helpful. IV access is important. It's often misstated that the reason for giving IV access is to be able to administer intravenous antihistamine, but in fact that's really viewed now as being an obsolete approach to this problem, and it would be far better to give the patient fluids through that IV line. There's no evidence in fact that intravenous antihistamines improves the outcome of treatment of anaphylaxis if you're giving adrenaline as well. So the correct treatment is adrenaline and antihistamines intravenously can confuse your assessment of the patient, particularly with respect to conscious level confusion, and they have been associated with worsening of hypotension. So at this stage, the international and local recommendations are not to give intravenous antihistamine in this setting. So you give one dose of intramuscular adrenaline. You did say something about lying them flat. I was just kind of, sometimes, obviously, they've got some airway edema and swollen tongue. Sometimes it's trying to balance that, sitting them up from that versus sitting them flat, because often they become hypotensive. Yeah, this is obviously the balance. And it is a matter of being aware that the airway can be compromised by posture and getting an optimal posture is key. These young children and adults should be having oxygen saturations monitored. Close and clear observation of respiratory movements and air movements etc. So I made the point that this is a medical emergency. This person is as much at risk of rapid deterioration as someone else is in imminent shock or pre-shock. So if they maybe they respond to the intramuscular adrenaline, if they didn't respond what would be your next step? Well the peak blood levels after intramuscular injection are achieved by about 10 minutes. So we usually wait about 10 minutes or so. And if we're not seeing evidence of some response by 10 minutes, then it's appropriate to administer a further dose of a similar, using the same formula for injection. So readministration is important. Make the point that in patients, adult patients, where one may be dealing with people, you know, 120 kilograms or more with anaphylaxis, obviously a very difficult situation. One may need to, you know, go to quite high doses. But it's rare for us to use more than 600 micrograms even in a large person as the initial dose and of course the older patients you have to be cautious about inducing adrenaline overdose and the tachycardic effects of that. So you know the different issues in the children and the older patient and concomitant medication are clearly important to know about to guide you in how one goes about administering adrenaline. Occasionally in a recalcitrant patient, an adrenaline infusion can be set up to just titrate adrenaline administration. Yeah, I must say in my experience, intramuscular adrenaline works probably 95% of the time and is a requirement. It's quite unusual to go to an adrenaline infusion in a response to an isolated anaphylaxis. A couple of other points are worth keeping in mind though. If the patient has vomited and the allergen has been a food allergen, of course that might reduce the further absorption of the allergen. People have been stung and are having stinging insect anaphylaxis will quite often vomit. That's doing nothing to help their allergen load. And occasionally, if we've got situations where people have been given intramuscular injections in hospital of an antibiotic that they're reacting to, of course, their absorption may be yet to peak. So, you know, the response to adrenaline is going to depend a bit on whether the allergen load was already absorbed and you're coming in after that, or whether you're in the midst of a rising allergen load. You haven't mentioned steroids. Do they have a role? Steroids have a role in the management of anaphylaxis but it's not in the emergency role.
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So steroids are generally viewed as not the necessary component of the emergency treatment. They are too slow in reducing the edema that might be occurring on the larynx or the pharynx. The adrenaline is the the way to get rapid control of that edema and that's what's providing the airways risk and steroids are not needed as a treatment for hypotension. What's needed for hypotension is an adequate fluid therapy and and chronotropic and inotropic drive to cardiac output. I just make one other point about assessing these patients. One should keep in mind that the mechanism is vasodilatory and consequently the patient may look much better perfused than the patients with shock that you see for other causes of hypotension. They also quite often are very pale because once you start giving adrenaline, then the vasoconstriction kicks in and they'll become pale well before their blood pressure actually rises. So in this case, the patient has improved after some intramuscular adrenaline. What are the ongoing monitoring requirements post-adrenaline and what are some of the complications of treatment maybe especially in older patients? So it's really the pharmacological effects of adrenaline, tachycardia, hypertension. So adrenaline, you can overdose obviously with adrenaline. They are the two key ones. One needs also then to look for the consequences of the period of shock, if there has been a period of shock, particularly with respect to the brain, the heart, the kidneys and the gastrointestinal tract. So someone who's been resuscitated from an episode of anaphylaxis may still be quite unstable for, you know, particularly the next 24 hours. If it's been a situation where you've averted shock, then, you know, the monitoring is, of course, going to be more straightforward. So we do look at, particularly in the older patients, for any evidence of myocardial infarction, ECG, troponin changes etc and keep in mind that you know anaphylaxis is one of the causes of a shocked heart as it were and they can be in a low cardiac output state after recovery. So they are the key aspects with respect to the acute deterioration. I did mention earlier the possibility of a secondary phase and what you've done is treated the acute mediator release but the mast cells and basophils may still be being stimulated by a bound antigen, you know, stuck on or bound to IgE on the surface of those cells. And so ongoing mediator release is potentially involved. So it's my practice to use corticosteroids for 48 hours in that setting to try and minimise the chance that, you know, during the period when you think things have improved and your guard may be down in terms of monitoring, that they start to get into strife again. And that obviously also goes for the administration of bronchodilators if they've had significant bronchodilatation as part of their reaction. So when you say, we'd like to say prednisone, is that one milligram per kilogram or half a milligram per kilogram? Look, I usually give 50 milligrams orally. Or if they've had hydrocortisone, we're usually giving them 100 milligrams of hydrocortisone. And you mentioned that kind of biphasic response. So how long do you keep somebody after they've improved? The guidelines vary. If it's been a situation where you've given adrenaline or the patient has given them self-adrenaline or their family in the ambulatory setting and has been brought to hospital, they've recovered quickly and you're confident that they're in good hands who will be able to monitor them well going forward, then you might just hold them for four to six hours. But generally generally we like to keep them for at least 12 hours after the episode and it's common to keep people particularly overnight if it's been in an evening because of the difficulties in appropriate monitoring outside. But it isn't the case that all anaphylaxis patients need to be admitted to hospital and of course there are some people who have multiple episodes of anaphylaxis over their lifetime and we get some sense as to the severity from how they responded previously as well. Yeah, it's something we commonly put in our short stay units and they stay overnight and get follow-up the next day and I guess the follow-up, what's appropriate for an outpatient follow-up for someone to their first episode of true anaphylaxis such as this case? So outpatient, the follow-up's really important. People shouldn't leave hospital not knowing what the diagnosis has been and if it's anaphylaxis to a suspected component of a food they've ingested, one may not be able to be specific about which component that actually was. You may have a higher suspicion that it might be a nut in a muffin or something along those lines. But in a young child, particularly a very young child, it might be first exposure to egg or to one of the other common allergens and not the one you think of first. So real caution in the advice to the parents if the cause of the anaphylaxis isn't clear. And if there's doubt about what caused it, they need to know there is doubt and they need to be very observant going forward and not to undertake self-testing at home to solve it. That's the sort of thing that should be done under medical supervision in the ambulatory care setting. So these are medical emergencies in the emergency department and they are medical emergencies for outpatient follow-up and these are the sort of patients for a phone call to to the allergy consultants who are involved in the case they will if you've got an allergy unit in the hospital you're working if you you're in a hospital setting, usually they will be triggering an urgent follow-up with the child or the adult, whatever, next available type of appointment so that the appropriate diagnosis can be reached and testing instituted if it requires skin testing or challenge testing to nail down the precipitant. And in regard to medications, are medications a common cause of an allergy or immediate hypersensitivity? Okay, so it's variable. Obviously in a in the pediatric setting there's not many children on medications and medication anaphylaxis is pretty unusual in children. It still does occur you know particularly in the setting of viral infections and the child you know may be getting lots of medications they've never had before. Keep in mind that even some of our very commonly used drugs you can have anaphylaxis to. So paracetamol can produce anaphylaxis. The non-steroidals and aspirin are relatively high on the candidate list if there's been exposure to those. Antibiotics as well. They would be the common ones in childhood outside of the foods. In adults of course we've got a much broader range of possible culprits and it can take quite a deal of investigation to identify the cause of the anaphylaxis. Anesthetic anaphylaxis is a complex issue because of the range of drugs given simultaneously. And so the timing, it's often very difficult to work out just from history what was the culprit. And in those settings, we often have to go to skin prick testing and challenge to identify the culprit, a drug that's involved. Yeah, it's interesting, I was reading something that they were really suggesting that given so much antibiotics is often for surgical procedures that they really probably should give the antibody before the patient's gone to sleep. Just because it's much more complicated to diagnose it when they're asleep because they've got all the other kind of drugs on. Yeah look I would agree there's a there's a reasonable case for you know for pre-medding including at the pre-med stage if you've got a short phase before the surgery actually takes place it just all depends on the timing when you need that peak blood level to protect the individual. Can I just say one other comment, which is, you know, a large number of people come to a hospital with a history that they're allergic to antibiotics. And the prudent thing to do is, of course, not to use that antibiotic or, you know, closely related antibiotics and to be cautious about the use of cross-reactive antibiotics. it doesn't matter how long ago the history was of the anaphylaxis or the widespread allergic reaction that was nailed down to or thought to be due to a particular drug. Having said that, if you test with appropriate skin tests and challenges people with a history of penicillin allergy, the majority of them in fact will be able to tolerate penicillin. So we do quite a lot of referral work coming from pre-surgical clinics where the team are anticipating that they'll want to use a particular antibiotic perioperatively, post-operatively, and it's appropriate to sort that out well before the surgery if you can, if it's an important component of the regimen that is going to be used. And that particularly applies to people who are polyallergic, where finding an appropriate set of antibiotics for them might be difficult if you excluded everything that they were by history possibly allergic to.
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Yeah, so I mean, how can we avoid anaphylaxis in the hospital? What are the key measures? Yeah, so I think, look, I think the key things are, it's really the whole quality cycle of what we do in hospitals. So we have to be really accurate about what we record and be very clear and unambiguous about the descriptions of any allergic reactions. So that if there are, you know, rashes that are properly described, you know, if they're urticar urticarial etc, the timing of any possible exposure is clearly documented so that you can apply some assessment based on the probability, based on the temporal sequence. That's obviously important. The prior history of related antibiotic use or other drugs that have got cross reactions potentially, that can help inform your use so that you might avoid those going forward. You know to prepare for anaphylaxis in the hospital, you know we obviously need to be well set up with our infrastructure, arrest trolleys well stocked, properly tested, lines available etc. So I think you know we just always need to be conscious that anaphylaxis can occur in settings, any setting in a hospital really because we are doing so many different things in the hospital setting, in diagnostic areas, in radiology, you know even occasionally in places where we're doing totally non-invasive things, there's contact agents applied to the skin, etc. Some of the people listening to this podcast may have even encountered people who've had hair dye allergy, where anaphylaxis has been triggered by the application of hair dye to the hair or henna to the skin. So it's not always even parenteral or oral exposure that's the problem. I mean, do you think having electronic medical record will maybe reduce the, I guess, anaphylaxis from medications? Look, one's really hoping that those alerts that we put on, the become more and more refined that over time people both diagnose allergy particularly to drugs more accurately but also that when people have tolerated antibiotics in a controlled setting that they are delisted as allergic and the patient's informed that they can have this particular drug or antibiotic in the future. So we really do have the potential in that setting to use the most appropriate antibiotics or the most appropriate drugs if we go to a lot of effort along the way to make sure those records are accurate. You described earlier on the clinical diagnosis anaphylaxis but do we need to also do blood tests or skin prick tests and in what cases would blood tests be indicated? So in the emergency setting it's a clinical diagnosis and you know in that setting you know we really need to act quickly and blood tests can be helpful particularly where there's doubt about it was whether it was anaphylaxis or a reaction particular one sees doubt in the anesthetic setting particularly where there are other vasoactive drugs being given and one's not sure whether it's the vasoactive drug or the an allergic reaction. So mast cell tryptase can be very helpful. It's not, there have been fatal cases of anaphylaxis with a normal mast cell tryptase and it's record as a test for anaphylaxis is better for bee sting and stinging insect than it is for food allergens. But it's still very useful to do it. Ideally, one does then baseline mast cell tryptos at another time. So it both helps you actually see whether there has been widespread mast cell degranulation, it serves another purpose as well because if the baseline is high then you may be dealing with someone with systemic mastocytosis. They may have had an allergic reaction which had they not had an excess number of mast cells in their body would not have been sufficient in its amplitude to actually trigger shock. But because of the large number of mast cells, they end up with a systemic reaction. So that's a useful additional thing. C4 is worth complement level, C3, C4, also worth measuring in context of angioedema, particularly if it's isolated angioedema without widespread urticaria, because some of those cases may be late onset acquired C1 esterase deficiency in which there's no family history, sometimes associated with lymphomas or other malignancies, etc. So those two tests can be helpful. principally this is a clinical diagnosis. So our four-year-old is better, we've organised an appointment to go home. The last thing is, should they go home with an EpiPen and if so, what are the logistics around to actually make that happen? Okay so we've used, most of our educational literature in the past has been related to the use of EpiPen because for a while that was really the only auto injector that was available on the market. So I think it's useful, one of the reasons for doing this update is the landscape has changed also with available licensed adrenaline auto injectors and they have different training, they have different application technique. So if someone is using one of the generic auto-injectors then the patient needs to be trained in using that because it's a different technique to the well-known EpiPen and there's also an Anakit type as well. So and the market is likely to expand for auto injectors of adrenaline. They typically have a junior version 150 micrograms of adrenaline and a standard version which is without the junior suffix which is 300 micrograms. So the patient also needs to know that those two different sizes exist and to be accurate to check their script that they're getting the right time, the right type. But you know in my view if adrenaline has been used because there's been anaphylaxis and if the trigger can't be avoided then it's appropriate for the patient to leave with an auto injector and then instructions about how to get proper allergist, immunologist, allergy clinic, respiratory physician assessment to institute PBS S100 arrangements for, well PBS, it's really PBS, PBS arrangements for the provision of adrenaline at the subsidised price and the PBS will allow two adrenaline auto-injectors without repeats. So if they use one up, they have to go and get another one. But a general practitioner can prescribe the continuing doses. The first PBS subsidised dose is under the authority of an immunologist or a respiratory physician or a pediatrician, registered pediatrician. So there are some places where it's very hard to get an immunologist to see the patient and the wording of the PBS is in association with, so that this is a situation sometimes that association may not be a face-to-face association where there's been a clear description of the problem and authority given from someone who's got the authority to institute it. So if people are leaving the emergency department with an auto-injector it's absolutely crucial that they've been trained in its use and there are dummy devices which are available for training and they're very easy to train someone in its use and they should also be leaving with an anaphylaxis action plan because you're giving them a potent drug and they've got to know when they might be it might be appropriate to use it and so the action plan deals much more than just when to give themselves adrenaline it It also deals with the assessment of themselves in the lead up to that decision. It tries to differentiate a moderately severe allergic reaction from an anaphylaxis or an imminent anaphylaxis occurring. And those action plans, of course, are then usually deposited with the the school the educational institutions of other sorts as well you know sometimes they're given to other people have responsibility for that child you know community groups sports you know scouts that sort of thing as well so they're very important documents they're usually done in the allergy clinic but they can be downloaded from the ASC the ASCIA site as well if you want to look and see what they look like. Good. And we'll give you a link for those listening to this podcast to that website. Probably the last one. I'm sorry, I should say that the key message, of course, is not about administering a treatment. It's absolutely got to be about avoiding the risk. And that's why I said at the beginning of that last piece that if the situation is one where you cannot avoid that particular risk. So someone who has had an allergic reaction to a drug, very clearly we can avoid that risk and they don't need to go home with with an adrenaline auto injector but if it's been a stinging insect or if it's been a food where it's really hard to be sure you can avoid it then you're dealing with you know a higher risk of a recurrence we also mentioned before about angioedema and anaphylaxis the differences i guess the important thing is just in our final kind of message in regard to the treatment of anaphylaxis versus angioedema and I guess the role of things like adrenaline. So they are different, different pathophysiology and anaphylaxis is a systemic mediator release that is causing vasoactive consequences with leakage across capillaries and tight junctions becoming more open and the edema that occurs in that setting is going to be more or less troublesome depending on where it occurs.
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Welcome to On The Boards, it's James Edwards and today we're talking about diabetes. We're speaking with one of our regular contributors, Dr Barbara Depczyinski, who's a Senior Staff Specialist in Endocrinology at Prince of Wales Hospital. Welcome, Barbara. Thank you. Now, we have discussed in different podcasts management of diabetes. This one's going to focus on the perioperative management of the patient with diabetes. So why is the perioperative management of a diabetic patient so important? Diabetes is very common amongst hospital inpatients and both hypoglycemia and hyperglycemia can be associated with adverse outcomes. So it's part of our managing our patients really well that we attend to their glycemic management as well. So we're going to provide a case and the case is a Miss Smith who's a 30 year old female who presents to the emergency department with appendicitis and she has a background of type 1 diabetes and is planned for an appendectomy and is now a nearby mouth. So what are the key considerations in managing this patient particularly from the aspect of their diabetes? So she needs a management plan that ensures that she maintains a normal metabolic state. So I want to prevent ketosis and I want to keep the blood glucose levels to an appropriate target for a patient in hospital. That will help avoid dehydration and electrolyte disturbances. So to do that, I need to have a plan where she can continue insulin because she has type 1 diabetes so that's an absolute deficiency of insulin. So I'm going to be influenced by the fact that she's come in as an emergency case rather than coming for an elective procedure. I'm going to be influenced by how long she might be nil by mouth for, so patients who are on the emergency list. It's very unpredictable in terms of when they're going to go to theatre and when they may have their next meal. And I'm going to be very interested in what the short-term in-hospital trend has already been for her blood glucose control and what her current biochemistry tells us about her current metabolic state. So what information do we need to ask in regard to the history, especially regarding her diabetes? So she's told us that she's got type 1 diabetes, so that's very important to know and document and the anaesthetist needs to know that she actually has type 1 diabetes. I want to know what insulin she's taking and what the current insulin doses are at home. Ms Smith might know what her HbA1c has been recently and that's useful to know in terms of assessing hyperglycemia in the context of what her outside of hospital glycemia has been like and it's sometimes useful to know a patient's weight and whether they've got any complications that are relevant for a hospital inpatient, in particular if she's got chronic kidney disease. We're going to discuss the approach to another case with type 2 diabetes and maybe just outline how the approach differs for the patient with type 1 versus type 2 diabetes in regard to fasting for operation or procedure. Okay. So I'll just do this in a very broad sense. So someone with type 1 diabetes doesn't make any insulin. So they need a constant supply of exogenous insulin. There's also other patients who are insulin deficient that we should manage in a similar way. So patients who have got diabetes due to chronic pancreatitis or patients who have type 2 diabetes who are being managed in the community on QID or basal bolus insulin. Quite often those patient groups are also quite insulin deficient so I'd manage those types of patients in a similar way to someone with type 1 diabetes. So for these groups of patients who are insulin deficient including type 1s they must have a supply of insulin continued whilst they're nil by mouth. It's great to involve the endocrine team. I don't think you'll ever be refused a consult if you ring up with regards to someone who's got type 1 diabetes or if you're in a small hospital then involving the general physician is useful as well. If someone's going for a procedure where they're just missing one meal then the patient can be managed by continuing their basal insulin and just skipping the meal time or prandial insulin, which would be the Novarapid or Pidra or Humalog for that meal, and then restarting their prandial acting insulin with the next meal. If they're an emergency case or they're going to be nil by mouth for two or more missed meals, then you may wish to consider using an IV insulin glucose infusion. In contrast, someone with type 2 diabetes who's on oral agents, they're not likely to become ketotic and we can manage those patients by just omitting their oral medications. And if you've got a type 2 who's on basal insulin, the basal insulin can be given as normal and their oral agents can then be restarted when they've recovered from their procedure. Are there any investigations that you'd perform in somebody who is going to go to theatre practitioner a call, or you may wish to order one. So maybe we'll go to the approach of management, and we'll go through different stages, but just in regard to the management of blood sugar levels while she's fasting, what's your general approach? So my general approach is for an emergency case and where there's uncertainty about how long the patient will be nil by mouth and they've got a form of insulin deficient diabetes, I think IV insulin glucose is the way to go and a JMO should involve their senior colleagues in that decision making. If the patient is relatively well and I'm quite confident that they're going to be eating again, then I would continue their basal insulin. And that's very important for controlling hepatic glucose output and preventing ketosis. And then give a correction scale of Novorapid or Humalog to adjust for any fluctuations in the blood glucose levels. How often should we be checking blood sugar levels? If someone's on IV insulin they need hourly blood glucose levels. If they're not on IV insulin and they're waiting for a procedure and they're relatively stable then every two to four hours. During the procedure itself and when they're in the post-op recovery ward, they should have hourly blood glucose levels and then two to four hourly, depending upon whether the glucose levels are in target, until that patient transitions back to their normal routine. And then it would be QID testing again. You mentioned using an insulin dextrose infusion. How would you calculate the insulin requirements? So most hospitals would have a protocol. So I'd look at the hospital protocol to see what the doses are. So for a patient who isn't in DKA or hyperosmolar state, most protocols have a variable rate. And so I would make reference to the hospital protocol or look at current published guidelines. And do they require any other fluids or is the dextrose enough fluid for someone who's reasonably young with appendicitis? That's going to be an individual decision depending upon how sick she is. Hopefully she doesn't need resuscitation in terms of being in septic shock and she may need maintenance fluid that might include potassium. So that's a case-by-case decision. And following her operation, when would you recommence her usual insulin regime? Quite often it's useful to continue the basal insulin, so the Lantus or the Levomir when someone's on IV insulin. And then when they're ready to eat their meal, they'd have their mealtime insulin, so the Humalog or Novorapid administered. They'd eat the meal and the IV insulin glucose infusion can be taken down an hour later. And the reason for doing that is that IV insulin's got a very short half-life and so we need to overlap the period of activity of the IV insulin with the subcutaneous insulin. And you mention asking for help from endocrine or general physicians. Who else can help you manage these complicated patients? Of course, the anaesthetist is critical to help guide the management of this patient. OK, we'll go to another case and this one's Mr. Jones who's 70 years old and he's playing for an elective total knee replacement. He has a background of type 2 diabetes which is controlled with metformin and glicoside MR. So how would your management strategy differ from the previous case of a young person with type 1 diabetes? Yes, so this is quite a different case. So Mr Jones is not likely to be insulin deficient. He's being managed in the community on two oral agents and so I wouldn't expect him to normally require insulin unless in the community he's actually got poorly controlled diabetes or some catastrophe arises perioperatively. If you're in the pre-admission clinic, it's quite useful to liaise with the GP in terms of obtaining a HbA1c because it's better for the patient that if they're admitted for an elective procedure that they have reasonable blood glucose control to help improve their outcomes. And in regard to management strategy and measurement of BSLs, what would be your approach?
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Welcome to On The Wards, it's James Edwards and today I'm joined by Professor Ian Katerson. Hi Ian. Hi James. Ian's an endocrinologist and has been an agronomist for Raw Pins Alpha since 1982 and we've been speaking to Ian this morning about a number of topics but now we're on to thyroid disease. I think thyroid function tests are a test that are commonly ordered by junior doctors but when should we actually consider it's appropriate to order thyroid function tests in patients? So firstly, there are a lot of people who've had thyroid disease and know they've had thyroid disease and probably in them you should organise thyroid function tests just to check. Secondly, in the clinical situations where you are worried about hypothyroidism, which tends to be slightly older people gaining weight, slowing down, feeling terrible, or conversely, in the other end, the anxious people who can't sit still, who are losing weight. And then the third situation is when there's an obvious goiter. I'm going to go through a few cases and the first one is a female who is admitted with a skimmy chest pain but has noted to gain some weight and felt a bit fatigued recently so some thyroid function tests were performed and shown an elevated TSH and a low T4. Right so this is relatively common and what you have to work out is what's the cause. So first of all what you would do is do some and the usual thing is anti-thyroid antibodies which would be high in a thyroiditis. And there are two really, or three common causes. There's Hashimoto's thyroiditis, which we've all heard about, which has very high levels of antithyroglobulin and antithyroid peroxidase antibodies. There is an acute thyroiditis which can be post-viral and then there's another thyroiditis which is called de Quervain's thyroiditis that the acute and de Quervain's can present with pain in the neck whereas the other tends to be a slow onset. So you would do low-ish TSH, low free T4. I would do a free T3 and do the antithyroid antibodies. I'd probably also organise an ultrasound of the thyroid so you could see if it's a multinodular goiter or the size of the thyroid. Scan is not really useful in these patients because if it's an underactive thyroid, it's not working and doesn't take up the scan. So that would be enough. And then what you would do is start them on some thyroxin, and the way you start people on thyroxin is fairly straightforward. If you think this is really long-term hypothyroidism, so really high TSH, classic history of slowing down, bit of weight gain, sitting in front of the heater in winter and getting burns on their shins, then you would start at a low dose of thyroxine and build it up because these patients have high cholesterols and are likely to have cardiovascular disease and you don't want to put a strain on the heart. In some of these with really long-standing hypothyroidism you might also consider adding in some cortisone replacement for the first three weeks because the thyroxine in a sense is a stress, the adrenals are hypothyroid and so they need a bit of cover. But that's not common. At the other end of the scale, which is probably the most common we see is someone with a TSH of 20 and a slightly low free T4, and you would probably start them on 100 micrograms a day, and then you adjust the dose. You have to remember that thyroxin takes about three weeks to build up to an appropriate level. So start someone on a dose, check their thyroid function a month or six weeks later, then adjust the dose appropriately. Yeah, so doing daily thyroid function tests would be appropriate. We've gone on to almost investigations. Is there anything particular on history that are particularly important? Well, family history is important, where they were born, whether they came and they knew they came from an area that had goiters. And then the classic history of how you're feeling. Yes, I'm tired. Yes, I've gained weight. Yes, mum is slowing down. And you mentioned on examination looking for a goiter. Anything else on examination that's helpful? In hypothyroidism, first of all, if there is a goiter, you need to know if it's shifting the trachea or if it's retrosternal and the only other thing in the neck that moves up and down when you swallow is a thyroglossal cyst so you can differentiate between the two I'm always interested in people with hypothyroidism particularly if it's long and their cardiac status, and then showing that their ankle jerks are hung up is one of the pleasures of clinical medicine. So what do you find on their ankle jerks for hypothyroidism? So you get them to kneel on a chair classically, but what happens is that when you do an ankle jerk and they're kneeling, it flips up, flips back. But when they're hypothyroid, it goes up slowly, stays at the top and then drops slowly. Okay. Hung up. Yes, hung up. Something to do for the physicians. Any other take-home messages of managing hypothyroidism on the wards? I suppose two. The first is we're often asked, I've got someone who's hypothyroid, needs an operation, can they have it? Yes. Right, doesn't need to get their thyroid function up. And secondly, the thing is, yes, once it's recognised, initiate treatment, but then organise for someone to see him in a month. Okay. Is that someone, a local doctor, endocrinologist? It could be a local doctor, it could be an endocrinologist, depending on the other issues they have. Okay, we're going to go to another case. This patient's a bit sicker. They're a 70-year-old in intensive care with pneumonia and you're part of the the ICU team and you looked at the thyroid function test which should be performed and show a low T3 and TSH. Yeah so this ended to low T4 sometimes so this is sick youth thyroidism and really what we forget is that when we were a fetus, we didn't run on T3. We actually use reverse T3. And so when we metabolise T4 as adults or children, we take off an iodine, we get T3. But interestingly enough, when we get in a sick situation, we start to take off one of the other iodines and we get reverse T3. So if in this situation you measured reverse T3, it would be high. So this is sick euthyroidism. It happens when people are very sick in ICU and really you just have to say, yes, this is sick euthyroidism, I'm going to treat them. They don't need intervention with intravenous T3 or anything like that. They just need to be watched. Interestingly enough, if you do do TSHs, as intensive care people seem to do on a regular basis, as they recover, their TSH will flip up for a few days and come down. So we would not recommend treating these unless we thought it was somebody who had pituitary disease and weren't capable of making TSH. Okay. So really the management is the underlying disorder and the thoracic lymph nodes will cover by themselves. And there's's no particular apart from a blood test being abnormal they're not going to be sick in any way from their thyroid so it's a response to the illness next case is a 50 year old female presented to the emergency department with palpitations and tremor, has known as weight loss and swelling of her neck recently. What's your overall approach to an assessment and management of a patient with these symptoms? So, first of all, it's history. If you're thinking thyroid disease and you can see the swelling in the neck, perhaps she's got shiny eyes and so on. So you need to take a history. How have you been? How's your weight been? How are your bowels? How's your muscle power? Are you weak? And family history of thyroid disease. And then do the appropriate examination, which starts, you ask, of course, about palpitations and tremors and so on, which starts with the hands looking at tremors, takes the pulse rate, looks at the eyes, looks at the proximal muscles, looks at the neck, remembers to listen for a brewy, looks at the heart because it can cause heart problems. If you're really doing the physician's exam, you'd feel for a spleen because 15% of them have splenomegaly and you do their reflexes.
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Welcome to On The Wards, it's James Edwards. Today we're talking about research and in particular how GMOs and why GMOs should get involved in research. And I think also a bit about why it's so important that clinicians and scientists work together. And to have this podcast and speak to Dr. Caroline Ford. Welcome, Caroline. Thank you for having me. Caroline is a head of the Gynaecological Cancer Research Group at University of New South Wales. I thought it would be a really great person to speak about research, and particularly about how JMOs can be involved. But maybe before we get started, maybe tell us a bit about yourself and how did you get going on your research journey? Sure, yes. So, yes, disclosure, I do not have a medical degree. I am a scientist. But I was always really fascinated by science that would have an impact on patients and health. So I did an undergraduate degree at UNSW many moons ago. And I really struggled in my first few years of university doing the core biology and chemistry. I couldn't connect with it at all. And I probably spent way too much time at the uni bar. And it really wasn't until third year when I started to do subjects like immunology or particularly for me the subject that changed it was a virology course, so viruses and disease, where we learned about all these incredible viruses and how they interacted with the host and sort of how remarkable that science is of both the body and the virus itself. So I got really hooked then and went on to do an honours year at the Prince of Wales Hospital, so in their virology laboratories, which are right inside the SEALS department. So it was right in the diagnostic area, completely integrated. You say SEALS. so southeastern area laboratory services so it's the huge you know laboratory service for all of southeast Sydney where they do all of the anthology and they do all of the blood testing and bacterial and viral testing so just being in that environment was very exciting and I think I had dreams of you know it was going to be like the movie Outbreak and I would have this career of sort of, you know, chasing down outbreaks around the world. And then I went on to do a PhD in the same research group and I ended up doing a PhD looking at the association of viruses and cancer. And then I got hooked into cancer. And so I became much more interested in the pathology of cancer and kind of switched routes a little bit and moved into becoming a sort of fully fledged cancer researcher. That's the short version. I mean, what do you kind of think, what was that key to get all this research started? Well, I mean, I think being a scientist is just the best job in the world. It's so exciting to be able to do experiments. So just to follow your curiosity, to actually look at a clinical situation, look at the challenges, think of a question, then do research and see what has been found out about it before, but then actually to be the first person in the world to actually test something, to see what's going on, to try to figure it out. I feel very lucky that you have that opportunity to try to answer things and it's constantly surprising. So it is never boring in any way because whatever you find is something new and unexpected. Is there anything you do differently if you had to time again? I don't think so. I do somewhat regret when I was at university I didn't take anatomy and histology and now that is such a core part of what I do that I actually went to the UNSW library, physical library a couple of weeks ago and borrowed some textbooks which was bizarre because just to try to... A big part of my research, which I haven't explained, is about metastasis and processes of metastasis in gynecological cancers. And so I actually needed to figure out, as a scientist, the anatomy of this region more closely and actually think about local spread and where things would go. And because I haven't had that that training it's actually really crucial that I learn that now at a more advanced stage in my career. I mean we'll go back to having a bit of a lens through what a junior doctor is looking at and lots of demands on their time already. I mean why should they consider adding research in there as well? Because well look I think ultimately that doctors are probably driven by a similar desire to many medical researchers in that you're looking to improve outcomes for your patients. And so we know that it's research that is going to provide the evidence that you guys can actually use to treat and best manage your patients. So we need you and you need us would be my argument. And I think sort of in any aspect of life, but definitely in research, we see the best results when we have diverse teams and we have multidisciplinary teams. So when we have people coming in from different perspectives, tackling the question, that's when we get to the interesting answers and the interesting solutions. And so I've always loved welcoming clinicians into our laboratory at different stages in their career because they tackle it so differently. And also because clinicians have the interface with the patients, you actually have the experience of being with them day by day and hearing what their concerns are or what their questions are and what their priorities are. And that's very different from an academic scientist where we're often driven just by the literature or by our own curiosity and thinking. And so, I mean, I think there's huge benefits that clinicians can bring to it. But the other things, I mean, there's basic things as well your names on publications it can be good for your CV you can have incredible networks you can be invited to conferences it's going to help you with future future positions and yeah let alone that it's probably a good thing to do. For a JMO who hasn't got any research experience what would be the best way in your opinion for them to get involved in research? Yeah I think certainly asking around like don't be afraid to email people and follow up on contacts even if they're not actively advertising that they're looking for someone but with all of this you can be strategic in some ways maybe you want to to particularly choose a research area that you're thinking of specialising in, but absolutely choose something that you are genuinely interested in and curious about, because that's going to provide you with the motivation to actually put that extra effort in. Because yes, you don't have to do it, but if you find something and you've always been curious in your studies about a certain question, then go for that, go for the thing that you care the most about. And for junior clinicians, how do they work best with non-clinical research? Yeah, look, we speak different languages and we have different training. So I think you just have to take a little bit of time and be patient to get to know each other. Certainly questioning, like scientists, we love questions. Like that's actually my favourite thing is when I'm challenged by members of my team. So don't be afraid to ask questions constantly. And even if you think that they're a really basic question, it can often be something quite revolutionary that needs to be discussed. So I mean, I often work with very senior members of the Royal Hospital for Women in their gynae cancer research group. And we sort of laugh about the different hierarchical structures of the hospital as opposed to the university and how we can work together. We have different languages, we have different schedules, we have different priorities. But it's all about relationships and communication. So I think if you're just open and agree on what the goal of the collaboration is, what you're actually aiming for and if everyone is indeed looking to just improve outcomes for patients then you're starting in a really positive place. This one's a bit out of left field. What have you learned about doing research that surprised you? I think how often it goes wrong and how often we are wrong. I mean, I think when you're learning about it as a more junior researcher, you think that everyone's incredibly clever and they must know exactly what they're doing and every experiment works perfectly and it's black and white. And science is muddy and dirty, as is medicine. And so experiments go wrong, we spend a lot of time troubleshooting, figuring things out, you have to be incredibly precise and you have to have great analytical skills. But probably more often than not in my research career, my hypothesis has been disproved. I mean,'s you know that's really often what happens and that is the most interesting and exciting part. It's the unusual result that you get and you think oh my goodness you know what have we done wrong and then you do all your validation and realise it's a real result and then it's fascinating because you have to throw everything out that you thought and then start again. So that to me is the exciting part of science. Yeah because I'm thinking that'd be disheartening.
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Well, it's rarely a dead end. I mean, I think everything usually means something, right? So it's just about you taking stock and thinking, okay, well, that's not what we were hypothesising and maybe that doesn't fit with what I'd read in the literature but now I'm going to think about that more and I think that's also important by spending any time in a research laboratory whether it's one year out of your medical career or whether it's a PhD or an entire career you very rapidly realise the reality of scientific research and what is required to result in a publication. And so I think for clinicians that are reading papers in order to decide, make decisions about your patients, understanding that not everything you read is the full story is really important. So being able to critically analyse papers and actually interpret data is a skill that's very important. And I think you do learn that to a higher level having actually actively been in a laboratory. What's the best opportunity that you've been given because of your research? So many. I mean, I think the exciting thing about research is its international aspect. So going to conferences, networking. I work primarily on ovarian cancer, which is considered a rare disease. So I can't work in isolation. I need to collaborate internationally, and that's really thrilling. And so that takes me back to my dreams of outbreak and travelling the world. So that's nice. And I think being able to now be in a position where our program of very basic research in the laboratory has led now to us developing a clinical trial. So to me that is absolutely thrilling to actually see that the research we have done has built the preclinical case for a potential new drug for ovarian cancer patients. And that may happen in my lifetime is incredibly thrilling. So for me right now is sort of the most, I feel like, hopefully not the peak, but I'm at a very, I'm at an exciting stage of my career. Look, we hear a lot about translating research into practice. I mean, what does it mean and why is that important? Well, I guess my interpretation of it is that you don't want research to just be done in isolation and to be published and never read by anyone. And that happens quite a lot, actually, that you actually want the research that you're doing to be meaningful and impactful. And certainly my field, which would be translational oncology, you want to ensure that both the questions that you're looking to answer as a research scientist are actually relevant to the patients and that's why it's so important not only to engage with clinicians that can talk to you about the clinical challenges but to the patients themselves or the consumer advocates and the carers and find out what's important to them. So what might be fascinating to me about a particular gene pathway and figuring out how these two proteins interact with each other at a very microscopic level may lead in 20 years time to the development of a new drug but that's going to be less interesting to a patient now they might be much more concerned about you know psychosocial aspects of fear of cancer recurrence or something like that so I think it's really important to think about who should be benefiting from this research and not just doing science for science's sake, even though that's wonderful. And I encourage that. I guess I'm more of the school of thought that you're doing it for a reason and your reason should always be about improving outcomes and increasing knowledge. And if clinicians don't have a lot of research experience, how can they improve or how can they help in that translational aspect? I think, yeah, either by spending some time in a lab and just listening to the scientists and coming along to things like journal club meetings where we discuss and analyse research papers. I think they can be great tools for junior medical officers to actually learn how to analyze critically research articles. But I think also as that critical interface, like I just love speaking even over a coffee, if that's all the time that you have, to actually speak to someone that works in ED or that works in the oncology department and say, okay, so what do the patients ask you most often? Is it about like, why did I get this cancer? Is it about like, what are the things that they are primarily interested in? And so for a scientist who's one step removed, that information is really important to me and really helpful. So I think there's lots of ways depending on how much time you have available and you've just got to be prepared to reach across the divide a little bit and reach out to your fellow nerds and work with them. What are some of the advantages and disadvantages of working in research? Well, I think I've already kind of raved a little bit too much probably about science. So, I mean, you know, science is exciting. You get to drive your own agenda. You get to think of ideas, you know, write a proposal to get funding for it and do things that no one else in the world has done before. So that's incredibly thrilling, at least if you're someone like me. And you feel like what you're doing is meaningful, that you're actually contributing at the end of the day, you've learnt something new or you've disproved something, you've moved the field forward and then over a career, hopefully, you've contributed in a really meaningful way. I think the disadvantages are that it is challenging. It's difficult work. You have to think hard and work hard to make a difference. It's constantly evolving. So while you're working on something, so are the many hundreds of thousands of other scientists. So it's a lot of time and effort to keep up to date on what's going on. Is it competitive? I mean, you talk about collaboration, but it is a kind of you're trying to find something. Yeah, of course it's competitive. And it's a bit like the newspaper business. You don't want to be scooped as well. You don't want someone else to publish a paper on the same topic as you before you do. So there is always a bit of a rush that you want to get things out. But I think it might be the field that I'm in, but I've always felt that it's actually quite collegiate rather than competitive in that way with people that are particularly focused on translational research. But it's hard, yeah. It's very competitive for research funding. So particularly in Australia, we don't have a fantastic allocation of medical research funding at the moment. And so that's getting harder and harder every year. And therefore, you have to be a little bit more creative about where you can get funding to keep things going and there's a real lack of job security as well which is problematic so a lot of people are hired on research grants that will tend to only run for 12 months or you know it's a good deal if you have a two or three year contract. So that lack of security and stability is really hard, particularly for early and mid-career researchers that are potentially trying to, you know, get a mortgage or raise a family or any of these issues. So I think it doesn't have the security of some other jobs, but then it has a lot of advantages in flexibility and international travel and excitement. They talk about it, do you wear a white coat when you go to work? Yes, so I do when I go in the laboratory, but that's because I'm a cell biologist and so we do a lot of work in tissue culture and we have models of disease. But I kind of hate that stereotype to tell you the truth and I was recently asked to do a photo shoot for something and they asked me to wear a lab coat or they asked all the scientists to come in a lab coat and I had an absolute rage at the poor stylist about how this was such an outdated stereotype and that we really need to be thinking a little bit more broadly about what a scientist is today and that it's generally not an older, white, crazy man with glasses in a white lab coat. You can be a woman, you can be young, you can be from a different background. Not everyone wears a lab coat. Any tips or advice you'd give a junior doctor thinking about pursuing a career in research? I think back to what I said earlier, go with what interests you. So don't try to think, oh, well, you know, the hottest thing at the moment is immunotherapy. So I've got a, that's what I have to do my research project on. Fine, if that truly fascinates you. But if what you're interested in is something very obscure that you learned in your embryology lecture, then go for that. You're going to benefit from something that you are genuinely interested in. Great. Well, thank you for speaking to the On The Wards audience today and giving some junior doctors a bit of advice about why research is so important and why they should get involved. Thank you. Thank you. Thanks for listening to On The Wards.
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Welcome to On The Wards, it's Jules Wilcox here and today we are talking about medical leadership with Professor Kirsty Forrest and Associate Professor Jo Bishop. Kirsty Forrest is the Dean of Medicine at Bond University. She's an accomplished medical education leader, teacher, researcher and clinician with proven strengths and skills acquired during her career in the United Kingdom and Australia. She has been involved in medical education research for 15 years and is frequently invited as a facilitator and speaker on education and leadership at national and international forums. Kirsty also practices educational leadership as an executive member and treasurer of the Medical Deans of Australia and New Zealand and chair of the Medical Education Collaborative Committee. Kirsty's passion for medical education extends beyond the undergraduate forum into the graduate forum through her roles as a member of the Education Development and Valuation Committee and a lead facilitator for the Educator Programme of ANSCA, the Australian and New Zealand College of Anesthetists. She works clinically as a consultant anesthetist at Gold Coast University Hospital and she's a fellow of ANSCA. Kirsty's clinical research areas include medical leadership, education and patient safety. Associate Professor Jo Bishop is the Associate Dean of Student Affairs and Service Quality and Curriculum Lead for the Bond Medical Programme, which enables her to work with key stakeholders within the tertiary and health service sector. Jo is a member of national working groups and contributes significantly to international discussions on student support and medical education and pedagogy. She has recently been involved with several webinars and international conferences. Jo has nearly a decade of experience as a curriculum director, an anatomist and a former stem cell biologist and sees herself as a medical sciences educator. So I welcome Kirsty and Jo. But what does medical leadership mean to you? Kirsty, I might start with you first. Thank you, first of all thank you for asking us to talk with you today, really excited to be here thank you. It's a very broad question that isn't it, what is medical leadership? For me it's a little bit interesting because I came from an education background and as you can tell from that long intro that you gave there, thank you, and what happened to me is I was actually thinking what is leadership myself and I looked into sort of the theory and the education of it and that's when I learned a bit more about it. I'm a great believer in you can't, about learning first about the education of it before then you can think about it. Leadership to me is a broad, broad church. So at the moment, I'm a leader. I'm a leader in work as the dean. And I've got a big team involved. And I'm looking after 700 plus medical students. And that's what I think at the moment. And then this morning, I was at home. And I wasn't the leader. I was the follower as my husband got everybody ready for school the next last day of school. So but sometimes I'm the leader at home as well. And so for me, it's about the roles of the time that you're doing. And what it's about for me is leadership is at that moment in time. What are you doing and why are you doing it? So I think that feels that feels very vague i know but maybe we'll get into a bit more about that as we go on but for me it was a lot about knowing how i work and what i need to know and how i interact with people and how to get the best work out of people if you like and the best things out of people for for what for what value and our values very much here are driven by what's best for students in Bond University. But at that moment in time, what are we all working towards? And I think that's, it's a very broad church. Jo, do you have any ideas? No, I would echo that. I mean, depending on the day of the week, I have different roles within the university, within the faculty, within different teams. And so to be a lead, I think you need to have the end goal in sight. What is the task? How are you going to get there? And, you know, it is very much, as Kirstie had indicated, about those relationships. So for me and the work I do, it's very much around the relationships. So you'll see that I'm actually a STEM cell cell biologist by background but what happened through my journey in my career is that my relationships and how I worked and interacted with people would bring them along on the journey even though at first they probably didn't even want to be on the same journey as me and I think what my colleagues saw was someone who could actually work with others and actually find their skill set so depending on the project involved involved, depending on what we needed to do, a leader will pick out. And so as Kirstie indicated, I hadn't done a medical education background, but I was able to achieve tasks and achieve goals. And it was only when the theory came, I really had those aha moments of, oh, this is what I'm doing and this is what a leadership is so it becomes quite natural but the theory does really help and once you've got that background of theory of putting those who is your team who is going to work with you and as as Kirsty's already said as well depending on on the day of the week I'm either the lead of the task or I'm part of the team and a follower of someone else who's leading and being a leader or being a true educator means that you can actually switch between roles comfortably and not have an issue it's not a competition it's about getting the task done and bringing people along on the long way and in the health service that ultimately is patient outcome and patient safety within our work day to day. It's around student experience, getting the best quality experience and the best education. But all of us have different skills to bring and a lead at the time will recognise that and form those relationships. Yeah, I think it's interesting that both of you sort of say there that you have different roles. Yes, you need to know what your is you know what are you trying to achieve but often it perhaps isn't about you it's actually about the others it's about your team and it's about you know your patients or your students which I think is a very I think leadership has changed over the years would you agree from? And I think if we think about corporate leadership, for instance, and you've got the corporate leaders in the past who used to cull 10% of the workforce, the bottom 10% every quarter or something, and was seen as this ruthless kind of person that you couldn't challenge and so forth. So now leadership has really, really changed. And I think that's, by understanding that, you then can work out kind of what skills you might need. One of the questions I was going to ask you is, do you think that that corporate definition of leadership, because there's so much stuff in the corporate world about leadership, do you think it translates well across to medicine or do you think our industry is too different? Jo, I might go with you first this time. Well, when you said that, when I do think of leadership, you know, when you think, when you ask a group of, when we facilitate workshops and they think of leaders, they'll think of perhaps presidents of the USA, which is quite an exciting time for us to think about that, or past... Great role models. Or past ruthlessness, you know, like that leadership by fear. Whereas now, leadership and actually good corporate is actually having a chief exec or someone who listens. You know, if you think of someone, I'm just going to say something like Richard Branson, for example. You know, some of his mottos is, you know, you look after your employees and they'll do the rest for you. You know, if you listen to the people you have working for you. And I think that goes to where we've had success in projects and outcomes. And, you know, Bond is number one for student experience because we actually listen, one, to to our key stakeholders but we listen to the teams involved with those key stakeholders and the feedback of what we can do differently and so there is a proportion of anatomy i'm an anatomist so there's a reason why we have two ears and one mouth so you listen more than you speak so that's something that i try to echo my husband and children might say something differently in kirsty but you know that's why i try to esteem my leadership is to listen more than i more than i speak and i think good companies or companies that thrive and have good um uh or have less attrition so people don't leave companies will have those core values and not just have them on the doors or the walls or their collateral, but actually speak the values that they want for their both employees and for their customers. Yeah. Yeah. Okay. Kirsty, do you have any thoughts on that?
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Oh, I think medicine in general is a bit too insulated and doesn't look outside to other disciplines a lot to learn things. And we're good at doing that, unfortunately. Even in medical education, we don't have to reinvent wheels. People have been through processes before. The skills and the processes that potentially these corporate companies go through are the same things. You talk about, you mentioned before, the skills and the processes that potentially these corporate companies go through are the same things. You talk about, you mentioned before about it not being about ourselves, but about other people. But one of the key things that all of these companies do with their employees would be about getting to know yourself and how you relate with other people. And then you get to know the other people and those that skills learning very much came from corporate companies on the back of say emotional intelligence and things like that Daniel Goleman he's the one that really led that and what you were talking about before is what's happened is the historical change has been that we've moved from or moving from great man leadership, heroic leadership, through to transactional to transformational leadership. And now we think we're coming along to sort of like eco sustainable leadership or moral leadership, compassionate leadership. And the big one in medicine and healthcare is servant led leadership. And that's definitely definitely the way where we come from. And if you look at high-performing teams, there's a book at the moment out called The Culture Code by Daniel Coyle. And he looks at high-performing teams and what they do to get things right. And one of the things he talks about is living the values and putting them out there all the time. So having the end goal in mind. He also talks about being vulnerable and shows that when leaders are vulnerable and show their vulnerabilities, you build psychological trust. And the first bit that you need is you need that trust. And this work has been coming out recently. And that's why we're moving towards different theories of leadership and living them. We realize living them is the important thing. Yeah, I think it's a bit like trying to be a comedian. If you can imagine you have someone like Billy Connolly or to use English on Jack D. Billy Connolly couldn't do Jack D's stand-up routine and neither could Jack D do Billy Connolly. You've got to do what fits for you naturally with your personality, haven't you? Whatever your skills and natural attributes are, work out how to leverage those within certain sort of frameworks and things that a leader needs to sort of fulfill. Sorry, go on Kirsten. Yeah, no, no. So I totally agree. And it's a bit like the new buzzword, as I call it, which is authentic. authentic self it's really obvious when you're not and it's hard to act in a different way I feel I can tell you about a time this year with Covid where things became bad and I had to take it felt like take back control and I felt like I became very autocratic and it was really, really uncomfortable to me. And it was like bringing everything back in to then rearrange the training for our final year medical students basically, you know, with the COVID hitting, there was rotations falling down. We managed to not have that happen, but it felt really, really uncomfortable to me. I had to sort of take, it felt like taking control back from other people. And I, it sat so uncomfortable with me that I had to go and speak to Jo a lot and just spoke to her a lot and just said, I'm really uncomfortable about this because this is not the way I like to be. And this, and it was awful, but it was what was needed right then. And now I've managed to let, to let go back. So I underpinned a theory on that one. It's adaptive leadership. You know, there's a pandemic. We can be forgiven for having to take control and be more direct than you would normally because it really did show how different people were coping recently. And sometimes people who would normally be quite self-driven, there was so much else going on. You know, the global pandemic had so many different undertones and concerns for people internationally. Abundant. I'm sure yourselves, Gold Coast is very international. So we all had family and friends who were being affected across the world. And sometimes for me personally, just coming in and being quite practical task focus actually got me through and other people who were you know me the person who likes to be around people all the time and get energy from people and then working remote there was different struggles there where some of our colleagues who actually preference working alone actually they're the ones who came unstuck quite quickly and we realized that we needed to do something differently. And so Kirsty's adaption was that we met weekly, both internally, but we met weekly with national colleagues and having somebody who's been there too or gets it really helped that positive psychology of what we needed to go and that adaption was okay and really the collaboration and the work that we've done nationally and then locally has been amazing but we had to adapt quite quickly to circumstance to support our colleagues and it's just kept on you know since March so there is a point now where I think we've really reached on to others for that peer support and mentorship. Yeah, yeah. Certainly we went through a huge amount of change and planning. And I mean, there were some benefits to that as well with, you know, IT coming on board and finally everyone being able to access Skype for Business at the hospital, which we weren't before. And, you know, just simple things like that. Totally echo that. We're trying to get some of our supervisors to do remote delivery and now they're, oh, why didn't we do this before, Joe? Yeah, absolutely. So I think one of the things I wanted to ask, in terms of if the audience listening is mainly JMOs, thinking of their career and becoming a medical leader, I think there's perhaps, maybe I'm wrong, but perhaps there's a perception that to become a medical leader, really that's defined as the people who go into the roles that you're doing or the role that I'm doing is the DPAT and things like that. You have to go into an academic type role or administrative type role. But that's not really true, is it, in terms of becoming a high functioning medical leader? Kirsty, do you want to comment on that? Yeah, I think it's important to realize that at any one point in time, you may be that leader at the moment. I mean there's the official roles like you talk about like we have but I think it'd be very good for people to understand or realize that at any one point in time the leader. So if you're on a ward round and you're leading that ward round you are the leader of that ward round at that time and that's why we talk about it as function as opposed to title because I think that's really important to understand and also the skills though that do come along from understanding leadership I think for me personally the realization that it's a lot about advocacy and communication and understanding how to do that well at any point in your career is really important but I think even more so for medical professionals advocacy is the one thing that actually I think we do when we do it we do it really well but we probably should do more of it and there's the point about advocacy not just being individual people there's a laugh about in the anesthetic curriculum I feel like I can say this that the only bit of advocacy that is there is to tell people to stop smoking and there's more to it than that and for me the skills that are there for advocacy and leadership are the same things about communication negotiation understanding people's motivations, just all of that aspect of it. And I just think that if you just think about it as a position, then that's when you become a bit unstuck. It's not about position, it's about the way you do things at that moment in time. Yeah, okay. So, I mean, you've mentioned a number of different skills. Do you think, I mean, obviously medical issue, we started at the beginning saying it's just this massive term, which is hard to define in some senses. And we also said that you need to be authentic. So you need to have, you need to sort of play to your strengths of things. But are there any skills that you think are absolutely crucial to being good medically that sit across? It doesn't matter what your role is, what your personality type is. There are some really core skills that people need to focus on. Jo, what do you think about that? When I think about leadership or good role modeling or someone that can be there for you when you need a task to be done.
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And then it was vision to keep going. This is what we need to do. So our end site was always to get our students graduated, you know, to get them competent. So depending on the task in hand. So to have that vision. And even when there's the naysayers or people that can't be done or there's this, there's that, the vision is still clear. So with that comes integrity. So someone that people can rely on. Integrity, you know, doing the right thing even when nobody's watching. So having that true integrity. Empathy. And I think empathy was a real need, more so now than ever, but it is to be empathetic to those around you who may have different stresses, different needs to you. And just because you're okay doesn't mean anyone else. So that real empathy and they're not optimism you really need to be optimistic and be that you know that that sunny shiny person but when you're not perhaps I often say that my doors closed it's because I'm in my docking station you know my doors always open for people to come and see me but sometimes sometimes you need your own wellbeing cup filled. You can't be optimistic for everyone 24 seven. So have those times for yourself, but optimism is really, really important and key for any project and for a leader to have those, I think I've said five, five qualities? I was just saying that how could JMOs go about developing some of these skills and developing themselves as a medical leader? Because when I was coming up, there was no teaching on this or anything whatsoever. And I don't even remember there being any committees in the hospital or anything that had a JMO on them. So things have really changed. So, Kirsty, how would you recommend JMOs go about developing themselves as a medical leader? Oh, look, we talk about vertical and horizontal professional development with leadership. So the vertical is knowledge and things like that. So around about courses and doing reading. I see my bookshelf there behind me. You can Jules, I know nobody else can at home, but a lot of these are laughingly self-help books where I get to know myself better and the skills that I am I am good at and therefore then I can notice them in others so I like reading about it I like the courses I get they're expensive though and you might not have time to do it so that's the knowledge base but then there's actually the horizontal as we call development in leadership and that's actually experience on the ground and reflecting on it. The R word, some people don't like the R word, do they? But for me, people will have had leadership positions and they will have used some skills. And it's almost like thinking to them, like we may have learned it tacitly when we were at medical school. But if we can actually go back and think, you know, even basic things like, did you try at medical school to get something to change like some assessments some grade or whatever you will have practiced some skills there of leadership and it's using those skills that you think you're good at I am good at communicating I'm good at negotiating and finding your niche so it's actually just thinking about it and thinking a little bit about what you want to achieve and what you think you're good at. Sometimes you don't know what you're good at until you do some of these sort of like I call them psychology self-help books of looking to what you know you're going to be good at. So some people will be driven by passion and by the energy of the end point. Some people will like the interaction with other people. So what is it? So for me, that's where I would start. If you're really interested is getting to know yourself and your skills and how you interact with other people. And then a passion or an end in mind. There's no point doing that by itself. So there's something about what do I want to change or what do I think needs work? What do I want to improve? And having a think about that. Yeah. Okay. Yeah. And I think, you know, that's one of the beauties of medicine, isn't it? It's so broad. It doesn't matter what your personality type, you're going to find a niche in there somewhere for yourself. And it's just a question of finding that. And I think one of the things I've done over the years is various sort of questionnaires, Myers-Briggs, Gallup Strength Finders, those sorts of things to get some insight into what I'm good at. It's funny because you read it and you go, oh, yeah, well, that's why I do all that. But it becomes a bit clearer. And so then you think, oh, well, then you can then use that to pick out tasks that you think you know are going to suit you rather than getting lumbered with stuff which you're going to hate, which is also really important when you become more senior and develop a non-clinical portfolio. You want to do the stuff you're interested in because then you enjoy going to work. Whereas if you get lumbered with stuff that you're not interested in, which I have to say for me, though, will be stem cell biology anatomy. I'd be like, oh my God, no. So I think it's really important to get to know yourself well. One of the things that I say to my juniors when they come to me looking at around sort of interview time or before that, saying, how can I develop my CV, depending on whatever they're going to go into? And I say, look at the medical expertise domain of things everyone goes oh I've got to do research I've got to do a masters in this so if we look at in New South Wales the HETI forms there's multiple domains that you're scored on and there's health advocacy there's communication there's you know just there's about 10 15 of them 20 of them I't remember. Find some of those things that interest you and work out how to factor that into, or if you've got a hobby, work out how to factor that into medicine or something. And then get some qualifications or get some skills around that. And then if you've got a passion, you can talk about that at an interview and you can feed it into a certain way really easily. And it comes across as having a passion rather than trying to fake it. It goes back to that authenticity. I so agree. So I passed my final FRCA in the UK. I still had a couple of years of training to do. That's the UK model. And I then thought, is this it for the next 30 years next 30 years anesthetics so then I went to do a master's in medical education and that's when I suddenly realized there was other things that you can do and I call it a win-win thing when you can introduce into your both aspects of your career when they overlap or whether they can feed into each other so anesthetics and education came together then and for me that's been my passion and my drive and I can't imagine what would have happened if that hadn't have happened so so I totally agree so that's why I'm loath sometimes to talk to people about certain things because I don't want to drive them down a path it's they have to find that path themselves a little bit but like you say medicine is such a broad church it's fantastic the actual areas you can go into and I find it interesting that those are the aspects that you talk of of the of um they're like the CAMMEDS roles and things like that that people don't think about advocacy activism and leadership as much as the other aspects because me, they are the bits that make everything else work. So with research and science and aspects of like that, yeah, yeah, we can look as much as we want. But tell you what, the example is the vaccine at the moment. We might be okay here, but the vaccine may be ready. But unless people take it and are accepting of it and how do you do that how do we ensure that people do the right thing it's actually a really interesting aspect to me so what about the role of mentoring or coaching uh in in developing leaders joe so when you were speaking about the junior doctors i was reflecting on a Bond University, which is quite a young medical school, but I was thinking about, I've been here seven years, but I'm thinking about the alumni that have gone on and what they've achieved. And those who seem to be quite successful actually working with people like the AMA and doing things like that, what I've realised is that they've surrounded themselves with really good role models and mentors. And I read recently that we should have a quilt of mentors. We shouldn't just have one. We should have a few people that we can rely on. Are they critical friends? I'm not sure. What are their roles?
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Welcome to On The Wards, it's Jules Wilcox here. This podcast was created in conjunction with our sponsor Global Medics, your career solutions recruitment specialist in permanent and local medical jobs across New Zealand and Australia, United Kingdom and Ireland. Today we're speaking with Dr. Hinemoa Elder, a leading New Zealand child and adolescent psychiatrist and author of two best-selling books. And today we're going to speak about self-compassion, imposter syndrome, anxiety, prevailing societal norms and the pressure that puts on people, as well as finding contentment in our lives. All themes discussed in her first book, Aroha. Aroha is an ancient Maori word and wisdom for a contented life lived in harmony with our planet. Dr. Elder is a Ngāti Kuri te Aroha, te Aoteopuri. I am soa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearoa Te Aotearo New Zealand Mental Health Review Tribunal, and she has a PhD in public health. She's received the MNZM for services to Maori in psychiatry in 2019. She's a member of the Bisada Circle, a group of senior international women leaders, which forms a critical support for the Homeward Bound Project, which is a global leadership program for women in science. She's also a board member of the Helen Clark Foundation, a non-profit, non-partisan public policy think tank, which generates public policy research and debate. She's a board member of the RANZCP Foundation and patron of Share My Super, a charity aimed at ending child poverty in New Zealand. She's written two best-selling books, Aroha, Maori Wisdom for a Contented Life, Living in Harmony with Our Planet, and that was named on the Oprah Winfrey Book Club in 2021. Her most recent book, Wawa Ta, is daily wisdom guided by Hina the Māori Moon. It was number one best-selling non-fiction book in New Zealand. She's also regularly invited to keynote presentations. She also has a background in theatre and dance. She performed in a New Zealand play at Edinburgh Festival in 1986. She's a past chair of the Auckland Theatre Company Trust and then the inaugural chair of the Te Taumata iwi arts foundation. And she's worked at New Zealand Children's Television way back in the 1990s. Enema, welcome. Kia ora. Kia ora, Charles. Nga mihi nui ki a koe. Ki a koutou katoa. Thank you so much for agreeing to do this. Reading your bio, you must be incredibly busy. Look, I do have a lot of interests and I suppose as doctors, we all get involved with a range of aspects that provide some sense of healing and comfort and support for people in our communities, don't we? So I see my remit is very broad. Yeah, yeah. But I'd imagine within that broad sort of brushstrokes, there's certain underlying unifying themes that you do with all of it. Indeed. And I think, you know, we can start by talking about the concept of Aroha, which was the title of my first book, as you mentioned, because I suppose that is a really wonderful wellspring and resource of energy and ideas for me and for many of us as Māori. And one of the reasons I wrote the book was that I wanted to provide examples for people around the world from our culture as a means to cope with the complexity and difficulties of modern life, including my fellow colleague doctors around the world. So, you know, aroha is a word that some people will be familiar with, others not so much. But it is, as you said, an ancient word and concept, which covers quite a lot. It's not simply the moonlight and roses kind of love. It carries with it a sense of fierce protection, a sense of compassion, sympathy and empathy. And as one of my mentors, Faya Moy Milne, stated, kātū koe i roti tō aroha. Stand in that aroha, stand in that loving energy that actually is available to us at all times. And maybe particularly in these very difficult times for doctors around the world we need to we're looking for other resources aren't we to cope with the very complex difficulties that we're facing all the way through from our from our precious students our students who are thinking about medicine our students who are in medical school and then doctors across the whole spectrum of the training experience and and through to sort of old stalwarts like ourselves yes that's a good way of putting it an old stalwart yeah I think it's it's really interesting and I think that the that like you said that very large encompassing which involves so many different facets, what I think you're really talking about here is cultivating an inner state that allows you to get the most out of life and deal with life in itself. Life is not always a bed of roses. There are challenges. And some challenges make you grow and some challenges set you back and it's so difficult sometimes but I think reading through your book which I have to say I absolutely love I think everyone everyone should read this uh it's a really really good book it's got an awful lot of wisdom in it um and I think it's got a lot of what I also found interesting some of that wisdom um the Maori have sayings which, having come from the UK, we have similar sayings. So there's that sort of connected wisdom from across the ages from different cultures, which I also think is quite interesting. And if people have worked that out on different sides of the world over hundreds of years, it's probably worth listening to. I think that's a really good point. And one thing I would add is that, you know, from various cultures, we see the observation of ancestors of the natural world and drawing on those examples which persist through time. So there's a sense of ongoing relatability, if you will, of drawing on experiences from nature and using those as sometimes as a cautionary tale, as an aspiration, as a reminder. So I think that one of the things that these whakatauki or whakatauaki, those are the words we use to describe Māori proverbial sayings, which are very much part and parcel of the Aroha Block 1 for every week of the year, is that they're these sort of nuggety bits of wisdom that have survived through time because they're still useful. And so I wanted to put them together in a really accessible little book that people could try to dip into when they needed to and hopefully find something that was helpful. Yeah, and I think that's the thing. You don't have to sit down and read it all in one go. You can read a little bit and you can come back to things.
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And what does that mean to you? Yeah, I think there's a problem, isn't there, with words like well-being that are used so much that they seem to lose a sense of meaning and almost are just a kind of a tick box. And that's a shame. So I think that we often present the idea of well-being as something that our doctors, I really don't like the term junior doctors, I have to say, because I find it's quite, I think it's really disrespectful of our other medical colleagues who are just at a different stage of the journey. And we know that, of course, we learn a lot from our members of the team wherever they're at on that career path. So when we think about proposing the idea that our medical colleagues need to achieve some state of well-being, I think that that's something we as doctors struggle with because on one hand, you know, the early part of our practical career is essentially sleep deprived and enforced. You know, we don't have regular meals. We're on some sort of intermittent fasting diet without really signing up for that. We have to learn to hold on. If we're in theatre with our consultant surgeon, you know, you can't just say, excuse me, I'm going to the bathroom. You learn to just hold on. So there are all sorts of things that we go through in those early years, which are so far from what we might call well-being. But I think when people raise this term, a lot of my colleagues go, well, that's so ridiculous. How can we possibly embody the kinds of things that we're actually talking to our patients about ourselves? So there's a sense of real disconnect and a sense that we're often not practicing what we're preaching at all. So this is certainly something that we talk about with the team at work about in trying to navigate what that could mean for people in those early years. I mean, for example, if we get one hour's extra sleep when we've been on call, and you've just been on call, so you know what I'm saying. One hour's extra sleep can feel like a mountain of well-being, even though if you analyze the rest of our week to somebody else's eye, that might not look like well-being. So I do think as doctors, we don't resonate with a sort of tick box approach tick box approach to you know what you're eating what you're sleeping exercise mindfulness it all it all blends into this sort of okay that's what we're supposed to be doing but what can we actually practically do so I think that there's a different kind of conversation the other part of that that really frustrates me is it reminds me a bit of women being told to lean into organizations that are frankly sexist and discriminatory. It's putting the responsibility on our colleagues at different stages of their careers to, well, you know, if only you would practice more of the wellbeing activities, then you would feel better when actually it's the structures that we work in that are deeply unhealthy. So, you know, I was reading a report just the other day about how half of our colleagues in the early phase of their career are exhausted. So we do need to keep advocating for the structures to change, especially after what we've been through in COVID and with the climate emergency and weather emergencies that we're facing on a weekly basis in some parts of the world. So I just hold those questions around how how we have practical meaningful conversations with our medical teams about what well what well-being actually means on the ground yeah okay and i and i so agree with you about that last section that you said as well where oh well if you do your if you learn to meditate and stuff then we don't have to fix the crap system that we've got. And it's like, no, sorry, that's not on. But yeah, and I think that's very useful. I think that's really what comes through in the book as well. These are practical things that you can do as a person that don't take very long, just a few seconds or a few minutes or something, or just changing that mindset slightly that may give you a lot of a strength and a mindset and a resilience to carry on when things are getting difficult. So one of the things I want to do and maybe starting with chapter one and I will leave you to say the Maori words but banish your fears because we're at the new year intake. You know, I've got all new interns starting a few weeks ago and saying, feel the fear and do it anyway. And I think that's a really important thing. But one of the other things that I think comes from the book is about connectedness. And I think perhaps you could just touch on those two things about for people who are just starting, any advice and things from the book or from your own experiences and the importance of connectedness as well. Sure. This is crucial. So the whakatauki that I use at the beginning of the book is tufpiti atihopo yes grasp your fears and do it anyway banish your fears and and in that opening chapter I do unpack some of the some of the dynamics that we all face on our journey through medicine which is not being good enough not being worthy being discovered as some sort of imposter. And I think that that's something that we have a particular vulnerability about in our discipline. We're all perhaps slightly obsessional and we want doctors to strive for excellence and have those sorts of dynamics. But we can be a little bit hoist on our own petard if we let those dynamics play out too much so it is about getting getting the balance right and one of the ways that I think that we get the balance right is to be deeply connected with those who we're traveling on the journey with and I suppose that's one of the ways that we all survive medical school, isn't it? We do it in groups. It's very, very hard to get through medical school on your own. And I think the modeling is that, of course, when we are out working in various facets of the medical system, we are not working alone. We are working in teams. We're working with people from other disciplines. We're working with other doctors in other fields. So the idea of connectivity is absolutely crucial to how we work safely and how we maintain safe practice and taking care of each other and our patients and their families. So I think that the team aspect, the connectivity aspect to our well-being and self-cares is absolutely the platform. And we know that when people become isolated, that's a major red flag. That's a risk factor for us as doctors to start losing that sense of safe practice. Yeah. And then I think also you see, unfortunately, the terrible rates of suicides and things as people become isolated and things. In fact, one of my friends on my med school WhatsApp group in the UK, her partner in her GP practice killed themselves last week. And then on that WhatsApp group, every single person on that WhatsApp group pretty much knew somebody who had committed suicide at some point in our careers it's a hell of a burn and I think yes that that connectedness is we are social animals we are and I think you know that saddens me deeply and I hope that people who are listening to this who are going through your own difficulties please seek help please reach out you are actually never alone it's vitally important that you get the trusted help that you need so we have a strange culture in our in our practice of medicine in the way that we, don't we? Because we do receive messages from the earliest days of medical school that we have to somehow be tougher and stronger and more robust mentally than other people. We have to push ourselves. We have to drive ourselves past tiredness, past mental fatigue. But of course, we know that there's a deeply unhealthy message there. We're not robots. We're not superhuman. We are human beings who go into medicine because we care deeply about the health and well-being of our communities. So we do come out of that factory system that produces doctors with some, I think, potentially harmful thoughts about expectations of ourselves. Many of us have these sort of high, unrelenting standards, and we are taught to pursue the absolute pinnacle of excellence, which, as I some of that is healthy but only focusing on that is deeply unhealthy so we do need that connectivity the teams and certainly when I'm at the hospital working with our with our new intake of registrars we have medical students we have trainee interns and house officers. One of my priorities is to walk the talk as a mental health professional and to be available to those other doctors in my team and ensure that they have time and space to actually talk through how their training is going. Because there are so many pressures outside of our control the roster placements people with children and we know that there are all sorts of biases that are that are impacting on on our on our medical team so I think it does behold we are we are responsible as senior medical staff to take this issue of the mental health of our teams very, very seriously. Yeah.
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So important. And, you know, unfortunately you also have toxic role modelling. You know, you say you have groups and we get through in groups. You know, if you want to belong to a certain group, there's this sort of explanation, you have to play the game and therefore you start to behave like maybe some other people in those groups. And some of those behaviors from that maybe date from, you know, years ago are not really acceptable nowadays, but people then develop that. And I think that's something we need to guard against and something we need to call out as well. And to have that, the ability to be able to do that, because it can be very destructive. And then I think also, striving for excellence, absolutely. Perfectionism, no. Perfectionism is really bad. And I see an awful lot of damage through that to people trying to get to this absolutely unobtainable ideal, which then generates those negative thoughts often. Which brings me on to another one, which, again, I'm definitely not going to try and say this one, but I'd like to hear you say it. While the mokororo grub is small, it cuts through the white pine, those power and small things. Yes, so the whakatau ki Māori goes like this, he iti hoki te mokoroa, so that's the, it's very little, the mokoroa grub, nāna i kakati te kahikatea, it is by that mokoroa that the kahikatea, which is a massive, huge tree, a white pine, can be cut down. And I think this is another really beautiful illustration, which highlights something that's pretty hard to really grasp sometimes, which is that little things bring us down. We can become really fixated on relatively small things and getting a perspective on them. Because of course, we as doctors are trained to be absolutely fastidious with details. So we have to check all the details. We also have to have an eye to the big picture. So we have this matrices of thoughts and formulations and possibilities that are going on all the time. And yet we can be fixated on small things and they can really upset us deeply. And, you know, there are many things that have happened that don't feel like small things at all that upset us. I mean, one of the things that I often reflect on, you know, I think it's really important to talk about when things don't go well. And so one of the experiences I had when I was a recent consultant, so this is going back to about 2006, was we were in the midst of doing a whole lot of things, rejigging, creating a Maori, kaupapa Maori service within the Child and Adolescent Mental Health Service here in South Auckland. And we were doing our usual clinical practice and seeing our whānau, seeing our extended families and patients. So I had a family booked in to see myself and our senior Māori cultural advisor, our elder, our kaumātua and at the same time our general manager of mental health said oh because you guys are working on a model of care, you need to come and present that to a team in the management. And so the mistake that I made was I thought that some of my other colleagues could see this whānau, see this family, and that myself and the kaumātua, the elder, had to go and to prove yet again to the senior people in the wider organization how important it was to create this Maori service what I should have done is I should have said I'm happy to come and do that after my clinical day is finished I'm not going to compromise patient care for this other thing and I didn't do that that. But I learned that it wasn't a terrible, terrible outcome. The family was seen, but they weren't seen by the people they were expecting to see. And so we had to do a lot of work afterwards to really make that right. Because for us, particularly as Māori, if we're not taking care of our own people, first and foremost, we're not really doing the job that we need to be doing. So that's one of the stories that I like to tell about a big learning I had early in my career as a consultant. So that's a bit of role modelling there, hopefully. Well, I think that's something that comes through in the book as well, is that you're obviously quite a reflective person. But you do it, I think, with self-compassion. And I think that's a really important concept that I would like to get across to people, because we all make mistakes. You know, I'm an emergency physician and I do 10- hour shifts. And I usually say to my medical students and registrars, you know, let's say I make 10 decisions an hour, which I don't, this can be way more than that. But let's just say, because it makes the maths easy. I'm making a hundred decisions a day. And if my error rate is 1%, I'm making a mistake every single day. Now, I guarantee you, I'm making a a lot more decisions than that and I'm making a lot more errors than that in those decisions I'm probably in the region of somewhere to 10 to 20 percent of mistakes now not all of them are going to be important but every now and then something's going to be so I'm probably making say 200 and then it's a you know a 10 percent error rate I'm making 20 mistakes a day you need get good at being reflective to learn from them, but you also need to get good at being kind to yourself. And I think that comes through in the book in a number of the little quotes that you have in the chapters, which we're going to have time to go into all of them. But there was another one that I, actually, even just in that chapter two about the little grub, and I wanted to just talk about this because I think this is a really important, really, really important practice as well, is that you say that before you go to sleep, one of the things that you do is to acknowledge the day that you've had and it's a way of practicing gratitude and accepting things no matter the ups and downs. Do you just want to touch on that a little bit? Because I think this is so vital. Yes. This is just part of my tikanga, my rules, the law, L-O-R-E, of how I live my life. And actually part of it came from our mother. She used to say when we were growing up, never go to sleep on an argument. And I think this is very good advice. So for me, you know, we have complex days, don't we, as doctors. And I think the other thing coming back to the connectedness part is there's actually people outside of medicine, they don't really understand what we do. They don't really understand the nuances of what we do. And of course, we can't talk to a lot of people about what we do anyway. So some of it can feel quite lonely at times and heavy without the connectedness of our colleagues in our discipline. So what I do at night, I'm in bed, turning off the light, and I just, I take a moment to say thank you. and I mihi to our Māori gods and I thank them for taking care of me I thank them for the lessons of the day some of the lessons might have been hard lessons lessons that you know I'd rather not have to learn because you think well I've got enough character now thank you very much I'd rather be a spineless jellyfish but um you know it's it's amazing how at our age and stage right Jules there's there's always something new to learn every single day and that's one of the great things that's why I love my job yeah me too and so that's another thing that I I'm grateful for and I say thank you for as I'm going off to sleep because for me it is and is, and I'm also an imaginative person. I was reflecting on this, actually. Loads of the people I went through med school with were really creative people. You know, we had piano players and musicians of other types and singers and painters and people who could draw. So actually, there's a lot of people in medicine who are creative thinkers. And so for me, I do imagine these sort of grubs transforming into moths and flying off into the night. And that's my way of letting go of my tendency to be really hard on myself and for my mind to sort of grip on to the various things that I wish I'd done differently in the day and to try not to chastise myself, to say, okay, that's what happened. Everybody is okay. And thank you for today. Yeah.
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Welcome to On The Wards, it's James Edwards and today I have the pleasure of interviewing Dr Angie Pinto. Welcome Angie. Thanks James. Angie is a staff specialist in infectious disease and microbiology here at Royal Prince Alfred Hospital. Today we're going to talk about penicillins and I think every junior doctor has prescribed penicillins at some stage during their term. So maybe we'll just start very broadly before we get into some cases. What are some of the common indications for prescribing the penicillin class of antibiotics in hospitalised patients? So penicillins are quite a broad class of antibiotics ranging from very narrow spectrum such as benzoyl penicillin through to broad spectrum such as tazosin. So some of the common indications would be things like skin and soft tissue infections or cellulitis, urinary tract infections, as well as mild to moderate community acquired pneumonia. So what is the mechanism of action of the penicillin group of antibiotics? So it's quite interesting in its discovery. So penicillin was actually discovered by Alexander Fleming, and it was observed that a mould called penicillium inhibited bacterial growth on the agar plate. So the mechanism of action was later found to be that it inhibits the bacterial cell wall synthesis. So this penicillin actually inhibits the enzymes that form the peptidoglycan cross-links, which gives structural stability to the bacterial cells. And without that, the cells die. So this means that the penicillins are bactericidal in this regard. Now you mentioned that some of the penicillins have a very narrow spectrum, have a broad spectrum. How do the penicillins differ in their spectrums of activity? So there's a number of different types of spectrum I guess you could call it in terms of penicillins. So the very narrow narrowest would be the natural penicillins like benzoyl penicillin, penicillin G and V, and they tend to be quite good against, and quite narrow in their spectrum against streptococci. Then moving to the next level, we have the anti-staphylococcal penicillins, such as flucloxacillin and dicloxacillin. Then we have another group, the aminopenicillins, such as ampicillin, and they tend to have slightly broader activity in being active against enterococcus faecalis, as well as some gram negatives. And then moving beyond that, we've got an even broader class, the broader acting agents, which actually have pseudomonal properties, such as ticacillin and piperacillin. So that gives a bit of an overview of the penicillin's use in hospitalised patients. So now we'll go to a couple of cases. Look, the first case is a 51-year-old male with type 3 diabetes, presents with a warm, tender, red-looking right thigh. You suspect cellulitis, and the hospital guidelines suggest prescribing flucloxacillin. What organism would you suspect in this case and why are penicillins recommended for cellulitis? So the most common organisms would be group A streptococcus or strep pyogenes as well as staph aureus and often the clinical syndromes between these are indistinguishable although there can be some subtle clinical clues. So therefore the empiric therapy should really cover both of these organisms. So the narrow spectrum penicillins like flucloxacillin has pretty good activity against both staph and strep and in fact are more effective against these pathogens than some of the agents with broader coverage. Allergies to penicillins are very common. Can you describe what a common allergy would look like to penicillin and is that an absolute contraindication to penicillin use? So I think it's important first to clarify what we mean by allergy and sometimes patients are mislabeled as having allergies when in fact it's a predictable adverse reaction such as nausea or vomiting. So in these cases an antibiotic could still be used but with careful management or monitoring for anticipated side effects. So second it's useful to classify the nature of the allergy and an allergic reaction is really an immune mediated hypersensitivity. So that we have the immediate reactions which can be life-threatening and are characterized by urticaria, bronchospasm, anaphylaxis and angioedema. And in these cases consultation with either an infectious diseases specialist and or immunologist might be useful to determine whether desensitization is needed or whether there is a non-betalactam class of antibiotics that could be substituted. The other type of reaction is a delayed type of reaction and they are usually characterised by a rash with the onset of days after the antibiotic exposure. It tends to be a macular papular rash, mild in severity and in these cases penicillin could be re-challenged or re-attempted in this setting or possibly even with other non-beta-lactam antibiotics. There can be some cross-reactivity between other beta-lactam classes like keflosporins, but this is much lower than we had previously thought and probably is in the order around 2.5% risk of cross-reactivity. And it's also important to remember the carbapenem class also has a beta-lactam ring and the risk of cross-reactivity is around the order of 1%. We mentioned some of the organisms that are covered by the penicillin group. What are some of the other organisms that are commonly been able to be treated by penicillins? So it is quite a broad range, as I said. There's a number of different antibiotics within that class. And the wide list of organisms ranges from the gram-positive, so staph and strep, as I've mentioned, as well as enterococcus faecalis. Some penicillins do cover anaerobes, and some also will cover gram-negatives such as E. coli, Klebsiella, Pseudomonas, and also other gram-negatives like Haemophilus and Neisseria species like Meningococcus and Gonorrhea even though resistance towards penicillin is increasing in this organism. Other infections we haven't already mentioned would include endocarditis where long-term penicillin is often a main component of treatment. You mentioned resistance. Is resistance a problem with penicillin antibiotics and how does it develop? Yeah, so penicillin resistance certainly has been a problem ever since penicillin has been around. We've seen bacteria emerge resistant mechanisms over the years and very quickly as well. Resistance is mainly due to destruction of the antibiotic by production of enzymes called beta-lactamases, which destroy the beta-lactam ring, and they're the critical structure of penicillins. So these enzymes may be found in different locations in the cell wall and can either be chromosomal or plasmid mediated, which means that they can transfer between bacteria. We may go back now to managing this 51-year-old male cellulitis. How do you determine the dose and the frequency of the antibiotic that you want to prescribe? So there's a number of factors when thinking about dosing penicillin. So both related to the host and also related to the bacteria and its microbiology. So essentially it's an interplay between how much antibiotics get getting to the site of your infection and how much antibiotics required to kill the bacteria. So regarding host factors certainly age and weight are considerations. Penicillins are also excreted renally into the urine quite rapidly and they have quite a relatively short life compared to other antibiotics. So that means the dosing regimens tend to be quite short, around four to six hourly. In terms of how much antibiotic is required to kill the bug, then it also depends the site of the infection. So penicillins tend to be quite well distributed to most tissues, but if you're dealing with infections of other sites, such as, for example, CSF, the dosing may change and higher doses may be recommended. In serious infections that need long-term antibiotics, then the dosing sometimes is dependent on the MIC of the organism, and that's the minimum concentration required to inhibit bacterial growth. So, for example, in endocarditis, the dosing guidelines tend to be based on the MIC of the organism. But if there's any uncertainty about dosing, check with your microbiologist for guidance. In regard to adjusting dosing in patients with impaired renal hepatic function, how would you do that? So in general, most penicillins, as they're excreted renally, do require dose reduction based on GFR and sometimes also interval reduction as well. And there's some good guidance on the therapeutic guidelines in terms of dose reduction in this setting. In patients with hepatic toxicity, although even though the penicillin primarily is excreted renally, some penicillins can cause hepatic toxicity. But dose adjustment usually isn't required.
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Welcome to On The Wards, it's James Edwards and today I'm talking with Dr. Jo Dargan, a Urology Registrar here at Royal Prince Edward Hospital on Urinaryinary retention. Welcome Jo. Thank you, thanks for having me. We're going to go through a few cases because urinary retention is a fairly common clinical problem that people find either in the emergency department or on the wards. And in this case you're working after hours covering the orthopaedic ward and called to see a 65 year old male who's day two post hip replacement. A nurse had done a bladder scan because he's had some pain and he showed he's got a large 600 mil bladder and he has failed his trial to avoid from his catheter that was removed this morning. What's your initial approach to this scenario? This is something that we get called about literally every day. It's a really common problem and often junior doctors are trying to sort this out without a lot of senior support. And so I guess the first thing that I usually try to consider in this scenario is whether the problem is acute or chronic and the patient has pain so that suggests with his recent removal of catheter that it's probably an acute problem. Some patients with chronic bladder outflow obstruction can sit with high residuals of 600 mLs routinely, and if he was not in any pain prior, when the initial retention was discovered, then you might think that this is his normal post-void residual and he needs more of an outpatient workup. The other thing in immobile elderly patients is that their poor mobility, post-operative status and opiate use can put them at risk of retention and could be contributing or causative factors. It's important to ask patients about their baseline urinary tract function when you're assessing them. In regard to questions, what sort of questions would you ask? So normally good screening questions are how's your urinary stream? How many times do you avoid during the day? How often do you have to get up to go to the toilet at night? I always ask if they have to push or strain to pass their urine or if they have trouble stopping and starting their flow. So what are some of the different presentations of urinary retention? So some patients come in with quite an acute history. They might have some difficulty initiating their stream and be voiding very small volumes but unable to completely empty their bladder. Some people are not able to pass any urine at all. Usually what determines whether we do any intervention is whether they're in pain and whether there's any associated sepsis, renal impairment. The other thing that we always have to consider with a new presentation of urinary retention is whether there are any red flag problems like underlying infection, neurological disease, any recent problems with mobility, falls, visual disturbance, then those suggest that we need to do more urgent extensive investigations. Yeah, and I think urination can present in other ways. Sometimes the elderly patients can be a cause of confusion or agitation. So, you know, although it often presents in males with pain some of them present atypically. In regard to history and your physical exam, can you just outline what your approach is to taking the history and also your examination? So I always start by asking patients when the problem started that they've come in with. So some people will have an incidental finding of a high post-void residual and it will be detected that way. So they might be referred to the casualty department by the ED, by their GP who's done an outpatient ultrasound with findings. And those people will often say, my stream's okay, I get up at night to pass urine often, but I didn't know that I had a problem. So a lot of people don't know that they have urinary retention, but more commonly people will give a history that they've had increasing difficulty avoiding and often have discomfort associated. And in regard to the exam, what do you look for in an examination? So it's a good idea to do an abdominal examination. Often if they have large volume retention, you can palpate the bladder. Sometimes it can be up to almost the zippy sternum if they're in very high volume retention. In men, I do a digital rectal examination to examine the prostate to see whether there's any enlargement or any evidence of prostate cancer because this is probably the most common cause of outlet obstruction. Can you explain some of the relevant underlying anatomy and pathophysiology of acute urinary retention? Urinary retention is usually a failure avoiding and there are two parts to avoiding one is that the detrusor muscle has to work and it has a very complex set of neurotransmitter receptors that act at the bladder and control its relaxation and contraction. And also you have to have a patent lumen to avoid that. So outlet obstruction from strictures or prostate enlargement, prostate cancer is something else that we need to consider. So the control avoiding is central, spinal and peripheral nerves and pathology at any one of these points on the pathway could contribute to a retention episode. So the list of differentials for causes of retention is pages and pages long but getting a good history from the patient about what specifically has happened for them and what the duration of their symptoms has been is usually the key to diagnosing what the cause is. So you said there's a very long list. We won't get you to go through a long list, but you can go through a short list of what are the usual triggers, I guess, of a hospitalised patient going to urinary attention? So probably the most common in males over 50 would be benign prostatic hypertrophy. In younger patients, it tends to be more related to infection or medication changes, so some antidepressants can cause it, anticholinergic medications can cause it, high-dose opiates can cause it. And it's very important in those patients to get a medication history to see what might have changed recently and whether any adjustments need to be made. Some of the more unusual presentations, urinary retention can be a first presentation for multiple sclerosis and obviously the multiple systems atrophy as well, although that's very uncommon. And then actually having an endoendrolytic catheter inserted, say for an operation, is that more likely to make you go under retention once it's removed? It really depends on what the surgery is that you've had done and what your baseline detrusor muscle function is like. So as we get older, a lot of patients lose a lot of detrusor strength. And if they have some baseline outlet obstruction, occasionally, you know, small other post-op factors like opiate dose, immobility, and comorbid respiratory illness can be enough to tip them over into retention when they were only just able to avoid preoperatively. So we have mentioned that in this case they've already had a bladder scan done already but when would you recommend a junior doctor asking for a bladder scan and how does it help you in decision when they need a catheter or not? I think the thing that you have to consider when you decide whether to bladder scan a patient or whether to put in a catheter for retention is what things you are trying to avoid. So you're trying to avoid renal failure from unrecognized bladder outlet obstruction, either acute or chronic. You're trying to avoid infection episodes from chronic stasis and retention. And you're trying to avoid a progression in their detrusor dysfunction. So chronic outlet obstruction causes detrusor underactivity and if you miss an opportunity to intervene with chronic retention those people can develop detrusor failure and even when you unblock their outflow obstruction they've got no muscle function left to void. So when you're thinking about bladder scanning a patient, anyone who's in pain or symptomatic, usually we like to monitor people after we've removed a catheter because people can have baseline problems that are unrecognised pre-operatively. If a patient complains that they are having increased symptoms or difficulty voiding or they have new incontinence, it's good to do a bladder scan to make sure they're not in overflow retention. And I guess anyone who's got a urinary tract infection, it's a good idea to get some kind of idea about their post-void residual to make sure you're not missing an outlet obstruction. So you mentioned post-void residual a number of times. What is that, and what's normal, and what's abnormal? So post-void residual can be measured a couple of different ways but essentially it's an estimate or a calculation of the residual bladder volume of urine immediately after someone's voided. So sometimes in theatre we'll use a catheter or a cystoscope and do a volumetric measurement of the residual urine but most often when we talk about post-void residual on the ward, we're talking about a bladder scanner. You can do a formal post-void residual measurement with an ultrasound and the sonographers are very good. That's probably the most accurate way to estimate the bladder retained volume without instrumentation. But bladder scan on the ward is very, very common. There are a few problems with that though.
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So what's a normal post-residual void volume? So for a healthy young person, you'd expect less than 30 mils as a post-void residual. Obviously, the inpatient population is not quite so fit and well usually. And what you accept as an abnormally high post-void residual really depends on the patient's baseline status and what you're worried about preventing by measuring it. So if you're measuring it because the patient has an infection then usually you would accept a lower post-void residual elevation i.e. 100 to 200 mils you would consider abnormal and put the patient at risk of further problems. If they've had a knee replacement and they usually have a bit of difficulty voiding and they've got a 600 ml residual but they're not in pain, that might be quite usual for them and they might not require any catheterisation. Is there a difference between male and females? No, I don't think so. I think it's more about the patient's baseline characteristics. But you might anticipate that if you had a high residual in a female as compared with a male, the male's problem would more likely be related to bladder outlet obstruction from, say, prosthetic hypertrophy, whereas bladder outlet obstruction in women is less common and might be associated with other problems like a cysticial or pelvic organ prolapse. So what investigation should we perform? Done a bladder scan, we've got urination, are blood tests helpful, looking at their renal function, or what other things should we look for? Yeah, so I think getting an idea about their current and baseline creatinine is very important. Sending off a urine MCS to ensure that there's no active infection at the moment is essential. And then the rest of the investigations really depend on the patient's presentation or other factors, what the history is. So in, say, a chap who's presented with a long history of baseline lower urinary tract symptoms, difficulty avoiding, strong suggestion that he probably has some prostate hypertrophy causing outflow obstruction. Those patients you would do probably an ultrasound KUB in a more formal sense to have a look at their upper tracts, get an idea about the prostate size and configuration, and you can also get an idea about whether they've got any detrusor thickening or diverticula or anything else unusual going on. You decide to insert the catheter and the catheter goes in smoothly. Yay. When would you repeat a trial of VOID for this patient? So for the immobile post-op patient, it's really a good idea to wait until they regain a better level of mobility that's closer to their baseline. You also want to encourage the teams who are looking after the patients to try and rationalise their opiate use as much as possible and really to make sure that you've excluded an infection before taking the catheter out again. And things like constipation, is that an issue or problem? Are you treating that more aggressively to try and reduce the risk of retention? Yeah, absolutely. That's a really good point. Regular appearance in these post-op patients are an important part of their urinary function care as well. And often I would, it depends on the patient, but I would usually say wait about a week, a couple of days at least. Okay, so waiting a week often means they will be going home, and I think we'll talk about that later. But I'm just interested in, is there a role in medications? I mean, I guess there's some of the medications like Flamaxtra. Is there a role for that in somebody who's got some urinary retention that has a catheter in? Yeah, so if this man has baseline lower urinary tract symptoms, then you could consider trialling an alpha blocker. So Flomaxter is a very common one. There are some considerations when you decide whether to start a patient on these or not. The main one is whether they have any likelihood of progression to cataract surgery. We know that even one dose of Flomaxter can cause phpy Iris Syndrome, which puts them at very high risk of complications for lens replacement. So in the patient group who we deal with who have benign prostatic hypertrophy and outflow obstruction, it's obviously a very important consideration. It is a very effective medication and it does help a group of patients, but you need to really carefully evaluate everyone who you start a new medication on. So in regard to this patient, they've failed their repeat trial avoid, you decide to put the catheter back in and discharge them home. Can you tell me what kind of discharge instructions and plans they require? Yeah, so patients need to be educated about how to manage the leg bag because it's obviously a pretty intimidating bit of equipment to go home with. They have concerns about how they're going to get around with it being tangled and most patients will go home with a leg bag device. Most of the devices have some kind of tap mechanism on the bottom and you can show the patients how to empty the bag into the toilet, what they need to do at night. Usually they have a larger reservoir night bag that needs to be hooked up. So the main considerations are they need to have reasonable eyesight, reasonable dexterity, and cognitive function so they can remember to do the steps and remember to empty the bag. If patients aren't able to care for themselves, you need to more carefully educate the family and make sure that someone's going to be able to look after it. Sometimes we see patients who have to stay in hospital for a longer time because there's concern about managing these kind of devices at home. It's really good at the moment, there's quite a few outpatient services that can facilitate a trial avoid at a later stage. So sometimes the community nurses will go to the patient's home. If we think that they're at high risk of failing or might be a difficult catheterisation for the trial avoid, then usually we'd encourage them to have the trial avoid somewhere in the hospital so that we're available to help if there's any problem. In generally, if the resident is asked by nursing staff that they want to remove a catheter, what kind of time of the day should the catheter be removed? Oh, that's an excellent point. There's nothing worse than being called at 9pm saying someone took the catheter out at 6pm and now the patient can't pass water, they're very uncomfortable and I have to come back in in. So starting a trial avoid as early as you can during the day is advisable. And in some of our patients, we'll even start the trial avoid at midnight if we don't think that they're going to go into rapid retention with a high volume. So usually 6 a.m. ideally. Never after 12 if I'm on call. And, you know, usually we try and get all of the catheters out by 10, kind of at the latest if we're giving an item. So we've had a good summary there of acute urinary tension. We may go to another case where you're a junior doctor in ED and someone's presented with a GP who sent them in notice of abnormal routine blood tests and an ultrasound showing that they've got 1.2 litres in their bladder but they don't have pain and they've had a history of TURP. What is your concern in this gentleman? Yeah this is a really common presentation. People who have greater than one litre of attention they don't know it. Often they'll be diagnosed on routine blood tests and in people who have a history of TURP or urethral surgery, the cause of their alpha obstruction can be difficult to determine without a scope. So this chap, if he's previously had a TURP, he could have had prostatic regrowth, he could have had a scar develop after his surgery, either in the urethra or the bladder neck, or he could have had a progress in the deterioration of his detrusor function, so the muscle that empties the urine may not work very well. So it's really important in these patients to get an idea about how long they've been having a problem for, when their last set of normal blood tests was, whether they've had any infections, any bleeding, and what follow-up they've had with any recent PSA testing. So in this type of patient as well, it's very useful if you do the catheter yourself because you can get an idea about the anatomy just by the passage of the catheter, what size catheter you can pass, where you think it gets held up. In someone with a tight urethral structure, you run into obstruction much sooner, and even a small-ball catheter, you can't advance easily. If someone has a detrusor failure, for example, you can pass a large catheter very easily and without any difficulty, and there's no evidence of obstruction. So sometimes the treatment as well can give you an idea about the cause. Are there any particularly serious causes we need to consider?
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Welcome to On The Wards, it's James Edwards and today we're talking about blood sugar management but this time it's part two. We've already gone with part one of speaking to Associate Professor Glenis Ross on the management of hyperglycemia in the wards and there was a lot of pearls, a lot of fantastic information that Glenis provided and really this is the next step. We wanted to really concentrate on what's happening here. We're going to have some fantastic resources associated with this, really help you enjoy this next part. Type 1 diabetes and ketoacidosis there is a different management strategy but maybe we'll just go to the B-cells high. It's really going back to that B protocol you know. Yeah that's the easiest way of introducing medication and given that the target for inpatient glycaemia is 5 to 10 millimole per litre if you're getting more than isolated reading over 10, then it is time to start introducing some management. Now, if they're purely dietary indiscretions with foods that are brought in and extras, then clearly that needs addressing as well. So those simple practical things always need to be considered. But otherwise introducing usually the triple B. And at the time when it's introduced, there also needs to be consideration, is this patient likely to go home on insulin? That question should start quite early in the patient's hospital journey. It is not a good thing for the patient to be down in the discharge lounge, not able to give insulin, but expected to continue on insulin after discharge. So if a patient hasn't been on insulin, has been introduced in hospital, is expected to continue it afterwards, at least in the short term, contacting again the diabetes educators very early in the hospital stay is needed. And many people that are on insulin, particularly on a triple B protocol in hospital, won't need insulin or certainly not a complicated regimen at discharge when other medications may be able to start getting reintroduced. And all of these patients will clearly need follow-up, partly with their primary general physician, but they will also often need follow-up through the diabetes team if they've been commenced on insulin. And as part of the protocol do they have a standard how often you measure blood sugars? Yes so as part of the BBB protocol there is guidance on monitoring glucose so the default monitoring of glucose in hospital is pre-meal and pre-bed. Now if you're actually actively titrating rapid acting insulin it is actually very helpful to have post-meal testing done as well. And many of these patients really should ideally be having pre-meal and two-hour post-meal testing done. Though this can be challenging on the nursing staff to try and ensure all of these are done. And periodically reviewing a 2am glucose in hospital, particularly if the insulin requirements are high, is important because routines are very different to at home. Dinner is much earlier, so that can be a problem. One of the problems indeed with pre-mixed insulins, which we don't really like that much in hospital, is that at home people often eat dinner a bit later, like several hours later than they do do when they're in hospital and that can cause the peaking of the pre-mixed insulin to be at the wrong time through the night. So testing pre-meal to our post-meal but the minimum is pre-meal for the BBB. If too much glucose monitoring is being done and it's driving more insulin orders it also becomes problematic because again there is the knee-jerk reaction that there'll be a phone call saying so-and-so's glucose is high and it's really important to try and resist the temptation to just administer more insulin and it's really important to try and establish what other insulin has been given in the preceding four hours in particular before giving another insulin order. And you mentioned one of the precipitants of hypoglycemia in hospitals, often high-dose steroids. Can you use it to a big protocol when they're on steroids? Or is that something more specialist kind of area? Yes, so it's very difficult. Steroid management of steroid-induced diabetes is extremely challenging and there are a lot of confounders, people that are put on very high-dose steroids initially, even if they're not known to have diabetes, should have their glucose levels checked at around three o'clock in the afternoon, certainly by day three of the steroids, and that should be done periodically if they're continuing on high-dose steroids because that's the time when you're getting the peak effect. If you only monitor these patients as a fasting glucose, you may miss what's happening the rest of the day and not manage. Now, with people that don't have underlying diabetes requiring a lot of insulin, if it's a standard type of steroid such as prednisone in the morning, the major impact is going to be from about lunchtime through to the evening meal or a little bit later and the glucose levels overnight fall. So the aim with any insulin regimen is to try and prevent that rise of the glucose and deal with the time when it's high. So some units recommend using morning longer acting insulin such as Atlantis. Other units prefer an intermediate such as Protofane and it may be giving it just at breakfast or often quite I found personally quite useful is to give it at breakfast guided by your pre-lunch glucose but then to give more protophan at lunchtime guided by the pre-dinner glucose levels as well as mealtime insulin if that is needed as well. Unless this is very simple, I would strongly suggest trying to get some more advanced guidelines. But initiating insulin, I wouldn't initiate the triple B because if you initiate in this one the triple B with a lot of nighttime insulin, the patients are likely to hyper overnight. Okay. So I mean, I think when you say... So it's complicated. Complicated, extremely challenging as an endocrinologist, I think as the intern at Gendarmes, I ask for help. And you really segues nicely into one of the risks of insulin use within hospitals, and that's hypoglycemia. And this is a similar patient who was on the ward, and maybe this patient, you started some insulin regime, but the blood sugar's gone low. The nurses ring you up and they say the blood sugar is three. Okay so this is a much more urgent situation to deal with than when you're being called with a glucose level of 14. So a low glucose level urgently needs treatment. So you quickly need to ask what the patient's mental state is provided and also whether they can take foods orally. So there is a guideline to hypoglycaemia management on the paper subcutaneous insulin charts and that has been put into eMeds as well well but the main thing is that you need to treat rapid acting you need to treat a low glucose with rapid acting glucose so wards should have hypo kits which contain that and you're aiming for 15 grams of glucose so examples of that are about half a cup of normal soft drink not not the diet version, half a cup of fruit juice or glucoside, or half a dozen jelly beans. If a patient has honey around, there can be three teaspoons, which is equivalent to a dessert spoon of honey. Any of these quick-acting sugars should be undertaken. Now, if this occurs and the patient has a meal in front of them, it is important that the patient have these quick-acting carbohydrates, not just proceed onto the meal. Because once there's mixed food there, the glucose will be absorbed more slowly and patients can continue to slide into more severe hypoglycemia. So once the patient has had that glucose, the routine should be that the glucose gets monitored every 10 to 15 minutes. If the glucose remains low, then further glucose is given. And once the patient's glucose is over four, the patient should be encouraged to have something more solid to try and keep the glucose levels up. So at that point, it could be proceeding into a meal, it could be proceeding into a meal it could be proceeding into having some biscuits having a piece of bread having a piece of fruit having some milk but you wait until the glucose is up to do that now if the problems arise clearly if the patient is unable to safely have anything orally so with that's due to their mental state or their physical state and in that situation the options are either to be administering some glucose IV so either running in some 5 or 10% glucose or giving a 50% push but that is a very thick solution to be given and so you do need to be careful with that. If the patient is unconscious or close to that you may need to consider an injection of glucagon. One of the limitations with glucagon is if it's a patient who has been eating poorly they won't have much glycogen store so the glucagon won't be very effective. Also glucagon can induce vomiting, nausea and vomiting, so that can then lead to some other problems. But that is another option available. But intrinsically, trying to get the patient's glucose up with glucose, particularly while they're actually inpatient.
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We've got Belinda Gray, one of our advanced catalytic training. We've trained her as a junior doctor before coming back and doing her catalytic training. And again, this will be, we'll start off with a scenario. You're the junior doctor on the ward. You get a call from the nursing staff about a patient who lost consciousness, but now seems more alert, almost back to normal. You get that phone call, Blinda, what sort of questions you can ask the nurse over the phone or maybe what instructions you want to give the nurse when you receive a similar kind of case presentation. Okay, thanks James. Well I think the most important thing to clarify is, is the patient conscious? If they're not conscious then obviously the nurse should be calling a cardiac arrest but if they are conscious then the most important thing to focus on first of all would be the patient's vital signs, particularly their heart rate and their blood pressure. And if the patient's kind of woken up and somewhat alert, then ask them to pop the patient back to bed and I'd ask them to start by organising an ECG and doing the patient's blood sugar level whilst you're on your way to review the patient. Okay, so you go see the patient, you're walking there, you're thinking this sounds like syncope. Are there other diagnoses that could be? How do you differentiate syncope from some of the other causes of loss of consciousness? So I think the most important thing is to determine whether indeed it was a syncopal episode. So the important things to find out from the nursing staff would be whether there was any other circumstances leading to the event such as whether there was any seizure-like activity witnessed, although that doesn't always exclude cardiac arrhythmias, whether it was during micturition or defecation or venipuncture or a painful episode. And I guess the other things to exclude would be kind of psychosomatic, but I think that that should be at the bottom of the list and excluded at the end. Yeah, so any other sorts of things? I mean, I often notice when I look at patients in the nurse's department often the patients who have kind of had a seizure often that kind of postictor a bit confused afterwards where syncope usually seem to return to their normal conscious state pretty quickly. Are there any other kind of indicators that maybe it's a different diagnosis? I think yeah I mean I think that if-like activity was seen with the patient and then they are confused afterwards and they were maybe incontinent, you may be more suspicious that it was a seizure. But patients who've had cardiac arrhythmias can look like they're having a seizure. But yes, I would agree, they definitely tend to wake up quickly. The other things that I'd be very concerned about is if the patient sustained a major injury, particularly a head injury because they'd lost consciousness quickly, that would be concerning. And I guess other causes like metabolic causes, whilst reversible, often take a while for the patients to wake up as well. Obviously if there's any sort of weakness noticed in any limbs, sometimes a stroke can cause someone to have a syncopal episode and other rarer causes like a massive hemorrhage on the ward if someone's a surgical patient and they had a drain that had a large volume in it, that'd be something to notice quickly. That's where I'd start. Okay, so when we think of syncope, have you got maybe a definition of syncope? So we define syncope as a sudden spontaneous loss of consciousness with associated loss of posture and tone from which the recovery is also spontaneous. Okay, and we want to take kind of a look at the causes or classify syncope would be a kind of a simple way for junior doctors to remember all the different causes. So I think it's important that we basically divide it into the different causes of syncope, but the two most common absolutely is neurocardiogenic syncope or vasovagal and then cardiac arrhythmias. Actually other causes like neurological causes are actually incredibly rare and are more at the bottom of the list. So with the cardiac arrhythmias, I like to differentiate them into tachyarrhythmias and bradyarrhythmias. And obviously within each of those groups, there's a number of different causes of syncope. Then we can have structural cardiac disease, such as aortic stenosis or pump failure. And pulmonary embolism also falls into the structural kind of cardiac functional abnormalities. And then neurocardiogenic syncope, which is vasovagal syncope, which is usually diagnosed on the history. And then the other rarer causes are the neurological causes that we alluded to earlier, seizures and stroke. Also metabolic causes, psychological causes, and obviously hypotension can cause syncope but I feel that that also falls into the kind of abnormal cardiac function loss of cardiac output type situation. So where does the ones kind of those ones who are dehydrated or have had blood loss where do they fit in? We basically put them into the kind of syncope due to orthostatic hypotension because the actual mechanism is that their blood pressure has dropped when they've stood up. So they fall into the same kind of category as medications, volume depletion, diarrhoea, vomiting, and postural hypotension from other rarer causes like Parkinson's disease. The kind of people that were done with neuropathy. Yeah, exactly. Okay, so yeah, I mean I guess the ones I know we tend to worry about in emergency departments are the cardiac ones. What sort of particular historical features would you be asking? Will you determine the different causes of syncope? I think the most important thing to find out is the events leading up to the syncopal episode. If the patient was feeling unwell prior, whether that was with palpitations or chest pain, whether or not the patient has had a history of syncopal episodes, particularly with standing, so someone who's known to have kind of collapsed many many times over the years when standing for long periods you'd be less concerned than someone who this is their first syncopal episode and they've collapsed quite suddenly with perhaps with some preceding palpitations that would be most concerning for cardiac syncope. The other things that I'd pay attention to in the history is whether or not the patient sustained a major injury because if someone suddenly loses cardiac output they don't have any preparation to put their arm out or anything like that and so often the patients that we see that have had proper cardiac syncope due to an arrhythmia or from a sudden cardiac obstruction like severe aortic stenosis, they have sustained quite a significant injury. I guess the other things that would be important in the history is if the patient is on a high dose of medications like beta blockers that could cause them to have a severe bradycardic episode then that would also concern us more. Okay other things like age, history of cardiovascular disease, do they increase your risk of having cardiac syncope? I don't think age helps at all although obviously elderly patients are more at risk of bradycardias but tachycardia, you know dangerous tachyarrhythmias can occur at any age. But yes, I think a history of cardiac disease is important. Obviously someone who has known structural heart disease is at risk of VT. Whether or not they've, whether or not, as I mentioned earlier, they're on medications like avianodal blocking agents that may precipitate bradycardias. Obviously if they've had a recent long trip or something like that then you'd worry about a pulmonary embolism or a history of malignancy, you'd worry about that. And I guess if they have an implanted device like a pacemaker or an ICD you'd worry that there may be a malfunction of that device and that may make you more suspicious of cardiac syncope. Okay. So how about in regard to doing an examination of someone who's had syncope with a target history, what particular signs or things would you look for on examination? So if you're doing a detailed examination obviously I think it's important if you can to do a postural blood pressure although this isn't always an option in the acute setting. Then the other important things to look for would be for a murmur particularly of aortic stenosis or LVOT obstruction. You'd want to assess the volume status of the patient and obviously a brief neurological examination to make sure that there's no signs that they've had a stroke or a TIA. And I guess BSL kind of falls into that category if you haven't done it yet. But in a focused examination, that's what you'd be looking for. If they had a cardiac arrhythmia you may not find anything on examination. Yeah and of course I guess you should emphasise trying to make sure they haven't got a complication from their syncope. Yeah. I know there's especially elderly patients often head injury they're on warfarin or even see spine fractures from their syncope. Yes we have seen that. So just remind me what LVOT obstruction is.
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Welcome to everyone from On The Wards. Today we're going to talk about post-operative neck swelling and I'd like to welcome Dr. James Wikes. Thanks very much for having me. James is the current Sydney Head Neck Cancer Institute Fellow based at Royal Prince Alfred Hospital and Lifehouse. He's got surgical training and trained at Bankstown, Liverpool and Prison Wales Hospital. And we're going to talk about something that probably doesn't occur commonly but is something I'm sure would be a bit scary for a junior doctor to face. And this is the scenario that we're going to put forward that you're asked to see a patient who's just returned from recovery following a total thyroidectomy. The nurses call you saying that it's developed some swelling around the wood, The patient seems anxious. What would you ask the nurse over the phone and what sort of priority would you put on seeing this patient? I think the first thing to note and to preface this conversation is if you get asked to see a patient with acute neck swelling in the post-operative setting of neck surgery, you should treat it as a surgical emergency. Nine times out of 10, it's going to be something that you can sort out very quickly and is minor. But the one time that you miss it and don't get on it straight away, you turn a manageable situation into a potentially very difficult to manage situation. So I think you should prioritize this as an emergency and get to it straight away. Almost stop what you're doing and take the call seriously. In terms of the questions over the phone, I think it's good to know what surgery they had, when the surgery was, and some very simple questions like, can the patient talk in sentences to you? And is the patient able to maintain their own air? Do they look comfortable? And then I would go and see the patient straight away, almost regardless of what they say anyway. Get there as quickly as you can. Okay, so you get there and you come and see the patient. The patient's kind of sitting up. They are talking. So why don't you just outline your assessment of the patient? So with any assessment, history and examination are the keys. The thing to note is that your history forms a lot of your examination. You need to listen to how the patient talks to you as much as anything else. So you've got the basic idea about what operation they've had. And the questions that I would like a junior doctor to ask is, does the patient feel symptomatically short of breath? And then that's an obvious question. And most patients will either be looking very well, or they'll quite obviously distressed and that's an easy decision for you to make. But then there are these people that fall into the grey area where you need to look for some subtle signs that are going to help you. So some subtle things that might help you in assessing someone who you're concerned about their airway is. Have they noticed their voice change at all? Often the patient's voices change when they have some airway compromise and they notice it themselves and the nurses might notice it as well. Are they having any difficulty swallowing, particularly swallowing their own saliva? That's another more subtle sign that we see with people with impending airway obstruction. And what I would like to know is can they talk in a full sentence without feeling breathless? And if they can, that's a pretty good sign that their airway is okay. And are they able to change their posture and have a normal and breathe normally? More specifically, can they lie down flat without feeling short of breath? And if they feel uncomfortable lying flat and they have to sit up, those are the, if they answered positively to those things, they're the things that would start to make me concerned that their airway might be at risk. So in summary, with those brief questions, some people clearly have a fine airway and you don't have to panic straight away. Some people clearly are in distress and that needs to be sorted out immediately. And some people have these impending signs, which would make me more concerned and make me want to act more quickly. So they're the few history things I would ask in terms of things that will help you with your examination. Again, if a patient's had a thyroidectomy, they usually have a central neck scar and there can be a little bit of swelling above the scar. If they have a frankly swollen neck, then you know that there's something significant that's occurred and that will need to be sorted out with another operation most likely. But some subtle signs are if the patient has lost the notch between the insertion of the sternocleidomastoid muscles, if that's no longer concave, it becomes convex, that to me is a sign that there might be some unexpected post-op swelling. And some people get to almost an edema of the skin, a dimpling of the skin, which is another more subtle sign that there's something wrong in terms of what you can observe. Those listening for voice change is important. Stride or people always talk about stride or I would regard as a late sign. Someone's already got stride or they're already in significant distress. So I would never wait for stride to occur before calling someone. If you think about someone's airway, flow is related to the diameter to the power of four. So halving someone's diameter will reduce their flow four times and further halvings will make it exponentially worse. So by the time someone has enough airway reduction in caliber to cause stridor, an arrest could be something that's going to happen imminently, not in that sort of linear time frame. So we're looking at some of those worrying signs or symptoms of airway compromise. And who do you call and what's the agency calling someone? So I think, again, if you are concerned, make a call straight away. And the people that I will call is the surgical team looking after the patient. So that's not always 100% clear who that is. There's lots of different teams that do thyroidectomies, for example, but mainly the teams are going to be the ENT team. And so you call the ENT registrar or the general surgery team or a head and neck team. So that's the advantage of looking at the op report is that you can see who the primary operator was and call that person straight away. They've done the case. They're going to be the most helpful person in that regard. The other person that's really going to help you, I think, is the anaesthetic reg on call. They're more than likely going to need to know about it anyway and will want to know, and they should be able to come quickly to give you assistance. Is there any sort of simple ward things they can do? I mean, you're making those phone calls that someone you're concerned about but obviously isn't every arrest. Yeah, I think the important thing with someone who has a potentially threatened airway is to leave them in the position that's most comfortable for their airway. So if the patient is sitting on the side of the bed and that's where they're most comfortable, leave them there. Don't force them to lie down or change their position in any way because if someone can maintain their airway, then that's working for you. You don't want to turn that to a situation that's going to work against you. We spoke about it briefly earlier, but there's often for a thyroidectomy still a scalpel or stitch cutter attached to the side of the bed. And that seems like an anachronism in modern medical practice, but is something that you might potentially need to use. So the reason why someone with a post-op hematoma, with a hematoma in their neck will have airway, potential airway obstruction is because the hematoma compresses the lymphatics and then the venous drainage and they get edema of their larynx. And that's the mechanism by which they obstruct and then lose their airway. So releasing the hematoma by opening their wound, cutting any stitches immediately under the skin and extracting any blood clot allows the venous drainage and lymphatic drainage to occur and can provide relief. So someone that's in real distress and you don't have help there and you're very concerned there's a significant tense hematoma, then releasing that wound is the right thing to do. And that's why the scalpel's there. And I don't think the junior doctor should be afraid to do that if they're waiting for help and they're really concerned. I don't think you're going to get, no one is going to get mad at you for doing that, causing a bit of mess. If we had to take someone back to theatre to close their wound again and it saved their airway, that would be no problems. And if it was a marginal call that didn't need to be done, I don't think you would get in trouble either.
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Are things like steroids and nebulised adrenaline, do they have any role or it's really just something mechanical that needs to be either released or um i think i think steroids and nebulized adrenaline are a probably shifting the deck chairs on the titanic if someone really has an airway problem and and be a decision that as a junior on the wards is not really your responsibility to make. Someone experienced with assessing airways might think that they could salvage the situation using those adjuncts in someone that they didn't think needed to go back to theatre. But I don't think that they're useful for an internal resident on the wards really. So the internal resident, really what they need to do is try and identify someone who could have an airway problem and then call for help. And if they're pre-arrest, grab the stitch cutter and... Yeah, that's right. And so that's the extreme situation. And then you have those equivocal situations and the safer situation. So if someone has a wound that looks slightly swollen and everything else appears to be okay, the best way of assessing them, I think, is A, to call someone for help anyway. But if they're not around, the best way of measuring whether someone's okay is to serially assess them. So if you think someone looks fine, all of those trigger, those danger things I've talked about are not there, then you can probably safely reassess them in a short period of time. So you might come back in 20 minutes. And if it's unchanged, that's fine. Come back in another 20 minutes. So make a couple of serial assessments for those kind of people. And then those people that have had some voice change or they can't swallow and you're concerned that they've got some significant swelling, I think you definitely need to call and get them attended to urgently and insist that they get reviewed. Again, waiting until someone has significant airway compromise before acting is a potential disaster. I've seen a number of situations where people have been talking to a patient and they've arrested out instantaneously. And I would certainly prefer to take back 100 people with a small hematoma to theatre in a controlled setting, control their airway, drain the hematoma, whether they needed to or not, than have one situation where someone has a respiratory arrest and someone who doesn't know how to do it is trying to do a surgical airway or a panicked airway and can potentially cause more damage. Any other kind of take-home messages? I think, again, I'd go back to my first point that you need to treat this as an emergency. And I think sometimes these scary issues, which medical students I don't think get a lot of training on, people can try and defer them to other people because they're not used to the situation or they don't know what to do. In my medical training, I can certainly say that I've regretted far more not looking at something than not knowing about something. And so I think the most important thing I would say is if you get caught about this, take it seriously and go and see the patient. And you will learn something from that regardless. Great. Thank you for that, James. We're continuing on with the same theme. And they went and reviewed the patient and the patient was fine. Did serial exams. But kind of two days later, they asked to asked to review the patient again. But this time they've got these strain symptoms and maybe a bit of numb around the mouth. What would you ask a nurse over the phone this time? Okay. So in this setting, someone who's two days post total thyroidectomy with some perioral numbness or anesthesia I'd be worried about hypocalcemia. So in contrast to an airway emergency this is something that is an urgent thing that we need to sort out but it's usually not in the same life-threatening category where minutes count but it's still an important issue to identify and fix. So again, the details I would want to know is what surgery they have had, and that does make a difference to whether someone could be hypocalcemic or not. The reason someone would be hypocalcemic after a thyroid or parathyroid operation is because there are four parathyroid glands that tightly control calcium hemostasis through the actions of PTH. And in the setting of a total thyroidectomy, their blood supply is closely related to the thyroid gland and they can get stunned into not working for a number of days. The reason that's relevant is that if someone's had, say, a hemothyroidectomy, only half of their thyroid removed, we almost never see significant hypercalcemia. And so we're really only concerned about this in patients who've had a total thyroidectomy or patients who've had a parathyroidectomy for an adenoma, which is a case of primary hyperparathyroidism, or sometimes patients with renal failure have operations on their parathyroids, which is usually part of secondary or tertiary hyperparathyroidism. So type of surgery is important. And the early signs of hypercalcemia, as you correctly said, are some perioral anesthesia and some peripheral tingling and numbness in their fingers. And that's an early sign that would make me concerned. I would want to know if they'd had any blood tests since their surgery and if they'd had any other, and whether they'd had renal impairment or any pre-existing medical conditions. Are most situations kind of post-operative hypocalcemia, are they usually picked up routinely through blood tests or when they become symptomatic? They should be picked up routinely through blood tests. So the traditional teaching of doing T's and C's on the patient, which is looking for Trousseau's and Travostek's sign, are signs elicited when you've got hyperexcitability of nerves related to hypocalcemia, which potentiates the action potential of nerves. Just as a quick refresher, Travostek's sign is when you tap over the root of the facial nerve in the preauricular region and you get some facial twitching. And Trisocin is when you tap over the median nerve and get some thin eminence and finger movement. And they're quite late signs of significant hypercalcemia. So we really should be able to avoid those by patients having routine calcium and parathyroid hormone tests in the perioperative period. That being said, they can be missed by the treating team or not done or done once and then assumed to be normal after that. And that's interesting. And I find that I often spend as much time talking to interns and residents on my team about this as I do the registrars because the registrars are often theater during the day these blood tests whilst ordered in the morning the results don't often come until later in the day and I think it's important that the interns and residents check these and stay on top of them and prevent these these prevent hypercalcemia becoming a problem so yeah it's usually investigated with blood tests in the perioperative period. So you have a fairly routine protocol of when to do blood tests post-thoridectomy or parathyroctomy? Yeah, so most thyroid endocrine units will have a ward protocol for both when you should, like the normal blood tests perioperatively for someone who's had a total thyroid or parathyroid operation and then what to do if their calcium is low. But then there's, despite this, every unit having this, there's always one or two cases a year that come up in M&M where, and it's often relating to a patient who's gone home and then presents to ED a couple of days later or someone who they haven't got on top of their calcium early in their post-operative stay and become quite profoundly hypocalcemic and begin to become symptomatic. So what would be your management or calcium management post or perioperatively and when they become symptomatic? Okay, so we check calcium and parathyroid hormone postoperatively. Calcium we check because that's the, we check serum calcium postoperatively. That's a reasonably good reflection of the active calcium in the body. The other option is to check ionized calcium, but most units don't check that. They just check the serum calcium. It's a reasonable reflection unless someone's got significant acid-base disturbance. And we check their PTH, which is more of a predictor as to which way we think their calcium is going to go. So someone who has a low parathyroid hormone immediately after surgery, we can fairly comfortably predict that they will become hypocalcemic. Parathyroid hormone has a very short half-life. So we know within four hours of the surgery that if it's low, that their calcium is going to drop down as well. And so most units will check it the same day of surgery and then the next day and daily until it normalizes. And the calcium replacement varies. It often involves oral calcium, oral vitamin D analogs, and in some places IV calcium.
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Welcome to On The Wards, it's James Edwards and today we're going to talk about Trachostomies. Welcome John Gatwood. Hi James, thanks for having me. John's a dual trained anaesthetist and intensivist from the UK but now working as a full-time intensive care specialist at Rural North Shore. He loves medical education, especially simulation and he also heads up the Rural North Shore Trachostomy team. So he's a perfect person to talk about Trachostomies and I must say when I hear Trachostomies I do get a bit scared. You don't see them that commonly and I guess depends on what setting you're in. I don't remember ever getting education about them and I always feel like if I do something wrong I'm gonna pull the tracheostomy out and that tract or hole will just suddenly close over. So they're my fears and I'm sure I've got some fears from JMOs will as well. So John, why don't we start with some general questions. What is a tracheostomy? So James, a tracheostomy is the insertion of a tube through the neck and into the trachea between the level of the larynx and the sternal notch. And you're not the only person to become anxious when you see a tracheostomy, don't worry. A lot of residents and medical students and even senior doctors have the same reaction. So there's a couple of types of patients that we're going to see out there on the wards in ED and in the ICU. So some patients have a tracheostomy. Now they have a potentially patent upper airway. But there are other patients who may look very similar from the end of the bed who have a laryngectomy. So they've had their larynx removed and the trachea has been brought out to the skin. So they're the so-called laryngectomy patients. Now these patients have no upper airway. But unfortunately from the end of the bedogram it is not helpful because both types of patients can have a tube in through the stoma. Some laryngectomy patients eventually go on to manage without a tube, whereas the vast majority of tracheostomy patients keep the tube until they no longer need it, at which point the stoma is covered up and it heals up. So what are the common reasons that you may insert a tracheostomy? There are three main reasons. Upper airway obstruction, which can be from tumour, surgery, trauma, a foreign body or infection or abscess. In my practice, the most common reason that we put in a tracheostomy is for prolonged mechanical ventilation. And that's really to prevent damage to the larynx and the upper airway from a long-term endotracheal tube. It also provides a much more stable airway for us, and so it improves patient safety. And the third reason is if patients have got copious secretions, it can help us to do tracheal toilet and help them by suctioning. What are the different methods of inserting tracheostomy? So tracheostomies can be inserted either in the operating theatre, and that's usually done by ENT surgeons, head and neck surgeons, or plastic surgeons. Although there are many surgeons, especially in rural and remote areas, who can pop in a tracheostomy tube, just general surgeons. But in my practice, they're more commonly inserted by us in the intensive care unit, and we use a slightly different technique. We use a percutaneous technique, which is a Seldinger guidewire technique. And most of our patients that we manage would have a percutaneous rather than a surgical tracheostomy. It's a bit cheaper to do. It doesn't need theatre time. It's more convenient for us in that we don't have to move the patient, especially when they're a bit unstable, to the operating theatre. And there's a few other advantages of the percutaneous techniques such as what we do know is that they have a decreased incidence of infection around the tracheostomy. Can you describe some of the essential features of a tracheostomy tube? So they come in a range of sizes from 4mm to 10mm internal diameter, that's the adult sizes, paediatric tubes go even smaller than that. Most trache tubes are of a standard length, but some are especially long for obese patients and some have an adjustable length, so they're otherwise known as adjustable flange trache tubes. Most tubes have an inner and an outer cannula, most ones you'll see in hospital anyway, and that's a real safety measure because these patients can get problems with tenacious secretions blocking up their trachea tube and so we can just pull out that inner cannula and that resolves the problem. So that's a real safety measure. It is important to know what type of tube your patient has got though because for example some trachea tubes can be connected to the vent circuit without their inner cannula, some connect via the inner cannula. So in patients whose circuit is connected via the inner cannula it's extremely important to have a spare inner cannula available. So if the first one gets blocked and you can't unblock it, then you can't ventilate the patient. Most trachea tubes are cuffed. This helps us to deliver positive pressure ventilation and does offer more protection against aspiration. Uncuffed tubes are often used in the weaning phase when patients have come off the ventilator but still need a trachea, for example, for clearance of secretions. The laryngectomy tube is a specialised type of tube which a lot of laryngectomy patients have. They're usually uncuffed. Then there's these fenestrated tubes that you might have heard of. Now these have a little window in the upper surface of the tube on the inside of the trachea, and this is really just to facilitate speech so that more airflow goes up through the vocal cords. They're the main types of tubes that we'll see. In regards to ventilation, what kind of different modes are patients often on who have tracheostomies? So they're pretty much ventilated in the same modes as patients with endotracheal tubes really but given that most trachea patients would be in the weaning phase from ventilation then a spontaneous mode would be more common. So it is a bit unusual to see a patient with a trache who's mandatorily ventilated, which does help you when you're dealing with trache patients, as the vast majority of them, if they do have a trache problem, they are at least breathing spontaneously. So can patients with tracheostomy talk or swallow? Trache patients can definitely talk. We see many patients coming to us who've developed different ways of talking. Some can talk around their tracheas without any aid at all. Some even who have the cuff inflated can manage to squeeze some air out around the cuff, especially high spinal cord injury patients. I've got a couple of those who I know who can speak through a cuffed tube, which is quite a feat if you ask me. But a lot of patients will need a speaking valve. One of the commonest brands of speaking valve is the Passy-Muhl valve, but there's lots of others available. Basically, this is a one-way valve which goes on the end of the trachea tube, which opens on inspiration and and closes on expiration so the air goes around the tube and out through the vocal cords. It's extremely important that the trache cuff if it's present is fully deflated otherwise the patient can only breathe in but can't breathe out and that results pretty rapidly in respiratory failure. Laryngectomy patients can also speak. They have often a voice prosthesis fitted, which is basically a surgically placed tracheoesophageal fistula with a valve in it. And that valve or voice prosthesis basically is a one-way valve which results in gas coming from the lungs through the trachea and out into the esophagus andesophagus and out through the pharynx and they can learn to speak by occluding their stoma and pushing air out through this valve. Swallowing is a problem in trache patients, especially patients with new large bore tracheostomies. They do eventually learn to swallow but it is more difficult and that's for a couple of reasons. One is that the cuffed inflated tube, the inflated cuffed tube causes a mechanical obstruction to swallowing, makes it more difficult to move the swallowing muscles. But also a chronic lack of airflow through the pharynx results in a kind of loss of sensation there and an inability to coordinate the swallow as well. So what we do in the weaning phase of removing a tracheostomy is we deflate, do cuff deflation periods so that patients get some airflow and they get that sensation back to improve swallowing.
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So I think all over the hospital, this is an interprofessional approach. These are complex patients, they have complex needs, and there's no doubt that you need some knowledge to deal with trache patients adequately. So we need experienced doctors and nurses, but physios and speech pathologists are absolutely essential. Physios are very helpful getting patients mobilising, getting them breathing, and getting them to clear their own secretions with help with suctioning, but then eventually patients coughing out secretions up around the tube into their mouth. They're very helpful getting them motivated to do that. Speech pathologists are experts in facilitating speech, obviously, as the name implies, but also they are very involved with the progression of patients' diet from fluids through to full diet. Now, all hospitals that care for these patients really should have easy access to all these disciplines, and preferably they should have a tracky team. Now I had the trache team up at North Shore and we found it to be very beneficial to these patients. The Agency for Clinical Innovation in New South Wales has actually recommended that all hospitals that care for trache and larry patients do have a trache team. They recommend that it's led out of the intensive care as ours is. We get involved in discussing these patients on an interdisciplinary basis, trying to streamline their care, get them moving through the system more quickly with the aim of getting them decannulated as quickly as possible. And the studies of trachea teams have shown that they do have those benefits. And it's just really good to share information and share expertise and do some education around the hospital as well and we've been doing all of that at North Shore. Okay, that's a really good overview John, but now we may go to a couple of cases. And the first one, you're a junior doctor working on an after-hour shift covering the spinal unit and you're just writing up some fluids, having a very nice shift and then suddenly get a call from the nurse, please come to this patient who's a 25 a 25 year old spinal patient who has a tracheostomy and now is having a little difficulty breathing. What would be your initial approach? So this is definitely an emergency. Most junior doctors faced with this situation would walk into the room see the trachea and have a sympathetic response and that's for a good reason is because this can turn very nasty very quickly. So if the patient is very distressed or looks peri-arrest there's no doubt you should be calling a code blue or cardiac arrest at that moment. At least then you'll get access to somebody with advanced airway skills, the intensive care docs, the anaesthetist hopefully. If the distress is mild it may be that the trachea is a problem or it may be that the patient has a problem related to neurological function or respiratory dysfunction from a pulmonary cause and at the very least a senior review is warranted here if mild distress but if any doubt at all that this could deteriorate quickly then a code blue I would put out. These can be very serious and nasty situations. So what are some of the common underlying reasons that a patient with a tracheostomy may become acutely short of breath? So most trache patients have an underlying reason why they've got the tube in the first place and an underlying reason why they might be breathless. So this might be a neurological condition, and in this case that might be likely in a spinal patient, but it could be a respiratory condition as well. But the really concerning thing is that the problem is with the trachea tube itself. For example the tube is blocked by secretions or blood or it's fallen out or it's become displaced into the subcutaneous tissue and that last one is the one that can really cause problems. In regard to, we may just take a step back, if they're not so bad and you get a chance to look through their notes, what particularly would be important looking at those notes? So we really need to know their past medical history and we really need to know why they had the trachea placed in the first place. It's very important to work out whether this is a tracheostomy patient or a laryngectomy patient. The ward that you're on might help you if you're in the ENT ward or head and neck ward then that patient is more likely to have a laryngectomy but trying to find out from the notes, asking the patient, looking for scars on the neck and in an ideal world they would have a sign above their bed like we do at North Shore now saying whether they're a trachea patient or a laryngectomy patient. So look around the room, you might get some clues. They're the main things I'd want to know. And in regard to examination, what are you going to particularly be looking for? So we want to have a look at the patient and their clinical signs, respiratory rate, signs of respiratory distress, work of breathing, all of those things. Having a look at the tube, what type of tube it is. Is it a cuffed or uncuffed tube? Look for the pilot balloon. Is it a single or a dual cannula model so that can you remove the inner cannula to help you? Does the patient have a patent upper airway? That's the thing. So asking the nurse who's looking after the patient, he or she really should know. Another thing to look for is signs of bleeding around the stoma because there's some unique management things that you need to do if the trachea is bleeding. You mentioned about the inner tube. I mean, how do you know that there is an inner tube or there's not an inner tube and when you can remove it? So really you've got to look at the actual opening of the tubes. So there may be a speaking valve on, in which case you're going to remove that. There may be a cap. A patient may be in the stage of weaning where we cap the trachea tube. You need to remove that. If there's a humidifying filter on there, remove that too. And then really, if you look at the tubes, some of them have a locking mechanism which is a little twisting device that helps you to remove it and there's an arrow on that to tell you which way to turn it. That's a clue that there's an inner cannula or you might just see it sitting on the inside of the tube in which case there's usually a ring pole that you can pull it out with. So they're the things to look for to know whether there's an inner cannula. And is it safe for a junior doctor to do that, obviously whilst waiting for help to come, especially in someone who's acutely deteriorating? Absolutely. It's absolutely safe to do that. And what's one of the reasons why they become blocked? Often it's tenacious secretions, but also if there's been a bit of bleeding, a blood clot can get in there. Or they might have coughed something up from the lungs that's got stuck in the tube you know a bit of a sputum plug or something like that. Are these patients routinely on a humidified oxygen? Not routinely more and more now we're doing active humidification now on the wards every patient in the intensive care has active humidification you'll often see them just with an HME filter on there. If there's any problems with secretions though, then you should push up to the next level and get them active humidification. So what's a HME filter? So that's a heat moisture exchanger, sorry James for the acronym. That's a spongy substance inside a plastic casing which basically water condenses on it on expiration and then when you breathe in you get some humidification back and really all patients with a trachea tube should have that as a bare minimum for humidification. So you've outlined some of the complications that could be a problem with the inner tube that could be blocked so you can take the inner tube out. What are the things that you would do in regard to management? So you need to deliver oxygen in this case. If the patient has a potentially patent upper airway, so they're a trache patient rather than a Larry patient, you've got to give oxygen in as many different ways as you can. So you're going to put oxygen over the face and you're also going to try and give oxygen over the trache tube or the st. Now, the bed space should have the facilities to do both of those things. If you're in doubt whether it's a trachea or laryngectomy patient, put oxygen in both places. If the patient looks at you strangely when you put oxygen on their mouth and starts to shake their head, they're probably a laryngectomy patient and they're thinking, what is this person doing?
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If the patient is really struggling, you're going to want to try and deliver some oxygen through the tracheostomy tube. And you can do this by attaching a bag valve circuit. There is a danger here though, and this is where we need to be very careful. I have in my junior years, which is one of the reasons I'm very interested in tracheostomies, I had a terrible disaster at work where I attached a breathing circuit to a man's tracheostomy and delivered two litres of oxygen into the soft tissues of his neck because his trachea was displaced and that made a bad situation a hundred times worse. So you need to establish that the tube is patent before you squeeze oxygen in under pressure. And there's many algorithms to help you with this. The best one from my point of view are the British guidelines. You can find those at tracheostomy.org.uk. We've adopted them wholesale with no changes in Sir Lawrence Shore Hospital. We have the bed bed head signs that they use and we have the algorithms that they use in every bed space where there's a trachea or Larry patient. Basically the steps of that algorithm are to listen and feel for airflow through the trachea tube, look for an end tidal CO2 trace if end tidal CO2 is attached depending on the clinical area. If the patient's not breathing in a rest, you're going to call a code and start CPR. If there's a speaking valve cap on there, or a filter, you're going to remove that. You're going to take out the inner cannula if it's present. Then you're going to get a suction catheter. Now, every trachea patient should have a bunch of clean suction catheters by the bed space at all times. You're going to try and pass that down the tracheostomy tube. And they're the kind of soft catheters, are they? Yeah, the soft ones that you have to put your finger over a little side port to get suction. But you're using this as a seeker at this point just to see if that tube is displaced or blocked. So if you put that cannula down, that catheter down, and it only goes a few centimetres, you know that that tube is either blocked irretrievably or it's in the soft tissues of the neck. At this point you're going to deflate the cuff just in case the cuff has herniated around the bottom of the trachea tube which can happen if it's over inflated. If there's still no airflow and the patient's still deteriorating, and this is the really important bit James, you're going to pull that tube out. Whoever you are, first responder, doctor, nurse, however junior or senior you are, you've followed your algorithm to this point, you're doing the right thing to pull the tube out. It's a big mental leap to do that, but it can be a life-saving intervention. So you've established that that tube is either displaced or not patent, and that it's not doing you any good. In fact, it's doing you harm because it's just in the way now. It's got to come out. So you pull it out. If you've managed to pass a suction catheter and you think that the problem might be with the lungs rather than the tube itself, you've established its patent in the right place, then you can attach your breathing circuit and you can help the patient breathing by giving them positive pressure ventilation. And if you follow that algorithm, it's in your head, you'll get into much less trouble in these situations. So when you say pull it out, the whole thing out, is that kind of connected? Is it switchered in? Do you have to kind of cut switches or just pull hard? Usually trachea tubes, especially in ward patients, are not stitched in, not sutured. They have some ties which go around the back of the neck. They're usually Vel you can just pull the velcro off deflate the cuff fully pull it out there are occasions when the pipe then when the tube is sutured usually in post-operative patients in which case you're going to get a stitch cutter and cut those stitches and pull it out in the case of my patient who I inflate his neck terribly badly with I was panicking by that that stage. He did have sutures. They didn't get in my way. I pulled it out anyway. And he lost two small patches of skin, but he survived in the end, and that's the important thing. Okay, we may go on to another case, one that you did mention earlier in regard to bleeding, but now you're after a junior doctor covering the head and neck surgical ward and a neurosurgical reviewer patient who's bleeding. She's not quite sure, or they're not quite sure whether it's around or maybe from their trachosomy tube. What's your approach for this patient? So this is a nasty situation that none of us wants to be found in, James. I've been involved in three of these, unfortunately, in my career, all torrential bleeders, not pleasant. The first thing to do obviously is you're going to call for help or get somebody else to run and call for help. If it's a mild bleed around the trachea and the patient is not distressed, this could just be some senior help in your team. If the patient is in respiratory distress or there's a lot of blood, call an arrest, call a code. The first thing to do is try and clear the airway so those suction catheters need to come out some gloves and definitely eye protection here because if there's blood around and a tracky tube it can come at you at high pressure and be sprayed all over you so you need to get PPE on minimum gloves and eye protection get a suction catheter in there try and clear the airway if there's bleeding the trachea site and it looks like it might be skin bleeding or external, just firm pressure with a finger either side of the tube can be very helpful and can stop that. You can use those hemostatic dressings if you like. But just some firm pressure. If it's obviously coming up the tube, this is a much more serious problem. What's described in the literature really, the only two things you can do are apply some firm pressure just above the sternal notch, just below the tube, and then super inflate or over inflate the tracheostomy tube cuff if there's one there. If this is a laryngectomy patient or a patient with an uncuffed tube, you haven't got this option. But what you can do is remove the uncuffed tube, place a cuff tube, and inflate that cuff. The idea is that there's some kind of vessel just inside that's been aggravated or eroded by the tracheostomy tube. And if you can inflate the cuff against it, you can tamponade the bleeding. One series shows that that's about 80% effective, that combination of pressure on the root of the neck and the overinflation of the cuff. So they are simple things that you can do in a very nasty, life-threatening situation. If that doesn't work, this is advanced stuff now, but you can put an endotracheal jam down past the bleeding if you want and inflate that cuff just to isolate the bleeding and at least you can then deliver oxygen to the lungs and the patient will continue to bleed but you can resuscitate them until you can get them to theatre. If the bleeding is uncontrollable this patient needs to go to theatre and you're going to need to get maybe ENT, maybe vascular, or occasionally cardiothoracic surgeons involved. And the real horror situation is where the tracheostomy tube is eroded through the right brachiosophallic or innominate artery, which are two of the three patients that I've had that's happened to, in which case sometimes they need to crack the chest. One of my patients died and the other one had a stent placed in his brachiosophilic artery once we'd managed to tamponade the bleeding with the methods I've said. So not one you want to be involved in. Call for senior help early. There are some simple interventions you can do. Yes, you're not making me more comfortable tracking my symptoms now. But okay, we'll go to another case and this one is similar. You're working in a head and neck surgical ward, writing up some fluids as you're doing an after-hour shift, but this time the nurse calls you over because they are concerned that trachosomy has fallen out. What's your approach here? Well, there's one good thing about this scenario in that there's no doubt what's happened. If the tube is on the bed, you know what's happened. Whereas with a displaced tube, it looks like it's still in. That's a much more frightening scenario and something that can result in real problems.
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Welcome to On The Wards. It's James Edwards and today we're talking about organ donation. And I have the pleasure of having a colleague, Dr. Nundrat Rashid, who's an intensivist here at Royal Prince Alfred Hospital and is also the director of the organ donation and I have the pleasure of having a colleague Dr. Nundrat Rashid who is an intensivist here at Royal Prince Alfred Hospital and is also the director of the organ donation and transplantation unit at Royal Prince Alfred Hospital. Welcome Nudhi. Thanks James. So we're going to talk about organ donation which I think is a really important topic and one that I think junior doctors probably need to know more about. Maybe we'll start very generally. Can you give a bit of a brief overview of organ and tissue donation in Australia? Yeah, sure, James. So in Australia, the organ and tissue donation program is run nationally by the Organ and Tissue Authority, which we call OTA. This then works with different states and territories and with the community sector to deliver the Australian government's national reform program. The national reform program was actually implemented by Kevin Rudd in 2008 and the hope was that it would improve organ and tissue donation and transplantation outcomes in Australia. One of the key nine initiatives of the reform program was to establish specialist hospital staff and systems in hospitals that were dedicated to organ donation. So I'm one of those hospital staff. So the OTA then provides leadership and collaborates with each of the states and territories and all the hospital staff and nursing staff that work in organ and tissue donation. All of these people together, which includes myself, and all the organizations that work together, compromise the Donate Life network. So organ donation rates vary very much, okay, internationally and regionally. And they're actually assessed by comparing the number of donors per million population. So our transplantation outcomes in Australia are second to none. But unfortunately, our organ donation rates have remained low compared to other developed countries. So countries like Spain, they lead the ranking system with donors of about 39 donors per million population. How does Australia rank? So Australia actually in 2015 had 18.3 donors per million population, so quite behind Spain of 39 donors per million population and ranked 18th internationally. Last year we improved our performance and were up to 20.8 donors per million. International rankings are still yet to be released. Unfortunately, as a state, New South Wales also ranks behind all other states with 17.7 donors per million population. So it's really important that we make every effort to identify every potential donor and that we offer organ and tissue donation to all their families. Can you give just a brief overview, I mean how does the donation process work? Yeah, so the donation process starts off when a member of our staff recognises someone who they think that could be a potential donor. The essential element is that the patient has to be intubated and all the medical teams that are and that the medical team that's looking after that patient has to be planning to withdraw active therapy okay or that they are starting to think about discussing end-of-life care with that family so any staff member in the hospital can contact the on-call donation staff and alert them regarding this patient usually we find find that it's the medical staff that alert us. We then work with the team. We do registry checks and this could allow us to obtain information about the patient's prior intent. So they could have consented to organ donation or they might have actually refused to become an organ and tissue donor. We also try and obtain further history from the patient and try and establish the pathway on which donation would occur. So whether they would be going down a brain death pathway or a DCD pathway. We ask for the medical suitability team to assess them and see whether they are medically suitable for organ and tissue donation and then have conversations with families regarding organ and tissue donation. So it's really, really important that these conversations are only held after there is medical consensus that the patient has a poor outcome. So if you have any doubt in your mind that the patient's not going to have a poor outcome or that the family is not accepting of this diagnosis, then those conversations shouldn't be held. Okay, so you've kind of described when, I guess, a donation should occur. What are the different categories of organ donation? Yeah, so there are two main categories or pathways for deceased organ donations. So obviously there's living organ donation. Yeah, you would have heard of that. Yes. Yeah, when someone gives like, for example, a kidney to a family member. And there are even now paired exchange programs where you don't have to give it to your family member. You can end up giving it to a stranger whose family, another, you know, that stranger has probably got another family or friend who's going to give another kidney to another stranger. So if you happens is if you have a family member that is in need of a kidney and you're not a match for that, there's a paired exchange program where lots of people donate and then matches are found and lots of transplants occur at the same time. But anyway, we're talking about deceased organ donation organ donation and in deceased organ donation there are two pathways, the brain death pathway and the circulatory death pathway. So the majority of our donors, about 75% of donors, for example, last year all came from the donation after brain death pathway. We may go into a bit more detail as we kind of go through some cases. Yeah, sure. The first case is you're a junior doctor, you work in the MS department and you were involved in as part of a trauma team of a really sad story of a 19 year old male who's brought in with a head trauma following high speed MVA and it seems that from either your limited experience I think this person's gonna likely die from his brain injury and his father's in attendance and he actually approaches you and says and brings up organ donation so what should we do how do we structure these conversations with family members and I guess who should do those yeah I mean that sounds like a terrible So we often have the situation arise, families raise organ and tissue donation to us, sometimes a bit too early even, you know, and we need to really screen these. And I know you're saying that the patient's death is inevitable, but I think he's just arrived in the emergency department. He's a 19-year-old. And it's interesting that organ donation is already at the front of the father's mind, but we need to slow it down. We need to make sure that all avenues for treating this young man have been explored and that if all teams, including the neurosurgeons, are all in agreement that there's nothing further that we can do, then only then can we explore the possibility of organ donation with this family. So at this stage, if this sort of conversation occurs, we usually ask our staff to respond by thanking the family. So really saying thank you for your generous offer. And if and when this situation arises that your loved one could be an organ donor then we would reassure you that someone with that appropriate experience will come and have that conversation with you. So that reassures them. The other thing to do at that time is to let staff know or document clearly that this was the wish of the family so that if and when the conversation does arise, the staff that are going to have that conversation kind of know that this conversation was held and support the family in that manner. So I suppose for this particular patient, he should be moved to the ICU. And if he spent maybe three or four days in the ICU and it continued on, then who should speak to the family then and why that person? Yeah, so in our ICU, we have trained requesters for organ and tissue donation and most ICUs are actually moving towards that. So people are undergoing training in learning how to have these difficult conversations and you can imagine they are very difficult conversations to be held and so these people the designated requesters are not only not do not only receive trainings with training about the conversation but they're generally advocates for organ and tissue donation there's generally good communicators and the other thing is that these conversations don't occur very frequently. So we don't have a lot of people that are suitable to become organ and tissue donors. So not many conversations take place annually in a unit. And if everyone was to have, you know, having a go at these conversations, then no one would be really, really experienced in them. So by choosing to have designated requesters and only a set number of people have these conversations, they get really good at them, get more confident with them, and that help is able to assist families. So we're able to provide information. We've answered tricky and difficult questions before and we're able to address those again. And if you're the intensivist looking after the patient, should you be the one requesting organ donation? I suppose it depends on where you work.
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So there are many, many ways in which you could address this. So you can be the, it could be that your intent, the conversation is intensivist led or it's a collaborative model where an intensivist brings the designated requester, introduces them and can stay with the requester and answer medical questions for the family while the requester answers the questions that the family has about the conversation, about organ donation. Or you can actually have all near the designated requester present. You can introduce them and leave. And also, most smaller hospitals would also have nursing staff that were trained to be designated requesters. So your organ donation nurse could come and you should never forget they're excellent communicators, strong advocates, and they've had the conversation before so we could enrol them. But if you're working at RPA then one of us, one of the intensivists or one of the designated nursing staff can have the conversation for you. And in regard to going back to the emergency department, the father actually brought up organ donation. The father did bring it up. Would it be the role of the ED staff to bring up organ donation? It would be great if they brought it up as well, but not, I mean, they could flag the patient to the organ donation team, but not raise the conversation. But don't speak to the family. No, no, no. So we would really, unless the ED staff was trained, but again, this patient sounds so early in the piece. I think that we would lose trust with the family if we went so quickly for organ donation. And in regard to how do you determine whether these young men's organs are eligible or appropriate for donation? Yeah, so that is actually a great question. So someone at this age of 19, I think, you know, generally we would feel that someone, this patient could be a multi-organ donor and actually could save, not only save, but transform lives of up to 10 different people. But then, you know, 19-year-olds do all sorts of crazy things. It could be that he could have disseminated cancer or be an IV drug user or, you know, lots of other things. So we really just can't say anything at the moment. What we need to do is actually take a detailed history, a medical history, find out more about the patient, send off bloods, and those bloods include serology for HIV, hep C. You find lots of things when you take the medical and social history regarding the patient. Hopefully none of those will be found on this young man. I mean, maybe can we just have a list of what organs could be? You said lots of different people. Just so we know what different organs could be. So organ and tissue. So someone of his age, I mean, if he was an isolated brain injury, he could donate heart and lungs and liver, both kidneys. The liver could even be split at this age. And so it could help two different people. Both kidneys, pancreas, intestine, sometimes you can donate those. Heart valves, corneas, you know, help people see again. Bone, and bone can be sent as well, so femoral heads. Yeah, skin. Skin can be given to people for grafting, you know, people who have had severe burns. So again, like up to 10 or even more people can be helped. And regard to determining death in regard to organ donation, how's that done? And I know you mentioned there are a couple of different groups. Yeah, so there are two different groups, but underlying the deceased organ donation process is the fact that the patient has to be deceased. And then we also have a rule that is present for us that work in donation, so it's called the dead donor so what none of us that or none of the people that work in donation or transplantation can hasten the patient's death so we can and the rule exists so that it protects us from litigation so the patient actually has to die on their own so the two ways they can die are if they become brain dead and I can go into into that in a minute, or they have a circulatory death. So brain death usually occurs when you have some sort of terrible injury to your brain. For example, a big traumatic brain injury like this boy had, or a subarachnoid bleed, or maybe a hypoxic injury. The pressures in the brain continue to rise. And at a point, you know, obviously the brain is enclosed within this tight skull, and at a point the pressures are so high that the blood supply to the brain ceases. The patient actually, the brain then dies. The patient is on a ventilator, and the ventilator supplies oxygen to the circulation and takes away the carbon dioxide, the heart is actually just fooled into thinking that oxygen is coming, the patient's still breathing, and the patient's actually unfortunately dead. If you take away the ventilator, the patient does not breathe, and then the heart would stop. So in these cases, we can actually clinically examine them and declare them brain dead and that has to be done with this strict criteria for diagnosing brain death. Or if you cannot perform a clinical examination you can proceed to a radiological examination. For the other pathway, the circulatory death pathway, that's more like a more traditional way of dying when your heart actually stops beating. So in this case, the patient usually has a poor neurological prognosis. It doesn't really have to be a poor neurological prognosis. They could have, for example, high cervical spine injury or muscular wasting disorder. But what it means is that once you take away their life-sustaining therapy, for example, a ventilator or their presses, once you take away the ventilator, they will die very quickly upon removal from that therapy. Only those sort of patients could be considered for organ and tissue donation. And what we have to do is actually wait for their heart to stop. And then we actually have a very short amount of time in which we need to get them to the theatre and get retrieval surgery on the way. And this is quite difficult, especially for families. They don't have a lot of time to spend with their loved one. But we find that these families are so pro-donation, they're so pro-helping people that they're ready to go that extra mile to help others. And on the other side, how are organs allocated to recipients? So I don't really deal with a lot of that, but organs are allocated on a needs basis also it depends on your blood type and tissue typing so they're definite their lists that agree exist for each of those organs but you also have to be typed to the right organ so but it just it cannot go and you know if the if a family member says that to donation, they can't dictate who it goes to, which religious group it goes to, or which race the organ goes to. So they're purely altruistic and purely on a needs basis. We'll go to another case example. And this is your work in the intensive care unit. And it's another 65-year year old female who's deteriorating following a massive stroke three days ago and you're asked to organise a family meeting which obviously the consultant will be present at to kind of look at prognosis and I guess direction of care. Again is this a kind of appropriate time to start commencing conversation about organisation with the families? I think it sounds like it's a little bit early because your prognosis and direction of care are yet to be discussed. So I think it perhaps might be that the consultant has started to think in their mind that this is a bad prognosis, has started to discuss this with either the neurologist or the neurosurgeon, and there's some sort of consensus this is bad, but it needs to be relayed to the family. I often receive calls at this stage, and we tell them, look, you know, once your family is convinced that this, and you are convinced, and everyone is convinced this is a bad prognosis, then let us know. We can at this stage, you know, perhaps do a registry check or suitability check so that we do not waste the family's time afterwards, but we do not have any conversations with families till they are accepting of that diagnosis. You can imagine if they don't accept, then there's no point in us getting involved. So I think that we would advise them to go back and speak to their family and thank them for the call and ask them to let us know when they are, what the results of their conversation are, and we'd be very happy to come back in. So what role do families play in organ donation decisions? They have such an important role. I mean, the final say is always with the families. So our role as designated requesters is to provide families with information regarding organ and tissue donation so that they can make an informed and enduring decision for their loved one.
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Welcome to On The Wards, it's James Edwards. I'm here today talking about when is hyperglycemia an emergency on the wards and And I'm welcoming back Barbara Depchinski, who's a senior staff specialist at the Endocrinology at Prince of Wales Hospital here in Sydney. Welcome back, Barbara. Thank you. So we're going to talk a bit about hyperglycemia and DKA and then provide a case for a bit of background of when a hyperglycemia is an emergency on the ward. So what is diabetic ketoacidosis or DKA? So DKA is the triad of ketosis, metabolic acidosis and hyperglycemia. What's the underlying pathophysiology behind the development of DKA? So it essentially relates to an absolute lack of insulin action. So if you're lacking insulin, you've got unrestrained gluconeogenesis, which then results in hyperglycemia. Hyperglycemia leads to an osmotic diuresis and loss of electrolytes. Concurrently, though, if you have a very low ratio of insulin to glucagon, you can get unchecked ketogenesis. Ketone bodies then dissociate into hydrogen ions and anions, and that leads to a raised anion gap metabolic acidosis. So is DKA a clinical diagnosis, or is it purely based on biochemical criteria? It is a biochemical diagnosis, so pH below 7.3 and an elevated blood glucose, but you can get euglycemic DKA and ketones are present. But there's also that clinical picture of a dehydrated patient with perhaps coarseussmaul's breathing and complaining of abdominal pain. Could you give a brief comparison of DKA with hyperosmolar hyperglycemia syndrome or previously known as HONC? So in that condition, there's a relative lack of insulin. So there's still an osmotic diuresis from unchecked gluconeogenesis leading to hyperglycemia and the patient becomes dehydrated. But there's still enough insulin action to suppress lipolysis and prevent ketone body formation. And so we don't expect to see acidosis arising, or or sorry ketoacidosis arising in a patient with hyperosmolar hyperglycemic state and usually the dehydration arises very slowly so it's usually in an older patient. We'll go to a case now and it's a 52 year old male submitted to the wards with renal colic secondary calculus he's nearby mouth awaiting surgery and he's diabetic he's type 2 diabetic but he's normally on some insulin some lantus and novorapid but his insulin hasn't been charted because he is fasting and the nurse calls you on the morning of the patient's surgery because the BSL is 21. What is your approach to this patient with hyperglycemia? Well, what's the cause of the hyperglycemia? I think it's evident in this case. He's not being given his insulin and he's unwell potentially from the calculus and so his insulin requirements are also actually higher than normal. So first, think about the cause. Secondly, think about whether this patient's at risk of metabolic decompensation. So when you, as the JMO, are rung by the ward RN, ask the ward RN to do an immediate set of observations on the patient. So what's the heart rate of that patient? What's the blood pressure? What's the level of consciousness? And you may wish to consider checking for ketones as well. I mean, could this be DKA? Yes, it could. And I think we've got a big clue here. This is a patient with type 2 diabetes who's actually on basal bolus insulin. So they're on a QID insulin regime. and it would be interesting to know how long this patient has had diabetes because that would be another clue if he's had type 2 for a long time he might actually be quite deficient in his insulin secretory capacity so in this situation given the fact that he's on a complex insulin regime, not received it and is hyperglycemic, yes I would check for ketones. Okay, so DKA can occur in type 2 diabetics or you've often thought it as type 2? Yes it can. So we normally think about type 2 diabetes as being a combination of insulin resistance and a reduced insulin secretory capacity. But we know from the UK prospective diabetes study that at diagnosis already about 50% of insulin secretory capacity is lost in someone who has type 2 diabetes. So with time there's a further diminution in that patient's insulin secretory capacity. So if someone's had long-standing type 2 diabetes they might actually be quite insulin deficient. The other thing to think about is that some patients who are labelled as having type 2 diabetes might actually have type 1.5 diabetes or latent autoimmune diabetes in adulthood and the other aspect to think about is if you've got someone who has type two diabetes that you wouldn't expect to have ketosis but does have what looks like diabetic ketoacidosis that can arise when there's very very severe intercurrent illness so myocardial infarction or ischemic gut or you know extremely severe pneumonia. So what are some of the important questions you would ask when taking the history for this patient? So I'd like to know how long he's had diabetes for, has he ever had diabetic ketoacidosis before, I'd like to check about his insulin regime and how long he's been on that for. For him specifically on the wards, I'd like to know what IV fluids he's been receiving. Has he received any particular drugs that could have caused hyperglycemia? Unlikely with him coming in with a renal calculus, but good to review. And then I'd like to know, prior to coming into hospital, did he have reasonably controlled diabetes? What are some of the common precipitants of hyperglycemia on the ward? So I've discussed some of those already. So drugs, so glucocorticoids or octreotide, patients who have their insulin omitted when it should have been given or someone who has been nil by mouth and has had their insulin or in particular oral agents withheld appropriately but then are starting to eat again and will require that regime to be modified. TPN or enteral nutrition can be precipitants and also giving IV glucose without taking that carbohydrate into account. Are there any key examination findings you should look for and maybe describe what the typical appearance of a patient with DKA is? So someone with DKA will look hypovolemic, so you can look for the typical signs. And I'd be very interested in this patient's respiratory rate because that will be a good clue in terms of him having a metabolic acidosis. So he might have Kussmaul's respiration. He might be able to smell acetone on his breath and he may be complaining of abdominal discomfort. His urine output might be misleading in terms of assessing his volume state because he's likely to be polyuric because of the hyperglycemia. And what investigations would you order? I think you mentioned looking for ketones. What kind of ketones would you look for, urine or blood, and what other investigations would be helpful? Okay. So most hospitals nowadays have the option to do point-of-care capillary ketone measurements. So that's to measure beta-hydroxybutyrate. So if that that's available I would measure that on the ward. If that's not available then all wards still have the facility to do a urinalysis and so you can check for ketones by measuring urinary ketones instead. So we've established whether the patient has one aspect of that triad of whether they're ketotic or not. We've got the blood glucose level, it's above 20, so he's hyperglycemic. And then the third part of that triad for diagnosing DKA is the metabolic acidosis. So this patient could have a VBG drawn off. I'd be very interested to look at his anion gap and know what his pH is. And what would be the expectation in this patient regarding the anion gap and the pH? So I'd expect the pH to be low, so less than 7.3, and I'd expect the anion gap to be increased. The patient does have hypoglycemia, ketonemia and ketoneuria and a metabolic acidosis. Now what are your management priorities and goals from here on? Okay, so we've got three immediate goals. The first is this gentleman needs fluid resuscitation, so he needs rehydration, and usually we would use normal saline. We need to ensure that his electrolytes are appropriately managed, so even though you might see hyperkalemia initially, most patients with DKA have an absolute deficit of serum of their total body potassiums and that will need replacement. And we need to switch off ketosis and that's more critical than controlling his blood glucose.
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Okay welcome to On The Wards, it's James Edwards and today we'll talk about one of our favourite subjects which is blood sugar management or blood glucose management. It is something all junior doctors need to do and we thought we'd have a bit of a refresh and update for 2018 with Associate Professor Glynis Ross. Welcome. Hello, how are you James? So Glynis is a visiting endocrinologist at RPA and also at Bankstown Hospital and has had a long involvement in diabetes which we'll read more about in your biography but we're going to get into some cases and I think we really wanted to focus on blood sugars because it's such a common call for junior doctors on the wards and I think all junior doctors, even those who have just started their internship would have had a call on an evening shift about a patient with a blood sugar of say 14 and now a bit of a story when speaking to the nurse is about maybe being pre-diabetic but not on any regular medications for diabetes and this is the highest sugar so far and the nursing staff are pretty concerned and also wondering whether she just maybe an insulin order would be best for this patient. But before we get into really the details, maybe just give us a brief overview of diabetes and hyperglycemia. That's a really big question. Let's just give a brief overview. Okay, so diabetes is very common. The majority of diabetes is type 2 diabetes with about 10% being the immune type, which is type 1 diabetes and that's the new nomenclature that really should be in use. There are a few other unusual types of diabetes but they're the main ones that need to be aware of. And on top of that there are people that will have temporary forms of diabetes such as steroid induced that may settle down when they're no longer on steroids, and that does need different evaluation and management. And then there are a large number of people that have pre-diabetes, however that's defined. There are some challenges in defining that very precisely, but that's somewhere where the glucose tolerance is somewhere between normal and diabetes. And so about 30% of inpatients actually have diabetes itself. And then there's an unknown number of people that will also have pre-diabetes. And in the hospital setting when they're unwell, they're on bed rest, they've got a whole lot of medications that may impact on their glucose levels. A lot of these patients may be found to have high glucose levels in diabetes range while they're an inpatient, but they may not continue to have diabetes once they're discharged from hospital. And for those patients in particular, it's important to record this on the discharge summaries as it goes so that the GP can be alerted that they need to re-evaluate this patient once the patient is fully recovered from the acute episode. And in general terms, in treating people in hospital with hyperglycemia, the goals of glucose are between 5 and 10 millimole per litre. If there is a glucose a bit higher than that, such as the 14 that was suggested, look, it's suggestive that the glucose is in diabetes range, but with a random glucose, it's always a bit difficult, and particularly when there are potentially other contributors, such as if the patient's been on steroids, they're infected, so their stress levels are high. Okay, so outside hypoglycemia is pretty common. It's very common, yeah. I mean is it bad having some high blood sugars? I mean it's annoying for the nurses, it's high, it's out of range, you do not get to call but does it do anything to a patient even just in the short term? Yeah so the concern if people in hospital have high glucose levels is that the high glucose levels do make them more prone to infection. The higher the glucose, particularly if they are running over 14 millimole per litre, make it quite difficult for the patient's immune system to deal with the infection. So infection can be harder to treat or they're more prone to getting other infections. Also, we know that people with diabetes tend to have longer lengths of stay. If they've had surgery, they may have more trouble with healing as well as with post-op wound infections. If glucose levels are extremely high, then they're at risk of either getting hyperosmolar problems or ketoacidosis, but those acute events occurring once they're actually in patients are not so high. And on the other side of things, we're talking at the moment about high glucose, low glucose levels are also very worrying. And there are many issues that interrupt patients' normal routines with meals, with medication suddenly being fasted, yet they've got medication for diabetes on board, and maybe then at risk of hypoglycemia. And we're actually at least as worried about hypoglycemia occurring in patients as we're about the higher levels. Okay, so we've identified that high sugars are bad in hospital, low sugars are bad in hospital. Is there evidence to say that if we really have a good control of sugars, the outcomes are better? Yes, so if glucose levels are kept within that standard range around about the 5 to 10 level or at least 4 to 10, that the patients do seem to recover better, they have shorter length of stay, so that's clearly better for the individual patients and it's clearly better for the hospital system because of the costs. Good, so it's good to have a patient-based outcome that we're really going to try and explore in more detail. You did mention that a number of patients have high sugars and then they go home and may not have diabetes. How do you make a diagnosis of diabetes? Yeah. So there are a number of ways of trying to make a diagnosis. So we've got to compromise while we've got inpatients because patients being on bed rest and acutely unwell are a bit more difficult to assess. So in an outside of hospital situation, if a patient was having a fasting glucose checked and it was seven or more, that would be consistent with diabetes, but you do need confirmation with a second test, either a second fasting or another version of a test. Normal is technically up to 5.5, though the definition of pre-diabetes on an impaired fasting glucose is 6.1 or above. But again, this is in a well situation. If a patient were to undergo a glucose tolerance test, which has been the typical way of diagnosing. The two hour glucose on that is 11.1 or more that's in diabetes range but normal should be up to only 7.8 and in between 7.8 and 11.1 is impaired glucose tolerance and sometimes it's not the same with the fasting in the two hour, one only may be up and you need a confirmation at another time. But over the last couple of years, the Commonwealth Government has allowed an HbA1c to be used to diagnose diabetes, and that's when the cut-off is 6.5% or above. Now, there are some confounders with that and there are some issues that can acutely alter or make the A1c unreliable, but in terms that is reasonable but you can have a lower A1C and have diabetes. It would be unusual to have an A1C of 6.5% or above and not have diabetes even if it were temporary. So one of the issues with inpatients is if a patient comes in particularly say through ED or on an admission and they had a mildly elevated glucose or even if this patient with a glucose of 14, if an A1C were to be checked and it was 6.5% or above, that is highly suggestive this patient does actually have diabetes undiagnosed. And certainly the higher that is, so if it's up in the 8% plus range, almost certainly has diabetes and may not need a lot of confirmation afterwards. But at that 6.5% range or below, it still needs some review postpartum. Okay. Post-delivery, post-discharge. Post-discharge, yes. We'll go post-discharge. In regard to classification of diabetes, you briefly mentioned before, can you just go through that again just so I find my line? Okay, so, yeah, so the majority of people with diabetes, so around 90% of people are classified as having type 2 diabetes. So in old nomenclature this was non-insulin dependent or older age onset. The age of onset is quite difficult because even though the majority of people when they're found to have type 2 diabetes will be at least 30 or 40 or older. We are now seeing, unfortunately, some teenagers and even sub-teens with type 2 diabetes. So using an age in the description is not very good. With type 2 diabetes, basically, there's usually a combination of insulin resistance, which then requires the person to be able to make a lot more insulin to keep the glucose levels in the normal range.
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But if there is a loss of beta-cell function and beta-cell production over time, then the glucose levels go up because the patient is unable to make sufficient insulin to control the glucose. But it's usually a combination of some insulin resistance and insulin production. But over time, type 2 diabetes is progressive. So even with best efforts, people will tend over time to lose more insulin production and need an increasing amount of medication. So the more medication a patient with type 2 diabetes is requiring is giving an idea of the degree of insulin deficiency, particularly once they're starting to move on to insulin. The other major group of diabetes is type 1 diabetes, which is predominantly in autoimmune condition. And these patients will, again again used to be called juvenile onset or insulin dependent but again poor terminology so they should be type 1. Again most of these tend to present at younger age so they may be children or teenagers and the majority will present under the age of 30. But people can present with true type 1 diabetes even in their 80s and will have an acute onset, have very high antibodies and be urgently requiring insulin treatment. And not surprisingly, these often get overlooked and can be very ill by the time they're detected and put on insulin. But it's predominantly an immune condition and we can check GAT antibodies, IO2 antibodies, zinc transporter antibodies to support that diagnosis and you can measure C-peptide levels to assess the patient's own production of insulin. So there are other ways we can identify. Okay, so it's a really good classification of diabetes. So let's go back to the case, the sugar's 14, you grew up pre-diabetes, what else would you ask the nurse over the phone? Well one of the issues, first of all if you're just being told the glucose is 14, is just confirming that the patient definitely hasn't been given a diagnosis of diabetes. But asking is the patient well or unwell, because that is one of the first things you're wanting to know. If the patient is unwell, it's more urgent for you to go and physically assess the patient. If the patient is well, there's a bit more time, and it's a matter of then working out what other medications have been on, what's the patient been eating, and a lot of this may be quite difficult to do on third-hand testing. But also, you know, you've got the ability to ask the nurse, have there been any other glucose levels being done? Have all the other glucose levels been fine? Have they all been trending high? Is it just a one-off? And if it is just a one-off, you may not need to do anything at that time. But you need to prioritise, just go and just do the review for yourself just to check that all of the information is actually correct and that it is a true reading. There can be confounders. So if a patient hasn't had a hand washed just before the test has been done but it handled some fruit, for example, it may be a false reading and it may be partly measuring the sugar from the fruit so again it's confirming that this reading is there and just looking at the overall pattern but the wellness and any other information that you can get but at 14 it's not an urgent panic situation that you have to be driven to give a phone order. Yeah so that's the next question would you give a phone order for a short-acting insulin and just want it to come back in the normal range and get on with all the other jobs you've got? Well, my preference is that no. I would prefer not to have a knee-jerk reaction to short-acting insulin. And it's really just looking at in the bigger picture and the context of that particular patient and making a decision. So in general terms, I would say the answer is no. But also then, you know, that does need to be documented, needing to make sure there is ongoing monitoring and that it is single, this is going to need to be a team review. So if you're on night shift, it needs to be a team review the following day, it should be left longer than that. Okay, so I mean, you did observe and you asked for more monitoring and they did more monitoring but now the sugar has gone up to 20 and as you suggested you were busy before but now okay it's time to go see the patient. Yeah. So just outline your approach. The blood sugar is 20, you're there at the patient's bedside, you've got the patient's notes, what's your approach to assessing someone with hyperglycemia? So just having to go again through all the different bits of information that are available to you, so talking to the patient, assessing have they got any hyperglycemic symptoms, what have they been having to eat or drink, has there been anything unusual that has been occurring and at that point really, because the concern once the glucose is up around 20 is that look this may need further this may then need treatment so if an HbA1c hasn't been done I would be putting an order in for that the next day but in general terms if it is around 20 it's a clear-cut diagnosis of diabetes I would be wanting to check that there weren't any ketones so the one thing that you're really most wanting to know is could this patient be presenting with type 1 diabetes and things deteriorating? Are they at risk of a ketoacidosis because they've got no insufficient insulin on board to stop fat breakdown? So you'd be wanting to just do some electrolytes, have a look at the bicarb in particular, and then beyond that to see what's happening. But the patient you would expect to be symptomatic. Now, if at that point you didn't feel the patient had any sign suggestive of type 1 diabetes, the decision is, are you going to start this patient on medication? Now, if you're starting medication in hospital, the general medication to use would be insulin. It's the easiest to tailor. There are many contraindications in hospital for most of the other diabetes medications, so I would be very cautious about introducing any oral medication without a great deal of thought. If it is someone with type 1 diabetes then you do need to immediately be introducing some insulin and these patients should be referred to endocrine. Now whether you'd have to make a decision at the time, whether you felt it was urgent enough to ring the endocrinology registrar on call, but there is an endocrinology registrar on call 24 hours, or whether you would just start the patient on some insulin. But if you are starting insulin, and this is whether it's type 1 or type 2 diabetes, just giving a knee-jerk reaction of insulin because the glucose is high and then not doing anything further is just going to bounce the glucose down and then the glucose will bounce up and the patient becomes very unstable. So at RPA we have got the triple B protocol and it is available through eMeds as well which basically gives a guide on how to introduce insulin particularly in an inpatient setting. And so one of the important things is to introduce some basal insulin just to try and generally control glucose levels and the calculation for that is weight-based and then introducing some insulin as required to cover meal times. It also allows for correction of insulin so that if the glucose is elevated prior to a meal that there's a standard amount of insulin added in and that is far safer than the old versions of sliding scale insulin where there would be a range of glucose written up with some insulin orders depending on what the glucose level was. The frequency at which it was to be given was all very random but they may be close together which can lead to subsequent insulin stacking when it all hits or too far apart so the glucose levels are just seriously swinging from high or low and so the triple B protocol allows for a much smoother situation that can be tailored for the patient. If the patient suddenly isn't able to have a meal because they're fasting for an ultrasound, the mealtime insulin just gets omitted and you can still give correction insulin if the sugars are high. But certainly type 1 diabetes or any possibility of type 1 diabetes, positive ketones should be referred to endocrinology without delay. So there'll be many lifting don't work at RPA and there'll be similar protocols at most hospitals that either endocrine or the medical teams know. And there is under very advanced development through the New South Wales Agency for Clinical Innovation both both teaching modules and some apps that will guide on this. And in the apps, it is based on the BBB protocol to give the guide for commencement of insurance. So even though I'm talking about it from an RPA perspective, this is actually going to be available soon statewide. Okay, fantastic. You mentioned some investigations ordering a HBA1c. Are there any others you'd consider? You said electrolyte. Do they end up being as blood gas? What sort of things?
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Welcome to On The Wards, it's James Edwards and today I'm talking about the unwell renal transplant patient and I have Dr Erin Vaughan. Erin is a renal medicine trainee here at Royal Prince Alfred Hospital. Welcome Erin. Thank you for having me. So we're going to go about the renal transplant patient and we'll start with the cases to provide some context and you're asked to see a 55 year old renal transplant patient who's now developed a fever of 38.6, a blood pressure a bit on the low side 95 over 60 and just feels generally unwell. You're taking this phone call from a nursing staff, what's your kind of questions you may want to ask at the end of the phone? Yeah I guess this is quite a common presentation both either on the wards or in the emergency department and the good triaging questions I always like to ask when I get a phone call about an unwell patient is their observations. So you've got a couple, they've got a fever and they've got low blood pressure. What are their saturations? Just get the complete set of observations. It's always a good triage. Also ask a little bit about the history as you're making your way down to see the patient. So why have they come to hospital? What are their presenting symptoms? And what medications they might be taking? Just have an idea in your mind, start running through some differentials that it could be. I mean, there are a number of cannulas that need to be put in. Is this a priority or should this be something you need to get now or can it wait till the end of the shift? Absolutely, this is a priority. This is a put down your blood tray for the cannula that you're about to do. And you'd be probably walking to see the patient if not already starting to manage them over the phone. So this should be on the wards, a clinical review call, which generally means within 30 minutes. But an unwell transplant patient is a clinical emergency. You should be going to see them. Okay, you get there and see the patient and you think they look well enough to take a bit more of a history. What sort of history are you going to take? So again you're thinking fever it's going to most likely be an infection so you want to get a good history as to what you think the cause of the infection might be. So full systems review would be warranted. obviously targeted a little bit to what their symptoms or signs might suggest. Important things to remember are that common things and common infections are still common in transplant patients, but you do have to have in the back of your mind other rarer complications. They do present subtly and often atypically as well. So particularly for us, urinary symptoms, so dysuria, haematuria, frequency, common things like that, or abdominal pain. And then I guess the other common infections would be respiratory infections. So I ask about respiratory symptoms, gastrointestinal symptoms, and sort of systemic symptoms. So do they have rigors and chills and how unwell have they been feeling and how long have these symptoms been present for? Another important question that I like to know is the renal registrar, are they still making urine? Because obviously the unwell transplant patient, as well as any other patient, they can get hypoperfusion to their kidneys and acute kidney injury. So in a transplant patient, that's an emergency as well as any other patient they can get hypoperfusion to their kidneys and acute kidney injury so in a transplant patient that's an emergency as well. Other ways to triage how you might be managing or how you keep going with this is what sort of infections have they had previously so depending how far out they are from transplant they might have been a type of patient who's had recurrent infections so it'd be good to know what infections they'd had previously, have a look at their microbiology if you can get the nurse to help you get the computer up and have a look at what infections that have had previously. It might trigger you to do some further investigations that way. And then you need to know enough detail about their transplant. So when was their transplant? How recently was it? Because based on when their transplant was, we can triage what sort of infections they might have and what immunosuppression drugs they're on. So all of our transplant patients have the orange card, which is usually an up-to-date list of their immunosuppression medications. So you want to know what's on that and are they taking it, importantly. And if they've had any previous episodes of rejection, that can be important because they might have had even more immunosuppression than just a regular standard immunosuppression, which makes them at higher risk for nasty infections. As with all histories, you want to know the rest of their background, medical problems. In particular, have they got diabetes that might make them immunosuppressed or they might be on some medications that can be contributing to making them more unwell and other risk factors like cardiovascular disease and things. I guess with any other infectious presentations, you want to know have they travelled, have they had any sick contacts and especially for the transplant patients have they been vaccinated. So we've got this really good thorough history that we've gone through. What do you particularly look for in examination for a patient such as this? So examination we know what the vitals are, we ask for those over the phone, but particularly get a regular set of observations, so keep a close eye on it, make sure the blood pressure's not trending down, the heart rate's not trending up, and just remember that the immune system is dampened in the transplant patients, so you'll find on our ward, the transplant ward, you'll get a clinical review call for a temperature of 37.2. So we have a lower threshold for triggering a review by a junior medical officer. So that's a review for a fever and they'll need to do the workup from that. And again, remember that they can present subtly and atypically. So particularly aside from your full thorough examination we want to look for any foreign bodies so indwelling catheters they might have drains if they've had recent surgeries, any dialysis catheters or if they've had previous dialysis access with grafts, any foreign bodies that might be a source of an infection. A good look at their skin, so if they have any wounds or any rashes that may be a source for infection. And then importantly as renal physicians, we love a good fluid assessment, so thorough fluid assessment, blood pressure, obviously don't really want to be doing postural blood pressures on these patients because this patient's already hypotensive. But if you can look at their trending weight and in particular their urine output, that would be really important. And then complete your cardiorespiratory and abdominal examination. And in particular, feeling over that graft, feeling if it's tender or if there's any bruise or anything abnormal in the abdomen. So Nitu you mentioned temperature, I mean an unwell renal transplant patient looks unwell without a temperature, can that still be infection? It's infection, infection, infection until proven otherwise as far as I'm concerned but certainly there are a number of other causes for a fever in a transplant patient that we would need to think about. So things like thromboembolism, rejection or in the longer term malignancy could present with fevers as well. In regard to investigations, what's your approach? So investigations, when they've got a fever, they need a full septic screen. So culture everything that you can, certainly at a bare minimum, blood cultures, urine cultures, viral splobs, sputum cultures, stool cultures. It sort of will be guided a bit by what you found on your systems review and your examination. But if you can culture as much as you can, as quickly as you can before you institute antibiotics. That's always really helpful for ongoing management. A baseline chest X-ray and then the rest of the imaging investigations would probably be determined by what you found on your examination. So abdominal CTs, renal tract ultrasounds, X-rays, those sorts of things we would determine. Yeah, I think it's also what we always emphasise within the podcast, if you're doing blood cultures, make sure you do two sets of blood cultures. Absolutely. Different sites is always helpful. If they've got central lines, catheters, sets from the central line, our nurses can access spas caths to take bloods from those vascular catheters. Very important. So we've identified that we're concerned about an infection, we've done some blood tests, a thorough examination, what next? So I think what I really wanted to get across is involve senior colleagues early. As a junior doctor, especially as an intern in emergency department, seeing these patients by yourself can be quite daunting because they're quite unwell and they do deteriorate rapidly.
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Okay, well welcome to On The Wards and another podcast. Today's podcast we're talking about prescribing, particularly relating to common errors, common interactions and side effects. My name's Bruce Way and I'm joined by Chi Tran. Chi is a senior pharmacist in projects at Prince of Wales Hospital. She studied pharmacy at Monash University and she has a particular interest in the quality use of medicines projects. Welcome, Chi. Thank you, Bruce. Okay, so we're going to go through a number of different issues around prescribing and we might start off just by asking a few general questions. So, Chi, what do you think are the three commonest prescribing errors in hospital? To start off, different hospitals be using paper prescribing, medical charts, and also electronic prescribing. So at Prince of Wales, we've moved on to electronic medical medication prescribing. So if we look at just paper prescribing and the potential errors with that, one of the common ones is different formulations of medications not being specified on the chart. So if it's slow release or immediate release, this is particularly important to communicate clearly to nursing staff which to give to prevent dose dumping. So they might give the immediate release by mistake and not the slow release product. So this would be things like Oxycodone and Oxycontin? That's right. So Oxycontin is a very common one. And with those particular drugs, we would recommend to prescribe both in generic name and in brand name just to increase the clarity. And on the paper charts, there is a box to tick slow release to make that quite clear to the nursing staff. So the more information will reduce the risk of error. Yeah, that's correct. Another common error is transcription errors with paper charts. So that means the charts last for seven days and so you need to write a new chart and that's called transcription. And during that process, sometimes I have seen doctors just blindly copy onto the new chart without thinking. And it's just really important to kind of review what you're prescribing and just to review the medications at that time too. If we move on to electronic prescribing, I think the most common thing that we have noticed is alert fatigue. So alerts popping up. It's important to stop and have a look at. They do pop up for a reason, mainly for drug interactions. So just stop, have a look and just make sure what you're prescribing doesn't harm the patient. And I think the other important thing is because with electronic prescribing, you're typing in the drug into the computer, the first few letters, you have to pick the correct product. And the number of products come up, but they all look quite similar. So it's quite important to pick the right one. It's very easy when you're scrolling down to click on the wrong thing as well, isn't it? Yeah. So I guess a lot of it's about mindfulness and concentration and not just seeing it as a rote task. Yeah, that's correct. How you would address those issues. And I guess the other thing is having somebody sort of check your work and that's what we value, the actions of pharmacists as well because it's part of your role. Yeah. Okay. What patient groups do you think are particularly at risk of medication errors? The older population, and that's because they have more comorbidities. They're usually on more medications, which then increases potential risk for more adverse drug events. And they've got decreased drug clearance, which is also associated with ageing, and therefore a lot of medications would need dose adjustments as well. Another group is the paediatric population. So in that group, all medications are normally doses calculated by weight. So it's really important to get that right with those patients. So anything involving arithmetic is prone to error as well. Yeah. Okay. And patients on many medications, so more than five usually, and again, it's to do with drug interactions, adverse drug events. And a group of medications, which is particularly at risk of medication errors, is the A-pinch drugs, so the high-risk drugs. And they include antimicrobials, the electrolytes, including potassium. Insulins is really important too. The opioids and the chemotherapeutic agents too. So they're particularly at higher risk as well. So that's the acronym, A-Pinch, for people that want to remember. Yeah. Okay, excellent. And what do you think are the commonest three drug interactions that might cause problems? I want to run through a couple which I think are quite important. So drugs with narrow therapeutic index. So therapeutic index is a range of doses where medication is effective without acceptable adverse events. So drugs with a narrow therapeutic index, it's much more important to get the dose right and the levels right. An example of that is digoxin. So I guess if a patient has renal impairments, you dose reduce that medication. And a lot of medications do interact with digoxin as well. And so that may increase the level of digoxin and cause increased toxicity associated with that. Another common drug interaction is called the triple whammy. Have you heard of that term? No, I haven't. Tell us about the triple whammy. So it usually involves a combination of three drugs, an ACE inhibitor or the Sartans, a diuretic and the NSAID. And these agents, when prescribed together, have an additive detrimental effect on the kidneys by reducing blood flow to the glomerulus and reducing the filtration rate and so it can cause acute kidney failure so that's quite important and a lot of the drugs now are available in combinations of the ACE inhibitors and a diuretic and just adding an NSAID to that can cause. Yeah because I mean NSAIDs are fairly commonly prescribed now and people sort of remember about gastrointestinal side effects and things like that, but they don't often necessarily think about the renal issues as well. As you say, particularly if they're on other drugs, which can affect kidney function too. Yeah. So I think that's potentially a common one. Yeah. A not so common one, but a very important one, is the interaction between allopurinol and azathioprine. And this interaction is potentially fatal. So allopurinol inhibits the metabolism of azathioprine, and then it can cause accumulation of toxic metabolites, which can cause bone marrow toxicity. And so the combination is best avoided. But if you do need to use a combination, the azithromycin, sorry, the azathioprine dose must be reduced by 25% to 33%. Okay. But if you're unsure, please ask the pharmacist. That's usually available in the wards. So I guess it's important whenever you're starting any new drug to review and think about what other drugs the patient's on and what the possible interactions might be. Yeah. Even the simple sort of things, as you say, like NSAIDs can have detrimental effects. Yeah, and NSAIDs are available over the counter and in supermarkets too. Yeah, exactly. All right, that's good. We might do a case now and discuss that. So I'll just, for the benefit of our listeners, I'll read through the case. So it's an 87-year-old non-English-speaking lady from home who's been brought in by ambulance after an unwitnessed fall and has had a long lie at home. She's suffered a fracture of the right greater drchanter and is awaiting orthopedic review for potential surgery. She's also suffered an acute kidney injury secondary to dehydration and to some rhabdomyolysis. She can only tell the people in the ED about part of her medications and you've just received the GP's complete list of medications for the patient and been asked to chart her regular medications. So she's on Avapro HCT for hypertension, aspirin and warfarin. The warfarin is for a metallic mitral valve. She's on metformin for type 2 diabetes, torvastatin for cardiovascular protection, pantoprazole for Gord, long-term diazepam and fluoxetine. Initially prescribed for sleeping and anxiety. So that's a reasonably common list of drugs for an elderly person. Yes. So her warfarin dose for the day was withheld in the AD in view of the potential surgery, and her INR has just come back as 2.1. Okay, so that's the history. So tell us, what do you think are the issues in this case, Chi? The first, I think, is her acute kidney injury and to consider whether her medications are suitable in light of this compromised renal function. The other thing to consider is she may potentially be going for surgery. So to consider stopping metformin and bridging anticoagulation for surgery. We also look at the reason for her fall.
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Rhabdomyolysis, is that due to, do you see what that's due to? And depropionis of a statin because she's on a statin. She's dehydrated, so the appropriateness of the diuretic. The reason for the PPI, so I think it was pentaprazole. And I'm unclear with the reason for being on both warfarin and aspirin as well. So those are the things I would look at. Okay, all right. We might explore those a bit more. So talking about the anticoagulation, the patient has a sub-therapeutic INR for the indication, may be going for surgery. What do you think we should do about the anticoagulation? So in this case, because she's potentially in for surgery, we would consider bridging therapy. So to stop the warfarin and to start either unfractionated heparin or low molecular weight heparin. But in this case, she's got acute kidney injury, so we would not use the low molecular weight heparin, just continue with the heparin IV infusion. Usually that would be ceased four to six hours prior to surgery. And most hospitals have a local heparin policy, so please refer to that for dose adjustments. I think that's what you would do. Yep, so we'd monitor the APTT once you started on the heparin and try and get that up to therapeutic for your indication and then we could stop it prior to the surgery as you said, four to six hours. Okay, so we were talking a little bit before about medication interactions. Warfarin is another drug that has a lot of interactions. So what are the sort of common ones that we need to worry about with regard to Warfarin? Warfarin's an interesting drug. Its mode of action's quite interesting. So if we understand how it's metabolised, you'll see the different types of drugs that can interact and how it interacts with warfarin. So it's made up of two isomers, the R-isomer and the S-isomer. And the S-isomer is five times more potent than the R. And it's metabolized by two ways. So the S is metabolized by the CYP enzyme, P450C29, and R is the CYP3A4. So obviously anything that interacts with the S-isomar or the CYP P450C29 pathway would result in a significant change in the INR. And again, with the CYP3A4, which is affected by the R-isomer, that would have a modest effect with the INR results. So anything that affects both CYPs would increase significantly the INR. An example of that is amiodarone. And other enzyme, hepatic enzyme reducers can cause a reduction in INR. So carbamazepine is an example of that. And those sorts of interactions are called pharmacokinetic interactions. And if we look at the pharmacodynamic interactions, which means how the body reacts to the medication, if you add things like SSRIs or benzos, fish oils, antiplatelets, that actually has an antiplatelet additive effect, which can cause increased risk of bleeding, but not necessarily changing the INR and causing GI bleed is the EBSEDS can cause that. Yes, through a different mechanism, right? Yes. One of the other common ones I see in the emergency department with warfarin is antibiotics and particularly the macrolides. Yes. That can cause an increase in the INR of the patients on warfarin as well. It's one that doesn't seem to be generally appreciated by GPs in the community who prescribe a lot of macrolides. Yeah. Okay. So one of the other issues you mentioned was the acute kidney injury and what medications may be contributing to that. So in that regard what sort of what would you stop or what would you be worried about? So we would worry about if the patient is hypervolemic we'll be concerned by her diuretics and antihypertensives so consider stopping withholding those. We also look for any other nephrotoxic drugs she may be on. It doesn't look like she's on any NSAIDs or she's on an ACE inhibitor. So we'll withhold that, as I said. She's also on metformin. So metformin, there's an increased risk of lactic acidosis in patients with reduced renal function, old age, and in this case she kind of fits that criteria. So we'll definitely consider withholding that as well in this patient. And you mentioned before the statin and the possible relationship with the rhabdomyolysis. What can statins do to muscle? It can cause muscle wasting. So that's a rare side effect, but one that we definitely tell patients about. So in this case, yeah, we would stop that too. I mean, I guess her rhabdomyolysis was most likely due to her being lying still for a long period of time. Yeah, but it would help. Yeah, but you'd also be thinking about, and she probably doesn't need to have the statin acutely anyway, so that's probably something you could think about withholding as well, at least until it's resolved. You mentioned before, I think, about with renal impairment and dosage adjustments of medications. Do you want to just talk a little bit more about that? Yeah, so with renal function, it's important to recognise those drugs that require critical dose calculation and renal impairment. There's a lot. There's a huge list of them. And we calculate the dose by using... Sorry, we calculate the renal function by using the Cockcroft-Golf equation or modified EGFR, which is modified for actual BSA. And we use that to determine the adjustment of the drug. So examples, I guess, of this is antibiotics. So it's quite important to check, because I think more than 50% you'll have to dose reduce. But you can look it up in the therapeutic guidelines. There is a big table on there that you can check. Another common drug is drugs that are renally excreted. So again, the metformin in this patient. Inoxaparin is a common one too. Most patients are on it in hospital. And so you need to check that and reduce the dose. Some drugs can cause great adverse effects or toxic levels, such as the sulfonylureas and digoxin. And some drugs have less effect in impaired kidney function, so drugs like frizomide, you need bigger doses for the same effect. And I think they're still called the newer oral anticoagulant agents, the NOACs. NOACs, yeah. They're anticoagulant agents used for DVT, PE, AF, and they include dabigatran, apixaban, rivaroxaban, and those drugs definitely require dose adjustment in renal impairment. And that's important because they're being much more commonly prescribed now. Yeah. That's an alternative to Warfarin. All right, good. Now, the elderly population, we've talked about the risk of polypharmacy and being on lots of medications. What are some of the common ones that often get stopped in hospital because they're not necessarily benefiting the patient? So there are many, but I think one of the main ones are the drugs that cause anticholinergic side effects, so the anticholinergic drugs such as oxybutynin, the tricyclic antidepressants. And it is because they can cause increased risk of confusion, delirium, dry eyes, dry mouth, urinary retention, tachycardia. So it's not very pleasant for patients. So we would consider... It's also a lot of the patients will come in with a delirium and say you're looking for a cause. So I guess you stop the medication and see if that makes a difference as well. Yeah. The statins we mentioned as well. A lot of elderly people, it's probably not a lot of value in them being on statins. And if they've got an issue with rhabdo or something like that, it's a good idea to stop that. Okay. Anything, any other? Yeah, I've got here also antihypertensives to reconsider, including thiazides. So there's limited data, but it does show there's no reduction in mortality in patients over 80 when stopping the antihypertensive. And they usually remain normal intensive six or five years after stopping the drug. So there's something to consider too. Yep. So don't be afraid to stop it. It's a quick situation to see what happens. Okay. And what about the falls? This patient's had a fall.
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Hi, it's James Edwards. Welcome to On The Wards. Sanjay Wariya, who's a VMO breast surgeon and general surgeon at RPO. Welcome, Sanjay. Thanks, James. My pleasure. We're going to talk about a pretty common problem that junior doctors face, either on the ward or in the emergency department, and that is abdominal pain. So we'll start with a case. They work in the emergency department, they pick up a patient and it's a 50 year old who's got some abdominal pain. Can you describe your approach to abdominal pain? Thanks James. So I think as a junior doctor I think it's important to have the basics right. The first thing that I would do with a patient with abdominal pain is start by calming the patient down and what that means is ensure that they've got appropriate lines and analgesia on board so that you can examine them. One of the early things to do is to assess whether or not how do they look. Do they look well or do they look unwell? Subjective assessment is generally a very critical part and underestimated part of an assessment and I think it's an important skill to develop which is how does a patient look. Another important aspect is checking the vitals and assessment of vitals should be performed early. If they are abnormal you need to deal with them and that means the mantra of airways, breathing and circulation as with any other emergency. Another area which is probably not focused on enough is history and particularly with somebody presenting to the emergency department I think it's important to have an understanding of the embryology of the gut. Embryology of the gut I can I can almost feel everyone going to sleep now tell me embryology of the gut is that important? I think I really do feel that we underestimate the importance of history and trying to ascertain where pain starts, when it started and where it's radiated to. For myself, I think to make sure that I'm not missing aspects about the pain history, I actually use an acronym and I use SOCRATES, which is based on sight, onset, the character of the pain, radiation, associated factors, the timing, exacerbating factors and relieving factors, and associated severity. And that way I'm being incredibly detailed with my history prior to jumping into an examination. At this point in time from history, you'll get an idea of what your differentials are prior to embarking on a clinical examination. So how does embryology relate to that? It comes back to the types of pain, visceral and parietal pain. And essentially a pain that started in, for instance, in the midgut will start around the umbilical area and it will start as a vague pain and then when the parietal peritoneum gets involved it will become a sharper pain and move to the particular organ that's involved. So having an understanding of clinical examination is probably underestimated I think. With regards to associated factors, it's also taking in are they having other symptoms such as dysuria or are they having associated nausea, vomiting or diarrhea which may give you an idea of the more likely differentials associated with that presentation. After taking a critical history, I think it's important then, we really are now at this point ready to examine the patient and part of the important thing here is to make sure the patient's appropriately exposed and appropriately positioned. So I do think it's important to put the arms by the side, make sure that they're as relaxed like we've mentioned before they've had appropriate analgesia and don't make things difficult, keep it as simple as possible but start with inspection. Don't just move on. Often what happens with junior doctors is there's such an impetus on the palpation part that it's almost like a camel burying their head in the sand. It's important to actually take the time to inspect appropriately. Looking for scars from previous surgery. You can actually, on inspection, an if a patient has abdominal breathing and respirations or whether or not there's guarding if if they're not moving their belly at all that's a sign that potentially they have a rigid belly and i think that's underestimated also in the setting of traumas so i do think it's important not to underestimate the importance of inspection as well yeah Yeah, I mean, I work in the medicine department and I think I can almost diagnose renal colic from just walking to the room. And sometimes even with the appendicitis walking from the waiting room into the bed, the way they sort of hold with appendicitis, you get a good idea whether they've got that, as you said, visceral pain or maybe parietal pain. Yeah, excellent. Then when it comes to the examination, which is a critical part, by the time you're starting to examine a patient with abdominal pain, hopefully there is a synthesising process that's occurring based on your history and differentials as well. It's important when you're examining an abdomen that we've mentioned about pain relief and we've mentioned about inspection, at this point it's important to probably start in the quadrant that isn't tender and move around towards a quadrant that is tender. And it's important to be systematic and not miss a quadrant as you can often find other associated signs which you'll miss if you don't examine all the quadrants. When you're thinking of a particular diagnosis such as cholecystitis it's important to assess for Murphy's sign and associated signs. In appendicitis, you should also be looking for associated Roswing sign and Sower sign. So look for things that will assist you prior to starting your investigations. I think you can get a lot from combining a good history and an examination. Can you just go back to what those signs are and how you examine for them? Yeah definitely. So I think for cholecystitis an important aspect is palpation and assessing for Murphy's sign which the important thing is to position your hand and use the flat part of your second digit and move the flat part starting in the right lower quadrant and get the patient to take big, deep, inspiratory breaths. And as they inspire, as you come closer to the gallbladder, there will be tenderness elicited, and this is a positive Murphy's sign. You then as they expire move your hand gradually towards closer to the liver and eventually a positive Murphy's will elicit this tenderness. In the setting of appendicitis Rosving's sign is placing your hand in the left rather than the right lower quadrant and palpating to deep palpation what you will get is guarding but tenderness that will actually radiate to the right lower quadrant. This is quite a good sign to use in conjunction with the fact that they're going to have guarding at McBurney's point, which is the point which is two-thirds towards the anterior superior iliac spine in a line from the umbilicus to that point. I think a psoas sign involves irritating psilocyne muscle, which is a posterior muscle in the abdomen, which will irritate the appendix and cause pain, again, in the right eyelid fossa. So how do you test for the psilocyne? The psilocyne can be quite difficult, like if somebody's in significant pain, but it involves... How do you do it generally, James? I kind of lift their leg up and wiggle around a few times and see if it hurts, but I'm not sure that's the right method. Yeah, look, I think the simplest way is essentially what you're trying to do is irritate the psoas and see if you're eliciting tenderness. And there are different ways of doing it. One is to change the position of the patient to a lateral position or a prone and try and flex the hip. I think the simplest way is what you're describing, which is essentially lifting, flexing the hip joint and externally and internally rotating and you'll elicit tenderness if there is a structure being irritated on the soleus muscle. So that, I think it's not a bad thing to be complete with you and systematic with your exam. If you're suspecting a diagnosis think about the ancillary signs which are an important aspect of the clinical examination. Okay so we've gone through a bit on a history and examination. What investigations are important in someone who's got a bone wall pain? Again I think it's very important to synthesise your history and exam before coming to investigations. Part of our baseline investigations includes a full blood count looking for a white cell rise which will be a marker of infection. We do an electrolyte count as a baseline as we would do a liver function test, particularly with upper abdominal pain. Somebody who is potentially a surgical candidate, it's good to know what's happening from a coagulation profile as well. It's also potentially, if you're thinking about a surgical course, an important thing to consider with doing a group and hold, and particularly if you're thinking about bleeding or their own blood thinners as well.
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It's also important not to exclude a lipase which is another masker for abdominal pain and it can present in a number of ways pancreatitis. For renal colic often like you've said James there is a certain way that a patient with renal colic, often, like you've said, James, there is a certain way that a patient with renal colic may present, and a urinalysis is an important aspect in that diagnosis, looking for blood on the UA. For patients who have severe abdominal pain and are giving a history of sudden abdominal pain, we're guarding. It's important to exclude perforation. And the best way to do this is simply with an erect chest X-ray. It's a simple test, but a very useful test in our SIV. I'm often asked by junior doctors what the role of abdominal X-ray is in someone who's got abdominal pain. What are your thoughts? I personally don't think you necessarily need to do erect and supine abdominal films for everybody. Again, it's placing, synthesising the history and examination. If you have a concern about a bowel obstruction, then your abdominal films are going to be more beneficial. If you're thinking about a large bowel obstruction with somebody who's got distention with abdominal pain, or if you have a distended belly with somebody who's had multiple operations or even a virgin abdomen and you're considering a small bowel obstruction with associated colicky pain and vomiting and distension, I would consider definitely doing erect and supine abdominal films as well. I think the usefulness in patients who are presenting with not bowel obstruction symptoms is probably less. And if you're concerned after doing this appropriate sieve about a potential of something serious, then we move into our management, which involves liaising with potentially a senior medical officer in the emergency department and also the surgical registrar who's on, who will be more than happy, I'm sure, to assist in guidance from there. Part of our ongoing management then is if you're concerned about the patient is organising a CT scan. When we're organising a CT, I guess we need to think what are the the underlying possible diagnosis person would have. Do you want to just outline some of the common cause of abdominal pain that we've probably seen in the emergency department? So pathological causes for abdominal pain, once you've got parietal pain you'd be thinking about the area of the body that's predominantly affected. So for somebody who's presented with right lower quadrant pain, probably the commonest thing we see is appendicitis, and this is independent of age. Other causes include rarely a colitis, sometimes, and that's in an older age group, sometimes on a background of an obstruction. Renal colic is a common cause for right lower quadrant pain and that's why history is important, working out whether it's actually started in the loin and moved to the groin. For a right upper quadrant pain, again, it depends on the surgical person, I mean, on the patient. If they've got a background of alcoholism, there may be hepatitis as a cause. But from a surgical perspective, high on our list would be cholecystitis. I think taking into consideration whether the patient's jaundiced as well is an important part to see whether or not they've potentially got cholangitis. In the central aspect and right upper quadrant again we'd be thinking about pancreatitis as a cause. Left upper quadrant pain is an interesting phenomena because there's not a lot of pathology that sits in the left upper quadrant and if somebody's got severe left upper quadrant pain and it's not going away with analgesia, I do become concerned that there may be something that requires a CT scan. And although an erectus x-ray is quite good at picking up perforated viscous, it doesn't always pick up all the retroperitoneal structures. So CT sometimes will pick up that group. So if we're talking about perforated viscous, when we've got air under the diaphragm, we're talking in general terms about two different areas. So in the upper abdomen, if it starts, we're thinking about a perforated stomach or perforated duodenum, generally. If it starts in the lower aspect of the belly, then I would be, higher on my list would be diverticular perforation. And these are the common hollow viscous perforations that cause air under the diaphragm. In more complex patients you may see variations based on complex pathology but these are the common causes for air under the diaphragm. And left lower quadrant would be likely to be diverticulitis? Yeah so by far the commonest cause we see for somebody who's got left lower quadrant is diverticulitis. Again, we'd be thinking about renal colic. Again, with females in childbearing years, and I always have high on my list just excluding an ectopic. With gynaecological causes for pain, I think it's important to keep them in the back of your mind, but at the same time, not just dismiss it as such, and make sure you've excluded other causes as well. And I think probably for those with upper abdominal pain who are elderly, they probably should have an ECG to make sure they haven't got a myocardial infarction and the chest x-ray can pick up a pneumonia that we didn't pick up on examination. Yeah, that's a very, very important point. So the next part, we've come into imaging. So CT abdomen seemed to be the imaging choice for a lot of surgeons. What patients should get a CT and which ones maybe should go straight to theatre? I think probably a good way of looking at it is, is the CT going to change your management? Have you already got your diagnosis? If you already have your diagnosis and the patient's got appendicitis, then the benefit of a CT scan, if you're already taking to theatre, is probably low. Somebody who has a good history and has a perforation, I would again be moving more towards theatre, getting a surgeon involved early, describing the history and then liaising with theatres about getting the process going. Somebody who has undifferentiated abdominal pain despite being as thorough as possible, they're the patients who benefit the most from a CT scan. People who are, I think the other group to think about, which we haven't quite touched on yet, is the elderly patient who may have grumbly symptoms, but they don't necessarily need to present with significant high white cell counts and I just have a low threshold for thinking about potential bad things happening in the elderly because they tend to mask their symptoms. So in terms of our sieve in terms of who are the people that need scans, it's undifferentiated abdominal pain and patients where you know they're not going to go to theatre or where the CT will assist you in what you're going to do in theatre. There are cases where, for instance, if you're thinking about a AAA, where there's a leak, that there may be a role for CT angiogram. But these sort of investigations would be in discussions with the surgeons involved. Another group which is important to emphasise on is the vascular paths. And particularly those who present with non-specific pain. Again, mesenteric ischemia can present with visceral type pain rather than generalized peritonism, and it's a difficult thing often in the early stages to diagnose. But I think you've just got to have your eye out for patients who are presenting with a history of multiple vascular procedures or cardiac procedures and really be thinking about mesenteric ischemia as a potential course. If they've got associated hypertension, I'd be thinking about a AAA as well in this group. Okay, so it's a good thing to think about. In regard to management, we've done the referral to surgery, there may be a CT or they're admitted under the surgeons, what other role, what other management priorities are for the junior doctor to make sure that the patient has before they go up to the ward? I think something that's underestimated in general is communication with a family And an important aspect is you'll have a surgical person coming on board. The first thing is making sure that there's appropriate analgesia on board. We've already taken the bloods and we're at the point that it's important if they're going to theatre that they've got appropriate measures such as a catheter in and appropriate fluids running, aiming for a urine output of greater than 30 mils an hour, depending on the body weight. But then once we've got those initial things going, I think it's an important part is to communicate well with the family while the patient's sick as well. So that's an important thing and communicating well with other staff such as the anaesthetist, emergency consultant and other members of the surgical team. I think the more you communicate about these patients, the more help you'll get and the smoother the process will run. Okay, so I think we've described a patient that you can see in the emergency department, but maybe we just move quickly to a patient you may see in the ward.
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Welcome to another episode of On The Wards. My name is Eloise Sobels and I'm very apologetic about my voice today, everyone. But today we're talking about non-traditional career pathways, software, innovation and digital health with Joshua Case, who is a junior doctor based in Queensland. I should also say this podcast is produced in collaboration with Vant, a proud partner of On The Wards. A little bit about Josh before we begin. He, as well as being a doctor, is a software developer who hopes to empower other doctors and medical students to build new software even without the tech background. He is passionate about making the world's hospitals safer and more efficient, as well as teaching clinicians how to code. He has written and contributed to many projects in this nature. Welcome, Josh. It's a pleasure to have you on today. Thanks very much for having me, Ali. I'm excited to be here. Excellent. So I guess we'll just start with, obviously, sort of going from medicine into a digital world is a bit of a transition and a bit of a step, but I kind of want to bring you back to where it kind of all began before med school days and kind of what actually drew you to medicine originally and then how was your med school journey? Yeah, so I think there's a lot of things that drew me into medicine. Things that I think were factors that I very much controlled and And then there was some, I would say there were factors outside of my control too. So, you know, I always knew that I wanted a people-oriented career, which is really funny because we're about to have a chat about software and all that kind of stuff, which I guess has a reputation for not being people-oriented. And then I was also very, very interested in physiology from an early stage. I was a competitive athlete growing up and I really liked, you know, I did a lot of sort of sports science at school. So I was really fascinated with, you know, oxygen exchange and getting oxygen to muscles and how that all works. So I think wanting to understand how the body worked at a deep level was another factor that drew me there. I was also very interested in, I guess, the altruistic side. So the capacity to help people, the capacity to have skills that can change lives in a way that I guess not many other careers can. And then outside of that, I would say, you know, from chatting to some of my peers, they also sort of echo this, you know, people who, you know, were quite good at exams, were quite detail-oriented, who were doing well in school. If you're above a certain yardstick when it comes to exams and sort of that thing, I think there's lots of people around you who are just saying, oh, you know, medicine is a quote-unquote obvious choice, which is, you know, I don't regret that at all, but I think there are people who do kind of go down that road and end up in a sticky situation. I guess I'm glad I'm not one of them. So a combination of all those things meant that it was a clear choice for me. Yeah. I think it's really interesting how you go through and you have these influences in terms of sport and then you have these influences in terms of, you know, I can sit exams and this might be an obvious choice and it's so funny how it kind of leads you down a particular path yeah it is yeah yeah absolutely um so uh did you kind of go straight from school into medicine or was there a bit of a time in between yeah I mean in the sense in the sense that I went straight into undergraduate study in biomedical science with an intent to do medicine. And then I actually grew up in Melbourne. And the reason I moved to Queensland is because it was sort of a very clear pathway for me into postgraduate medicine. And so I think my intent from very early was to study medicine as soon as I possibly could after high school. If I had my time again, I think I can remember thinking at that stage that the only thing that mattered was my career and that I had to get it, quote, unquote, over and done with as soon as possible and every year mattered in the grand scheme of things. And I probably regret that approach a little bit. And it may, and it honestly may have contributed to, I guess, the diversification of my career at the moment was this, I guess, desire to see something a bit different, to even see what else is out there. You know, I think I was probably quite close-minded to other career paths relatively early. And that may be one of the factors that's led me to where I am today. Yeah, that's actually a really interesting answer. I think we'll touch on a little bit later, but I think this idea of, you know, the medicine escalator, as I've been described before. But we'll touch on that in a little bit, but we'll come back to that because I think that's a really interesting point in terms of feeling almost trapped, but you've done it yourself in a particular pathway. Yeah, absolutely. Yeah, yeah. I think if we just go from that medical school kind of journey and how you were sort of finding it then and then your first kind of, I suppose, experiences with digital tech, did that start in medical school? Yeah, I think things were probably underway in the hobbyist sense well before probably even university, to be honest with you. There was a long stretch in high school where I was, you know, trying to make my own computer games, trying to make websites, you know, in a fairly haphazard fashion, mind you. But all of those, I look back on all those projects fondly now as kind of, I guess, building blocks that have helped me establish a skill set that have gotten me to where I am today. And certainly by the time I got to postgraduate medicine, I think, you know, the listeners who have been through medical school know, you know, at times there's a really, really kind of high workload. And I think I kind of used my software projects related to medicine as a way of tricking myself that I was really studying medical school really, really hard. So I made lots and lots of quizzes and sort of exam generators where there'd be, you know, 5,000 questions in a database, some of which I'd written, some of which I'd sort of crowdsourced. And, you know, you could put which subjects you wanted to study and this thing would spit out an exam because, you know, we had this chronic problem of not having enough practice exams. And, of course, when you get a few hundred type A high-achieving students together, not having enough practice exams is the worst possible problem you can imagine. And so tools like that. And I think, you know, one of the reasons I got so deep down this rabbit hole is, A, it was my leisure time that I was using on these things. And B, it was a way of, I guess, helping people that, you know, I could do from home in my pyjamas. I could do it at scale. So, you know, people all across the world, you know, the stuff I was making back then certainly wasn't getting clicks all over the world, but hypothetically could be used from anywhere in the world. It could be done in an innovative, transformative way. I could create something new. It provided an outlet for me to put things into the world. So some people like to write music. Some people like to paint. Some people like to knit. I like to make tools that have utility that people could use and share and all that stuff. It was really a creative outlet for me. So I think it kind of scratched a lot of areas that, or scratched a lot of itches that maybe weren't being fulfilled in my day-to-day, certainly medical school life and residency life. And in that sense, it was really a natural evolution. Yeah. Yeah. I think I would have loved to have been your friend during medical school. Having access to all those exams and popping through. No, that's really interesting. I think, too, it's really hard to find balance when you're studying so much. And our schedules during medical school at the very beginning are always very intensive and finding an outlet no matter what way that might come out if for you that's your digital kind of as you said you scratched that itch I think that that's always super important to have and then integrating that into a way that's also useful for others, I think, is quite incredible. So it's really interesting that you sort of were able to take something that you were really passionate about on the side of medicine and kind of incorporate that into your other passion of medicine, which I think is...
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I think that was also a lie I told myself too, you know, not that I think any student should need a reason to take leisure time, but it was definitely a psychological trick I used to make me feel like I was, you know, improving my GPA or whatever when I really wasn't. Yeah. I think we all use that. Yeah. I think sometimes with Grey's Anatomy too, we watch that and we go, I'm studying. Yeah, exactly. This is revision, right? This is revision. Absolutely. No, I agree. Absolutely. So I think then, you know, how did this sort of transition into your business that you have now, which is undeniably going to take up some of your time? Yeah, definitely. How did that happen? So I think certainly by the time I was doing my rotations in medical school, I developed a pretty good skill set as far as being generally knowledgeable of software systems on multiple platforms and how to make them from scratch and how to sort of reason around problems that can be solved with software. And then by the time I got into my in-hospital rotations sort of every I mean you know what it's like when you walk into the hospital for the first time there's things that you've never seen before in a good way and there's things you've never seen before in a bad way as well with respect to data processes and the complexity of the systems that function and so know, with almost every rotation that I was doing in my last two years in med school, every department, if they caught wind of the fact that I was sort of software inclined, there was a project for me. And I realized very early there was this sort of titanic appetite for the type of skill that I had, which was understanding, I guess, day-to-day workflow problems from a medical perspective in a fairly, maybe not deep way by that stage, but deep enough to see that there are clear shortcomings. And then the ability to sort of take that problem and then say, right, well, you know, is this solvable by software? What would that look like? You know, let's start throwing something together. And so I already knew by the end of med school that my career was not going to look like a lot of my peers. And I think if you polled my classmates, I think by the end of first year, I think they would have said, you know, he'll be the last one to make consultant if he ever does. Because, you know, I think the signs, honestly, I think the signs were there to other people before me in some ways that I was going down another road. And then I got this absolutely unbelievable um to do an internship in tel aviv in in uh israel which is kind of like the silicon valley of the middle east um there was this awesome company with that um made basically medical software for iphones uh for mobile phones and the web and stuff like that and i had 80 employees and no doctors on board. And they put up this internship and then the University of Queensland helped me get there. And then, you know, I had this, I finished medical school the next day, flew out to Tel Aviv and had the most unbelievable five or six weeks in Tel Aviv, you know, dealing with, dealing with technologies that are just absolutely incredible. And then I came back from Tel Aviv, I think it must have been around New Year's Eve prior to me starting my medical internship. And so 10 days later or however many days later was at Toowoomba Hospital, which for the record is an incredible place to do an internship. And I would do it again in a heartbeat. But, you know, going from the technology hub of the Middle East right into Toowoomba Hospital, which I think it's fair to say is a fairly dated campus with, you know, paper forms everywhere and, you know, all the other problems that we know about hospitals. And that kind of culture shock really affirmed to me that I wanted to combine those two. I was almost leading this kind of double life by that stage. And I really wanted to combine those two worlds in some way. And then my internship was incredible, but I was also spending a lot of hours just out of my own desire, out of a desire to make change, out of frustration with the systems that are in front of me. I spent a lot of time writing software to solve problems that were immediately in front of me. So much so that, you know, in some ways I burnt out. You know, internship is a big undertaking and I was, you know, trying to get my peers to kind of see the way that the world that I, the way, well, the way that I do as well. So I was, you know, giving talks about doctors in software and trying to, you know, I was kind of burning the candle at three ends, if that's an expression I can use. And I realized that for me to be able to make the change at the scale that I wanted to, it wasn't going to happen between the hours of 6 p.m. and 8 p.m. on a Tuesday after I'd come home from work. And I realized late in the piece that, yeah, I won't be able to do that full time. And I dropped my clinical hours back, you know, that's, you know, a portion of the people that I told this thought I was crazy doing that as PGY2. And I'm still not completely sure that I'm not, but, you know, this combined lifestyle is doing wonders for me and I'm getting closer to my goals every day. And I don't feel like I've missed the boat. I think that was a big fear for me. I think I thought that I was going to, you know, after spending so many years being a doctor is a huge part of your identity and it's almost, you have to almost mourn this version of yourself that maybe you've intentionally crafted, but certainly other people have this perception of you of this high-achieving doctor and you're losing your way. And ideas like this, you really have to put to bed. And since I've made the jump into more of a mixed career path, I've never been happier and I don't really miss that version of me at all. That was a very long-winded answer. I can't even remember. No, no, that was so interesting. No, thank you for sharing all of that. I mean, wow, first of all, how that has developed into this now. I can certainly see that through that answer so thank you for sharing um I just want to go back and touch on when you sort of were speaking I suppose just then about this sort of idea that people had about you and perceptions that you have and the part that you've sort of created for yourself in terms of your identity as a doctor rather than just being a human and who you are. I think that there's probably interns and JMOs out there at the moment and certainly within my own friendship group who are kind of dealing with maybe medicine isn't exactly, in terms of clinical medicine, isn't exactly what they want to do or where they want to go. And was that quite challenging? And were you scared that things, you know, weren't going down that particular, I suppose we're touching now on the medicine escalator type thing? Yeah. Yeah. What's kind of, what were your emotions, I suppose, going through all of that? Yeah, I think, yeah, this concept of the escalator or the Kinzai belt. I was in the UK recently and I caught up with some graduates of UK medical schools that I know. And it's funny, this is a global problem. It's not something that just happens in Australia or all across the world. I think people who've picked this career path are kind of encountering similar problems, which I think we should take reassurance in the fact that, you know, it's not us. It's not because we're not cut out for this profession. It's not. It's a multifactorial thing. It's the systems that we operate in. It's the conditions. It's a – this is happening everywhere. So it's not just us. I guess that's the first thing I'd say. I think for me, it was actually a long time coming to the realisation. So by the time that it, by the time I finally said, you know, right, I'm pulling the pin and look, you know, I didn't even really fully pull the pin in a sense, you know, I still do a little bit of clinical work. I think giving myself permission to take time to make that decision was really to my benefit because I think I was quite ready. In fact, I probably, you know, I think you could almost say I was ready before medical internship or I knew that life was going to be different, I guess.
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So I think that was more sort of sense and sensibilities that kind of kicked in at that time. One thing I would like to try and, I guess, normalize a bit more is, you know, I think if you look at the way our career progression is structured, one-year contracts from the time you get out of medical school, recruitment starts, I don't know, it's something ridiculous. It's like April for the year before. I kind of want to normalize taking the time to think about what you want to do with your career. And when I say take the time, I mean, it may be several years where can you just, if this is what you want to do, can you just rotate as a medical officer, as a PHO, as an SHO? There just seems to be this, certainly within chapters of our cohort, because we're surrounded by wonderfully talented career-driven people who are all trying to get on to whatever competitive specialty pgy3 for or certainly that's what it can feel like you can certainly feel like there's people all around you who've already got their papers published you've already got all this and that's that's actually not the reality for many and i suspect most of the people who graduate medicine don't quite know yet. Don't, you know, still working it out. I really want to normalize that for that to be quote unquote, okay. I think, you know, specialist training is this enormous, enormous undertaking, you know, normally, you know, four to six years, you know, plenty of exams in there, clinic exams, written exams, fellow years. And I don't think, at least for me, I've kind of realized like, I'm not going to get serious about specialist training until I'm absolutely certain or absolutely ready for that undertaking. And I do wonder if some of the unrest we have is people getting on or people striving for this sort of career progression primarily due to external factors and not because people are really ready for it. And of course, I guess that. But, you know, I've been around the traps long enough to kind of see this pattern happening, people all around me. And I think another thing, you know, another thing to mention about making this sort of relatively big career change is it was just so wonderfully exciting. It was scary, but it was so exciting because I think if I looked down the lens of my career in one sense, intern year, JHO year, SHO, PHO year, a couple of O's, get into whatever specialty, it was all very linear. It was all, I don't want to say predictable, but within a certain set of constraints, I could kind of see what my career looked like. And I went into this world where I was like, huh, anything is possible. You know, in software, I can theoretically work remotely. So why can't that be from Reykjavik or London or Bangkok? You know, I could travel anywhere. Suddenly borders were opening up, right? Because, you know, it's quite hard to jump across the pond with a medical license. But once you have other skills, great. I also was really excited by, you know, I had a number of experiences both in my last year of medical school and internship where I saw patients come to harm from IT related areas, you know, systems not booking their appointment, whether appointment whether there's you know i won't go into too much detail i saw some some i saw i had enough experiences that made me realize that our information systems were equally or as important as say our clinical knowledge or this you know very very expensive research into um genotyping of specific cancers and all that sort of stuff, I kind of felt like the information system, the yield we'd get from investment in our information systems was equal or more than we would in these, you know, kind of sexy, deep science fields. And so for me, my venturing into technology was also an extension of my clinical work. It was an extension of my desires to make change and improve care delivery. And so it was exciting to finally be able to say, hey, I've got daylight hours that I can now pour into these difficult but very exciting problems. And for me, that pull was certainly outweighed all that other stuff that took me a few years to digest. And that's really how it all happened. Yeah. And I think that goes back to, you know, when you were saying initially why you wanted to do medicine and that altruism. And that's still something that's still front and centre of what you do day to day. It doesn't have to be in a necessarily clinical capacity, even though, you know, you still dabble in the clinical fields. It can be in a different way that still gives you that passion and that flame and makes you or fulfils you in a slightly different way. I think as well when he was stating, you know, I think it's really reassuring to hear someone like yourself say, you know, normalising the fact that you don't have to know what you want to do. You don't have to go down this path. You can take time to figure things out. Not everything's a race. You've got many a year to live that, you know, not everything has to happen as it, you know, is on the conveyor belt or the escalator. One thing I read recently that really gave me confidence about this, and look, if people are thinking about doing this, please get your own advice. However, I'm pretty sure the APRA recency of practice guidelines, which is like, so if you want to take a break, like how much practice do you have to have done before you come back? I'm pretty sure it's something like four weeks clinical work in 12 months or 12 weeks in three years, something like that. That is not very much. And obviously, you're not going to hit the ground running if you've done four weeks in 12 months. But it is so, so fine to take some time off, skip some rotations, go travel. I think people feel trapped when they don't have to be. Yeah. There you go, everyone. From ARPRA themselves. So now delving more into what you're doing now and the projects that you're working on, with regards to your experience with those, how do you think the digital world is impacting healthcare and what are you doing now in terms of that space? So I guess the biggest headline here is, man, I'll muck up the stats, but health is a big chunk of our GDP at the moment. So the total amount of money that Australia spends with our aging population in the next sort of 20 to 30 years, it's going to be, again, don't quote me, well over half the amount of money that we spend is going to go into healthcare. Healthcare costs are exploding like crazy. There's an awesome, awesome community in Australia of talented doctors, entrepreneurs, developers, designers, all sorts of people in this kind of startup community who are looking at this big problem and saying, A, oh, bugger. B, saying, well, this is exciting. There's a really big opportunity here. And C, there's an obligation to try and find ways to lower the cost of healthcare delivery. That's kind of the big overarching problem. There's lots of sub-problems here, like can patient care delivery be more patient-centric? Can it be easier for people from diverse backgrounds to interact with? Can it be less demanding for doctors to interact with this healthcare system? All that kind of stuff. They're all sub-problems within, all really, really important too. So that's kind of like the headline is that things are on fire and we need people to try and extinguish them. And kind of joining this national and global community of entrepreneurs who are trying to do this is has been awesome like the community is really really supportive if there's not a lot of the cultural hierarchical things that exist within medicine do not exist within the startup community to the same degree so there's you know CEOs of companies worth you know eight or nine figures who are there with people who are just getting started. And, you know, there's been an open-door policy, which has been really kind of refreshing. And for me personally, I guess I, as I alluded to before in my intern year, sort of writing lots of little software modules that were solving terrible, terrible problems that medical interns have to deal with. I'm not sure if you did a medical internship at Shim, you did, but lots of other interns all know the same types of problems, administrative tasks, data entry tasks, all that sort of stuff. And that grew and grew and grew and got to a point where, you know, with the complexity of the tools that I was making, there was some, shall we say, bureaucratic challenges associated with being the one building and making and using these tools. And, you know, I was putting a lot of time and expertise into it.
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It was very complicated to do that as an RMO inside a large public health organisation. So the hospital I work at now is actually an excellent hospital, but it's not part of a large public hospital network, which gives me, I guess I'm more of an external body now, which kind of allows me to interact with the network in a different way. And one of the challenges of making change in hospitals is that they're large, complex organizations with many different departments. No one really understands how it works from A to Z. So, you know, I might be able to tell you a patient journey, but do I know how they get fed? Do I know how they get transported? Do I know who fixes the vents? No, it's like no one understands it all, right? And so what that means is building kind of like grassroots innovations inside those systems are incredibly difficult. And so when I was thinking about, well, you know, obviously there's a lot of problems that I want to solve. Can I find a problem that wouldn't have to sit directly inside a hospital ecosystem to grow because of all those other factors, you know? And so what I really found is, you know, Australia's having this terrible problem with medical workforce at the moment, both the overall supply and how they are distributed. So, you know, a lot of our doctors live in the cities and, you know, that's typically where they're trained, you know, and where the training opportunities are, like their sort of career progression opportunities are. So I don't blame any individual doctor. But what I'm building now is a medical workforce marketplace that connects hospitals to doctors to fill urgent roster vacancies. So we're kind of taking that locum agency model that's existed for many years in a certain form and really trying to turn that on its head. So we're trying to basically make getting a locum job as easy as booking an Airbnb. So we've got really cool technology to basically allow doctors to rifle through and find the jobs that they want, a self-service model combined with automation tools to allow hospitals to credential you really quickly. And it's since finding a problem that, I guess, isn't really constrained by the same degree of bureaucracy that things inside a hospital would be, but also has an opportunity to make change on one of Australia's biggest healthcare problems, which is workforcing. It's really, really been exciting to almost, I don't want to use the expression, find my calling, but, you know, to find something that's directly coupled to my purpose, to my mission for my own career, it's been really, really exciting. And I think I wouldn't have found that, this kind of sweet spot that I'd landed in if I hadn't taken a risk, if I hadn't rolled the dice, if I hadn't tried something different, if I hadn't looked outside my immediate environment to find something new. So in that sense, I have no regrets. Yeah, that's great. I am actually currently completing my internship. Oh, nice one. Yeah, so I've had, I've recently, I'm doing some, most of my rotations have been in the largest city hospital, but recently been completing a term in regional and rural New South Wales. Nice, got to do it. Yeah, so it's the workforce shortages is quite marketed as soon as you start going outside of the city and having something like what you're developing is going to be incredibly useful for regional and rural workforces all over the country and obviously can be used as a platform for other countries and other workforces. Absolutely, That's certainly the reason. Yeah, yeah. So I think that's really important. That's really exciting that we have someone like you who also has the understanding of the challenges of the medical system, who has those kind of experiences that are looking to redesign the way that we are looking to address that issue of workplace shortages. I think that's great. I suppose just kind of wrapping everything up, if you had any tips or advice for any kind of junior doctors or medical students looking to balance or forge into a different space like you have with coding? What would that advice kind of be? Yeah, I think there's, you know, there's a thousand different ways to skin a cat. So I think generalisable advice would be, A, take your time. So does that mean you do, like we were alluding to before does that mean you do a couple of sho years or srmo years or a couple of pho years or why you still work out um what you want to do what you want to what you want to be what you want to do when you grow up um i think not everyone has to go to the lengths that i've gone in terms of getting deep into this ecosystem. And I don't want people to think that to be a meaningful contributor to that kind of startup community that I was talking about before that you have to be as nuts as I am. So there's a couple of ways you can dip your toes in. If you want to, a really good thing to do is to go to in-person events. So, so certainly across, you know, Melbourne, Sydney, Brisbane, there's a very vibrant ecosystem of live events where you can just go there normally free or might, there might be like five bucks where you can just go to these startup community events. They might have a guest speaker and then, you know, there's drinks and nibbles and you just sort of chat to people and you meet people and it's not like these, like I know we have career nights in medicine as well, but I basically have found the community a lot more, the startup community a lot more open-minded and welcoming and, you know, I don't think we network very well in medicine compared to other fields. And so I kind of walked into this thing where everyone was just sort of really friendly and nice and genuinely interested. And I almost feel like being embraced by the community was like one of the big things that pulled me over. So if you can get to in-person events, I recommend that. See, you know, I guess it's along similar lines, but like surround yourself with similar people. So the number of bizarre opportunities that I've had that have come from just surrounding myself by the right people has been huge, you know, showing a genuine interest in what they're working on. And, you know, they introduced me to people that they know, I introduced people that, you know, and before you know it, you've got some fantastic opportunity that's dropped into your lap. And I think finally, and we haven't really touched on this, one other thing that really absolutely changed the direction of my career in a big way was I started writing about the problems that I was facing, the solutions that I concocted, how I reasoned about how our systems could be better. Basically, I started a blog and I started just putting my ideas out into the world. And what that does, it's almost like a battle cry for people who are interested in those types of problems. And they all just found me. They started adding me on LinkedIn. They started sending me messages. It was almost this magnetic effect of people around you who had a similar interest. And this is not just for people in technology and startups. If someone wants to be a jazz singer, go and start. And that's a bit scary, but at least it's scary for me as someone who can't sing at all. Go and put things out into the world that are around your niche. Is it videos? Is it music? Is it writing? Is it knitting? Is it any sort of, whatever your interest is, if you start putting things out into the world, you will attract people who are interested in that thing and who want to connect with you and that itself will open so many doors so i guess those are the things you know take your time go to in-person events if you can surround yourself with the right people and put things into the world and just watch what happens i can't i can't stress that last one enough yeah i think i know we didn't touch on it but i think it's a really great point. It sounds like you honestly just created a community by putting things out there. And it's also lovely for other people because it feels like they probably belong or, you know, they have someone who's been through a similar situation. So I think that's really great. And I think that's actually one of the powers of social media and the internet is that you can find like-minded people through different social media platforms. And I think that's one of the pros, certainly, of the digital world. So, yeah, I think it's really important that you did touch on that before we wrapped up.
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Hi, welcome to On The Wards, it's James Edwards again and today we're talking with Dr Amy Freeman Sanderson. Welcome Amy. Thank you. Hi. Amy's the Head of Speech Pathology here at Royal Prince Alfred Hospital. And we're going to talk about the assessment of safety to eat in a patient who may be dysphasic or dysphagic. So we'll go through our case, Amy. It's Friday afternoon. You're called by one of the nurses on the ward regarding a new patient who's come from ED asking where they can eat and drink. The patient is an 84-year-old female who's come from a retirement village after a stroke and has a dense right hemiplegia. Is this a type of decision you can make over the phone? Well, there's a few things, particularly with stroke patients, because we know that they're very high risk of having swallowing problems or being dysphagic and we actually have a statewide screener that's used called the ASIST which is assessment of swallowing and it's a tool that nurses and some doctors use to screen the patients initially to see if they're appropriate to start eating and drinking because we know the prevalence of swallowing problems is around 23 to 50% in stroke patients. So essentially that tool is initiated here at RPA, we have it implemented and the nurses in ED and on the neuro ward will actually do the screener with the patient. So in regards to decision over the phone, before a patient can eat and drink, even looking at their risk factors, we want to know if they're actually alert and they can maintain that for 15 minutes. And in regards to their neuroscience, so if there's a dense facial hemiplegia or facial weakness, that will place them in a high risk category. So they will need to remain meal by mouth until they're seen by a speech pathologist. Okay, so in regard to over the phone, maybe the initial decision is no, and a few questions over the phone you could ask, but maybe it's safe to just go assess the patient. Yeah, correct. So if they're alert and they're able to have the screener done by the nursing staff, then that would be something that we could initiate there in ED or on the neuro ward with the staff so it doesn't need a speech path. So I guess that's step one. So we have found that by doing that tool, it's actually a group of patients that haven't needed speech path assessment, they can get to oral intake and oral meds much faster. So that would be the first step. And I think it's really important on a Friday afternoon. Oh, definitely. You don't want someone to be nil by mouth for over 48 hours. No. So it's not routine. In some hospitals, there are limited weekend services. But quite right in terms of after hours, it's not routine for speech pathology. But it is important for the team to be aware of what the risk factors are and if there's a major risk factor like alertness and facial weakness, for this to be assessed properly because we want to make sure the patient resumes oral diet if they can safely. Okay. Is there anything else further in the assessment of the patient or using that kind of assist criteria is probably what a junior doctor would be expected of? Yeah. Are there any investigations to be helpful in the short term? Nothing, look, nothing particularly in regards to swallowing. I mean, we always like to know that there is a confirmed stroke. I mean, sometimes this comes up on CT, but sometimes it doesn't show up up as well so it's nice to know if it's new onset of signs and if a CT has been done confirming this. In regards to other things we're really looking for is really the previous medical history because it's not just what the patient's presenting with but there might be some other conditions that they have that make them prone to having a dysphagia. What sort of conditions would they be? So if they have any neurological conditions, so whether it be acute or progressive, so progressive might be Parkinson's disease, MS. Patients with a history of dementia, they're at high risk of having a swallow problem as well. Any head and neck surgery and any reported modification of diet. Often these things come up by patients or their family. They might say, oh yeah, I've been modifying mum's diet for a while and things will start to come out once a clinical history is asked. Okay, how would you minimise the aspiration risk in a patient with varied degrees of unsafe swallow? Okay, there's a few things that we can do. So I guess first of all if the patient is eating and drinking we want to make sure they're on their optimal diet. So that might include some diet modification of either solids or liquids. So that would be the first thing. It's good to be upright, so to be, if you can, 90 degrees upright, or at least as upright as possible. To be very alert for oral intake. If a patient's nil by mouth and you want to minimise aspiration risk, again, it would be nursing them upright, maintaining oral care and that's a that's a big factor patients can develop aspiration from not managing their saliva and we've got a lot of bacteria in our mouth so you need to have really good oral hygiene to try and prevent a development of an aspiration pneumonia so despite them not eating or drinking they can still develop aspiration, yep. We have about two litres of saliva we swallow per day, so that's on top of eating and drinking. So if you have difficulty with your saliva and you have poor oral hygiene and a poor cough response, it can certainly develop to an aspiration pneumonia. And in regard to people who may have sort of mild or moderate or severe degrees of unsafe swallow, what else can we institute? I guess what is good to know is this going to be a dysphagia that is static or is it something that they're going to recover from? Somebody may present with severe dysphagia to begin with but they may have good recovery so it's important that they get ongoing review because the actual risk might change. And I guess the risk is also looking at if they develop any other symptoms, so if they have a new cough or their mobility has decreased, that can sometimes change the severity. So in the community, some patients will aspirate a small amount, but if they're mobile, some people manage this and that doesn't develop into an aspiration pneumonia. But if you're less mobile and depend on people for feeding, that can increase your risk. So how do you decide what kind of diet they have whether it's kind of thickened fluids you know what kind of makes that decision so maybe such as this has had a stroke? Yeah so there's a couple of things that we use to try and make that decision so it's getting a based on the clinical history the current presentation so we want to have a look at their alertness their their respiratory status, the function of their cranial nerves, so we're particularly interested in their tongue, their palate, their cheeks, their cough reflex. So a speech pathologist will do a bedside clinical exam of swallowing. And if it's not conclusive, if the patient's safe, we'll talk to the medical team about doing an instrumental assessment. There's a couple of instrumental assessments we can do. So one is video fluoroscopy or called modified barium swallow. Some people might know it as. And that gives us an objective view of what's happening from the oral to the pharyngeal phase. Or we could do a nasoendoscope, or it's called PHES which is Fibro-Optic Endoscopic Evaluation of Swallowing and that's done with a nasoendoscope via the past via the nose and we can have a look into the pharynx so there are two exams where there might be a high risk of silent aspiration we might like to do that and I guess that's important to flag that if a patient's not managing one of the first signs that you hear about is somebody coughing or spluttering and that's something a common response because the body will have that response if something enters the larynx the body wants to cough it out but some people actually have reduced sensation and they won't have that response so they might look like they're eating and drinking okay with some particular stroke patients but they people actually have reduced sensation and they won't have that response. So they might look like they're eating and drinking okay with some particular stroke patients, but they're actually high risk of silent aspiration. So it's good for us to consider whether people need instrumental assessment. And is the decision about what type of, you know, thickened fluids, is that usually made by the speech pathologist or is that something the gene doctor needs to know about? Yeah, so normally the speech pathologist. So with thickened fluids, I guess if you think about it, it's like a hierarchy of fluids.
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Welcome to our podcast series and this one's on alcohol withdrawal. We've invited Professor Kate Conagrave to come and speak with us today. She's an addiction medicine specialist here at RPA. Hi. Welcome. Again, as we do with all these podcasts, we start with a scenario and we're really aiming these at the junior doctorate and obviously alcohol withdrawal is pretty common. And you get a call, it's after hours, kind of 10.30 at night, the nurses are concerned about one of their patients who's a bit agitated and they think they may go in alcohol withdrawal. Are there any sorts of things before you get to see the patient, the junior doctor, you may ask the nurse to do or ask questions over the phone? It could be worth asking how long the patient's been in hospital because you can start thinking then even as you're walking down, does this add up? Could this be alcohol withdrawal've already been in hospital for two weeks for example it's not alcohol withdrawal you can ask them if they haven't already to do an alcohol withdrawal scale so you've got the score all waiting when you arrive there and do they already have a drip in but then presumably the nurses are going to tell you if they've had a seizure or if they're delirious to give you a sense for how urgent it is. Okay, yeah, good. So you can try and prioritise how urgent it is to go see the patient on the ward. So you go see the patient on the ward. What's your kind of approach to someone who may have alcohol withdrawal? I think the first thing is as soon as you walk in, you're looking to see if the picture is consistent with withdrawal. If you walk in and the person's lying there dozing off to sleep it's not going to be alcohol withdrawal because in withdrawal they get insomnia by night and by day they're restless they're agitated so any significant withdrawal that needs treatment they're not going to be nodding off in front of you. The other thing, if you go and shake their hand, take the feel of their hand. A warm, sweaty palm is very typical. And if they've got a bone dry palm and they've got a rip-roaring tremor, then you're starting to think, well, is the tremor due to something else? Is it that they're anxious, which is very common in an alcohol abusing population. You're also going to look as you walk in have they got any resting tremor even before you test. As a withdrawal gets more severe it moves from a tremor that's just evident when you test them with their forearms extended to one that's there at rest. But look at the nature of the tremor. If it's alcohol withdrawal, it's normally a fine tremor, as distinct from a cerebellar tremor, which is a much coarser tremor. And it can be a real trap. If someone's got a cerebellar tremor that they might have had for 10 years, and you keep dosing it up and dosing it up to try and get rid of it with the Valium, you can potentially kill them off. So we're looking for overall consistency, a person who's at least awake. And if it's a significant withdrawal, agitated, fine tremor when you test it, you often anchor the forearms, anchor the elbows by the side and just extend the forearms because then you're not testing for upper arm strength because people often get a bit of proximal myopathy or they might have just been eating poorly and they're tired and weak and frail. So anchor their elbows by the side and get them to extend their forearms and see if there's any tremor of the hands. So you're looking at all that even as you go in. Before you're doing a systematic history, you're going to take just a quick history if it's in the middle of the night and you're busy, but you're going to check when was the last drink. If the last drink was more than a week ago, then it's highly likely you're looking at something else. So your typical withdrawal starts within a day and it's finished within a week. Occasionally a more severe withdrawal can go on a few extra days. You're going to check how much they drink. Is it consistent with a withdrawal? Usually people have to drink at least six drinks and typically more than eight drinks before they'll get an alcohol withdrawal and usually pretty regular. Like some people can drink a bottle of whiskey but they only do it once a week. They're less likely to have a withdrawal. So how regular is it? How much is it? When was the last drink? Another important question that people often forget is what's their withdrawal usually like? Do they usually get seizures for example and that's important because you can get a seizure before you get an awful lot of other symptoms and the signs of withdrawals. So if someone has seizures every time they go through alcohol withdrawal you're going to start up some regular diazepam or other sedative early on. So people have a stereotypical kind of pattern withdrawal they have withdrawal one way you know one year the next year they come into hospital will be similar? Yeah it's typically and typically each year that they keep drinking the withdrawals get a little bit worse but you can usually get a good idea based on what their last withdrawal was like and sometimes you'll say what was your last withdrawal like and they say I've never stopped then ask them what's it like first thing in the morning before you have a drink do you have the shakes if they don't have the shakes in the morning before the first drink you've probably got a bit of time to sort out what's going on and think it through but if if they always get seizures or really severe withdrawals or DTs you're going to want to get probably put in some regular benzodiazepine pretty early on, even before there's a lot of overt signs. That make sense so far? Yes. Okay. So, okay. So we've got just a little bit of history and we're going to keep an eye out for other medical conditions because, of course, what looks like withdrawal might be something else. And a lot of common conditions that are even more common in people with alcohol dependence can mimic withdrawal. So for example chest infection or aspiration, have they got drunk, aspirated, now they've got a rip-roaring pneumonia and the reason they're restless is they're hypoxic, they've got a high temperature and they're agitated and if you treat them with Valium and they're hypoxic you're not going to help their case. So common things like infection, lung disease and also of course a lot of alcoholics get bangs on the head so always keeping them back in the mind if they're confused. Could it be've they've got a head injury and a subdural or something like that or extra dural and where are we up to so we've done how about things like i mean often we worry about benzo withdrawal and alcohol withdrawal how can you tell the difference between benzo and alcohol withdrawal really good question in fact you often can't they look very similar and it's a really useful question to check. Do you take any pills or any sleeping tablets? Or on the street, they're often just referred to as pills or Xannies or Rivies. But get them to describe anything they take. Because if someone's withdrawing from benzos and from alcohol, they're likely to have a much more severe withdrawal and they might need higher doses of benzodiazepines to treat it. Okay, so we've done a history and exam, just want to work out whether they've got alcohol withdrawal and think about some other causes. What's your net management if someone has got alcohol withdrawal? Yeah, and I forgot to say, of course, you've already looked at their withdrawal scale because you're expecting their blood pressure is going to be a bit up their temperature is going to be a bit up but not not 39 type but more just 38.5 usually and you look at the withdrawal scale on the back it tells you what the common signs are. So the management you ask well it depends on how severe the withdrawal either is or you expect it to be. Say you've got someone who's come in and they drink 12 drinks a day, a bottle and a half of wine, say. Their withdrawals, they get a bit shaky, but they never have seizures. They may be fine just to go on a sliding scale. And all around the hospital, you'll see the alcohol withdrawal charts. And on the standard hospital protocols, you've got an alcohol withdrawal protocol, and it's got a sliding scale there. So if they score four or five on the withdrawal scale, they get 10 milligrams, usually of diazepam. If they score six or more, they get 20 milligrams. And that's orally? And that's orally for your standard withdrawal. And that's your sliding scale with PRNs.
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Yeah, exactly. So it's on the PRN chart. And of course, if you just write it there and don't tell anyone, nothing may happen. So really important you communicate with the nurses, tell them how often you want the withdrawal scale measured, which most often will be every four hours for a mild to moderate withdrawal. And show them the PRNs there. And if there's anything curly about that patient, for example, if you know they've got cellulitis in their leg and they're spiking temperatures from that, and you look at the back of the withdrawal chart and you notice temperature is one thing that's being rated you might actually change the scoring on the temperature chart and so that they score one less for the temperature items else you're going to be treating their cellulitis with diazepam yes which doesn't make sense no no all right so um yeah and then if it's a more severe withdrawal if they've already you know got dripping with sweat rip-roaring tremor, and maybe they're scoring six or seven when you first see them, then you probably, as well as giving them a stat dose according to their withdrawal scale, you start them on some regular diazepam, which is typically 10 milligrams QID. And if someone drinks two litres of wine a day or they've had past complicated withdrawals like seizures or DTs, again, even before they go into a severe withdrawal, you'll put them on that regular dose because we know if you get in early with the prevention, they get a more controllable withdrawal. they're less likely to go into DTs. Okay we've a lot of chronic liver disease patients here at RPA can you use dazepam when the patient has got bad chronic liver disease or do you need to change to another benzo? Yeah good question if they've got liver failure you'll typically you'll use one a benzo that doesn't have active metabolites so you're going to use typically oxazepam and it's easy to convert the smallest oxazepam tablet is 15 milligrams and your standard diazepam is five milligrams so 15 of oxaz is the same as five as diaz and you just convert it out one for one with your sliding scale okay it's interesting you mentioned dt's i mean is alcohol withdrawal and DTs the same or they're ends of a different kind of parts of the same spectrum? Yeah exactly they're parts of the same spectrum so DTs is severe withdrawal so and the word DTs it's delirium tremens so they've got the tremens from the withdrawal and they've got the delirium, the confusion. And if someone starts their withdrawal in hospital, you rarely see DTs if it's properly managed. Occasionally you will if they've got organic brain syndrome, a bit of alcohol-related cognitive impairment, but your standard withdrawal should never get to DTs. So early treatment's vital. Oh, and by the way, the other time that you use Oxaz instead of Diaz is if they've got respiratory failure or if they're old and frail, any situation where the sedation has extra risks. So what was your question? So in regard to looking at, yeah, just to see alcohol withdrawal and delirium treatments at different diseases or really just the same spectrum and do they presented at different times? Yeah, so DTs is the severe alcohol withdrawal. It usually takes a day or two for it to build up to DTs. Withdrawal starts on day one, usually after a person's stopped drinking, but it peaks at day two to three or even for DTs it can peak at day four, but already in the first few days you can see it's heading into a severe withdrawal. So I think the critical thing is as well as the delirium they've got all the other features of withdrawal they've got the tremor they've got the agitation their temperatures a bit up their blood pressure and their pulse is a bit up. If you see someone who's just got delirium but they haven't got all those other bits, then look at other diagnoses because if someone's got delirium for some other cause and you pile them full of diazepam, it often just makes their confusion worse. So you're looking for consistency in the picture. Everything fits, the story fits, the observation fits. We didn't talk much about thiamine but that's of course another major differential diagnosis for delirium and again is Wernicke's and again someone who's been treated from the beginning of their withdrawal in hospital hopefully never is going to go into Wernicke's because they're going to have had their prophylactic thiamine the minute they've come in but if they they've come from outside, they might be a bit confused, they might have withdrawal, and you've got to strongly consider the possibility it could be Wernicke's. Treatment of Wernicke's, of course, is safe and simple. So it doesn't matter if you give Wernicke's treatment when you don't need it, but it matters a huge amount if you don't give it because, as you know, people can then get lifelong disability from the Korsakoff syndrome. So you mentioned Wernicke's encephalopathy and I remember there's a triad of signs in Wernicke's encephalopathy. Do you need to have all three to have Wernicke's or can you just have one or two? Yeah, it's quite rare to get three you typically have just one so if someone's confused and they're a heavy drinker you treat it as Wernicke's until even while you look at other possible causes so you might you're obviously going to have to exclude things like head injury but you're going to give them their parenteral thiamine even while you're looking for other potential causes of the confusion because treatment is safe and not treating has the lifelong disability. So what are the three political signs? So the three are confusion or delirium, eye signs, so paralysis of lateral gaze most often, but also nystagmus. And nystagmus is a relatively common feature of Wernicke's. Confusion, eye signs and ataxia. So you'll check for your cerebellar signs if they're not fit to get up and look for the past pointing but that can be a bit hard to assess if they've also got alcohol withdrawal. So if in doubt treat anyone with severe withdrawal always give them parenteral thiamine anyone who's not even in withdrawal but's got but a really heavy drinker like a couple of liters of wine a day always give them parenteral thiamine okay what doses is that you read different areas you know is it kind of 300 a day is that 300 IV 100 TDS what's the kind of dosing schedule you recommend? There's a reason for confusion is that everyone does different things because we haven't got great evidence to guide us but what we know is that you need parenteral if there's even a chance or a risk of Wernicke's. The minimum even for any alcohol withdrawal for any alcohol dependent person the minimum is probably 300 milligrams a day and and if it's oral that might be 100 TDS for a mild withdrawal but with someone who's got more severe alcohol dependence then if they've got a drip in for any reason always give it IV because you get better levels and if there's a bigger gradient across the blood brain barrier then that's likely to give you a better effect. If they've malnourished living on the street couple of litres of wine a day I'd go for 300 milligrams TDS IV but if in doubt check with the specialist on. If you actually think it's Wernicke's if they've got one of those features of the triad then use high doses at least 300 TDS and some people use 500 TDS so you're looking for really big doses for people with alcohol withdrawal are there any particular investigations you think are worthwhile doing blood tests that help in the management of alcohol withdrawal? So you're already going to have done your routine ones, your electrolytes and your full blood count. The ones that are useful to add on, and magnesium is often low, and if your magnesium's low, you've got a higher risk of having a seizure. So that one's important. Your sugar's useful because, again, acutely alcohol can suppress your blood sugar. Chronically it can raise your blood sugar so it can be one or the other. The other thing that when you ring your specialist or the registrar they'll nearly always ask what's their INR or what's their platelets. You're after a measure of hepatic synthetic function because if their liver's really fragile, you're probably going to use oxazepam rather than diazepam for the sedation and you're also going to have in your mind, could this person be encephalopathic if they get confused. Those are the main ones and platelets can be an early sign the liver's going off if they're low.
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Welcome to On The Wards. It's Rob Mitchell here and today we're talking about pre-hospital and retrieval medicine with doctors Pat Gillespie and John O'Neill. Welcome Pat and John. Hi Rob, thanks for having me. By way of introduction, John and Pat both work at Cairns Hospital in far north Queensland. They also work with Life Flight Retrieval Medicine, principally on the Rescue 510 helicopter based in Cairns. Pat is an advanced trainee in emergency medicine and is currently completing a term in pre-hospital and retrieval medicine. And John is an emergency and retrieval consultant with many years of experience in a variety of aeromedical organisations in both Australia and the UK. Today we're going to discuss pre-hospital and retrieval medicine from the JMO perspective, particularly through the lens of a junior doctor undertaking a rural rotation. We'll cover how to prepare a patient for retrieval and the various clinical and logistical factors that retrieval teams and coordinators need to consider when arranging patient transfers. To start with, we would like to acknowledge that it's common for junior doctors to feel apprehensive about heading on a rural rotation. It's understandable. Apart from having to work in a new and different environment, rural rotations often require more independent decision-making and often without the available resources of large teaching hospitals. In Queensland, where this podcast is being recorded, JMOs are commonly rotated to small rural hospitals and assist senior medical officers or SMOs to provide clinical care in the ED and on the ward. The JMO will often be the first on call for emergency presentations, so they may be exposed to patients with all sorts of acute and undifferentiated illnesses. So while they say Queensland is beautiful one day and perfect the next, the medical reality is intern one day and rural generalist the next. For this reason, it's not uncommon for junior doctors on a rural term to have to refer a patient for retrieval. In Queensland, high acuity transfers are coordinated by Retrieval Services Queensland. There are equivalent organizations in other states and territories, such as MedStar in South Australia and Adult Retrieval Victoria. The principles discussed in this podcast apply to all settings, although there will obviously be some differences in processes between retrieval organisations. Bear that in mind as you listen to this discussion. So, John and Pat, to start with, what advice would you give a junior doctor who needs to refer a patient to be retrieved to another facility? I think it's not too distant memory of myself doing the term in a rural facility, and I do remember it being a very daunting experience. I think arriving in a small facility and taking on those additional responsibilities, it's important to get to grips within your environment very early and the local teams of nursing, admin, wards people and the senior medical officers can be an enormous help to you so use their experience. If you're unsure about treatment options or are overwhelmed by the acuity of your patient, it's important to ask for advice early would be my main point of advice. You're not alone, even if it feels like it sometimes. And if it's not clear, there's always a coordination service or a point of contact from a larger metropolitan hospital that you'd be able to contact for further clinical advice. John, did you want to add anything to that? Yeah, for sure. I mean, I think those are all really, really sensible points. And I'd echo all of those, that feeling when you're on the ward in the middle of the night, it's 2am and suddenly the patient that you've been dealing with for a day or two has deteriorated and you're having to deal with them, it can feel like a pretty lonely place. But as Pat says, there certainly is help available, both from the excellent nursing staff that work in those places and also the retrieval services. But I think when it comes to a stage where you're at a point where the patients need to move to another facility and you're engaging with the retrieval service, I think it's really important to just take a minute before you make the phone call just to run through a few things in your head and make sure that you've got a clear idea of, as best you can, the background of the patient and specifically what the acute problem is. And it's a good idea just to make a few notes to try and summarize the key points of the problem. And if you've got somebody there with you, perhaps just talk it through and say, look, the reason that we think this patient needs to be moved is this. And try and come up with a problem list. These are the key issues at the moment, and this is the reason why we think this patient needs to move. And there are times when we don't know what the diagnosis is and I think that's okay. You know, maybe that we need a range of investigations to actually get to the bottom of things but actually saying, you know, the key problems at the moment are this patient's hypotensive or they're hypoxic and actually having a list of what those things are when you make the call, I think that's really helpful and practice that a little bit would be a bit of advice for people before they do that. So John and Pat, to follow on from that, what type of information will the retrieval coordinator request when, as a junior doctor, you pick up the phone to make that referral? So I think that point John was saying of structuring your handover is really important and you can structure your details which is what what's important to the coordinators and the retrieval teams as well so starting with simple things an introduction of who you are and where you're calling from um it's important not to forget that this that this isn't always available to them so and then simple patient details the name of the patient the age of the patient sex of the patient and the weight of the patient is also really important from a retrieval point of view. I like to myself use the ice bar system. I know it's quite common to and familiar to a number of junior medical people. So provide them with a brief situation summary of the patient. So you could say for example this is a 65 year old patient who's presented with two hours of central chest pain and has new hemodynamic instability and you're concerned regarding new ECG changes. That provides a summary for the coordinator of your concerns and then you can outline the background, the assessment and your particular recommendations for transfer of that patient. Yeah, that's great, Pat. So when the retrieval coordinator hears this information, what do they do with it and how do they factor it into their decision making about particularly around mode of retrieval and around urgency of retrieval so i guess it's it's important for the coordination service to triage your retrieval based on incoming traffic from other multiple service providers much like yourself and so the time to retrieval is not only based on the acuity of your patient but also on what assets are available to the coordination service whether there's planes helicopters or motor vehicles to transport that patient. If something bad is happening somewhere else, it means that you may be waiting a little bit longer for your retrieval. And certainly other aspects of that patient in terms of their weight, for example, if they're quite a large patient, that may have an impact on their ability to fly. And if they have certain injuries, that may also impact on their suitability to fly by certain aircraft. John, did you want to add anything to that? No, I think those are all good points. I think the other thing to bear in mind is the person on the other end of the phone. Certainly for us here in Queensland, the medical coordinators are all very experienced specialists in critical care, as are the nurses who who answer the phone so they're also an additional resource so as well as actually outlining what you think the issue is with with the patient that if you have specific questions about what you think might be the best ongoing treatment in the run-up to retrieval then it's also an opportunity to to ask them those things and try and get a little bit of guidance as towards what you can do in the meantime until a retrieval asset is able to get to you. So again, try and think about those questions that you might have before you make the phone call. And if you haven't been able to get answers to them locally, either through the nurses or the SMOs, then by all means use the retrieval resources as a little bit of extra help. And I think telehealth is a developing technology in this area, I think can be used really effectively if it's available to you. I have a distinct memory of a multi-trauma that I was involved in as a JMO in a rural facility, and having that remote SMO available on telehealth to coordinate the resuscitation of multiple trauma patients was an enormous asset to us and certainly put the room at ease and also managed that, was able to manage the transfer of those patients more effectively for that reason. Okay, that's terrific advice.
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Obviously that's going to vary depending on the particular clinical situation, but are there any kind of principles that apply to all patients? Yeah, so I'd say focus on your resuscitation first. And so in all cases, you're responsible for doctors ABC and make sure that you resuscitate the patient appropriately while you're waiting for the retrieval team to get there. And you can certainly get guidance on the best ways to do this and any additional features that can be provided before the patient is picked up. It's always good, if possible, to have two IBC access in before the retrieval team gets there. And it's always a relief when these sorts of things are performed before we get there. Obviously having the documentation is vital. And so ensure that you've photocopied all of the relevant documents such as the ECGs, any blood gases, the notes and any advanced healthcare directives, for example, because this is important not to miss this information when we hand it over to the receiving facility. And obviously it's important to prepare the family for the retrieval as well. And so a number of these patients are leaving their hometown, certainly within the Indigenous group, for example. It's a huge step for them to be transferred to another facility. And so trying to prepare the family for what's going on in terms of the actual retrieval and how far they're going, how long they're likely to be away. Yeah, terrific. John, did you want to add anything to that? Yeah, I think I'd just pick up on that last point Pat made about discussing with the family and the patient because that certainly can be a complex issue. And particularly with elderly patients, with multiple comorbidities who've developed significant critical illness, this can be a pre-terminal event sometimes. And the process of actually retrieving these patients from home, from their family support and their networks is a huge undertaking. And sometimes we find that the discussions around that haven't progressed very much when it comes time to do the retrieval. So I think talking to the patient at an early stage and making it clear to them what we think is the most appropriate treatment in terms of transporting them is important and getting a feel for how they feel about that as well as involving the family. Now you can't realistically do that all the time before you've made the call to the retrieval services but I think in the meantime while you're waiting for them to come to progress that discussion is really important. Also if there are advanced directives for patients in terms of care if a patient has said that they don't want to be intubated or they wouldn't want to go to you know higher level care setting then it may not be appropriate to for us to transfer them if the main reason we're transferring them to another facility is so that they can have respiratory support or inotropic support it's really important to check with the patient before they go that actually that's something that they that they want and would be prepared to to go through and those those discussions can be difficult but i think the sooner you start them and have them with the patient and the family, then often the better the outcome. Yeah, that makes a lot of sense. So what happens when the retrieval team arrives? Obviously, the junior doctor will be required to give some sort of handover. Do you have any advice about how that can be done succinctly and effectively? Yeah, I think you've said it. Keeping it succinct and simple is the key. And so again, I think using something like the iSPA system, introduction, situation, background, assessment, and your recommendations, and keeping that very simple. If the retrieval team have any specific questions, then they can ask them after that. And if you're unsure about any of the questions or unsure about the answers to those, just say so if if it's unclear why the retrieval team is asking something or doing something it's a really good opportunity for you to learn as a clinician from that from that case and so just take the opportunity to ask questions and engage with the with the retrieval team yeah i'd echo those thoughts i think it can be a bit stressful sometimes doing doing handover, trying to put together what's happened to the patient over a number of days and a number of interventions and just spend a little bit of time and maybe jot down some notes about what you think are the key issues and practice it, run through it with one of the other doctors there or one of the other nurses before the team arrive. But it's perfectly fine to add things after you've done your initial handover. If other things come to mind, that's absolutely fine. So when the retrieval team has arrived and they've completed their initial assessment of the patient, what are some of the factors that they consider when they're thinking about how they will manage the patient in the air or in the back of an ambulance, say. Are there any particular clinical or logistical factors that the team need to take into account before they transport the patient? Yeah, so I think the retrieval team really have to consider the duration of the patient's transfer and an expected or possible treatment requirements. So really have to prepare for multiple different scenarios. And you may note them sort of taking special note, for example, of the access and the security of the IVCs, for example, as these are much harder to put in the air. They may ask for additional drugs, drugs just to be prepared in the event of deterioration because point A to point B can sometimes be much more challenging than it seems. And that's especially true if you're not prepared. Yeah, I sometimes think as a retrievalist that we tend to be born pessimists in that we try and think of what the worst case scenario is or what the likely complications are that are going to arise during the retrieval and then try and plan for them and try and obviously avoid them occurring. I guess there's two sides to that. There's the patient's natural underlying condition, whether that's medical or trauma. And it may be that as time progresses, their condition worsens. And if that's going to be in the back of an aircraft, then we might need to do some other interventions before we leave. But there's also some of the factors around retrieval itself, particularly if we're going to fly patients to altitude, that can certainly exacerbate some of their conditions. It can certainly worsen respiratory failure. And so it may be that we decide to intubate a patient who, if they were in a recess bay in a bigger hospital with an emergency department, we might be happy to just observe them for a little while. But if there is a chance that they're going to deteriorate in the next hour to them perhaps we would intervene where we otherwise might not and similarly starting inotropes for instance would be one of the other things that we might do to anticipate a potential deterioration in the in the coming time during the retrieval yeah okay that makes a lot of sense so it sounds like there is a role for the retrieval team in trying to predict and preempt some of those potential complications that might occur during transport. Well, on that background, why don't we talk through a couple of cases just to provide some practical examples of how these principles can be put into practice. So why don't we discuss a case of acute coronary syndrome? Let's imagine it's 10 o'clock in the morning and a 50-year-old patient has presented to your rural hospital with central crossing chest pain, and that chest pain started about two hours ago. You're the sole doctor on site, but there is a senior medical officer or an SMO on call. One of the two nurses has performed an ECG and it shows an anterior STEMI, and the referral hospital is a two-hour drive away, but a 30-minute flight by helicopter. To start with, Pat and John, what should the JMO's next step be in this situation, having been presented with a patient who looks unwell and an ECG that shows an anterior STEMI? So I think, as we mentioned before, that resuscitate early and call for help are really the focus here and so if the patient's having a STEMI just expect them to become unstable and expect them to drop their blood pressure have issues with arrhythmias or develop a malignant rhythm and even if they don't you'll be prepared for it so put the pads on early get some access give you judicious fluid boluses move them to a resuscitation bay and call in the SMO early for advice. Getting involved with the local facility and cardiologist may be appropriate and having that discussion with your SMO before you contact the local cardiologist to discuss the case and send off the ECGs may provide you with further clinical information and a means to transport this patient for definitive care. Yeah, that makes a lot of sense. So at what stage, Pat and John, should the junior doctor make the referral either to the cardiology department or to the retrieval organisation? What's your advice around that?
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Start some initial treatment, some pain relief, some anti-platelet therapy, that sort of thing. Make sure that we've got an ECG and other investigations as we need them. And probably once we've started that, and once you've contacted the local SMO for some help, that's probably the time to start thinking about the next stage. And as Pat says, really the big question here is going to be around reperfusion. Are we going to thrombolyse the patient locally, given the time it's going to take them to get to PCI? Or are we in a setting where potentially there is time to get them to a centre that can provide primary PCI and certainly in our environment in North Queensland it's pretty uncommon for us to be able to get patients into the centres for primary PCI in time and so a lot of these patients end up with thrombolysis in the regional centre but that's certainly a discussion to have with the cardiologist initially and then once that decision's been made I think the retrieval team would be the next people to talk to. Often in our setting here one thing that works very well is to try and have a conference call so you get the referring hospital on the phone along with the cardiologist and the coordination centre and potentially if the patient's unwell and they may need intensive care or that sort of thing uh then you can involve that that team as well and that really really helps to have everybody on the same page from from the beginning yeah okay pat did you want to add something yeah i think i think sometimes discussing with um metropolitan clinicians it's sometimes they're not also aware of what's available to do to colleagues. And so making it clear what you can and can't do in your own facility is really important as well. So they may ask for some things which aren't available to you as investigations, for example, pathology or more invasive imaging such as CTs. And just be clear about what you can and can't do in that facility. Yeah, okay. that makes a lot of sense. So is there anything else that the JMO might be able to do after they've provided the initial resuscitation to preempt and minimise the impact of complications? You mentioned some of these things already, Pat. Yeah, so I think, as I say, placing the pads on early and being prepared for this patient to deteriorate. So you give some fluid resuscitation, you give some pain relief, you give oxygen if they're required, if their saturation is less than 93%, and just being prepared for this patient to deteriorate. So having some resuscitation drugs on hand, and this is things that you'll discuss with your SMO or your senior colleagues, but having simple things prepared, perhaps like some adrenaline, for example, may be appropriate in the setting. Terrific. Okay, well, why don't we now talk about a trauma case just to give a different perspective on these matters. Let's imagine it's an unfortunately busy day. It's now 2pm and a 25-year-old male has fallen off his motorbike at high speed. He's been brought into the rural hospital. You're still on shift. And his vitals are as follows. He's got a GCS of 12, he's got saturations of 100% on high flow oxygen, his heart rate's 100, and his systolic blood pressure is also 100. So it's clear he's got a head injury. It also looks clinically like he's got a left-sided pneumothorax, and on the basis of extensive bruising over his left upper quadrant, you're worried about a splenic injury. He's got no apparent limb injuries at all. Fortunately, the retrieval team's only five minutes away because they were pre-notified about this patient's arrival via the ambulance service. But there is five minutes where you're potentially by yourself there as a junior doctor or hopefully with a senior medical officer to assist you. What can the JMO do in this situation to resuscitate the patient and also prepare them for transfer? So I sort of break this down into three elements. So finding an appropriate space for this patient in the first instance, so a resuscitation area is key. Arranging a team, and so you arrange a resuscitation team in the same way you would for any other resuscitation engage your nursing colleagues and any other medical team members that are available you may be able to actually get the wards people and other attending people from the hospital to assist with certain elements of the task and also organizing your equipment and so as i say and again call your senior staff early now this may your first experience with trauma. And just remember that the algorithm for resuscitation trauma is slightly different from the algorithm that we use in normal resuscitations. So rather than doctors ABC, we tend to look at managing life-threatening hemorrhage first. So you might have heard of C, A, B, C, D. And so managing bleeding first is key and stopping any life-threatening hemorrhages is really important. So that first C, circulation. Circulation, that's right, yeah. Maintain spinal precautions, splint any fractures and give really good pain relief. They're the other keys, I guess. Yeah. John, did you want to add anything on that, on the initial trauma reception and management in a rural facility? Yeah, I think I would come back to one of the points you made earlier about the pre-notification from the hospital because certainly trauma patients do tend to be time critical this this patient's already got some altered physiology with the reduced gcs and uh from a hemodynamic perspective you know that systolic of 100 is certainly lower than than we'd expect it to be and uh at that level that is associated with a high likelihood of uh of some significant bleeding so if you're in a facility where that pre-alert hasn't been made by the ambulance service, when these patients arrive, coming back to the point earlier about when do you call the retrieval team, I think almost as soon as these patients come through the door, once you've done a very quick primary survey to make sure there's nothing they need immediately, the sooner you can activate the retrieval system, then certainly the better. As Pat says, going through a process and having a system in your head is certainly helpful because these patients are stressful when you're dealing with them. Often in the bigger hospitals, you may have been part of a resuscitation team, but this might be the first time where you're actually dealing with these patients and people are looking to you to make decisions and decide on treatment. And when you're put in that situation for the first few times, that can certainly be quite an anxiety-provoking situation. But I think stick to ABC or see ABC, as Pat says, and also think forward. This patient sounds like, as you say, they've got a pneumothorax, so we're going to be doing a chest strain or some sort of intervention on their chest. And even though the retrieval team's only five minutes away, they potentially will still be doing some of those interventions. So still perhaps get the equipment ready. Start thinking if this patient does drop their blood pressure, what are we going to do? Do we have blood products available here? Hopefully the retrieval team may well be bringing some with them. But think ahead, even though the retrieval team's a few minutes away, this patient's still going to need some significant intervention. So start trying to plan for those if you can. And when the retrieval team does arrive, John and Pat, what are they going to do? What will the retrieval doctor and paramedic, what were their initial steps and how will they go about assessing the patient? So there's a fairly rapid assessment of the patient from the end of the bed in terms of their vital signs and often the way the patient looks on the bed as well. And so you can establish pretty quickly whether that patient is unstable and then you do a head-to-toe secondary survey to identify any other life-threatening injuries that need to be immediately treated. So ideally if the patient's relatively stable then on arrival we'll talk to the treating team, the doctors and the nurses who've been involved and try to get a handover with a summary of the key issues if the patient's been there long enough for us to establish that and then progress to an assessment and putting together a plan for the retrieval. There are some cases though where when the patients are unstable, when they're deteriorating, that actually on arrival there needs to be a combination of getting the hand over and actually starting to do some treatment and those can be very challenging both for the retrieval team and also for the referring team and and if you're the the referring doctor in in the hospital and you see that the patients are unstable there are things that they need immediately then i think don't be afraid to say look that these are the key issues at the moment you think we can start looking at this and this and then perhaps we can do a more detailed handover in a. And that's certainly very helpful for us when we're coming in as the retrieval team, because things may well have changed.
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Okay, welcome everyone to On The Wards. Today we have Safe Professor Shabel Sandrisa with us. Welcome Shabel. Thank you. Thank you for asking me to participate. So look, we're doing something I think most junior doctors don't know much about. I know as a senior doctor I don't know much about, is nutrition. So we're going to kind of talk a bit about nutrition on the wards. You're an upper GI surgeon. Why is nutrition important in a perioperative setting? Nutrition is important for several reasons. Preoperative nutrition and particularly changes in preoperative nutritional states influence the outcomes after surgery. If your patients have either too much nutrition or too little nutrition, they have a much greater rate of perioperative complications, longer hospital stays and an increased morbidity and mortality from particular operations. Also, we need to have an assessment of the baseline nutritional state for certain operations, particularly major upper GI surgery, because those patients often have disordered nutrition after surgery. You need to try and restore that nutrition back to their original state. So that kind of leads into my next question. What features on the history and exam or investigations contribute to your assessment of the nutritional status? The most important thing to assess the nutritional status is the history and physical examination. And there's several things. One is an obvious history of how their nutrition has been over the past few months, significant changes in weight, and also significant changes in physical function. When we look at patients, we do what's called a subjective global assessment. And that's looking at how they get up out of a chair, walk around, how they look, whether they've got features of malnutrition, such as muscle atrophy and loss of fat in particular places. And you can get a very good idea about whether someone is well-nour undernourished or overnourished just from that. There are specific things like the body mass index and the patient's weight, but they're often less important than significant changes in weight over a short period of time. And the blood tests are adjuncts to that. Things like the levels of certain vitamins such as vitamin K, their INR, their pre-albumin level and albumin level, and also their iron studies, their ferritin, things like that are also additional things which you can check to see whether they've been taking an adequate amount of nutrients. And in patients who have long-term nutritional deficiencies, there are trace elements that you need to check because they can actually manifest as diseases in the patients, things like selenium, manganese and zinc. And they can manifest as diseases in the patients, so they're important to know beforehand. But the most important thing is an individual's just general assessment of whether someone's nourished well or undernourished. That's a subjective global assessment. I may go on to one of the investigations you meet with albumin. I mean, is albumin a good indicator of nutritional status, especially in inpatients? No, in inpatients it's actually not. Albumin's an acute phase reactant, and so for patients who have got infections and who have had major operations their albumin always drops but the patients who are out on out in the community who haven't had any interventions no recent no recent changes in their in their sort of physical situation the albumin can indicate that they have it can be one extra indicator that they've had relatively poor nutrition over a period of time. But the most important thing is your clinical assessment of the patient, much more important than any tests. What are the different types of nutritional supplementation? So the two types of, the main types are enteral nutrition, which can be delivered by the patient. They can eat and drink more, and we can give them supplemental drinks which have high calories and high levels of protein and fat and things to supplement what they're normally eating. They can also be tube-fed either into the stomach or into the intestines, depending on where the problem with their gastrointestinal tract is. And then there's parenteral nutrition, which is intravenous nutrition, which is a total replacement of the person's caloric and lipid amino acid and sugar needs, as well as replacement of their vitamins and trace elements intravenously. We might talk about total parenteral nutrition later, but what are the risks and benefits of the enteral versus parenteral routes? So the main enteral nutrition, if it's possible, is always preferable. There are mechanical problems with enteral nutrition because the delivery of enteral nutrition relies on a functional gastrointestinal tract. So it relies on someone being able to swallow their esophageal peristalsis being normal and their gastric emptying being normal. And often people who have had major operations or who are very unwell for other reasons can have disordered gastrointestinal function. They have a high risk of aspiration and reflux. And sometimes they don't pass the food out of their stomach and it sits there and then it becomes an aspirate or they vomit it out. And then there are complications related to the mode of delivery. So tubes can have complications, they can block and dislodge, they can be put in the wrong spot and they can perforate various organs or they can leak. And finally, there are rare complications with tube feeding in certain patients where the feeds can get inspecated into the intestines. For patients with very high vasopressor requirements, low volume, high output states, their small intestine becomes poorly peristaltic and the food can actually slow down in the intestine and it can cause distention and necrosis of the intestine. So that's a rare complication, but it's very serious if that occurs. Parenteral nutrition, most of the problems are related to the catheters and infection related to the delivery of the nutrition. And that's unfortunately a very common problem. Okay, Shabel, you're asked to review a patient on the Aplogia surgical ward who's developed a post-op ileus and remains nil by mouth. What is your approach to deciding when to introduce a diet into a post-operative patient? So in a normal post-operative patient, there are two schools of thought. In the past, we used to wait until they had established bowel sounds and bowel function before we started on them on fluids and food that's that's really unnecessary for the vast majority of patients even if they've got a post-operative alias which is kind of universal in anyone having major abdominal surgery more recently there's been a move to early recovery and enhanced recovery after surgery and that includes commencement of liquid diet which carries some nutrition very early after surgery within 24, 48 hours of the operation commencing or being completed and then you upgrade the diet as they tolerate and as their bowel function works. And do you make that decision every day? It's usually done once a day. Patients who are progressing very well, tolerating their fluids, and they have no gastrointestinal symptoms, they can progress their diet during the day. So it's fairly, these days it's more loose than what it was in the past where people followed a strict regimen of introducing sips of water, then 20 mils, 30 mils, 40 mils of fluid an hour and then clear fluids and then free fluids. We just allow patients to drink freely normally after surgery and then the moment that they feel like eating and they're okay to start eating. And when they start eating they just have a normal diet or is there a particular diet? That depends on their operation. So certain operations require patients to either have a pureed diet or a soft diet. So people having fundoplications or gastric bypass surgeryagectomy, you will need to have a normal diet is less. And then the rest of the patients generally can eat normal food. So patients who have had liver resections and things like that, and also large bowel resections, they can eat and drink whatever they feel like, essentially. What is the role of the dietician in the perioperative setting? The dietitian is very important, particularly for upper GI patients who have significant nutritional deficiencies after surgery for the most part. They will monitor their caloric intake, monitor the consistency and type of food they're eating and provide advice and help about supplementation in the early perioperative period. They also follow them up to assess their ongoing nutritional deficiencies and nutritional needs. And they sort of play a 50% role in their recovery to normal function. They're very important for our patients particularly. We've mentioned TPN previously. What are the indications for commencing TPN? So there are several indications. Short-term TPN is used as a bridge between when the patients have stopped eating and when they can start eating again or when their gut function returns so that they can commence reabsorption of the nutrients from their gut. And in general, in someone who's post-operative, we would wait five to seven days before we think about the commencement of TPN.
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Welcome to On The Wards, it's James Edwards and today we're talking about interviewing, well we have Dr. Sarah Dalton with us. Welcome Sarah. Hello James. Sarah is a regular on the wards and it's a consultant paediatric emergency physician and also currently the president for the division of paediatrics and child health at the Royal Australasian College of Physicians. Now Sarah I have always thought because we've known each other for a number of and I always thought if I was going for my dream job and I walked in and saw you sitting for the same interview, I'd walk out knowing that you would nail it. So you're a perfect person to talk about interviewing well. Oh, you're being very kind, James. But I will say on reflection, I've had 10 different jobs in the last 10 years, so I've had a lot of practice. A lot of practice. Well, that is a good thing. Now, look, I guess we're looking at the role, you know, I guess some tips and tricks about you feel well for junior doctors because I look back at my experience. I went straight into medical school without an interview, then got an internship and really got a whole bunch of jobs without particularly doing much interviewing. And then I went for a consultant job and went, wow, I'm not overly prepared. And I think a lot of junior doctors have only really interviewed for having a job at the local pub or something. And this is a bit different and high stakes. So maybe we'll ask a really simple question. I mean, why do we conduct job? Well I guess ultimately as employers and as hospitals we want to make sure that we've got the best people for the job and in particular we want to make sure that we've got people who are a good fit which means that you get along with them, they're interested in the same things and they've got the qualities that you would look for in someone to have on your team. So given that most most of our interviews for SMO registrar positions are 10 or 15 minutes, fairly short and brief. I mean, within that short timeframe, do you think we can really gauge all those facets you described? Yeah, I think that's a really big challenge. And people probably know there's a lot of debate about how good interviews are at picking that. That's part of the reason why usually the interview is not just an isolated event. It happens in the context of submitting a CV and talking to your referees and the reality for a lot of us is that we actually know many of the people on the panel. So the interview itself is not the be-all and the end-all but having said that it is important, it is part of a structure and of whether it's fantastic or not, the reality is we've got to do them. And it's an opportunity to shine and do well if you can think about it in the right way. Okay. And I guess we'll go back to, who sits on the interview panel? Well, it can be quite variable. And I think one of the things in preparing for an interview is to ask that question. Sometimes you'll be surprised how much information you can find out in advance, like who will be there, what number you are in the interview scheme, how many people will be in the room, but sometimes you can't. So if you haven't had the chance to prepare, I think most interviews for junior doctors would have about four to six people in the room, and there'll be people from the hospital and also not from the hospital. There'll probably be people you know, and often they'll be in the specialty for the area that you're looking for a role. But there's always independent people. And sometimes these can be from another specialty or another hospital. Sometimes we have consumers and patients and other people like that on the interview panel. So I guess you've got to be prepared to talk about yourself in front of people who know you, which can be quite embarrassing, but it's also a good opportunity to speak to people who don't know you and often that's where I focus my attention when I'm doing an interview. Now, are interviews for medical patients structured? I mean, does everyone get asked the same questions? Yeah, they pretty much do. I mean, the interview process is one that aims to be really transparent and really fair. So although people will debate whether that's the best way to do an interview, it does mean that the questions will probably be the same and you'll be given a mark on the marking sheet by the interviewers so they can compare everybody's performance. They'll probably also write down what you're saying so that there's a record, which can make it a bit difficult because you're looking for eye contact and to have a conversation with people, and instead they're listening and writing notes, which can be a bit disconcerting. Yeah, I mean, I find it challenging someone who's trying to select a candidate to work out what kind of score I give them, you know, what I'm based on that score. What do you kind of think most people in the selection panel are looking for? Look, if they're doing the job well, they should have some idea beforehand around the sorts of answers they're looking for for each of the questions. And the really good panels will have actually got some kind of score where they've decided that the middle range is a three, for example, and then you use your gut instinct, I guess, to decide whether this person is, sorry, you can use your gut instinct and reaction to establish whether you think this person is performing at a three or above. I do think that the person who goes first has an advantage to some extent because they do set the bar. And if you're a good candidate, it's quite good to go first because you can set the bar high and then it'll be clear, of course, that no one else can meet your standard. But if you're coming along later, just be aware that they probably are using a barometer that's been set earlier in the day. Now, before you get to front up for the interview, what groundwork would you consider doing before applying for the job? Well as you know, preparation is everything and of course preparation prevents piss-poor performance, so we're going to do a lot of preparation to do a good interview. I think that if you haven't done them before, actually there's a lot of thinking time involved. I've done a lot of interviews and I find myself when I'm preparing for them, if they're important to me, it feels a little bit like preparing for an exam. Because that means you're sitting down thinking about what questions could I be asked? How am I going to answer them? How am I going to answer them if I don't know how to answer them? So I think that actually preparing answers to questions is really important. I think the other thing is it's important to have some sense of what the job is and what people who have worked in the job have thought of it, if that's possible. Because in reality, people who are appointing you would like to know that you've got some idea what you've got yourself in for, partly so that you have already assessed yourself as being ready for the job, but also so that they know that you care enough about the job to have talked to a few people to understand what it is that you think will be good about the job, but also have some insight into the challenges. And in regard to doing interviews beforehand, doing mock interviews, is that something that you would, I guess, suggest for trainees, especially if they haven't done many interviews before? I think mock interviews are one of the most important things. And in fact, I think that it's really, really, really important to say things out loud before you do it for the first time. Because you might write on a piece of paper, I have a great strength in communication skills. And when you come into the room, and hopefully they won't ask you what are your strengths, because that's bit of an old question now but they might and if you just say out loud I have good communication skills it might not come across like you actually have good communication skills so there's a number of ways you can do it and it's always a bit embarrassing doing a mock interview but it's a little bit like doing preparation for clinical exams it's embarrassing doing it in front of people but it's nowhere near as stressful as the real thing. So choose some people you trust, and you might even want to start yourself by interviewing yourself in the mirror and putting it on video and watching it back yourself. And that way you don't have to involve anyone else to start with if you don't want to. You mentioned some common questions. And so which ones should you prepare for and any pointers on how to approach these type of questions? I think that most interviews start with the question, which is something along the lines of, tell us a bit about yourself.
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The next question that often comes is something like, and why do you actually want the job? And I think that both those are a good opportunity. You really, in my book, you really need to be prepared to answer those questions. Because the first one gives you an opportunity to showcase what you think is the specific thing you have to offer. And the second one shows that you've got insight, you've been prepared, and you actually do want that job for a specific reason rather than I just need to get some training and it happens to be close to where I live or whatever the reason is. You've got to be a bit careful. You've got to be honest, but you don't want to be too honest. And so you can maybe tell them a bit about yourself. And I guess it's also why you want this job, why you're choosing this often comes up as potential questions. Yeah, yeah. I think that showing that you've done a bit of homework about the role is really important. I think that in answering what it is about yourself that you want them to know, one of the things that I always prepare is what are your three key messages you want to get across? So for me that's an important part not only in being prepared, so thinking about what is it that makes my application different to other people's and what is it that I can show where I bring value that other people don't bring value because that is what distinguishes you from the other people in the interview regime. In answering that as well, once you've got your three key messages, there's two other things I think that helps you with. One is when you're asked a question and you don't really know how to answer it, you can do that segue thing and you can acknowledge the question and then segue into the message that you really want to get across. So if the message you want to get across and you've practiced it is, for example, you've got really good communication skills and if you're asked a question about a conflict resolution or something and you don't know how to answer it, you could sort of say, look, I acknowledge that that's a really big issue in healthcare and I've done some thinking about it. I'm not particularly sure in this example because it's challenging. But what I know about myself is that I have good communication skills and on occasions where I'm not quite sure what to do, I know that I manage it well and I would seek advice afterwards in order to establish that I'd done the right thing. That's not a great example, but there's a technique that they explain this as, which is called ABC, which is answer, bridge, and then communicate your key message. Sounds like what politicians do. I think a lot of this is media training, to be honest. I've done a bit of media training as well, and it's very similar. Okay. I mean, look, I agree entirely what you say. I mean, sometimes I do think one of the risks is that some people almost come in with an answer and then try and answer for whatever question is delivered that same answer and they don't actually answer the question so I think it's one of those risks I guess you're talking about having a segue but I think we you know you need to have that preparation and try not to just answer the actual questions asked rather than the the that you want to give. Yeah, and I actually think the other really important part, which I try to be conscious of every time, is you've really got to listen to the question, especially the first few questions when you're really nervous and you almost need to have a little mindful moment of your own where you say to yourself, just chill and listen. It doesn't matter if you're slow. It doesn't matter if you take a minute to answer. And in fact, it doesn't hurt to repeat back the question if you're not sure. So I think if you were to be asked a question, which was a double barrel question, which unfortunately is not uncommon, it's not unreasonable to say, so what I've heard you say is a scenario that involves negotiation skills and leadership skills. What I might do is answer the question around negotiation first, and then I'll come back to leadership if you wish. Because that way, not only you're clarifying that you've heard the question properly, you're showing to them that you've been listening and that you've got an approach to answering the question. And if, for example, the key message they really want to hear from you is leadership and you start talking about, I don't know why I said negotiation, but something like that, they can then bring you back at the end and say, you know, earlier you said you could talk about leadership skills, could you go on and expand on that? Whereas if you just started talking and you didn't outline your questions in the way you might answer them, it's harder for them to bring you back to the message that they want to hear. And potentially, if you've got the structured questions where they're looking for a specific answer, they might actually want the opportunity to lead you there. It's very much like in fellowship exams you almost have a motherhood statement that almost outlines what you're going to say in the next five minutes so they can see exactly what you're saying and if it's like exams sometimes you say the fantastic initial statement they go oh they've got this they know exactly they've found out exactly what they want to speak to. I completely agree. And they almost close off for three minutes while you talk, but they understood in the first minute that yes, you understood what the question was and you were going to answer the question appropriately. I think that's right. And sometimes we see interviews as being an unnecessary hurdle for what we really want to get to. But in fact, preparing for an interview is very much like preparing for a clinical exam. And I think that you can see a lot of synergies and learnings in both. Now you did mention I guess talk about stories you know how important are describing I guess your experience within a story or a scenario rather than I guess just a list of what you probably see as I'm a good communicator I'm a good negotiator I'm a good leader what's the role of stories? I think you have to tell a story. And in fact, I would always prepare a few stories that you're willing to talk about that you think demonstrate some of your key messages. So this is, I mean, this is an interview that you really care about because this takes a lot of preparation. But if you think about your three most important messages you want to get across, and using the example we've been talking about, say you want to get across that you've got really good communication skills. I would take that to the next step and think, okay, what example am I willing to speak about that shows that I've got good communication skills? So, for example, you might have worked with a colleague who was difficult to get along with and everyone else found them hard, but you had really good collaboration skills and you managed to work with them effectively. There is actually a good acronym for remembering how to answer a question like that and the acronym is SCAR, S-C-A-R, and that means what was the situation, what was the complexity of the situation, what action did you take and what result did you get to. And the reason I like that is it's not just a story that says, I did this thing and it was really hard. You're saying, I did this thing, it was really hard. This is the actions that I took so that it could be more effective in my situation. And the results are that I was effective. So, for example, I had a colleague who I couldn't get along with. It was very difficult because they were actually the registrar and it was really important that I got along with them and I didn't know how to manage them. The actions I took were the following and the result of it was that by the end of the term we actually had a really good collaborative team and I felt like I could really trust this person. And perhaps you might add some way that that's been validated. So for example, you might say, and my supervisor at the end of the term said to me that they saw that I'd made a really big effort to work well with that registrar. So that's a really good framework for answering questions like that. Yeah, and I almost add another reflection. I kind of think whenever you have an experience, you can see what's happened. I think, you know, what we're looking for is reflective practitioners. If you can go, you know, when looking back at that experience now, I saw what I did well and not so well and that has now been incorporated into my, you know, how I communicate with people more senior to me or other colleagues, I think it's important. Yeah, I reckon it's a great one. In regard to clinical questions, I mean, is a clinical question appropriate for an interview?
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So if you've showed your clinical ability in other ways that feed into the interview, it might be the interview panel don't want to hear that. But on the other hand, using a clinical scenario can actually give people a sense of what experience you've had, how you would approach a problem, but also perhaps an insight into your technical expertise. So sometimes people do use questions like that. What do you think, James? I know you've done a lot of interviews. Look, I think for a junior doctor, going to a like an SRMO or registrar, I think a clinical question is helpful. I think when you actually go to a consultant, you know, I think you could probably argue that you've passed a fellowship exam, it really should be retesting you on your fellowship skills. But I think it probably does give us a bit of an indication of maybe not your clinical skills so much, but your approach to a problem. And it's not so much about getting the answer right, it's probably having a sensible approach to a clinical problem is probably what most people on the panel are looking for. I imagine that's right. And I imagine also that honesty is really important in that. I mean, obviously you need to temper that. You can't just say, oh God, I've got no idea. I'll just run away. But I think the worst thing is to pretend to be something you're not or to pretend to really know something that you don't. And even though it might feel more comfortable to do that, and to be honest, I think in the end, it's always better to temper everything with a bit of honesty. Yes. And look I look at me and with all those critical questions they'll often be a component of knowing when you're asking for help so it depends on which position you're going for but typically you'd be going for a registrar position knowing that you may have more leadership over junior doctors but also that escalating to a senior consultant is what they want to hear they don't want to hear you being a rogue registrar doing yourself. So I think that will be important. I guess another group that comes up is some of those tricky professional ethical questions. Are there particular ones that are often in interviews or ones that you've found particularly tricky? I think there's always a question of conflict resolution because that's a reality for humankind, I suppose, but certainly in healthcare as well. So I would have a prepared answer for how you would manage some kind of conflict or any other challenge. And honestly, if junior doctors think about the challenges they've had already in their careers, they're probably the things that would come up in an interview. So what have you done when you've seen a colleague of yours in distress? What would you do if you felt you were being bullied or you thought someone else was being bullied? What would you do if you really felt out of your depth and you were being asked to do something that you were uncomfortable with? Some of those questions which are the reality of what concerns and rightfully concerns junior doctors I think would be the sorts of questions that you would be asked. Yeah I mean I entirely. I think they would be very topical at the moment. I think also, almost going back to the clinical questions, there will often be a quality and safety component at the end of it that, you know, for those who answer it particularly well, especially if there's been an error or something, we'll look at other quality and safety measures, so it's probably worth thinking about those too. We've covered a lot of ground so far. Any, I guess, general tips on how to interview well? You know, just general sorts of things that you think are important and you notice of people who actually interview well or, you know, seem to be more comfortable in interviews. I think that the X factor is just the way you come across and your presentation skills in general. And that's extremely hard when you're feeling nervous. And it's exactly like a clinical exam. Basically, if you can be yourself and if at some point in time you can relax and smile, and I have a little KPI for each interview I do, which was that I got the whole room laughing at some point. It's not necessarily belly laughing, but if you can get them to smile and have a little bit of of a giggle then I think that shows that you've got a relaxed environment and you're being real I think people it's worth reflecting on how important your body language is and what you wear and that's not to say that you've got to wear a suit and go and get your hair done but you do need to present in a way that you think they will see you as looking professional as and I think that being able to be confident or at least to appear relaxed is really important there's a really interesting study many years ago and I'm sure there's many since that shows that about 50% of the message that comes across from people is their body language and that about 40% of it comes from the way they talk. So they talk about the tone and the music in the voice. And less than 10% comes from the actual words. So if you notice, if you walk past a clinical space and you can see doctors and nurses either talking to each other or talking to patients, even though you can't hear the words they're saying, you'll have a pretty good sense of what they were talking about and how well it was going. Which just is a really important reflection that the words you say are important, but the body language and the way you talk and the eye contact and the interactions that you have are equally important and they mustn't be forgotten. Are there particular areas that you think candidates do poorly in or I guess are particularly, sort of things that are particularly and maybe really annoy people on the panel? I guess one of the things that annoys me is when people don't listen and they don't answer the question that I've asked and that's not because I don't understand that they're nervous or because I feel like they're just telling me their own story. It's partly because I just feel like it's a very uncomfortable situation for them and I do understand that. But I'm really trying to help them. And the way that I'm trying to help them is to ask questions that they can listen to and give me some answers that I can write on the piece of paper so I can give them a good score. And I often sit on the other side of an interview table willing the person to answer the question that I've actually asked and not answer the question in some way that isn't relevant. I understand why that happens, but I do think the key to overcoming that is to really listen and to ask to repeat back and then to outline the areas that you want to speak to so that people can bring you back to specific things if they want to hear more. What about you James? What annoys you? Look, I do prefer when they actually make a bit like a story or personal. Sometimes I do feel like they've given me a list of the selection criteria and it's just a very bland list of things that they think I want to hear but I don't want to hear that I want to hear about them and what they can contribute to I guess my department or or my service obviously little things just in regard to your body language just try you know try and sit forward don't try and lay back I know you may want to try and feel relaxed, but kind of too laid back and looking like, oh, I don't care at all. You need that balance between not being too nervous and not being too relaxed. That's a really interesting point because I've asked a few of my colleagues in the past about what do they think are big mistakes that junior doctors make. And one of my friends who's a surgeon said that a number of her candidate interviewees come in and just look really arrogant. Yes. And they lean back and they cross their legs and they kind of, I don't know, chew gum, but almost chew gum and look at the people on the other side of the table with a kind of, well, what can you offer me type approach. Now, it's a balance, isn't it? You want to be confident, but if you appear arrogant, then you're really sunk. Yeah. So, look, I've said this in different blogs. It is really not about what you're trying to get a job with this hospital or this department. It's not about, not about, it's more about what you could provide to my department rather than the other way around. You know, I think that's some people very much, well, this is why I'm coming here because you can give me all this. I'm looking for what you can provide me. I think that's absolutely right. It's a quid pro quo. But you're giving me a lot, I'll give you much more back.
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Welcome to On The Wards. It's James Dent and today we're talking about clinical pathology with Dr. Robert Rawson. Welcome Robert. Thanks James, nice to be here. So Robert's a pathologist at Royal Prince Alfred Hospital. He's worked around Sydney and around Australia, most recently up in Darwin and has returned back to RPA about 18 months ago. He's got an interest in dermatopathology and gynaecological pathology as well. He's also got an interest in keeping fit, does triathlons. In fact, he's good enough that he's been selected into the Australian team to travel to the World Championships next month in Switzerland. Is that right? That's right, yes. Should be an interesting little trip. Excellent. Okay, so Robert, can you please start by giving our audience a brief introduction to your role as a pathologist? Yeah, sure. So pathology really is the basic science of disease and that really underpins nearly everything we do in decision-making in medicine and therefore pathologists are really central to patient care within both the hospital setting but also within primary health care and in most cases pathology is really required for a diagnosis but we start to provide so much more than that we provide information on prognosis and also guiding management. Now there's numerous types of pathologists and subspecialties within the College of Pathologists. There's haematologists, microbiologists, chemical pathologists, genetic pathologists, forensic pathologists and I'm an anatomical pathologist or in other countries it's called a surgical pathologist. I'm a medical specialist with an extensive training. Now I deal a lot with surgeons and people who we deal with a lot are really quite surprised sometimes when they find out their pathologist has had just as much training as their surgeon has. It really is a specialist area with really specialized skills. And what do I do? Basically I look at biopsies and excisional specimens and provide information to clinicians to help guide them. Primarily mainly in diagnosis, that's really what we're known for. But as I said previously, we really give more information that we give information on prognosis and also management. Okay, excellent. So I'd like to frame this discussion by talking about a case. So we have a 52-year-old woman who presents to the emergency department and she has left lower quadrant abdominal pain. She's also got some nausea. She's vomited today and is unsure when she last opened her bowels. Her abdominal examination shows bloating, tenderness at the left delioposar and no bowel sounds are audible. Unfortunately, a CT of her abdomen shows a large left ovarian mass causing extramural large bowel obstruction. So what additional history will be useful to you as a pathologist in establishing a diagnosis? Yeah first of all I might just start there by saying when when a specimen is sent to pathology what I believe is happening is the clinician is asking for a medical consultation and that's the same as when a radiology is requested but also as when a request is made to a surgical team or a medical subspecialty team. And I think we really should be getting the same amount of information that is made with those requests. Saying that, what we often get is a specimen request form that says pathology please, or sometimes they add in where the biopsy is taken from, but we don't get much more information from that. And I don't think that's really good enough for the patient because we know that the biggest risk of misdiagnosis from a pathologist such as me is the lack of information and not understanding the clinical context which surrounds the patient and why the biopsy was taken and all the other additional information which the clinician knows but they haven't articulated to the pathologist. And in cases such as this when when a tumour has been located, we go through a sort of a broad differential tree of diagnostic thinking. Primarily, we start off is we're wondering if this could be a neoplastic process or a non-neoplastic process. Could it be an inflammatory or infective condition? If it is neoplastic, is it benign or is it malignant? And if it is malignant, is it a primary malignancy or could it be a metastasis? So any information that a clinician has which would help in that decision-making tree is really important. Particularly, I think, in this case, is there any information that could indicate an inflammatory condition? Does the patient have a history of things such as pelvic inflammatory disease, endometriosis, inflammatory bowel disease, or is there a particular gynaecological, obstetric, or gastrointestinal history that they know about which might indicate why the person has this lesion. A history of malignancy is also very important, particularly when a tumour has been seen, and this patient's reasonably young, so any family history of malignancy is also important. Are there any systemic conditions the patient has? Could they be immunosuppressed? Has there been any previous treatment? And I suppose a bit more information, it's a bit better these days when we have EMR and PowerShout and we can look up radiology if the patient's an inpatient. I've had inpatient studies. But if they haven't, then how is the mass that's seen in the ovary, how does that relate to the surrounding structures? So where is it arising from? That can be really informative for us. And also really important, what some people don't think about is what is the clinician actually thinking? And what is the question they want answered? Because unless we know that, it's very difficult to give them the information that they want. So if there's a particular diagnosis or a particular thing they want us to comment on, it's really important they let us know. Okay. So what are the next steps to establishing what the diagnosis is for this patient? Yeah, sure. So there could be further investigations before I become involved. There could be serological tests such as serum tumour markers might be performed or further radiological studies. That's a lesion in the pelvis and often a pelvic ultrasound can provide significant information. Has there been spread through the pelvis or into the peritoneal cavity or a mental caking, et cetera? But at some point, a pathological diagnosis really is required. Yeah, we're going. Okay, so basically when talking about the biopsies that we encounter, there's two particular broad types of things that we look at. We look at cytology, which is a study of cells, just purely looking at cells. And there's histology, which is a study of tissue, and that's looking at the cells within the tissue, the matrix, and all the structures that support the cells, all the nerves, the fat, the muscle, etc. Each of these, the cytology and the histology, has positives and negatives. So cytology, first of all, how do we do it? So cytology is performed on a number of different specimens. It can be performed on fluids, so a pleural fluid or an acidic fluid, and looking for cells that are suspended in that fluid. A very fine needle can be put into a lesion and try to extract or aspirate out some cells from that lesion. Or something could be scraped or smeared, such as a pap smear, and then put onto a slide to look at. The positives of a cytology is it can be a quick study and is relatively cheap. If it's a superficial lesion, it can often be performed in rooms and get an answer really quite quickly. The negatives, I suppose, of cytology, what it doesn't do well on occasion, is that cytology, it might not be, you don't get all the clues as a pathologist. You purely get the cells. And so you're making a decision about just in the cells, not the entire tissue and what you can see in the surrounding tissue and how it interacts with other parts of the surrounding tissue. So you don't get all the clues you're looking for as a pathologist. The other thing is that you might not get enough material to do additional tests, which we'll talk about in the next little while, which really may be able to help out because you often have a small amount of material available. Conversely, histology, you do get that interaction between the cells and the lesional cells you're looking at and the surrounding tissue. So you really get a lot more information from which to make your diagnosis. And you do get often more material, which then you can go on to do other tests. I suppose it's the opposite in the fact that it is really quite a labour-intensive and often a manual process. I think people often aren't aware of the time that things take in pathology. So a specimen might arrive on one day, and then a pathologist, a registrar, looks at the specimen. They have to decide what parts of the specimen to examine, if it is a large specimen.
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So it's fixed usually in formalin. And then it goes under a series of chemical processing steps to make the specimen stable so it can be stored and looked at for a long time. And that often happens overnight. And after that, the tissue is placed in a block of wax. It's cut very, very thinly, so thin enough so we can shine a light through it and look down the microscope. Then it has to be stained. And so then it can be a 24- to 48-hour period from the process the specimen arrives to when the pathologist actually gets the case on their desk to look at. So understand that it can be a significant delay. That's I suppose one of the main problems I suppose with histology is that it can be quite a delay in actually getting the results if something is really needed quickly. And what test is best in what situation? It really depends on the situation of what the question is being asked and where it needs to be biopsied. In a case such as this, if there is some acidic fluid, it could be quite a simple process of tapping that fluid, spinning it down and see if there's any cells which could be originating from that ovarian mass to guide us on what that lesion could be. Generally with a biopsy such as a fine needle biopsy or a core biopsy, we generally don't do that in ovarian lesions as there's a risk of rupture. If it's a cystic structure, you could rupture it. And there's a risk of seeding that tissue through the pelvic or the peritoneal cavity. So in a case such as this, what would normally happen would be an excisional biopsy of the ovarian mass, often taking out the tube as well. And that can also be done in conjunction with a frozen section during the operation where we become involved. So that takes away, I suppose, the time delay in the processing steps. Instead of going through that long process of stabilising the tissue and fixing it, we snap freeze it and then we quickly slice it, stain it up and look at it whilst the operation's going on. And so we can provide some intraoperative advice and a preliminary sort of answer of what this process could be. Now, people say, why don't you do that for every case to speed things up? Well, the problem is this is a lot more labor intensive than the rest of it takes away a registrar, a pathologist and a scientist for up to an hour. And also the process of freezing tissue quite degrades it significantly. So it's not as, we don't get as much information. The tissue is not as clear to look at down the microscope if it's been frozen and it can sort of destroy it for future testing. So the future testing we do might not actually work. So that's why we don't do it for all cases. But when there's a case which we can provide actually informative information which would guide intraoperative management, such as this case, depending on what we find, they might go on to take out omentum, the contralateral ovary and tube, or the uterus, or sample some nodes. It can really be helpful in that regard. Or a case such as Whipple's, when they're really chasing a margin to know if that margin's involved, that can also be helpful in that occasion as cases such as whipples when they're really chasing a margin to know if that margin is involved they can also be helpful in that occasion as well. Okay excellent. So I'm interested what ancillary techniques might you use as a pathologist to get to the bottom of the diagnosis and what might those techniques be both in this case and kind of more generally? Yeah, overwhelmingly, we get the majority of our information from what we call morphology, looking at the cells down the microscope with our standard staining, the standard H&E, hematoxin, EOS and staining. We get, far and away, we get the most information. We're usually able to move the diagnosis along and get to a certain point, if not the whole way with that. But we do have numerous other skills in our bag, tools in our bag to help us if it's proving difficult to prove what this lesion may be. In this lesion, if it's a primary lesion, what a pathologist would be thinking, could this be an epithelial lesion? Could it be arising from the stromal cells within that ovary? Could it be a germ cell tumour? They're the primary ovarian lesions, what they generally arise from. The other big area is, could this be a MET? And so we have other tools to help us with that. The first tool are special stains. And what they are, they're chemical stains. And they're usually looking for a substance that could be present within the tissue. So something such as a mucin stain might be performed. And if mucin is found on the stain, then that indicates that this could be a glandular. This could be a lesion which is producing mucin, like a glandular lesion. So this could be an adenoma or an adenocarcinoma. If a biopsy is done of a liver, then we usually do an iron stain, just to rule out if there is possible hemochromatosis in the liver. If a biopsy is done on myocardium, we usually do an amyloid stain, such as a Congo red, to rule out the presence or absence of amyloid, which can be very difficult to tell just down the microscope. Moving on from that, what the majority of people hear us talking about are immunohistochemical stains. They're a widely available stain, relatively cheap. And I think I'll describe what they are for people that don't understand what they are. They're an antibody which are attached to a dye that we can see down the microscope. And that antibody is washed across the tissue on the slide. And if there is a particular antigen on the surface of the tissue, then that antibody attaches to that antigen along with the dye. And when we look down the microscope, we can see that was a positive stain because the dye is staining up. And we basically know that there's all these huge amounts of tumours and they all have a different sensitivity and specificity profile when it comes to all these different stains we can do. To all these different tumours have different, to all these different stains. And so what we would do in this case, I would choose a panel of stains, which I know would help me tease apart these different differential diagnoses, which I talked about previously. And I would do this panel of stains, and that would normally sort of narrow down and help me show the tumour differentiation and help me subclassify the tumour further. And therefore, that helps the clinician know exactly what they're dealing with and that guides ongoing prognosis and treatment. Now, going forward to molecular tests, I suppose there's been a real leap forward in the last 10 years. It's really been exponential of the understanding of the molecular basis of tumours and what's driving tumours. And I think us as pathologists, we can utilize these, and that really helps us with diagnosis and once again prognosis and treatment. So one of the tests we use is fluorescent in situ hybridization or FISH. So what we're looking for with that are large changes in the chromosomes of tumors or possibly amplification. So, you know, big deletions, big translocations. We know that numerous sarcomas, so soft tissue tumors, hematological malignancies, neuropathology, so brain tumors, they have particular molecular features which can often be proven with these FISH studies. So that can be diagnostic when they're performed. In addition, there's a huge amount of sequencing techniques which are available to be able to prove distinct mutations, in particular mutations in tumour. So I deal a lot in melanomas, and sometimes there might just be a really poorly undifferentiated tumour, and we're trying to figure out, is this a melanoma, or could this be adifferentiated carcinoma? Could it even be a lymphoma? And so then we might perform a, first of all, an immunohistochemical stain for a BRAF mutation, then go on to perform in-depth sequencing to prove there's a BRAF mutation. If that BRAF mutation is proven, then it's overwhelmingly that this is a really de-differentiated or undifferentiated melanoma, which has huge implications for the patient in being able to access immunotherapy and other appropriate treatments. And it also can give access to treatments, so people with lung cancer, if they have an EGFR mutation proven, then we know they respond to certain treatments, and so then they get access to those treatments, which they hopefully will respond to. So it's sort of numerous different modalities we can use to prove different molecular features of the tumour. But also there are different investigations and other things that can be done within pathology. So we collaborate with a haematologist.
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We really look at microbiology and serology as well. We're always checking PowerChart and seeing how our findings sort of interact with other findings from other pathologists and clinicians. Okay. Now, some of the results I suspect that you get on patients have implications for those patients' families. So how do you as a pathologist provide assistance in counselling family members on their risk of diseases? And do you find that a multidisciplinary approach is helpful for that? Yeah, sure. So I suppose over the last century, I think there's been a real increase in the recognition of familial syndromes and clustering of different tumours in people. And I think that's grown as we've understood the molecular processes behind tumours. And I think pathologists are in a unique position to be able to identify when someone could be at risk of having one of these tumour syndromes or a familial syndrome. Because we deal with these tumours every day and often the tumours that are involved or the first presentation of one of these tumours might be quite a rare tumour that most clinicians might not have heard of or this particular subcategory of the tumour might be a real one they don't understand the implications of. So I think we're in a really unique position to be able to identify when this is at a risk and be able to communicate that generally to clinicians. They're the ones that have the relationship with the patients and sort of communicate the risk that's a potential for some kind of familial syndrome or a genetic predisposition syndrome for this patient and to get further investigations and genetic counselling if that's appropriate. In this particular case, if there was a serious carcinoma diagnosed on the ovarian mass, then we would usually, depending on the age of the patient, but recommend at least the clinician thinks about a BRCA or a BRCA mutation in this patient and to forward them to genetic counselling if appropriate. Or if there was an endometrioid or possibly a clear cell carcinoma. We know these patients are at high risk of having Lynch syndrome. So often they are then at risk of getting a colorectal cancer. And we can even do immunohistochemical standards which can act as surrogate markers to show a loss of expression in a couple of the enzymes. They are surrogate markers for actually the genes that are lost, the mutations that are lost. So we generally communicate that to the clinicians and recommend further counselling as recommended. We're always happy. We train medical professionals. And occasion I've spoken to patients as well when clinicians haven't been totally across why I've been worried about it and the patients are really interested and want to know why I've come to a decision that I have and so I've spoken to patients before and we're always happy to do that as well if clinicians think that's appropriate, if they think that we probably know more about it than them. A multidisciplinary team, I think studies have shown that patients who are discussed in MDTs have a better outcome. I spend a large part of my week preparing for the MDTs. And I think it's a really great, it is time consuming, but it's a really great atmosphere to be there with everyone that's involved in the patient's care. You've got all the clinicians that are there, the radiologists, the pathologists, genetic counsellors, allied health. And as a pathologist, we can talk to radiologists and really correlate what we're finding to what they're finding. We can gain even further information. We can talk to clinicians. We can outline if we're having any uncertainty about the diagnosis, seek more information. Or if there's something interesting about the case, about prognosis, or monitoring for a patient, or getting further testing for a patient, we can articulate that there to make sure that is followed up. Okay. That's really interesting. I actually didn't realise that sometimes you speak to patients directly about... Yeah, it's not often, but when... Especially, it usually happens when I know a clinician well, and and they know me and I've made a recommendation or a statement in my report that they find unusual and they find it interesting and it's obviously, it's when a patient's engaged in the process a lot more and they ask for further information and the clinician often thinks, well, Rob's probably the person that's best to describe this to the patient. He knows more about this than I do. And they often, yes, I mean, even if I say you're happy to talk to this patient, we're always happy to talk to patients if there's some information and we can pass on information to put their mind at rest or understand the process of what's going on with that particular part of their health care. All right. Well, that's great. Well, Rob, what are three take-home messages about pathology that you'd like to share with junior doctors? Yeah, sure. The first one is what we talked about, I think. The real importance of providing clinical information to pathologists. We don't do it, we're not moaning for our own point of view. We're saying it for patient care. We really think it's really, as pathologists, we really need that information to make the right diagnosis in a timely manner to ensure appropriate care. Second of all, I think it's understanding the time processes that take place in pathology, and particularly with histology, that it's not an instantaneous process. Often there's an assumption that we're computers and a specimen goes to pathology, and it's a black and white answer. It's cancer or it's not. It's renal failure or it's not. But there's huge shades of grey and that's why we have this really large training program to get through and to understand the process that it can be sort of a one to two day process even before I see the specimen. And I often get calls and I've never seen the case before just to understand that it can be a bit of time before it gets out and we are often doing extra testing as well. But if there is an urgent case, definitely tell us that it's urgent and we will do everything in our power to expedite that case. We can do same-day processing to get things out the same day, particularly for small specimens and core biopsy where it really is important to get information for patients. We're always happy to do that, but just understand sort of the time pressures that we're under as well. And finally, I suppose I'd like to just promote pathology and say from my point of view, it's a really fascinating career. It's something that I really enjoy. I'm fielding calls from surgeons, from oncologists, from renal physicians all day every day. I'm really involved in the center of patient care, really guiding management across the entire hospital and also out in the community. And you're answering and you're solving questions and problems all day and I find that's a really fascinating area to be involved in. In research as well, not much advancement in medicine gets done without understanding the pathological basis behind it. So if you're interested in research, you don't have to be a pathologist, but understanding where we're coming from and some basic pathological principles is really important as well. So I just like to promote pathology as a fascinating career to be involved with. Do you think that's something for you? I've actually got a couple of friends who tried a lot of different medical specialties on their way through their training and then ended up in pathology and love every day that they go into work. It's a really interesting job and has so many attributes that you don't really get a lot of exposure to because you rotate through a lot of different specialties when you're a junior doctor, butology generally isn't one of them so how would you recommend that people get some experience generally after medical school as you say that you get taught depends where you went to university but um after you get generally taught some some pathology at at university but after that unless uh it's sort of a almost an invisible specialty at times because we're often away in the laboratory um you only really see us in multidisciplinary teams is one of the only places. Going forward, there's starting to be a lot more placements for medical students in particular to have exposure to pathology, to spend a few weeks in pathology, to understand what we do, to see if it's something they would enjoy. But if there's junior doctors out there like me, I did some physician training for a while and made the jump across to pathology. If you're interested in it, approach a pathologist, often at an MDT meeting. We're always happy to talk and talk about the process of what it needs to become a pathologist and the training program involved. Get in touch with your local pathology department and talk to registrars that are going through the training or the pathologists.
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Okay, so welcome to On The Wards, it's Tom Aiton. Today we're talking about a new way of reconstructing the eyelids, which is commonly indicated following skin cancer removal with Dr. Michelle Sun. This podcast is produced in collaboration with Avant, a proud partner of On The Wards. Welcome, Michelle. So Michelle has just completed her training in ophthalmology and completed a PhD in 2017. She has close to 50 peer-reviewed publications and has attracted over $500,000 in research funding. Having been a previous recipient of the Avant Research Grant, in recognition of her achievements, she was recently awarded a fellowship at Stanford University, where she will continue to develop her clinical, surgical and research skills in ophthalmology. As a previous recipient of the Avant Doctor in Training Research Scholarship, Michelle's goal is to advance the application of bioengineering in the field of ophthalmology. So welcome, Michelle, and thanks for coming on to On the Wards. Thank you. So it's quite a portfolio of research you have behind you. Before we get into that, perhaps we could hear a little bit more about your career as a junior doctor and even further back as your time as a medical student. Yes, so I was an undergrad at the University of Adelaide and medical school, as any medical student would know, is lots of fun. I don't think we studied very much, but we certainly partied very hard. But at the end of first year, I went on an elective to India as part of just out of interest and just did a week of ophthalmology there and happened to meet two ophthalmologists who were from Adelaide visiting India at the time for a conference just for those two days. And I got in touch with them and started research when I was a second year medical student. And that's really my first introduction into ophthalmology. And so I was lucky to have found it very early so that I could start early. And then I continued doing a little bit of research on the side throughout medical school and started a PhD after I graduated from my medical degree. Then I interned at Royal Adelaide and spent a year overseas working in Oxford as well before coming back to Adelaide and doing some ophthalmology time at the Royal Adelaide Hospital and starting training thereafter. Oh, wow, that sounds great. And so when you were over in the UK for one year, what did you get up to over there? So I was just doing my general year. So as part of training in ophthalmology, you have to have done two years of non-ophthalmic time. I actually did some urology, which is the complete opposite of ophthalmology. I certainly don't have any plans to do any more of that in the future. Okay, great. And so it sounds like you were always interested in ophthalmology. If you could choose another area of medicine, what do you think it would be? To be honest, from first year onwards, ophthalmology was it. And I don't think I could do any other area of medicine. It's so, it's just the best specialty. And yeah, if I weren't doing that, I probably wouldn't do medicine. Well, I have to agree. What in particular did you like about ophthalmology? I think it was, you know, the surgery is really, it's just really neat. and it's incredibly rewarding. The outcomes are wonderful for patients. You can make such a huge difference to a patient's life, especially patients who are quite elderly as well, who, you know, for them, a lot of interventions don't really improve quality of life. So to be able to improve quality of life later in life and change their ability to be independent is something that I found quite rewarding. There's also so much research in ophthalmology, which is a particular interest area of mine. And, you know, we know how disabling it is to be blind. So it's just such a rewarding specialty in medicine. And I think it gets overlooked quite a lot. You don't really get a lot of exposure during medical school, but it really is. I think it's the best kept secret. That's an inspiring answer. And certainly having a look at everything you've done, Michelle, you know, you've done some really inspiring things. So in 2016, you received the Avant Doctors in Training Research Scholarship, where your research goal was to further progress bioengineering and cell culture studies in ophthalmology. Can you outline your research project for us briefly? Yeah so that was back when I think I was an intern at the time and at the time I'd just finished my PhD we looked at making an alternate cartilage tissue so when you because Australia, there's such a high rate of skin cancer, a lot of it occurs on the eyelids. And when you remove the skin cancer, often there's a very big defect and there's not a lot of cartilage that's similar to eyelid cartilage. So we were looking at making a bioengineered eyelid cartilage. And for that, you need a scaffold, which is biocompatible and biomechanically similar to eyelid cartilage. And then you also need to be able to culture the cells from the eyelid onto the scaffold. And so at the time back then, we had just started the process. But with the help of the ADVANCE scholarship, we were able to advance that further into animal studies. So we implanted the scaffold we made into several rats and that was found to be quite biomechanically similar and also biocompatible. And so since then, we've been able to progress that further and potentially are looking at human trials in the next year or so. So that's quite exciting. Yeah, yeah, absolutely. It is. And so what long-term benefits are you hoping your research will bring to cancer treatment and your patients? Yeah, so I think bioengineering and tissue culture has so many applications, not just obviously in ophthalmology, but within ophthalmology, you know, not just in eyelid tissue, but we're looking at applying these techniques to progressively more complex tissue. So since eyelid cartilage, we've since been working on lacrimal gland culture. So we've been able to take a biopsy sample of lacrimal gland and propagate the cells, which have been found to secrete tears, which is a huge step towards being able to regenerate a functioning gland obviously there's still many steps to go but in the future we're hoping to progress that area but also move on to more complex tissue you know ultimately tissue like the retina which is you know the the seeing part of the eye so that's kind of the end game and the end goal. And that would have, you know, huge implications for being able to treat a wide variety of blinding conditions. Okay. And so you mentioned about clinical trials. Where are you up to in the trial phase? Yeah, so we've finished all the animal studies for the cartilage tissue and we've now obtained kind of medical grade scaffold material, hoping that we can hopefully progress that to human trials sometime in the next year or so. And then we're going to progress our lacrimal gland studies into animal trials, hoping that in the future then we can apply that to human studies. And at the moment, we're just starting to propagate, you know, retinal cells. We're kind of at the beginning phases of that. So we're kind of working our way slowly towards applying it to different tissues. Great. And logistically, how are you going to manage that when you're over in America? These days, Zoom is everything. So I think if anything, 2020 has taught us is that you can do so many things remotely. So we have a great team of researchers and a lot of the work that I'm doing here, I picked Stanford because they're leaders in neuro regeneration and they've got a very active glaucoma research department there. So hopefully it's something that I can continue there and bring back more skills when I come home. Yeah, that sounds great. And I guess as an intern, how did you end up in a research project like this? It sounds like it's really, you know, developed into something quite large. Yeah. So this was something that I'd started back when I was a medical student. So I was lucky enough to have found ophthalmology early. So I could start research at the same time as completing my medical studies. So this is something that's really been kind of 10 years in the making. That is the thing about research. It does take a really long time, but it's certainly very rewarding. Absolutely. And have there been any, you know, speed bumps along the way, any hiccups? Yeah, I think COVID has hiccuped everyone.
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Welcome to On The Wards. It's James Edwards and today we're talking about approaching biomedical research and interpreting the data. I'd like to welcome Professor John Myberg. Welcome, John. Thank you, James. Professor Myberg is an intensive care consultant at St George Hospital in Sydney, also a professor of intensive care medicine at the University of New South Wales, and has a long and extensive track record in research. Maybe I'll just ask, just from a personal aspect, has research always been of interest to you or something you've just fallen into throughout your career? Oh yes it has been James, very early on in my career but that was largely in front of my father who was a researcher, he was a professor of surgery in Fed and was a well-recognized researcher in liver transplantation. So I grew up in that environment through my career and there's no doubt that his influence affected my ability. But also, I've always had an inquiring mind and I had some very good mentors and people who inspired me to say that research is as important as clinical medicine and that we base our practices on evidence we think or on research. And the sort of three arms to being a good doctor I believe is obviously clinical medicine, education and research. And you don't need to be a Nobel Prize winner to do research, but what research does do to you is gives you an ability to think critically, an inquiring mind, and also I think it keeps you humble because things change over time. And when I hear people laughing about the leeches and the bleeding and all those things, I mean, those are the best physicians in the world at the time who were doing what they believed to be correct based on the evidence that they knew. And in fact, a lot of those older therapies formed new innovations, perhaps by learning what not to do, but also to take those things forward. And I'm sure that long and far gone, a lot of my research will be regarded like leeches. Or maybe as a consumer of all the research coming out, how do you try and keep on top of the vast volumes of research that comes out every week? That's a really good question, James, and it's very hard because we are bombarded by information, particularly in the modern age, you know, the way of the internet and the rise and rise of what I call predatory journals where you can get anything published anywhere and you can publish complete and utter nonsense and it'll get published somewhere. And, you know, all of us, and particularly our emerging physicians, are bombarded by rubbish. And so it's hard, it's hard to do that. I think the way to do that is to really select a couple of the well-recognized journals that have a reputation for producing excellence, and that would include, in my view, the New England Journal of Medicine, which I still think is the best journal in the world right now. And they have a very highly selective and vetted editorial process. And they have been true to the notion of advancing science rather than making news. A lot of the journals now just of newspapers and become tabloid and take on political things the Lancet the second journal that I think is worth to read because it has a global perspective and Those are probably enough. That's point enough. I'm not to read if you read the million gentlemen us and And the Lancet as a general physician, that would be enough for for you obviously in your specialty you've got to find your own craft groups and look for the ones that I think are that are most relevant to your practice in intensive care medicine for example we've got a large number but you know I'm obviously making a plug here you know our local journal critical care association that is the general of the college um is a very good journal written by australian physicians and intensivists um and that's a good read in terms of up to date with what's happening and a lot of review articles so i would make a suggestion that you know avoid you know the deluge of of social, of what's coming out there. Don't listen to too much what you see online. Certainly don't read anything that's pay-per-view and not openly accessed. Avoid evangelical podcasts like this one. Because there's a lot of opinion out there, but they are useful. Vet the people that are doing them and restrict yourself to what is coming out of the high quality journals. When you read your research, what things are important to you when you evaluate its design and also look at some of the conclusions made by? Yeah, that's also a very good question. So most people who read literature, as practicing clinicians I'm talking about now, most people will scan the table of contents, see if something catches their eye that they sort of like it. They'll go to the journal, either online or on paper now, obviously always online. They'll read the conclusion of the abstract. That's all they read. What's the conclusion of the abstract? And that's a very important piece of information because the conclusion of the abstract is what triggers keywords and usually informs practice. And I do that as well. Of course I do. I look at the title, but then what I'll do next, really, if it's in a good journal, is I'll go down to what the aim of the topic is. What question were they asking? Because research and original articles are designed to answer one question. Does drug A work better than drug B in this condition? And you can have a hypothesis, which is there's no difference or there's a difference, it doesn't matter. And I ask, what is the objective of this study, or of this paper? This is in scientific terms. And then I'll go down and I'll look at the metrics. I mean, how are they going to assess the aim? What outputs or outcomes are they going to do this? Are they robust? Are they robust outcomes? Will the objectives or the aim be addressed by the metrics they're using? And most importantly, I believe, are these outcomes patient-centered? Do they affect how patient feels functions and survives? Can you give an example that? Yeah We can talk about the studies that we did the adrenal study published last year biggest study of septic shock we tested with our heart of cortisone Improved survival in patients with septic shock. This has been a debate that's been going on for 50 years and there were strong opinions for and against and there was a changing paradigm over the years in terms of dosing and structures and stuff and so we did a big study of 3,000 patients looking to see whether or not hydrocortisone improved outcome and the question was, that was the question, does hydrocortisone improve outcome? And the outcomes we were looking at was mortality at day one, and that was how the trial, sorry, at day 90, I'll be quiet. And that was the question that we wanted to know whether it improved survival rates. And then that's the primary outcome, and the study was powered on that basis, so we had enough power to answer that question. And then that's the primary outcome and the study was powered on that basis so we had enough power to answer that question. And then secondly whether or not there was an improvement in shock. In other words, was shock shortened because that's an important outcome that the duration of shock was improved. The longer the shock the worse the organ failure that you get. And then we also looked at the influence of that process on improving organ failures and such. And so that was the question we did. We designed the study to the highest levels of internal validity that we could muster for the study. So it was prospective, it was designed testing an applicable intervention and a dose that we used in clinical practice. It was randomized, so people were given a quarter to randomization schedule, so there wasn't bias there, selection bias. It was blinded, we gave a blinded infusion of hydrocortisone or placebo in identical samples. And all the investigators and all the clinicians and all the outcome adjudicators were blinded to intervention until the trial was broken. We also had a pre-specified analysis plan, which we had put in public domain so people could see what our question was and how we were going to analyze this. We had a pre-published protocol, which everyone could read. And so you could check that what we said we were going to do, we actually did. We looked carefully at adverse events and symptoms of harm. And we did a big study like that. And that was how we designed the study to have the highest level of internal validity, which is a way of minimizing bias. Recognizing that bias occurs in all studies, but the least you do, the better result. In other words, the results become believable. And then we also conducted it in a system that was generalizable to Australia and the rest of the world.
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More importantly we collaborated with our colleagues and friends in Scandinavia and in the United Kingdom and in Saudi Arabia and we had more generalizability across different health systems, even though Scandinavia, United Kingdom, Australia, and New Zealand are similar systems. And we saw some differences in mortality rates between the different regions, but overall, the results were consistent in the same direction. What we show, fact that while there was no statistical difference in mortality, and I'll talk about that briefly, in terms that the p-value was greater than 0.05, the signal, the direction of the signal favoured high-recorded zone. But there was a significant reduction in the duration of shock. And that secondary measure was powerful enough to be a real phenomenon in terms of the trial design. So we showed that in fact whilst mortality wasn't changed, duration of shock and ventilation duration was lower with hydrocortisone. There was no adverse effect of hydrocortisone that we could see, which we looked carefully for, such as bleeding or GI bleeding or infection rates or neuropathies. So therefore, we more or less asked the question that hydrocortisone probably has a beneficial role in septic shock. That's an important study. It's an informed practice. Now, you know, is it the final word on steroids in septic shock forever? Probably not. Are there subgroups of patients who may benefit more than others? Possibly. We didn't see it in our subgroups, but there may be a benefit is a duration of shock an important patient-centered outcome well does it affect how patient feels functions and survives probably not but if you get out of hospital and icu earlier that's important to a patient because the you know the the survivors that we produce often live with a long burden of disease over and above the initial presentation. And in fact, that's an important outcome to measure as well. And more importantly, it gave us insights into the history of the disease, how patients respond. We were able to, in this trial, do a sub-study looking at genomic expression of patients with septic shock and how they respond or didn't respond to corticosteroids and looked at other mapping of neuroendocrine profile expressions. So therefore we got a whole new insights into developing new studies. So these trials, this trial will generate a whole series of additional analyses making this process an ongoing exercise of research and that's the beauty of research we inform clinical practice we think will help our patients but we also create opportunities for further research and create new knowledge that will will help you know researchers and clinicians in the future you talked about generaliz, but how do you work out whether a new piece of research will change your practice? Well again, it comes down to reading the study carefully. Was the question accurate? Was the design, the methods, where they've had it? So was the trial design done well? Was there obvious bias in how the trial was designed? And if the bias was mitigated, then are these results generalizable to my population of patients? So where was it done? In whom was it done? What outcomes did they measure? And are these patients the same as mine? Because it's important that if you see results in of a study this is why you shouldn't change your practice on the basis of the abstract you need to work out in whom this was done and then if the results are positive for that intervention or negative in other words that you shouldn't be doing this to people and a negative study with no positive result is a good study because it tells you what not to do, which is equally as important as what to do. Then only apply the results of the study to that patient population. What clinicians do is they upgrade it or they take the concept and apply it across patients in whom it wasn't studied. Indication creep. Indication creep, indeed. And that's a big phenomenon. So you need to understand what it does. And that's why when I read a paper, the last thing I read, if I read it at all, is the discussion. Because a lot of journals, particularly the less credentialed journals, allow the investigators to editorialize the results. And all the bias mitigation strategies they try to do in their design gets obviated by an over interpretation of the results, a speculation of what it means, even in the absence of plausible findings, okay, and editorializing the results for their own interests. And there's a lot of that in papers which causes confusion and actually facilitates indication creep and bias. So what I try to do as a clinician researcher is I interpret the results of the study on the results alone, understanding the methods, and then make my own decision what it means before I see what the authors did. And that's why journals like the New England Journal and the Lancet, where they really are very strict on what the authors can say in terms of editorialising and speculating on the results is there. One of the key things about understanding research is plausibility. The effect that you see is biologically implausible or too good to be true, it all certainly is. I tell my students this, if you think about what was, apart from penicillin, what has been one of the most successful interventions in clinical practice, which has changed outcomes and improved survival. And that's a thrombolysis and a cubicoccal dysfunction. You know, chrysoconin and aspirin changed the survival courses and paradigm of acute coronary syndromes enormously. But the net reduction in mortality of all the trials of thrombolytics was 5.5% reduction in mortality. And that's a magic bullet. That's as good as it gets. That's penicillin and thrombolysis in acute coronary syndromes. And coronary syndromes are easy to measure because they have time zero, and you can measure the impact, and you can give an intervention, and you can look at the outcomes in a very short period of time. If a study or a clinician or researcher is saying that his or her drug drops mortality by 15%, it's almost certainly a type 1 error or a false positive. And it doesn't take long to look and see what they did as to why this result was not what it was. It probably wasn't randomized, it probably wasn't blinded, probably a small sample size, it didn't have analysis, it was probably a subgroup, and this gets blown up into a thing, and this becomes a magic bullet. And in our current climate in the case of care medicine, the whole vitamin C debate is one of those. The effect size that the evangelists or protagonists are talking about is almost certainly a false positive, and you can't change practice on the basis of that. Yet the speculation, the hyperbole, the biological impossibility is there. It may work. It may work. It may be a positive thing. I don't know. But I'll only change my practice when a definitive trial is done looking at that particular image. We may move from being a consumer of research to, as a junior doctor, the whole world of research can seem a bit overwhelming. And as part of getting onto programs, postgraduate programs, often being part of research is important. I mean, how would you suggest a junior doctor start to get involved in research while also having a large clinical load? Yeah, it's hard, James. It's a good question. And, you know, research isn't for everyone. You know, that's for sure. But then publishing a paper in the New England Journal of Medicine isn't only for research. You know, there's a whole range of research stuff. And people need to tailor their research needs or their research desires with their other lives. Research should be seen as a complimentary activity, not as a burden. It's a really important thing. And I think learning some of the basic principles behind good research, understanding the basis of trial design and what trials mean, so you can interpret the literature, understanding the basics of statistics, not high-level stuff. Understand what it all means, what the top one area is and what a p-value means and those things so you can interpret it are important. And also, you know, when you design a study, even if you're doing a simple audit or a survey in your unit, and people do these things all the time. Surveys, audits, cohort studies, case reports, that's all good stuff. I would never ever suggest that that kind of activity is second-rate research. It's not at all. It's the building blocks of what we do. So if you're going to write up a case report and send it to your local journal, then apply the same levels of probity to a case report or case series as you would to a big clinical trial. In other words, what's the question? What is the question that we've asked of this study or studies and how do we interpret it?
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Hey, and welcome to the On The Wards podcast. My name is Eli Mattar, and I'm joined today by my good friend and colleague, Dr. Arby Powell. It's our first international edition of the On The Wards podcast. We're recording from the United Kingdom in London. Today, we're going to be talking about overseas fellowships. So Arby, at the moment, is a third-year medical oncology trainee who originally trained in Sydney, but is now a clinical fellow in the drug development unit, the Royal Marsden in Sutton in the United Kingdom. So the topic of fellowships overseas is something that came up in my mind as an intern, so it was quite very early on, and it's something that I'd always thought about. So today's podcast is kind of exploring, you know, through Arby's experience, why to do a clinical fellowship, what are some of the logistics, what are the highlights, what are the challenges, so that you can think and prepare early on if that's something that you're interested in. So we'll hopefully cover a range of practical questions that will help you in considering whether it's the right thing for you. So Arby, welcome. Thanks for having me on. Really excited to be on my first podcast. It's great to be doing it together. We've both been involved in On The Wards since its beginning. So, just to start, maybe we'll ask you, just tell us a bit about your position at the moment and what are you doing? Yeah, basically, so I'm in my final year of training to be a medical oncologist through the RACP and and I decided to come overseas for this non-core year. And I'm doing a clinical trials job in the drug development unit at the Royal Marston. So I'm doing predominantly early phase, phase one and two clinical trials. Okay. So why did you choose to do a fellowship overseas, in this particular fellowship? Well, I think overseas fellowships provide a lot of benefits in terms of increasing exposure to different practices, being exposed to larger research units. But I have to say one of the biggest reasons was that my wife wanted to travel overseas and live in the UK for a year. So that was a big contributor to my decision. But they're some of the main reasons. And I've often heard about doctors going overseas. And I was really excited to be able to consider this option and do it finally. So why don't you take us through what have been the great positives? So you've been here for about, you're just saying you came in February. You've been here for about nine months, almost 10 months. So what have been the positive aspects of your experiences so far? Was it what you expected? I think it's probably exceeded my expectations in that the amount of travel we've been able to accomplish in Europe has been phenomenal. So we have easy access to Germany, France, Italy, all these countries we'd hope to visit, but are unfortunately more than 25 hours away from Australia, are now about two hours away. So it's been an excellent travel experience. I think professionally, it's been a fantastic experience as well. So I've been able to be part of multiple research projects and get trained by some of the leaders in my field of medical oncology, which has been a great personal growth experience as well. So that's great. What have been some of the challenges, you would say, or the more negative or lowlights, as you put it to me earlier? I think some of the lowlights are probably the preparation required for an overseas fellowship can be fairly time-consuming and fairly involved. So there was a fair amount of organisation that went into this year prior. And financially, it is somewhat challenging with the realisation that Australian doctors get paid very well and doctors in other countries don't get paid as well as we do back home. But on occasion, I found it stressful. I've also commenced a part-time PhD this year, but that was self-imposed. And the job I'm doing is fairly busy jobs, so some of the weekends I am doing work. But those are fairly minor things compared to the overall benefits of being overseas and being in a large unit like this. So my understanding is that it's been a positive experience overall for you. I think my key message to junior doctors listening is that going on an overseas fellowship can be a really fantastic experience to broaden your horizons, enhance your CV, increase your exposure. And ultimately, I think the one thing I want to explain to people is that it's not as difficult to organise as it might seem to you at this point. I remember thinking as an intern looking at these rare people who went overseas and I wondered, how did they do that? How did they get there? And it seemed like a very opaque process. But really, my experience, I've realised that it is a bit opaque, but there are a lot of people to help. And with a few emails and reaching out, you will be able to do what you want to do and go where you want to go. And a bit of preparation as well. Okay. So let's talk about that preparation. So tell us, when did you start organizing your fellowship? When did you start? So I am a fairly anxious person, and I started about 12 months prior to coming here. So the first email I sent was in December 2017. I started my fellowship in February 2019. So that email set off. So the next step was having a chat to some of the doctors who had worked here before and that the unit I worked at set that up for me. I then had a video interview. I then had an informal interview. And then I went to Chicago to one of the biggest oncology conference in the year, ASCO, where I had a formal interview and after that, the job application. And so after that, I had to organise the visa requirements, the overseas registration. So in the UK, it's called the General Medical Council. It's the APRA equivalent. And so that all started there. So there are quite a few steps involved. And generally, most people will say you need to have at least six months, but preferably 12 months to start organising it. And that's really, I guess, people start thinking, do I want to go on? Don't I want to go on? From the moment you decide to pick a unit, that's about when you need that six or 12 month gap because it does take a lot of organising. Yeah, I mean, I would imagine if you didn't start preparing that early, it would have been very difficult to organise a formal interview at a big international conference because often international conferences, you need to submit an abstract something like six months in advance. So having that foresight and getting to it early. And can I ask, how did you know about this particular person? How did you choose the contact that you got to? So I had one of the oncology fellows who had gone before me had been to the drug development unit and I'd always been interested in the idea of drug development. So that drew me to it. And one day I saw an email from the oncology organization, MOGA, saying that they were interested in fellows applying and I simply sent an email. So it wasn't that I knew anyone in the unit or that any of my consultants knew anyone in the unit. I simply sent an email to an advertisement, and that's where it all started. And MOGA is an international? MOGA is the Medical Oncology Group of Australia. So that's every specialty the junior doctors will think about, whether it's gastroenterology or cardiology, will have a similar national society and they will filter and display advertisements from overseas posts. So that's one way of learning about possible posts. So it sounded like you were primed for it by your networks and people you knew and then you saw the opportunity on the website that you might potentially have ignored earlier because you wouldn't have any idea about this place. And then based on that, you kind of applied and sent the email. That sounds like it. And I wanted to go to the UK. And you wanted to go to the UK. So those things lined up. So you started planning about 12, you know, 14 months ahead. So what are some of the steps that you kind of have to get organized? You mentioned them a little bit. So once you've decided who you're going for and you've arranged the interviews, what are kind of some of the practical hurdles? You don't have to go into them in too much detail, but what are the things that people should be aware about to overcome? So breaking it down, I guess the first thing is, do I want to go on one or don't I want it? So you decide you want to go on one.
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So Australians will go to places like the US, Canada or the UK. And that's a fairly simple decision because the US requires licensing examinations. Canada requires a weather change. The UK requires GMC. So just thinking about which country you want to go to and that's probably guided by the centre you want to go to. So you might go overseas to get a specialist experience in a particularpecialty of your choice, and that will depend. So once you've picked your country and the institution, your next job challenge is to get a job there. How do you get a job? You need to get an interview. So you may have worked with a consultant who knows someone at that unit and can put you in touch with them. You may just email someone like I did. You may have network with someone. And one of my best pieces of advice is to really reach out to people who have gone before you and they will have contacts that they can put you in touch with. Once you have done that, hopefully you get the job. And after that is the, I guess the first one is your Australian training requirements. So think about where you are in your own training. So for me, I had my this year accredited for the RACP by a supervisor back home and a supervisor here. So that does take a bit of juggling in different situations, but usually most colleges will accommodate and find a way to do that. Your next step is obtaining overseas medical registration. So that'll differ in different countries and different stages. So if you come as a resident, for example, you might have to do an English test or a clinical examination test for the UK. I came as an advanced trainee, so I have sponsored, so I didn't have to do any examinations. But obviously, medical councils are complex and hierarchical, and it can be challenging. Finally is your immigration requirements. So thinking about your visa, the type of visa and the length of stay, and then getting that processed before your date of arrival is all challenging. And finally, when you arrive here, there are some minor logistic challenges of getting a rental, opening a bank account. But it is a fairly long process. But it's definitely navigable and it's definitely worthwhile at the end of it for some people. But definitely they're the main steps. How did you navigate through that and find all the relevant information you needed to know what you need to do for getting accredited over here and registration and so forth? What did you rely on? I think I reached out for help at multiple points. So there are fellows who had been to my unit before and they were Australian fellows. So I talked to them on WhatsApp and email and they were very supportive and they often, and you'll find that as well, that most fellows who've been overseas are quite happy to help and offer support. The unit that I worked at is one thing to realise is that these international units accepting international fellows have done this time and time again. And so they're very used to helping you. So I had a lot of support from my unit in terms of navigating those difficult challenges. But that ultimately wasn't that hard. Yeah, so I think the combination of previous fellows and the institution will support you as well. So you've taken us to the journey of getting here. Tell us a little bit about some of the logistics while you're here. Tell us about your hours. Tell us about your pay, you know, other types of leave. What are kind of the, what's the training environment like here in the United Kingdom? So I'll provide the details of my particular example. So I'm a trials fellow. I work nine to five during the week. I don't do any on-call. I don't do any on-call shifts. I don't do any after-hours work. And my pay is about going to be, in Australian terms, would be about $75,000 to $80,000 Australian dollars. So that's a significant pay cut from a PGY-7 registrar in Australia. And that's one thing to realise, that Australian doctors get paid well. So that may have the potential to impact your lifestyle, but it does, and it depends. Every doctor's in different financial situations. You might have a mortgage, you might have a partner that's not working, but you take that into consideration. My hours in general are quite good here. I am in a trials unit, so I can't speak for the NHS, but the hours are fairly reasonable. I've imposed these extra research projects on myself so my hours are worse in that I do do work after hours on the weekends and do work in my spare time. But otherwise, the conditions are good. I had 32 days of annual leave. So in Australia, you get 20 days. So the UK has more generous annual leave allowances. I get 15 days of study leave. So it is generous that way. And overall, it's the UK and transitioning from Australia to the UK was very simple. I think UK doctors respect Australians in that they are generally well-trained, work hard, and we find it very simple to integrate ourselves into their system. Well, so the tip there is really to do your homework as to your position to find out what are the financial benefits that you're going to get and so forth. It's going to change from country to country. We were just talking about our friend who is a classic medical overachiever, but he's currently doing a full year of fellowship unpaid, which is quite rare, I would say. So not many people have the luxury to be able to do that. And you also mentioned another example where maybe someone had finished their training because you're doing your fellowship year or your overseas year as part of your college training program. Some colleges will allow that, but it's also very common to do it at the end of your training, where most people try to get that extra skill. And some people might choose, because of the differences in the calendars between the Australian calendars and overseas, in that time intervening period, people will do kind of locum work to try to build up their financial reserves to be able to support that pay cut that they then get early on. So there seem to be a lot of different strategies that people take and you've just got to go with the one that works for you. Definitely. I think just finances are not that interesting to think about, but they do restrict your ability to travel or to enjoy yourself. So just a bit of forward planning and thinking about where you're spending your money is a great idea. That's really good advice. So we talked about the reasons for doing a fellowship. We've talked about organising, preparing for it, what it's like when you're there. So we're just going to finish on some of the main tips that you have after reflecting for the year. What's your main advice for junior doctors who are interested in pursuing a fellowship overseas? So if you're sitting in your car right now driving to work, my first message is to think that this is an option for you and your family or your partner in your relationship. It's a really exciting option that you can, and whatever specialty you're in, there is opportunity to go overseas. So my first thing is think about going. I think Australia is a great healthcare system, but ultimately it's one system. But being able to experience what it's like to work in a different country with different populations and different resources is invaluable for your future practice. Especially for physician trainees particularly, the level of research opportunity is often quite different overseas as compared to Australia. And so you'll be able to be exposed to a larger volume of patients and a larger number of trials and research activity. And the personal benefits of being able to travel widely and to take that year off the treadmill, it's hard to explain how beneficial that can be as well. Dr. Burnout is an endemic problem where people are getting increasingly frustrated and tired with their work. And going overseas is a wonderful way to refresh your interest in your specialty and to do some other things in your life as well and to have that space to do that, to give yourself that. And I've been on that PGY1, 2, 3, 4, 5, 6 treadmill. And it can feel repetitive and you can feel like you're getting really stuck going overseas. Great way to break that up. Having said those two things, I guess it is challenging to organize the overseas fellowship. I won't dismiss that. And I think my biggest tip is that networking is crucial. And networking is a buzzword that's used by many people all the time. I mean, networking in a very practical way that you need to know what jobs are available at which centres. And that information is not going to be displayed on any website. There is no website that says, these are the oncology fellowships available in the UK.
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Welcome to On The Wards, it's James Edwards here again. We have a podcast today on identifying the sick patient and we're the pleasure of welcoming Dr. Olly. Welcome, Ollie. Hi, James. Thanks for having me. Ollie is an intensivist at Royal North Shore Hospital in Sydney, also is the founder of the Intensive Care Network website and also the founder of the quite famous, among critical care circles at least, the SMAC Conference, which has been going for the last four years. We've spoken to Ollie about doing an intensive care consult, and the next one is really trying to tease out how a junior doctor can identify if their patient is sick or at risk of becoming sick or unwell. So Ollie, maybe we'll just outline from an intensivist perspective, what are the indications for admission to intensive care? Okay, well that's a fairly complex thing to try and summarise, but I think in general it's when they need some form of organ support or if their clinical needs are more than what can be provided for on the ward, I think, in a simple way. And that's fairly nebulous, but that's kind of what we're thinking when we're thinking about admissions. So when we're considering whether a patient's sick or not, how can we define that? What will help us determine whether someone's sick? Well, I suppose there are different ways of being sick and of showing that and defining critical illness. One way that is used commonly is looking at the vital signs and in many hospitals there are rapid response teams that are alerted when certain vital signs are abnormal. And that's where I work, that's a practice and I think it's a very helpful one. And that is one way of sort of defining when a ward patient is becoming unwell. But patients also come to ICU if they've had major surgery or if they've had major trauma or there are other reasons why they may come directly to ICU rather than deteriorating from the water gas. When we go back to vital signs, can you be sick with normal vital signs or not sick with abnormal vital signs? Yes and yes. But in general, if the vital signs are becoming deranged, it's a trigger to look more closely at the patient to see whether they are actually sick and whether they would benefit from escalation of care and having more done to them to try to prevent deterioration or help the patient in some way. So for example you might look at the heart rate being too high or too low, the respiratory rate is a particularly powerful indicator of respiratory dysfunction. If it's above 25 it's concerning, if it's above 30 it's more concerning or if it's very low obviously that's a worry. Oxygen saturations and temperature, that's not normally a trigger but it's something that obviously we measure and is important. Blood glucose is another thing that's not one of the triggers for review but it's an important thing that's measured on the wards and can be a marker of critical illness as well. And I guess the advantage of the vital signs is often you can view a trend of the vital signs which often the trend can be important identifying absolutely deteriorating over time yeah then we've gone to people who have got normal vital signs but are unwell why why hacking down well with a normal vital signs so uh i guess you could be compensating you know um so young people in particular are able to compensate with critical illness up to a point. They may have a metabolic acidosis and they've got respiratory compensation for that and they're maintaining their blood pressure, they're maintaining their heart rate until a point at which that drops off and maybe only one of their parameters is abnormal. For example, they might be tachypneic to compensate for metabolic acidosis and everything else might be normal until they really deteriorate. So it is possible to compensate fairly well yet still be unwell and sort of near the precipice of deteriorating. And how about things like age and medications? How can they alter people's vital signs and maybe would have been a normal range when they could usually they'll stick with it? Absolutely, so you know older people might not be able to as much of a tachycardic response, people on beta blockers, absolutely people on antihypertensives might or people on, yeah the variety of medications can affect your vital signs and mask these symptoms a bit. So that should be taken into account, absolutely. And then we go back to what we mentioned in our previous podcast about your, I guess, your gut feel about someone being sick. Is that something you need experience with or something you can identify as a junior doctor? I think anyone can experience that and it's something that we just detect. Like you can ask a child to look at someone and say whether you think they're sick or not and they often know when someone looks sick just by looking at them. That gestalt impression, that system one impression that someone's not well. I think as you increase your bank of experience you get to hone that and it becomes better and better just from more clinical experience and that's nothing magical about that basically you're just you have a bank of experience that you're relating those impressions with and your intuitive response gets better but i think anyone who has a gut feeling that someone looks really unwell you then need to try to objectify that and work out why they're unwell to um to address that to resuscitate them to work out what's going on and to describe it to your colleagues. I think it's important I tell most junior doctors that they should really trust their gut instinct about lots of things that they see. They may not know why they've got that feeling that something's not quite right but they shouldn't discount it just by often even a senior person says they're okay or the vital signs are okay. I think if they're worried, they should escalate. And interesting, lots of places in New South Wales have now got families being part of the trigger system that you described because they often identify that their mother, father, child is sick before doctors do and they're actually usually probably fairly accurate in some ways. And they've got that longitudinal view of the patients. They know how they've changed which is critical and that's also if you're not sure whether somebody's unwell or not or you've got a gut feeling the thing is to stay with that patient or review them regularly to keep a really close eye on them because that longitudinal impression is also really important. Are there any particular conditions or comorbidities that place people at particular risk of it deteriorating quickly? Yes. I'm trying to think of good examples. I guess sepsis is one where it can ramp up fairly quickly, especially in people who are compensating for it well, and they rapidly deteriorate. If someone's got decompensated heart failure and they've not got much reserve left, they can deteriorate quickly and descend into acute pulmonary edema and have respiratory failure and cardiovascular collapse pretty quickly. Have you got any others in mind? Yeah, look, I'm thinking of people with underlying, you know, cancer, neutropenic, immunosuppressed. Absolutely, yeah. You know, it can look okay and then suddenly go very quickly. We see that with febrile neutropenia quite often. Yeah, that's a very good example, yeah. They can look really well and then be incredibly sick. Are there any subtle clinical signs that you look for that would ring alarm bells, identify somebody you seek? Well it depends on the clinical context a bit as to what you're looking for but if a patient's got cool peripheries and they look shut down, that's always a worry and a concern that they've got a shock state and inadequate cardiac output. And even if the vitals are normal, that's something that I want to investigate a bit further and look at a bit more. So when you say cool, how do you examine that? What do you do? So laying hands on a patient as part of your cardiovascular examination, you're going to be feeling for the warmth of peripheries because if the hands and the feet are cold, that's a sign that there's reduced cardiac output. If their feet are cold and their shins are cold, then it's another sign that they've got even more poor perfusion. If they've still got knees that are cold, that's even worse, you know what I mean? And there's a correlation between that and the cardiac output that's well documented. But it's just another part of the whole picture. I wouldn't just say that independently. There are other reasons why you could have cold feet. If in the context of you being worried about a patient and they're shut down with cold peripheries, that can be really important. Any subtle signs that are easily missed if we don't look? As in, okay, well, I guess rashes are important that could be missed in the context of acute sepsis and emergency, looking for meningococcal septicemia or something like that.
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Welcome to On The Wards. My name is Michael Seker and I'm an intern at RPA. I'm speaking to Dr. Rewa Keegan today about planning an operating list. Rewa is a general surgeon and is currently working as a surgical superintendent here at RPA. Welcome Rewa. Thanks for having me. So we're going to start with a scenario. You're working on the general surgery team in a tertiary hospital managing patients with a variety of different surgical conditions and your team is also on call for trauma surgery. Your consultant has asked you to plan the operating list for the next day. What are the key steps that you take when planning an operating list? So I think just to start with the overall kind of things that we want to focus on when organising an operating list, it's really based on really meticulous planning, communicating well with all your colleagues and really focusing on the fact that it is a very multidisciplinary activity and an approach to patient care. So generally I like to think that when the list begins it's really at the time of the initial assessment and that might be in the surgeon's rooms or often it'll be in an outpatient clinic at the hospital. From the JMO perspective the first contact with the patient's often in the pre-admissions clinic and this is kind of unique in the fact that the registrars don't normally see the patient here and at that time the jmos should really have an approach of keeping track of questions and concerns so these can be you know discussed if they need to be and we're going to touch on that a little bit more later on when i'm planning an operating list there's a few things that i would take into account i think probably the most important thing is how long do i actually have for the list? And that really involves making a realistic estimate of the time. So you might often see surgeons who'll think, oh, great, 10 hours of time on my list means 10 hours of cases. But it's very important to factor in the turnaround time between cases. And often in public hospitals, you know, eight to 10 hours of operating time that's allocated might really only be four hours of actual cutting. And the rest of it is all the in-between activities that we often forget about. The next thing that I think is important to acknowledge is that there's a lot more people involved than just the surgical team. So you might want to think about ICU or HDU or the wards where the patient will go. People like porters who will help transfer the patients and maintain that efficiency. Other teams or consults that the patient might require. Services such as blood bank and then there's people like cleaners. Say you do a case with infective patients and you need to terminal clean the theatre. And then there's sort of people extraneous to the hospital such as surgical reps who will be required if there's particular prostheses and implants. From the point of view of a JMO when we plan operating lists particularly in this hospital that we work at the responsibility is actually in submitting the list the day before and that's when it's really important that all those details have been thought through and that theatres actually knows what's required and they have that time to plan ahead and get everything ready for the cases. So what factors determine the clinical urgency for placement on an operating list? All right, that's a good question. And there's a couple of different things to take into account here. So the first thing is the priority of actually getting patients on an elective operating list in the first place and then looking at actually specifically ordering an individual list in terms of which patient goes first. So when we plan an elective operating list, this is kind of something that happens outside the guise of the teams we work in, but it basically works on the principle that the surgeon who sees the patient will prioritise them based on a clinical urgency code. And at RPA, the patients are sort of loosely put into four categories. So elective patients who need an operation quickly are category A, and that means they need to have their surgery within 30 days. And those might be patients that have something like a cancer or a very painful condition that's significantly affecting them. Category B means they need an operation within 90 days. So it's not something life-threatening, but obviously significant. And then we sort of have elective patients who might need an operation within a year. So that might be a patient that has a lipoma or a skin lesion or a hernia. And usually an operating list is comprised of a mixture of patients from all these categories and they're planned ahead of time. So then these patients will come and then we need to decide actually who's going to go in what order on that list. And that is quite important because this really determines how efficiently the list will run. And that determination is quite complex and it kind of involves multiple factors. We take into account things such as patient comorbidities, the sort of case mix that we're doing on a particular list, and then things like the equipment or the specialist availability. So if you are thinking about creating the order of a list, it often is important to think which patients might need to be operated on first thing. And these can include a range of patients, but children are definitely top of the list and usually the youngest will go first. Patients that are developmentally delayed or people that will be non-compliant with fasting and waiting. Diabetic patients for obvious reasons and that we don't want to keep them fasting for a long time. Very elderly patients who generally also tolerate waiting for a long time not very well. And then there's a whole range of sort of specific medical issues. So you might have, for instance, an anticoagulated patient who's on a heparin infusion that you'll need to cease at a specific time. Other patients, haematology patients who might require specific blood products or a patient who has liver failure who needs FFP. And it's important to time those interventions very carefully with the time that they're going to have their procedure. And then there's other sort of extra things to think about, like a patient who might have a latex allergy or suffer from malignant hypothermia who generally need to go first. So it's quite complicated. Usually the end of the list is reserved for cases that can be done under local anaesthetic because they have a short recovery time, inpatients who already have a bed allocated, and then patients who have certain infections or biohazards like your MRSA patients. So it's quite complicated as you can see. So is there a system for categorising the clinical urgency of theatre cases? There is and this is kind of when the emergency caseload comes into the picture. So we've been talking about essentially elective operating lists but as we all know we are constantly having new admissions and many of those will require emergency procedures and they may take place on an emergency list specifically or they may be integrated into the elective operating list, depending on how busy things are. And in terms of prioritising these emergency cases, we have a clear system where there's six categories that range from category one. And patients in this category have an immediately life-threatening condition, and that means they need surgery within 15 minutes or they'll die. So that's a ruptured AAA or a kind of catastrophe on that level. That works the way down. Category two patients need surgery within an hour, so they have a life-threatening condition. Category three, they are organ or limb-threatening conditions, so that might be something like an ischemic leg. Category four is a lot of the cases we do, so it's non-critical but emergent. And those patients usually need to be operated on within eight hours. And an example of that would be someone with acute appendicitis. Category five, non-emergent but urgent. And then the last category is category six. And those patients are people that are quite stable, but they can't really leave the hospital without an operation, so that might be a minor orthopaedic or plastic procedure. And we have to weigh up the urgency of these cases and then decide also whether we need to push these emergencies into the elective theatre time. The implications of that being that elective patients can be cancelled. So it's quite a delicate balancing act to get it right. Okay, So what role does the anaesthetist play in preparing the list? And also, what is the role of the pre-admission clinic? So the anaesthetist is obviously very important. And I think, you know, in theatres that run well, it's really due to good communication between surgeons and anaesthetists. And from both points of view of those consultants and teams involved, it's letting you know your surgical colleagues or your anesthetic colleagues know about any concerns that there may be regarding the patient.
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So for example, the easiest surgical case on the list may be the most anaesthetically complicated. They might have a difficult airway. And so a balance needs to be found between the priorities of the two teams. The anaesthetist is obviously very important in the pre-admissions process. So usually once the patient has seen a surgeon and been consented, they will go to a pre-admissions clinic. And the anaesthetist, in conjunction usually with the JMO, is responsible essentially for conducting a risk assessment of the proposed surgery. They need to think about what method of anaesthesia they're going to use. Obviously, a history and examination is performed. And then one of the most important things is thinking about what potential problems the patient may have. And they often sort of occult things like diabetes or minor cardiovascular or respiratory problems. Often the surgeons may overlook these. The anaesthetist usually decides on the management of medications that might influence the surgery, things like anticoagulant or antiplatelet agents, diabetic medications and cardiovascular medications. And in this regard, the pre-admissions clinic is so important to screen patients and kind of identify potential problems before they arise. And from the JMO point of view, as there is a funny system that we have where often the registrar is the last person to meet the patient, the JMO is responsible for quite a lot in terms of ensuring that these checks are carried out, that the appropriate blood tests, imaging, ECGs and things like that are done, and to ensure that there's a good perioperative plan that gets documented in the notes. Okay. And what other units need to be involved when planning the list? So it'll obviously depend on the patient. Certainly the most important thing to think about is after the operation's done, where is the patient going to go? So if it's on your home ward, the NUM will definitely need to be aware and they should usually be anticipating admissions. If the patient needs to go to a higher care area, such as an ICU or HDU, then that usually involves pre-booking the bed, discussing that with the ICU doctor and then checking that the bed's actually available on the morning of surgery. The bed manager is really important, particularly in allowing emergency patients the access to theatre, because essentially if they come in through emergency, no bed means no surgery. So that is very important to involve them early on. And then other units that we mentioned earlier, so radiology. If a case needs to use any I.I. or we're using a hybrid suite at RPA, radiology need to be involved, the radiographer and often a radiologist as well. And then blood bank for patients who have particular blood products that are required. So this is where it's really important to identify before the day of surgery who needs what and to make it very clear to these people. The biggest wastes of time we find are when people forget that someone needs a transfusion or no one books the bariatric bed or something like that, and it leads to a big waste of time, and that means people's surgeries are cancelled, which is obviously something we want to avoid. And what happens when you're asked to book an emergency or a trauma case during the day? So this happens frequently and it is difficult because an emergency case will often interrupt the flow of the list whether it be because this case needs to take place in the elective theatre or because the staff need to leave. Ideally we would book the emergency case and try and obtain access to the emergency operating theatre. We're lucky in this hospital to have that resource, but a lot of other hospitals don't have that and the list will need to be interrupted. And that's why it's really important to decide on what category this case is and how urgent is it really. Can it wait four or five hours until the last elective patient and be added on at the end, or is it something that needs to happen within the next hour? The most important thing here is really communicating well. So that means with the theatre numb, the anaesthetist, other members of staff in theatres to get the right equipment. And often because the registrar and the consultant may be scrubbed, the JMO is a very important person to kind of facilitate that communication happening. And what happens when a case takes longer than anticipated? I'd like to pretend that this did not happen as often as it did and the sad thing is this is usually due to surgeons over or underestimating how much time they're going to take and it is a huge problem and it has huge consequences for the hospital and for the patients. Obviously if a case takes a lot longer it then means that the following cases may be delayed or cancelled and that can cause significant repercussions in terms of obviously the cost, resources, patient flow. Patients have often arranged to have time off work and have carers so it's really something to be avoided. Obviously this will happen because medicine is unpredictable but the most important thing is that when a case is running longer or is more difficult than someone has anticipated, that you identify this early and that this is communicated to the number of theatres who will communicate with other teams to see if there's perhaps theatre space in another theatre. The patients need to be informed early and I think a very good practice is, even if you think there might be time, is just go and let the patient know, explain to them that there's a medical emergency that's taken place, that we will try and do everything we can to do their case, but let them know that it may be cancelled. And then if you are going to cancel them, do it early, let them be fed and rebooked. And usually patients will not have a problem. It's when you leave them waiting for hours and hours with no information that they'll get very upset understandably. And what are some of the common mistakes or pitfalls that people make when planning an operating list? I think the biggest one we've just mentioned is overbooking the list and usually that's the surgical consultant's fault. Sometimes having a list in the wrong order, not identifying certain equipment that may be used. Sometimes we need to use the same equipment over and over again and there might only be, say, two sets of that equipment and it actually needs to be sterilised rapidly and that can lead to delays if you don't leave time between cases. I think from a JMO point of view, there's some very important details that need to be put on theatre lists and these include things things like how much the patient weighs, if they've got a high BMI, because they may need a bariatric bed, the need for blood products, and whether a cross match has been done. Obviously, if the patient needs radiology or special equipment or prosthetics, and if these things are not put on the list, I think that leads to chaos potentially. So those are the important things to remember. And are there any guidelines available that can help you? Or is there anyone that you can ask? Look, there aren't any specific guidelines in Australia that we use, but there's some very good articles about, and I think we're going to include some as a link for everyone to have a read. Obviously, if you're given the responsibility of arranging a list and you're unsure about it, it's really important that you ask your registrar or the consultant directly. Often the registrar actually doesn't know that much about the patients because they're kind of left out of the equation until the surgical procedure happens. So never be afraid to ask your consultant. They'll always be happy that you are showing initiative and that you actually care about, you know, the way the list is running and you're wanting to prevent problems. So never be afraid to ask. And finally, any take-home messages? Look, I think really it just comes down to being good at organising things well and really preparing for the list and communicating what you need to the other members of the team. The list order, as I've emphasised, is very important and influences how efficiently the day will run. If you think there's a problem, and honestly, you'd be surprised how often consultants will leave important details out. If you're at pre-admissions clinic and you realise that, you know, this patient actually needs a transfusion or that no one's figured out the patient has a latex allergy or that they're diabetic, then bring it up, because if you can figure this out beforehand, everyone will be grateful, particularly your consultant. Pre-admissions clinic can be torture. I remember doing them as an intern. But they're actually a great opportunity to practise seeing patients in a kind of long-case setting. They're also a very good way to make sure that all the details have been checked and double checked and, you know, make up for mistakes before they happen.
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Welcome to On The Wards and it's James Edwards and I'm here again and we're talking today about stroke and I have Dr. Alice Maher. Welcome Alice. Thank you. Now Alice, you've got a bit of a different background, trained in ICU and neurology and now you're doing a neuro-interventional fellowship at Royal North Shore. Yes, that's correct. So a perfect person to speak about stroke and we'll go to a case as we do every time we do a podcast. You get a call, you're on the ward from the nursing staff and they're concerned about a patient who's become confused and maybe it's right this me and don't they've had but when you go to see the patient you notice his speech isn't quite right and looks like there's a facial droop. Can you give us your outline as a neurologist and an intensive care trainee of what you do? So I guess the main thing that we need to assess is what the neurological deficit is. And the main thing is to know what the patient was like before and what's changed. Quite often the nursing staff are really switched on in terms of what the patient was like prior and sometimes they may have even witnessed the onset of the symptoms. It's important to assess the patient because there are some aspects of strokes which are not easily seen unless you specifically examine for them and that's why focusing on a targeted neurological exam is really important and if you are the first doctor on the scene that's the first thing you'll need to do. The other thing you do need to do is also establish a history of that patient. So basically for this patient I would go and look at the patient, focus on motor deficit, neglect, visual fields, and targeted cranial nerve examination. Things like parietal strokes, occipital strokes are quite often missed, and that's why it's very important to specifically test for those. And also confusion, dysphagia, they can be quite difficult to establish at the bedside. And that's why, especially when you're a junior doctor, if you do have concerns with the patient and you're uncertain about the assessment, to rapidly escalate that. And rapid escalation is important. Why is it so important for rapid escalation? So stroke is a time critical emergency and essentially it's like having a cardiac arrest of the brain and even though stroke patients they may have stable vital signs they're losing a large number of neurons every minute that there is any delay and the faster we treat them will result in a better outcome for these patients. So when we see these patients it's a matter of urgent assessment, escalation to either a rapid response call or a stroke call depending on which hospital you work at. Are there particular key features you'd want to ask on history? So the main thing, and it's always helpful to get a collaborative history, is to know when the onset time was. And if that's not well established, then the last seen well time. And quite often that may require speaking to family members, nursing staff. Sometimes the patient can report when those symptoms came on, but they're not going to be as accurate because of the chances they may have some neurological impairment from the stroke itself. So time of onset, anything else particularly that's important? So the other thing is to establish whether the patient has any other medical background, which would mean they would be contraindicated to thrombolysis. So you want to know whether they have a bleeding risk and whether that's intracranial bleeding from prior events or active bleeding or if they're on any medication, particularly the novel oral anticoagulants or warfarin, that's a contraindication to thrombolysis. So it's very important to establish that early on. And we may go through the examination. You gave some brief outlines of areas we should look at, particularly any particular tip. So we go in order, motor deficit, what should you look for? So the main thing, and we'll see this more in large vessel occlusion strokes or even lacuna strokes, is, and this is the thing that's the most apparent at the bedside, so facial droop, so asymmetry, weakness of the upper or lower limbs. And sometimes it can be quite subtle. So remembering to test not just for power but for drift as well particularly in the upper limbs and also the lower limbs to check for drift as well that can be helpful. And how do you do that? So there is a standardized stroke assessment scale which is used for research but focuses on the key aspects of the exam that is good for a focus bedside neurological exam. So that would be asking the patient to lift both arms and to see if it drifts down towards the bed or hits the bed. And we would usually, on the standardized scale, give 10 seconds for the arm, 5 seconds for the leg. But the important thing is to determine a focal deficit that's acute. Okay, so that's how to do motor. The other key parts of the exam were? So visual field. So make sure you check, particularly as this will help pick up some occipital strokes, and also check whether the patient has any gaze deviation because this can pick up some frontal strokes as well. And these things may not be apparent unless you look for them. So that would mean directly looking at the patient and moving. So having a movement stimuli in all four quadrants and seeing if the patient is able to detect that and then asking them to look left or right just to see whether they do have a full range of eye movements. The other thing is to, as part of the assessment, is to check their sensation and then do a brief exam of orientation, cerebellar function and also... You also mentioned parietal, doing a parietal test. Yeah, so this is something that we do see sometimes that's not very commonly examined for. And patients can have substantial strokes with no motor deficit, and they may even have a significant large vessel occlusion. So the best bedside testing for parietal deficits is to test for sensory neglect. And that's to check if the patient can detect stimuli with simultaneous stimulation on the left and the right side of the body and it's good to do that on the face, on the arm and the leg as well. You've also described the severity of the stroke, looking at that as part of your assessment. How do you kind of document that? So at the initial assessment, the main things are to determine a clinically significant deficit and to rapidly escalate that. To communicate that effectively between other neurology teams, particularly when we're transferring patients between hospitals or we're communicating to our interventional neuroradiology service, the important thing is to use a standardised scale. The most commonly used scale is the NIS score and that is a scale which attributes a point to each aspect of the neurological exam and particularly focused on certain areas that are significant in assessment. These scales were used largely for stroke studies but is also a very effective tool to communicate that. So you think this person does have a stroke. What are your key priorities in your initial assessment? So the first thing is to determine that the patient's clinically stable, to assess the patient's blood pressure, heart rate, and the standard things you would at a bedside assessment, and then to determine the onset of the deficit, and then to rapidly proceed to further imaging of this patient and assessment for acute stroke treatment. So we're going on the stroke pathway but maybe before we go there, what are some common stroke mimics and how do you, any tips on differentiating the stroke, the common mimics we may see? So there can be a number of things that may look almost identical to strokes. So things that you may commonly encounter would be Bell's palsy. And we see these come through a stroke course quite frequently. The main thing is taking a history and examining the patient. For Bell's palsy, sometimes in the early stages they may not have full frontalis involvement so it can look clinically like a large, like an upper motor neuron lesion, but quite often patients won't have the same history in terms of a sudden onset and also with Bell's palsy there wouldn't be and there shouldn't be any other neurological deficits. So both those aspects can help determine that both from the history and examination. Other things that can mimic stroke, things like migraine and particularly with hemiplegic migraine, patients may have a presentation that's very similar to an acute stroke. Sometimes the history can provide clues if the patient has a history of recurrent migraine and particularly a family history of severe migraine. But quite often these patients, we will need to make a clinical assessment and consider treatment in a time-dependent fashion. And it can be difficult at times, and patients may be treated on the basis of their neurological deficit if there is some uncertainty of the nature of their presentation. Okay, well, thanks for that. Now we're talking about stroke, but what are the different types of stroke or how do you classify stroke?
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And then there's different subtypes of ischemic and hemorrhagic strokes. So the main thing is in simple terms whether there's a blockage of a vessel or there's bleeding into the brain and we treat them quite differently. Most strokes are ischemic about 80% and we need to give these patients medication that opens up the vessel whereas patients with hemorrhagic strokes we need to either stop what's causing the bleeding or minimize the consequences of that. So that really brings us now I guess the role of doing a CT brain which we need to do urgently. Just describe what are we looking for in the CT brain? Is it looking for ischaemia versus hemorrhage or looking for the location of potential ischemia or looking for more large facial occlusion? Yeah. So the CT brain is a great tool. It doesn't tell us everything, but we can do a CT on almost every patient and we can usually do that very quickly in the vast majority of hospitals. What we need to assess primarily is what the cause of the neurological deficit is and in the case of ischemic stroke we need to make sure that there's no contraindications to thrombolysis. So if there's any bleeding then that automatically means that the patient is not eligible whether that's bleeding into a stroke or bleeding as a primary cause of the stroke. Other things that we can ascertain from the CT brain are areas of established infarct, meaning that we can't salvage certain areas of the brain because the stroke has been there for too long. And also in some cases, we can see things that suggest that there's a large vessel occlusion. So like a dense vessel sign or something like that. But ultimately we need to proceed to more advanced imaging to make a diagnosis of a large vessel occlusion. So that would be CT angiography or CT perfusion scanning. But in general having a non-contrast CT brain is the initial test or there is a bit more with non-contrast CT brain and then leading on to other tests depending what the first scan shows? So if a patient has a suggestive history of a large vessel occlusion, most patients will proceed to all of the series scans, including CTA and CT perfusion. In some cases where there's bleeding on the brain, it may not be required to do CT perfusion studies. But for certain kinds of bleeding, like subarachnoid hemorrhage, that may be part of the assessment for that. And for some patients, they'll have established infarcts seen on the original CTs, so there wouldn't be a lot of added value to proceed to further imaging. The CT brain is obviously really one of the first investigations we'll do, but what other investigation would you consider? So other things like MRI imaging can be very helpful for certain patients. It is much more sensitive to detect early strokes and it can tell us a lot more of other things in the brain. But quite often patients require MRI safety questionnaire, MRI scanners are not as available. So usually that's not something we can do in a time critical manner. How about other things like an x-ray, ECGs, blood sugars, UECs, COAG? All those things take up a lot of time and time is critical in brain, in salvaging the brain. So we would advocate urgent CT scanning and a primary assessment with routine bloods, including a BSL. If clinically indicated, the patient may require a chest X-ray or an ECG, but quite often these things can wait until after the initial assessment with the CT brain. And you've mentioned a number of times thrombolysis. This is obviously a decision usually done by stroke neurologists, but as I guess a brief overview for our junior doctors, what are some of the time windows for indication of thrombolysis and also things like clot retrieval? So I guess the main thing is time is brain, and the shorter the time, the better the outcome for the patient. In terms of actual kind of license indications, 4.5 hours is the cutoff for thrombolysis. And that's from starting the infusion. And the 4.5 hours when it's unclear onset time is to when the patient was last seen well. And this is the same for wake-up strokes and situations where there's some ambiguity. For thrombectomy, the target is rapidly evolving with new evidence, and we're seeing now with more recent trials like DAWN and Diffuse 3 that patients up to 24 hours since last seen well time, if they have a clinically significant stroke, can still benefit from thrombectomy at that delayed timeframe. So it is something that is evolving, but particularly for thrombolysis, there's a very clear evidence-based window for that 4.5 hours. So we look at management, we see thrombolysis and clot retrieval. Are there other key management strategies, I guess, particularly I'm thinking about blood pressure management? Yeah, so there are, it depends on whether the stroke is ischemic or hemorrhagic. For ischemic strokes, hypertension is one way of the brain counteracting ischemia. So we often let patients auto-regulate in the acute phase. And that may mean letting their blood pressure go up to 220. But after they've been assessed and they're thrombolyzed, we decrease that target. And quite often now, if they've had a thrombectomy, we may even decrease that target even further. And that's because ischemic brain is vulnerable. And once we reestablish blood flow, then we need to lower that target to make sure they don't develop a hemorrhagic transformation. And in regard to if they've got a hemorrhagic stroke, is blood pressure management even more important? It is. It is a bit controversial. There's been a few trials recently, and I would always speak to the neurologist or the neurosurgeon who is on call because we do know that having the blood pressure too high is a problem but having it too low for hemorrhagic strokes may not be good either. But the general kind of clinical management for most patients would be not too high, less than 140 for most patients unless there's a specific reason. And you mentioned neurosurgeons here. In regard to intra-dural bleeds, I guess probably not the sub-ratinoid variety but others, is there indication for neurosurgical intervention in this group or is it usually medical management such as blood pressure control? So intra-dural bleeds? Yes, intra-pericardial bleeds? Yes, intrapericardial bleeds. Yeah, I mean sometimes acute management by neurosurgical teams are required if the mass effect of the bleed is significant and particularly if the patient has severe deterioration whether they become drowsy or have substantial midline shift. There's also a role for neurosurgical teams in the acute management of stroke, particularly if they have a very large stroke. Decompressive craniectomy can improve outcomes for patients in that group as well. So we've got a brief overview of the number of teams involved and some of the management strategies, and I guess we've had a very much focus on the medical teams. What's the kind of role of other nursing, allied health within stroke management? So there's been quite good evidence that stroke units do make a substantial difference to patient outcomes, and that's a multidisciplinary approach with speech pathology, physiotherapy, specialised nursing staff and that's all important because the cumulative benefit of addressing all of the potential complications of stroke is quite important. Quite often patients have swallowing difficulties, they'll have difficulties with movement and function and to optimise their outcome stroke units are the best place for this patient population. And what sort of complications do we expect in stroke patients and how we try and prevent those? So patients often will develop complications as a result of their neurological disabilities. So swallowing is the first thing we assess and most patients will be kept near by mouth initially until we can adequately assess their swallowing function. So sometimes that means they may require feeding via NG tubes or even longer-term feeding if they have swallowing difficulties. Strokes affecting the posterior circulation, particularly bulbit function, have the greatest potential to cause problems there. And the main thing is the risk of aspiration pneumonia and complications from that. Stroke patients quite often may have risk factors that predispose them to other conditions, so ischemic heart disease, vascular disease, so it's always important to make sure that we're addressing those risk factors too, but particularly for the inpatient population, pulmonary emboli and making sure all patients are assessed and given DVT prophylaxis if required. And tell me about kind of what the outcomes of stroke patients typically is, I know that's a very vast and wide question. But people who do get thrombolised or do have some weakness, like what's the time frame that they tend to recover in?
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Hi, I'm Anna McLean, one of the Respiratory Registrars at RPA, and I'll be talking today with Dr Laura Glenn, a fellow Respiratory Registrar with me at RPA. Hi, Laura, and thank you for being involved in this podcast. We'll be discussing how to recognise the deteriorating respiratory patient in the context of the COVID-19 pandemic. Hi, Anna. Thanks for having me. As most of you well know, coronavirus disease 2019, or COVID-19, is a respiratory tract infection caused by a newly emergent coronavirus. This was first recognised in Wuhan, China in December of last year. While most people with COVID-19 develop only mild or uncomplicated illness, approximately 14% will develop severe disease and that requires hospitalisation and oxygen support, and 5% will require admission to an intensive care unit. Identifying those with severe or worsening symptoms early allows us to optimise supportive care and enable safe, rapid referral to appropriate management areas such as ICU. Today we'll be going through the management of a real COVID case with some dramatic license, in particular focusing on recognizing signs of deterioration as well as the appropriate investigations and management steps. The management of COVID-19 is not dissimilar to any lower respiratory tract infection and through this podcast we hope to reassure you that you have the skills required to manage these patients well and that support is available. There are a few specific take-home messages in relation to COVID-19 that we would like you all to be familiar with. So Laura, the case. Mr Smith is a 44-year-old male who presented to ED with a one-week history of fevers and rigors associated with dyspnea, lethargy and anorexia. He had no significant past medical history and no regular medications. On initial examination, he was saturating at 99% on room air with a rest rate of 18. His blood pressure was 120 on 80 and his heart rate was 87. Chest x-ray, bloods and a COVID-19 swab were performed and he was admitted to the ward. You were called by the nursing staff to see him as on routine observations he was noted to be saturating at 87% on room air and had a respiratory rate of 23 per minute. In this case Laura what are the key questions you would ask over the phone? Okay so the things I would like to know over the phone would be a basic is bar handover from the nurse and the patient's vital signs in order to enable me to triage the urgency with which I review the patient given that I'll be looking after a ward full of patients. I would like to know whether the patient has had a COVID swab performed and whether the result is known. I would like to know whether the patient has had an NFR status documented and whether this is in the notes and be asking the nursing staff about any basic investigations or interventions that can be arranged prior to my arrival, such as supplemental oxygen, an ECG, or whether a staff member outside the room could have intravenous fluids arranged. Some corridor thoughts that I would be running through in my head en route to review the patient would be that COVID-19 has high transmissibility and the routes of spread we know are through respiratory droplets and there's now some evidence to suggest that it can be transmitted via the airborne route and remain on surfaces for extended periods of time. And so PPE and the avoidance of aerosol generating procedures are essential to protect yourself, colleagues and other non-infected patients. I would be thinking about risk factors for COVID-19 positivity, such as whether this patient has had a history of travel or whether they've been exposed to any known cases, and whether they have any risk factors associated with more severe disease, such as age or comorbidities. I'd be thinking about where they might be up to in their duration of the illness, thinking about the natural history of COVID-19 and reports now that there is a trend for deterioration in the second week of illness. And also in terms of what potentially might be going on, the various syndromes that are now recognised to be associated with COVID-19, such as a mild illness versus a more acute and progressive respiratory illness. All right. So now that you've got some more information about the patient, what are you thinking are the possible causes of his deterioration? What are your differentials? Okay. So in this case, I'd be thinking about whether the patient has deteriorated because of a complication of COVID itself or whether there is something else going on. So particular COVID complications or syndromes that are now recognised to be associated with COVID-19 include mild illness versus progressive pneumonia, including severe pneumonia, acute respiratory distress syndrome or ARDS, a superimposed bacterial infection with sepsis and or septic shock, and there's also been reports of associated cardiomyopathy. Now, remembering importantly that there could be something else going on simultaneously. So particularly in clinical scenarios where you're seeing, for example, an older patient or a post-op surgical patient. Other things to think about might be acute pulmonary edema, tachyarrhythmias such as atrial fibrillation, exacerbation of underlying chronic comorbidities such as COPD or asthma, metabolic acidosis due to renal failure or sepsis or particularly in the older patients aspiration pneumonia in the post-op setting atelectasis hospital-acquired pneumonia or pulmonary embolism. So two important points to remember there may be one more than one process occurring particularly in older patients with comorbidities who are prone to cardiac and other complications of infection and treatment. And also, please remember that although it can feel overwhelming to list all these potential differential diagnosis, if you go back to basics, you will be able to hone your differential list using your bedside clinical assessment and basic investigations. All right, thanks, Laura. So you've now arrived at the bedside to see this patient. What does your initial assessment involve? So when I arrive outside the room of the patient I would like to conduct a brief file review before entering the room. So assessing the patient's demographics, their age and other relevant information from the file including past medical history, their comorbidities and confirm that they have an NFR documentation recorded in the file. Importantly, I would at this stage apply my personal protective equipment and have a buddy check that I have done so correctly prior to entering the room. After entering the room, I would then conduct an end of the bed assessment. So looking to see whether the patient is responding appropriately and their level of consciousness, which will give me an assessment of their airway. I would assess their breathing by looking at signs such as use of accessory muscles of respiration, tripod positioning or intercostal recession. I would then also like to assess their vital signs, in particular looking at their respiratory rate and oxygen saturation, noting that tachypnea is the earliest and most sensitive sign of deterioration. I would then consider whether I need to escalate and call for help immediately using my assessment of their vital signs, whether there were any vital signs in the red zone on the OBS chart, and all my level of concern. So if there were any immediate concerns to life or any concern that this patient was deteriorating rapidly, I would call for help immediately. If not, and I had time to proceed with a more focused examination, I would then focus more on the respiratory examination to see if I could hone down a differential diagnosis. Thanks, Laura. So it is very important to call for help early if you're worried. But moving on to the focused respiratory exam, what does that involve? So in addition to the specific signs on observation at the end of the bed, which is very important, as mentioned looking for their level of consciousness and other specific signs such as cyanosis or asterixis in the setting of evolving respiratory failure. I would also like to listen to the patient's chest to auscultate for any signs to rule in or rule out various differential diagnoses. So I would be listening for crackles, for example, unilateral crackles or bronchial breath sounds in the setting of consolidation or bilateral basal inspiratory crackles in the setting of heart failure. I would also be listening for wheeze, such as in the setting of an exacerbation of underlying airways disease or reduced air entry and or an altered percussion note in the setting of pleural effusion or a pneumothorax. I would also be looking for additional signs outside of the chest to again help to rule in or rule out various diagnoses. So assessment of the JVP and looking for peripheral edema such as in the setting of cardiac failure. So you examine the patient and note the following. His respiratory rate is 23 per minute. He's saturated at 92% on 4 litres of nasal prong oxygen. His blood pressure is 130 on 80 and his heart rate is 94. His temperature is 37.6. The patient is alert and oriented. He is using his accessory muscles of respiration. On auscultation of his chest, you hear bi-basal crepitations.
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Is there anything you would do now immediately for this patient, Laura? And what other investigations do you think you'd do to help you initiate management in this patient? Okay, so at the bedside, I would recheck and continue to monitor the patient's oxygenation by checking their oxygen saturation with a pulse oximeter and I would then titrate the supplemental oxygen accordingly. So it's very important particularly in the setting of an infectious illness such as COVID-19 that we consider the most appropriate delivery of oxygen. So in this case I would continue to up titrate the FiO2 by increasing oxygen via the nasal prongs to five litres a minute, as required to maintain SATs over 90%. And above this, a Hudson mask would be required for higher flow rates of oxygen. Remember, if you're considering instituting any empiric therapies, that we should not be using any nebulised therapies. And so all of of the jmos listening should be familiarizing themselves with how to use an mdi and spacer and should be able to demonstrate this to patients remember that high flow nasal prong oxygen shouldn't be used in the management of a patient with suspected or confirmed covid19 without consultation with a senior because of the risk of aerosolisation and infection of others. Moving on to the investigations that I would perform at this point. So I would like to review the blood tests performed in ED, specifically looking at the patient's full blood count, biochemistry with renal function and liver function, inflammatory markers such as their CRP, and markers that have been associated with prognosis in COVID-19 such as the D-dimer and LDH. I would like to repeat an ECG if indicated, plus or minus additional cardiac investigations such as a troponin. And I would consider performing an ABG if indicated, as well as repeating a chest x-ray using a mobile chest x-ray machine on the COVID-19 ward. All right so in this case our patient has a white cell count which is normal but with a mild lymphopenia or low lymphocyte count. His CRP is mildly elevated 89. He's's got slightly deranged liver function tests, and his ABG shows a pH of 7.44, a PO2 of 63 millimetres of mercury, and a CO2 of 35 millimetres of mercury. The chest X-ray shows subtle bi-basal interstitial changes. So in this case, why do you think an ABG was performed, and what particular information can you gain from doing an ABG? And why would it have been done? Okay, so I think importantly, the first thing to remember for safety reasons is that oxygen should never be removed from a hypoxic patient in order to assess their PO2. Practically, when would I perform an ABG? So the indications to perform an ABG would be if you have a deteriorating patient and you're concerned about their adequacy of ventilation. If you're seeing a patient who is prone to hypercapnia, so they're a CO2 retainer, looking for any evidence of type 2 respiratory failure. And this third indication will be mostly for ICU medical officers for monitoring progress and response to therapies in the ICU setting. So in this patient, I would perform an ABG because he has had a clinical deterioration since he was reviewed in the emergency department and I am concerned that he may have evolving respiratory deterioration and or respiratory failure. When reviewing the arterial blood gas result, I am looking at the pH to determine if there is an acidosis indicated by a pH of less than 7.35. I would also look at the PCO2 to determine if the acidosis is predominantly respiratory, indicated by a PaCO2 of more than 45 millimetres of mercury, or whether there is a metabolic component. I would then look at the PaO2 to determine the patient's oxygenation, with hypoxia being indicated by a PaO2 of less than 80, and that can be classed as mild, moderate or severe, depending on whether the PaO2 is less than 80, 70 or less than 60, indicating a severe hypoxia, and taking into account the FiO2 that the patient is receiving as well. In addition, an elevated lactate, importantly, can suggest inadequacy of perfusion as seen in the setting of septic shock. So in this case, our patient has moderate hypoxemia despite four litres a minute of supplemental oxygen. There's no evidence of hypercapnia or acid-base disturbance at this stage. And the chest x-ray, Laura, what are the key findings you're looking at when you perform a chest x-ray? So I'm looking at the chest x-ray to see if the changes are consistent with COVID-19 disease, whether there's been any progression since the patient's prior chest X-ray to indicate radiological evidence of deterioration or worsening, or whether there's any changes consistent with additional or superimposed processes. So for a viral pneumonitis, I would be looking for unilateral or bilateral patchy opacities or interstitial change. In a patient with COVID that's progressing to develop ARDS, I'd be looking for more coalescent bilateral opacities associated with respiratory failure clinically with worsening hypoxia. In terms of thinking about differential diagnoses, in lobar pneumonia, I'd be looking for more dense consolidation affecting one or more lobes of the lungs. In fluid overload, you would see upper lobe blood diversion, curly B-lines and or pleural effusions. In a pneumothorax, looking for a lung edge and absence of lung markings at the site of the pneumothorax. So now putting your clinical findings and results of the investigations together, what is your management plan for this patient? So our patient is hypoxic with bi-basal crackles. His chest x-ray demonstrates changes with viral pneumonitis or evolving ARDS. He has no evidence clinically or on investigations of fluid overload. He has no wheeze suggesting airways disease. So I don't think at this stage there is a role for empiric treatment with Lasix, bronchodilators, steroids, other specific therapies, but I would consider those if any of those indications were present in another patient. I would document a plan for monitoring clearly in the patient notes and make sure that I'd handed over my plan for monitoring and escalation to both the nursing staff looking after the patient and to my team. So this patient has a low-grade fever and elevated inflammatory markers. What do you think is the role for antibiotics in this patient and would you prescribe them? So antibiotics should be administered or at least considered where there is suspected co-existing bacterial infection and especially if there is evidence of sepsis. So empiric treatment should be based on your clinical diagnosis. So if you think the patient has a co-existing community acquired pneumonia, a hospital acquired pneumonia aspiration or if there's evidence of another source such as a urinary tract infection you would treat as with empiric therapy for those diagnoses. ETG is a useful resource to direct choice of empiric antibiotic therapy. So in this case, given that the patient's viral swabs are still pending, he's got a fever and elevated inflammatory markers with chest x-ray changes, I would certainly consider antibiotics. That's great. And so a little while later, you're called back to see this patient as despite the management you've initiated, he continues to feel more breathless and you're now unable to maintain his saturations above 90% despite the fact you've escalated his oxygen significantly. He's now on eight litres via a Hudson mask. What would you do next, Laura? Okay, so I'm now concerned that this patient is now too unwell to remain on the ward and is at high risk of continued deterioration. I think he will require ICU level care. So the most important thing to remember is to call for help and to call for help early if you are concerned that the patient is deteriorating. Remember your doctor's ABCD approach to assessment and management of the patient and bearing in mind your hospital-specific BLS or ALS protocols, which will be coming out in hospitals around the state and country this week. You should continue to monitor the patient closely and initiate any appropriate empiric therapies whilst awaiting for help. Thanks, Laura. I think it's been really helpful to go through this case and there's been a lot of important information that you can take home. But for you, what are the key messages that you think people should take from this case? Thanks, Anna. So I've got four very important take home messages. So if you take anything away from this, these would be the things to remember. Number one, the general principles of bedside clinical assessment and recognition of a deteriorating patient have not changed because of the pandemic. You guys all have the skills to be able to assess and escalate appropriately. Number two, your first priority is and should always be to protect yourself and your co-workers. So that involves knowing the patient's COVID-19 status and wearing PPE as per protocol.
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Welcome to On The Wards, it's James Edwards and I have the pleasure of welcoming back Dr. Paul Hamer. Very glad to be back,, James. Paul, as many of you know, is the DPET here at RPO. He's also a respiratory physician and has spoken to us on a number of occasions about respiratory topics, and one of them was non-invasive ventilation, which we may touch on today because today we're going to talk about chronic obstructive pulmonary disease, or COPD. We have a few cases, but I may start with something very broad. What is COPD? So COPD, chronic obstructive pulmonary disease, is actually a bit of a mismatch of terms. So it's a combination of emphysema and chronic bronchitis, and we lump them into this overarching term called COPD. It's defined by three things. You actually have to have all three to have a diagnosis of COPD. The first is a reduced spirometric ratio. So that's a ratio less than 0.7. So that's the FEV1 over the FEC, and that ratio is basically a representation of limitation of airflow. So if it's 0.7, you're limited in the amount of air you can blow out quickly. And that's chronic obstruction. So that's sort of the definition. The second two things you need are really important too. So you need an exposure to something. So cigarette smoke or it might be pollutants. So a lot of people in India who use indoor cooking furnaces and things can develop COPD. And the third is symptoms. So you have to be symptomatic in some way. So coughing up phlegm or you've got dyspnea. So the triad of low spirometric ratio, less than 0.7, plus symptoms, plus exposure is what gives you COPD. And I think it's really important to define because a lot of people get slapped around with this term COPD because they see their GP once, they're short of breath, the GP doesn't do a spirometry and they get put on a puffer. And then forever on after that, they're labelled as COPD. So it's really important to know whether they truly do have chronic obstruction in their airflow by definition. So how is COPD different to asthma? So asthma is reversible airways disease so someone with COPD even when they're well they'll have chronic obstruction in their airflow whereas someone with asthma when they're well will have normal airflow so it could be like you or me, but when they're sick, their airflow will drop. And that's when their spirometric ratio also drops and they develop airflow obstruction. So the difference between the two is asthma is a reversible obstructive airways disease and COPD is a chronic obstructive airways disease. Okay, I think that really helps, Paul, before we go on to some cases. So we do go to our first case. You're a junior doctor and called to review a 64-year-old female who presented to the ED earlier in the day with what sounds like a neck and femur fracture and is waiting for an operation but does have a background of COPD and type 2 diabetes, and the nurses report that she is having difficulty breathing. Mm-hmm. You get that phone call. What sort of questions do you ask over the end of the phone? So I suppose you have to evaluate. So a lot of people have difficulty breathing. I suppose you want to find out what her obs right then and there. So do you know what her obs you ask and they're saying on room air the saturations are 86 percent and respiratory rate's high at 28 and she's got a normal temperature okay so i mean i suppose the first thing is that um even someone who is well with copd shouldn't be hypoxic unless you're they're known home oxygen or something like that. So I think you need to recognise straight away that this is not normal. And it's actually a clinical emergency. And whether you call that a between the flags in your hospital or a MET call or a SIRS call, you need to go and see that patient with relative urgency because hypoxia kills. So that's the first thing to recognise. The second thing, I suppose, is that you probably need to see her quickly. And you can tell the nurse over the phone to start applying some oxygen and doing some initial management while you go down there straight away and review her. So you get down there, you're the first one there before some of your senior team has arrived. What's your approach to assessment of this patient? Well, it's an emergency patient, so you go back to the basics, Dr. A, B, C, D, E. So check her airway and make sure it's patent. Make sure she doesn't have a foreign body that's causing her wheeze. Check her breathing to see if she's using accessory muscles and have a listen to her chest and see if it does sound wheezy. Check her heart rate and check it's regular or irregular and so on. So your basic assessments first. I suppose initially you want to correct the basic abnormalities of her physiology. So you'd apply the oxygen and hope that that improves her oxygen saturations and decreases her respiratory rate. And then we can go start asking her some questions as to why she's become like that. Are there any other different diagnosis you consider, or is this just definitely a COPD exacerbation? So she's come in with the term COPD, but she may or may not have COPD because of the things we talked about before. So I know that she's also got type 2 diabetes and she's probably been given the term COPD because she was a smoker before. So people with diabetes and smokers have a high incidence of heart disease. So she might be having a heart attack. It could be silent MI because she's got diabetes and she's gone into APO. So chronic or APO actually causes wheeze as well. So wheeze, hypoxia and tachypnea. So it's important to sort of try and figure out what the timeframe of this was. If it came on relatively suddenly and was associated with some mild chest heaviness and things like that, and she's got bi-basal crackles and some wheeze as well, then you have to consider whether she's had a heart attack. Do an ECG and make sure you've ruled that out. If you speak to her and she says, look, I get this wheeze all the time, I've got COPD, I had a cold a few days ago and this is what I always take and I just take some Vinflin and I seem to get better, then I probably would be more reassured that she had COPD. But you can't forget the very important things because people with COPD also have risk factors for heart disease. What other questions would help you work out whether this is maybe an exacerbation of COPD? So whether someone has an exacerbation of COPD depends on their spirometric ratio. So if someone has, you need to know what their baseline spirometry is like, and you will judge that purely by the FEV1. Severity is rated by the FEV1. The diagnosis is by the ratio. So if someone has an FEV1 that's above 70%, then that's relatively mild COPD. And as you have an exacerbation of COPD that FEV1 will fall and so the more severe the exacerbation the lower the FEV1 will fall. You don't look at the ratio just the FEV1. So after you've determined that you need to figure out and if the FEV1 is low you sort of need to figure out whether it's at her baseline or worse than baseline. And if it's worse than baseline, that's an exacerbation of COPD. Now, to determine whether it's infective or non-infective exacerbation of COPD, that's a different question. And for an infective exacerbation of COPD to treat with antibiotics, we generally look at three cardinal symptoms. So the first is increase in sputum volume a change in the sputum color or an increase in dyspnea if you have two of those three cardinal symptoms then you've probably got an infective exacerbation that would warrant giving some antibiotics in regard to you've done a history and exam now and any other particular signs you think are important to look in examination? I suppose you want to see whether she looks well or unwell. So you see if she's using accessory muscles, if she's got some tracheal tug, if she's using her clavicles and her sternocleidomastoid to breathe. You'd want to have a listen to her chest, see if she has wheeze. Give her some salbutamol and see whether the wheeze improves.
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You might want to have a listen to the heart and see if she's got any signs of pulmonary hypertension, such as a loud P2, that might be co-contributing. They're the main things I'd be looking at in this lady. You get a bit more information. It sounds like she has had a chronic cough, which you state is unchanged. And on examination, she has some expiratory wheeze. And you look through her medication chart, and you do note that she's on a serotide puffer, but no other medications. So I suppose that's quite good that she's already on serotide, so maybe that's appropriate. But serotide is only a preventative puffer and it's not acute management. So serotide puffers generally come as an emitted dose inhaler, which is a pressurized canister. It puts out the medication at a very fast velocity. So you want to slow that down somehow and you do that with a spacer. So it's important that you chart in the medication chart that serotide should be used with a spacer. And then for the acute management, you can give Ventolin MDI, or metered dose inhaler, via a spacer as well, between six and 12 puffs. 12 puffs is usually the adult dose, and that can be given every two to four hours in someone who's acute or up to six or eight hours if they're recovering from their exacerbation. Now, Paul, you told me that chronic obstructive airways disease, it's a chronic obstruction. Then why will it serve you to more work? So that, yeah, so very good point. So people say to me, or I've heard before, I've looked at her old spirometry and they did pre and post bronchodilator and there was no response. So there's no point giving her salbutamol. That's wrong, wrong, wrong. So salbutamol is actually one of the only medications we have to really get a hold of a patient with COPD other than steroids. So one of the important things that you need to know about flow is that the rate of flow in a tube is proportional to the radius to the power of four. So you only need a very, very small increase in dilation of the bronchi to achieve increase in flow. And that's what bronchodilators do, such as salbutamol. When someone is as severely constricted as someone in an acute exacerbation of COPD, you want to give them all the help that they can get. And that's where bronchodilators come in. In combination with that, after you've done spirometry and you've confirmed that she does have an exacerbation of her COPD, it would be worth giving her prednisone or hydrocortisone, depending on the severity as well, so you can start that going. It takes about six to eight hours for those steroids to kick in, and in the meantime, you can treat it with inhaled bronchodilators. Thanks for that, Paul. That's something that's always bothered me. I think it's an excellent explanation. What other investigations in this patient would you order? You've mentioned spirometry. What other investigation do you think would be helpful? So I think a few things. You can start with some bloods and just check if she does have an infective pattern on there. And really just looking at the white cell count on that. And you might want to also look at the potassium if you're giving her a lot of salbutamol just to check she's not already starting low because the salbutamol will drop your potassium. The second thing which you're going to order is a chest x-ray. Make sure that she doesn't have any consolidation because if she does have any new patches of consolidation on the x-ray then you're dealing with pneumonia as well as an infective exacerbation of COPD if she's got the sputum color and volume as well they're the main things I'd order look one thing that does come up is is what are your indications for doing an arterial blood gas yeah so that's a good point so I you probably would do an ABG in this person as well because they're hypoxic. Generally, anyone who's got hypoxia and who's got chronic obstructive pulmonary disease, you do an arterial blood gas to see what their carbon dioxide level is. You don't need it to look at their oxygen level. You don't need to do it on room air. It's not necessary because oxygen measured by a SAPS probe is more than accurate enough for us to titrate oxygen levels. So you'd never need to take someone off oxygen to do an ABG unless you're approving them for home oxygen therapy. So you do it purely to look at their carbon dioxide and their pH. And that's why you do an ABG. A controversial question. Is a VBG enough to exclude someone with high CO2? Well, it is controversial. So the studies show that it's actually variable. So there is actually no accuracy in either way. So even in someone who has a, I mean, you'd think it's safe enough. So if their CO2 is normal or low, then it's unlikely that their ABG, it will also be high. So I think that's probably a fair assumption. But if the CO2 is on the upper limit of normal or above, then you definitely need to go ahead and formalise that with an arterial blood gas. I agree. I think a high CO2 and a VBG just means you have to do an APG. In this patient, you do notice their PaCO2 is 52, but their pH is normal and their bicarb is 33. What does this suggest? So she's got a compensated respiratory acidosis. So the CO2 should normally be between 35 and 45, and hers is 52. And she's a person without any compensation that would cause an acidosis. She's compensated for that by raising her bicarbonate to 33. And so she's probably had this for a while. So we'd probably call her in chronic type 2 respiratory failure or chronic hypercapnic respiratory failure. It shows that she, as a whole, doesn't ventilate well enough to blow off all her CO2. But in this acute situation, because her pH is normal, it's fine. She doesn't need to go on bio-level ventilation or have any other excessive treatments other than treating her COPD and managing her hypoxia. But you do need to make sure that you don't give her excessive amounts of oxygen. So you want to titrate her oxygen therapy to aim for sats between 88% and 92%. If you go higher, she has a risk of carbon dioxide retention. Excellent point, Paul. Any other management strategies for this patient? You've kind of touched on some regular bronchodilators, maybe steroids. What would be your approach for this patient? Look, it depends what her spirometry shows. But yeah, if she's wheezy and we've said that it's a COPD exacerbation, then steroids certainly does help. Generally, you'd start with 50 of prednisone. And sometimes it depends on your consultant and their preferences. But my practice is 50 of prednisone for at least five to seven days. And some extend it to 10. But there's not really any benefit to extending it past 10 days. If they're going to respond to prednisone, you'll probably see it in the first five to seven days. And the role for intravenous steroids versus oral? So that's usually got to do with their ability to take oral medications and the rapid effect of it. So if someone who's very unwell is too short of breath to swallow tablets and you want a more fast onset of action, then you might consider hydrocortisone. What would be the equivalent dose of IV hydrocortisone that you typically use? So 100 IV would probably be equivalent to 50 of oral prednisone. Do you just give that hydrocortisone once a day? It's four times a day. Okay, well, that's the kind of somebody's probably exacerbation, maybe not infective. We may talk about another case that could explore some of those other discussion points we've already mentioned. Sure. This one's a 52-year-old male who's admitted for investigation of malignant weight loss on a background of CFPD. And this time study has been asked to review the patient and they've developed a fever now of 38.6 and their tachypneic and their SATs are low with 90% on 6 litres. We've mentioned about the clinical feature that would make suspicious for effective exacerbation of COPD.
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Welcome to On The Wards, it's James Edmondson today. We're talking a very important topic of consent and we'd like to invite one of our partner organisations, AVAR, and two guests from AVAR, Georgie Hasem and Dr Jane Hingham. Welcome Georgie and Jane. Thanks James. Georgie is the Head of Research, Education and Advocacy at AVAR and has also worked in health law for nearly 25 years. And Jane is a Senior Medical Advisor in AVAR's Research, Education and education and advocacy team and is also a physician with special training in palliative care. Consent is something so important and I don't really remember ever getting taught about it in medical school. We're going to have a slight of consent from a medical legal perspective so why is informed consent a concern from a medical legal perspective, Georgie? Well James, what we find in our claims and complaints is that they're often less about whether consent has actually been obtained or the forms been signed and more about whether the patient's understood the proposed treatment. So what we've seen over the last several decades is that there's been a shift from that paternalistic approach to consent where the doctor says, right, this is the procedure you need to have and the patient goes, yep, signs the form and off they go, to the shared decision-making model of patient-centred care where there's a shared understanding of outcomes that's focusing on what's important to this patient who's in front of you making a decision. Have you got some examples for that? Yeah, so I guess a good example is a case that we recently wrote up and it involved a patient who was a coach driver and he had a ruptured Achilles tendon and went along to hospital and was treated conservatively. He ended up with a lengthened tendon as a result of that and that impacted on his ability to work. So there was an allegation in the case and it wasn't so much about whether or not conservative treatment was the appropriate treatment in this case. It was more about the fact that he wasn't informed of the option of surgical treatment and surgical treatment had a lower risk of tendon lengthening. So therefore the patient wasn't given sufficient information about options and the relative risks and benefits of either the conservative management versus the surgical management to allow him to make an informed choice about what he wanted. There's other sorts of examples as well. So for example, we've seen cases where a patient wasn't informed about the side effects of medication particularly long-term side effects in the orthopaedic situation leg length discrepancy where patients had cataract surgery and doesn't realize they need to wear glasses afterwards they weren't expecting that so there's all those sorts of examples. Okay so it really seems to be important that the person who's getting the treatment understands all the different options to make that decision. Yep, that's right. I mean, given it's really looking at understanding, how do you test that understanding for a patient? Well, I find it helpful with any aspect of medicine to start with a question about what the patient understands. So especially as a junior doctor or a new doctor on a team, you can start with a question. Just so I understand what you understand, can you tell me what the doctors have told you about this procedure so far, this treatment so far? What do you understand about your situation? And often that will give you a good sense of where the patient's up to in their understanding and what areas you're going to have to cover off. You've got to avoid the temptation to sort of embark upon a list. It's important to engage with the patient in shared decision making. So can the person explain in their own words what the procedure might involve? Can they explain to you the alternatives of the treatment? What results are they hoping for for the procedure? What's worrying them? What are their greatest fears? And do they have questions that are unanswered? I think sometimes going through a series of questions with the patient rather than a list of the problems gets you a good understanding of where you've got to start in the conversation. Interesting what you mentioned about looking at alternatives which is not doing anything because you get a bunch of doctors in a room and ask what they tell a patient in this case, what operation you would do this. When you ask a whole doctor the same question, they're, oh, I wouldn't do anything. We're much different to our patients than to ourselves sometimes. I don't know where you should ask what you do in your situation or what you do for your mum, but sometimes what doctors do is not always what they say they'll do. And that's an interesting question about whether you can talk a patient out of surgery, for example. So they might come to see you because they're expecting some surgery. If you don't think that that's appropriate, then you shouldn't proceed with it. You should be recommending the appropriate thing for that patient in that circumstance. And it may be that it's not a procedure. I think it's very important to think about your language in that context. And the not do anything sounds very much like abandonment to a patient. And there's always, especially I'm a palliative care doctor, so there's always things we can do. And it may not be the individual in front of the patient, but the surgeon who's got something that they can do. But the team of medical people around this person, there's often treatment options, be that symptom management, rehabilitation, support in some ways. So the not do anything thing is a very loaded phrase that we have to be careful of using, I think. And we should be offering patient the alternative treatment option not nothing. Yes. Maybe we'll go on to who is responsible for getting the patient's consent. Sure. So the person who's doing the procedure is the one who's legally responsible for obtaining the consent or having the consent discussion but that can be delegated. The important thing is that the person performing the procedure needs to be confident that the person they've delegated to has sufficient skill and competence to have the discussion with the patient. So do you think that depends on the seniority of the doctor or depends more on their competence? Well, I think the responsibility lies with the person doing the procedure. And so I think the delegation has to be to someone competent. The level of that person can be sort of senior, junior, or quite junior. Some hospitals have policies that suggest that interns, for example, should not be doing procedures. I think your audience could be from an array of different locations and health systems. So I think it's always prudent to check what your local policy is in the hospital you're working in. But the competence is the important thing, generally speaking, in addition to what the policy says you can do in the environment you're in. And so a junior person might be involved in decision, in consent, in seeking consent. And I think it depends what job you're doing and what you're going to be called upon to do in the term you're in or on the rotation you're on. And it's always prudent to look at what sorts of things you're going to encounter and, if possible, find out early what you're going to need to do. If you have been delegated the task of seeking consent for surgical radiological procedures, blood transfusions, you should feel quite competent yourself. And if you don't feel competent, you ask more questions. It can be a good idea to ask the questions early in your term. Ask the surgeon what they would like, what they usually explain to the patient in their rooms or wherever and what they would generally feel it was really important to explain to the patient so that as a team you're working well together and that you're imparting the knowledge that the person who's going to be doing the procedure would expect you to impart. So I don't think people should hesitate to ask questions about what the person doing the procedure would like the patient to know. Work well as a team, the patient will get the right information. I mean you've almost covered it but what are some I guess tips for junior doctors to be able to I guess get the appropriate consent for a patient? Well I think one thing to remember is that consent's a process and not a form. So I think we said earlier, avoid the temptation to just go through a checklist of risks and complications and things like that. It's really more than that. It's about having the discussion. And that can happen over a series of consultations, for example, if you're the one doing the procedure. And in regard to, I guess, in regard to consent, I mean, there are different types and we're talking about written consent here or can you just have verbal consent and when can you have either or when can you put a cannula in without having consent? Well, from a legal perspective, you don't have to have written consent for everything, but there are hospital policies that will require you to have a signed consent form before a procedure is done.
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Welcome to On The Wards, it's James Edwards and today we're talking about the concerning and scary post-operative airway problem and we welcome Dr. Timato. Welcome, Tim. Thank you for having me. Tim's our anaesthetist at Nepean Hospital in Sydney. And we're going to go to an initial overview of how would you define a post-operative airway emergency. Okay, so really, a post-operative airway emergency is where there's a derangement either in clinical or physiological signs or symptoms that's attributed to the airway so signs of airway obstruction or impending airway obstruction. So we'll go to a case just to explore that in more detail And you're on night shift and you're called by a nursing staff concerned about a 67-year-old female who's day one post-thyroidectomy for thyroid cancer who is complaining of worsening pain at the surgical site. The nurses are concerned about the increased swelling of her neck. When you're on the other end of the phone, what sort of questions would you ask that nurse? Okay, so I guess the first thing is if a nurse calls you about this, there should be a little flag in the back of your mind saying, okay, this is a potential issue and I need to be careful here. So, I mean, the first thing that you want to find out is what are the patient's vitals, okay, and the trend in the vitals. So, particularly the respiratory rate, you know, and if there's any high-risk features such as stridor. Is there any noise with her breathing that was not there previously? Okay. That's a big red flag, and that mandates. I mean, any time that a nurse has a concern about an airway on the ward, you know, that mandates a review. Certainly in this particular case, you know, this is a surgery on the neck, you know, and somebody who's had previous cancer. So these are high-risk features and, you know, this is somebody that we need to attend to fairly quickly. Well, the junior doctor is a very good junior doctor and has identified this is a high-risk patient and rushes down to see the patient. And when they arrive, they notice that there's moderate respiratory distress with a respiratory rate of 30. And obviously they look like in some sort of discomfort at the end of the bed. Swallowing and talking makes the pain worse and there is a small fluctuant mass inferior to the incision site which the nurses say was not there on the afternoon shift. What would be your approach from here? Okay, so really this is a, you've identified some of the high-risk features. This is one where we are going to attempt to try to both assess as well as treat the patient. So you want to make sure that you're giving the patient some... supporting the patient in terms of oxygen. If they haven't been on oxygen, you put some oxygen on. This is a, in terms of the examination in this situation, you're obviously looking for, we know that they've got a respiratory rate of 30, but you're also looking for increased work of breathing. You know, you're talking to the patient, you know, can the patient even speak? Those are, again, you know, high-risk features of impending airway obstruction. If you weren't in that situation, you can almost divide things up into sort of, you know, early, late, and very late signs and symptoms. So, you know, early signs would include things such as dysphagia, you know, having some difficulty with swallowing, change in their voice, dysphonia. And then things, you know, when things progress, you will have problems with breathing, obviously. There's this increase in their work of breathing. You can see that with their intercostal muscles. Sometimes patient positioning will give that away. There's tripodting, needing to sit up, positional dyspnea where even going back a little bit on the bed causes or worsens the breathing effort. And really, these things, I mean, in terms of the look, and obviously you're looking at the airway, at the neck area. In this situation, it's one where we need to just basically deal with the airway situation. It's one where we need to get help early. What's going through your backyard miners? What are the potential causes of why this airway has deteriorated? Okay. I suppose, I mean, I think that we, in any sort of head and neck surgery, you're thinking, is this a surgical problem in the sense that we've got bleeding now at the site, which is the reason why we've got this fluctuant mass anteriorly? Is there a problem internally in the sense that we've got airway edema? Again, possibly related to trauma during surgery. It could have been trauma. It could have been lung surgery related to the endotracheal tube. The cuff pressure in the endotracheal tube could have been high high. Normally, hopefully you'd sort out these issues in recovery, but it doesn't always happen. So we need to have a high index of suspicion. There could be other reasons such as stretching or injury to the recurrent laryngeal nerve causing vocal cord dysfunction. That's another potential issue. Other thing, particularly in thyroids that are retrosternal, you have tracheomalacia. It's almost this softening of the trachea where the trachea becomes malleable and then you have issues particularly with lying supine with obstruction at the trachea. You're obviously concerned about this patient based on what we've described. Is it time to do some investigations, get some bloods done, maybe an X-ray? No, in this situation, you need to deal with a clinical situation. It's not time for investigations. Those things take time, and they detract from what could potentially be a catastrophic situation. So impending airway obstruction is the problem. This is where, I guess, elements of crisis resource management need to be instituted. So it's really about, you know, recognising that this is an emergency, you know, and getting help early. It's communicating effectively to the people, you know, escalating this to the people that are able to deal with the situation in a timely manner. And then supporting the patient until help arrives. I mean, I suppose one of the tempting things in this situation, because we've got a patient in pain, is to give IV opioids. And we really have to be careful about that just because we can actually make the situation worse when we have already a situation with airway compromise. So who do we want at the bedside now? So this really is one where you'd want to get the medical emergency team. We need to have the intensive care, anaesthetics, as well as a surgical registrar, or if it's during the day, it might be the actual team involved. A lot of these patients will have a scalpel by the bedside, or what I've seen recently is different types of sutures that you can actually pull right away in where you suspect there's bleeding to be able to evacuate the hematoma early and easily. Are these patients going to be managed on the ward or are they going to need to go to theatre? So these patients, if you had to do that certainly on the ward, they'll need to go back to theatres for some sort of investigation, evacuation of hematoma and then repair. I've alluded to some of the other issues, airway edema, recurrent langen nerve problems. These patients will need to go to intensive care. They might need a short period of post-op ventilation in support of treatment, other medications such as steroids to deal with the edema. So they'll need intensive supportive treatment for a short period of time. Are there any other goals of management in the longer term? Well, we've talked a little bit about short to medium term, which is, you know, obviously securing the airway and treating the cause, you know, supportive treatment for a period of time. The other things, in the longer term when they come out of intensive care, these patients need to be, we just need to be a bit more careful with them. In some hospitals, in our hospital, there's an acute pain service that also reviews patients with airway problems that have been flagged. There may be different services in other hospitals, but they're reviewed, and we determine how often they can be reviewed. And particularly those patients that not only have had an airway problem, but then have, you know, perhaps other comorbidities that make them more susceptible to these things like, you know, significant respiratory disease or, you know, significant cardiac disease. Okay, that, anyway, you know, that would be one of the other issues to consider. Maybe we just kind of follow up generally.
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Okay, welcome everyone to On The Wards. It's James Edwards and it's March 2015 and today we have Dr. David Joe, an upper GI surgeon and transplant surgeon here at Rupert and Salvatore Hospital and he's going to talk about surgical drains. Welcome David. Thanks for having me James. Look we may just ask some general questions about drains. It's something that gene doctors do deal with on a probably day-to-day basis in a surgical term and sometimes after hours. What is the purpose of a surgical drain? I think generally there are two broad categories of purpose for the surgical drain. One is either to remove some fluid of some description, whether that be, you know, pus causing an infection or blood causing a hematoma or maybe some bile, you know, some serious fluid, some air in an hematoma, something that's causing a problem. So it's either to remove that fluid to minimise the problem or it's to characterise the fluid. So, you know, we want to make sure that there is no bile in a drain, for example, after a gallbladder operation and we leave the drain to ensure that the biliary tract is intact. Similarly, sometimes people leave drains in to ensure that there's no blood after an operation to ensure that there's no bleeding. The benefit of that is sort of a bit controversial, but that's generally the principle. So I think that'd be the two categories, to remove the fluid or gas to minimise the problems with it or to characterise the fluid. Have you got a definition that's fairly simple for a junior doctor to understand what is a surgical drain? I think it's essentially a tube. A surgical drain is placed at an operation, although of course we're getting more radiological drains now, aren't we, in terms of our interventions. So you'd probably have to include both of those things. And it's used to remove fluid which could be harmful from a surgical wound, remembering that a surgical wound can be a superficial wound or it can be a deep wound. It can be intraperitoneal or intraarticular or wherever. What are the different types of drains are there? You can sort of think about drains in a couple of ways. First of all, you can think of them as either open or closed drains. A closed drain is usually a tube system which is attached to a bottle and that may have a sort of Belovac or concertina suction on it. And that tends to be associated with less infection because it's a closed system, it's not open to the air. And that might be used in an elective setting, for example, again, after a gallbladder operation or definitely after a knee replacement, sometimes drains are left in and where you want to minimise the risk of infection. An open drain would classify something like a corrugated drain or a flat drain. And that's when you, it looks quite primitive. You know, they've got an abscess or they've got a wound that's literally got a piece of plastic that's come out of that wound, which is secured in some way. And that just facilitates the fluid, which shouldn't be there, and usually that's an infection of some description, to come out through the wound. So that's one classification. The other one is whether it's active or passive, and that's relating to how the fluid comes out. So we talked briefly about the suction drain before. That's an active system, a demonstration of an active system where it will create a negative pressure and that will actively pull fluid out of wherever the end of the drain is, versus a passive one where it just uses gravity and it just requires the differences in the pressure, say, in the abdominal cavity compared to the outside. I'd say they're the two sort of main broad categories. If a junior doctor needs to work out what type of drone it is, where do they get that information from? I think the best way, and the way, whether you're a junior or a senior doctor, the best way to do it is to look at the operation report or the radiology report when they put it in. Often people, particularly if they've had complex operations, will have multiple tubes. Some of those tubes, of course, might be drains. They might be PTCs or they might be gastrostomies or jaygenostomies or there might be something into which we're actually injecting something or administering something. So it's important to look at the operation report, make sure you work out the number of tubes that were left, which were drains, which were other things, where they were placed. And usually what will be written in the report is in the left upper quadrant, the lateral drain was placed in the gallbladder fossa or wherever. So I think the best way to do that is with the operation report. Now sometimes that's not available. Sometimes the patient can tell you where the drain was poured, particularly if it's a radiological drain. Some patients are very knowledgeable, but of course not always. And secondly, sometimes the appearance can give you an indication, but I must say it wouldn't be something that you rely upon as to whether you can take something out or not. A radiological drain often has the three-way tap because they have to use the cannulas to get in, whereas the surgical drains tend to be the red of X or the bell of X and they can often have the suction catheters on the end of them. So probably important for the junior doctor to recognise that not everything that is coming out of someone's abdomen is a drain. Absolutely right. Yeah, you can have things like T-tubes, although that's not that common today, but it's essential that those sort of tubes aren't removed, mistakenly taken for a drain. So very important that they understand and the nursing staff who they're working with understand exactly what is and is not a drain and which one needs to be removed. And it sometimes does take a while to work out, but definitely an important investment. Okay. We will go to a case now. You're asked to review a 55-year-old female who's day one post-op from a lap collie, and the nurses are concerned that there's some coloured output from the drain. When you get that phone call, what questions would you ask the nurse over the phone? And i guess trying to work out what the urgency of that problem is so the first thing like like we like an answer that we often say to this kind of problem regardless of whether it's drain or not is how well the patient is and that will sort of define how urgently you need to go and see the patient of course if they're um they look as though they're septic so they're tachycardic or hypotensive or in any other way looking unwell, then obviously it's very important to go and see them regardless of what's coming out of the drain. However, assuming that they're fairly stable and the nurse's concern is about the drain itself, the questions I'd be asking are what sort of volume has come out over the last 24 hours. Usually the nursing notes are extremely complete in terms of that, which is good. So you want to know the volume, you want to know the colour of what's coming out. In this circumstance, this patient's had a gallbladder operation and always worried if you've left a drain that there might be a problem with the bile duct or a bile leak. And so if there was any kind of yellow or green fluid coming out, that would be very important to know. Usually if a drain has been left after an operation, there is a reason for it. It's unusual that drains are left routinely. And so it would be worth getting some more information. It's probably going to be on the ward once you actually get to the patient as to why the drain was left. Was it a difficult operation? Were they worried about any kind of infection? Also, of course, there can be problems with bowel and so forth, and if there was any sort of brown or small bowel-coloured content coming out, that would be obviously a very important thing to know and important to escalate to a senior person, perhaps the surgical registrar or the registrar on the team. OK, you arrive to go see the patient. What's your general approach to seeing the patient when you're there? Okay, so I guess it sort of reflects the physical actions of what we just talked about. So you go and see them, get a general idea of how they look. Are they in bed? Are they writhing around in agony? What are their vitals? Are they febrile? Are they tachycardic, hypotensive? Are they saturating okay? That will give us an idea about how quickly we need to act.
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And so you want to examine the abdomen, make sure they have a soft and non-tender abdomen. Sometimes it's difficult to assess when someone's had recent surgery, but you do want to assess whether they've got any peritonism, because if there is bile in a drain, it might mean that the bile is not only in the drain, but it's actually throughout the peritoneal cavity, and that would be an urgent sort of referral to the surgical team, because they may need to take the agent back to theatre. What are some of the common complications you'll find that relate to surgical drains that a junior doctor may get called about? I think a very common reason to be called about a surgical drain is that there's a query infection around the site of the drain. And I think that it's very rare that a drain does get infected, at least at the site. There might be draining infection, it might be there for an infection, but often you do get some scarring and some scabby sort of tissue around the drain site. And that's usually nothing too much to worry about. The other thing that you might get called about as a junior doctor is that the drain has moved. So often it's sutured in, but sometimes these sutures, particularly if the drain's been left in for a long time, can cut through the skin. And when the drain does move out, then the nursing staff may ring you to make sure that it's okay. And if that is the case, again, go back to the notes, work out why the drain was there. If the drain was draining some fluid and now the fluid has stopped, so if you look at the OBS chart and there was like a litre draining yesterday and since the dislodgement, in inverted commas, now there's nothing, that would be very concerning that all that fluid is not going somewhere. And so that's something, again, to identify as an issue and to escalate to your senior team. Okay, Dave, we now go back to the junior doctors now on the day surgical service. When we look at daily management issues for surgical patients, what sort of issues particularly about drains should they be including their daily medical notes? Okay, So when you're doing the ward round in the morning and you see the patient in their drain, it's very important to get an idea about what the volume was over the last 24 hours and how that relates to previous days. Usually a drain fluid output will decrease over time and that's usually the way you work out when you're going to remove it. You also want to note what colour. So we've talked about this previously when you're talking to the nursing staff on the phone. If it's often what we say is haemocerous, if it's a drain that's been put in to assess for any kind of leak of any description and it's haemocerous, that's reassuring because it's just, you know, general sort of ooze which occurs around a surgical wound inside a body cavity. But if there was any unusual sort of fluid, such as coloured fluid like yellow, green, feculent, et cetera, that would be very important to identify as well. And usually you'll be doing this on a ward round with other people who will be able to help with that decision-making process. Do you ever send off the fluid to work out whether it's bile or is it just enough to have a look? Yep, absolutely. So sometimes, for example, after... I'm obviously an upper GI surgeon, so I've got a predilection for upper GI problems, but let's use an example. Say someone has a Whipple's procedure, so they get part of their pancreas removed and they've had these joins. Those drains usually stay in for about five days as a routine just because the leaks can occur up until then. On day five, what we tend to do in the upper jar department is to send those off for a bilirubin and or an amylase level to tell us whether there might be a leak biochemically. So someone might be clinically well, but we might actually want to know that their amylase level is normal or that their bilirubin is normal. And that is very helpful because then we can compare the drain fluid bilirubin or amylase to their serum bilirubin amylase. And if it's the same, then you can fairly confidently remove the drain knowing that it's essentially a hemocerous fluid. But if it's elevated, then you might have the suggestion of a leak which needs to be addressed or at least the drain may need to stay in. So the other thing which you sometimes do in a drain is that you might send it off for culture. The only problem with culture in a drain is you can get colonisation from the outside and so it can be difficult to interpret sometimes what that drain fluid is. Obviously, if you've had an abscess somewhere and that's been drained radiologically, usually that's under sterile conditions and that fluid is usually sent off initially. But if there was a problem with that specimen, you could send off another one knowing that sometimes you can get problems with colonisation. Okay. One other question that occasionally comes up, and I guess it's probably to do with the surgeon, but what implements your decision whether you put a drain on free drainage or suction? It's a really good question, and I think that it's very, very surgeon-dependent. The difference between the suction system is that suction probably more effectively evacuates a space. And if that is the purpose of the drain, then that's probably the best way to do it with suction. If it's not on suction, then you're relying on the difference in the body cavity pressures. And some people believe that if you use a non-suction drain, for example, in an you might promote a fistula so let me give you an example after a liver resection you've got lots of little bile ducts on the transected margin and some people leave it believe that if you leave a suction drain in then that promotes bile to come out those little ductules as opposed to going down the bile duct that's not held by everybody that's an argument that some people say for using a non-suction drain. I don't think there's consensus. There's definitely no consistency in terms of surgical protocols or treatment. Yeah. So junior doctors should just follow what their team does. Yeah, I think, yeah, exactly. I think the teams have, are consistent within themselves but not amongst, not in between teams. Do all patients who have a drain in need to be on antibiotics? No, they don't. So sometimes drains are put in and you might have some antibiotics around when the drain goes in. That's quite possible, particularly if it's for an infected collection or they might be having not that it's a drain but a PTC into the bile ducts, and that can be cholangitic, and they might need antibiotics before the procedure. But the specific presence of a drain does not mandate antibiotics. You might be on antibiotics for an abscess anyway, but not for the drain itself. And what determines when a drain should come out? Sometimes drains are kept in routinely for five days or a specific length of time regardless, and it's just a temporal issue. Other times we're waiting for fluid or quality of the fluid to improve. So if someone has a bile leak and their volume goes down and their bile-stained fluid turns into a haemoserious leak, then that is the indication to take it out. If their volume goes down but they still have bile-stained fluid, then it's probably something which needs to remain in. So it's something that needs to be tailored to the exact problem that the drain was put in for. But generally speaking, what you're looking for is volume to go down and the colour of the fluid to become more consistent with haemocereus fluid. Are all drains sutured in? Most drains are sutured in, not every drain. Some of the radiological drains are held by a sort of fixation device that sort of clips the drain in. But drains should be secured. It's important that they are, particularly for drains that could potentially be sucked into the body cavity where they are. And you see this sometimes when drains are being shortened, whereby they're initially sutured, then the drain is pulled out, the suture is cut, the drain is pulled out a little bit, and if the drain is not secured with a safety pin or another suture, what can happen is when the patient manoeuvres, you know, gets up or walks around, then the drain is pretty well secured inside their belly and it pulls it back in, and that can be very difficult to manage. They may even need another operation to get the drain out. So it is very important to make sure that a drain is secured even after it's been shortened or manipulated. Once the drain does come out, how do you care for the drain site? It's always...
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Okay, welcome to On The Wards, it's James Edwards and today we're doing something a bit different. Rather than talking about a clinical topic, we're going to talk about what makes a good junior doctor. And we've invited a number of different people today. We've invited Ken Liu, who's our liver transplant fellow. Welcome, Ken. Hello. Bridget Barbaro, who's the acting NUM at RPA. Welcome, Bridget. Hi, welcome. And Amy Freeman-Sanderson, one of our senior speech pathologists also at RPA. Welcome, Amy. Thank you. So what does make a good junior doctor? Maybe we'll start with you, Bridget. Okay, so I guess from a nursing point of view, first and foremost, it's someone really that is a good communicator and they are approachable and someone that can identify, you know identify, you know, that's the acting NAM or the in-charge on the ward and what do I need to communicate about what the plan is for the day or hand over any things that need to be done. There's nothing worse, and it drives nursing staff insane, when you see a round that's happened and, you know, things are documented in the notes and then there's no verbal handover and we might find out about a plan or a discharge or something an hour or two later. So communication, I think, is key. So, yeah, that's it. Yeah, so that communication. So who do they communicate with? The nurse looking after the patient or, as you said, the NUM? How do they work out which one to go after the ward round? So I think they need to set that expectation at the beginning of their rotation with the NUM on the ward. I would think my ward and most wards would be, you know, you hand over to the NUM or the team leader in charge so that then that can be passed on to the nursing staff looking after that particular patient. But that may vary. So I just think it's about having clear expectations right in the beginning, you know, when you start on a particular ward. And we all know also the big focus and drive around patient flow and discharges these days. So it's about also being organised and clear around, well, you know, what are my priorities for for the day and what discharge letters what things need to be done so that we can discharge patients safely and in a prompt way by 9 or 10 a.m. Okay so I mean I think communication will probably be a theme that goes through today but Amy in regard to communication for junior doctors as a speech pathologist and someone from allied health what is in the key messages? I think as Richard was saying from assessment to discharge so in terms of assessment I guess being aware of our role in allied health what different disciplines can offer and being clear about your management goals for that patient so are you looking for assessment and management of an acute problem or are you looking medium term management so being clear in your mind where the management's going for this patient. And in regards to discharge, maybe at the beginning of the rotation if you're at a particular ward, finding out what are the requirements, what do I need ticked off in terms of those boxes, what are those boxes? So there's nursing needs, there's medical needs and there's allied health needs. So just being aware and then you can just always ask a question just knowing that we're contactable and to ask a question. So how will they find those needs? Is it best they speak to you, introduce themselves when they first move to the wards? Yeah, I mean introducing themselves to the team. I mean each team is different in regards to rotation. So medical is very different to surgical and within medical, neurology is very different to aged care, for example. So I think being aware of those needs and introducing themselves to the team at the beginning. So they're opening the lines of communication and you know how to best manage all the best pathways for that particular area. Okay, so Ken regard a communication for junior doctors? What do you think when they guess they're almost communicating up to their registrar, what do you think are the key messages you'd like to send to the junior doctors? Yeah, I think the good junior doctors can sum up a patient, their background and their current issue in a very nice, succinct way. So like, for example, those who use the ISPAR system rather than those who just tend to waffle on and not get to the main point. I think that's very useful in terms of doing handover when you're in emergency, for example, trying to admit someone over the phone or when you're asking for a consult. I think having a good framework for that is very useful. Yeah, I mean, I think we've emphasised on these podcasts, often having a clinical question is kind of one of the keys. So you're asking me to come see, you're asking me what's the question, what do you want me to do? Yeah, so often when I'm on call after hours, they say, oh, can I talk to you about so-and-so? And then they go on a long rant about the past medical history and I often have to cut them off and say, oh, sorry, can you just tell me the problem right now? And that helps me put in context what they're about to tell me later. I think when getting referrals as well, the junior doctor may be on a ward round, something's come up, a referral to Allied Health, and the junior doctor will phone us up or put through the referral and will say, what's the reason? And they say, I'm not sure. So I think if in that moment they're not sure why they're referring, they need to ask whoever they're around, what's the purpose of the referral and what outcome would I like from this? Because often we don't know what the reason is either, So it's good to get clarity at the time and discuss it. Definitely. Any other things on communication that you'd like to emphasise? I think it's also good to close the loop. So often on the ward round I might give some instructions and I think the juniors understood it but it's often good for them to repeat it back to me. So this is what you want me to do. And that's why we often do paper rounds afterwards and that's why we often find the NUM or the nurse in charge and verbally hand over so everyone's on the same page. Yeah, so I think there's different ways of communicating. Obviously having written communication on the notes is important especially for people after hours because you weren't there on the walk around but I think the verbal communication is equally important. Bridget what's some other characteristics of junior doctors that you do like working with? Obviously someone you know that's professional and they're approachable someone that you know if nursing staff ring up and request something that they respond in an And also, I think, give a bit of a time frame. Well, I can't do this right now, but I'll be able to do it within a couple of hours, or I'll be straight up, or just setting that expectation again. And it goes both ways. I know nursing staff could do the same, definitely. So professionalism, just friendly and someone that's organised, I think, and can see sort of, I guess, into the future, just around plans for patients and, you know, whether it be having to chart certain medications or organise certain tests or make referrals or something. And also, you know, having, say, patients that are being discharged, you know, having a letter that's already half written instead of just doing it on the day of discharge and the patient's being with us for two weeks. So organisation is key, I think, as well. And sort of, and, you know, we're all not perfect. So just, you know, saying that, you know, I am maybe struggling sort of with these sort of priorities. Can you help me a bit as well? Because sometimes the nursing staff can, you know, just be open with us and we can guide you and help you as well. Yeah. No, I mean, I think gene dogs can learn a lot from nursing staff. Do you think some of them don't want to let on they don't know things?
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This is how you need to do it. Do you know what I mean? And we're okay with that. Like, we would rather that and know that it's done correctly for the patient than it just not be done or we have to wait four hours or something for it to be done and just get frustrated. I mean, I know it's a fine line between asking for help and then wanting to learn and have a go at something themselves. But maybe just being upfront saying, I haven't done this before, I'd really like a chance to just have a go at this myself. This is my time frame. If it doesn't work, then can I come to you for help? Because we understand that they need the opportunities to learn themselves, but we don't want them to be doing something wrong when we could be giving them a helping hand. What are your thoughts, Candy? You've been a junior doctor a number of years ago, but do you feel like you're losing face if you ask nurses for help? Is that why some doctors, do you think, avoid asking for help or avoid saying they don't know something? Yeah, I think that's the reason why some people are hesitant to ask for help. But I should point out that some terms where you, for example, it's an ICU or cardiothoracics, which are sort of more sub-specialised, the nurses who've been working there for many years, like longer than you've been a doctor, often just know how things are meant to work because they've been there and seen it before. And those who are willing to learn from anyone, not just their seniors, and those who are willing to take feedback on board often do better than those who don't. Okay. So in some ways by getting more help from, I guess, a team of allied health, nursing, the gymnasium perform better than trying to act like they need to know everything themselves. Yeah, and I think the other staff react better to you that way as well. They feel involved. They know that you're keen to learn. I was going to say learning is an evolving process so even those of us that have been there for a while have a lot to learn from the junior doctors as well that are coming through with new ideas and different ways of doing things. So I think it's being respectful and being collaborative, listening to each other. Just because somebody's had minimal experience doesn't mean that they don't bring knowledge to a job, so it's being respectful both ways. And it's interesting you mention the word professional. What does professionalism mean for a junior doctor? What is being professional? I think being honest and open is professional so thinking about what you're saying, the environment in which you're saying it, who you're talking about so who's within earshot so where are you having the conversation. Sometimes there are sensitive conversations that need to happen. So just taking that away and being mindful that it's always the patient that's at the centre of it. So they're the reason why we're here. So including them in a respectful way. I think as Allied Health, we look at the way that doctors interact with other members of their team, with the nursing staff, and that's how you form an opinion about them, whether you think they're good value or whether, and somebody that you want to work with in the future. I think it comes back to good role modelling behaviour as well and leading by example. You know, the nursing staff that are doing things around the nurses station don't really want to hear about a round that's taking forever from doctors and they can't wait to get to breakfast you know because that's sometimes what we we do here even though like we may be thinking that um so we just rather that you know see that the round happens in a professional manner and that you know handover takes place and then you can go and get your breaks and do whatever you've got to do. So, you know, we work as a team and that comes down to professionalism and I think just leading by example and it's not just by the seniors, it's by the juniors as well because, like Amy was saying, we can all learn from each other. Yeah. Ken, what do you think being a professional junior doctor is about? Well, I think something I was going to add was we're all stressed, you know, it's a busy job and when people get stressed they have less patience and they can often be more curt and even rude. I think that's unprofessional and I think there are many ways of dealing with it so this also goes back to also being organised and time efficient. If you can think of ways to help reduce your stress level, even if it's like coming in early for half an hour to just get started on some jobs before your day starts, or if you think your phone man is bad and the nurses just paid you from next door, you might want to see them in person. And just keeping in mind that, you know, someone might ask you what you think is a stupid question, but to them they don't have the same training as you and they may not have the same knowledge about the patient and everything's around them, the patient's care is you. So, I mean, it's so easy to judge people based on that, but you just need to put yourself in their shoes. Yeah, I don't think there's any place for being rude or discourteous at work. And I suppose if you're under stress but maybe just saying, is this really urgent? I've got something really pressing I need to do. I don't have time to talk about it now. Can I call you back? And just being honest that way. Or if you've had a conversation that you think is rude, following up with that person and saying, look, the way that we interacted, I wasn't comfortable with that because that will help build relationships and improve teamwork. One of the other things that junior doctors often, they rotate usually through five different terms. They always seem to be starting a new term. Any suggestions about when they do start on the ward, something they could do in the first week or even before they start on that ward that could help them function well within that term? I think from a nursing point of view, just finding out who the key people are. So who's the NUM? Who's the clinical nurse educator or the CNE? Who are the CNCs or particular roles that happen from a nursing point of view on that ward? What are the expectations around discharge planning and And also admitting patients. What are the, you know, where are forms kept? Things that are just going to make their day a little bit easier. Where are jobs or tasks written up on that particular ward? Just getting a bit of an orientation to what happens on that ward because, you know, they're all slightly different. I think you should be not afraid to ask for help. You're in a new environment. A lot of the processes in that term are probably foreign to you. And, yeah, asking maybe the doctor beforehand who's done it for a handover, talking to the numb on the ward, talking to the other allied health on the ward will be very useful. And we should always not forget the ward clerk. The ward clerk is usually a very important member of that ward team. They're the people in the middle that you know have a lot to do with. It's really true. It's really important to get to know and have a good relationship with the ward clerk early on in your term. They can make your life so much easier and make lots of appointments. Yes, that's true. In regard to, maybe we'll go from, to speak to Amy, in regard to allied health, what sort of, do interns understand anything what allied health clinicians do? And what are some of the barriers you may have about the relationship between junior doctors and allied health? I don't think they always understand what the full role of allied health is because it can be so varied depending on the case and what type of management you're doing. Sometimes we'll get asked and I think it's great in context of a patient because that's when you can remember how allied health were involved. I mean asking them at the start of your term what's the role of the occupational therapist here? What's the role of the physio? So you know exactly what's involved. We're often happy to do in-servicing. We've got information, so happy to share that with the interns as well, or the junior medical officers. I think in terms of assumptions is the worst part, when they assume that you just do one thing or assume that it's a pass or a fail, it's not a continuum, I think it's just lack of understanding and there's always a point to ask for clarification.
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Yeah. Maybe you should have called me before. Yeah, that's right. Do you say that or do you think that? I mean, we do say it. And obviously, I mean, there are certain types of discharges where something will come up all of a sudden and we understand that when things need to happen happen but when it's being planned and known and it's not being communicated that's when it's quite annoying because sometimes it will be written in the notes but if that phone hasn't been picked up, if that referral hasn't been made we've got no way of knowing if the patient needs to be seen and what needs they've got. Some needs can be addressed then and there, but some needs take a lot of planning. So a lot of the outreach services or follow-up in the community have different wait lists, so it's good if we've got pre-knowledge and we can speak to the medical team and they're making an informed decision about discharge and discharge risk. Ken, what kind of JMOs do registrars like and what are some of the things they don't like about the gym doctors? I think we've covered a lot of things like people who are organised, efficient, who just have a good attitude to work. I think what I really like seeing is people who are switched on. So, for example, let's say I'm consenting someone, or I'm telling someone about a procedure I'm going to do, like a colonoscopy, and then I turn around and there's the consent form ready, it's filled out. So an intern who's switched on thinking, okay, what does he need next? Or let's say I think this patient might go home by the end of the week and the discharge is 90% return, all their meds are sent, et cetera. So someone who thinks ahead and has initiative. Similarly on after hours or if they call me about a problem about one of my patients, someone who's thought about it and think, look, I think this person's got this, how I would do it is this, this and this, rather than this patient has low blood pressure. So a more active approach rather than just a passive reception of knowledge. Yeah. I think the things that we dislike generally are people who cut corners. So, for example, notes that you can't really decipher what happened on the ward round, discharge summaries that don't really reflect what's really happened, or, yeah, like after-hours reviews that haven't thoroughly gone through the patient to figure out what's wrong. I also don't particularly like people who turn up late. It sort of gives you a message that maybe their time is more important than yours. Yeah, I think, if anything, you should try and be there on time, if not a little bit earlier, just to get everything started. And we've already covered this. I think people who think they know everything already and don't need feedback or aren't willing to take on what other people say. So how important are clinical knowledge? Is that something that defines the doctors who know more are the better doctors? Is that probably in your experience true or not? Look, I don't think so. I think a lot of an intern's job is organisation and prioritisation and knowing how best to get all their jobs done during their day. I do think clinical knowledge is handy in certain situations. For example, if you get called to see a sick patient and you've done a good exam with your good skills and you've got good knowledge of the patient, that's often more helpful when you're calling the registrar to tell them about the situation. Or similarly, when you've called for a consult and you have a fair idea of what questions to ask when someone has GI bleeding or something like that, then you will have all that information on hand. That's when good clinical knowledge is useful. But I think the majority of the intern's job, which is essentially carrying out instructions, which is given by the boss or the registrar, that doesn't necessarily need clinical knowledge. And you can learn that along the way and actually progress anyway. Have you found an issue sometimes when there's doctors who don't want to do your specialty or want to do surgery, doing physician training, does that sometimes cause a barrier to their performance at work? I think it depends on their attitude. So, for example, if someone does a medical term but their surgery is what they want to do, they can still have a good attitude to the term. They still want to do the best they can at this term. Then those people don't have a problem. But if they are disinterested and just want to get through the term, do the bare minimum, then there's a problem. I don't generally treat people differently if I find out, oh, they don't want to do physician's training. I still try and teach them. I still, you know, treat them the same way. But what I do find is I have less sort of wisdom to pass on to them about, oh, this is how you get on to surgical training because I don't really know how. Okay Bridget why do you think being why does a good intern matter? I think at the end of the day we've all got to remember why we're here and it's about delivering safe good quality patient care and I think at the end of the day it matters because we're all looking after our patients with a common goal in mind you know to have good allied health care medical care nursing care so that they're you know they have a good admission and they're safely discharged hopefully so and the intern is really important to the functioning how well that that admission goes, you know, the little jobs that need to be done, the paperwork, the communication, escalating issues to their seniors, liaising with allied health. It really matters for an easier admission for the patient at the end of the day and a safe discharge. I think that's why it matters. Yeah, I agree. I mean, it just all adds up to quality care for the patient and everyone that's involved with that admission. So it has ripple effects out to the relatives and sort of the other rest of the team as well. I find as a supervisor, I don't think I realised how important the G doctor was until there was a G doctor who wasn't performing well. And then really almost not the ward fell apart, but it really became a struggle for everyone in that ward when the G doctor wasn't performing. So when they are performing, which I expect they will most of the time, it really makes a big difference to patient care but also the whole performance of the ward. Given that often the supervisor is the one that judges and assesses the intern, but they only see them twice a week, do you think they're in the best position to assess the intern or who should be asking to judge junior doc performance? I think like I always liaise with the intern themselves and then the registrars if I'm having any issues or if there's any feedback because that's just how we work on our ward. So, you know, yes, their seniors are good to give feedback but they're only sort of getting an opportunity a couple of times a week maybe to place that judgment. So, you know, it's multidisciplinary again. So, you know, it's important to get feedback from Allied Health and nursing as well. And it depends what part of their performance because it's also from the patient. So, I mean, truly, you know, it'd be good to get a 360 approach and even their peers, because they're often on a team with other juniors as well to find out how that's worked, because performance can encompass so much. I mean, do you ever see some people who seem to perform very well when the consultant's around and when the consultant goes out the room, their performance or their professionalism drops? You can see it at times. You know, people that want to get on particular programs will perform in a certain way when the bosses are around and then, you know, may appear to slacken off or just become a little bit lax maybe, you know, at other times. But that's not to say that allied health and nursing, we all talk. Do you know what I mean? You know, and hopefully in a professional manner because it comes back to the patient at the end of the day. And, you know, I know for a num, we just want our ward to be well-functioning and have a good quality standard of care because we're responsible for that at the end of the day. And everyone needs some downtime and some of that downtime is at the nurse's station when you're writing up notes but just still keeping it professional. Yeah, I think Regina and Amy will agree that the good terms supervising consultants will have consulted them about a particular intern to give holistic feedback to them. So, yes, they don't see them very often, but they should ask other people for their feedback as well before formulating their own.
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Welcome to On The Wallwards, it's James Edwards and today I'm not talking but we have an invited interviewer, Dr Bruce Way. Welcome Bruce. Thanks James, it's good to be here. So Bruce is similar to me, he's an emergency physician, works at Prince of Wales Hospital in the eastern suburbs of Sydney, not far from Bondi Beach for those who are not from New South Wales. He's also been a long time director of pre-vocational education and training at Prince of Wales Hospital, so has a large involvement in supervising junior doctors, so is well-placed to speak and interview on the wards. Okay, welcome everyone. Today's podcast is titled Diagnostic Error. I'm Bruce Way and I'll be doing the interview today. We're joined by Associate Professor Amanda Walker. Amanda is a specialist in palliative medicine and is also working as a clinical director of the Clinical Excellence Commission. And she's leading a project analysing and addressing diagnostic error in New South Wales health facilities, which makes her ably suited to discussing this podcast. So Amanda, we'll get started if that's okay. First question is, define diagnostic error for us. It's basically when a diagnosis is delayed, missed or incorrect, even though we had the appropriate information to make the right decision at the time. And is it a significant problem in our healthcare system? It's a serious problem. We think that 90% of the time we get it right, about 10% of the time we get it wrong, but we know that here in New South Wales, every week we have a root cause analysis for a really serious, catastrophic diagnostic error where someone has died as a consequence of a failure in diagnosis. So what are some of the common causes that we might see? Look, there's a whole series of causes and the first is about communication and perception and so the difference is between what a patient tells us and how we hear that and how deeply we explore the information that they give us and then breakdowns in information gathering, so when we're taking our history and when we're doing our physical assessments. And then there are breakdowns in when we actually kind of integrate and interpret that information, so our decision-making as a consequence of the information we've gathered. So they're the primary causes. Insufficient knowledge is actually not a really big factor. It is there, but it's not a big factor. The biggest issue with inexperience is when you miss a key sign that would have changed what you did. So they use the term cognitive bias in this area, and they can certainly contribute to error. So how do the different cognitive biases we're subject to contribute to error? Well, cognitive biases fit into both areas in what information we gather and also how we interpret and process the information. It impacts on the questions that we ask and what we look for when we're examining. So, for example, how thoroughly we examine, how we interpret the information, what we dismiss as irrelevant. So, for example, if someone presents who's anxious, tachypneic, and has pins and needles in both hands, or in one hand, if it's framed as this patient is profoundly anxious, we might think, oh, pins and needles, they're hyperventilating, the tachypnea is not serious. And then that's a kind of a framing or context bias. And then we confirm that with a confirmation bias because when we look at them, we go, oh, their oxygen saturations are fine. So that's consistent with someone who's hyperventilating. And I've seen a patient who had a pancreas tumour missed because it was assumed that they were anxious and hyperventilating. They actually had a really large lesion eroding through into the brachial plexus. And so how we hand over information has a big factor, so it has a big impact, but also how we process that. Our brain is designed to jump to conclusions. We need information quickly and we're built to make assumptions. So we see someone approaching from the distance, we think friend or foe. And so when we start thinking about how we think, we understand that there's the quick things we think about and there's the things that we take time to process. And junior doctors sort of work under conditions of sort of not a lot of knowledge or experience, a lot of stress. So what sort of environmental factors could impact on the likelihood that they might make a diagnostic error? Look, there's a whole bunch of them. And the really tricky thing is some of them are really difficult to solve. So we talk about HALT, which stands for hungry, angry, late and tired. Now, I can't think of the last time I did a clinic where I wasn't one of those. And I can think of a fair few clinics where I was all of the above. So when people are working night shift, when they're working late, when they've had a really big day, but also when you're emotionally distracted, you know, when something's happening in your life. And there is a lot of those things that we just can't actually exclude. So if you've got sleepless babies at home, if you've got family distress, if you're having tensions in your relationship, all of those things can be serious problems in how we think. And they can make us more prone to errors when we're thinking in the fast thinking, the systems one kind of thinking. And one of the other things about how doctors think is we're often very good at focus. And when you're good at focus, you don't see distractions. And there's some really interesting information about how people think. And when you're focusing on something, you won't see the things around it. So if you go on YouTube and you actually search for the invisible gorilla experiment, there's a fantastic experiment where they've actually asked people, there are two teams playing basketball, bouncing a ball. Some of them are dressed in black, some of them are dressed in white. And if you say, count the times the people in white, the white team, bounce the ball, you don't actually notice that in the middle of the video, a person in a gorilla suit walks in, turns, waves at the camera and walks off because you're so focused on counting. And when you do that in front of a group of doctors, they're really good at focus. And so they get the right number of bounces of the ball, but they don't notice that a gorilla walked through. So the flip side of that is when we hand over information, we look for the things we're looking for. So along the same lines of the invisible gorilla experiment, there's a fantastic study that recently demonstrated that if you say to radiologists, here is a CT of a patient we are concerned they may have metastases, please examine it. 83% of them missed the fact that there was a picture of a gorilla in the middle of the CAT scan. And it's because they were focusing on what they were looking for. And so sometimes we're so good at seeing the wood that we don't see the trees. And if you hand over information, the way we think and the way we're taught to focus means we're really good at that. So some of it's ambient and environmental factors and some of it's actually how we process information. Okay, there's those commercials on TV as well that you see where suddenly one part of the picture moves and you realise it's something completely different to what you thought you were looking at. Absolutely, absolutely. And it reframes how you're focusing. Yeah. Which I guess is a good advertising technique that shakes up your head as well. Yeah. And gathers your attention. So I suppose one of the things that you can do about that is, first of all, recognising when you're hungry, angry, late, tired, and recognising when you're emotionally distracted. And in medicine, we're not very good at actually saying to our peers, I'm having a bad day. And when I reflect on my career, I think the worst day I ever had was the day when someone very dear to me had shared with me that they'd been sexually assaulted. And in the back of my head, I had visual things running through my brain, and it was really hard to focus on what was in front of me. And it was really hard to acknowledge to someone, I'm not in a good space. I need you to keep an eye out and make sure that I'm on track and make sure that I'm not missing things. So I think culturally we need to kind of shift the culture a bit and be prepared to acknowledge that we are human and that we do have good days and not so good days. But I think there are other areas where, for example, in the army, they teach soldiers processes like tactical breathing.
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And in the army, they teach soldiers to do this tactical breathing where you breathe in for three or four seconds, you hold it for three or four seconds, breathe out for four seconds and then hold it. And you just keep doing that box breathing and it will slow your mind a little bit and actually allow you to focus a little bit more clearly. So when you do have raging emotions, it does actually help you be a little bit clearer. So recognising that we've got issues and that we're not automatons and that we may need to stop pretending that we are automatons and actually acknowledge our humanity and recognise when you need to question and challenge. We talked about how we make decisions and there's this conceptual framework which I think also has some physiological basis as well when they talk about type 1 and type 2 decision making. Can I ask you to talk about that for a moment? Yeah, look, we're wired to jump to conclusions. Our brains need a lot of energy to make decisions, and so we get better and better at making decisions. So the more we see something, the more experience we have, the more we recognise subtle patterns. We get better at saying one plus one plus one is three and we start moving towards that. So it's the difference between watching a third year medical student and a registrar sitting their basic training taking a clinical history. It's a very different process because people have learnt what are the important things to ask, what are the important ways to phrase it, how do you get the information, that kind of thing. So type one thinking is kind of, it's the very automatic, very quick, it's very rapid and it's enough most of the time. So we jump to the conclusions because we know on history, you know, we know in our past experience that when this happens, it means this. But system two is actually kind of true reasoning. It's analytical. You're stopping and you're actually moving through step by step by step. If this is the problem, then this is the different options and you're working through in a very kind of analytical kind of way. It's a bit like with familiarity with a restaurant. So if you go to your local Thai takeaway all the time and you don't even need to look at the menu when you think, oh, I'll have Thai. Okay, I'll have this and this and this. But if you go to a new restaurant, you'll stop, you'll look over the menu, you'll toy with the different options. You'll think, I don't like beetroot, but I really like asparagus. And you'll process everything and weigh up the options one by one. And so the intuitive kind of rapid thinking, we need that to get through our day. We can't do type 2 thinking on everything all the time. Otherwise, we wouldn't tie our shoes and get dressed. But there are risks with it when we are hungry, angry, late, tired. So having said that, it's not necessarily all bad type 1. As you said, we need to use it on certain occasions. Yeah, absolutely. And you don't have time in a cardiac arrest to do a whole lot of type 2 thinking. You need to actually be pretty quick and recognise the things that are happening. But most of the time, 90% of the time, we've got the data, 90% of the time type 1 is enough. The tricky bit is recognising when it isn't, you know, and when your type 1 is at risk. And when do you need to stop, take 2 and think it through? So I guess in terms of training, when you're in your junior level, very junior medical officers are going to be, won't have the experience to do a lot of sort of type 1 thinking. A lot of that will have to be type 2 for them. And then as you get into your middle grade, your registrar training, you probably start to use a lot of type 1 thinking then. Yep. And that's when it's really dangerous because you don't know necessarily when not to use it, which is sort of when you get to the specialist stage. You would hope you have enough experience to be able to know when you shouldn't be using type 1. I was fascinated to watch the difference between interns at the start of the year and interns at the end of the year. So the way a first week intern approaches a patient with chest pain compared to the way someone at the end of their internship does. So even in the space of one year, there's already a dramatic increase in knowledge and people are starting to process, is it tight? Is it sharp? Is it, you know, and they've got their questions down. So what used to take them three quarters of an hour now takes them 10 minutes. So it happens remarkably quickly if you have a lot of experience in that period of time. So internship is clearly a period of incredible growth. But at the same time, we've got junior doctors who are tired, who are overworked, who are going through a lot. And so it can be really tricky. We talk about heuristics, always struggle with how to pronounce that word, but what are heuristics? Look, they're kind of the mental shortcuts that we make. So they're kind of the rule of thumb strategies. If this, then this. That kind of thing. So it's kind of how our brains make those shortcuts and those mental jumps. Yeah. So again, that's maybe useful in some circumstances. So it's not always a bad thing, those mental jumps. It's the ability to recognise when you should and when you shouldn't be using. Absolutely. So, you know, there's the aphorisms like when you hear hoofbeats, think of horses, not zebras. But every now and then, zebras stroll right through your emergency department or on your wards. So what are some of the ways that we can reduce our risk? The first thing is awareness, but in fact the most important thing is to document and work through a differential. It's an underestimated skill to actually put down on paper, these are the things I think may be happening. I put most of my money on number one, but I'm going to continue to consider and rule out two, three and four. And if we keep a focus on what our differential is, rather than just a simple impression, but actually work out what do we think is happening and what are the pros and cons of each of those ones, then we keep our eye on the ball. It's amazing how often the eventual diagnosis was considered, but not thoroughly considered. So that's probably the most important thing. Because there are a number of electronic medical record templates which sort of ask you to do that by, you know, what's the most likely diagnosis, what are the other possible diagnoses. Yeah. I guess the one thing I've seen with that that you need to be careful of is discharge letters that go with the patients that list a whole bunch of possible things that, you know, including the... Which were eventually ruled out. Which were eventually ruled out. It's not necessarily clear that they were ruled out to the patient. So the patient then sees the word cancer, for example, and that causes some distress as well. So I think it's important that that communication about all that goes along with that as well. And there's, I think, acknowledging that there's a difference between the working diagnosis at the start of an admission and what the final eventual conclusion is. And we need to be really clear when we're handing over to other clinicians and also for patients and families information what the final diagnosis as a result of investigation is. One of the other things to consider when you're making a diagnosis is to actively identify and rule out the worst-case scenario. So I think it's this, but I'm going to make sure it's not this. So we know across the state that a huge number of people present with undifferentiated abdominal pain, but there's a reasonably large number of people who have unidentified rupturing triple a's so rupturing aneurysms and people clearly haven't considered and appropriately ruled out the worst case scenario so there are some other times to watch out for so when things just aren't quite fitting so when the when there's an odd result on the test um or you or the electrolytes just don't quite fit that picture, or the patient's journey is not proceeding as you expected. So if you're giving a treatment and they should be responding, if they're not responding, why aren't they responding? One of the things that we see with the MET calls, so the rapid response team calls across the state, is that sometimes you'll have, for example, a patient who has five MET calls before someone realises, wait a minute, the treatment we're giving them is not actually working and that's why they keep hitting the calling criteria.
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Okay, welcome everybody to On The Wards. It's James Edwards and today I have the pleasure of speaking with Dr. Nhi Nguyen. Welcome Nhi. Good morning James. Nhi is an intensive care specialist at Nepean Hospital, also the Director of Pre-Vacational Education and Training and an obstetric physician. So very well placed to speak to us today on obstetric emergencies. Now as a senior doctor the idea of an obstetric emergency scares me. I can imagine for junior doctors it would be fairly confronting to get a call to the delivery ward about someone who's sick. So we may just go through some really basic kind of principles about the assessment and management of someone who has an obstetric emergency. Maybe we'll start with when you assess and manage a patient in an obstic emergency, how are they different to a non-pregnant patient? I think in first principles, the overlying considerations is that you've got two patients effectively. You've got the mother and the baby. And there are implications with that in regards to which trimester of pregnancy. You have to consider that there are some very normal physiological changes which might affect the way that you assess your clinical signs and what you attribute them to. And so those are sort of the overlying principles. But on the other hand, my approach to assessing a pregnant patient or attending to any emergency is the fact that in general terms, what's good for mum will be good for bub. And we need to do what we can that's best for mum. So do the goals differ in a pregnant patient? Are they really the same? I think the goals are the same. I think the goals are the same. I think that we, obviously, you're looking after young women who are pregnant. There's a lot of emotion associated with it, both from the clinician as well as the patient and their families. But if you sort of take it back to the very basic principles of pregnant women will present with problems that non-pregnant women present with, and then there's a few others which are specific to pregnancy, which we might get a chance to talk through throughout this podcast. Any other important considerations and management of emergencies in obstetric patients? So I think that what is really important is the fact that you need to have very senior involvement very early. Okay, so this is one particular scenario where it should be immediately called the consultant rather than the natural hierarchy of the hospital, which is, let me call the registrar first, because you need to escalate very quickly. Okay, well maybe we'll start with a case as we often do. A 29-year-old female, G1P0, and present at term in labour. She's admitted to the delivery ward, but a rapid response call is made because of a seizure and a decreasing level of consciousness. What is your immediate management of this patient? So I bet everyone's heart's racing when this rapid response call goes out. Getting to the patient is very basic principles of airway, breathing and circulation before anything else. You need to put the patient on the side, provide high flow oxygen. And putting on the side is particularly important in pregnant patients, particularly at term, because of the implications of autocavable compression of the inferior vena cava causing hypotension. Now, the most common cause of seizures in a patient who's pregnant is still the usual causes of seizures otherwise. However, what is well known is the fact that seizures in pregnancy could be a manifestation of eclampsia. So those are sort of taking A, B and C, airway, and often these seizures are very brief. So not a lot is required apart from just putting the patient on a lateral position and oxygen. If you needed to sort of stop the seizure, then you could use standard things like midazolam, 2.5 milligrams, IV, because often these women in labour have already got IV access. And then sort of involve the obstetrician and so I guess the likely event will be expediting delivery but it's really about deciding about their immediate management at that point in time. Can I just take you back to that issue about kind of IVC? So you say someone who haven't had a seizure and they didn't need it on their side, what would you do to kind of prevent them getting that kind of low blood pressure or hypotension? So... Say they're lying on their back. Yep, yep. What would you do? So you would turn them to the left lateral position. Yes. Often make sure the airway's not obstructed. That may require a good L, but usually, as I said, the seizures are quite brief, so the patient may not tolerate that. So left lateral, IBC, start some IV fluids, 250 ml of normal saline, whatever's hanging up, and then start that and then... Okay. So the usual approach is a kind of ABCDE approach to someone who's got a reduced level of consciousness. What are the other important diagnoses we need to consider in this patient? So if you're able to get their obstetric card, it gives you a, and you may be able to glean from that, is this, they may have a previous history of seizures. Have they had some recent drugs which have attributed to seizures? So things to think of are if they've had an inadvertent epidural anesthetic or local anesthetic that's gone intravascularly or intravenous. If they've had an adverse reaction to an antibiotic or whatever's been given. But generally, I guess those are the main things you need to look at. If we take it away from having a seizure, but it was just a collapse by itself without a seizure, are there any other diagnoses we would need to consider? Okay. So the postural hypotension, hyperventilation associated with inhalational analgesics like nitrous oxide. And if patients sort of hyperventilate on nitrous, they can get sort of hypocarbic enough that they may become unconscious. And it's inadvertent medications. And, you know, I think it's pretty unusual. I mean, there are certainly case reports, and this is really where a lot of maternal mortality data come from, case reports of rare things like aortic dissection, myocardial infarction, stroke. Those are really, really rare things. Now, you mentioned about looking at their previous history, but particular features that are of a history are relevant? If a patient, so I think that in general principles is that if you have a seizure and delivery suite, although other things can be possible, the most likely is going to be preeclampsia or eclampsia and thinking through the management of that. Now the eclampsia is quite different in regards to the seizure management rather than a seizure on the ward for other reasons because what we do know is the prevention of further seizures and delivery of the baby are the two most important events or important management principles. And the management of or the prevention of further seizures is done by magnesium loading, and that's with four grams of magnesium. Now, we sort of don't usually think of magnesium in grams, but each of those ampoules of 10 millimoles is roughly 2.5 grams. So if you think of loading the first ampoule, maybe one and a half ampoules, that's your four grams of magnesium. That's been shown to certainly prevent the recurrence of seizures. There is very little role for things like phenytoin, which is usually what's pulled out of the cupboard first. And in the midwives, or I guess the history, you may be able to get a sense of have they had hypertension leading up to delivery because eclampsia is part of the spectrum of the hypertensive disorders of pregnancy where they may have had features of preeclampsia, which just to take, I guess just to recap, it's a disorder of pregnancy where they may have had features of preeclampsia which just to take I guess just to recap it's a disorder of pregnancy it occurs after 20 weeks it's a constellation of signs and symptoms which involves hypertension, proteinuria and you can get abnormal creatinine, abnormal LFTs there's some clinical symptoms like headache, epigastric pain. You don't have to have the full hand for all those sort of things to call it preeclampsia because an eclampsia can occur a bit out of the blue in a way. Is there anything further things on examination look at particularly? Okay, so examination whilst you're organising or the team's organising delivery which requires an obstetric team theatres, your clinical examination you may find edema, a lot of peripheral edema. You may find hyperreflexia and the association, and you might find sort of sustained clonus. And this is all a manifestation of a cerebral irritation in the spectrum of neurological presentation of eclampsia. Okay, so any investigation will be helpful. They've got a cannula in.
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The one thing that may impact is what their shivers are. So certainly we didn't mention earlier, but hypoglycemia can certainly cause seizures. And there's an increasing number of patients who develop gestational diabetes during pregnancy. And during delivery, they're often managed with an insulin dextrose infusion because they'll be fasting. So that's certainly another consideration. If they've got some insulin hanging up, for instance, you would want to know what their sugar was. So things like COAGS would be important? Look, I think that all those blood tests are important after the fact, in a way, so after the immediate management, because part of the spectrum, the woman might have abnormal coagulation. She might have a thrombocytopenia associated with preeclampsia. And if you got some blood tests back and found that her platelet count was low, it certainly impacts on the surgery, so caesarean section. But it may hint at the possibility of intracerebral hemorrhage, for instance, because normally you wouldn't need to rush this woman off for a CT head, for instance. But if you got that back and that test back, so I think those blood tests will help you once the dust has settled, baby's delivered, and mum's back in a critical care environment like the intensive care. Any take-home messages about this case? So I think take-home messages are it's a scary situation, there's no doubt. The delivery of the mum, the delivery of the baby is vitally important. And with very simple measures and not a lot of concerns about ongoing investigations, you can make a really big difference as the junior doctor first approaching this patient. Very simple things. Oxygen, putting the patient on the side, making sure there's some IV access, loading with four grams of magnesium. So they're an expediting delivery. Okay, so there are five good things to remember. We'll go to another case that's similar but also slightly different. A 35-year-old female, G4P3, and is 27 weeks pregnant. She presents to the delivery ward complaining of shortness of breath. What would be your approach to the assessment of this patient? So what I say to pregnant women when they come in and they say they're short of breath, most of them are when they're in their second trimester, big baby. And there's a real sort of well paradigm, which I like to sort of highlight, is that you've got women and midwives and their carers who want to normalise pregnancy. And they downplay a lot of their symptoms. So the art of this particular assessment of a pregnant patient is to work out what you should pay attention to. Should you take this seriously or not? And there are some things that I sort of keep in mind. It's a very, very careful history. So it's a really, really careful history. Be mindful that a lot of their symptoms may be hidden in physiology. Sorry, their symptoms and their signs may be hidden in some natural physiology of pregnancy. On the other hand, there are some really important diagnoses that you need to be able to exclude. And some of this comes with a combination of the careful history and the decision-making about whether you should investigate further or not. Because investigation further often will involve tests which may impact the baby and the mum. So I'll go through that in just a minute. A woman who presents with shortness of breath, you need to take the thorough history. Is this something that would occur when she's not pregnant? So does she have a history of asthma in the past? Does she have a recent history of cough, fevers, flus? Has she, is it allergy? Did it come on suddenly? Has she had any previous cardiac disease? So all those very simple history in order to work out is this an entity that is unrelated pregnancy and happens to present it in pregnancy because of the physiological demands of pregnancy or is it something new? So having taken that history, it helps you to divide things up a bit. Underlying cardiac disease certainly occurs but is rare. The two important diagnoses at this time that you need to have clinical awareness of is pulmonary embolus and the cardiomyopathy of pregnancy. So they're sort of the two diseases, I guess, that may manifest in pregnancy. Asthma, as an aside, it's pretty difficult to work out. So in a group of women who have asthma, some get better with pregnancy, all their asthma seems to be better controlled, and others get worse. So you can't hold too much on the severity of their asthma previously. Pulmonary edema, as you know, can sort of manifest as wheeze, which may be confused as being asthma. So just taking through the two diagnoses which requires clinical awareness and also this is what kills patients, I guess, you know, if it's not recognised, is let's start with pulmonary embolus. The... Where in a non-pregnant patient, or you can get a pretty good history, pyloric chest pain, sudden onset, travel, all those things often you can't pinpoint in a pregnant patient. Pregnant patients, by the physiology of pregnancy, they're in a hypercoagulable state. So therefore, and a gravid uterus also increases the risk of DVTs. So the clinical suspicion for PE must be high on your list, irrespective of what the history is. If there is a clinical suspicion of PE, the discussion then is what form of investigations should you do? And there's lots of concerns about radiation dose. Firstly, so I guess if you think about the modalities that we have that we can help work out what the diagnosis is. Firstly, a plain chest X-ray in order to work out, is it pneumonia? Is there anything on the chest X-ray that might hint at this being common variety community-acquired pneumonia which obviously occurs in pregnant patients? A completely clear chest x-ray may then lead you to a decision about CTPA or VQ. And when you think about radiation doses, the VQ is your first best non-invasive test that you should order. All those implications, is it available at the hospital you work at? Is it after hours? Often with the pragmatism of management of these patients, sometimes the CTPA is the first test that's ordered. This decision should be done at a high, at a consultant level. It should be done at a consultant level to make a decision about that. The VQ has a very good negative predictor. So if it's negative, then you know that it's safe to say this is not PE. Other blood tests like D-dimer is not very reliable. Clinical examination is not very reliable. And the reason for that is often patients may have very swollen legs from edema of pregnancy rather than having a unilateral swollen leg from a DVT. The other cause of shortness of breath could be a cardiomyopathy of pregnancy, which is much rarer, but it certainly does occur, and therefore the discussions around ordering a cardiac echo should be considered. Are there any particular things on history and exam that would really make you more likely that those more severe or more concerning underlying causes are possible? Is there, with a normal saturation, a normal respiratory rate, normal pulse rate, can you say it's not those? I think that if you... So, tachycardia exists in pregnancy even without a PE. So it's very difficult to make any judgment on heart rate. If their pulse rate is 70, it's certainly more reassuring. But a pulse rate of 100 doesn't help you either way. History. I think that if they have a history of asthma in the past, you can get the sense that this is, you know, there's wheeze, it's very typical to the pattern they've had before, you might sort of be able to sit on the fence a little bit. I think that for me, the management of these women, it's about the so I guess just what overrides a lot of my decision making is that women who die of pulmonary embolus or have significant morbidity from it is because of the lack of recognition of it. So anoxaparin is very safe. If there's any doubt, and it's about this whole world paradigm, there's any doubt, a few days of anoxapin in order for you to gather more information and have consultant level examination and sort of weighing up of all the clinical signs is certainly will still be the safest route. It's one instance where I would be very careful about erring on the side of safety. And even if it means that they've presented, you're not quite sure, keep them in hospital to observe them. You mentioned in regard to your management involved consultants. Which consultants should be involved? Okay, all right. The obstetrician should always be the first person.
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Okay, welcome to On The Wards, it's James Edwards and I haven't done a podcast for a while but really excited to do one today and we're talking about something different, aviation medicine. And with us today is Squadron Leader Nicola Boyd. Welcome, Nicola, or Nick. Nick is fine. So Squadron Leader Nicola Boyd is part of the Royal Australian Air Force and joined in January 2008 and completed a medical degree. And since then, he's also done a number of different degrees, a Diploma of Child Health, Postgraduate Diploma of Aerospace Medicine and a Diploma of Aviation Medicine. And we'll find a bit more about your career. But I guess, first question, I mean, why did you decide to join the Australian Defence Force? That's a really good question and something I've been pondering for a while. And I guess the main thing is that it comes down to a number of reasons. It wasn't one single thing. I think initially finding a sense of belonging and wanting to do something as a bigger part of the community. But also I was attracted to that sense of adventure and travel. And ultimately it was going to provide me with a career that was quite unique, with some unique opportunities. And it has certainly lived up to that expectation, for sure. Okay, it'd be really interesting for listeners, tell us about your career so far, where you've progressed from and where you are now. Yeah, so before medicine, I was an occupational therapist. And so for a few years there, I was thinking was thinking oh maybe I should do medicine and decided to take the plunge and so I'd gotten into medicine and at the same time had applied to the graduate medical scheme so I ended up doing a four-year medical degree, did my internship and residency at a regional New South Wales hospital and then once I put on the uniform I I had a couple of postings, one to two Expeditionary Health Squadron, which is in Williamtown near Newcastle. And then the second one was to one Expeditionary Health Squadron in Sale in Victoria. And that was largely doing primary care, GP type stuff, aviation crash response, being on call for humanitarian and disaster relief and things like that. And during that time, I did my GP specialty training. I got promoted and posted back to EHS and that time as the senior medical officer or SMO there. And shortly after that, decided that actually, I really, really like aviation medicine. And I decided to take the plunge and do a second specialty in that area. So how long does that take, the aviation medicine? So it's a four-year program. It's quite new, so it's only been around for a few years now and part of that is doing a diploma of aviation medicine and then some on-the-job training for a few years, yeah. Okay, so what are some of the opportunities that the Defence Force career has provided you? So there's been a lot of opportunities. One of the big ones is obviously being able to do lots of courses to expand your skills and all of that's paid for by Defence. So my diploma in child health and aviation medicine degrees and things like that were all paid for. But then we also get trained in EMST and other little courses as well. And certainly we've had a lot of opportunity to work in some unique places as well and lots of travel, as I mentioned before. You know, a couple of weeks ago I was in Malaysia training fast jet pilots. So that was a lot of fun and it's been really good from that perspective. And then, of course, deploying. So I had a deployment to the Middle East where I was the sole doctor looking after the Australians with a small team of medics and a nurse. So not your average sort of career. Not your average day, yes., yeah. So there's a lot of variety with it for sure. And what are some of the highlights for you? I think there's probably two things that I can think of that are highlights. One, probably the big one, was a course that I got to do with the United States Air Force. So I went over there for two weeks to Phoenix, Arizona and flew in the back of F-16 fighter jets. And so that was a course for what they call flight surgeons, which is our equivalent of an aviation medical officer. So yeah, you can imagine that was an absolute blast. Was that like Top Gun? Yeah, pretty much. Yeah, so I was in the back. So I wasn't actually flying the plane, unfortunately. But yeah, got to experience a lot of the training missions. And so as a doctor, you know, doing a lot of occupational medicine with these pilots, assessing their fitness to fly, it's really important to actually experience what that environment's like. So that was fantastic. And one of the other highlights was, of course, doing the Diploma of Aviation Medicine in London. So that's run by King's College London and the Royal Air Force. And so it's a six-month degree full-time and pretty much was just paid to study. And we had awesome side trips where we visited British Airways for a week. We went to the European Space Agency in Germany. We went to the Martin Baker ejection seat factory to see where they're made. So, you know, a lot of experiences there that you wouldn't normally get to do. So it's fantastic. And why did you decide to pursue medicine within the context of the Australian Defence Force? Yeah, it wasn't one single thing. I think for me, I love aviation. I come from a long line of pilots. And so I was brought up in and around aircraft throughout my life. And so I was really attracted to Air Force. I think they actually asked me in my selection interview, why not Army or Navy? I said, I don't do boats. But yeah, I just, I really was set on, on air force for that reason. And it does, it combines that love of aviation with my love of medicine. And I'm not stuck doing the same thing day in, day out, not stuck in the same four walls that you would find in, in civilian general practice. And, and while that might be fine for, for some people, I do get bored easily. So, you know, one day I might be doing primary care and then the next I might be, you know, off somewhere else supporting an exercise or on deployment, for example. So, yeah, it's a lot of variability and some degree of unpredictability there. What are some of the responsibilities that you have, I guess it's a medical health profession within your work? Yeah, so I guess primarily we're there to make sure that our people are fit and well and able to do their job. So we do provide care to all members of the ADF. So even though I'm Air Force, I see Army and Navy as well. And primarily it's general practice. So anything that you'd see in GP land, coughs, colds, mental health, sporting injuries, all of those sorts of things we would see on a day-to-day basis. But we also do a lot of health surveillance and preventative care as well. So again, getting on the ball and making sure that people are able to do their jobs. We also do crash stuff, so what we call airfield crash response. So being on call just in case one of the aircraft have an issue. Fingers crossed they never do, but we're there just in case. And we're also on call for the humanitarian aid and disaster relief stuff. So think Bali bombings and tsunamis or the New Zealand volcano, that sort of thing. And then, of course, support to deployments and exercises is a big one. So you could find yourself anywhere in Australia or overseas doing that sort of thing. So, I mean, you've kind of said it's a fair bit of variety. I mean, what would a typical day in the life of an Australian Air Force doctor look like? Yeah, it depends where you're posted. So it depends what sort of squadron you're part of. Usually we're trained in general practice. And so most people will either be a GP registrar or be a GP specialist and have finished that training. But everyone in the RAF that's a doctor will have completed the Aviation Medical Officer course, which is a five-week course that we do down in RAF Base Edinburgh at the Institute of Aviation Medicine and that allows them to see air crew as well. So a typical day would be you rock up at 7.30 in the morning and you start with what we call sick parade, which is like a walk-in GP clinic. So if you're not feeling well that day or something's going on in your life, you can rock up and see a doctor. And then after a couple of hours of that, you'd have some booked appointments as well. So as I said, typical GP sort of stuff.
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So all the aviation medical officers are assigned to a squadron. And so they might attend their weekly brief or provide some education to the squadron on an aviation medicine issue or they might be lucky enough to go flying for the afternoon which is of course a lot of fun, a real perk of the job. You know and then there's the mundane stuff like meetings and those sorts of things but there's also opportunities to run education sessions for other doctors or nurses and medics and things like that. So look, each day is never the same. It's really variable. And I think that's one of the really good things about working in defence. And I guess the cohort you look after, they're kind of younger than the usual general practice population. Yeah. So obviously we don't see too many PEDs in our job unless we're on an exercise or on deployment. But, yeah, so our typical population that we see is ranging from about 18 to about 55, 60. Yeah, so it is a young, fit, healthy population. So that does really skew some of the things that we see. So it's a lot of sporting injuries, a lot of mental health, a lot of just general coughs, colds and things like that. But we do have some interesting presentations. We do have some people with chronic disease as well. So we do get a fairly wide variety considering the population we have here. So maybe you can describe to us what is aviation medicine? Yeah, so it's a field of medicine that relates to all different types of aviation. So whether that be military aviation or civilian, recreational, commercial, even sporting aviation, so think Red Bull sort of race. And then there's also another area called aerospace medicine, which, as it sounds, also includes spaceflight and astronauts and all of that really cool stuff as well. So ultimately the field is concerned with the health and safety of anyone who flies so whether that be air crew or passengers and to do that we draw on all different areas of medicine so occupational medicine, preventative health, the whole raft of clinical medicine And then we combine that with our knowledge of what happens to the physiology and psychology of humans when they're in flight. So it's quite, I think, a really interesting field within medicine because we sort of cover off on a bunch of things. Yeah, no, it sounds fascinating. I'd be interested in what does a typical day look like for you when you're in your aviation medicine specialist role? Yeah, so it's really variable. And I think for me, you know, I said I get bored easily. So there's a lot of autonomy and flexibility within the role. So at the moment, I'm a senior aviation medical officer and I'm at RAF Base Edinburgh at our Institute of Aviation Medicine. And so I sort of wear three hats. There's the clinical staff, training, and then a bit of research as well. So a typical day for me would be going down to the flying squadrons of a morning to attend their weekly brief. And that just helps me to maintain an understanding of the roles that they do in that squadron and keep aware of some of the issues that they might be having and assist with anything particularly aviation medicine related. I might then go to the clinic and spend the morning seeing some patients, again mostly air crew, GP staff and a bit of that occupational medicine piece. So whenever we see an aviator we have to make sure that they're fit to fly as well, so making those sorts of decisions. Then once I'm back at the Institute I might be delivering some training to aviators. So we do a lot of aviation medicine training so that our pilots and our aircrew have an understanding of the environment and are able to recognise any issues that might come up. Or we might be running a course for our doctors and nurses. As I said, they need to do a course on aviation medicine to be able to see aircrew as well. And then in the afternoon, you know, I might be reviewing some really complex cases. So, you know, aircrew have been diagnosed with some significant conditions like cancers or Parkinson's disease or significant depression or something like that. And obviously you can imagine that's going to have a significant impact on their fitness to fly. So we do a lot of work behind the scenes in working out what the risk is for being able to let those people fly. Or, you know, it might mean that I don't do any of those things on a day and I'm off flying with one of the squadrons. So it can really vary and I guess we have full control over what's happening in our day, so that's really nice. And why do you think we need some specialists within this field? Yeah, I think ultimately the limiting factor of aircraft performance has always been the human. Historically that that's certainly been the case, and I think that'll be the case for a long time in the future. I guess with aviation, we're flying at altitude, and with increased altitude, we end up with an increasingly hostile environment. It gets colder, the availability of oxygen reduces, so we get hypoxic. There's a risk of decompression illness, similar to what you'd have with diving. You get pressure changes that can lead to expansion of gases, so that can cause pain in teeth and sinuses in the gut, things like that. But flying also puts extra stresses on the pilot as well, so acceleration, like g-forces, like think Top Gun, spatial disorientation, so where the pilot doesn't know where they are or where the aircraft is in relation to the ground, fatigue, vibration, noise, a whole raft of psychological and human factors as well. So, you know, we were designed for sea level at 1g. So for us to survive the flying environment, we really need a bunch of things as part of the aircraft to keep us alive and healthy. Things like oxygen or cabin pressurisation, anti-G suits, ejection seats, all of that sort of stuff. So for us in aviation medicine, flight safety is paramount. That's the most important thing. And so what we do is provide inputs into that risk assessment. You know, what is the risk of incapacitation of someone with breast cancer? What is the risk of incapacitation of someone with a pneumothorax or something like that? So, you know, we keep abreast of all those health conditions. But it's also about the passengers, as I mentioned. You know, we're not just interested in what's happening with the air crew, but also with the passengers who are flying with existing disease. So how has the Australian Defence Force innovated and, I guess, leading the way in some of the fields within medicine and health? And how does that translate to what we're probably seeing in civilian medicine? Yeah, so in aviation medicine, I guess historically, if a pilot developed a significant health issue like diabetes, depression, cancer, you know, that would have resulted in them not being recommended to fly due to that risk of incapacitation that I was talking about, or it might influence just their general performance of their duties as well. So from a safety perspective, you know, we thought, okay, it's safe just to ground you rather than looking at what the actual risk is. These days we take a more pragmatic approach and look at those cases on a case-by-case basis. So we review the medical evidence and really look at that risk of incapacitation, risk of recurrence and things like that and apply an individualised risk assessment to determine that fitness for flying. So what that means is someone with a diagnosis of cancer who might not normally have been able to return to flying, once they've had appropriate treatment, that they can go back to what they enjoy. And what are some of the lessons that healthcare can learn from, as you mentioned, aviation medicine and what does it get to border implications does aviation medicine have on what we see on a daily basis? Yeah, so as I mentioned previously, we're not just concerned with pilots and air crew, but also the health and well-being of the airline passengers as well. So it's important for anyone who's ever flown in an aeroplane, really. So where it becomes really important is for other doctors, particularly doctors of patients with chronic disease like emphysema, for example, or even acute issues like recent surgery, those doctors need to be aware of any potential health implications of the aviation environment. So as I said before, it's not an entirely benign environment. There are some risks there. And even the cabin of a Qantas jet or Virgin Australia jet, the cabin's pressurised pressurised to six to eight thousand feet and this still has implications for passenger health. So a healthy passenger at eight thousand feet might saturate their oxygen at about 90% which is quite low. If we saw someone in the emergency department with SATs that low we'd be worried, you know, and a healthy person will hyperventilate to increase their SATs to about 95%.
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Welcome to On The Wards, I'm James Edwards and today we're talking about mandatory reporting. Mandatory reporting has been in the news of late here in Australia and I'm welcoming Georgie Hasen with us. Welcome Georgie. Thanks James. Georgie is the head of advocacy at Avant, one of our partner sponsors and has worked in health law for 25 years and we really thought we would discuss the topic because it has been very topical. So maybe what is mandatory reporting of medical practitioners and why is it in the news? Yeah well it has become very topical. So maybe what is mandatory reporting of medical practitioners and why is it in the news? Yeah, well it has become very topical of late James. Mandatory reporting has been around since 2008 actually, it started in New South Wales and there's been long ongoing concerns about mandatory reporting and obligations that doctors have and the way the laws work in practice. But in more recent times, we've seen an increase in the media discussion about mandatory reporting, I think prompted by some very terrible suicides of junior doctors in particular recently. So the issue has come to a head. And maybe, so just give us a bit more about what is mandatory reporting? Yeah, so mandatory reporting under the, it's under the national law, which is the law that applies to all healthcare practitioners around the country. And it applies not only to doctors, of course, but to every registered health practitioner around the country. And to medical students? And to some, perhaps I can talk about medical students a bit later because there are slightly different requirements, but the obligation is on registered health practitioners. And the obligation is to report what's described in the legislation as notifiable conduct. There are four types of notifiable conduct. There is practising whilst intoxicated. There is engaging in sexual misconduct. Having placed the public at risk of substantial harm because of an impairment in your practice. And having placed the public at risk of harm because someone's practised in a way that's a significant departure from accepted standards. So there's a lot of words in there. But basically there's sex, practising whilst intoxicated with drugs or alcohol, impairment, where you're putting patients at risk, and significant departure from accepted standards. And how, as a doctor, if you hear about something, I mean, how much do you need to know before you need to report? Yeah, so the obligation is that you need to report if you have a reasonable belief that someone has engaged in this. And the other thing I should say about the way in which it's worded, it's focused on the past, so it's past conduct. So if you as a medical practitioner have a view that someone has practised or a reasonable belief that someone's practised whilst intoxicated in the past, then you need to report that. Now, there's discussions about what is reasonable belief. That's a very legalistic kind of term. I guess the thing for that is that it shouldn't be based on gossip or innuendo. It can't be based on speculation. You have to have more than a suspicion that something's happened. So you have to have a fairly solid grounds, but you don't have to have proof. No. Yeah. Okay. And you've mentioned it's a complex area and subjects of recent concerns. Why is it so problematic? Well, I think there's a couple of things. The first thing is the way in which it's worded. So it's worded in the past tense. That can be quite difficult. So your obligation is only if you know that someone has done something in the past. The legislation doesn't focus on future risk. The other thing is that, perhaps most importantly, is that there's been ongoing concerns about the barrier that mandatory reporting might be to practitioners seeking help for their mental health issues. So even before the law was introduced actually there were concerns expressed about mandatory reporting laws being a barrier to doctors seeking help and that's been an ongoing concern and one that hasn't really been resolved. So in the Beyond Blue survey that was done in I think it was around about 2013, there were a large number of doctors who said that one of their concerns was about mandatory reporting laws and being a barrier to seeking help because they were fearful of how that would impact on their ability to practice and their registration. So that is a concern. And there does seem some differences within Australia in different jurisdictions about which ones have mandatory reporting, which ones don't. Can you tell us about the treating practitioner exemption? Yep. So this is an exemption specifically in WA. And WA went on its own, I guess, and decided that they would have this exemption through a lot of lobbying on behalf of the profession. So what it means is that if a treating practitioner of another practitioner doesn't have an obligation to report, if they find out about this notifiable conduct within the context of a therapeutic relationship. So if in WA you go along to a doctor and you are seeking treatment about stuff and you mention your past conduct, the treating practitioner doesn't have a mandatory legal obligation to report it. That doesn't mean to say that they can't report it, it just means there's no legal obligation. They might actually think that the patient is putting the public at risk and they would have an ethical obligation to report it but they don't have a mandatory legal obligation to report it. And in Queensland, is there a difference in Queensland? So there's another provision in Queensland and the Queensland provision also relates to impairment or only relates to impairment and it is that if the patient is not putting the public at risk in the future, or is not a future risk, then they don't need to report it. So it's slightly different from the WA one. The WA one is a complete exemption from past, future, whatever. Queensland focuses on future. So even if you've had an impairment that's put the public at risk in the past, if you're not a future risk, if you're undergoing treatment and the like, then there's no obligation to report in Queensland, as long as it's not professional misconduct. So it gets really complicated. Are they going to sort it out across Australia soon? We hope so, we hope so. I mean in this country, we're quite a small country really, and we've got three different regimes around the country of this mandatory reporting and one of the main things about the national law was to have consistency across the country for dealing with regulatory matters. That's not the case in mandatory reporting unfortunately. In regard to if I decide to report, am I protected when I've decided to report a colleague who I'm concerned about?, you are. As long as you do it in good faith, then you're protected. And that's even if, so this is, we're talking about mandatory reporting. I mentioned before about voluntary reporting, which is your professional ethical obligation, which as a doctor you have always had if you're concerned about someone putting patients at risk. You're protected if you make a voluntary report and you're protected if you make a mandatory report, as long as you're doing it in good faith. So if you're being malicious or vexatious or doing something that is really in bad faith, then you won't have that protection and you can be investigated, I guess, by the regulatory authorities for making a bad faith report. So I guess within Australia, what do we know about the sort of conduct that's been reported previously? The sorts of things that we've seen is there's been a little bit of research that's been done by some people, Marie Bismarck, who's well known actually in this area of doing regulatory research, and she's looked at all the APRA data on mandatory reports, and she looked at the ones particularly in relation to impairment. And she found that mostly, so it's this issue of treating practitioners and when they would report, and mostly the reports by treating practitioners are when the treating relationship's been broken down and it's usually the doctors who are non-compliant with treatment regimes, who show a lack of insight, dishonesty, and where the treating practitioner has a concern that the doctor might be engaged in self-harm or otherwise have access to drugs or something like that. So they're actually, themselves are at risk or they are potentially putting patients at risk. So they're the ones who are being reported and it's focused on future risk rather than the past risk. That's what the literature says. So that's one of the other problems with the current regime is that there's a bit of a disconnect between what the law says about this past conduct and what's actually happening in practice. And if a doctor is concerned about another practitioner, what should they do? Yeah, well, we get a lot of, quite well, a reasonable number of calls about this in our advisory service because it is confusing. So people really don't know what the test is. So the first thing they should do is just think carefully about it.
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Okay, welcome everyone to the JMO RPA podcast program. We've had a number of different podcasts over the previous weeks and now we've got Dr. Peter Lim, gastroenterologist at RPA, who's going to talk about upper GI bleeding. Welcome, Peter. Thanks, James. Okay, we're going to start with a case scenario. Imagine you're the junior doctor on the ward, seeing a 70-year-old male who was admitted with a neck and femur fracture, is now two days post repair, and you get the call from the nursing staff that the patient has some haematemesis. The nursing staff know they've been nausea and that there was maybe this history of having a black stool. What's your approach maybe over the phone to start? Sure, so I guess in this situation, you would expect it's important to try and figure out how unstable the patient is and over the phone immediately I'd like to know a set of OBS to try and determine the urgency of this situation. Particularly the heart rate and blood pressure would be important. I'd probably go and see this patient straight away because upper GI bleeding is a medical emergency and I guess I'd want to assess the patient and see how unstable they were to determine what needs to be done next. When I went to see the patient, of course, starting at the beginning, airway breathing and circulation, but particularly in this situation, circulation would be important and making sure that they're not tachycardic or hypotensive. Okay, so you get there, you have that bit of an end-of-the-bed look and maybe that their blood pressure and pulse rate is seen within fairly normal limits. What sort of history do you you think is important if someone's got upper GI bleed? Yeah, so I guess the first thing to look at or to check for on the history is, I guess, the causes and the consequences of the bleed. So looking for causes, I'd be asking about a past history of any bleeding, particularly of peptic ulcer disease. Medications would be important, so anything that makes you bleed, so non-steroidals, particularly in an elderly population, as well as anticoagulants or antiplatelet agents. It'd be interesting to know a history of liver disease because that of course increases the risk of something more serious like a variceal bleed. And then looking at the consequences, so looking for symptoms of anemia such as lethargy, shortness of breath or chest pain, palpitations, and I guess getting a bit more of a history of this haematemesis and trying to localise where this bleed might be coming from. So asking about whether it's bright red blood that has come up. And certainly bright red blood, there aren't many things that give you bright red bleeding that aren't from an upper GI source. It'd be important to know about this black stool and make sure that it is jet black because it has to be jet black to to be classed as melina and whether there's any red bleeding below because I guess that usually that means a lower GI bleed except in two situations where you have a very brisk very big upper GI bleed which is either going to be a duodenal ulcer or varices. Interestingly in the 1940s they did some great studies and you can't do these studies nowadays but they looked at how much blood you needed to ingest to actually develop melina and the reason you can't do that anymore is because they made medical students drink their own blood and they found that you need to ingest about 50 to 100 mils of blood to develop melina and in fact they found that if you drank 500 mils to a litre of blood you could get red PR bleeding so only those really big bleeds will give you red PR bleeding and otherwise a small amount of bleeding from the upper gut should give you melina. It's important to localise the bleeding because it then determines how you're going to be investigated and what the therapeutic options are. So when you say localise, you're between upper GI and lower GI? Yeah. So really, those are the two main places that you'll bleed. It's pretty uncommon, I guess, to be bleeding from the small bowel. You can get angioectatic lesions in the small bowel, but the first things to check for are the things that we can immediately fix, which are upper GI bleeds and lower GI bleeds. And so localising something to an upper GI bleed, i.e. anything above the ligament and trees, or the second part of the duodenum, or a lower GI bleed, meaning the colon. So we've done a bit of a history examination. What do you look for in an examination? Yeah, the main thing to look for on examination, I guess, are the simple things. So to start with the blood pressure, and one of the things that junior doctors often forget to check is the postural blood pressure and it's critically important because it helps you triage how urgently this patient needs intervention. Postural blood pressure of course tells you how volume deplete they are and if they're significantly volume depleted then you might see a postural drop and that would be important to resuscitate this patient before any therapeutic intervention can be done. Equally, it's important to check for the presence of liver disease. So looking for those things that we learn in medical school, those peripheral stigmata of chronic liver disease, such as leukonychia, palmar erythema, spider neumia, gynecomastia and also looking for signs of portal hypertension such as splenomegaly or ascites because these sorts of things upgrade you into a higher category or higher risk category because if you have portal hypertension it's possible that this could be from varices and that's certainly something that could be life-threatening. In regard to that blood pressure, we do lots of blood pressure in the meds department, what's a significant postural drop? Yeah, so a significant postural drop is a drop of about 30 millimetres of mercury in terms of systolic blood pressure is what we usually class as a significant drop. Yeah, I know somebody getting a posturalstery tachycardia without upholstery drops, so sometimes it's also a marker that someone's fluid deplete or has been bleeding. And interestingly, in the studies that have been done to try and predict markers or clinical signs of a GI bleed, tachycardia is quite significant. So beware the tachycardic patient. If someone has a suspicion of an upper GI bleed and they're tachycardic, it actually increases the relative risk that this is a massive upper GI bleed. So if you ever see someone who you think might be bleeding who has a tachycardia, then you need to start thinking about the resuscitation and getting some help pretty quickly. Do these patients need a PR exam? I think so. If there's red blood coming up the top, then it's pretty clear that it's an upper GI bleed. If there's any question of that, then I think that a PR exam is important to try and help localise it because if you again if you get Molina on the glove that will help you localise where the bleeding is coming from and what the next step or the therapy is going to be. Again in those studies that looked at the predictors of an upper GI bleed, the presence of melina on examination gave a likelihood ratio of about 25 that this is an upper GI bleed. So finding melina really helps you nail down that diagnosis. Sometimes it's tricky, they're on iron tablets but they've got this history of a dark stool. What's the difference between someone who's got iron tablets and has got melina? It is very difficult. Melina is, true melina is jet black. There's no in between. If it's just a little bit dark or if it's greyish black, then that's not melina. It has to be jet black to be melina. Okay, that's great. Okay, so we've done a history exam and they may need resuscitation. So they've kind of got that hypotension, tachycardic. So I guess one of the things that we notice at the other end when we come in to see these patients and want to take them to theatre, often they're very under-resuscitated. And incredibly, it's one of the simplest things to do and one of the things that is most poorly done. So resuscitation of course means large bore intravenous access so two large bore IV cannulas, at least 16 gauge, making sure you get some blood tests sent off at the same time, particularly getting a group and hold or a cross match if you think it's more urgent, and giving whatever fluid is available to begin with, particularly if they're hemodynamically unstable, it's important to get any sort of fluid going and then think about blood products down the line.
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I think one of the things or one of the big delays to getting someone to endoscopy is getting those blood products down to the ward or down to emergency and actually administering those blood products. The sooner you can resuscitate a patient, the sooner we can scope them. Okay. So give a bolus of fluid. You mentioned a full blood count, a grip and hold. What other blood tests would you suggest? I think the other blood tests which are important are urea, electrolytes and creatinine. The urea, again, in those studies that look for predictors of upper GI bleed, a disproportionately elevated urea from the breakdown of blood products in the stomach is suggestive of an upper GI bleed. It's also important to do some liver function tests and looking particularly for signs of hepatic synthetic dysfunction, so a raised bilirubin, a low albumin and a raised INR, which might point you towards a diagnosis of portal hypertension and cirrhosis which again elevates you into the territory of possible varices. So COAG's obviously are important as well and I think noting what the platelet count also is in an upper GI bleed is important because a thrombocytopenia related to liver disease is also a clue that there might be varices. But also if they are low in platelets for another reason that might be something that you might need to replace in the process of resuscitating the patient. Are other investigations, is a chest X-ray or ECG helpful? I think if a patient has significant risk of chest pathology, so if they've got significant smoking history or significant cardiac history, then those sorts of investigations might be appropriate. Elderly patients, so over the age of 50, I would say an ECG is probably useful. In terms of the management of the upper GI bleed, probably not so important, apart from the preoperative assessment of the patient and thinking about them going down for a procedure. Okay, so you've said the blood's off. Is there any management you're going to start before you get the blood results? You've started fluid resuscitation. In this kind of patient where it depends, I guess, whether you think they've got liver disease or not. If you don't suspect liver disease or cirrhosis, then I think the first step is to treat with a proton pump inhibitor infusion. There's a little bit of, I guess there's a bit of data recently looking at whether pre-endoscopy PPI helps. In fact, those studies have not shown that there's any mortality benefit or benefit from re-bleeding or progression to surgery. So the outcomes of patients who receive PPI treatment before endoscopy isn't actually different to those who don't. Interestingly, pre-endoscopy PPI has been shown to reduce the risk of finding a high-risk lesion at endoscopy. But why that doesn't translate into a benefit, we're not too sure. At the end of the day, there's good evidence for post-endoscopy PPI, particularly if there's a high-risk lesion that we need to treat with an endoscopic modality. So I think the bottom line is, even though there's not a lot of evidence to show a benefit for PPI pre-endoscopy, I think it's safe to say that most gastroenterologists would be fairly comfortable with starting a PPI infusion pre-endoscopy. We do know that an acidic environment in the stomach is related to poor haemostasis. So why that benefit pre-endoscopy isn't there in the studies, we're not sure. But I think most centres in the world would start a PPI at this stage. Okay, so how would you give that PPI? Did you give it IV? Did you give it bolus? Did you then have an infusion? Yeah, the current standard of care in the early studies was a bolus of PPI, so for example, 80 milligrams of pantoprazole as an IV bolus, followed by an infusion of 8 milligrams an hour. There again has been a little bit of recent evidence to suggest that giving a bolus dose twice daily, so for example, pantoprazole 80 milligrams IVBD is equivalent to an infusion. And I think there might be some legs in that and they may be equivalent, but I think most centres would still accept the standard of care as an infusion. And by infusion, I mean a loading dose followed by the infusion. So if they do have chronic liver disease and you're about baroceal bleed, how does that change your management? There's two other things that I would do at that stage. Octreotide, a somatostatin analogue, has been used in this situation. And if you think about the portal system being a reservoir of blood from which varices bleed, giving an octreotide somatostatin analog, this vasoconstricts the splanchnic vasculature, reducing the amount of blood that can bleed out of the varix. So an octreotide infusion is important to commence then. The other thing that has been shown to improve mortality in variceal bleeding is antibiotics, and this is something that not many people know. We know that infection in cirrhotic patients with upper GI bleeding is very common. In fact, one study put the numbers at about 50% of patients in hospital after a GI bleed with cirrhosis having an infection of some sort. And SBP seems to be, or spontaneous bacterial peritonitis, seems to be quite predominant in that group. I guess biologically it seems plausible. There's a varix with a hole in it, and this hole is open to the enteric floraora and it would be very easy for an organism to then get into the systemic system. So antibiotics have been shown to reduce mortality, have been shown to reduce infection and also re-bleeding. So if you want to save someone's life on the ward with a variceal bleeder, give them some antibiotics. And the evidence really points to third generation keflosporins, things that will cover those enteric organisms. But we tend to use Tazacin at this hospital. Yeah, I think there isn't a really good reason for that. I think the bottom line is antibiotics equals improvement in mortality. So whatever antibiotics will cover gut flora, and Tazosin certainly will do that, that's what you should initiate at that stage. And that's independent whether they have ascites or not? Independent of ascites or not, yes. Okay, okay. So chronic liver disease, start up triotide, start some antibiotics. Yes. Obviously we're basing that chronic liver disease on blood results, we haven't got those back yet. If you didn't have physical signs of chronic liver disease, we just start off triatide just based on a strong alcohol history. What do you feel you need, physical signs or abnormal blood tests? Usually we would base it on physical signs and abnormal blood tests. If you don't have that, if you have significant portal hypertension and cirrhosis, you would expect to find those physical signs and abnormal blood tests. Okay, so we do get some blood results back. We get the hemoglobin comes back at 78. Does this patient need a transfusion? And I guess in this setting, it looks like they've had an acute bleed. I guess we could put it in two settings. One, they've got an acute bleed now. and two, they just come in with a history of upper GI bleed maybe a couple of days ago. Sure. Whether someone needs a transfusion with a haemoglobin of 78 will really depend on the type of bleeding, as you've alluded to. If the patient's relatively haemodynamically stable, there has actually been some data recently looking at restrictive versus liberal transfusion strategies. We know from the critical care literature that patients who are critically unwell, there have been better outcomes with transfusing them in a more restrictive fashion, so not transfusing them all the way up to say a haemoglobin of 100, but maybe aiming for a haemoglobin more of about 80. And there's clear evidence for that. That evidence didn't include upper GI bleeders. There was a recent study earlier this year, or there have been some recent studies, but there was a big article in the New England Journal in January of this year which looked at that question whether a restrictive strategy of transfusion was better than a more liberal strategy. And by restrictive, I mean transfusing if the haemoglobin was less than 70 and transfusing up to a haemoglobin between 70 and 90 versus transfusing if the haemoglobin was less than 90. And they actually found that the outcomes were better in that restrictive group. So their re-bleeding rates, their mortality were better with a restrictive strategy.
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Welcome to On The Wall, it's James Edwards and today we're speaking to Dr Rewa Keegan. Welcome Rewa. Thanks James. Rewa's a general surgeon who's currently working as a surgical superintendent at RPA. And today we're going to talk about nasogastric tubes. And obviously nasogastric tubes are commonly used on surgical wards. And junior doctors often insert nasogastric tubes and manage them, especially within their first few terms can be quite a daunting task. So we thought we'd try and answer some of the unanswered questions that maybe the junior doctors have out there. We'll start with a case, Rewa. You're covering the wards after hours and one of the nursing staff asks you to insert or place a nasogastric tube. The patient has a small bowel obstruction. What are some of the common indications for a nasogastric tube? So I like to think about nasogastric tube uses sort of for four major purposes, which are draining, feeding, medication, administration, and less commonly for lavage. So drainage is probably the most common reason that we see them used, and that's irritation that would have a small bowel obstruction or ileus and the reason we drain the stomach is for several reasons. Firstly relief from nausea from vomiting and distention. Secondly it allows us to actually measure the fluid losses and monitor progress and then replace the fluid losses as well and thirdly to prevent aspiration although that can be a little bit controversial. Nasogastric tubes can also be used for short to medium term feeding. We often see them also in the form of a nasojejunal or nasoenteric tube. And it's anticipated that if a patient requires long-term enteral nutrition, it's preferable to use something such as a PEG because obviously the NG tubes can be quite irritating to patients. So what's a PEG? Sorry, so a PEG is basically a percutaneously inserted or endoscopically inserted gastrostomy tube. So it basically goes straight in through the skin to the stomach and avoids the nose, which is what patients don't like. So the third reason we might use an NG tube is a patient who can't tolerate oral medications. That's not a common use, but patients who have swallowing issues or have a neurological impairment, we might use a tube intermittently to put medications down. And lastly, and this is something we're definitely using less and less, is for gastric lavage. It can be used in patients who might have had a large volume upper GI bleed or have material in their stomach that needs to be removed prior to an endoscopy. So what are some of the common contraindications to use of a nasogastric tube? So probably the biggest contraindication would be patients that have esophageal pathology, particularly esophageal varices or esophageal strictures. And in those patients, there's obviously a very high risk of bleeding or perforation with NG tubes. And we need to think very carefully and avoid their use as much as possible. Patients that have bleeding disorders, so they might have thrombocytopenia or high INR and we're seeing these patients more and more who are warfarinised, elderly patients. And in these cases, minimal trauma of the nasopharyngeal or esophageal mucosa can actually trigger quite significant bleeding, so we need to be really careful. Patients who have base of skull fractures, so trauma patients, and you've sort of heard these stories about nasogastric tubes going intracranially and it does happen. So that's definitely a situation where you would want to avoid using one. So would you use an orogastric tube instead? Exactly. Usually using an orogastric tube and it needs to be sort of inserted under guidance using a laryngoscope. Once we've taken a bit of a history exam and had a chat with the surgery registrar and made sure that we're safe to go ahead with the procedure, maybe just outline, would you have a brief with the different types of nasogastric tubes and how do you work out what's the appropriate size to insert? Sure. This always used to confuse me quite a bit as an intern, I remember. So when we talk about nasogastric tubes, we can talk about the different materials they're made of. So those include PVC, polyurethane and silicon, and then the size. So we talk about the size using the French system. And commonly, we would use a 14 or 16 French in terms of a patient who needs drainage for a bowel obstruction. But the actual sizes available range from about a 4 French right up to a 20. So there's quite a big range available. Can you just remind me which one's the smallest? Yeah, so with the French system, the numbers are actually directly proportional to the size. So the bigger the number, the larger the tube diameter. So a 14 or 16 is relatively large, but that's good because we want to use that to obviously drain contents out. Feeding tubes can be smaller, French. They can also have a varying number of lumens. So the most common type of tube we use is the Salem sump tube and this actually has two lumens, the larger of which is connected either to a drainage bag or wall suction and that aspirates the gastric contents and then it has a second smaller lumen that vents to the atmosphere. And basically this stops the little side holes on the tube from sticking to the GI mucosa. And that's the type of tube you would commonly use for a patient with an obstruction or an ileus. We also have smaller single lumen tubes. They're commonly used for feeding only and they can be placed either in the stomach or distally, usually in the jejunum and you may hear them referred to as NJ tubes, nasojejunal tubes. Often because these tubes are so fine and quite lightweight, they'll have a little weight in the tip and that helps it to fall into the correct position and they can be left in for a longer duration, up to a few weeks and patients obviously find these less irritating than the larger bore ones. And what would make your decision to use one tube over another? I guess the most important thing is why you're putting a tube in. So if you are using, if you're asked to put a tube in for a patient with a bowel obstruction, I would go straight to a larger size Salem sump tube, a 14 or 16. If it's for feeding, you can think about using one of the smaller tubes, And you might have seen these on the wards. The feeding tubes are often a yellow colour, whereas the larger Salem sump tubes often are clear with some plastic lines on them. So that's how you can tell the difference as well. Okay, now you've selected the appropriate tube, what tips can you give junior doctors out there about placement and technique? All right, I think the first thing to remember is to keep calm. It's quite stressful to put an azogastric tube in. It's quite unpleasant for the patient. So just, you know, make sure you take your time, get all your equipment together and relax and the patient will relax too. You need to really just make sure before you put one in that you have made the right decision and that this patient doesn't have, you know, they're not on anticoagulants, they don't have a bleeding problem or esophageal pathology. If you can avoid those things, you'll stay out of trouble. Generally, we like patients to be alert and compliant and able to sit up and have an intact swallow, but that doesn't always happen. So the first thing you want to do is measure basically the depth of insertion. And the way we do that is to basically measure the distance from the tip of the nose around to the top of the ear and then down to the xiphoid process. And you can actually take the tube holding the tip at the nose and kind of curling it down. It's a bit hard to talk about without having a visual illustration, but we might be able to put a picture up. And then basically you want to mark on the tube the kind of level that you think corresponds to the tip of the xiphoid process. And hopefully if you insert it to this level, it should be just below the diaphragm. Get your equipment together. So you'll want two or three tubes just in case. You can bring a couple of different sizes, lots of lubricant to help it ease in, a spigot tip syringe that you might want to use to aspirate, and a cup of water for the patient. I find that using xylocaine spray is very helpful and it really suppresses the gag reflex and makes it much more comfortable for the patient, so I would recommend using that.
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And obviously pick the side that looks the easiest to access. You want the patient to be upright, slightly leaning forward and the neck relaxed and in slight flexion and the chin on the chest. So once you've selected a side, you want to give them a couple of sprays of the xylocaine. Leave that for a few minutes while you get everything together. Make sure you use a lot of either water or lubricant on the tube and then basically insert it straight into the nostril and maintain the tube position parallel to the floor. So remember that the floor of the nose is actually parallel to the floor. It doesn't angle up. You should be able to insert it quite easily and once you've got it in about 10 or 15 centimetres get the patient to start taking some sips of water and that will help them to sort of swallow it down and get past the oropharynx. Once the tube is in position you need to make sure the patient's okay. Make sure you tape the tube immediately. That's probably the biggest problem they have is having tubes fall out. And you want to use the brown elastoplast tape, I think is definitely the best. Don't use just the micropore. It doesn't stick very well. And have a little masonry of tape around the tube that you can pin onto the patient's gown that will kind of act as a protective mechanism in case it accidentally gets pulled. And then hopefully it's in the right place. Is any different for a nasoenteric tube or nasoadjuvenal tube? No the process is the same. What may happen with these tubes because they're finer bore is that they'll have a tendency to coil and patients can often feel it coiling in their mouths or the distal esophagus so it's usually not as distressing for the patient because it's a finer tube, but you may need to be more patient and have a few more attempts to get it in the right position. And if you're having difficulty, have you got any special tricks or tips you can use to try and insert the tube? Look, it is difficult. I think that the first thing you need to think about is, is it too big or too small? So sometimes a patient will have quite a tight nasal cavity and maybe trying a smaller tube would be easier. If in doubt, certainly use either more water or more lubricant and don't be afraid to get the patient to drink water. You can get them to slightly change the position of their head. So maybe get them to flex more or flex slightly less. Those are the types of things I would do. If you're having a lot of trouble, I think after two or three attempts and the patient's distressed, have a break, get some senior help. Don't persevere if you're having a lot of trouble because you'll end up causing yourself and the patient distress. You put the tube in now and you think it's in the right spot. How do you ensure that the nasogastric tube is in the right place? It's a very important question. And in my opinion, I think the only acceptable method is to actually get an x-ray to check the position. It's really the only way that we can know sure. There are some other techniques which you can use, you know, as adjuncts, but I wouldn't rely on these. So you can aspirate the contents. And obviously, if it has the appearance and pH of gastric fluid, so you would expect anything between 1 and 5.5 to indicate it's in the stomach. That can help you to, you know, before you've got an X-ray, help you have an idea of where it is. There's an older technique of flushing air into the lumen of the tube and then auscultating the stomach to see if you can hear any bubbling. That technique is not particularly reliable, but again, it may help. I think if there's any doubt that the tube has gone not either into the wrong place, particularly into the bronchi or the trachea, the patient will usually cough a lot and you need to take the tube out immediately if you're worried about this. Don't ever leave it if you think it's gone into the lung. It can happen quite easily, particularly in obtunded patients who obviously won't have a cough response. I think the important thing is don't let anyone put anything down a nasogastric tube until the position has been radiologically confirmed. And that means that I think the radiology registrar or boss needs to give a report. Don't just on looking at it I think you know we need to be really careful about checking and documenting that. So what's your method when you look at a chest x-ray to make sure you think the tube is in the right position? So what we're really in essence looking for is to see whether the tip of the tube has passed the diaphragm because in that scenario we can usually be quite confident that it's in the stomach. One of the tricky things with nasogastric tubes, depending on the exposure of the film, is they can sometimes be quite difficult to see. What I find quite useful in some cases, if it is difficult, is to reverse the image and put it in a negative view and sometimes that makes the nasogastric tube easier to see. So if it's above the diaphragm, you should not be happy. If it looks like it's in the midline and it's just short and the patient's clinically okay, you can try advancing it because it may just be in the esophagus. Obviously, if it's going out of the midline on either side, you would have to be concerned that it could be in the respiratory system and I would remove that tube and start again. Yeah, I'm going I think the point everyone has the method of checking because not every hospital will be able to get... That's true, sorry. ...protein radiology reports. That's right, that's right. So I think you need to have a method, and I think I will include a kind of a method for checking nasal gastric tube insertion possibly with the notes. Okay, I think that's a good idea. So we've kind of mentioned some of them, but maybe what are some of the common complications of nasal gastric tube insertion? So there's obviously minor complications and serious complications. Probably one of the most common things that can happen is that they can cause aspiration, and that can be if you have obviously a patient who's obstructed, who's got a big stomach full of gastric contents, they can vomit and aspirate during the procedure. The tube can also go into the pulmonary tree and cause aspiration and that can lead to pneumonia, which is obviously potentially quite a serious outcome. They can cause trauma during their insertion, so particularly oropharyngeal trauma, nasopharyngeal trauma and esophageal trauma, and patients may experience either spitting up or vomiting of blood. If they have a large volume of blood vomitus after a nasogastric tube insertion that's quite serious and they may need a scope to check that there's no serious injury. Perforation is uncommon but it can happen. Patients who have for instance an esophageal pouch that can perforate, there's very rare instances of the tubes actually going into the lung and perforating the lung and causing a pneumothorax. They're quite serious problems, but they are a dangerous piece of equipment. Probably one of the most annoying complications is just not being able to get it in, having incorrect placement or the tube falling out. Those are the common ones. You're asked to put now the nasogastric tube on suction because they have a bowel obstruction. How do you do that and what level of suction and what type of suction? Yeah, so there's a few different thoughts about how we use nasogastric tubes. Some people will only use free drainage and if you hear that term free free drainage it basically means that the tube is connected just to a drainage bag and left to drain with gravity as the only thing pulling it out. If you're asked to put a tube on suction you can can check sometimes people want continuous suction and other times it will be an intermittent suction but usually that will be connected to the actual suction on the wall and it's relatively low pressures of about 20. The nursing staff will usually do this, but it is important that you know how to do that. You don't want to use high-level suction because obviously there's more chance of sucking the gastric mucosa into the tube, which will occlude it.
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Welcome to our next series of our RPA podcast series and we're talking with Rob Hissop, one of the intensives here at RPA and talking about one of Rob's pet topics, oligouria. So it's a very common case scenario that our junior doctors will see, especially when they're at night nights and we'll start with the case rob sure you're working on the night's shift covering the surgical wards and the nurses ask you to review a patient who's day one post-op and has poor urine output they've noticed for the last two hours only 20 mils per hour of urine output and the nurse knows you're busy and really just wants you to write up a fluid bolus and then get all the rest of your duties. How would you respond or how would you approach this patient? Okay, so I think one of the first tips is not just to tell the nurse to chart 500 ml of fluid stat and hope that it fixes things. Another error would be just to tell the nurse to give the patient some Fruzomide and hope that that makes their urine output more than it is. Ideally one should go and see the patient and assess them properly. Now at times one may be too pushed to be able to do that and if you are there are some certain questions you should ask and these questions are the same things you should address when examining the patient. So the first thing you really want to know is what are the hemodynamics like of the patient, what's their pulse and what's their blood pressure. It's also a good idea to look at their JVP, we all get taught that at med school, we all think we should forget it but it's a good thing to look at. And we should also pay some attention to what the patient's respiratory status is like. So when we're managing low urine output in patients, we're really managing the nexus between the kidneys and the cardiovascular system, and whenever we're managing that, we are also managing the nexus between the cardiovascular system and the respiratory system. So from a risk management point of view, if we're giving patients fluid when they're already very hypoxic with lots of pulmonary infiltrate, then we're on a bit of a hiding to nothing because the chances are that we'll worsen their lung water problem, worsen their hypoxia. But on the other hand, if you have a patient who's sitting there on remare or on nasal prongs oxygen with a nice normal respiratory rate saturating very well, then you're unlikely to get into too many problems quickly if you give that patient some fluid. However, this kind of scenario is one of the most common scenarios in hospital and it's probably one of the most poorly dealt with. And it is something I'm reasonably passionate about, as you're aware. And I think that all too often what is done is a blanket approach is to give these patients fluid on the assumption that low urine output is always the result of low perfusion to the kidney, and that is always the result of hypovolemia or dehydration. In my experience in hospital, that's actually the minority of patients. It's probably less than 20%, I would say, who are in that category. And what is very common is for patients to have a lowish or relatively restricted urine output as a response, as a normal physiological response to the stresses that they're undergoing, either as post-operative patients or as patients who are unwell in hospital. So after that long diatribe, if one was to examine such a patient and find that the hemodynamics are reassuring, that they had a normal pulse, like a pulse rate of 60 or 70 or 80, and they were normotensive and they're relatively well perfused, then it's very unlikely that this low urine output represents hypovolemia or dehydration. It's much more likely to represent either an issue with the IDC, and always if we're seeing patients with low urine output, we should ask the nurses to flush the catheter and we may well find that we're being led up the garden path and actually the urine output's fine. However if the catheter is flushed and this urine output is true then we do probably need to worry. One thing that I think is a real problem for us in the medical world and in the nursing world is that I think we use the wrong number as an oliguria number. So it's very cultural for all of us to use half a mil per kilo per hour as the cut off. So urine output above that good, urine output below that bad. I take a difference with that number. I think that's absolutely the wrong number. And I can go into that in more detail. Really what we're getting caught up with here is the difference between what is obligatory and facultative urine and how much a normal functioning kidney, how much urine a normal functioning kidney must make for a patient to be well or have normal renal function. And half a ml per kilo per hour is the wrong number. I don't know where we got that number from. I suspect we got that number from observing well subjects and seeing what their lowest normal urine output was. But we must remember that when we're dealing with post-operative patients or patients who are sick in hospital, we're not dealing with subjects, we're dealing with patients, and their urine outputs are often less than yours and mine will be under normal circumstances when we're well. And that is the difference between facultative and obligatory urine. So I don't remember these terms from medical school, but I wish someone had told me, but obligatory urine is the minimum amount of urine that a person has to make under maximum concentrating abilities in order to get rid of all of the toxins that they need to, the creatinine they need to get rid of, the potassium they need to get rid of, the acids they need to get rid of. And actually when you look at the obligatory amount of urine that most people have to pass, it's in the realm of about 400 mls per 24 hours. Now that's not a hard and fast number, and our concentrating abilities change in different circumstances and related to various things like protein intake and our serum urea and stuff like that. And also to our diet. But if you remember that a relatively normal sized adult having a normal diet can get away with passing 400 mls of urine a day and not be in renal failure, that's actually how quite a lot of our patients behave. That's because a lot of them are under high ADH tone and there are a lot of circulating serum catechols and things like that which can decrease urine output. And when we do the numbers on 400 mls of urine per day that's actually more like it's roughly 15 mls per hour which for most normal sized patients is much more in the realm of a quarter of a mls per kilo per hour rather than half a mls per kilo per hour. It may sound like I'm splitting hairs here but I don't think I am because actually it's double. So anything below that quarter of a mil per kilo per hour or below 400 mils a day is a very serious problem. That is true oliguria as opposed to the lowish or restricted urine output of roughly half a mil per kilo per hour. When a patient is passing less than the obligatory amount of urine, less than that 400 ml a day or less than that one quarter of a ml per kilo per hour, then we know by definition that they're going to be, that they have renal dysfunction. The urea and creatinine are going to be rising. They're very likely to develop a metabolic acidosis. They're very likely to get hyperkalemic. And these are the sorts of patients that can actually die overnight from a hyperkalemic arrest. So that sort of patient, that very severe oliguria, that true oliguria is something we should worry about in the extreme. But a urine output above that may well actually represent normal renal function and may well represent normal cardiovascular function and may just be a sign that your patient is actually a patient and has some other problem going on. Either they've just had a big operation like this patient has or they're sick for other reasons which we would expect because they're in hospital. So perhaps I'm getting sidetracked there. But with this patient, what I think we should do is assess the hemodynamics. If the hemodynamics are very good, reassuring, then we've got some other cause for this urine output not being very high. On the other hand, if we look at the patient and we see that they're a bit tachycardic or very tachycardic, their blood pressure is marginal, it's more like, you know, it's 80 or 90 systolic, and their peripheries are cool, or even their peripheries may be warm, then we should be concerned that this lowish urine output may represent a pre-renal problem.
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In which case, what I would suggest is if we're going to give a fluid bolus, we should give a reasonable sized bolus and we should do it as quickly as possible so we can assess well what sort of change we're making to that system. And I always advocate if we're going to give a fluid bolus we should have looked at the JVP beforehand and we should see how it changes in response to the fluid we're giving. And a lot of people tend to get this upside down but if a patient is exquisitely volume responsive what we tend to see is the bolus of fluid goes in, the JVP doesn't really change very much, but what does change is the heart rate or the blood pressure or the urine output. And if we've made the assessment that this patient has a pre-renal cause of their low urine output, then when we give an aliquot or two aliquots of fluid, we should see very little change in the JVP, we should see the heart rate come down nicely, we should see the blood pressure come up nicely and we should see them starting to pass urine. If we don't see that, we may well have been wrong. If what we see instead is the JVP rising very quickly and not much of a change to the blood pressure or the heart rate and the urine output, then we should be concerned that there's another cause for shock. Perhaps they've got cardiogenic shock, perhaps they're tamponading, something like that. Or what we may see is that as we're giving this fluid, the JVP is rising, the heart rate and the blood pressure don't change much, and neither does the urine output. And that may well indicate that the cause for the lowest urine output in this patient isn't pre-renal. It might be something else. Good, thanks Rob. That's a good overview of the patient that commonly see on the ward but I guess we could ask why don't we just give fluids? I mean is there anything wrong with patients being a bit on the wet side? That's a great question and I think absolutely yes there is something very wrong with patients being on the wet side. We have lots and lots of data particularly from intensive care that shows that the more positive a patient's fluid balance the worse their outcome and many studies yeah many studies correlating fluid retention and water retention with bad outcome. And there are even some other, there are some other levels of evidence that suggest that injudicious use of fluids is a bad thing. So I view fluids as a drug. When they're needed, they're very helpful. And I think I have a bit of a reputation in the hospital for being a dryer, but I'm not. I'm actually an advocate for doing the right thing for your patient at any one time. So I think if your patient needs volume resuscitation or rehydration, you should, well, volume resuscitation you should do aggressively. Rehydration you may do more slowly. But many patients get far more fluid than they need. And the nature of being a patient tends to impair one's ability to get rid of free water. Now knowing that and knowing that we don't want to commit the sin of running our patients overly dry or hypovolemic then we do give them fluid but because the patient has lost their homeostatic ability to get rid of free water that they don't need, most of our patients fill up with fluid. So we do have to be a bit careful about it. Some other evidence that I wanted to mention about the harm of fluids was a study done in sub-Saharan Africa called the FEAST study. So this was published in the New England Journal about two years ago, 2011. And in that study done in several countries, they took sick septic kids with high fevers and signs of hypoperfusion, and they bolused them with fluid, either saline or albumin. And they had to, sorry, they divided these kids into two groups. And in one group, they got boluses of fluid, saline or albumin, and in another group they essentially ignored them and left them in the corner. And this study they had to stop at an interim analysis because the fluid therapy group had a high mortality. So that's just an indication for us that fluids at the wrong time, in the wrong way, in the wrong dose, for the wrong patient can be very be very harmful it can kill you and perhaps it might be a bit rich to extrapolate from sick kids in sub-saharan Africa to patients in you know adult patients in in the western world but I don't think it's too too long above and certainly just it can just remind us that something that we think is universally harmless at worst and good at best actually may well be harmful. So I think we need to view IV fluids as a therapy, as a drug, something that can be very useful when it's needed but something that can be harmful if it's used when it shouldn't be or used in excess. So that's just some of the reason I'm concerned about this. And one of the things I see very commonly as an intensivist is people having to come down to ICU from the wards because they've gradually filled up with fluid. Over a period of days and weeks they've just ended up wetter and wetter and wetter. They come down with anisarka, they come down with pulmonary edema. and actually a lot of it can be avoided by cutting back on the fluids and us avoiding that knee-jerk response to just give intravenous fluids whenever our patient's urine output is low. We need a deeper understanding of how the kidney works and how urine is made and under what influences are certain volumes of urine made in a certain amount of time. And we do need to understand that the common factor that makes patients patients makes them bad at excreting excess free water. So earlier I mentioned these concepts of obligatory and facultative urine. So if obligatory urine is the minimum volume you have to excrete with all the toxins and poisons in, then facultative urine is any volume of urine you pass over and above that in a day. And conceptually that is just free water. When we're well, that is a passive process. If we ingest more fluid, if you and I went down to the pub and got a skinful, our plasma volume goes up, our glomerular filtration rate goes up, we make more filtrate through into the Bowman's capsule and that just goes through the nephron and comes out as an increased urine output. And we might wake up the next morning with a hangover, but we don't wake up with pulmonary edema or peripheral edema. But when patients are patients, many of them have high ADH tone. There's all sorts of things that cause us to release ADH. And unfairly, the medical profession says that there's only two appropriate causes for ADH release. One is hypovolemia and the other is hyperosmolality. But whether we think it's fair or not, we need to wise up to the fact that lying supine makes you release more ADH. Pain, nausea, vomiting, opiates, being ventilated, all these things make us release more ADH. And once we release more ADH than we should, we hold on to more free water than as medical professionals we might think it's inappropriate but that's what happens. Once you're under high ADH tone you start to make a restricted urine output. So the classical example is a patient who just like this one who've presented, is post-operative or sitting on a ward and is making about 20 mls of urine per hour and the nurses ask residents over and again to see the patient because their urine output's low. They get volumes and volumes and volumes of fluid. Very little happens to their urine output. Occasionally people will lose their bottle about all this fluid and give them Fruzomide and lo and behold they'll find that they make plenty of urine. But if they don't give them the Fruzomide, then people, we might come along the next day and have a look at the patient and look at their blood tests and see that their serum sodium has gone down. And that starts us moving along a diagnostic approach. And when we go through this, we have a look at the patient and we see that they're euvolemic, they're not hypotensive, they're not dehydrated, and we look at everything else. We rule out adrenal, thyroid dysfunction, hepatic dysfunction, cirrhosis, heart failure, and we come up with the diagnosis that they have SIDH. And what we do today is we fluid restrict them. And this is the same patient who yesterday had the same urine output. So yesterday it was 20 mls an hour, today it's 20 mls an hour, but it's only once we see the serum sodium fall that we feel safe enough to diagnose them with SIDH and we fluid restrict them. Nothing else changed. The hemodynamics didn't change. Their renal perfusion never changed.
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But we wised up the day later when we saw the hyponatremia. And I'm saying we can be smarter than that, because we can pick the patients who will be hyponatremic tomorrow if we think about them better today. So if we look at this patient with this lowish urine output, but certainly more urine output than Frank Oliguria, if we look at them and we see that their hemodynamics are fine, their pulse and blood pressure are normal, and they're not on funny drugs to bring them up, like noradrenaline in ICU or something, if they're not on vasoactive agents and they have a normal pulse and a normal blood pressure and they look reasonably well and we look at their renal function and their creatinine today is the same as it was yesterday and the same as it was the day before, then these are the kinds of patients that if we flood them with fluid that they don't need, tomorrow after they hold onto the water in that fluid and excrete the sodium in it, tomorrow we'll see their serum sodium low and tomorrow we'll know that we should fluid restrict them. But we can see it coming beforehand. Okay, so the concern that maybe the poor urine output, the kind of canary in the mine shaft before blood pressure, pulse rate change, the urine output be the one that drops first and by not giving fluids we're missing or delaying resuscitation of the shock? Another great question and this is something that is essentially drummed into us and very cultural but wrong. There are some good papers out there that describe that really what happens is, well let me go back a step. What we have here, when we're dealing with low-ish urine outputs, quite often what happens is we get our logic slightly wrong. And this is one case. So we know that you can only make urine if you perfuse your kidney. And we know that if your urine output is nice and normal and high-ish, that your cardiac output must be fine. But we make an error of assuming that the opposite to that holds true. So the assumption that a high urine output is a very good negative predictor of shock, that is true. But then the reverse of that, that a low urine output is a very good predictor of shock, is actually false. Does that make sense? So I want to say that one more time. A high urine output or a good urine output is a good negative predictor of shock, but a low urine output is a very hopeless positive predictor of shock. And what adds weight to that positive predictive value is the haemodynamics. So in fact, what we've had for a long time, we have had this approach of saying that a low urine output tells us that the patient's shocked. That's actually not true. If the patient has a low urine output and normal haemodynamics without vasopressor support, then they're not shocked. However, if you have a patient whose haemodynamics are sort of borderline and you're not too sure whether they're okay for this patient or not, so for instance you've got a patient with a blood pressure of 90 on 40 or 80 on 50 and a heart rate of 100, you know, is the heart rate 100 just because they're a bit septic because they've got pneumonia? Are they adequately filled or not? Is their cardiac output all right? I don't know. If that patient has a urine output of 10 mils an hour, they're much more likely to need volume resuscitation than if their urine output's 40 mils an hour. So the urine output can put marginal haemodynamics into some kind of context. However, a urine output alone in the absence of haemodynamic signs of pathology, then urine output alone is a hopeless positive predictor of shock. So I have a problem with actually urine output alone mandating emergency responses. I don't have a problem with a very low urine output mandating an emergency response. So urine output less than 15 mls per hour or less than a quarter of a ml per kilo. That does mandate very serious quick response. But a urine output that's higher than that, say 30 mils per hour or 20 or 25 mils per hour alone, I don't think we should worry about it. But what we should worry about is a urine output like that together with marginal hemodynamics. I guess it would be difficult for junior doctors on the ward because the culture is on surgical wards that the nurses do want that fluid to be charted. And I guess I need to think why do we put catheters in post-op surgical patients? You're really saying the urine output's not that important. Yeah, I am saying it's not that important. Once it's above that absolute minimum threshold, once it's above 15 mls per hour, it's not that important. And in fact, many of my patients who are making 20 mls an hour are the ones who I cut back on their fluid because I've already assessed them as being well filled or even slightly overfilled but before they get super overfilled or terribly edematous or huge pleural effusions I cut back on it because I know this patient's physiology is one where they're no longer very good facultative urinators. So if I give them all this water they don't need they they won't be able to get rid of it. But you're right, this is, you know, we're fighting strong culture here. We're fighting years and years and years of practice that, yeah, is almost like a religion. So, I mean, I give this, I've given presentations to both nurses and doctors about how I think we should do things slightly differently and the nurses say look it makes lots of sense Dr Hislop but you know you'll have to tell the residents because every time we tell the residents about the low urine output they give the patients fluid or fruzomide and when I tell the, when I give this presentation to residents or registrars they say well you have to tell the nurses because they keep bugging us every time the urine output, they give the patients fluid or fruzomide. And when I give this presentation to residents or registrars, they say, well, you have to tell the nurses because they keep bugging us every time the urine output's below 30 mils an hour. Well, we each need to cut each other some slack, but we should try and break that nexus of the knee-jerk response of giving fluid just for the urine output. We need to think a bit more deeply than that. One of the problems, one of the difficulties with all of this is that the kidney is a complex organ. And it's a very natural human response to want to simplify an approach to a complex problem. And we should simplify things as far as possible, but only so far as the model holds true or holds up under scrutiny. And actually I think if we delve down and we're really to question a lot of our colleagues, both nursing and medical, many people operate on a model by which the kidney is a bucket with a hole halfway up the side. And if the bucket's full of water, then urine will flow out the hole. And once the bucket gets empty enough so that the water falls to the level of the hole or below the hole then the urine output slows down or stops and we should just fill the bucket up. Now the kidneys are more complex organ than that. That is the model a lot of people operate by but it's not the model which actually respects the complexity of the kidney and its neuro hormonal inputs. So if we on too simple a model, we're likely to get it wrong as often as we get it right. But in fact, my strong belief is that low urine output due to pre-renal problems is by far and away the smaller fraction of low urine output patients. So if we operate on that model, we'll actually get it wrong much more often than we get it right. So, you know, there are some things I can do to try and change people's thinking. There are some studies I can talk about which can flip things on people's heads in terms of how they understand how the kidney works. And a great one of these is a study by a fellow called Rinaldo Bellomo. So he's a very clever intensivist down in Victoria. And he did this fantastic study where he took a whole bunch of sheep and he measured their renal blood flow by doing nuclear medical scans on them all. And then he made them all sick by injecting them with E. coli. And he and waited as they became septic and all of these sheep became very septic. They became hypotensive, tachycardic, oliguric and at the same time he measured their creatinine and their creatinine all started going up. So what he had was a model for septic multiple organ failure. Then he did something very clever.
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Welcome to On The Wards. This is Jules Wilcox and today we're going to be talking about well-being with John Scott. John is an emergency physician up at Gosford and the director of well-being at Gosford Emergency Department, or as it has been renamed now, director of performance and culture. And I'm also an emergency physician that works with John, and we have a specific interest in well-being. I'm also the DPET for Gosford. So, John, there's been so much stuff in the wellbeing space. Let's just quickly go over some basics because I think we have a slightly different take on it to others. Why do you think wellbeing is important? I think wellbeing is important because not only does it help us to do the job that we want to do to do well and to be able to do it for a long time? It actually directly relates to the patient care that we can give. And then there's the quality of care that we give, the use of resources and sort of direct implications for the hospital in which we work and sort of financial implications. So it's not really, I tried to move away from it just being about us. It's actually much bigger than that. Yeah, I agree. I think a core part of wellbeing for me is my work and my purpose. And so I find a lot of the wellbeing is about going away from work and leaving work. It's actually, it's not necessarily about that. Often it's looking at the focus of what you do away from work so that you can perform well at work. And I want to touch on something that you just said then about being able to perform for a long time. Your career in medicine, what's your retirement age? What, 67 now? Probably going up to 70 soon. So if you become a consultant aged 35, you've got 35 years as a consultant. That's a hell of a long time. And you need to perform at a very high level for that time period because medicine is a high-performance endeavor. There's high stakes critical decision making you know and it's physically tiring as well if you're in theater all day or in the emergency department all day yeah absolutely yeah absolutely i mean i think obviously we're emergency physicians so it's a particular sort of unique skill set isn't it um or challenge set and i don't think there's a that often i think with emergency medicine the things that are at times the best thing about it can be flipped on the head and also be the worst thing about it. And it all depends on your approach and how you look after yourself and each other and where you sit in that spectrum. Absolutely. And I think the other thing that I think is important, so the whole thing about burnout and stuff, it doesn't just happen just like that. No. It's a continuum from wellness to burnout and you gradually go down that thing. And the really good news about that is that you can, if you recognize it, you can then go back up the thing. You can institute practices and things that stop you sliding down that path and get yourself back up to the other end. It's not an all or nothing. It's not a sudden thing. This is something that comes on over a period of time which then also takes an awful long time to get better if you do end up down there yeah for sure Jules I could totally relate to that I mean that's where how I found myself I think in the last podcast was saying you know I found myself quite surprised to be burnt out but I turned up in Australia I think he was the best place in the world. Loved working in emergency medicine. I went surfing every day. Did a fun job that I really enjoyed working with great people and got paid pretty well for it. I thought I'd have to have my cake and eat it. But then I started advanced training, took on all these extra responsibilities, got a mortgage, got married, had a child, and then did my stuff, preparing for my final exams. And I suddenly found myself like totally burnt out, found myself walking into work with a knot in my stomach, resenting my patients, feeling very distant from my colleagues, and feeling like I just wanted to cry and walk out of there sometimes. So, you know, that didn't happen. And how do you think you're performing when you're at work then? Terrible. Yeah. Yeah, terrible. As your DMT, no. Yeah. Yeah. But at the time, that wasn't really something that was really recognized and we didn't really know how to deal with it. But then when we did look into it and, you know, made a few changes and some of the practices that we can talk about, we could rapidly, I turned that around rapidly and it totally changed my outlook. Yeah, because I think you were on the continuum between wellness. You weren't totally burnt out, but you were definitely sliding down that scale. I fully was, yeah. And I found myself, you know, in the shower after commuting back from Westmead, you know, after a long day there, standing in the shower just thinking, oh man, I just don't want to wake up tomorrow and have to do this all over again you start having those dark thoughts a few nights in a row and I was like whoa hold on that's not right that's not me I've got to do something about this and luckily you know I did do something about it but I've had seen other colleagues you know who've dropped out they've had to take a long time out of medicine or go and do something else and I think that's a real a real loss. Yeah, absolutely. When there are things that we can do that can really avoid that turnaround. So I think you and I both agree that if you want to be the best doctor that you possibly can be, you need to be well. You cannot look after a patient to the best of your ability if you yourself are not well. Do you think that's a fair comment? 100%. And there's a whole heap of data that would back that up too. Well, that's the interesting thing now, isn't there? Because it's gone from the touchy-feely, you know, kind of, oh, you know, let's all hold hands and meditate kind of stuff, to there's a lot of research out there now that says that this is abundantly true and we can prove this. Yeah. And that comes from, you know, yeah, exactly. It's not just the softies. This is sort of the most profitable companies in the world that are doing this kind of stuff. You know, Google's and Apple's and Microsoft, they're all spending money investing in these things. Not because they inherently love people, it's because they like the results that it gets. And interestingly, there's a study released by the Mayo Clinic where they're basically advocating that physician wellness should be a key quality indicator because of that, because it drives better patient care. It cuts costs. Doctors don't quit. Doctors don't call in sick. They don't make errors, all those things. Well, that's one of the benefits of COVID now, isn't it? People are actually calling in sick and staying home. Yeah, exactly. Looking after themselves a bit. Exactly, yeah, which doesn't decimate the workforce further. Yeah, yeah. And I was going back to that, something you said about that Mayo Clinic thing there. So I'll just have a look at your slide thing that you had. Oh, the quality of medical errors. And that was really borne out in a number of studies, wasn't it? That your likelihood of making a medical error, and so being a major medical error, in other words, really not being a very good doctor at all, is massively increased if you're burnt out because you have low compassion scores and so forth. You just don't care. You're not going to take the time. We all make mistakes, but you know it's it's you're much more prone to doing that and I think if you are if you're not prioritizing your own well-being so that you can perform at a high level then you are doing your patients of this service exactly so I do colleagues because you have people I get to live with so for the junior doctors who are just starting you know I guess just like you mentioned, just recognising burnout and what it is, is probably the first step, isn't it? Yeah. Yeah, I guess that's the first step. So what are the symptoms that they should look out for? In terms of when you start to slip down from that wellness towards the... Yeah, when you start looking burnt out. Yeah. I guess we can look at it that way or we could look at what are the things that you can do to stop yourself being burnt out.
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Yeah, we'll go through both. So I mean, I kind of mentioned them when I was saying that those symptoms that I had when I was feeling burnt out, the term that we're using. And the first thing is, the first tenet of it is emotional exhaustion when you just get up in the morning, you feel like you haven't got the energy to get through the day. And the second one, I think we talked a little bit about in the last podcast, is that depersonalization. When you stop seeing patients as patients, they're just a... You just don't care. Yeah, it's just the back pain is annoying. Exactly. Chest pain in bed five, the geriatric urosepsis in B10. They're just problems to be solved. And as we talked about in the Compassion podcast, if you're there, if you're not making a connection with your patient, there's no way you can take your history, really find out what's wrong with them, and you're not going to get the diagnosis. And that then that then is a self-defeating cycle isn't it because you're not going to get any joy out of that that interaction it's going to suck energy for you for your next patient yeah and um so that's that's a vicious cycle um and then the final um sort of element of um of burnout is that sort of feeling of lack of personal accomplishment that if you turn up there's going to be 20 more patients anyway any other doctor could have done it or it's not going to make a difference it's going to be 20 other idiots with back pain coming the next day um and i guess this is all a bit of a continuum as well isn't it we all feel elements of this at some point but it's when they all get to a high level that we start suffering. Yeah, yeah. I think so. And I know, speaking to somebody who had gone through burnout in the corporate world, and it's not, you're just tired. No. And a bit pissed off. Yeah, just need a couple of days off. Yeah, a holiday will not fix it. Yeah. He took a whole year, and for three months of the year, he struggled to get out of bed he was so completely emotionally and physically exhausted and you know so you really don't want to go down that road no you don't because if you don't yeah that's right you can take the time off but if you don't do anything to change your approach when you come back the same problems are going to happen and I'm aware of doctors who have been through that they've taken a break and they've come back and then the same issues have just raised their head again because the challenges in the workplace don't change well unless you change your underlying psychology about things or how you see things and your mindset it's not going to change absolutely yeah so I guess we've talked about there some of the personal impacts of what, well, yeah, I guess that's what burnout is. That's how in some ways it can affect us. But, you know, there's some pretty horrifying statistics around that, isn't there, for doctors in general. Yeah. And so one thing actually I find really worrying is a lot of this actually relates most to the junior doctors there that most risk for it because I guess they haven't built well why do you think that is? I think it's also partly and I don't know I've got no research to back this up but I think it's not helped a lot because as a junior doctor you are actually not totally in control of your own destiny absolutely you are subject to the whim of exams and college requirements and various other things. Whereas as a consultant, I can do what the hell I want, basically. So if I decide I want to go and work in Alice Springs or New Zealand or the UK, I can do that. It's up to me whether I do that. It's not up to my work, unless I really screw up or something. But it's up to me whether I do that. I don't have to do any more exams. I always knew that I was going to pass my exams or I had the belief I was going to pass my exams. I just didn't know when. And that uncertainty and things plays on your mind. And you're trying to buy a house and have a family and you don't quite know when you're going to get a consultant job. All these unknowns just heap loads more stress on things. Whereas when you become, you call the shots a lot more when you're a consultant yeah and i think that really happens that's definitely a big bit actually that mayo um clinic um study had that sort of the drivers of you know from engagement and thriving to burnout and you know having sort of control and flexibility or um yeah control over your life was a big part of that yeah in a place where you don't have any control then um you don't have that autonomy and you feel you're much more of a at the whim of the system that you're working in yeah um so yeah so so if we've talked about some of the consequences i mean everyone knows the consequences and things of that um of burnout and you, the horrendous stats that are out there looking at junior doctors and senior doctors. Depression, suicide, drug and alcohol, all that stuff, lots of relationships. Yeah, and I think we all know somebody who's been through that or, you know, we know somebody or have heard of somebody who's killed themselves and things like that. Yeah, there's been plenty of that in the papers recently in the last few years. Yeah, absolutely. You know, we both of us have a friend who did that. What are we going to do then to achieve this well-being? Yeah, what have you done? Yeah, sorry, Jules. Well, I can say there's often all this sort of stuff about it, but then it's actually, you know, if the system's not changing, what do you do? And so I think one of the talks that I've given to my juniors a number of times is sort of some specific things that people can do to get that resilience, to get those resources so that they can deal with the stresses of the job and things. So perhaps you want to touch a little bit on that. What specific practices and things would you recommend to somebody? If you had a junior doctor who you thought was slipping down, that slowed down towards the burnout end, what would you say? What sort of advice would you give them? So, yes, I guess, yeah, this is, I'd say this with this proviso that, yeah, burnout is a result of personal actions, but also the institution that you're working. So none of this is supposed to be to deny the fact that or to say that just by meditating it's going to compensate for a toxic environment. I totally get that. As consultants we have to create that culture but there are definitely some specific things that we can do. I think that's really important. Before we dive into that, to say that it is absolutely your personal responsibility to be as well as you can. But having said that, that doesn't absolve organizations from the responsibility of providing an environment where you can be well. You know, I get really irritated by the, you know, oh, let's do some mindfulness things in that. You will do mindfulness programs and then we won't change all the shit at work because you're doing the mindfulness exercises so therefore we don't have to bother about changing, looking to any of the issues that are going on in the organization. That is wrong. It becomes very tokenistic, doesn't it? Yeah, absolutely. And organizations, whether they're corporate or health or whatever, they have a responsibility to provide for your well-being and to look after your well-being. But you also have an equal responsibility to do that yourself. And I think that's a bit we should talk about now. Yeah, exactly. And once I did that stuff, I found it just made my whole life better. So it didn't just make me better at work. It made my life outside of work better. So it's so worth investing in it. So yeah, what are the things that have been helpful for me? Yeah. What specific practices would you say for people? So there's a whole bunch of things. For me, exercise has been really helpful. So getting regular exercise, you know, just changes your whole outlook on life, gets the endorphins going, you feel better about yourself. There's heaps of evidence around the multitude of benefits of exercise. I found meditation for me has been very helpful in sort of just calming my mind and helping me to be more sort of present and in the moment. And that's had actually really profound effects for my work with patients and dealing with the multitude of challenges of working in a dynamic ED.
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Yeah. And I think the evidence on the amount of research on meditation now has gone up exponentially in the last 10 years. I mean, I learned to meditate in 2000, I think it was. My wife's been doing it since she was about 16. She got me into it, and just what an amazing difference that made. It really does, yeah. Yeah, that could be a podcast in itself. Yeah, absolutely. And the neuroscience now backs this all up as well. Yeah. So So again, this isn't just airy-fairy type stuff. The functional MRIs on that, the guy who's the happiest guy in the world. Yeah, I love that one. Looking at that and how that works. So this is not a fluffy kind of, oh, do this to be well type of thing. Sitting in the latest position, om for a it's no no specific stuff that really does make a difference with long-lasting benefits as well a 20 minute session you know 48 hours worth of things yeah so yeah so yeah so yeah the meditation definitely I think gratitude so spending simple thing you can do just before going to bed or before you you know switch on before driving home is just spend a few minutes just thinking about all the things that went well that day. Yeah, absolutely. That's one I really like. In fact, that's probably my number one on the list is gratitude practice. I've used it with my kids and I do it myself pretty much every day. Although there is some research to say it's actually more effective if you do it every two or three days. But I think I've been doing it quite a bit, quite a lot. So it's just a habit now. And how does that change things for you, Jules? What has it done? Yeah, so interesting. I was speaking to one of our registrars, our old registrars, about that because I was talking to some other juniors about it and she said, oh, you know, I've been doing that. She said, and you know, I found it so useful because at the end of a term in ED, I don't actually remember any of the bad stuff. There's been bad stuff happening, but I don't remember it. I only remember the good things. I was grateful for this and I was grateful for that, and so forth. And I did actually give this advice to all the new interns a couple of years ago. And I said to them, at the end of the day, you think of three things that went well and something you're grateful for, or three things that you're grateful for, 10 things, it doesn't matter. And you can write them down as well and journal it. It's really effective as well. And at the end of the year, I ask all the interns for the best bit of advice they had in the year and I collate them all and I give them to the incoming interns the next year. And some of them are quite funny. Don't worry about the patient's urine output if it's less than your own. But several people said that they had done that gratitude practice through the year and they thought that it was the best thing that they had done for the entire year. And I was really surprised that, A, anybody had actually listened to me and done it. And B, that they found it had such powerful impact. And I was talking to a neuroscientist at a conference last year about some of this stuff. And she said that actually you start to reframeame your reality and they've got the functional MRI studies and things like that. So basically there's so much sensory information coming in every second that your brain can't cope with it. And I can't remember the exact numbers but it's millions and millions of bits of sensory information and so you ignore most of it and your brain makes quick shortcuts and so forth. Your brain's sort of inherently lazy. And so you have these sort of filters and your mindset dictates what you pick up on. And by doing a gratitude practice regularly, they've shown that it increases your happiness scores. And what happens is you actually start to change what you're seeing and what you're perceiving. And you're changing your filters and you are actually changing your reality, which is quite a powerful thing. Yeah, and then it makes it more likely that the good thing is going to happen to you because you're interacting with the world in a way that's more positive. Yes, and you're more likely to take advantage of those positive interactions when they come along rather than just not seeing them. So I think the gratitude practice is really important. One of the things I would say to anyone who's listening is that you've got to set it up and make it a habit. So what I did was I have this little journal and I bought myself a nice journal. I think it was like 50 or 100 bucks for this leather bound thing thing. Because I wanted it to be a positive experience. It's nice. I have to put it on my pillow. Because if it's next to my bed, I just get into bed and go to sleep. But if it's on my pillow, I have to pick it up to then put it down. And I pick it up and then it's like, all right, I better do this. And so then I do it. And so it's about creating routines and things. It just becomes a habit then. You just do it. And you only have a certain amount of willpower every day. And if you use it up on something, then it's not going to be there for something else. So do the gratitude practices. And you can even tie that into stuff. If you say, what three good things that happened today? Say you got a recess and it went really well. The other thing you can do, and this isn't part of the gratitude practice, it's just part of professional development. Why did it go well? What did I do that made this go particularly well? And just reflect on that because you might be able to learn something from that and then take that into another clinical environment. So that's a little extra thing that you can do. Yeah, yeah. I wanted to touch on one thing that you were saying because you were saying about the exercise and the meditation and all that sort of stuff. And I think we all know that we should be doing exercise. Yeah, exactly. One study that came out of the trading environment where you had traders who are under a lot of pressure, very high performance, a lot of critical decision making, I think. So it's fairly similar to what we do. And large rates of burnout as well. But they found that if they did four things, so something that made them happy, something that gave them connection, so romantic or friendship, something like that, something that stimulated them physically or mentally, and something that made them feel fulfilled, if they did those things on a regular basis, they were protected from burning out, could perform at that very high level for a very long period of time without burning out. The problem is that those are the first things that go. Absolutely. Isn't it true? I know I should go and do some more exercise, but I get home and I'm tired and I'm just going to get a bottle of wine and sit on the sofa and watch Netflix. Yeah, you don't call up your mates and go for, you know, have a chat with them or have a coffee. You avoid doing that. You withdraw. Yes, if it gets bad, you do. Absolutely. And so if you schedule these things, again, it's about creating habits and routines. If you schedule it, like the other day when I rang you up and I said, hey, do you want to go for a surf in the morning? Because I knew it was going to be cold the next morning. And I wouldn't have gone if you hadn't phoned. Yeah, exactly. That's for sure. Exactly. And I wouldn't have gone either because I'd have gone, oh, it's a bit cold and maybe it's going to be a bit small and, you know, ah, I'll just stay in bed. And, yeah, it was a bit cold and it was a bit small, but it was a beautiful sunny day and we had a great hour and a half until my feet froze. But scheduling it is really important. And you don't have to do all of these every day. So do something that makes you happy. It doesn't have to be like I have, you know, we've got a bunch of herbs and flowers and stuff outside at the back of our house and a sofa in the sun undercover where the sun comes up in the morning. So I'll make myself a nice coffee and sit out there and smell the nice flowers and herbs.
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And it takes a couple of minutes. Tonight, I'm going to be playing tennis with some friends. So that's going to tick off my exercise. It's going to tick off my connection and happiness all in one go. And it's scheduled. But if I didn't schedule it, because I've already replied on the WhatsApp group that I'm going to go. So now I have to go. Because I know that I'm going to be tired by the time we get home tonight. Just get your shoes on and go. Otherwise I'll get home and I'll just go, I'll go next week. So scheduling is really important. Get your roster. Once you've got your roster, schedule when you're going to go and meet with people. When you're going to go for a walk on the beach. When you when you're going to do your exercise you're far more likely to do it and if your life seems a lot fuller then and a lot more rewarding and paradoxically you end up with more energy yeah that's true that's true yeah any other ones um so no i think you're totally right you know like especially with the the social connection that's that's really really massive and we talked about the um you know all the studies showing how social connection is really important um so i think when things are tough really value that and uh you know pull your friends tighter in those hot those tough times yeah that's a great line big wednesday isn't it you remember the uh the surf movie yeah yeah surf movie from the 70s about the guys made some did something, you know, bad and stupid and that stuff and he goes, oh, my friend's, you know, go with my friends this and the guy says to him, you don't need your friends when everything's going well. Yeah, that's right. You need your friends when it's all going shit. That's when you find out who your friends are. Yeah, yeah, but that's when you need them. Yeah, which is all fine, you don't actually need them, you can do whatever, you're going to feel fine. So, but you need to cultivate those friendships during the good times. I think another one thing that I would recommend people do is to go to Kristen Neff's website and work on your self-compassion. There's so much evidence showing links between well-being and depression and so forth and your level of self-compassion. Medics, I think, are particularly bad. We're terrible. All type A's, aren't we? All type A, all beat yourself up about the smallest mistake and imposter syndrome and all that sort of stuff. And so doing some work on that, I did a whole lot of work on that and I found it really, really useful. So yeah, self-compassion and combined with self-compassion is working on yourself not to be a perfectionist because perfection in medicine doesn't exist. It's a game of incomplete information just like poker and you cannot play poker perfectly. So if you agree that you can't practice medicine perfectly because you don't have all the information about that patient, then you can stop trying to be perfect and stop trying to be a perfectionist. So important, Jules. Yeah, and that sort of comes back actually to the social side of things. I found when things are really tough and you think you've made some error that no one else would have made, just going and talking to one of your mates and you find they've all been in a similar situation or they all would have found that equally difficult or don't know the answer. And that sort of brings the humanity of it all back that, like you say, this is an imperfect game. All we can do is our best with what we've got at the time. Yeah, you strive for excellence, but don't go for perfection. Because that is just destructive and it's not helpful. And I think part of the three things of self-compassion, one is the mindfulness to realize what that voice is saying inside your head and it's not a good, healthy chat. It's got your best interest at heart, but it just sometimes goes about it in a funny way. But the common humanity and knowing that other people are going through or have gone through the same thing that you're going through. And so you don't have to feel so alone and so terrible about it. I think that's what's always led to these bad outcomes for junior doctors is they felt very isolated because of that perfectionism and so they haven't opened up to groups. Yeah, that it is a weakness. There is a stigma and so forth. Shame in there. Yeah, we've all been there. Everybody's been there. So I think reaching out from that but Kristen Neff's website, she's the lead person on self-compassion. And on her website, you can do scores, quizzes to see how self-compassionate you are. There's exercises to get you to be more self-compassionate. And with neuroplasticity, the neuroscience shows that you can change your levels. It's not fixed. So you can make a difference over time. And it's all on her website. So just go to, just go to selfcompassion.org. Yeah. So I think that's a really important one. And if you can't be kind and compassionate to yourself, you're not going to be kind and compassionate to others. And again, there's a lot of data to show that. So again, if you want to be a better doctor, work on yourself as well in that sense because you will end up being more compassionate for your patients. And go and listen to the compassion podcast that we've just done. Read the book Compassionomics. It's fundamental to what we do. Yeah, exactly. We talked about Ikigai a minute ago, didn't we, on the last podcast, and that really should be the center of it all. That should be your reason for being. And there's a lot of evidence as well to show that if you have a lack of purpose, that is really bad for you. Really bad for you. Yeah, actually, on that note, there is something called the 20-80 rule. So if you can just spend 20% of your time doing something that has real purpose for you, real meaning, that's incredibly helps give you resilience against all the bad stuff. So that will get you through burnout. Just 20% of the time, if you could just recognize, be mindful of the next patient that you treat, that there's some part of it that you're going to enjoy and go in with that intent, then that will really protect you from burnout. Yeah. So just be mindful of what your purpose is. Yeah, and I think that's where some of those mindfulness practices come in, where there is a lot of value to the mindfulness practice. I know one bangs on about it, but I think sometimes it gets lost in the overall sort of fluffy well-being kind of stuff. But no, it's crucially important for the aspects of compassion, for self-compassion, for that ikigai, that purpose and things. And that's why it's good to cultivate that. And by doing that, you are in the present and you're not ruminating and all those other things that then spin off. Yeah, there's destructive thought processes. Yeah, absolutely. So I think that is really important. Yeah, certainly that's probably a good overview, isn't it? Yeah, I think that's sort of certainly some of the basics there that we, specific things that I found useful over the years. And it is a work in progress. It's always a work. And that's okay. Yeah, yeah, yeah. Don't be so type A that you think, oh, I could do that. I didn't do any mindfulness. Oh, bugger. I'm terrible. And you beat yourself up again. I should be kinder to myself. Damn it, why can't I do that? And you beat yourself up. You get into this vicious circle. For sure. I don't meditate anywhere near as much as I should do. No, neither do I. But I know when things get tough, I always go back to it. Yeah, absolutely. But I think that's the other important thing, that all of these things, you need to practice them regularly for them to work. They're not going to work if you just go, well, I'm going to ignore all that until I need it, and then I'm going to go and meditate. It's not going to work doing it that way. You've got to build in that resilience. You've got to build in those healthy habits. And you need to make this a priority.
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Welcome to On The Wards, it's James Edwards and today we're going to be talking about hyperkalemia. And given we're talking about hyperkalemia, I have the pleasure of introducing Associate Professor Darren Roberts, who's a physician who works in both clinical pharmacology, toxicology and nephrology. But we're going to take his expertise in nephrology to talk about hyperkalemia. Welcome, Darren. Welcome. Thanks very much. It's good to be here. And we're going to just start with a bit of an overview before we dive into a case. Can we define hyperkalemia? Yeah, we can. We've got a whole bunch of, there's a whole bunch of different definitions that are used for hyperkalemia. So depending on where you work, their diagnosis or definitions may vary. What we do know is that more than 5.5 is abnormal. But when we start to talk about hyperkalemia that we should get worried about, much higher levels than 5.5 should actually get you alarmed. So in particular, above 6 and 6.5 in particular is something which should really trigger a new concern regarding hyperkalemia. But anything above 5.5 is abnormal and should make the doctor think, well, why is this high and what should I do about this? So in regard to how concerned you are, obviously you've got a number. Is there anything else that will make you more concerned? Yeah, there's a few things. So first of all, it depends, well, why is it high? Because that's important for how it might change after that. So if someone's come in and they've got kidney injury and they've got some other sort of tissue injury, then the potassium may go up higher. You might be seeing it early. And that's why it's very important to understand the cause of the hyperkalemia. Because the measurement that you're looking at might have been from a blood result taken two hours ago, in which case by the time you've got the result, it's already higher. So you really need to think about the patient as a whole when interpreting results. In regard to making sure the measurement's accurate, because we've all got that blood test, it looks terrible, but they go, it's haemolysed. How can we really make sure that the potassium measurement is accurate? Well Well we're lucky if they tell us it's haemolysed because then we know it's abnormal. The danger is that sometimes laboratories don't have an automated process for picking that up and they may not actually know if it's been haemolysed. So this is where it often relates in part to the person who took the sample to have an idea in terms of was it difficult to get the blood from that patient? Could there be haemolysis? Sometimes we look for other measurements on the bloods as well. So if you've taken a full electrolyte biochemical profile, you may see that the LDH is high. This may be another measure. But if in doubt, that's often where we get a check. And in regard to getting a repeat sample, what would make you think I need a repeat sample here? This is a very hard thing. And in general, I've got low threshold for getting a repeat sample. But it largely depends on who took the sample. Other measurements that you might see in a blood test which will tell you that it's haemolyzed would be a high LDH, for example, lactate dehydrogenase. This tells us about the red cells being broken down and tissue stress. But again, that can go up for other reasons. And not all blood tests come back with that as a report. So it depends in part on the conditions of taking that sample. But if in doubt, just get another measurement. Yeah, and often when we get another measurement, in most hospitals we've got the opportunity to get a blood gas. Yes. And either venous or arterial blood gas. And how accurate is that for potassium? They're accurate. They're fine. In some cases, less so with potassium, but actually blood gas can be more accurate than a regular blood test, which is sent off to the laboratory because it measures changes in the iron concentration, whereas the automated blood tests look at the concentration of an electrite in the volume. So if you've got something displacing it, for example, high triglycerides, hypercholesterolemia, then it can actually give a low, well, it's actually more of a low measurement, I'm sorry. But in terms of blood gases, they're accurate. And in particular, you get the result back faster in most cases. It depends on the institution where you work. Now, what are some of the most common causes of hypercholemia that a gene doctor will see, particularly on the wards? So if your potassium's high, that just means either there's too much potassium coming into the blood or it can't get out. And so it's useful to think about in those two mechanisms. When we're talking about in the hospital, in most cases it relates to either tissue injury, which is causing the potassium to come up, or kidney injury, which means that the body can't get rid of the potassium. The body's key organ which gets rid of potassium is the kidneys. So when there's impairment of kidney function, then that's when the potassium can go up. So it's most often seen in patients who come in with some degree of acute kidney injury. There are medicines that can also cause potassium to go up and again that's because they muck around with the systems of the kidneys and so it's a bad combination when you've got medicines that muck up with potassium and also impaired kidney function. So it tends to be the older patients who have some degree of impaired kidney function, so they can't compensate for high potassium, who are taking multiple medications such as angiotensin 2 receptor blockers, the SARTANs or ACE inhibitors. And more recently, we're seeing an increasing number of patients who are getting it through trimethoprim and some other antibiotics also associated with hyperkalemia as a side effect. But there's other medicines as well. Spironolactone is commonly being used. That, with all of the other medications, in an elderly person is a bad combination. Patients on that combination of medications also are at increased risk of kidney injury. They get an acute illness when they're not eating and drinking, but they're still compliant and keep on taking their medications. Bad combination for drug effect and impaired kidney function, causing hyperkalemia. We're going to go to a case now. And this case is a fairly diagnostically not overly difficult because it's a 70-year-old man who comes in with end-stage renal failure, who's on dialysis, but has actually missed his last two hemodialysis, and he comes in with a serum for taxing and potassium concentration of 9. What are the immediate risks to this patient? Death. That's bad, isn't it? It is bad and it looks very bad on your record. It makes us all feel terrible and he's probably a lovely man who's got a family who like him and would all feel terrible. Potassium of 9 is an emergency. This is something where you need to mobilise senior help as soon as possible to get this person fixed. Already we know that this guy is at risk of hyperkalemia because he depends on dialysis to remove his potassium since he's got failed kidneys. A level of 9 is never ever going to end in a benign outcome without some sort of intervention. We have to always consider in this patient whether or not there's some sampling error, but based on everything in front of us that he's missed dialysis, he's got end-stage renal failure, we must assume this is a correct measurement. We need to act immediately. So in regards to doing a history and exam for this patient, do you think you should get on and start treating them rather than going through their social history? That's right. This is a case whereby, I mean, we often do a lot of these things concurrently, but the most important thing in this person is to risk stratify them in terms of what our intervention is going to be. Level of nine is life-threatening. So while we are working out what treatments we would do, we get more information in terms of the effect this potassium may be having on him, and an ECG would be the first-line investigation to do that. What are you looking for in the ECG? The ECG, there's multiple changes that are reported associated with hyperkalemia.
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And that's due to the very prolonged QRS with a big T wave. These are a range of possible ECG changes that can be seen, but not all of them will happen in any particular order. And in particular, some of these things may be hard to interpret in an elderly patient. For example, if he's had a prolonged history of hypertension, then he might actually have some, and most of our renal failure patients have this, they have some degree of cardiomyopathy, left ventricular hypertrophy. So I already have a big Q, a tall T wave with repolarization, which goes to get tricky in comparing the T wave to the QRS relatively. But nevertheless, level of 9, always assume worst-case scenario. But there are a whole range of possible ECG changes. But the main ones we look for in the beginning is a peak T wave and changes in the QRS. Do you base your treatment on the level of the potassium or the ECG changes or both? Both. So the reason we do an ECG is that changes to the ECG tell us what is happening at the myocardial level in response to the potassium. In the event that there's abnormal ECG changes, then this would be an indication for giving calcium. Calcium, we think, stabilises the membrane of the myocardium. We think that calcium is useful for helping to prevent bad cardiac outcomes. It only has a short-lived effect, maybe 10 minutes, maybe a bit longer. Data are poor, but nevertheless, changes in the ECG would suggest give calcium while also giving some treatments for the hyperkalemia, because there's a delayed onset until these treatments for the potassium will actually kick in. So we said for this patient, potassium 9, missed allicis, start calcium. What kind of calcium, what kind of dose? So normally we give calcium gluconate. Calcium gluconate is given because calcium chloride is actually very irritating to the vessels. The way I think about calcium gluconate is 10, 10 and 10. It comes, one vial contains 10% of calcium gluconate. If you put that into a syringe with 10 mils in total of saline and you inject it over 10 minutes. So 10, 10, 10. That's a safe way to give calcium. You can actually probably give it fast for that and you could probably give it undiluted, but it tends to be a way that people can remember to give it and in general there's safety of that, particularly in the water. Okay, that's a great tip. That won't change the potassium level though, will it? No, this has nothing to do with the potassium. This is a common misunderstanding. People say we gave calcium persistent hyperkalemia. The whole point of the calcium is really just to protect the myocardium from the high potassium while we're giving other treatments to treat that potassium. What other treatments would you give? There's a range of treatments and, there's a bit of controversy recently in terms of what the best treatments are. So the main two treatments that most doctors are going to be using is going to relate to insulin. Insulin pushes potassium to the intracellular compartment. And we're going to talk about why that's very important in a moment when we're talking about patients with renal failure. The other drug that people tend to use is salbutamol or in Northern American, albuterol. Salbutamol, as you know, Ventolin is a, not that I'm into brand names, is a medicine that's used for the treatment of asthma. And similar to insulin, it also pushes the potassium into the cells. The problem with salbutamol as a treatment is that only it works in maybe 40 to 50% of people. And people who are on beta blockers, for example, may actually not get an effect from the salbutamol. So when it comes to choosing which of these two main treatments to give, often we don't know, so we give both. Would you like me to talk about how I give them? Yes. So the way I tend to give insulin is I give 10 units of soluble insulin with 50 mils of 50% glucose. Technically, you should give the glucose before the insulin because we don't want them to get hypoglycemic. There is always a slight delay in the onset of the insulin, so that's probably unlikely, but let's reduce risk. Always start with the glucose and the insulin. Some people spend time mixing the two together to give them together. There's no harm in that. It just may be associated with a delay in administration of these medicines. This largely depends on where you work and the staff that are around to support you. So it's probably a local decision. My practice is I give glucose and I give insulin. And so short-acting insulin. Short-acting insulin. So act rapid and over-rapid. Soluble insulin is what it's called on the label. It's normally got a yellow colour on the vial. So we give that. The only thing is that the onset of low potassium from that is probably delayed by at least 30 minutes, if not longer. And it's a short-acting insulin, so it may have a non-sustained effect, in which case you need to anticipate the fact that potassium may go up again and you need to consider other treatments. And we'll talk about that when we talk more about this case. Okay. And this salbutamol? So salbutamol is where the controversy is. So in the past, we used to just say nebulize salbutamol. It was said you needed at least 10 milligrams of nebulized salbutamol to get a response, maybe even 20 milligrams. So that's four of the nebulules. So that's a much larger dose than we'd normally use up front for asthma. And it is believed that this was what was required to actually get an effect. Where some of the controversy regarding this is coming from is that it involves nebulising, and sometimes it involves nebulising acutely unwell patients. After the SARS outbreaks that occurred within South Asia, there's been concerns in some organisations about the use of nebulisers as to whether or not it will help transmit viral infections around the ward and infect other patients or staff. So some units or some hospitals are now saying that nebulising of salbutamol is not allowed unless you're in a negative pressure isolation room, which isn't always practical. And in particular, with these patients, they should be on a monitored bed, so that may not be possible. You'll need to speak within your own institutions regarding the best ways to do this, but where I've worked, what we do is we put a mask on everyone around us, including the staff, and we nebulise the salbutamol. There are some new nebulised machines, the ultrasonic ones, that are less likely to transmit infections, I'm told. It would be useful to work that at a local level. But nevertheless, in most cases, we use nebulised salbutamol. It is possible to give it intravenously, but this can be associated with some more side effects, we think. And in terms of the dose response, that's less clear. What other treatments are available to treat hyperkalemia? There's two other treatments which we really don't use very often. They don't have much of a role in terms of management of acute hypokalemia. One is risonium. There's sodium and calcium salts. I don't really differentiate those two. K-Xylate is a brand name elsewhere, and the drug name is the polystyrene sulfonate. This is a medicine that's called a resin binder. So in the gut, it pulls potassium from the splanchnic or gut circulation into the bowel and helps to remove it. It's probably relatively low in potency. For it to work, you need a, there's a delayed onset. I'll talk about alternatives in a moment. It does have some side effects that people get worried about in terms of gut ischemia. But in general, we consider that it's a low potency treatment. What has happened is that some people will give it as an enema, and this may help to 30 grams, for example, as an enema may be more effective. But this certainly should not be a frontline treatment. It might be a later one. The first front two lineline treatments are ones that I've mentioned. There's been some data. There's a RCT, a randomized controlled trial, that suggests that rosonium may be useful in patients who have chronic hyperkalemia to keep down their potassium.
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But in terms of treatment of an acute case of hyperkalemia, it wouldn't be one of your first-line treatments. The other treatment that we sometimes talk about is sodium bicarbonate. Bicarbonate, anything which alkalemia causes a hypokalemia, drops of potassium. The problem with giving bicarbonate is it's associated with lots of other electrolyte abnormalities, including hypocalcemia. It may cause hypernatremia, and alkalemia itself, we think, may cause vasoconstriction. There can be a lot of complications with this. If a person has impaired heart function or, for example, end-stage renal failure where you may have impaired kidney function and volume overload, this guy's already missed two episodes of dialysis, bicarbonate may be bad. So in general, this is not something which I think most doctors would need to consider as an option. There are other treatments as well, although they probably wouldn't work in this patient, diuretics. So furosemide, for example, or furosemide is a very potent loop diuretic. It's associated with hypokalemia. Some patients who come in with fluid overload, for example, due to heart failure, where they've got a hypotension due to an inefficient, they may have hyperkalemia and a nice big dose of furosemide can be enough to offload some fluid and also drop the potassium. So as you can see, there's lots of treatments available. It can be complex in terms of choosing between the two. A lot of it depends on the patient who you're treating in front of you. In the case of diuretics, if they've got end-stage renal failure, they probably don't work, and therefore it has no role in this patient. But there may be other patients where it has a role. So this person needs to go to dialysis? Yeah. So the definitive treatment for this guy is going to be dialysis. Now, something I sort of hinted to beforehand, all of these treatments that I've mentioned generally work by pushing potassium from the blood into the cells. The problem with end-stage renal failure is that their body can't get rid of potassium, so they've got a chronically elevated potassium level in their whole body. So any sort of treatments that you give, A, will have a lesser effect of pushing the potassium into the cells compared to someone who doesn't have that issue, but also will be very much non-sustained. So the definitive treatment for this person is dialysis as soon as possible. So while giving these treatments that we've already discussed, you need to be on the phone to whichever nephrology service which is close to you or intensive care service in the event that they provide acute dialysis in your institution so that you can get a definitive treatment, which is dialysis. Are there other indications for dialysis? You say this person would develop, I guess, an acute kidney injury and hyperkalemia. Is having a high potassium level an indication for dialysis? Controversial. In some places it is. The main indications that we have for dialysis, the clearest indications for acute dialysis is electrolyte abnormalities that are refractory to treatment. So the first thing we would do is we'll try medical treatment, as I've mentioned, refractory fluid overload or refractory acidosis. So there may be a combination of these things. Again, whether or not we start or the timing of starting dialysis in acute kidney injury largely relates to the cause of the acute kidney injuries. They're dehydrated, you give fluids and you can already see the creatinine's coming down, then you would think that the potassium will probably follow. A great case of this is actually patients that come in with obstructive uropathy, whether they relate to a big prostate or if there's some sort of cancer. Often the potassium is high, there's kidney injury, and the minute that the catheter goes in, there's a prompt diuresis, excellent urine output, potassium drops quite quickly as well. So that would be an example where you would very uncommonly consider dialysis. So decisions about dialysis with acute kidney injury really can be complicated and relate to exactly what the cause is and anticipate a time course. We've organised the dialysis, we've given some calcium, we've given some insulin dextrose. What's the timeframe before we need to re-measure the potassium to see whether it's been affected and especially whether it's going to spike up again? That depends on how high it was to start with. This is all a gut feel. For example, if it's more than seven, I would be repeating it within one hour to get an idea of what's going on. I'd continue to repeat it every hour until there was a clear trend coming down or, in this case, a guy was on dialysis. If it was less than seven, for example, between six and seven, I'd probably do it every two hours. But close monitoring, regular monitoring with blood tests is crucial. In regard to monitoring, ECG monitoring, is that indicated in patients with hyperkalemia? So all patients with hyperkalemia should go into a monitor until a definitive treatment or time course of potassium is clear. That's very important because cardiac arrhythmias and death is largely cardiac driven. Are there any take-home messages regarding hyperkalemia for the junior doctors who are working on the wards? I think the main things I'd like to say is that hyperkalemia kills people and so you've got to be very careful. It's difficult in many cases to over-treat hyperkalemia. If in doubt, I think you give the treatment, except if there is concern that the person had clearly a haemolyzed specimen. But once you've got any evidence, particularly of ECG changes, go ahead and do the treatment. You can always give potassium afterwards if required. But again, that's often unlikely. But close monitoring, giving the treatment, anticipating a delayed onset, close monitoring to see that things are improving. It will take at least 6 to 12 hours after the presentation of a patient with hyperkalemia to actually work out what direction they're taking. Are they getting better? Are they getting worse? Are they staying the same? And the thing to remember is that as a junior medical officer, you may not be in a position to provide all the care that's required for this patient during that time frame. And this is where you really need to speak to doctors that are more senior to you to work out whether or not they're best on the ward with you, if they should be in intensive care, or if we need to escalate to a more definitive treatment, for example, such as dialysis. The other thing to remember with dialysis is that while dialysis removes potassium, it's really only removing it from the blood. Some potassium, of course, will come out of the cells, but you should anticipate that after stopping dialysis, potassium will flick up again. And I've seen this in my patients who've come in, one with a potassium of nine, we dialysed him, finished, took a potassium half an hour after dialysis. It was seven. We started another four hours worth of dialysis. So just a single four-hour dialysis may not be sufficient to cure someone of hyperkalemia. They may need more treatment. The other thing I think that junior doctors really need to think about is that what is the cause of the hyperkalemia in that these things may not always be appreciated at the time of presentation. Now traps for young players are number one, not looking at the medication chart. So many medications cause hyperkalemia. If you don't know, you need to check. Digoxin, antibiotics that I mentioned before, many of the medicines that are used for blood pressure, diuretics, these medicines can all put up the potassium. And sometimes these patients are admitted and all their regular medications are continued. So it's important to review all medications, consider which ones should be withheld or stopped in case they're contributing. I think the other thing that's very important is that there are sometimes cases of patients who are admitted, particularly if they're elderly with a degree of confusion, where there may have been trauma that hasn't been picked up. So rhabdomyolysis and this muscle injury can cause potassium to go high, can continue to be high and things can get worse. So thinking about doing a full and detailed examination, looking for other markers of other causes where there may be hyperkalemia and addressing these. Internal bleeding is another example. So intra-abdominal hemorrhage has been associated with hypokalemia due to the lysis of cells as well. So look at the full blood picture and consider how any of these other factors may potentially have contributed to the blood results.
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Welcome Junior Doctors to our podcast series and I'd like to welcome Dr Raj Puranik. Thank you James. Raj is a cardiologist here at RPA but also did his Junior Doctor training at RPA, is that right Raj? That's right, been here since about 1993. Okay, that is a long time. Look, we're going to talk predominantly about chest pain. It's a very common after-hour scenario for junior doctors, and I'm sure when junior doctors start on the ward, it's one of the things they probably fear the most. So maybe give me briefly just an overview of how you'd approach a patient with chest pain on the wards. Look, I think the approach should be fairly broad. The way I approach chest pain is to think of it as the life-threatening causes and everything else, basically. And looking at the life-threatening causes, the three most important category of disease would be ischemic heart disease, aortic dissection or aortic pathology and pulmonary embolism. They're probably the three most important categories of life-threatening chest pain and then you have all the other things that can cause chest pain which are often the nemesis for us in the differential but you know gastroesophageal reflux disease, musculoskeletal chest pain and lower respiratory tract type infections probably constitute the ballpark of the differential for chest pain. Okay so that gives a good overview of some of the cause of the differentials. You know what's your approach of trying to differentiate between all those different? Yeah look the clinical history is fundamentally the most important aspect and that's why from a junior medical officer's point of view this is vital information that every doctor should be able to obtain. So the classical features of chest discomfort that we're looking for to exclude ischemic heart disease would be a retro-sternal chest pressure that radiates, possibly radiates into the neck or the arm that may have had an exertional component in the past, but often on the ward or in the emergency department will be at rest. Nocturnal component to chest pain is often very suggestive of a coronary problem. And the unstable features, so where someone has had stable or exertional symptoms where it becomes unstable are very very important and the hallmark of this would be prolonging symptoms symptoms that are getting worse symptoms that are not alleviated easily by rest symptoms which exist despite the use of nitrates for example or very prolonged nocturnal symptoms, as I've said before. So where stable disease becomes unstable starts to become a much more worrying entity. And wrist pain, of course, is the most worrying of those because this may represent an imminent infarct. We'll probably talk about ischemic chest pain in more detail, but what are some of the features of aortic pathology that you would be suggestive of someone who's got aortic dissection? So I think very quickly in the chest pain questionnaire when you're approaching a patient is to understand if pain radiates through to the back, a question which is not always asked, but intrascapular pain, severe onset of back pain, even lower back pain can often be the beginning of an aortic problem and I think should be very important in the differential. If you have a chest x-ray to reference to, widening of the mediastinum is something that is actually quite easy to identify if it's bad enough to cause chest pain. For pulmonary embolism, the pleuritic aspect of pain, so worse with respiration. And pleuritic pain I divide up into that which could be due to pulmonary embolism and that which could be due to pericardial disease. And the way to differentiate these would be the difference in positioning of a patient. So pericardial disease is often much worse lying down and much better sitting up whereas the pleuritic pain from pulmonary embolism may be independent of that and just worse with respiration. Okay so we'll give a scenario that you're a junior doctor, it's after hours on the ward, you get paged by a nurse that a patient in bed six has got chest pain. What information would you get over the phone from the nurse before seeing the patient? So I'd really like to understand the clinical history in a nutshell. I'd like to know these hallmark features that we've just spoken about. We'd like to know the vital signs of the patient because that acutely determines how quickly and rapidly we need to approach the patient. The patient needs to have had a basic ECG at least in the process of having one and needs to be attached to some oxygen and potentially start thinking about administering some nitrate or pain relief. So what sort of things would determine how quickly you go to see chest pain or chest pain would be a priority? Look I think patients who are complaining of rest and severe prolonged pain would worry me. Any pain which is accompanied by a hemodynamic compromise, so rapid heart rate, irregular heart rate, low blood pressure. A patient who generally just looks unwell, if the patient, if the nurses are saying look this patient has changed in their appearance and now looks unwell, I think you must respond urgently to that sort of patient even if it's to reassure everyone that it's okay but it's our responsibility to tease that out and of course if there are ECGs that people think have changed then certainly one would need to assess that to understand how rapidly we need to activate invasive approach to management. Okay, so we'll give a case. You've got a 50-year-old male who's day one post-TERP with a background history of diabetes, hypercholesterolemia and smoking, who's got a 10-minute history of some 9 out of 10 central heavy chest pain right down near the left arm. At the bedside he looks sweaty. What sort of some of the features of the or some of the features of assessment history and exam suggest that this patient has an acute coronary syndrome? So on history and examination you've elicited a classic history of unstable angina, someone at rest post-operatively who's developed chest pain. They look unwell, they're sweaty, so that perspiration is representative of that catecholamine surge that acutely occurs with acute coronary syndrome. You've got multiple risk factors in the background. This is an emergency and needs a rapid fire activation of a plan, an urgent bedside assessment. We need to ascertain if this patient needs to be acutely resuscitated and hemodynamically stable, and then move on to activating an ischemia-based management plan, that is, to have some ECGs acutely to compare to previous ECGs, and to some empiric therapy and that will involve nitrates and possibly antiplatelets. That was a fairly classical history of ischaemic chest pain. Can you tell me, they're not always that easy straight out of the textbook, what are some other history or historical features you particularly look for? Yeah look I think the accompanying features of chest pain can be useful so if patients have breathlessness and breathlessness is often our nemesis breathlessness can be cardiovascular or respiratory or a hematologic problem but certainly chest discomfort accompanied by breathlessness is certainly worrying from a cardiac point of view. That issue of sweating and that perspiration, that catecholamine surge is often very important from a cardiac point of view. And accompanying arrhythmic symptoms, so people who are presynchable, who've had syncope in the past, who feel lightheaded, again that usually reflects low coronary blood flow, low cardiac output, and that can all be a manifestation of a coronary syndrome, where the symptoms are a little more subtle than having the classic chest pain. These are the features I'd look for. Are there risk factors important in identifying patients who do have an acute coronary syndrome? I think the way to think about that is that the absolute risk of a coronary event is dictated by coronary risk factors. And the classic age, male sex, smoking, diabetes, hypertension, hypercholesterolemia, and a family history of premature coronary artery disease. So someone who's had a coronary event under the age of 60. This gives you an idea of what someone's absolute risk of coronary disease is, and on that background, you can assess their risk, and that's classically used in primary preventative strategies. It does help in the acute situation, but when you have a patient who's actually symptomatic, and it's not about screening of the asymptomatic individual, independent of any risk factors, every chest pain needs to be treated on its merits. Of course, additional risk factors are very helpful and will allow you to risk stratify them further and every risk factor potentially gives you a little bit more weighting than what you're listening to is definitely ischemic chest pain. But fundamentally, the history that you get, independent of any risk factors, is the primary driver of how you treat them. In emergency departments, risk stratifying people with chest panic acute coronary syndrome is, I guess, something we do all the time. Is that important to do on the ward?
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So they can be managed with simple anti-platelets on the ward and anti-anginals or you can escalate the type of therapy so that they are monitored in a monitored facility and not in a general post-operative ward where you're worried because in the first 48 hours after a significant coronary event you're at risk of arrhythmic consequences and so you can upscale to do that and of course then there's the angiogram lab itself where if a patient is imminently in daytime hours or after hours looks like they're going to put their ST segments up and have a full-blown transmural infarct that we can reduce the time that the muscle is ischemic salvage myocardium by expediting a coronary intervention 24-7. So as a junior doctor you need to be aware of the possibilities even if you're not the person making that call, you need to understand how the problem could be escalated and your job is to capture that initial history that sets the scene for that subsequent management and that's very very important especially if it's at 2 in the morning. Okay you reviewed a patient with chest bone, the history and exam and the ECG is put in front of your face. What are the particular things you look at the ECG that suggests this patient could have acute coronaryary syndrome? Yeah look the first thing is I always like to have a previous ECG. On this day and age with the electronic system we have a greater ease with which we can review ECGs from the past and understanding acute changes should always be in that context. So whenever someone puts an ECG in front of you the two questions you ask is it has the patient got chest pain now? Because that would warrant you an urgent bedside review, not just to look at the ECG. And have you got a previous one for me to look at? And then the actual surface ECG, the things that we're very interested in are, of course, identifying acute changes in the ST segment. So the J point is about 40 to 60 milliseconds after the S wave. So that's one or two little boxes after the QRS complex, small boxes on the cardiograph. And you can adjudicate from baseline whether there's been a shift in the ST segment either up or down. And that will be indicative of either ischemia if it's down or infarction if it's up. And accompanied with this is T-wave inversion. Often in the hyperacute phase, the T-waves will be upright and will be dramatically upright. They'll be very, very acute changes, and then they flip and become inverted. And if someone has had chest pain and this is a recurrent process, you look for Q-waves to see if they've had any previous coronary events, which would be indicative of transmural myocardial infarction. Of course, the rhythm is important as well. So a patient who is in atrial fibrillation for the first time, that in itself may be the manifestation of coronary ischemia or ventricular arrhythmias are very important. And there can be some more subtle changes on a cardiograph. For example, a prominent R wave or an upstroke in V1 is a very pathologic sign, which could be indicative of posterior infarction, a very subtle finding, which may otherwise look like a normal ECG to lesser experienced people, but is a pathological finding. So ECG is important, we often take troponins in the setting of chest pain. What's the role of taking a troponin in someone who's had some chest pain say 20 minutes ago? Look troponins really revolutionize the way we manage patients and the thing that is most important, the take-home message is still that your fundamental approach to these patients is based on the history. The pre-test probability of any test showing significance is determined by, well the post-test probability is determined by the pre-test probability. That is, your assessment of the clinical aspect of the patient is the fundamental driver of whether the test is useful. So if the chest pain is atypical and the troponin is positive, that troponin result is much less useful to us. It is a confirmatory test rather than an acutely diagnostic test in my eye, because most of the confirmation really comes from your clinical evaluation of the patient. Now that said, there are very many patients who fit into this intermediate category where you're uncertain about the chest pain and that can be with lesser experience or even with very experienced people and that's when the troponin adds a lot of value where you've got some factors of the chest pain that we've already spoken about but not all and you're not completely sure and then the value add of a troponin to confirm that there has been unstable angina that has now become infarction is actually a very important finding. It's important because it confirms your suspicion but it also changes the way you manage the patient because the fact that troponin has leaked from the myocardium now puts the patient at risk of imminent transmural infarction and arrhythmia and changes the way we manage the patient. So troponin has a very important role in the correct clinical context but out of context can represent a number of important false positives and that should also be taken into consideration. The important false positives would be inflammatory processes affecting the myocardium or the pericardium. Troponin is known to be elevated in just arrhythmia cases alone, independent of infarction. Heart failure itself can promote troponin and of course if troponin is a large macromolecule cannot be excreted by the glomerulus in the kidney because of a low GFR may just represent poor prognosis because the patient has renal impairment and so it's a diagnostic utility in that scenario is much less but it has prognostic value of course people who retain trop troponin, just like having a low GFR, don't do as well as those who have a normal troponin. Other causes of a troponin include exercise, just strenuous exercise. You can release troponin, septic processes, even in stroke it's been known to be elevated. This person, the case we've got is post-op. Can you get a troponolise post-operatively or only in cardiac surgery? Look, it depends on the haemodynamic insult during the surgery. So it's very possible that under general anaesthesia in a predisposed individual, and a lot of it depends on what their predisposing factors are, such as undiagnosed coronary disease and a low blood pressure through the procedure may actually lead to a minor coronary event. So it isn't just cardiac surgery which can release troponin, and I think that tells you that there has been some important damage. It's a very sensitive test. It's also very specific for the myocardium. And so there are a few other tissues that release troponin. So one would suspect that there's been a hemodynamic insult in a predisposed individual and to always take that seriously. We often say that you shouldn't just do one troponin or one ECG, do serial troponin ECGs. What's your perspective on those and when should they be done? Again, the earliest timeframe that troponin is elevated after the onset of symptoms is usually about six to eight hours. And in that ballpark, if someone has clear onset of symptoms, and that's very important to establish, often people who wake up from sleep with symptoms, because classically coronary and cardiac problems occur at 2 in the morning when people are very uncertain of when a process has started. Usually six to eight hours after a troponin, if there's a significant event, will be elevated. Now if you have a normal troponin but a strong clinical suspicion, then a repeat troponin in a similar time interval of six to eight hours would be very useful to confirm that there's been a process. Again acute process that's led to infarction but that said even if troponin is not elevated and the clinical history is compelling that patient could still be admitted and have an angiogram and found to have triple vessel disease or left main. So please don't exclude the patient from higher escalation of therapy just on the basis of a normal troponin. But I think it is a very useful test in the serial testing. Okay, I think we'll move now to management. And we suggested, I guess, some of the management strategy you may use. One which has come in a bit more controversial, the Ronald Oxygen acute coronary syndromes. Should all patients who have chest pain go on Oxygen? Look I think Oxygen is a fundamentally important aspect in managing acute coronary syndrome. The only caveat to that is really patients who are CO2 retaining and where their drive to ventilate is determined by that a mild degree of hypoxia. So the standard response will be to provide high flow oxygen. Why is that important? Because the myocardium is under extreme demand and supply issues in terms of coronary blood flow. So the supply of blood to the myocardium is dropped.
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Okay welcome everyone to On The Wards, it's James Edwards and today I have the pleasure of speaking to Dr Ying Li. Hi Ying. Hi, hello. Thank you for inviting me. Dr. Ying Li is a self-specialty fellow in reproductive endocrinology and infertility at Jenea and Aurope and Salvatore Hospital. And today we're talking about vaginal bleeding in the non-pregnant patient. So the non-pregnant patient who has vaginal bleeding presents sometimes in the men's department, sometimes you'll see on the ward. And we'll start with a case. You're a junior doctor working in an ED and you're about to go and see a 22-year-old female with vaginal bleeding. The triage nurse has noted a negative urinary pregnancy test. So what are the kind of common causes of abnormal vaginal bleeding in a woman of reproductive age who is not pregnant? So the common causes have been listed by the Federation, International Federation of Obstetrics and Gynaecology as under structural causes or as functional causes. So when you're looking at structural causes, you're looking at things like polyps, endometrial polyps, adenomyosis, which is endometrial glands in the muscle, which can cause quite painful and heavy vaginal bleeding. Lyomyomas, so fibroids, they can cause very heavy menstrual bleeding. And malignancy, obviously. So when we're talking about malignancy, we're talking about things that are not just malignant as in cancers but also pre-cancers to hyperplasias. When you're looking at functional causes then you have to consider things like coagulopathy especially iatrogenic coagulopathy and some of the inherent bleeding disorders such as von Willebrand's. You can also look at ovulation disorders. So things like PCOS, which is probably the most common ovulation disorder, causes quite heavy but irregular PV bleeding. And you suppose on the other side of the spectrum, you're looking also at irregular light bleeding, which is looking at suppression of the hypothalamic pituitary ovarian axis, things like LH surges, microadenomas and so forth. You can also look at endometrial causes of abnormal uterine bleeding. Sorry, not endometrial causes. Yes, endometrial functional causes, so things like infection, especially in the postpartum woman, and also inherent imbalances in the way blood can clot and lyse that can cause heavy bleeding either in the period or in between periods. Iatrogenic causes are always an issue that we should consider, especially hormonal therapy. And finally, we have a classification called not yet classified by FIGO, which is essentially saying that we don't know. Okay, so that gives us a bit of a background to thinking what the underlying causes are. So you're walking to see the patient, when you go in and see her, she looks a bit pale and you measure her pulse rate and she's tachycardic 105, although the blood pressure seems to be okay. What's your initial approach? So I think like all presentations in emergency, we do focus on hemodynamic stability. So the most important thing would be to put a cannula in, resuscitate the patient as appropriate. I think the thing to understand with 22-year-old gynecology patients in general is that they are well patients that are very well compensated and they can be compromised without a drop in blood pressure. With gynecologists, we would like to confirm a state of non-pregnancy, so always a serum HCG over a urinate CG, and obviously pulling off blood such as full blood counts, and if she's bleeding heavily enough, looking at a coagulation profile. And yes, and we've mentioned the resuscitation. And then once the patient is stable and all those things are done, then obviously a history examination is very important. So when you think about history examination, maybe just go through some of the historical features. So I think one of the things to establish is convince yourself that this is vaginal bleeding. So sometimes people are very unsure about whether this is coming rectally or vaginally. And also, for me, it's very important to work out whether this is bleeding during the period, which is much more common in things like fibroids, or whether this is bleeding outside your period, which in terms of intramuscular bleeding, we mentioned some of the ovarian dysfunction, endometrial dysfunction or bleeds. The other thing will be to work out whether this is provoked or unprovoked. Just to keep in mind that bleeding is not always uterine. Bleeding can be vaginal, vulval, and there are causes of post-coital bleeds, traumatic bleeds that we need to elicit, and generally a background history in terms of general health or whether they've got any predisposition to make them bleed, such as von Willebrand's or coagulopathies, and any surgical histories which may impact upon treatment. And after that, you will then move on to an examination, which would include a general inspection of the patient, a feel of the abdomen, which in most cases in women who have a non-pregnancy-related vaginal bleeding is probably not going to be very much. Sometimes if they have a fibroid uterus, you can feel a mass, but in most cases the abdominal examination is probably going to be fairly benign, which means that the vaginal examination and the speculum examination is going to feel important. Maybe before we go on the examination, just trying to work out how much bleeding. Yes, definitely. What's a kind of a way of assessing the amount of bleeding? It's fairly difficult, and women will always tell you it's a loss most of the time because when it does go on, it's fairly traumatic for them. So I use things like things you can quantify and define, things like pads, how many pads that are filled or soaked and soaking through pads onto their underwear. In terms of cloths, it's always used to get an idea of how big they are, whether they're the size of a 50-cent piece or they're bigger, the size of a golf ball and so forth. And also it's always handy to see how much they've bled since they've been to ED. So often the nurses will change a pad or change a bluey when they get onto a bed, and it's useful to say to them, you know, between admission and now, have you filled up what we've given you? Also, in regard to the use of the old contraceptive pill and things like that in regard to bleeding, is there a certain pattern that sometimes when they normally expect to have their vaginal bleeding but sometimes they don't always take the pill each month. Sometimes they back up over three months, and sometimes you're not quite sure when they should be bleeding. How do you kind of sort that out? So if they are on the oral contraceptive pill and they do take the sugar pills, they should bleed fairly regularly, and they will know whether this is a regular bleed, and sometimes this is a regular bleed but heavy, but regular in terms of timing, or if they've forgotten to take the pills and they've been taking them fairly erratically, irregularly, then yes, the bleeding can be fairly irregular in terms of timing. And it's important to ask them how they are taking the pill exactly and whether they give themselves breaks or no breaks. In regard to the examination, as part of the hemodynamic, I know we routinely often do a postural BP. Yes. Especially to make sure they haven't got, I guess, maybe some volume loss that we haven't identified on the normal blood pressure. But one of the big controversies is the speculum exam and what's the value between the speculum exam and the vaginal exam and what should we be looking for in particular? So I think a speculum and a vaginal examination is fairly important especially as an initial presentation and from a very basic perspective looking at inspection of the vulva, looking at signs of trauma and when you insert the speculum don't just focus on the cervix. A lot of junior doctors, it's really important about finding the cervix. And yes, it is very important to see where the bleeding is coming from. Also, as you open up the speculum, look at the vagina, sidewalls, especially if there's a history of trauma, to see whether there's any lacerations there that are causing the bleeding. Because the vagina is very well vascularized and they can lose quite a lot of blood if there is trauma there. The other thing with speculums is that once you get to look at the cervix, if there's a big clot sitting there and the patient is, for example, bradycardic and hypotensive, then that is the reason why they're hemodynamic unstable. If you remove the clots at that time, then that vagal response caused by stretching the cervix will be removed and they become normal heart, nomocartic and quite stable blood-wise.
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Okay, welcome to In The Wards, it's James Edwards and today we're talking about fracture assessment and management and I'd like to introduce Dr. Nick Maluga. Welcome Nick. Thanks James, very good to be here. Thank you very much for inviting me. Nick's an orthopaedic registrar currently working in Sydney, currently at Nepean Hospital. Yes, correct. And we're going to go through, I guess, fracture assessment because it's something the junior doctors do see a lot within the emergency medicine term but also many people doing orthopaedic terms. Well, you know, up to 70% of emergency presentations are musculoskeletally related. So it's an area that, you know, junior doctors get a lot of exposure to. So we'll start with the case. You work in the emergency department as a junior doctor and you see the next patient. It's kind of crash bright, obvious deformity to left leg. He's got a splint put in by the AMBOs and you rush in to go see the patient. When you go see that patient just outline your initial assessment. Yeah so just to mention that's like a typical triage note so you expect to see a lot of those. I guess the assessment of what sounds like a trauma patient is very protocol driven and standardized. So every patient should be approached in exactly the same manner and that manner is based on EMST principles. The emphasis on life-saving skills and systematic approach, and systematic approach cannot be emphasized enough, and establishing of management priorities in that trauma situation. So obviously everyone's heard about ABCs, and I'll repeat that again, ABCs. So airway maintenance with cervical spine protection. B is for breathing and ventilation. C is for circulation and hemorrhage control. D is for disability, so neurological assessment. And don't ever forget the glucose, you know, E, F, G. So you start off by exposing your patient and controlling the environment. Very important to assess every inch of the patient. At each stage, once you identify the problem, whether it's the airway, the breathing, the circulation, once you've fixed it, you go back and start the process again, re-evaluating the patient at all steps. The easier way to perform the ABCs is to talk to the patient. If they can respond, their airway, their breathing, they obviously are okay because they're able to voice. The circulation must be sufficient for them to perfuse their brain, so you don't have to worry about that at right that stage. What else? Once identified, you deal with that problem, then you stop, reassess, re-evaluate, go back to A, come back. So in regards to this patient, because obviously we're going to get down to the fracture or the acute orthopedic injury, assuming the patient is stable, you've done a thorough assessment, and really what you've got now is predominantly somebody who's got a deformed left leg. What are your particular things in the history and examination you'd like to know as an orthopaedic registrar? Yeah, so luckily for the junior doctors, these sort of patients are never approached on an individual basis. They're always managed as a part of the trauma team. But that doesn't mean that you should lose track of all the parts that are going on and having an understanding of all the different steps allows you to carry that much more experience out of managing that sort of patient. I think something like AMPLE, an acronym A-M-P-L-E, would be helpful. A for allergies and ADT status, very important if you're planning to administer medications. M's for medications, what patient's taking now, can there be any interactions, can it affect their presentation. P's for past medical history, can potentially give you an idea of the cause of their situation. L, last ate and drank. Very important if the patient's potentially for surgical intervention. The surgeons, they need to just, everyone will want to know that. And E is for events, how the patient came to be from normal to where they are now. And any pictures from car crashes that ambulance can take, try to get those, very important. Has there been an intrusion into the cabin? Has the patient extricated themselves? Did they have to be cut out? How far the motorcyclist has traveled from the point of impact to where they came to rest? That all gives you an idea of the potential severity of their injuries and also the potential, I guess, coalition of them. Can there be any internal injuries associated with that obviously broken leg? Is there likely to be C-spine? Do they wear protection? That sort of stuff. So you've mentioned about the past history as well as mechanism. Any other particular points on the history and exam? Once you've done, I guess, the examination of the primary cyclical survey. Well, once you've established that the patient is safe and they haven't got any life or limb-threatening injuries, you can perform a targeted examination of any deformity that you have identified. So you perform a neurovascular assessment. You make sure that it's a closed injury, as the management of a closed injury is vastly different from the management of an open injury. Also, if there is a neurovascular compromise, again, the timeframe shifts to the left a lot in terms of management and we say neurovascular is that mean testing sensation motor and testing pulses both so you you want to assess the neurovascular status distally so you try to target most of the major nerve distributions so in the leg you know you want to take the deep and superficial branches of the major nerve distributions. So in the leg, you know, you want to check the deep and superficial branches of the common perineal nerve and posterior tibial nerve. You want to check the pulses. You want to check, you know, the salispedia, posterior tibial pulse. And so I guess if you can't feel the pulses, see if you can find them with a Doppler. See if the legs perfuse because sometimes you can't feel the pulses because of the swelling or because of compromise to a particular blood vessel, but there might be collateral supply. So perfusion is probably the initial most important assessment, and then you can start working from there. Capillary refills is a good indicator of perfusion and temperature. So you've done a trauma review, you've organised some trauma standard trauma x-rays and as part of that you did a x-ray of the left leg and looks like on that x-ray there's a fracture of that left tibia. Can you just give people an overview how you should be describing x-rays, which is very important when you speak to somebody over the phone. Okay, well, describing x-rays is an integral part in communicating with the orthopedic team. We look at a lot of x-rays and a lot of our management decisions would come from how the x-ray looks. So very briefly, without going into too much detail, you have to identify the film that you're looking at. So obviously you're going to make sure that it's the same patient, patient that's the appropriate location and you can do that before you make a call and when you're speaking to someone it's just assumed that you've already done that but in terms of the fracture you try to describe the type of fracture where the fracture is located and whether it's displaced and is there anything else going on. So if you just hit those major points, I'll just cover them in more detail one after the other. So the type of fracture, you want to see what, explain whether it's a complete or incomplete break. And if it's a complete break, there's a couple of main patterns. And the key words for those are is it a transverse? Looking at the line across the bone, right? So the fracture patterns are described in terms of the line that's along the bone. So transverse fracture is at a 90-degree line to the length of the bone. Oblique is kind of self-explanatory, once you know that, and spiral is kind of like a corkscrew shape. And it can be a combination of the two. And in that case, if there are more than two parts, it becomes a comminuted fracture. And the comminuted fractures can have special subnames such as a butterfly fragment or a segmental fracture but that's kind of next level if you can hit that you know you'd be in the top 5% of the GMOs with the incomplete breaks you know you want to describe whether it is bowing or a buckling of the cortex things like green stick fract fractures and torus fractures, predominantly this is in the pediatric population, as their bones contain a lot more elastin and they tend to bowl rather than break. Sota-Harris classification is excellent for describing those kind of injuries.
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That kind of gives you an indication of the potential surrounding damage and whether the joint is likely to be involved. Sometimes naming an anatomical part of the bone would be helpful such as you know base or shaft or neck or the head. So knowing your anatomy is very important if you don't look it up it's very easy. And the displacement of the bone can be described in angulation, translation, rotation, distraction, or impaction. So angulation, you're talking about distal fragment comparatively to the proximal fragment. So the angle of that, the translation of that fragment along the proximal fragment, the rotation of it, and whether it's been shortened or lengthened. This kind of describes what has happened to the bone during the injury. And I think a lot of people will stop at that point, but it's also important to mention that the most commonly missed fracture is the second one. So what else is going on? Is the involvement of the joint line? Has the fracture extended into the joint? Is the joint still congruent? Has it been subluxed or dislocated? Is there a big step or gap in the joint? You don't have to quantify it, but if you say there's a big gap in the joint, it makes us look at it twice. And obviously the second fracture, such as with the distal radius fractures, you tend to get radial neck fractures or scaphoid fractures. Is there a dislocation of the joint? Very important not to miss. So you've described the fracture and you get a ring orthopedics and describe that fracture. When you do, they suggest putting a trauma backslab on. Yes. So why put the backslab on? They're going to go to theatre anyway, so why put a backslab on now and what sort of backslide would be appropriate for this type of patient okay well immobilization of any fracture is an essential part of the emergency management okay most importantly it's pain relieving patients get pain from instability of the fracture patterns bones are or the periosteum specifically is very very charged with nerve endings. So when you get the two bone ends rubbing against each other, that causes intractable pain. No amount of analgesia is going to reduce that. The only way to stop that pain and provide pain relief to the patient is to splint it and stop it from moving. And the best way to do it and the easiest, most accessible way of doing it is with a backslap or a plaster cast of some description. And we know from statistics that pain management is probably something that's very poorly done in emergency. On average, it takes about 40 minutes for a patient to receive any kind of initial pain management. So if you can get that done quickly, you're already winning. The second most important reason for that is it prevents further trauma to that region. Bone ends when they break, they're sharp. So if there has been no initial compromise of the surrounding soft tissue or the neurovascular structures, you can be pretty certain that as the time goes on, that risk increases. So you want to prevent any damage to the surrounding structures. And the third important reason for that is you want the body tries to create a splint in its own right. It's just not as good as us doing it externally, but it still tries. So it swells the area, which will increase the risk of compartment syndrome, makes it more difficult to operate on, and it will create a clot to bridge that gap and to start healing the break. It happens immediately. But the continuous movement of the fracture fragments will destabilize that clot. It will make it bleed more, causing increased swelling, but it can also cause clot to go into the system, giving you pulmonary emboli or strokes or localized ischemic strokes of the limbs. It's very rare, but it can happen. The other thing in long bones, such as a femur, you can get a fat embolus as well, just from the fracture fragments not being stable. And that's quite a severe complication that all we can do is supportively manage the patient for is actually not treatable. So what are some of the principles about applying a backslide? Right so I think the most important thing is you want it to do the job that you want it to do okay so you the easiest way to think about it and a it comes with experience and practice, is you want to splint the joint above and below, because a lot of the muscle groups act across several joints, and that will affect your splinting. You want to make sure it's robust enough to provide sufficient support, but at the same time, not so occlusive that it will prevent the inevitable swelling in the area and compound your dangers of compartment syndrome. So you use a backslab rather than a circumferential plaster. Correct. So in an emergency situation always use partial plasters. This allows for whatever swelling to happen to happen naturally and allows easy access in an emergency situation to whoever might be following on from yourself. So to put this backslab on, the registrar, ED registrar gives us a procedural sedation. You bat with the backslab on, and you notice on the medial side of the tibia, around the fracture site, there's a little laceration, a little bit of ooze. It makes some droplets of oil floating in it. That's what it looks like. Is this, by definition, an open fracture now? That is correct. Any hematoma, fracture hematoma that communicates with the outside environment, such as in this case, will be defined as an open fracture. So basically there's a direct tract for the bacteria from outside straight into the break where there's all this goodness and nutrients which they love and so they like to make a home there. So this means that it requires a slightly different approach to management. It's also very important to classify this kind of injury and the best classification system that we have to date is a Castillo classification for open fractures and it's been found robust and useful as it's a predictive classification to the likelihood of complications down the track so it's can they look it up or do it so yes we just say we just have a link. Okay. Yeah But it's out of three progressively the higher the number the more severe the injury So in an emergency situation when you're managing open fractures you One of the things that has been shown to have the highest positive outcome to these is removing any obvious debris or any dirt from the injury and early administration of antibiotics. So the evidence at this stage is for G antibiotics with the cephalosporin and the anaerobic cover such as imetronidazole but if there's gross contamination with dirt you also add gentamicin. Open fractures can bleed a lot so you have to control the bleeding whether it's with a compression bandage or you need to clamp off artery. Unlikely to be doing it on your own, but part of a trauma team that's going to happen. Dressing with betadine salt gauze or normal saline gauze allows sort of that capillary effect of all the dirty hematoma to be sucked out from the wound and also ensures that the soft tissue underneath the kept moist and not dried out and then as previously discussed stabilizing in a trauma and how about irrigation irrigation is controversial personally I if the patient's sedated and there's gross contamination I don't see any harm in trying to clean it all out and try to reduce the bacterial load. But if it grossly appears to be minimally contaminated, you potentially can get away with without irrigating as inexperienced irrigation can cause further damage however I would performing something like that I would advise to have somebody more experienced around so ask for help early it's not something to be managed on your own. Good yeah I think the importance of we've mentioned before about making sure tetanus vaccination. Yes. And what are your thoughts on photographing these wounds? Because often we put some dressing on it afterwards. We won't go through the medical legal aspects. That's what I was just going to mention. So if you remove yourself away from the medical legal aspects, it's an extremely helpful tool. There's multiple people, multiple specialties involved in management of these patients, and all of them will want to see the extent of the damage to make their own assessment and judgment. And it's just not practicable to continuously take the dressings down, put them back on, take the slab off, put it back on. One, it's uncomfortable for the patient. Two, it's a waste of resources. And so for communication purposes, the pictures are very, very helpful. It also helps you monitor progress. So you know where you started with. You can communicate with the bosses, you can plan the procedures that are required, the extent of potential debridement that may need to be done, and later on you can continue to take photos and monitor the progress of the wound, both for the patient and for yourself.
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Welcome to On The Wards, it's James as I'm here again and today we'll be talking about quality and safety for junior doctors. Before I start I would like to tell everyone that On The Wards is available through iTunes and also we would please ask that you write a review on iTunes about On The Wards. And today I have the pleasure of speaking to Dr Sarah Dalton. Sarah is a paediatrician and she's a clinical director at the Clinical Excellence Commission. I've known Sarah for a long time. Sarah and I worked together in paediatrics a long time ago. I won't say how long ago, but it was before the Sydney Olympics. So that's just how old we are. Sarah, welcome. Hi, James. How are you? So given your role within the Clinical Excellence Commission within New South Wales, we thought we'd come and chat about quality and safety, and particularly quality and safety in regard to the junior doctor. So maybe just a broad question to start with, how would you define quality and safety? I think that's a really good question, James. People will define it differently depending on where you are. I guess the easiest way to define it is any way that we make care better or safer for our patients. There are official definitions of quality and safety and they talk about the six domains of quality and safety, all of which would mean something to you. I might just run through them briefly as an overview. So it's care that is safe, effective, patient-centred, timely, efficient and equitable. And depending on where you work, you can imagine that you have different focuses on many of them, but for many of us, it's a lot about timely. Yes, I do know timely. So in regard to that pretty broad definition, I mean, has a junior doctor got a role in quality and safety or should we just leave that to quality and safety officers? There's a guy called Bertolden who talks about quality and safety and he says everybody who goes to work has two jobs, to do their work and to improve their work. And I think there's nothing truer for junior doctors and in fact for everybody in our hospitals. When we talk about quality and safety improvement, we talk about doing it in teams and that means the doctors, the nurses, the allied health, the cleaners, the clerks, everybody doing the same thing together. So if we say the junior doctors should become involved in quality and safety, how do they do that? Well, in fact, just delivering really good patient care, appropriate care, patient-centered care. We do that every day in our clinical roles and our consultants, I hope, emulate that a lot of the time as well. Being able to ask questions, to listen and to offer appropriate advice around diagnostic choices is a really important way of your clinical role delivering quality care every day. But with those other domains, there are other things that we can do to actually step back and reflect on our practice, to work out whether our practice is in fact as good as it could be and what we might need to do to get better. So talking about appropriate care is something we do a lot of, and M&Ms and other things that we do in health care has been, for doctors, one way that quality and safety has been championed for many years. But there are things about the way the hospital works, the way the systems work in the hospital, that junior doctors can play a really important role in. So if you think about taking blood cultures, it's actually something that is not just a junior doctor's job to go and take something out of a trolley and start taking some blood out of a patient and put it together the whole system in taking blood cultures is what are the indications for taking it where's the equipment kept what time is it taken where is it put afterwards there's a whole process involved including when it becomes positive who tells someone about the result what has happened as a result of result And all those things are different people in the system working together, but they can all be improved. And a junior doctor's perspective is really important in that. One part of quality and safety that many junior doctors know about is conducting audits. So we may go to a kind of, I guess, a case that you're working within a team and your consultant asks you whether you can help with an audit and you need to assemble and present some data. Now you have not much experience with audits so we may just try and help that junior doctor. What is an audit? Can I start by saying and in some ways answering your previous question about what is quality and safety? Anything that is a problem that can be improved in a hospital is a quality and safety issue. And if a junior doctor wants to get involved, doing an audit is a really good start. I suggest that if you are going to do an audit, you do it on something that you really care about and that you see as a problem. So if you choose to get involved in your own way, you can do it on something you want. If you're asked to do it by your boss, you might not have much of a choice. But either way, if possible, you should choose something that is a problem for everybody. Otherwise, there's no point collecting the information. So if we were to talk about a problem that we want to do an audit on, for example, a problem as a junior doctor might be that all these patients are coming from emergency and none of them have had their med charts written up. So an audit is at its basic level just a count. How often do we do the right thing? If you wanted to do an audit of patients who had their medication charts completed successfully from the emergency department it's just as simple as picking out 10-20 patients on your ward and then completing a tally chart really to see who has or has not had it completed successfully. There are many levels of detail and you can do a very complicated audit but it's really just looking at a bunch of things and choosing when it has or has not been done properly and recording that so you have some evidence of the problem. So an audit really is maybe one of the first steps in a quality improvement cycle. So can you describe what a quality improvement cycle is? An improvement cycle is finding a problem and fixing a problem. You could argue that the diagnostic cycle of medicine is an improvement cycle. As doctors, we are taught to take some history, find some information, agree on what the problem is, and then think about what a solution might be, propose the solution, try it for a little while, and then see if it gets any better. So a quality improvement cycle is no different. It's saying, you know, we've got a problem with maybe admission medications. What are we going to do about improving that? Well, the first thing you need to do is get all the information. Why is there a problem? And then you need to do a diagnostic and think about why the problem might exist. And then when you've thought about all the different things that might cause the problem, you can propose a few different solutions to that problem. You can try some of them, and we can talk about that later in more detail. But for each of the things that you try, you need to measure whether they've worked. And then at the end, hopefully, you'll have come up with a solution that will work and is sustainable. So what sort of information is best gathered in an audit? Audits are good basically for simple things where you just want to investigate three or four parameters. You know if we talk about research studies and we're doing investigations into large data sets and an audit is not that. An audit is a very small amount of information and often for junior doctors it will involve a medical record review. Perhaps looking at how many patients got the appropriate VTE prophylaxis or how many patients got their antibiotics within an hour for sepsis. So there are lots of different ways to get involved, as I said, starting with the thing that you think is a real problem and then working out what's the question you want to answer and then you need to find out what's the evidence I need to support me both in the question and the solution that I need for that. So this one's fairly practical. You see a problem and you're a junior doctor. How is it best to initiate or become involved in an audit? I think the best way to get involved in an audit is if it's part of a team that is already looking at something and it's a bigger piece of work. I say that because the audit itself is sometimes the easiest part of the whole quality improvement cycle and the audit can be just the data collection phase. If you're lucky to have the opportunity to join a team, say a ward is looking at their VTA prophylaxis, doing the audit for them is an excellent way of learning how to do an audit and hopefully also going on to observe the improvement cycle.
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Welcome to On The Wards. It's James Edwards and today we're talking about Haematuria and I have the pleasure of inviting back Dr. Jo Dargan who's a Urologist in training. Welcome back Jo. Hi, thanks very much. Jo's spoken before on urine retention and today we're talking on Haematuria and as usual we'll start with a case. You're a junior doctor working on the wards and you're asked to review a 72 year old male who's had an he's got an IDC and now the nurse has noticed that it's bloodstained. Do you want to describe your general approach to a patient such as this? Yeah this is probably a call that I receive at least five times a day and it's something that I know that a lot of the juniors get called about after hours so you know it is a really common problem on the ward is probably the first thing to say. We have a lot of catheterised patients in hospital, and especially in older patients it can happen spontaneously, it can be associated with other complications, so it's important to have a good approach. And the first thing I guess to say is that haematuria should always be taken seriously. And the reason that we say this is that there is a chance that there's an underlying malignancy and we need to work to exclude that in all patients. Unless they're very young, in which case there's another workup that you should do, but anyone over say 35 should really have a full investigation of any haematuria episode. So when I get called about patients with haematuria on the wards, I usually want to know whether it's microscopic or macroscopic. And by microscopic, I mean whether it's blood on a dipstick analysis, as in a UA result, or whether it's macroscopic, as in it's visible to the naked eye. And then if it's macroscopic hematuria, usually the next thing that I'll ask is, is it frank hematuria, as in is it more viscous than urine or thicker than urine? More like a blood with or without clots. And if they do have frank hematuria, then usually I want to know, are they in clot retention? Which means that they have a blood clot blocking the outflow of the bladder. And in regard to hematuria, you notice that sometimes it can be, I guess, an underlying kidney problem or more other lower urinary tract. So how do you kind of decide or work out which one that is? Yeah, so usually I try to think about problems that I can fix on the ward immediately. So do they need a catheter because they're in retention and they've got a UTI and the hematuria is the heralding signal? Or do they have an injury from a recent catheterisation? Are they in clot retention? Or do I think that there's another pathology that I should investigate either when they're in hospital or when they're out of hospital. And so the things that I would say that we most commonly see, and you can get bleeding from any part of the bladder tract, urinary tract, and probably the most common thing that we see is an E. coli UTI. And inpatient and outpatient, it accounts for about 13% of hematuria episodes. And then you're talking about less common things, but still very serious things like bladder cancer, kidney disease, stone disease, and then kidney cancers and prostate cancer, upper tract cancer, or radiation cystitis are some other causes that are less common, but that you need to work to investigate and exclude. And you mentioned common ones associated with IDC insertion. What are the common reasons why people may get hematuria following an IDC insertion? Yeah so I often get calls from juniors where they've say got an elderly patient who's been in retention, tried to insert a catheter and after inserting the catheter they notice that there's quite bright bleeding from the urethra and sometimes this means that there's been a minor urethral injury with the catheter insertion. Sometimes it's just the catheter passing the prostate in an older chap with some fragile blood vessels growing over the surface of the prostate which which is quite common. And usually, once the catheter's in the right place, it drains quite easily in that situation. Is that the question? Yeah, and sometimes I know working people who do have urethane, you put the catheter in and initially it's fine, and you come back an hour later and it's... Bright red. Yeah. What's happened? Yeah, so sometimes people, if they're in chronic retention, they can develop what we call decompression haematuria. And there are some theories about, you know, fragility of the blood vessels and that a static pressure from expansion of the bladder with chronic retention can help to compress and stop bleeding. But usually that's self-limited. Sometimes you might need a three-way catheter if the person's blocking the drainage catheter because of clots in the bladder. And another one, a lot of patients on anticoagulant medication. So can that cause hematuria in itself or is it usually underlying lesion? Yeah, so sometimes people have a catheter inserted say when they have an end-stemmy or some cardiac event or a vascular event when they require anticoagulation and the trauma is not enough to make them bleed until they're anticoagulated or sometimes they'll have an underlying say bladder or kidney lesion and the herald bleed can be with the commencement of anticoagulation, either as an inpatient or outpatient. So very commonly we will see patients, we're called to the cardiac ward, and it'll be a 65-year-old smoker who's had a recent heart attack, and when they've started the dual antiplatelets, they've had quite a large hematuria episode. And when you do a CTIVP, you'll see a bladder lesion. Okay. So in regard to, you mentioned the CTIVP, what is the standard workup for a patient that, say, such as this, has hematuria that's macroscopic? Yeah, so we usually recommend that all patients who have macroscopic hematuria should have, as a minimum, a urine cytology times three, a cystoscopic examination and a CTIVP. If the patient's very young and you're worried about radiation exposure, sometimes you can do an ultrasound, but it's less sensitive in detecting cancer. So you really need to do that in consultation with a urologist. Okay. And urine cytology, so when you say three, is that just over three days or three times in a day? Yeah, so the best time to collect urine cytology is the second void of the day. The urothelial cells shed in the urine and they spin the urine and examine it under a microscope to see what the cellular type is. So it is a little bit subjective according to the pathologist who's reporting. But the first morning urine, the urine cells have been sitting in the bladder overnight and they're a little bit more degenerated so you can get more rate of atypical reporting even though there's a normal bladder if you take the first morning urine. Okay interesting. Okay so we'll go back to our patient. You arrive to find the patient has a lot of blood it looks like Frank Himachew with clots in the bag. What do you do now? Yeah, so usually I give patients who have suspected clot retention a stat dose of antibiotics because they can get a septic shower with any blockage of the bladder. And the antibiotic that I give them depends on whether they're high risk for a major infection. So if it's an at-risk patient, I might give them gentamicin and ambicillin, or if it's low-risk, oral Keflex or IV Kefazolin. Then I want to get a bladder scan and see how well that current catheter is draining the bladder. And I think that's probably the most important thing about this evaluation initially. Okay, and if you do find that they have clot retention, what would you do next? Yeah, so usual ABCs, make sure they're not hypotensive with the retention, don't have a febrile episode, and make sure I've got EUCs and full blood count sent off. Although anemia is rare with the bleeding episodes, it does happen sometimes. If the bladder scan result shows that there's over 100 mils in the bladder, then I probably want to do a washout. So use a Tumi syringe and some sterile saline, a sterile set up and drape, and basically try to wash the clot out of the bladder. If I can easily wash the clot out of the bladder with a two-way catheter, I leave that in.
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