Wardround 3viii18

Welcome to C5. The ward's Consultants, Drs McMahon, Jones, Munang, Russell and Buabeng, look forward to working with you and hope you will get the most out of your attachment.

This blog will be a reminder of your training assignments each week. In addition to the departmental teaching sessions we have three ward based events:


1. Read & think :Each Tuesday there is a discussion of a subject or paper. I will usually set a paper but if you come across something which you believe we should read, I am happy to include it. Give yourself time to think.

2. Two Minute talks: each Friday you will give the team a talk on a subject you have researched that week. Again I will set the topics unless you come up with one yourselves. I am strict about the time and will not allow more than two minutes. (Not one second more). Don't waste time telling us things that are obvious. Your talk can be illustrated with an A4 size handout which should be info-graphic rather than prose.

3. Morbidity and mortality meeting: bimonthly, I will give more info nearer the meeting.

Do read regularly and check your management against protocols and guidelines.


The paper to read for next Tuesday is On Breaking Bad News. Walter Klyce, JAMA. 2018;320(2):135-136. 

The two minute talks next Friday will be:

Anaphylaxis RM
Hyperkalaemia PF
Unconsciousness GD
Hypoglycaemia FR
Seizure SG

Practice your talk, get the timing right, make it illuminating and tell us your sources. Have a look at this example handout... Anaphylaxis by Dr Hannah Gunn (once a trainee here, now a consultant). The talk is more important than the handout so use your time appropriately. The trust sometimes blocks access to images but if you have internet access elsewhere you should be able to see them.



Interesting topics
Treatment of Hypercalcaemia in Malignancy
Erythema Annulare Centrifugum
Common peroneal nerve palsy
Periventricular white matter lesions

Wardround 2xii11

Our Topic for discussion this week was Driving and Medical illness with regard to the DVLA medical regulations. It was instructive to look how these would impact on patients on the ward.


One way to bring driving history into our routine assessments is to regard driving as part of our ambulation/motility questions. If it is missed during initial clerking it should then come up as we approach discharge planning.


The DVLA has its at a glance guide which can be easily assessed but a good aide memoire for fitness to drive at patient.co.uk.


I missed the discussion about avoiding finding yourself out of your depth, but hope it stimulted some thought.


For Next Week:


Tuesday, please read the consensus document for the use of dabigatran in atrial fibrillation available from the Health Improvement Scotland website. You may find it useful to refer to the  SMC detailed advice document to which their is a link on the same page.


Friday's two minute talks are on common tests. Please choose between d-dimer, troponin, CRP and choose another if there are enough people. We need to know when to use them and how to interpret them given the hard facts about their accuracy etc.


Interesting papers:


Can we reverse Factor Xa inhibitors

MJM

Wardround 25xi11

Reading for Tuesday

How to Handle Being Out of Your Depth: 6 Tips from a Con Man
Can be found on website www.artofmanliness.com


Two minute talks for Friday

If each of the patients on today’s wardround had asked “can I drive when I go home?” what would be the answer?

Have a look at the DVLA guidance on driving and tell us what you have learned


Clinical Question

How common are serious infusion reactions with Infliximab and how should they be managed?

Review and Expert Opinion on Prevention and Treatment of Infliximab-related Infusion Reactions. Medscape. LLA Lecluse, et al

Audit question

If patients have a condition that would require advice on driving has that advice been recorded in the case notes. Had a driving history been taken?

MJM

Have you fallen? Not a question of morals.

An interesting set of talks about nosocomial illness. I liked the Falls in Hospital handout: Simple, clear, no waffle. We have agreed that "have you had any falls" should be a routine question. I tend to put it in the neurology section of systems review.

It was good to see our local data for C. difficile. Always good to include local information in a talk. SS will read one of the C. Difficile ICP sheets.

Next Friday's topic is Electrolyte disturbance. Research, cogitate and give the group two minutes on one of the topics below. Clarity, practicality and memorability (for the right reasons) will be assessed.

Sodium
Potassium
Calcium
Magnesium

The reading for Tuesday is Mistakes. R Lesnewski. JAMA 2006: 296 (11); 1327-8


Monday's Audit: Have you fallen?


Interesting topics

Ecthyma Gangenosum
Staphylococcal infection
Amiodarone Lung
Campylobacter

MJM

Glucocorticoid adverse effects

Our topic today was adverse effects of glucocorticoids. These are commonly used drugs with significant adverse effects. If we wish to limit unwanted effects we need to know how common they are, harness patient's concerns to help us and have a plan for when we use steroids.

Your talks showed that you had put effort into researching the topic, but there needs to be a little more planning on the presentation side. The time allowed means that you have to be concise, and to make it sharp you must always be precise. Numbers (10%) not descriptors (quite common). List your sources on the handout so the audience can follow up if they want to.

Here are some useful papers. The links are to abstracts but the full versions are only a password away via ATHENS.

Monitoring adverse effects of low dose glucocorticoid therapy: EULAR recommendations for clinicalk trials and daily practice. MC van der Goes et al Ann Rheum Dis 2010;69:1913-1919

Epidemiology of glucocorticoid-assoiated adverse events. AK McDonough et al. Curr Opin Rheumatol 2008 Mar;20(2):131-7.

Patients’ and rheumatologists’ perspectives on glucocorticoids. MC van der Goes et al. Ann Rheum Dis 2010;69:1015-1021.

The acronym below which is an aide-memoire for reducing adverse drug effects in general. Apologies to its author, who I can't remember, but I first heard it at a meeting about 5 years ago.

S...Stratify: is the patient at higher risk of an ADR: comorbidities, drugs, age.
A...Assess: Hepatitis status, TB risk, vaccinations up to date?
F...Fend-off: vaccinate, optimise health (stop smoking etc).
E...Evaluate: check what ADRs might be expected, look for them.
T...Treat: nip it in the bud (UTI is easier to treat than septic multi-organ failure).
Y...Yearly: re-evaluate all of the above regularly. The frequency depends on the drug.

The topic for next Friday is Nosocomial illness:

Falls
C. Difficile
MRSA
Line infections

Two minutes please. Be concise yet precise. Tell us your sources. you are allowed an A4 (single side) handout.

Audit standard for next week. All casenote sheets have the patient's name and CHI.

MJM

11viii11

The two minute tutorials for Friday are focused on the adverse effects of corticosteroid therapy:

General overview
How to work up a patient prior to treatment
How to assess a patient on treatment
What are patient's views on steoid side effects


Tuesday's read and think will be A 76-Year-Old Man With Multiple Medical Problems and Limited Health Literacy. Amy Ship. JAMA August 10 2011.


Interesting topics

Illiteracy in rheumatoid arthritis patients as determined by the Rapid Estimate of Adult Literacy in Medicine (REALM) score. Gordon et al. Rheumatology (2002) 41 (7): 750-754

It's Good to Feel Better But It's Better To Feel Good and Even Better to Feel Good as Soon as Possible for as Long as Possible. Response Criteria and the Importance of Change at OMERACT 10. V Strand et al. J Rheumatol August 2011 38(8):1720-1727


MJM

It starts again: August 2011

Welcome to Ward 10. I hope you will both enjoy your stay with us and make the most of it. Learning does require a little effort but hopefully we can help each other by sharing the task.

The two minute tutorial topic for Friday is The Normal ECG. I would like you to choose amongst yourselves from: P wave, QRS complex, T wave, PR interval, Axis. The goal is for us to be able to recognise a normal ECG. You are limited to two minutes. Be precise yet concise and tell us your sources.

The paper to read, digest (intellectually) and then discuss on Tuesday is The Road to Recovery, by David Psetsky.

We usually have a weekly topic for audit, but we can choose our first topic on Friday.

There are at least two on-going audits of which you should be aware:

Antibiotic use is checked against local guidance (available on the intranet and due to be updated any day). It is important that the correct empirical antibiotic is chosen or the reason for chosing an alternative is clearly stated in the case notes or prescription kardex. The indication and expected duration of treatment or review date should be recorded.

We audit the recording of DNA-CPR and ceiling of care weekly (well you do).

Interesting papers:

Paracetamol, ibuprofen, or a combination of both drugs against knee pain: an excellent new randomised clinical trial answers old questions and suggests new therapeutic recommendations.


PS the links in the frame on the left are mostly inactive at present, awaiting my guiding hand.

MJM

Interesting Publication

EXPERT CONSENSUS DOCUMENT
ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use

There is a brief comment in JAMA 2011;305(2):135-136.

Welcome to 2011

My Work related NYR for 2011 is to reanimate this blog. Wish me luck.

MJM

Reading for Tuesday 31viii10

RANDOMISED TRIAL OF INTRAVENOUS STREPTOKINASE, ORAL ASPIRIN, BOTH, OR NEITHER AMONG 17 187 CASES OF SUSPECTED ACUTE MYOCARDIAL INFARCTION: ISIS-2.

The Lancet, Volume 332, Issue 8607, Pages 349 - 360, 13 August 1988

Why have I chosen this paper.

MJM

16viii10

The reading for Tuesday 24th will be Assessing a learning disabled patient's capacity to manage his own care and make important decisions. Read the material and share your thoughts with the team.

Friday 2oth two minute talks are on the topic of cellulitis: epidemiology; diagnosis; treatment (uncomplicated case); complicated cellulitis; recurrent cellulitis. Keep it concise yet precise. Quote your sources.

Pre-warning for Friday 27th because it might take a little more work...
Thucydides described of the plague of Athens, in 431BC in The History of the Peloponnesian War. If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague. The challenge is to make a diagnosis. You will have two minutes to make your case for the diagnosis of your choice. We will then have a chat about how you would manage the situation.

MJM

Wardround 11viii10

The read and think for Tuesday is Communication discrepancies between Physicians and Hospitalized patients. DP Olsen, DM Windish. Arch Intern Med 2010: 170 (15); 1302-1307.

Two minute talks for Friday: Reducing adverse effects from:

NSAIDs

Glucocorticoids

Anticoagulants

Antibiotics

Statins

Pilot Audit for Monday:

DVT prophylaxis; standard=handbook.

Interesting Topics:

New classification criteria for Rheumatoid arthritis

Glioblastoma

GIFTASUP

MJM

Welcome to ward 10

Welcome to your attachment on Ward 10

Farewell to the old guard and welcome to the new batch. Get ready to gorge yourself on fruit from the tree of knowledge.This blog will be a reminder of your training assignments each week. In addition to the departmental teaching sessions we have three ward based events:


1. Read & think :Each Tuesday there is a discussion of a subject or paper. I will usually set a paper but if you come across something which you believe we should read, I am happy to include it. Give yourself time to think.

2. Two Minute talks: each Friday you will give the team a talk on a subject you have researched that week. Again I will set the topics unless you come up with one yourselves. I am strict about the time and will not allow more than two minutes. Don't waste time telling us things that are obvious. Your talk can be illustrated with an A4 size handout which should be info-graphic rather than prose.

3. Morbidity and mortality meeting: monthly, I will give more info nearer the meeting.

Do read regularly and check your management against protocols and guidelines.


The paper to read for next Tuesday is Clinical craft: a lesson from Liverpool. DM Gore. Med. Humanit. 2001;27;74-75

The two minute talks this Friday will be medical emergencies: choose between yourselves from the following topics...

Anaphylaxis
Hyperkalaemia
Sudden loss of consciousness

If any other doctors are taking part they can choose from...
Sudden hypotension
Sudden hypoxia

Practice your talk, get the timing right, make it illuminating and tell us your sources. Have a look at this example handout... Anaphylaxis by Dr Hannah Gunn, or this slightly busier one on aspiration pneumonia by YT. The talk is more important than the handout so use your time appropriately. The trust blocks access to images but if you have internet access elsewhere you should be able to see them.

Next week we will start an audit of ..... HIV testing. Have a look at BHIVA guidelines for HIV testing 2008.

MJM

What's the diagnosis?

The reading for Friday is a description of the plague of Athens, written in 431BC by Thucydides in The History of the Peloponnesian War. If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague. The challenge is to make a diagnosis. You will have two minutes to make your case for the diagnosis of your choice. We will then have a chat about how to manage the situation.

MJM

Something to read 5i10

Medical Care for the Final Years of Life: "When You're 83, It's Not Going to Be 20 Years"

JAMA. 2009;302(24):2686-2694 (doi:10.1001/jama.2009.1871)
David B. Reuben


This is the first in a series....

Is this true in medicine?

“Any truth is better than indefinite doubt… – Arthur Conan Doyle”

Something to read

The Personal Equation in Medicine. JAMA. 2009;302(20):2265 reprinted from JAMA. 1909;53(22):1825-1826

Couldn't find it? !!!

If you would like to read more, there is a good discussion of the approach to diagnosis in The cause of the plague of Athens: plague, typhoid, typhus, smallpox, or measles? Burke A. Cunha, Infect Dis Clin N Am 18 (2004) 29–43.

MJM

Making a diagnosis

The reading for Friday 18th is a description of the plague of Athens, written in 431BC by Thucydides in The History of the Peloponnesian War. If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague. The challenge is to make a diagnosis. You will have two minutes to make your case for the diagnosis of your choice. We will then have a chat about how to manage the situation.

MJM

Pharmaceutical Sponsorship

There is a suggestion that pharmaceutical companies sponsoring meetings should only be able to talk about drugs on the area formulary. What do you think about this? Do you think we should have sponsorship at all?

Have a read of The road to recovery. Is it time to bid farewell to the drug reps? by David Psetsky. It is on Medscape, but registration is both easy and free.

For the Friday meeting, those not presenting the case (and only one is doing that) are asked to give brief presentations on:
Benign Intracranial Hypertension
Aseptic meningitis related to drugs
Tuberculous meningitis
Herpes simplex encephalitis

Share them out between yourselves. I am looking for two minutes on the subject. Keep it concise and precise. No waffling. No powerpoint!

MJM

What's this?

Welcome to Ward 10

Welcome to Dumfries and Galloway. I will consider giving a prize to anyone who can identify where this picture is.

And welcome to the ward. You will find more information about your time on ward 10 by clicking here.

If you are reading this page in the hospital you will not be able to see the image above.

MJM

2vii9

Summer Break....

Back for the new intake in August.

MJM

Wardround 5vi9

The talks for Friday will be The use of serology in the diagnosis of:

Hepatitis B (ZB)

Hepatitis C (CM)

HIV (FY1)

Keep to the two minutes, drop the snippets of information that we already know and aim to leave your audience able to use serology appropriately in these situations. Remember to quote your sources. I am away on Friday, but will be testing the effects of the talks by asking some questions on the following Tuesday.

The paper to read for Tuesday will be Spellbinding and spellbreaking in convalescence<. George Day. Lancet 1961; 279 (7222):211-213. Log on to the NHS Scotland elibrary with your Athens password and choose the Lancet. You will be offered several sources, choose the Sciencedirect Lancet site.

For 19v9

The reading for Tuesday will be Ethical Debate: serious drug overdoses, B Dahal, BMJ 1995;311:115-116

You already have your talks for Friday, about diagnosis of various rheumatological conditions. remember classification criteria are not diagnostic criteria....or are they?

MJM

Wardround 24iv9

The reading for Tuesday will be "Stepford doctors": an allegory. GM Sayers. Medical Humanities 2006;32:57-58. Read and think.

This week’s two minute talks were about drugs with significant potential for adverse effects: warfarin, rifampicin, aminoglycosides and penicillin (with reported allergy). Take a minute or two and ask yourself what you now know about the the use of these drugs that you didn’t know before.

For next Friday the task is a two minute tutorial on the interpretation of results from:
Urinalysis
Arterial blood gases
Pulmonary Function tests
(and an extra in case we have an extra person…oxygen saturations)

MJM

wardround 3iv9

This week's talks were a challenge of summarising what needs to be done about a coincidental chronic illnes in a surgical patient. Both of you recognised the need to address issues directly related to the surgical aspects (risk of hypoadrenalism and thrombosis in lupus and blood sugar/ketones in diabetes) as well as a plan for checking that their longer term management was on track. That's your first two minutes out of the way. Now for next week, the two minute talks onFriday will be recognising the effects of:

Heroin (AB)
Cannabis (free)
Cocaine (CM)
Amphetamine (BS)

Be concise yet precise, and remain anchored in the real world... and just two minutes please.

For discussion on Tuesday I would like you to read Why are medical journals so dull by Richard Asher. Originally published in the BMJ in 23 August 1958. Tempted as I am to leave you to get hold of the paper using your own initiative there is a link here if you do not feel like taking up the challenge. The link works for me but if you are unsuccessful I can give you a paper copy (folded in the shape of a dunce's hat!)

MJM

Wardround 27iii9

We did not get to discuss our paper on Tuesday so let's give it ago this coming week. Read and think, then discuss intelligently It's the evidence stupid, F Godlee, BMJ 2008;337:a2119

The talks today were the management, in two minutes of particular scenarios. The mild biochemical hypothyroidism (FI) was well researched and summarised, since it is in fact quite a complex topic. It is important to consider the usefulness of recommended tests both from a resources standpoint but also as a discipline for yourself. When would you order thyroid autoantibodies?

The abnormal LFT scenario talk (BS) had less meat to it, but thereis always next week eh? Think carefully about timing of tests and use investigations as part of an overall plan.

For next Friday the scenario is a patient under orthopaedic care with a wrist fracture. The surgeons have asked for the patient's medical condition and treatment to be reviewed and optimised. The osteoporosis team are already on the case. So what will you be checking for this patient with:
SLE (FY1)
Chronic liver disease (BS)
Type 2 Diabetes mellitus (CM)

MJM

Wardround 20iii9

The two minute tutorials for Friday are "What to do about..."
A 45 year old woman with aches and positive ANA (CM)
A 60 year old woman with abnormal LFTS ALP167 AST 60 ALT 90 (BS)
A 40 year old with TSH 7 T4 12 (FI)

Two minutes only, be practical rather than theoretical.

The tuesday reading is It's the evidence stupid, F Godlee, BMJ 2008;337:a2119

MJM