Wardround 24x8

The Two minute talks today were about arrythmias. Well researched and reasonably timed, but I would suggest more thought is given to the two minute limit. For next week : opportunistic infections with HIV: Pneumocystis pneumonia, atypical mycobacteria, toxoplasma, candida and cryptococcus. You have your assignments. If we have any extra people gatecrashing the talk they should choose another to do eg aspergillus, TB etc.

The paper for discussion on Tuesday will be The kindness of strangers. Eileen Palmer, BMJ 2008;337:a1993.



MJM

Wardround 10x8

The Reading for Tuesday is Trust, Anonymous, Bandolier. Read and think. Articles can be like lamps. Look at them carefully before choosing to use one for illumination. It could enlighten the subject matter, cast important issues into relative shadow, or even blind you to the whole subject.

The talks this week were excellent. Imported infections are not as uncommon as you might think, even in a place like D&G. The important thinks to know are where they have been, what they have been doing, who else has been involved. Use a resource such as travalax to find what is happening in the region and don't overlook the treatable (malaria, bacterial sepsis). I wondered about putting rabies in those parentheses, but perhaps that should be in the preventable category. I would suggest you read the local viral haemorrhagic fever protocol.

For next Friday the talks will be about the patient with an acute abdomen who finds themselves on a medical unit. No cop-outs here, I don't want a two second talk "refer to surgeons". The surgical team are all very busy in theatre. Only the surgical F1 is available and you are going to be forced to manage the patient initially.

Acute Pancreatitis F
Acute Vascular Events A
Perforated hollow Viscus O

Two minutes please. Keep it precise and concise.

Interesting Topics

Sepsis resuscitation bundle

How tired are you?


MJM

Wardround 3x8

The reading material for Tuesday is Commercial Features of Placebo and Therapeutic Efficacy, Rebecca L. Waber; Baba Shiv; Ziv Carmon; Dan Ariely, Journal of the American Medical Association, March 5, 2008; 299: 1016-1017. Get it via the elibrary, read and think.

Our two minute tutorials for Friday are Imported diseases. You each have two minutes to enlighten us on the patient who is feverish and:

Fell in the water of Lake Malawai (H)
Was bitten by a dog at Giza (F)
Was bitten by a bug on the Amazon (A)
Has a nosebleed having returned from Wagadugu (Z)

MJM

WR 27ix8

The read and think for Tuesday is Orphan diseases: which ones do we adopt? T Richards, BMJ 2008;337:a1225.

The two minute talks for Friday are themed around Acute Hepatitis. Educate the yourself and the group.

Alcoholic (H)
Viral (A)
Autoimmune (F)
Toxic (Z)

MJM

Wardround 12ix8

The reading assignment for Tuesday is Titrating Guidance, Nathan Goldstein, Anthony Back, Sean Morrison. Arch Intern Med. 2008;168(16):1733-1739. 

Friday's two minute talks are the recognition and management of psychiatric disorders on medical wards: Delerium tremens, Depression, the aggressive patient.

MJM

Wardround 5ix8

The reading for next Tuesday will be Mistakes. Ruth Lesnewski. JAMA. 2006;296:1327-1328. get it with elibrary.

Read and think.

Friday's tutorial assignments will be Acute Colitis

Ischaemic

Infective

Inflammatory

Two minutes please, keep it precise and concise, quote your sources and illustrate with a handout.

Interesting Topics

Transverse Myelitis

MJM

Wardround 29viii8

Why was a rheumatologist asked to see this patient?

The reading this week about the methods magicians use to distract their audience led to some discussion of distraction, its benefits and pitfalls in medicine, the importance of not interrupting the 'rituals' of medicine that doctors use to keep on track and recognising when we ourselves have been distracted from the path.

For next week 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!)

As ever the original responses to a paper can be illuminating. It is well worth getting used to reading the letters written to the editor about papers you read.

I was sorry to have been called away before the end of the Gram talks. It sounds obvious but the information Gram pos/negative cocci/bacilli should prompt immediate thoughts: does the patient have features of systemic sepsis syndrome? what do I need to check to further identify the type of organism and the likely spectrum of antibiotic sensitivity. Be sceptical about any comment from someone who has not assessed the patient that an organism could be a just a contaminant. How about clicking the comment button and writing in one sentence about something particularly interesting you found in your reading on the subject.

The talks for next week will be Epilepsy.
I was not able to assign these so it will be first come first served. Click the comment and claim the subject you will take. On offer are:
Epidemiology
Classification
Investigation
What to tell a patient after their first seizure
Treatment

Interesting topics

Lofgren's syndrome (what I was called away to see)


MJM

How weary, stale, flat and unprofitable, seem to me all the uses of this world
Fie on't ah fie! 'tis an unweeded garden, that grows to seed ...
That it should come to this.

Wardround 22viii8

The reading for next Tuesday will be Magician's Hand: How Humor And Misdirection Can Manipulate Levels Of Attention. You may also want to look at this related article.

Please read the articles and give them some thought. Is this relevant to medicine?

The two minute talks this week were the ECG. What is normal and what is not? What do you think was the most interesting or useful point in your talk. Click the comment button and type it in. I put together a little list a couple of years ago that you could revise from.

The two minute talks for next Friday will be mibrobiology 101: what should go through your mind when you get a call that your sick patient's blood cultures have grown:

Gram positive cooci HM
Gram negative cocci SV
Gram positive rods ZB
Gram negative rods HJ

Keep it precise (actual figures not general descriptions) and concise, educate your audience, quote sources, produce a handout and keep to two minutes.

Interesting topics:

Hyperkalaemia...read the handbook
Atrial flutter
Korsakoff syndrome

MJM

Wardround 15viii8

The reading for next Tuesday will be The road to recovery. D Pisetsky. Please read the article and give it some thought.

The two minute talks this week were about common drugs: Furosemide, Coamoxiclav, Enoxaparin. The prize this week goes to HM. What do you think was the most interesting or useful point in your talk. Click the comment button and type it in.

The two minute talks for next Friday will be The ECG. What is normal and what is not? Let's have two minutes on:

P wave HJ
QRS complex
Axis
ST segment HM
T wave SG

Keep it precise (actual figures not general descriptions) and concise, educate your audience, quote sources, produce a handout and keep to two minutes.

The morbidity/mortality meeting is on Thursday 28th August. Time to start preparing now.

Interesting topics:

Fallot's tetralogy

Wernicke's encephalopathy

Dressler's Syndrome

MJM

Wardround 8viii8

On Friday I will talk to you about the training side of the ward work, so you are spared giving a talk until next week.


The reading for next Tuesday will be The minefield of medical morals. D Sokol.
Please read the article and give it some thought.


The two minute talks for next Friday will be common drugs. Let's have two minutes on:

Furosemide HM
Coamoxiclav HJ
Enoxaparin SG
Omeprazole RV
Prednisolone just in case

Remember, the aim of the aassignment is that both you and your audience increase your knowledge or understanding of the topic. Don't waste too much time telling us things we will already know. The time is limited to two minutes and you should practice your talk and timing before the big day. Don't give a five minute talk in two minutes, edit it down to time. Always quote your sources so others know where to go to check things out for themselves. You should produce a single side of A4 handout. This is to illustrate your talk, not to provide a textbook level detailed article. Hand drawn pictures with arrows and signs beat something that looks like a cv every time.

The usual advice is keep your talk precise and concise, educate your audience, quote sources, produce a handout and keep it to two minutes.

Interesting topics this week:

Where to look up complementary medicines
DGRI antibiotic guidelines (I can't make the link work so you will need to navigate to it so it's intranet only. Go to the DGRI homepage, at the top choose select a service, then prescribing support, then click go. The document is listed there).

MJM

Welcome to the new trainees, goodbye to the old.

The reading for thought on Tuesday will be Meeting the ethical needs of doctors. Daniel K Sokol. BMJ 2005;330:741-742.

Welcome to the new trainees. Could I ask you to look over to the right hand side of this page and click on the "Training" link please. There is a little about work on the ward there and a timetable for yourself and me.

There will not be any assigned two minute talks this Friday. What I would like each of you to do is tell us a little about yourself and what you wish to do this year, and after that. The usual Friday rules apply. Only two minutes please.

MJM

Holiday break

I am off to the land of large portions for a couple of weeks, there to stress my labyrinths and top up my vitamin D. The blog will resume on the 28th.

MJM

Wardround 4vii8

The reading for Tuesday will be Precision in diagnosis, John Todd, Lancet 1952: 260 (6748); 1235-37. It is available via the elibrary. You may be able to use this link after logging in to elibrary/Athens...but if the link fails you....you should still have enough information to find the pdf.


We will decide upon Friday's topics on Tuesday.


MJM

Wardround 20vi8

The reading for Tuesday will be The rational clinical examination. Does this patient have abnormal central venous pressure? Cook DJ, Simel DL. JAMA 1996; 275: 630-4.

The two minute talks for Friday will be slightly different. I would like you to look over a guideline of your choice (but related to adult general internal medicine, of course) and present 5 useful points from the document. As a warning example I would not find it useful to be told that nebulised beta agonists are useful in the management of acute exacerbations of COPD (I know that already), but I don't know how useful.

Not education except in its widest sense, but here are some pictures from the Summer Ball.

MJM

Wardround 13vi8

The reading for next Tuesday will be The Midnight Meal and Other Essays about Doctors, Patients, and Medicine, Jerome Lowenstein. I have put a copy on the ward.

The two minute talks for next week will be your diagnosis of the Plague of Athens. You will find a description of the outbreak in The History of the Peloponnesian War written by Thucydides in 431 B.C. 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.

You need to have an opinion on the diagnosis and be prepared to argue your corner. Make sure you revise the signs and symptoms of the disease you choose. I will post the discussion the following week and award a prize to the best argument/diagnosis.

The NPSA have issued guidance to improve the safety of chest drains.

MJM

Wardround 6vi8

The reading for Tuesday is Doctors, Lawyers and Wolves. George J Annas, Lancet 31 May 2008. Read and reflect please.

The two minute talks are neurologically themed. The specific assignments are no longer in my possession, but you have them and can forewarn the newcomers.

A short post I am afraid but as well as working this weekend I have been sorting out my email account at home which had been reporting "2,147,433,168 messages unread". 

MJM

Wardround 30v8

An interesting update on skin infections. What did you learn?

Cellulitis is a common condition in acute medicine. Always ask yourself if this is 'simple' or complicated. Is there immunosuppression, skin integrity, rapid progression, unexpected pain, recurrence, poor response to treatment?

You already have your asssignments for next week's talks and the discussion for Tuesday was posted last week.

The May M&M meeting when very well I felt.

Interesting topics

Unsuspected Pulmonary thromboembolism

MJM

Wardround 23v8

Endocrine emergencies. Well done. I had given YA 10/10 in my notebook for his talk on acute hypoadrenalism, so I was forced to give Thyrotoxic storm by EM a 10+. I think you have grasped what is needed.

Many of the emergencies discussed can be misdiagnosed as other common conditions and considering the possibility is just as important as knowing what to do.

I will share with you that my soul shudders each time someone recommends "routine bloods". I can cope with "x, y and z should be routine bloods in the investigation of...". Be specific.

For next Friday the assignments are based on skin infections:
Infection following animal bites
Lower leg cellulitis (A)
Cellulitis in the immunocompromised host. (S)
Necrotising fasciitis (Y)
Facial cellulitis (N)
Shingles

requirements: Concise, unrushed, precise, sources quoted, USEFUL.

For Tuesday you have been given a grey case to consider. By the way, what is a grey case and how should you deal with it? Prize 9virtual) to the best definition of a grey case.

The reading for a week on Tuesday will be The boards and executives of drug companies could catalyse action against the AIDS epidemic by immediately reducing the costs of HIV drugs in poor countries to zero. Donald Berwick BMJ 2002;324:214-218

Interesting topics

Pneumocystis pneumonia see uptodate

Adult onset Still's disease

Neurofibromatosis

MJM

Wardound 16v8

Our discussion paper last week was The reading for discussion on Tuesday will be DNR or PEACE. J Crampton. BMJ 2008;336:1015. An interesting discussion ensued. If you would like to read more on the subject could I suggest you take a look at Decisions relating to cardiopulmonary resuscitation A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing from October 2007

For next Tuesday the reading will be Liz Wager: Training and the placebo effect.

Our talks this week were about poisoning, and overall I think they were well researched and presented as spoken mini-essays. I would like you, now, to think about these talks in a different way. The aim is to teach/train/educate your audience. This differs from writing an essay (or giving presentations, which are much the same thing) as you have done in the past. Those were to assess your ability to collect and critically appraise information. I want you to take that information and teach me and your colleagues. And by teach, I mean convert me from someone who could not do something into someone who can. Your handout is for that purpose as well.

Bear that in mind for this week's two minute talks on endocrine emergencies:

Hypoglycaemia A
Thyrotoxic Storm E
DKA N
Adrenal crisis Y
Phaeochromcytoma crisis S

Interesting topics

Antibiotics and seizures


MJM

Wardround 9v8

Our discussion this week, in the absence of a paper to read, was about improving practice by Morbidity and mortality meetings. We will now run an M&M meeting on the last Thursday of each month. There is an M&M folder in the Nurses office. All deaths for the month should be listed there. The GAJ team will review MJM patients and vice versa. The Necessary patients notes will need to be pulled the week before.

Our two minute talks were about the investigation of malignancy of unknown origin. A useful discussion I think. We heard about the more common cancers nad discussed how that should guide our history, examination and investigation. The use of tumour markers produced further discussion, which can I think be generalised to the use of many tests in medicine.

For next week:

The reading for discussion on Tuesday will be DNR or PEACE. J Crampton. BMJ 2008;336:1015

Read it, think, and share your thoughts.

The two minute talks for Friday will be about Poisoning:

Paracetamol (ST)

Carbon Monoxide (NV)

Methanol (EM)

Tricyclics (YA)

The usual advice. Keep it concise and precise, quote your sources and make a handout. Having heard your talk I should be able to manage a poisoned patient. The handout should be visual rather than textual. Example.

Interesting Topics

Group A streptococci

Do you know what streptococcal toxic shock is? UpToDate also has some good articles on the subject.

MJM