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

Wardround 25iv8

The discussion this Tuesday began with the paper The strange malady of Alessandro’s uncle, Neil A (Tony) Holtzman. I was prompted to choose the paper following the journal club discussion last week about the genetic markers for responses to warfarin. The paper describes the development of a new (genetic) investigation and treatment and its impact on the aforementioned uncle. Many interventions will appear better than they prove to be when evidence is limited.and the passage of time gives more accurate assessments.

The paper for discussion next week will be Screening for MRSA, M Wilcox, BMJ 2008;336:899-900

The two minute tutorials on diagnoses were well done but I would recommend adding an additional aliquot of thought to the planning stage. Ask yourself, “what do I want the listener to be able to do or know after this two minutes?” Detailed discussion of diagnostic criteria may contain all the necessary information but that alone does not complete the task. Keep the handout to one side of A4 and make it memorable. Ask yourself the questions MJM or GAJ might ask. Be honest with yourself about the handout. Would you read or keep somethiong that can be printed from a website in 10 seconds? What would be more useful?

Next week’s talks are about Colitits: epidemiology, investigation, treatment.

MJM

Wardround 18iv8

Back on-line.

The reading for Tuesday will be The strange malady of Alessandro’s uncle, Neil A (Tony) Holtzman. BMJ 2007;335:1306-1307, (doi:10.1136/bmj.39407.647014.80). Read it and think, then share your views.


The two minute talks for Friday will be Making a diagnosis: you can decide among yourselves who will make each presentation.

What constitutes Diabetes mellitus?
What constitutes COPD?
What constitutes Coronary artery disease?
What constitutes Delirium?

Two minutes please. practice it and make sure your timing is accurate. be concise and precise, quote your sources.

Interesting topics

Hypereosinophilic syndrome or look in uptodate which has an excellent article on the subject.

And here is an article worth a read, Blood Eosinophilia: A New Paradigm in Disease Classification, Diagnosis, and Treatment, A Tefferi, Mayo Clin Proc. 2005;80:75-83

MJM

Out of action at present

Wardround 7iii8

Last week's talks were about substance abuse: acute management and harm reduction. Good talks, full of useful information but the handouts were a little to bulky for my liking...try something that can be taken in with one or two glances rather than a page that requires reading. Have a look at this as an example. This would probably be the equivalent of all the talks at a Friday meeting.

What pearls have I taken away from these talks? (if I've missed a good one just add it to the comments section)

Myocardial sensitisation to catecholamines with solvent inhalation: aim for calm and quiet surroundings, monitor cardiac rhythm and use sedation if necessary. The acute effects should have worn off by 6 hours , and if not consider a complication such as myocarditis.

In acute alcohol withdrawal there is no one-size-fits-all regime. The benzodiazepine dosing must be titrated to control withdrawal but avoid over sedation. SIPS scoring is a good way to do this but if not in use you will have to use some common sense. (It's certainly better than using none.)

Identifying alcohol misuse in patients presenting with other conditions is important. A reported alcohol intake less than the recommended level does not exclude abuse. Be aware, ask more detailed questions (eg CAGE) if you are suspicious.

Further reading

Alcohol - problem drinking
Opiod dependence

Next week's two minute talks will be about Parkinson's disease:

Diagnosis
Management
Problems with treatment

This time try to have visual rather than written handouts. If you want to give out lists, just tell us where to find them e.g. more information at www.listsofcauses.com.

The discussion for Tuesday will be "Should doctor's who see prisoners insist hand-cuffs are removed?" You may want to read Restraint of detainees in NHS facilities.

MJM

Wardround 29ii8

The talks this week were about interstitial lung diseases. You are getting the hang of it now; Information targeted at clinical practice and delivered so as to be memorable. The best talk/handout this week was Extrinsic allergic alveolitis (Dr NNT). Remember to ask about activities up to 6 hours before the onset of acute dyspnoea. Always consider infective causes. (I have a feeling that I need to take care not to evolve into an Infectious Diseases evangelist.)

For next week the assignments are based on substance misuse:

Glue (MR)
Alcohol (NNT)
Cocaine (KL)
Crystal Meth (R)

Two minutes please on the management of acute toxicity and harm reduction.

The reading last week was Doctors’ education: the invisible influence of drug company sponsorship. Ray Moynihan. BMJ 2008;336:416-417. You may want to have a look at Who pays for the pizza? by the same author.

For next Tuesday I would like you to read and think about Junior doctors' shifts and sleep deprivation. Carol Black et al, BMJ 2005;330:1404.

You may want to test your own level of tiredness with this online psychometric test

Interesting topics

Alternative causes for elevated cardiac troponin levels.
Ann Intern Med 2005;142:786-791

Clozapine myocarditis

Marfan's Syndrome

MJM

Wardround 22ii8

The reading for Tuesday will be, Doctors’ education: the invisible influence of drug company sponsorship. Ray Moynihan. BMJ 2008;336:416-417 (23 February).

There is an extended podcast on rheumatoid arthritis, with slides available (60 minutes duration) at the training site.

MJM