Friday, 19 January 2007

A Humane Death- the Role of the Palliative Care Team

In the UK and USA there are specialist teams that work both in the Community and Hospital referred to as the Palliative Care team.

These doctors and nurses deal soley with palliation and providing a painless, anxiety-controlled and humane death for terminally ill patients.

Terminally ill patients not only include those with cancer, but also those patients suffering with end-stage conditions such as COPD, Heart failure, Liver Disease and Chronically progressive debilitating neurological conditions.

They will review patients on a general ward and provide advice on stopping treatments that are not helping and commencing medications to help a whole host of different symptoms that the terminally ill may suffer such as pain, anxiety, constipation, ascites, respiratory secretions, etc...

Their role in the hospital setting is very important because when they are called in, a patient's treatment can be significantly altered from one of full active treatment to one which palliates, and the medical staff are then able to provide a different, more private and dignified standard of care, such as treatment in a side-room, less disturbance by medical personnel, less painful blood tests etc..

The palliative care team also run the Community Hospice care and in the UK, these small units are a cross between a hotel and hospital providing comfortable and relaxing surroundings for treatment. Not all patients are admitted in terminal stages; some are admitted for temporary treatments such as drainage of ascites (paracentesis) , respite care or even just to adjust pain relief under under a controlled environment.

In the UK, it is sometimes more important to provide the patient with a decent, humane and painless death rather than continuing to press on with aggressive pro-active medical therapy which is clearly futile. This sometimes involves stopping antibiotics, stopping drugs that are there to reduce risk factors of cardiovascular disease, such as stopping some blood pressure drugs, anti-platelets agents, statins as these may be unnecessary at their terminal stage of illness.

One could look at this type of medicine as 'giving up', but I do not see it as this, as usually the patient's condition reaches a point when it is clear that it is unfortunately not going to improve and therefore, it is better to alter therapy with the progression of their illness.

As far as I am aware, the Palliative Care services in Japan are not as developed as those in UK or America, and I truly believe that such services would make a wealth of difference to patients and it would also help patient's families to accept the inevitability and futility and also to enable them to make plans for the short-term future and allow for acceptance thereby making grieving easier to take.

Patients have a right to continue living but also the right to not have intolerable medical treatment, and as doctors, we must listen to our patients about what they want, rather than what we think is best for them. We are not special people with God-like powers and rules. We too are human and we must treat people equally as we ourselves would like to be treated.


The 'take home message' is Listen to, Respect and be Humane to your patients and do what is right for your patients at all times.

If you have any views on today's blog then please write me :) !!

Thursday, 18 January 2007

Predicting Mortality for Pneumonia

Yesterday, I did my usual conference and I asked my Residents how they would decide whether to admit a patient with pneumonia or to treat them as an outpatient. Moreover, I asked them how long they would treat an uncomplicated typical community acquired pneumonia.

Well, I got some interesting answers, with one reason for admission being the wishes of the family or the patient.

We listed many possible criteria, all of which seemed reasonable, but one Resident quoted that he would use the PORT STUDY CRITERIA to decide whether he would admit a patient. Well, I was surprised and impressed.

The PORT study was described about 10 years ago and it was a Validation Cohort testing the Pneumonia Severity Index Score (Fine et al, NEJM Vol 336, No 4, Pages 243-250) to determine the mortality of patients taking into account history, physical, laboratory and radiographic data.

From the study, the investigators were able to determine whether patients could be safely treated as an outpatient with pneumonia.

Despite this study being 10 years old, at my last hospital in the UK, it was only just being introduced in order to try and reduce inpatient admissions and obviously expenditure!

So, by using the criteria in the above study, the physician has at least some evidence based way, which has been validated, to decide whether sending a patient home with pneumonia is safe.

The next question was how long do you treat a typical community acquired pneumonia?

The Residents quite rightly gave the stock answer of at least a week and some said up to 2 weeks, whereas one Resident said just 5 days. So, there appeared to be a consensus of at least a week for treatment.

However, although UK practices for treating pneumonia are identical to Japan in the length of time, where is the evidence base that treatment for one week is actually the minimum time for treatment???

Well, a paper from a Dutch group published in the British Medical Journal from last year (el Moussaoui et al, BMJ,2006: 332:1355) addressed this question and the investigators looked at 3 day versus 8 day treatment with amoxicillin (yes, we still use this alot in the UK) in mild to moderate-severe pneumonia in the community setting.

The results were quite astounding in that, in those patients who had improvement in their pneumonia after 72 hours and who had their antibiotics stopped, they had the same resolution of their pneumonia as those patients treated for 8 days with the same antibiotic regimen.

Please read this article as it will be most enlightening!

So, it is therefore possible to be able to determine whether it is safe to send patients home or admit them for antibiotic treatment and if mild-moderate pneumonia, then treatment could be provided for just 3 days after which time, if the patient has improved enough, could have treatment stopped and could be reviewed in outpatients or, if an inpatient, could actually go home!

The short period of treatment could be justified to try and reduce bacteria becoming resistant to the antibiotic due to prolonged exposure, it would reduce expense and the possibility of adverse side-effects.

This is quite a controversial way of treating pneumonia and each patient has to be considered on a case-by-case basis as there may be social circumstances or other valid reasons that preclude the patient from returning home.

I would be interesting to know your thoughts-- so please let me know.

THOSE WITH PDAs CAN DOWNLOAD SOFTWARE RUNNING ON PALM OR POCKET PC WHICH IS CALLED PNEUMO CALC (THANKS SHIN-SAN) WHICH IS A CALCULATOR FOR THE PORT STUDY AND IS VERY CONVENIENT AND QUICK FOR MAKING YOUR DECISIONS. IT CAN BE DOWNLODED AT WWW.FREEWAREPPC.COM (ppc) OR WWW.FPPDA.COM (palm)


Wednesday, 17 January 2007

Epocrates-- Drug Software for PDAs


Today's blog is a bit shorter than usual as I have a conference to host this evening.

I wanted to return to the importance of using drugs.

A good example of multiple drug interactions was in a patient who I saw recently with a pneumonia and long standing depression.

The pneumonia was consistent with an atypical organism being the cause and hence, a macrolide such as clarithromycin or a quinolone such as levofloxacin could have been used except for one very good reason:

This patient took a combination of 1) Two tricyclic antidepressants 2) a Noradrenaline uptake inhibitor drug.

The combination of the two classes is in fact quite problematic as it can cause hypertension but more importantly, the tricyclic levels can increase due to the presence of the latter drug.

The patient had been taking 3 anti-hypertensive drugs when the probable exacerbating factor of his blood pressure was the combination of anti-depressants!!

With my resident, we checked the possible drug interactions very speedily on a piece of software which is FREE called Epocrates (www.epocrates.com) and it enables you to do a comparison of any drug against another for interactions.

We were then able to check the two antibiotics clarithromycin and levofloxacin and unfortunately, they in combination with Tricyclic antidepressants, can cause a Long QT Syndrome and hence, Polymorphic Ventricular Tachycardia (Torsade de Pointes).

Hence, it was a very valuable way of checking potential drug interactions which allowed a modification of drug therapy to either Clindamycin or Doxycycline, both of which are alternatives and do not appear to interact with Tricyclics.

Thus, my advice is ALWAYS CHECK FOR POSSIBLE DRUG INTERACTIONS when considering adding in a new treatment of any kind. It can be life saving and using Epocrates software can save you time and it can tell you all the relevant drug information. However, it is not based on Japanese drug dosing but American drug doses which are higher, so you should, if you use this software, check the doses with a Japanese drug text instead.

Tuesday, 16 January 2007


Have you ever asked yourself the question why we do CT scanning?

Well, we get very sharp and accurate pictures that allow us to determine, in some instances, the possible cause of a particular medical or surgical problem.

I am not a surgeon and therefore, it would be inappropriate for me to comment on imaging studies for surgical problems in any detail other than generally accepted concepts and as a result , I shall mainly concentrate on imaging modalities for medicine.

CT HEAD SCAN

The CT head scan has revolutionised medicine in being able to see directly inside the cranium and to be able to identify a whole host of problems such as cerebral infarction/bleeding, tumours, raised intracranial pressure etc...

It is sometimes the only way to find out a problem.

I regularly hear of patients admitted with some type of confusion or reduced conscious level who, for example, may have a pneumonia or urinary tract infection, or an obvious acidosis / hypoxaemia or electrolyte disturbance. With the diagnosis being quite clear in most instances I have seen, on occasion, the patient is also put through the scanner to check their brain.

All patients with reduced consciousness should have a full physical examination first which includes a thorough neurological examination to see if the patient has any focal neurological impairment. If present, I would whole heartedly agree that a CT scan should be performed.

However, if there are no focal neurological signs and another causes of impaired conscious level can be identified, e.g. UTI causing an acute confusional state and with no signs of meningism, then performing a CT scan, in my experience, is usually normal and offers no additional value in diagnostic terms and the physician will have exposed the patient to radiation unnecessarily.

For example, hypercarbia as part of type 2 respiratory failure can result in cerebral oedema, but it also causes papilloedema. This is a physical sign that can be elucidated by fundoscopy which my provide the clue that there is cereberal oedema.

Moreover, I often hear that a patient needs a CT head scan prior to lumbar puncture. If there are no focal neurological signs and that includes NO PAPILLOEDEMA of the fundi (in the eye), then a CT head scan may not be required. This was confirmed in a paper in the New England Journal of Medicine several years ago (Hasbun et al, Computed tomography of the head before lumbar puncture in adults with suspected meningitis. NEJM 2001; 345: 1727-33)

However, as I understand it, fundoscopy is not routinely taught at medical school in Japan, which is quite different to the UK where it is taught. I also teach fundoscopy examination here in Japan, and when there is an emergency case in ER, on occasion, I am usually called to perform the fundoscopy examination. Hence, the only way to try and identify raised intracranial pressure (rather than ruling it out) is to perform a CT head at most institutions.

Fundoscopy is a dying art but it can potentially save a patient's life. A CT scan cannot always determine if there is raised intracranial pressure (false negative), and the same is true for an MRI scan. However, if fundoscopic papilloedema is present, then the patient has raised intracranial pressure until proven otherwise, and a lumbar puncture should not be performed as to do so might result in brain stem herniation( a good reference is Diederik et al, Community-Acquired Bacterial Meningitis in Adults. NEJM 2006. 354: 44-53).

The latter paper talks about repeated lumbar puncture or placement of a temporary lumbar drain to 'effectively reduce' intracranial pressure, although it does not allude to the mortality of such patients treated or the rate of cerebral herniation and as far as I am aware, this is not standard treatment.

I have personally seen a case of a patient with encephalitis whose only complaints were headache, fever and memory loss and papilloedema was identified by me, and when the CT was reviewed, there were indeed signs of raised intracranial pressure and cerebral oedema.

Hence, there must always be a good reason to do a CT head rather than just to screen the patient. If you suspect a brain tumour then a CT is reasonable, but if the cause of the confusion is due to a severe pneumonia, then performing a CT head scan with a normal neurological examination, might seem over intensive especially if there is no real clinical indication.

At the end of the day, the whole matter comes back to History and Physical Examination, as they are your guide to the cause of the problem (in most cases).

In order to consider doing any imaging, you have to consider what you are going to do with the result! For example, does every patient with a clinical catastrophic stroke with a GCS of 3/15 really require a CT head scan if the history and physical examination are consistent with the diagnosis? Most physicians would go ahead and scan such patients, if only for medical defence purposes, but a patient with a very low GCS usually portends a grave prognosis.


Some physicians would argue that to do a CT head scan in such circumstances could pick up an intracerebral problem that could be treated. However, in a terminal patient, it is sometimes far more humane to optimise their palliative therapy and make the patient as comfortable as possible in their last hours, days or weeks rather than putting them through perhaps unnecessary tests, treatments or surgery which the patient may not have wanted or in fact needed.

It is essentially, a case-by-case decision as no one patient is the same as the next, but the physician should always bear in mind 'am I going to gain anything from doing this test?'

So, when doing a scan, one has to take into account the social circumstances of a patient, their pre-morbid condition, their wishes, the severity of their present condition and whether by doing the scan, it will actually change your management of the patient.

CT Chest Scans

Pneumonia seems very common here in Japan. In the UK, most pneumonias are seen in the Winter/Spring months and very few are seen at other times. From my short experience here, the same is not true and pneumonia is common all year round with a higher number in Winter.

I have seen many chest x-rays (CXR) with old tuberculosis (TB) usually in the elderly age group. The vast majority have completely inactive disease. Without the usual symptoms of cough, fever, sweats, weight loss etc is unconvincing to me to perform a CT chest scan, unless there is CXR evidence of active disease.

Pneumonia can usually be diagnosed on CXR WITHOUT the need for a CT chest scan. However, again I have seen at various hospitals the acquisition of CT scans for uncomplicated and quite obvious pneumonias and I see this as unnecessary.

History and Physical should at the very least provide enough information to make a diagnosis of pneumonia (except perhaps atypical pneumonia, where chest sounds may appear normal) and CXR can usually suffice to confirm the diagnosis. If the suspicion is strong for an atypical pneumonia, with a normal CXR, then I would be the first to say 'get a CT'. However, the 'reflex' to always obtain a CT chest for pneumonias is not necessary as it usually does not change the management in the vast majority of cases I have experienced.

The patient is going to usually receive a Broad-spectrum antibiotic unless there is definite identification of the organism and sensitivities are known, in which case, a narrow spectrum antibiotic would be used. Basically, antibiotics are going to be given and hence, doing a CT in an uncomplicated pneumonia does not help treat the patient.

Blood cultures, sputum examination, urinary antigens may be far more helpful than a CT.

Repeat CXR after clinical resolution, normally at 4 weeks, is the usual way to detect any unusual features that come to light such as the hiding malignancy, and it is at that time that a CT should be done, if of course, there were no sinister signs of an underlying disorder on admission.

If on the other hand, the patient's hypoxaemia is out of keeping with a small area of consolidation on the CXR, then one must always consider a complicating Pulmonary Embolism, and the modality of imaging would be a SPIRAL CT or the new technique of MR pulmonary angiography, rather than a Plain CT. Hence, when thinking of imaging, one must always consider what one is looking to diagnose or exclude. Doing a Spiral CT will aide in the diagnosis of PE and hence, it would alter the patient's treatment, for example, the patient would need heparin added or thrombolysis or thromboembolectomy.

ABDOMINAL CT SCANS

The abdomen was once described by my best friend as a 'box of magic tricks', as was told to him by his General Practitioner. Clearly, the abdomen being only partially radiolucent to Xrays is difficult to image.

I think that formal imaging of the abdomen requires an even higher level of suspicion of a serious problem, because doing a CT exposes the patient to a higher level of radiation.

History and Physical Examination may be helpful, but an ultrasound performed by an experienced doctor or ultrasonographer specialist may provide the answer, thereby negating the need for a CT scan.

For example, I have been informed that at another hospital, a patient was admitted with a history of fresh rectal bleeding which was consistent with a clinical diagnosis of inflammatory bowel disease. Whereas the patient should have been prepared for a flexible sigmoidoscopy or colonoscopy, the patient was put in the CT scanner, and the report confirmed that it looked like inflammatory bowel disease. The patient still needed a colonoscopy in any case, which is the Gold Standard Test, so was the CT necessary? No.

The usual way of imaging is an abdominal X-ray to rule out Toxic Megacolon or perforation. Only if perforation is suspected, but not detected on Xray, would a CT be required, although a traditional decubitus abdominal film might also provide the answer. Thus, CT should not be routinely performed in such cases. In cases where there is straight forward peritonitis, a CT can be a very helpful tool.

If on the other hand, the physician was considering a bleeding divertiulum or an abscess, for the former problem, a colonoscopy may still provide an answer (bearing in mind not to perforate an diverticulum) or ultrasound scanning the area and then draining percutaneously. If colonoscopy was considered too dangerous, then a barium enema can also provide the answer and although several pictures of the abdomen are taken, it provides less radiation than with a CT.

Patients with an appendicitis normally have a good history and in advanced cases, a physical examination consistent with the diagnosis. Performing an ultrasound may reveal the swollen appendix or ' free fluid'. Watching the patient, the temperature, pulse, blood pressure should be the reason for surgical intervention or conservative management, and doing an abdominal CT, although producing very fine pictures, is exposing the patient to radiation, which in a young female patient is of great concern in respect of possible future reproductive problems.

Finally, you must be worn out reading today's blog, but fertile female patients requiring any abdominal imaging involving X-rays MUST be pregnancy tested. Although the patient may say that are not pregnant or there is no possibility of being pregnant, there are some cases when the patient IS pregnant, and proceeding with a scan in the absence of testing the patient is negligent. Pregnant women can shed some of their uterine lining in early pregnancy which may look like a period and so, it is always best to test anyway, with the patient's consent of course.

You should always explain to the patient the risk of exposure to, for example, a full body CT scan.

David Brenner and Carl Elliston of Columbia University for Radiologic Research have been able to calculate the life time risk of developing cancer due to radiation from a single body scan which is 0.08%. That is equal to one in every 1,250 people who has a full body CT will develop cancer as a result. That is quite a worrying figure!

Extrapolating this further, a 45 year old person having a full body CT every year for 30 years would cause one in 50 to develop a radiation-induced cancer.

If you are interested you can read the article for yourself: Brenner, J. J. and Elliston, C.D. Estimated radiation risks potentially associated with full body CT screening. Radiology. Vol 232 (September) P 735-738. 2004.

Monday, 15 January 2007

Medico-Legal Medicine: the Musts of Medicine

The following blog, is soley my opinion from what I have read in respect of medicolegal cases in the UK and I hope it is enlightening.

Medicolegal cases in the UK are on the rise, and the payouts for medical negligence are reaching mammoth amounts.

Why is taking a history and performing a detailed physical examination important?

Well, it protects the patient and the physician alike.

Taking a thorough history shows that the physician was trying his or her best to find the problem. It also identifies areas that the physician forgot to ask. Hence, having an armory of stock questions to cover all the possible life-threatening problems protects the patients, as the diagnosis will be made quickly, and this protects the physician as a result.

This is the purpose for the Review of Systems Questions. I always describe it as a 'safety net' as it will catch those problems that the patient or the doctor forgot to touch on in the earlier part of the interview. In doing so, problems that were previously unidentified come to the foreground, some of which might be serious e.g. prostate cancer, and the physician will be complemented for finding the problem that others have missed, rather than miss it and be scorned for failure.

Performing a rectal examination is a MUST do part of the abdominal examination as a way to identify the rectal cancer or prostate problem. It must always be performed in cases of anaemia, diarrhoea (it might be overflow diarrhoea from an obstructing cancer), constipation, change of bowel habit, fresh rectal bleeding, weight loss, jaundice (rectal tumour with mets to liver), groin lymphadenopathy (rectal tumours can spread to the groin as well!!), unusual utero-vaginal bleeding in case of the neoplastic fistula to bowel.... If you avoid the Rectal test, the patient fails to get diagnosed and the physician gets wrongly labeled as negligent by the lawyers!

Examining the external genitalia is ALSO part of the abdominal examination with a chaperone of course!

Pyrexia of unknown origin in a man, the physician MUST examine the testicles because testicular tumours can cause fever (and spread to the lungs), and the lump of the testicle may have gone unseen by the male patient.

Also, patients with congestive cardiac disease, liver disease, nephrotic syndrome or severe low protein states can develop genital swelling to the extent that their urethra cannot be identified and they may develop urinary obstruction. Failing to inspect the genitalia can be disastrous leading to suprapubic catheterisation, that might have been avoidable if diagnosed earlier, and again, the physician might be labeled as negligent.

Writing all the physical examination down and the vital signs is extremely important as it is your only proof that you did the job correctly.

Failing to write down the heart rate, blood pressure, temperature, respiratory rate and SpO2 and sometimes even the capillary blood sugar might be taken as negligence by a court.

For example, a patient who is severely unwell and who has shock vitals on admission and who subsequently dies due to their illness is not uncommon. However, if the doctor fails to write down the full set of vitals can be be accused of not treating the patient correctly even if they did their best.

Here is a good example:

Lawyer ' So, this patient had severe breathlessness in your ER department right?'

Doctor ' Yes, that is right.'

Lawyer ' So, where is your record of the respiratory rate and SpO2?'

Doctor ' I am sure I wrote it down'

Lawyer ' Where. There is no electronic record of it!'

Doctor ' But...'

Lawyer ' Is it not true, that the reason there is no respiratory rate and SpO2, is that the patient was already dead!'

Doctor 'No....'

Lawyer ' Well, doctor, we have no proof. You never wrote it down. The patient died in your ER department. How do we know that the patient was alive?!'

The above is a made-up example of just how important the vitals can be.

Vitals are important as they tell the senior doctors of how severe the patient's condition is and how quickly they need to act and where the patient should be located e.g. a normal ward or the ICU department !

Always documenting the important positive findings and the negative findings shows that the physician actually checked rather than saying everything was normal. My 'Everything' and the inexperienced junior doctor's 'Everything' are completely different, and what a junior may miss a senior would hopefully identify.

Hence, writing everything 'normal' without qualifying why it is normal is incomplete and not good enough for notes that might one day end up in the hands of lawyers who may not care about your career at all...just about winning their case and of course, getting paid!

Timing and dating notes and signing the entry (by signature or electronically) shows that the physician did attend their patient, for example, before their unexpected sudden death on the ward, which shows anyone looking, that the problem may have not been readily identifiable or that some other problem arose. It also shows that the physician did not neglect their patient.

Writing a summary and differential set of diagnoses also shows that the physician had made a diagnosis and that treatment was then initiated for the problems identified. Failing to make a diagnosis at all might be construed as incompetence by lawyers, but making a differential diagnosis shows that the physician thought of many problems rather than nothing being documented at all.

So, you may have been thinking that patient notes are there just to tell other doctors and the nurses what is going on with the patient. Think again!

Patient notes if kept poorly maybe the thorn in the doctor's side despite them being an excellent doctor, whereas perfect notes may show that the doctor did a superb job for the patient and that the end result was unavoidable.

Although the litigation in Japan is not as high as in Western countries, it should always be borne in mind that it will increase in time and that when you put 'pen to paper' or 'fingers to the keyboard', you may need to defend it in court one day and sometimes, many years later, when you can't even rememer the patient you saw at the beginning of the busy clinic this morning.

I hope this gives you something to ponder about.

All the best!

PLEASE FEEL FREE TO GIVE ME YOUR OPINIONS!!