Saturday, 2 June 2007

Busy, Busy Busy

This week has seen Dr Aoki begin his lectures for the new first year doctors. Many of the junior doctors turned up with their copy of Dr Aoki's book and he was happy to answer questions for the residents during and following the lecture.

Here are some photos below:

This week also saw me invited to conduct Bedside Teaching Rounds in the ER department. The residents, myself and Dr O. saw a great case that turned out to be a different diagnosis to what I had initially expected and putting together the history, physical examination and laboratory data provided the clues to the probable diagnosis.

I will therefore be teaching in both General Internal Medicine and Emergency Medicine in the foreseeable future.

I have also had my Kyorin medical student shadow me for the last 3 weeks and I think his eyes have been opened as to how a good history and physical examination are sometimes better than machines ! :)

I have noticed both from medical students and junior doctors that their knowledge of drugs including generic names, mode of action, side effects and interactions are not as good as they should be. This is a very important part of being a practising physician and although, as i am informed, it is not an important part for passing the final examination, it is however important for treating patients safely and effectively.

For example, in a recent case, a patient was admitted after overdosing on anti-epileptic agents, neuroleptic agents and tricyclic anti-depressants. After checking the drug interactions, which had not been done, we found that the combination proved to be a potentially lethal cocktail which could induce a Long QT interval and hence, Torsade de Pointes. After reviewing the ECG it indeed showed a prolonged QT of 458 msec !!!!! Hence, if the patient had developed a tachyarrhythmia or VF, the therapy would have been Magnesium rather than other anti-arrhythmic drugs which is a very important point.

Unfortunately, there is no guarantee that the previous physicians checked about the interactions of these drugs which brings me back to the emphasis on the proper education of pharmacology.

It is very, very important to know details about drugs and especially about Generic names and junior doctors by just re-writing the drugs on admission to hospital or on discharge without knowing why they were prescribed or checking side-effects / interactions is not sufficient and this needs to change.

There are some very good British and American pharmacology textbooks and I would strongly suggests that medical students and junior doctors obtain such reading material to improve upon where they may have deficiencies in their knowledge on pharmacology.

Next week sees the Famous Professor Stein visit from the USA and it should be a very busy week for me again and most enjoyable too!!

Have a great weekend.

Monday, 28 May 2007

Never Move An Unstable Patient

This story is anonymised and is from the UK.

A very sick patient who was admitted following an out of hospital cardiac arrest with a substantial time without effective CPR before arrival of paramedics, rendering the patient with likely global hypoxic-ischaemic brain damage.

The admission ECG showed diffuse anterior ST depression and with resolution there was persistent ST change consistent with a N0n-ST Elevation MI (NSTEMI) which is an acute coronary syndrome (ACS).

Following admission, the patient developed recurrent generalised seizures requiring intubation to protect the airway.

The CT head scan showed an old infarct and frontal cerebral wasting but no SAH or intracerebral haemorrhage.

Diazepam was given followed by phenytoin rapid infusion, but both failed to curtail the seizure activity.

There were recurrent Jacksonian seizures every 2-3 minutes and lasting up to one minute, and the junior doctor was not completely certain how to proceed from there.

However, because a bed was then ready on another ward, the staff were hastily collecting the notes to transfer the patient despite recurrent seizures being present. Despite a protected airway, this did not prevent the patient from developing possible complications of seizures such as recurrence of a cardiorespiratory arrest, intracerebral haemorrhage etc...

The junior doctor was advised that a patient must be stable prior to being moved and when eventually moved, they should be accompanied by doctors and nurses who can perform CPR and they should have the correct resuscitation equipment with them in the case that the patient was to have a further cardiorespiratory arrest en route.

Sometimes, the eagerness to clear a bed space and move the patient from an emergency department to reduce nursing work can actually place the patient in a dangerous predicament.

One must always remember that the patient comes first.

The ultimate responsibility lies with the doctor overseeing the patient's care and it is the duty of the doctor to ensure that the patient is stable before moving them.

In this case, the junior doctor gave an infusion of midazolam which terminated the recurrent generalised seizures providing a hiatus of stability thereby allowing the patient to be moved safely.

This case demonstrates the importance of stabilising patients and although each situation is different, the general principle applies.

There are sometimes exceptions to the rule such as the patients with severe haemorrhage who require immediate surgery and patients in an unstable environment e.g. war zone.

However, patients with upper GI bleeding who require an emergency gastroscopy who are haemodynamically unstable should not be moved and such patients should have this examination with gastroscope done in the emergency room.

As a doctor, you are responsible for the patient and other staff rely on you to make a plan of action. It is your responsibility to ensure that the patients can be stabilised and if you need help then ask your senior to come.

Never be pressurised to move an unstable patient when you know it is the wrong thing to do.

Sometimes standing your ground and reasoning the point with staff who do not fully appreciate the problem can save your patient from complications.