Tuesday, 17 August 2010

Japanese Medicine Should Use the iPad at the Bedside

Dear Bloggers

Yes, it's been 6 months since I last put finger tips to keys to write on this blog. I have been busy with many things :-)

Since I last wrote, the iPad and the iPhone 4 have come on to the market.

The iPad is a really neat device albeit somewhat heavy. The screen is a nice size but grainy unlike the new iPhone 4 retina display. But, it makes a great eBook reader, word processor, newspaper reader etc. However, I think it has many more uses including within medicine.

It can potentially be used to 'clerk' patients. That means it can be used to record the patient interview and physical findings etc. Basically, a portable electronic patients records device that can upload to the main system for synchronising data. From my experience of seeing Japanese patient record softwares, they are cumbersome and complicated. Also, you either have to have a PC desktop or a laptop. Use of a laptop even at the patient bedside is cumbersome and the battery last about 4 hours if you are lucky ! Usually, it's about an hour in reality as someone else has used the machine without plugging it in.

The iPad has a 10 hour battery after a four hour charge and it much lighter than a laptop. With the touch screen technology, you can tap boxes referring to positive or negative findings, draw diagrams, add voice notes etc This cannot be down so easily or so cheaply on the current PC technology. The iPad is cheap enough and advanced enough to take medicine into a new era where the doctor can be freed up to see the patients at the bedside rather than being tied to the nurse station where the PCs are.

In the 'good old days' the papers notes meant that you could write the patient notes directly at the bedside and define an immediate plan and decide on your tests. But, there was never a way to make that information immediately known to relevant members of the team if they were in another location. Also, it meant that in order to see something relevant in the notes everyone would have to crowd around the patient notes. With the iPad, if every member of staff had such a device, all team members could read the notes simultaneously, check the lab data and radiology on the move from patient to patient so that problems are not missed.

Taking an iPad to the bedside and clerking the patient melds the old with the new and allows immediate updates for the patient care.

Now all that is needed is for some clever software makers to liaise with what physicians need and to make a package in Japanese to allow the doctors to be freed up to practice medicine at the bedside. Such software could also include the 'Review of Systems' with check boxes that would then organise the data later on to auto generate problem lists so that the physician does not overlook the information.

Integration with other software packages that could generate a differential diagnosis would be the next step but let's get 'denshi kalte' made portable first and bring medicine into the new age of technology the way it should have always been!

Have a good week :-)

Friday, 19 February 2010

A Friday Rant On Infection

Dear Bloggers

When we do invasive procedures, we should consider whether we are doing the procedure for the right reason, that the right equipment is used, and in an aseptic manner and maintained correctly.

Should we regard urinary catheterisation as a procedure less important than let's say, central line insertion? Should we be any less careful?

Well, the UK Department of Health figures from 2001 showed that about 25% of patients end up being catheterised during their inpatient stay. The risk of developing bacteriuria is about 5% per day and of those who develop it, about 4% will develop bacteraemia. The death rate from such bacteraemia can be as high as 30%. Clearly, the numbers of patients developing infection are not insignificant at all with the knock on effects of increased morbidity, increased hospital stay, increased cost and even death.

In a review of awareness of catheterisation, the attending was the least likely to know that their patient had been catheterised and up to 22% of residents were also unaware! Unawareness led to an increase in the inappropriate use of catheters. Documentation of the reason for catheterisation was also shown to be poor. In several studies based on the appropriateness of catheterisation, up to 50% of such procedures were deemed inappropriate!

Hence, when we perform urinary catheterisation, we need to appreciate why we are doing it and is there another option. Patients should NOT be catheterised to just 'help the staff'. It is an unfortunate practice in some institutions to place a catheter in elderly patients who are otherwise continent because of mobility problems such that the staff need not toilet the patient regularly. This is not a good reason to catheterise a patient.
Even patients with low urine output do not always need to be catheterised. A bladder volume scanner can be used to estimate the amount instead of passing a catheter.

If we do decide to catheterise, the right equipment should be used including sterile gloves, a sterile sheet (with a circle cut in the middle for exposure of the genitalia) and sterile 'one use' lidocaine gel. All equipment should be prepared in advance of putting on the gloves.

There is no excuse for using non-sterile gloves or previously opened gel, as this increases the risk of transferring bacterial infection into an otherwise sterile environment and which bacteria may be potentially highly resistant to antibiotics e.g. pseudomonas.

A basic but important thing to do is Wash Your Hands before the procedure. Medical staff are not immune from carrying infection. Far from it. Use of a sterilising hand wash is ideal.

There are several instructive formats available for teaching the Global Standard of urinary catheterisation and they include the New England Journal of Medicine videos of the procedure for men and women and the new ABC of Practical Procedures, BMJ Press 2010.

  • In the following explanations, the doctor has a 'clean hand' for using the sterile equipment and a 'dirty hand' for holding the penis or preparing the female labia. After placing on sterile gloves, and a sterile drape over the groin to expose only the genitalia, in men, the dirty hand pulls the penis is a vertical direction. If there is a foreskin present, it should be retracted with the dirty hand and the glans cleaned with sterile water using the clean hand. There is no reduction in bacterial infection from using a sterilising agent on the glans. Likewise, in female catheterisation, the labia should be parted with the dirty hand and the urethral area cleaned using the clean hand.
  • Following this, 10ml of STERILE lidocaine 'one use' gel should be injected down the male urethra via a prepared syringe until all of it has been instilled. The tip of the penis is then pressed to maintain the gel inside the urethra for about 1 minute to allow the lidocaine to take its anaesthetic effect. Then, the pre-opened 12F-14F male catheter is placed down the urethra. The use of such gel is to reduce trauma, patient discomfort and infection.
  • When the prostate is reached the patient should be told to take deep breaths which can relax the bladder neck and the catheter can be twisted slightly which can help entry of it into the bladder. In female catheterisation, as the urethral is very short, the gel can be placed on the shorter female catheter after which it can then be inserted. Once inside the bladder, the catheter is pushed in to the full extent and sterile water (usually 10ml) is injected into the balloon port and the catheter is pulled back. Urine should flow out into a prepared kidney dish and then, the collection bag can be attached. In men, the foreskin should then be return to its usual position to prevent the glans from swelling.
  • The catheter bag should be placed on a stand by the bed and it should NOT touch the floor. It should NOT be placed above the level of the bladder to avoid reflux of urine from the bag into the bladder. The bag should be in a place which avoids the lower exit tubing coming into contact with footware e.g. when staff come to review the patient.
In this closed system, unless the bag needs to be drained, it should not be touched. Taking Catheter Specimens of Urine should be avoided unless necessary. Routine change of the catheter is not recommended.

The procedure should always be documented in the patient notes in addition to why it was necessary to place the catheter in the first place. Another important thing is to document the residual volume to know if the patient has outflow obstruction.

For example one can write the following in the notes, DATE / TIME: Mr Jones not passed any urine for 12 hours. Complaining of pain in the lower abdomen. Examination revealed a large distended bladder than was dull to percussion up to his umbilicus. Prostate examination: enlarged, no central sulcus, smooth and non-tender ; likely BPH. Likely urinary outflow obstruction from BPH. Need to rule out UTI. Hence, need for insertion of Foley Catheter.

Procedure explained to patient with his verbal consent to proceed. Aseptic technique carried out. 10ml of 'instillgel' inserted down the penis. A 12F Foley catheter passed with ease into the bladder. Free flow of clear urine observed. 1200ml of residual urine in the bag post-catheterisation. Sample of urine sent for MC&S [microscopy, culture and sensitivity]. Foreskin returned to usual position post-catheterisation. Collection bag placed on bedside stand. Patient now much improved with relief of pain.

The need for the patient to continue using the catheter should be reviewed on a daily basis. It should not be kept in place just for the staffs' convenience. If the patient needs to toilet at night then it is the ward staffs' job to assist the patient rather than getting the doctor to come at 2am to put in a catheter for incontinence. Moreover, a diaper can be used instead of inserting a catheter. However, there will be some occasions when placing a catheter may be necessary e.g. try to heal decubitus ulcers and avoiding urinary contamination of the sores. However, such sores should usually be covered to aid healing with water-proof dressings. The need for a 'Foley' should be assessed on an individual basis rather than carte blanche' insertion of catheters.

We should also be aware that if we decide to remove the catheter, it should be done in the morning as a Trial With Out Catheter (TWOC). Hence, if the patient goes into obstruction, it will usually be during the daylight hours when the usual team are present and a catheter can be reinserted. It is not good etiquette to expect the on-call doctor to perform a chore that the daytime team can easily do.

Condom Catheters for men who are incontinent can be used in place of a Foley catheter. There is also Intermittent Catheterisation which can be taught to competent patients, which may avoid the need for a long term catheter.

Essentially, we must try and cut down on nosocomial infection. We must take all procedures seriously and use due care and attention to maintain aseptic technique. Just because we regard good aseptic technique important for CV line insertion, it does not mean that it is unimportant for Foley catheter insertion.

Please consider.

Tuesday, 9 February 2010

A Flurry of Endocarditis

Dear Bloggers

There have been two recent cases of infective endocarditis in young adults -- both aged below 30 years with 3rd degree mitral valve prolpase, both growing streptococcal spp from blood cultures and both with previous valvular abnormalities. One had a 'floppy' mitral valve and suspected endocarditis several years before and the most recent patient had confirmed endocarditis in the past.

In the latter case, the patient had a history of preceding tooth extraction prior to the original onset of endocarditis. In this recurrence, the patient had lost the cap to a repaired tooth several months previously. There was no complaint about tooth pain or current problems on direct questioning.

However, on examination, using a simple spatula and a pen light to inspect the teeth, it soon became clear that the base of a previous tooth [the one that lost the cap] was fully exposed and tender to touch. This was the probable site of bacterial entry.

Inspection of the nails revealed two fresh splinter haemorrhages which had occurred since the admission and whilst using antimicrobial agents at the appropriate dose and fully sensitive for the organisms identified.

Bedside fundoscopy examination revealed no abnormalities.

In the former case, there was no evidence of tooth problems. However, in view that the patient also presented with a 'pounding' headache, despite the lack of neurological signs, a mycotic aneurysm needed to be excluded. An MRA indeed revealed an early mycotic aneurysm.

Interestingly, both patients' original chief complaint was fever. Both patients had upper respiratory tract symptoms e.g. rhinorrhoea in the former case and cough with sputum in the latter case. In both instances, the patients were misdiagnosed with conditions such as a 'common cold'. How could this be?

Making a diagnosis of a relatively uncommon infection can be difficult for the uninitiated. More often than not, such symptoms are due to a common cold. Although I do not support such practice, for convenience, it is quick and easy to prescribe 'cold' medications and antibiotics for 'fever' after a cursory look, without appreciating the importance of doing a thorough work up e.g. full history, physical examination and labs, which are time consuming in a hectic outpatient clinic where patients are lucky to get 5 minutes with the doctor. In the season of H1N1 influenza, it is easy to consider everyone has possible flu or a 'common cold'. Hence, without a full workup, endocarditis can be missed and was missed - twice.....

Learning Points and Pearls in Endocarditis

  • Take a thorough history ! That includes previous medical history, medications, allergies, sexual history, travel history etc. If there is any hint of possible valvular disease, ask about dental treatment, rheumatic fever, previous murmurs etc. Don't make assumptions as you may get caught out.
  • Examine the patient with focus on the potential areas that might be affected by what comes to light from the history e.g. cough and sputum = thorough chest examination; fever and previous endocarditis = look for peripheral signs and listen to the heart sounds.
  • Use the modified Duke's Criteria for diagnosis of endocarditis.
  • If there is a suspicion of endocarditis, ask about the patient's dental history. Even if there is no complaint of current problems, nevertheless, inspect the teeth and gums. Do not merely look. Tap them gently with a sterile instrument. A painful tooth / teeth raises the suspicion up a notch. If dentists merely looked at our teeth without touching and prodding them, they might never find the tooth decay!
  • Get into the habit of doing bedside fundoscopic examination. It provides an immediate answer and saves time and money instead of sending the patient to the opthalmologist. The technique requires practice but is invaluable. It is especially important to do if the patient cannot be moved. Patients may not complain of visual loss especially if the peripheral retina is affected so again, we should not make assumptions that there are normal eyes just because the patient has no eye symptoms.
  • Blind prescribing of antibiotics for 'common colds' is not justifiable without a firm assessment and can lead to unwanted side effects and bacterial resistance. Such treatment can result in culture-negative endocarditis thereby making treatment much more difficult to tailor later.
  • Suspected endocarditis patients need 3 sets of blood cultures and an echocardiogram; trans-esophageal if possible. Remember that 'vegetation-negative' endocarditis exists and that trans-esophageal echo is not 100% sensitive. Newer modalities are coming to the fore such as PET-CT for identifying infected valves in 'vegetation-negative' endocarditis. If you are interested in further reading, please see A Bright Spot: Infective Endocarditis and PET/CT. Huyge et al. The American Journal of Medicine, Vol 123, No 1, January 2010
  • A pulsatile headache in a patient with fever and a heart murmur or other peripheral signs suggesting endocarditis, should make one consider a mycotic aneurysm. It is reasonable to undertake further investigations e.g. contrast CT or MRI.
  • Embolisation whilst using appropriate antibiotics is a possible indication for urgent surgery as is a vegetation >10mm. Definite indications for surgery include heart failure (moderate-severe), severe aortic or mitral valve incompetence with evidence of abnormal blood flow, fungal endocarditis or a highly resistant organism and perivalvular infection with abscess or fistula formation. UpToDate support surgical intervention after a second episode of embolisation whilst on antimicrobial agents.
  • Inflammatory markers play very little role of when surgery should be undertaken. Making a decision to operate or not based on the level of CRP is nonsensical as any decision should be based on the degree of haemodynamic instability. Moreover, severe aortic or mitral valve incompetence is usually associated with some heart failure and this condition may further decompensate. Hence, aggressive treatment with early surgery should be considered in such situations. Even in asymptomatic severe valvular incompetence without heart failure, early surgery may show benefit. In a paper by Habib et al on native valve endocarditis and optimal surgical timing, it is stated that 'Patients with severe aortic leaflet destruction and congestive heart failure, patients with perivalvular extension or uncontrolled infection, and patients with high embolic risk have poor outcome under medical therapy. Early surgery is necessary in all such patients with 'complicated' endocarditis unless severe comorbidity is present'. Curr Opin Cardiol. 2007 Mar;22(2):77-83.

Wednesday, 20 January 2010

A Classic Bedside Physical Sign - Asterixis


Dear Bloggers

Above is the classic sign of Flapping Tremor, also termed Asterixis, commonly seen in hepatic encephalopathy and CO2 retention. It is also seen in uraemia. The clues for the cause in this patient were the obvious jaundice and palmar erythema. Smelling the breath also revealed the classic Fetor Hepaticus -- sadly there is no current technological means to purvay this smell across the internet! Abdominal palpation revealed hepatomegaly.

The technique for asterixis is performed by asking the patient to extent their arms so that they are straight at the elbow. The patient is then instructed to extend the wrists and spread the fingers wide. This will allow asterixis to be uncovered.

Pearl: When you see a jaundiced patient ask them to perform the test for asterixis. A positive test suggests encephalopathy e.g. Grade 2 Hepatic Encephalopathy. If the patient has known COPD, e.g. the archetypcal chronic bronchitic 'blue bloater' and a positive asterixis sign, checking a blood gas for rising CO2 levels is justified. Remember that Type 1 respiratory failure patients e.g. emphysematous 'pink puffers' can also develop type 2 respiratory failure on occasion!

Tuesday, 19 January 2010

Blue Sclera Sign

Dear Bloggers

As part of inspection of the patient, one is occasionally faced with the Blue Sclera Sign as seen below:

Often, the patient is unaware that the 'whites' of their eyes are in fact, blue.

I was first introduced to this sign as a junior doctor by a neurologist, and the patient turned out to have osteogensis imperfecta !

However, there are several causes of this unusual physical sign that are listed below:

Congential (rare)
  1. Osteogenesis imperfecta type 1
  2. Ehler's-Danlos Syndrome
  3. Marfan's Syndrome
  4. Adult type osteogenesis imperfecta
  5. Pseudoxanthoma elasticum
  6. Kabuki Make-Up Syndrome
  7. Crouzon disease
  8. Hallermann-Streiff-Francois Syndrome
  9. Velocardiofacial Syndrome
  10. Weaver (Marshall-Smith) Syndrome
Acquired (more common)
  1. Any cause of severe scleritis with resulting thinning which reveals the underlying choroid tissue (scleromalacia) e.g. Rheumatoid arthritis, Relapsing polychondritis, Opthalmic Zoster infection (rare) [this can lead to rupture of the eye --> scleromalacia perforans]
  2. Iron Deficiency Anaemia
  3. Drugs: Corticosteroids (thinning of the connective tissue of the eye), Tetracyclines (chronic administration)
When one finds this sign, a hunt for the cause should be undertaken. In the newborn, children, adolescents and young adults, congenital disorders should be considered. Often, other features of the disorder present to help with the diagnosis e.g. repeated fractures (osteogenesis imperfecta), tall body habitus and high arched palate (Marfan syndrome). Moreover, there may already be a family history and hence, the diagnosis may be straightforward. In other cases, genetic testing may have to be undertaken.

In adults, other causes should be considered e.g. scleritis, drugs and iron deficiency. The history and physical examination may again be helpful to decide on the likely cause. A thorough history is required such as inquiring about symmetrical small joint problems, morning stiffness (rheumatoid arthritis), painful red ears (relapsing polychondritis), orogenital ulceration (Bechet's disease), etc... A careful history about upper GI problems, change in stool consistency and colour, medication use e.g. aspirin, weight loss, decreased appetite, dietary history, etc, should be undertaken for identifying the cause of an iron deficiency anaemia. A full drug history is essential. Steroids and long-term administration of oral tetracyclines can be an obvious cause.

Physical examination for connective tissue diseases can be straight forwards with joint swelling and deformity and nail / skin changes. Iron deficiency can be considered by finding koilonychia, glossitis, mouth ulcers and angular cheilitis. Steroid side effects may include centripetal obesity, 'Moon face', telangiectasia, proximal muscle atrophy, thin skin, subcutaneous bleeding, and striae etc. Hence, the cause of the blue sclera sign may be obvious. Last and by no means least, tetracycline administration can cause the blue sclera sign along with the 'blue nail sign'. By finding these two signs co-existent in the same patient and with a history of tetracycline administration e.g. minocycline, makes the diagnosis straightforward.

So, the next time you look at a patient's eyes, don't just look for 'jaundice' and 'conjunctival pallor', as they are signs that touch only the tip of the 'ocular iceberg'. Remember the Blue Sclera Sign as well, but only mention it to your attending physician if you find it! It is rare enough to not be mentioned as part of the 'pertinent negatives' list during oral presentation, but it will certainly prick up the ears of the attending if you find it!

The Blue Sclera Sign is one of those signs that makes one reconsider whether Hens really do have teeth, as in fact, sometimes they do! [Click on both links for some funny explanations!]

Have a nice week!

Monday, 11 January 2010

Simulated Training of Practical Procedures

Dear Bloggers

Some training institutions are instructing medical students and residents in performing medical procedures using 'simulated training' on special manikins. The aim of this kind of training is to teach the 'global standard' for such procedures with the expected outcome to make us 'better doctors' and to reduce mistakes made on the patients.

When techniques are taught on a 'see one, do one, teach one' basis, there is a tendency for the teacher to introduce their own variations or mistakes, which are not be in keeping with the global standard and may not have any evidence basis.

However, by doing such training in accordance with standardised procedure guidance, it is often possible to identify resident 'bad habits' e.g. failure to use local anaesthetic for performing lumbar punctures, and to then introduce how the standard techniques should be done.

One cause for confusion of junior residents has been the type of equipment and the inappropriate use of it. For example, although a chest tube comes with a central trochar, for years, it has been taught that the trochar should not be used for fear of puncturing internal organs. However, unless there is stipulation from 'trainer' that the trochar should not be used and that forceps introduction of the drain is safer, it is easy to see how wrong techniques and subsequent mistakes on patients can occur, especially if supervision of junior residents is not optimal. No junior doctor should ever be 'let loose' to 'Just Do It' without first training the doctor appropriately and ensuring that they are 'safe' for the patients. Many modern texts exclude the use of the trochar because it is dangerous. It should not be used. We need to diverge from the Eminence Based Instruction of 'this is how I learnt it and this is how I will teach it to you' concept and use Evidence and Benchmarking as much as possible, for attaining the best and most standardised technique for a particular procedure.

When performing simulation training, the trainer needs to be aware of the various global standards rather than teaching their own favoured technique, otherwise we fall into the 'see one, do one, teach many' concept that I see as being a problem as described above. There are many texts and videos now available to aid in procedure training.
A recent book for 2010 is the ABC of Practical Procedures from the BMJ Press - this teaches the way procedures are taught in the UK with evidence to support certain aspects of the text. I would recommend using this book because it has clear descriptions, good pictures, and an evidence basis. However, some procedures differ to those performed in the USA ! For example, in the UK, chest drains are inserted whilst the patient is leaning forwards with the arms and head supported on a table, whereas in the USA (and Japan), such drains are generally inserted with the patient recumbent. This can indeed be a challenge to the trainer to find the best 'global' technique to teach and which has the best outcome or the best evidence for its use.

The New England Journal of Medicine produces procedures on video that can be streamed or downloaded from their website. Although these are only produced in English, they are easy to understand and can aid in training with the use of manikins and patients. In fact, all the NEJM videos are demonstrated using real life subjects.

Most recently, the iPhone AppStore has started selling Procedures Consult -- a massive multi-megabyte programme and relatively inexpensive when one compares this to a regular medical textbook or video. This software has text and video demonstrations to guide you on procedures, and I would recommend it to residents and senior doctors alike to keep refreshed on how to do techniques.

The use of evidence for procedures has helped to dispel certain ideas such as:
  • patients do not need iv fluid before a lumbar puncture
  • they do not need to lie down for several hours after a lumbar puncture -- it may in fact make a post-LP headache worse
  • purse string sutures no longer need to be used for chest tube insertion when withdrawing the tube; a Z incision, sealant and pressure dressings provide a better cosmetic result
  • local anaesthetic should be used for lumbar punctures; use of a 'small' needle is still painful
  • 5 litres of ascites can be safely removed by paracentesis in one go without the need for using fluid replacement in liver disease. Colloid can be used in place of the traditional albumin infusions if required. There is no evidence that albumin is any better. Ascites can be removed in one session so long as there is no cardiovascular compromise. Drains are removed the same day and not left in overnight or clamped for long periods.
It is important that the students / residents have an opportunity to be observed performing the techniques after their training period. This is done to ensure good technique and that they have an understanding of the complications. Moreover, sometimes, although there is no complication, the technique does not go as planned e.g. the guidewire seems to be going up rather than down when doing a subclavian vein 'central line' cannulation. Knowing that turning the head to centre, pressing on the internal jugular vein to feel if the wire is ascending and sometimes, replacing the wire completely to get better downward angulation, can sometimes overcome the 'hiccups' of this procedure. These Procedural Pearls can be extremely helpful and are rarely printed in regular texts -- it is rare that any of these 'get out of trouble' techniques have evidence to back them up, but sometimes, they do work ! :-)

The trainee also needs to understand that it is sometimes fruitless to continue with a procedure that is going wrong. It is better to start again and / or call the senior doctor to take over. As humans, we have good days and bad days, and no one is perfect. By recognising our weaknesses as doctors, this makes us safer and stronger individuals at the same time. We then know how far we are safely prepared to go and when to refer to someone with superior technique, experience and knowledge. It is better to be cautious and careful when doing procedures than being maverick. It is the latter type of way that will end up with a disastrous outcome for the patient and for the resident.

Finally, although the modern era of technology is upon us with the use of portable ultrasonography for use in procedures, we should not forget the traditional techniques. I for one, fully support the use of ultrasonography for identifying veins from arteries and fluid from solids when doing procedure training. However, we as physicians, will not always be in a situation with technology to assist us. There was a famous situation many years ago when a person developed a tension pneumothorax whilst in-flight, and two doctors ingeniously used a coat hanger and a bottle of whiskey to make an under water chest drain. There was no x-ray technology and no ultrasonography. They used their knowledge of anatomy and procedural techniques to save a life without modern technology.

Hence, when we do simulation training, although we should teach the most up-to-date technology driven procedures e.g. ultrasonography during CV line insertion, we should also consider teaching the traditional techniques too so that the residents will be fully prepared for any event whether it is first world, third world or 30,000 feet in the air.

Have a good week.

Monday, 4 January 2010

Look at the patient

Dear Bloggers

Although technology has taken medicine into a new age, we should not leave the fundamental skills of doctoring behind.

The following case is a vignette and has been anonymised to safe-guard patient confidentiality.

An elderly lady of 86 years of age had been admitted to a hospital with severe dehydration, vomiting and abdominal distension and she was tentatively diagnosed with paralytic ileus. The patient was treated with intravenous fluid and kept nil by mouth with nasogastric tube suctioning whilst undergoing investigation for the cause.

The patient had a urinary catheter placed to measure urine output and post-renal obstruction had been excluded by a normal appearance of kidneys, ureters and bladder on ultrasound scan. High doses of furosemide were also used at the same time as the intravenous fluid with the aim to 'kick start' her ailing kidneys and to avoid heart failure.

A plain CT of the abdomen had shown distal loading of the large colon with faeces and dilated small loops of bowel.

Initial blood gas on the admission revealed a severe metabolic acidosis.

Several days into the admission, the patient started to produce bloody coloured fluid from the NG tube, and upper GI bleeding was strongly suspected. Intravenous proton pump inhibitor therapy was commenced in addition to continuing fluid resuscitation whilst awaiting gastroscopy.

However, the patient's heart rate was then seen to slow on the monitor to 40/min and last the recorded blood pressure was 160/80mmHg. Initially, the physicians were looking at the monitor abnormality, but when the patient was assessed, she was found to be completely unresponsive and there was no respiratory effort. After pulse check, there was found to be no cardiac output. Pulseless Electrical Activity (PEA) was immediately considered and CPR was commenced.

In addition to the blood in the NG tube, the diaper also contained fresh pungent malaena.

This patient's circulation was initially restored with crystalloid fluids (several litres) and later with red cell transfusions, in addition to using atropine, adrenaline and high dose dobutamine support. However, the initial haemorrhagic shock and use of vasoconstrictors resulted in cardiac ischaemia. Moreover, it was unclear how long the patient had been in cardiac arrest prior to starting CPR and despite restoration of her circulation, there was no improvement in cerebral function with GCS of 3/15. Despite the resuscitation, the patient appeared inotrope-dependent, a commonly seen sequal to cardiac arrest. Unfortunately, the patient reverted to PEA and despite further attempts at CPR, she could not be revived.

An autopsy was performed which revealed an acute duodenal ulcer and distal ischaemic colitis.

The Learning Points from This Case Vignette

If there is a monitoring abnormality, look at the patient and recheck the vital signs, manually if need be, and repeat the physical examination. You should seek out the cause.

Remember to Check the Airway, Breathing and Circulation in unresponsive patients.
Focusing only on the monitor can distract you away from the patient - remember that both are important.

A bleeding patient needs rapid assessment and restoration of circulation with fluids and blood +/- clotting factors (if required).

Circulation is difficult to assess and this can be improved by placing a central venous line to monitor the central venous pressure.

Urine output needs to be measured hourly to ensure that there is no deterioration. Often, the urine output drops consistently in shocked patients before they develop cardiac arrest -- this depends on the velocity of bleeding -- it can be an early warning sign of problems to come.

Low pulse rate needs assessing just the same as high pulse rate -- this patient should have developed a tachycardia but instead had bradycardia which might reflect a severely ischaemic heart e.g. from severe bleeding on a background of coronary heart disease.

In acutely unstable GI bleeders, the endoscopy equipment can be brought to the bedside and therapeutic intervention can be done there and then. It may not be safe or practical to wait and despite the best attempts to stabilise the patient so as to get them to the endoscopy suite, it is sometimes not possible. Doing intervention at the bedside is sometimes the only viable way.

Unstable GI bleeders need to be in a monitored bed e.g. a high dependency unit, acute bleeder bed, or an ICU. They should not be managed on a general ward if they are unstable.

Group and Save blood for all bleeding patients. Those with significant losses should be cross matched and transfused rapidly. Don't rely on the haemoglobin level in acute GI bleeding as it can be falsely normal. If there is no time for the cross match then give Group O blood (universal donor) until the cross matched blood is available. Don't wait for your patient to bleed out.

Inform the surgeons in the case of a patient who is admitted with upper GI bleeding. Doctors may sometimes become over confident that 'it's just another GI bleeder' until the disaster of when the patient bleeds out. If the upper GI bleed cannot be resolved through conservative methods e.g. clipping, cautery, hypertonic saline-adrenaline, transfusions etc, the patient should be considered for surgical intervention. However, if the surgeons hear about the patient for the first time as 2 litres of malaena hit the floor, they will not be very pleased with you for telling them at the last minute. Remember, it is better to operate on a patient who is stable than on one who is unstable and which situation could have been avoided if preparations had been taken sooner. Have a low threshold for getting a surgical opinion early.

Do not be blase' about GI bleeding. It is serious and as the above vignette case demonstrates, it can lead to serious consequences. In this case, the upper GI bleeding led to unexpected and profound haemorrhagic shock and then PEA.

When you have a monitor showing unusual readings, look at it in combination with the patient. The monitor is a guide and not an absolute. Unless the patient is linked to direct arterial pressure monitoring, or transoesophageal cardiac output monitoring, it may not be possible to know that PEA has occurred. Relying on an ECG rhythm strip can be misleading especially if there is implantation of a pacemaker. Look at the patient! Check the carotid pulse. Sometimes the most simplest of things can be the most significant and helpful.

This brings me back to a previous issue of an Early Warning System -- a UK idea of several years standing, that scores patients according to their vital signs. If there is a deterioration from the normal variability, then the score rises and once a threshold is met, the doctor is called for the patient to be reassessed. Many UK hospitals utilise this system for spotting the 'deteriorating patient' with the aim to avoid problems.

The drop in pulse and an unresponsive patient would have resulted in an EWS score of 5 (>4 = call doctor as soon as possible). The low amount of urine in the catheter bag is another tell tale sign of problems. Such a low output without evidence of urinary tract obstruction makes one consider either pre-renal or intrinsic renal failure. In the event of bleeding, the former is a more likely cause.

When we look at the BUN and creatinine of a patient, don't just think dehydration if the ration of BUN-to-Creat is increased. Also think Bleeding specially if the ratio >20:1 ! This means performing a rectal examination looking for blood, passing an NG tube to check for upper GI haemorrhage, and serial haemoglobin measurements (plus renal function tests too) in addition to repeated physical examinations of the patient to look for signs of ensuing hypoperfusion e.g. cold extremities, confusion, decreased urine output etc....

Providing intravenous fluids AND diuretics to 'kick start' the kidneys is NOT the standard way to treat a hypovolaemic patient. Remember, when a patient is hypovolaemic, there is increased output of vasopressin and angiotensin II to cause the reabsorption of H2O and Na+, to try and stabilise the blood pressure and hence, renal blood flow. It is therefore no surprise that the urine is decreased and concentrated in hypovolaemia. The important thing is to replace volume to improve perfusion but NOT using diuretics as this makes matters worse by decreasing the intravascular volume yet further.

Moreover, patients can develop acute tubular necrosis which has an initial oliguric phase followed by a diuretic phase. This can be avoided if there is adequate fluid resuscitation performed early. To understand fluid status more accurately, a CV line should be placed. There is no additional benefit placing a Swan-Gantz catheter. Some physicians rely whole heartedly on the IVC compliance measurement (as assessed by echocardiogram) to make decisions, with them sometimes ignoring all other evidence of hypovolaemia when an IVC compliance appears normal, at the potential detriment to the patient. Remember, no one physical sign and/or test is always going to give the right answer, but usually a combination of signs and/or tests does. Also, the result of an echocardiogram is only as good as the practitioner performing it.

Please try and look at the overall picture of the patient and remember that it is better to give generous fluids rather than judicious fluids and catecholamines with the latter causing the potential risk of arterial ischaemia and organ failure if used inappropriately. Consider heart failure as a potential outcome of too much fluid but do not let that stop you giving adequate fluid resuscitation. Boluses of fluid to maintain circulation and re-examining for heart failure is one way to try and gauge how much fluid to infuse into the patient.

If after fluid resuscitation is performed and CVP is adequate e.g. 12cm H20, and BP still remains low, then giving catecholamines is justifiable e.g. septic shock, cardiogenic shock, adrenal failure etc, but certainly NOT diuretics as an initial therapy to try and 'kick start' kidneys or to try and avoid possible heart failure.

In summary, let's get back to basics and review the patient's status through physical examination rather than just looking at numbers and blips on a screen. The 'red flag' signs of GI bleeding e.g. haematemesis, malaena, hypotension and low urine output, are serious and require immediate assessment and intervention. No inpatient being actively treated should succumb to GI bleeding without having first, established a cause, and secondly, having attempted to abrogate the problem. Remember the H's and T's of the reversible causes of cardiac arrest of which Hypovolaemia (including haemorrhage) is one.

I hope this is food for thought. Have a good week.