A New Year, New Resuscitation Guidelines

 Happy New Year!

In her first editorial of the new year, the BMJ editor chose to wish everyone 'a rational new year'. The emphasis is definitely placed on promoting rational healthcare decisions which are based on the best available evidence. A good example of using evidence to change medical practice is shown in the changes to resuscitation guidelines released towards the end of last year:


New Guidelines on Resuscitation - Student BMJ, January 2011. In October last year, a large review of available literature on resuscitation guidelines was carried out and there have been new recommendations made following this.

• Chest compression only CPR is recommended if a rescuer is not trained in CPR.
• Compressions should now be delivered to a depth of 5-6cm, not 4-5cm as was previously recommended.
• Rescuers (wearing gloves) should continue compressions while the defibrillator is charging.
• Use of three consecutive shocks may be considered in VF/VT during cardiac catheterisation, in the early post-op period after cardiac surgery, and in a witnessed VF/VT cardiac arrest when the patient is already connected to a manual defibrillator.
• Every patient in hospital should have a documented care plan for monitoring vital signs including criteria for escalation of care to prevent cardiac arrest.
• If IV access is not available, the intraosseous route should be used.
• When treating a VF/VT cardiac arrest, adrenaline 1mg and amiodarone 300mg are given after delivery of the third shock once chest compressions have restarted. Adrenaline is otherwise administered during alternate cycles of CPR.
• Atropine is no longer recommended for routine use in asystole or PEA.
• Real time use of echocardiography increases chance of diagnosis of potentially reversible causes of cardiac arrest eg.cardiac tamponade or pulmonary embolism.
• Oxygen saturation rates of 94% - 98% should be targeted when spontaneous circulation has been re-established.
• There are also slight changes to the paediatric guidelines.

Links to the new guidelines are available here: http://www.resus.org.uk/pages/guide.htm
 Doctors in Scotland recommend radical cuts to medical school intakes (Student BMJ News December 2010) - Doctors in Scotland have called on the government to reduce the numbers of medical students in the forthcoming years in order to stop the oversupply of doctors applying for registrar positions. In an article in the Student BMJ News, the current projections for specialty training numbers from 2011 to 2015 indicate that 21 percent of Scottish foundation doctors are unlikely to progress further in Scotland.

Registration cuts fees for foundation years (Student BMJ News January 2011)  - Some good news! The GMC has agreed to cut down registration fees for junior doctors. According to the student BMJ in January, FY1s will now pay £100 for provisional registration (down from £145), and in FY2 will pay £210 (down from almost double this amount). Perhaps this is a positive sign that some attention is being taken the BMA about the high costs for training in medicine.

Merry Christmas 2010!

Merry Christmas and a happy new year, good luck for all that 2011 brings! 

Save a Life in 5 Minutes

At Heathrow airport all you need now is 5 minutes to learn how to save a life. I saw this video on the BBC News website and thought it was a great initiative by the London Ambulance Service which could probably be rolled out to a greater number of people. In particular, I thought that it was a good idea including a demonstration of using a defibrillator. It seems that there's still a widespread opinion amongst the lay public that the 'old-school' paddle set-up and the whole 'clear' then 'shock' method as performed on TV is still being used.

Using a defibrillator is something which anyone who can do. It's really not that hard. A lot of busy places now have defibrillators available but there may still be people who are not trained how to use them. CPR and chest compressions is all about buying time, but really if a patient has a shockable rhythm, then access to a defibrillator as fast as possible is what is required. It was interesting talking to Helen Brady this week, who runs the Heartstart in Dundee, that defibrillators have now been included in Heartstart training videos shown at teaching sessions. The defibrillator has simple diagrams, instructions and a voice to tell the user how to use it. I'll put my hand up and say that I have not been needed to use one in a 'real-life' situation, but having done some training and used the defibrillator in a mock set-up, I would certainly feel confident about using one in a life-saving situation.

End of Life Assistance Bill and PCOS Discussed

This week the Scottish Government voted overwhelmingly against the End of Life Assistance Bill in parliament. It's interesting that when I started at medical school 6 years ago, euthanasia was a topical subject, and it still is today. As with many difficult ethical dilemmas, no doubt this is a subject which will come up time and time again over the next 100 years. The End of Life Assistance Bill was thoroughly studied and discussed by an ethical board consisting of doctors, legal experts, religious groups and experts from countries where end of life assistance has been legalised, such as in the Netherlands. I think it is possible to see where the arguments FOR the bill exist ie. not to prolong suffering, beneficence (doing good) etc. However I believe that there are few doctors out there who would agree to be involved in the process of assisting someone to die. The main reasons why the bill was rejected were because of a fear of how the system could be abused and the doubt as to whether there really was any need to change the current system. I'm going to sit on the fence with this one as I don't think there are good enough arguments for either side to have a majority. Besides, sometimes sitting on the fence is the best place to take a good look at the bigger picture.

When the post did finally arrive today for the first time in over a week, one of the things which dropped through the letterbox was this month's student BMJ. The editorial and center articles were about the shortage of jobs predicted for foundation programme applicants this year. We find out on Wednesday this week how we got on in our applications so fingers crossed for a good score. There were a couple of interesting edicational articles such as this one on Polycystic Ovarian Syndrome. This condition is the commonest cause of anovulatory infertility in women and affects up to 10% of women of reproductive age therefore it is common. There are several pathological abnormalities in the condition such as abnormal ovarian morphology, insulin resistance and increased androgenicity. It is recognised as a diagnosis of exclusion. Patients with clinical features matching the condition should have other endocrine abnormalities ruled out such as Cushing's syndrome and adrenal hyperplasia. The management of the condition is complex and requires consideration of subfertility, metabolic consequences such as diabetes and obesity, and symptoms of hyperandrogenism.

SNOW DAY. Lessons on Improving Patient Safety.

This was the photo that made page two of the Dundee Evening Telegraph tonight thanks to our resident journalist Katie. A short clip about the 'avalanche' of snow which fell of the roof of the house and bashed in the roof of the car. Luckily I was able to push out the roof from the inside back into shape but a good story none-the-less! Shame about the neighbour's car whose back windscreen wiper snapped right off though.

I'm into the second week of the Improving Prescribing Theme SSC at the moment and much of the emphasis on the first week has been patient safety and reporting of errors. This is an important topic because a study in 2001 found that 12% of UK hospital admissions involve some form of adverse event. People never make mistakes intentionally but they are a common occurrence, even in the top medical institutions. Much of the time the mistakes come down to faults in communication and it's important to emphasise that it is nearly always the system which is at fault rather than individual blame. In the past there was much more of a 'blame and shame' culture of reporting errors however this has now changed with an increasing shift towards open reporting of incidents. One way to think about the way errors to occur is to imagine the 'Swiss-Cheese Model' where an adverse event occurs when a series of holes in the system are breached.

Ways of investigating an incident can include a 'Root-Cause Analysis' which is often started using a simple 'fish-bone' diagram. The factors to consider in how an incident occurred include:

1. Patient Characteristics
2. Task Factors
3. Individual Staff
4. Institutional Context
5. Work Environment
6. Organisation and Management
7. Team Factors

After considering each of these areas in turn, it is then possible to get an idea of the bigger picture of what led to an event occurring. We've been set a task in a small group to investigate an incident on one of the wards in Ninewells where an error was made an a patient was prescribed an overdose of an anticoagulant. During this week we'll meet as a group to discuss each of the factors in turn and then generate a report. Hopefully the plan will then be that once we have made our report, we'll be in a position to make a recommendation on how practice can be changed to stop this kind of incident from happening again. It's been an interesting course so far and will hopefully continue this way, unless the snow interferes too much! I'd advise anyone interested in this to look at the IHI Open School Website for more information.

Slip, Slop, Slap

I've started writing a case discussion on the subject of health promotion and disease prevention. Since I'm on a Dermatology placement at the moment, it seemed that writing about skin cancer would be the way to go. Rates of malignant melanoma have tripled over the past 20 years. The main reason why people think that may has been the case is the increasing tendency for people to travel abroad for holidays. With so many cheap flights abroad, its no wonder that people with fair skin are taking in more unaccustomed high intensity UV light. In order to try and curb this trend, there have been some pretty good health promotion campaigns to go ahead, led primarily by Australia, the country with the highest rates of melanoma in the world. In Australia one in twenty five men will get a malignant melanoma in their lifetime. The best known campaign was the 'Slip, Slop, Slap' campaign launched in 1981. The idea was to slip on a t-shirt, slop on sunscreen, slap on a hat. Since 1981 rates of melanoma have increased in Australia however the widespread uptake of this campaign has almost certainly slowed down the progression and increased public awareness of the disease. Here in the UK, the public health campaign is led by the British Association of Dermatologists and Cancer Research UK. It'll be interesting now to read more and find out exactly how much of a difference the UK campaign has made since it started.