Royal College of Physicans and Surgeons of Glasgow Undergraduate Conference

Outcomes from the Royal College of Physicians and Surgeons of Glasgow Undergraduate Conference - January 15th 2010

Dr Pauline Gross – Acute Medicine

·      Acute Medicine is a subspeciality which has only been recognised for about 10 years.

·      It is possible to specialise between general medicine and acute care

·      Top 10 A&E admissions – no.1 cause for presentation is chest pain.

·      Non rebreather mask and a reservoir mask are the same thing.

·      Respiratory rate is often not measured accurately yet it is the most sensitive physiological parameter of acute illness.

·      Even if you have a low index of suspicion for sepsis, take blood cultures – wont harm the patient!

·      Shock is inadequate tissue perfusion, not just hypotensive. Elevated lactate levels are a simple test. Elevated in patients who will be in shock.

·      Cardiogenic shock will lead to an increase in JVP.

·      Septic / hypovolaemic shock will cause a decrease in JVP.

·      Fluid challenge is a useful diagnostic tool.

·      Creatinine levels should always be compared with what is NORMAL for the patient.

·      Remember after finishing ABCDE, RESTART at the beginning.

·      Sepsis is often missed in its early stages yet early recognition is proven to improve outcomes.

·      SIRS = a clinical response arising from a non-specific insult. When infection is confirmed, it is sepsis.

·      Less fluids over a fast period of time leads to better outcomes than lots of fluids over a long period of time.

·      Management of organ failure = early involement of critical care and HDU.

Dr David McCarey – Rheumatology

·      Osteoarthritis is much more common than rheumatoid arthritis.

·      ANAs is a sensitive test for all inflammatory rheumatology disorders.

·      Joint pain – is it inflammatory or degenerative? Inflammatory will include morning stiffness, joint swelling and synovitis. Also rapid onset and functional loss.

·      Inflammatory back pain vs degenerative can be hard to distinguish. Does the pain move site?

·      Reactive arthritis is a more likely diagnosis if recent infection eg. UTI, LRTI.

·      Pseudogout causes calcium pyrophosphate crystals.

·      Very early use of methotrexate in patients with raised antiCCP antibodies and single joint pain can halt early onset of RF symptoms and changes.

·      Ultrasound scans have an important role in diagnosing joint disease.

·      MRI scan = gold standard but is not a routine diagnostic tool due to costs.

·      Three key DMARDS: methotrexate, sulfasalazine and hydroxychloroquine.

·      Anti-TNF alpha and other biological therapies eg Etanercept – can cause as much as £10,000 per patient!

Dr John Leach – Neurology

·      Speed of onset is very important when assessing neurological disease. Ie. Fast onset is likely to be vascular.

·      A pyramidal posture is a spastic posture.

·      UMN lesions cause a ‘spastic’ increase in tone ie. clasp knife appearance.

·      Parkinsonian disorders cause a ‘lead pipe’ consistent resistance to tone.

·      Corneal reflex is a CNV test. Sensation to the eyeball.

·      MRC Muscle Grading = 0 to 5. Tone, Power, Reflex, Sensation and Coordination.

·      Full testing of sensation should include: light touch, pin prick, vibration and proprioception.

·      A cervical myelopathy could cause UMN signs in the legs and LMN signs in the arms.

Dr Allan James – Oncology

·      Usually you cannot have invasion of cancer without metastases.

·      Endometriosis is an example of a metastasising benign process.

·      It is usually metastases which ultimately lead to the patient’s death.

·      Staging is describing a primary cancer and the extent to which it has spread from the site of origin ie. ‘PROGNOSTICATING’ the patient.

·      Therapy: Is this a treatable cancer? Is this a treatable patient?

·      MDT is the cornerstone of cancer treatment. Don’t engage in a discussion about this in the exam without mentioning the MDT!

·      Radiotherapy causes molecular DNA damage. This may be enough to cause cell death.

·      All cancer can be eradicated by radiotherapy. The skill is delivering it without causing the undesireable side effects which can be short term or long term (long term are much more worrying).

·      Good cancer medicine is often not knowing WHO to treat but knowing who NOT to treat.

·      Don’t forget about oncological emergencies such as neutropaenic sepsis, spinal cord compression, stridor and hypercalcaemia.

Dr Mitchell – Palliative Care

·      Good palliative care is the responsibility of ALL doctors.

·      Intrathecal local anaesthetic drug delivery into the CSF: leads to a lower incidence of side effects. It is a subcutaneous device and knowing about its existence is important.

Dr Colin Perry – Medical Training

·      Look up postgraduate medical training: The Gold Guide.

·      This contains the Core Medical Training curriculum.

·      Try and sit Part 1 of the MRCP exam as an FY2. There is still credit for trying even if it leads to failure because it shows commitment to the specialty.

·      The MRCP has 3 parts: Part 1, Part 2 and PACES.

The Jewish Surgeon and the Patient with a Nazi Tatoo

Sunset in Aberdeen with Girdleness Lighthouse in the background

This was an interesting case which was reported recently in the Telegraph newspaper. A Jewish surgeon at a German hospital reportedly walked out of an operating theatre and refused to operate on a patient requiring thyroid surgery because he spotted the patient had a swastika tatooed onto his arm.

The family of the patient want this doctor struck off because he didn't uphold the Hippocratic oath and didn't carry out his duty to care for the patient. Others however have praised the doctor for his moral courage. The doctor found another surgeon to carry out the operation but the question remains - was this doctor guilty of misconduct?

On one hand a doctor's duty is to provide care for a patient, regardless of their age, sex, beliefs etc in an unbiased way. However there are exceptions to this rule for example doctors are allowed to opt out of termination of life practice in the field of gynaecology. What if this patient was a convicted murderer. Would I walk out of the operating theatre on the basis of my moral views and beliefs?

The fact that this was probably not a life-saving operation should not affect the case. The only situation I can imagine which would have justified the surgeon leaving and asking another person to carry out the case, would be if the patient was at risk of harm / the surgeon felt that he could not carry out the task asked of him safely after finding out about the patient's past. If the surgeon felt he was not able to carry out the case, perhaps he was right in finding another surgeon to carry out the operation. Of course in private, everyone is rightful to have their own views and moral beliefs. However as doctors and in our service to the public, we must not allow these beliefs to cloud our judgement or to affect our decisions.

In my opinion I believe that this surgeon should not have walked out of the operating theatre. He should have withheld his duty of care to the patient, irrespective of his past history and carried out the operation.

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.