April Reading Week

 I managed to pack a lot in to the reading week, including the trip to Amsterdam to the International Forum on Quality & Safety in Healthcare and finishing up with the Edinburgh Half Marathon this Sunday. I managed to beat my half-marathon time from the last one which I did a couple of years ago in Dundee so I was pleased with how it went. Perhaps next step up to the marathon? I'll be watching the London marathon this weekend!

The conference was a great experience. I was there with three other students (see left) and we met up with elective Rob! (Glasgow final year student) who happened to be there at the same time. It was good to see that the UK was the most represented country at the conference and this reflects the amount of work being carried out in the NHS. I was amazed that our poster on venous thrombo-embolism prevention was one of literally hundreds at the reception on the Wednesday evening and there was an entire section of posters dedicated just to VTE prevention. The conference was quite inspiring and I had a chat with some FY1s/FY2s who had done similar work. I had been concerned about the difficulty of undertaking improvement work during the foundation years due to the clinical workload I would be faced with but they provided some encouraging advice which has given me some more confidence that it is possible.

The most interesting talk was given by Professor Emily Friedman from Boston University on the topic of global health and the dramatic changes to healthcare provision which have taken place in Cambodia over the past 50 years since the devastating genocides which took place previously. I'm now in Inveraray to do my one month GP placement, to give me a taste of health-care provision in a rural community and looking forward to the next few weeks!

Reucing Harm, Improving Healthcare

 <---- Photos from yesterday at the 'Reducing Harm, Improving Healthcare' conference at the Suttie Centre in Aberdeen.

The day involved a combination of lectures and small group workshops on different aspects of improving patient safety. It was good to see a whole range of people there, not just medical students. Our Tayside cohort did however dominate the poster presentation at lunch time with over half of the posters on show being from Dundee University! The first workshop I attended was on 'Speaking Up' and we were given a scenario which really happened where a final year medical student noticed an error when watching a patient having a major operation. We discussed the differences between 'mitigating speech' ie. the hint and hope method, as opposed to direct messages ie. Stop now. Also we talked about how as a trainee, a query can be raised as a question, ie. Can I just check that this is what you want to do. Or why are we not doing it this way. I think this is something I'll probably try and do alot as a foundation doctor with the exception of being emergency situations where I hope to think that if I see something being done wrong I would be able to say STOP or WAIT etc if I thought it was incorrect. We talked about critical language approaches, such as the 'probe, concern, alert' method and 'I'm concerned, I'm uncomfortable, I'm scared'.

The second workshop was on antimicrobial prescribing. We were given scenarios where antibiotics had been given and asked questions such as 'What are the risks to the patient', 'What are the information gaps' and 'What are the issues/risks for staff?'. I now know that Tazocin and Co-Amoxiclav contain penicillin and are contraindicated in patients with penicillin allergy. There are some antibiotics such as Ceftriaxone which can be given to penicillin allergic patients but only in an emergency situation. The '4Cs' of C.Diff i.e. the antibiotics which are most likely to cause C.Diff are Co-Amoxiclav, Ciprofloxacin, Ceftriaxone and Clindamycin. There is also some evidence that Tazocin also leads to increased rates of C.Diff although this is yet to be confirmed.

Take home message of the day, in the words of Tommy who is an FY1 at the moment in Ninewells is to make friends with your ward pharmacist when you start work because when it comes to prescribing they are the fountain of all knowledge.

Some useful websites for more information:
www.abdn.ac.uk/iprc - Industrial Psychology Research Centre
www.chfg.org - Clinical Human Factors Group
www.who.int/patientsafety - World Health Organisation

Photos and Update on Legionnaires' Disease + NHS Reforms

Laparoscopic Surgery - Wellcome Image Awards 2011

After last weeks report about the dangers of imaging, a letter to the BMJ this week points out that reluctance to image pregnant women contributes to maternal mortality. On one hand, there is evidence that imaging mothers during pregnancy increases the risk of childhood cancer and leukaemia, however it is not clear that the risk of this is very small and relatively insignificant. The writer of the letter argues that the evidence described in the previous report is outdated and not relevant to modern day practice. The letter states that this kind of information could be dangerous in the wrong hands and could almost be described as 'scaremongering'. There have already been lots of high profile examples of hiw evidence has been mistaken and led to the public being misinformed.

In the BMJ News this week, the lead article is on doctors' opposition to the English health care bill. The feeling is that the Health and Social Care Bill is too rushed, too much, too soon. Fragmentation of care and undermining of doctors' ability to make decisions in the best interests of their patients have been highlighted as potential problems with the new system. On the other hand, doctors have reportedly always been resistant to change. The reaction to the new healthcare bill has been compared to doctors' initial negative reactions to the introduction of the NHS. The BMA is continuing to press for changes to these new healthcare bills and it will be interesting to see what happens over the forthcoming months and the effect that this has on the NHS in Scotland. GPs in Scotland have already voiced their opinions against the controversial health reforms being proposed in England.

An interesting article on the BBC News website this week was that a patient is currently being treated in Ninewells Hospital for Legionnaires' Disease. The patient had been staying at the Landmark Hotel (by the roundabout on the Kingsway where the Swallow hotel used to be) and used the leisure club facilities. This story came the same week that Piperdam Holiday Resort was fined £120,000 for breach of health and safety back in 2008 where a patient died following exposure to the disease. Legionnaires' disease is a potentially fatal infectious disease caused by Gram negative aerobic bacteria. Potential sources for contaminated water include the hot water systems of some hotels where disinfection and maintenance programmes are not closely adhered to. Interestingly, in 2010 a report published in the European Journal of Epidemiology identified car windscreen washer systems as a potential source.

In January this year I helped to develop an online dermatology tutorial on the treatment of psoriasis and it can now be downloaded online from the following link: Psoriasis Treatment Tutorial.

Here are some of the best photos from a recent trip to visit my flatmate Scott who's on his rural GP placement in Islay!

Salago Bay

Kindalton Cross (early Christian, 8th century)

Gordon and I, Jura in the background

How have prescriptions changed over the past 20 years?

I saw an interesting article in the Guardian newspaper health section on Tuesday 15th March titled "Drug Culture: How have prescriptions changed over the last 20 years, and what does this tell us about our health?"

Top 5 Drugs Prescribed in England in 2011
1. Simvastatin
2. Aspirin
3. Levothyroxine Sodium
4. Ramipril
5. Bendroflumethiazide

Top 5 Drugs Prescribed in England in 1991
1. Salbutamol
2. Amoxicillin
3. Paracetamol
4. Co-proxamol
5. Beclometasone

So 20 years ago if you went to your GP, you would be most likely to receive an inhaler or an antibiotic whereas today, treatments for hypertension and hypercholesterolaemia are the most common. Simvastatin is the most commonly prescribed medication and approximately 1 in 4 people in the UK are on a statin. When statins were first introduced, they were only given to patients with very high cholesterol however now they are started in patients with lower cholesterol levels. Statins have definitely had a positive impact on atherosclerotic vascular disease over the past 20 years, however they still have undesireable side effects and are not suitable for all patients.

The incidence of antibiotic resistant bacteria and healthcare associated infections has increased over the past 20 years and this has led to a major change in the way which antibiotics are prescribed. Antibiotics now only make it to number 14 on the list of commonly prescribed drugs in 2011. Other major differences have been in prescribing of paracetamol and levothyroxine. Looking ahead to the next 20 years, it is predicted that whilst treatments for blood pressure and heart failure will remain high, drugs used to treat neurological conditions such as Alzheimers disease may overtake them as the most commonly prescribed medications if there are significant breakthroughs in the treatment of these diseases.

Focus on Japan

Japan was struck this week by a devastating earthquake which measured 9.0 on the richter scale. The compounded effects of the earthquake, a tsunami and damage to nuclear power stations has meant that Japan faces the worst catastrophe since World War II. I heard that doctors from the UK were flying out to offer assistance in the on-going relief effort and I started wondering. Who are these doctors? How are they contacted? Do they just drop all of their clinical workload at short notice and shoot off to the far-east, or are they already contracted to help wherever they are required? I wondered whether there is something I can do in future to help with scenarios like these. Once I have the experience I need, I hope that one day I'll be able to help those in desperate need in parts of the world. I feel that in the role of the doctor, there is a duty to help out our neighbours, even if they are on the other side of the world.

For the past few weeks I've been watching the BBC Three programme "Junior Doctors: Your Life in Their Hands". It's half-way through the series now and I have to admit that it's been quite compelling viewing. It's on BBC Three at 9pm on Tuesday nights. The programme follows 6 FY1/FY2 doctors in their work and home life during the first four months of their new jobs. I don't think I would have agreed to take part in the programme if I had been asked. I'm always skeptical about how the media portrays these things and I thought that the BBC would edit the programme to make it seem more drammatic than it actually is. What I've found though is that it looks like quite a realistic portrayal of life on the wards. Talking to Amy (who's an FY1 in Glasgow), she agrees. It's interesting hearing about the doctors' thoughts and attitudes towards their new jobs. Some of the FY2s offer very good advice to the FY1s and I hope that that is always the case. It's good to have role models to look to support when times are tough. Fortunately the programme hasn't put me off medicine and in fact the effect has been quite the opposite!

On a good news note, there is an article in the BMJ about Cystic Fibrosis this week which follows on quite nicely from the talk given by Dr McCormick at the paediatrics symposium earlier this week. It reports the results from a cohort study carried out between 1990 and 2007 which has found improved survival rates in patients with low respiratory function. Over the past 20 years, CF patients with FEV1 of <30% have seen an increased median survival from 1.2 years to 5.3 years. The study reflects the major improvements which have taken place in the management of CF over the past 20 years, however much more work needs to be done to look after these young patients.

Annual MSC Symposium: Medicine and Crime (+Paediatric Symposium)

Here are some key learning points I picked up from todays talks:

1. The Role of the Forensic Pathologist
Atherosclerotic cardiovascular disease is the most common primary cause of death on a death certificate. A post-mortem examination should never be carried out without the context of the death being known ie. what the circumstances of the death were. The aim of the autopsy is to work out the cause of death, the mechanism of death and the manner of death.

2. Witness Familiarisation
This talk was all about what to expect if asked to attend court as a witness. It was interesting to give an insight into how the court system works. Familiaristation is now recommended for all witnesses but it is important to stress that this is not the same as "coaching" which is an illegal process where witnesses are coached on what to say when cross-examined in court. Most people who go to courts are disadvantaged by ignorance of the court process. In Scotland there are three courts: high court, sheriff court and district/JP court.


3. Forensic Psychiatry
The Mental Health (Care + Treatment) Scotland Act (2003) applies to forensic psychiatry patients. CORO is a type of restraining order. Detaining someone in hospital is effectively "taking away somebody's freedom in order to treat them". These patients do not have insight into their conditions. For a successful outcome, reciprocity is of paramount importance. Balanced attitudes towards offenders is required. Have the ability to step back and not get involved with what patients have done in the past. The role of the doctor is not to be judgemental.

Folie A Deux is "shared psychosis", a rare psychiatric phenomenon where symptoms of a delusion are transferred from one person to another.

Paediatric Symposium:
1. Paediatric Prescribing
Lack of evidence in paediatrics leads to increased errors in prescribing. In children there are changes in absorption, distribution, metabolism and excretion. IM injections should be avoided in children where possible. For IV injections / cannulas, local anaesthetic cream can help. Dose calculation is based on age, weight and surface area but the dose MUST NOT exceed the adult dose. Round off the calulated dose for easier administration. Be careful with DECIMAL POINTS! Be very cautious about ALLERGIES in children. Licensed medicines should be used but this is not always possible. A good idea is to keep a prescribing checklist ie. dose and frequency of medications. If prescribing unlicensed products, the prescriber must take full responsibility.

2. Cystic Fibrosis
Scottish newborn screening for CF was introduced in 2003. Presentations of CF: newborn screening, failure to thrive, steatorrhoea and recurrent LRTIs. There are >8000 patients in the UK with CF today. Males generally live longer than females. Respiratory failure is the commonest cause of death. CFTR channel is anapical membrane chloride channel of exocrine epithelial cells which is defective. CFTR gene is located on chromosome 7. Respiratory exacerbations of CF can be identified by change in sputum colour/volume, increased cough, dyspnoea, haemoptysis, fatigue, lethargy, fever and weight loss. Meconium ileus presents in the newborn period with bowel obstruction and insippated viscid meconium in the bowel. Laparotomy, small bowel resection and temporary ileostomy may be required. Pancreatic insufficiency occurs in 85% of patients with CF. A,D,E and K are fat soluble vitamins. CF related diabetes occurs in 12% of CF patients age 15-19 years. Young women with CF often develop secondary amenorrhoea and men are almost always infertile.

3. Childhood Leukaemia
Dramatic improvements in survival rates have occurred in the past 30 years. AML and ALL are the most common forms of childhood leukaemia in children. Leukaemia is the commonest form of cancer seen in childhood.


4. Faints, Fits and Funny Turns
Seizure is a transient abnormal excessive discharge of neurons residing primarily in the cerebral cortex. The diagnosis is ALL IN THE HISTORY. Status epilepticus is the commonest neurological emergency. Ask how the child's general school development has been. A witness report of a seizure is VERY IMPORTANT. What were they doing at the time, sleeping? LOTS of differential diagnoses exist which are NOT epilepsy. Day dreams and absence seizures can be hard to tell apart. Absence seizures never last more than 30 seconds. Cardiac symptoms of a vaso-vagal attack include sweating, palpitations, pallor, tunnel vision are tinnitus. Conscious level tends to return FAST (unlike in epilepsy). Investigations are often not require. Negative effects of too many tests can include excessive worry and anxiety for the family.

5. Neonate - Newborn Examination
Cephalohaematoma doesn't cross suture lines. Caput succadaneum can cross suture lines. Thin upper lip, smooth philtrum - signs include fetal alcohol syndrome. Pre-auricular skin tags can be a sign of kidney disease. Barlows/Ortolani's tests are only 30% - 40% sensitive. Erb's Palsy (birth trauma) leads to the "waiter's tip" sign. Erythema toxicum is a harmless dermatological syndrome.

6. Neonatal Transport
Fascinating lecture from one of the new paediatric consultants in Ninewells on his experiences transferring neonates between hospitals in England, Scotland and Australia. ECMO stands for extra-corporeal membrane oxygenation.