Differential Diagnosis

<--- This is a picture of the Pollok Country Park O-Map used last Sunday at the STAG score event. A good run and very mild for the time of year. Finished sixth probably thanks to a little bit of local knowledge of the park! Next event is the Edinburgh street event at the end of January which will be a first for me.

It's a new year and I've made a new years resolution to restart writing the blog after about six months without a new post. It's taken a bit of time to adjust to work and life after uni but time now to get back involved.

2012 and Henry's back at Arsenal!

The major news affecting doctors at the moment is the re-structuring of pensions proposed by the government. All public sector workers are feeling the cuts and NHS staff are no exception. After the BMA balloted it's members this week about the possibility of strike action, it'll be interesting to see what develops over the forthcoming months, I know that we've not heard the end of this. The referendum on Scottish independence also hit the headlines today - what could that potentially mean for healthcare provision north of the border?

In the BMJ this week the article which caught my attention was the obituary to the legendary football player Socrates, who captained the Brazilian national football team and was known as 'The Doctor'. I'll admit I didn't know that Socrates was an orthopaedic surgeon in his part time while not playing football, and was renowned for turning up late for training in surgical scrubs having finished late in theatre. He held a medical degree and had already passed his residency exams when he finally decided to devote his time to football (the salary at the small professional club he first signed for was already reportedly ten times more than that of a local junior doctor). In the end it was too much booze that led to his downfall and he died of intestinal septic shock on the 4th December.

The MPS send me a monthly or bi-monthly email with occasional medico-legal cases of interest. Today's edition recounts the story of a young 20 year old girl who presented to her GP with headache and dizziness. She was treated for vestibuloneuritis but was bed-bound for several days with persistent vomiting. The GP was concerned about the patient becoming dehydrated due to vomiting but was reassured that the patient was passing good urine volumes. She had also developed excessive amounts of unquenchable thirst (polydipsia). When the patient was finally admitted to hospital, she was diagnosed with diabetic ketoacidosis (DKA) and was left with serious neurological impairment secondary to the delayed diagnosis. The GP practice had to settle the case for a large sum. They had missed DKA because they had been too focused on the diagnosis they had made. It goes to show the importance of considering a differential diagnosis, and considering alternative causes when patients don't respond to treatment as expected.

BMJ Articles from July

Diabetic Ketoacidosis - For children and adolescents with type 1 diabetes this remains a major cause of morbidity and mortality. The most dangerous aspect of the condition is cerebral oedema but other life threatening aspects of the condition include hypokalaemia, pulmonary oedema and cerebral thrombosis. So what are the factors which can predict patients at risk? Younger age of onset of diabetes, missed diagnosis and certain ethnic groups are at higher risk. Protective factors include family history of diabetes and improved education levels. There has been a drive to increase doctors' abilities to recognise the signs of DKA and all hospitals should now have protocols in place which can be followed in the event of an emergency.

Malnutrition and Mortality in Africa - There hasn't been an awful lot of media coverage of the devastating droughts which have hit several countries in the Horn of Africa this year. Countries such as Ethiopia, Kenya and Somalia and in desperate need of aid. Acute malnutrition is a major health risk in these countries. The situation worst for the thousands of refugees who have been displaced from Somalia who are crossing into Ethiopia and Kenya. The WHO has set an emergency acute malnutrition threshold of 15% yet as many of 55% of children from arriving in refugee camps from Somalia are malnourished. Unicef have regional emergency health centres with experience in nutritional rehabilitation activities to try to tackle the ongoing problem.

What is the Evidence for Drinking Water? - Margaret McCartney, a GP from Glasgow, writes in the BMJ about the real evidence behing claims that we are not drinking enough water. It is recommended that adults drink 1.5 to 2 litres of water per day. But who is providing the evidence behind all of this? It's all backed by mineral water companies and food giant Danone. They all say that we are not drinking enough, however independent research has concluded that not only is there no scientific evidence that we need to drink that much, this recommendation could actually be harmful by precipitating hyponatraemia. Closely examining the evidence supported by Danone finds it to be weak and subject to selection bias. I think this is a good example of why it is important to see who is sponsoring research articles and to use critical appraisal when searching for information.

Pain Management to Treat Agitation in Dementia - Lastly, in this weeks BMJ is an article about treating agitation in patients with dementia. While neuropsychiatric symptoms are very common in dementia, it is often not managed well. New evidence published this month shows that treating underlying pain may be an effective method of intervention. The authors hypothesised that undertreated and underdiagnosed pain is associated with agitation in dementia. They carried out a randomised controlled trial and were able to show improved outcomes for patients given analgesics. This study opens up a new opportunity for improving the way we look after agitated patients with dementia.  

Graduation and Summer Holiday

Graduation (24th June 2011) Caird Hall, with Heather

Garden Party - Outside the Union

Graduation Ball (4th June 2011) Aviemore

A few things that have been going on since last month - Grad Ball in Aviemore, Rockness, T in the Park, Graduation in Dundee and the University Grad Ball, Northern Ireland for MacFest and Banchory. Here's a couple of photos.

Start my shadowing at the end of the month so enjoying a final week off and getting organised before it all kicks off!

Updates from the BMJ

Preventing Stroke in Atrial Fibrillation

New guidelines have recently been published by the European Society of Cardiology on the management of patients with atrial fibrillation. They are summarised in the article New European Guidelines on Atrial Fibrillation BMJ 2011;342:d897. Two of the most important recommendations are the increased identification of patients at risk of stroke, and wider use of anticoagulants. The original CHADS2 score has now been replaced with the CHA2DS2-VASc system. Patients with each of the following demographics score a point (congestive heart failure, hypertension, diabetes, vascular disease, age >65 and female). Patients with each of the following score an additional 2 points: previous stroke or TIA, age >75. For a patient with a score of zero, no anticoagulant is required. For those with a score of 1 or greater, oral anticoagulants are recommended over aspirin 75mg. Although aspirin is still considered a reasonable option for patients with a risk score of zero to one following initial assessment, it is no longer the preferred option for most patients.

The new guidelines have been created following a wave of evidence of the benefits of oral anticoagulants over aspirin and new evidence has been released which shows that patients on warfarin or aspirin have a similar risk of bleeding. In addition, new oral anticoagulants are beginning to emerge which may replace warfarin in the future because they don't require therapeutic monitoring of levels. Dabigatran is a direct thrombin inhibitor that does not require therapeutic monitoring. Patients who are on warfarin presently and stable on the drug should not be changed to dabigatran but pending approval of the direct thrombin inhibitor, it may replace warfarin in the forthcoming years.

National Patient Safety Agency: NG Tube Placement

On a separate note but carrying on with the national patient safety agency theme, an article appeared in the BMJ this week on the topic of Checking placement of NG feeding tubes in adults. BMJ 2011;342:d2586. NG feeding tubes are frequently used for patients who develop dysphagia or those on ventilators in intensive care for short to medium term use as an alternative to longer term feeding via a PEG tube. Most NG tubes are inserted safely however there is potential for serious patient harm to occur should the tube become displaced from the stomach. Aspiration pneumonia following incorrect NG tube insertion can be potentially fatal. So how do we reduce the risk of this occurring? Testing acidity of stomach contents by using pH litmus paper is the gold standard first line check, with X-ray interpretation as second line. However, since 2005 in England there have been 21 reported deaths resulting from misplaced NG tubes with misinterpretation of xray images the leading contributary factor. This is a serious avoidable event, and in one audit, less than one third of junior doctors had received training on interpreting Xrays for misplaced tubes or were aware of existing guidelines. Ways to stop adverse events from occurring:

• Avoid placing NG tubes outside normal working hours wherever possible.
• Do not give NG tube feeding to patients at high risk of aspiration
• Do not place NG tubes without prior training including how to interpret the xrays
• Use the online website www.trainingngt.co.uk for guidance
• Do not flush the NG tube with anything until pH testing is completed
• pH level of between 1 and 5.5 is acceptable. No more.
• If no aspirate can be obtained or the pH level is >5.5, Xray request asking specifically for interpretation of NG tube placement. Ask a radiologist for interpretation advice if unsure.
• After radiography, clearly document decision and next steps for the patient eg. safe to use.
• Tubes should be checked once daily for correct placement and before giving feed or medication because they may have become displaced.

Scottish election - SNP win an overall majority

The major news in Scotland this week was the Scottish election. The map on the left shows the SNP (yellow) dominance and the Scottish National Party have won an overall majority in the Scottish parliament (Scottish election: SNP majority for second term). Like it or not, the SNP are going to be at the centre of any decision making processes in Scotland over the next five years, but what does this mean for healthcare and the NHS in Scotland? The SNP outlined in their manifesto that they would "ring-fence" NHS spending in their budget, but is this enough? Over the next five years the NHS in Scotland is going to need significant amounts of investment in order to carry on providing a high-quality service to its patients. Continuing with the current level of spending may not be enough. Scotland is facing an ageing population and the government is going to be expected to foot the bill of the countries increasing health burden. But where is this money going to come from? The SNP have said that they will freeze council tax for five years, so not from there. Prescription charges, they were abolished as well. Perhaps the SNP's proposal for minimum-pricing on alcohol will make a return to the forum after it was rejected last year. What will Scotland's reaction be to any proposed NHS reforms in England, will Scotland follow suit? Even the government in Westminster cannot seem to agree on the correct course of action (Clegg fights back with NHS pledge - BBC News). It has been quite widely commented that the SNP defeated Labour in the election due to Labour's 'negative' tactics in contrast to the SNP's 'positive' visions. I just hope that behind the promises and pledges which won the SNP the election there is a sustainable vision for the future of Scotland's economy. And what about the independence referendum? Surely that is something that the country can ill afford at this point in time and could turn out to be a costly waste of time. On the other hand, with the SNP winning such a large majority of seats in the government, perhaps Scotland will become an independent country within my lifetime. I never thought I'd see the day but all of a sudden it becomes quite a realistic, albeit concerning prospect. On one hand, the next five years could either be one of many successes and improvements for Scotland, but on the other it could be a very difficult one if the correct decisions are not made.

Patient Safety in the Undergraduate Curriculum

Furnace, near Inveraray

First photos from the rural GP placement here, one from Furnace with a view of Loch Fyne on the background, and another of Inveraray castle. Don't think it has rained a single day since I got here 3 weeks ago, maybe a first for the west coast of Scotland.

Inveraray Castle, home of the Duke of Argyll

I read the following editorial in the BMJ this week with interest: Paterson-Brown S. Improving patient safety through education. BMJ 2011;342:d214. According to the author "a window of opportunity exists to include training in human factors in undergraduate and postgraduate training". I thought that what we'd done over the past four months was pretty relevant, so submitted this to the BMJ as a 'rapid response'...

" Teaching undergraduate students about human factors and how to investigate adverse events should become part of the curriculum. In some places, teaching on this subject is already attracting the attention it deserves. Here, a small group of medical students undertook a selected study module in patient safety in their final undergraduate year. Clinical supervisors identified areas where patient safety was at risk, including shift handover, venous thromboembolism prophylaxis and oxygen prescribing. Using guidance from the Institute for Health Improvent, the students spent four weeks carrying out improvement projects using ‘plan, do, study, act’ (PDSA) cycles. The “bundles of care” or changes otherwise introduced resulted in improvements in patient outcomes by the end of the project period. The efforts resulted in benefit for the students who learnt about patient safety, and the patients who received better care. One way of teaching this subject is by investigating either incidents where errors have occurred or areas where improvement is required. Patient safety is not currently as high up the educational agenda as it should be. An opportunity exists now to introduce this into the undergraduate curriculum for the benefit of the next generation of doctors and patients."

I'm lucky to have had teaching on this already as an undergraduate but I don't think everyone is being given the opportunity at the moment. It seems to me that this is pretty important for all future doctors to know so I think the emphasis should be placed on teaching students, rather than postgraduates, in order to make improvements from the bottom upwards.