Blood Tests - Why Do We Do Them?

Raised Inflammatory Markers - Yesterday when I was on-call I was reviewing the blood results from a patient and noticed that CRP (C-reactive protein, a commonly tested inflammatory marker in the hospital setting) was suddenly elevated. Why was this? Why do we do a CRP test on so many patients in hospital on a near daily basis? I then saw this article which answered a few questions:

Normal levels of inflammatory markers are useful for ruling out a few specific conditions, such as giant cell arteritis. They are also useful for monitoring treatment to disease. So what to do with a suddenly elevated CRP? CRP is particularly useful in identifying bacterial infection. According to this article, if the history and examination yeild no clue as to cause, it would be sensible to do nothing and wait to see if symptoms develop. Incidental abnormalities can lead to unnecessary and potentially harmful investigations. This is supported by follow-up studies in asymptomatic patients with incidental findings of raised inflammatory markers over a six year period.

Hand-Washing Compliance - I was sent an email with a copy of a letter from the Scottish Health Secretary Nicola Sturgeon this week with an update on hand-hygeine compliance. Apparently doctors have a consistently lower hand hygiene compliance rate than other staff groups in the hospital settings. The question I wondered about this was why? Is there a reason for this and what can be done about it?

Disappointing for Scotland this weekend!

The Running GP - This was an article on the BBC News website which was also printed in this week's BMA News. A GP based in Edinburgh with a passion for long-distance running ran from John O'Groats to the Sahara desert in 77 days and has been appointed by the Scottish Government to promote physical exercise. He states that according to research having a low physical activity level is equivalent in risk to health to smoking, having diabetes and being obese all combined. I don't think we give patients enough advice on physical activity and it certainly doesn't feature on routine hospital 'clerk-ins' whereas alcohol, smoking and BMI do. Perhaps we should be asking all physically able patients on admission to hospital what their levels of physical activity are. I fear that in Glasgow the standard is pretty low.

Vital Signs + Abbreviations - I read a letter to the BMJ this week from a GP who complains about the use of abbreviatons in discharge summaries sent to GPs. One particular script had the abbreviation 'MIRO'. The GP phoned the consultant, who had no idea. The consultant then asked the FY1, who said it stood for 'myocardial infarction ruled out'. Embarrasing for the FY1 and a fair reminder about the dangers of using abbreviations which can widen the communication gap between primary and secondary care.

Consultant Feedback - Finally, a junior doctor in London writes in about the '360 feedback' which doctors are required to fill out every 4 months, where at least 2 respondents must be consultants. At first I thought this was going to be a moan about feedback but actually he makes the point - when do the juniors get the opportunity to feed back to the consultants? Perhaps junior doctors should become involved in feedback about consultants from time to time - I think this sounds reasonable!

See One, Do One, Teach One

'See one, do one' is a weekly column in the BMJ based on life as a junior doctor. A lot of the time it's written by doctors with at least one or two years experience but occasionally it's written by a first year doctor and these entries are the ones which I relate to the most. This week's submission relates to the problem which arises when there is lack of clarity over the team looking after a patient due to lack of communication following transfer from wards. When this happens, I think that the ward based junior doctor should always take responsibility to be up-to-date with which consultant is looking after the patient and while I sympathise with the situation, I think that the consultants and the junior doctors share responsibility in ensuring that patients are seen by the relevant team every day. I think that having ward based junior doctors is much preferable to having team based doctors to prevent the problems of patients being 'missed' from occurring.

Carrying on with communication, in Glasgow there's a thriving multinational community and often this poses significant language barriers when patients are admitted for urgent medical treatment. On a few occasions it's been difficult to gain access to either a translator or a relative who speaks the language required at short notice. Des Spence is a GP in Glasgow who writes a weekly column in the BMJ. This week he talks about this problem. "Having an 8 year old boy translating in a consultation about his mother's mood is less than ideal" is very true! Interestingly, Dr Spence uses Google translate with his patients - I've never come across this before but it sounds like a good idea. When there is a third party in a consultation, such as a translator, there can be an effect on the dynamics of a consultation. For example information can be mistranslated and frank discussions can be difficult. I can't think of an easy solution to this problem but perhaps more of a mobile phone or on-line based translation service would be preferable.

Finally, there is an article in this month's BMJ on the topic of doctors' use of social media and networking sites. This topic has received a lot of attention over the past 5 years since the massive increase of the use of on-line networking. From personal experience, I'd say all junior doctors use email,  nearly everyone has Facebook and a probably a smaller proportion use online discussion based websites. I don't think that there should be restrictions on doctors using online websites however I think that people need to be sensible about what they post. Discussing clinical cases where a patient may be identifiable is obviously very unprofessional. I think it's a good idea that the BMA has published guidance on what can and cannot be posted online because it shows awareness of the issue, however I don't think that there should be restrictions on doctors liberties or even worse - regulation over doctors lives outside of work - heaven forbid!

100 Today

I've just noticed that this is my 100th post! It may have taken over 2 years to reach but none-the-less it feels like a significant moment. Had a harrowing experience this afternoon when I found out that one of my friends from work had been admitted to the neurosurgical department with a head injury he sustained at the weekend after he was knocked off his bike. He's pretty sore but sitting up and talking now, plus it was good to see his parents and brothers were up visiting at the same time as me. Get well soon Michael!

Today is the first episode of the new TV Series being run by the BBC called "Junior Doctors - Your Life in Their Hands". Firstly, I disapprove of the title. It smells of over-dramatisation and gives the impression that every moment of every working day is made up of life-or-death decision making. The junior doctor is very much part of a greater team that looks after the patient. I agree that the junior doctor may be the first person on scene in an emergency but back-up is always available so your life isn't really in their hands. It's a good job that the series is filmed over several weeks / months because approximately 95% of the job is ward rounds, writing letters, making referrals and so on and so forth. Whilst I agree that this is an important part of the job and I enjoy it - I don't necessarily think it makes for great TV viewing for the general public. After all, it's no Holby City! I'm looking forward to watching the series though to see how the TV spin on things looks and how the doctors being filmed cope with starting work.

A selection of interesting articles in the BMJ this week:

1) Multiple Myeloma - This is an easily missed disease. The condition is basically neoplasm of plasma cells characterised by production of monoclonal immunoglobins by malignant cells. It predominantly affects older adults. Normochromic, normocytic anaemia occurs in approximately 70% of patients. The other more common features are bone pain, renal impairment, fatigue and weight loss. Routine initial investigations include full blood count, biochemistry (renal impairment, hypercalcaemia), blood film (looking for roleaux), and liver function tests (raised total protein).

2) Mobile Phones - Harbouring Bacteria - This was a letter sent in from an infectious diseases registrar in London. He did a small study which looked at the increasing incidence of doctors using mobile phones for medical apps, stopwatch when checking the pulse etc. What he found is that mobile phones were harbouring significant amounts of bacteria and could be responsible for transmitting MRSA to patients. I think it's time for Apple to develop a bacteria repellant surface for their mobile phones. If I cracked that I'd be a millionaire.

3) Psoriasis & Psoriatic Arthritis - A 41 year old man presents with an itchy, scaly rash and is diagnosed with having plaque-type psoriasis. Psoriasis is a systemic condition and co-morbidities of psoriasis include cardiovascular disease, obesity, depression, type-2 diabetes and hypertension. Systemic treatments include methotrexate however this is contra-indicated in patients with large quantities of alcohol intake.

Hospital-At-Night (HAN) / Skin Camouflage

Costa Concordia lying just off the island of Giglio

Mortality Rates among Hospital Patients - A review of hospital care last year claimed to have found that higher death rates existed among hospital inpatients outside normal working when less consultants were available on call for advice. The press jumped on this, remarking that "junior doctors were often left in charge". To a large extent this is true. The hospital at night is staffed by less experienced doctors. Obviously we all have to be exposed to out-of-hours work in order to gain experience, but surely there should be someone more experienced on-site overnight. An article in the BMJ this week argues that the analysis of the data used to make these assertions was flawed however it remains true that at the weekends or at night patients in hospital are less safe. Out-of-hours there are always on-call, experienced consultants and experts available for advice however they are only available in emergencies. But if there were more experienced doctors on-site seeing patients before they deteriorated, could these situations be prevented? Or perhaps a more experienced doctor in A&E would be more to identify the one patient needing urgent attention, out of the ten or more who have illnesses which will be straightforward to treat. I don't think that there is an easy solution to this problem but one thing is clear to me - junior doctors need more senior support out-of-hours.

Port wine stain (eg. Sturge-Weber syndrome)

Dermatology - Skin Camouflage: An educational article in the BMJ this month. It opens with the reference that 15% of people seek help from their GP for a skin condition and most patients have their skin condition diagnosed and treated in primary care. In many cases, skin disfigurement can have serious long term psychological consequences. Various health related quality of life indices consistently show a link between severity of skin disfigurement and impact on quality of life. Skin camouflage can help patients adjust to an altered image and disguise an alternated appearance with good effect. Examples of conditions which respond well to skin camouflage include vitiligo, scarring from burns and port wine stains (see above). Skin camouflage services are not readily available in primary or secondary care and most access is private. However given the mounting evidence of the impact of skin disease on mental health perhaps there is good evidence for it being made more widely available. Or is skin camouflage just changing the skin appearance (symptom control) and not treating the underlying cause? Does this matter?

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.