Hands only CPR - No kissing!

Vinnie Jones is here to teach us a lesson. This is brilliant! Watch it if you haven't already seen it! Although it seems that the public are getting a bit of a mixed message about CPR. Since 2005 we've gone from:
2 breaths, then 15 chest compressions to 2 breaths,
to
30 compressions then 2 breaths
to
Just compressions.
Is this evidence based or is simplification the best way to improve outcomes? Only criticism is not enough emphasis on calling for HELP - I think that is THE most important thing to do in an arrest situation!!

Hip Fractures and Falls in Older Patients

What's going on this week... a news article in the BMJ follows on from an earlier post I had on here about hospital at weekend. Apparently the new 'evidence' of worse outcomes for patients at the weekend is re-igniting calls for more out-of-hours cover to allow hospitals to offer a full service at weekends. Sounds great in principle and would no doubt lead to better outcomes for patients but how's it going to be funded, and where are the added staff going to come from? Interestingly the Royal College of Physicians have issued a call for any hospital that admits acutely ill patients to have a consultant physician on site for at least 12 hours a day, seven days a week, who should have no other duties during this time.

An article was published this week about the use of anti-hypertensives in patients with gout or symptomatic uricaemia. This caught my eye because last week one of the doctors I work with was telling me about a patient on her ward who developed gout but had acute kidney injury. The acute management of gout mainly comprises non-steroidal anti-inflammatories eg. ibuprofen, however these are contra-indicated in renal impairment. It's long been known that hyperuricaemia and untreated hypertension commonly co-exist. High uric acid levels in the blood can predict development of hypertension, diabetes and chronic kidney disease. A recent study however shows that amongst UK GPs, the use of calcium channel blockers and losartan in patients with hypertension was associated with a significantly reduced risk of incident gout. Diuretics, beta-blockers and ACE inhibitors were associated with increased risk of gout. As well as preventing gout, losartan in particular is believed to protective renal effect.

Teaching this week was on the topic of falls, one of the 'geriatric giants' that's talked about at medical school. Every night shift - it's the same story. Request comes in to the FY1, please review patient - fall. The frequency that this happens at night in a hospital where there are nursing staff keeping a close eye on patients makes it alarming to think how many 'falls' happen in the community on a day to day basis. In particular, older patients suffering from hip fractures have poor outcomes (see dramatic photo). The main points I took from this teaching was that the diagnosis is all in the history. 'Dizzy' is not a good descriptive turn because it means something different for so many people, ask the patient 'what does dizziness mean to you?'. The examination should include balance tests eg. the sit to stand test, assessment of gait and the push test. All too often patients admitted with falls are assessed by having an ECG with a 24 hour cardiac monitor and lying / standing blood pressures. However cardiology is only one group of causes. Look for neurological signs in older people, such as nystagmus. Think about otological causes eg. inner ear diseases. Don't miss hip fractures and of course mechanical is a major cause of falls so it's worth remembering that simple prevention can be much better than a cure. Having an occupational therapist go out to see a patient's home and suggest ways to make it safer could prevent a hip fracture and save a life.

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?