Simple approach to PAIN

Pain is ubiquitous in medicine and often overlooked. Despite a thorough definition, 'an unpleasant, sensory and emotional experience associated with actual or potential tissue damage', it is impossible to really understand someones pain unless you have felt it yourself. It is a highly diffuse symptom with a massive impact on patient well being and quality of life (it may even be much more diffuse than believed). It is an all encompassing entity which if you take Dame Cicely Saunders concept of 'total pain' concerns not only physical aspects but also social, spiritual and emotional aspects. 

If you take cancer pain, it is the most frequent presenting symptom and present overall in the majority of cancer patients. Shockingly pain is reported in a minority of cancer medical records, it would seem that many oncologists dont assess pain, probably fixating on battling the cancer itself (one of the toughest battles in medicine to add). Pain should be considered a disease entity itself and if it is properly assessed, addressed and treated, it could go a long way to enhance patient quality of life.

Here is a simple approach to pain you should consider whenever a patient says they are in pain:

First ASSESSMENT:

ABCDE 

A is for Ask: Ask about the pain: use the OPQRST approach:

• Onset
• Provoking factors 
• Quality of pain
• Region and Radiation of pain
• Severity 
• Timing and history 

When assessing severity use the NRS or VAS technique; "on a scale of zero to ten, where ten is the worst pain imaginable and zero is no pain, how would you describe your pain severity" (this is NRS, VAS is the application of a mark on a 10cm line to indicate pain severity in the same way).

score of 1-3 is mild  (VAS would be 1-3cm)

score of 4-6 is moderate pain (4-6cm mark)

score of 7-10 is severe pain (7-10cm mark)

One really important thing to think about after you have taken a thorough history is "what is causing the pain?"

B is for Believe the patient, don't dismiss them.

C is for Control: choose and appropriate pain control method, best way to apparoch pain treatment is with the WHO pain treatment ladder, which can be applied to all pain and not just cancer pain. move up the steps if pain is not well managed or still present.

• 1st step: PARACETOMOL (to treat mild pain)
• 2nd step: WEAK OPIOIDS (for example tramadol or codiene, these are opioids with a ceiling effect where inceasing drug dosgae will not improve effect from a certain point)
• 3rd step: STRONG OPIOIDS (consider for mod-severe pain). (for all opioids "start low and go slow"
• at any point you can add adjuvants to the ladder: NSAIDS, corticosteriods, antidepressants, anticonvulsants, benzodiazepines.

D is for Deliver pain control in a timely manner

E is for Empower the patient in pain control, patient education is so important. 

Second MANAGEMENT:

The four A's:

• Optimize ANALGESIA
• Optimize ACTIVITIES of daily living
• Minimize ADVERSE EFFECTS due to treatment
• AVOID unnecessary  drug taking

Third REASSESSMENT:

Simply, reassess often!

Summary: ABCDE OPGRST AAAA Reassess!

Hollywood needs to be more unpredictable

Jennifer Lawrence and Chris Pratt , two of the most popular A-list hollywood stars around at the moment, some romance, great CGI, and chuck some 3D effects in there, you’ve got a box office money maker.  I guess that was what was going through the mind of the producers when they decided to produce ‘Passengers’.  With the absence of any real decent major Hollywood films in 2016, passengers was Hollywoods last gasp to make something of 2016. With harsh reviews from major newspapers and a measly 31% on Rotten Tomatoes, you could say they failed.

Chris Pratt puts in an awesome performance, managing to act convincingly as a type of castaway-esk stranded-in-space near suicidal space caveman in the first half of the film. Probably the most interesting and captivating part of the film was Jim’s (Chris Pratt) struggle wih loneliness and the choice whether to wake up Aurora (Jennifer Lawrence). When he finally does choose to wake her up (come on, not a spoiler, obvious isn’t it!), you find yourself involuntarily on the edge of your seat trying not to scream, don’t DO  IT! And its horrifying..

Unfortunately its from this point the film goes down hill. Not to reveal spoilers, basically despite the interesting relationship dynamic between Jim and Aurora, there is a very predictable sequence of impending doom with a very predictable they save the day type rhetoric. (see no spoilers)

I mean, who doesn’t love a film where the hero saves the day. You leave the cinema feeling or fuzzy and warm. But they win Every. Single. Time. In. Every. Single. Film.

Maybe its time the bad guys win?

Don't Let 2016 Get You Down!

Christmas holidays are over for me and the year is almost at its end. Most people have declared 2016 to be an awful year, the never ending list of celebrity deaths and countless negative political events seem to have shaped the year overview. In medical world it seems as if its even worse with junior doctors contracts being imposed, poor evidence circulating mainstream media and bombings of hospitals in the middle east (a recent BMJ editorial highlights this casting aside of moral boundaries, a dangerous development).

Its easy to think that it has indeed been a 'crap year' but I think this just highlights an underlying frustration with how things are going. Its for the first time I highly recommend we all listen to the Queen. And no not the Freddie Mercury kind, although 'don't stop me now' always made me feel hyped up in a 'tiger defying the laws of gravity' kind of way. For those who arn't familiar with it, every year on Christmas day just after lunch, the Queen gives a speech to the nation. It's usually just a well orchestrated and politically-correct summary of the charitable acts and travels around the world she undertook, this year despite not mentioning Brexit once (come on queenie, its history) and seeming to be fixated on the olympics (I bet she always wanted to compete that's why, corgie hurdles anyone?) she decided to focus on the theme of INSPIRATION.

Yes well, 2016 has left nothing to inspired from unless you are a fake news producer, a dedicated neoliberalist or loving Pokemon Go. We should all INSPIRE, take a deep breath (see what i did there) and take on 2017 with new vigor. And not just skip into 2017 like all the gym goers who will be skipping through the gym entrances on January 2nd to only find themselves two weeks later using their new running shoes to microwave pot noodles in (I might have exaggerated here) BUT to take on 2017 full on! 

What does that mean? you will ask, honestly I don't know, I'm writing in a stuffed airport lounge in Luton so its hard to be inspiring here, I guess what im trying to say is:

"Don't let 2016 get you down!" which may be hard to say to a hardcore Star Wars fan a day after Carrie Fisher (princess leia) dies (she died drowning in moonlight strangled by her own bra). 

Go into 2017:

• Prepared for the worst (yes David Attenborough will die one day) 
• Know your enemy! what is neoliberalism, best 2016 comebacks
• Make a new years resolution 
• Stick to your new years resolution (hardest challenge yet)
• Read every day (top articles of 2016)
• Always check the evidence and for gods sake don't listen to fake news

AA Gill Faces Up To His Cancer

Yesterday the prolific writer and restaurant reviewer AA Gill died. 2016 has been a torture to many and just when you thought it couldn’t get worse, it took away another loved human being. The cycle of life and death is of course inevitable but even that resounding truth doesn’t make it any better. (someone please please put Sir David Attenborough in a bubble or something).

I actually first came across AA Gill when I was quite young and had just moved to the UK, my mom would read the Sunday times leave it lying on the dining room table after she finished. I would come in and pick through the various smaller newspapers and magazines in search for sports, motoring or kids sections and briefly read about the rugby scores or some fantastic gadget that will come out in the future (can you believe this iPhone gadget!). As I was flicking through the pages looking at the pictures of far off paradises in the travel section and the contrasting war torn battlegrounds in the Sunday Times magazine as I usually would, my mom came in once and pointed out I should actually READ the paper and not just look at the pictures. Of course I wasn’t interested in Tony Blair or The Foot and Mouth crisis but defiantly I decided to read something and one of the many articles I read that day was by the late great AA Gill.

Today I read his final piece in the Sunday Time magazine, a fantastically written and honest piece about his cancer and experiences with the NHS. I highly recommend reading it. 

The article: “More life with your kids, more life with yourfriends, more life spent on earth — but only if you pay” AA Gill.

He points out that the UK shockingly has some of the worse cancer survival rates in Europe, a third the percentage as Sweden in some instances. This is primarily due to the late diagnosis of cancer propagated by waiting times and turtle paced referral. The NHS, The jewel of the british isles, the pride the UK, might not be so brilliant after all, AA Gill writes:

“We say it’s the envy of the world. It isn’t. We say there’s nothing else like it. There is. We say it’s the best in the West. It’s not. We think it’s the cheapest. It isn’t. Either that or we think it’s the most expensive — it’s not that, either. You will live longer in France and Germany, get treated faster and more comfortably in Scandinavia, and everything costs more in America.”

RIP Mr Gill 

Picture: pic.twitter.com/A7WI9o8jWX @jenbalcombe 

Forensic Pathology UPDATED Long Version

Forensic pathology regards the diagnosis of when a lesion occurred and how it occurred. All physicians will have to deal with violence and trauma at some point. It is important you can describe a lesion well and accurately as your report may be used as evidence in a court case. You should be able as a doctor to diagnose a lesion, age it, describe it and know what to do to preserve evidence.

Forensic pathology starts with a physical exam. You need to assess the whole body (you also need to listen to the patient, don’t forget!). If you don’t document a lesion or ‘crime’ and the victim doesn’t talk, then any evidence of the ‘crime’ will disappear. No sign of a crime will remain if there is no documentation. You need to have a keen eye to spot scars or bruises on darker skin.

Description of lesions needs to be metric and repeatable, there is no reason to not take a photo of a difficult to describe lesion. (although now there are issues with tampering of photos with programmes such as photoshop). If you take a picture, place a ruler in the periphery of the lesion at the same level of the lesion and consider putting a coin in the photo to help spot distortion or modification of the image later (make sure you take the picture perpendicular to the skin surface and the macro function on the camera will help). Remember you may need to share this information later with someone who didn't attend the visit, so they need to understand the lesion exactly as if they were there just from your description.

"...which criminal matters and medical negligence are key examples. In both cases the medical practitioner’s records will be scrutinized by a number of lay persons and medical and legal professionals, and failure to have kept appropriate records can lead to criticism of a practitioner’s competence, or fitness to practice. It is therefore in the interest of every medical professional to take great care in the contemporaneous documenting and recording of notes." Encyclopedia of Forensic Medicine 2005

How do you describe a lesion?

Need to record:

Officially the best Christmas advert this year!

Fantastic Talk about Leadership #ilooklikealeader

How to stay well this winter, a short video by the NHS choir explaining exactly that.

The chart-topping @Choir_NHS are here to help everyone to #StayWellThisWinter – show your support and share their song! pic.twitter.com/VHlwVJR49R

— NHS Choices (@NHSChoices) December 5, 2016

What did I learn today? 3

Back from England after taking the SJT exam, learnt alot today.

• You cant be a person and doctor.
• Italy yesterday had a referendum to change the constitution, a move by Prime minister Renzi to overcome the political gridlock that makes passing laws so difficult in Italy. The vote ended 60:40 in favour of the NO vote.  A result alongside the election of a far right prime minister in Austria and Brexit, could further push the eurozone into the shadows. 
• When to order a CT when the GCS is normal after a minor head injury, follow the 'Avoid Driving if you Get SSmashed And Vomit' rule. 
• Some native Indian foxes explain the concept of mindfullness and how it, works. 
• It might be better to diagnosis someone with 'ACL tear 90%' or 'Congestive heart failure 55%' with a percentage indicating our diagnostic certainty. First10EM talks about diagnostic uncertainty and how it might help prevent misdiagnosis and the alarming frequency that provisional diagnoses become permanent diagnoses. 
• People are happier when they talk to strangers
• By April 2018 the UK could see a sugar tax, a law capable of preventing 3.7milllion people from getting obese. The debate is this spring and will take around a year to take full effect. 

This Guy Summarises 2016 With His Music

source: ThatCelloGuy

What Did I Learn Today 2

Thursday morning in sunny Brighton, I'm getting ready for the SJT exam tomorrow and getting a little sidetracked:

• Vegans and vegetarians have been in outrage in UK against the new five pound note as it contains tallow, an animal product. However, All the new five pound notes in circulation together contain the same amount of Tallow thats in only half a cow. 
• Paramedics in the UK are struggling with the number of calls, triple the number ten years ago, with increasing calls for things like needing a glass of water, a cold or cat bite. Check out a day with ambulance crews and BBC
• How to create simple and beautiful books using this website Blurb, my cousin recently documented his travels around Japan, the book is beautiful. 
• How to be a master when inserting chest drains
• Its WORLD AIDS DAY! a quick video summary by the NEJM of the ring study and ASPIRE studies. Here is the executive director of UNAIDS video message for today