Lacerations in the ER Part 1: Before you stitch!

Here are my notes from the 'Advanced wound care' lecture, the last lecture before graduation. After just an hour with this prof I felt like I could handle any laceration that comes into the ER. Hopefully after this post you will feel a similar confidence:

History is important!
Before touching the wound, you should know exactly how it happened, when it happened and what instrument/surface cause the laceration. Its important because wounds heal differently and are devitalised in many different ways depending on these factors.

Location is relevant, the face heals better than the hands. Some areas are more mobile and better perfused.

Patient factors;
Patient factors will affect healing and can be important clues for risk of infection (diabetes), healing time etc.
Steroids slow healing, HIV doesnt affect wound healing, Keloids are common in afro-americans.

Find out the patient's Tetanus Status,  you have probably heard about tetanus prone wounds, this is a myth. You can get tetanus from a corneal abrasion. Make you sure you find out about the primary series of vaccinations! no good giving a booster if someone hasn't had their primary series! this is a common situation with immigrants in our ER. Many people forget to ask! CDC advice

The key to good wound practice is IRRIGATION. rememeber: "the solution to pollution is dilution" Water is the best irrigant, you can use plain old tap water, its the volume that matters, taking the patient over to the tap you can supply much more water than a simple syringe from a saline bag. You will never completely eliminate the bacteria, it just needs to have a lower enough concentration so that colonies don't form (sample principle as the lab). Consider the environment, kid falls and hits head on table legvs kid who falls and hits head on road kerb. You need volume and pressure

Sensation:
The gold standard to test sensation is a 2 point discrimination (5mm apart for the hands), make sure there eyes are closed of course. A plastic surgeon can repair most nerves proximal to the DIP joint of the fingers, you will need them to fix any nerve injuries. From a malpractice point of view you need to perform the gold standard.

You can investigate tendon injuries in a variety of ways, a good way to test is to ask the patient to assume the position of  function, you will spot any flexor injuries easily.
Position of function: arms raised to shoulder height, with hands pointing up and open chest position. imagine a policeman says "hands up!"
Flexor injuries you should call the surgeon. There is a small no mans land, the deep palmar lacerations. If the palm hurts when they move their hand then they have probably knicked the palmar sheath. With little pain you can probably leave this but a surgical referral is probably best.
Many extensor tendon injuries can be splinted and will heal well.

Remove foreign bodies. 90% of glass can be seen on X-ray

Use anaesthetic, local anaesthesia or nerve block. nerve blocks are very useful and with ultrasound very easy to perform (with practice). Use Lidocaine (short acting) or Bupivicaine (medium acting 8hours half life). Some areas are tender, for example the sole of the foot, do a nerve block!
Allergic reactions to lidocaine itself are impossible! (only to the preservatives used within, which are rare now). You can be almost 100% sure  there will be no allergic reaction if you use single use vials or cardiac lidocaine.
There has never ever been a documented case of allergci reaction to cardiac lidocaine.
Most lidocaine reactions are just a vasovagal reaction to the needle ha.
When dealing with the face or kids, topical agents are great eg. Tetracaine. You can wack it on in triage.

Explore all Wounds!

Anaesthesia, Betadine on the neighbouring skin surface (not inside the wound). you are ready to suture!

SUMMARY:

• History of injury
• Location considerations
• Pateint factors
• Tetanus status
• Good neurovascular and functional exam
• Irrigation
• Anaesthesia

Get ready to stitch this guy up

Quality Improvement in Hospital

These notes are based on a wonderful lecture I had today titled 'quality improvement in health care pathways'. It was a short lecture full of simple but powerful ideas.

I am quite fortunate that my hospital is modern and has a lot of money. One of the ways the administration has decided to spend this money is on a 'quality care' unit whose job is simply to improve patient outcomes and increase the 'quality' of care. 

Quality is notoriously difficult in healthcare to measure. The main way that quality is measured in most institutions is by comparison to local and national mortality and infection rates. Yet these gives you no idea about the actual quality of care, it only tells you if more or less people are dying at your hospital compared to another hospital.
Quality is the actual clinical outcome, the treatment of the 'disease' and the patient well being, does the patient leave the hospital in a condition comparable to how he/she was before getting the 'disease'?
A great idea that came out was to use the percentage of patients that returned for follow up as a surrogate for quality, and they are investigating that now.

One way you can indirectly determine quality of care is by using patient forums (groups of patients meeting together), or using patient questionnaires. Many points that are raised by patient forums are simple and often overlooked. One group of patients who had urological operations, noted how they all had no idea what underwear to wear. It may sound stupid to the consultant who is focusing on defeating the cancer being treated (yes the true priority), but the underwear was important to the patient and the source of a great deal of stress.

"If you improve the little things the cancer becomes just a little less important"

The quality care programme at the hospital is a relatively new concept and has taken a very long time to be adopted. Apparently it took about 7 months to get a group of 20 people to talk together, 20 people all involved in different parts of the patients care pathway; nurses, doctors, physiotherapists, radiologists etc.
Communication is a big issue if you want to work on improving quality.
Unfortunately many doctors didn't appreciate advice from the nursing staff at the start, it took a long time for this communication loop to open up. Doctors interpreted the advice as nurses telling the doctors how to do their job, hostile thinking. Just because you’ve done something for 20 years doesn’t mean it is right or couldn’t be better.

Once the problem of communication is solved, drastic changes are seen. The benefits are seen not only among the hospital staff. Patient counselling groups offered to all the patients undergoing prostate cancer resection, were very popular. Patients spoke in a large group with all the staff involved in their care. Hearing about all the people going through the same problem was incredibly enlightening for the patients, even if it regarded embarrassing topics like sexual life after surgery. Understanding the process and what life is like around and after the surgery was helpful. Clinical outcomes were even seen to improve, for example continence after prostate resection was improved. Well prepared patients took their pelvic floor muscle training before surgery seriously, understanding the importance and hearing from other patients.

The quality care team started their approach with observation. They took doctors along and tried to be patients, from the start of the process to the very end. Starting from the parking lot straight away they realised why the little things are important, they couldn't even find the department, there were no signs! We need to take care of patients from the very beginning.

Their are little things you can do that can have a massive impact on patient outcomes and quality of care. Two small examples of changes at our hospital that improved quality of care:
- When a stroke victim is on the way to the hospital emergency department in the ambulance the neurologist is called before and is ready at the door when the patient arrives. as apposed to waiting ten minutes for the neurologist to arrive who has been called only on patient arrival. Time is brain after all. The Dr waits for the patient the patient doesn't have to wait.
- A case manager, who calls patients and organises their follow ups with them on the phone as apposed to the normal "see so and so after six months for ct scan" etc. speaking directly with the patient you can assure they book an appointment and also it fits around them.

Some of the hospitals ideas came from the famous Toyota LEAN method which you can find out about in this interesting BBC discovery podcast:

http://www.bbc.co.uk/programmes/p042k1bf

A Brief History of Stroke

Stroke is a leading global cause of death and disability-adjusted life years (DALYs, see below for definition), second only to ischemic heart disease. The incidence of stroke varies across different countries and increases exponentially with age. 

First defined as ‘apoplexy’ by the father of medicine Hippocrates himself in 2400BC, it was not until around the 1600’s that the link between the potentially devastating sudden symptoms and the brain was made (hence the name ‘apoplexy’, which meant in Greek ‘struck down by sudden violence’). This discovery was made by the documentation of intracranial haemorrhage in the brains of cadavers who died of stroke by Johannes Wepfer (Since 2005 the “Johann Jacob Wepfer Award” is given at the European Stroke Conference for outstanding work in cerebrovascular diseases). 

After extensive work in defining the anatomy of the cerebral vasculature by Thomas Willis in Oxford 1664, and the discovery of an anatomo-pathological association by the Paris Medical School in the late 1800s, apoplexy became better known as ‘cerebrovascular accident’.  The term ‘stroke’ was a lay term, originating from the belief the disease was a sort of ‘stroke of gods hand’ or ‘stroke of justice’, a punishment for wrongdoing or pleasure-seeking. It later became the definitive name for the disease in 1962 when the chest and heart association produced a booklet titled ‘Modern Views on ‘Stroke’ Illness’.

Even at this time, the mid twentieth century, it seemed doctors still approached stroke with slight nihilism or hopelessness. Up until 1935 bloodletting was the primary therapy for stroke. Vomits, purges and enemas were all treatments for stroke in the beginning of the nineteenth century, not so different from Hippocrates own ‘replacement of humours’ before the start of the millennium. Nothing seemed to improve the prognosis, patients miraculously recovered, died or faded away with permanent disability; modern medicine had a long way to go still!

Bloodletting, 'back in the day'

In the 1950s doctors began to experiment with angiography, anticoagulants and surgery for the treatment of stroke. A few years later, team approaches to stroke patients started in many hospitals with the collaboration of physiotherapists, nurses, dietitians, surgeons, internists, occupational therapists, speech therapists and general practitioners. Rehabilitation became one of the main contemporary treatment responses to stroke. By the end of the 20^th century and with birth of stroke associations around the world, there seemed to be some light in the tunnel, perhaps stroke is curable and preventable. 

Stroke treatment and management has come a long way in the last fifty years, advancements in angiography and the introduction of aspirin therapy and intravenous thrombolysis have improved survival massively. 

In 2008, stroke moved from being the 3^rd leading cause of death in the USA to the fourth, it then jumped a further rank to fifth in 2013, a reflection of accelerating science and improving prognosis!

DALY: The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability. One DALY can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.

References:

-http://vizhub.healthdata.org/gbd-compare/ Institute for health metrics and evaluation. Accessed 03/04/2017. Images.

-Catherine E. Storey, Hans Pols, Chapter 27 A history of cerebrovascular disease, In: Michael J. Aminoff, François Boller and Dick F. Swaab, Editor(s), Handbook of Clinical Neurology, Elsevier, 2009, Volume 95, Pages 401-415, ISSN 0072-9752, ISBN 9780444520098, http://dx.doi.org/10.1016/S0072-9752(08)02127-1.

 -Molnár Z. Thomas Willis (1621-1675), the founder of clinical neuroscience. Nat Rev Neurosci. 2004;5(4):329-35.

-Van der worp HB, Van gijn J. Clinical practice. Acute ischemic stroke. N Engl J Med. 2007;357(6):572-9.

-Pound P, Bury M, Ebrahim S. From apoplexy to stroke. Age Ageing. 1997;26(5):331-7.

Twitter Conference: Charing Cross Vascular Symposium #cx2017 Day Two

Since my paper is being presented and I am unable to be there, I will be 'attending' the Charing Cross Vascular Symposium through the wonderful medium of twitter. Following the hashtag #CX2017  I hope to catch as much as possible here on my blog. This is what I caught from Day 2:

Again the organisers continued with there fantastic ask the audience sections

And the results were interesting...

thanks to the twitter warriors: @cookEVAR @claudicant @perealtes @ozvascdoc @veryanmed1 @torbjornlundh @cxsymposium @vascularMD

The Obesity Paradox in Type 2 Diabetes

Summary of a guest lecture given today by Dr P Costanzo an Interventional radiologist working in the UK. You can find him on pubmed here and on twitter here: 

Increasing BMI has been shown to increase all cause mortality in this NEJM study in 1.46 million white patients. Further extrapolation showed this was mainly due to cardiovascular death. 

Furthermore obesity levels are on the rise. So too are the levels of type 2 diabetes. However, the mortality levels for patients with type 2 diabetes has not shown the same rise infact it has been petty stable for many years. 

A large cohort of type 2 diabetic patients (T2DM) was taken by Costanzo et al. and divided into categories of weight and then following up over 10 years for mortality. The kaplan meier survival curve was interesting, displaying the so called obesity paradox. Patients who were underweight with a low BMI (less than 20 or 18.5) had the highest mortality. Increasing BMI showed a protective effect with the highest BMI values having the lowest mortality. A paradox indeed. 

Further extrapolation of the data by cause of death showed a protective effect of obesity in T2DM in sepsis and cancer (again paradoxical, considering cancers relationship with obesity). 

Dr Costanzo went on to explain possible mechanisms of this, citing the important relationship between low birth weight and increased lifetime risk of T2DM. And how this may be part of the so called evolutionary Thifty phenotype, a phenotype in which high blood sugar can be maintained in starvation providing a survival advantage. It is well known that subsaharan populations (and also indian populations) who move to say the UK  (or anywhere) and start a western diet are likely to develop diabetes. He mentions the lipgenic model of T2DM and how subcutaneous fat is neutral to us but visceral fat is the fat that as it accumulates increases cardiovascular mortality. There is a kind of tipping point where when lets say SC fat is full, visceral fat begins to accumulate (where is the level?). 

The last part of Dr Costanzos talk was incredibly interesting. HB1AC levels documented across all values of BMI is more or less the same in his cohort (unreleased data unfortunately, paper release in 2017), except for the underweight BMI values in which it generally higher. You can postulate that HB1AC is therefore not linked to mortality, and infact other studies confirm this. My notes run out at this point, I guess I was trying to concentrate, but the final part of this section he shows that good BP control in T2DM can reduce mortality in T2DM and perhaps glycemic control has little to do with cardiovascular mortality. 

In fact a nice point was that two new anti-diabetic drugs being studied at the moment; Liraglutide and Empagliflozin, are the only drugs that have been shown to reduce cardiovasuclar mortality in T2DM. These two drugs also have a blood pressure lowering effect. 

My 2017-2019 Foundation Programme (UK) Application Experience

Almost a year after starting the process, I finally got my foundation programme (FP) placement on Thursday. I am dead excited to start work as a junior doctor, seriously cannot wait! I thought I would do a quick breakdown here of how the process went, so maybe some future applicants can have a better idea.

Some Background:
-International undergraduate from Italy
-Fourth Decile class rank (This doesnt tell you anything about the level of clinical skill just how awesome your class is, :P)
-Previous degree
-A single publication (nothing groundbreaking, but many a late night spent writing and researching)

Eligibility (August 2016):
In order to start the whole process the FP office had to make sure I was eligible. This eligibility process required identity documentation and a deans statement from my university (basically a statement saying I have enough clinical experience from my degree for the programme). I also had to sit the IELTS english exam in June in order to be eligible for the programme. This was all done in the summer 2016 (before foundation programme allocation applications began).
My IELTS academic score average was 8.

October 2016:
In October the applications began properly and I submitted evidence of my degree and all my personal data. I also had to find two references, a clinical one (my mentor) and academic one (dean of the school who knew me well).
My final EPM score was 44 (not bad)

Within that application in October I had to rank the UoAs (the different regions of England). I ranked the UoAs in the following order:

December 2016: I then sat the SJT (situational judgement test) on the first sitting in December. I flew in from Italy and stayed in Brighton the night before. Unfortunately, I ate the dodgiest salad at the LEON restaurant in Brighton centre (sorry to call them out, but there was no doubt that that salad was dodgy). After explosive vomiting all night, and no sleeping a wink, I got the train to London the next morning for the exam, dehydrated and pale as milk. Sat the exam and staggered home.

My final SJT score 36.66 (awful score considering the studying I did, brilliant score considering the physical state I was in ha).
Finished the entire exam without leaving any questions, reviewed about half my answers before time was up.

Beginning of March 2017: Got into South Thames Foundation school!! Fantastic!

Due to the fact that South Thames foundation school is so large (over 800 placements in total), they decided to split the area into six STHAM groups. I had to do an additional ranking of the six STHAM groups. Due to the lack of crossover between the two cities I had the hard choice of choosing between London or Brighton. I really wanted to go to Kings College for the liver transplant unit and London for other reasons so I ranked the groups like this:

End of March 2017: Got into London Links 2 area, woohoo!

Then I had to rank my programme preferences. There were 152 in total to rank. In the end I ranked about 110 of them. I realised at this point I had probably made a big mistake, having got my second choice of STHAM group I would probably have a low decile compared to the other applicants for entering the programme I wanted. (In fact I checked the STFS website and the decile averages for each STHAM were released, I was in the last deciles, sad face).

Ranking all the programmes is difficult and you have to decide what you want to priotize, the location or the rotations (London or surgery, which is more important?). You also want a good variety in your programme without any lets say 'wasted'  or repeated rotations.
I spoke to a bunch of friends who had gone through the programme and this was their advice:

• Don't do emergency medicine in the first year, do it in the second year
• Avoid highly specialised rotations for example like opthalmology (sorry eye guys, no offense)
• GP rotations are nicer in the summer
• Get as much ward time as possible
• Rotations are more important than location but try and get at least one year in a big teaching hospital

Spending about two days on excel with the list of placements, I ordered everything based on the advice above and with two main priorities:

Had to contain Surgery

Had to have Emergency Medicine in F2

After finding all these rotations, I then ranked them in order of location, prioritising placements at Kings College or Guys hospitals (which I'm sure everyone did). 

(There were about 40/50 of these, the rest I literally ranked based on the awesomeness of rotations). 

The excel file I created kind of looked like this after colour coding and moving around everything a million times.

(looks like a mess right, but I had a system)

Last Thursday (April 2017): I found out my placement! F1 Maidstone F2 Croyden! Cannot wait! 

Pretty damn chuffed, the placementwas my 17th ranked placement. 

So from today there is still lots to do, mainly issues now regarding provisional licensing and transfer from Italy to England. I'll keep y'all posted. 

(Pretty sweet ey, look forward to many blog posts relating to these topics)

(Disclosures: All the information is regarding my own application and I do not believe I am revealing any information without consent). 

NEJM Maternal Immunization Review 2017 Summary

(A medical student orientated summary of a recent NEJM review)
Most childhood vaccines do not start providing adequate protection until the infant is several months old. The immunity gap between birth and this time can be addressed by maternal immunization.

Sex hormones modify immune responses:

• Increase in estradiol is associated with increased Th2 responses and reduced Th1 immune responses.
• Increased progesterone levels is associated with reduced immune response in general
• Overall phagocytic responses, alpha-defensin expression, neutrophil, monocyte and dendritic cell numbers may be increased in 2nd and 3rd trimester in general during preganacy. 
• (may explain suboptimal responses to viral infections such as influenza in pregnancy)
• pregnancy is not a generalised state of immunosuppression.

Evidence regarding the immunogenicity of vaccines administrated  during pregnancy is mixed

Current recommendations are for pregnant women to have influenza and Tdap (tetanus-diphtheria-acellular pertussis) maternal immunisations

Influenza vaccine:

• Few low income countries regularly vaccinate pregnant women against influenza
• A substantial burden of illness among pregnant women is attributable to seasonal influenza
• The efficacy within infants after birth ranged from 30% to 63% (good for mom, ok for baby)
• There may be potential for protection against adverse birth outcomes, two studies detected a difference in low birth weight however the others did not. One study was sufficicnetly powered to detect a difference but the promising result was offset perhaps by the overall low baseline birth weight. So perhaps the vaccine is more useful as a protection against adverse outcomes. 
• influenza infection is associated with  an increased rate of subsequent bacterial infection particularly pneumococcal disease. (in fact a substantial proportion of deaths during the 1918 flu epidemic were probably due to strep.pneumoniae). 
• use of maternal vaccine and infant vaccine together showed better results than infant vaccine alone in prevention of respiratory illnesses with fever and medically attended acute respiratory illnesses. 

Pertussis vaccine:

• Young infants have a disproportionately high burden of severe pertussis in the population.
• studies on the pertussis vaccine have shown high effectiveness and a reassuring safety profile (there were no increaes in adverse birth or pregnancy outcomes). 
• There was a slightly higher rate of chorioamnionitis but the authors explained this as perhaps due to practice of labelling fevers as chorioamnionitis to protect from litigation in the USA where the study was conducted
• There is concern though that the vaccine may reduce the immungenicity of the infant DTP (diphtheria-tetanus-pertussis) vaccine. With studies suggesting this, however the clinical relevance is uncertain. 

Maternal vaccines in development include vaccines against RSV (respiratory syncytial virus) and GBS (group B streptococcus).

RSV vaccine:

• RSV is the leading cause of viral acute lower respiratory tract illness and the highest morbidity is among preterm infants. Most deaths due to RSV occur in infants
• 2-3% of all neonatal deaths are attributable to RSV.
• Vaccine is needed due to the high burden of RSV infection, particularly among young infants.
• Several RSV vaccines are in development, targeting the RSV F and G proteins mainly. 
• Given that preterm infants are a high risk group, recommendation for the gestational age of vaccination will have to take into account adequate antibody transfer for preterm infants. 
• In the 1960s a formalin inactivated form of the vaccine against RSV for children was researched. It led to an 'enhanced RSV disease', and increased rates and severity of RSV lower respiratory illness. Thought now to be due to a lack of protective antibodies being produced with an increase in CD4+ priming in the absence of CD8+ cells. This abherrent vaccine slowed further research into RSV vaccines.
• The benefit of a maternal vaccination is that it would bypass immunologic events that would lead to an enhanced RSV disease in infants. 

Group B strep vaccine:

• Early onset GBS infection occurs in neonates younger than 7 days and is characterised by sepsis without a focus, pneumonia or meningitis.
• Late onset GBS infection occurs in infants who are 7 to 89 days of age and is characterised with higher rates of meningitis.
• Invasive GBS infection in pregnant women is associated with stillbirth
• GBS is transmitted from colonised mothers during birth (hence why there is universal maternal screening with intrapartum antibiotic prophylaxis).
• One in five pregnant women have evidence of GBS rectal or vaginal colonisation at 23-26 weeks. 
• Screening with prophylaxis programmes mentioned above have resulted in reductions in early-onset GBS disease but NO reduction in late onset disease. 
• A maternal GBS vaccine could help reduce the burden of GBS disease, particularly late-onset disease in infants. 
• there is a trivalent vaccine in development that covers serotypes Ia, Ib and III. The global disease burden includes serotypes II and V, therefore a vaccine will need to be developed still to cover against also these subtypes

Incorporating maternal vaccines into antenatal care has been a challenge in many locations, with the maternal influenza vaccination rate in the US estimated to be around 50%.

Link to paper: http://www.nejm.org/doi/full/10.1056/NEJMra1509044

(all the points above and images were taken from the paper linked above)

Michael Debakey: The Janitor and I, Saving Lives Together

There are already milions of blog posts all over the internet about the many wonderful things Michael Debakey did and invented. I love reading stories about him, besides being the father of cardiothoracic and vascular surgery and prolific surgeon he was also a down to earth and wonderful man it seems. below is my favourite story of his;

In one particular encounter, DeBakey began chatting with an elderly janitor who was sweeping the floor. DeBakey asked the man about his wife and children. He told the older man, obviously not for the first time, that the hospital couldn’t function without the janitor because germs would spread, increasing the chances of infection in the hospital. Later in the day, our colleague tracked down the janitor and asked him, “What exactly do you do? Tell me about your job.” With pride, the janitor replied: “Dr. DeBakey and I? We save lives together.”

He’s right. After all, consider what would happen to our healthcare systems if the cleaning crews went on strike. DeBakey understood that showing the janitor exactly how he contributes to a larger, more heroic cause is crucial. This creates a powerful dynamic. Realizing that he is working toward a worthy goal, the janitor’s perceptions about his work changed. It had new meaning and his enthusiasm for the job was rejuvenated.

Source: http://www.freibergs.com/resources/articles/leadership/10-things-we-can-learn-from-the-worlds-greatest-surgeon/  (its a great post and worth a read, it certainly makes a young doctor feel inspired).

Summary: WHO Recommendations for Surgical Site Infection Prevention (December 2016)

Surgical site infections (SSIs) are one of the most preventable of all healthcare associated infections,. Prevention is complex and relies on many factors, an integration of a wide range of measures before during and after surgery. In fact SSIs are the most frequent healthcare associated infection in low income countries (second in Europe and USA). Below are the current recommendations from the World Health Organisation that are all aimed at reduced SSIs.

1. Don't discontinue immunosuppressive medications before surgery. It can induce a flare of disease activity and interruption of therapy may induce anti-drug antibodies. There is low quality evidence that there may be a reduction in SSIs with anti-TNF drug discontinuation only. 
2. Give multiple nutrient-enhanced nutritional formulas to underweight patients undergoing major surgery.
3. Patients should bathe or shower before surgery with either plain or antimicrobial soap. Either type of soap can be used based on the evidence. 
4. Patients with known nasal carriage of Staphylococcus Aureus should recieve intranasal applications of mupirocin 2% ointment. The ointment should be applied nasally twice daily for five days. S.aureus carriage is a risk factor for SSIs. There is evidence for effectiveness of this for only cardiothoracic and orthopedic procedures but the panels suggests for all types of surgery. The ointment is only for KNOWN carriers to prevent unnecessary treatment and resistance spread. 
5. Adult patients undergoing colorectal procedures should have preoperative antibiotics combined with mechanical bowel preparation (MBP) prior to surgery. The use of MBP reduces the intraluminal faecal mass and therefore bacterial load, alongside further bacterial load reduction with antibiotics. The potential harms of MBP should be considered; patient discomfort, electrolyte abnormalities, dehydration, acute phosphate nephropathy. Most common antibiotic regime in the evidence was aminoglycosides combined with anaerobic coverage (metronidazole). 
6. Hair removal should be with clippers NOT with shaving. This is because microscopic trauma to the skin can increase SSI risk. 
7. Surgical antibiotic prophylaxis should be done within 120 minutes before skin incision. The evidence showed increased SSIs if the antibiotics were given after skin incision or before 120minutes (note the evidence was of low quality though). Antibiotics with a short half life such as cefazolin or cefoxitin should be given closer to the skin incision time e.g. less than 60min before. 
8. Surgical hand preparation is vitally important! scrubbing should be done with either antiseptic soap or an alcohol based hand rub (ABHR). There was no difference between povidone-iodine or chlorohexidine. ABHR reduced the number of colony forming units more than antiseptic soap. 
9. Alcohol based antiseptic solution based on chlorhexidine-gluconate should be used for skin preparation. Alcohol solutions were shown to be more effective than aqueous solutions. Although alcohol based solutions should not be used on neonates and caution should be exercised to prevent contact with eyes, mucosa or accumulation for its flammable nature. Chlorhexidine should absolutely be kept away from the brain, meninges, eyes and middle ear.
10. Antimicrobial sealants should not be used. There was no benefit for their use in the literature in preventing SSIs. 
11. Adult patients undergoing general anaesthesia with endotracheal intubation should receive an 80% fraction of inspired oxygen intraoperatively and if feasible in the immediate postoperative period for 2-6 hours. Infected tissue tends to have a lower oxygen tension than tissue that is non-infected, perhaps due to enhanced oxidative killing by neutrophils. In the postoperative period this benefit was observed with use of a high-flux mask and when normovolemia and normothermia was maintained. 
12. Normothermia should be maintained with the use of warming devices during the procedure. There are many adverse effects from a hypothermic state (<36degrees); increased cardiac complications, impaired coagulation, impaired wound healing, decreased drug metabolism, decreased immune metabolism and increased SSI incidence. 
13. Intensive perioperative glucose control. Using an intensive protocol reduced the SSIs although neither an optimal target glucose concentration or timing of control coudl be defined by thepanel. Blood glucose must be closely monitored and hypoglycemia avoided at all costs. 
14. Sterile disposable or reusable drapes and gowns should be used (Duh!). Although interesting the panel says plastic adhesive incise drapes should be avoided something we use regularly in my unit hmm (apparently they don't effect SSI incidence at all, yeah maybe they dont effect skin edge infection rates but im sure they can help prevent graft infection rates if you are using non native prothesis or grafts, a question for another time, let me find out). 
15. Wound protector device use should be considered. These devices, small clips that cover the wound edge have been associated with significantly reduced risk of SSI. 
16. You should irrigate the incisional wound with an aquaous povidone-iodine solution before closure. It removes cellular debris and dliutes possible contamination, results were heterogenous, favouring wound irrigation slightly.
17. High risk wounds should be treated with prophylactic negative-pressure wound therapy (pNPWT). PNPWT was shown to significantly reduced SSIs compared to conventional dressings in abdominal and cardiac high risk insicions. A high risk incision is one with  poor tissue perfusion, decreased blood flow, hematoma or obvious dead space. 
18. Antibiotic coated/triclosan coated sutures should be used. Evidence showed that ticlosan coated sutures had a significant effect in reducing SSIs, although there was a statment over possible study limitations due to industry sponsorship. 
19. Laminar airflow ventilation has no benefit compared to conventional operating room ventilation and shouldn't be used to reduce SSIs.
20. Antibiotic prophylaxis should not be prolonged for presence of a wound drain and drains should be removed when clinically indicated. drains can adversly effect the outcomes by affecting anastomotic healing and propagating infections.  
21. Advanced dressings should not be used over standard surgical dressings for purpose of SSI prevention. There was no evidence that advanced dressings (e.g. silver impregnated) had any benefit over standard gauze dressings. 
22. Surgical antibiotic prophylaxis (SAP) should not be prolonged after the operation. Most guidelines recommend a maximum SAP duration of 24 hours, infact a single preoperative dose might be non inferior. Surgeons are regularly documented prolonging SAP, this is unnesscary and risks increasing antibiotic reisstance rates. Author does note that prolonging SAP may have a benefit in cardiac and orthognathic surgery only. 

The links to the papers where all this was taken from:

Part 1: https://www.ncbi.nlm.nih.gov/pubmed/27816413

Part 2: https://www.ncbi.nlm.nih.gov/pubmed/27816414

Burns

Over 175000 patients visit the emergency department every year with a burns injury in the UK. Burns can be life threatening in the acute phase and severely affect quality of life in the chronic phase with scarring and sometimes even loss of limbs and body parts. Care in the first hours can have a massive impact on the long term outcome, so here is the facts on burns! 

FIRST AID:

If you approach a burns patient outside of hospital adopt the SAFE approach first always.
SAFE: Shout for help, Assess scene (is it safe?), ensure its Free from danger before you approach, Evaluate the casualty (ABCDE)). Pay particular attention to the A for Airway in your primary and secondary surveys and look for signs of inhalation injury (listed below).

After you have done a general assessment of the patient with ABCD, remove any clothing and jewellery around the injury unless they are stuck to the wound, then leave it. 

Manage the burn with the 3 C's:

COOL CALL COVER

Cool the burn with normal running tap water for at least 20 minutes, the water should be around 15 degrees. Cooling is beneficial up to three hours after the burn. The rule is to cool the burn but warm the patient! so make sure the rest of the patient is well covered up, you must prevent hypothermia at all costs. Don't use ice. 

Call an ambulance. 

Cover the injury, use loose clingfilm, on the face you should use wet gauze instead. 

EXAMINATION AND HISTORY:

The severity of a burn is judged by the percentage total body surface affected (%TBSA) and the depth of the burn.

3 methods for Judging %TBSA: 
- Wallaces rule of nines (adults, picture below)
- Lund and Bowder chart (accounts for age differences)
- Number of hands (Area of palmar surface of hand is equal to1%)
Include all burnt areas in the surface area but NOT very superficial burns, with no blistering and only red and dry.

Judging depth of burn, four levels of depth:
(-Superficial (dry, red and painful, normal capillary refill)
-Superficial dermal (erythematous, small blistering, moist, painful, brisk capillary refill)
-Mid-dermal (dark pink, blistered, sluggish capillary refill, dull sensation)
-Deep-dermal (blotchy red, may be blisters still, no refill, no sensation)
-Full thickness (white or black, eschar often present, no refill and insensate)

This system has largely superceded the degrees system but is roughly the same:
superficial dermal=first degree burn
mid-dermal and deep dermal= second degree burn
full thickness= third degree burn
note that deep dermal and full thickness burns will not heal!

You should pay pay aprticular attention to signs of impending airway obstruction; hoarseness, stridor, snoring and smoke induced inhalation injury which can result in airway oedema and obstruction. So look for signs of burns to mouth, nose, face, singed nasal hairrs, carbonacous sputum. 

If any of the burns are circumferential in nature, they could act as a tourniquet with scarring and tissue swelling underneath. This could lead to limb ischemia or even respiratory compromise if the chest wall is involved. You need to look out for this! To preserve the limb the patient may need an 'echarotomy' a surgical incision of the burnt tissue to allow the tissue to expand. 

FLUIDS:

Loss of water from the burnt area and generalised oedema caused by systemic inflammation can cause a life threatening hypovolemia and organ failure.
Start fluids with all burns greater than 15% TBSA using m-Parkland formula below
and aim for a urine output of 0.5ml per kg body weight.
Remember inhalation burns also lead to fluid losses! (you cannot see the extent of internal burns).

The Modified Parkland Formula:
-give 3-4ml Hartmanns solution per kg body weight per %TBSA over 24hours (half given over first 8hours, over half given over next 16hours).

Dilutional hyponatremia is common and so is hyperkalemia with extensive muscle damage. Electrocution burns can cause rhadbomyolysis and myoglobinuria. You may need to increase the fluid resuscitation to prevent acute tubular necrosis from kidney myogobin overload.

MANAGEMENT and pearls:

Inhalation injury management:
-establish patent airway early and consider intubation early. oxygenate and ventilate. Get arterial blood gases and CO levels.

Get tetanus status

Gastroparesis is common and you should consider inserting a NGT.

Patients are often in pain and emotional distress so give IV analgesia early. Consider opioids as first line (titrated to effect).

Avoid antiseptics and dress wounds with non-adherent dressings and gauze, applie covering bandge very loosely. In a first aid setting clingfilm works very well.
-Paraffin gauze and silver sulfadiazine cream, covered with gauze and bandage.

Consider non-accidental injury and abuse, (does the pattern of injury fit the story).

Antibiotics not indicated in early care

Children: start fluids with 10% TBSA burns and aim for urine output of 1ml per kg body wt.

When to refer to a burns specialist/burns centre:

• Any chemical or electrical burn
• Any burn to face, perineum/genitalia, hands and feet
• TBSA greater than 25% second degree burn
• All full thickness burns

Main complications of full thickness/third degree burns:

• Infections, sepsis
• Tetanus
• Hypothermia
• Hypovolemia

Chemical burn management:

-Brush off any powder first, flush the area with copious amounts of water for 20-30minutes. Note duration of exposure and whether chemical is acid or base. 

Surgical management:

(generally by  a plastic surgeon or burns specialist)

Dressing, Escharotomy, Escharectomy, Flaps, Graft

-late escharectomy has better aesthetic outcomes but early escharotomy may be necessary for circulation or ventilation problems. 

Sources:

-Emergency medicine secrets 6th edition Dr Vincent Markovchick 2016

-Student BMJ January 2016 volume 24

-Lecture notes Prof Klinger Humanitas University 2016 and seminar 2015

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!

Fantastic Talk about Leadership #ilooklikealeader

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. 

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

What did I learn today

• As a predictor of early death loneliness surpasses even obesity. The following paper, a meta-analysis, concludes that social isolation and loneliness increases risk of mortality of ~30%. 
• A universal income could make life alot happier and creative, Alan Watts argues https://www.youtube.com/watch?v=OhvoInEsCI0 (may even be a solution for an increasing global unemployment issue). 
• How to manage mild hypertension.
• The is no proven benefit of peer review and tonnes of evidence of the downsides of it. Fraud, repeatablity, slow, biased, luck can be involved, wasteful of scientific time, irrelevant, no quality assurance, inefficient and easily. The perils of Peer Review. 
• Free lessons on behavioural medicine
• The so called 'overjustification effect', that a reward can reinforce the belief that a task isnt worth doing. So rewarding children for doing chores or helping out is potentially a bad thing and rewarding yourself for goals an potentially be detrimental.
• How to teach medical students
• that OK GO are back with a new video: https://www.facebook.com/okgo/videos/10153836041340683/

How do I study for this?

Studying in my final year of medicine, there is one question I get asked by the years below me all the time. "how do you study for this? what should I study from, the books, pubmed or the internet?"

Compared to twenty-thirty years ago and with the boom of the internet we have a huge amount of resources at our disposal. And its this huge variety in educational resources makes this question an increasingly common one. Here is my answer:

Disclaimer: First of all, everyone has their own best method, some people learn best from videos, others from quizzes and case studies, this is an important disclaimer when considering study methods.

What is there?:

• Fundamental textbooks
• Wikipedia
• Pubmed
• Uptodate
• Lectures and lecture notes
• Clinical case and question books/sites
• Revision books
• Senior and classmate notes
• Group sessions
• Youtube
• The ward
• medical blogs
• FOAMed/MEDed and twitter

(SKIP TO SUMMARY/ANSWER AT THE END IF YOU LIKE)

Textbooks:
The bread and butter of medical study. Often huge, boring and full of what some may consider unnecessary detail. Older doctors will swear by them and the younger doctors may completely avoid them. Use your textbooks as reference! No one has time to read the entire Goodman and Gilmans pharmacology or Kandels textbook of neuroscience. Textbooks are becoming increasingly thicker and thicker and the level of information can terrify first and second year students. When it comes to the fundamentals however, use them! but look for concise or targeted student versions:
Anatomy - Greys anatomy for students
Physiology- Berne and levys physiology
Pharmacology- Rang and Dales
These kind of books for the basic sciences are a must read in their entirety, try and find a smaller concise version for each core subject afterwards. Its in the clinical subjects where you should only use textbooks for reference, Harrison Cecils etc.

Read them, make brief notes, highlight important concepts, bookmark pages, the fundamental textbooks need to look like they have survived a train-wreck after the first couple years of medicine.
moving to the clinical years is where things get tricky...


Wikipedia:
Whenever you google a clinical condition the first post is most likely to be wikipedia post. Hugely informative and structured perfectly with sections for diagnosis, presentation, prognosis and related diseases etc. Take it with a grain of salt. Wikipedia is created by hardworking freelance contributors, many the posts are accurate and uptodate but you never know, they may not be! Until wikipedia has more efficient controls in place, its best used as a quick refresher and definition search tool 

Pubmed:
The centre of all that is EBM (eveidence based medicine), you can effectively answer any clinical question here for free. however, its hard work! often you have to search  hundreds of articles, and even if you find a nice review, it will probably contain many pages of information that you just arn't ready for yet as a medical student. which brings me to Uptodate

UptoDate:
Requiring a login or at least a registered institution, its not free! However this is the best place hands down to answer any clinical question you may have. The information is reviewed regularly and all the relevant clinical information that is interspersed through articles on pubmed is concentrated here. Again there is the issue of perhaps being a little too advanced for the average medical student. Best used a reference to clinical questions especially patient and disease management questions. 

Lectures:
Tedious, time consuming and highly dependant on the skill of the lecturer. We have all sat through a lecture so boring that you struggle to keep your eyes open, it can be a waste of time. On the contrary we have all been to that amazing lecture that kept us on the edge of our seat and full of curiosity at the end. Sometimes I feel I learn more from certain lectures than I ever could in a day reading through the relevant textbook. As much as we moan and and groan about them, lectures are important! attend them, drink coffee, and make notes! lectures will form the backbone of your study and are an important place to cement the core concepts you will need to study in revision. The medical exams are often about what you were lectured on remember.

Clincal cases and question books/sites:
Use these after you have studied, prior to exams. The best way to really test if you really know a subject is to test yourself. Often through testing yourself you find the holes in your knowledge base. it really works! Clinical case books are excellent, a little tedious but are probably the best way to test yourself in a way that will prove to be useful when you start work as a doctor (that special way of thinking when you approach a patient). Multiple choice question books and similar quiz books have now been surpassed by websites with endless question banks. The BMJ on examination site (which I use regularly) is just fantastic. One of my colleagues swears by the Firecracker app, where he answers about 50 quick questions a day on the metro/underground on the way and back from university. Unfortunately there is a catch, these questions banks can be incredibly expensive, so maybe its best to use these resources only before the big exams such as finals or end of phases.

Senior and classmates notes:
Forget it, the source isnt always reliable and most of the learning is in producing the notes yourself. One of my colleagues makes a killing selling his anatomy notes to first years, perhaps a good buisness solution, dont fall for it. On the plus side, notes may be targeted to an exam well and help when you have missed lectures. My advice, avoid if possible.

Group sessions:
Moving a bit away from the topic of resources, group studying is a real preference for some people. I think I will address the debate 'group vs solo studying' in another post. It depends a lot of the group itself and the study method, tackling clinical cases together is a good method.

Youtube:
What a resource, there are hundreds of videos on youtube and many of them are fantastic. I mentioned in a previous post Paul Bolin lectures and how they are brilliant for students preparing for the USMLE. Youtube is probably the best place for people interested in surgery and procedural medicine. Intubation, inserting catheters, chest drains and surgical approaches its all there (although can take some searching to find decent videos and in the correct language). Its incredibly difficult to learn a procedure from reading a book or passage, they are best learnt visually in a step by step matter, or better yet on the ward!!

The ward:
A must for all students. Spending time on the wards presents potential learning opportunities in areas which are favoured by in examinations, particularly practical assessments. Remember that medical school is a precursor for life as a doctor and thus, adequate exposure is necessary to assimilate the abilities expected of new doctor when they start. Although tempting to spend less time on the wards, especially near exams, try not to skip these session. Take a pen and note pad, note down everything you learn or new drug/disease/concept you hear. Try and take at least one history every time you are on the ward.

Medical blogs (like me :)):
There are some incredible medical blogs out there, life in the fast lane and emergency anatomy to name a couple that I usually use. It can be difficult to keep track of the variety in posts and to stay on track when studying a particular subject. You have to be careful with the accuracy of the information and sometimes it best to use the references in the post and read the original material before even reading the main post. I kind of feel that blogs are actually best for gaining an insight into the world of medicine, for opinions on the latest research and methods and for all that humanitarian stuff that forms much more of medicine than most of us are aware about. Patient care and professionalism are fundamental to a great doctor, it can be hard to find a good understanding about some of these issues from textbooks, blogs are invaluable! (not many textbooks will have a part about how to study like this will they ha).

Twitter:
There is an amazing movement happening in medical education at the moment, the hashtag or FOAMed movement. Hashtags like #FOAMed and #MEDed are attached to various things from the internet (videos, blogs, websites) to form this huge collection of medical education resources. More specific hashtags can be used to focus on the subject at hand #FOAMcc for crtical care for example or even summarize the findings from important conferences like #AHA16. Its a wonderful movement and its keeping medicine uptodate almost instantaneously and completely for free. Watch this space!

Ok I have rambled on a bit now and my lunch break is ending. Here is my best answer to the question above:

Attend lectures, make notes and read through them briefly that same day. Use the lectures to form a kind of back bone of core topics. Use the text book to cover these core topics by subject. And use the entire textbooks when addressing core fundamentals like anatomy and physiology. 
When you start clinical modules, use smaller review books with a more concise approach (I'm thinking Kumar and clarks vs Harrisons for example or Surgical talks vs Sabistons surgery). Whenever you have a clinical question use Uptodate and Pubmed. If you feel you need to understand something better use the fundamental textbooks. Try and explore the topics with twitter and blogs. When you are close to exams use clinical case books and online question banks, referring to the textbooks when you find a hole in your knowledge. 

NOTEs:
_The Eisenhower box to time management, works for studying too:

Remember you don't have to study everything in order, spaced repetition is the better way of learning in the long term.

Any questions feel free to comment and Ill get back to you, gotta runn..