I have stumbled accross some great medically-related blogs recently:

http://blogborygmi.blogspot.com/
http://doctormama.blogspot.com/
http://insidesurgery.com/
http://www.islandmedstudent.com/home/
http://www.medschoolhell.com/
http://med-source.blogspot.com/
http://megspeaks.blogspot.com/
http://prep4md.blogspot.com/
http://pharmamotion.com.ar/
http://drdeborahserani.blogspot.com/
http://improbableoptimisms.blogspot.com/
http://surgeonsblog.blogspot.com/
http://www.thefurrymonkey.co.uk/
http://oldmdgirl.blogspot.com/
http://blog.usmleturk.com/
http://www.usmlemd.wordpress.com/

Over a recent 4 month stint in general practice I have been presented with several patients trying to get fit and loose weight, often unsuccessfully, for many years. Not an unusual scenario. However, a handful of these patients had opted for e-fitness. Yes, they had a purchased a Wii Fit with the belief it would help. Perhaps it will, I'm sure it won't. Merely loosing a few pounds from their pocket is my sceptical interpretation. 

All things considered, however, if a patient has motivation, who are we to stand in their way? Purely for reasons of professional development I decided to purchase a Wii Fit to se what it was all about so I can further empathise with my clients. You will be pleased that an in-depth thesis of my findings is beyond the scope of this blog but I was pleased to see that there are several motivational aspects to the product. These range from serial BMI measurements to promoting some yoga moves and mild muscle workouts by unlocking more games after doing them. But how do we know how much they are doing? I think we're experiencing the evolution of a new subject we need to enquire about in addition to simply asking how much they use it! Questions might include the following: How many hula-hoops can you do? What's your score in the yoga tree pose and step aerobics? Which games have you unlocked?

Johari Window

New Year's Eve in Accident & Emergency!

Sadly, I saw my New Year in in Accident and Emergecy - as a doctor of course! The temptation of a well paid locum was too much!

It's quite enjoyable and satisfying to see some acute cases which can often be sorted quite easily. It was quite unusual that there was only one intoxicated patient and the rest were normal run-of-the mill A&E cases. The following are some of the cases I saw that I feel have some learning points.

Pulled Elbow

My first case was a 3 year-old child who wasn't using her right arm after she was caughtby her outstretched hand while sliding down a slide. She was holding her arm by her side, not bending it and not using it to play with. On examination there was no deformity, swelling or bruising and it seemed to be tender over her radial head. Putting firm pressure on the radial head with my thumb while pronating the forearm and flexing the elbow produced a satisfying little click (along with a bit of crying)!

After leaving her to play for 15 minutes it was quite obvious she was now using the arm much more normally.

A pulled elbow occurs when sharp traction is applied to a child's forearm/hand, for example when they trip whilst walking holding a parent's hand. The radial head slips slightly out of the annular ligament whcih usually holds it close to the proximal ulna. X-ray would appear normal so is not indicated unless there is suspicion that there may be a fracture (based on history). The above procedure will relocate the radial head and no more treatment is required except for warning the parents to try to avoid pulling on their arm!

Dog Bites

I saw 2 people with dog bites. The first was a child who presented over 12 hours after the attack which rang alarm bells in my head that a delayed presentation is inappropriate and may signify NAI or neglect. Social services were contacted.

The second patient was an adult with a partial amputation of his ear in addition to some severe neck lacerations. Fortunately there was no significant neurovascular damage. It is important to clean animal bites well with copious irrigation, leave them open to heal by secondary intention and prescribe broat spectrum antibiotics that cover anaerobes (eg, co-amoxiclav) . However, in this case I couldn't just leave his ear handing off! So he was warned about the risks of infection but cleaning, antibiotics and a primary closure was advised and carried out in this case.

COPD Exacerbation

I saw a lovely 89 year old lady with a fever, cough with purulent sputum and shortness of breath for the last 4 days. She has been commenced on amoxicillin by her GP 2 days ago but had deteriorated slightly. She denied any significant smoking history but was on salbutamol and tiopropium which suggests a diagnosis of COPD has been made. Her chest demonstrated a diffuse wheeze but no signs of consolidation and her CXR showed emphysematous change only. On this basis I diagnosed an infective exacerbation of COPD which should normally be treated with at least 10 days of steroids in addition to antibiotics. This was commenced and she was observed overnight and discharged home the following morning.

RIF Pain

The final case that springs to mind was a 14 year-old boy who complained of vague abdominal pains that were worst in the RIF. He was off his food but had normal bowels, no nausea or vomiting, no urinary symptoms and no fever. On examination he was not tachycardic or febrile. He did declare tenderness over McBurney's point but there was no guarding here and psoas sign and Rovsing's sign were negative. Urine dipstick was also negative.

Although RIF pain alerts us to appendicitis, the history suggests it probably isn't because of minimal systemic upset and no clear migration of the pain from the midline. The examination virtually rules this diagnosis out although some would argue that it could be a very early appendicitis but discharge with a warning to come back if things get worse would still be adequate.

The final part of the examination of this child was crucial because we should never forget that gonadal pain is usually vague in the lower abdomen because of their embryological origin. Examination of the testicles showed a high riding, transverse and tender right testicle. Exploration under anaesthetic revealed testicular torsion so ipsilateral and contralateral orchidopexy was performed.

Delay in the diagnosis and treatment can lead to infertility so it is incredibly important to consider in any male with RIF pain Common misdiagnoses include renal/ureteric colic and appendicitis.

Upper Respiratory Tract Infections

In the last week it feels like I've seen more URTIs than I've had my lifetime! URTI is the posh word for the common cold. Because the ambient temperature is lower in winter the viruses involved survive for longer in droplets in the air so are more readily transferred between hosts. Needless to say one of my patients seems to have already given me a cold!

So what causes an URTI?

Most are caused by starins of the rhinovirus group (picornaviruses) although the list of causative viruses is long and includes adenoviruses, coronaviruses, coxsachie viruses, echoviruses, influenza and parainfluenza viruses and RSV.

If the larynx, trachea and major bronchi are affected the likely viruses are the adenoviruses, influenza and parainfluenza (I & II) viruses and RSV.

Symptomatic Relief

The debate over antibiotics will probably never end but there is no clear benefit of using antibiotics for URTIs because the cause is viral. Possibly they shorten the duration of illness by 24 hours but they always carry the risk of side effects and resistance. In cases of a proven secondary bacterial infection they are of course indicated and also probably in patients who are not improving after a couple of weeks.

This leaves us with treatments that target the symptoms rather than the cause which the body will fight in due course.

• Steam inhalation (and spicy foods!)
  • loosens mucous so cleared more easily
    • can reduce cough due to postnasal drip
    • can improve sinus pain and earache as they drain better
• Decongestants (norephedrine, oxymetazoline, or pseudoephedrine)
  • helpful for up to 10 hours
  • nasal vasoconstrictor leads to reduced oedema and mucous production
    • helps sinus pain and earache by opening up eustacian tubes and sinus ostia so improving drainage
  • no more than 2 weeks as withdrawal can then make things much worse (rhinitis medicamentosa)
  • can cause tachyarrhythmias
• Paracetamol +/- NSAID
  • good for aches and pains and for reducing fever
• Cough suppressants (antitussives)
  • theoretically increase chance of sputum retention and chest infection but good symptomatic relief
    • not in very young or in COPD sufferers
  • dextromethorphan
    • cough suppressant, not addictive
  • diphenhydramine (Bronylin)
    • cough suppressant, antihistamine (sedative & decongestant) and anticholinergic (dries up secretions)
  • combination of above = Benylin Dry Cough
  • opiates
    • powerful cough suppressants but chance of addiction
• Mucolytics
  • no help, reserved for chronic asthma and COPD

Complications

Sinusitis and otitis media are probably the most common complications of the common cold. They both should resolve with conservative management but occasionally require antibiotics if not settling after 2 weeks. Otitis media sometimes leads to rupture of the typanic membrane which would lead to a resolution of pain followed by purulent fluid from the ear.

Those with asthma and COPD often suffer exacerbations (it may herald the diagnosis) and this should be treated with steroids and antibiotics (commonly amoxicillin) if there is any reason to suspect bacterial infection.

Occasionally a common cold leaves patients simply more vulnerable to a LRTI (ie pneumonia) which should be treated with antibiotics. This would be suspected if they are not getting better for over a week, are short of breath, coughing up purulent sputum or compain of pleuritic chest pain. Auscultation of the chest should demonstrate signs of consolidation but if the history is convincing do not rely on the absence of crepitations!

General Practice

I've just started working as a General Practitioner for 4 months so will be adding some of my experiences.

At the heart of general practice is the consultation and there are many models to assist us in perfecting this art. One common one is the mnemonic ICE which prompts us to explore the patient's agenda (Ideas, Concerns and Expectations). This is especially useful if it is not immediately obvious why the patient is attending because they seem quite well. In guiding us towards a hidden agenda it is also important to respond to any cues which may be verbal but are often non-verbal.

The points described above relate to patient-centred consultations in which we ask open questions, actively listen and challenge and reflect patients words and behaviour to promote their unique input.

In contrast, a doctor-centred consultation is dominated by the doctor who asks closed questions, rejects the patient's ideas and evades questioning. While this style seems to go against a lot we have been taught, it is often necessary to some degree and it is often useful to 'mix and match' according to the situation.

Animal Learning Psychology

It is very interesting to consider the way animals learn because this opens a window onto the complex learning strategies we employ.

The Russian physiologist Ivan Pavolv famously demonstrated respondent conditioning (associative learning) in dogs. In his experiment he associated a meaningless stimulus (bell ringing) with a meaningful stimulus (food) and demonstrated that the dogs made a stimulus association (acquisition of knowledge/meaning) because salivation eventually occurred only to the bell ringing.

Later, Burrhus Skinner, an American psychologist described operant conditioning (instrumental learning) which defines the modification of a voluntary behaviour (unlike the involuntary salivation Pavlov described). For the first time he showed that if an animal is consistently given good consequences to an action it will incorporate this action into it's activity.

Virtual Patients

Virtual patients are proving to be a good way of delivering PBL, self-directed learning and assessment. Their success lies in the fact that each student can choose management strategies and become involved in the case before finding out what should have been done. This utilises the experiential cycle in developing deep learning.

The potential of virtual patients is highlighted by the existence of eViP who aim to collate and translate virtual patient cases.

Anyone can make a virtual patient case but it does take time! For a full case, maybe 8 hours! There are two open source programs which automate the process. The Visual Understanding Environment program allows information to be presented in a nonlinear form and is an ideal platform for presentations if you don't like to be restricted by going from one page to the next. It is ideal for virtual patient cases because a program called Open Labyrinth is able to convert these files into an interactive web file that gives the user choices on which path to follow.

Can I Cut It?

In general doctors are a politician's dream: hard working and intelligent but conformist. Yes, we are akin to clever sheep. We tend to be easily steered by barking managers and politicians and continue to try our best no matter what pen we find ourselves in. At most we muster an objectionary sound, but not in unison. Clever? Just foolish enough to be shepherded into any corner.

I think of myself as a show-sheep, jumping through hoop after hoop to impress, only to find out I too will make the slaughter-house.

I have dedicated several years of my life to pursuing a career in surgery. One cannot belittle the easily forgotten hurdles of getting into and out of the Southampton Medical School sheep-dip. But now, carried on a wave of enthusiasm I decide I can make a difference: I want to be a surgeon. I compete for the surgical jobs, trying to make the quality of my Merino wool look better than the next up-and-coming lamb. I sit and watch my interviewers, suddenly understanding why the phrase 'counting sheep' exists as I try to rouse them by reeling off my strengths.

I realise I need something else! I go on every course in the book despite massively exceeding my measly annual study budget of about £600. Surely the tax man can help? 'No, any essential courses will be paid by your employer'. The fact that to do the essential courses and exams costs more than the annual budget matters not. I push on and am awarded the prestigious pat-on-the-back by Royal College of Surgeons at my first attempt but I need to keep going, I need to stand out.

I work in a competitive voluntary (yes these words do belong together in surgery) post at Oxford University demonstrating anatomy to the prize lambs who I am sure will soon overtake me. I have no money so sleep in the back of my van unless I choose to take the 113 mile journey to my wife to share the single bed she has managed to pay for at the hospital she managed to get a job at.

Eight months later, with some luck, we escape to pastures green, manage to get on the housing ladder and work in the same city of Brighton. Success! Well, for a short while, yes, but the shepherds soon notice our escape and throw a spanner in the well-oiled works. Known as Modernising Medical Careers to the shepherds and Mangling Medical Careers to the sheep, the MMC spanner randomly alters the assembly so most of us fall off as it comes to a grinding halt. Strangely, I cling on, suspended between a malfunctioning production line and the prospect of escape.

Having no fingers, sheep are not skilful at clinging on so after a year I become weary. I try to get back on but I find out repairs to the production line will take at least another 2 years. Do I continue to cling on to this uncertain future? Not I. Not any more.

I think the wise person retires before dismissal but they have had their way: another statistic removed from the neck of the bottle of surgical trainees. I have proved I am no more than a sheep and have diligently been led by the barking dogs.

It appears that when I let go, only yesterday, I fell into the nearby childrens animal farm also known as the general practice training pen. I was welcomed with open arms and cuddles and am promised that I will be looked after for the next 3 years. What a relief. I have green grass. At the moment.

Admitting you're not perfect!

This morning I had an informal conversation with a consultant colleague. We were talking about the importance of admitting you don't know something or admitting you have made a mistake.