Broome Docs

Clinical Case 052: Belly, bum and balls…

Casey Parker — Mon, 14 May 2012 13:53:10 +0000

Today’s case is not in the ED. This one unfolds on the ward – the morning after the admission. So imagine yourself there – on the Paeds surgical ward.

6 year old boy was admitted last evening after referral from the local GP to the on-call Surg team.

He has a 24 hour history of increasing central abdominal pain. The pain wa initially periumbilical, but overnight it has localized to the lower abdomen – maybe a bit more on the right. Urinalysis was normal

The surgical team have been on their super-early orning rounds and seen the child – they have written in the notes:

“ tender lower abdo, no rebound, guarding, otherwise soft, afebrile. Bloods all normal. PLAN: Med team consult please.? epurients”

OK, now that is Surg -speak for – we aren’t operating on this kid – not a likely appendix. Turf to med, maybe its constipation?

Half way though your ward round the nurse- coordinator calls you to say: “You had better come see this kid – he has just had a bout of melena”

Hmmmm… not sounding like your average “un-appendix”. So you pop in and see him. Mum is looking worried. His obs are normal, his belly is ‘as described’ by the Surg team. When you pull down his jocks for a gander at his bottom you notice his scrotum is a bit red, and on examination his left testis is tender and there is a definite hydrocoele. Hmmmmm…

OK – can you solve this Paediatric puzzle?

What is going on? Well here is the clincher.

2 days later this rash developed

Rash

What are you going to do next?

Congrats to Dr Bek – who as it turns out practices about 500m down the road from me at the local Aboriginal Medical Service. Bek gave the right and most insightful answer. Good call from Maj and Patrick also – honorable commendations. I happen to know Bek was at a recent talk I gave which covered HSP – so technically she did cheat? But I think she already knew before I got to her!

Now what is HSP?

HSP (Henoch-Shonlein purpura) is an IgA-mediated leukocyoclastic vasculitis which produces a syndrome in children as described by the eponymous gents (and Heberden 30 years earlier). They described the quadrad of: purpura, arthralgia, abdominal pain and melena. Of course, they missed the meat – the renal disease. The disease involves a vasculitis of small vessels in the skin, gut, joints, glomeruli etc. It is pretty much the same disease as IgA nephropahy (Berger’s disease) in adults. HSP ends to occur in young children 4 – 10

How to diagnose HSP?

I love HSP as a diagnosis as it is one of those end-of-the-bed diagnoses which can present in a number of ways – a rash, joint pain, belly aches etc. You have to keep it in you thoughts or you might miss it. The diagnosis is basically clinical – unless it is unclear as to the cause of the rash – so you might check for other causes of purpura. As opposed to ITP etc the platelets will be normal or elevated.

How to treat HSP....

Treatment is mainly symptomatic – analgesia and “surgical” management of complications such as intussusception or torsion. GI bleeding, abdo pain and joint pain are usually treated with oral steroids. Does it work? Well – maybe. There are papers in both direction but they are all small and lack the power to say yes or no. A rough summary is that they might make you belly pain get better sooner, make the likelihood of an operation or CT scan lower and just might improve joint symptoms. Now onto the million dollar question… the beans.

What about the renal disease?

The reason HSP is an important problem in the long term is that there is an incidence of chronic renal disease. Usually a nephritic syndrome (though some mixed or nephrotic). And some of these kids will progress to renal failure. Here is the problem – there are studies that show that early steroids, and even cyclophosphamide do not reduce this progression. So we cannot treat the serious complication.

Monitoring includes urinalysis testing, BP monitoring – as there is about a 7% recurrence rate and the risk of renal disease goes up with recurrence and older-age of the kid.

Ultrasound for Epidurals… I ask an expert: Dr Mitch

Casey Parker — Thu, 10 May 2012 12:45:25 +0000

I have had a few readers ask questions about the use of ultrasound for the difficult epidural – usually in the labour ward context, but we sometimes run into this in the OT for combined spinal-epidural blocks. Now I love all things ultrasound – but looking at the literature it is tough to get a read on the utility of US in the often troublesome area of epidurals. All those bones – can we see anything useful? So I have asked an expert, and gotten a few handy, practical pointers.

Dr Chris Mitchell is a Consultant Anaesthestist at King Edward Memorial Hospital for Women in Perth, Western Australia. But Mitch is more than an Anaesthetist – before he went into specialist training Chris was a rural GP-Anaesthetist in NW WA. In fact my first job after my training in Anaesthesia I actually replaced Chris!

Now onto the meat of the post – here are Chris’s tips in beautifully illustrated form – click here [US for Epidurals]

I think it should be said – epidurals in the labour ward are an elective procedure. There is a risk : benefit pay off. If you are increasing the risk side of the equation as a result of a difficult insertion, then you need to discuss that with the patient – so before calling for he US machine I think it is worth a pause to consider if this is worth a try – I am sure that for the occasional operator this technique wil help, but is no magic bullet!

We usually try and avoid the patients with really tough anatomy – if the BMI is over 35 we usually start to strongly consider referral to a larger institution for a whole raft of safety reasons.

Huge thanks to Dr Mitch for his pearls on epidurals and US. I would love to hear your experiences and if you have any questions for Chris I will pass them along. Comments please

Casey

Clinical Case 051: Cardiac conundrum

Casey Parker — Sun, 06 May 2012 10:56:46 +0000

This week’s case is “chest pain” in a relatively young man.

I am going to make it tricky by giving you info bit by bit – see if you smart buggers can work it out.

Step 1 – here is the initial ECG. 2 hours of central chest pain. What is happening? what are you going to do?

Does he meet criteria for thrombolysis?

OK – so you all seem to agree he has pericarditis on the ECG. And the history was convincing – 23 yo, pleuritic left chest pain, radiating to the left arm. He had a story of an acute “strept throat” and was just finished a week of oral penicillin. BUT – the initial tropT was 0.88, and in the morning it was up to 16! So he clearly has more than a simple pericarditis.

Just to be sure, late at night I did a bedside ECHO to check if he had anything suspicious. This showed a small pericardial effusion and no “eyeball” evidence of regional (inferior) wall motion abnormality (for what it is worth with me – an ECHO gumby looking with my eyeballs!)

So lets say he has a myopericarditis. Let us now look at the treatment. How do you manage this? And if you are super-smart – are there any other causes to consider other than “viral”?

Let me know on he comments.

Medical Myths: Fever = blood cultures now!

Casey Parker — Tue, 01 May 2012 09:08:20 +0000

When I was an intern in a big old hospital one of the tasks we did was taking blood cultures off of patients who spiked fevers on the wards. In fact thinking back on it, I think I was taking cultures to appease the senior ward nurses and not really stopping to think about the why? Probably stabbed any number of patients with early sepsis and happily continued onto the next job without even worrying about the BP, lactate, line sepsis etc etc… It was an annoying task as it was “time critical” – you had to get the cultures ASAP as the fever spiked – or else the boss would be grumpy, we might “miss the sepsis”.

Were we right to worry about getting the cultures done in a timely fashion? Did it have to be “during the rigors?”

My colleague pointed out this paper by Riedel et al, Journ Clinical MIcro (April 2008). This case-review looked at 1436 patients and their fever – culture timing profile and found that it really didn’t matter when you took the cultures in realtion to the spike of a fever – the majority of positive came from cultures taken hours after a fever. This study cannot comment on the numbers of “missed” bacteremias as a result of wrong / delayed timing.

So what does it all mean for you, next time the nurse calls to tell you Mr Jones has spiked a temp….

Walk, don’t run – it really doesn’t matter if you do it now or in an hour.
Go there, look at the patient and think “what is going on here?” Does he have a reason to be febrile already documented, on appropriate therapy? Or, is he someone who needs to be reassessed for sepsis – does he have a line infection? Does he have a wound infection? Is he in SIRS or worse? Do you need other sites cultured – urine, chest etc?
Take cultures as clean as possible – aseptic approach – try and avoid those frustrating false positive BCs
Contemplate changing the plan – look at the AB cover – is is sensible? Do you need to yank a line or call a surgeon to drain some pus?

Thanks Ben for the article. Interns – relax, but do a more thorough job! Casey

Clinical Case 050: Think Better, Do Better

Casey Parker — Mon, 30 Apr 2012 07:57:13 +0000

Last week I received the following comment from a reader in a country nearby. This was a great story for me to hear as it made all my long hours of reading and writing seem worthwhile. There are plenty of podcasts and blogs that will teach you how to do life-saving stuff – but this story is about how a reader took something from Broome Docs and ‘saved a life’ in a very different way. It is not about a single trick or a procedure – but about how to approach the daily practice of medicine in a better, patient-oriented and effective manner. For me this is the essence of why I do what I do at Broome Docs. Here is the story from Dr Tom:

Hi Casey,

Straight after I read your first article on Consult Skills, I clipped and saved it using Evernote so that I could access it on my iPhone whenever needed.

Lo and behold, last week I had my first opportunity to use it when a middle–aged lady presented with a two year history of severe low back pain, bilateral hip pain and right leg pain. She had had multiple visits to her GP, several locums and 3 different orthopedic specialists over that time. Even though she was on a benefit, she had paid to see a couple of specialists privately because she was so desperate.

When she arrived in our ED, one of our relatively new Resident Medical Officer’s went to see her. The RMO came back very frustrated and said that both the patient and accompanying relatives were very angry and demanding, and that she wasn’t really able to get anywhere with her.

At that stage I said to the RMO that we had two important functions to fulfill:

1. To make sure that the patient didn’t have any emergent orthopedic conditions e.g. cauda equina syndrome, spinal abscess etc.

2. To try to understand the patient’s point of view.

The latter was met with a slightly quizzical expression so I pulled out my iPhone, opened my Evernote application and showed her the section I had clipped a few weeks ago:

1. They want to know the doctor is listening to them

2. They want to know that the doctor cares

3. They want to make sure the doctor understands what is going on

4. They want the Doc to “get it right” – that is make the right call / decision / do the right test etc…

5. They want to know what to do next “what will happen to me now?”

At that stage I went into the patient’s room and said:

‘Hi, my name is Tom – I am the senior ED doctor on duty today. I understand you have been going through a really rough patch lately. The first thing I am going to do is to take your pain way with some morphine. Once you are comfortable, I would like you to tell me everything that has happened to you over the last couple of years; then I will have a good look at you, review your results, talk to the orthopedic specialist on call today and together, we will try and come up with a plan to get things sorted for you.

After 10mg of morphine she said – ‘Doctor, you know this is the 1st time in over two years that I have not been in pain’.

She then proceeded to tell me:

• Her marriage had broken up and she was looking after 6 children on her own.

• She was in so much pain that she was unable to dress herself (mainly because she could not bend down or stand on one leg), was unable to walk more than a few steps, had hardly been out of her house in the past few weeks and was largely confined to her bed or a chair.

• She had a history of multiple severe drug reactions and was not currently taking any analgesics.

• She suffered from stress incontinence and wet herself at least 2-3 times every day.

• When she fell over, she was physically unable to get off the floor unaided.

• Her teenage son had to take time off school to help dress and wash her, clean the house and do the cooking – this was now starting to adversely affect both his education and their relationship.

• She was not eligible for any government subsidies (e.g. home help).

• She was often tearful due to a combination of pain and frustration.

After listening to her history, I briefly re-capped to make sure that I had not missed any important points. I then examined her and reviewed her recent imaging.

Next I rang the on-call Orthopedic Specialist and said – ‘I’ve got a lady with chronic severe lower back, hip and leg pain; a plain film of her pelvis and hips shows severe bilateral hip OA; she doesn’t appear to have any new emergent orthopedic conditions but I would like to admit her so that we can sort out her analgesia, home help, mobility and definitive treatment’.

I returned to the patient and told her: ‘Great news, the Orthopaedic Surgeon has agreed to bring you into hospital, sort out your pain, get you a bit more mobile and most importantly, try and fast track some surgery on your hips.’

At that point she started crying and said:

‘You know, of all the doctors I have seen over the last few years, you are the only one who has ever sat down and really listened to what has been going on. Thank you so much’.

PROGRESS REPORT

After initially being admitted to hospital for a week, she has gone on to have her 1st hip replacement done and is due for her 2nd operation in 3 months time.

Great work Dr Tom. I really appreciate your sharing this story with me and knowing that we can do better by changing the way we think and talk to patients.

Broome Docs in the Fast Lane

Casey Parker — Fri, 27 Apr 2012 13:16:35 +0000

Apologies to the regular readers (and the slightly odd ones too!). It has been a slow week for updates at Broome Docs as I have been in the big smoke (Perth) doing a bit of a refresher in all things Crit Care in SCGH - and catching up with the Life In the Fast Lane crew at the same time. It has been a discovery tour where I have had the chance to practice a few skills, ask a lot of difficult (?stupid) questions and learn a thing or two about what it is we do!

Met Dr Mike Cadogan (@sandnsurf) today and I can say it was a “blog changing” experience! I recorded a chat with Mike for his upcoming podcast and learned stuff about blogging, education, life etc that I didn’t know I didn’t know! Left Mike’s office with the feeling I was thinking in slow-motion! I hope to be making my own contribution to his upcoming iMeducate program, providing cases / fodder in this intriguing project which will change the way we access our education and learning at all levels.

If you want to hear me going on about the whole interweb thingy with the master then click here for the 9 minutes of CITFL chat we recorded in his tiny, but very busy office

Anyway – I’ll be back in sunny Broome next week and hope to bring you a whole heap of new stuff, cases and evidence that I have garnered over the last week!

Casey

Clinical Case 049: the Unseen ECG

Casey Parker — Sun, 15 Apr 2012 13:33:44 +0000

I was sitting at the desk writing up some notes when the triage nurse stuck the following ECG strip under my nose.

The story was that this chap was a hypertensive, obese, diabetic vasculopath with impaired renal function who had presented with a fever of 39 deg and nasty looking diabetic feet (see Clinical case 047 for example…). He was looking unwell so she did an ECG on the off chance he might be having a silent infarction.

So here we are – sick looking, high-risk sounding patient.

Q 1: What else do you want to know?

No chest pain; No previous IHD documented; Previous ECGs? – he had a normal exercise stress test 2 years ago with a normal baseline ECG in the chart

OK, all you smart ED types. Can you make the diagnosis? What is going on here? There might be a trick or two …..

The Answers you seek...

Ok a few observant comentators noted the machine was running at 50mm/sec – and the V leads were missing. The patient was running at 126 bpm clinically and on the monitor. Unfortunately our new nurse who was not familiar with the machine pushed the wrong buttons and gave me a terrifying minute or two as I made my way to the bedside! The penny eventually dropped and I could breathe a big sigh of relief!. The true ECG showed a tachy @ 126 with a RBBB pattern and no convincing P waves. So channeling Chris Watford (Emcrit) I did a Lewis lead config – and the P-waves popped up like they should! Sweet – we were back to boring old sinus tachy in a septic patient and all was well!

Lessons learned here...

1. Always look at the patient before the ECG, or at least shortly thereafter!

2. If something doesn’t add up, check the basics, repeat the test and ask, ask, ask

3. Septic patients can develop nasty arrythmias – SVT, AF, transient heart blocks (RBBB), VT etc – so beware the sepsis with tachy, find those P-waves – as all the other options are not good for their cardiac output.

4. Lewis leads (S5) actually works, it is cheap, easy and makes you look smarter!

Clinical Case 048: We Ask an Epidural Expert

Casey Parker — Wed, 11 Apr 2012 13:31:34 +0000

This case is an opportunity for us to learn from an expert. Epidural analgesia in labour can be rewarding and infuriating. So I have enlisted the help of Dr Roger Browning – Consultant Anaesthetist at Fremantle and King Edward Memorial Hospitals {tertiary maternity centre in WA}. I put a few questions to Roger based around a real case to see how the expert goes about troubleshooting common epidural problems. Here we go:

26 yo primigravida, induced for postdatism @ 41 weeks. She is now ~ 6cm dilated with slowish progress. You have been called to put in an epidural after she has tried nitrous and a dose of IM morphine. As you arrive she is clearly very distressed with each contraction. They are coming every 4 minutes on an Oxytocin infusion. She is otherwise fit and well, normotensive.

Practitioners should use the technique they have learnt and are most familiar with. I would place a lumbar epidural using a 16G tuohy kit and loss of resistance to saline, and thread the catheter in leaving 4-4.5 cm in the space and secure it to her back using a “lockit”, medium tegarderm and surrrounding fixomull dressing for reinforcement. I would aspirate the catheter to check for blood or CSF and then test the catheter with a 7-8 ml injection of bupivacaine 0.125% + fentanyl 5mcg/ml. If there is no major motor block within 5min (ie indicating subdural or intrathecal catheter) I would then give another 5-8ml of solution ie 15ml in total to get initial analgesia.

At KEMH we use bupivacaine 0.0625% + fentanyl 2.5mcg/ml background infusion of 5ml/hr and PCEA 10ml with 20min lockout, via a CADD pump. In a rural hospital (and other metro hospitals like osborne park) I would prescribe intermittent topups: bupivacaine 0.125% + fentanyl 5mcg/ml 10-15ml hourly PRN, for breakthrough bupivacaine 0.25% 5ml hourly prn, rectal pressure pethidine 50mg/5ml hourly prn, and instrumental delivery / suturing ligonocaine 2% + adrenaline 1:20000 4ml + 4ml one dose only.

3 hours later….

You are called by the midwife for help. She states that the epidural you put in worked great initially, but… now it is not so good. She hasn’t made much progress up to 8 cm now. We are still expecting a few hours of pain at best….

You need to assess whether or not you think the epidural cathetter is still in the epidural space. Check the patient’s back & dressing, if the catheter is now less than 3cm in the space, or there is a lot of fluid under the dressing don’t waste time trying more drugs etc, it has come out, take it out and place another epidural. If everything looks ok then carefully titrate in more bupivacaine 0.125% + fentanyl5mcg/ml solution, larger volumes will often “spread further” and tend to be better than small volumes of more concentrated LA. I will give up to another 20-25ml in increments over 10-20min. If this doesn’t work you should probably take it out and place a new epidural catheter.

Our 26 yo primi has made it to fully, but not really descending well. The CTG trace has been getting ugly… some decelerations at first, but now it has become flat / unreactive. The Obs team call you for a Csection. It is not Cat 1 urgent, but you want to get her ready ASAP.

Before starting an epidural topup for a CS once again you want to be sure the catheter is in the epidural space and it is working. Look at her back is the catheter < 3cm in the space? is there a lot of fluid under the dressing? has it been working well down in labour ward? If the answer is no to any of these you are probably better off taking it out and doing a spinal. At KEMH to topup a epidural we use lignocaine 2% + adrenaline 1:200000 (which comes in a 20ml ampoule) and fentanyl 50-75mcg. You should aspirate the catheter to check for csf / blood and then give 5ml as a test dose, check for early profound block (?intrathecal) or tachycardia, perioral tingling (?iv). You should titrate in the lignocaine in 5ml increments every 5min, to max of 7mg/kg (in the average female this is around 25ml) checking the block height regularly, aiming for loss of cold sensation to T4 (nipples) and signs of sacral spread also (difficulty lifting legs off the bed). If after the maximal dose you have an inadequate block you should consider doing a CSE or spinal (using a smaller dose than usual as there is a risk of a high spinal) rather than causing local anaesthetic toxicity with even more lignocaine. I often also give pethidine 50mg (personal practice not dept) as it decreases the severity / incidence of shivering.

You give your top-up, get her ready and the Obs team start cutting. As soon as they hit the peritonela layer she winces and says she feels sick. A minute later and she is crying in pain – her husband is looking very scared.

And how do you go about making this decision?] This description suggests she has an inadequate block and you should stop the surgeons before they proceed to making a uterine incision. The critical issue here is that once the surgeons incise the uterus they are commited to continuing, placental perfusion and foetal oxygenation is impaired and maternal haemorrhage starts, the surgeons cannot / should not be asked to stop for 15min whilst you try to “fiddle with your block”! You need to make a decision prior to this point. Clarify with the patient are they feeling pain or merely touch, believe them if they say it is pain. Check the dermatomes with ice and get the surgeons to “check with forceps etc in the surgical field. If the patient has significant pain at the point of peritoneal incision as in this scenario, and the block appears to be obviously inadequate I would err on the side of converting to a GA before then letting the surgery proceed. If you have already “topped up” with a decent volume of lignocaine 2% + adr (ie 15-25ml) and given this time to work (15-30min) it is unlikely that stopping for another 10min and giving another 5-10ml will make it into a working block. Having said that if they have a difficult airway or look high risk for a GA and you think some more time and more drugs will make a difference then it might be worthwhile to persist, this is an individual risk/benefit decision and you need to talk to the patient /surgeon and explain all of these issues. The most common scenario for pain during a caesarean occurs post delivery, is usually only mild, and related to temporary surgical stimulation whilst swabbing high in the abdomen or fiddling with the ovaries etc. Often you can get a patient through this with iv opioids, inhaled N20, some surgical infiltration of LA (beware max dose if you used alot in the epidural) and distraction with the baby! Sometimes you still need to do a GA to allow the surgery to finish though…

OK – that is epidurals through the eyes of an expert. Big thanks to Dr Browning for taking the time to answer my questions. This is certainly a part of medicine with plenty of art, less science and a lot of inter-individual variation. I am keen to hear your tricks and techniques. Let us know on the comments.

Casey

Consult Skills 3: Being Good at Bad News

Casey Parker — Tue, 10 Apr 2012 08:13:58 +0000

We have a great job, but sometimes it sucks! Forget the annoyance of shift work, the heirarchy and long hours – for me the worst part of the job is when we find something nasty, or have a poor outcome – giving bad news to nice people is never easy. Why? well it goes back to the type of people we medicos are ‘on average’. We are usually pleasant, we like to make others happy, ease suffering and get good results – this is one scenario where none of these is likely to occur. So how do I think about “giving bad news”?

There are a lot of teachings out there, and anyone who has done any GP training will have had this drilled into them throughout their training. In Australia you can be guaranteed that you will get a “bad news” case on your fellowship clinical exams. So here is a case and my “rules” for being good at bad news.

You are in your office checking your emails when the radiographer calls you to say she needs help….She has been doing a 19/40 anatomy US on a nice young lady with her husband watching to catch a glimpse of a face or a gender. All seemed well, until the radiographer realised that this baby had no brain – it is anencephalic. It is a small town – the radiographer plays netball with the expecting mother and cannot hold her poker face. She stops scanning and tells her she is going to find a doctor to get a second opinion. This is when she called you.

If you are like me – you know what this means, but the exact logistics of dealing with anencephaly are well beyond my scope of practice. I need help and will be calling my local ObGyn for advice. However, the young couple are aware that something is wrong. You need to talk to them and provide counsel – so how to do this in real terms…

Here are my rules:

1. Know your stuff

This will depend on your own knowledge and the scenario in question – but before you walk in the room you need to have a clear understanding of the problem, the management and prognosis.

This might mean doing some research or asking for specific specialist advice – but you have to know. If you are unsure – you know that will be the first question they ask – and you need to be able to provide clear and concise counselling. This is not the time for ummm or errs – the patient needs clarity and a direction. Any vague responses will likely provoke anxiety and confusion in a person who is already having the worst day of their life.

You do not need to have encyclopedic knowlege – but you should be able to provide clear and accurate information now, today! So take a few minutes – call someone who does know and get the facts straight in your noggin

2. Clear your books

This conversation is going to take time – and it is the most important thing you will do today (this year?) so create plenty of time. Hand your phone or pager to a colleague. There is nothing worse than feeling time-pressured or being interrupted for trivial problems in the middle of this crucial dialogue. This conversation will be stamped into your patient’s memory for years to come so make sure you do all you can to make it quality. If you cannot make time in the day – then plan to see the patient at the end of your day / shift – that way you are free to take as long as required without the pressure of the waiting room etc.

3. Get the venue right

You need uninterrupted privacy. It is really hard to predict how any individual will react to the news you are giving them – so do it in a priavte room, away from traffic or onlookers. The curtained bay of an ED cubicle is not the place to do this! I once saw a doctor give a trisomy 21 result through the bullet-proof glass of the triage window – that is just wrong.

Beware that some folks will have a dramatic response – crying is normal, butI have seen a few people have syncope and prolonged, almost catatonic responses – so it is helpful to have a bed or somwhere the patient can lay down if the need arises.

4. Get the right people in the room

It would seem obvious, but not always done. You want to ensure that the patient brings along all the people who they need – spouse, parent, children etc. If you get this wrong there are a few possible problems. You need to ensure the patient is happy for those people to be there from a confidentiality POV.

- Talking to somebody alone is not advised – they need a support person to help them through and share the experience. Sometimes even to get them home safely.

- If an important family member or person is not there – they will likely get the message indirectly and inaccurately – this will lead to tension, misinformation and sometimes anger

5. Keep it simple - no sugar coating

You need to decide the words you will use up front. You need to get the message across in clear, simple, unambiguous language. It is human nature to want to hear things in a positive light – so you need to use clear language to avoid any misunderstanding.

The use of subtlety or pleasant euphemism is not allowed – that is about you wanting to avoid the unpleasant nature of the conversation. In order to do this right you will probably feel uncomfortable – that is your problem – not the patient’s!

6. Say what you need to, then shut up

Once you have given the patient / family the information you need to be quiet. Usually you are delivering life-changing news and it takes at least a few minutes for people to process and begin to comprehend what is happening. Talking at this point is unhelpful at best! Let them process and just wait – when they are ready they will ask you what they need. You may feel uncomfortable with a prolonged silence, but wait, resist to urge to add info or interpret their response.

It is well studied that patients recall very little of the data received in these scenarios. They remember the demeanour of the doctor, but often not the simple things – like what happens next. So before you start this consultation – have a clear plan / referral /investigation or next appointment prepared. The patient will walk out in a haze often – so giving them a firm “next step” is vital – avoid open-ended time frames and the “I’ll get back to you” strategy. I usually plan to see them the next day – they usually have a lot of questions. In reality this is not a ‘one stop’ consult – it is the start of an important therapeutic relationship.

OK – that is my simple approach to the delivering of bad news. Do you have any pearls or strategies that you have found useful in your practice? Let me know

Course Review: Advanced Paediatric Life Support (APLS)

Casey Parker — Mon, 09 Apr 2012 14:58:33 +0000

Last week I completed the APLS course over 3 days. I am an impartial educator and thought I would give my review – so what did I think?

APLS is a well organised and run course. It covers a lot of material over 3 days. The level is pitched at the post-graduate trainee – ideally PGY 2 -4 I think. The days were long – 11 hours of material in a day… this is probably counterproductive. The course could be streamlined I think without losing too much.

At ~$1900 – it is a reasonably expensive course. For that money you get a lot of theory, manikin-based scenario training, but no animal / cadaveric models to improve your clinical skills.

The learning is largely based around lectures – not everybody’s preferred format! I found the lectures a bit long and repetitive, especially if you had done the required pre-course reading of the manual. The teachers were friendly and well-informed, and an effort to remain entertaining was evident.

The scenarios and skills stations were OK. As a more experienced participant I found being put on the spot in simulation to be a strong learning tool and allowed me to identify my weaknesses and cognitive errors. I was aware that some of the more junior participants found the live simulation a bit confronting.

The material presented is largely up-to-date, though there are some areas where there is a lack of evidence base. For a ‘resus course’ the absence of ultrasound strategy was striking. The preference for ETT over LMAs in resus seemed odd given recent changes in most major guidelines

The testing and scenarios were OK, but did lack some flexibility to allow more experienced clinicians to make judgement calls rather than blindly follow protocol – ie. there is some ‘lowest common denominator’ effect – I guess this is a function of running such a broad ranging course. Good for jnior staff, but a bit frustrating if you are 10+ years into your career.

Summary:

APLS is a well run course that covers an ambitious amount of material in 3 days. The educators are entertaining and well-versed. I recommend it to junior doctors, and staff who are unfamiliar with Paeds patients and wanting to extend their knowledge from adult care. For the office GP who wants to brush up their resus skills – it is OK.

If you already do a lot of Paeds, especially in ED or anaesthesia environments than this course might e aiming a bit below your educational needs.

Any one out there got experinces of the APLS to share? Casey