Infertility (or sub fertility – to be PC) is a common problem for which women (and men / couples) presen tto GPs.  It can be a really tricky area trying to work out the how, why and what.  I think we tend to do a lot of tests where often a careful history and rational approach to the patient and their partner can be really useful.

I enlisted Dr Penny Wilson once again to chat (teach me) all about infertility in the GP office.  DIRECT DOWNLOAD here

Enjoy
Casey

In rural areas there are no dedicated services for the initial management and forensic examination of victims of sexual assault.  As such rural GPs and emergency doctors are required to perform this difficult and important task.  There are a heap of good training courses and resources out there for clinicians who want to learn how to perform forensic examination and provide the initial care for these patients.

In WA we have a wonderful service based at King Edwards Memorial Hospital for Women – it is SARC [Sexual Assault Referral Service ].  When I was a trainee in the metro area we were lucky to be able to refer victims to this service 24/7.  However, in the rural areas this is not usually possible.

So I thought I would put together the basic approach and a few tips I have learned over the years for a podcast.  I am definitely not an expert, so I am really hoping there are some pearls from the listeners to help us out on this one.

Have a listen and let me know if you have any resources, experience  or pearls you can share. DIRECT DOWNLOAD here

Casey

Dysmenorrhea is a very common problem in primary care, and can even turn up in the ED from time to time.

As a bloke GP mainly doing ED stuff, I rarely have to treat it beyond suggesting some OTC NSAIDs and a hot pack.

So I have teamed up with Dr Penny Wilson (@nomadicgp) who writes the Nomadic GP blog about her experiences as a roving rural GP trainee and now locum in all parts of the country.  I could particularly relate to this recent story where she failed to locate a cervix on speculum exam (though in her defence it wasn’t actually there! ;-) ).

Penny is a bit of a gun when it comes to ladies health – so I asked her about some really dumb stuff and I hope you can learn as much as I did.

DIRECT DOWNLOAD - or get it from iTunes

Imagine this scenario.

You turn up to work your day shift and see you have been assigned to the Obs ward for the morning.  It is your task to see the dozen or so patients sleeping off the evils of the night before in the small ward out back of the ED.  You know the drill – a few minor tox cases, a Psych sedation, maybe an old guy with a bump to the head etc….

As you look at the list of patients under your care – you have a heart-sink moment as you recognise Phineas’ moniker.

Phineas.  Well Phineas is a well known individual.  He is about 50, and you have seen him many times over your tenure in this ED.

Phineas was a successful independent builder, running his own small company and living in a well-healed suburb with his wife and 3 kids until he had his accident.

About ten years ago Phineas had a few too many drinks and drove into a wall.  He suffered a nasty frontal brain injury and spent a month in ICU, a craniotomy and a prolonged rehab saw him back to full physical function. But…. his brain injury left him with seizures and “Phineas Gage” persona.  Phineas became impulsive, disinhibited, drank to excess and had trouble organizing his life.  His marriage had disintegrated over a few years and he couldn’t hold any sort of job.  Phineas doesn’t have a diagnosable primary mental illness and he has seen a number of Psychiatrists who have all agreed – he does not need their help.

Over the last few years he has been living in a series of supported housing units, but he tends to get into a lot of fights and never stays anywhere longer than a few months.  However, the ED is one of the few permanent fixtures in Phineas’ life.  He frequently presents via ambulance after experiencing secondarily generalised seizures in public.  He is prescribed phenytoin but whenever he gets a level done in ED it is close to ZERO.

You read through the chart from the night before – same old story.  He was drinking in a local park, when he had a convulsion.  A passerby called 000 and the Ambos brought him in.  He was GCS 14/15 on arrival and blew 0.09 on the BAL analyser.  All his obs and examination were “normal for Phineas”.  He received an IV load of phenytoin 1000 mg over an hour, some thiamine and a hot meal.  He required a few doses of diazepam after this for “twitches”.

The resident decided to admit him for “Neuro obs and  Neurologist review in the AM”  This brings a momentary smile to your face!  This is Phineas’ 23rd admission in 3 years.

You wander into his cubicle, and he greets you with a knowing smile.  ”Gday Doc!  I’m glad it is you on today.  That young guy last night seemed very serious!”  Phineas is his usual, jovial self.  

After you check him out and talk about the footy for a while Phineas is keen to leave.  He tells you he is staying in a nice flat with a few other “mental defectives” and plans to head back there for a rest and to make sure they have not knocked off his stash of Bundy rum.

So here we are.  The point of the exercise today is to explore a few issues that this sort of patient can present to us, Emergency Physicians who are sometimes by default the primary carers for some patients.  SO have a ponder on these questions;

Q1:  Would you load Phineas with phenytoin each time he presents “post-ictal”?  If so, would you give him IV phenytoin, or something else?

Q2:  Clearly compliance is a problem. You are an ED doc.  How far do you go to try and get Phineas to take the meds he needs?  Do you give him a prescription?  Hand him a bottle of pills with instructions?  Get a blister pack made up.  Get a Social worker / community health worker involved?  Do you go round to his flat and check on him?  OR is it ethical to accept that Phineas will not take anything you give him and not bother with the meds?

Q3:  Is this a competence question?  That is – is this man competent to make his own health decisions?  Given the facts:   he has clearly and repeatedly put himself in harms way, has a brain injury yet seems insightful enough when you talk to him.  How do we go about deciding on competence in this situation?

OK.  Enough clinical and ethical food for thought there.  Hit me on the comments page or twitter @broomedocs with your thoughts.

Casey

The pain felt almost metallic in nature, which didn’t mean anything to me at the time. He had returned from Thailand with a strange rash over his flank that two other experienced GP’s at my practice could not identify when I sought their help.

 Just then a still small voice flashed into my consciousness about using my iPhone to take a picture and submit this unto the TeleDerm website. To my surprise within 30 minutes I received a text message saying that Dr. Jim Muir had reviewed the case and posted a reply. The rash in question was Cutaneous Larva Migrans!

 This was case was submitted and published in the Australian Family Physician last year.

This encounter is echoed across Australia with similar consultations and enquiries being made of the TeleDerm service everyday.

The word has powerfully spread through Australian medical circles via twitter and multiple blog posts highlighting the outcry that this essential service may lose its federal funding from the Department of Health and Ageing.

TeleDerm addresses the lack of access rural patients have to specialist dermatology services and recognises the vast distances they may need  travel to seek specialist dermtatological review.

To lose this service would be significant to the landscape of rural and remote medicine and again deepen the disadvantage felt by our rural patients.

Here at BroomeDocs both Casey and I would like to throw our support behind the #SaveTeleDerm campaign and encourage all doctors to unite in taking this cause straight to the Department of Health and Ageing.

So how can you help?

1)   Sign the petition which will send an email to the Health minister alerting her to the dire consequences of losing TeleDerm

2)   Tweet #savetelederm and tell everyone your story!

May is still Women’s health month – so I invited my mate Dr Geordan Shannon back onto the podcast in order to get a refresher on cervical cancer screening – yes, the dreaded Pap smear.

Geordan is a passionate advocate and researcher for Women’s health, sexual health and especially Aboriginal health issues related to reproduction and inequity in health outcomes.  Cervical cancer is a disease that highlights the huge gap between white and Aboriginal Australia.  We had a chat about why this might be still happening and then Geordan schools me in the basics of Pap-smearology.  What is new, how do we decide what to do with the results.

Sorry if this seems a bit basic – but I am [as previously stated ] a really inadequate gynaecology practitioner, so for me this was helpful!

Enjoy the podcast.  DIRECT DOWNLOAD  or listen in your browser below.  PLease go onto iTunes and subscribe.  Even give us a review if you are enjoying the podcasts [or not!]

Casey

OK, I have a confession to make.  I am a truly appalling gynaecologist!  I know, I claim to be a generalist – one who loves it all – but when it comes to the non-pregnant women I admit that I am sometimes less than enthusiastic.

Now this is not such a dilemma as I work in an ED, and there are not a lot of non-pregnant Gynae emergencies that I cannot sort out with a quick US and examination.  But here is my dilemma [maybe you share this one?]:  I have trouble finding the cervix on spec exam.  I know if I practiced more and got good at it I would be an ace cervix-locator. But….  I do i so infrequently and poorly that I just never really got there.

So, why worry?  Well I work in an area where STIs are rampant – we need to get good Micro samples and sort out who has go what.  And my training was to get an endocervical swab to prove (or disprove) these diagnoses.  I have always been told that clinican-obtained swabs were the gold-standard.  Accept no less.  In the last few years there has been a trend towards SOLVS (self-obtained lower vaginal swabs) for STI testing.  And I have been of the belief that they were the poor cousin to my fumbling attempts to swab the cervical canal.

BUT, wait!  News just in….  SOLVS might actually be better than my swabbing samples.  2 recent papers that I have seen looking at the diagnosis of Chlamydia and Gonorrhea indicate that the patients are better than me at getting a diagnostic sample.

This Paper from Stewart et al in BMJ Dec 2012 compared SOLVS to clinician-endocervical swabs for the screening of asymptomatic women for chlamydia.  In summary the SOLVS had a sensitivity of 97%, compared to the endocervical swabs 88% (P – significant) with narrow CI.

So I think it is fair to say that SOLVS is at least non-inferior to clinician-obtained swabs.  And I would go further to state that SOLVS is definitely superior to Doc-swabs when the Doc happens to be me!

Now, one last word of caution.  This does NOT mean that clinical examination is useless.  It would be tempting to say that we can manage a PV discharge or pain without having to get the patient undressed and have a look.  This is not the case.

I can recall countless cases where I have seen women either self-diagnose or be “diagnosed” blindly and empirically treated for what was thought to be thrush or bacterial vaginosis.  They eventually get a proper examination and it is clear that the culprit is something else – herpes, trichomonas etc.

So by all means get the patient to do a SOLVS – but you still need to have a look, to ensure you are not missing anything.  Although I think when we are prely screening for STI or other micro in an asymptomatic woman, then a SOLVS alone should suffice.

Now – not sure if this is news to anyone else?  BUt would love to hear your comments.  More Women’s health coming all month.

Casey

Hi All

If you are a regular reader / follower of the blog and live in Australia then you might be interested in a new training course being offered by SAPMEA in South Australia.  This new 2-day course is being held on idyllic Kangaroo Island – and is the brain child of Dr Tim Leeuwenberg and others.  It is on this September  15 – 16th so plenty of time to get your leave form in, your locum booked and start swatting up on the FOAMed goodness that will no doubt be required to “pre-read” for this event.

This is what I have been hoping to see for some time –  an emergency skill and training course that goes beyond the ABCs more than a “one size fits all” model of resuscitation and critical care.

The idea is to look at teamwork, critical event management, logistics and all the stuff they never taught you in Medical school – or on any of the traditional courses.

So, please, please – go over to KI Docs and check it out

The direct link to the post is HERE.  Or you can email the coordinator, Erin Gray cme@sapmea.asn.au with your registration of interest.

If you have done all the courses and need to take your emergency skills to the next level – then this is the way to do it.  You will be exposed to ideas and people who are experts in the practical application of emergency care out there in your world!

[Plus, Tim won't stop harassing me until you sign up.  So tell him Casey sent you, I think I get 1 can of Dr Tims Lager for every doc I recruit!]

Casey

Its a quiet night shift – you are contemplating a third cuppa when the triage nurse rolls in with a young woman on a wheelchair.

Your powers of observation tell you three things:  (1) she is heavily pregnant, (2) she is in a lot of pain and (3) there is a trail of blood flowing behind the wheelchair.

This is not good.  If you work in an adult ED this is probably a pretty rare occurrence – but in a mixed Obs / Paed place this is one of those moments – action stations!

Now I imagine most of you will be thinking – “get that patient outta my ED ASAP!”, however this is a scenario where time is of the essence – and it is worth knowing where the decisions are made, how to start the resuscitation and how do obstetricians think about this scenario

I sat down with my old sparring partner – Dr Wendy Hughes, our resident O&G specialist to go over a case – how should we go about the early management and where are the crucial decision points.

Have a listen and let us know if you have any insights.  There are a heap of pearls and great practical tips crammed into about 20 minutes.

Casey

Welcome back – It is May, and this month we are going to focus on Women’s Health – the O & the G, pregnancy, family planning and preventative care for the ladies.

I am going to be brave and open a discussion on Abortion [I may regret this].  I do not wish to alienate anybody or sensationalise this issue – I do believe that it is an important discussion to be had between peers of different persuasions.

This is where I see the current state of play for abortion in Australia. I work in an area where I deal with abortion as a routine part of my practice.

• Termination of pregnancy is a reality of modern medicine.
• I know that the medical community is clearly split – those who do and those who do not.
• Women [in most developed countries] have the right to choose and control their own bodies.
• We – the medical profession, have a duty to provide this care in a safe and unimpeded manner.
• I am a pragmatist and strongly believe in harm minimisation. (most of the women I anaesthetise for a TOP also agree to an implantable, longer term contraceptive device)
• For me a TOP is a symptom – of poor sexual health education, often a relationship under strain, and a woman at risk of other problems – STIs etc.  This is an opportunity to intervene and make a difference, rather than an end in itself.

This story caught my eye this week – it was a piece in “The Telegraph” out of Sydney.  Link is HERE.

Essentially it is a story about a GP who refused to refer a woman (couple ) to a Gynecologist for a termination of pregnancy.  The GP is openly anti-abortion and has run for a political party on this platform.  However, in this case he refused to refer as he believed the couple were planning to terminate in order to achieve “gender selection” – i.e they did not wish to have daughter.

So I am going to go beyond the usual abortion debate – I am NOT asking if you feel it is right or wrong.  That debate has been well documented over many years.  I am going to ask a few more practical questions.  Imagine that you are a GP, take your own ethics into the room when your next patient requests a termination referral….

The Pinnion poll below includes 3 questions.  Feel free to answer them or not – you can select multiple options on the last question.

Or leave a comment on this topic – the story above and let me know what you think.

Lots of Women’s health coming up in the next few weeks – will be significantly less controversial I promise!

Oh, the last Ethics poll on post-mortem intubation is completed – check out the results on that post.

Casey

This is episode #8 of the Lessons Hard Learned Series.

I am once again joined by Dr Rob Orman – the “one and only” guy behind the awesome ERCast blog and podcast.  Rob shares a story from his early days as an attending – its about how to be more humble, more human and more happy in your workplace.

So tune in HERE and have a listen.  Let us know if you have any pearls from your career – we can all learn from our errors.

Thanks

Casey

Ok, the Paeds month is coming to its end. But here us a common, curly clinical question. 13 yo girl presents complaining of a sore, red, smelly toe.  It is stopping her from soccer practice – cant Bend it like Beckham any longer….

How do you manage this:

Specifically – what do you do with this patients toe :

today?

next week?

and for the longer term?

This is really GP bread n butter stuff. But I know there are heaps of opinions out there – are you passionate about paeds peds?
Casey

Hi Listeners

Dr MEl Thompson is back for a second bite of “lessons hard learned ”

This case is a lot close to home, I think these types of errors / system problems occur in large multi-department hospitals all the time – you might evne have seen it recently.

SO have a listen and send me & Mel your comments          DIRECT DOWNLOAD in new window

Casey

One of my jobs is acting as a supervisor / mentor to the next generation of doctors – medical students in the final phases of their training.

Recently one of my students  (Anton Lavell) posed an ethical question – I think I know what my “position” is on this question.  But, I want to know yours!

Anton is writing his final year Medical Ethics paper – so I thought rather than just write a dry discussion – why not poll the readers of Broome Docs to ask what their ethical position is on the following:

Ethics Case:

One morning in the emergency department, Mr Smith, a 90 year old retiree is brought in  by ambulance after being found to be unresponsive on his bathroom floor, by his daughter. He has a background of ischaemic heart disease, atrial fibrillation, hypertension and osteoarthritis. On arrival at the emergency, he was initially tachycardic and hypotensive with a low GCS of E2V1M2. But was soon found to have no pulse. Advanced life support and CPR was commenced. Up until this time Mr Smith was being ventilated with bag and mask  and endotracheal intubation is being considered and about to be performed. However, the CPR being performed is seeming futile. Ultrasound showed no cardiac activity. The senior consultant decided to cease CPR. 

Whilst Mr Smith’s death is still being confirmed and documented. The registrar who was present at the attempted resuscitation, is eager to complete to the endotracheal intubation. Additionally, there are two interns present, who have limited experience in endotracheal intubation are eager to have a shot afterwards.

These subsequent practices can serve as important practice opportunities, that can increase a junior doctor’s competence, which will better equip them future situations, and may even prove to be life-saving. Many would argue, that deceased patients offer a unique consequence-free environment, if you will, in which to practice intubation, as no further harm can be caused. Additionally, if survival had seemed likely, the responsibility of intubation would normally go to the most experienced doctor. Hence, intubation opportunities for the vast number of doctors in training can seem few and far between.

Practicing medical procedures, such as endotracheal intubation on newly expired patients has been a traditional activity among training doctors (Berger et al., 2002). Consent for these procedures by next of kin is not commonly sought, but rather performed surreptitiously out of site from family or friends of the deceased (Berger et al., 2002). Yet, consent is generally considered a mandatory requirement for all medical procedures to be performed. But now that the patient is dead, does autonomy become less of an issue? Some could argue that  because corpses can not have autonomy violated and families’ have only limited authority over the decedent’s remains, unconsented training is permissible. Furthermore, discussion with family members to obtain consent may cause additional emotional stress.

 The use of corpses for training purposes may provide benefits for other living patients, as more experienced doctors may be less likely to fail or harm future patients. Since the patient is already deceased, there is no risk associated with failing to secure the airway, and any physical harm is inconsequential. Thus in a purely secular sense, maleficence is not an issue. However, such actions may be in direct conflict with various religious, spiritual and cultural beliefs or customs. Additionally, it offers no direct patient benefit and may damage public trust in the medical profession. 

Thus if the decision were yours, would you allow the registrar and two interns to practice endotracheal intubation on the now deceased Mr Smith? 

Is endotracheal intubation of deceased patients in emergency departments an acceptable practice?

OK, now I want you to put yourself in the shoes of the supervising Senior Doctor in this ED.  If you have a few minutes please complete the following poll, so we can get an idea about the spread of opinion out there and gauge the current ethical landscape of this practice.

Thanks for your time.  Comments are usually better for this type of thing – so let me know your practice.  Casey

Gday, it is still Paeds month – so I have dragged an unsuspecting local Paediatrician up to the mike!

This is # 6 in the series of Lessons Hard Learned.

IN this episode Dr Mel Thompson recounts a truly terrible experience in a remote, resource poor and difficult environment.

However, some of the lessons from this experience can be really useful – even if you work in a big hospital.  Do you know where the bag-valve mask is in the Radiology department?  Maybe one day it will come in handy!

So have a listen HERE or play in your favourite podcast app.

Feedback is, as always, most welcome

Casey

OK Here is a quick case.  One that is a bit outside the norm – not your usual dislocation.

In this case a 14 yo boy presents after falling on the football field.  He landed awkwardly on his hand “popping” his index finger at the knuckle.

On arrival he has an obviously swollen, deformed MCP on the 2nd digit.

A quick X-ray looks like this (click to make the picture bigger!):

Q1:  What is the diagnosis?  Who is it named after?

Q2:  After a quick local block – you pull on the finger – but it aint budging.  Why?

Q3:  What is the most oft described strategy for managing this injury?

OK

Finally here, the last of the 3 part series on Paeds Spot diagnoses.

So get you mouse over the pause button…. and try not to make any rash decisions…hehheheheheh

Enjoy

Casey

 DIRECT DOWNLOAD available here

This is episode #3 of “Lessons Hard Learned”.

It is Paeds month at Broome Docs – so this is a Paeds case that demonstrates at least 7 lessons we can all learn.

It is a bit of a Swiss Cheese scenario – lots of errors aligning to create a perfect storm where disaster can occur.

Have a listen and let me know what you think.

Lots of biases on display here – Casey

DIRECT DOWNLOAD HERE

OK, this is it – part 2 of the Paeds Quiz.

Hope you enjoyed the first one – this carries straight on from where we left off.

In case you missed part 1 – here it is.

Part 2 is below, or DIRECT DOWNLOAD

PArt 3 will be out later in the week – so get your thinking hats on!  Try not to make any rash decisions (Hehehehehehhe)  I use that joke EVERY time one of the JMOs asks me to have a look at a rash.

Never gets old!

C

It is Paeds month at Broome Docs.

A series of 3 image-based quizzes are coming your way.  These are rapid-fire cases, have your mouse hovering over the PAUSE button.

Here is part 1:  PAEDS SPOT DIAGNOSIS QUIZ  PART 1

Or download it from your favourite vodcasting app / iTunes

Let me know – any questions, corrections or suggestions.

Do you like the format?

Parts 2 and 3 coming up soon!    Casey

Hi readers – another case-based quiz for you all.

In case you had not noticed – it is Paeds month here at Broome Docs.  So, apologies to all you adult docs out there.

This case falls into the category of Boring EM. {check it out if you like common, everyday ED pearls}

A 17 month old girl is brought into the ED at 2 in the morning.   Her mother has spent the last few nights trying to get her settled – but she keeps waking up crying and irritable.  She is scratching her perineum in her sleep and mum is concerned that she might be developing a UTI. Mum has been changing her nappy regularly – and she says it all looks normal to her.

She is otherwidse well, growing and developing normally.  No history of UTI.

On examination – her abdomen is soft.  Urinalysis is normal – maybe a few red cells – but expected on the history.

 “More is missed by not looking than by not knowing” as spoken by Dr Thomas McCrae, [protege of Osler].

So, always examine the perineum of children.  This is often overlooked – but as you will find – many diseases manifest themselves in this area – and it can often be the clue in Paeds that clinches an otherwise perplexing cluster of symptoms into a diagnosis.

So I had a quick look.  Her vulva was a bit inflammed.  And then I saw the problem.  Diagnosis confirmed!

Q1.  What did I see?

Q2.  What is the treatment?

Q3.  What are the possible [albeit rare] complications of this disease?

Be a Broome Docs Quiz legend and get your answers in first. C

A quick disclaimer – I know that PK talks are supposed to go for 6 minutes and 40 seconds – but I am a lazy man.

So this one is a bit longer. Still 10 minutes is respectable for such a fascinating topic.

I love Paediatrics – acute, ED / GP Paeds!  Why?  Because I reckon Paeds is the alst bastion of good, old-fashioned clinical medicine.

This PK is all about one of my favourite diseases, its uncommon, but important.  YOU do not want to miss Kawasaki’s disease, so don’t miss the PK and you will be well equipped to be a diagnostic hero and call a few cases of KD in your career!

Enjoy

Casey

Gday,

This is the second episode of “Lessons Hard Learned”.  This one is a little different.  When I put out the call for readers to tell how they have learned valuable lessons from their practice the hard way I got a lot of responses.

One letter was really powerful – because it was from a doctor who was telling the story from the other side.

I believe this is a truly profound lesson, one we all need to remember everyday of our careers.  We, doctors, occupy a privileged position in society – and it is very easy to forget the impact our words and actions can have upon those we care for.

This is a lesson in mindfulness, empathy and compassion.  I think that the letter speaks for itself – so have a listen.

I would really appreciate your comments and discussion of this story.  And I know that the author would like to engage in this discussion – so please let me know your feelings and share with us all your insights into this most fundamental part of our day to day practice.

Thanks

Casey

First of all, forget about ‘medical clearance’ of mental health patients – this terminology misses the point of the ED assessment of MH patients – after all, true medical clearance of ANY patient, let alone a MH patient ,is probably impossible. Really what we are aiming to do here is to provide an assessment for this important subset of patients so that they receive timely and appropriate care from the right part of the health care service.

If you only read one article about this topic check this one out – a snappy summary of the important issues in the area with some nice tables of information.

Essentially it this:

1. Gain an overview of the biopsychosocial factors influencing the presentation – precipitating or perpetuating factors that have resulted in the patient’s presentation to hospital today.
2. Ascertain the appropriate location of care for the patient – general vs. MHU vs. outpatient vs. prison
3.  Investigate for an organic cause for the patient’s symptoms or behaviors. Particularly important if 1^st presentation
4. Identify medical issues which may require treatment during inpatient admission and determine which patient’s may not be fit for management on psychiatric ward
5. Attempt to exclude medical emergencies

The following are the high yield points of assessment you should consider including each time you assess a MH patient.  For the best rundown on the evidence behind the suggested hierarchy below, read this nice review article.

1. History

2. Review of systems

3. Assessment of orientation

4. Physical examination

5. Tests???

The formal mental state examination is of limited use in the ED setting for a variety of reasons, not least because our patient population do not often fit well into the rigid descriptive framework of this testing. Forget about it and just describe what’s going on. [CP:  Although the Psych lingo, the description of psychiatric phenomenology which a formal MSE involves should be included in your assessment.]

• Collateral sources
  • Friends, family, other hospital staff
  • GPs, MMex – sometimes good for medications etc.
  • Old inpatient notes. Discharge summaries. Psolis database entries
  • Community mental health triage team
  • Call RuralLink (1800 552 002) after hours and they can hook you up.
• HPC, PMHx, Meds, Allergies
  • Think about acuity of onset, fluctuating course, atypical presentation.
  • Could this be delirium/dementia/organic brain syndrome?
• PΨHx – can be very important. If first presentation psychosis late in life, be suspicious of organic origin.
• Social supports, carers – I usually start with ‘who’s at home with you?’
• Brief risk assessment:, use your own –  or a specific form which gives a good overview of important factors to consider when assessing risk.

IS THIS PATIENT LIKELY TO NEED ADMISSION? IF SO, WHY???

I think in terms of ‘head to toe’ so that I don’t forget a system. It’s a bit like a secondary survey in ATLS but I do it before the physical examination.

• Neuro – headache, poor coordination, difficulty walking, dropping things, tremors
• ENT – dental pain, dentures, ear pain or effusion
• CVS/Resp – hemoptysis, chest pain, SOBOE, symptoms of HF
• GIT – abdo pain, anorexia, PR bleeding, change in bowel habit and weight loss
• MSK – back, bone, joint pain and disability
• Skin – especially at this time of year… pus is everywhere.

• Aim to ascertain whether patient is disorientated – ? secondary to drug/infection/electrolyte imbalance or psychosis
• Consider simple opening questions – how did you get here today? What is this building called? What time of year is it (wet vs. dry)?
• Elderly patient? Consider MMSE or KICA-Cog assessments. If pushed for time, consider doing a clock-drawing test only (good single test for dementia) – see here.
• [CP:  I would add that a basic assessment of the patients ability to "hold attention" - e.g. recall 3 items, or stay focused during interview is also gold.]

Targeted exam based on findings of systems review but usually including the following:

• Review the patient’s observations including BSL. Remember – VITALS ARE VITAL!
• If pregnant urine HCG (risk Ax)
• Abbreviated CVS, respiratory and abdo exam
• Targeted neuro exam – gait, gross assessment of function. Looking for focal neurology or abnormal movement patterns

DOCUMENT THE EXTEND OF ASSESSMENT AND ANY DEFICITS

TIME TO THINK ABOUT CALLING THE PSYCH TEAM

Basically, the Psychiatrist wants you to have considered the range of possible causes of this patient’s presentation and to consider what it is they actually NEED and what benefit would be had from admitting them to BMHU.

They want a synopsis of the patient including a formulation of the patient’s and your concerns, rather than regurgitating what the patient has said to you. Consider MH patient’s like other specialty patients – e.g. referral to cardiology for probable NSTEMI because they’re going to need an angiogram.

If you’re going to be ordering tests and you want to facilitate your referral to the mental health unit then it probably makes sense to consider what the Psychiatrists want to know about.

Bloods:

1. ‘Metabolic screen’ – FBC, UEC, LFTs, TFTs, Ca2+, Fasting lipids, Fasting glucose or HbA1c
2. Drug levels (valproate, lithium, clozapine)
3. Prolactin if on antipsychotics
4. bHCG if woman child bearing age

Imaging

1. CT head – very low pre-test probability in acute psychiatric assessment (see here). In essence, you probably shouldn’t CT the patient’s head in ED unless there is focal neurology or something atypical.

Other

1. Urine drug screen
2. ECGs – should probably do for most patients on antipsychotics [CP: for more on QTc and Psych - see Antipsychotics, ECGs, QTcs and Catastrophes.]
3. Sometimes EEG (can’t be done in Broome)
4. Very occasionally  – lumbar puncture

Casey’s 5 cents on investigations in the ED:

The ordering of investigations falls into 2 main categories -

• Forget about medical clearance – think about assessment to determine appropriate and timely care and avoid medical emergencies
• Think about where the patient will best be managed – avoid the knee-jerk referral to inpatient MH for all patients with MH issues
• Think about what the MH ward can offer the patient and what they lack
• Take a history, including a review of systems. Assess for orientation and consider additional cognitive testing (clocks). Perform a targeted physical examination but particular attention should be paid towards an abbreviated neurological examination.
• Consider whether the patient is intoxicated, if so, what are they on?
• Special attention should be given to the patient who is presenting for the first time. This is particularly true at the extremes of age or if displaying any atypical features.
• Consider doing a psych term to fully understand the perspective of the MHU and the mental health team.

Last week I put up a series of 5 quick tox cases for you all to ponder. In case you missed it – it is HERE

And you all gave great answers.  In there amongst the commenters was Dr Bryan Hayes  - Clinical Pharmacist, Academic Life in EM author tweeting as @PharmERToxGuy

Bryan works at the Uni of Maryland – which is a hotbed of FOAM goodness – with Amal Mattu, Mike Winters, Rob Rogers and Haney Mallemat sharing the hallways of his hospital.

We got together and went through the cases one by one and I asked all the stupid questions I have always wanted to ask a really smart clinical pharmacist!

It is 30 minutes of toxicology goodness.  Enjoy

OR Direct DOWNLOAD

Casey

Hello readers – especially to all you GPs / Family Physicians / Primary Care Providers out there.

This is a special post – not one of any clinical merit.  This is an invitation to become a part of the free, open-access medical education (FOAM) world for GPs.  For too long the ED / crit care Docs have had all the fun in online learning – and I believe that this medium is ideally suited to busy, isolated or knowledge-hungry GPs.

This week a long-dreamt up vision has become a reality.  A group of FOAMite GPs with an interest in online education have launched a new blog / website / repository which is aimed specifically at GPs, GPs in training and those of us who are far enough down the learning road to need a refresher in the basics.

The new website is called  FOAM4GP.com

Who is running this site – well this is a collaborative effort, the founding authors include:

Dr MInh Le Cong,

Dr Tim Leeuwenberg,

Dr Gerry Considine,

Dr Melanie Clothier and

Dr Jonathan Ramachenderan….

oh… and me of course!

So how does it work, and how can you get involved?

This website is different to the others out there aimed at GP education – this is not a static library of material – this is an interactive forum, supported by Social Media platforms.  This is not a one man show or a money-making exercise – we want to have a thousand authors, and we will not make a cent.

Think of this as your local study group gone viral, or a hallway chat in the ether.  We want as many trainees and older heads to get involved in the conversation.  Teach each other online and provide a really dynamic learning tool.

Now – I know, most of you are super busy and could think of 1000 things more fun than learning how to write a blog post, or produce a podcast.  However,  you are all super smart and contain pearls of wisdom that we need to share, stories from which we can all learn.

So here is the offer – if you can write an email, or use a telephone then you can become an author of this mega-project.  All you need to do is let me (or one of the other founders) know – send us an email, tweet or call us up.  You can write about what you are passionate about, something you have developed an expertise in through necessity or just something that tickles your fancy.

If writing is not your thing we can arrange to do a spoken interview with you and put it up as a podcast for all to hear.

Or maybe you know of an awesome learning resource out there that we can utilise and share through the blog.

And no, this is not just for Aussies – we take all flavours of Generalists – even New Zealanders.

Still not sure?  Well just read the site for a while, get a feel for the ethos and when you get inspired – just let me know.  WE WANT YOU to teach us.  We’ll do the annoying hard work on the technical side – you just need to share your wonderful knowledge.

In case you cannot tell – this is really exciting for me.  This could be the start of a great thing

Please come to the party!

Casey

G’day readers and listeners,

This is a new concept for the Broome Docs blog.

I am really interested in the psychology of Us – how our brains work (or not on occasion).  I really believe that there is a lot we can learn from the lower points of our careers – the times when things go wrong, often through no fault of our own.

So I am planning to do a series of confessional interviews with my colleagues where we discuss these moments and then dissect them – try and get to the bottom of what went wrong, the common errors and how we might change our practice as a result.

The first “Lesson Hard Learned” comes from Dr Tor Ercleve – Emergency Physician, Cartoonist, LITFL contributor and Excel Enthusiast.

Direct Download

Have a listen – this is really an open mike concept – I want to hear your stories and thoughts on these discussions.  So please send us your comments.

Thanks for listening, Casey 

Well I am just back from Sydney – SMACC2013.  It was heaps of fun, and I got to meet a lot of my FOAMy heroes, long time collaborators and heaps of you folk that read this.

SMACC will be slowly trickled out over the ether in the coming months so you can enjoy it all and see what you missed – don’t worry there is a SMACC2014 in Brisbane – watch this space.

I will do my best to let you know when and where the SMACC material is released – or you could just sign up to Twitter and follow the guys who put the whole shebang together.   OK enough ramble.

This week I am giving not 1, not 2…  but 5 cases in a single hit.   It is a toxidrome showdown.  Imagine you are in a medium-sized ED when these 5 characters all present.  Here is what I want form you for each case…

A)  Name the toxidrome (or specific drug if you can)

B)  Outline what specific investigation you might consider

C) Outline in a few words your specific management plan – assume the basics are done.

The prize will be love and respect, I might even be able to get you one of Dr Tim's kitten / cric T-shirts!

Say no more  

OK, here they are 5 cases – a quick background, Obs, Exam, ECG – and being Broome – there are no bloods etc available for now…  carry on.

Case #1

Case #2

Case #3

Case #4

Case #5

Traumatic fluid resuscitation.  This is one area of Emergency medicine where the dogma is pretty entrenched and the evidence has moved on quite a bit in the last 10 years.  It is a poorly understood area of practice – probably because it has gone thorugh several permutations of name and ideology in recent history – “permissive hypotension”, “minimal volume resus”, “damage-control resus”….

There has also been a quick increase in the range of fluids and blood products, factors and other agents that we use in big, traumatic bleeding patients in the last few years.  So I thought I would throw a case out there and let you know what I do, based on my reading, the guidelines and practical possibilities in a smallish hospital.

So here is the case:

23 yo builder was working on a roof when he tripped and fell over the scaffolding and landed awkwardly on an upturned wheelbarrow.  His left flank took the brunt of the fall.

After a quick scoop the Ambo crew have inserted 2 x 14 Ga IVCs and he has received 1.5 L of normal saline over 15 minutes en route.

On arrival to the ED his vitals are as follows:  pulse = 120 (though weak at the radials), BP is 90/60,  RR 18/min, Spo2 97% on 6L/min, he is alert but looks scared / in a lot of pain.

A quick look at his chest shows some deformity of the left lower rib cage with lots of contusion over the LUQ.  He is in C-spine precautions, no obvious trauma to the head or neck.

OK – as per ATLS / EMST etc.  You start with your primary survey:

A:  He is talking, asking for pain relief, seems oriented to the situation and can give an AMPLE history

Don’t forget the C-spine.  OK he has lots of reasons that we cannot clear him clinically – mechanism, distracting injury – so he is going to need some imaging – but for now we need to move onto B and C – keep him still.

B: Hmmm. He is not breathing well at all.  He is splinting his left chest wall and you think there might even be some paradoxical movement – Hey? Is this a flail?  His Sats seem OK, but he does appear to be labouring to move air.

C:  Just as you arrive at C he goes all grey and ashen and vomits (not pretty in a collar).  Now – DO NOT reach for the anti-emetic meds! Vomiting in this context (trauma & bleeding) is due to hypovolemia until proven otherwise!

I think we can all agree that his numbers and the mechanism suggest he is bleeding somewhere – could be into his chest or maybe a spleen… or both.

Here is the part of “C” that is often missed – you need to look and see if there are any obvious bleeding sources that you can control easily – pack, sew, tamponade or compress.  Sounds obvious, but a lot of the manuals will insist that you ignore “dramatic distracting injuries” on your mission to complete the primary survey.  This is just bonkers – if you see something you can fix – then do it.  Pull that femur straight, bind the pelvis, whack on a tourniquet.  Sure – if you are all alone, then you need to be quick, but in even the smallest hospital you can ask the orderly, trainee nurse or even a Medical Student to lean on a pulsing arterial spurter for a few minutes.

Now back to our case – he clearly has some bad bleeding in his torso somewhere and is unstable.  If you have the crew you might do a super fast FAST scan to confirm this.  In this case it looks a bit like this:
     What does this LUQ view show?

OK, we are worried.  Lets pause the clock here and outline the dilemma.

You are in a small hospital, the surgeon and theatre team are 30 – 45 minutes away from knife time [ this is reality in my shop ].  Lets assume his Obs are as they are stated above

Here are my questions for you to ponder this week and I will give you my answers in a day or two:

(1)  What are you going to hang next on this guy’s IV?

(2)  Given he is going to need an operation – will you go ahead and tube him in the ED, or wait for the tea to be ready to go in theatre then do it at the last minute?

(3)  Are there any other medications / devices etc that might be worthwhile in the meantime – and how will you get ahold of them?

(4)  Just for fun – what is your intubation plan for a chap with an uncleared C-spine injury who really needs a blue cigar soon?

OK – let me know your answers to these questions.

I will post my thoughts in a day or two for your dissection.

And what does this have to do with “midnight at MacDonalds” – well you will just have to wait and see…..

Casey

This podcast is all about the diagnostic approach to headaches, the red-flags, but more about the common primary headaches syndromes that we see in office-based GP.

For your reference – go back and check out the PHARM podcast on the severe headache in ED setting – but this one is more about the chronic or recurrent headache which is one of the commonest symptoms we see in practice.

Dr Minh Le Cong in Cairns (@rfdsdoc) and Dr Gerry Considine in the Adelaide hills (S.A) (@ruralflyingdoc ) join me over the ether to discuss all things headache in primary care.

Apologies: the audio background is the result of tropical cyclone Rusty’s shoulder bashing into the window of my office.  But that is life in beautiful Broome during the monsoon!

Enjoy

Here are a few references from the show that we mentioned:

POUNDing criteria: POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling)

Dexamethasone for migraine recurrence: the NNT review of the evidence 

Ondansetron might be bad for migraine.  FDA have issued a warning.  When you read te packet information you see that in the chemotherapy setting the commonest minor side effect of ondansteron is in fact a headache – so maybe this makes it a poor choice for treating a migraine?  I think we need a trial, but for now I am using a dopaminergic agent first line.