Uncertainties…By José Ramón Garmendia

I usually say in my clinical practice that "It´s better a bad certainty that the best of the uncertainties...", mainly by the anxiety and uneasiness that doubt, indecision and dilema create. Our own uncertainty.

When a patient comes into any consultation, the physician doubts. Doubts about the expectations of the patient, the requests, the clinical diagnosis. Doubts about if test should be performanced and what are the most appropriate; doubts about the treatment to choose; doubts about the response to treatment in each patient...doubts, doubts, doubts.



In a society in which the exposure of our reality, the demand for answers and immediacy is forced, doctors must think about actions to propose to our patients. Society demands information (sometimes so voracious and ephemeral), action (not always proportionate or coherent) and reaction (serene attitudes or peacekeeping surprise us). And both patients and health care providers have to think about if carrying out tests provides or not really something positive about health. It is not always true.

A medicine based on the indiscriminate application of diagnostic tests, far from favouring a right or proper diagnosis, can confuse us, as well as generate logical anxiety about the unknown or uncertain of the requested test result. I think that a simple question put on the table by the health care professional would bring an extra dose of light on this uncertainty: what does this or that test give to the knowledge of our State of health and subsequent decision making? And it is not clear that diagnostic testing has "value-added" inherently in each of them. From various discussion forums, it puts into question an interventionist, aggressive and sometimes even iatrogenic medicine. We need to do test, but only missing that, those that are really necessary.T

he consultation should be an environment for sharing knowledge and concerns in both directions. The patient is more interested in recovering the health or deal with the fear of the disease. And the doctor is the main defender of this path.

Professionals and actors (patients) must be able to share the uncertainty of the diagnostic process and the decision on the tests or guidelines to follow. The doctor, from the light that gives knowledgement and the study of disease processes. The patient, from the joint responsibility in the decision, supported by a simple, accurate, adequate and easily understandable information.

Our duty as professionals is to be updated on the issues that we have to deal with. And the duty of the patients is to require professionals that they do so.

None are essential, but the effort to reduce the clinical variability depending on who we meet, should be an non-waivable objective.

The implementation of these attitudes will facilitate recoverying and extoling the human condition shared by professional and patients, above application of technology, which is necessary but by no means sufficient.

"Smile me, touch me, love me... because I have to put my health in your hands".
 
José Ramón Garmendia
Family doctor, currently in the Admission and Clinical documentation  Service of the Complejo Asistencial Universitario de Palencia

Dr Fiona McKinnon: On the Path to GP Obstetrics

Bits & Bumps

On this episode of the podcast we are joined by Dr Fiona McKinnon, a soon-to-be-fully-fledged GP obstetrician from Ipswich in Queensland.

We chat about:

  • The process for training in GP obstetrics through the DRANZCOG (basic and advanced)
  • Tips and tricks on getting through the program
  • Gaining confidence after qualification
  • The highs and lows of the job and why we do it!

Resources:

About diploma and womens health certificate training through the RANZCOG

Rural Health West GP obstetrics mentoring program

Also, be aware there is Commonwealth funding available to support GPs to undertake DRANZCOG advanced training via the GP Procedural Training Support Program

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PALS: Hard, Fast and Emotionally Charged

PALS: hard, fast and emotionally charged.

And made even more difficult by shifting algorithms. They change with each successive generation of ILCOR. This scratchy looking video is from 2008. Great CRM on show – but how does current practice differ?

Bonus points if you picked up on the slow compressions and low energy (in more ways than one – hey those guys barely broke sweat).

But are you completely up to speed? Do the quiz to find out: it’s based on the 2016 ANZCOR Guidelines. There’s a good discussion of their scientific basis in COSTR 2015. And for a primer, here’s the ARC Flowchart.

PALS Flowchart

 

1. At which age does PALS stop and ALS start?

Click here to reveal the answer

  • Arbitrarily, 9.
  • The European Resuscitation Council places the boundary at the onset of puberty.
  • The ERC rationale (fairly obviously) is that adolescents have more similar anatomy and physiology to adults.
  • It probably doesn’t matter if you are a year or two out on either side: just don’t do PALS on a pub-going teenager, or ALS on a Octonaut fan.
Octonauts: Best PALS

Octonauts: Best PALS

 

2. Should your priorities run ABC? Or CAB?

Click here to reveal the answer

  • ABC.
  • The majority of paediatric arrests are respiratory, so it makes sense to get to A and B first.
  • There are a couple of small studies of compression-only CPR in kids: each showed a worse outcome. So don’t forget to breathe.

3. How much energy for the first shock – in Joules/kg?

Click here to reveal the answer

  • 4 J/kg.
  • Back in the dark ages (pre-ILCOR 2010) it was 2J/kg followed by 2J/kg and 4J/kg for second and third shocks. This strategy had something to do with transthoracic impedance affecting older monophonic defibrillators. But they went out with the ark.
Back To Mono: Hasn't yet caught on in the world of defibrillators

Back To Mono: Retro chic hasn’t caught on in the world of defibrillators

 

  • There isn’t any real evidence for the benefit of 4J/kg over 2J/kg and some resuscitation councils elsewhere in the world continue to advocate the lower energy.
  • However it is probably unnecessarily complicated to have more than one value so the Aussies have decided to stick with 4J/kg for every shock. More power to them.

4. Should you ever use stacked shocks?

Click here to reveal the answer

  • Probably not.
  • As above, the habit dates back to monophasic defibrillators when a sequence of shocks was thought to be more effective than single shocks.
  • Any marginal benefit is probably outweighed by the effects of prolonged breaks in CPR. These cause worsening hypoxia and acidosis, both cardiac and cerebral.
  • The only occasion when you have time to give stacked shocks is when the arrest is witnessed AND monitored with immediate access to a defib. Heart and brain should be sufficiently well oxygenated to allow 3 stacked shocks.
  • Otherwise, one shock each round only and minimise the breaks in CPR for defib and pulse checks or focused echo. With practice, you should be able to get gaps down to 4 (four) seconds.

5. How many percent of paediatric arrests have a shockable rhythm?

Click here to reveal the answer

  • 10-15%
  • In adults, the figures range widely in different studies, from about 15-35%.

6. How would you gauge a child’s weight for calculation of drug dosage?

Click here to reveal the answer

  • On the basis of an ideal weight, judged by his height.
  • If you have one, use a Broselow tape.

  • If you don’t have a Broselow tape, use the following formula for kids below 9 years: weight (kg) = 2x(age+4).
  • Most resus drugs like adrenaline and bicarb are distributed in lean mass. So calculating their doses on the basis of actual body weight may cause overdosage in overweight and obese children.

7. What is the best method of airway management during CPR:

  • Bag valve mask (BVM)
  • LMA
  • ETT.

Click here to reveal the answer

  • The method that works most quickly, reliably and effectively.
  • Intubating a sick child is a very stressful business for anyone. Doing it during CPR is a high-wire act, and likely foolish unless you are an ETT acrobat. Not one of those? Then read on.
  • LMAs have not been formally evaluated in paeds resus but they are easy to insert and afford a better degree of airway protection than BVM. They are sized according to weight as follows:
    • size 1 < 5kg
    • size 1.5 5-10 kg
    • size 2 10-20 kg
    • size 2.5 20-30 kg.
  • However BVM remains ILCOR’s recommendation of choice. In out of hospital paed arrests, BVM is at least equivalent to ETT, or better, in terms of outcome.

8. Can you use an adult AED (Automatic External Defibrillator) on a child?

Click here to reveal the answer

  • Yes.
  • If you have nothing else, you can use adult pads too. Even on an infant. Just put them A-P.
  • If the AED comes with paediatric pads, these will attenuate the energy by about 50-70J.
Paeds Pads for PALS

Paeds Pads for PALS

 

  • If you have a manual defibrillator, use paeds pads if you have them. NB these ones don’t attenuate the shock and will deliver what you dial up. Which will be what is written on the Broselow tape, or 4 J/kg.

9. Should you ever use bicarb?

Click here to reveal the answer

  • Never say never.
  • But probably not just for respiratory or lactic acidosis caused by preceding respiratory failure or downtime: go for good quality CPR.
  • Bicarb shifts the O2 dissociation curve to the left making it harder for red cells to deliver O2 to the tissues.
  • The CO2 that is released causes hypercapnaemia: CO2 then diffuses into cells and worsens intracellular acidosis.
  • Exceptions are hyperkalaemia e.g. in renal failure, and TCA overdose.

10. What are the common causes of paediatric arrest?

Click here to reveal the answer

  • Mercifully, it isn’t that common.
  • 90% of cases are due to hypoxia, secondary to respiratory failure. The majority are infants, and of these the majority are male.
  • Rarer causes include SIDS, submersion and drowning, trauma and sepsis.
  • Consider cardiac causes in children with known congenital heart disease, and older children like Ella.
Learn Your PALS, and Don't Give Up

Learn Your PALS, and Don’t Give Up

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VA AM Report: “Needle in a Haystack”

Title courtesy of Goop. Awesome case presented by the inimitable Michelle Matzko, with a case of legit spinal GOUT. Crazy.

Back pain in the clinic

https://remote.ucsf.edu/afp/2012/0215/,DanaInfo=www.aafp.org+p343.html

Big picture on back pain in the clinic plus some pearls: Acute low back pain is one of the most common reasons people seek medical care in the US, cough being the most common.

Table 2.

Red Flags for Serious Etiologies of Acute Low Back Pain (technically age>50 is one as well though very sensitive)

Possible etiology History findings Physical examination findings

Cancer

Strong: Cancer metastatic to bone Intermediate: Unexplained weight loss

Weak: Vertebral tenderness, limited spine range of motion

Weak: Cancer, pain increased or unrelieved by rest

Cauda equina syndrome

Strong: Bladder or bowel incontinence, urinary retention, progressive motor or sensory loss

Strong: Major motor weakness or sensory deficit, loss of anal sphincter tone, saddle anesthesia

Weak: Limited spine range of motion

Fracture

Strong: Significant trauma related to age*

Weak: Vertebral tenderness, limited spine range of motion

Intermediate: Prolonged use of steroids

Weak: Age older than 70 years, history of osteoporosis

Infection

Strong: Severe pain and lumbar spine surgery within the past year

Strong: Fever, urinary tract infection, wound in spine region

Intermediate: Intravenous drug use, immunosuppression, severe pain and distant lumbar spine surgery

Weak: Vertebral tenderness, limited spine range of motion

Weak: Pain increased or unrelieved by rest


note: Presence of one or two weak or intermediate red flags may warrant observation because few patients will be significantly harmed if diagnosis of a serious cause is delayed for four to six weeks. Presence of any strong red flag warrants more urgent workup and probable referral to a spine subspecialist.

*—Fall from a height or motor vehicle crash in a young patient, minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis.

Information from references 5, 6, and 8.

We all know the red flags, but what do you do if there are no red flags? Most back pain will resolve within six weeks with conservative management like activity modification (NOT BED REST), NSAIDS and Tylenol. For pain that has not resolved it is then reasonable to prescribe formal physical therapy, and again most back pain will resolve over the next 6-12 weeks.

Exam maneuvers: With an anterior disc herniation extension theoretically relieves the pressure on the disk and improves pain, whereas extension in any lumbar stenosis worsens compression of the nerve roots and thus symptoms. Bharat pointed out the “shopping cart sign” with lumbar stenosis, that slight forward flexion relieves the pain of lumbar stenosis as one would while pushing your shopping cart.

Spinal Gout: LT has seen three cases so you know, super common disease. It’s actually interesting, among pts w/ tophaceous gout and persistent symptoms/pain, one study found radiographic evidence of spinal gout to be 35%, though few of those patients actually had back pain. It can mimic metastatic disease or infection/epidural abscess, definitive diagnosis can often only be obtained through examination of surgical specimens and/or IR guided aspirate of the fluid around the spinal cord which will show no organisms and may contain crystals. Attached here is a case report goop co-authored in JHM about a similar case. jhm-2013-a-multifaceted-case


Filed under: Morning Report