Wear Sunscreen: Tips for New Doctors

It's that time of year again; the medical new year where 5 years of medical school comes to fruition and students become F1 doctors.  I've thought back to my time as an F1 and here's 50 tips.  If you don't get the Sunscreen reference then I'm officially old...

  1. Medicine is a noble art dating back throughout humanity.  We will outlive any government or Health Secretary.  I've never not experienced anything other than respect from lay people when I've told them I'm a doctor.  We get cynical in our bubble but what we do is amazing.  Don't forget that.
  2. Make your intentions noble.
  3. Chocolate will always go down well with your new colleagues.  Tea and coffee or at least the offer of them will go down well with your patients and relatives.  
  4. Chest pain always needs an ECG.  Regardless of description.
  5. Abdominal pain and trauma rarely present in a straightforward way in the elderly.  Have a low threshold to CT scan and always discuss with a senior.
  6. Beware posterior STEMIs.  If you see regional ST depression look for ST elevation in other leads.  Make sure you check if any LBBB is old or new.
  7. Know your trust's PCI, Stroke and Upper GI Bleeding protocols early.  Don't wait until it's 0300 and you're with a poorly patient to find out.
  8. Back pain + Collapse = AAA until proven otherwise.  
  9. 'Nurse' is not a first name.  Learn the names of your colleagues.
  10. All women are pregnant until you prove otherwise. 
  11. Don't forget the aorta.
  12. If you think it's a PE it probably is.
  13. 'Senior Review' is not a plan.
  14. 'C?C' is not a diagnosis.
  15. 'Acopia' does not exist.
  16. It's never alcohol until you rule out everything else.  If it is alcohol consider Chlordiazepoxide and Pabrinex.  
  17. Gastritis is not an F1 diagnosis to make.  I'd argue it's not an Emergency Department diagnosis to make.  Rule out more serious causes first.
  18. Know the head injury guidelines.
  19. You can't always cure but you can always be nice.
  20. Be judicious with requesting D Dimers.
  21. Analgese often and early.  Document it.  If your patient declines then document that too.
  22. Always listen to your gut - whether it's telling you your patient is ill or that you're hungry.
  23. Your nursing colleagues won't kiss you backside but will certainly save it.  Be kind to them. 
  24. Monitor your urine output and urine colour and hydrate accordingly.
  25. Don't just write ''ECG nil acute'' in the notes.  Write your findings even if it's just ''Normal Sinus Rhythm.''  Your colleagues later on will thank you.
  26. Remember to prescribe time critical medications - Anti-Epileptics, Anti-Parkinsons, Antibiotics and Insulin.
  27. Respiratory rate is often the first observation to go off.
  28. Remember mean arterial pressure.  Your patients brain (GCS) and kidneys (U&E/Urine output) need monitoring.
  29. Remember that amazing 360 degree human being you were on your application to medical school?  Who sang, played instruments, played sports, danced, had dreams and passions?  Don't forget that person.  Use your free time.
  30. Take annual leave. Travel.
  31. Not every patient is nice but they still deserve your best.
  32. Mental health and serious organic disease are not mutually exclusive.  Don't be biased.
  33. Don't say 'unresponsive'.  Use GCS.
  34. Migraine and epilepsy don't start in later life.  Rule out sinister causes first for new headaches and seizures in the elderly.  
  35. Don't wear suede to work.  
  36. How to SBAR: 1). Say who you are and where you are calling from. 2). Say the reason you are calling. 3). Then start your SBAR.
  37. Don't judge others with different values that you judge yourself with.  
  38. See the bigger picture.  This is one of my favourite pictures taken from the edge of our solar system showing Earth.  It reminds me to see the bigger picture, a very valuable lesson when there is a 10 hour bed wait or a 5 hour wait to be seen in the department.  Always see the bigger picture.  Remember the 18 year old you who was so excited to get into medical school.  

39. It's not OK to not be OK.  Talk to someone.                                                                                                   40. There is nothing more contagious in healthcare than emotions.  Smile.  Be positive and it will spread.  41. Doctors consistently are amongst the most respected professions.  Never abuse that trust.                    42. Remember #HelloMyNameIs.                                                                                                                          43. Always get your sleep.                                                                                                                                      44. Coffee is your friend.                                                                                                                                       45. You should always get more out of alcohol then it gets out of you.  If that changes get help.                  46. Pain and Urinary retention are two important causes of agitation.                                                              

47.  Be careful what you post on social media.                                                                                                                 

48. Not matter how hard breaking news is for you it is worse for the patient/family receiving it.                                                                                                                     

49. Chew your food.  Especially watermelon - trust me on this.                                                                          

50. Wear sunscreen.

THIS IS THE ORIGINAL MUSIC VIDEO Great Music video from the nineties ! The lyrics are taken from a famous essay - written in 1997 by Mary Schmich, a columnist with the Chicago Tribune - which gives some amazing advice for life, thoroughly recommend everyone to watch this ! enjoy !

How I Learned to Stop Worrying and Love the ECG

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ECGs are an essential part of Medicine and unavoidable as a student and junior doctor.  I remember being bleeped as an F2 on call by an Orthopaedic surgeon to read the ECG of one of his patients as he had forgotten...ECGs are definitely a case of improving confidence and knowledge through repeated practice and exposure.

Once again I cannot recommend Life in the Fast Lane enough for incredible resources when it comes to ECG.

Here is our video on how to take an ECG:

In the latest Take Aurally podcast I discuss an approach to ECG interpretation and in this blog I've enlisted the help of Albert Einstein to help me through.  You can find the tool for making this meme here.

Remember, it doesn't matter how the patient describes their chest pain as an ''ache'', ''twinge'', 'indigestion''...whatever chest pain is chest pain and needs an ECG.   

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This step is vital, is the ECG in your hands from the right patient, right day and time?  Also, get an idea about the presentation behind the ECG, do they have pain, shortness of breath, collapse or palpitations?

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Only in certain BBC television dramas (cough, Casualty, cough) does a flat line on an ECG mean death.  In real life it means that the ECG lead in question is not connected properly and needs reattaching.  Make sure you can see electrical activity in all 12 leads.  

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Most ECGs will tell you this anyway but it is important to be able to work this out for yourself.  In a regular rhythm (equal distance between all R waves) you can count the number of large squares between each R wave and divide 300 by this number.  Alternatively you can count the number of beats on the rhythm strip and times this by 6.  

There's about 3.5 big squares between each R wave here.  Using 300/3.5 gives a heart rate of 86.

Alternatively, there are 15 beats on the rhythm strip,  15 x 6 = 90.

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This is all about looking at the R-R distance for successive beats.  This can be marked on a separate piece of paper and moved along to confirm.

If the rhythm is irregular you can then also see if it's regularly irregular or irregularly irregular 

By looking at successive R-R distances we can see that this ECG shows a regular rhythm.

The QRS complex should be 3 small squares wide.  This is important for two reasons.  In tachycardia the duration of QRS points to the diagnosis and management as shown in the Resus Council flowchart below.  In normal rates it also points to a bundle branch block.

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Taken from Resus Council UK

My method for working out LBBB or RBBB...without a William or Marrow in sight

P waves indicate sinus rhythm.  PR interval should be 3-5 small squares.  

First degree heart block: PR interval is prolonged and remains the same (occurs between SA and AV node)

Second degree heart block: Mobitz 1 - the PR interval gets longer and longer until there is a dropped QRS and the cycle starts again.  (Occurs in the AV node) Mobtiz 2 - the PR interval is long, stays the same length but there is a dropped QRS in a ratio: 3-1, 4-1 etc (occurs after AV node in bundle of His/Purkinje fibres)

Third (complete) heart block: No relationship between P waves and QRS (occurs anywhere from AV node down)

PR interval could also be shortened as seen in WPW.

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Axis is all about the general spread of electrical activity across the heart.  

Here I look at leads I and II.  Usually the R waves should both be positive as here:

In left axis deviation the R wave in II is now negative so they pointing away from each other or 'leaving'.

Leaving = Left Axis Deviation

This is a sign of ischaemia 

Here the R wave is I is negative so they reaching for each other.

Reaching = Right axis deviation

RAD is a sign of RVH

This is important to notice ST elevation - STEMI (2mm or more in 2 or more chest leads or 1mm or more in 2 or more limb leads) or ST depression or T wave inversion - can be seen in NSTEMI

Be wary if you see regional ST depression - this could be reciprocal depression so make sure you look for ST elevation in other leads

Remember to look at the J point - the point where the S wave joins the ST segment - this can be raised in young, thin patients giving the appearance of ST elevation.  This is caused benign early repolarisation or 'high take off'

T waves can also point to other conditions - the tall T waves in hyperkalaemia; biphasic T waves in hypokalaemia or ischaemia; or flattened in ischaemia or electrolyte imbalance.

U waves, small deflections after the T wave can be seen in a number of conditions; hypokalaemia, hypothermia or antiarrhythmic therapy like digoxin

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My colleague James Pratt has made an excellent e-Learning package on ECG interpretation which can be found here

Geeky Medics have a great page on ECG interpretation here

ECGs courtesy of the amazing Life in the Fast Lane

You can hear our ECG Interpretation podcast here:

UMEC, I MEC, We MEC

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It was an honour to be asked to present at the 4th annual Undergraduate Medical Education Conference (UMEC) at the University of Nottingham on 7th July.  It's a great opportunity to see the great work being done to improve the teaching of our students.  

I think we were all impressed by the work of WAMS (Widening Access to Medical School) a programme run by medical students in association with work by the university to widen access to students who might otherwise not go to medical school.  I was very lucky with the support from home I received; many are not so lucky. 

                                              The DREEAM team out in force for UMEC 2017.

It was great to hear from my fellow podcaster Charley Peal on her work 'Nifty Fifty' giving clinical students a booklet of 50 challenges such as escorting a patient to X-ray to help them orientate and stay on the ward.  Or as she and her fellow medical fellow Becca Noble put it ''avoid being a trip hazard''.  Not saying I actually caused people to trip up when I was a medical student but I certainly had some near misses.

There was a good discussion about the difficulties of sharing educational resources.  This is why I support FOAMed despite its detractors.  No paywall; no firewall.  The challenge is quality control of course but I've often thought that there's great work going on that just isn't celebrated enough.  I've regularly been in conferences and felt it just seems like some institutions are better than others at getting their message out there.  There must be reasons at the individual level to explain this but it must also be due to leadership and the culture of an institution.  

We also discussed the conundrum at the heart of medical education I feel.  Our students want to pass exams.  We want them to be safe doctors.  It's sad but understandable when in the past I've had to cancel sessions because they're near exams and whilst they'd help the students as doctors I know engagement would be poor if I put it on.  

My DREEAM colleague Matt Govan kindly filmed me.  It's actually hard to boil a subject down into 7 minutes and it took a lot of practice.  Looking at it I hope it shows a progression with using the P3 approach to presentation.  The last time I presented I was told I dance about a bit so here I'm routed to the spot by 'anchoring' against the podium.    

In my last blog at Das SMACC I mentioned how SMACC has helped change the approach to conferences at this philosophy was evident at UMEC; short presentations, workshops dotted amongst the schedule with social media being used throughout.  As someone who attends a lot of conferences it's a great development and one to be continued.  Thanks to everyone at the UMEC organising committee.  

Das SMACC Day Three

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And so Das SMACC ist fertig and I am sat in my office in Nottingham reflecting on an amazing three days.  Thank you to all who made Das SMACC happen and thank you to my colleagues for accompanying me on the ride, tolerating me and allowing me to convert their voices into MP3 format.

So, Day Three.  It's fair to say that I was not in the best of humours at the beginning of the day which may have had something to do with the Das SMACC party the night before.  Maybe.  

LIGHTING THE FLAME: CRITICAL CARE EDUCATION
Chair: Simon Carley
Panel: Jenny Rudolph, Walter Eppich, Chris Nickson, Victoria Brazil, Sandra Viggers, Daniel Cabrera

The morning however was worth the trek in.  An inspiration panel of educationalists (new word for me) on the future of education in Critical Care. There is a Storify thread which you can follow here as otherwise my succinct points below won't do it justice.

  • How do we train doctors now to deal with the future? - train the basics well and use these as the building blocks for the future, teach empathy and compassion as these will still be needed as automation increases
  • Interprofessional education should be the norm and used throughout medical school, teach the fundamentals (anatomy, pathology) together and then subspecialise later - I completely agree with this and think this should be the way all universities function, if I come to power...
  • We don't actually teach how to be a doctor at medical school, we teach students how to be a resident (F1) which is where they learn to be a doctor - Amen Walter!
  • Don't focus on learning from simulation, rather simulate to learn from work
  • The future will not be simulation centres but rather each hospital having a fluid, focused simulation team who will able to provide expertise to all departments within the hospital, we can't assume anyone can facilitate simulation, treat it as a skill like ECMO or REBOA
  • Look at your coaching conversations, tailor your approach, ask your students what they would like you to look out for at the beginning of the session - YES! Definitely going for this approach in the future, I regularly find it hard to discuss everything in a debrief
  • Always talk after simulation, whether good or bad or indifferent
  • Also a big discussion on the best time to give feedback and Work Based Assessments - a recurring problem I have!  
  • We don't train people to give or receive feedback - another recurring problem

How to Fail - Kevin Fong

Another new man crush!  Anaesthetist/Astronaut Kevin spoke about failure.  The old saying is true; it's not an option.  Failure will always happen.  We have to adapt to accept this and approach our safety mechanisms and responses to failure appropriately.  Hypercompetence is a myth.  Hubris is wrong.  We have to have 'graceful failure' otherwise human factors fails and we will let out patient down.  I also liked his point that maybe the only reason medical science began to see the heart as a pump was because mechanics had invented a pump and we had a frame of reference.  Makes me wonder what fundamental point we're currently missing because we don't have that frame today.  

Helping Without Harming - Jenny Rudolph

An inventive and entertaining talk.  Rather than being annoyed at someone and thinking WTF think another WTF (What's Their Frame?)  The hashtag #WTF2WTF is alive and kicking on Twitter and it will be interesting to see how this goes.  More about fundamental-attribution bias.  Thought provoking, something I will try.


The Global Refugee Crisis: Why it’s Critical that we Care - Vera Sistenich

The only talk to get a standing ovation.  I can't do it justice, watch it at the SMACC website.  The more people who watch the better.

How to Fail… Part Two - Martin Bromiley

We all know his late wife's story.  How he does it I don't know but another great talk.  A man with much to be angry about who actually chose to understand and help.  His thoughts were inspiring on human factors:

  • "I would't do what they did" - not helpful, next time you catch yourself thinking that think instead "Why did it make sense at the time?" 
  • Confident humility - no one is too senior to seek feedback
  • Look at our systems in place, do they make it hard to be right and easy to be wrong?

This isn't a cop out but I genuinely couldn't do the last session featuring Martin Bromiley and James Piercy justice so please check it out on the Das SMACC site.  Amazing human beings and it was a privilege to hear them.  I hope I don't have to go through what they did but I hope I could always be as kind.  

So that was Das SMACC.  Personally I love FOAMed and it was great to be with like minded people in an amazing city.  Berlin is an amazing mixture of beauty and horror and needs to be seen.  What about SMACC?  It is a bit cultish if I'm honest.  I can see the point of some of its detractors pointing out the swearing, the hashtags, how something is either great or sh*t.  And it has made 'celebrities' of medics - yes I know the irony as someone who blogs and records his voice in his spare time - which is something that may create challenges in the future.  But I loved it.  SMACC has challenged the old school.  Conferences where someone stands at the front and talks with no engagement are thankfully dying out.  It's been great to see the smart conferences adapt with workshops, social media and an open minded approach.  'Punk movements' like SMACC are the vehicle of such changes.  I hope I will always be so open minded. The focus on the next generation and innovation was a pleasure to see as well.  Danke Berlin.  Danke Das SMACC.

 - Jamie 

  

Das SMACC Day One

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Just a few initial thoughts whilst the first day of Das SMACC is still free in my head!

Pre-Hospital Medicine: The Future is Now: Brian Burns

Trauma is a silent killer with 14,000 killed every day or 5 million a year.  As a proud geek I fully approved of the demonstration of technology as a 'meerkat system' to predict severity, POCUS and point of care TEG with drones providing tailored blood products to the scene. Early day yes. Orwellian possibly. Exciting definitely. 

Jonathan's Story: Jessica Mason
 

I'm always looking for new ways of teaching and found the approach by Jess Mason of using a patient story inspiring. She said "remember the story, remember the medicine" as she used the story of a patient of hers with sickle cell anaemia to make an important point: it is a terminal disease and should be treated as such; be kind with analgesia - opioids are the best. 

Voices in my Head: Sarah Gray

Do you talk to yourself in the same way you would talk to a patient? Sarah talked about self compassion, an area of interest for me as my masters dissertation looks as mental health and resilience. This may be the subject of a future blog as she recommended the site selfcompassion.org as a window into our emotional health. Asked the audience to put their hand in the air and then lower it down if we knew someone who had died of suicide, suffered depression or self-harm. One hand out of 2500 was left in the air at the end... Don't burn out!


“Everything” at the End of Life: Alex Psirades

It's a fact that all medical students are trained in CPR but not in how to discuss DNAR. There were powerful reminders that as healthcare workers we all share the same ultimate fate of our patients: our mortality. Even with improvements in medicine the mortality rate in the 21st century remains the same as the 17th. Alex mentioned optimism bias and how as clinicians prognostication of terminally ill patients actually worsens as we know them more as people.  He highlighted the HHHHHMM scale used in veterinary medicine which I think actually has some transferability to human patients. 

The Problem with Physiology: Rinaldo Bellomo

"Today's medicine is tomorrow's derision" Rinaldo highlighted the problems of physiology with example discredited practices such as Early Goal Directed Therapy, replacing albumin, replacing Protein C or prophylactic craniotomy. More biases here - attribution bias & immediacy bias. That fluid bolus you gave to correct your patient's BP? In 20 minutes it will be back to baseline. Mad Physiology leads to Mad Medicine. 

Four Tragic Dog Deaths: Lessons in Program Design and Development: Resa Lewiss

A good look at programme design with the four pillars I recognised from DREEAM: Clinical Excellence, Education, Research and Administration.  Resa used the deaths of four of her childhood dogs as examples of how a project may die: Cancer - a slow, insidious killer such as a cultural or personnel issue, Homicide - someone outside comes along and pulls the plug, Suicide - something you do kills your project and Old Age - your project fails to adapt and grows old and gets passed by. Powerful and like all good presentations memorable. 


Endocarditis will also f&*k you up: David Carr


Endocarditis. There is a 1% risk per year of endocarditis for patients with valve replacement. The risk is 1-2% in intravenous drug users. There thrombotic non-bacterial endocarditis: marantic endocarditis seen in malignancy and anti-phospholipid syndrome related endocarditis seen in lupus. 95% will have fever. 90% will have a murmur. To think of it as 'fever plus one'. Fever plus stroke in the young - usually MCA infarct - should make us think endocarditis. Fever plus back pain (osteomyelitis suggest haematalogical spread of the organisms which can also cause endocarditis). Fever plus heart failure (especially if there is no history of CCF - 'virgin' heart failure. Failure plus arrhythmia. (First degree heart block may be boring but suggests pervalvular abscess). Only 5% will have peripheral stigmata such as Janeway lesions or Osler's nodes - I'm going to have to change my teaching. Far more important is to look in their mouth, dental work in the preceding fortnight is suggestive and easier to identify than Roth's spots.

Plenty to discuss in the future.  For now I hope you enjoy reading.  Off to upload the podcast!

 - Jamie