OSCE Teaching Session 1

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					 Zubairs slides
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  will be held liable and neither myself, nor Muslim Medics will take
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       human rights and expose yourself to an ASS WHOOPING.
PBL Exam 2008
          Faisal Majid – 5th yr
     Mohammed Jawad – 2nd yr
        Zubair Sarang – 3rd yr
Outline of Exam
 One Hour
 5 out of 8 SAQs
 About 10 mins per answer

 10 sheets of A4
 8-10 learning objectives

During the Christmas holidays you drove some fellow
 students to a concert in Oxford. You had an RTA
 because a car coming in the opposite direction hit the
 front of the car and your car was spun off the road into
 the hedges at the side. Initially you thought everyone
 was unhurt but Karina, who was sitting in the middle
 seat at the back, seemed to have blacked out.

The ambulance came quickly and took you all to the John Radcliffe Hospital.
Karina was rushed into the Resus’ area and it was some hours before you had
news. The Registrar from A and E told you that Karina’s trauma GCS score
had been only 6 on admission and that she had needed resuscitating for
hemorrhagic shock.
Karina’s trauma GCS score had
  been only 6 on admission

+seems to have ‘blacked out’
Glasgow Coma Scale (GCS)
 Eye opening           Motor response            Verbal response

 Spontaneous      4                   Obeys 6            Orientated 5
   To speech      3                Localises 5            Confused 4
    To pain       2              Withdraws 4          Inappropriate 3
     None          1     Abnormal flexion 3       Incomprehensible 2

                         Extensor response 2                  None 1

                                      None 1

  •Patient scores BEST response
  •Good indicator of how ill patient is
Haemorrhagic Shock
 “Acute circulatory failure with inadequate or inappropriately
  disturbed tissue perfusion resulting in generalised cellular
  hypoxia” (K&C)

 Causes:
 Cardiogenic
 Distributive
 MI
 Arrhythmias
 PE
 Tension Pneumothorax
 Tamponade
Hypovolaemic shock
 Exogenous Losses: Haemorrhage/burns
 Endogenous Losses: Sepsis/Anaphylaxis
 Signs:
    Inadequate tissue perfusion
    Cold extremities
    At first BP ok but quickly falls (systolic BP <90mmHg)
    Tachycardia (>100bpm)
    Oliguria (<30ml urine/hr)

 In her case: RTA Impact Trauma Organ/Vascular
  Damage  Internal Bleeding  Hypovolaemic Shock
Grades of hypovolaemic shock
 Grade 1
   15% blood volume (~750 ml)
   Mild resting tachycardia
 Grade 2
   15 - 30% blood volume (750 - 1500 ml)
   Moderate tachycardia, fall in pulse pressure, delayed capillary
    return, RR 20-30
 Grade 3
   30 - 40% blood volume (1500 - 2000 ml)
   Hypotension, tachycardia (>120), low urine output, RR 30-40
 Grade 4
   40-50% blood volume (2000 -2500 ml)
   As above but with profound hypotension
 Oxygenation and ventilation
 Restore cardiac output and BP
 Underlying cause
 Treat any complications
Expansion of circulating volume:
 Whole blood – Haemorrhage: Complications of O neg
 or ANY BIG transfusion include-
   Hypothermia, thrombocytopenia, hypocalcemia,
    depletion of clotting factors

 Colloids- (Dextran, Haemaccel, Gelofusine) increase
 colloid osmotic pressure - better maintanence of
 plasma volume than Crystalloids but no O2

 Crystalloids – eg 5% dextrose or 0.9% saline->>
 interstitial fluid, so need LARGE volumes to restore
 circulating volume and may get pulmonary oedema
 not normally >2litres given
How Much
 In the Field:
    250mls  assess  250mls BUT only if evidence of
     hypovolaemia AND no peripheral pulse

 In Resus:
    2l Crystalloids or 1l Gelatin/Starch

 Want to REVERSE signs of hypovolaemia and urine
  output of at least 1ml/kg/min
To Monitor Response to fluid
   Peripheral oxygen saturations
   Pulse
   Respiratory rate
   Urine output
   Base deficit/lactate (from arterial blood)
   Temperature
   Mental state
   Pulse pressure
   Central venous pressure
   Arterial pressure
She had needed several units of emergency stock blood before she could be
taken to theatre; she was now having an exploratory laparotomy for a suspected
ruptured spleen. You were told to go home and call in the next day. You all
spent the night frantically trying to look up about the operation. The LSS
website links on the Intranet were really helpful for the anatomy and blood
Indications for laparotomy

 Unexplained shock
 Rigid silent abdomen
 Evisceration
 Radiological evidence of intraperitoneal gas
 Radiological evidence of ruptured diaphragm
 Gunshot wounds
 Positive result on diagnostic peritoneal lavage
Over to Mo….
Exploratory Laparotomy
 “You all spent the night frantically trying to look up
  about the operation” – HINT HINT

 Pre-operative e.g. type of anaesthetic, emergency stock
  blood, staff involved
 The procedure itself e.g. incisions, instruments,
  anatomy etc.
 Post-operative e.g. recovery unit, drugs
“But we haven’t started anatomy
of the abdomen yet!”
 That’s no excuse

 You’ve done MCD Immunology – you should know
  about the spleen ANYWAY!!! (Immunology Two, Slides

 Refer to it
What The Don Says..

                      AND Left
What I Say…
 Mesentery – big membrane
 of support for organs, out of
 which ligaments stabilise
   Attaches organs to the body wall
 What’s the blood supply?
 How does the spleen work on an
 immunological level (red pulp, white pulp)?
 Find out.
                               Ribs 11 and 12 not visible here

Abdo + Thorax
 Compact
 Protection
 Ribs 11 and 12 – “floating
 Spleen – 9 till 11

Blood Supply
Blood Supply
 Splenic Artery (one of 3 branches of coeliac trunk, the
  other two being the left gastric and common hepatic)

Describe it’s route:
 Ascending aorta
 Aortic arch
 Descending aorta
 Abdominal aorta – branches into:
 Coeliac trunk – branches into:
 Splenic artery
Ruptured Spleen
   Blood leaks into abdominal cavity (spleen pools blood)
   Medical emergency
   Causes – mainly trauma
   Signs & Symptoms (also, what’s the difference between these two?)
     Pain – abdomen and left shoulder-tip pain (referred pain – expand on
     Hypotension, dizziness, loss of O2
 Treatment – repair, remove, stop bleeding - depends
 Prognosis
NOTE: If spleen is removed, your immune system is slightly buggered
 so you need extra jabs to protect you – which ones?

When you telephoned it was difficult to find out what was happening. The
Receptionist on the ITU ward said something about the ‘code of confidentiality’
& that it was ‘all explained in the patient information leaflet & on the
website’. You recall that the GMC has advice about confidentiality.
‘Code of Confidentiality’ – GMC Advice
 DoH website: 52 pages long – missions to read (but I
  read it)

 Remember those little booklets on your first day...?

 ...get reading!

 Ok I’m not that evil, I’ll summarise what’s relevant to
  this case, but make you sure you know as much as
Confidentiality Stuff: Summary
 Patients have a right to keep their details private
 Doctors need patient consent to disclose info about

Over to Zubair….
   But the girl’s clocked out, so you can’t get consent
   So you don’t disclose anything to avoid getting in trouble
 You can share info within the health team
 See Data Protection Act 1998
 What if this wasn’t a medical emergency???
   Consent needed from next of kin
NOTE: Anonymised info is NOT confidential (fyi)

However, Karina’s parents contacted you to say that she was stable. Her spleen
had been removed, but there was still worry about something called an
‘immediate transfusion reaction’ and ‘DIC’. Her parents asked you if you
could explain to them what either of these complications mean and whether they
can be treated.
Transfusion Reaction
 Immediate
 Complement activation
 Time period…
 Normally would cross match
ABO System
 The antigens of the ABO system are glycoproteins of various types present on the
  surface of red blood cells. People with blood group A have A-antigens, and people
  with blood group B have B-antigens. Unsurprisingly, people with blood group AB
  have both, and people with blood group O have neither.

      Blood                   Antigens        Antibodies present         % of UK
      group                   present              (IgM)*               population
        A                         A                  Anti-B                42%
        B                         B                  Anti-A                 9%
        AB         AB            AB                  None                   3%
        O          OO           None                                       46%
                                                             IgM (e.g. anti-A, anti-
    monocytes express                                      Complement
    tissue factor and                                      Activation via              Haemolysis of
    cytokines + release                                    classical pathway           transfused
    of procoagulant                                        & other                     blood
    material secondary          Shock (fall in             associated
    to haemolysis               BP)                        immune
                                                           Occlusion of
                                                           responses                   Haemoglobinaemia
                                                           renal tubules
                                                                                       (free haemoglobin
                                                                                       proteins present in
                                                                                       blood plasma)
                                Renal                      casts
                                                             Acute Tubular             Haemoglobinuria
                                                             Necrosis                  (haemoglobin in


                                                             ? Lumbar

    Activation of coagulation pathway and platelet aggregation

Widespread intravascular coagulation                       Platelets consumed (thrombocytopenia)

                                                           Fibrin deposited but low
                                                           platelet levels mean no           Bleeding (DIC)
                                                           platelet aggregation on
                                                           fibrin meshwork

You were able to visit Karina a few days later and she was making a wonderful
recovery. She was about to be moved to an ordinary ward but was very tearful.
The young man in ITU next to her had been declared ‘brain stem dead’. She
told you that she watched the doctors do the assessment.
Brain Stem Death + Assessment
What Is It?
 World Medical Association in 1968 as it represented a
  state when:
 “the body as an integrated whole has ceased to

No Consciousness

No central Respiratory Drive
To Diagnose Brain stem death
 Preconditions
    Diagnosis compatible with brain stem death
    Presence of irreversible structural brain damage
    Presence of apnoeic coma

 Exclusions
    Therapeutic drug effects (sedatives, hypnotics, muscle relaxants)
    Hypothermia (Temp >35°C)
    Metabolic abnormalities
    Endocrine abnormalities
    Intoxication

 Bedside Tests
Clinical tests

 Confirmation of absent brain stem reflexes
 Confirmation of persistent apnoea
 Clinical tests should be performed by two experienced
   At least one should be a consultant
   Neither should be part of the transplant team
   Should be performed on two separate occasions
   There is no necessary prescribed time interval between the
   ABC and GCS
Clinical tests for absent brain stem reflexes

 No pupillary response to light
 Absent corneal reflex
 No motor response within cranial nerve
 Absent gag reflex–Move endotracheal tube
 Absent cough reflex- Move tube
 Absent vestibulo-ocular reflex- cold
Cold calorics

 Do not do calorics in an awake patient
 Look in the ears first
 Then get a 50 ml syringe with an 18 gauge angiocath, fill
  it with ice water and squirt the entire syringe into the ear,
  having you or your assistant hold the eyelids open.
  Normal response:
  eyes conjugately deviate towards the cold ear, then snap
  back to midline
  Record any response, either normal, abnormal
  (describe), or absent
  Repeat in the other ear
Test for confirmation of persistent apnoea

 Preoxygenation with 100% oxygen for 10

Over to Mo….
 Allow PaCO2 to rise above 5.0 kPa before test
 Disconnect from ventilator
 Maintain adequate oxygenation during test
 Allow PaCO2 to climb above 6.65 kPa
 Confirm no spontaneous respiration
 Reconnect ventilator

Then they talked about whether there were any contraindications to him being a
suitable organ donor and whether his wishes were known before they asked his
family. Karina asked you to check that doctors have to ask the family about this;
she’d been having bad dreams about it. You remembered reading something in
January about the Prime Minister wanting a debate about presumed consent for
organ removal; it was on the Number 10 website.
Organ Donation + Consent
 “a debate about presumed consent for organ removal; it
 was on the Number 10 website” – HINT HINT


 What’s the big fuss about donation?
What’s a Contraindication?
 Don’t be fooled, it just means “not suitable” for a
  certain type of treatment

 So for organ donation:
    Contraindication: Infectious / malignant disease, organ
        HIV
        Syphilis
        Cancer (not all types, depends on stage eg skin cancer)
        Hep B/C (but still under research)
This debate: Opt-out scheme
 Currently “opt-in”, wanting to be changed to “opt-out”
 Current shortage of donors
 Aim: Take organs without “explicit consent”
 Basically, consent for donation will be presumed
 unless you:
   Opt out of the National Register
   Have family members that object
 Gimme the pros and cons; stay updated with the news
Consent: In General
   Patient must be capable of giving consent
   Must be sufficiently informed
   Different forms of consent eg implied, explicit etc
   Consent must be given voluntarily
   Incompetent – Dr’s call
   Refusal? Advanced directive, courts, etc
   Emergencies
   Organ Donation

 I hate ethics
Organ Donation: Human Tissue
Act 1961
 The Act states that if a person has expressed a wish in writing, or orally in the
   presence of two or more witnesses during his or her last illness, that their body or
   any specified part may be used after death for therapeutic purposes or for medical
   education or research, the person lawfully in possession of their body may, unless
   there is reason to believe the request was subsequently withdrawn, authorise
   removal from the body of any part in accordance with the request.

 If there is no evidence of such a wish the person lawfully in possession of the body
   may still authorise the removal of any part from the body provided that, after
   making reasonable enquiries, there is no reason to believe that the deceased had
   expressed an objection or that the surviving spouse or any surviving relative objects.

 Link to this case:
     The dude has died
          He’s died in a way which makes him suitable for organ donation (eg cerebral haemorrhage, RTAs)
          He probably isn’t a registered donor
          So ask his family he would have objected
          Then ask his family if they themselves object
          If not, whip out his insides!
The Human Organ Transplants Act
 Commercial dealings in human organs for transplant illegal

 Illegal to advertise the buying or selling of organs or to withhold
  information required by law about transplant operations

 Illegal to transplant an organ removed from a living person
  unless the donor and recipient were genetically related
You and your other friends were anxious for Karina and how she would cope
with all that had been happening to her. She was able to come home to her
parents by early February and planned to return to Imperial in the summer. You
wonder what signs you will need to watch for to make sure that she is not
getting depressed and, if she is, which health professionals she should
contact and what they would do to help her. You realize that you need to find
some reliable UK sources of information and be able to tell her why they are
worth using as a patient.

 Every year 20% population experiences Clinical
   Low Mood
   Sleep disturbance
   Change of appetite
   Hopelessness
   Pessimism
   Suicidal Thoughts
Major Depression

 Anhedonia – Loss of interest or pleasure. PLUS >3 of
 the following for >2 weeks
   Reduced Appetite and wt loss
   Early Waking – diurnal mood variation
   Psychomotor Retardation
   Reduced Sexual Drive
   Poor Concentration
   Feeling of worthlessness, guilt
   Recurrent thoughts of Death, Suicide +/- attempts
High risk groups
   History of depression
   Family history of depression
   Multiple physical illnesses
   Neurological conditions
   Chronic pain
   Another psychiatric diagnosis
   Traumatic childhood experiences
   Recent adverse life events
   Recent childbirth
   Frequent users of health services
 Will normally need to have at least 3 symptoms for at
  least two weeks
 Some Possible Screening Questions:

 (1) During the past month, have you often been
  bothered by feeling down, depressed, or hopeless?
 (2) During the past month have you often been
  bothered by little interest or pleasure in doing things?
 (3) Do you want help with these problems?
Help & Support
 GP lead care Diagnosis and RA
 Biopsychosocial approach
 If Mild:
    Watch and Wait – 2/52, Support,
 If biological/moderate/severe –
   SSRI/TCA/MAOI for 4-6 weeks and then 6
 Psychological
    CBT- Identify distorted or illogical thoughts-
     and replace
 Always start with Royal College Guidelines:
 Always start with NHS:
   And then Patient UK:
   NIMH:
   EQUIP: Has many good links
  Thank You
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