SIMA-PROSPECT Oct2009

I ssue #3
O ctober 2009
www.studentima.co.uk
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www.studentima.co.uk
I ssue #3 • O c t 2009
CONTENTS
From the President...
It is hard to believe that just over a year ago, SIMA: Prospect was little more than a
farfetched idea that could have gone so terribly wrong. Thankfully, a year has passed
and we are putting out this, the third edition of our publication.
Editorial
United we Stand, Divided we Fall
The essence of SIMA: Prospect can be seen on the front cover of every edition
- progress through opportunity. I am a firm believer that it is not what you have that
is important, but what you do with it. Prospect was launched in the hope that it would
highlight some of the opportunities to be taken advantage of that will allow us
to continue to progress.
The Case
We wanted to provide you with a platform, and you have grabbed it with both hands.
In making your voices heard, you have honoured the Iraqi spirit that remains as far
reaching as it has always been.
Through this publication and all of its other endeavours, SIMA continues to
demonstrate the importance of the Iraqi cause. A cause, that extends far beyond race
or religion; that stands for truth, and looks to its tainted past to prepare for the hopeful future. It is fitting that a group of allied healthcare professionals took it upon
themselves to wave the banner of hope for the future, to encourage giving, and to use
the power of the written word to forge new opportunities that shape progress.
And so, as I hand over the reigns of the Student Iraqi Medical Association, I offer my
thanks for your support and kindness in helping this society grow. I have no doubt
that the new committee will do a fantastic job in taking SIMA in its new direction, and
I hope that you continue to read Prospect, and continue to offer your kind support to
the team in the hope that we can all be the change that we hope for.
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Features
Pre-Hospital Care
Accident & Emergency
The Pharmacological Management of the TBI patient
Food for Thought...
TBI in the Dentist’s chair
The Beginning of the End
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21
24
Iraq Relief Essay Competition
Sami the Methanol Guy
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Workshop: Online Resources
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-Yasmin Al-Asady
[email protected]
Editorial Team
Yasmin Al-Asady
•
Faezeh Godazgar
•
Maram Habib
• [email protected] •
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The Case
Editorial
United we Stand,
Divided we Fall
Hello, ambulance service...
by
Yasmin Al-Asady
The hospital environment is a very
strange place; a frenzy of activity that often
leaves you yearning for a solitary moment
of quiet, mirrored by the times of quiet
sadness that lead you in search of the
distracting hurry.
At some point in your career as a hospital
doctor you will have been called upon at every
hour of every day. You will have seen the
changing face of the hospital in all its glory.
By day you may be immersed in the
seemingly never ending flurry of patients and
their problems. By night you find yourself
fighting tiredness as you wait to rectify
whatever may go wrong.
In the summer months you swelter in the
sticky heat as you climb the endless flights of
hospital steps, yet ever grateful for the sun’s
glow, in memory of the dark winter nights spent
on call.
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In its all consuming eminence, the hospital
can find itself becoming a micro-cosm of
wonder within the universe of life. Hidden in
its depths you can find an analogy for every
aspect of life and society.
In keeping with this, we bring you this
special edition of SIMA: Prospect. With the
aid of a hypothetical case study, our wonderful
authors walk you through the stages of our
patient’s care. We begin from the moment
the emergency services receive the call for
assistance, through the different stages of
our patient’s care, exploring the roles of the
plethora of healthcare professional involved in
providing each stage of this care as a united
multi-disciplinary team.
CALLER
OPERATOR
Hi, yea ambulance - erm, there’s been an accident, a cyclist has been hit by a car
Ok, can you tell me where you are?
CALLER
OPERATOR
CALLER
We’re on [gives addrress]
Ok, an ambulance is on its way, now can you tell me exactly what happened?
Erm, I was ust walking past, but I think the guy’s just come around the corner and
taken the bike out.
OPERATOR
CALLER
OPERATOR
CALLER
OPERATOR
CALLER
OPERATOR
CALLER
OPERATOR
CALLER
OPERATOR
Ok, and are you with the cyclist now?
Yeh.
Ok, is he conscious?
Erm, I don’t know. He’s lying pretty still.
He’s lying quite still is he? What position is he in?
Looks like he landed on his back
Ok, and is he talking to you?
No, I don’t know him, I was just walking by
Ok, What’s your name sir?
My name? John.
Ok John, whilst we’re waiting for the ambulance I’m going to talk you through a
few things that I need you to check for me, ok?
Erm , Ok
Great. First, I need you to check his airway. Can you look into his mouth and see if
there’s anything stopping him from breathing?
Ok, it looks pretty clear, but he’s got loads of cuts on his face from the windscreen.
Ok, can you see if he’s breathing? I need you to put your ear just over his mouth
and listen for any breathing, or if you can feel any breath on your -
CALLER
OPERATOR
CALLER
OPERATOR
So what is the analogy I hear you ask?
Hour by hour, day by day, you work tirelessly
in service of a group of total strangers, united
by their faith in you. Each and every day you
get out of bed ready to face the battleground
that is the hospital, and whatever it feels like
throwing at you today.
Iraq and its people have been suffering
from a severely debilitating chronic illness for
far too long. Having identified and attempted
to excise the cause, we now find ourselves at
the first step of many in the rehabilitation of this
great nation. As we embark on this journey;
Iraqi, non-Iraqi, local and ex-pat, we each fill an
important role as individuals, that have come
together to stand united in the pursuit of one
noble cause.
CALLER
OPERATOR
CALLER
OPERATOR
As you arrive at the hospital, you file in with
your colleagues; your teammates; the people
that rely on you to deliver. The people that you
can call upon to share the load. Everybody
pulls together to fight their part of this neverending battle.
As you read through these articles and
consider the different roles involved in the
care of this one patient, spare a thought for
all the different roles required to secure the
future of this great nation as it embarks on its
rehabilitative journey.
OPERATOR
publication
CALLER
OPERATOR
CALLER
CALLER
Yep, yeah, I can feel something on my face
Excellent, you’re doing really well John
What do I do now?
Ok, the ambulance is almost with you now.
I need you to look around John, is he bleeding from anywhere?
Erm, he’s got loads of cuts on his face
Is he bleeding from his nose or ears?
Yeah, he looks like he’s got a bit of a nose bleed but his helmet is in the way so I
can’t really see his ears I can hear the ambulance. They’re here now.
Ok John, you’ve done really well, just tell the paramedics what you’ve told me
Ok, Thanks for your help. Bye.
The clock is ticking...
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Jemma Batte
In high risk cases, such as those
involving Traumatic Brain Injuries (TBI),
every second that passes by signifies a
drop in the patient’s chances of survival.
From the moment the call is received, basic
first aid is available from the operator. Once
the paramedics arrive, the priority is to get
the patient to the most suitable hospital as
soon as possible, however, they cannot wait
until they arrive before treatment begins.
What is pre-hospital care?
Pre-hospital is the care delivered to a
patient before they arrive at hospital. In this
case, it will be the care given to the cyclist at
the roadside and in the back of the ambulance
on the way to the hospital. It could involve
members of the public, such as the caller who
dialled 999 in our scenario, who may be given
instructions on how to give first aid. Second
on the scene will be the paramedics who arrive
by ambulance. If it is a very serious road
traffic collision (RTC) and an air ambulance is
dispatched, a doctor may also be brought to
the scene.
Arrival at the scene
On arrival, the paramedics’ first priority is to
assess the scene for danger. The cyclist may
be lying on a busy road with other cars driving
past at high speed, or there may glass strewn
over the road. Drivers of other cars may slow
down to take a closer look, increasing the risk
of another accident occurring nearby. The
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Primary survey
Once the paramedics reach the cyclist,
they carry out the primary survey. This is an
initial assessment of the cyclist to identify lifethreatening injuries, so they can be treated
rapidly upon arrival at A&E and to begin
resuscitation. These guidelines for the primary
survey are set out by the Advanced Trauma
Life Support (ATLS) programme and they are
used in more than fifty countries worldwide1.
police and fire services will also have been
dispatched to the scene, in order to certify
the scene safe for the ambulance crew to
approach the patient. As the paramedics
approach the patient, it is important that they
quickly assess the scene for clues regarding
the patient’s injuries.
Eye Opening
Spontaneous
A note should be made of the number and
type of vehicles involved. Was there only one
car and the cyclist involved, or are there other
damaged vehicles in the vicinity? What is the
damage to the bicycle and the car? Important
clues may be given away by the way in which
the windscreen has been smashed – for
example, the classic ‘bulls-eye’ pattern, with
cracks radiating outwards from a central point
of impact, caused by a victim’s head hitting
the windscreen, often suggests that the cyclist
has sustained a serious head injury.
To speech
To pain
No response
Verbal Response
Orientated
Confused conversation
Inappropriate words
Incomprehensible sounds
No response
Motor Response
Obeys
Localises pain
WIthdraws from pain
Flexes to pain
Extends to pain
No response
Maximum Score
Where is the car? It may have hit a lamppost
or another vehicle after veering away from the
cyclist. The car may even have rolled over,
suggesting that the collision took place at high
speed. This increases the chances that the
car driver, too, may be injured.
Finally, where is the cyclist? Is he trapped
under the car, or has the speed of the collision
caused him to be thrown some distance?
Importantly, is he wearing a cycle helmet?
This is particularly significant if the windscreen
has been “bulls-eyed” as the head injury will
Score
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1
Score
5
4
3
2
1
Score
6
5
4
3
2
1
15
The Glasgow Coma Scale
Right : Cervical spine immobilsation
using neck collar , backboard and sandbags
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Maintaining ventilation using a bag-valve oxygen mask
Transfer to Hospital
Once the patient has been stabilised at the
roadside, he is ready for transfer to hospital. The
first hour after a life-threatening haemorrhage
begins is referred to as the ‘golden hour’ as
it is within this hour that surgical intervention
may save the patient’s life. The paramedics
will aim therefore to spend no more than ten
minutes at the scene, rushing the patient to
the hospital best equipped to treat the patient’s
injuries whether or not it is the closest
Once in the ambulance, movement of
the cyclist should be kept to a minimum to
prevent the worsening of his injuries. He
will be strapped down to a backboard and
the ambulance driver must take extra care to
minimise sudden acceleration, braking and
http://rationalrevolution.net
by
Wikimedia Commons
Features
Pre Hospital
Care
be much more serious if he is not wearing one.
All of these details should be assessed
in a matter of seconds as the paramedics
approach the patient. Often the police or fire
services will take photographs of the scene
to help determine the mechanism of injury,
since these details may be forgotten once the
paramedics have attended to the cyclist.
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Features
The Primary Survey
Indications
A: AIRWAY AND CERVICAL SPINE
Is the cyclist breathing?
Is there a suspected injury to
the neck?
YES
Maintain open airway
NO
Identify what may be obstructing the airway.
Consider using an airway adjunct or tracheal intubation*
YES
Immobilise cervical spine using a rigid collar. Fix to
backboard with sandbags either side of head and
tape across forehead.
hospital
Impaired conscious level at any time
Amnesia for the incident or subsequent events
Neurological symptoms (vomiting, severe
persistent headache, fits)
Clinical evidence of a skull fracture (CSF leak,
periorbital haematoma)
B: BREATHING
Is the patient breathing
normally?
YES
Maintain respiratory rate at 10-24 breaths/minute
NO
Begin ventilation with a bag-valve mask and
oxygen. Look for signs of life-threatening breathing
problems and treat immediately.
Significant extracranial injuries
YES
Is there any sign of external
haemorrhage?
YES
Continuing uncertainty about the diagnosis after
first assessment
Medical co-morbidity (anticoagulant or alcohol
Suspect spinal cord injury.
NO
Suspect damage to brainstem or nerves of the eye.
Adverse social factors (e.g. alone at home)
Taken from the Oxford Handbook of Emergency Medicine, 3rd
edition (2006)
NAI = Non-accidental injury
sharp cornering as even slight movement
may cause further damage to internal organs.
A paramedic will travel in the back of the
ambulance with him to monitor his condition
on the way to hospital. They will monitor his
breathing – or, if he has been intubated, that
ventilation is adequate – and that the pulse,
blood pressure and oxygen levels in the blood
remain normal. Appropriate analgesia will be
given to alleviate the cyclist’s pain, however,
must be carefully titrated so as not to mask
important clinical clues.
>13: Minor head injury
9-12: Moderately severe head injury
< 8: Severe head injury.
If GCS falls below 8, breathing is impaired and
intubation required.
E: EXPOSURE
Are there any other injuries?
Finally, once transfer to hospital is underway,
the trauma team at the receiving hospital
must be informed of the cyclist’s expected
time of arrival and the nature of his injuries
so they can prepare the resuscitation room in
Accident and Emergency to treat him. They
will need to know his age, the mechanism of
injury and his vital signs at the scene, as well
as the treatment given so far and his response
Cut away all patient’s clothing to ensure no other
injuries have been missed. Broken limbs should
be splinted. External bleeding controlled and vital
signs monitored continuously. Cover the patient
with blankets to avoid hypothermia.
IF AT ANY STAGE THE PATIENT DETERIORATES, BEGIN THE PRIMARY
SURVEY AGAIN TO FIND AND FIX THE CAUSE!
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Jemma Batte
Fourth year medical student
use)
Begin fluid resuscitation and continue monitoring
pulse rate and blood pressure.
Monitor pulse rate and blood pressure.
Apply pressure to bleeding wounds.
NO
A thorough primary survey followed by
rapid transfer to hospital is the key to prehospital care. As simple as it may sound,
ABCDE saves lives every day.
possible penetrating injury)
D: DISABILITY
Can the cyclist ‘wiggle
fingers and toes’?
Are pupils responsive to
light?
What is his score on the
Glasgow Coma Scale (GCS)?
to it. One of the accompanying paramedics
will also note his vital signs en route and all
drugs and fluids administered, which will be
relayed to the trauma team when the cyclist
arrives and all documentation handed over to
the hospital staff.
Worrying mechanism (high energy, possible NAI,
C: CIRCULATION
Are there any signs of
shock?
for referral to
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References:
1) American College of Surgeons at www.facs.org/trauma/
atls/history.html
2) ABC of Major Trauma, Edited by Driscol et l., 3rd Edition,
2000, BMJ Books
3) British Association of Immediate Care at http://www.
basics.org.uk/what_we_do
4) ABC of Major Trauma, Edited by Driscoll et al., 3rd
Edition, 2000, BMJ Books
5) A Simple Guide to Trauma, R. L. Huckstep, 5th Edition,
1995, Churchill Livingstone
6) Clinical Anaesthesia, Carl Gwinnut 3rd Edition, 2008,
Wiley-Blackwell
7) Major Trauma, Chan et al., 2005, BMJ volume 330, p.
1136-38
8) The Basics of Endotracheal Intubation, Maura Polansky,
1997, The Internet Journal of Academic Physician Assistants,
Volume 1
9) The Management of Major Trauma, Colin Robertson &
Anthony D. Redmond, 2nd Edition, 1994, Oxford University
Press
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is vital. The PaCO2 is one of the most potent
factors affecting cerebral blood flow and thus the
levels should be tightly controlled: hypercapnia
increases cerebral blood flow and can increase
intracranial pressure, whereas hypocapnia
reduces cerebral blood flow and may lead to
ischaemia.
Features
ACCIDENT
&
EMERGENCY
Circulation
Hypotension has been identified as the most
important factor in secondary brain injury, and
has a huge effect on morbidity and mortality.
NICE guidelines recommend maintaining
Mean Arterial Blood Pressure above 90mmHg
or a systolic BP of over 120mmHg. Any
haemorrhage should be controlled and two
large-bore peripheral cannulae inserted for
good vascular access.
by Noor Jawad
Head injury is a common presentation in the
Accident and Emergency Department, with up
to one million people in the UK attending per
year4. Falls, assault and road traffic accidents
account for the majority of these cases.
Assessment and management of head injury
in emergency departments is based around the
2003 National Institute of Health and Clinical
Excellence (NICE) guidelines. Pre-hospital
care, carried out by the London Ambulance
Service, as well as general bystanders, is aimed
at addressing immediate concerns: ABCDE. It
is the role of the paramedics to decide whether
a patient requires referral to hospital, as outlined
in the previous article5.
Glasgow Coma Scale
> 13: Minor head injury
9-12: Modeartely severe
< 8: Severe head injury
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The doctors may also consider placing a
central femoral line should inotropes need
to be administered. Normal saline or colloid
should be the fluids of choice, never dextrose
saline, unless a hypoglycaemia needs to be
corrected. An arterial line should be inserted,
as well as a urinary catheter to monitor fluid
status. Inotropes such as Noradrenaline are
often required to counteract the hypotensive
effects of the sedation used in ventilation.
On arrival of the patient to the hospital,
communication between the paramedics and
hospital staff is vital to ascertain important
aspects of the history that may be impossible
to gain from the patient, in particular any eyewitness accounts or relevant past medical
history obtained from family members.
The patient should be transferred straight to
the resuscitation room and should continue to
be managed according to the principles set out
in Advanced Trauma Life Support (ATLS).
The effectiveness of the resuscitation should
be monitored using physiological parameters:
pulse, blood pressure, skin colour, capillary
refill time and urine output. Any acid-base
abnormalities should be corrected.
Airway
The airway should be checked to confirm
patency and the cervical spine should be
immobilised until an injury is excluded. An
anaesthetist or intensivist should be involved
when the GCS falls below 8, to prepare for
intubation and ventilation. An orogastric tube
should be inserted to decompress the stomach
(a nasogastric tube in the presence of a base of
skull fracture puts the patient at risk).
Disability
Head injury is a dynamic state which needs
constant reassessment and monitoring should
there be deterioration in the patient’s condition.
All emergency departments should have a
neurological observation chart, which should
monitor at the bare minimum the Glasgow Coma
Score, pupil size and reactivity, blood pressure,
heart rate, respiratory rate, temperature,
oxygen saturations and limb movements
[example opposite]. Any slight deterioration in
the patient’s condition may indicate a serious
complication developing, such as fits or an
Breathing
Adequate ventilation of the patient should
be ensured, mechanically if necessary in order
to maintain arterial blood gases within their
normal ranges (PaO2>13kPa and PaCO2 4.55.0kPa). Regular arterial blood gas analysis
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Arterial Blood Gases
PaO2 >13kPa
PaCO2 4.5-5.0kPa
intracranial haematoma.
The Glasgow Coma Scale was devised
in 1974 by Teasdale and Jennett from the
University of Glasgow3. Their score, based
on eye, motor and verbal responses, gives
the patient a score between 3 and 15 that
can subsequently be used to reassess the
status of their central nervous system. It is
the most common method by which the acute
assessment of patients can be made.
The greatest risk to the patient from
complications is within the first 6 hours,
and hence the frequency of neurological
observations should be staggered in this
manner. NICE guidelines clearly state that a
depressed conscious level should never be
assumed to be due to alcohol intoxication unless
a significant brain injury has been excluded.
Observations should be carried out half-hourly
in a patient with a GCS of less than 15. If the
GCS is 15/15 then half-hourly observations are
required for two hours, followed hourly for four
hours, and two hours thereafter.
Exposure
The patient should be adequately exposed
for a full examination.
Once all clinical parameters have been
stabilisted the team must investigate the extent
of the injury beyond the GCS classification. CT
scanning is the imaging modality of choice in
head injury, the indications for which are clearly
outlined in the NICE guidelines overleaf.
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Features
Are
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-
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Tertiary Referral
Approximately 25% of patients with a severe
head injury have an operable intracranial
haematoma, and the Royal College of
Surgeons of England recommend that surgery
to decompress such injuries should be carried
out within 4 hours. Aside from the findings on
CT, other features that may indicate the need
for a neurosurgical referral include:
any of the following present?
GCS , 13 when first assessed in -
emergency department GCS < 15 when assessed in emergency depratment 2 hours after the injury
Suspected open or depressed skull fracture
-
Post-traumatic Seizure
- Sign of fracture at skull base
(haemotympanum, ‘panda’ eyes’ ,
cerebrospinal fluid leakage from
ears or nose, Battle’s sign)
Focal neurologival deficit
> 1 episode of vomiting
-
-
-
-
-
- - - Amnesia of events > 30mins before impact
YES
NO
Any
amnesia or loss of consciousness since the injury?
YES
Are
imaging should be carried out within 8 hrs of injury, or immediately
if patient presents 8hrs + after injury
imaging should be carried out and results analysed within 1 hour
of request being received by radiology department
KEY:
NO
Persisting coma (GCS≤8)
Unexplained confusion for more than
4 hours
Deterioration in GCS after admission
(particularly the motor component)
Progressive focal neurological signs
Seizure without full recovery
Definite or suspected penetrating
injury
CSF leak (rhinorrhoea or otorrhoea)
Important information for
Neurosurgical Referral
any of the following present?
Cardiorespiratory status (heart rate, blood
pressure, respiratory status)
- Age > 65 years
- Dangerous mechanism of injury
- pedestrian/ cyclist struck by motor vehicle
- occupant ejected from a motor vehicle
- fall from .> 1m or stairs
Glasgow Coma Score
Pupillary response
Motor pattern
- Coagulopathy
(history of bleeding, clotting disorder, current treatment with warfarin
Request CT scan
Immediately
Noor Jawad
Final year medical student
Name and age of patient
Mechanism and time of injury
YES
The neurosurgical team will then liaise with
intensive care staff to ensure adequate facilities
are available to receive the patient, in particular
an ITU bed. If the patient is accepted, the
referring hospital needs to adhere to their
local guidelines on the transfer of seriously
ill patients. For an emergency transfer an
adequately experienced doctor should travel
with the patient. The transfer team should be
able to communicate with their base hospital
and the tertiary centre whilst en route. The
patient should be adequately stabilised and
intensively monitored prior to departure to
reduce the risk of complications en route. If a
patient has a persistent hypotension then the
cause should be identified and dealt with prior to
departure. Once the patient has arrived at the
neurosurgical centre, adequate communication
between the team members is vital to transfer
the care of the patient from one team to the
other.
Alteration in baseline observations
Non-cerebral injuries
NO
References:
1) Fairley, S. & Hardy, P. (2004) Acute Management
of Adults with Traumatic Brain Injury, A Pocket Guide, The
National Hospital for Neurology and Neurosurgery, University
College London Hospitals NHS Foundation Trust.
2) NICE Guidelines (2003) Head Injury: triage, assessment,
investigation and early management of head injury in infants,
children and adults, HMSO.
Results of investigations
3) Teasdale, G. & Jennett, B. (1974) Assessment of coma
and impaired consciousness – a practical scale, The Lancet, 2:
81-84.
Relevant past medical history, medication,
allergies
4) Wasserberg, J. (2002) Treating Head Injuries, BMJ,
325(7362): 454-455.
Referring doctor, location and return phone
number
No Imaging
Required Now
5) Wyatt, J.P., Illingworth, R.N., Graham, C.A., Clancy,
M.J., Robertson, C.E. (2006) Oxford Handbook of Emergency
Medicine. Third Edition. Oxford, Oxford University Press.
NICE Guidelines: Indications for CT imaging
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Features
Pharmacological
Management
of the TBI patient
by Husam Jafar
Traumatic brain injury (TBI) is the
leading cause of death and disability in
children and young people1. However,
the literature suggests that effective
management of the TBI patient can
significantly reduce mortality.
Effective management of the TBI patient
requires a good understanding of the
pathophysiology of head injury. Aside from its
functional differences, the brain has several
features that distinguish it from other organ
systems in the body. One such feature is
the containment of the brain within the skull;
a rigid and inelastic container. Because of
this inelastic nature, only small increases in
volume within the intracranial compartment
can be tolerated before the pressure within the
compartment rises dramatically2.
This concept is defined by the Monro-Kellie
doctrine that describes the pressure-volume
Monro-Kellie Doctrine
that the central nervous system and its
accompanying fluids are enclosed in a
rigid container whose total volume tends
to remain constant. An increase in volume
of one component
or
cerebrospinal
(e.g.,
fluid)
brain, blood,
will
elevate
pressure and decrease the volume of one
of the other elements
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relationship between intracranial pressure
(ICP), volume of cerebrospinal fluid (CSF),
blood, brain tissue, and cerebral perfusion
pressure (CPP)2.
In the event of a significant head injury,
cerebral oedema may develop resulting in an
increase in the relative volume of the brain3. In
the absence of a compensatory mechanism,
such as a decrease in the volume of one of
the other intracranial components, the fixed
nature of the intracranial volume will cause
the intracranial pressure to rise. Medical
therapy in TBI is thus directed at controlling
intracranial pressure (ICP) and preventing
secondary damage4. The drugs employed
include a range of sedatives, neuromuscular
blockers and diuretic agents. With such a range
of therapeutic agents, particular care must be
taken to avoid any unfavourable interactions
and also not to mask any clinical signs that the
medical team are reliant upon to assess the
patient’s neurological status.
The first step for the management of a
patient with TBI is the securing of the airway
since ventilation is a vital factor in controlling
raised ICP5. In most emergency cases,
clinicians use rapid sequence intubation
(RSI) to achieve this task. RSI is the virtually
simultaneous administration of a sedative and
a neuromuscular blocking agent to render a
patient rapidly unconscious and flaccid in order
to facilitate emergency endotracheal intubation
with minimal the risk of aspiration.
Suxamethonium is a neuromuscular
blocking agent that has a rapid onset (30-60
seconds), and short duration of action (5-10
minutes)6. Suxamethonium causes prolonged
depolarisation of skeletal muscles to a
membrane potential above which an action
potential can be triggered8. It is thus used to
facilitate endotracheal intubation and provide
neuromuscular relaxation during intubation and
mechanical ventilation7. Muscle paralysis can
be maintained with intermittent intravenous
boluses.
Propofol is a short-acting anaesthetic
with a rapid onset of action that is given
intravenously7. Since both the hepatic and
extrahepatic metabolism of propofol is rapid,
continuous infusion is possible rendering
it an ideal sedative. However, prolonged
infusions can lead to increased triglyceride and
cholesterol levels. Other disadvantages include
cardiorespiratory depression, particularly in the
elderly, septic or hypovolemic patient9.
Once successful intubation has been
achieved, sedation can be continued with
titrations of Propofol and Fentanyl dependent
upon the patient’s cardiovascular response7.
Fentanyl is an opioid analgesic that works
by mimicking endogenous endorphins that
stimulate opioid receptors in the central and
peripheral nervous systems and is thus a
widely used analgesic10.
Barbiturates are also used as an adjunct
for intubation in patients with head trauma7. By
binding to distinct sites associated with a Clionopore at the GABAA receptor, Barbiturates
such as Thiopental, increase the duration of
time for which the Cl- ionopore is open. The
post-synaptic inhibitory effect of GABA in the
thalamus is, therefore, prolonged causing
a sedated state in the patient. Thiopental
however, may cause significant cardiovascular
depression. The accumulation of the drug
during infusion also lends itself to prolonged
recovery times12.
Aside from its sedative effect, Barbiturate
therapy also lowers the ICP and exerts cerebral
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protection through alterations in vascular
tone, inhibition of free radical–mediated
lipid peroxidation, and the suppression
of metabolism. By lowering the metabolic
demands, this drug group decreases the CBF
thus providing beneficial effects on the ICP11.
!
ask yourself...
will this
prescription mask
an important
neurological sign?
Barbiturates are the most common class of
drugs used to lower ICP in this way. Thiopental
is still used occasionally in severely raised
ICP to induce a ‘barbiturate coma’, initiated
in brain-injured patients whenever elevated
intracranial pressure remains unresponsive to
other interventions11. Barbiturates are avoided
where possible however, due to their effects
on cortical activity that may hinder clinical
evaluation of the patient’s condition.
A second class of psychoactive drug
used in treatment of the TBI patient are the
Benzodiazepines. By enhancing the effect of
GABA at GABAA receptors, Benzodiazepines
result in an increased depressant effect
on the CNS and are thus of benefit in both
the immediate control of seizure activity or
as an adjunct to neuromuscular blocking
agents to control ICP in patients with head
injury. Midazolam is a very short-acting
benzodiazepine that has seen extensive
use in intensive care units. As with the
Barbiturates however, Benzodiazepines may
cause both cardiovascular depression and
a hypotensive state. Careful monitoring of
the patient’s response to treatment is thus
essential. Prolonged use of Benzodiazepines
may also alter neurological examination
findings11. Precise dosing and careful titration
are therefore required to ensure that crucial
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I ssu e #3 • O c t 2009
clinical signs as to the patient’s condition are
not masked.
Diuretics are potent agents that can be used
to decrease brain volume and, therefore, to
decrease ICP. Mannitol, an osmotic diuretic,
is the most common diuretic used for this
indication. It is a sugar alcohol that draws
water out from the brain into the intravascular
compartment11,13,14. It has a rapid onset of
action and acts for a duration of 2-8 hours and
has been shown to be more effective when
given intermittently rather than a continuous
infusion.
Because mannitol causes significant
diuresis, electrolytes and serum osmolality
must be monitored carefully during its use.
In addition, careful attention must be given
to providing sufficient hydration to maintain
euvolemia14. At high doses mannitol may cause
renal toxicity and so serum levels require
constant monitoring also.
An alternative to osmotic dieresis is
the administration of more potent loop
diuretics such as Furosemide. Loop diuretics
achieve their diuretic effect by inhibiting the
reabsorption of electrolytes primarily in the
ascending limb of the Loop of Henle. Excretion
of sodium, potassium, magnesium, calcium
and chloride ions is increased and water
excretion enhanced. Furthermore, they may
also increase renal blood flow and prompt the
redistribution of blood flow within the renal
cortex13.
Despite these enhanced effects, Mannitol is
preferred over Furosemide as it tends to result
in less severe electrolyte imbalances. Bolus
doses of Furosemide may be administered
however, if a rapid diuretic effect is required,
followed by more long-term administration
of Mannitol. The synergistic use of these
agents can be very effective, although it
may render the patient at risk of severe
electrolyte imbalance. As with all of the
powerful pharmaceutical agents that have
been mentioned thus far- careful monitoring of
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the patient’s vulnerable physiological state is
crucial to the achievement of an effective care
plan.
In summary, the treatment of elevated ICP
is focussed on optimising the conditions within
the brain in order to prevent secondary injury
and allow the brain to recover. Optimising both
the cerebral blood flow and the metabolic state
of the brain is achieved by maintaining the
intracranial pressure within reference ranges.
Due to the complexity of such treatment the
care of a TBI patient should be tailored to their
specific situation.
Husam Jafar
Pre-Registration Pharmacist
Discuss this article and more
on our online forums
www.studentima.co.uk/forum
***
References:
1) Langlois JA, Rutland-Brown W, Wald MM. The
epidemiology and impact of traumatic brain injury: a brief
overview. J Head Trauma Rehabil2006;21:375–78
SIMA: Prospect Issue #4
2) http://emedicine.medscape.com/article/433855-overview
3) Larsen and Goldstein Consultation with the Specialist:
Increased Intracranial Pressure. Pediatrics in Review.1999;
20: 234-239.4 [accessed 27/8/09] http://www.springerlink.com/
content/x6973441672465m5/
FEB 2010
5)http://www.uptodate.com/patients/content/topic.
do?topicKey=~HIgBxeceqpT1Kj
6) http://www.nda.ox.ac.uk/wfsa/html/u01/u01_010.htm
7) Greater Manchester Traumatic Brain Injury Audit Group,
Head Injury Management in Adults in Greater Manchester,
January 2006 page 22
submit your article to
[email protected]
8) http://www.anaesthesiauk.com/article.aspx?articleid=229
9) http://www.medicinescomplete.com/mc/
martindale/2007/7000-a6-27-z.htm
10) http://www.patient.co.uk/medicine/Fentanyl.htm
any other queries
[email protected]
11) http://emedicine.medscape.com/article/433855treatment
12) http://www.mongabay.com/health/medications/
Thiopental.html
13) http://www.icm.tn.gov.in/drug%20formulary/
DIURETICS%2814%29.htm
htm
www.studentima.co.uk
14) http://www.umm.edu/altmed/drugs/mannitol-079300.
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I ssu e #3 • O c t 2009
www.studentima.co.uk
nutritional support must be delivered in one of
two ways; enteral or parenteral feeding. Enteral
feeding involves the delivery of a nutritionally
complete feed direclty into the stomach,
duodenum or jejunum, and is often used in
patients who are unable to maintain an adequate
or safe oral intake. whereas parenteral feeding
bypasses a dysfunctional or inaccessible
digestive tract. Both are equally effective
methods, however the advantages of providing
nutrition through an enteral feed are greater,
associated with a lower risk of hyperglycaeimia,
lower risk of infection and reduced cost when
compared to Total Parenteral Nutrition2.
Food for
Thought...
by Neam Al-Moussawi
Traumatic Brain Injury (TBI) can
potentially cause significant morbidity.
Alongside
efficient
pre-hospital
care, prompt triage, and careful
pharmacological management of this
vulnerable patient, the nutrition team have
a significant role to play in rehabilitation
once their initial injury has been dealt
with and their condition stabilised.
The principal tasks for the nutrition team in
treating our injured cyclist are;
- Assessment of nutritional status
- Management of nutritional care
- Patient and family education
Nutritional Assessment
Nutritional assessment of a patient with TBI
centres on
1)Nutritional status prior to the accident
2)Current nutritional status (and how it will
impact recovery and functioning).
Factors to consider in evaluating the past
nutritional status of the patient include age,
height, weight, eating habits and intolerance
histories. It is not uncommon for patients
with significant brain injury to experience
compensatory weight loss as a metabolic
response during the acute phase of injury.
Comparison of the patient’s current nutritional
state with their pre-injury weight may help
inform treatment.
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Enteral feeding however is by no means a
flawless treatment option. Because the cyclist
has a depressed level of consciousness,
elevation of the head of the bed can result
in a marked decrease of reflex episodes and
monitoring should include examination of
abdominal distension and checking for high
gastric residuals.
Using this
information, an
estimate of the
patient’s calorie,
protein and fluid
goals based upon
healing and weight
needs should be
established; with particular attention to the
requirement of special nutrients for wound
healing, anaemia and fluid imbalance, alongside
any other relevant medical problems.
If the patient has multiple episodes of
gastroesophageal reflux, medications such
as metoclopramide and cisapride may be
prescribed to increase lower oesophageal
pressure and improve gastric emptying.
Alternatively, feeding could be administered
directly into the small bowel rather than the
stomach3.
The final step of the nutritional assessment
is to determine a nutritional care plan for the
future. The patient’s weight dictates a large
part of this plan. If the patient is significantly
underweight, slow weight gain is preferred
(rather than rapid weight gain which leads to
excessive deposits of fat stores).
Past Nutritional
Status:
When faced with the physiological stress
of TBI, the body may respond by making
alterations in metabolic homeostasis resulting in
both increased energy expenditure and protein
metabolism. Several studies have shown that
as these changes arise secondary to the head
injury itself, early feeding may contribute to a
reduction in mortality1.
contributary factors
age
height
weight
eating habits
In addition to the changing metabolic state
of the patient, the practicality of his unconscious
state also contributes to his nutritional care.
The inability to swallow normally means that
intolerance histories
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Nutritional Content
Once the method of providing nutrition is
established, the nutritional formula of the feed
needs to be determined.
Optimal protein use has been found to be
heavily dependent on the adequacy of caloric
intake. After a TBI, energy requirements
rise and nitrogen excretion increases4. In a
normal fasting human 3-5g of nitrogen are
broken down per day, however, our patient
is more likely to register a figure of 14-25
g N/day. Nitrogen equilibrium is therefore
seldom achieved spontaneously. This almost
inevitable disequilibrium therefore needs to be
prevented by increasing the nitrogen content
of the nutritional formula from 14% to 20%,
thus achieving an acceptable level of nitrogen
retention5.
Protein needs are estimated at 1.2-1.6/kg
of body weight, with the suggestion that any
additional protein is simply oxidized, adding to
the nitrogen load to be excreted. Calorie intake
on the other hand is estimated to lie 40-70%
above basal needs, 30-40% of which should be
in lipid form in order to minimize hyperglycaemia.
Although studies have shown that a measured
energy expenditure of 30-40 kcal/kg is required
to take place in the patient with TBI, it is not a
universal recommendation as providing such an
amount in order to provide an energy balance
could severely disrupt glucose homeostasis.
Despite an approximate energy expenditure of
30-40kcal/kg, careful readings of randomized
control trials suggest that energy provided
in the 25kcal/kg range is more appropriate6.
Hence our injured cyclist would require 140%
of the normal caloric demand (approximately
3500kcal/day in a 70kg man).
As the patient’s nutritional formula is acting
as a substitute for a normally balanced diet, it
must consider all of the patient’s physiological
requirements. For example, Linoleic and
Linolinic acids are essential fatty acids without
which the patient would more susceptible to
cardiac dysfunction and infection. Similarly
Thiamine (Vitamin B1) is a cofactor essential to
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I ssu e #3 • O c t 2009
carbohydrate metabolism. Although abundant in
a normal balanced diet, the body can only store
a ten day supply. Consequently, if the patient
was to stay in ICU for a long period of time,
Thiamine replacement would be necessary to
prevent an almost inevitable deterioration in
cardiac function, Wernicke’s encephalopathy
and lactic acidosis. The same applies for a
range of other vitamins and minerals such as
Vitamin A, B12, B2, B6, C, D, E, biotin and
folate, as well as certain trace elements such
as copper, iron, iodine and zinc.
Despite the increased metabolic demands
of a TBI patient, as with one’s day to day diet,
overfeeding remains undesirable. In this case,
the prospects of hyperglycaemia, uremia and
increased carbon dioxide production as a result
of overfeeding render the task of predicting
our patient’s nutritional needs rather complex.
Major trauma induces metabolic alterations
that contribute to an immunosuppressed state,
Additional
Nutritional
Requirements
Essential Fatty Acids :
Linoleic & Linolinic acids
Thiamine
Vitamins:
A, B2, B6, B12, C, D, E,
Biotin, Folate
Trace Elements:
Copper, Iron, Iodine, Zinc
www.studentima.co.uk
inevitably increasing the risk of infection and
post traumatic organ failure. The appropriate
selection, timing and dose of nutrients required
for metabolic resuscitation must therefore be
individualized with clear aims and opportunity
for review.
TBI in the dentist’s chair
by Dr Thuha Jabbar
No single test can predict the nutritional
requirements of a patient, as the nutritional
status does not remain static in recovery
from a brain injury; periodic assessments and
readjustments are necessary dependent upon
the patient’s changing weight and metabolic
capability. Based on the extent of injury and
underlying deficiencies, an optimal feeding
formula will be designed to provide the nutrients
required specifically by this patient, necessary
to balance his hypermetabolic state and thus
promote optimal recovery. In so doing, the
nutrition team are providing the physicians
responsible for his care the ideal physiological
and metabolic platform from which to address
and treat his injury, without which the success of
any medical intervention cannot be guaranteed.
Neam Al-Mossawi
Third year Nutrition & Dietetics student
References:
1) Intolerance to enteral feeding in the brain-injured patient.
Norton JA, Ott LG, McClain C, Adams L, Dempsey RJ, Haack
D, Tibbs PA, Young AB. J Neurosurg 68 (1988) p.62
2) Effect of parenteral nutrition on cold-induced vasogenic
edema in cats Waters DC, Hoff JT, Black KL. J Neurosurg 64
(1986) p.460
3) Contemporary Nutrition Support Practice; A Clinical
Guide. Saunders 1998
4) Nutritional support and neurotrauma: a critical review
of early nutrition in forty-five acute head injury patients. Hadley
MN, Grahm TW, Harrington T, Schiller WR, McDermott MK,
Posillico DB. J Neurosurg 19 (1986) p.367
5) Enteral hyperalimentation in head injury Clifton GL,
Robertson CS, Contant CF. J Neurosurg 62 (1985) p.186
6) Nutritional Considerations in the ITU, Scott A; Shikora A;
2002 p.46
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a
In a patient with head injury, the
primary concerns are the patient’s level of
consciousness and responsiveness. Having
addressed the patient’s raised ICP and
attained a stable condition, it is important
to consider other less obvious morbidities
that may have resulted from the accident.
The lacerations sustained to the patient’s
face indicate that he may have some more
serious damage within the mouth cavity,
and so he requires some maxillofacial /
dental attention to ascertain the extent of
injury and whether or not any surgical /
dental treatment is indicated.
A mandibular fracture is one of the most
significant sequelae of a road traffic accident,
and may have serious complications for
the patient if not managed effectively. On
examination, there were no signs to suggest
fracture of the mandible. However, due to his
high speed impact with the car windscreen and
subsequently the road surface the patient had
sustained a number of superficial lacerations
to the extra-oral area, which may require
suturing, and continued wound care in the ICU
as the healing process may be impaired due
the requirement of an endotracheal tube and
orogastric feeding tubes.
Extra-oral examination
The first step in assessing the extent of
this patient’s dental needs is to perform a full
examination. Beginning, extra-orallly, one
needs to assess the possibility of a mandibular
fracture. This would be suggested by:
• Pain, swelling and tenderness in the fracture site
• Bleeding, bruising, or haematoma, at fracture site
• Displacement, step deformity
• Change in occlusion (how the teeth normally meet)
• Mobility of fragments or teeth
• Difficulty on opening the mouth or in lateral excursion (moving the lower jaw from side to side while the upper and lower teeth are in contact)
• Paraesthesia or anaesthesia on the distribution of nerves involved in the fracture.
Intra-oral Examination
Continuing the examination, one has to
inspect intra-orally to assess the extent of the
damage.
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Although less likely to be affected as a result
of head injury, it is still important to check the
gingiva (gums), buccal mucosa, tongue, floor of
the mouth, palate and teeth for any pre-existing
morbidity that may inform current treatment.
Our patient has sustained fractures to both
the upper central incisors and has lost the upper
left lateral incisor. The upper central incisors are
grade 2 mobile (>1mm movement horizontally).
The patient otherwise has good oral hygiene
and has a very minimally restored dentition
Initial Investigations
Once the initial findings have been noted
from the complete oral examination, any
discrepancies should be investigated further to
21
assess the full extent of the damage sustained.
It is important that several radiographic images
are carried out at the first visit to ensure the
patient
a) has no facial fractures,
b) not inhaled the missing tooth and
c) there are not tooth fragments in any of the lacerations
The following images can be taken:
• 10o and 30o occipitomental views or a posterior-anterior jaw and a dental panoramic tomogram.
• A posterior-anterior radiograph of the chest
• Soft tissue radiograph of the extra-oral area.
Investigation of the teeth
Mobility
The teeth need to be tested for mobility in
the buccopalatal (horizontal) direction using a
hard instrument such as a mirror handle. The
degree of movement and the position of the
fulcrum of the movement should be noted. All
teeth should be checked in this case.
The upper incisors were all mobile by 1-2mm,
apparently about a fulcrum close to their apices
Occlusion
This is to determine whether all teeth make
contact in a stable intercuspal position (position
of maximum contact between occluding
teeth) and that no pain is elicited on closing
or excursive movements of the mandible.
Poor occlusion, where the teeth do not meet
properly, would suggest a tempero-mandibular
joint (TMJ) dislocation.
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Interpreting the findings
Combining the examination findings and
results of the various investigations, will give
a better indication of the treatment required to
restore an acceptable level of dental health.
The mobility of the incisors about a point
close to their apex suggests luxation injury
(displacement of the tooth) rather than root
fracture. This is consistent with the crown
fracture as , unless the injury is really severe,
crown fracture is usually not accompanied
by root fracture as the energy of the blow is
absorbed by the crown.
The fractured teeth have exposed pulps
which will require extirpation (removal of the
pulpal tissues) regardless of the vitality.
To complement our initial radiographic
investigations, and better appraise the extent
of the injury, further imaging is required:
• Upper occlusal radiograph shows the left lateral incisor is missing.
No root fracture is evident.
• Long cone periapical image of the incisors shows widening of the periodontal ligament (fibres that attach tooth to bone) due to the luxation injury.
Degree of fracture
If the fracture reaches as far down as the
level of the pulp where the nerve and blood
supply to tooth is, it will require endodontic
treatment (root canal treatment) to restore
the tooth at the very least. Failure to treat an
exposed pulp me lead to tooth extraction.
Emergency Treatment
Now that the extent of damage has been
understood, the most suitable treatment can
be planned accordingly. Initially.,the incisors
need to be splinted to promote healing of the
periodontal ligament fibres. This is done using
stainless steel wire acid etched to the upper
incisors, lateral incisor and canines and kept in
place for 10-14 days.
The pulps of both central incisors were
involved in the fracture and the pulp exposure
was relatively large.
The occlusion should be checked carefully
to avoid causing further trauma to the teeth.
The pulps should be extirpated first and a
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calcium hydroxide dressing placed in the root
canal to prevent root resorption and infection
developing in the periapical area, that may
in turn compromise the integrity of the tooth,
and may lead to its loss. The teeth can then
be restored temporarily with composite filling
material.
Vitality
The degree of fracture will thus influence the
vitality of the tooth. None of the incisors gave a
positive result to cold (ethyl chloride) or electric
pulp tester suggesting tha the nerve supply to
the teeth is damaged.
Treatment options
PARTIAL ACRYLIC DENTURE
Advantages include ease of fabrication,
acrylic flanges mask bone defect following
alveolar remodelling and relatively low costs.
Disadvantages include the fact that many
patients, especially those who are young,
dislike removable prosthesis and would prefer
a fixed option.
RESIN RETAINED ADHESIVE
This is a fixed replacement which will
provide gingival coverage and will require no
further tooth preparation to the canine. The
disadvantage of such a bridge is the fact that
it is difficult to mask the space formed beneath
the pontic (replacement tooth) following bone
remodelling. The bridge is also very difficult to
remove.
CONVENTIONAL CANTILEVER
BRIDGE CEMENTED OFF THE
CANINE
This tends to be the last option that is
considered due to the fact that it requires a lot
of unnecessary tooth tissue removal from the
canine which in this case is a sound tooth.
IMPLANT
Given that there is sufficient bone and space
between the remaining teeth, this would be the
treatment of choice. An implant is the closest
treatment option to the patient’s natural teeth
and with careful pre-operative assessment and
post-operative care, can last a lifetime, unlike
the other options which will inevitably fail and
require replacement. The main disadvantage
to this treatment option is financial as most
implants cost 3-4 times more than the other
options
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A Chlorhexidine mouthwash is prescribed
for use until the tissues have healed sufficiently
to aid oral hygiene and prevent plaque
accumulation around the fractured teeth which
may be tender to brush.
Treatment Plan
Once the splint is removed, the upper central
incisors will require endodontic treatment
(permanent root filling). Once this is completed,
the teeth will require permanent restoration and
this is best achieved in the form of a ceramic or
metal ceramic crown.
The upper lateral incisor will require
replacement, the treatment options for which
include:
1.Partial acrylic denture (removable)
2.Resin retained adhesive bridge bonded to the canine (fixed)
3.Conventional cantilever bridge cemented off the canine (fixed)
4.Implant (fixed)
Ultimately, the final decision lies with the
patient. It is the duty of the practitioner to fully
inform the patient of the pros and cons of each
treatment option to allow the patient to make an
informed decision. The extent of the patient’s
oral injuries is favourable in light of the high
impact collision that caused them, and should
not pose considerable trouble during treatment.
Although the nature of these injuries is not
immediately life-threatening, they are most
likely to be the first thing the patient will see
when he looks in the mirror. Similarly they are
likely to be noticed a lot more by family and
friends than any internal injuries. Sensitive
management and follow up of these injuries is
therefore essential to ensuring an aesthetically
as well as functionally pleasing outcome.
Dr Thuha Jabbar
VT1 Dentist
Dr Zeena Mohammed
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I ssu e #3 • O c t 2009
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The Beginning
of The End
by
Yasmin Al-Asady
Any form of illness or injury can be
a difficult experience. As you have read
by now, the long road back to good
health begins before the patient even
arrives at the hospital. In the same vein,
a patient’s discharge from hospital does
not necessarily represent a new lease of
good health. On the contrary, if anything,
a patient’s discharge from hospital care
often represents the beginning of the
long, arduous road to a full recovery. In
recognition of this, both the UK Audit
Commission Department of Health
highlight the importance of the provision
of follow up services and a good level
aftercare for patients recovering from
critical illness4. Almost a decade later,
where do we stand in relation to these
recommendations?
In the UK, the number of follow-up services
in all their possible forms is unknown. Recent
surveys estimate that approximately 30% of
Intensive Care Units (ICU) in the UK currently
offer a specific follow-up clinic, with ‘financial
constraints’ being cited as the primary reason
for the lack of this important service4. So what
exactly are the follow-up needs of this patient
group, and do they justify this seemingly
expensive provision?
More than 110 000 people are admitted to
critical care units in England and Wales each
year, of whom 75% survive to be discharged
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a formal diagnosis of Post-Traumatic Stress
Disorder (PTSD)1. An appreciation of the wider
psychosocial implications of the patient’s
physical illness is therefore essential to aid his
recovery and long term health.
Moving one step further out into the
patients circumstances, it is also important to
consider the effect of his treatment on family
and friends. The difficulties of watching a loved
one in a critical condition with the constant
stress associated with their fluctuating state
can have lasting effects on family and friends,
leading to high levels of anxiety, depression
and PTSD-related symptoms1 in this
population.
EXIT
home2. Having survived a life-threatening
critical illness, this group of patients will
often experience the range of physical and
psychological sequelae of critical illness.
It seems clear therefore that the end of our
patient’s treatment is nothing but his ticket
for the journey that lies ahead of him. How
can an ICU follow up clinic make it a more
comfortable ride?
Physiologically, the body is ready to adapt
to periods of inactivity that may optimise its
function in the short term, but in turn, will
require extensive rehabilitation in order to
return to previously held state of good health.
Muscles will atrophy by approximately 1-1.5%
per day, alongside a loss of 6mg of calcium
per day, leading to almost 2% bone loss
per month. Furthermore, decreases in VO2
max lead to a compensatory rise in heart
rate and a decreased stroke volume that in
turn predisposes to a compensatory ejection
fraction. Patients are therefore not only coping
with the initial injury that led to their admission,
but the multitude of systemic consequences
that ensue3.
Different clinics will have different criteria
for their patients, but most will offer an
invitation to attend the follow-up clinic to all
patients who stayed on the ICU for a specific
number (often 3-4) of days. Not every patient
will accept the invitation; some prefer not to
return to the unit as not to trigger any painful
memories, whereas others do like to see the
bed in which they stayed and meet the team
members responsible for their care.
Until earlier this year, despite the
recommendations for the provision of followup care, there were no clear rules stated
regarding how exactly this care should be
provided. With the publication of the new NICE
guidelines for critical illness rehabilitation,
various forms of patient- centred consultations
are adopted with the aim of the identification
of rehabilitation goals and monitoring the
patient’s progress in reaching these goals.
Moreover, as if the physical strain isn’t
enough to handle, the combination of the
immediate threat to life and the invasive
monitoring and interventional processes that
these patients endure, washed down with
the cocktail of narcotic and sedative drugs,
all within the bustling artificial environment
of the ICU can often precede significant
psychological difficulties. Up to 80% of
ICU patients report troubling incidences of
delirium, delusional memories, nightmares
and amnesia that may in turn predispose to
The multi-disciplinary teams involved in
running the clinics, provides a fountain of
knowledge and expertise ready to allay any
worries the patient may have. Any expertise
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that is not represented at the clinic may
be provided by external team-members or
through referral to support groups and other
resources that best fit the needs expressed.
A key principle of these clinics is to ensure
continuity of care to the patient, where they
are seeing familiar faces that they have grown
to trust at a particularly vulnerable time in their
lives. This level of trust also lends itself to
very open consultations about the potentially
very personal troubles that may arise. Some
patients find it comforting that they are able to
go through their experience with somebody
who is aware of their previous treatment, some
even opting to run through their notes from
their ICU stay4.
When asked about their opinions on
the value of ICU follow up, patients have
also highlighted their appreciation for the
opportunity to ask questions about what
to expect and in turn understand that their
feelings are a normal part of the healing
process. As with any rehabilitative process,
the effort required to stay motivated through
the lengthy journey, may itself lead to further
feelings of anxiety and depression that in
turn, may hinder recovery and contribute to
prolonged physical morbidity1. Patient reports
have highlighted that knowing what troubles
to expect significantly improved their ability
to cope with such situations4. Furthermore
by inviting family and friends to attend followup session and making them aware of the
obstacles they may anticipate, the clinics
also emphasise the importance of a longterm support network, in preparation for the
patient’s final discharge.
In addition to all of the aforementioned
issues, the nature of our cyclist’s injury may
cause further cognitive impairment due to
the increase in intracranial pressure and
neurosurgical interventions. This may have
profound effects on both home and work
life and so his particular neuropsychological
needs need to be carefully addressed. Some
patients have difficulty in returning to their day
25
Features
I ssu e #3 • O c t 2009
www.studentima.co.uk
PHYSICAL DIMENSIONS
Physical Problems
Sensory Problems
Communication problems
Social Care
Weakness; inability or partial ability to sit, rise to standing, or
walk; fatigue; pain; breathlessness; swallowing difficulties;
incontinence; inability or partial ability to look after oneself
Changes in vision or hearing; pain; altered sensation
Difficulties in speakinf or using language to communicate; difficulties in
writing
Mobility aids; transport, housin, benefits. employment leisure
NON-PHYSICAL DIMENSIONS
Anxiety, depression,
and symptoms related
to post-traumatic stress
Behavioural and
cognitive problems
Other psychological or
psychosocial problems
New or recurrent somatic symptoms, including palpitations,
irritability, and sweating; symptoms of derealisation and
depersonalisation; avoidance behaviour; depressive symptoms,
including tearfulness and withdrawal; nightmares; delusions;
hallucinations; and flashbacks
Loss of memory; attention deficits; sequencing problems;
deficits in organisational skills; confusion; apathy; disinhibition;
compromised insight
Low self esteem; poor or low self image and/or body image
concerns; relationship difficulties, including those with the family
and/or carer
winning entry
Sami the Methanol Guy
by Dr Nabil Al-Khalisi
Indicators of physical and non-physical morbidity
to day routine for fear of a recurrent injury. Our
patient may therefore be wary about crossing
roads, driving a car, and whether or not he
should cycle the roads again. His personal
needs will need to be gauged by the team
that has so far taken such great care of him
whilst in hospital, to ensure that it continues
throughout his aftercare.
As the patient is handed his discharge
papers, with his wounds healing, painkillers
in hand and follow up appointments booked,
he walks out of the hospital as a testament to
the fantastic efforts of the team of dedicated
healthcare professionals responsible for his
recovery. A team of individuals that are able
to put aside any differences they may have,
and pull together their abundant skills and
expertise, to provide an optimal level of care
and attention that will hopefully allow him to
enjoy a good quality of life for many more
years to come.
26 a
publication
:
Thankyou to all of you who entered the competition.
It was a real privilege to read all of your thoughts and
experiences.
Yasmin Al-Asady
Fourth year medical student
Keep an eye out for the next essay competition coming
very soon
References:
1) Sukantrat et al, Physical and psychological sequelae
of critical illness, British Journal of Health Psychology 2007, 12,
65-74
www.studentima.co.uk ~ [email protected]
2) Tan et al, Rehabilitation after critical illness: summary
of NICE guidance, BMJ 2009; 338:b822
3) http://www.acprc.org.uk/dmdocuments/Early%20
Rehab%20-%20ACPRC.ppt
kindly sponsored by the
Medical Protection Society
4) Prinjha et al, What patients think about ICU follow-up
services: a qualitative study, Critical Care 2009, 13:R46
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27
Essay Competition Winner
I ssu e #3 • O c t 2009
www.studentima.co.uk
Sami the
Methanol Guy
Sami’s hands were cold and he was
clearly unbalanced; he smelled like alcohol
or something; his clothes were stained with
vomit. I asked him what was wrong but
he replied with a faint smile and a vague
sentence “nothing, I feel sleepy; where is
mum?” Just then I turned to the old man next
to me in search of an answer. The grandfather
was shaking and stuttering obviously; he
said “Doctor, he almost drunk the whole
bottle, all of it, thinner, we were painting, the
whole bottle!” I suddenly realized that I am
dealing with a time bomb here! Paint thinner;
methanol.
by
Dr Nabil Al-Khalisi
Treating patients is a multi step process;
it starts with community awareness and
ends with health care. When the level of
education in the community is below zero
you can do nothing to help others, no
matter how skilled you are. This article
tells us a story of a horrible night shift in
an Iraqi ER. I had a problem that was ten
times more technical than clinical and I
could not face alone. I was psychologically
traumatized; threatened to be killed; I had
flashbacks and deep moral conflicts; I ran
away. A horrible tragedy indeed.
It is now midnight; the weather is cold
and foggy. I sat behind the glass door of
the peadiatric emergency department main
entrance. I was so tired and really confused; I
had spent the whole day working with one of
my seniors. We both tried doing things quickly
and discharging as many stable patients as
possible. Unfortunately, he left me alone to
face the night shift so that he can get some
rest and I would gain some misery.
I looked far away through the glass door
trying to predict whether or not there was
someone approaching. I hoped that no one
would come; I really needed a break because
after sixteen hours of deathly labour, my
headache was intolerable. The thought of the
eight hours left alone on my shift was enough
to make me sick, but I tried to be optimistic.
28 a
conversation with little Sami ; he just wanted
to tell me the truth in a nutshell as if he really
knew that we were all running out of time.
publication
A loaded night shift may bring up to twenty
patients; I was aiming for four or five at a
maximum. The good news is that at that night
only one patient came asking for help. The bad
news is that after I finished my duty I wished
I’d had thirty patients screaming and shouting
instead of this miserable case.
I fetched my stethoscope and listened
to the child’s chest which was mostly clear
with a few scattered wheezes; I asked the
grandfather whether he had a fever or had
vomited. I ordered Ipecac solution and IV
fluids right away. I tried to talk with Sami in
order to assess his level of consciousness;
he seemed to be quite oriented but a little bit
sleepy. Telling Sami that everything will be ok
felt ridiculous, but I had no other choice; I had
to lie; at least I could alleviate his fears.
Sami had brown hair, blue shiny eyes and a
small mouth hanging wide open. He was about
five years old. He was so drowsy that he was
unable to keep walking for a distance without
stumbling. He arched his back a little and
hung over his grandfather’s big hand. They
were both walking in a slow stride that made
me follow their every move thoroughly as they
advanced towards the main entrance. Sami
looked curious about what was really going on;
I guess he hadn’t been into a hospital before.
He kept on asking his grandfather time after
time but he never seemed satisfied with his
grandfather’s brief answers.
Thinking about treating methanol poisoning
is quite simple. You bring some friendly
ethanol molecules that shift hostile methanol
molecules away from liver cells and we are all
happy and safe; no retinal damage; no liver
failure; no nothing. The problem was that I had
a list composed of twenty names of commonly
used drugs; this list represents the contents
of our pharmacy; the paediatric emergency
department pharmacy at the medical city
complex; the grandest health institution in Iraq!
Unfortunately ethanol was not listed. I had to
figure a way out to save this child. How could
I get some ethanol in Baghdad at midnight?
No stores are open; no pharmacies; no one
but me and the poor kid. I remained silent for a
while thinking deeply trying to solve a problem
As they opened the door I could not face
Sami without a smile on my face as if his
charm cast a spell on me from the very first
glance. He was an adorable little fellow who
made me feel that every little effort and every
drop of sweat for the sake of every child I
cured today is worthwhile; I totally forgot about
my excruciating head ache and started talking
to Sami right away. His grandfather was very
anxious and he always tried to interrupt my
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that was ten times more technical than
medical. I’d never come across anything like
this during my entire year as a junior doctor.
I bent down and looked directly into Sami’s
eyes; I touched his cheek with my hand; I
said to myself that this kid must make it; it is a
shame if I could do nothing for him; if he was
somewhere else he would have been much
better by now; I must do something. I was
bothered by the strong aromatic smell with
every one of his little breaths as if he was an
alcoholic; just then I got it! Let’s have a party;
let’s drink some Arak (A traditional colourless
Iraqi spirit that contains up to 80% ethanol).
That is really good, affordable and at hand. I
had an idea; simple but effective; it was my
only hope, so it had to work. My initial plan
was to make the grandfather get us a bottle
or two of Arak from a nearby shop as alcohol
stores in contrast to pharmacies tend to stay
open late at night.
Here comes the hard part.
I turned to the grandfather; took him
away from Sami; I tried to be assertive and
informative in the same time; I said “Sir,
Sami is dying ,we have got only one shot, he
has methanol poisoning. It is very serious,
we need to act fast. Methanol has only one
antidote which is ethanol and unfortunately
we do not have medical ethanol in here;
do not panic please; we can make it; Arak
contains ethanol as its main component ;we
can use it to cure Sami; bring me a bottle of
Arak and I promise to do my best but please
hurry”. After this short speech of mine things
changed dramatically; the grandfather’s face
turned from pale yellow to red; he became
obviously angry and aggressive; he attacked
me instantly using both his hands trying to
smother me. He was taller and heavier than
me so within seconds he was in control of my
small neck. He started shouting “You bastard;
you have no mercy; you want me to bribe
you? Are you trying to blackmail me? Are you
bargaining Sami’s life for alcohol? If he dies
you die too, understand?”
29
I ssu e #3 • O c t 2009
Soon after that the Facility Protection
Service (FPS) intervened. Suddenly I became
surrounded by guards; they pulled the mad
man away and tried to calm him down. I was
gasping for air, I felt like my throat had been
crushed; I fell down holding my hands around
my neck and took a few deep noisy breaths.
Just then I saw noticed that Sami was looking
at me in a strange look; just like if he is saying
“What is going on? Grandpa loved you a
moment ago? What did you do to make him
so angry?” In this moment I felt that time had
stood still and it was just me and little Sami
looking at each other. I realized that Sami’s life
was hanging in the balance; I had to convince
his grandfather that I was telling the truth.
Time is running out and I had to move fast.
In the other corner of the ER Sami’s
grandfather was forced to sit down to the floor;
they tried to calm him down but he kept on
shouting and threatening me. He felt so angry
that his both hands were shivering. Convincing
such a man seemed impossible but I had to
try. I slowly advanced and stopped about a
metre away from him while the guards were
still holding him down to the floor. I asked
him to listen carefully. He looked at me with
disgrace and disgust and told me that God
will punish me for my horrible acts. I talked as
keen as I could and tried to be so convincing
I said “I am not asking for a bribe; this is my
job and I am doing it in the best way that I
can; Arak contains ethanol; we really need it;
bring it and you will see that I will not have a
single drop. Trust me please; Sami’s life is on
the line here”. He replied in an indignant way
“Drinking alcohol is a sin; God told us that
no benefit can be sought from alcohol; God
knows what He is doing”. It became obvious
that I failed in convincing him about my idea. I
went to the lobby and called the chief resident
immediately; fortunately he was awake and
willing to come to the ER right away. Five
minutes later the chief was examining the
child and soon after that he talked to the
grandfather, repeating everything I had said.
At this very moment the grandfather became
insane; calling me names and shouting very
loudly “corruption, you both are corrupted
30 a
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www.studentima.co.uk
physicians, you do not deserve to live, God
help me , if anything happens to Sami I will kill
you both , I will tell the Minister of Health”. The
chief resident felt disappointed and drowsy;
he came nearby and whispered a few words
in my ear; he told me to discharge the kid and
stay safe; he did not really care about the
outcome. He explained that we’d done what
we had to do and that the grandfather would
have to live with the consequences of his
actions, and in an instant, there I was again;
alone to face this horrible dilemma.
as soon as he could. I was so tired and
confused. I allowed my eyes to close. The
old man had grown tired of shouting too, and
stayed quiet interspersed with a brief weep
every now and then. At 4am the three of us
fell asleep..
Suddenly at 5:30am a scream broke the
silence. The patients, the guards and I were
all awakened by the scream but Sami seemed
indifferent. The grandfather had woken us all
into a panic. He was screaming “Help me, he
is not breathing, his hands are turning blue,
God please save him, he is still so young to
die, oh God, help”. I rushed instantly to Sami
with my stethoscope; checked his vitals...he
was dead.
While the man was crying for help and
cursing me in the same time, I was standing
a few metres away trying to think of an
alternative. I thought about going to buy
the bottle myself but then I realized that
this was impossible; there were too many
critical patients in the ER that I could not
leave. I thought about waking one of my
colleagues to buy the bottle, but then would
the grandfather let us use alcohol to cure
Sami? Why would anyone risk their life at this
hour to help someone who was refusing help
in the first place? Finally, I was overcome with
hopelessness; I was out of choices. There
was only one option left. The child’s condition
would inevitably deteriorate, would this
convince his grandfather? This was my only
hope.
I tried to resuscitate him but to no avail.
A few minutes later when I’d lost all hope of
bringing him back, I stopped. I looked into his
face and said deep inside me “Forgive me
dear Sami , I did my best, I hate this world for
not giving you another chance that you really
deserve”
He was cold and pale. His face was still
as charming as before but less viable. He
seemed to be indifferent yet satisfied. I doubt
that he even knew what had happened to him.
He was just lifeless. The grandfather collapsed
soon after that.
Time passed slowly. I watched Sami fading
minute by minute without being able to do
anything. First he started vomiting; then he
became drowsier and drowsier. A few hours
later he became completely unconscious.
His grandfather didn’t change his mind; he
continued to blame me for what was going
on and promised to get revenge if anything
happened to his grandson.
I spent the next two hours wallowing in my
misery. I remembered every little detail about
what had happened, and I just wanted my shift
to end. I wanted some rest and good sleep.
Five minutes before my shift ends “Mr. no
for alcohol” woke up; he passed into denial.
He started weeping and then went straight
to my desk; looked me in the eye and said “I
will kill you, Sami must be avenged. You are
corrupt, and I will never feel peace until you
are dead” I was scared, but more so, I felt so
sorry for everyone including me. I took my
things and left in a hurry.
At the beginning I had felt sorry for not
being able to do something but as time
passed by I realised that it was not my fault.
I felt so sad for watching a charming child’s
life like Sami’s be taken in vain. Despite
the deteriorating condition of the child, the
grandfather decided to stand still, waiting to
report what happened to the hospital officials
behind this event. I felt that medical training
alone was not enough to cure people here. It
is not always about training and equipment.
Sometimes ignorance, illiteracy and luck are
all that matter. Putting the pieces of this story
all together tells us one thing, healing people
is a multi step process. It starts with education
and ends with health care.
What happened was that I could not
face false society values by myself; this
requires a mass effort and the will to
conquer longstanding misconceptions that
have become engrained in everyday life; of
everybody’s lives without any questioning.
Being a doctor here is a double edged
sword. You can help many sick people, more
than you could ever imagine. On the other
hand; providing health care alone is not
enough; herd health status is a complex issue;
everyone must feel responsible for his as well
as other people’s well being. We need to adopt
a new way of thinking. Humanity is precious;
we should cherish our lives; know how to live
in prosperity and abandon everything else
because it simply it does not matter.
As the night drew to an end dozens of
questions popped up into my exhausted mind.
Can I keep doing this in here? Should I try
harder or just give it up? Whose fault is it?
Why? Should I stay in here or get the hell out?
Am I doing the right thing?
I arrived home. I took off my shoes and lay
on my bed. I closed my eyes and escaped. I
slept like a dead man. I ran away. I could not
face the truth so I ran away, far away in my
dreams.
Dr Nabil Al-Khalisi
Junior House Officer, Medical City Complex
Baghdad, Iraq
On my way back I kept having flashbacks;
I thought deeply about the hidden meaning
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31
Workshop
I ssu e #3 • O c t 2009
www.studentima.co.uk
What?Why?
Who?workshop:
online resources
When?
How?
Where?
Following February’s inaugral workshop on how to write an article, Dr Matthew Burman
shares his experience of the vast sea that is evidence based medicine, highlighting a few of
his favourite online hotspots.
If there is any particular area that you would like featured as a workshop get in touch
with us at [email protected] and we’ll try to find the right person for the job...
Today a wealth of resources is available
on the Internet to assist medical students
and doctors alike. It can be quite daunting
knowing which sources of information
to trust and where to look for particular
information. The aim of this review is
to detail a few selected resources that I
have had personal experience of using
with some background information on
each one. All the resources discussed
can be accessed worldwide at the time
of writing. The majority are free, however
I have included a one paid-for resource,
which, as I will explain in more detail
later, provides information not found
elsewhere.
Evidence-based Medicine
General and Free
Cochrane Library
This is one of the oldest electronic
resources in existence, founded in 1988.
32 a
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regarded as the most thorough evidence
resource on treatment available today.
eMedicine
This free American database, founded
in 1996, provides peer-reviewed evidence
based articles on diseases in medicine,
surgery and paediatrics written by more than
10,000 physicians and surgeons worldwide.
Each review offers detailed information on
every aspect of a particular disease that
is suitable for medical students up to fully
trained specialists.
Revision
aides
General Practice Notebook
(www.gpnotebook.co.uk)
This British resource is written by 8 general
practitioners and specialist physicians and
is aimed at general practitioners working in
the UK who with as little as 10 minutes perconsultation require concise information. It is
not formally peer-reviewed and articles are
not all fully referenced. However, it offers
clear summaries on a huge range of topics
and is ideally suited to revision. For detailed
specialist information it is limited.
Initially compiled as an electronic database
analysing published data in the field of perinatal medicine, it soon expanded to cover
the huge range of medical subjects it does
today. It is named after Archie Cochrane,
a Scottish epidemiologist, who in the late
1970s called for the regular publication of
analysis on all randomised controlled trials. It
is an independent not-for-profit organisation
with specialist working groups based around
the world.
It produces in-depth reviews of all known
randomised controlled trials on a particular
medical intervention. Particular emphasis is
placed on avoiding bias by seeking all trials
regardless of the language of the authors or
whether trials have been published. Trials
are then assessed for good mathematical
design and only valid trials are included.
The combined trial data is then analysed to
create pooled results. The conclusions are
available in many formats including a plainlanguage summary to allow access to a wider
audience. The Cochrane Library is widely
to all references cited can be accessed
directly from links within the article. Any
statistics given are usually qualified with
information on the study from which they
were taken. Where investigations are used
in the diagnosis links are given to figures
explaining how to interpret the results. The
website is aimed at practising doctors and
provides detailed specialist information
written for a North American audience.
www.emedicine.com
Paid-for Resouces
UpToDate (www.uptodate.com)
Although
expensive,
with
yearly
subscription rates for trainees costing $195,
this website provides in my opinion the
most comprehensive information on clinical
medicine, obstetrics, gynaecology and
paediatrics available on-line. The website
offers a data-base of detailed peer-reviewed
articles updated on a yearly based. Each
article provides summaries of the current
evidence on all aspects of disease, from
epidemiology to management. The abstracts
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PassMed (www.passmed.co.uk)
Concise and clear covering a wide range
of material for medical students preparing for
their finals. Although aimed at exam revision
it contains very clear basic information on a
wide variety of medical topics.
For Variety
when
Learning
Podmedics (www.podmedics.co.uk)
Run by a small number of junior doctors
and medical students at Imperial College,
London, this website offers short podcasts on
various clinical topics that are often available
as videos with accompanying slides. The
audio-only versions can also be downloaded
33
I ssu e #3 • O c t 2009
as MP3 files. They are designed for medical
students as an accompaniment to standard
learning tools and provide well-structured
summaries on a range of topics in clinical
medicine.
My Medical Podcasts
(www.mymedicalpodcasts.co.uk)
For more advanced information aimed
at those sitting membership exams in the
UK and designed to enable people to learn
whilst “on the move”, this website offers
a small number, currently less than 15, of
detailed consultant-reviewed podcasts on
clinical medicine. The podcasts are given
by Consultants and Specialist Registrars.
Similar to the previous website it offers some
of the podcasts as videos. Despite the limited
number of podcasts available the information
provided is extremely well presented and
evidence based.
www.studentima.co.uk
Surgical Tutor
(www.surgical-tutor.org.uk)
This website is entirely the work of one
surgeon, Mr Richard Parker, based in
Coventry in the UK. It provides a combination
of short notes of common surgical
pathology with relevant findings on common
investigations. It provides useful information
for those revising for undergraduate medical
examinations.
accompanying video and quizzes to test
and improve the understanding of common
radiology. The material is suited to both
undergraduate and postgraduate trainees.
University of Virginia
The website of the university provides free
tutorials aimed at improving understanding
of common radiological investigatons.
Dermatology
Dermnet (www.dermnet.co.nz)
This vast resource, based in New Zealand,
provides a seemingly limitless supply of
information and clinical images on all things
dermatology.
Other Specialty Information
www.learningradiology.com
Orthopaedics
Wheeless’ Textbook of Orthopaedics
(www.wheelessonline.com)
This extensive textbook is available in
its entirety for free online
.
Whilst this summary is in no way
exhaustive, I hope it offers a brief introduction
to some of the on-line resources available
today. As with textbooks different people will
find different resources work better for them.
If nothing else, perhaps access to paper free
information will reduce the backache caused
by heaving large textbooks to and from the
library.
Dr Matthew Burman
FY2 Doctor
Colchester, UK
For Surgery
WebSurg (www.websurg.com)
The website was created by Professor
Jacques Marescaux and his team at
the European Institute of TeleSurgery
(EITS), France, as a free electronic
resource for surgeons. Focusing on
laprascopic techniques, a wide range of
learning resources is available: to assist
understanding of surgical techniques there
are tutorials starting from basic anatomy,
there are short videos of real cases which
talk the viewer through particular procedures
and other learning tools including recorded
lectures. For those with limited time or
access to particular surgical specialties this
resource provides a valuable opportunity to
watch the latest surgical techniques.
34 a
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Prospect
wants
YOU!
that’s right,
www.websurg.com
we are looking for
new members to join
Radiology
the
Learning Radiology
(www.learningradiology.com)
Prospect
team,
so if you fancy your
hand at editing
or a bit of design,
Another one-man website, compiled by
William Herring based at the Albert Einstein
Medical Center in Philadelphia, USA, offers
a variety of learning tools including lectures,
podcasts available through iTunes with
get in touch at
[email protected]
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I s s u e #3 • O c t 2009
Iraq then
Iraq now.
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