Transitions

Before I pack up for the Christmas break – the last one in uni!!! – some thoughts to round off the past few months. We’ve been running at full pelt, Naruto-style, from placement to placement, after about a 6 month break from clinical medicine for many of us.

Hospital medicine is increasingly about learning to care for older people. I’ll leave you to look up the statistics, but there’s a reason we have substantial (for medical school placements) chunks time on care of the elderly hospital wards.

Transition 1

The transition between community and acute hospital is fraught and full of uncertainty. Discharge planning is such a risk/benefit analysis! Add to that the new peril that if you err on the side of caution, your patient might catch covid in hospital. I was mildly surprised how embedded into specialty training this was, though in hindsight, it’s really not that uncommon. Fascinating to learn about the work of, say, hospital outreach, hospice and rapid response community teams to catch people wherever they might be.

Transition 2

There’s a pun here, but it’s a bit surgical…

But if people in old age medicine seem keen on keeping their patients regular, they really are. It’s possible to approach bowel management somewhat logically, but no one seems to understand it. There must be a better way than sennalactulosedocusatephosphateenema: I haven’t learned it. Being regular, though: important. Eat your fibre while you still can, please.

Transition 3

Everyone comes from a different place. Understanding a person’s baseline is key to discharge decisions. And we in hospital don’t often get to see that because there is such a divide between community and hospital (see 1). I’m realising (late!) that acute hospitals work well for – as the name suggests – acute problems with a defined solution. Patients pass in and out from the category that benefits most from acute medicine to people who need a longer-term vision. It’s just bottlenecks every single step of the way which keep them on acute wards with the slightly useless note “MSFD” (medically suitable for discharge) in the daily review.

Which brings me on a slight tangent to the way we learn medicine traditionally: one thing at a time, considering how they affect a person in isolation. Bodies don’t read the textbook though, and are allowed to have more than one thing going on at any one time. This is increasingly evident in tools like BMJ Best Practice and its “co-morbidities” function which allows you to see how common underlying health conditions affect a presentation or condition. We even joke about it – the laundry list of medications, our incredulous looks when patients say they don’t have any health problems, as if old people were trying to trick us with their good health. How we’re taught to deal with that, though, is still

My Budget Million-Pound Question

What does a “properly” staffed healthcare system look like?

How you get the exact numbers, I don’t know. Maybe it doesn’t matter that much when the NHS has that many unfilled vacancies. But what difference would it make? And what will it take to get us there?

Medical school resources

Widely available – free

 

Not including all the FOAM stuff (LITFL, Geekymedics, numerous podcasts) and the usual stuff: CKS NICE, NICE guidelines, etc. – because there’s so much of that!

 

  • Indextra has been made free until July 2020.
    • Textbooks mainly from the Oxford Handbooks, ABC of… and “At a Glance” series.
    • The layout is deliberately mobile-friendly; I would have preferred something resembling the printed layout more closely.
  • Royal College of General Practitioners undergrad resources
    • Clinical toolkits are organised topically and link to further information
  • BMJ infographics are really well-designed – good for a one-page summary.
  • Learning in 10: short video lectures by Duke University and National University of Singapore

 

Widely available – paid

 

  • Passmedicine: starting from £12/4 months. Classic, and not just for medical school finals. Enough questions to set a good base.
  • Quesmed: More obscure questions than Passmed for £10/month or £35/12 months. Fewer, but trickier questions
  • Pulsenotes: lecture notes for £5/month. Range is still small, but the live events seem pretty decent.
  • Geekymedics: free app with in-app payments. Geekymedics is already a treasure trove, the in-app payments allow you to access the clinical resources in a mobile-friendly format.

 

Access granted via uni

 

 

Other resources

 

 

Aware of gaps – e.g. @brownskinmatters for clinical skin signs on non-white skin – I do need to look for more. Because racism is a cause of preventable deaths!!

MRT CPD: When you must stay and play

This follows on from the previous session on ‘scoop and go’ and refers to the pre-hospital principles of “scoop and go” vs “stay and play”.

Alex T from North MRT delivered this session.

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“When we can’t RAPID ALE” – reasons for delayed extraction

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LAGERRR – a system of organising your time on scene

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Environment/equipment considerations

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Resources, record, report

Clubbing (not that kind…)

Oh, clubbing, the clinical sign that medical students will rattle off without fail… so many things can cause clubbing, but why do they seem such disparate disease processes?!

In today’s episode of “I promise I’m not procrastinating” is a very brief and incomplete trip down some cell pathology!

clubbing

  1. Dickinson and Martin’s 1987 Lancet paper detailing the “megakaryocyte hypothesis”
  2. Atkinson and Fox’s 2004 paper on the role of VEGF and PDGF
  3. Lefrançais et al 2017 on the role of lungs as a site of platelet biogenesis

Questions that I haven’t answered:

  • how does this work in chronic inflammation not centred in the lungs e.g. inflammatory bowel disease?
  • why the predeliction to fingernail beds?
  • …what’s this hypertrophic osteoarthropathy and is it the same phenomenon?

Traumacare 2020: Doing the Essentials Brilliantly

Paramedic Jamie Todd gave this talk at the Traumacare conference 2020 at Stone, Staffordshire as part of the First Aid stream. (I had a sponsored ticket from St John Ambulance.)

 

Apologies it gets a little more disorganised in the second bit. Questions from the audience were also included.

MRT CPD: crowd theory

Our session on crowd theory was done 30 April 2020 by Matt Leopold. Or, as he called it, “Two’s company. Three’s illegal.”

Videos referenced in the session:

Example of a crowd wave surge: crowds behave a bit like… I dunno, particles maybe
Merging crowds during evacuation: architectural features affect crowd flow rates – there tends to be a much denser crowd when rounding the corner
Faster is slower in pedestrian evacuation: when a crowd rushes throuhg a restricted exit, they tend to clump up and actually leave more slowly
Pedestrian-dynamics experiment: when moving against a crowd, it’s easier to follow people who are already moving
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