Committed to Research

Interns in residence

Thursday JMO Tutorials

Westmead runs a Pre-vocational Education program aligned to the JMO Forum syllabus. This is protected teaching time and occurs every Thursday between 1-2pm on Level 2 of the Education Center (unless otherwise notified). Lunch is provided and you need to hand in your page at the door. Please aim to arrive at the Education Centre at least 5 min before the presentation commences. 

If you have any difficulties getting away from your team please let the DPET know. Also if you have any suggestions for different topics or improvements to the education program please contact the DPET directly or via the form below (include your name of you want a response).

FEEDBACK FORM

Term 4 Week 9 - Thurs 8th November
Oxygen and NIV 
OXYGEN THERAPY & NIV
Respiratory AT

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Term 4 Week 8 - Thurs 1st November
Lower Limb TN

ORTHOPEDICS FOR INTERNS - LOWER LIMB INJURIES
Jason Chow - Orthopaedic Senior Registrar

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Term 4 Week 7 - Thurs 25th October
Introduction to Trauma
INTRODUCTION TO TRAUMA
Clare Bouffler - Trauma Fellow

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ORTHOPEDICS FOR INTERNS - UPPER LIMB INJURIES
Jason Chow - Orthopaedic Senior Registrar

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Interpreting AXR JMO TNTerm 4 Week 5 - Thurs 11th October

INTERPRETING AXRs FOR INTERNS
Nandu Dantanarayan - Radiology Registrar

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JMO accordian image 181004Term 4 Week 4 - Thurs 4th October

INTERPRETING CXRs FOR INTERNS
Ismail Goolam - Radiology Registrar

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Unemployed DoctorTerm 4 Week 3 - Thurs 28th September

HOW TO AVOID UNEMPLOYEMENT IN PGY3
Dr Jo Hely, Medical Insights Consulting & Dr Andrew Baker, DPET

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NOTES FROM PRESENTATION

This is advice explicitly for interns who are 12 month away from applying for a hospital position and the central thesis is to start planning now rather than put this off for 6 months

The genesis for this talk – at this point in your careers – was the following observations regarding current RMOs applying for a job this year.

  1. As happy as I am to look over CV’s a month before the interview, at this stage the only meaningful intervention I can make is around issue of presentation, not around the infinitely more important issue of content. If there are things missing from your CV a month before the interview, it is too late to correct it. You need to be undertaking this analysis a year before- not a month before.
  2. At interview, too many applicants made bold assertions, or even timid assertions, but failed to demonstrate "authenticity" (eg I believe communication &/or teamwork is important and I think I am good in these domains). Better applicants provided some examples or vignettes to demonstrate the point, but the best applicant were able to demonstrate they had internalized these values, and had been living them for the past 2 years. To do this effectively you have to have thought about them seriously and practiced them for some time in advance. If you haven’t already, you need to be internalizing these desired attribute right now.

Milestones over the next 12 months
  • Term allocation: In a little while you’ll asked about what terms you want next year. There are not enough of the "desirable" terms for everyone to get everything they ask for - so what it most important to you, both in terms of content and timing
  • College Application: Some of you will be required, or at least expected to join the college. If you haven’t given this any thought, start researching now. Start with the college website and the directors of training in your specialty
  • Other absolute or relative pre-requisites: Each area often has its own little quirks - eg you wont get a surgical skills interview without the GSSE. You wont get a Crit Care SRMO interview without having done or been scheduled to an ICU, HDU, or anaesthetics term. You need to be finding out about these pre-requisites now.
  • Four new terms: You have only four more term changes between now and then. That’s four opportunities to plan how to impress a new group of people and extract the maximum possible benefit from the situation. Maximizing this opportunity requires effort and planning.

What to expect at recruitment time 
  • Annual recruitment is a statewide process directed by NSW Health in accordance with their timetable
  • All applications, interview offers and job offers are controlled by a single statewide on line process
  • All jobs have "Position Descriptions" and "Selection Criteria". You will be required to describe briefly on line, how your application addresses each of the selection criteria
  • Selection for interview is based on CV and your answers to the selection criteria. For most panels the CV is the more important, but failure to adequately address the selection criteria can and will be used as the basis for culling
  • Success at interview should be based on your answers to questions framed around the selection criteria, but will also depend on how well you connect with the panel

3 Key questions
So let's consider three key questions about what next years interview panels might be looking for and what you should be doing over the next 12 months to best match thei expectations
  1. What are they looking for on CV
  2. What are they looking for on Selection Criteria
  3. What are they looking for at interview

What are they looking for on CV?

Some specialties, eg surgery, have explicit criteria for evaluating CV. More often these criteria are less formal, but usually this involves awarding points to different domains, or aspects of your CV; eg continuing self education, teaching, research ,general contribution (particularly to the hospital but also to society).

One of the most important implications of this approach is that at this level, diversity tends to outweigh depth on CV. You often benefit more by scoring some points in all domains, rather than top marks in just one.

Over the next 12 months:
  • physically write up your CV NOW, and then add to it as you go
  • evaluate the deficits,
  • show it to, and take advice from relevant commentators (like directors of training),
  • start the planning and research for plugging the gaps now.

What are they looking for with Selection Criteria?

In general, it is good practice to start a record / diary / logbook now which includes not just specific technical abilities, but non technical; interesting challenges, ethical conflicts, difficult conversations. These speak to the diversity and the maturity of your experience, but are easily forgotten over time and difficult to recall on the spur of the moment at interview. You should get into this habit now.
  1. Communication
    How can you consciously practice and improve communication over the next 12 months? You are probably the best judge of this but he first step is to ask the question and the best time is now. Here's a few thoughts:
    • Start consciously practicing - Specifically practice ISBAR
    • Tell your Reg /boss that you want to practice presenting patients in handover situations and ask for critique
    • Force yourself to confront conversations which you otherwise try to avoid. Spend a bit of extra time with that difficult patient
    • Look out for courses / workshops aimed at improving communication (eg we run a breaking bad news session -make every effort to be there)
    • Can you contribute to communications skills acquisition during intern orientation, or medical student teaching
    • Ask for critique of your written documentation – especially discharge summaries
    • Try to become an expert – does the hospital have a documentation audit procedure and are they looking for auditors
    • Use the Rover and term handover process to improve you communication. Make sure your Rover forms reflect optimum communication ability

  2. Teamwork
    How can you consciously practice and improve teamwork over the next 12 months?
    • Simple things like introductions and learning names
    • ORIENTATION - Learn yours and other's roles and expectations. Force rather than avoid the issue of medical orientation with your term supervisor & make the effort with nursing & Allied Health
    • Involve yourself in things which promote team work eg Rovers and Term Descriptions
    • Participate in MDTs. These may not always be required by your role, but if not attend some anyway
    • Join in other simple things birthdays & team building activities
    • Try to draw students into your team
    • Walk the talk – be known as the person who helps out your colleagues
    • Recognise the people on the periphery of your extended team who contribute to your role eg in pathology, imaging outpatients etc

  3. Ongoing learning and Self Education
    Apart from the planning of the obvious things – like courses and higher qualifications
    • Plan for what you might want to get out of each term between now and the interviews
    • What reading should you do before hand when you change terms
    • Think about learning objectives. Your term supervisor should recognizes that you are behaving not just as a blank canvas but someone with clear goals
    • What quality audits and departmental process can you get involved in
    • Try seeking out your new term supervisor in advance of term
    • You can even plan active learning in your relief term, if for know other reason than this will often give you some spare time to achieve some goals

  4. Teaching
    • Talk to the clinical school now – leaving it to early in the new year is too late for their planning cycle
    • Try to get formal qualifications
    • Look out for “Teaching on the Run” or similar courses
    • Look out for other teaching opportunities – nurses? Simulation? ALS instructor etc etc

  5. General Contribution
    • Look out for the hospital committees
    • turn up to PCTC regularly
    • get involved in Intern Orientation
    • become a mentor
    • look out for specific or generic quality improvement projects
    NB when it comes to topics like quality improvement, do some research NOW so you can integrate this into your practice, rather than leaving it to next year to find out about topics like "clinical governance" and "medical error" and "open disclosure" and "quality improvement" and "patient safety" . Start looking at the CEC, ACI & ACSQHC websites now

What are they looking for at interview?

The best thing to be doing is asking people now – while its still fresh in their minds. If you can, seek out the opinions of panelist & of people who have recently been interviewed and look at the questions that were asked. The questions are revealing. More often than not they are aimed not at specific selection criteria, but at “what sort of person are you” and “how well will you fit into our team”, and what is considered desirable is a well rounded “authentic’ person.

VTETerm 4 Week 2 - Thurs 20th September

VTE PREVENTION PROGRAM
Andrew Baker - DPET

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Term 3 Week 8 - Thurs 23rd August

A QUESTION OF QUALITY
Andrew Baker - DPET

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Urology TNTerm 3 Week 7 - Thurs 16th August

UROLOGY 101
Kieran Beattie - Urology AT

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Fever2Term 3 Week 6 - Thurs 9th August

FEVER
Sue Maddocks - Infectious Diseases Staff Specialist

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PregnancyTerm 3 Week 5 - Thurs 2nd August

COMPLICATIONS OF EARLY PREGNANCY
Amy Goh - O&G Senior Registrar

  • DOWNLOAD THE PRESENTATION
  • LISTEN TO THE AUDIO

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Anticoag pathwaysTerm 3 Week 4 - Thurs 25th July

ANITICOAGULATION
Gajan Kailainathan - Haematology AT


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antimicrobial2Term 3 Week 3 - Thurs 19th July

ANITIMICROBIAL
Matthew O'Sullivan - Infectious Diseases Staff Specialist


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Sats ProbeTerm 3 Week 2 - Thurs 12th July 

OXYGEN DESATURATION
Giles Miller  - Staff Specialist Anesthetist


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RACP TNTerm 2 Week 10 - Tues 19th June 

RACP PRESENTATION - WHAT TO EXPECT IN YOUR RMO YEAR
Isabel Roos, RACP Medical Support Officer

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bp TN.jpgTerm 2 Week 9 - Thurs 14th June 

Hyper and Hypotension
Dr  Giles Miller, Staff Specialist Anaesthetist

Gastroscopy TN.jpgTerm 2 Week 8 - Thurs 7th June 

GI BLEEDING
Dr  Raj Uchilla, Gastro AT

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AnaestheticsTN.jpgTerm 2 Week 7 - Thurs 31st May 

PERI-OPERATIVE ANAESTHESIA
Dr  Anne Marie McCallum, Staff Specialist Anaesthetist

ConsentTN.jpgTerm2 Week 6 - Thurs 24th May

SIMPLE MEDICO-LEGAL PROBLEMS
CONSENT, CERTIFICATES, CORONER AND CONSTABLULARY

Dr Andrew Baker, Director Pre-vocational Education & Training


SYNOPSIS


Today’s topic is intended to cover some of those policy/admin/legal topics that interns tend to run into and get confused by.

Consent
Everything we do to patients requires their consent. Without consent our actions would leave us open to being sued. For consent to be valid, it needs to be “informed” – that is the patient needs to be provided with adequate information about what is intended to be done and the accompanying risks. It is a fact, that when things go wrong, one of the commonest grounds on which patients sue, is failure to provide adequate consent.

For this reason, NSW Health consent policy (PD2005_406) is that it is the responsibility of the admitting doctor and should not be delegated to interns. Interns should be aware of the policy, be able to find it quickly, when required (google NSW Health consent policy) and NEVER become involved in consent, other than for minor procedures, if you do not know enough yourself to provide adequate information to the patient.

Although we do not see many children at Westmead, it does happen occasionally, and consent becomes a little tricky with minors. For now, the main thing to remember is that under the age of 14, parental consent is required, for age 14 and 15 it is NSW Health policy to seek consent from both the child and a parent, and at age 16 and above, only the patient can consent. Interns should be aware that patients are entitled to deny consent for treatment, and (assuming they have capacity) we are required to respect this choice, even if it does not seem to be in the patient’s best interest. However, you should also be aware that parents are NOT legally entitled to deny treatment for their children.

What if the patient is unable to give consent?
This is another tricky area which interns may have to navigate. Patients may be unable to consent because of their acute illness (ie they are unconscious), or due to diminished capacity. In either event the provisions of the Guardianship Act apply and interns should be broadly aware of the effect of this legislation. In a nutshell, it specifies that in an emergency, consent is not required. In less urgent situations it sets out a hierarchy of individuals who are entitled to consent on behalf of the patients ie
  • Appointed guardian
  • Spouse (or partner)
  • Carer
  • Friend or relative (who has a close personal relationship

Advanced Care Planning and Resuscitation Plans
Consent with regard to treatment at the end of life is another area which can create difficulties for interns. Like out generic policy on consent, our policy for Resuscitation Plans places the responsibility on the Admitting doctors and prohibits interns from acting independently in this regard. You will all come to realise, during your after hours shifts the distress which can be caused to staff family and patients if resuscitation plans are not completed when they should have been, so interns should be advocates for their patients in ensuring that, when appropriate, a resuscitation plans has been completed.

Police
Interns may encounter enquiries from the police in a variety of circumstances. They may make an informal request for information in the process of undertaking an investigation. You should always be circumspect in providing patient information to any third party – even those who may have a right to that information. Usually, police requests for information should come through a formal channel. If in doubt you should escalate your concern to someone more senior.

A request coming through a formal channel often takes the form of a police statement, which will usually take the form of a statement of your involvement with the patient. You should not ignore these requests. If police don’t receive a response you are likely to be subpoenaed to give evidence in court, which might sound exciting, but is generally not an enjoyable experience. In a police statement, or in court appearance, you should always stick to a recitation of the facts, rather than be drawn in to offering an expert opinion. You are not yet an expert!

Error, litigation, investigation and the Coroner.
Sometimes interns get caught up in events which they worry will result in some form of investigation and possible sanction. No matter what the investigation, high quality documentation is always a protection, and, like James Comey, it is useful to make your own contemporaneous notes, bearing in mind that most investigations take a long time to bear fruit. Don’t forget to inform your Medical Defence Union and also tell someone in Medical Administration. You should remember that you are also legally covered through the hospital’s indemnity – but for this to occur, the hospital needs to know about the events.

The sorts of enquiries which can occur are:
  • Root Cause Analysis - An in-depth investigation conducted by the hospital aimed at identifying the underlying root causes of serious adverse patient events. The hospital’s investigators may wish to talk to junior staff, to get your perspective. You should be aware that it is beyond the scope of these investigations to assign individual blame, and they usually take 2-4 months before you will hear of any outcome.
  • Health Care Complaints Commission – An independent statutory body charged with investigating complaints (usually from patients or families) about doctors. If you were involved in the care of a patient who has made a complaint to the HCCC it is likely that they will ask you for a statement. While you are legally obliged to respond to such a request, you should ensure that the hospital is also made aware of the request and you should consult with your Medical Defence union before submitting your response.
  • Coroner’s Court – Of all the cases referred to the coroner, only a tiny fraction result in a full inquest, so the likelihood of you ever being involve in the coroner’s court is low, and if it does occur, it will be at least 2-3 years after the death of the patient. If you are called as a witness, make sure you have adequate support. The coroner’s court is a surprisingly adversarial environment and can feel highly threatening to junior medical staff.

Death Certificates
Technically you do not write a “Death Certificate”. A Death Certificate is a document produced by the Registry of Births Deaths and marriages. Doctors are required to write a Medical Certificate of Cause of Death, which is sent by the hospital to the Registry of Births Deaths and Marriages and transcribed onto a Death Certificate.

Interns may get confused about when they can and can’t write a Medical Certificate of Cause of Death. Never having treated the patient prior to death is NOT a reason for declining to write one. Indeed it is our policy that the certificate should be completed by which ever staff is available at the earliest opportunity. Commonly this will mean the after hours interns. Most of the time you should be able to deduce the cause of death from the notes and the clinical circumstance. If you are very unsure, you should discuss with the admitting doctor, before reporting to the coroner that the cause of death was unknown. Remember that the degree of certainty is not high. You only have to be convinced “on the balance of probabilities”

There are a variety of mandatory reasons for deaths to be reported to the coroner – all of which are documented on the Coronial checklist. Those which commonly catch interns out are:
  • Prisoners
  • Patients who came in after an MVA and whose death occurs after a lengthy admission and seems unrelated to the MVA
  • Patients from a Mental Health facility
  • Patients who did within 24hrs of an anaesthetic is NOT a reason for mandatory reporting. Although this ceased being the law almost a decade ago, it is still a powerful myth that all anaesthetic deaths need to be reported to the coroner. If the death was causally related to the anaesthetic then we would need to report (irrespective of timing with the procedure), but it is no longer mandatory to report all deaths occurring within 24 hrs of an anaesthetic.

Occasionally interns make minor errors on Medical Certificates of Cause of Death and are asked by families to correct them. Under these circumstance, you are able to write an amended certificate, label it a duplicate and ensure that it is sent to the Registry of Births Death and Marriage, from whom the relatives can request an updated Death Certificate.

For further information about Death Certificates, see Orientation Information, under Clinical Processes and Systems

DiabetesTN.jpgTerm 2 Week 5 - Thurs 17th May 

TYPE 1 DIABETES
Dr  Sylvia Lim-Tio, Staff Specialist Endocrinologist


VFTN.jpgTerm 2 Week 4 - Thurs 10th May 

ECGs - TACHYARRHYTHMIAS
Dr  Sumita Barua, Cardiology Advanced Trainee

BradyTN.jpgTerm 2 Week 3 - Thurs 3rd May 

ECGs - BRADYYARRHYTHMIAS
Dr  Dinesh Selvakumar, Cardiology Advanced Trainee


InsulinTN.jpgTerm 2 Week 2 - Thurs 26th April 

INPATIENT DIABETES - REVISITED
Dr  Jasper Sung, Endocrinology Advanced Trainee

ToxicologyTN.jpgTerm 2 Week 1 - Thurs 19th April 

INTRODUCTION TO TOXICOLOGY
Dr  Naren Gunja, ED Physician and Toxicologist


Fluids.jpgWeek 9 - Thurs 5th April 

FLUID MANAGEMENT
Dr  Vincent Lee, Staff Specialist Renal Physician

Delerium.jpgWeek 8 - Thurs 29th March

ASSESSING AND MANAGING DELERIUM
Dr Henry Muang, Geriatrics AT

 

Abdo Pain.jpgWeek 6 - Thurs 15th March

ASSESSING ABDOMINAL PAIN
Dr Benedict Kakala, Surgical Skills Trainee

Synopsis

Key Concept
Try to think of the different regions of the abdomen, linking the site of the abdominal pain to the underlying anatomy and related pathology. Click here for a comprehensive differential diagnosis by region from Life in the Fast Lane

What should you be thinking of (& what should worry you the most?)
  • Most abdo pain on after hours shifts will be mild or recurrent, but beware of acute severe pain of recent onset, or associated hypotension, fever or peritonis
  • Life threatening causes of acute abdominal pain include leaking AAA, ruptured ectopic, perforated or necrotic viscus, or intraperitoneal septic focus
  • Remember some medical problems can present as abdominal pain, such as ACS, Basal PE, DKA

History
  • Nature, Onset, Duration and Character of pain. How is it described, does anything make it better or worse, is it localised or diffuse, constant or intermittent
  • Has the pain changed, moved or radiated anywhere
  • Are there associated symptoms: ask about nausea and vomiting, bowel or urinary symptoms
  • Ask about fever or rigors and check temp. Is the patient on antipyretics or steroids which might mask a fever?
  • Is there a previous history of abdominal surgery or recurrent abdominal pain
  • Always check when they last ate or drank
  • For female, document the LMP
Remember that when you ring your registrar – these are all question they will want to know the answers to!

Examination
  • On inspection you should note the general shape and contour of the abdomen. Is there any distension, localised swelling, old scars or wounds, discoloration – such as erythema or jaundice. Are there any hernias or masses, drains or IDC?
  • Auscultation: Listen for bowel sounds: Normal range is every 2-5 sec. Hypoactive may suggest peritonitis. Hyper active is more typical of obstruction. Aneurysm may be associated with a bruit.
  • Percussion: Tympanic suggest presence of air. Dullness may be fluid or masses. Loss of liver dullness can indicate free air in peritoneum.
  • Palpation: Examine each region systematic starting with light palpation trying to elicit tenderness or signs or peritonism (guarding, rebound tenderness, rigidity), which would always be a reason for rapid escalation. Deep palpation to elicit any masses or hernias. Can you ballot the kidney or spleen?

Investigation
  • Bloods: FBC, UEC, LFTS, Lipase, VBG (for Hb, lactate/ph/BE), Beta HCG
  • ECG: To exclude ACS
  • UA
  • Imaging
    • CXR – looking for evidence of free air or basal lung pathology
    • AXR – not essential: only if clinical suspicion of pathology which will be demonstrated on AXR such as obstruction, kidney stones
    • Ultrasound – Useful to diagnose rule out AAA, ectopic pregnancy and to visualise biliary disease, and uretolithiasis
    • CT – with oral contrast

Treatment
In the after-hours situation, the sorts of management that interns will usually initiate are: analgesia and antiemetics, NBM & IVF. You would also be thinking about if an NGT was necessary or an IDC. You may need to commence antibiotics or PPI. You should always be thinking about the need for escalation to your surgical registrar, or whether criteria for PACE/ALS have been met. You should also be thinking about disposition, bearing in mind that surgical patients often need further imaging, possibly radiological interventions, transfer to theatres, HDU or ICU.

Useful Resource

Pain.jpgLAST WEEK: Week 5 - Thurs 8th March

MANAGING ACUTE PAIN
Dr Richard Halliwell, Staff Specialist Anaesthetist & Director Acute Pain Service


Managing Pain - Synopsis


Under Construction

dyspnea.jpgWeek 4 - Thurs 1st March

ASSESSING SHORTNESS OF BREATH
Dr Archit Chawla, Respiratory AT


Assessing Shortness of Breath - Synopsis


Key Concepts
Dyspnoea is a subjective sensation of breathlessness, and is different from tachypnoea and hypoxia. It is a frequent complaint for ward review calls and hospital presentations. Given it can be a manifestation of pathologies involving airway, breathing or circulation, you need to be able to work up undifferentiated dyspnoea and manage acute and potentially life-threatening medical conditions that cause this.

Over the phone
  • Onset and severity of dyspnoea? Sudden onset or worsening needs urgent review.
  • Vitals - Note that while Sp02 is important, you also need to ask for FiO2.
  • Check AB&C are all intact. Are PACE/ALS criteria being breached? If so, initiate PACE/ALS.
  • Establish reason for admission and relevant background medical history
  • Think about organising investigations or commencing therapy over the phone: e.g. O2 therapy, bronchodilators, ECG or organising IV trolley

What should you be thinking of (& what worried you the most)
  • Common causes will include exacerbation of Asthma, COPD or ILD, pulmonary oedema, ACS, Aspiration/Pneumonia
  • Life threatening conditions include acute Coronary syndrome, PE, Pneumothorax, Cardiac Tamponade, Upper Airways obstruction, Anaphylaxis and Aortic Dissection
  • Uncommon but worth thinking about: Anxiety, compensation for metabolic acidosis (often cause more tachypnoea than dyspnoea)

On the Ward
  • Often may need to start with a brief screening exam before going back to history. Does the patient look unwell? Cyanotic, agitated, drowsy? Hunched over, slouched?
  • Are there associated symptoms? Chest Pain, cough, haemoptysis, fever, wheeze,
  • Comprehensive A-I assessment: A, B, & C then (D=disability/ GCS, E=Exposure, F=Fluids, G=Glucose, H= Haematology, I=Infections)
  • Check med chart. Have routine meds been altered? Have new drugs been commenced? How frequent is PRN medication use (e.g. salbutamol)?
  • Check team notes to compare what patient has been like, or if plans are in place in the event of a review call (including AMP)
  • Obvious red flags: acute onset, worsening O2 requirements, altered mental state, Obs outside the flags. Note that RR of >40 can not be sustained for long before tiring.

Investigation
No hard/fast rules RE: which ones absolutely must. Strongly consider:
  • ECG
  • CXR: Need to think about safety of transfer to Radiology for CXR (ALS during transfer or unsupervised transfer will often have worse outcomes for the patient)
  • ABG (my number one blood test for any one critically unwell for any reason)
  • FBC, UEC. Do Troponins /Coags if ACS is suspected
  • Consider CTPA if PE is suspected
  • Spirometry: use in chronic dyspnoea. Avoid in acute – contraindicated in PE, ACS, severe wheeze)

ABG Interpretation:
  • Look at pH, pCO2, pO2, HCO3, lactate, FiO2.
  • Differentiate between metabolic vs. respiratory causes of derangements, and address each pathology.
    • For hypoxia, use P/F ratio and A-a gradient
    • For hypercapnia, assess compensation with pH (pH < 7.35 with pCO2 > 45 generally means B5B admission for NIV). Discuss with Respiratory failure (24 hours) if concerns.
    • For metabolic acidosis, work out high vs. normal anion gap. For high anion gap, work out delta ratio.
  • P/F ratio (PaO2/ FiO2): use to address degree of hypoxia and monitor progress
    • E.g. Patient 1 with Spo2 99%, PaO2 80mmHg on 40% FiO2 (P/F ratio 200) is MORE HYPOXIC than Patient 2 with SpO2 90%, PaO2 60mmHg on 24% (P/F ratio 250)
  • A-a gradient is a measure of gauging adequacy of oxygenation with respect to the degree of ventilation and supplemental oxygen. Can be used to decipher causes of hypoxaemia. Estimate of normal value is (Age/4 + 4) OR (10 + 1 for every decade of life)
    • E.g. hypoxia with normal A-a gradient implies hypoventilation (e.g. drowsy patient with low respiratory rate). Same degree of hypoxia with an elevated A-a gradient implies pulmonary parenchymal or vascular pathology (e.g. hypoxic/ tachypnoeic patient with PE)

Treatment
  • Oxygen is a treatment for hypoxia and not dyspnoea. Target ranges for Sp02 should be 92-96% unless a known C02 retainer or high risk of such, in which case targets will be 88-92.
    • note: SpO2 92% does not mean this is normal, but patients unlikely to benefit from higher oxygen levels
  • Oxygen delivery devices:
    • Nasal prongs can deliver up to 35-40% 02 (allow 3% for each extra lpm)
    • Hudson mask can deliver 35-50% 02 with 6-10 lpm. Use minimum 6L
    • Venturi Mask gives a more precise FiO2 than Hudson.
    • Non Re-breather for emergencies when 100% O2 required. Requires high flow (12-15 L/min).
    • High flow nasal prongs: in HDU settings mostly. Allows humidified air at high flow rates (gives some PEEP in addition to high FiO2)
    • NIV (CPAP or BiPAP): in HDU settings. Useful for APO, COPD
  • What is your follow up strategy following review?
    • Assess risk of further deterioration
    • Escalate concern and medical handover to medical registrar as required
    • Is the patient suitable to remain in current ward? Note, FiO2 requirements > 40% or salbutamol use < 2hourly need to be in HDU
    • How frequently should obs be performed if patient is staying on your wards
    • When do they need a follow up review to ensure stability?
    • Do patients need a change in PACE/ ALS criteria or an updated AMP?

Pearls for common conditions:
  • Asthma – Can deteriorate suddenly (past history of exacerbations is a good guide). Need for <2 hrly salbutamol or rising Co2 are worrisome signs. Call for help early.
  • COPD – Prior Spirometry FEV1 is useful in predicting how unwell the pt might be. High risk of hypercapnia with low FEV1 (usually < 1L)
  • ILD – Can have very high 02 requirements. Tachypnoea is common, Hypercapnia is not (unless end stage)
  • Cardiac causes – Pulmonary oedema is common! Consider coronary risk factors when suspecting ACS.
  • Aspiration and Pneumonia – look at the airways on CXR / CT

TAKE HOMES
  1. Treat dyspnoea calls as high priority
  2. Be systematic with your assessment (A-I approach) to assess aetiology and severity.
  3. Consider pre-test probability in working out underlying aetiology. Always consider the need to rule out ACS/ PE (common life-threatening causes).
  4. Escalate if concerned. False alarms are MUCH better than missing a deteriorating patient. Don’t forget the ‘post-review-call plan’ and appropriate medical handover.


Shortness of Breath - Reflections

Thanks for your presentation Archit. As a Respiratory AT, you must see the best and worst of interns when it comes to their approach to acute shortness of breath. With this in mind I have a few questions

  1. What common mistakes do you see interns making, or what are areas worthy of improvement?
    • Failure to carry out a systematic assessment of patients.
    • Escalating concern without appropriate medical handover of patients. When asking for advice from registrars, try and get in the habit of performing your own history/ exam +/- investigations, then posing your differentials and management plans to the registrar for confirmation as opposed to asking open ended questions on how to proceed.
    • Not making follow up plans following initial review

  2. What advice can you give about when it is critical to contact the registrar
    • if you note any red flags (see notes)
    • if there is significant JMO/ nurse or patient concern
    • Alert the medical registrar if you think there is a need for Respiratory failure team (24 hrs on call) to be involved

  3. How much should interns they do themselves?
    • There is no correct answer. If you’re uncomfortable or just need to be double sure, ask for help.
    • Stat doses/ once-off medications can be done on your own.
    • if regular medications need to be commenced, e.g. antibiotics/ anticoagulation, registrars +/- consultants need to be aware.

  4. What do they universally fail at when consulting Resp Reg.
    • Interpreting investigations and understanding their role in working out underlying aetiology of dyspnoea

  5. Do you have any tips for good resources to help understanding ABGs, PF Ratio, A-a Gradient etc.

  6. Other good resources
    • Wikipedia/Youtube are always a good start! Consider the BASIC course for understanding crirically unwell patient.

Week 3 - Thurs 22nd FebruaryCGU Logo TN.jpg

CLINICAL GOVERNANCE FOR INTERNS
Dr Andrew Baker DPET




Clinical Governance - Synopsis


The actions of well trained and well meaning clinicians do not automatically equate to safe high quality patient care. Even if doctors did not have their own foibles or blind spots, the complexities of modern health care systems will always give rise to the possibility of medical error and patient harm. Working together to plan means of avoiding this and improving health care outcomes is the focus of clinical governance.

Definition
While the principles have been around for a long time, the term “Clinical Governance” became popular at the turn of the millennium, particularly after investigations into a health scandal at Bristol Royal Infirmary. This concluded that the hospital’s administrators failed to ensure that there were basic systems in place to monitor quality and identify problems. This was the birth of the modern clinical governance movement defined as “the framework or system by which clinicians, working in partnership with administrators, organise the provision of healthcare to result in high quality clinical outcome”

Regulatory Response
In NSW, as around the world, there have been a variety of regulatory and organisational responses. In the early 2000s the forerunner of the Clinical Excellence Commission was established and individual NSW hospital were required to establish Clinical Governance Units, with Directors of Clinical Governance appointed as members of the hospital executive.

State Wide Quality Initiatives
Many standard clinical routines which interns will encounter today have been developed on a statewide basis over this timeframe, either by NSW Health or the Clinical Excellence Commission. These include:
  • Blood Transfusion Guidelines
  • Incident Reporting Systems
  • Time Out
  • Hand Hygiene
  • Between the Flags & Standard Adult General Observation (SAGO) Chart
  • ISBAR & Clinical Handover
  • National Inpatient Medication Chart (NIMC), Medication Safety & Antimicrobial Stewardship
  • Falls Prevention
  • Sepsis Kills Program
  • VTE Prophylaxis and Risk Assessment

Hospital Clinical Governance Activities
Within hospitals a wide variety of activities have been promoted under the banner of Clinical Governance
  • Employing appropriately trained staff: eg Credentialing / Performance Review/Competency training / Entrustable Professional Activities
  • Incident Reporting: eg IIMS, Root Cause Analysis, Critical Incident Review, Complaints management
  • Defining & measures outcomes: eg Data collection, chart audit, clinical indicators, KPIs
  • Peer Review: eg M&M, Death Audit
  • External review: eg Accreditation, benchmarking
  • Reduction in variation: eg MDT, Policy & Protocols, Clinical Pathways, Standardised Charts)
  • Evidence Based Medicine
  • Development of quality culture and leadership

Intern Involvement
Interns will typically become involved in Clinical Governance through IIMS, interaction with Patient Safety Officers, participating in critical incident investigations, being involved in audits and data collections, discharge summary review, M&Ms, compliance with the many CEC/hospital policies around quality and safetyMaking a differenceWhile much of the planning and organisation which is essential to clinical governance may seem remote to the junior medical staff, interns can still make a difference by:
  1. Participating in their own organisational committees – like PCTC
  2. Promoting a culture of quality, by:
    • Role modelling
    • Being a patient advocate and promoting safe practices to other team members
    • Being aware of their own limitations, only carrying out procedures for which they have been trained, and knowing when to escalate issues to their seniors
  3. Adopting safe work practices
    • Prevention of nosocomial infections through hand washing
    • Reducing medication errors by having ready access to prescribing information and always checking and documenting allergies
    • Reducing errors of communication through the use of structured handover processes (including discharge summary), and escalating problems to seniors in accordance with policy
    • Prevention of VTE through risk assessment and prophylaxis
    • Prevention of falls, by being aware of the falls risk assessment
    • Understanding and complying with the clinical emergency response systems, knowing the between the flags criteria

Resources
Clinical Excellence Commission website
Australian Commission on Safety and Quality in Health Care website
UK National Institute of Clinical Excellence (NICE) website

Week 2 - Thurs 15th FebruaryDiabeteslogoTN.jpg

HOSPITAL DIABETES MANAGEMENT
Dr Sylvia Lim-Tio - Endocrine Staff Specialist


Hospital Diabetes Management  - Synopsis


Glycaemic control in hospital is important because hyper and hypoglycaemia are both associated with increased inpatient Mortality, Morbidity and Length of Stay. A broad overview of the general approach to inpatient diabetes management is outlines in the attached handout - "Inpatient Diabetes Management"

Identification
As an intern you will never be allocated to the endocrinology team, but diabetes is still an extremely common co-morbidity for patients under all other teams. You may be alerted to the fact that your patient has diabetes because of their documented history, or an HBA1c of >6.5% or a random BSL of >11mmol/l.

Assessment
In assessing the known diabetic inpatient interns should consider:
  • Type I vs Type II - important because inpatient treatment differs
  • Glycaemic  Control
    - for diabetics we do BSLs before and after meals overnight and fasting
  • Risks for Hyper/Hypoglycaemia 
  • (eg Oral/enteric intake, Sepsis, Ischemia, Steroids, Changes in mobility)
  • Targets for therapy BSL 5-10, Avoid hypos, Avoid DKA/HHS
  • Preventable Factors Causing Hyper/Hypoglycaemia
    • Insulin missed  or given late
    • Usual Prednisolone not charted of given late
    • Steroid dose increased or decreased
    • Enteric feed started/increased/ceased
    • Wrong insulin charted (for instance, its easy to confuse different variants of Humalog)

Insulin initiation
Hospital admission may be the point where poorly controlled diabetes is first detected, or diabetes which is normally well controlled may deteriorate, either because of the illness for which the patient was admitted, or its treatment. In either case interns should be familiar with the anticipating these possibilities and knowing the indications for and process of initiating a basal bolus regime. These are described on the attached handout  - "Commencing Basal Bolus Insulin"

Once commenced interns should be aware of the necessity to review the pattern of blood sugars daily and the principles of titrating both basal and bolus doses in response to blood sugars.

Ins-Dex infusionTN.jpgInsulin dextrose infusion
Diabetic patients who are fasting –eg perioperative patients – may need an insulin /dextrose infusion. Interns should be familiar with the indications for this, how to commence an infusion, when to stop other medications, and when to recommence them, while transitioning off the infusion. This is documented on the Algorithm for Insulin Adjustments Chart 

Discharge Planning
If an inpatient had been commenced on insulin in hospital, interns should be thinking about discharge plans which may involve reverting to the admission medication, or continuing on insulin, either basal bolus or pre-mix. In the case of the latter, the Endocrine service will need to be involved and will need to be contacted with adequate warning – ie 48hrs beforehand. 

Summary
All of the above are common problems and considerations with which interns will face frequently with their diabetic inpatients. With all of these, you will start this year seeking advice from your registrar and/or the diabetic consultative service, but with experience you should find that by the end of the year it would be reasonable for you to be able to initiate a basal bolus regime, monitor and titrate accordingly, and start and stop a variable rate insulin dextrose infusion for your perioperative patients with a degree of autonomy.

Resources:
JMO Handbook - Inpatient Diabetes Managment
JMO Handbook - Complete Endocrinology Chapter
JMO Handbook - Surgical Endocrinology
On the wards podcast  - Type 2 Diabetes
On the wards podcast - BSL Management on the Ward
On the wards podcast - Perioperative Management of Diabetic Patients
Australia Diabetes Society Perioperative Diabetes Management Guidelines

Week 1 - Thurs 8th FebruaryChest Pain TN.jpg

THE PATIENT WITH CHEST PAIN"
Dr Sumita Barua - Cardiology AT

Chest Pain - Synopsis

Over the phone
  • Vitals (HR,BP, RR, Temp). Ask the nurses to do an ECG. Background – why are they in hospital. Significant cardiac history?

What should you be thinking of (& what worried you the most)
  • Pain can be Cardiac, Respiratory, GIT, Musculoskeltal and even Psychiatric 
  • Life threatening conditions include STEMI, Aortic dissection, PE, Tension Pneumothorax, GI bleed

On the Ward
  • Quick review of Observations, EMR and ECG. 
  • If there is an obvious STEMI call an ALS straight away

At the bedside
  • Are they stable and well or unstable and unwell? If unwell (eg increased RR, decreased level of consciousness, pale & clammy) escalate straight away

The History (should only take 2-3 mins)
  • Nature of the Pain. 
  • Questions related to other life threatening causes (eg Wells Criteria, Back Pain, other GIT history symptoms). 
  • Questions related to other differentials.  Risk Factors and past medical history.
  • If this is cardiac pain it is very likely they have had previous exertional ischemic pain. How does this compare?
  • What is their normal function like? (& is there a resuscitation plan?)

Examination
  • JVP elevated? Trachea Midline, Breath Sound both sides, added creps or crackles?
  • Obvious heart murmers? Muffled heart sounds
  • Tenderness to palpation – chest or abdomen
  • Calf swelling? Pitting oedema?

ECG (once more with feeling)
  • Rhythm –  P waves before each QRS? QRS broad or narrow? ST isoelectric, elveted or depressed, T waves - flipped since admission
  • Take the time to compare with previous ECGs : Lead by Lead! (NB: previous ECGs are filed in ECG documents under Clinical notes in the EMR)

Bedside Treatment
  • Depending on your differential - O2? Analgesia? (GTN, Gastorgel, Morphine), Antiemetics?

Investigation
  • CXR
  • Bloods FBC, UEC, LFTs & Lipase, Coags, CRP, ABG/VBG. 
  • Troponin will be required if you think pain is cardiac but should be discussed with registrar. Can always be added on to UEC
  • NB: Many sick patients in Westmead for other reasons will have an elevated troponin
  • Repeat ECG (looking for dynamic changes)

Call your Registrar
  • ISBAR handover and don’t hang up until you have an agreed  plan 
  • Are other investigations required and who will chase the results?
  • If PE suspected and CTPA ordered should clexane be commence?
  • Should antiplatelet therapy be commenced
  • Does the patient need to be moved to a higher level of care
  • What is the plan for review
  • What it the plan for handover at the end of shift

TAKE HOMES
  • If you are worried – call for help early
  • If you are thinking about STEMI, OPE, Pneumothorax, UGI Bleed or dissection call for help straight away – don’t wait 20 minutes to finish your assessment of the patient
  • Once you have finished the assessment, make sure you have a plan which includes follow up and handover


Chest Pain - Reflections



AB:
That was a great practical talk for JMOs, Sumita – I just wanted to follow up a few issues. How common a clinical scenario is the one we discussed today in the life of an after- hours intern?

SB: It doesn’t happen every shift but, it’s not at all uncommon. It’s certainly a topic new interns should very clear about.

AB: And how often does it turn out to be cardiac pain

SB: At Westmead – other than on the Cardiology ward - most calls for chest pain won’t turn out to be cardiac in nature. Pulmonary pathology of some nature is probably more common. A new STEMI on the ward (other than A5) is actually very rare.

AB: All the same, if the first thing an intern sees when they get to the ward is an ECG with obvious STEMI, then what is the appropriate form of escalation?

SB: As an intern you need a senior person there to help immediately. The best way to achieve this is via an ALS call. The trouble with a PACE call is that the registrar might take up to 30 mins to arrive, and a STEMI demands a more rapid response. If the appropriate registrar happens to be on the spot, this would be appropriate escalation, but otherwise, you will never be criticised for calling an ALS for a patient with known chest pain and a STEMI on ECG – even before you see the patient.

AB: You seemed to be against ordering troponins before discussing with a med reg.

SB: As ATs we are asked to review a large number of elevated troponins. The trouble is that the significance really depends on the pre-test probability, so we are keen NOT to order them unless this is high. This means that if you think a troponin is indicated, you really should discuss it with your registrar first.

AB: For patients with ACS, GTN is one of the treatments interns might initiate. When should they be hesitant about doing so?

SB: The most important situations which interns should know about is hypotension, and non-cardiac pain. GNT should be withheld in inferior and posterior infarcts as well, but given that these should have been escalated to an ALS, this should be a registrar – not an intern – decision.

AB: In your experience as an AT – what are the biggest problems interns encounter when assessing chest pain, and what annoys you the most when they ring you.

SB: When it comes to cardiac patients, the management which interns might initiate would involve oxygen, analgesia (GTN, morphine), and aspirin. Interns should take care with GTN in hypotensive patients, they should remember about anti-emetics when prescribing morphine, and they should think carefully about aspirin in post op patients

SB: As an AT one of the most annoying things I notice is junior staff omitting key parts of the relevant cardiac history, like relevant medications, especially anticoagulants.

AB: You mentioned a “Med Calc” App twice – once for Wells Criteria and once for A-a gradient. Which one do you use?

SB: I think they’re all probably much the same, but I use Med CalX (link below)

AB: If they want to do some extra reading what do you recommend?

SB: It’s hard to go past Life in the Fast Lane which has a great ECG library and good summaries of all the common causes of chest pain

Links

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