Student Iraqi Medical Association United Kingdom: Prospect Journal Issue # 3

I ssue #3 O ctober 2009
www.studentima.co.uk
I ssue #3 O c t 2009
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. 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. 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.
CONTENTS
Editorial United we Stand, Divided we Fall The Case Features Pre-Hospital Care Accident & Emergency The Pharmacological Management of the TBI patient Food for Thought... TBI in the Dentists chair The Beginning of the End Iraq Relief Essay Competition Sami the Methanol Guy Workshop: Online Resources 4 5
6 10 14 18 21 24
28 32
-Yasmin Al-Asady
president@studentima.co.uk
Editorial Team
Yasmin Al-Asady Faezeh Godazgar Maram Habib
prospect@studentima.co.uk
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United we Stand, Divided we Fall

by
Editorial
The Case
Hello, ambulance service...

CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER OPERATOR CALLER Hi, yea ambulance - erm, theres been an accident, a cyclist has been hit by a car Ok, can you tell me where you are? Were 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 guys just come around the corner and taken the bike out. Ok, and are you with the cyclist now? Yeh. Ok, is he conscious? Erm, I dont know. Hes lying pretty still. Hes 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 dont know him, I was just walking by Ok, Whats your name sir? My name? John. Ok John, whilst were waiting for the ambulance Im 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 theres anything stopping him from breathing? Ok, it looks pretty clear, but hes got loads of cuts on his face from the windscreen. Ok, can you see if hes 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 Yep, yeah, I can feel something on my face Excellent, youre 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, hes got loads of cuts on his face Is he bleeding from his nose or ears? Yeah, he looks like hes got a bit of a nose bleed but his helmet is in the way so I cant really see his ears I can hear the ambulance. Theyre here now. Ok John, youve done really well, just tell the paramedics what youve told me Ok, Thanks for your help. Bye.
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 suns glow, in memory of the dark winter nights spent on call. 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. 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. 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 patients care. We begin from the moment the emergency services receive the call for assistance, through the different stages of our patients care, exploring the roles of the plethora of healthcare professional involved in providing each stage of this care as a united multi-disciplinary team. So what is the analogy I hear you ask? 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. 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. a
OPERATOR CALLER
The clock is ticking...

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Wikimedia Commons
Pre Hospital Care

Jemma Batte
In high risk cases, such as those involving Traumatic Brain Injuries (TBI), every second that passes by signifies a drop in the patients 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 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 patients injuries. 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 victims head hitting the windscreen, often suggests that the cyclist has sustained a serious head injury. 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
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. 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.
Features
Maintaining ventilation using a bag-valve oxygen mask
Eye Opening Spontaneous 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
The Glasgow Coma Scale
Score 4 3 2 1
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 patients 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 patients 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
Right : Cervical spine immobilsation using neck collar , backboard and sandbags
http://rationalrevolution.net
Score 5 4 3 2 1 Score 6 5 4 3 2 1 15
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The Primary Survey
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A: AIRWAY AND CERVICAL SPINE Is the cyclist breathing? YES NO Is there a suspected injury to the neck? YES Maintain open airway Identify what may be obstructing the airway. Consider using an airway adjunct or tracheal intubation* Immobilise cervical spine using a rigid collar. Fix to backboard with sandbags either side of head and tape across forehead. B: BREATHING Is the patient breathing normally? YES NO Maintain respiratory rate at 10-24 breaths/minute Begin ventilation with a bag-valve mask and oxygen. Look for signs of life-threatening breathing problems and treat immediately. C: CIRCULATION Are there any signs of shock? Is there any sign of external haemorrhage? Can the cyclist wiggle fingers and toes? Are pupils responsive to light? What is his score on the Glasgow Coma Scale (GCS)? YES Begin fluid resuscitation and continue monitoring pulse rate and blood pressure. Monitor pulse rate and blood pressure. Apply pressure to bleeding wounds. D: DISABILITY NO NO Suspect spinal cord injury. Suspect damage to brainstem or nerves of the eye. >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? Cut away all patients 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.
Indications
for referral to
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) Significant extracranial injuries Worrying mechanism (high energy, possible NAI, possible penetrating injury) Continuing uncertainty about the diagnosis after first assessment Medical co-morbidity (anticoagulant or alcohol use) Adverse social factors (e.g. alone at home)
Taken from the Oxford Handbook of Emergency Medicine, 3rd edition (2006) NAI = Non-accidental injury
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. 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.
Jemma Batte Fourth year medical student
YES
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 cyclists pain, however, must be carefully titrated so as not to mask important clinical clues. Finally, once transfer to hospital is underway, the trauma team at the receiving hospital must be informed of the cyclists 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
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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
IF AT ANY STAGE THE PATIENT DETERIORATES, BEGIN THE PRIMARY SURVEY AGAIN TO FIND AND FIX THE CAUSE! a publication
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www.studentima.co.uk 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. 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. 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. 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. Disability Head injury is a dynamic state which needs constant reassessment and monitoring should there be deterioration in the patients 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 patients condition may indicate a serious complication developing, such as fits or an a publication
ACCIDENT & EMERGENCY

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. 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). 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). 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
Features
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.
Glasgow Coma Scale > 13: Minor head injury 9-12: Modeartely severe < 8: Severe head injury
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Features
Are
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, Battles sign) Focal neurologival deficit > 1 episode of vomiting
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: - - - - - - - Persisting coma (GCS8) 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)
- Amnesia of events > 30mins before impact
YES Any
NO
amnesia or loss of consciousness since the injury?
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.
YES
KEY:
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
NO
Are
any of the following present?
Name and age of patient
Important information for Neurosurgical Referral
Noor Jawad Final year medical student
Mechanism and time of injury

- Age > 65 years - Dangerous mechanism of injury - pedestrian/ cyclist struck by motor vehicle - occupant ejected from a motor vehicle - fall from .> 1m or stairs - Coagulopathy (history of bleeding, clotting disorder, current treatment with warfarin
Cardiorespiratory status (heart rate, blood pressure, respiratory status) Glasgow Coma Score Pupillary response Motor pattern Alteration in baseline observations Non-cerebral injuries Results of investigations Relevant past medical history, medication, allergies Referring doctor, location and return phone number
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. 3) Teasdale, G. & Jennett, B. (1974) Assessment of coma and impaired consciousness a practical scale, The Lancet, 2: 81-84. 4) Wasserberg, J. (2002) Treating Head Injuries, BMJ, 325(7362): 454-455. 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.
YES Request CT scan Immediately

NICE Guidelines: Indications for CT imaging
NO No Imaging Required Now
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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 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 patients 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 patients 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 a publication
Features
protection through alterations in vascular tone, inhibition of free radicalmediated 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 neurological sign? an important
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 patients 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 patients 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
Monro-Kellie Doctrine
that the central nervous system and its accompanying fluids are enclosed in a rigid container whose total volume tends of one component or cerebrospinal to remain constant. An increase in volume
(e.g., fluid)
brain, blood, will elevate
pressure and decrease the volume of one of the other elements
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www.studentima.co.uk the patients 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.
Features
clinical signs as to the patients 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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Husam Jafar Pre-Registration Pharmacist

References: 1) Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil2006;21:37578 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/ 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 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 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 14) http://www.umm.edu/altmed/drugs/mannitol-079300.
*** SIMA: Prospect Issue #4

FEB 2010
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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. 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. 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.
www.studentima.co.uk 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 patients nutritional formula is acting as a substitute for a normally balanced diet, it must consider all of the patients 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
Features
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 patients current nutritional state with their pre-injury weight may help inform treatment. Using this information, an estimate of the patients 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. The final step of the nutritional assessment is to determine a nutritional care plan for the future. The patients 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). 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. 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 a
Past Nutritional Status:

contributary factors age height weight eating habits intolerance histories
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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, Wernickes 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 ones 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 patients nutritional needs rather complex. Major trauma induces metabolic alterations that contribute to an immunosuppressed state,
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. 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 patients 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.
Features
TBI in the dentists chair

by Dr Thuha Jabbar
In a patient with head injury, the primary concerns are the patients level of consciousness and responsiveness. Having addressed the patients 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 patients 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. Extra-oral examination The first step in assessing the extent of this patients 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. a publication 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. Intra-oral Examination Continuing the examination, one has to inspect intra-orally to assess the extent of the damage. 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
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
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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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.
www.studentima.co.uk 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. 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. 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 occlusion should be checked carefully to avoid causing further trauma to the teeth. The pulps should be extirpated first and a 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. 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 patients 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.
Features
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 patients 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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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. 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. The pulps of both central incisors were involved in the fracture and the pulp exposure was relatively large.
Dr Thuha Jabbar VT1 Dentist
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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 patients discharge from hospital does not necessarily represent a new lease of good health. On the contrary, if anything, a patients 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
Features
a formal diagnosis of Post-Traumatic Stress Disorder (PTSD)1. An appreciation of the wider psychosocial implications of the patients physical illness is therefore essential to aid his recovery and long term health.
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 patients final discharge. In addition to all of the aforementioned issues, the nature of our cyclists 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
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. 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. Moreover, as if the physical strain isnt 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 a
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. It seems clear therefore that the end of our patients 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? 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 patients progress in reaching these goals. 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 publication
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Features
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
Indicators of physical and non-physical morbidity
winning entry
Sami the Methanol Guy

by Dr Nabil Al-Khalisi
Thankyou to all of you who entered the competition. It was a real privilege to read all of your thoughts and experiences. Keep an eye out for the next essay competition coming very soon
www.studentima.co.uk ~ prospect@studentima.co.uk
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.
Yasmin Al-Asady Fourth year medical student

References: 1) Sukantrat et al, Physical and psychological sequelae of critical illness, British Journal of Health Psychology 2007, 12, 65-74 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 4) Prinjha et al, What patients think about ICU follow-up services: a qualitative study, Critical Care 2009, 13:R46
kindly sponsored by the
Medical Protection Society
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www.studentima.co.uk 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. Samis 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. I fetched my stethoscope and listened to the childs 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. 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 a publication that was ten times more technical than medical. Id never come across anything like this during my entire year as a junior doctor. I bent down and looked directly into Samis 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! Lets have a party; lets 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 grandfathers 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 Samis life for alcohol? If he dies you die too, understand?
Essay Competition Winner
Sami the Methanol Guy

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. 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 Id had thirty patients screaming and shouting instead of this miserable case. 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 grandfathers 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 hadnt been into a hospital before. He kept on asking his grandfather time after time but he never seemed satisfied with his grandfathers brief answers. 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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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 Samis 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 Samis 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; Samis 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 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 wed 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. 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 childs condition would inevitably deteriorate, would this convince his grandfather? This was my only hope. 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 didnt change his mind; he continued to blame me for what was going on and promised to get revenge if anything happened to his grandson. 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 childs life like Samis 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 a 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. I tried to resuscitate him but to no avail. A few minutes later when Id 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. 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. On my way back I kept having flashbacks; I thought deeply about the hidden meaning publication
www.studentima.co.uk 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 everybodys 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 peoples 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
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Workshop
online resources When? How?
What?Why? Who?workshop: Where?
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.
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. Revision
aides
Following Februarys 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 prospect@studentima.co.uk and well try to find the right person for the job...
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.
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.
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
www.emedicine.com
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
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
a publication
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
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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. Other Specialty Information 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. 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. 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. 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. 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.
www.learningradiology.com
Dr Matthew Burman FY2 Doctor Colchester, UK

www.websurg.com
Prospect
wants
YOU!
thats right, we are looking for
Radiology Learning Radiology (www.learningradiology.com) 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
a publication
new members to join the
Prospect
team,
so if you fancy your or a bit of design, get in touch at hand at editing
35
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I s s u e #3 O c t 2009
Iraq then Iraq now.
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Student Iraqi Medical Association United Kingdom: Prospect Journal Issue # 3

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Student Iraqi Medical Association United Kingdom: Prospect Journal Issue # 3

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I ssue #3 O ctober 2009

From the President...

United we Stand, Divided we Fall

Hello, ambulance service...

The clock is ticking...

Pre Hospital Care

Maintaining ventilation using a bag-valve oxygen mask

Jemma Batte Fourth year medical student

ACCIDENT & EMERGENCY

Arterial Blood Gases

any of the following present?

- Amnesia of events > 30mins before impact

any of the following present?

Name and age of patient

Important information for Neurosurgical Referral

Noor Jawad Final year medical student

Mechanism and time of injury

YES Request CT scan Immediately

NO No Imaging Required Now

Pharmacological Management of the TBI patient

ask yourself... will this prescription mask neurological sign? an important

brain, blood, will elevate

pressure and decrease the volume of one of the other elements

Discuss this article and more on our online forums

Husam Jafar Pre-Registration Pharmacist

*** SIMA: Prospect Issue #4

submit your article to

any other queries

Food for Thought...

Past Nutritional Status:

TBI in the dentists chair

Neam Al-Mossawi Third year Nutrition & Dietetics student

Dr Thuha Jabbar VT1 Dentist

The Beginning of The End

Sami the Methanol Guy

Yasmin Al-Asady Fourth year medical student

kindly sponsored by the

Medical Protection Society

Essay Competition Winner

Sami the Methanol Guy

online resources When? How?

What?Why? Who?workshop: Where?

Dr Matthew Burman FY2 Doctor Colchester, UK

thats right, we are looking for

new members to join the

so if you fancy your or a bit of design, get in touch at hand at editing

Iraq then Iraq now.

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