Onco 16 – Brain Tumors – where even benign ones are bad news.

It’s like an obnoxious little friend that didn’t want to leave you and decided to hide in a place you can’t reach.

Find out why even a benign tumor can be deadly.

Onco 15 – The common skin tumors you MUST know

Did you know that a third of Australians will get some form of skin cancer in their lifetime?

Learn how Skin cancers form and what are the common ones to look for with Hamed and Andy.

Onco 10 – Cancers of Unknown Origin

What do you do when you’ve got a cancer that you’re sure is a metastasis but you can’t figure out where it’s from? Who you gonna call? Maybe your pathologist… Anywho, we’ll go through what they’ll be looking out for.

Checklists – How we can reduce harm done in medicine

Doctors are humans, and humans are not perfect. We will all make mistakes sometime in our life, and because of our job, we can risk harming patients.

The teaching theme this week at university was medicinal safety – teaching us common prescribing errors and bad habits junior hospital doctors often make due to inexperience. Habits such as using abbreviations, writing ambiguous directions, and even bad handwriting seemed were common reasons for medical emergencies to occur. The important thing to remember is that these could all be preventable.

The following is a list of some bad habits that could be easily fixed to prevent patients from prescribing errors.

• Write drugs in their generic (drug) name – don’t write the drug in abbreviations or in the brand name
  
  • e.g 1. How many people know that DDAVP is an abbreviation for desmopressin
  • e.g. 2. Cyclosporin (Chemo drug) was accidentally given instead of Cyklokapron (Tranexamic acid used to stop heavy bleeding)
• Use your decimal points carefully – People can lose the decimal point
  • e.g WRITE 0.5mg instead of .5mg because people can easily miss the decimal point and administer 5mg
  • e.g. But write 100mg instead of 100.0mg because the decimal point can be missed and 1000mg will be administered instead.
• Clearly articulate your dosing directions – spell out your intentions
  • Don’t use OD,BD,TDS and instead write Daily, Twice Daily, Three times daily
• If you don’t know what you’re charting, look it up or ask for help.
  • There were cases where dosing errors were copied from the previous chart to the next as the doctor just transcribed the drug directions out of uncertainty.

There are many more good prescribing habits that could be found in your local hospital procedure guidelines. If in doubt, have a look there. Otherwise, grab a pharmacist and ask for help!

One very interesting point brought up in class was to use checklists. In certain parts of the world, hospitals are implementing checklists as part of day-to-day practice to reduce preventable harm in medicine. The idea may have originated from airline companies that use checklists as a way to reduce errors on board an aircraft.

I love this idea and it sounds awesome. This is a simple and cost-effective way for doctors to double-check everything is in order before starting or finishing a procedure.

On the other hand, I’m aware that people are against the idea of checklists. Some doctors feel that checklists limits their autonomy, others feel that they have experience and know what to do and thus don’t see the need of it.

This may be the case for some people, but for the most of us errors are bound to be made in busy and stressful situations. It doesn’t hurt to be more careful, especially if the harm goes towards your patients.

Where do you stand on checklists?

Tests in clotting disorders

The following are some tests ordered when assessing/diagnosing some clotting diseases.

Platelet tests:

A normal platelet count would yield ~ 150 – 400 x 10^9 /L platelets.

Bleeding time (BT) evaluates the platelet function up to the formation of the temporary platelet thrombus (primary hemostasis). A normal bleeding time is around 2 – 7 mins.

Platelet aggregation tests look at the aggregation response in response to regents such as ADP, adrenaline, collagen and ristocetin (induces platelet aggregation).

Tests for von Willebrand  factor (vWF) include ristocetin cofactor activity or vWF antigen assays. Ristocetin cofactor activity evaluates the function of vWF, where as the assays measures the quantity of vWF present in the serum.

Coagulation tests:

Prothrombin time (PT) assesses the extrinsic and common coagulation pathway. It involves factors VII, X, II and I. A normal PT is around 11 to 15 seconds. PT is commonly used to evaluate liver synthetic function, detect factor VII deficiency or monitor patients who are on warfarin.

The International normalized ratio (INR) is a value derived from PT, used as a standard to monitor patients on warfarin. While varying with the condition, a normal INR target for warfarin patients is between 2-3.

The activated Partial Thromboplastin Time (aPTT) evaluates the intrinsic and common pathway. The factors involved are XII, XI, IX, VIII, X,V,II,I. The normal reference interval would be 25-40 seconds. It is most commonly used to monitor heparin anticoagulation therapy. It’s also used to detect factor deficiencies in the intrinsic coagulation system.

Fibrinolytic sytem tests:

Fibrin(ogen) degradation products (FDP) are used to detect fragments associated with the plasmin degradation of fibrinogen or insoluble fibrin in the fibrin clots.

D-Dimer assays are specific tests that determine degradation of cross-linked fibrin monomers only. It does not detect fibrinogen degradation products as they do not form cross-links. It’s of particular clinical use when assessing deep vein thrombosis, pulmonary thromboembolisms and disseminated intravascular coagulation.

Reference:

Goljan Rapid review Pathology 4^th edition

What would you do? – Tough decisions in health care

Life is usually not what you expect.

Have you realised that the things taught at school are a lot simpler than what happens in the clinical world?

In the real world, the case studies and scenarios becomes broader than just the patient, their disease and treatment plan. Sometimes we need to consider the patient’s living arrangements, family background and financial capacity.  If you’re really unlucky, the universe will find two seemingly distinct events, mash them together and present them to you as a problem to solve.

Recently I came across a situation where I had to make a decision. No class in pharmacy school prepared me for this scenario. Place yourself in my shoes and see how you’ll handle the situation. What would you do?

Clinical Practice Resources

• ABC of Clinical ECG (Textbook)
• ECG Library 
• ECG Made Easy – David Adlam, John R. Hampton (Textbook)
• ECG Wave-Maden (lots of quizzes and cases)
• Examination Medicine – Talley and O’Connor (Textbook)
• Harrison’s Principles of Internal Medicine (Textbook)
• Life in the Fast Lane
• Mechanisms of clinical signs – Mark Dennis, (Textbook)
• Making Sense of the ECG – Andrew R. Houghton, David Gray  (Textbook)
• Therapeutic Guidelines
• Oxford Handbook of Clinical Medicine (Textbook)

PHYSICAL EXAMINATION RESOURCES 

• A Systematic Guide to Physical Diagnosis  – Tally & O’Connor  (Textbook and Videos)
• Auscultation and Heart Sounds
• Blaufuss Heart Sounds
• Bates Visual Guide to Physical Examination
• Geeky Medics (Youtube)
• OSCE Skills
• Oxford Handbook of Clinical Examination and Practical Skills (Textbook)
• Secrets Heart and Lung Workshop- Salvatore Mangione (Audio CD)
• Understanding Lung Sounds

KNOW OF OTHER USEFUL RESOURCE? LET US KNOW!