DIARY AUTUMN 2006
12/10/06
12/10/2006 Mental Capacity Act 2005
Mental Capacity act is a wide subject and it can stimulate rich discussion as people have different opinions viewing the same issue form different angles.
Tom was the mastermind of the session. He presented us with an excellent presentation. He started with definition of capacity and the legal tests for it:
Then we split up into six small groups, each had two classical –real life cases to discuss together. Cases were picked up by Tom and prepared by Muna. The cases were about patients refusing medical treatment. We discussed their mental capacity, right of refusal, legal tests for their capacity as well as patient’s best interest and other moral issues.
We then had a large group discussion and feedback on the sensitive and controversial areas in our small group discussion.
Tea and biscuit brought by Kerli. We then came back together for the second part of Tom’s presentation which explained the following areas:
The Act Main ideas is a list of 5:
The Act sets out the rules on:
The Act introduces:
There was no hot topic. Chris invited us to share some interesting cases that we saw during the previous week which we had useful discussion on.
Muna
19/10/06
Palliative Care - Group 5
A very interactive session, started off with Sunil giving a chance to the various groups to come up with their ideas of palliative care and the various people forming the team providing it, before coming up with the definition of palliative care (working and WHO).
‘Comprehensive, interdisciplinary care of patients and families facing a terminal illness, focusing primarily on comfort and support.’
WHO: "An approach that improves the quality of life of patientsand their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."
.The key issues in the discussion being symptom control, psychosocial and spiritual care, personalised management plan, and family oriented care- during illness and during bereavement. The various conditions needing palliation (terminal cancer, dementia, CHF, COPD.) were discussed as was the contrast in the kind of services provided for some of these conditions (cancer Vs. CHF)
Emma soon took over and discussed the clinical aspects of palliative care (things that we thought we knew, but soon realised otherwise!) The presentation mainly dealt with symptom control, ‘pain’ being perhaps the most common and important symptom requiring control (though 30% of people with cancer have no pain).Regular analgesia, pain ladder.
.The use of strong opioids was discussed as was the mode of delivery of drugs ( using syringe driver) oral being the preferred route.
.Nausea and vomiting( address the cause), constipation(prevention better than cure), breathlessness(positioning, stream of air, explanation and reassurance,oxygen,BDZ, opoids, nebulised saline etc. ) anorexia and cachexia(diet/nutritional supplement,Cortcosteroids, Prokinetics) confusion and agitation, and mouth(unsweetened chunks of pineapple for coated tongue!) and skin problems being the other symptoms needing attention.
Chin gave a new dimension to the discussion when each group were given a situation / scenarios to have a feel of the patient’s perspective of concept of palliative care. Thought provoking discussions about ‘End- of-Life’ issues, good/ bad death, advance directives, resuscitation status, and religious and spiritual needs, took place.
Muna presented the hot topic on TIA’s which was well prepared and reinforced the management of the same.
Sunaina
09
/11/06Thursday 9th November 2006 – Travel Medicine (Group 6)
The session started with feedback on the Balint session of the previous week – it was suggested that perhaps we should have these sessions more regularly, possibly including a case every other session or so.
Then Alex and Lizzie did a role play – A pregnant lady wants to go abroad on holiday
Learning points –
We split into 4 groups to discuss 2 scenarios Alex had prepared regarding giving advice to people going on vacation
A few of the learning points -
Alex also provided us with a useful pre holiday advice sheet.
A break for cake (oops no-one brought any but Alex kindly saved the day with some hospital donuts)
Shambhawi started off the next part of the session with an overview of rabies and yellow fever, she had also prepared Japanese encephalitis and tick bourne encephalitis but as time was running short didn’t present them. All of the information was however provided on a hand out for us.
Misbah provided a handout about malaria.
We had a quick break from Travel medicine whilst Shambhawi did her hot topic – a case presentation of a patient with Q fever. An interesting DD for PUO!!
http://www.cdc.gov/ncidod/dvrd/qfever/
Back to travel medicine we then split back into the 4 groups to discuss 4 scenario’s of post holiday presentations which Lizzie had prepared – travellers diarrhoea, DVT, insect bites, STIs, sun burn and sun stroke.
For each case we discussed what the important questions to ask were and examinations to perform, the differential diagnosis, management and advice that you would give the patient for the future.
For more information check out - http://www.traveldoctor.co.uk this is a really good site with loads of info on lots of aspects of travel medicine.
The only area not covered on this site is gonorrhoea which you should suspect if a man presents with a thick purulent penile discharge – generally I would advise that you refer them asap to a GU clinic for formal diagnosis, treatment counselling and contact tracing but if you do not have access treat with either azithromycin 1g/ PO stat or ciprofloxacin 500mg stat and then refer on if poss. See http://www.emedicine.com/med/topic922.htm
Mary then concluded our session with a fun quiz of contraindictions to flying and provided a hand out summarising the facts.
NB.
If anyone missed the session and would like copies of the handouts I will try to organise to get these on line.
Lizzie
16/11/06
Your next patient comes in and he has a letter in his hand. He is visibly upset, shaking and VERY annoyed. He has been told that at the time of his successful hip operation he had nearly 3 years ago, he might have been exposed to a ‘health care worker’ who has subsequently tested positive for HIV and Hepatitis. The news is bad and you have to deal with it. Can you do it? How good are you with breaking bad news? This was the theme for this afternoon, led by group 1- Dave, Kerli, Uzma, Soumen and Manuel.
We met up at the Post Grad Centre at Kidderminster (not so promptly – I might add!). After a brief introduction by Dave Hughes, we split into 5 groups of 3 each (that’ll give you the number of attendees). We were all given 3 scenarios each, which we had to ‘role-play’. One had to pretend to be a patient (difficult), the other had to observe and the third one had to pretend to be a doctor (extremely difficult). However, I think we all knuckled down to our tasks. Coffee break was tempting, as Uzma had placed the Tesco bags strategically.
Scenario 1
Doctor
Mr/Mrs Jones came to see you after receiving a letter from the hospital concerning exposure to a certain healthcare worker. They are very concerned and come to see you. You need to explain about the recent HIV/HEP B positive Health Care Worker and break the bad news.
Patient
You are Mr/Mrs Jones and you receive a letter from the hospital concerning exposure to a certain healthcare worker. They are very concerned and go to see your GP. You have seen the news about the recent HIV/HEP B positive HCW and are now convinced that you have both the conditions. (Feel free to be outraged and lay it on thick).
Scenario 2
Doctor
You have been asked to see a 90 yr old lady in a nursing home who has dementia, diabetes and IHD and PVD. She is totally dependent, doubly incontinent and has been refused surgery previously on the basis of her quality of life and co morbidities. Today, the home says that she is unwell and "Knocked Off". When you examine her it becomes obvious that she has an acutely ischaemic leg.
Mrs Smith’s daughter/son arrives and asks to speak to you.
Patient
Your mother, Agnes Smith is 90, in a nursing home and has dementia. She has many other diseases including heart problems, diabetes and vascular disease. The home ahs called you to say she is unwell, can you come to see her immediately. The GP is present and you want to speak to him/her.
Reluctantly, you agree with his/her plan but you are very aware that your older brother will disagree.
Doctor
Mr/Mrs Jones came to see you with a chest infection that did not resolve. You diligently arranged a CXR. The report shows widespread cannonball metastasis. Mr/Mrs Jones comes for the result.
Patient
You are Mr/Mrs Jones. You have been treated for a chest infection, but it did not resolve.
Your GP suggested a CXR and you come for the results.
After the first 2 scenarios, we broke for coffee and regrouped to continue with the ‘role-plays’. After finishing the 3rd and last scenario, we all sat together again to share our experiences and lessons.We learnt the following points.
Do’s and Don’ts Of Breaking Bad News
Do’s
Have the facts to hand.
Clear enough time
Control Potential interruptions
Switch off bleep
Ask colleagues not to disturb you
Divert phone calls
Use ‘do not disturb’ sign if in general office.
Check if patient wishes anyone else to be present
Negotiate approx time consultation will take and explain need to take notes
Clarify what the patient already knows or suspects
Be prepared to follow the patient’s agenda
Observe and acknowledge patient’s emotional reactions
Nervousness
Fear
Stop if patient indicates that they do not wish to continue
Check patients understanding of what you are saying
Don’t
Make assumptions about
The impact of the news
Patient’s readiness to hear news
Who else should be present?
Patient’s priorities
Patients understanding
Give too much information at one time
Decide what is most important for the patient
Give inappropriate reassurance
Answer questions unless you have the facts to hand
Hurry the consultation
Use euphemisms eg. "little ulcer" when you mean ‘cancer’
Block emotional expression from the patient
Break bad news to relatives before telling the patient
Agree to relative’s demands that you withhold information from the patient
23/11/06
Child psychiatry/ Behaviour
Group 3
The session started off with a presentation by Sarah
Key points
Child & adolescence mental health service
- 5 –layered structure with Layer 1 being those directly in contact with children/adolescents and Layer 5 being the specialist mental health teams.
-Focuses mainly on psychological assessments
- Multidisciplinary team involving psychiatrists, clinical psychologists, psychiatry nurses, social workers, educational therapists etc
- Normal emotional development of children is influenced by genetic predisposition, environment and family (parenting styles, adversities etc)
- Lengthy separation from parents leads to protest, despair and eventually detachment
Problems can be sub divided into 3 categories
Sleep related problems
Tantrums
Breath-holding attacks
Aggressive behaviour
Autism
Faecal soiling
Recurrent abdo pain
ADHD
Antisocial behaviour
Anxiety
School refusal
Chronic fatigue syndrome
Depression
Deliberate self harm
Drug misuse
- then we went on to see video clips from a popular television programme showing commonly encountered family situations involving children and different strategies to manage them.
- we had an interesting discussion regarding different ways of dealing with ‘bad behaviour’ in children which included
This was followed by a presentation by Urmila about enuresis and ADHD
Key points
-very common
- boys> girls
- familial predisposition
- can be associated with psychological issues
- avoid undue anxiety , most will resolve spontaneously
-enuresis alarms- attached to child’s pants
-drugs – last resort
then Fiona did a quiz involving key points regarding ADHD
- diagnostic features of ADHD – inattention, impulsivity, hyperactivity
-DDs- autism, learning disorder, thyroid disease, psychological problems,epilepsy, drugs etc
- more common in boys
- ?incidence increasing
Bipin
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