Posts tagged medicine

Antibiotics Resistance and the Race for New Bacteria

I remember going to an infectious disease lecture some time ago and hearing the specialist paint a grim portrait of the future: the rapid resistance bacteria is developing against our weaponry will make antibiotics obsolete in the next fifty years. Unless we do something about it, we will be propelled back into the dark ages.

This article is a good snapshot of where we stand now in the search for novel therapies.

The Half Measure

I recently had the opportunity to work with a medical student while on call. I had received notice of a ward issue to see that sounded appropriate for his level. I asked him to go first and that I would join him shortly thereafter.

When I arrived, he briefed me on the problem at hand. When I asked what his thoughts were and what he wanted to do, he supplied me with a full and extensive workup for a simple case of pain. 

At one in the morning, I reminded him that our job was to make sure nothing life threatening was happening, that we have done enough investigations to aid us in that cause, and to keep patients alive until the morning.

Without the backup, manpower or support, we were not in the best position to start investigating and treating everything fully, unless something truly worrisome was suspected. 

Put simply, our job boils down to a half measure.

The Key Word is ‘Surviving’

When the emergency department is inundated with people, every service feels the pressure. Consults are requested, teams are pressured to admit or move patients. The night seems endless.

Last night, the emergency department was packed to the brim. I had never seen it so busy. There was no particular cause for this influx, no mass casualties or public event gone wrong; people just got sick at the same time for different reasons.

The night was steady until three in the morning. Many of my classmates on other services were present as well seeing patients. In those hasty moments between cases, we caught our breaths and checked on each other.

The key word to all of our conversations was “surviving.”

With great power comes great responsibility.

This quote comes to mind when I think about the new addition in my toolbox. I now have the authority to prescribe narcotics with my triplicate prescription pad. These are highly regulated substances for obvious reasons.

I must ensure that I dispense them appropriately. More crucially though, I must keep my prescription pad safe from theft.

History Taking

In a previous post I highlighted some positive feedback I received about my history taking. I received a lot of comments about sharing what I was doing. I think that history taking is a very individualized process. In all honesty, there is no right or wrong way to take a history. Each person’s style is a reflection of their thinking process, their knowledge base, and their comfort level and that naturally evolves over time.

Having said that, this is what I generally do now.

History’s Worst Contraceptives by Engender Health.

Taking a Manual Blood Pressure Reading.
Find the right-sized cuff: The bladder width should be roughly 40% the circumference of the arm; alternatively the bladder length should be roughly 80-100% of the arm circumference. If it is much larger or smaller than this, the reading could be inaccurate.
Line up the arterial line: On the cuff there is a line demarcating where the brachial artery should be. Place this line over the artery, which is located just medial to the biceps tendon. The bladder cuff should be approximately 2-3cm above the antecubital fossa.
First reading: Palpate the radial artery. Inflate the cuff until the radial pulse is obliterated. Remember this reading. Deflate the cuff. 
Second reading: Place the diaphragm of the stethoscope just under the cuff above the brachial artery and reinflate the cuff to 20mmHg above the previous reading. Slowly deflate the cuff at a rate of 2-4mmHg per beat. Listen for the appearance and disappearance of the Korotkoff sounds as turbulent blood flows through the partially occluded artery. 
Korotkoff markers: The first Korotkoff sound that appears (phase I) signals when the pulse pressure is just enough to overcome the external cuff pressure. This is the systolic reading. When there is no sound (phase V), this signals the diastolic reading.
Pre-reading Considerations
Avoid any activities that may affect the blood pressure including but not limited to coffee, smoking, low temperature, stress, or exercise. Pain can also affect blood pressure.
Before taking a measurement, ensure the patient is in a quiet area. Ask if they have gone to the washroom as a full bladder can affect the blood pressure. Make sure they are sitting with their feet touching the floor, not cross-legged. Ensure that the patient has rested for at least 5-10 minutes before taking the reading.

Taking a Manual Blood Pressure Reading.

  1. Find the right-sized cuff: The bladder width should be roughly 40% the circumference of the arm; alternatively the bladder length should be roughly 80-100% of the arm circumference. If it is much larger or smaller than this, the reading could be inaccurate.
  2. Line up the arterial line: On the cuff there is a line demarcating where the brachial artery should be. Place this line over the artery, which is located just medial to the biceps tendon. The bladder cuff should be approximately 2-3cm above the antecubital fossa.
  3. First reading: Palpate the radial artery. Inflate the cuff until the radial pulse is obliterated. Remember this reading. Deflate the cuff. 
  4. Second reading: Place the diaphragm of the stethoscope just under the cuff above the brachial artery and reinflate the cuff to 20mmHg above the previous reading. Slowly deflate the cuff at a rate of 2-4mmHg per beat. Listen for the appearance and disappearance of the Korotkoff sounds as turbulent blood flows through the partially occluded artery. 
  5. Korotkoff markers: The first Korotkoff sound that appears (phase I) signals when the pulse pressure is just enough to overcome the external cuff pressure. This is the systolic reading. When there is no sound (phase V), this signals the diastolic reading.

Pre-reading Considerations

  1. Avoid any activities that may affect the blood pressure including but not limited to coffee, smoking, low temperature, stress, or exercise. Pain can also affect blood pressure.
  2. Before taking a measurement, ensure the patient is in a quiet area. Ask if they have gone to the washroom as a full bladder can affect the blood pressure. Make sure they are sitting with their feet touching the floor, not cross-legged. Ensure that the patient has rested for at least 5-10 minutes before taking the reading.
I really like your approach to asking those questions…I might steal that and use it myself.

Surprising feedback I received today about my history gathering method.

30 grams a day except on Sundays.
Old paediatric saying for average weight gain in an infant.
Meeting a friend.
I received an email recently from a friend who is currently going through fourth year medical school remotely. To my pleasant surprise, she was in town for an elective.
After a brief correspondence, we managed to find time this morning to meet for coffee. We talked about our lives, our respective training thus far, and our future plans. It is remarkable to hear how our lives and experiences can be so similar despite how different our programs are, from the challenges of clerkship to the stresses of applying for residency.
The story of medicine is truly a universal one. 

Meeting a friend.

I received an email recently from a friend who is currently going through fourth year medical school remotely. To my pleasant surprise, she was in town for an elective.

After a brief correspondence, we managed to find time this morning to meet for coffee. We talked about our lives, our respective training thus far, and our future plans. It is remarkable to hear how our lives and experiences can be so similar despite how different our programs are, from the challenges of clerkship to the stresses of applying for residency.

The story of medicine is truly a universal one.