Gunners

 

Urban Dictionary – A person who is competitive,overly-ambitious and substantially exceeds minimum requirements. A gunner will compromise his/her peer relationships and/or reputation among peers in order to obtain recognition and praise from his/her superiors.

It’s good to be good…

It’s always good to want to improve your own ability, build upon your existing knowledge and broaden your knowledge base. Medicine is a continuously evolving subject that requires by law that you do the same. I’d be worried if I knew my doctor wasn’t at least trying a little bit to learn more about the subject they’d chosen for their career…

However, comparing yourself to others can be dangerous. When we go out in the world we put on our public face, our public clothes, and our public attitudes. We don’t reveal our inner fears, our problems, our weaknesses. And since everyone else is doing the exact same thing we don’t ever see theirs. This combination of caging away our own issues and not witnessing those of others gives us the false impression that they’re finding everything so much easier, or that they’re so much better off than we are. This is further perpetuated online, as Facebook and Instagram give the opportunity to sell yourself to the world as that perfectly happy, exciting and fulfilled individual that couldn’t possibly exist in real life. It’s not exactly a recipe for sound psychological well-being.

But there is a limit…

Medical schools rank their students. Presumably it’s intended as an incentive to work harder, as a higher rank apparently brings the tantalising promise of a better job, more research opportunities and greater respect. Maybe it produces better doctors, maybe it doesn’t. What it definitely does do is discourage students from helping each other out. The stakes are raised, forcing us to show that we’re not struggling, that we know the required information, that we can hack it in this apparently brutal world of medicine. People become so preoccupied with that centile rating that they will give up relationships with their peers in an attempt to make excruciatingly small gains over them, be that by hiding information or learning opportunities, or even misleading them deliberately in the hope of sabotaging this ‘competitor’ and boosting their own ranking.

WTF?

I once asked someone what topics were covered in a teaching session that I had missed through illness, and they said to me, “It’s your fault you weren’t there”Turns out it was the Krebs’ cycle…

I’ve also heard rumours of students sabotaging the computers/iPad available during OSCEs to disadvantage those yet to complete that station.

It’s crazy!

The qualities we want in our doctors are compassion, teamwork, communication and integrity. Healthcare is never done on an individual basis, it’s always a team of teams of teams, each with their own area of expertise and interest, cooperating and communicating to ensure the best outcome for the person that really matters most – the patient. You can only gain by communicating well with others. Either you find out something you didn’t know before, you deepen your own understanding of a subject, or you have that satisfying feeling of helping someone else understand something just a little bit better, and knowing that you’re helping their patients as a result.

So I ignore the rankings. Always have, always will. I don’t care if the person I’m talking to is going to score higher than me. In fact, I’m happy if they do. Why? Because I’m determined to be a good doctor – it’s what I’ve always wanted to be – so anyone scoring higher than me in the rankings has to be pretty good as well, and they might be looking after my Mum one day.

 

Don’t be that guy – help each other!

How I work

Deciding how to work

After more than fourteen years of school and six years of Medicine at University, you’d think I’d have figured out how I work best when it came to studying for exams. Surely after that many years of studying, cramming seemingly endless reams of information into my head for retrieval on the big day, I would know whether I was benefiting most from writing out notes, listening to lectures and podcasts, making flashcards, or reading the textbooks…

 

I didn’t.

 

This was a constant source of stress for me as each year I would begin the process of walking out into the lapping waters of bottomless information, and not have a clue as to how best to study. Should I try and write everything down? Type it out? Make flashcards? Just listen? Whichever tactic I tried soon became either unmanageable, tedious, or I simply didn’t think I was learning anything from the process. So what did I do?

I thought about what I do when I come to retrieving the information. That is, in exams, whenever I’m trying to remember answers from my brain and wondering why I couldn’t remember medical facts like I could with cat videos or insulting jokes, how was the information presented in my head. Was it remembering the page of notes? Remembering the lecturer’s voice? The diagram on the flashcard?

It turns out that there were three main ways that I was retrieving these facts:

  • Remembering answers to previous questions that were similar to the one in front of me
  • Recalling specific experiences I’d had on the wards
  • Diagrams that I’d drawn and re-drawn until I could do it by heart
  • Flashcards that I’d done so many times that I didn’t even have to try and remember them.

It was a very rare occasion that I would remember a piece of information from notes I’d written or textbooks I’d read. So I figured I’d stick to these four categories, and hope that my analysis wasn’t way off..

How I work now

  1. I spend as much time on the wards as possible. This is largely because final year is meant to be as much of an apprenticeship as possible; you’re learning how to do the job of those a year ahead of you, so you’ll benefit most from observing, trying (and failing) to do the same things. Your brain is very good at remembering experiences that it has because it has so many ways of programming the information; sights, sounds, smells, temperatures, emotions – think of a time you screwed something important up – bet you never had to revise that again!
  2. I make flashcards. This is largely a convenience thing as you can make one or two in a spare moment, and review them during quiet parts of the day. I use Anki, purely because it’s free on android and you have your cards with you wherever you go.
  3. Nearer the time, when exams are looming, I talk myself through a topic, while drawing out diagrams. I then use the books to check what I’ve missed, and add the information to the diagram. Then I store the diagram away until next time, and attempt to copy it perfectly. Repeat until smart.
  4. teach! You never know information properly until you can teach it to someone who knows nothing about it. If you can explain something simply to a friend or patient, then you truly understand a topic.

Find your own groove

Learning is incredibly personal, and everyone does it differently. Try different methods, see which you like, and more importantly, which ones seem to work, and focus on those, rather than spending time doing ineffective studying that bores you and doesn’t help your exam performance.

 

Good Luck!

 

 

 

The metaphor

Don’t take life too seriously – nobody gets out alive anyway…    

-many people, at varying points in time

 

I’m rather firmly of the opinion that there isn’t much to life other than surviving as long as you can, having kids if you want them, and spending as much of that time being as happy and kind as is humanly possible. As far as I can see, If you nail those things, you’re pretty much golden. You’re going to die at some point, *sniff* and the world is going to carry on as it was, drifting through the inky abyss, until everything explodes, collapses, and maybe starts again. (contentious)

 

 

Maybe you’ll come back as a duck or something.

 

I’m a complete sucker for the feel-good, motivational, ‘you-go-girl’ quotes that get banded around the internet. They’re often pretty quirky, and leave you with a quick, tingly feeling of motivation or sudden renewed faith in humanity.

Always do your best. What you plant now, you will harvest later – Og Mandino

Life is 10% what happens to you and 90% how you react to it – Charles R. Swindoll

Start where you are, do what you can, use what you have – Arthur Ashe

Other times they’re just crap.

I can’t see myself without pink lipstick. I can go without it for a couple days, but if there was no more pink lipstick in the world, I’d be useless. Seriously. – Nicki Minaj

 

 

Sometimes they have a really profound impact on me, and I actually try and learn something from them, such as – The Magical Bank metaphor…

It goes along the lines of:

  • Each morning you get £84000 thrown into your bank account
  • At the end of each day your account is wiped clean, and you start again the next day
  • The bank might crash at any point, and the game is over
  • Anything you don’t spend is lost, anything you buy you get to keep

Sounds awesome right?

Gives you a new perspective on the 84,000 seconds you wake up with each morning to spend how you please, knowing that any time you don’t use will be lost forever. If someone stole £300 from you, would you spend the remaining £83,700 trying to get them back for it? Probably not… So why spend the rest of the day fretting about something that can’t be changed, or someone that wasted your time? Surely you can’t afford it!

 

 

Don’t watch the clock. Do what it does, keep going – Sam Levenson

 

 

 

 

Coeliac disease in children

You’re at work in your clinic, and this pale and thin-looking boy wanders in with a half-eaten loaf of bread in his hand. He pulls down his trousers and does the single worst smelling poo all over the floor. It’s pale and very oily, and just as he’s finished his legs give way and he falls over, landing right in it. Unfortunately he lands on his front, right on top of his bread, making his tummy hurt.

  • caucasian
  • failure to grow
  • foul smelling faeces
  • steatorrhoea
  • muscle wasting
  • abdominal pain

As he attempts to get back up, he continues to slip and slide, gliding around the room like an ice rink. After a little while he gets tired, and you’re worried because you start to see some blood on your new poo-ice-rink floor, and you think he may have broken his arm in the process of trying to stand up.

  • gliadin protein sensitivity
  • fatigue
  • anaemia
  • osteoporosis/osteopenia 

To try and cheer him up a little, you hand him some toys from Star Wars, and after deb8-ing for a little while he chooses a plastic R2-D(Q)2. While he’s playing you notice a nasty rash over his legs, and so you ask him what his name is in order to call his parents. He says his name is Marsh and his parents can’t come to help him because his mother is pregnant.

  • HLA-B8
  • HLA-DQ2
  • Dermatitis herpetiformis
  • Marsh classification
  • pregnancy complications

Finally you ask why he’s come in today, and he says he thinks his spleen is too small, and he’s broken his toy dIgA (digger).

  • Hyposplenism
  • IgA deficiency

Hopefully this particularly ridiculous scenario will help link some of the features and associations of coeliac disease in your mind. Feel free to change what you will, and the details are summarised below.

The Background

Coeliac disease is a condition in which the small intestine undergoes villous atrophy as the result of a T cell mediated autoimmune sensitivity response to gliadin and other gluten proteins found in wheat. These proteins set off an inflammatory cascade that causes the villi of the intestine to be burned away, reducing the ability of the intestine to absorb the necessary nutrients, and the characteristic features of foul-smelling diarrhoea and failure to gain weight result.

Symptoms

  • Those related to the villous atrophy
    • pale, loose, fatty stools that smell foul
    • abdominal pain and cramping
      • sometimes with distension, though to be due to fermentation in the gut
  • Those related to the malabsorption
    • weight loss
    • fatigue
    • anaemia
      • iron deficiency
      • B12 deficiency
      • Folate deficiency
    • Calcium and vitamin D deficiency
      • osteoporosis
      • osteopenia
    • Rarely – coagulopathy
      • vitamin K deficiency

Genetics

  • Incidence 1/1000-2000
  • very common in caucasians, rare in black/asian populations
  • HLA-DQ2 (95%)
  • HLA-B8 (80%)

Diagnosis

  • History
  • Examination
  • Jejunal biopsy
  • Antibody tests are useful for screening
    • anti-endomysial 
    • anti-gliadin

Pathology

The pathology of coeliac disease is categorised by the Marsh Classification.

  • Marsh stage 0
    • normal mucosa
  • Marsh stage 1
    • Increased number of intra-epithelial lymphocytes (IEL)
  • Marsh stage 2
    • proliferation of the crypts of Lieberkuhn
  • Marsh stage 3
    • partial or complete villous atrophy and crypt hypertrophy
  • Marsh stage 4
    • hypoplasia of the small intestine architecture

Associations

Coeliac disease is linked with a number of other conditions, although it is not clear as to the causal nature of the relationship.

  • IgA deficiency
  • Dermatitis Herpetiformis
  • Growth failure
  • Pregnancy complications
  • Hyposplenism
  • Abnormal liver function tests

Risks

Coeliac disease confers greater risk of:

  • adenocarcinoma
  • lymphoma
    • enteropathy-associated T cell Lymphoma (EATL)
  • ulcerative jejunitis
  • stricturing

Treatment

At the moment, the only known successful therapy for coeliac disease is a gluten-free diet for the rest of the individual’s life.

but…cake

Santa’s AAA

Santa has an abdominal aortic aneurysm. Sad I know, but what with his lifestyle of inactivity and indulgence he has brought it upon himself, and after all, he does have all the risk factors.

He’s a fat, old man who does very little all year and then has one night of unbelievable stress that puts his already high blood pressure through the roof. You don’t see them often but he has insanely long fingers, it’s how he reaches down the chimney to deliver the presents. These long fingers are due to his diagnosis of Marfan’s, and he always wears his big black boots to keep his feet warm because his peripheral artery disease makes his feet very chilly when he’s flying over the Baltic States. You probably also didn’t realise but his mum and dad both died of abdominal aortic aneurysms and he is now destined to the same fate.

The risk factors for an abdominal aortic aneurysm are important when you see a patient with abdominal pain, especially if the pain was sudden in onset.

male
– age over 60
– family history of AAA
– Marfans disease
– artery disease
– hypertension
– obesity
– diabetes



poor guy

Paediatric headache history

This post is designed to help you remember the sorts of questions you should be asking when taking a history of headache in a child.

Harry gets lots of headaches. In the morning, his headache wakes him up and he vomits all over the bed.

This makes his mother very angry and she smacks him over the head. He doesn’t notice the warning signs that she’s coming, because he has a very stiff neck.

He tries to get out of bed, but his legs have gone all tingly. So he crawls towards the bathroom, but he can’t really find it because his vision has gone all blurry, and the bright bedroom light hurts his eyes.

He goes downstairs to have his breakfast, but it hurts when he chews, and he starts coughing and spluttering because his nose is blocked.

Finally he says he wants to take the day off school because he has a fever his tummy hurts, but when he goes to lie down, the headache just gets worse!

Questions to ask:

  • What does it feel like?
    • Tight band – tension
    • Throbbing – migraine
    • smack in the head – subarachnoid haemorrhage
  • How bad is it 1-10?
    • worst ever – SAH
  • Where is it?
    • band around head – tension
    • unilateral – migraine
    • frontal/occipital – migraine
  • Do you have any ‘warning’ signs that it’s about to happen?
    • aura – migraine
  • Does it affect your vision at all?
    • migraine
  • Do you have any other sensory/movement changes?
    • migraine – children may get abdominal migraines and complain of tummy pain
    • raised ICP
  • Have you noticed if it occurs at a particular time of day?
    • pregnancy
  • Have you had them before?
  • Have you had a fever recently?
  • Have you noticed anything that sets it off?
    • Alcohol
    • Solvents
    • Drugs
    • Menses
    • Medications – are you on any medications?
  • Is it worse when you lie down?
    • Space occupying lesion – raised ICP
  • Have you been suffering from any neck stiffness?
    • meningitis
    • raised ICP
  • Have you had any photophobia?
    • meningitis
  • Have you had any morning vomiting?
    • SOL
    • viral illness
  • Has it woken you from sleep?
    • Migraine
  • Are there any stressors at school/home (emotional angst)
  • Have you had any problems with nasal congestion?
    • Sinusitis
  • Is it worse when you chew?
    • Temporomandibular Joint discomfort
  • Have you had your vision checked recently?
    • do they wear glasses?
    • Intracranial pressure – 6th nerve palsy
    • refractive error headache
  • Have you had any head trauma recently?
  • Have you had any changes in consciousness?
    • Raised ICP

Causes of acute headache in children:

  • Ice cream
  • Febrile illness
  • Migraine
  • Stress
  • Acute sinusitis
  • Meningitis/encephalitis
  • Subarachnoid/intracerebral haemorrhage
  • Medications
  • Benign intractranial hypertension
  • Reflex neuralgia

Types of headache:

  • Tension
  • Migraine
    • with aura
    • without aura
    • complicated
  • Space occupying lesion
  • Other
    • sinusitis
    • TMJ discomfort
    • Medication
    • Refractive error
    • Solvent/drug abuse
    • Benign intracranial hypertension
    • Hypertensive headache

can we stop now?

Intussusception

Here’s a story to help remember some of the details of intussusception. Remember to try and really picture this event, in your garden. If you can use children that you’ve seen or know, it will help make the story stick better. If you can make it even more ridiculous than I have, then go for it – the weirder the better!

Two boys and a girl are playing in the garden at a family barbecue. The boys are 6 months and 18 months old, and the girl is 12 months old.

  • Typically affects children between 6 and 18 months
  • Boys are twice as affected as girls

They’re all dancing, and doing a special dance where they have to jump as high as they can, and bring their knees up to their chest. As they’re doing this, they all turn completely white and start rolling around on the floor complaining of pain in their abdomen.

  • Child complains of abdominal pain
  • Often characteristically draws knees up to chest
  • Pale
  • Characteristic ‘Dance’s Sign’ (retraction of right iliac fossa)

One of the boys then does a poo. Unfortunately all he’s been eating is jelly, so he blasts jelly all over the other two. They both vomit, but since they’ve just been eating sausages from the barbecue, there’s now jelly and sausages all over the garden.

  • Vomiting
  • Blood-stained faeces (like jelly)
  • Sausage like mass palpable in the lower right quadrant

The children then all start screaming, but they’re screaming at such a high pitch that it’s causing all the windows to smash, so you then have to go on a trip to Target to buy replacements.

  • Ultrasound is the primary imaging modality
  • Characteristic ‘target’ sign seen

The Background

Intussusception is a medical emergency in which part of the bowel collapses into the adjacent part like a telescope (or extendable selfie-stick for those born after 1994). It can lead to obstruction and perforation, and then sepsis and shock.

The reason it’s dangerous is because the segment of bowel that is drawn in can have its blood supply cut off, and become necrotic and then perforate. The ischaemic bowel loses its mucosa into the bowel lumen, and this forms the characteristic ‘red jelly’. In reality, any type of blood in the stool should have intussusception on the differential diagnosis, especially if the child is between 6 and 18 months.

Causes

A variety of things can cause intussusception, although how it is that they do it isn’t well understood. It is thought that enlarged lymphoid tissue after an infection may play a role, and this would also explain why intussusception is relatively rare in the first three months of life, while the infant is still protected by passive immunity.

The different types include:

  • ileocolic (90%)
  • ileoileocolic (less common)
  • ileoileal (rare)
  • colocolic (rare)

Diagnosis

The diagnosis is made based on:

  • clinical examination
    • PR exam can be very helpful in children
  • history
  • Dance’s sign
    • emptiness in the lower right quadrant
    • sausage shape in right upper quadrant
  • Ultra-sound Scan
    • diagnostic imaging modality of choice
    • gives a characteristic target shape

If you google intussusception you get some awesome radiographs

I can’t put any on here because I don’t own them

sad face

The DMARD pyramid

How to remember the DMARDS commonly used in rheumatoid disease?

There’s a special place, where all of the people suffering from crippling rheumatoid arthritis can go for treatment. It’s a huge golden pyramid with a log flume running down from the top.

  • Gold
  • Leflunemide (pyrimidine synthesis inhibitor)
  • pyramid also describes the therapeutic pyramid of drugs in rheumatoid arthritis

At the top is a meth addict with spina bifida who tells you when you can ride the flume. He shouts go, and turns on a huge hydro-chlorine hose that fires you down the chute. The chlorine is to keep the mosquitos away.

  • Methotrexate (folate antagonist)
  • Hydroxychloroquine (antimalarial)

At the bottom you land in a huge pit full of aspirin pills that stink of sulphur, each of which is the same size as a thigh of pure chicken.

  • Sulfasalazine (5-ASA salicylate)
  • Azathioprine (purine analogue)

It’s a suitably weird story, feel free to make up your own….

Why you should care about Magnesium

I never learned much about Magnesium in the first few years of med school, which was a mistake, because it’s awesome.

Here I’ve tried to outline why it’s important and when to think about it in a clinical setting.

1. There’s loads of it

Magnesium is the ninth most abundant element in the universe, and the eleventh (by mass if you’re being pedantic) in your body. It’s required by every single cell as it is crucial to the basic nucleic acid chemistry that makes life possible, over 300 enzymes need it as a co-factor, and even ATP likes to hang out as a chelate of magnesium ions.

2. It’s useful as medicine

Magnesium has been used for many medicinal uses. It is a common laxative, antacid and it can stabilise muscle spasm in eclampsia. It increases production of prostaglandins and reduces that of thromboxane and angiotensin II. It also, in low doses, makes mineral water taste tart apparently (that was just for interest).

3. You can get it from loads of places

Clearly the ninth most abundant element in the universe isn’t going to be difficult to find, and you can find buckets of it in foods such as:

  • Spices
  • Nuts
  • Cocoa
  • Vegetables (given it’s crucial to chlorophyll, green stuff’s your best bet)

4. It does a lot of stuff in the body

Magnesium’s pretty busy in the world of metabolism. Most of it (60%) just chills in the bones, and the rest is mostly intracellular (20% in skeletal muscle). About 1% sits in the extracellular space, so clearly measuring your blood levels of magnesium isn’t going to tell you much about how much there is in your body.

It interacts with three major ions and their conduction channels:

  • Sodium
  • Potassium
  • Calcium

Sodium

Magnesium is required for the NaKATPase to function correctly in myocytes. Thus low magnesium means the sodium isn’t being pumped out and potassium isn’t being brought back in. This leads to a tachycardia and a predisposition to arrhythmias.

Potassium

To begin with, magnesium inhibits potassium leaving the cell through its channels. This means that too little magnesium, and you’re going to start losing potassium from the kidneys, and develop hypokalaemia. So – if you have a patient who’s hypokalaemic, and they’re not responding to potassium supplementation, start thinking about magnesium! In addition, patients in DKA (diabetic ketoacidosis) should have their magnesium monitored, so that the hypokalaemia caused by insulin driving the potassium into the cells isn’t compounded by renal losses.

Calcium

Magnesium suppresses release of calcium from the sarcoplasmic reticulum. This has several effects

  • reduced muscle contraction
  • reduced neuronal excitation through two mechanisms:
    • blockage of NMDA glutamate receptors
    • inhibition of acetylcholine release
  • reduced production of parathyroid hormone
    • interestingly mild reduction of magnesium stimulates PTH release, however
    • severe drops in magnesium reduce PTH release
  • hypocalcaemia
  • reduces sensitivity of skeletal muscle to parathyroid hormone 

Clinically this is important, as magnesium sulphate can be used as a bronchodilator in severe asthma.

5. Too little is bad 

As explained in point 4, you can have a normal blood magnesium while still being significantly deficient, and there isn’t really a reliable biomarker to measure. The best way to test whether someone is deficient is to load them with magnesium (a magnesium loading test… weirdly) and see how much of it they retain. If they hold onto more than 20%, they were definitely deficient in the first place. You’ve also just fixed the problem, so win win!

Symptoms of magnesium deficiency include:

  • weakness
  • muscle cramps
  • abnormal heart rhythm
  • tremors and athetosis (fidgeting)
  • extensor plantar reflex
  • confusion
  • hallucinations
  • depression
  • seizures
  • tetany

It’s a scary list but it makes sense – the muscle cramps largely due to the increased calcium that results from low magnesium, and the potassium leakage from cells that occurs.

Reasons for low magnesium in the blood are put into three categories:

  1. not enough uptake
  2. redistribution into the cells
  3. too much loss

Not enough uptake

Magnesium is absorbed in the duodenum and secreted by the colon, so malabsorption or excessive throughput will prevent it being absorbed into the blood. Conditions such as Crohn’s or Ulcerative Colitis will cause hypomagnesaemia by causing diarrhoea.

Redistribution into the cells

Adrenaline and other catecholamines tend to shove magnesium ions into the cells. Thus after a heart attack, 80% of patients will have low serum magnesium. Drugs that cause intracellular shift of calcium will drag magnesium with it, so things like Digitalis are also a risk factor.

Too much loss

A huge cause of hypomagnesaemia is alcohol. 30% of alcoholics have low magnesium, as do 85% of those with delerium tremens. In terms of medications, anything that inhibits reabsorption in the Loop of Henle is going to result in shedding of magnesium into the urine. The most common are:

  • loop diuretics
  • antibiotics
  • proton pump inhibitors

6. Too much is equally bad

Equally, too much is rarely good for you, and magnesium toxicity can happen even if the serum levels are normal, so knowing what to look out for in a clinical setting can be life-saving for the patient. Usually this is rare because your kidneys are seriously good at shifting it from the blood, so you don’t tend to get it from dietary overdose. Typically it’s your renally-impaired patient who’s on magnesium supplementation who sees their blood levels gradually climbing, and as expected, there is usually concurrent hyperkalaemia and hypocalcaemia, which generate most of the symptomatology:

Symptoms of hypermagnesaemia:

  • arrhythmias
  • hypotension
  • respiratory depression
  • hypo or areflexia
  • dizziness and somnolence

Treatment of hypermagnesaemia is done by antagonising it with calcium. Calcium gluconate IV help to reduce the cardiac manifestations of hypermagnesaemia, while diuretics and dialysis can reduce the magnesium levels in the body to a more tolerable level.

So there you go, a brief intro into why you should care about magnesium. It’s a puppet-master, controlling potassium and calcium, and for the most part it’s your friend, as long as you don’t have too much of it!