Catatan Pelajar Perubatan: The ups and down of 5 years in medical school. From the bottom of Jacknaim's heart. The murmur of whisper. Dear almighty Lord, I pray unto Thee for my patient.

February 12, 2015

The Compassionate Approach: Helping Patients to Heal

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The Compassionate Approach: Helping Patients to Heal
By Laura Mavers (Invited Author)


From the moment we decide we want to become a doctor (formally finalised when we take the Hippocratic Oath) we pledge to dedicate our lives to helping others, whether it is ensuring their wellbeing or saving their lives. As doctors, we take on two roles – one is the technical, medical aspect of our profession where we must apply our ever-evolving knowledge and use it with intuition to correctly diagnose a physical problem, and the other is to become mentor to offer guidance and emotional support for our patients.

Mental and Emotional Healing

Keeping an open mind and practicing compassion is relevant to all aspects of our journey as professional medical practitioners. But it especially applies to those whose mental and emotional condition is deeply interwoven with their physical condition. This could apply to a whole range of scenarios, but it is particularly valid in the case of people who are suffering from substance abuse such as drug addiction and alcoholism. These are complex illnesses, involving chemical, biological and physical components as well as emotional ones; there is always more to a case than meets the eye.
In these cases, practicing compassion is more important than ever. We must take an objective and unbiased view of the situation also. An individual may have come from a background where drug and/or alcohol use is common, establishing it as a “normal” habit. They could be suffering from extremely difficult circumstances and have seen drugs or alcohol as the only escape. Or they simply could have strayed down the wrong path, and where many people are able to get back on track, they have been hooked since their first experience. While we can draw specific correlations to different habits based on different communities (like impoverished, vulnerable ones for instance) a person does not need to “fit” into any label to become susceptible to substance abuse. And therefore, while we can trace patterns and demographics which help us to address the larger social problems of substance abuse, we still must treat each case without discrimination or judgment. 

Open Arms, Open Hearts, and Open Minds

It is important to remember that for many abusers of drugs and alcohol, their perception may place these substances in the role of “healer” or at least a kind of escape. In this case, it is difficult to “replace” that healer and convince someone that their substance addiction is something that is negative which they must be taken away from. Some people do not even acknowledge that they have a problem. Some are more self-aware, and want help, but no longer have the confidence to believe they can break free. In all of these cases, we must be compassionate. When we judge, we incite feelings of shame and guilt which are already experienced by users, ironically driving them back towards the very same behaviours which they themselves disapprove of. We must instead help them to become empowered, and give them the resources they need to succeed, and this will vary on each individual case. We must treat the “individual” aspect very seriously, rather than come across as a textbook speaker. We must be there to listen, guide, to offer help if that person is involved in other circumstances – such as a domestic violence issue – and help take them away from that situation where they can more easily heal. More than anything, we must be patient. We must not treat people like goals for success – relapses are very human, and very common, and can very easily feed a defeatist attitude. When we do this, we build trust with our patient, and they are able to reveal to us the circumstances which they face and we are able to understand much more than any information medical records can give us. This operates on a larger social scale too, where marginalising and victimising people who suffer from addiction as if they have made a failed moral choice has caused more harm than good.

Most importantly, compassion forms what is so instrumental in our medical practice; we should always have love for those who need it through the presence of compassion which heals the soul as well as mind and body.

*Disclaimer
Article was written by Laura from ProTalk group.

October 24, 2014

Image of the Day 40: Anteroseptal STEMI (Hyperacute T Wave)

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41 years old gentleman, ex smoker with family history of Ischemic heart disease presented with central sharp chest pain one and half hour prior to presentation to casualty. Pain is non radiating, persistent with score of 9-10/10 and associated with shortness of breath, palpitation, nausea and vomiting. BP on arrival 184/128, Pulse rate 62/min.


ECG shows sinus rhythm with Left Axis deviation,  rate of 80 b.p.m with presence of hyper acute T wave with ST elevation of lead V1-V4 and reciprocal ST depression in lead II,III, aVF.


Patient was load with T.Aspirin 300mg stat, T. Clopidogrel 300mg stat, S/L GTN 0.5 Mg X1, IV Morphine 3mg and IV Metoclopromide 10 mg. IV streptokinase 1.5 Megaunit in 100cc D5% was commerced after BP stabilization with IV GTN Infusion.

ECG upon patient presentation
 
Subsequent ECG 5 minute before presentation shows progressively increase in T wave and ST height
 
Immediately Post Streptokinase shows poor R wave progression in V1-V3, upsloping of ST segment in V4-V5 and slightly reduce in ST segment height in V1-V3


30 minute post streptokinase. Not much changes seen

1 Hour post streptokinase shows reperfusion ischemia and variable block

24 hour post streptokinase shows formation of Q wave in V1-V4 and normalization of ST segment elevation as well as T inversion in lead V1-V3.




Well i definetely learns something from this case. Most of the time, i will get straight forward ST elevation and not hyper acute T wave. The tips to recognize pure ST Elevation MI of anteroseptal infarct is large T wave and reciprocal changes in inferior lead. Present of risk factor like in this gentleman; age, hypertensive emergency, smoker and age and together with history of chest pain will give stronger points pointed to cardiac event.


Another differential diagnosis should also be think of especially ventricular aneurysm and also other cause ST elevation (refer to my post ABCD Help in ST Elevation ECG)


Another tips if you see this ECG especially in younger age patient is possibility of Coccaine induce Myocardial Infarction.

Let us revise the ST and T wave changes in Acute Myocardial Infarction


Disclaimer: Image taken from ECG pedia and not belong to blog author


 A very good reading material for Anterior ST elevation is from this website Life In The Fast Lane: Anterior Myocardial Infarction [link]

 This ECG taken from the Life in the Fast Lane website is almost identical to the ECG of the patient that has been discussed earlier on.

  • ST elevation is maximal in the anteroseptal leads (V1-4).
  • Q waves are present in the septal leads (V1-2).
  • There is also some subtle STE in I, aVL and V5, with reciprocal ST depression in lead III.
  • There are hyperacute (peaked ) T waves in V2-4.
  • These features indicate a hyperacute anteroseptal STEMI 
* Source: Life in the Fast Lane website by Edward Burns
Ok, this interesting clinical PEARL tips is taken from Edward Burns article and not written by myself. I just found it interesting and share it here just in case you are not in the mood to click on the above link.


Clinical Relevance

        Anterior STEMI results from occlusion of the left anterior descending artery (LAD).

        Anterior myocardial infarction carries the worst prognosis of all infarct locations, mostly due to larger infarct size.

        A study comparing outcomes from anterior and inferior infarctions (STEMI + NSTEMI) found that on average, patients with anterior MI had higher incidences of in-hospital mortality (11.9 vs 2.8%), total mortality (27 vs 11%), heart failure (41 vs 15%) and significant ventricular ectopic activity (70 vs 59%) and a lower ejection fraction on admission (38 vs 55%) compared to patients with inferior MI.

        In addition to anterior STEMI, other high-risk presentations of anterior ischaemia include left main coronary artery (LMCA) occlusion, Wellens’ syndrome and De Winter’s T waves.


How to Recognise Anterior STEMI


        ST segment elevation with Q wave formation in the precordial leads (V1-6) ± the high lateral leads (I and aVL).

        Reciprocal ST depression in the inferior leads (mainly III and aVF).


NB. The magnitude of the reciprocal change in the inferior leads is determined by the magnitude of the ST elevation in I and aVL (as these leads are electrically opposite to III and aVF), hence may be minimal or absent in anterior STEMIs that do not involve the high lateral leads.



Patterns of Anterior Infarction


The nomenclature of anterior infarction can be confusing, with multiple different terms used for the various infarction patterns. The following is a simplified approach to naming the different types of anterior MI.


The precordial leads can be classified as follows:


        Septal leads = V1-2
        Anterior leads = V3-4
        Lateral leads = V5-6

The different infarct patterns are named according to the leads with maximal ST elevation:


        Septal = V1-2
        Anterior = V2-5
        Anteroseptal = V1-4
        Anterolateral = V3-6, I + aVL
        Extensive anterior  / anterolateral = V1-6, I + aVL


(NB. While these definitions are intuitive, there is often a poor correlation between ECG features and precise infarct location as determined by imaging or autopsy. For an alternative approach to the naming of myocardial infarctions, take a look at this 2006 article from Circulation)


Three other important ECG patterns to be aware of:


        Anterior-inferior STEMI due to occlusion of a “wraparound” LAD: simultaneous ST elevation in the precordial and inferior leads due to occlusion of a variant (“type III”) LAD that wraps around the cardiac apex to supply both the anterior and inferior walls of the left ventricle.

        Left main coronary artery occlusion: widespread ST depression with ST elevation in aVR ≥ V1

        Wellens’ syndrome: deep precordial T wave inversions or biphasic T waves in V2-3, indicating critical proximal LAD stenosis (a warning sign of imminent anterior infarction)

        De Winter’s T waves: upsloping ST depression with symmetrically peaked T waves in the precordial leads; a “STEMI equivalent” indicating acute LAD occlusion.



Credit to Dr Aslannif Roslan, Dr Azlan Kamalludin and Dr Azlean for sharing knowledge and tips...

October 23, 2014

Image of the day 39: Assymetrical shoulder tips

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This middle age man presented to casualty after alleged fall from height. He complained of disfigured and inability to move his left arm. What is your observation on the pictures and the treatment that you would like to suggest?

There is asymmetrical of this patient shoulder tip. the left shoulder is displaced downward and externally rotated. Patient was asked to tap his right shoulder tip with his left index finger but failed.
There is also bruises at his left shoulder region.otherwise, no open wound.


Chest X ray shows left anterior shoulder dislocation


Closer look of the picture of left anterior shoulder dislocation. This patient need urgent Close manual reduction.

October 21, 2014

Serpent starfish (Ophiolepsis sp.) Stings

Comment (1)



Serpent starfish (Ophiolepsis sp.)




15 years old boy was brought to casualty by bystander after stung by serpent starfish at his right forearm while swimming in Lahad Datu Coastal region. He develops severe intense burning pain at the stung area. Vital signs are normal and no evidence of anaphylaxis. He was treated with hot water immersion at the temperature of 45 degree celcius for 20 minutes. However, intravenous weak opiod was given as he could not tolerate the pain. He was discharged well after three hours of observation in casualty.


.  

Tourniquet is un necessary first aid method and not proven to be beneficial. 

Examination of the hand showed lashes mark at the postero medial aspect of distal right forearm region associated with redness, warm and local swelling. No active bleeding noted and range of movement of wrist joint was intact








Discussion

Serpent starfish (Ophiolepsis sp.) is classified under phyllum echinoderm together with starfish, sea urchins, sea cucumbers, crinoids (sea lilies) and sand dollars. Serpent starfish use their flexible arms for locomotion and crawls across the sea floor. This five long slender, whip like arms' creature is a nocturnal detritivore.

This organism rarely causing severe anaphylaxis but the heat labile sting may cause severe pain and uneasiness to the patient.

Management for the sting includes hot water immersion temperature 43-45 degree Celsius for 20 minutes followed by 10-15 minutes rest then repeated for 2 hours. This technique is usually adequate to alleviate the pain. However, some patient may need intravenous pain killer including opiod. Although rare, patient should also be looked for sign and symptoms of anaphylaxis. Anti histsmine, steroids are not proven beneficial but may be used to treat symptoms of itchiness or urticaria. IM Adrenaline should be started if patient develops sign of anaphylaxis.




Immersion in hot water can alleviate the pain causing by this heat labile sting

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