SUPPLEMENTARY MATERIALS

for RESIDENT MEDICAL OFFICERS

by Grzegorz Chodkowski, MD
Jacob Stephanus Drotsk, MD
NES Healthcare 2007
All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system or transmitted,
in any form or by any means, electronic, mechanical, photocopying, recording or otherwise
without the prior permission of the copyright owner.
RMO Course 2007 3
Index
Educational Objectives of the RMO course . . . . . . . . . . . . . . . . . . . . . . . 5
RMO Duties and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Medical Supplies and Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Emergency equipment for RMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Early Warning Scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
The Most Common Medical Abbreviations . . . . . . . . . . . . . . . . . . . . . . 19
Body Parts (Medical/Colloquial) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Physical activities (Medical/Colloquial) . . . . . . . . . . . . . . . . . . . . . . . . . 27
Needle Stick Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
How to Learn English. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Dialogue 1 Patient in Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Dialogue 2 Cannulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Dialogu 3 Catheterisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Glossary of Plastic Surgery Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Surgical terminology for RMOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Glossary of Job Titles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Job titles/grades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Drug Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Drug Dosage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Helping patients to cope with tablets . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
The Most Common TTOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Tips on writing TTOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
History Taking Mnemonics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
History Taking Skills. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Physical Examination Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Presenting During Ward Rounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Ortopaedics post-op notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Arterial Blood Gas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Blood Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Cohort Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Pain Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
ECG Monitoring and rhytm strips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Drug Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Acute Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Cannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Venepuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Venepuncture Vocabulary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Emergency Scenarios. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
PCA Pumps Patient Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
PCA Pumps for the RMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
SI Conversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Laboratory Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Sample hospital documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4 RMO Course 2007
Educational Objectives of the RMO course
1. To share information regarding the duties of a Resident Medical Officer.
2. To experience practical Basic Life Support based on the new UK Guidelines (2005).
3. To have hands-on training in the safeguarding of the airway with insertion
of various airway devices.
4. To gain knowledge regarding defibrillasation and ECGs and BNF pharmacology.
5. To master prescription facts about important emergency and non-emergency drugs.
6. To have hands-on practical experience in venepuncture and cannulation techniques.
7. To gain knowledge regarding arterial blood gas sampling, blood Transfusions
and chemotherapy.
8. To master the practical skills of male and female catheterization.
9. To gain practical experience of the setting of a PCA machine and an Infusion pump.
Skills and knowledge that will be acquired during the course
1. Acquire knowledge of the duties of a Resident Medical Officer
and medical English.
2. Adult, child and baby CPR skills.
3. Intubation skills and airway insertion techniques.
4. Correct use of defibrillators and AEDs.
5. Acquiring and reading ECGs.
6. BNF knowledge regarding emergency and non emergency drugs.
7. Venepuncture and cannulation skills.
8. Knowledge regarding arterial blood gas sampling, blood transfusion and Chemotherapy,
Early Warning Scores (EWS), Prescription and medical note writing.
9. Urethra catheterization skills.
10. PCA and infusion pump settings.
Reading material provided 4 weeks prior to the course include:
1. RMO Course Manual
2. Beginner to Specialist
3. ECG Made Easy
4. BNF
5. Medical IELTS
RMO Course 2007 5
6 RMO Course 2007
RMO Duties and Responsibilities
Emergency
to be familiar with the location and use of emergency equipment
to demonstrate competency in ACLS/PALS
to respond immediately to clinical emergencies / lead the resuscitation team
in an emergency situation undertake emergency investigations and procedures
in accordance with hospital policy and as directed by the patients Consultant
Ward Duties
be present and contactable within hospital premises at all times
to clerk and assess patients on admission according to the hospital policy
to maintain individual contact with patients, carrying out ward rounds and other duties
detailed by the individual hospital
to attend communication (handover) rounds as require
to update clinical notes on all patients attended according to best practice
for record keeping
to respond promptly to the request of all medical staff
(Consultants and other doctors, nurses) to see any patients within the hospital
and to advise or start any treatment as indicated
undertake specific medical procedures on patients within all departments in the hospital
as requested by medical and nursing staff: cannulation, commencing i.v infusions, urinary
catheterisations, administration of i.v drugs, ECG, phlebotomy, etc.
to check blood sample results and take necessary actions
to assist with pre-operative /admission and outpatient clinics, if requested
to prescribe medicines to take home and complete discharge letters
as requested according to local policies
before going off duty ensure written appropriate communication to the oncoming RMO
specifying any requirements of individual patients
Responsibility to Consultants
inform Consultants of any change in the condition of their patients
and any emergency procedures undertaken
in a routine situation initiate requests and treatments with the prior consent of the
patients Consultant
in the event of death of a patient inform the Consultant, and the patients GP
(if the Consultant is unable to do so)
advise the Consultant immediately who threatens to discharge themselves
against medical/nursing advice
see and examine discharged post-operative patients, on requests of the consultant
RMO Course 2007 7
Other duties
RMOs must not routinely perform the role of surgical assistant in the Operating
Department, but are required to respond in the event of an urgent/emergency situation
dispense drugs from the pharmacy as required following the local hospital policy
to examine a sick/injured member of hospital staff and offer appropriate advice in respect
of treatment RMOs are expected to look smart and presentable at all times, wearing
a white coat and a name badge when attending patients
Administrative Duties
comply with the hospital consent and confidentiality policy
maintain comprehensive clerking notes and treatment records for all patients
read understand and adhere to hospital policies and procedures
complete hospital administrative documentation as required
ensure correct procedures are carried out in respect of patients discharging themselves,
deaths in care and coroners requirements
Health and Safety and Quality Assurance
be familiar, understand and adhere to all Health and Safety regulations including
evacuation policy and the RMOs role in such an event
participate/assist/attend in-house trainings as requested. This may include: fire safety,
infection control, manual handling, blood transfusion
be aware of the promotion of effective customer care and public relations in order
to promote the good reputation of the hospital
Medical Supplies and Tools
Here is a list of some of the most common supplies found in doctor's offices, operating
rooms, and medical kits. Write describing words down from your native language next to
the text.
antiseptic liquid used to sterilize (clean) the surface of the skin
adhesive wound dressing a cloth covering for a wound or sore
bandage a cloth covering that is placed over a wound to prevent
bleeding, swelling and infection
bandage scissors tool used to cut bandages
blood pressure monitor a tool that measures the force of blood flow through
a person's body
dressing protective covering that is placed over a wound
elastic tape a thin roll of stretchy material that is sticky on one side
eye chart a poster of letter, word, and number combinations of
various sizes used to test a person's eyesight
forceps instrument used during operations and medical
procedures
(assists the doctor in pulling, holding, and retrieving)
gauze thin, netted material used for dressing wounds
gauze pad
gurney a metal stretcher with wheels
hypodermic needle sharp pointed metal piece that pricks the skin
(attached to a syringe), used for taking blood
or administering medicine
IV bag the pouch that contains liquids to be pumped
into a patient's body
medicine cup small plastic measuring cup
microscope equipment that makes small things appear larger
than they are
otoscope a device used for looking into a patient's ears
oxygen mask equipment that fits over the nose and mouth
and supplies oxygen
8 RMO Course 2007
Emergency equipment for RMO
Bag valve mask
Resuscitator
An obsolete term for an apparatus that forces gas (usually O2) into lungs
to produce artificial ventilation.
Ambu bag
Proprietary name for a self-reinflating bag with nonrebreathing valves to provide positive
pressure ventilation during resuscitation with oxygen or air.
Oxygen cylinder
Oxygen mask
Nasalcanula
Oropharyngeal airway
Oropharyngeal passage
Fauces
Anatomy the narrow passage from the mouth to the pharynx, situated between the soft
palate and the base of the tongue; called also the isthmus of the fauces. On either side
of the passage two membranous folds, called the pillars of the fauces, inclose the tonsils.
Intubation
Procedure the insertion of a tube into a body canal or hollow organ, as into the trachea
or stomach.
Introducer
An instrument, such as a catheter, needle, or endotracheal tube, for introduction
of a flexible device.
Synonym: intubator.
Stylet/introducer
Defibrillator
Equipment a device which delivers a measured electrical shock to arrest fibrillation
of the heart (ventricle).
RMO Course 2007 9
Automated external defibrillator
Sudden cardiac arrests can happen to anyone at any time and therefore any building that
hosts a large throughput of people on a regular basis should carry out a risk assessment
in line with the resuscitation council guidelines for treatment of cardiac arrests victims.
In reality, cardiac arrest impacts all age groups, genders, and levels of fitness. For many
victims there are no outward signs of a problem until it is too late. It can strike at anyone,
anytime, anywhere.
Sudden cardiac arrest (SCA) causes the hearts normal rhythm to suddenly become chaotic.
The heart can no longer pump blood effectively and the victim; collapses; stops breathing;
becomes unresponsive; and has no detectable pulse. SCA can strike anyone and at anytime.
Although the risk of SCA increases with age and in people with heart problems, a large per-
centage of the victims are people with no known risk factor. SCA is an electrical problem
with the heart and should not be confused with a heart attack which is a pumping problem.
Sometimes a heart attack, which may not be fatal in itself, can trigger a sudden cardiac
arrest.
Defibrillation is the only treatment proven to restore a normal heart rhythm. When used
on a victim of SCA, the automated external defibrillator (AED) can be used to administer
a lifesaving electric shock that restores the hearts rhythm to normal. AEDs are designed
to allow non-medical personnel to save lives.
If the victim receives defibrillation within three minutes the chances of survival are 70%.
Every minute that the heart is not beating lowers the odds of survival by 7%.
After 10 minutes, the chances of survival are negligible. CPR can buy a little time
but ultimately SCA requires a shock to restore a normal rhythm.
AED defibrillators uses advanced biphasic technology.
AEDs are very simple to operate and can be used by either medical or non-medical person-
nel. Voice prompts guide the rescuer through the steps involved in saving someones life,
including calling an ambulance and performing CPR in compliance with new 2005
Resuscitation Council guidelines. The AED is self-contained with pre-connected pads and
a lit status indicator. It also features an audible alarm if an internal problem is detected
when performing self-tests. A computer inside the unit analyses the patients heart rhythm
and determines if a shock is required to save the victim. If a shock is required, the AED uses
voice instructions to guide the user through saving the persons life. Safeguards designed
into the unit means that non-medical responders cant use the AED to administer a shock if
the system determines that no shock is required.
Everyday, lives could be saved by the prompt delivery of a life-saving defibrillation shock
from AEDsNow there is something that can be done to improve the odds for your students,
staff and guests that is easy to use and inexpensive to buy.
10 RMO Course 2007
Automatic External Defibrillator Training
Although Guidelines 2005 contain recommendations for changes in the sequence of shock
delivery, there are no fundamental changes to the sequence of actions, since users should
be taught to determine the need for an AED, switch on the machine, attach the electrodes,
and follow the prompts.
The main guideline changes are:
Place the axillary electrode pad vertically to improve efficiency.
If possible, continue CPR whilst the pads are being applied.
Program AEDs to deliver a single shock followed by a pause of 2 min for the immediate
resumption of Compressions and then ventilations.
LMA Laryngeal Mask Airway
1. Laryngeal Mask Airway will be referred to as LMA
2. Ensure Basic Life Support is on going
3. Collect together the items needed to insert LMA
a) Working Suction
b) Bag Valve Mask with Oxygen attached (BVM)
c) Gloves
d) LMA size 4 (Reusable LMAs should have had the cuff over inflated
on return from TSSU to ensure no herniation has occurred)
e) 50ml syringe
f) Lubrication Gel
g) Stethoscope
h) Bite Block
i) Tape to secure LMA in place
4. Put on Gloves
5. Check the interior and exterior of the LMA (for reusable LMAs Flex the tube to ensure no
kinks occur)
6. Deflate the cuff fully ensuring correct shape
7. Prepare the syringe with 30mls of air
8. Apply lubricant to the rear of the LMA only
9. Hold LMA like a pen, ensuring the black line is facing you
10. Ensure head is in position Neck flexed, head extended
11. Ask assistant to remove ventilation and count for 30 seconds.
12. Insertion of LMA should take no longer than 30 seconds
13. Follow the palate of the mouth, centrally, pushing the LMA into the oropharynx, once
resistance is felt, stop, index finger should have disappeared into the mouth
14. Once in place hold the LMA with the other hand before removing finger from the mouth
15. An attempt to push the LMA further into the hypopharynx can now be made.
16. Let go of the LMA
17. Inflate the cuff, watching to see the LMA move
RMO Course 2007 11
18. Attach BVM and ventilate ensuring Oxygen is attached. The chest should rise. If no rise
of the chest remove and re-insert.
Ensure oxygenation is taking place if reinsertion is going to be delayed
19. If chest rises, listen to lungs and stomach to confirm placement (if listening to lungs is
not something you usually do, now is the time to start practicing on your colleagues and
patients)
20. Insert Bite block and tie in place
21. If there is no air escaping at the mouth asynchronous chest compressions and ventila-
tions may be performed
Removal after successful resuscitation
Remove LMA still Inflated with suction available
Apply oxygen via non re breathing mask
Combi tube
Combitube Protocol
Indications for Combitube Use
Patient is unconscious and unable to protect own airway; no apparent gag reflex.
Contraindications
1. Patients under 70 lbs. and under 5 feet tall.
2. Responsive patients with an intact gag reflex.
3. Patients with known esophageal disease.
4. Patients who have ingested caustic substances.
5. Known or suspected foreign body obstruction of the larynx or trachea.
6. Presence of tracheostomy
Procedure Prehospital
Cardiorespiratory/Respiratory (Pulse Present) Arrest
a. The first priority is to defibrillate the patient in cases of ventricular fibrillation.
The AED should be applied first, using conventional airway management, following
the AED protocol.
b. The Combitube should be placed during the two minutes of CPR between sets of AED
analyses. (This may somewhat delay subsequent AED analysis).
c. Hyperventilate the patient prior to Combitube insertion for 10-15 seconds using either
a BVM or Mouth-to-Mask device with supplemental oxygen.
d. Insertion done quickly between ventilation
I. Except in cases of suspected cervical spine injury, hyper-extend the head
and neck.
12 RMO Course 2007
II. In cases of suspected cervical spine injury, c-spine precautions will be taken at all
times.
III. Patent airway and ventilation should already have been established by other basic
methods.
IV. In the supine patient, insert the thumb of a gloved hand into the patient's mouth,
grasping the tongue and lower jaw between the thumb and index finger, and lift
upward.
Caution: When facial trauma has resulted in sharp, broken teeth or dentures, remove
denture and exercise extreme caution when passing the Combitube into the mouth to
prevent the cuff from tearing.
V. With the other hand, hold the Combitube with the curve in the same directions as the
curve of the pharynx. Insert the tip into the mouth and advance carefully until the
printed ring is aligned with the teeth. Caution: DO NOT FORCE THE COMBITUBE.
If the tube does not advance easily, redirect it or withdraw and reinsert. Have suction
available and ready whenever withdrawing tube.
VI. If the Combitube is not successfully placed within 30 seconds, remove the device and
hyperventilate the patient for 30 seconds using basic methods, as described in C
above, before re-attempting insertion.
e. Inflation of Combitube
I. Inflate line 1, blue pilot balloon leading the pharyngeal cuff, with 100ml of air using
the 140ml (cc) syringe. (This may cause the Combitube to move slightly from the
patient's mouth).
II. Inflate line 2, white pilot balloon leading the distal cuff, with approximately 15ml of air
using the 20ml (cc) syringe.
f. Ventilation
I. Begin ventilation through the longer blue (distal) tube (Number one). Watch for chest
rise. If auscultation of breath sounds is positive and auscultation of gastric air sounds
is negative, continue ventilation.
II. If no chest rise, negative lung sounds, and/or positive gastric air sounds with ventila-
tion through the distal tube, begin ventilation through the shorter clear (proximal) tube
(Number 2). Confirm ventilation with chest rise, presence of auscultated lung sounds,
and absence of gastric air sounds.
III. If there is no chest rise or positive lung sounds through either tube, remove the
device, hyperventilate the patient 20-30 seconds as described in C above, and repeat
the insertion/inflation/ventilation procedures.
IV. Continue to ventilate the patient through the tube which resulted in lung sounds using
a BVM or a manually triggered oxygen delivery value.
V. REASSESS TUBE PLACEMENT FOLLOWING EVERY PATIENT MOVEMENT.
g. If two consecutive attempts at intermediate airway placement fail to result in a proper
placement and ventilation, do not attempt placement again. Ventilate the patient using
basic methods and equipment.
RMO Course 2007 13
h. Removal of Combitube at direction of Medical Control or when attempting reinsertion,
or if the patient awakens. Remove combitube as follows:
I. Have suction ready
II. Deflate blue tube Number 1
III. Deflate white tube Number 2
IV. Remove combitube
V. Be prepared for vomiting
NOTE ON SUCTIONING THROUGH THE COMBITUBE: When suctioning the patient through
the Combitube, always introduce the suction catheter through Tube Number 2 (white).
Because the Combitube will usually be in the esophagus 80%, most through the tube suc-
tioning will be gastric suctioning and will result in decreased gastric distension. In the event
that the Combitube is in the trachea 20%, suctioning of the patient's airway will result.
14 RMO Course 2007
Early Warning Scores (EWS)
What is an Early Warning Score?
In the United Kingdom Early Warning Scores (EWS) are now commonly used for the assessment
of unwell hospital patients. The Early Warning Score is a simple physiological scoring system
that can be calculated at the patient's bedside, using parameters which are measured in the
majority of unwell patients. It does not require complex, expensive equipment to measure
any of the parameters. It is reproducible1 and can be used to quickly identify patients who
are clinically deteriorating and who need urgent intervention. EWS can be used to monitor
medical, pre and postoperative surgical, and Accident and Emergency patients.
Early warning scores are sometimes also referred to as Patient at Risk scores (PARS)
or Modified Early Warning Scores (MEWS).
How do you calculate an Early Warning Score?
An EWS is calculated for a patient using five simple physiological parameters. Mental
response, pulse rate, systolic blood pressure, respiratory rate and temperature. For
patients who are postoperative or unwell enough to be catheterised a sixth parameter,
urine output, can also be added. The idea is that small changes in these five parameters
will be seen earlier using EWS than waiting for obvious changes in individual parameters
such as a marked drop in systolic blood pressure which is often a pre-terminal event.
Of all the parameters, respiratory rate is the most important for assessing the clinical state
of a patient, but it is the one that is least recorded. Respiratory rate is thought to be the
most sensitive indicatory of a patients physiological well being. This is logical because
respiratory rate reflects not only respiratory function as in hypoxia or hypercapnia,
but cardiovascular status as in pulmonary oedema, and metabolic imbalance such as
that seen in diabetic ketoacidosis (DKA).
When and why to use an Early Warning Score?
An EWS score should be calculated for any patient that nursing staff are concerned about.
It gives a reproducible measure of how at risk a patient is. Patients who have suffered
major trauma, or have undergone major surgery, can be started on an EWS observation
chart as soon as they arrive on the ward to monitor their clinical progress, and give early
warning of any deterioration. Repeated measurements can track the patient's improvement
with simple interventions such as oxygen or fluid therapy or further deterioration. Serial
EWS readings are more informative than isolated readings as they give a picture of the
patient's clinical progress over time.
The scoring system was developed because not all unwell patients can be monitored on
intensive care or high dependency units. It allows deteriorating patients to be identified,
before physiological deterioration has become too profound. Once an unwell patient has
been identified, with an EWS score of 3 or more, this should stimulate a rapid assessment
of the patient by a ward doctor or, if available, the intensive care unit (ICU) team. The result
RMO Course 2007 15
of the review should be the modification of patient management to prevent further
deterioration. If deteriorating patients are identified early enough, simple interventions
such as oxygen, or fluid therapy, may prevent further deterioration and imminent collapse.
The use of EWS has been shown to be effective in reducing mortality and morbidity
of deteriorating patients as well as preventing ICU admissions.
What should happen if a patient has an Early Warning Score of 3 or more?
Studies have indicated that score of 3 or more requires urgent attention4,6. The level of
response is dependent on the facilities available. In many UK hospitals a score of 3 triggers
an immediate review by a ward doctor. If no improvement is seen the most senior ward
nurse can then call a senior doctor. This gives the ward nursing staff the authority to refer
upwards to more senior members of staff if a patient's clinical situation is not improving.
Some UK hospitals have gone further and a score of 3 results in an immediate call, by the
nursing staff, directly to the Intensive care unit registrar for a ward review. Other hospitals
have been more cautious and use a score of 4 or even 5 as a call out trigger4.
Case Histories
1. A 60-year-old man arrived in hospital with increasing shortness of breath. He had no
chest pain. He had a past history of a myocardial infarction and was awaiting coronary
artery bypass surgery; he was also a known asthmatic. On arrival in hospital he was
alert with a respiratory rate of 30, a pulse rate of 130 and a blood pressure of 108/60,
his temperature was 38.5C. He therefore had an EWS score of 5. He was assessed
by the emergency doctors. A salbutamol nebuliser and oxygen therapy were given.
After 15 minutes, on clinical observation, he looked better. His respiratory rate had
dropped to 24, his pulse rate was 124 bpm, temperature remained the same but his blood
pressure had dropped to 95/55mmHg. Therefore despite looking better his EWS score had
risen to 6, suggesting he was still deteriorating. The intensive care team were called and
he was admitted to the high dependency unit for observation and treatment. He was
found to be septic from a chest infection. This case shows that subjective judgements
made on appearance only can be misleading. More objective judgements are often made
on the basis of physiological parameters.
2. A 72 year old patient arrived in recovery after a Whipple's resection of his pancreas for
a pancreatic tumour. He had lost 3 litres of blood intra-operatively and was receiving
a blood transfusion in recovery. Initially in recovery he was alert with a heart rate
of 70bpm, a respiratory rate of 15, a blood pressure of 110/70mmHg, and a urine output
of 20ml/hr. His EWS was 1. Over the next 3 hours in recovery he became more tachycardic
and hypotensive. He was alert with a heart rate of 105, a respiratory rate of 20, a blood
pressure of 95/50 and a UO of 10ml/hr. His temperature was not recorded. Therefore his
EWS can be calculated as having risen to 4. Despite this a doctor did not review him, and
he was sent back to the ward. By midnight he was drowsy, had a respiratory rate of 30,
temperature of 38.5C, heart rate of 120bpm, blood pressure of 90/50mmHg and his urine
output was negligible. This made his EWS 11. He was finally reviewed, actively resuscitated
and taken immediately back to theatre for an exploratory laparotomy. Two litres of blood
16 RMO Course 2007
and clot were found in his abdomen from a bleeding artery. He was in hypovolaemic
shock. He was sent intubated to the intensive care unit and remained there overnight.
If the EWS protocol had been followed this patient should have never left recovery.
All the signs were there from a very early stage that he was deteriorating.
Early intervention would have prevented the development of hypovolaemic shock
and possibly an ICU admission.
Taking the lead in resuscitation
It will be expected of the RMO as the only doctor in the hospital to take the lead and the
responsibility for all resuscitations. A dedicated team will assist the RMO with resuscitation.
Leadership during stress full situations call for a calm open minded knowledgeable RMO It
is therefore of utmost importance to know the emergency protocols, the staff that will assist
you, the hospital floor plan and where the emergency equipment is based in the hospital.
What makes an effective leader? A person with leadership skills has the ability to take
initiative, make swift, concise decisions and accept responsibility for their actions. They are
also the type of person you probably want on your resuscitation team when faced with a life
or death situation in the hospital. Resuscitation requires coordination and cooperation
between professionals. When it gets down to it, we believe that there has to be a leader
(on the resuscitation team) because someone must be able to make quick decisions.
When a team leader is not identified during resuscitation, several scenarios can occur.
For example, they have observed more than one person doing a single task, such as
preparing medication, no one giving a heart rate or assisting with oxygen during intubation,
and no one coordinating compressions and ventilation. The leader is the person who says
to a specific individual, Can you listen for breath sounds? or stops an intubation attempt
which has gone on too long. Someone in the hospital has to make sure that the overall plan
is being followed rather than having each person think independently, leaving some tasks
uncompleted and some done multiple times.
Specific functions for the leader and team members must be delegated before the actual
resuscitation begins. After selecting a leader, and before the actual resuscitation, the team
should review member tasks and relevant basic and advanced life support guidelines pertinent
to a specific task, such as defibrilization.
Its important to note that, overall, the process must also include prompting
and supporting each individual with positive feedback, providing objective
input and allowing time for a debriefing period after the actual resuscitation is completed.
People can shift and change roles, but when they step into the leadership
position, they need to focus on overall priorities. Problems that arise in the absence of
a leader involve losing awareness of the overall situation. Thats the biggest single issue
that weve identified.
RMO Course 2007 17
A good leader is experienced, decisive and positive, and possesses the ability to know when
a specific action is needed, as well as when they personally need to perform this action.
Finer and Rich have identified the following six attributes of a well functioning team:
Good Communication
Adaptability
Flexibility
Coordination
Initiative
Team Spirit
During resuscitation, someone saying good job means a tremendous amount
to the people on the team. This sort of thing show people what positive reinforcement can
do resuscitation, such as trauma resuscitation and adult cardiac arrest, theres always
someone running those codes. Thats the norm and expectation in these resuscitations,
but its not really the expectation in neonatal resuscitation, Rich said. With a newborn,
you are also faced with a variety of possible scenarios. We believe there are a lot of lessons
to be learned from other resuscitation circumstances and are amazed at the applicability
of these lessons to neonatal resuscitation.
18 RMO Course 2007
RMO Course 2007 19
The Most Common
Medical English Abbreviations
Abbreviation English Your own language
a. lat. anno
ABCD Airway Breathing Circulation
Defibrillation
Ab, abor abortion
ACLS acute cardiovascular life support
ACS Acute Coronary Syndrome
AED automated external defibrillator
AD lat. auris dextra
AHA American Heart Association
AI artificial insemination
AIDS acquired immunodificiency syndrome
AIHA autoimmune haemolytic anaemia
ANS autonomic nervous system
AXR abdominal X-ray
BD lat. bis in diem (twice daily)
BLS Basic Life Support
BMI body mass index
BP blood pressure
BT bone tumour
Bx, bx biopsy
CA, Ca cancer, lat. carcinoma
CAD coronary artery disease
CF cancer free
CHF Coronary Heart Failure
CISD Critical Incident Stress Debriefing
CLL chronic lymphocytic leukaemia
CN cranial nerve
CNS central nervous system
20 RMO Course 2007
CPR cardio-pulmonary resuscitation
CPSS Cincinnati Prehospital Stroke Scale
C-sect caesarian section
CSF cerebrospinal fluid
CSM Carotis Sinus Massage
CSU catheter specimen of urine
CVA cerebrovascular accident
CVP central venous pressure
CVS cardiovascular system
Cx Circumflex
CXR chest X-ray
Dg. lat. diagnosis
DNR do not resuscitate
DOB date of birth
DOPES Displaced Obstructed Pneumothorax
Equipment Stomach Distension
DU duodenal ulcer
DVT deep vein thrombosis
dx. lat. dexter
EBL estimated blood loss
ECC Emergency Cardiovascular Care
ECG electrocardiography
EDD eosaphegal detector device
EUA examination under anaesthesia
Ez eczema
FBC full blood count
FDIU fetal death in utero
EF Ejection Fraction
EMD Emergency Medical Departament
EMS Emergency Medical Services
EMT Emergency Medical Technician
FBAO Foreign Body Airway Obstruction
fra. lat. fractura
RMO Course 2007 21
FX, Fx fracture
GA general anaesthesia
GI gastrointestinal
GI and GII lat. gravida I and gravida II
ging. gingiva
GP General Practitioner
gr. lt. Gradus
GU gastric ulcer
Gyn gynecology
h. hernia
H/ct haematocrit
Hb. haemoglobin
HD haemodialysis
HDU high dependancy unit
HGH human growth hormone
HHH Hazards-Hello-Help
HIV human immunodficiency virus
ICD Implanted Cardioverter Defibrillator
ICP Intra Cranial Pressure
IDDM insulin dependent diabetes mellitus
IM, i.m intramascular
in dec. lat. in decursu
in st. lat. in statu
INR international normalised ratio
(clotting time)
IOFB intra-ocular foreign body
IUC idiopathic ulcerative colitis
IUD intra-uterine death
IV, i. v intravenous
IVF in vitro fertilization
IVI intravenous infusion
KUB kidney, ureter, bladders
LA local anaesthesia
22 RMO Course 2007
La labial
LAD Left Anterior Descending
LaG labia and gingiva
LAPSS Los Angeles Prehospital Stroke Screen
LCA Left Coronary Artery
LFT liver function test
LLL left lower lobe
LLQ left lower quadrant
LMA Laryngeal Mask Airway
LMWH Low Molecular Weight Heparin
MAT Multifocal Atrial Tachycardia
m. lat. modo
MCP multidisciplinary care pathway
MD muscular dystrophy
MD medical doctor
med. medial
meta. lat. metastases
MFT muscle function test
MRI magnetic resonance imaging
MRI magnetic resonance imaging
MSU midstream urine
my myopia
N&V nausea and vomiting
n. s lat. non specificata
NAD no abnormality detected
nas. nasal
NBM nil by mouth
NEC not elswhere classified
NG tube naso gastric
NHS National Health Service
NIDDM non insulin dependent diabetes mellitus
NIHHS National Institute of Health Stroke Screen
NMR nuclear magnetic resonance
RMO Course 2007 23
No number
NOS not otherwise specified
NP. nasopharynx
npl. neoplasma
n. p. o lat. non per os
NRCPR National registry of Cardiopulmonary
Resuscitation
NSR Normal Sinus Rhythm
obs. lat. observatio
OD lat. oculus dexter
OE lat. otitis externa
OM lat. otitis media
OP operation
OS lat. oculus sinister
OU lat. oculus uterque
P pulse
PAD public access defibrillator
PBLS Paediatric Basic Life Support
PCA patient-controlled analgesia
PCI Percutaneus Coronary Intervention
PE pulmonary emboliom
PEA Pulseless Electrical Activity
PEEP Positive End Expiratory Pressure
PID prolapsed intervertebral disc
PMB post menopausal bleeding
PNS peripheral nervous system
PO lat. per os (orally)
PO, p.o lat. per od
POP plaster of paris
pos. position
post. lat. posterior
PPH postpartum haemorrhage
ppt. lat. propter
24 RMO Course 2007
PR per rectum
PRN lat. pro re nata (as&when required)
prob. lat. probabiliter
pros. prostate
PU peptic ulcer
PV per vagina
PVC Paroxysmal Ventricular Contraction
PSVT Paroxysmal Supra Ventricular Tachycardia
PWB partial weight bearing
qa lat. quoad
QDS lat. quarter in die summendus (four times daily)
RA rheumatoid arthritis
RBC red blood count / red blood cell
RCA Right Coronary Artery
RE rectal examination
RMO resident medical officer
RT radiotherapy
RTA road traffic accident
RTW return to ward
RUQ right upper quadrant
S.A, Sa sarcoma
SAH Sub-Arachnoidal Haemorrhage
s.f sub forma
SC. subcutaneus
sin. sinister
SM sclerosis multiplex
SPP suprapubic prostatectomy
ss. lat. subsequens
ST skin test
st. post status post
susp. lat. suspicio
syph. syphilis
T temperature
T tumour
t terminal
Tb, Tbc tuberculosis
TCI to come in
TCP Transcutaneus Pacing
TDS lat. ter in diem summendum (three times daily)
TED anti embolic stockings
TEE trans oesophageal echocardiography
TLD thoracic lymph duct
TNM tumour, node, metastases
TSH thyroid stimulating hormone
TTA to take away
TTO to take out
Tu tumour
TURP transurethral resection of the prostate
U&E urea and electrolytes
UC ulcerative colitis
UG urogenital
UFH Unfractioned heparin
UGI upper gastrointestinal
URTI upper respiratory tract infection
USG ultrasonography
UTI urinary tract infection
utr. lat. utriusque
VAIN vaginal intraepithelial neoplasia
VD veneral disease
VE vaginal examination
VF Ventricular Fibrillation
VT Ventricular Tachycardia
WBC white blood Mount
WPW Wolf Parkinson White
WR Wasserman reaction (test for syphilis)
XR X-ray
RMO Course 2007 25
26 RMO Course 2007
Medical Colloquial
anus back passage
bowels gut(s),innards, insides(s)
breasts bosom, bust, chest
buttocks behind, bottom, botty, posterior, rear, seat
cervix neck of womb
elbow funny bone
foot Tootsy
genitals down below, private parts
groin and skin crotch, crutch
cov. genitals
hand mitt, paw
head bonce, nut napper
heart engine, ticker
intestines bowels, guts, innards, insides
little finger finky
lungs bellows, tubes
neck (a) nape, cruff
oesophagus gullet
spine backbone
stomach belly, tummy, guts, innards
throat gullet
trachea windpipe
umbilicus belly button, navel
urethra pipe
urinary system waterworks
uterus womb
uterine tubes tubes
vagina birth canal, down below, front passage,private part
Medical/Colloquial English
Body Parts
RMO Course 2007 27
Medical Colloquial
to belch to burp
to copulate to have sexual intercourse, to have sex, to make love, to be intimate,
to go to bed with, to sleep with, to go with, to perform
to defecate to open the bowels, to do a motion, to go to the toilet, to do number
two, to poop
to die to pass away, to depart, to conk out, to croak, to go to Part 4, to kick
the bucket, to peg out, to pop off,to pop ones clogs, to snuff it, to
turn up ones toes,
to pass flatus to break wind, to fluff, to poop, to fart
to hit to bash, to belt, to biff, to bop, to give a bunch of fives(punch),to
clobber, to clonk, to clonk, to clout, to crown(on the head),to floor
(to the ground),to knock out (on the head causing loss of conscious-
ness), to take a pop at, to sock, to smack, to stick one on, to thump,
to wallop, to whack
to beat up to do over, to duff up, to dust up, to give a hiding, to knock about, to
give a pasting (to paste), to rough up, to sort out, to thrash
to lose consciousness to pass out, to black out, to conk out, to flake out, to zonk out
to menstruate to be indisposed, to be on a period, to at the time of the month, to
have ones monthly,
to be pregnant to be expecting, to be having a baby, to be in the family way,
to regain consciousness to come to, to come round
to have stomach ache the collywobbles
to urinate to pass water, to do number one, to spend a penny (women), to tid-
dle (childish), to tinkle (women only), to wee-wee (childish), to pee,
to piddle,
to vomit to bring up, to be sick, to puke
Activities
28 RMO Course 2007
Needlestick Injury
A needlestick injury is any injury where the skin has been breeched with an infected sharp.
This can include grazes as well as puncture wounds.
Similarly, splashes of blood or blood stained fluid into the eye is considered as carrying the same
risk but of a different order.
Following a mucocutaneous exposure, via the mucous membrane, the average risk is estimated
to be less than one in one thousand.
Where intact skin is exposed to HIV infected blood, no risk of HIV transmission is considered.
With HIV/AIDS, the chance of contracting the infection from a needlestick injury in one in 300,
whereas with hepatitis C it is one in 30 and hepatitis B it is one in three.
More than a third of all incidents happen after the completion of procedures such as cannulation
and phlebotomy, often as a result of resheathing needles. Health professionals should not under
any circumstances resheath needles.
Sharps bins should never be more than two thirds full.
A Needlestick Injury is an Emergency
Stop what you are doing immediately
Force the wound to bleed
Wash under running water
Report immediately to your immediate manager
Report to Ocuppational Health/ Accident and Emergency (as per protocol)
Needlestick Injury and Post Exposure Prophylaxis (PEP)
Consider with the Accident and Emergency clinician/Occupational Health clinician whether
or not to take PEP.
This is a short course, generally around three months, of anti-retroviral triple therapy which is
thought to be of value in preventing seroconversion when an individual has been expose
to the HIV infection.
RMO Course 2007 29
The most usual regime offered is a three drug combination of:
*AZT
*3TC
*Indinavir or Nelfinavir
These drugs are started immediately. A case control study amongst healthcare workers exposed
to HIV has found that the administration of AZT for four weeks after exposure was associated with
an 80% reduced risk of seroconversion.
AZT treatment at this stage is believed to block the infection of immune system cells by HIV, so
prompt AZT treatment is likely to block the establishment of HIV infection in an individual who has
been exposed to the virus. It is assumed that a combination of two or three drugs may be even
more effective than AZT alone at blocking HIV infection.
The Decision to commence PEP
Risk assessment:
Was the donor patient HIV positive?
Was the patient known to have a high viral load at the time of inoculation?
Was the injury received a deep injury from a large diameter needle?
Despite the benefits of PEP, there is evidence that the standard regime of AZT, 3TC and Indinavir
is poorly tolerated.
Nine out of 18 healthcare workers at three London hospitals who commenced this regime stopped
or changed therapy due to side effects within four weeks.
Six of the nine who started Indinavir required more than two weeks off work. Among the other 9,
only one required more than 7 days leave. There were no discontinuations among the five people
who received saquinavir.
PEP Department of Health guidance
If exposed in the course of your work you may well have access to triple therapy on site which
could save time.
Local policy will include instructions to inform occupational health in the instance o exposure.
Training on prevention of needlestick injuries and post exposure procedures, including AZT
treatment, should also be included.
Ideally administration of PEP, should commence within1hour of exposure. If not at least
within 24 hours of exposure.
All NHS Trusts should have a post-exposure policy. Starter packs of triple therapy should
be available on site for use following occupational exposure.
30 RMO Course 2007
How to learn English
List of Useful Websites
General English
www.esl-lab.com
listening exercises
accent.gmu.edu/searchsaa.php
a collection of listening exercises witha variety of acents
www.focusenglish.com/dialogues/conversation.html
a collection of dialogues on different topics
www.tolearnenglish.com/english-videos.php
free audio and video materials with tapescripts
www.angielski2.host.sk
free komputer programs for learning english
ebib.oss.wroc.pl/2005/65/slowniki.php
a collection of free computer dictionaries and translators
www.elllo.org
listening exercises
www.fullbooks.com
hundreds of books to read
www.gutenberg.org/browse/categories/1
a collection of books to listes e.g Sherlock Holmes
Medical English
www.englishmed.com
the most comprehensive website on learning Medical English
www.flashandbones.com
Medical Picture and exercises, great for learning Medical vocabulary
RMO Course 2007 31
www.englishforums.com
a forum for all English language learners around the Word. On the website a big part
on medical English.
www.medicalstudent.com
the greatest collection of Medical links on Internet
www.ugent.be
internetowy sownik zwrotw i terminw medycznych Uniwersytetu w Gandawie; take
odpowiedniki znaczeniowe w innych jzykach europejskich
www.bbc.co.uk
high class resources for all learning English and Medical English
(www.bbc.co.uk/health)
www.patient.co.uk
a service created by Medical Professional for patients, including hundreds of disease
and drug leaflets (also audio), links etc. Not to miss !
www.nice.co.uk
National Institute for Clinical Excellence an independent organisation setting
standards In disease prevention and treatment In the UK
www.bmj.com
a must for all thinking of working in the UK the language of UK doctors
Internet Dictionaries
Zagraniczne
http://dictionary.cambridge.org/
www.m-w.com
www.alphadictionary.com
www.wordsmyth.net
www.onelook.com
www.dictionary.com
32 RMO Course 2007
Dialogue 1 Patient in Pain
DOCTOR: Ah Mr Dixon what seems to be the problem?
PATIENT: Its my back Dr its killing me
DOCTOR: Which part your back?
PATIENT: Right at the bottom, down here
DOCTOR: Ah I see, your lower back. What sort of pain is it?
PATIENT: Its like knife, it comes and goes. But even when its not too bad, it hovers in
the background, if you see what I mean Dr
DOCTOR: Umm, so does anything make it worse?
PATIENT: Yeah, definitely, lifting. Before this happened I really enjoyed building, Ive got
my own business, but since my fall, I fell of the roof, Ive become an office
boss. I hate not being out there, you know the banter with the lads. Its so
frustrating, I want to do it but my body isnt willing.
DOCTOR: Yeah I appreciate how frustrating it must be for you. Im just looking at the
pain chart you filled in, you have problems walking sometimes?
PATIENT: On a good day, I havent any problems with walking but on a bad day I cant
manage 50yards. Well and as for sitting, thats a nightmare, I can only sit
for 10 minutes then I have to stand up to relieve the pressure. My wife bought
me this special cushion from one of those mobility shops. It helps a bit, but
its still there.
DOCTOR: Right, I see, what about sleep, do you manage to get any sleep at all?
PATIENT: Well sometimes I can sleep like a log but when the pains bad, I cant get to
sleep at all, and even then when I do the pain wakes me up 2 or 3 times a night.
DOCTOR: So the pains so bad it disrupts your sleep.
PATIENT: Too right.
DOCTOR: I see. Does anything relieve it at all?
PATIENT: Well those pain killers are useless, I dont know why I bother to take them at
all! When its really bad, I have to lay on the floor or in my bed, on my right or
left side, with my knees bent up to my chest, sort of curled up in a ball. After
about 30 minutes the pain is loads better.
DOCTOR: Yes I see, it must be very difficult when your trying to run a business. Have
you noticed if theres a pattern to your pain at all?
PATIENT: Umm, no not really Dr, thats the problem I cant plan anything at all
because I never know from one day to the next if Ill be well enough or not.
DOCTOR: Yes, Ive read your chart, it looks as if this pain is affecting every aspect of your
life.
PATIENT: God yeah Dr, my family stay well clear of me when Im in a lot of pain, Im like
a bear with a sore head.
DOCTOR: [small laugh] Well its understandable Mr Dixon, long term pain would affect
anybody.
RMO Course 2007 33
Dialogue 2 - Cannulation
DOCTOR: Hello Mrs Dixon, how are you today ?
PATIENT: Well I'm a bit better than yesterday, but Im not my usual self Doctor,
not by along chalk.
DOCTOR: I see, well try not to worry Mrs Dixon we' re going to be carrying out a lot of
tests and investigations this week, to find out what the problem is.
So you need a drip Mrs Dixon, because youre not eating or drinking properly
at the moment. So I'll need to insert a cannula, before we can start the drip.
PATIENT: I see Doctor, I thought you might have to.
DOCTOR: So is that alright Mrs Dixon ?
PATIENT: Yes of course Dr, if it needs to be done, that's that Dr.
DOCTOR: Ok Mrs Dixon, how are you with needles, have you ever felt faint or passed out
before ?
PATIENT: No Dr, I don't find it too bad.
DOCTOR: Where would you be more comfortable, sitting in the chair or sitting on the bed?
PATIENT: I'll sit on the bed Dr.
DOCTOR: First I need to pop a pillow under your arm Mrs Dixon, just to support it. Now
I just need to look at your arm Mrs Dixon, so I can find a good vein. Oh yes, I'll
put it in this one. Try and not move Mrs Dixon until its done. First Mrs Dixon
I'm going to put this tourniquet, around your arm, It'll feel a bit uncomfortable.
PATIENT: Don't worry Dr I've had this before.
DOCTOR: Alright Mrs Dixon, I'm just going to clean the area a little, it might feel
a bit cold.
PATIENT: That's fine Dr.
DOCTOR: I'm going to stretch your skin a tiny bit, just to stabilise the vein a little. OK,
that's fine, well done. When I insert the cannula you'll feel a sharp prick, its
uncomfortable, but its not for long. Here we go, Ok that's good I'm just pulling
it back a little to make sure its in the right place. Smashing, I'm going to
release the tourniquet now. That's good, just stay still abit longer. Right now
I,m going to press on your vein a little, while I remove the needle. Ok, I'm
attaching this 3-way tap, and I'm going to flush it with a little fluid. Oh yes,
we're almost done Mrs Dixon.
PATIENT: Phew, I'm glad that's over with, you always think that it will be worse than
it actually is !
DOCTOR: That's it Mrs Dixon, I'm putting this dressing on it, so it stays in place.
PATIENT: I see Dr, yes thats feels fine.
DOCTOR: Good well attach the drip now.
34 RMO Course 2007
Dialogue 3 - Catheterisation
DOCTOR: Hello Miss Grey, how are you today?
Miss GREY: I still can't manage to pass water Dr.
DOCTOR: I see, well after discussing it with Dr Bart, we feel that a catheter would be
the best option at this point. At least then, you won't feel as bloated and it'll
certainly relieve your stomach pain.
Miss GREY: Well anything is better than feeling like this Doctor, but does it hurt?
DOCTOR : Well its not painful as such, just a little uncomfortable.
Miss GREY: Ok Dr if you think it'll help I'll have it.
DOCTOR : Well its only temporary until we find the root of the problem.
Miss GREY: Umm
DOCTOR : Well, I'll just draw the curtain, so its private. I'll need you to lay on your
back. This is a sterile procedure, so I'll be using a special pack. I'll wear
gloves, and clean you down below, then till insert the catheter. Once I'm
sure its in the right place, I'll then fill up the small balloon with sterile
water, you won't feel this at all, but it stops the catheter falling out.
Finally I'll attach the catheter bag, so the urine can drain out freely.
Miss GREY: Alright Dr that doesn't sound too bad.
DOCTOR : I appreciate that its a bit embarrassing for you, but it will be over
in minutes.
Miss GREY: Alright Dr, I'll lay on my back.
DOCTOR : That's right, but could you bend your knees and just let your legs open.
Good that's fine, Ok I'm just going to clean you down here, it might feel
a bit cold.
I have the catheter tray down here, so if you can stay as still as you can.
Ok, I'm lubricating the end of the catheter, so it'll go in easily, it may feel
a little uncomfortable. Good well done, its in, now just take a deep breath
for me. There we go I've filled up the balloon, so it shouldn't come out.
Right, I'm attaching the bag, and its draining clearly.
Glossary of Plastic Surgery and Surgical Terms
Since Plastic Surgery constitutes a high percentage of the operations
carried out in Private Hospitals you might find these terms helpful.
We also recommend that you familiarize yourself with the most common
complications regarding these procedures.
Abdominoplasty (Tummy Tuck)
Sometimes after multiple pregnancies or large weight loss, abdominal muscles weaken, and
skin in the area becomes flacid. Abdominoplasty can tighten the abdominal muscles and, in
some instances, improve stretch marks. In both men and women, the procedure will remove
excess skin and fat. Generally, an incision is made across the pubic area and around the
umbilicus (navel). When skin laxity and muscle weakness is confined to the lower part of the
abdomen, a modified abdominoplasty that limits tissue removal and muscle repair to the area
below the umbilicus may be performed. This usually leaves a shorter scar and no scarring
around the navel.
Alpha Hydroxy Acids
Alpha hydroxy acids are derived from foods, such as fruits and milk, and can improve
the texture of skin by removing layers of dead cells and encouraging cell regeneration.
Augmentation Mammoplasty (see Breast Augmentation)
Blepharoplasty (see Eyelid Surgery)
Breast Augmentation (Augmentation Mammoplasty)
Breast augmentation is typically performed to enlarge small breasts, underdeveloped
breasts or breasts that have decreased in size after a woman has had children. It is accom-
plished by surgically inserting an implant behind each breast. An incision is made either
under the breast, around the areola (the pink skin surrounding the nipple) or in the armpit.
A pocket is created for the implant either behind the breast tissue or behind the muscle
between the breast and the chest wall.
Breast Lift (Mastopexy)
Frequently, a woman elects this surgery after losing a considerable amount of weight,
or losing volume and tone in her breasts after having children. The plastic surgeon relocates
the nipple and areola (the pink skin surrounding the nipple) to a higher position, repositions
the breast tissue to a higher level, removes excess skin from the lower portion of the breast
and then reshapes the remaining breast skin. Scars are around the areola, extending verti-
cally down the breast and horizontally along the crease underneath the breast. Variations on
this technique, in some cases, may result in less noticeable scarring.
RMO Course 2007 35
36 RMO Course 2007
Breast Implants (Textured-Surface)
The shell of textured-surface breast implants are made with the same silicone elastomer
that is used for the shell of other types of breast implants, but a special manufacturing
process creates a textured surface.
Breast Reduction (Reduction Mammoplasty)
Breast reduction is normally classified as a reconstructive procedure, since oversize breasts
interfere with normal function and physical activity. However, there is an important aesthetic
component to the operation, since the plastic surgeon can improve the shape of the breasts
and nipple areas. Breast reduction involves removing excess breast tissue and skin, repositioning
the nipple and areola (the pink skin surrounding the nipple) and reshaping the remaining
breast tissue.
Buccal Fat Pad
Buccal fat pads are located above the jawline near the corner of the mouth. They can be
removed in individuals with excessively round faces to give a more contoured look, sometimes
referred to as the waif look. However, plastic surgeons warn that, in some individuals,
removal of the buccal fat pads can lead to a drawn, hollow-cheeked look as aging progresses.
Buttock Lift
Excess fat and loose skin in the buttock area can be reduced by performing a buttock lift in
combination with lipoplasty (liposuction). Incisions required for skin removal can often be
hidden in the fold beneath the buttocks.
Calf Augmentation
Increased fullness of the calf can be achieved using implants made of hard silicone which
are inserted from behind the knee and moved into position underneath the calf muscle.
Cannula
A hollow tube attached to a high-vacuum device used to remove fat through liposuction. The
plastic surgeon manipulates the cannula within the fat layers under the skin, dislodging the
fat and vacuuming it out.
Capsular Contracture
Capsular contracture is the most common problem associated with breast implants. It
occurs when naturally forming scar tissue around the implant shrinks and tightens, making
the breast feel firmer than normal and sometimes causing pain and an unnatural appear-
ance of the breast.
Cellulite
Cellulite is the dimpled-looking fat that often appears on the buttocks, thighs and hips. While
there is no treatment that will eradicate this problem, aesthetic plastic surgeons are exploring
new techniques which may improve the condition. One method is to cut the fibrous tissue that
binds the fat down in these areas and creates the lumpy appearance, and then to inject fact
withdrawn from elsewhere in the body to smooth out the unevenness. Another technique, called
the cellulite lift, surgically removes excess skin and fat, leaving a thin scar that may extend
around the full circumference of the abdomen but is placed discreetly within bikini lines.
Chemical Peel
Fine lines and wrinkles around the mouth and on the forehead and cheek areas may be
improved with a wide range of skin treatments. A chemical peel solution is applied to the
entire face or to specific areas to peel away the skin's top layers. Several light to medium-
depth peels can often achieve similar results to one deeper peel treatment, with less risk
and shorter recovery time. Peel solutions may contain alpha hydroxy acids, tricholoracetic
acid (TCA) or phenol as the peeling agent, depending on the depth of peel desired and on
other patient selection factors.
Chin Augmentation (Mentoplasty)
Chin augmentation can strengthen the appearance of a receding chin by increasing its
projection. The procedure does not affect the patient's bite or jaw. There are two techniques:
one is performed through an incision inside the mouth and involves moving the chinbone,
then wiring it into position; the other approach requires insertion of an implant through an
incision inside the mouth, between the lower lip and the gum, or through an external incision
underneath the chin.
Collagen Injections
Collagen is an injectable protein that can be used to treat facial wrinkles. Patients to be treat-
ed with collagen should first be tested for any allergic reaction. The results of collagen injec-
tions are not permanent, and treatments must be repeated periodically to maintain results.
Dermabrasion
Dermabrasion is a procedure in which a high-speed rotary wheel, similar to fine-grained
sandpaper, is used to abrade the skin. It may be recommended when there is extensive sun
damage and heavy skin wrinkling. In addition, dermabrasion can be used to improve the tex-
ture of pockmarked skin resulting from severe acne or chicken pox. Following treatment, the
skin should appear firmer and smoother, but permanent pigment changes may occur.
Earlobe Reduction
A simple, 30-minute procedure, earlobe reduction can be performed in a plastic surgeon's
office or at the same time as a facelift operation. The earlobe should not comprise more
than 25 percent of the total length of the ear. In cases where it exceeds this dimension,
an L-shaped wedge is cut away, the earlobe edges are brought together and sutured.
Eyelid Surgery (Blepharoplasty)
Aesthetic eyelid surgery can brighten the face and restore a more youthful appearance
by reducing the fat that causes bags beneath the eyes and removing wrinkled,
RMO Course 2007 37
drooping layers of skin on the eyelids. Blepharoplasty is often performed along
with a facelift or with other facial rejuvenation procedures. Incisions follow the natural
contour lines in both upper and lower lids, or can be done through the lining
of the lower eyelid, providing access to skin and fatty tissue. The thin surgical scars
are usually barely visible and blend into the eyes' natural lines and folds.
Facelift (Rhytidectomy)
A facelift can reduce sagging skin on the face and neck. Incisions are placed in the hairline
and then pass in front of and behind the ears; the exact design of incisions may vary from
patient to patient and according to the surgeon's personal technique. For younger patients,
more limited incisions may be appropriate. When necessary, removal of fatty deposits
beneath the skin and tightening of sagging muscles is performed. The slack in the skin
itself is then taken up and the excess removed. Scars can usually be concealed by hair and
makeup.
Fat Injections
Fat withdrawn from one body site can be injected into another for example, to smooth lines
in the face or build up other features such as the lips. In most cases, a percentage of injected
fat is resorbed by the body, and the procedure must be repeated. Injection of fat to enlarge
the breasts is a dangerous procedure and is not recommended because of the possibility of
dense scarring that may seriously hinder accurate interpretation of both breast self-exams
and mammograms.
Fibrel
Fibrel is a synthetic substance which is an alternative to collagen and fat injections for the
treatment of facial wrinkles. As with collagen and fat, fibrel treatments must repeated at
intervals to maintain correction.
Forehead Lift (Brow Lift)
The forehead lift is designed to correct or improve skin wrinkling, as well as loss of tone
and sagging of the eyebrows that often occurs as part of the aging process.
The procedure may also help to smooth horizontal expression lines in the forehead
and vertical frown lines between the eyebrows. Incisions are placed behind the hairline
above the ear and pass over the top of the head. In some cases, incisions may be placed
in front of the hairline.
Some patients may have the procedure performed with the use of an endoscope,
requiring much shorter incisions. Improvements are made beneath the skin and on the
deep muscles; skin and muscle are then tightened to give a fresher, more youthful
appearance.
Hydroxyapatite Granules
Hydroxyapatite granules are a bone substitute made from coral that can be used
to enhance facial contours, such as forming more prominent cheekbones. The substance
also has reconstructive uses in craniofacial surgery.
38 RMO Course 2007
Lasers
Lasers can be effectively used to eliminate surface blood vessels on the face that become
reddened and enlarged due to sun exposure. The problem is most often seen in fair-skinned
individuals who cannot tan or have difficulty tanning. The use of lasers for skin resurfacing
is effective in reducing the effects of sun damage. Laser resurfacing is an alternative
to chemical peel for some patients.
Lip Augmentation
A permanent method of augmenting the lips is accomplished by surgically advancing the lip
forward, with incisions placed inside the mouth. A dermal-fat graft, taken from the deeper layers
of the skin, may then be positioned under the mucosa (the lining of the lip) to add additional
plumpness. Injecting fat collagen or other substances for lip augmentation is another
alternative. The correction is not permanent, and injections must be repeated periodically
to maintain results.
Lip Lift
A technique that surgically lifts the corners of the aging mouth can eliminate the pronounced
droop and unhappy facial expression that often develops with advanced age. By cutting away
small diamonds of skin just above the corners of the mouth, the vermilion (border of the lips)
is raised into a slight smile.
Lip Reduction
To reduce the lips, a small strip of the mucosa (the lining of the lip) is surgically removed to
narrow the lips to the desired proportion. The small scars on the outside of the lips are bare-
ly noticeable.
Lipoplasty (Liposuction)
Lipoplasty allows the plastic surgeon to remove localized collections of fatty tissue from the
legs, buttocks, abdomen, back, arms, face and neck using a high vacuum device. The procedure
leaves only minute scars, often as short as one-half inch in length or less. The use of refined
equipment allows removal from delicate areas such as calves and ankles. Lipoplasty
removes fat, but it cannot eliminate dimpling or correct skin laxity. If a patient's skin has lost
much of its elasticity, the plastic surgeon may recommend a skin tightening procedure such
as a thigh lift, buttock lift or arm lift, all of which leave more extensive scars.
Malar (Cheekbone) Augmentation
The cheekbones may be built up by placing an implant over them. This is usually performed
through an incision within the mouth, but it may be done through a lower eyelid or brow
lift incision.
Mastopexy (see Breast Lift)
Otoplasty (Ear Surgery)
The ears are positioned closer to the head by reshaping the cartilage (supporting tissue).
RMO Course 2007 39
This is usually accomplished through incisions placed behind the ears so that subsequent
scars will be concealed in a natural skin crease. Otoplasty can be performed on children
as early as age five or six.
Peel: Buffered Phenol
Buffered phenol offers yet another option for severely sun-damaged skin. One such formula
uses olive oil, among other ingredients, to diminish the strength of the phenol solution.
Another slightly milder formula uses glycerin. Buffered phenol peels may be more comfort-
able for patients, and the skin heals faster than with a standard phenol peel.
Phenol
The chemical phenol is sometimes used for full-face peeling when sun damage or wrinkling
is severe. It can also be used to treat limited areas of the face, such as deep wrinkles around
the mouth, but it may permanently bleach the skin, leaving a line of demarcation between
the treated and untreated areas that must be covered with makeup.
Platysma
The muscle which, when tight and firm, gives the neck underneath the chin and jawline its
youthful contour. The platysma muscle can be tightened during a facelift or as a separate
procedure.
Reduction Mammoplasty (see Breast Reduction)
Retin-A
Retin-A cream may be applied to enhance the overall texture of the skin and is often
prescribed as a pre-treatment prior to a facelift or chemical peel.
Rhinoplasty: Open
The open rhinoplasty technique can sometimes benefit patients who need more complex
correction or are undergoing a secondary rhinoplasty procedure. A small incision is made
outside the nose across the columella (the tissue that divides the two nostrils). This enables
the plastic surgeon to turn the outer tissue of the nose back, providing visualization of the
structures inside. Additional incisions, like those used in the traditional closed approach, are
made inside the nose as well. The scar resulting from the incision on the outside of the nose
eventually becomes barely visible.
Rhinoplasty (Nose Reshaping)
Rhinoplasty is usually performed to alter the size and shape of the bridge and tip of the nose.
Reshaping is generally done through incisions inside the nose, but there may also be an
incision passing across the central portion of the nose between the nostrils. It is sometimes
necessary to narrow the base of the nose or reduce the size of the nostrils, which involves
removing small wedges of skin at the base of the nostrils. The nose is reduced, or sometimes
built up, by adjusting its supporting structures, which is done either by removing or adding bone
and cartilage. The skin and soft tissues then redrape themselves over this new scaffolding.
40 RMO Course 2007
Rhytidectomy (see Facelift)
Superficial Syringe Liposculpture
Use of a syringe to withdraw fat, instead of vacuum suctioning pumps, allows for less blood
loss and speedier postoperative recovery. Superficial syringe liposculpture is performed on
the layer of fat just beneath the skin.
Tattooing (Cosmetic)
Cosmetic tattooing, or micropigmentation, can be used for permanent eyeliner, eyebrows or
lip color. It can also be used for permanent blush and eyeshadow, though this is infrequent.
Other uses by plastic surgeons include recreating the coloration of the areola around the
nipple following breast reconstruction; restoring the color of dark or light skin where natural
pigmentation has been lost through such factors as vitiligo, cancer, burns or other scarring;
and eliminating some types of birthmarks or previous tattoos. Micropigmentation should be
performed only under medical supervision by appropriately trained personnel.
TCA
Trichloroacetic acid is used for peeling of the face, neck, hands and other exposed areas
of the body. It has less bleaching effect than phenol, and is excellent for spot peeling
of specific areas. It can be used for deep, medium or light peeling, depending on the
concentration and method of application.
Thigh Lift
A thigh lift can be performed to tighten sagging muscles and remove excess skin in the thigh
area. Because a thigh lift leaves noticeable scars in the inner or outer thigh area that some
patients find undesirable, it is not a frequently performed procedure.
Tissue Expansion
Tissue expansion is a technique in which skin or other tissue is stretched using inflatable
balloons. It can be of particular value in performing breast reconstruction, breast enlarge-
ment or treatment of male pattern baldness.
Transconjunctival Blepharoplasty
Transconjunctival blepharoplasty (eyelid surgery) is performed by making an incision from
inside the lower eyelid. It avoids any scarring on the lower lid. It is a useful technique when
only fat, and not skin or muscle, needs to be removed from the eyelid area.
Varicose veins twisted, widened veins caused by swollen or enlarged blood vessels.
The blood vessels have enlarged due a weakening in the vein's wall or valves.
RMO Course 2007 41
Surgical Terminology for the RMO
ectomy - means the surgical removal of something for instance the appendix
in an appendectomy or appendicectomy
otomy means the surgical or slicing of a body part, for instance Laparotomy an operation
to open the abdomen/stomach
stomy is the creation of an artificial opening, as in a Colostomy an opening through
the wall of the abdomen for the colon to divert waste through
pathy suffering or disease as in neuropathy which is disease of the nerve
itis means inflammation as in Gastritis which is inflammation of the stomach
emesis is to vomit as in Hematemesis vomiting blood
42 RMO Course 2007
Glossary of Job Titles for Doctors
(source: www.nhs.org.uk)
Summary
Doctors are the primary managers in the treatment of most patients. They examine symp-
toms, consider a range of possible diagnoses, test the diagnosis, decide on the best course
of treatment and monitor the progress of that treatment.
All doctors, in the NHS or private practice, must be registered with the General Medical
Council (GMC) to undertake clinical practice in the UK. Doctors, particularly in the hospital
setting, are often known by the specialist area in which they practise, for example an anaes-
thetist or an obstetrician, but will practice at a certain grade depending on their level of
training and experience.
Doctors start as medical students and, typically, continue training until they become
a consultant or GP general practitioner. Doctors are assessed and examined during their
training, with the ultimate aim being the award of a certificate of completion of training fol-
lowed by entry on the GMC's specialist register or general practitioner register. Doctors from
overseas can also gain entry to the specialist or general practice registers providing they
have the right qualifications, training and experience. Entry on either of these registers is the
marker that says the doctor can act as an independent doctor in the NHS.
The doctors listed in this section of the glossary are all medically qualified and will usually
use the title Dr before their name. However, doctors that perform surgery may, due to histor-
ical reasons, use the title Mr or Mrs, for example, instead. A doctor could also be a university
Professor and use that title instead of Dr.
Academic doctors
Academic or clinical academic doctors are those who often work in hospital or general
practice but also spend time teaching or researching at a university. As well as performing
the usual duties of a doctor, academic doctors are responsible for teaching new generations
of doctors and/or undertaking research in order to forward the science of medicine. Common
job titles for academic doctors are: clinical academic fellow, clinical lecturer, clinical
research fellow, lecturer, senior lecturer, professor or reader. Academics who are professors
or senior lecturers will normally have a consultant contract at a hospital or be a GP general
practitioner. A doctor in a post such as clinical lecturer will also normally also have duties
as a specialist registrar or GP registrar.
RMO Course 2007 43
Medical students
Medical students typically undertake a five-year course of study to become a doctor two
years studying basic medical sciences followed by three years of more clinical training
during which they work in hospital wards under the supervision of consultants. If the hospital
or practice you attend is one where teaching takes place, you may see medical students
accompanying qualified doctors on, for example, ward rounds or in out-patient clinics.
As a patient, you should be asked whether you mind a medical student(s) being present.
Following success in final examinations, newly qualified doctors receive their primary medical
qualification typically denoted in the UK by one of the following: MBBS, MBChB, BM, MB BCh.
Junior doctors
Junior doctors are doctors in training usually in hospital or in general practice. They will
have been through medical school and have obtained registration with the General Medical
Council, but are not yet trained to a level which allows them to work as a consultant or gen-
eral practitioner. However, as they progress through training and gain experience their
responsibilities increase, but they are always under, though not necessarily directly, the
supervision of a senior doctor. On completion of training they gain a certificate of completion
of training and gain access to the General Medical Councils specialist register, for those
completing specialist training, or general practitioner register for those completing training
as a general practitioner. All postgraduate training in the UK is overseen by the Postgraduate
Medical Education and Training Board. Junior doctor grades are foundation year 1,
foundation year 2, GP registrar, senior house officer and specialist registrar.
Senior doctors
Senior doctors are consultants or general practitioners. They are allowed to practice inde-
pendently (ie without supervision), and will have been fully trained or have gained an appro-
priate level of experience. Before a doctor can become a consultant or general practitioner
they need to be listed on the General Medical Councils specialist register, for hospital and
other specialists, or the general practitioner register for general practitioners.
Staff and associate specialist grade doctors
Staff and associate specialist doctors are neither junior nor senior doctors. Doctors at this
grade are hospital doctors who will normally have spent some time as a junior doctor but will
not have formally completed training in the UK or have not yet been judged to have acquired
an equivalent level of experience to be registered on the General Medical Councils specialist
register. The main job titles for these doctors are staff grade or associate specialist.
44 RMO Course 2007
RMO Course 2007 45
Job titles/grades
Associate specialist
Location: Hospital
Description: An associate specialist is a doctor who will have trained and gained experience in
a medical specialty but has not yet attained the status of a consultant. They will often work without
direct supervision, but will be attached to clinical team lead by a consultant in their specialty.
Training: An associate specialist will have undertaken some specialist training and will
almost certainly have attained the professional qualifications to be a member or fellow of the
relevant medical royal college or faculty.
Consultant
Location: Hospital
Description: A consultant is a doctor who is fully trained in a particular specialty area and has
the ultimate responsibility for the clinical care of patients. Most consultants work in hospitals in
multidisciplinary teams which will include nurses and other healthcare professionals as well as
other doctors. Consultants are responsible for the education and supervision of junior doctors in
their team and also for the supervision of staff and associate specialist grade doctors.
Training: Completion of a specialist training programme (or assessed as equivalent) leading to entry
to the General Medical Councils specialist register, plus continuing professional development.
Foundation year 1 (alternatives: house officer, pre-registration house officer),
Foundation year 2 (alternative: senior house officer)
Location: General practice, Hospital
Description: Foundation year doctors are newly qualified medical graduates who undertake
a two-year programme of training in order to gain practical experience of being a doctor and
gain the general competencies required to be a good doctor. They undertake supervised
training in hospitals and sometimes in general practice. After the first year of foundation
training the doctor will become fully registered with the General Medical Council. After the
second year of foundation training the doctor will decide whether to enter training in a spe-
cialist area of medicine or as a general practitioner.
Training: The foundation training programme
GP general practitioner
Location: General Practice, Health centre
Description: General practitioners have overall responsibility for the management of patient
healthcare, including the diagnosis and treatment of health problems and referring patients
for specialist treatment where necessary. They are increasingly responsible for monitoring
their patients health on a regular basis. Some general practitioners develop an interest
in a special area, for example, dermatology, epilepsy, mental health or sexual health.
Training: Completion of a general practitioner training programme (or assessed as
equivalent) leading to entry to the General Medical Councils general practitoner register,
plus continuing professional development.
GP registrar general practitioner registrar
Location: General practice, Health centre
Description: A GP registrar is a general practitioner in training. During this time,
under the guidance of a GP trainer, they will learn about how general practice is organised
and managed and will see patients both in the surgery and at home. GP registrars also have
the opportunity to gain extra skills in areas such as womens health and drug misuse.
Training: Following foundation training, at least three years of further training in approved
training posts including at least one year training in a general practice or health centre
under the guidance of a GP registered as a trainer. The period of training done in hospital
will be as a senior house officer. Successful completion of training will lead to entry
on the General Medical Councils general practitioner register.
Senior house officer
Location: Hospital
Description: A senior house officer is the first rung of training in hospital after foundation
training. They train in a specialist area and learn the basic skills and knowledge of that
specialty, and will work towards, or have obtained, some professional qualifications.
As senior house officers gain experience they may manage some patients with basic
complaints which they are competent to treat, but will always, though not directly,
be supervised by a consultant.
Training: Following foundation training, normally one to two years' further basic training
in approved training posts often leading to a professional qualification, or part of, from the
relevant medical royal college or faculty.
Specialist registrar (alternatives: registrar, senior registrar)
Location: Hospital
Description: A specialist registrar is a doctor in the advanced stages of training towards
becoming a consultant. They will have increased clinical responsibilities and though always,
though not directly, supervised will see and manage patients with complaints that they are
competent to treat. A specialist registrar will have attained or be in the process of attaining
all the professional qualifications required for their specialty area.
Training: Following basic training as a senior house officer, normally between four to six
years of further training, depending on the specialty, in approved training posts leading
to a professional qualification from the relevant medical royal college or faculty and, on
successful completion of training, entry on the General Medical Councils specialist register.
Staff grade (alternatives: hospital doctor, trust grade doctor)
Location: Hospital
Description: Staff or trust grades are doctors who work in a specialist area and undertake
clinics and perform procedures under the supervision of a consultant.
Training; They are not trainees but will have done some training and are likely to have
a professional qualification, or part of, from the relevant medical royal college or faculty.
46 RMO Course 2007
Specialty doctors and related royal colleges and faculties
The medical royal colleges and faculties are the professional bodies for doctors in a certain
specialty or specialty area. They also design the curricula that doctors undertake during
training and conduct examinations which doctors must pass if they are to progress.
Anaesthetist
Emergency medicine doctor (A&E)
General practitioner (GP)
Gynaecologist
Obstetrician
Occupational medicine doctor (occupational health physician)
Ophthalmologist
Paediatrician
Pathologist
Pharmacologist
Physician
Gastroenterologist
General physician
Geriatrician
Haematologist
Neurologist
Oncologist
Renal physician
Respirologist
Rheumatologist
Endocrinologist
Cardiologist
Dermatologist
Psychiatrist
Public health doctor
Radiologist
Surgeon
Cardiothoracic surgeon
General surgeon
Neurosurgeon
Oral and maxillofacial surgeon
Otolarnygologist (ENT/ear, nose and throat)
Paediatric surgeon
Plastic surgeon
Orthopaedic surgeon
Urologist
RMO Course 2007 47
Drug forms
Your own language English
tablet
effervescent / soluable / dispersible tablet
coated tablet
kapsule
granule
suppository
suspension
oral suspension
syrup
injection
ointment
gel
vaginal gel
solution
foam
pessary
aerosol
dry powder for inhalation
patch
spray
nasal spray
aerosol
drops
eye drops
oral drops
48 RMO Course 2007
Your own lnguage. English
RMO Course 2007 49
Drug dosage
Your own language Abbr. English/Latin
od once daily
b.i.d lat. bis in die / two times daily
b.d.
t.d.s, lat. ter in diem summendum
t.i.d lat. ter in die, three times daily
qd, lat. quarter in die
q.i.d, lat. quarter in die
q.d.s lat.quater in die summendus
four times daily
p.r.n lat. pro re nata / as and when required
stat lat. statim / at once
Nocte at night
qh lat. quaque hora / every hour
q2h lat. quaque seconda hora / every
2-nd hour
a.c lat. ante cibum / before meals
o.m / man lat. omni mane / every morning
o.n lat. omni nocte / every night
p.c lat. post cibu,m / after meals
t.q.d three or four time daily
Routes of Administration
Your own language Abbr. English
i.m intra-muscular
i.v intravenous
s.c subcutaneus
top. topical
i.a intra-articular
p.o by mouth / orally
p.r per rectum
top. topical
To help patients cope with tablets
Breaking tablets in half
When a tablet is manufactured with a line down the middle it may be easily broken, espe-
cially if it is a big tablet with a deep scored line.
Method
Place the tablet on a flat surface with the line uppermost.
Place one finger on each side of the tablet and press down firmly
The tablet will split .
Swallowing tablets
This method is recommended for those who may have trouble swallowing tablets.
Method 1
Try swallowing the tablet with the head bent forward
Method 2
Simply place the tablet on the tongue and drink water through a straw with the head slightly
flexed forwards. The stream of water hoses the tablet down the throat.
50 RMO Course 2007
RMO Course 2007 51
Most Common TTOs
Generic Name Brand Name Dose range Pack size
Alfuzosin 10mg Xatral XL 10mg once daily 7
Tamsulosin 400mcg Flomax 400mcg daily 30
Amoxycillin 125mg/5ml Amoxil 125mgtds (up to 8yrs) 1 X 100ml
syrup can be doubled
Amoxycillin 250mg tabs 250-500mg tds for 5-7 days 21
Amoxycillin 250mg/5ml syrup 250mg tds 5-7days 1 X 100ml
Amoxycillin 500mg tabs 500mg tds 21
Cefuroxime 250mg tabs Zinnat 250-500mg bd for 5-7 days 14
Cephradine 250mg caps Velosef 250mg tds/qds 5-7 days 20
Cephradine 500mg caps Velosef 500mg tds/qds 5-7 days 20
Ciprofloxacin 250mg tabs Ciproxin 250mg-500mg bd 5-7 days 14
Ciprofloxacin 500mg tabs Ciproxin 500mg bd 5-7 days 14
Clarithromycin 250mg tabs Klaricid 250mg bd 7 days 14
Clarithromycin 500mg tabs Klaricid 500mg bd 7 days 14
Co-amoxiclav 375mg Augmentin 375mg tds 5-7 days 21
dispersible Tablets
Co-amoxiclav 375mg tabs Augmentin 375mg tds 5-7 days 21
Co-amoxiclav 625mg tabs Augmentin 625mg tds 5-7 days 21
Co-codamol 30/500mg tabs Solpadol, 1-2 qds maximum of 8 in 24 hrs 30
(codeine phosphate 30mg Kapake,
+ paracetamol 500mg) Tylex
Co-codamol 8/500mg tabs 1-2 qds maximum of 8 in 24 hrs 30
(codeine phosphate 8mg
+ paracetamol 500mg)
Codeine Phosphate 30mg tabs 30-60mg tds/qds 240mg/24 hrs 28
Co-dydramol tabs 1-2 tablets every 4-6h 30
(dihydrocodeine tartrate
10 mg + paracetamol 500mg)
Co-fluamicil 250mg/250mg
Capsules Magnepan 1 tabl. qid for 5 days 20
52 RMO Course 2007
Co-fluampicil 250mg syrup 250mg qds 5 days 1 X 100 ml
Co-proxamol tabs 30
(dextropropoxyphene
hydrochloride 32.5mg
+ Paracetamol 325mg)
Diclofenac 100mg supp Voltarol 100mg once daily
maximum dose 150mg/24 hrs 5
Diclofenac 100mg Voltarol Retard 100mg once daily 7
Retard tablets
Diclofenac 25mg tabs 1 tds maximum 150mg/24hr 28
Diclofenac 50mg tabs 50mg tds maximum 150mg/24 hrs 28
Diclofenac 75mg SR tablets Voltarol SR 75mg bd 28
Dihydrocodeine 30mg tabs 1-2tds/qds 28
Domperidone 10mg tabs Motulium 10-20mg tds/qd 30
Doxycycline 100mg caps 100mg-200mg daily 7
Erythromycin 125mg/5ml 125mg qds 5-7 days 1 X 100 ml
syrup
Erythromycin 250mg tabs 250mg qds 5-7 days 28
Erythromycin 250mg/5ml 250mg qds 5-7 days 1 X 100 ml
syrup
Flucloxacillin 250mg caps 250mg-500mg qds 28
Flucloxacillin 500mg caps 500mg qds 28
Fybogel orange Sachets 1-2 daily 10
Ibuprofen 200mg tabs 200mg-400mg tds 24
Mefenamic acid 500mg tabs Ponstan 500mg tds 14
Metoclopramide 10mg tabs Maxolon 10mg tds 14
Metronidazole 200mg tabs 200mg tds 5-7 days 21
Metronidazole 400mg tabs 400mgbd/tds5-17days 21
Milpar 200ml 15ml bd 200 ml
Norfloxacin400mg tabs Utinor 400mg bd 5-7 days 10
Omeprazole 10mg tabs Losec Mups 10mgod/bd 7
Omeprazole 20mg tabs Losec Mups 20mg daily (40mg 7
in triple therapy)
Pantoprazole 40mg tabs Protium 40mg daily 7
Paracetamol 500mg tabs 1-2 4-6h 32
maximum of 8/24 hours
Penicillin V 250mg tabs 250mg qds 5-7 days 28
Prednisolone 5mg tabs Varied no standard dose 28
Rofecoxib 25mg tabs Vioxx 25-50mg daily, orthopedics 7
Rofecoxib 25mg tabs Vioxx Acute 25-50mg daily gynae. 6
Sea water spray Sterimar 1 spray both nostrils bd mdu 1 canister
Senna tablets Senokot 2 nocte 20
Tramadol 50mg tabs 50-1 O O m g upto qds
maximum of 8/24 hours 20
Trimethoprim 100mgtabs 10Omg once/ twice daily 14
Trimethoprim 200mg tabs 200mg bd 5-7 days I 14
RMO Course 2007 53
54 RMO Course 2007
Tips on...
Writing TTOs
The TTO (to take out), also known as the TTA (to take away), is a form that should be
completed for all patients being discharged from hospital. It both summarises the patients
hospital stay for their general practitioner and acts as a prescription to order the drugs
they need to take home with them.
Here are some tips on filling in the TTO form.
All information should be legible and accurate
If possible, complete the TTO the day before the patient is discharged. That way
there is no delay in getting the patients tablets from pharmacy
Check the patients details. If you are using addressograph labels,
remember to put a sticker on each of the pages
Document the ward, consultants name, and the GPs name and address
Document the dates the patient was admitted and discharged
Record the diagnosis
List the investigations performed and the results (briefly)
Highlight any changes to drugs
Document any treatment on discharge
Write names of drugs to be taken after discharge in capital letters
Spell out the plan on discharge and any follow up arrangements for example,
date of appointment in outpatient clinic
Document where the patient has gone for example, discharged to nursing home
Document any allergies to drugs
Ensure enough drugs are given (for example, to last over a holiday period)
Prescribe dosages of controlled drugs in numbers and words, with the total dose
to be dispensed
Sign your name and then print it and give your bleep number in case the GP
needs to contact you
First Glance Assessment
An initial assessment of a patient highlighted as in rapid deterioration should follow a pro-
cedure such as:
Is the patient likely to arrest imminently?
How long do I have to assess before action?
Are there any immediate signs?
What other information do I Have available?
Can any other information be gained? If so, what?
Remember, a crash call can be made prior to a patient having respiratory or cardiac arrest.
Resuscitation in such circumstances (peri-arrest) would generally have a better outcome
than resuscitation of an arrested patient.
Information obtainable at bedside
Are there any signs of low cardiac output?
Sweating
Pallor
Cold in extremities or centrally
Clammy
Impaired consciousness
Are there any signs of respiratory distress?
Breathlessness can the patient manage full sentence/phrases/words?
Cyanosis
Poor chest movement
Agonal breathing
TachypnoeaExhaustion and confusion
History Taking Mnemonics
SAMPLE
Symptoms
Allergies (Remember cross allergies between penicillin and cephalosporin
and between Furosemide and Sulphonamides)
Medication (chronic and acute)
Past Medical History
Last Meal
Events leading to the symptoms
RMO Course 2007 55
56 RMO Course 2007
History Taking Skills
HISTORY TAKING FORMAT
Chief complaint
History of present illness (HPI)
Past medical history, which includes
Childhood
Medical
Surgical
OB/GYN
Psychiatric
Family history
Medications
Allergies
Personal/social history
Review of systems
Chief complaint
problem / condition that motivated patient to seek care
To elicit the chief complaint, ask broad questions:
What brings you in today?
Tell me what has been going on.
What seems to be the problem?
What are your complaints?
History of Present Illness (HPI)

Patient's age, sex, occupation

Symptoms (or immediate cause of admission)

Chronology and the seven characteristics of the current symptoms:

Anatomic location
Quality
Quantity or severity
Timing
Setting in which the symptoms occur
Aggravating or relieving factors
Associated symptoms
Use facilitating expressions to encourage the patient to continue:
Mmm Hmm.
Yes?
Uh Huh?
And what else?
I am with you
Listening body language
Once the patient has had a chance to tell his or her story you can move on to more directed
questions to clarify.

What is wrong?

Where is it wrong?

When did it start going wrong?

How did it go wrong?

Why do you think it is wrong?

Directed or closed questions
Multiple choice
Do you have nausea, vomiting, constipation or diarrhea?
Is the pain sharp, dull or shooting?
Have you had this for days, weeks or months?
How long is the pain: minutes or hours?
Important: Pause to wait for each response!!
Yes or No questions
Do you have diarrhea every day?
Do you have any allergies?
Quantitative questions
How many loose stools do you have a day?
Avoid leading questions
You dont smoke do you?
You havent had any chest pain?
Your wife is your only sexual partner, right?
Avoid compound questions
Do you have trouble sleeping? How much sleep do you get?
Do you use cocaine, marijuana or alcohol?
L: Location
O: Other symptoms
C: Characteristic of the symptom
A: Aggravating or alleviating factors
T: Timing
E: Environment
S: Severity
RMO Course 2007 57
Location:

Where does it hurt?

Which part of your chest/head/abdomen is affected?

Does it stay in one place or does it radiate anywhere else?

Other symptoms:
Pertinent positives and negatives to help you rule in or rule out disease
Associated symptoms
Other new symptoms that may not be related
Other symptoms questions

Apart from your chest problem are there any other problems

Hows your appetite?

Do you have any problems with passing water?

Are your bowel motions regular?

Have you noticed any blood in your stools?

Characteristics quality of the symptom
Get the patient to use their own descriptive words if possible.
What does it feel like?
What kind of pain is it?
Can you describe the pain?
Does it affect your sleep/work?
How often are the attacks?
Is the pain continuous or does it come and go?
What makes it better?
What makes it worse?
What has the patient done to try to feel better?
What seems to bring the pain on?
Does anything make it better / worse?
Is the pain relieved by drugs / rest / changing position?
Have you taken any medicines for the pain?
(over the counter medications, friends medication)
Timing: onset and duration
When did it start?
How long have you had this pain?
When did you first notice it?
Is it intermittent or continuous?
How long does each episode last?
Does the symptom vary with time of day?
Have you ever experienced this before?
Associations with specific events
58 RMO Course 2007
What places or events affect the symptom?
Work vs. home
Leisure activities
Diet
Emotions
Heat, dust, altitude
How is the symptom interfering with the patients daily functioning?
If the patient has pain, how bad is the pain on a scale of one to ten
Patients interview
Past Medical History
General state of health
Chronic medical problems
Hospitalizations
Surgical history
History of trauma
Childhood illnesses
Gynecologic history
Health maintenance
Past Medical History

Childhood illnesses

Adult illnesses

Medical conditions

Surgeries

Obstetric/gynecologic

Psychiatric
Eliciting the Past Medical History
How would you describe your health?
Are you having any other problems with your health?
Do you have any other medical problems?
Are you treated for any other medical conditions?
You may learn more about this with medications!
Medical Problems
Chronic problems like:
Diabetes mellitus
Hypertension
Chronic back pain
Depression
Coronary artery disease or MI
Congestive heart failure
RMO Course 2007 59
You cant always accept the patients diagnosis, use records to confirm
Are any of these problems active?
Childhood Illnesses
Birth defects, ex., undescended testicle
Attention deficit
Drug use
Anorexia
Meningitis
For Pediatrics information about the birth is importan
Hospitalizations
When?
Where?
Why?
For how long?
Past Surgical History

What part of the body?

Why?

When?

Where?

Any complications?

Reactions to anesthesia?
Trauma
What part of the body?
How injured?
Where hospitalized?
Reproductive History
Menstruation
Start
Length and frequency
Pregnancies
G = Gravida=pregnancies
P = Para = Live births
Birth Control
Medications
Health Maintenance
Immunizations
Screening Tests
Medications
60 RMO Course 2007
Medicine name
Purpose
Dose
Route
Frequency
Side effects
Taking as prescribed?
Cost issues
Dont forget!
Over the counter drugs (OCD)
Vitamins
Nutritional supplements
Any borrowed medications
Personal and Social History (PSH)

personal status

occupation

education

home conditions

interests
Known allergies and resulting symptoms
e.g penicillin (rash)
Medications
What is the reaction?
Other substances, if severe reaction
Ex. Peanut or bee sting allergy
Family History
Major illnesses in the immediate family (parents, grandparents, siblings)
Genetic diseases
Sickle cell anemia, cystic fibrosis
Familial diseases
Type 2 diabetes, breast cancer
Psychiatric diseases
Heritable
Affect patients psychosocial environment
Contagious or Toxic
Lead poisoning, influenza
RMO Course 2007 61
Review of Systems (ROS)
Sample Note Combining Time And Exam

HPI: Mary Smith was seen in my clinic today. She presents with a right breast lump
which she noticed 2 weeks ago. The lump is quite firm. She denies weight loss or nipple
discharge. ROS: She has noticed some swollen lymph nodes in her neck and axillary
regions. Other systems are negative. PMHx: Her only hospitalizations were for the births
of her 2 children over 20 years ago. SHx: She does not smoke or drink. FHx: Her mother
had breast cancer and a mastectomy.

PE: Mary is healthy appearing. Her eyes clear. Oropharyngeal membranes are pink and
moist. Neck has good range of motion with no lymphadenopathy. Heart has a regular rate
and rhythm and lungs are clear to auscultation. Abdomen is soft and non-tender. Breast
exam revealed normal shape with no skin discoloration. A solid mass was identified in the
right breast with some swelling of the axillary lymph nodes. She is alert and oriented x 3
and neurologically grossly intact.

Labs and x-ray: Mammogram reveals a 2 cm mass in the right breast. She also has
a small cyst in her left breast but no clear lymph node involvement.

Impression: Otherwise healthy 46-year-old woman with right breast lump and axillary
lymph node swelling. Plan: Mary and her husband were at my office for about 45 minutes
and I spent 30 minutes talking to them about her prognosis and risks and benefits
of surgery. She agrees to breast biopsy with sentinel node biopsy on Tuesday.
Physical Examination Description
The patient is a healthy young male who appears fit and muscular. He is pleasant
and cooperative. Blood pressure is 120/80; heart rate, 80 and regular; respirations, 16;
afebrile. Skin is warm and moist. Nails without clubbing or cyanosis.
No rashes, petechiae, or ecchymoses.
The skull is normocephalic/atraumatic (NC/AT). Pupils are 4 mm constricting to 2 mm
and equal, round, and reactive to light and accommodation (PERRLA). The discs are flat,
without hemorrhages or exudates. TMs clear. Oral mucosa pink; dentition good; pharynx
without exudates. Neck supple: without thyromegaly. No lymphadenopathy.
Thorax symmetric with good excursion. Diaphragms descend 4 cm bilaterally.
Lungs are resonant, breath sounds vesicular; no wheezes, rales, or rhonchi.
JVP is 6 cm above the right atrium; carotid upstrokes brisk, no bruits. PMI tapping, 8 cm lateral
to midsternal line in fifth intercostal space (ICS). Good S1, S2; no murmurs or extra sounds.
Abdomen is scaphoid. Bowel sounds are active. The abdomen is soft, nontender. Liver span is 9 cm
in the right midclavicular line (MCL); edge is smooth, palpable one finger-breadth below the right
costal margin (RCM). Spleen not felt. No CVA tenderness, no abdominal or femoral bruits.
62 RMO Course 2007
Radial, brachial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+
and symmetric. Extremities are warm and without edema.
Calves are supple. No epitrochlear, axillary, or inguinal adenopathy. Good range of motion
in all joints. No joint swelling or deformity.
The patient is oriented to person, place, and time. Cranial Nerves II through XII are intact.
Motor: good bulk and tone. Strength is 5/5 throughout. RAMs, F-N, H-S intact. Gait with
normal base. Sensory: Pinprick and light touch are intact and symmetric throughout.
Reflexes: 2+ and symmetric with toes downgoing.
Presenting During Ward Rounds:
An average presentation should take no more then a few minutes.
The following is a sample presentation for a patient on the General Surgery service:
Mr. Smith is post operative day #2 from his appendenctomy, day #3 of 7 of
Ampicillin, Gentamycin and Flagyl.
Events over the past 24 hours include:
1. CXR performed as part of a fever evaluation; no pulmonary pathology identified
2. Passing of flatus.
3. Decreased abdominal pain.
Patient appeared comfortable, without specific complaints Vital Signs:
T Max 37.3 yesterday, 36.9 over past 8 hours
Heart Rate 80s to 90s, Blood Pressure 120s-140s over 70s
Respiratory Rate in low 20s, Sat'ing at 95% on Room Air
Weight 150 pounds, down 1 pound from yesterday; still up 5 pounds from pre-op
Is and Os: 2L IV NS at rate of 100/hour. Additional 500 ccs IVF from antibiotics.
Still NPO. Urine Output total 2 L, approximately 50 cc/h.
Lungs: Clear
Heart: regular rate and rhythm without murmurs
Abdomen: hypoactive bowel sounds now present; slightly distended; wound without
erythema or discharge; minimal pain at incision site
Labs: This morning's Chem 7 and CBC pending; Yesterday BUN and Creat 11
and 0.8, which are consistent with baseline; White count 16, down from 20 the previ-
ous day. Intra-operative cultures still negative; blood and urine cultures from day of
admission and yesterday negative.
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64 RMO Course 2007

Assessment and Plan:
G. I. (Gastrointestinal): Patient S/P appendectomy. Had prolonged ileus associated
with significant peri-appendiceal inflammation. Now with apparent recovery of gut
function as evidenced by flatus, bowel sounds.
Plan:
Advance to sips of clear liquids this A. M... If tolerated, will allow full clears this
afternoon and then hep. lock IV as appears to be euvolemic.
Encourage ambulation around floor
I. D. (Infectious Disease): Recurrent post operative fever, presumably secondary to
residual peri-appendiceal infection. Fever curve now trending down, white count
decreasing, and improving clinically. Cultures from all other sources negative. Exam
does not suggest infection elsewhere.
Plan:
Continue current antibiotics for additional 24 hours. If remains well, change to
oral ciprofloxin and flagyl to complete 7 day course.
Follow up on cultures.
Ambulation and incentive spirometry may help if atelectasis contributing.
T/L/D (Tubes, Lines, and Drains): Patient has adequate IV access. Foley catheter
still in palce.
Plan:
D/C Foley
Dispo (Disposition):
Plan:
Expect patient may be ready for discharge in 2 days

RMO Course 2007 65

A lot of private hospitals focus on orthopaedic surgery, and the worst post-op
complication that needs to be taken into account in all patients is a risk
of pulmonary embolism. Deep Vein Thrombosis prophylaxis plays an important
role in PE prevention.
Chapman's Orthopaedic Surgery3rd edition (January 15, 2001):
by Michael W. Chapman (Editor) et al.
Lippincott Williams & Wilkins Publishers
POSTOPERATIVE PATIENT CARE
Postoperative care varies tremendously depending on the operation performed and the
condition of the patient. Several general principles apply to the majority of patients, however.
Elevate limbs postoperatively to improve venous and lymphatic return, but not so high that
arterial input is compromised. In general, the ideal level is where the most distal portion of
the extremity is 10 cm above the heart. Elevation on pillows is usually more comfortable for
the patient and less hazardous than slings. Immobilize only joints that must be immobilized.
Unless contraindicated, all mobile parts must be moved after surgery, either by active,
active-assistive, or passive exercises.
Early mobilization of patients into a chair at bedside, to the toilet, and subsequently for
ambulation is important. With today's surgical techniques, enforced bed rest after surgery is
unusual. If a patient is on enforced bed rest, it is important to institute an in-bed physical
therapy program to maintain joint range of motion, muscle strength, and, if possible, aerobic
conditioning. Not only does such a regimen play a major role in mobilizing the patient later,
but it also provides great psychological benefit.
VENOUS THROMBOEMBOLISM PROPHYLAXIS
Prevention of thromboembolic disease is a critical issue in orthopaedic surgery. Recent stud-
ies have highlighted the pervasiveness of this problem among several orthopaedic patient
populations. Without prophylaxis, a deep venous thrombosis may occur in 40% to 60% of
patients undergoing total hip or knee arthroplasty. Proximal deep venous thrombosis may
occur in 15% to 20%, and a fatal pulmonary embolism may occur in 0.5% to 2%. Risk factors
that have been identified for thromboembolic disease include age (becoming clinically important
by age 40 and increasing thereafter); prolonged immobility or paralysis; history of prior
thromboembolism; cancer; major surgery (particularly operations on the pelvis and lower
extremities); obesity; varicose veins; congestive heart failure; myocardial infarction; stroke;
fractures of pelvis, hip, or leg; and possibly high-dose estrogen use.
Numerous methods of prophylaxis have been investigated, and authorities recommend both
mechanical and pharmacologic methods. Intraoperative anesthetic techniques including
hypotensive and epidural anesthesia have been shown to reduce the risk of thromboem-
bolism. Mechanical methods include use of compression stockings and various pneumatic
compression devices. Pharmacologic methods include dextran, aspirin, warfarin, heparin,
and low-molecular-weight heparin.
Diagnosis of thromboembolic complications, most of which are asymptomatic, remains difficult.
Methods for diagnosis of deep venous thrombosis include impedance plethysmography,
fibrinogen I-125 scanning, venography, and duplex ultrasound.
Diagnostic methods for pulmonary embolism are ventilation-perfusion scanning and
pulmonary angiography. There is controversy over the ideal diagnostic testing modality
because of variation in sensitivity and specificity of the different tests. They also vary
in their ability to image different parts of the venous systems, and in the invasive risk
they pose to the patient.
In cases where deep venous thrombosis is diagnosed, controversy also exists over whether
all thrombi should be treated, what method of treatment should be used, and how long
treatment should last. Low-molecular-weight heparin, which does not require laboratory
monitoring, is increasingly the treatment of choice in the outpatient management of deep
venous thrombosis. The numerous investigations and recommendations on this important
subject are beyond the scope of this chapter. While many therapeutic methods have been
shown to reduce the risk of thromboembolism, no single method is completely effective
or applicable to all situations. Metaanalysis of recent randomized clinical trials has shown
low-molecular-weight heparin to be superior to warfarin in prevention of deep venous
thrombosis, but its use is associated with a greater number of minor bleeding complications.
Each surgeon must assess the varying risk that thromboembolism presents to each
individual patient, selecting the prophylactic method that appears to provide the greatest risk
reduction when balanced against any potential risk of the treatment itself.
66 RMO Course 2007
RMO Course 2007 67
Arterial Blood Gas
Although taking an arterial blood sample may be considered one of the doctors more
advanced techniques, it is actually a relatively simple procedure:
Check collateral circulation Allens Test
The Allens test is used to ensure that there is collateral arterial supply from the ulna artery
to the hand. It is unusual but not unknown for the sole supply of blood to the hand to be
from the radial artery and in this instance disruption could be disastrous.
To perform the Allens test
Occlude the radial and ulna arteries by applying pressure to them with finger tips. As blood
supply is interrupted the hand will blanch.
On blanching of the hand release pressure from the ulna artery, the hand should rapidly
become pink again, asserting collateral circulation.
Confirm by means of patient history if there is coagulopathy or if the patient is undergoing
anti-coagulant therapy. Peripheral vascular disease is also a contraindication and undertak-
ing this procedure in any of these circumstances should be considered against the value of
further patient management.
Locate the artery by palpation of the pulsatile vessel at the radial site
Estimate the depth beneath the skin and direction of travel by running a finger over the
vessel from side to side
Use a hepparinsed ABD syringe
Prepare the radial site (brachial and femoral may also be considered for use)
Locate the radial artery by palpation
Expel heparin from syringe
Aim the needle bevel up at 45 degree angle, aim upstream and away from hand
Fill syringe to at least 1ml, under artery pressure
Remove syringe and apply pressure to site of puncture
Normal ABG values
Normal Arterial Blood Gas values
pH 7.35 to 7.45
PaO
2
10.8 to 15.0 kPa
PaCO
2
4.5 to 6.0 kPa
HCO
3
22 to 28 mmol/L
BE +2 to -2 mmol/L
Taking Blood
Who takes it?
The RMO or nurse may take the sample
A trained phlebotomist (a specialised clinical support worker) will take a small sample
of your blood usually from a vein near your elbow. The blood will be extracted by either
a syringe with a needle, or more often a needle attached to a device where different vacuum
vials-(small glass bottles) can be connected so a small amount of blood goes into each vial
for a variety of tests. It is then sent to a laboratory where it is analysed.
Some people have a fear of needles or of blood and can feel faint. If this is the case do make
sure you tell the person who is taking your blood so you can be positioned to reduce this
situation arising.
What is it made of?
Blood is made up of two main elements:
v The fluid which is called plasma
v Cells there are three kinds of cells
Red blood cells- deliver oxygen around the body
White blood cells- leukocytes defend against infectious diseases
Platelets- these lead to forming blood clots
Blood Tests
Below is a list of some of the blood tests which are more commonly taken
with the abbreviations used:
68 RMO Course 2007
ALT- Alanine aminotransferase This is done to see if you have a liver problem.
Amylase This is done to diagnose pancreatitis (the pancreas is important for secreting
enzymes for digestion and regulating blood sugar levels).
B12 and Folate This is done to diagnose the cause of anaemia or nerve damage-
Neuropathy.
Card Enz Cardiac Enzymes This is done when a heart attack is suspected.
Chol Cholesterol This is to test if you have heart disease or circulatory problems.
Elecs Urea and Electrolytes This is done to assess your Electrolyte (term for salts,
electrically charged ions) levels also to check your kidneys are working.
ESR Erythrocyte sedimentation rate This screens for infection and monitors
inflammation.
Ferritin A protein This is done to check the levels are correct as they are important
for red blood cell production, and the levels of iron in your body
FBC Full blood count This is done to check your general health and to screen
for disorders, such as anaemia, infection, and nutrition.
FSH Follicle stimulation hormone This is done to check your pituitary gland which
regulates the hormones that control your reproductive system
Glucose This checks the levels of glucose in your blood as it may indicate diabetes.
INR International normalised ratio This is to test your blood clotting mechanisms
for people who take anti-coagulants (blood thinning medicine) like Warfarin.
RF Rheumatoid factor This is done when rheumatoid arthritis is suspected.
TFT Thyroid function test To test for levels of TSH Thyroid Stimulation Hormone
this shows if the thyroid is under active or over active.- this relates to your energy levels.
PT prothrombin time To check how well your blood thinning (anti-coagulants)
medicine is working.
WBC White Cell Count This is done when you may have an infection or an allergic
reaction, also to monitor treatment .
RMO Course 2007 69
Cohort Nursing
1. This is where a group of patients who are suffering from the same infection are nursed
together in a ward/bay area
When you have commenced treatment for MRSA you will have swabs taken at various
intervals to check if the infection is being eradicated. When you have three MRSA-negative
swabs, these tests usually take 2-3 days, it means you are no longer infected you will be
returned to the general ward area.
MRSA surveillance in hospitals all over the country is recorded so you can see how well
your hospital performs
Pain control
Pain Relief After your Operation
v Definition
v Pain Relief
v Acute Pain
v Chronic Pain
v Malignant Pain
v Pain Teams
v Pain Scales
v Types of Pain Relief
Tablets and Liquids
Injection
Patient Controlled Analgesia (PCA)
Suppositories
Definition
The International Association for the Study of Pain defines pain as an unpleasant
sensory and emotional experience associated with the actual or potential tissue damage,
or described in terms of such damage or both.
Pain relief is probably one of the most important factors relating to your operation.
If you are in pain before your operation you will be expecting relief immediately afterwards
but sometimes this isnt the case the operation itself may cause pain which you hadnt
expected.
Pain Relief
Different pain relief is available in many different forms and when you discuss this with
your anaesthetist they will advise you of which forms they believe will offer you the best
results. This conversation is extremely important for you as you will then feel confident
70 RMO Course 2007
that you will not be left in pain at any time, anxiety about pain increases the amount
of pain which people feel.
Pain relief can be:
Increased
Given more regularly
Given in different combinations
Good pain relief = Good practise
The aim is to relieve your pain if you are able to move without pain you are less likely
to develop a blood clot, also you are less likely to develop a chest infection as you will
be able to cough.
The Health Care Commission which was set up in 2004 to promote quality in the private
and public sector, carried out an audit 73% of people questioned felt that their pain had be
managed well- with staff doing all they could to relieve it.
There are three types of pain:
Acute pain:
Acute is the term applied when the attack is sudden, severe and of short duration. This is
caused by:
Surgery
Injury or trauma
Illness
Painful medical procedures
Once the cause has been treated or healed the pain disappears.
Chronic pain:
Chronic is the term applied when a condition is ongoing and of a long duration. The intensity
of chronic pain can range from mild to severe causing quality of life issues. The pain may
well have resulted from an initial injury resulting in the pain becoming an ongoing problem.
This can lead to long term stays in hospital and repeated outpatient appointments.
Chronic pain complaints often include
Lower back
Cancer
Arthritis
Neurogenic this is pain resulting from damage to nerves or to the central nervous
system
Psychogenic this pain is not due to past disease or injury or any visible sign of damage
Migraines and Headaches
Angina
Pelvic
RMO Course 2007 71
Malignant Pain:
This pain is associated with diseases like cancer the pain is caused by the tumour affecting
the surrounding tissues, most commonly bone tumours. The pain needs to be carefully
assessed and appropriately treated.
Pain Teams:
Most hospitals have pain clinics which have Anaesthetic Consultants who specialise in pain
relief; often these are supported by nursing staff that specialise in pain relief as well.
The nurses will visit patients regularly on the wards to ensure you are comfortable and that
their pain is being well managed The RMO will be responsible for the PCA.
Pain scales:
Pain scales are a really useful tool for you to use they help you to assess your pain. They are
also useful for the people who are treating you; to be able to treat it appropriately with the
correct types of pain relief medicines. Pain intensity can vary between mild, moderate,
or severe pain.
Pain score cards can be used as visual prompts like smilie faces which change depending
on the level of pain- especially good for children.
For adults a scale of 1-10.
1 = no pain and 10 = the most excruciating pain.
It is much easier to relieve pain if it is dealt with before it gets bad, ask for help
as soon as you feel pain, the treatment for pain needs to be regular for it to be effective.
The British pain society www.britishpainsociety.org have developed a pain scoring standard
which can be downloaded in many different languages to help with the description and
management of pain.
Types of pain relief
Tablets and Liquids
The most common mild to moderate pain relief tablets are:
Aspirin active within 20-30 mins lasts for approx 4hrs. for pain and inflammation
Aspirin has an association with Reye's syndrome and should not be used to provide
analgesia in children under the age of 12 years.
Paracetamol active within 20-30 mins lasts for approx 4hrs.-for pain
not inflammation.
72 RMO Course 2007
Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation. They are useful
for superficial pain arising from the skin, mouth mucosa, joint surfaces and bone. Care
should be taken when using these medicines if you have asthma or impaired renal function.
Benefits
Aspirin, Ibuprofen or Paracetamol can be taken by mouth. Tablets and liquids cause less
discomfort than injections into a muscle or the skin. They are easy for you to take when you
go home from the hospital.
Drawbacks
These medicines can't be used if you aren't supposed to take anything by mouth or if you're
nauseated or vomiting. However some of these medicines come in a rectal suppository, so
you can take them even if you're feeling sick.
Injection
Systemic (This means it has an effect on the whole body) or local
Intramuscular into the muscle /upper thigh /upper arm/ buttock,
Intravenous into vein drugs act more rapidly,
Subcutaneous under the surface of the skin.
Injected medicines given into muscle can take from 20minutes to half an hour to work.
The most common pain relief for severe pain are in the opioid group:
Morphine used for short term acute pain after your operation.
Benefits
Opioids work well for severe pain. They don't cause bleeding in the stomach or other parts
of the body. Medicines given as injections can work even if you're nauseated or vomiting.
Drawbacks
Opioids may cause drowsiness, sickness, constipation or itching. They can also interfere
with breathing and you may have difficulty passing urine. The injection site usually hurts for
a short time afterwards.
Patient-controlled analgesia (PCA)
This is an excellent device which has been designed so you are able to administer
pain relief when you need it. The pump has a controlled amount of an opioid which
you are not able to overdose on. Every time you press the button, a dose is administer
via the cannula (a small plastic tube) which is in you vein, the doctors will have calculated
how much you may require. You will be shown how to use it before your operation.
RMO Course 2007 73
Benefits
Because it is in the vein the medicine works faster than either tablets or intramuscular
injection. You do not have to keep asking staff for pain relief and have to wait for them to get
it for you it is immediate.
Drawbacks
Where you go the pump needs to go. Same drawbacks as opioids.
Suppositories
These are waxy bullet shaped capsules that are placed in your back passage (rectum).
The capsule dissolves and the drug is absorbed easily by your body.
Benefits
They are useful if you cannot swallow or if you are likely to vomit. They are often used
to supplement to other pain relief methods.
Drawbacks
We here in Britain are not great fans of suppositories as a form of taking medicines
whereas elsewhere in the world this is quite common.
74 RMO Course 2007
ECG MONITORING AND RHYTM STRIPS
Monitors with 3 leads are connected as follows:
Red right arm or second intercostal space to the right of the sternum,
Yellow left arm or second intercostal space to the left of the sternum,
Black or Green left leg or more usually in the region of the apex beat.
P = Atrial activity
The second wave of activity is a result of ventricular depolarisation, rapidly followed
by ventricular contraction.
QRS = Ventricular activity
The third wave of activity is the repolarisation of the ventricles, or T wave.
T = Repolarisation of the ventricles.
Five stage ECG monitor/ Rhythm strip interpretation.
1. Rate: what is the QRS rate?
2. Rhythm: is the QRS rhythm regular or irregular?
3. Is the QRS width normal or prolonged?
4. Is there atrial activity present? If so what is it? Is there a normal P wave?
5. What is the relationship between atrial activity and ventricular activity?
DRUG ADMINISTRATION
When administering drugs, the following checklist should be adhered to:
Name,
Date,
Time,
Route,
Allergies,
Interactions with other prescribed drugs,
Correct dose,
Appropriate drug for this patient with this condition.
RMO Course 2007 75
ACUTE ABDOMEN
Acute presentation
Unwell,
Signs and symptons within abdomen.
Look for signs of shock:
Low blood pressure,
Postural drop in blood pressure,
Tachycardia,
Peripherally shut down,
Poor capillary refill.
Look for signs of Peritonitis:
Shock,
Lying still,
Abdominal pain on coughing,
Tenderness,
Rebound,
Board-like abdominal rigidity,
Absence of bowel sounds,
Possible gas under diaphragm on chest x-ray.
Possible causes:
Rupture of internal organ,
Spleen, aorta, ectopic pregnancy, history of trauma, particularly blunt trauma.
Possible causes of peritonitis
Perforation of,
Duodenal ulcer,
Peptic ulcer,
Appendix,
Diverticulum,
Bowel,
Gall bladder.
76 RMO Course 2007
CANNULATION
Pre-procedure
Identify patient,
Ensure procedure still relevant eg. should patient be taking IV antibiotics or does
patient still require IV hydration,
Gain informed consent,
Before undertaking this procedure, the patients general circumstances should be
considered, including the following:
> Mental health, neuro-motor disorders,
> Allegies, latex, tape, plaster,
> Fears and/or phobias,
> Faints,
> Clotting or bleeding disorders,
Gather equipment,
Wash hands,
Apply tourniquet,
Prepare and check equipment.
Equipment
Gloves correct sizing is important,
Tourniquet,
Alcohol wipe or Chlorhexidine spray,
Cotton wool, gauze or tape,
Appropriate cannula dressing,
Sharps bin,
5ml syringe,
5ml normal saline for flush,
Choice of cannula:
> Size 14 to 16g in Hypovolaemia,
> Size 18g for blood, if possible,
> Size 20 to 22g in all other cases,
The smaller the cannula gauge size, the wider the bore of the cannula.
Selection of the vein
This is the most important part of the procedure.
Make sure both you and patient are comfortable, raise chair or bed to avoid bending,
Support the patients arm on a pillow,
Reassure patient, advise them you will examine arm first and warn them immediately
before cannula is inserted,
Choose a site lower down the arm, the anti cubical fossa site is more appropriate,
if patient is likely to need aggressive fluids, is peri-arrest or in cardiac arrest,
Palpate the vein to ensure it is elastic (bouncy),
Note the path of the vein and any bends or changes in direction.
RMO Course 2007 77
Areas to avoid
Fibrosed veins, these may appear good but on palpation will be hard to the touch and
inelastic,
Inflamed veins,
Close to infection,
Bruising,
Directly over joints,
Side of CVA/post mastectomy,
Arm with infusion,
Dominant arm, if possible,
Placing a cannula in the hand unless no other site available. This position is very
uncomfortable for patient and extravasates easily because of frequent hand movement
and of cannula in the vein.
Hints and Tips
Ensure tourniquet is applied tightl,y
Apply tourniquet before equipment preparation, this gives time for veins to fill,
Tapping the vein can help,
Clenching and unclenching of the fist can make veins more readily available,
A hot compress with a small electric pad like those used for palliation of localised pain,
A hot water dip can make veins expand due to the heat.
VENEPUNCTURE
Venepuncture with the vacutainer system
The vacutainer system is designed to reduce the risk of an infected needlestick injury by
an enclosed sharp filling system with blood bottles pre-charged with vacuum.
Correct usage means the only sharp exposed is the one inserted into the vein,
then immediately disposed of into a sharps bin.
Incorrect use of the system can lead to a problem when not all elements are available
and vacuum charged bottles are filled with the syringe and needle used to take the blood.
This increases the risk of a dirty needlestick injury by having a potentially infected
needle pointed towards the practioners hand and as such is dangerous.
78 RMO Course 2007
RMO Course 2007 79
Venepuncture and Phlebotomy are medical terms for blood taking. This is the
most common procedure carried out by Resident Medical Officers on daily basis.
Some of the vocabulary below is really basic, however you might find it useful
whilst explaining things to the patient.
Venepuncture/Phlebotomy Vocabulary
ABG (arterial blood gas)
a test which analyses arterial blood for oxygen, carbon dioxide and bicarbonate content in
addition to blood ph. used to test the effectiveness of respiration.
anaerobic
growing, living or occurring in the absence of molecular oxygen; pertaining to an anaerobe.
as in phlebotomy, the drawing of blood cultures for the purpose of possible isolation and
identification of anaerobic bacteria.
antecubital
that part of the arm opposing the elbow.
anticoagulant
anticoagulant solutions used for the preservation of stored whole blood and blood fractions
are acid citrate dextrose (acd), citrate phosphate dextrose (cpd), citrate phosphate dextrose
adenine (cpda 1) and heparin. anticoagulants used to prevent clotting of blood specimens for
laboratory analysis are heparin and several substances that make calcium ions unavailable
to the clotting process, including edta (ethylenediamintetraacetic acid), citrate and oxalate.
antiseptic
something that discourages the growth microorganisms. by contrast, aseptic refers to the
absence of microorganisms.
arterial blood
blood contained within the arteries and which carries oxygen from the heart and lungs
to outlying organs and tissues.
aseptic
the absence of microorganisms. by contrast, something that just discourages the growth
of microorganisms is antiseptic.
aspirate
the material that is withdrawn with a negative pressure apparatus (syringe).
basilic vein
large vein on the inner side of the biceps. often chosen for intravenous injections and blood drawing.
betadine
a popular trade name iodine-containing topical antiseptic agent; povidone-iodine.
blind stick
performing a venepuncture with no apparently visible or palpable vein. though this technique
is discouraged, it is occasionally necessary requiring a skilled phlebotomist who is experi-
enced and well versed in vascular anatomy.
blood
the fluid in the body that contains red cells and white cells as well as platelets, proteins,
plasma and other elements. it is transported throughout the body by the circulatory system.
arterial blood is the means by which oxygen and nutrients are transported to tissues, venous
blood is the means by which carbon dioxide and metabolic by-products are transported for
excretion.
blood cell
there are three main types of cell in the blood stream. the red cell, which carries oxygen, the
white cell, which fights infections and the platelet, which helps prevent bleeding. the correct
balance between each cell type must be maintained for the body to remain healthy.
blood clot
the conversion of blood from a liquid form to solid through the process of coagulation. a
thrombus is a clot which forms inside of a blood vessel. if that clot moves inside the vessel it
is referred to as an embolus (embolism).
blood culture
a test which involves the incubation of a blood specimen overnight to determine if bacteria
are present. blood is collected in a special media which enhances the growth of both aerobic
and anaerobic microorganisms.
bloodborne pathogen
pathogens which are present in the blood stream and which may be passed to others.
butterfly
a small needle with two plastic wings attached which are squeezed together to form a tab
that is used to manipulate the needle. a long 6-12" plastic tubing is attached which again
offers better manipulation. this assembly is then attached to a syringe or vacutainer holder
for the purpose of drawing a blood sample.
80 RMO Course 2007
centrifuge
a laboratory apparatus that separates mixed samples into homogenous component layers by
spinning them at high speed.
circulation
the movement of fluid in a regular or circuitous course. although the noun "circulation" does
not necessarily refer to the circulation of the blood, for all practical purposes today it does.
heart failure is an example of a problem with the circulation.
citrate
a compound that is an intermediate in the citric acid cycle (krebs cycle). citrate chelates
(binds) calcium ions, preventing blood clotting and, thus, is an effective anticoagulant.
citrate phosphate dextrose (cpd) an anticoagulant.
clot
a semisolid mass of blood found inside or outside the body.
coagulate
the process of clot formation.
coagulation factors
group of plasma protein substances (factor i-xiii) contained in the plasma, which act together
to bring about blood coagulation.
complete blood count (cbc)
the number of red blood cells, white blood cells and platelets (per cubic millimeter) that are
present in the patients sample of blood is determined. also included is the hematocrit (%),
hemoglobin concentration (gm%) and the differential. most common test done on the blood.
contamination
the soiling or pollution by inferior material, as by the introduction of organisms into a wound.
coumadin
trademark for the preparation of warfarin sodium.
diaphoretic
formation of profuse perspiration (sweat). a symptom of syncope.
differential
a count made on a stained blood smear of the proportion of the different leukocytes (wbc's)
and expressed as a percentage. a differential is a normal part of a complete blood count (cbc).
ecchymosis
the skin discoloration caused by a bruise (contusion).
RMO Course 2007 81
oedema
the swelling of soft tissues as a result of excess water accumulation. it is often
more prominent in the lower legs and feet toward the end of the day as a result of pooling
of fluid from the upright position maintained during the day. development
of collateral circulation will result in a reduction of water accumulation.
EDTA
ethylenediaminetetraacetate. a calcium chelating (binding) agent that is used as
an anticoagulant for laboratory blood specimens.
electrolyte
a substance that will acquire the capacity to conduct electricity when put into solution.
electrolytes include sodium, potassium, chloride, calcium and phosphate. informally called
"lytes".
embolus
a sudden blockage of a blood vessel by a blood clot or some other obstruction which has
been transported through blood vessels and lodged at a site too small for passage. examples
of emboli are a detached blood clot, a clump of bacteria, or other foreign material, such as
air. contrast to thrombus.
erythrocyte
cells that carry oxygen to all parts of the body.
Factor VIII
one of a number of coagulation factors. classic hemophilia (hemophilia a) is due to a congen-
ital deficiency in the amount (or activity) of factor viii. the gene for factor viii (that for classic
hemophilia) is on the x chromosome so females can be silent carriers without symptoms and
males can be hemophiliacs.
fasting
without eating. a number of laboratory tests are performed on "fasting" blood specimens
such as sugar (glucose) levels. specimens are usually taken after overnight fasting.
fibrin
the protein formed during normal blood clotting that is the essence of the clot.
fibrinogen
the protein from which fibrin is formed/generated in normal blood clotting.
flash-back
relative to venepuncture, the appearance of a small amount of blood in the neck of a syringe
or the tubing of a butterfly. this is a sign that the vein has been properly accessed.
82 RMO Course 2007
gauge
needle diameter is measured by gauge; the larger the needle diameter, the smaller the
gauge.
for example:
21 gauge (yellow) used primarily for large antecubital veins
23 gauge (green) for smaller antecubitals, medium size forearm, hand and foot veins
25 gauge (black) only for the smallest veins, usually in the forearm, hand and foot.
germicide
an agent that kills pathogenic microorganisms.
glucose
the sugar measured in blood and urine specimens to determine the presence or absence of
diabetes. glucose is the end product of carbohydrate metabolism and is the chief source of
energy for all living organisms.
heparin
an anticoagulant that acts to inhibit a number of coagulation factors, especially factor xa.
heparin is formed in the liver.
haematocrit
the ratio of the total red blood cell volume to the total blood volume and expressed as a per-
centage.
haematoma
a localized collection of blood within tissue due to leakage from the wall of a blood vessel,
producing a bluish discoloration (ecchymosis)and pain.
hemoconcentration
a decrease in the fluid content of the blood (plasma), resulting in an increase in concentra-
tion. this is determined by an increase in the hematocrit. caused by a filtration of plasma into
body tissues and often created by dehydration.
hemoglobin
the oxygen carrying pigment of the red blood cells.
hemolyze
the breaking of the red blood cells membrane releasing free hemoglobin into the circulating
blood. in phlebotomy, this is usually the result of mechanical damage due to poor technique.
heparin
an anticoagulant that acts to inhibit a number of coagulation factors, especially factor xa.
heparin is formed in the liver.
RMO Course 2007 83
hypodermic needle
a needle that attaches to a syringe for the purpose of injections or withdrawal of fluids such
as blood.
LPT
lpt are lipid/triglycerides.
lymphedema
lymphedema is a type of swelling which occurs in lymphatic tissue when excess fluid collects
in the arms or legs because the lymph nodes or vessels are blocked or removed. regarding
phlebotomy, this can be a major complication of mastectomies.
multi-sample adapter
a device used with a butterfly and vacutainer holder to allow for the withdrawal of multiple
tubes of blood during a venipuncture.
order of delivery
a term used to define the order in which tubes should be filled with blood after being drawn
by syringe.
order of draw
terminology used to define the order in which blood sample tubes should be drawn using
a multi-sample technique such as the vacutainer system.
oxyhaemoglobin
hemoglobin that has been bound with oxygen in the lungs for the purpose of transport
of oxygen to cells of the body. in the cells oxygen is exchanged for carbon dioxide.
palpate
to examine or feel by the hand. in relation to venipuncture, this technique is used to "feel"
a vein which will tend to rebound when slight pressure is applied with the finger. the technique
is used to help determine the size, depth and direction of a vein. in relation to arterial punc-
tures, this technique is used to determine the position and depth of an artery (see pulse).
pathogen
any microorganism that produces disease.
pathogenic
having the capability of producing disease.
peripheral blood
blood obtained from the circulation away from the heart, such as from the fingertip, heel
pad, earlobe or from an antecubital vein.
84 RMO Course 2007
pH
the symbol used to depict the hydrogen ion concentration of a solution, i.e. acidity. ph 7.0 is
neutral; above 7.0 is alkaline, below is acid.
pipet
a glass or transparent plastic tube used to accurately measure small amounts of liquid.
plasma
the fluid portion of the blood in which the cellular components are suspended. plasma is
different from serum!
platelets
also known as a thrombocyte, this is a particulate component of the blood,
approximately 2-4 microns in diameter and known for its involvement in blood coagulation.
this structure, which has no nucleus or dna, is formed by breaking off from the cytoplasm
of the parent cell, known as a megakaryocyte in the bone marrow. under normal
conditions, platelets will aggregate at the site of a break in vascular integrity,
forming the beginning stages of a clot. normal platelet counts range from
150,000-450,000/cm?.
povidone-iodine
used as a topical antiseptic, this is a compound made by reacting iodine with povidone which
slowly releases iodine. same as betadine .
red blood cells (rbc)
one of the solid components of the blood which is normally a biconcave disc
with no nucleus. this is the component of the blood that contains hemoglobin which
is responsible for oxygen and carbon dioxide exchange. a red cell count is performed as part
of a complete blood count and ranges from 4,500,000-5,000,000 rbc's
per cubic millimeter.
sclerosis
a hardening; especially from inflammation and certain disease states. though sclerosis may
occur in many areas of the body, the term is most often associated with blood vessels.
serum
referring to blood, the clear liquid portion of blood that separates out after clotting has taken
place. since clotting has occurred, serum is fibrinogen deficient. contrast to plasma.
tourniquet
in regards to venipuncture, a constrictive band, placed over an extremity to distend veins for
the purpose of blood aspiration or intravenous injections. materials used may be rubber,
latex or other synthetic elastic material. a blood pressure cuff may also be used.
RMO Course 2007 85
vacutainer
vacutainer is an internationally registered trademark owned by bd (becton, dickinson and
company) that is used in connection with a complete system of tubes, needles and needle
holders, sharps collectors, and safety devices in blood collection. the vacutainer evacuated
tube, for example, automatically aspirates the correct amount of blood into a tube. it is used
instead of a syringe. despite of the fact that bd owns the vacutainer trademark, the term
has become so widely used to describe similar blood collection tubes and devices, that it has
become a generically used term.
vacutainer holder
a cylindrical shaped holder that accepts a vacutainer tube on one end and a vacutainer
needle on the other. the holder, tube and needle comprise the vacutainer system, used to
draw multiple tubes of blood with one venipuncture.
vacutainer needle
the needle used to attach to a vacutainer holder. the needle has a male thread on one end
which screws into the holder. the threaded end also has a large gauge needle, enclosed by a
rubber sheath. this needle will puncture the stopper of a vacutainer tube allowing blood to
enter the tube. upon withdrawal of this needle from the tube, the rubber sheath covers the
needle bevel, stopping the flow of blood. thus, any number of tubes may be drawn with only a
single venipuncture.
vacutainer system
the combination of a vacutainer holder, needle and sample tube which allows for a more
automated method of drawing blood. when a multi-sample needle is used the system will
allow for the aspiration of any number of sample tubes with only one venipuncture.
vacutainer tube
blood sample tubes containing a vacuum. when the tube stopper is pierced by a vacutainer
needle which has been properly positioned in a vein, the vacuum draws blood into the tube.
vein
blood vessels carrying blood to the heart. blood contained within these vessels is generally
bound with carbon dioxide which will be exchanged for oxygen in the lungs. the presence of
carbon dioxide and the absence of oxygen accounts for the dark red appearance of the blood
in venous circulation. the only exception to this is the pulmonary vein which is the vein
returning to the heart from the lungs, this time with oxygenated blood (no carbon dioxide).
venipuncture
the puncture of a vein for any purpose.
venous
pertaining to the veins, or blood passing through them.
86 RMO Course 2007
venous blood
blood contained within the veins.
warfarin sodium
the sodium salt of warfarin, one of the synthetic coumarin anticoagulants. coumadin.
white blood cell
also leukocyte. a variety of cells within the blood and bone marrow whose general purpose is
to help in fighting infection. each type is differentiated by use of a stained preparation (see
differential) and is separated based on how the cells and their components take up the stain.
the five general cells thus distinguished are neutrophils, lymphocytes, monocytes, basophils
and eosinophils all of which are nucleated cells.
white cell count
the number of white blood cells (leukocytes) found in the peripheral blood and measured per
cubic millimeter. see also complete blood count.
whole blood
blood from which none of the elements have been removed. it is usually referred to as that
blood, collected from a donor and anticoagulated for the purpose of blood replenishment for
a recipient.
RMO Course 2007 87
88 RMO Course 2007
Recommendations:
Problems Encountered:
Attendance Arrival Time
1. _____________________ :
2. _____________________ :
3. _____________________ :
4. _____________________ :
5. _____________________ :
6. _____________________ :
7. _____________________ :
8. _____________________ :
Team Leader: ________________________
DD /MM / YY
Date: ___ / ___ / ___
Hospital: __________________________
Scenario place: __________________________
Scenario given: __________________________
___________________________________________
___________________________________________
___________________________________________
Matron: __________________________
Observers: __________________________
__________________________
Emergency scenarios
RMO Course 2007 89
Contact Number: ___________________
Copy signed by: ______________________________ ______________________________
Print name Signature
Resus Officer: ______________________________ ______________________________
Print name Signature
Date: ____________________
Address: __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
90 RMO Course 2007
Basic Life Support
Time in minutes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
1. Safety
2. Check responsiveness /
Stimulation
3. Call for help / Shout for AED
4. Spinal stabilisation
Technique:
_________________________
5. Airway open: Jaw Thrust /
Head tilt / Chin Lift
6. Breathing: Look Listen Feel
7. Rescue Breaths: 0 / 2 / 5
Mouth to Mouth/Mouth to Mask/
Bag Valve Mask
Barrier Device
Adult/child/baby
8. Compressions: Start
Stop
8. Correct Rate / Depth
30:2 15:2 3:1
9. Compressor rotation
10. Defibrillator:
AED / Monophasic / Biphasic
11. Rhythm: VF
VT Pulseless / Pulse +
Tachycardia PEA
Bradycardia Asystole
Other: ____________
12. Shock: 200J / 360J /
Other: ___________
Paddles / External Pads
Adult / Paediatric
13. Pulse Check: Carotid /
Femoral / Brachial
14. Other: __________________
________________________
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
RMO Course 2007 91
Advanced Life Support
Time in minutes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
1. Airway:
Nasopharyngeal tube size: _____
Oropharyngeal airwaysize: _____
Endotracheal tube size: _____
Cuff inflated
Placement: Trachea / Oesophagus
Laryngoscope: checked /
blade size
Placement confirmation
EDD / CO2 / Clinical
2. Breathing rate per minute: _____
3. Circulation: IVI / IO / Central
Position placed: ______________
Fluid:
NaCl 0. 9% Hartman/ Blood Other
Ringers
ml ml ml
Repeat Bolus
Maintenance fluid
Drugs:
1. Adrenalin: 1:1000 / 1:10000
2. Atropine: Dosage:
3. Amiodarone:
Dosage: 150 / 300 / 360 / 540
Dextrose / Sterile Water: ____ ml
4. Other: __________ Dosage: _____
5. Other: __________ Dosage: _____
6. Other: __________ Dosage: _____
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
92 RMO Course 2007
PCA Pumps Patient Guide
What is PCA? It is the abbreviation for patient controlled analgesia.
What does a PCA pump do? A PCA pump allows you to give yourself pain killing
drugs whenever you need them and without having to wait for the nurse to bring an
injection.
When do I get the PCA pump? When you awake after your operation you will be con-
nected up to the PCA pump.
How does it work? When you feel pain you press the white button on the handset,
which will be in your hand (this is connected to the PCA pump). You will hear a beep
to confirm that the pump has acknowledged this request. The pump delivers the drug
down a fine length of tubing to the drip in your arm.
Does a PCA pump always administer the drug when I press the button? No! The
pump
is programmed to allow the drug to exert its effect (it takes a few minutes). After this
period, if you are in pain the pump will allow you to have another dose of pain killers.
How much pain control should I try to get? Most patients aim to get as comfortable
as possible, without getting too drowsy.
Why is PCA better than conventional treatment methods? You get your pain killer
immediately when you need it, as often as you need it and it acts rapidly. If you dislike
PCA Pumps for post operative pain control*
injections PCA is an extra bonus. Furthermore, patients with good pain control tend
to make faster progress and, on average, leave hospital earlier.
How long will I be on the PCA pump? You can have the pump for as long as you need
it. Most patients progress to oral medication after a couple of days.
Will PCA help me to cope with physiotherapy and other nursing procedures? Yes!
You can get pain relief before, during and after many procedures using PCA.
Is it safe? PCA pumps have been in use for many years now and they incorporate a
number of safety features. If used sensibly, they are very safe.
Can I overdose myself? Provided you only press the button when you feel pain it is
virtually impossible to overdose yourself.
Will I become addicted? You will only be on PCA for a relatively short period of time.
Addiction is therefore highly unlikely.
What are the side effects? The main side effect is the same one you might experi-
ence after repeated injections of pain killers from the nurse. This is drowsiness, but it
is usually much less intense.
Does using the PCA pump mean that the nurses will pay less attention to me? On
the contrary. The nurses will have more time to monitor your condition while you are
on the pump, and attend to your other needs
PCA PUMP FOR THE RMO
Preparing Your Therapy
Prepare your medication and attach the administration set. Follow the basic steps:
1. Remove the administration set from the package.
2. Twist the break-away tab off the yellow Flow-Stop.
3. Insert the bag spike into the IV bag so that it is not contaminated.
4. Gravity prime (remove air) from the IV bag and the administration set by squeezing the
Flow-Stop between your thumb and forefinger until air is removed and the tubing is
filled with fluid. Release the Flow-Stop and close the slide clamp on the set.
5. Install the set into the pump.
6. Close the door of the pump all the way, and latch the door securely. Note: If a Check Valve
Adapter is provided with your administration set, remove it from the package and connect
it to the distal end of the set.
RMO Course 2007 93
Installation of Administration Set
1. To open the door of the pump, lift the latch on the top of the door and pull the door up and
all the way to the right (this might differ from set to set).
2. Place the blue Tubing Guide completely into the tubing guide receptacle. CAUTION: The
tubing should be placed IN FRONT of the door hinge.
3. Lay the tubing over the yellow dot in the center of the gray pumping section and insert the
Flow-Stop into its receptacle Caution: do not press the top of the Flow-Stop, as this
will allow fluid to flow through the set.
4. Gently press the tubing into the black air detector slot.
5. If the slide clamp is closed, open it before closing the pump door.
6. Close the door of the pump by firmly pushing down the door and securing the latch.
Important Notification: Please center the tubing in the pumping area when installing the
administration set. A lack of compliance with proper positioning of the tubing could result in
infusion inaccuracies.
Removal of Administration Set
1. Open the pump door and remove the blue Tubing Guide from its receptacle.
2. Pull tubing toward the Flow-Stop and disengage the Flow-Stop from its receptacle.
3. Dispose of the used IV administration set as directed by your healthcare provider.
Twist and remove breakaway tab from Integral Flow-Stop Squeeze Integral Flow-Stop
between thumb and forefinger as shown to allow fluid to flow through tubing after the break-
away tab has been removed.
Open Closed Slide Clamp Air Detector
Note: Open the slide clamp before closing the pump door
Priming the Administration Set
The air can be removed from your administration set as shown previously by gravity priming
the administration set. Air can also be removed by utilizing the PRIME function of the pump.
CAUTION: Be sure the administration set is disconnected from your IV site before priming.
Priming with the set connected to the IV site could result in overdose and may cause injury
or death.
1. Press and release the PRIME key from Run Options Menu.
2. Release any clamps on the administration set.
3. Press and hold the PRIME key until priming is complete.
4. When all the air is removed from the IV bag and the administration set, release the PRIME
key and press the YES/ENTER key to exit prime.
5. Connect the administration set to your IV site and then press the RUN key to begin your
infusion.
Note: If you use alcohol to cleanse your access device, let the alcohol dry completely before
connecting the administration set.
94 RMO Course 2007
Starting the Pump
1. Turn the pump on by pressing the blue ON/OFF key. The pump will perform a self-test,
and then will beep three times. (Beep sound may differ from set to set)
2. After passing the self test, the screen will display the remaining battery life or the external
power source.
3. Next, a screen with PROGRAM, or SETUP options will be displayed. Select PROGRAM or
SETUP by pressing the YES/ENTER key.
4. The screen will change. The cursor will be on RESUME, REPEAT Rx, or NEW PROGRAM.
Move the cursor to the proper selection and press the YES/ENTER key. (Note: If your clinician
has programmed a delayed start, select RESUME, skip step 5 and 6, go directly to step 7).
5. If you select REPEAT Rx and your pump has more than one programmed therapy, a screen
will display the therapy choices. Select which therapy to repeat at this time by using the
arrow keys to place the cursor on the desired therapy and then press the YES/ENTER key.
NOTE: If your pump is programmed for a single therapy, the screen will go directly to that
therapys programmed prescription screens.
6. Your preprogrammed prescription values will appear in the next two display screens for
your review. The display screen pump will scroll automatically. To halt the automatic
review, press any key (except ON/OFF), then complete the prescription review by pressing
the YES/ENTER key at each successive field. The RUN OPTIONS menu will now appear on
the screen.
7. If there is no air in the IV bag or tubing, connect the new administration set to your IV site.
Press the RUN key to start your infusion (If there is air in the line, refer to the priming section.)
Power
PCA pumps can be powered by:
1. Two C size ALKALINE batteries, installed in the compartment on the back of the pump,
2. A rechargeable Battery Pack, or
3. An AC Adapter.
Low Battery Alert
A beep will sound and a Low C-BATTERIES alert will display when the power in the
batteries/battery pack is low. Depending on the therapy infusion rate, you will have approxi-
mately 30 minutes to 4 hours of battery time remaining.
When this alert occurs, replace batteries or the Battery Pack.
Changing Power Sources
To replace the C size batteries, turn the pump OFF or connect the AC adaptor. Hold the
pump so that the back of the pump is facing you. Push a coin into the slot at the bottom of
the battery cover and pull in a downward direction. Replace batteries with both positive (+)
poles at the top of the battery compartment.
Attaching the External Power Source may be an option. Use if available
RMO Course 2007 95
Alarms
When an alarm sounds you will hear a beep (s), the red alarm light will flash and the data
screen will display the reason or the alarm. To resolve alarm situations refer to the alarm
chart below.
To silence the alarm, press the SILENCE button. This will silence the alarm for one minute.
Alarm Conditions and How to Resolve Them
INFUSION COMPLETE
Programmed amount to be infused has been reached (is 0).
Press PAUSE, add another IV bag if indicated and select Repeat function to continue the
therapy; or, turn the pump Off by pressing the PAUSE key, then OFF key.
ALARM AIR-IN-LINE
The pump has detected air in the administration set. Remove air from the administration set.
ALARM DOWN OCCLUSION
The pump has detected an occlusion between the pump and your access site.
Check the tubing from the pump to your IV site. Un-kink the tubing or open the clamp if its
closed. When the occlusion is resolved, the pump will automatically restart the infusion. If
the alarm continues, notify your clinician.
ALARM UP OCCLUSION
The pump has detected an occlusion between the IV bag and the pump.
Press PAUSE key, check administration set from the IV bag to the pump. Un-kink the tubing
or remove any clamps. When problem is resolved, select Resume to resume your therapy.
If this alarm continues, notify your clinician.
ALARM HIGH UP PRESSURE
The pump has detected pressure on the IV bag.
Press PAUSE key, check for excessive pressure in the IV bag, and relieve it. To begin infusion,
select Resume.
ALARM SET NOT INSTALLED
The administration set has not been installed or has been installed improperly.
Install the administration set as directed.
ALARM UNATTENDED PUMP
When a therapy is in progress and the pump is paused for more than two minutes, this alarm
will occur.
To resolve, press RUN/PAUSE key and resume the therapy or continue with operating proce-
dure.
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ALARM REPLACE SET
The pump has detected that the administration set must be replaced.
Replace the administration set following your instructions for this procedure.
ALARM DOOR OPEN OR SET NOT PROPERLY INSTALLED
Pump door is open or Tubing Guide not correctly inserted.
Check placement of the Tubing Guide and close the pump door properly.
ALARM EMPTY BATTERY
The batteries no longer have sufficient power to run the pump. If the battery pack is being
used, both it and the CCell batteries are depleted.
Replace both of the C-Cell batteries. Recharge or replace the battery pack if applicable.
ERROR CODE
The pump has detected an error.
If an error code occurs, turn pump off then back on. If it reoccurs, notify your clinician.
Battery life
Battery life depends on the usage. The following times are approximate only:
Nominal 85 hours at a rate of 2 ml/hr
Nominal 30 hours at a rate of 125 ml/hr
Nominal 10 hours at a rate of 400 ml/hr.
However, if the patient is frequently pressing keys, that action will illuminate the display and
the battery life will be shortened. To extend battery life, the AC Adapter may be used at night.
How can I determine how much battery power is remaining in the pump?
Read the power bar graph when you first turn on the pump.
It is recommended that the External Battery Pack be charged for at least 8 hours prior
to each subsequent use.
Frequently Asked Questions
How do I move around with the pump? PCA pumps have a carry pack specifically
designed to allow you to be mobile and active while receiving your therapy.
Where do I leave the pump when I want to sleep? Place the pump at your bedside or next to
you on the bed.
How do I bath or shower during my therapy? The pump is water resistant, but not water
proof, so it should be placed outside your tub or shower.
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10299 **CONFIDENTIAL**
Dr John Smith
Winterton Medical Practice
Manlake Ave
Winterton
N. Lincs DN15 9T
Tel. 01465 245508
Please allow a minimum of 2 WORKING DAYS when ordering your Prescription repeats
PLEASE ALLOW 3 WORKING DAYS AT BANK HOLIDAYS AND CHRISTMAS
REMEMBER Week ends and Bank holidays are not working days.
There are 5 items on this re-order form
1. AMITRIPTYLINE HCI tabs 50mg. Mitte (84) tablet (s) 3 EVERY NIGHT
Last ordered on 02/10/2006. You may order 5 more.
2. DIHYDROCODEINE tabs 30mg. Mitte (60) tablet (s) TAKE 1 OR 2 3 TIMES/DAY
Last ordered on 02/10/2006. You may order 4 more.
3. FERROUS SULPHATE tabs 200mg. Mitte (84) tablet (s) TAKE ONE 3 TIMES/DAY
Last ordered on 02/10/2006. YOUR PRESCRIPTION HAS RUN OUT.
PLEASE SEE THE DOCTOR BEFORE YOUR NEXT REPEAT IS DUE.
4. QUINNE SULPHATE tabs 200mg. Mitte (28) tablet (s). 1 EVERY NIGHT
Last ordered on 02/10/2006. YOUR PRESCRIPTION HAS RUN OUT.
PLEASE SEE THE DOCTOR BEFORE YOUR NEXT REPEAT IS DUE.
5. DICLOFENAC SODIUM mr tab 75mg. Mitte (56) tablet (s) 1 TWICE NIGHT
Last ordered on 02/10/2006. You may order 1 more.
End of re-order form for 5 items
PATIENTS please read the notes overleaf
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