I ssue #3

O ctober 2009

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 I ssue #3 O c t 2009 www.studentima.co.uk

From the President... CONTENTS

It is hard to believe that just over a year ago, SIMA: Prospect was little more than a
farfetched idea that could have gone so terribly wrong. Thankfully, a year has passed Editorial
and we are putting out this, the third edition of our publication.
United we Stand, Divided we Fall 4
The essence of SIMA: Prospect can be seen on the front cover of every edition
- progress through opportunity. I am a firm believer that it is not what you have that
is important, but what you do with it. Prospect was launched in the hope that it would
The Case 5
highlight some of the opportunities to be taken advantage of that will allow us
to continue to progress. Features
Pre-Hospital Care 6
We wanted to provide you with a platform, and you have grabbed it with both hands.
In making your voices heard, you have honoured the Iraqi spirit that remains as far
Accident & Emergency 10
reaching as it has always been. The Pharmacological Management of the TBI patient 14
Food for Thought... 18
Through this publication and all of its other endeavours, SIMA continues to
demonstrate the importance of the Iraqi cause. A cause, that extends far beyond race TBI in the Dentists chair 21
or religion; that stands for truth, and looks to its tainted past to prepare for the hope- The Beginning of the End 24
ful future. It is fitting that a group of allied healthcare professionals took it upon
themselves to wave the banner of hope for the future, to encourage giving, and to use
the power of the written word to forge new opportunities that shape progress. Iraq Relief Essay Competition
And so, as I hand over the reigns of the Student Iraqi Medical Association, I offer my
Sami the Methanol Guy 28
thanks for your support and kindness in helping this society grow. I have no doubt
that the new committee will do a fantastic job in taking SIMA in its new direction, and
Workshop: Online Resources 32
I hope that you continue to read Prospect, and continue to offer your kind support to
the team in the hope that we can all be the change that we hope for.

-Yasmin Al-Asady
president@studentima.co.uk

Editorial Team

Yasmin Al-Asady Faezeh Godazgar Maram Habib

prospect@studentima.co.uk

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 I ssu e #3 O c t 2009
United we Stand,
Editorial
Divided we Fall
by
Yasmin Al-Asady
The hospital environment is a very
strange place; a frenzy of activity that often
leaves you yearning for a solitary moment
of quiet, mirrored by the times of quiet
sadness that lead you in search of the
distracting hurry.
At some point in your career as a hospital
doctor you will have been called upon at every
hour of every day. You will have seen the
changing face of the hospital in all its glory.
By day you may be immersed in the
seemingly never ending flurry of patients and
their problems. By night you find yourself
fighting tiredness as you wait to rectify
whatever may go wrong.
In the summer months you swelter in the
sticky heat as you climb the endless flights of
hospital steps, yet ever grateful for the suns
glow, in memory of the dark winter nights spent
on call.
Hour by hour, day by day, you work tirelessly
in service of a group of total strangers, united
by their faith in you. Each and every day you
get out of bed ready to face the battleground
that is the hospital, and whatever it feels like
throwing at you today.
As you arrive at the hospital, you file in with
your colleagues; your teammates; the people
that rely on you to deliver. The people that you
can call upon to share the load. Everybody
pulls together to fight their part of this never-
ending battle.
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Hello, ambulance service...
The Case
CALLER Hi, yea ambulance - erm, theres been an accident, a cyclist has been hit by a car
OPERATOR Ok, can you tell me where you are?
CALLER Were on [gives addrress]
OPERATOR Ok, an ambulance is on its way, now can you tell me exactly what happened?
CALLER Erm, I was ust walking past, but I think the guys just come around the corner and
taken the bike out.
OPERATOR Ok, and are you with the cyclist now?
In its all consuming eminence, the hospital CALLER Yeh.
can find itself becoming a micro-cosm of OPERATOR Ok, is he conscious?
wonder within the universe of life. Hidden in
CALLER Erm, I dont know. Hes lying pretty still.
its depths you can find an analogy for every
aspect of life and society. OPERATOR Hes lying quite still is he? What position is he in?
CALLER Looks like he landed on his back
In keeping with this, we bring you this OPERATOR Ok, and is he talking to you?
special edition of SIMA: Prospect. With the CALLER No, I dont know him, I was just walking by
aid of a hypothetical case study, our wonderful OPERATOR Ok, Whats your name sir?
authors walk you through the stages of our
CALLER My name? John.
patients care. We begin from the moment
the emergency services receive the call for OPERATOR Ok John, whilst were waiting for the ambulance Im going to talk you through a
assistance, through the different stages of few things that I need you to check for me, ok?
our patients care, exploring the roles of the CALLER Erm , Ok
plethora of healthcare professional involved in OPERATOR Great. First, I need you to check his airway. Can you look into his mouth and see if
providing each stage of this care as a united theres anything stopping him from breathing?
multi-disciplinary team. CALLER Ok, it looks pretty clear, but hes got loads of cuts on his face from the windscreen.
OPERATOR Ok, can you see if hes breathing? I need you to put your ear just over his mouth
So what is the analogy I hear you ask?
and listen for any breathing, or if you can feel any breath on your -
Iraq and its people have been suffering CALLER Yep, yeah, I can feel something on my face
from a severely debilitating chronic illness for OPERATOR Excellent, youre doing really well John
far too long. Having identified and attempted CALLER What do I do now?
to excise the cause, we now find ourselves at OPERATOR Ok, the ambulance is almost with you now.
the first step of many in the rehabilitation of this I need you to look around John, is he bleeding from anywhere?
great nation. As we embark on this journey;
CALLER Erm, hes got loads of cuts on his face
Iraqi, non-Iraqi, local and ex-pat, we each fill an
important role as individuals, that have come OPERATOR Is he bleeding from his nose or ears?
together to stand united in the pursuit of one CALLER Yeah, he looks like hes got a bit of a nose bleed but his helmet is in the way so I
noble cause. cant really see his ears -
I can hear the ambulance. Theyre here now.
As you read through these articles and OPERATOR Ok John, youve done really well, just tell the paramedics what youve told me
consider the different roles involved in the CALLER Ok, Thanks for your help. Bye.
care of this one patient, spare a thought for
all the different roles required to secure the
future of this great nation as it embarks on its
rehabilitative journey.
The clock is ticking...
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 I ssu e #3 O c t 2009
Features
In high risk cases, such as those
involving Traumatic Brain Injuries (TBI),
every second that passes by signifies a
drop in the patients chances of survival.
From the moment the call is received, basic
first aid is available from the operator. Once
the paramedics arrive, the priority is to get
the patient to the most suitable hospital as
soon as possible, however, they cannot wait
until they arrive before treatment begins.
What is pre-hospital care?
Pre-hospital is the care delivered to a
patient before they arrive at hospital. In this
case, it will be the care given to the cyclist at
the roadside and in the back of the ambulance
on the way to the hospital. It could involve
members of the public, such as the caller who
dialled 999 in our scenario, who may be given
instructions on how to give first aid. Second
on the scene will be the paramedics who arrive
by ambulance. If it is a very serious road
traffic collision (RTC) and an air ambulance is
dispatched, a doctor may also be brought to
the scene.
Arrival at the scene
On arrival, the paramedics first priority is to
assess the scene for danger. The cyclist may
be lying on a busy road with other cars driving
past at high speed, or there may glass strewn
over the road. Drivers of other cars may slow
down to take a closer look, increasing the risk
of another accident occurring nearby. The
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be much more serious if he is not wearing one.
Pre Hospital
All of these details should be assessed
in a matter of seconds as the paramedics
approach the patient. Often the police or fire
services will take photographs of the scene
Care
to help determine the mechanism of injury,
since these details may be forgotten once the
Wikimedia Commons
paramedics have attended to the cyclist.
by
Primary survey
Jemma Batte Once the paramedics reach the cyclist,
they carry out the primary survey. This is an
initial assessment of the cyclist to identify life-
threatening injuries, so they can be treated
Maintaining ventilation using a bag-valve oxygen mask
police and fire services will also have been rapidly upon arrival at A&E and to begin
dispatched to the scene, in order to certify resuscitation. These guidelines for the primary
the scene safe for the ambulance crew to survey are set out by the Advanced Trauma Transfer to Hospital
approach the patient. As the paramedics Life Support (ATLS) programme and they are Once the patient has been stabilised at the
approach the patient, it is important that they used in more than fifty countries worldwide1. roadside, he is ready for transfer to hospital. The
quickly assess the scene for clues regarding first hour after a life-threatening haemorrhage
the patients injuries. begins is referred to as the golden hour as
Eye Opening Score it is within this hour that surgical intervention
A note should be made of the number and may save the patients life. The paramedics
Spontaneous 4
type of vehicles involved. Was there only one will aim therefore to spend no more than ten
car and the cyclist involved, or are there other To speech 3 minutes at the scene, rushing the patient to
damaged vehicles in the vicinity? What is the To pain 2 the hospital best equipped to treat the patients
damage to the bicycle and the car? Important No response 1 injuries whether or not it is the closest
clues may be given away by the way in which Verbal Response Score
the windscreen has been smashed for Orientated 5 Once in the ambulance, movement of
example, the classic bulls-eye pattern, with the cyclist should be kept to a minimum to
Confused conversation 4
cracks radiating outwards from a central point prevent the worsening of his injuries. He
of impact, caused by a victims head hitting Inappropriate words 3 will be strapped down to a backboard and
the windscreen, often suggests that the cyclist Incomprehensible sounds 2 the ambulance driver must take extra care to
has sustained a serious head injury. No response 1 minimise sudden acceleration, braking and
Motor Response Score
Where is the car? It may have hit a lamppost Obeys 6
or another vehicle after veering away from the Localises pain 5
cyclist. The car may even have rolled over,
WIthdraws from pain 4
suggesting that the collision took place at high
speed. This increases the chances that the Flexes to pain 3
Extends to pain 2
http://rationalrevolution.net
car driver, too, may be injured.
No response 1
Finally, where is the cyclist? Is he trapped Maximum Score 15
under the car, or has the speed of the collision
The Glasgow Coma Scale
caused him to be thrown some distance?
Importantly, is he wearing a cycle helmet?
This is particularly significant if the windscreen Right : Cervical spine immobilsation
has been bulls-eyed as the head injury will using neck collar , backboard and sandbags
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The Primary Survey to it. One of the accompanying paramedics

Indications for referral to
Features

will also note his vital signs en route and all

A: AIRWAY AND CERVICAL SPINE
Is the cyclist breathing?
Is there a suspected injury to
the neck?
hospital drugs and fluids administered, which will be
Impaired conscious level at any time relayed to the trauma team when the cyclist
YES Maintain open airway
Amnesia for the incident or subsequent events arrives and all documentation handed over to
Identify what may be obstructing the airway. the hospital staff.
NO Neurological symptoms (vomiting, severe
Consider using an airway adjunct or tracheal intubation*
Immobilise cervical spine using a rigid collar. Fix to persistent headache, fits) A thorough primary survey followed by
YES backboard with sandbags either side of head and Clinical evidence of a skull fracture (CSF leak, rapid transfer to hospital is the key to pre-
tape across forehead. hospital care. As simple as it may sound,
periorbital haematoma) ABCDE saves lives every day.
B: BREATHING Significant extracranial injuries

Is the patient breathing Worrying mechanism (high energy, possible NAI,

normally?
Are there any signs of
shock?
Is there any sign of external
haemorrhage?
Can the cyclist wiggle
fingers and toes?
Are pupils responsive to
light?
What is his score on the
Glasgow Coma Scale (GCS)?
Are there any other injuries?
IF AT ANY STAGE THE PATIENT DETERIORATES, BEGIN THE PRIMARY
SURVEY AGAIN TO FIND AND FIX THE CAUSE!
YES Maintain respiratory rate at 10-24 breaths/minute
NO Begin ventilation with a bag-valve mask and
oxygen. Look for signs of life-threatening breathing
problems and treat immediately.
C: CIRCULATION
Begin fluid resuscitation and continue monitoring
YES
pulse rate and blood pressure.
Monitor pulse rate and blood pressure.
Apply pressure to bleeding wounds.
YES
D: DISABILITY
NO Suspect spinal cord injury.
NO Suspect damage to brainstem or nerves of the eye.
>13: Minor head injury
9-12: Moderately severe head injury
< 8: Severe head injury.
If GCS falls below 8, breathing is impaired and
intubation required.
E: EXPOSURE
Cut away all patients clothing to ensure no other
injuries have been missed. Broken limbs should
be splinted. External bleeding controlled and vital
signs monitored continuously. Cover the patient
with blankets to avoid hypothermia.
possible penetrating injury)
Continuing uncertainty about the diagnosis after
first assessment Jemma Batte
Medical co-morbidity (anticoagulant or alcohol Fourth year medical student
use)
Adverse social factors (e.g. alone at home)
Taken from the Oxford Handbook of Emergency Medicine, 3rd
edition (2006)
NAI = Non-accidental injury
References:
sharp cornering as even slight movement
may cause further damage to internal organs. 1) American College of Surgeons at www.facs.org/trauma/
A paramedic will travel in the back of the atls/history.html
ambulance with him to monitor his condition 2) ABC of Major Trauma, Edited by Driscol et l., 3rd Edition,
on the way to hospital. They will monitor his 2000, BMJ Books
breathing or, if he has been intubated, that
3) British Association of Immediate Care at http://www.
ventilation is adequate and that the pulse, basics.org.uk/what_we_do
blood pressure and oxygen levels in the blood
remain normal. Appropriate analgesia will be 4) ABC of Major Trauma, Edited by Driscoll et al., 3rd
Edition, 2000, BMJ Books
given to alleviate the cyclists pain, however,
must be carefully titrated so as not to mask 5) A Simple Guide to Trauma, R. L. Huckstep, 5th Edition,
important clinical clues. 1995, Churchill Livingstone
6) Clinical Anaesthesia, Carl Gwinnut 3rd Edition, 2008,
Finally, once transfer to hospital is underway, Wiley-Blackwell
the trauma team at the receiving hospital 7) Major Trauma, Chan et al., 2005, BMJ volume 330, p.
must be informed of the cyclists expected 1136-38
time of arrival and the nature of his injuries
so they can prepare the resuscitation room in 8) The Basics of Endotracheal Intubation, Maura Polansky,
1997, The Internet Journal of Academic Physician Assistants,
Accident and Emergency to treat him. They Volume 1
will need to know his age, the mechanism of
9) The Management of Major Trauma, Colin Robertson &
injury and his vital signs at the scene, as well Anthony D. Redmond, 2nd Edition, 1994, Oxford University
as the treatment given so far and his response Press

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 I ssu e #3 O c t 2009
ACCIDENT
Features
& ischaemia.
EMERGENCY
by Noor Jawad
Head injury is a common presentation in the
Accident and Emergency Department, with up
to one million people in the UK attending per
year4. Falls, assault and road traffic accidents
account for the majority of these cases.
Assessment and management of head injury
in emergency departments is based around the
2003 National Institute of Health and Clinical
Excellence (NICE) guidelines. Pre-hospital
care, carried out by the London Ambulance
Service, as well as general bystanders, is aimed
at addressing immediate concerns: ABCDE. It
is the role of the paramedics to decide whether
a patient requires referral to hospital, as outlined
in the previous article5.
Glasgow Coma Scale
> 13: Minor head injury
9-12: Modeartely severe
< 8: Severe head injury
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On arrival of the patient to the hospital,
communication between the paramedics and
hospital staff is vital to ascertain important
aspects of the history that may be impossible
to gain from the patient, in particular any eye-
witness accounts or relevant past medical
history obtained from family members.
The patient should be transferred straight to
the resuscitation room and should continue to
be managed according to the principles set out
in Advanced Trauma Life Support (ATLS).
Airway
The airway should be checked to confirm
patency and the cervical spine should be
immobilised until an injury is excluded. An
anaesthetist or intensivist should be involved
when the GCS falls below 8, to prepare for
intubation and ventilation. An orogastric tube
should be inserted to decompress the stomach
(a nasogastric tube in the presence of a base of
skull fracture puts the patient at risk).
Breathing
Adequate ventilation of the patient should
be ensured, mechanically if necessary in order
to maintain arterial blood gases within their
normal ranges (PaO2>13kPa and PaCO2 4.5-
5.0kPa). Regular arterial blood gas analysis
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is vital. The PaCO2 is one of the most potent
factors affecting cerebral blood flow and thus the
levels should be tightly controlled: hypercapnia
increases cerebral blood flow and can increase
intracranial pressure, whereas hypocapnia Arterial Blood Gases
reduces cerebral blood flow and may lead to
Circulation
PaO2 >13kPa
PaCO2 4.5-5.0kPa
Hypotension has been identified as the most
important factor in secondary brain injury, and
has a huge effect on morbidity and mortality.
intracranial haematoma.
NICE guidelines recommend maintaining
Mean Arterial Blood Pressure above 90mmHg
The Glasgow Coma Scale was devised
or a systolic BP of over 120mmHg. Any
in 1974 by Teasdale and Jennett from the
haemorrhage should be controlled and two
University of Glasgow3. Their score, based
large-bore peripheral cannulae inserted for
on eye, motor and verbal responses, gives
good vascular access.
the patient a score between 3 and 15 that
can subsequently be used to reassess the
The doctors may also consider placing a
status of their central nervous system. It is
central femoral line should inotropes need
the most common method by which the acute
to be administered. Normal saline or colloid
assessment of patients can be made.
should be the fluids of choice, never dextrose
saline, unless a hypoglycaemia needs to be
The greatest risk to the patient from
corrected. An arterial line should be inserted,
complications is within the first 6 hours,
as well as a urinary catheter to monitor fluid
and hence the frequency of neurological
status. Inotropes such as Noradrenaline are
observations should be staggered in this
often required to counteract the hypotensive
manner. NICE guidelines clearly state that a
effects of the sedation used in ventilation.
depressed conscious level should never be
assumed to be due to alcohol intoxication unless
The effectiveness of the resuscitation should
a significant brain injury has been excluded.
be monitored using physiological parameters:
Observations should be carried out half-hourly
pulse, blood pressure, skin colour, capillary
in a patient with a GCS of less than 15. If the
refill time and urine output. Any acid-base
GCS is 15/15 then half-hourly observations are
abnormalities should be corrected.
required for two hours, followed hourly for four
hours, and two hours thereafter.
Disability
Head injury is a dynamic state which needs
Exposure
constant reassessment and monitoring should
The patient should be adequately exposed
there be deterioration in the patients condition.
All emergency departments should have a
for a full examination.
neurological observation chart, which should
Once all clinical parameters have been
monitor at the bare minimum the Glasgow Coma
stabilisted the team must investigate the extent
Score, pupil size and reactivity, blood pressure,
heart rate, respiratory rate, temperature,
of the injury beyond the GCS classification. CT
scanning is the imaging modality of choice in
oxygen saturations and limb movements
head injury, the indications for which are clearly
[example opposite]. Any slight deterioration in
outlined in the NICE guidelines overleaf.
the patients condition may indicate a serious
complication developing, such as fits or an
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Tertiary Referral The neurosurgical team will then liaise with

Are any of the following present? Approximately 25% of patients with a severe intensive care staff to ensure adequate facilities
Features

head injury have an operable intracranial
haematoma, and the Royal College of
Surgeons of England recommend that surgery
- GCS , 13 when first assessed in - Sign of fracture at skull base to decompress such injuries should be carried
emergency department (haemotympanum, panda eyes , out within 4 hours. Aside from the findings on
- GCS < 15 when assessed in emergency cerebrospinal fluid leakage from CT, other features that may indicate the need
depratment 2 hours after the injury ears or nose, Battles sign) for a neurosurgical referral include:
- Suspected open or depressed skull fracture - Focal neurologival deficit
- Post-traumatic Seizure - > 1 episode of vomiting - Persisting coma (GCS8)
- Unexplained confusion for more than
- Amnesia of events > 30mins before impact 4 hours
- Deterioration in GCS after admission
(particularly the motor component)
- Progressive focal neurological signs
YES - Seizure without full recovery
NO
- Definite or suspected penetrating
injury
- CSF leak (rhinorrhoea or otorrhoea)
Any amnesia or loss of consciousness since the injury?
are available to receive the patient, in particular
an ITU bed. If the patient is accepted, the
referring hospital needs to adhere to their
local guidelines on the transfer of seriously
ill patients. For an emergency transfer an
adequately experienced doctor should travel
with the patient. The transfer team should be
able to communicate with their base hospital
and the tertiary centre whilst en route. The
patient should be adequately stabilised and
intensively monitored prior to departure to
reduce the risk of complications en route. If a
patient has a persistent hypotension then the
cause should be identified and dealt with prior to
departure. Once the patient has arrived at the
neurosurgical centre, adequate communication
between the team members is vital to transfer
the care of the patient from one team to the
other.

YES NO Noor Jawad

Important information for Final year medical student
KEY:
Neurosurgical Referral
Are any of the following present? Name and age of patient
imaging should be carried out within 8 hrs of injury, or immediately

Mechanism and time of injury

imaging should be carried out and results analysed within 1 hour

References:
Cardiorespiratory status (heart rate, blood
of request being received by radiology department

- Age > 65 years

pressure, respiratory status)
- Dangerous mechanism of injury 1) Fairley, S. & Hardy, P. (2004) Acute Management
if patient presents 8hrs + after injury

- pedestrian/ cyclist struck by motor vehicle
- occupant ejected from a motor vehicle
- fall from .> 1m or stairs
- Coagulopathy
(history of bleeding, clotting disorder,
current treatment with warfarin
YES NO
Request CT scan
Immediately
NICE Guidelines: Indications for CT imaging
Glasgow Coma Score of Adults with Traumatic Brain Injury, A Pocket Guide, The
National Hospital for Neurology and Neurosurgery, University
Pupillary response College London Hospitals NHS Foundation Trust.
Motor pattern 2) NICE Guidelines (2003) Head Injury: triage, assessment,
investigation and early management of head injury in infants,
Alteration in baseline observations children and adults, HMSO.
Non-cerebral injuries 3) Teasdale, G. & Jennett, B. (1974) Assessment of coma
and impaired consciousness a practical scale, The Lancet, 2:
Results of investigations 81-84.
Relevant past medical history, medication, 4) Wasserberg, J. (2002) Treating Head Injuries, BMJ,
allergies
325(7362): 454-455.
Referring doctor, location and return phone 5) Wyatt, J.P., Illingworth, R.N., Graham, C.A., Clancy,
number M.J., Robertson, C.E. (2006) Oxford Handbook of Emergency
Medicine. Third Edition. Oxford, Oxford University Press.
No Imaging
Required Now

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Pharmacological
Features
Management
of the TBI patient
Traumatic brain injury (TBI) is the
leading cause of death and disability in
children and young people1. However,
the literature suggests that effective
management of the TBI patient can
significantly reduce mortality.
Effective management of the TBI patient
requires a good understanding of the
pathophysiology of head injury. Aside from its
functional differences, the brain has several
features that distinguish it from other organ
systems in the body. One such feature is
the containment of the brain within the skull;
a rigid and inelastic container. Because of
this inelastic nature, only small increases in
volume within the intracranial compartment
can be tolerated before the pressure within the
compartment rises dramatically2.
This concept is defined by the Monro-Kellie
doctrine that describes the pressure-volume
Monro-Kellie Doctrine
that the central nervous system and its
accompanying fluids are enclosed in a
rigid container whose total volume tends
to remain constant. An increase in volume
of one component (e.g., brain, blood,
or cerebrospinal fluid) will elevate
pressure and decrease the volume of one
of the other elements
14 a publication
by Husam Jafar
relationship between intracranial pressure
(ICP), volume of cerebrospinal fluid (CSF),
blood, brain tissue, and cerebral perfusion
pressure (CPP)2.
In the event of a significant head injury,
cerebral oedema may develop resulting in an
increase in the relative volume of the brain3. In
the absence of a compensatory mechanism,
such as a decrease in the volume of one of
the other intracranial components, the fixed
nature of the intracranial volume will cause
the intracranial pressure to rise. Medical
therapy in TBI is thus directed at controlling
intracranial pressure (ICP) and preventing
secondary damage4. The drugs employed
include a range of sedatives, neuromuscular
blockers and diuretic agents. With such a range
of therapeutic agents, particular care must be
taken to avoid any unfavourable interactions
and also not to mask any clinical signs that the
medical team are reliant upon to assess the
patients neurological status.
The first step for the management of a
patient with TBI is the securing of the airway
since ventilation is a vital factor in controlling
raised ICP5. In most emergency cases,
clinicians use rapid sequence intubation
(RSI) to achieve this task. RSI is the virtually
simultaneous administration of a sedative and
a neuromuscular blocking agent to render a
patient rapidly unconscious and flaccid in order
to facilitate emergency endotracheal intubation
with minimal the risk of aspiration.
Suxamethonium is a neuromuscular
blocking agent that has a rapid onset (30-60
seconds), and short duration of action (5-10
minutes)6. Suxamethonium causes prolonged
depolarisation of skeletal muscles to a
membrane potential above which an action
potential can be triggered8. It is thus used to
facilitate endotracheal intubation and provide
neuromuscular relaxation during intubation and
mechanical ventilation7. Muscle paralysis can
be maintained with intermittent intravenous
boluses.
Propofol is a short-acting anaesthetic
with a rapid onset of action that is given
intravenously7. Since both the hepatic and
extrahepatic metabolism of propofol is rapid,
continuous infusion is possible rendering
it an ideal sedative. However, prolonged
infusions can lead to increased triglyceride and
cholesterol levels. Other disadvantages include
cardiorespiratory depression, particularly in the
elderly, septic or hypovolemic patient9.
Once successful intubation has been
achieved, sedation can be continued with
titrations of Propofol and Fentanyl dependent
upon the patients cardiovascular response7.
Fentanyl is an opioid analgesic that works
by mimicking endogenous endorphins that
stimulate opioid receptors in the central and
peripheral nervous systems and is thus a
widely used analgesic10.
Barbiturates are also used as an adjunct
for intubation in patients with head trauma7. By
binding to distinct sites associated with a Cl-
ionopore at the GABAA receptor, Barbiturates
such as Thiopental, increase the duration of
time for which the Cl- ionopore is open. The
post-synaptic inhibitory effect of GABA in the
thalamus is, therefore, prolonged causing
a sedated state in the patient. Thiopental
however, may cause significant cardiovascular
depression. The accumulation of the drug
during infusion also lends itself to prolonged
recovery times12.
Aside from its sedative effect, Barbiturate
therapy also lowers the ICP and exerts cerebral
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protection through alterations in vascular
tone, inhibition of free radicalmediated
lipid peroxidation, and the suppression
of metabolism. By lowering the metabolic
demands, this drug group decreases the CBF
thus providing beneficial effects on the ICP11.
ask yourself...
!
will this
prescription mask
an important
neurological sign?
Barbiturates are the most common class of
drugs used to lower ICP in this way. Thiopental
is still used occasionally in severely raised
ICP to induce a barbiturate coma, initiated
in brain-injured patients whenever elevated
intracranial pressure remains unresponsive to
other interventions11. Barbiturates are avoided
where possible however, due to their effects
on cortical activity that may hinder clinical
evaluation of the patients condition.
A second class of psychoactive drug
used in treatment of the TBI patient are the
Benzodiazepines. By enhancing the effect of
GABA at GABAA receptors, Benzodiazepines
result in an increased depressant effect
on the CNS and are thus of benefit in both
the immediate control of seizure activity or
as an adjunct to neuromuscular blocking
agents to control ICP in patients with head
injury. Midazolam is a very short-acting
benzodiazepine that has seen extensive
use in intensive care units. As with the
Barbiturates however, Benzodiazepines may
cause both cardiovascular depression and
a hypotensive state. Careful monitoring of
the patients response to treatment is thus
essential. Prolonged use of Benzodiazepines
may also alter neurological examination
findings11. Precise dosing and careful titration
are therefore required to ensure that crucial
15
 I ssu e #3 O c t 2009
clinical signs as to the patients condition are
not masked.
Features
Diuretics are potent agents that can be used
to decrease brain volume and, therefore, to
decrease ICP. Mannitol, an osmotic diuretic,
is the most common diuretic used for this
indication. It is a sugar alcohol that draws
water out from the brain into the intravascular
compartment11,13,14. It has a rapid onset of
action and acts for a duration of 2-8 hours and
has been shown to be more effective when
given intermittently rather than a continuous
infusion.
Because mannitol causes significant
diuresis, electrolytes and serum osmolality
must be monitored carefully during its use.
In addition, careful attention must be given
to providing sufficient hydration to maintain
euvolemia14. At high doses mannitol may cause
renal toxicity and so serum levels require
constant monitoring also.
An alternative to osmotic dieresis is
the administration of more potent loop
diuretics such as Furosemide. Loop diuretics
achieve their diuretic effect by inhibiting the
reabsorption of electrolytes primarily in the
ascending limb of the Loop of Henle. Excretion
of sodium, potassium, magnesium, calcium
and chloride ions is increased and water
excretion enhanced. Furthermore, they may
also increase renal blood flow and prompt the
redistribution of blood flow within the renal
cortex13.
Despite these enhanced effects, Mannitol is
preferred over Furosemide as it tends to result
in less severe electrolyte imbalances. Bolus
doses of Furosemide may be administered
however, if a rapid diuretic effect is required,
followed by more long-term administration
of Mannitol. The synergistic use of these
agents can be very effective, although it
may render the patient at risk of severe
electrolyte imbalance. As with all of the
powerful pharmaceutical agents that have
been mentioned thus far- careful monitoring of
16 a publication
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the patients vulnerable physiological state is
crucial to the achievement of an effective care
plan.
In summary, the treatment of elevated ICP
is focussed on optimising the conditions within
Discuss this article and more
the brain in order to prevent secondary injury
and allow the brain to recover. Optimising both
on our online forums
the cerebral blood flow and the metabolic state
of the brain is achieved by maintaining the
intracranial pressure within reference ranges.
Due to the complexity of such treatment the
www.studentima.co.uk/forum
care of a TBI patient should be tailored to their
specific situation.
***
Husam Jafar
Pre-Registration Pharmacist
References:
SIMA: Prospect Issue #4
1) Langlois JA, Rutland-Brown W, Wald MM. The
epidemiology and impact of traumatic brain injury: a brief
overview. J Head Trauma Rehabil2006;21:37578
2) http://emedicine.medscape.com/article/433855-overview
3) Larsen and Goldstein Consultation with the Specialist:
Increased Intracranial Pressure. Pediatrics in Review.1999;
20: 234-239.4 [accessed 27/8/09] http://www.springerlink.com/
FEB 2010
content/x6973441672465m5/
5)http://www.uptodate.com/patients/content/topic.
do?topicKey=~HIgBxeceqpT1Kj
6) http://www.nda.ox.ac.uk/wfsa/html/u01/u01_010.htm
7) Greater Manchester Traumatic Brain Injury Audit Group, submit your article to
Head Injury Management in Adults in Greater Manchester,
January 2006 page 22 prospect@studentima.co.uk
8) http://www.anaesthesiauk.com/article.aspx?articleid=229
9) http://www.medicinescomplete.com/mc/
martindale/2007/7000-a6-27-z.htm
any other queries
10) http://www.patient.co.uk/medicine/Fentanyl.htm secretary@studentima.co.uk
11) http://emedicine.medscape.com/article/433855-
treatment
12) http://www.mongabay.com/health/medications/
Thiopental.html
13) http://www.icm.tn.gov.in/drug%20formulary/ www.studentima.co.uk
DIURETICS%2814%29.htm
14) http://www.umm.edu/altmed/drugs/mannitol-079300.
htm
17
 I ssu e #3 O c t 2009
Features
Food for
Thought...
by Neam Al-Moussawi
Traumatic Brain Injury (TBI) can
potentially cause significant morbidity.
Alongside efficient pre-hospital
care, prompt triage, and careful
pharmacological management of this
vulnerable patient, the nutrition team have
a significant role to play in rehabilitation
once their initial injury has been dealt
with and their condition stabilised.
The principal tasks for the nutrition team in
treating our injured cyclist are;
- Assessment of nutritional status
- Management of nutritional care
- Patient and family education
Nutritional Assessment
Nutritional assessment of a patient with TBI
centres on
1) Nutritional status prior to the accident
2) Current nutritional status (and how it will
impact recovery and functioning).
Factors to consider in evaluating the past
nutritional status of the patient include age,
height, weight, eating habits and intolerance
histories. It is not uncommon for patients
with significant brain injury to experience
compensatory weight loss as a metabolic
response during the acute phase of injury.
Comparison of the patients current nutritional
state with their pre-injury weight may help
inform treatment.
18 a publication
Using this
information, an
estimate of the
patients calorie,
protein and fluid
goals based upon
healing and weight
needs should be
established; with particular attention to the
requirement of special nutrients for wound
healing, anaemia and fluid imbalance, alongside
any other relevant medical problems.
The final step of the nutritional assessment
is to determine a nutritional care plan for the
future. The patients weight dictates a large
part of this plan. If the patient is significantly
underweight, slow weight gain is preferred
(rather than rapid weight gain which leads to
excessive deposits of fat stores).
When faced with the physiological stress
of TBI, the body may respond by making
alterations in metabolic homeostasis resulting in
both increased energy expenditure and protein
metabolism. Several studies have shown that
as these changes arise secondary to the head
injury itself, early feeding may contribute to a
reduction in mortality1.
In addition to the changing metabolic state
of the patient, the practicality of his unconscious
state also contributes to his nutritional care.
The inability to swallow normally means that
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nutritional support must be delivered in one of
two ways; enteral or parenteral feeding. Enteral
feeding involves the delivery of a nutritionally
complete feed direclty into the stomach,
duodenum or jejunum, and is often used in
patients who are unable to maintain an adequate
or safe oral intake. whereas parenteral feeding
bypasses a dysfunctional or inaccessible
digestive tract. Both are equally effective
methods, however the advantages of providing
nutrition through an enteral feed are greater,
associated with a lower risk of hyperglycaeimia,
lower risk of infection and reduced cost when
compared to Total Parenteral Nutrition2.
Enteral feeding however is by no means a
flawless treatment option. Because the cyclist
has a depressed level of consciousness,
elevation of the head of the bed can result
in a marked decrease of reflex episodes and
monitoring should include examination of
abdominal distension and checking for high
gastric residuals.
If the patient has multiple episodes of
gastroesophageal reflux, medications such
as metoclopramide and cisapride may be
prescribed to increase lower oesophageal
pressure and improve gastric emptying.
Alternatively, feeding could be administered
directly into the small bowel rather than the
stomach3.
Past Nutritional
Status:
contributary factors
age
height
weight
eating habits
intolerance histories
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Nutritional Content
Once the method of providing nutrition is
established, the nutritional formula of the feed
needs to be determined.
Optimal protein use has been found to be
heavily dependent on the adequacy of caloric
intake. After a TBI, energy requirements
rise and nitrogen excretion increases4. In a
normal fasting human 3-5g of nitrogen are
broken down per day, however, our patient
is more likely to register a figure of 14-25
g N/day. Nitrogen equilibrium is therefore
seldom achieved spontaneously. This almost
inevitable disequilibrium therefore needs to be
prevented by increasing the nitrogen content
of the nutritional formula from 14% to 20%,
thus achieving an acceptable level of nitrogen
retention5.
Protein needs are estimated at 1.2-1.6/kg
of body weight, with the suggestion that any
additional protein is simply oxidized, adding to
the nitrogen load to be excreted. Calorie intake
on the other hand is estimated to lie 40-70%
above basal needs, 30-40% of which should be
in lipid form in order to minimize hyperglycaemia.
Although studies have shown that a measured
energy expenditure of 30-40 kcal/kg is required
to take place in the patient with TBI, it is not a
universal recommendation as providing such an
amount in order to provide an energy balance
could severely disrupt glucose homeostasis.
Despite an approximate energy expenditure of
30-40kcal/kg, careful readings of randomized
control trials suggest that energy provided
in the 25kcal/kg range is more appropriate6.
Hence our injured cyclist would require 140%
of the normal caloric demand (approximately
3500kcal/day in a 70kg man).
As the patients nutritional formula is acting
as a substitute for a normally balanced diet, it
must consider all of the patients physiological
requirements. For example, Linoleic and
Linolinic acids are essential fatty acids without
which the patient would more susceptible to
cardiac dysfunction and infection. Similarly
Thiamine (Vitamin B1) is a cofactor essential to
19
 I ssu e #3 O c t 2009
carbohydrate metabolism. Although abundant in
a normal balanced diet, the body can only store
Features
a ten day supply. Consequently, if the patient
was to stay in ICU for a long period of time,
Thiamine replacement would be necessary to
prevent an almost inevitable deterioration in
cardiac function, Wernickes encephalopathy
and lactic acidosis. The same applies for a
range of other vitamins and minerals such as
Vitamin A, B12, B2, B6, C, D, E, biotin and
folate, as well as certain trace elements such
as copper, iron, iodine and zinc.
Despite the increased metabolic demands
of a TBI patient, as with ones day to day diet,
overfeeding remains undesirable. In this case,
the prospects of hyperglycaemia, uremia and
increased carbon dioxide production as a result
of overfeeding render the task of predicting
our patients nutritional needs rather complex.
Major trauma induces metabolic alterations
that contribute to an immunosuppressed state,
Additional
Nutritional
Requirements
Essential Fatty Acids :
Linoleic & Linolinic acids
Thiamine
Vitamins:
A, B2, B6, B12, C, D, E,
Biotin, Folate
Trace Elements:
Copper, Iron, Iodine, Zinc
20 a publication
inevitably increasing the risk of infection and
post traumatic organ failure. The appropriate
selection, timing and dose of nutrients required
for metabolic resuscitation must therefore be
individualized with clear aims and opportunity
for review.
No single test can predict the nutritional
requirements of a patient, as the nutritional
status does not remain static in recovery
from a brain injury; periodic assessments and
readjustments are necessary dependent upon
the patients changing weight and metabolic
capability. Based on the extent of injury and
underlying deficiencies, an optimal feeding
formula will be designed to provide the nutrients
required specifically by this patient, necessary
to balance his hypermetabolic state and thus
promote optimal recovery. In so doing, the
nutrition team are providing the physicians
responsible for his care the ideal physiological
and metabolic platform from which to address
and treat his injury, without which the success of
any medical intervention cannot be guaranteed.
Neam Al-Mossawi
Third year Nutrition & Dietetics student
References:
1) Intolerance to enteral feeding in the brain-injured patient.
Norton JA, Ott LG, McClain C, Adams L, Dempsey RJ, Haack
D, Tibbs PA, Young AB. J Neurosurg 68 (1988) p.62
2) Effect of parenteral nutrition on cold-induced vasogenic
edema in cats Waters DC, Hoff JT, Black KL. J Neurosurg 64
(1986) p.460
3) Contemporary Nutrition Support Practice; A Clinical
Guide. Saunders 1998
4) Nutritional support and neurotrauma: a critical review
of early nutrition in forty-five acute head injury patients. Hadley
MN, Grahm TW, Harrington T, Schiller WR, McDermott MK,
Posillico DB. J Neurosurg 19 (1986) p.367
5) Enteral hyperalimentation in head injury Clifton GL,
Robertson CS, Contant CF. J Neurosurg 62 (1985) p.186
6) Nutritional Considerations in the ITU, Scott A; Shikora A;
2002 p.46
a publication
www.studentima.co.uk
TBI in the dentists chair
by Dr Thuha Jabbar
In a patient with head injury, the A mandibular fracture is one of the most
primary concerns are the patients level of significant sequelae of a road traffic accident,
consciousness and responsiveness. Having and may have serious complications for
addressed the patients raised ICP and the patient if not managed effectively. On
attained a stable condition, it is important examination, there were no signs to suggest
to consider other less obvious morbidities fracture of the mandible. However, due to his
that may have resulted from the accident. high speed impact with the car windscreen and
The lacerations sustained to the patients subsequently the road surface the patient had
face indicate that he may have some more sustained a number of superficial lacerations
serious damage within the mouth cavity, to the extra-oral area, which may require
and so he requires some maxillofacial / suturing, and continued wound care in the ICU
dental attention to ascertain the extent of as the healing process may be impaired due
injury and whether or not any surgical / the requirement of an endotracheal tube and
dental treatment is indicated. orogastric feeding tubes.
Extra-oral examination Intra-oral Examination
The first step in assessing the extent of Continuing the examination, one has to
this patients dental needs is to perform a full inspect intra-orally to assess the extent of the
examination. Beginning, extra-orallly, one damage.
needs to assess the possibility of a mandibular
fracture. This would be suggested by: Although less likely to be affected as a result
Pain, swelling and tenderness in the of head injury, it is still important to check the
fracture site gingiva (gums), buccal mucosa, tongue, floor of
Bleeding, bruising, or haematoma, at the mouth, palate and teeth for any pre-existing
fracture site morbidity that may inform current treatment.
Displacement, step deformity
Change in occlusion (how the teeth Our patient has sustained fractures to both
normally meet) the upper central incisors and has lost the upper
Mobility of fragments or teeth left lateral incisor. The upper central incisors are
Difficulty on opening the mouth or in grade 2 mobile (>1mm movement horizontally).
lateral excursion (moving the lower jaw The patient otherwise has good oral hygiene
from side to side while the upper and has a very minimally restored dentition
and lower teeth are in contact)
Paraesthesia or anaesthesia on the Initial Investigations
distribution of nerves involved in the Once the initial findings have been noted
fracture. from the complete oral examination, any
discrepancies should be investigated further to
21
 I ssu e #3 O c t 2009
assess the full extent of the damage sustained.
It is important that several radiographic images
Features
are carried out at the first visit to ensure the
patient
a) has no facial fractures,
b) not inhaled the missing tooth and
c) there are not tooth fragments in any of material.
the lacerations
The following images can be taken:
10o and 30o occipitomental views or a a better indication of the treatment required to
posterior-anterior jaw and a dental restore an acceptable level of dental health.
panoramic tomogram.
A posterior-anterior radiograph of the The mobility of the incisors about a point
chest
Soft tissue radiograph of the extra-oral (displacement of the tooth) rather than root
area.
Investigation of the teeth
Mobility
The teeth need to be tested for mobility in
the buccopalatal (horizontal) direction using a
hard instrument such as a mirror handle. The
degree of movement and the position of the
fulcrum of the movement should be noted. All
teeth should be checked in this case.
The upper incisors were all mobile by 1-2mm,
apparently about a fulcrum close to their apices
Occlusion
This is to determine whether all teeth make
contact in a stable intercuspal position (position
of maximum contact between occluding
teeth) and that no pain is elicited on closing
or excursive movements of the mandible.
Poor occlusion, where the teeth do not meet
properly, would suggest a tempero-mandibular
joint (TMJ) dislocation.
Degree of fracture
If the fracture reaches as far down as the
level of the pulp where the nerve and blood
supply to tooth is, it will require endodontic
treatment (root canal treatment) to restore
the tooth at the very least. Failure to treat an
exposed pulp me lead to tooth extraction.
The pulps of both central incisors were
involved in the fracture and the pulp exposure
was relatively large.
22 a publication
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Vitality calcium hydroxide dressing placed in the root A Chlorhexidine mouthwash is prescribed
The degree of fracture will thus influence the canal to prevent root resorption and infection for use until the tissues have healed sufficiently
vitality of the tooth. None of the incisors gave a developing in the periapical area, that may to aid oral hygiene and prevent plaque
positive result to cold (ethyl chloride) or electric in turn compromise the integrity of the tooth, accumulation around the fractured teeth which
pulp tester suggesting tha the nerve supply to and may lead to its loss. The teeth can then may be tender to brush.
the teeth is damaged. be restored temporarily with composite filling
Treatment Plan
Interpreting the findings Once the splint is removed, the upper central
Combining the examination findings and Treatment options incisors will require endodontic treatment
results of the various investigations, will give (permanent root filling). Once this is completed,
PARTIAL ACRYLIC DENTURE the teeth will require permanent restoration and
Advantages include ease of fabrication, this is best achieved in the form of a ceramic or
acrylic flanges mask bone defect following metal ceramic crown.
alveolar remodelling and relatively low costs.
close to their apex suggests luxation injury Disadvantages include the fact that many The upper lateral incisor will require
replacement, the treatment options for which
patients, especially those who are young,
fracture. This is consistent with the crown include:
dislike removable prosthesis and would prefer
fracture as , unless the injury is really severe, 1. Partial acrylic denture (removable)
a fixed option.
crown fracture is usually not accompanied 2. Resin retained adhesive bridge bonded
by root fracture as the energy of the blow is RESIN RETAINED ADHESIVE to the canine (fixed)
absorbed by the crown. 3. Conventional cantilever bridge
This is a fixed replacement which will
The fractured teeth have exposed pulps cemented off the canine (fixed)
provide gingival coverage and will require no
which will require extirpation (removal of the 4. Implant (fixed)
further tooth preparation to the canine. The
pulpal tissues) regardless of the vitality.
disadvantage of such a bridge is the fact that
Ultimately, the final decision lies with the
To complement our initial radiographic it is difficult to mask the space formed beneath patient. It is the duty of the practitioner to fully
investigations, and better appraise the extent the pontic (replacement tooth) following bone inform the patient of the pros and cons of each
of the injury, further imaging is required: remodelling. The bridge is also very difficult to treatment option to allow the patient to make an
Upper occlusal radiograph shows the remove. informed decision. The extent of the patients
left lateral incisor is missing. CONVENTIONAL CANTILEVER oral injuries is favourable in light of the high
No root fracture is evident. BRIDGE CEMENTED OFF THE impact collision that caused them, and should
Long cone periapical image of the CANINE not pose considerable trouble during treatment.
incisors shows widening of the This tends to be the last option that is
periodontal ligament (fibres considered due to the fact that it requires a lot Although the nature of these injuries is not
that attach tooth to bone) due to of unnecessary tooth tissue removal from the immediately life-threatening, they are most
the luxation injury. canine which in this case is a sound tooth. likely to be the first thing the patient will see
when he looks in the mirror. Similarly they are
Emergency Treatment IMPLANT likely to be noticed a lot more by family and
Now that the extent of damage has been Given that there is sufficient bone and space friends than any internal injuries. Sensitive
understood, the most suitable treatment can between the remaining teeth, this would be the management and follow up of these injuries is
be planned accordingly. Initially.,the incisors treatment of choice. An implant is the closest therefore essential to ensuring an aesthetically
need to be splinted to promote healing of the treatment option to the patients natural teeth as well as functionally pleasing outcome.
Dr Zeena Mohammed
periodontal ligament fibres. This is done using and with careful pre-operative assessment and
stainless steel wire acid etched to the upper post-operative care, can last a lifetime, unlike
incisors, lateral incisor and canines and kept in the other options which will inevitably fail and
place for 10-14 days. require replacement. The main disadvantage
to this treatment option is financial as most Dr Thuha Jabbar
The occlusion should be checked carefully VT1 Dentist
implants cost 3-4 times more than the other
to avoid causing further trauma to the teeth.
options
The pulps should be extirpated first and a
a publication 23

The Beginning
Features
of The End
by
Yasmin Al-Asady
Any form of illness or injury can be
a difficult experience. As you have read
by now, the long road back to good
health begins before the patient even
arrives at the hospital. In the same vein,
a patients discharge from hospital does
not necessarily represent a new lease of
good health. On the contrary, if anything,
a patients discharge from hospital care
often represents the beginning of the
long, arduous road to a full recovery. In
recognition of this, both the UK Audit
Commission Department of Health
highlight the importance of the provision
of follow up services and a good level
aftercare for patients recovering from
critical illness4. Almost a decade later,
where do we stand in relation to these
recommendations?
In the UK, the number of follow-up services
in all their possible forms is unknown. Recent
surveys estimate that approximately 30% of
Intensive Care Units (ICU) in the UK currently
offer a specific follow-up clinic, with financial
constraints being cited as the primary reason
for the lack of this important service4. So what
exactly are the follow-up needs of this patient
group, and do they justify this seemingly
expensive provision?
More than 110 000 people are admitted to
critical care units in England and Wales each
year, of whom 75% survive to be discharged
24 a publication
EXIT
home2. Having survived a life-threatening
critical illness, this group of patients will
often experience the range of physical and
psychological sequelae of critical illness.
Physiologically, the body is ready to adapt
to periods of inactivity that may optimise its
function in the short term, but in turn, will
require extensive rehabilitation in order to
return to previously held state of good health.
Muscles will atrophy by approximately 1-1.5%
per day, alongside a loss of 6mg of calcium
per day, leading to almost 2% bone loss
per month. Furthermore, decreases in VO2
max lead to a compensatory rise in heart
rate and a decreased stroke volume that in
turn predisposes to a compensatory ejection
fraction. Patients are therefore not only coping
with the initial injury that led to their admission,
but the multitude of systemic consequences
that ensue3.
Moreover, as if the physical strain isnt
enough to handle, the combination of the
immediate threat to life and the invasive
monitoring and interventional processes that
these patients endure, washed down with
the cocktail of narcotic and sedative drugs,
all within the bustling artificial environment
of the ICU can often precede significant
psychological difficulties. Up to 80% of
ICU patients report troubling incidences of
delirium, delusional memories, nightmares
and amnesia that may in turn predispose to
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a formal diagnosis of Post-Traumatic Stress
Disorder (PTSD)1. An appreciation of the wider
psychosocial implications of the patients
physical illness is therefore essential to aid his
recovery and long term health.
Moving one step further out into the
patients circumstances, it is also important to
consider the effect of his treatment on family
and friends. The difficulties of watching a loved
one in a critical condition with the constant
stress associated with their fluctuating state
can have lasting effects on family and friends,
leading to high levels of anxiety, depression
and PTSD-related symptoms1 in this
population.
It seems clear therefore that the end of our
patients treatment is nothing but his ticket
for the journey that lies ahead of him. How
can an ICU follow up clinic make it a more
comfortable ride?
Different clinics will have different criteria
for their patients, but most will offer an
invitation to attend the follow-up clinic to all
patients who stayed on the ICU for a specific
number (often 3-4) of days. Not every patient
will accept the invitation; some prefer not to
return to the unit as not to trigger any painful
memories, whereas others do like to see the
bed in which they stayed and meet the team
members responsible for their care.
Until earlier this year, despite the
recommendations for the provision of follow-
up care, there were no clear rules stated
regarding how exactly this care should be
provided. With the publication of the new NICE
guidelines for critical illness rehabilitation,
various forms of patient- centred consultations
are adopted with the aim of the identification
of rehabilitation goals and monitoring the
patients progress in reaching these goals.
The multi-disciplinary teams involved in
running the clinics, provides a fountain of
knowledge and expertise ready to allay any
worries the patient may have. Any expertise
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that is not represented at the clinic may
be provided by external team-members or
through referral to support groups and other
resources that best fit the needs expressed.
A key principle of these clinics is to ensure
continuity of care to the patient, where they
are seeing familiar faces that they have grown
to trust at a particularly vulnerable time in their
lives. This level of trust also lends itself to
very open consultations about the potentially
very personal troubles that may arise. Some
patients find it comforting that they are able to
go through their experience with somebody
who is aware of their previous treatment, some
even opting to run through their notes from
their ICU stay4.
When asked about their opinions on
the value of ICU follow up, patients have
also highlighted their appreciation for the
opportunity to ask questions about what
to expect and in turn understand that their
feelings are a normal part of the healing
process. As with any rehabilitative process,
the effort required to stay motivated through
the lengthy journey, may itself lead to further
feelings of anxiety and depression that in
turn, may hinder recovery and contribute to
prolonged physical morbidity1. Patient reports
have highlighted that knowing what troubles
to expect significantly improved their ability
to cope with such situations4. Furthermore
by inviting family and friends to attend follow-
up session and making them aware of the
obstacles they may anticipate, the clinics
also emphasise the importance of a long-
term support network, in preparation for the
patients final discharge.
In addition to all of the aforementioned
issues, the nature of our cyclists injury may
cause further cognitive impairment due to
the increase in intracranial pressure and
neurosurgical interventions. This may have
profound effects on both home and work
life and so his particular neuropsychological
needs need to be carefully addressed. Some
patients have difficulty in returning to their day
25
 I ssu e #3 O c t 2009 www.studentima.co.uk

PHYSICAL DIMENSIONS
Features

Weakness; inability or partial ability to sit, rise to standing, or

Physical Problems
Sensory Problems
Communication problems
Social Care
NON-PHYSICAL DIMENSIONS
walk; fatigue; pain; breathlessness; swallowing difficulties;
incontinence; inability or partial ability to look after oneself
Changes in vision or hearing; pain; altered sensation
Difficulties in speakinf or using language to communicate; difficulties in
writing
Mobility aids; transport, housin, benefits. employment leisure

New or recurrent somatic symptoms, including palpitations,

Anxiety, depression, irritability, and sweating; symptoms of derealisation and
and symptoms related depersonalisation; avoidance behaviour; depressive symptoms,
to post-traumatic stress including tearfulness and withdrawal; nightmares; delusions;
hallucinations; and flashbacks
winning entry :
Sami the Methanol Guy
Loss of memory; attention deficits; sequencing problems;
Behavioural and
deficits in organisational skills; confusion; apathy; disinhibition;
cognitive problems
compromised insight
Low self esteem; poor or low self image and/or body image
Other psychological or
psychosocial problems
concerns; relationship difficulties, including those with the family by Dr Nabil Al-Khalisi
and/or carer
Indicators of physical and non-physical morbidity
Thankyou to all of you who entered the competition.
to day routine for fear of a recurrent injury. Our It was a real privilege to read all of your thoughts and
patient may therefore be wary about crossing
Yasmin Al-Asady experiences.
roads, driving a car, and whether or not he
Fourth year medical student
should cycle the roads again. His personal
needs will need to be gauged by the team Keep an eye out for the next essay competition coming
that has so far taken such great care of him
whilst in hospital, to ensure that it continues
References:
very soon
throughout his aftercare.
1) Sukantrat et al, Physical and psychological sequelae
of critical illness, British Journal of Health Psychology 2007, 12,
As the patient is handed his discharge 65-74
papers, with his wounds healing, painkillers
2) Tan et al, Rehabilitation after critical illness: summary
www.studentima.co.uk ~ prospect@studentima.co.uk
in hand and follow up appointments booked, of NICE guidance, BMJ 2009; 338:b822
he walks out of the hospital as a testament to
the fantastic efforts of the team of dedicated 3) http://www.acprc.org.uk/dmdocuments/Early%20
healthcare professionals responsible for his
Rehab%20-%20ACPRC.ppt
kindly sponsored by the Medical Protection Society
recovery. A team of individuals that are able 4) Prinjha et al, What patients think about ICU follow-up
to put aside any differences they may have, services: a qualitative study, Critical Care 2009, 13:R46
and pull together their abundant skills and
expertise, to provide an optimal level of care
and attention that will hopefully allow him to
enjoy a good quality of life for many more
years to come.

26 a publication a publication 27
 I ssu e #3 O c t 2009
Sami the
Essay Competition Winner
Methanol Guy
by
Dr Nabil Al-Khalisi
Treating patients is a multi step process;
it starts with community awareness and
ends with health care. When the level of
education in the community is below zero
you can do nothing to help others, no
matter how skilled you are. This article
tells us a story of a horrible night shift in
an Iraqi ER. I had a problem that was ten
times more technical than clinical and I
could not face alone. I was psychologically
traumatized; threatened to be killed; I had
flashbacks and deep moral conflicts; I ran
away. A horrible tragedy indeed.
It is now midnight; the weather is cold
and foggy. I sat behind the glass door of
the peadiatric emergency department main
entrance. I was so tired and really confused; I
had spent the whole day working with one of
my seniors. We both tried doing things quickly
and discharging as many stable patients as
possible. Unfortunately, he left me alone to
face the night shift so that he can get some
rest and I would gain some misery.
I looked far away through the glass door
trying to predict whether or not there was
someone approaching. I hoped that no one
would come; I really needed a break because
after sixteen hours of deathly labour, my
headache was intolerable. The thought of the
eight hours left alone on my shift was enough
to make me sick, but I tried to be optimistic.
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A loaded night shift may bring up to twenty
patients; I was aiming for four or five at a
maximum. The good news is that at that night
only one patient came asking for help. The bad
news is that after I finished my duty I wished
Id had thirty patients screaming and shouting
instead of this miserable case.
Sami had brown hair, blue shiny eyes and a
small mouth hanging wide open. He was about
five years old. He was so drowsy that he was
unable to keep walking for a distance without
stumbling. He arched his back a little and
hung over his grandfathers big hand. They
were both walking in a slow stride that made
me follow their every move thoroughly as they
advanced towards the main entrance. Sami
looked curious about what was really going on;
I guess he hadnt been into a hospital before.
He kept on asking his grandfather time after
time but he never seemed satisfied with his
grandfathers brief answers.
As they opened the door I could not face
Sami without a smile on my face as if his
charm cast a spell on me from the very first
glance. He was an adorable little fellow who
made me feel that every little effort and every
drop of sweat for the sake of every child I
cured today is worthwhile; I totally forgot about
my excruciating head ache and started talking
to Sami right away. His grandfather was very
anxious and he always tried to interrupt my
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conversation with little Sami ; he just wanted
to tell me the truth in a nutshell as if he really
knew that we were all running out of time.
Samis hands were cold and he was
clearly unbalanced; he smelled like alcohol
or something; his clothes were stained with
vomit. I asked him what was wrong but
he replied with a faint smile and a vague
sentence nothing, I feel sleepy; where is
mum? Just then I turned to the old man next
to me in search of an answer. The grandfather
was shaking and stuttering obviously; he
said Doctor, he almost drunk the whole
bottle, all of it, thinner, we were painting, the
whole bottle! I suddenly realized that I am
dealing with a time bomb here! Paint thinner;
methanol.
I fetched my stethoscope and listened
to the childs chest which was mostly clear
with a few scattered wheezes; I asked the
grandfather whether he had a fever or had
vomited. I ordered Ipecac solution and IV
fluids right away. I tried to talk with Sami in
order to assess his level of consciousness;
he seemed to be quite oriented but a little bit
sleepy. Telling Sami that everything will be ok
felt ridiculous, but I had no other choice; I had
to lie; at least I could alleviate his fears.
Thinking about treating methanol poisoning
is quite simple. You bring some friendly
ethanol molecules that shift hostile methanol
molecules away from liver cells and we are all
happy and safe; no retinal damage; no liver
failure; no nothing. The problem was that I had
a list composed of twenty names of commonly
used drugs; this list represents the contents
of our pharmacy; the paediatric emergency
department pharmacy at the medical city
complex; the grandest health institution in Iraq!
Unfortunately ethanol was not listed. I had to
figure a way out to save this child. How could
I get some ethanol in Baghdad at midnight?
No stores are open; no pharmacies; no one
but me and the poor kid. I remained silent for a
while thinking deeply trying to solve a problem
www.studentima.co.uk
that was ten times more technical than
medical. Id never come across anything like
this during my entire year as a junior doctor.
I bent down and looked directly into Samis
eyes; I touched his cheek with my hand; I
said to myself that this kid must make it; it is a
shame if I could do nothing for him; if he was
somewhere else he would have been much
better by now; I must do something. I was
bothered by the strong aromatic smell with
every one of his little breaths as if he was an
alcoholic; just then I got it! Lets have a party;
lets drink some Arak (A traditional colourless
Iraqi spirit that contains up to 80% ethanol).
That is really good, affordable and at hand. I
had an idea; simple but effective; it was my
only hope, so it had to work. My initial plan
was to make the grandfather get us a bottle
or two of Arak from a nearby shop as alcohol
stores in contrast to pharmacies tend to stay
open late at night.
Here comes the hard part.
I turned to the grandfather; took him
away from Sami; I tried to be assertive and
informative in the same time; I said Sir,
Sami is dying ,we have got only one shot, he
has methanol poisoning. It is very serious,
we need to act fast. Methanol has only one
antidote which is ethanol and unfortunately
we do not have medical ethanol in here;
do not panic please; we can make it; Arak
contains ethanol as its main component ;we
can use it to cure Sami; bring me a bottle of
Arak and I promise to do my best but please
hurry. After this short speech of mine things
changed dramatically; the grandfathers face
turned from pale yellow to red; he became
obviously angry and aggressive; he attacked
me instantly using both his hands trying to
smother me. He was taller and heavier than
me so within seconds he was in control of my
small neck. He started shouting You bastard;
you have no mercy; you want me to bribe
you? Are you trying to blackmail me? Are you
bargaining Samis life for alcohol? If he dies
you die too, understand?
29
 I ssu e #3 O c t 2009
Soon after that the Facility Protection
Service (FPS) intervened. Suddenly I became
surrounded by guards; they pulled the mad
man away and tried to calm him down. I was
gasping for air, I felt like my throat had been
crushed; I fell down holding my hands around
my neck and took a few deep noisy breaths.
Just then I saw noticed that Sami was looking
at me in a strange look; just like if he is saying
What is going on? Grandpa loved you a
moment ago? What did you do to make him
so angry? In this moment I felt that time had
stood still and it was just me and little Sami
looking at each other. I realized that Samis life
was hanging in the balance; I had to convince
his grandfather that I was telling the truth.
Time is running out and I had to move fast.
In the other corner of the ER Samis
grandfather was forced to sit down to the floor;
they tried to calm him down but he kept on
shouting and threatening me. He felt so angry
that his both hands were shivering. Convincing
such a man seemed impossible but I had to
try. I slowly advanced and stopped about a
metre away from him while the guards were
still holding him down to the floor. I asked
him to listen carefully. He looked at me with
disgrace and disgust and told me that God
will punish me for my horrible acts. I talked as
keen as I could and tried to be so convincing
I said I am not asking for a bribe; this is my
job and I am doing it in the best way that I
can; Arak contains ethanol; we really need it;
bring it and you will see that I will not have a
single drop. Trust me please; Samis life is on
the line here. He replied in an indignant way
Drinking alcohol is a sin; God told us that
no benefit can be sought from alcohol; God
knows what He is doing. It became obvious
that I failed in convincing him about my idea. I
went to the lobby and called the chief resident
immediately; fortunately he was awake and
willing to come to the ER right away. Five
minutes later the chief was examining the
child and soon after that he talked to the
grandfather, repeating everything I had said.
At this very moment the grandfather became
insane; calling me names and shouting very
loudly corruption, you both are corrupted
30 a publication
physicians, you do not deserve to live, God
help me , if anything happens to Sami I will kill
you both , I will tell the Minister of Health. The
chief resident felt disappointed and drowsy;
he came nearby and whispered a few words
in my ear; he told me to discharge the kid and
stay safe; he did not really care about the
outcome. He explained that wed done what
we had to do and that the grandfather would
have to live with the consequences of his
actions, and in an instant, there I was again;
alone to face this horrible dilemma.
While the man was crying for help and
cursing me in the same time, I was standing
a few metres away trying to think of an
alternative. I thought about going to buy
the bottle myself but then I realized that
this was impossible; there were too many
critical patients in the ER that I could not
leave. I thought about waking one of my
colleagues to buy the bottle, but then would
the grandfather let us use alcohol to cure
Sami? Why would anyone risk their life at this
hour to help someone who was refusing help
in the first place? Finally, I was overcome with
hopelessness; I was out of choices. There
was only one option left. The childs condition
would inevitably deteriorate, would this
convince his grandfather? This was my only
hope.
Time passed slowly. I watched Sami fading
minute by minute without being able to do
anything. First he started vomiting; then he
became drowsier and drowsier. A few hours
later he became completely unconscious.
His grandfather didnt change his mind; he
continued to blame me for what was going
on and promised to get revenge if anything
happened to his grandson.
At the beginning I had felt sorry for not
being able to do something but as time
passed by I realised that it was not my fault.
I felt so sad for watching a charming childs
life like Samis be taken in vain. Despite
the deteriorating condition of the child, the
grandfather decided to stand still, waiting to
report what happened to the hospital officials
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as soon as he could. I was so tired and
confused. I allowed my eyes to close. The
old man had grown tired of shouting too, and
stayed quiet interspersed with a brief weep
every now and then. At 4am the three of us
fell asleep..
Suddenly at 5:30am a scream broke the
silence. The patients, the guards and I were
all awakened by the scream but Sami seemed
indifferent. The grandfather had woken us all
into a panic. He was screaming Help me, he
is not breathing, his hands are turning blue,
God please save him, he is still so young to
die, oh God, help. I rushed instantly to Sami
with my stethoscope; checked his vitals...he
was dead.
I tried to resuscitate him but to no avail.
A few minutes later when Id lost all hope of
bringing him back, I stopped. I looked into his
face and said deep inside me Forgive me
dear Sami , I did my best, I hate this world for
not giving you another chance that you really
deserve
He was cold and pale. His face was still
as charming as before but less viable. He
seemed to be indifferent yet satisfied. I doubt
that he even knew what had happened to him.
He was just lifeless. The grandfather collapsed
soon after that.
I spent the next two hours wallowing in my
misery. I remembered every little detail about
what had happened, and I just wanted my shift
to end. I wanted some rest and good sleep.
Five minutes before my shift ends Mr. no
for alcohol woke up; he passed into denial.
He started weeping and then went straight
to my desk; looked me in the eye and said I
will kill you, Sami must be avenged. You are
corrupt, and I will never feel peace until you
are dead I was scared, but more so, I felt so
sorry for everyone including me. I took my
things and left in a hurry.
On my way back I kept having flashbacks;
I thought deeply about the hidden meaning
www.studentima.co.uk
behind this event. I felt that medical training
alone was not enough to cure people here. It
is not always about training and equipment.
Sometimes ignorance, illiteracy and luck are
all that matter. Putting the pieces of this story
all together tells us one thing, healing people
is a multi step process. It starts with education
and ends with health care.
What happened was that I could not
face false society values by myself; this
requires a mass effort and the will to
conquer longstanding misconceptions that
have become engrained in everyday life; of
everybodys lives without any questioning.
Being a doctor here is a double edged
sword. You can help many sick people, more
than you could ever imagine. On the other
hand; providing health care alone is not
enough; herd health status is a complex issue;
everyone must feel responsible for his as well
as other peoples well being. We need to adopt
a new way of thinking. Humanity is precious;
we should cherish our lives; know how to live
in prosperity and abandon everything else
because it simply it does not matter.
As the night drew to an end dozens of
questions popped up into my exhausted mind.
Can I keep doing this in here? Should I try
harder or just give it up? Whose fault is it?
Why? Should I stay in here or get the hell out?
Am I doing the right thing?
I arrived home. I took off my shoes and lay
on my bed. I closed my eyes and escaped. I
slept like a dead man. I ran away. I could not
face the truth so I ran away, far away in my
dreams.
Dr Nabil Al-Khalisi
Junior House Officer, Medical City Complex
Baghdad, Iraq
31
 I ssu e #3 O c t 2009
What?Why?
Who?workshop:
Workshop
When?
online resources
How?
Where?
Following Februarys inaugral workshop on how to write an article, Dr Matthew Burman
shares his experience of the vast sea that is evidence based medicine, highlighting a few of
his favourite online hotspots.
If there is any particular area that you would like featured as a workshop get in touch
with us at prospect@studentima.co.uk and well try to find the right person for the job...
Today a wealth of resources is available
on the Internet to assist medical students
and doctors alike. It can be quite daunting
knowing which sources of information
to trust and where to look for particular
information. The aim of this review is
to detail a few selected resources that I
have had personal experience of using
with some background information on
each one. All the resources discussed
can be accessed worldwide at the time
of writing. The majority are free, however
I have included a one paid-for resource,
which, as I will explain in more detail
later, provides information not found
elsewhere.
Evidence-based Medicine
General and Free
Cochrane Library
This is one of the oldest electronic
resources in existence, founded in 1988.
32 a publication
trained specialists.
Initially compiled as an electronic database
analysing published data in the field of peri-
natal medicine, it soon expanded to cover
the huge range of medical subjects it does
today. It is named after Archie Cochrane,
a Scottish epidemiologist, who in the late
1970s called for the regular publication of
analysis on all randomised controlled trials. It
is an independent not-for-profit organisation
with specialist working groups based around
the world.
It produces in-depth reviews of all known
randomised controlled trials on a particular
medical intervention. Particular emphasis is
placed on avoiding bias by seeking all trials
regardless of the language of the authors or
whether trials have been published. Trials
are then assessed for good mathematical
design and only valid trials are included.
The combined trial data is then analysed to
create pooled results. The conclusions are
available in many formats including a plain-
language summary to allow access to a wider
audience. The Cochrane Library is widely
regarded as the most thorough evidence
resource on treatment available today.
eMedicine
This free American database, founded
in 1996, provides peer-reviewed evidence
based articles on diseases in medicine,
surgery and paediatrics written by more than
10,000 physicians and surgeons worldwide.
Each review offers detailed information on
every aspect of a particular disease that
is suitable for medical students up to fully
practitioners and specialist physicians and
www.emedicine.com
Paid-for Resouces
UpToDate (www.uptodate.com)
Although expensive, with yearly
subscription rates for trainees costing $195,
this website provides in my opinion the
most comprehensive information on clinical
medicine, obstetrics, gynaecology and
paediatrics available on-line. The website
offers a data-base of detailed peer-reviewed
articles updated on a yearly based. Each
article provides summaries of the current
evidence on all aspects of disease, from
epidemiology to management. The abstracts
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www.studentima.co.uk
to all references cited can be accessed
directly from links within the article. Any
statistics given are usually qualified with
information on the study from which they
were taken. Where investigations are used
in the diagnosis links are given to figures
explaining how to interpret the results. The
website is aimed at practising doctors and
provides detailed specialist information
written for a North American audience.
Revision aides
General Practice Notebook
(www.gpnotebook.co.uk)
This British resource is written by 8 general
is aimed at general practitioners working in
the UK who with as little as 10 minutes per-
consultation require concise information. It is
not formally peer-reviewed and articles are
not all fully referenced. However, it offers
clear summaries on a huge range of topics
and is ideally suited to revision. For detailed
specialist information it is limited.
PassMed (www.passmed.co.uk)
Concise and clear covering a wide range
of material for medical students preparing for
their finals. Although aimed at exam revision
it contains very clear basic information on a
wide variety of medical topics.
For Variety when Learning
Podmedics (www.podmedics.co.uk)
Run by a small number of junior doctors
and medical students at Imperial College,
London, this website offers short podcasts on
various clinical topics that are often available
as videos with accompanying slides. The
audio-only versions can also be downloaded
33
 I ssu e #3 O c t 2009
as MP3 files. They are designed for medical
students as an accompaniment to standard
learning tools and provide well-structured
summaries on a range of topics in clinical
medicine.
My Medical Podcasts
(www.mymedicalpodcasts.co.uk)
For more advanced information aimed
at those sitting membership exams in the
UK and designed to enable people to learn
whilst on the move, this website offers
a small number, currently less than 15, of
detailed consultant-reviewed podcasts on
clinical medicine. The podcasts are given
by Consultants and Specialist Registrars.
Similar to the previous website it offers some
of the podcasts as videos. Despite the limited
number of podcasts available the information
provided is extremely well presented and
evidence based.
Other Specialty Information
For Surgery
WebSurg (www.websurg.com)
The website was created by Professor
Jacques Marescaux and his team at
the European Institute of TeleSurgery
(EITS), France, as a free electronic
resource for surgeons. Focusing on
laprascopic techniques, a wide range of
learning resources is available: to assist
understanding of surgical techniques there
are tutorials starting from basic anatomy,
there are short videos of real cases which
talk the viewer through particular procedures
and other learning tools including recorded
lectures. For those with limited time or
access to particular surgical specialties this
resource provides a valuable opportunity to
watch the latest surgical techniques.
34 a publication
www.studentima.co.uk
Surgical Tutor accompanying video and quizzes to test Orthopaedics
(www.surgical-tutor.org.uk) and improve the understanding of common
radiology. The material is suited to both Wheeless Textbook of Orthopaedics
This website is entirely the work of one undergraduate and postgraduate trainees. (www.wheelessonline.com)
surgeon, Mr Richard Parker, based in
Coventry in the UK. It provides a combination University of Virginia This extensive textbook is available in
of short notes of common surgical its entirety for free online
pathology with relevant findings on common The website of the university provides free .
investigations. It provides useful information tutorials aimed at improving understanding
for those revising for undergraduate medical of common radiological investigatons. Whilst this summary is in no way
examinations. exhaustive, I hope it offers a brief introduction
to some of the on-line resources available
Dermatology today. As with textbooks different people will
find different resources work better for them.
Dermnet (www.dermnet.co.nz) If nothing else, perhaps access to paper free
information will reduce the backache caused
This vast resource, based in New Zealand, by heaving large textbooks to and from the
provides a seemingly limitless supply of library.
information and clinical images on all things
dermatology.
Dr Matthew Burman
FY2 Doctor
Colchester, UK
www.learningradiology.com
Prospect wants YOU!
thats right,
www.websurg.com
we are looking for
new members to join
Radiology
the Prospect team,
Learning Radiology so if you fancy your
(www.learningradiology.com)
hand at editing
Another one-man website, compiled by or a bit of design,
William Herring based at the Albert Einstein get in touch at
Medical Center in Philadelphia, USA, offers
a variety of learning tools including lectures,
podcasts available through iTunes with prospect@studentima.co.uk
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 I s s u e #3 O c t 2009

Iraq then
Iraq now.

a publication