17- Trouma & ER Refrence 2 + ِATLS Flashcards
How is medical professionalism defined by the Royal College of Physicians?
It is defined as “a set of values, behaviors, and relationships that underpins the trust the public has in doctors”
What is situational awareness?
It is the ability to perceive and respond to changes in one’s environment, involving detection, diagnosis, and prediction
Can you provide an example of situational awareness in a surgical setting?
A patient undergoing a carotid endarterectomy shows signs of neurological deterioration upon clamping, which must be recognized and communicated to the surgeon for appropriate action
What is decision-making in medicine?
It is the process of choosing a course of action from available options, balancing risks using new information and past experiences
Is decision-making a dynamic process?
Yes, continual re-evaluation is necessary to assess the outcomes of previous decisions
Does good situational awareness guarantee good decision-making?
No, although it is linked, good situational awareness does not guarantee good decision-making
What are the four principles of ethical decision-making in medicine?
Autonomy, beneficence, non-maleficence, and justice
What does autonomy mean in the context of medical ethics?
It refers to an individual’s right to self-determination, and doctors must respect this by providing information for informed decision-making
What does beneficence mean in the context of medical ethics?
It describes actions carried out for the benefit of others, serving the best interests of patients at all times
What does non-maleficence mean in the context of medical ethics?
It means “first do no harm,” patients should not be exposed to risks of harm without clear benefit
What does justice mean in the context of medical ethics?
It refers to fairness and equality of treatment and access, including the allocation of scarce resources
What is the concept of “double effect”?
It describes how an intervention can have both intended and unintended consequences, where an action with two opposite outcomes is morally justifiable if the intention is to achieve the good effect
Can you provide an example of a clash of ethical principles in medicine?
A patient who is bleeding but refuses a blood transfusion due to religious beliefs, creating a conflict between autonomy and beneficence
Should a patient’s autonomy be respected even if it conflicts with beneficence?
Yes, if the patient is mentally competent, their wishes should be respected to maintain autonomy and avoid deterring similar patients from seeking medical attention in the future
What does task management entail?
It involves planning and prioritization to carry out work efficiently and effectively using available resources
Is the ability to deal with stress and fatigue considered a non-technical skill?
No, it is not considered a discrete non-technical skill, but it influences each of the four domains
What percentage of medical litigation is related to poor communication?
70%
What are some reasons for initiating litigation in medical cases?
To correct deficient standards of care, find out what happened and why, enforce accountability, and gain compensation for costs of care
What are some basic communication skills that healthcare professionals should be aware of?
Appropriate use of open, focused, and closed questions, avoiding leading and multiple questions, overcoming responses such as denial and blocking, and using empathic statements
What are some communication problems in critically ill surgical patients?
Background obstacles to communication, such as patient illness and fear, busy staff, lack of concentration, operational fatigue, irritability, tension, confusion, distress, tearfulness, and high expectations
What are some specific communication strategies for the critical care setting?
Provide explanations at each stage of care, explain the role of equipment, discuss upcoming interventions, and clarify the overall management plan. Use aids to orientation, such as readable clocks and name badges. Address acute confusional states through assessment rather than immediate sedation. Repeat questions and explanations, go back over the history, offer repeated explanations to reduce fear, and use check-backs to ensure understanding
How can aids to orientation be helpful in managing confusion in critical care patients?
Photographs of loved ones and easy-to-read name badges can help patients with organic confusion maintain orientation
Why is it necessary to repeat questions and explanations in communication with critically ill patients?
Patients may have difficulty recalling information from a single communication episode, so repeating questions and explanations ensures understanding
What is the three-stage assessment process for addressing acute confusional states?
It is a process used to identify and address the underlying causes of delirium before resorting to sedative-type medications
What are some general principles for breaking bad news?
Consider the “set” including the environment and who will be present. Provide an introduction to the purpose of the conversation, discuss the details, and summarize the key points. Confirm patient permission to inform relatives. Understand intra-family dynamics to effectively communicate with relatives.
How can you initiate a conversation when breaking bad news?
Start with an open question like “What is your understanding of the present situation?” or “What have you been told so far?” This allows the patient or relative to share their perspective and expectations.
What should you do during moments of silence in a conversation about bad news?
Avoid the urge to fill the silence with your words. Allow time for information to be absorbed, and encourage a question and answer format where the patient and/or relatives can ask their questions.
Why is it important to use direct and understandable language when discussing difficult topics?
Using clear language, including difficult and emotive words when appropriate (such as “cancer” or “death”), helps patients face the reality of their situation and allows them to start dealing with it.
What are the communication issues that arise when there is a medical complication or error?
When a medical complication or error occurs, there are additional communication issues to address, such as breaking bad news, handling guilt, and addressing the fear of litigation.
What is the Duty of Candour and how does it relate to disclosing medical mistakes?
The Duty of Candour is a concept introduced in the UK that requires hospitals to inform patients if mistakes in their care have caused significant harm. As a trainee, it is important to recognize situations where a patient has experienced harm that would require disclosure under the Duty of Candour rules.
Why is it important to avoid criticizing the actions of others without careful consideration?
Criticism of others should be approached with caution, as it is easy to comment on something without knowing the full details. General Medical Council guidance emphasizes the importance of collegiality, and even innocent off-hand remarks or body language can imply criticism and lead patients to make complaints or seek legal advice.
What are traumatic stressors and how do they affect emotional reactions?
Traumatic stressors are events that create intense pressure or tension and are associated with negative emotions like fear and sadness. In some cases, the initial emotional reaction to these events can be so intense that the individual resorts to preventing or avoiding the painful feelings. This can involve avoiding places or objects that remind them of the trauma or suppressing emotions altogether.
What is post-traumatic stress disorder (PTSD)?
Post-traumatic stress disorder (PTSD) is characterized by a cyclical reaction of intrusive recollections and defensive avoidance. It occurs when the adaptive mechanism for coping with traumatic events is overwhelmed, and the emotions associated with the event are suppressed rather than declining. If left unresolved, PTSD can become chronic and disabling.
What are some symptoms of PTSD?
Symptoms of PTSD can include recurrent and intrusive distressing recollections of the event, including flashback episodes. These recollections can be triggered by cues that symbolize or resemble aspects of the traumatic event. Individuals with PTSD may also avoid thoughts or cues that activate memories of the event, and they may exhibit withdrawal, detachment, or signs of depression.
What are some common psychological difficulties that may occur in surgical critical care?
Traumatic life events in surgical critical care can trigger various psychological difficulties, including feelings of depression, anxiety, and even relapse of certain psychoses. It is important to assess the full range of psychological problems that patients may experience.
What are some common symptoms of anxiety in hospital patients with serious conditions?
Mild feelings of fear, apprehension, sadness, and emotional turmoil are common in patients admitted to the hospital with serious conditions. The clinical team’s approach and communication with patients can greatly impact the level of distress experienced. Symptoms of anxiety may include autonomic symptoms like tachycardia and high blood pressure, as well as visible overbreathing, which can be a clue to the presence of chronic hyperventilation syndrome.
What are the core features of major depression?
Major depression is a common condition that often goes unrecognized. It is characterized by a low mood, loss of pleasure and enjoyment, reduced interest, hopelessness, helplessness, and pessimism for the future. There may also be biological features such as weight loss, impaired sleep with early-morning wakening, and a diurnal variation of mood that is worse in the early morning. In some cases, major depression may include mood-congruent delusions and hallucinations.
What are acute organic reactions and what are their characteristics?
Acute organic reactions, also known as confusional states or delirium, are short-lived disturbances characterized by confusion, clouding of consciousness, disorientation, and fearfulness. They may involve delusions, often persecutory in nature. Alcohol withdrawal and prescribed medication can be common causes, but they can also occur in the context of various medical conditions. Assessment of these reactions involves evaluating cognitive state, awareness of the environment, and identifying possible organic causes through a comprehensive assessment and review.
When should a referral to a psychiatrist be considered?
Referral to a psychiatrist may be necessary in situations where the diagnosis is uncertain or when there is a suspected psychiatric component. Extreme examples such as somatization disorder and Munchausen’s syndrome occasionally occur in the surgical population, highlighting the complex interactions between physical and psychological processes that may require assessment. Referral is also appropriate and often urgent in cases involving the severity of the psychiatric condition or the level of danger associated with it, such as deliberate self-harm or the development of persecutory beliefs leading to thoughts of harm towards others. Psychiatrists can also provide guidance on consent for surgery, as they have specialized knowledge of the legislation related to treatment consent for psychiatric illness.
What are the “zones of change” described by Critchley?
The “zones of change” described by Critchley refer to three zones in which individuals position themselves based on their confidence with a situation. The comfort zone is where individuals feel secure and competent, while the high-risk zone presents significant challenges. The zone of development is the space in between where learning can occur. By attending the CCrISP course, trainees position themselves in this zone of development, gaining confidence in caring for critically ill surgical patients and taking more responsibility for patient care, which is essential for transitioning to specialty training.
What is the difference between a “change” and a “transition” in social psychology?
In social psychology, a “change” is a rapid event that happens to people regardless of their readiness. On the other hand, a “transition” is a slower, developmental process that occurs in people’s minds when experiencing change. Viewing the move to specialty training as a transition allows individuals to prepare more fully by building upon the skills they have acquired during core training.
What responsibilities does a specialist registrar have during daily business ward rounds?
As a specialist registrar, one of the main responsibilities during daily business ward rounds is actively managing patients. This includes looking for and identifying problems, making decisions about patient management, and contacting the consultant when necessary. While the consultant may not conduct a formal ward round every day, the trainee must take an active role in patient care and communication. As experience grows, the trainee’s scope for safe practice expands, but it is crucial to understand when decisions need to be made and who should make them throughout training.
What must a senior trainee be prepared to do in terms of their patients’ progress?
A senior trainee must be prepared to overcome obstacles that block their patients’ progress. This may require assertiveness, but it is important to exercise caution and avoid appearing aggressive to prevent alienation. Building strong working relationships with other key members of the multidisciplinary team is crucial in ensuring that patients receive the necessary treatment. Senior nurses, advanced nurse practitioners, outreach nurses, emergency theatre nurses, and radiologists are examples of individuals who can help facilitate the progress of patients.
What is one of the key skills required for doctors at any level of training?
One of the key skills required for doctors at any level of training is working within their limitations. This is especially important in the current climate of surgical training, where operative exposure during core training is significantly less than before. It is crucial to banish any feelings of dismay or inadequacy regarding surgical skills. As a senior trainee, you will quickly develop new operative skills and start feeling like a competent surgeon.
What are some basic communication skills mentioned in the glossary?
In the glossary, some basic communication skills are outlined. These skills include using an appropriate range of open, focused, and closed questions during data gathering. It is recommended to use the open question “Is there anything else?” as a final question when taking a history. The glossary also highlights the potential pitfalls of leading questions and multiple questions in checklist approaches to history-taking. Checking back and using a summary of the main features are mentioned as ways to confirm understanding and ensure an accurate history. Additionally, the glossary emphasizes the importance of empathic comments as a way to understand and acknowledge patients’ emotional reactions.
What does “blocking” mean in terms of communication?
In terms of communication, “blocking” refers to not facing up to an issue or avoiding discussing it. An example of blocking is when a patient asks about potential complications of an operation, and the surgeon dismisses the question with a reassurance like “Don’t worry, it’ll all be fine.” Another example is when a doctor informs a patient of a cancer diagnosis, and the patient denies the possibility by saying, “It can’t be cancer, I feel too well.” Blocking hinders open and honest communication about important matters.
What is “mirroring” in communication?
Mirroring in communication involves reflecting the tone of voice and body language used by the patient. For example, if a patient is speaking softly and timidly, responding in a similar tone can help establish rapport. Similarly, if a patient is sitting leaning forward, mirroring that posture can promote a sense of connection. Anti-mirroring, or doing the opposite of the patient’s tone and body language, can negatively impact interactions. Mirroring is a technique that can enhance communication and understanding.
What are the differences between assertiveness, passivity, and aggression in communication?
In communication, assertiveness involves expressing honest opinions while respecting others, without needlessly hurting them. Passivity, on the other hand, involves suppressing honest opinions and not speaking up. Aggression is the use of excessive force or power, causing unnecessary suffering. It can manifest as either active aggression, such as violent or insulting speech, or passive aggression, such as emotional manipulation. Assertiveness is generally preferred as it allows individuals to express themselves honestly without causing harm. In assertive statements, the pronoun “I” is commonly used, whereas aggressive statements often use the pronoun “you” to blame or attack the other person.
What percentage of total hospital inpatients undergoing surgery are considered to be at high risk of adverse outcomes?
Approximately 15% of total hospital inpatients undergoing surgery, which amounts to around 250,000 patients, can be considered to be at high risk of adverse outcomes during their procedure.
Why is minimizing the risk associated with surgical procedures important?
Minimizing the risk associated with surgical procedures is vital to improve outcomes because high-risk patients account for 80% of deaths after surgery. The presence of any comorbidity increases the risk, and therefore, risk assessment plays a crucial role in improving patient outcomes. It is also important for comparative audit purposes, such as the National Emergency Laparotomy Audit (NELA) and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) studies.
What are some challenges associated with existing risk assessment systems?
Existing risk assessment systems present challenges. Simple scales, like the American Society of Anesthesiologists (ASA) grading system, can be subject to varied interpretation among experienced medical assessors. On the other hand, more complex systems, such as the physiological and operative severity score for enumeration of mortality and morbidity (POSSUM), are often too complex for daily clinical use or have a retrospective element that limits their reliability in preoperative risk assessment.
How can coexisting diseases complicate surgical procedures?
Coexisting diseases can complicate even simple operations and increase morbidity and mortality. For example, a patient with a heart transplant who needs to undergo surgery for a cholecystectomy may face increased risks. The level of care required for such patients needs to be anticipated, and consideration must be given to transferring them to units with appropriate facilities. Additionally, expertise is needed to advise on preoperative optimization and perioperative management of individual comorbidities.
Why is it important to repeatedly assess high-risk patients throughout their hospital stay?
It is important to repeatedly assess high-risk patients throughout their hospital stay in order to minimize the risk of developing complications. While the concept of a “high-risk” patient is generally understood, it is crucial to recognize the specific factors contributing to that perceived risk and continuously reassess these patients to ensure appropriate care and intervention.
What is the metabolic response to injury?
The metabolic response to injury refers to the physiological changes that occur in the body following major injury, surgery, or severe infection. It occurs in two phases known as the “ebb and flow” phases. During the ebb phase, which lasts 24-48 hours, there is a neuroendocrine response to tissue injury and hypovolemia. Energy stores are mobilized, glucose concentration increases, and there is an increase in lipolysis. In the flow phase, which occurs after the initial phase, there is an increased metabolic rate and muscle catabolism. Protein catabolism affects skeletal muscle, and there is an increase in proteolysis and urinary excretion of nitrogen and creatinine.
What are some effects of the metabolic response to injury on glutamine?
The metabolic response to injury can affect glutamine in several ways. Intramuscular glutamine concentration is decreased due to increased efflux and possibly decreased de novo synthesis. Glutamine is an important fuel for immune cells, a precursor for glutathione (a free radical scavenger), and plays a role in nitric oxide metabolism and maintaining the gut mucosal barrier. After injury, the levels of glutamine may be compromised.
What is insulin resistance after injury?
Insulin resistance after injury refers to the reduced response of the body to insulin’s anabolic effects. It can result in increased hepatic glucose production, lipolysis, and net efflux of amino acids from skeletal muscle. Insulin resistance is characterized by elevated plasma glucose and insulin concentrations that are inhibitory in uninjured individuals. Glucose uptake into skeletal muscle is also reduced, primarily due to impaired glucose storage rather than oxidation. Insulin resistance may be partly influenced by counter-regulatory hormones such as cortisol, adrenaline, and glucagon, as well as pro-inflammatory cytokines.
Which pro-inflammatory cytokines are correlated with insulin resistance?
Pro-inflammatory cytokines such as IL-6 in cancer patients, IL-1 in endotoxemia, and TNF in diabetes and obesity have been found to be correlated with the degree of insulin resistance. These cytokines can modulate insulin sensitivity and contribute to the development of insulin resistance in injured or septic patients.
What are the mediators involved in protein metabolism during the injury response?
During the injury response, there are mediators involved in protein metabolism. These include the induction of increased hepatic synthesis (IL-6 induced), increased microvascular permeability, raised plasma concentration of fibrinogen and C-reactive protein, and a decrease in plasma albumin concentration.
What are some counter-regulatory hormones involved in the injury response?
Some counter-regulatory hormones involved in the injury response are catecholamines (adrenaline), cortisol, glucagon, and antidiuretic hormone.
What are some pro-inflammatory cytokines involved in the injury response?
Some pro-inflammatory cytokines involved in the injury response are TNF-α, IL-1β, IL-2, IL-6, and IL-8. These cytokines mimic certain responses, but their plasma levels are not universally linked to injury, indicating their autocrine/paracrine function rather than endocrine function.
What are some medical disorders associated with obesity?
Obesity increases the likelihood of associated medical disorders such as ischaemic heart disease (especially central obesity), hypertension, oesophageal reflux, diabetes, obstructive sleep apnoea (OSA), osteoarthrosis, gallstones, varicose veins, and haemorrhoids.
What is the normal range for BMI?
The normal range for BMI is 20-25 kg/m^2.
How is obesity defined based on BMI?
Obesity is defined as a greater than 20% increase over the ideal body weight, which equates to a BMI over 30 kg/m^2.
What is considered morbid obesity?
A patient with a BMI over 35 kg/m^2 can be considered morbidly obese.
What is the STOP-BANG questionnaire used for?
The STOP-BANG questionnaire is a screening tool used to identify predictive factors for OSA. A value of 5 or more indicates the likely presence of OSA.
What is metabolic syndrome?
Metabolic syndrome is a collection of symptoms including central obesity, insulin resistance, dyslipidaemia, and hypertension. It significantly increases perioperative cardiac risk.
What is the impact of obesity on OSA (obstructive sleep apnoea)?
OSA is frequently undiagnosed but present in 10-20% of morbidly obese patients. If untreated, it can lead to heart failure and pulmonary hypertension. Predictors of OSA include male gender, older age, diabetes, hypertension, snoring, and large collar size.
What is recommended for obese patients requiring elective surgery?
For obese patients requiring elective surgery, preoperative weight loss should be recommended.
