And after reading his case, the diagnosis is:

d. Ramsay Hunt Syndrome

Firstly this is a lower motor neuron (LMN) facial (CN VII) palsy: facial weakness of the whole of the face.*

Bell’s is a lower motor neurone lesion which is idiopathic in nature.

The aetiology is probably thought to be a herpes virus and there is some evidence to support the use of short course oral corticosteroids and aciclovir.

• about 50% of people will get better with no treatment
• steroids for approximately 1 week seem to help 50% of cases
• the benefit of aciclovir remains controversial

Read the Bandoleir review here

However: Ramsay Hunt is a facial nerve palsy caused by associated herpes zoster infection (as manifested in this case by the vesicles). When a patient presents with a CNVII weakness, this is one of the key reasons to perform otoscopy, as otherwise you may miss the vesicles.

*Remember in UMN lesions the upper half of the face (highlighted here in yellow) is spared as there is bilateral UMN innervation. You would not expect this in Ramsay hunt as its a LMN lesion. The image below shows a LMN CNVII weakness.

Remember, we have a completely free question bank in our login area – register now for more free questions!

The most likely diagnosis is:

a. Steven Johnson Syndrome
b. HIV
c. Stroke
d. Ramsay Hunt Syndrome
e. Bells Palsy

Leave your answer as a comment below – answer in a few days!

Photo by upsuportsmouthPoorer medical students’ debts have also soared. Those from low-income backgrounds graduate over £13,000 more in debt than better off students – graduating with a projected debt of £37,588 (up from £26,324 in the past 12 months).

The survey from the BMA also reports that the number of medical students from the lowest income brackets is in decline over the past 12 months.

Co-chairwoman of the BMA Medical Student Committee Elly Pilavachi said:

“Medical students are now facing extremely high levels of graduation debt. Many are clearly heavily dependent on financial support from their families and friends to get through the intensive, five to six-year medical course. However, the picture for those from low-income backgrounds is particularly alarming with their debt levels a staggering £13,000 higher than those from higher income brackets.”

Clearly there is a lot to think about if you are planning on becoming a medical student, or already are one. What do you think about the current financial plight of med students?

An Emergency Department doctor tells you that he feels the patient can be discharged. He tells you this because he shows you the D-Dimer result, which is “negative”. The result is shown below.

Which of the following statements is true about D-Dimer testing in general patients with a suspected DVT?

a. Following a clinical assessment, clinicians should not rely on the test as a basis to ‘discharge’ or ‘investigate’

b. It is of no use in patients who have had recent surgery (e.g. within the last 12 weeks)

c. It is of no clinical use in patients with malignancy and secondary metastases

d. It can be used to discharge patients based on their underlying estimated clinical risk score

e. None of the listed answers are correct.

The emergency department is the frontline of medicine, and as with any soldier you’d better be ready to give your life for the cause, says Dr Will Dawson, GP Trainee working at the West Yorkshire Deanery.

Emergency medicine (EM) is a common rotation during foundation training and GP training. It is a far cry from most of the things you have done before, and can seem an intimidating and terrifying prospect – new doctors need to know how to survive.

Fasten your seat belts, it’s going to be a bumpy night

Be ready for a hard slog and not just for yourself. EM is well known as an unforgiving rotation – especially with your time. Be prepared to sacrifice nearly all your extra–curricular activities and weekends, as you learn how to adapt to a different way of living. You will learn to make the most of your days off; just remember to book them – this is best done before you start the rotation.

Remember the anti-social hours EM requires does not just affect you; it can be your close friends, partner or family who struggle the most. Make sure your partner and family really understand the state of play. Nights and often weeks of spending little or no time with you is always surprisingly difficult, especially if they do not have a medical background, so it is important to spend quality time with loved ones whenever possible.

And as I was warned on starting my rotation, if you have relationship problems they are not going to get any better.

Be professional, be respectful and don’t be late

Teamwork is a crucial part of EM. Be punctual; it is important to be on time, and that means being dressed and ready and picking up your first patient card as your shift starts. It may sound obvious, but in such a pressurised environment no-one likes tardy colleagues at handover. After an exhausting shift, the last thing you want is your replacement to be late.

Yes, you are a doctor and “in charge”; however, most of the other medical staff will have years of experience and technical ability. If a member of staff suggests something or questions your management, do not just dismiss them. They have probably been doing it longer and could even – gasp – be right.

Remember that nurses are not your servants. Do not demand they do investigations that you could easily do yourself, especially if they are busy. If you can help them with jobs, it will pay dividends. Most will do basic investigations and cannulate patients if they are able to, but will not thank you if you order them to do so when they are rushed off their feet and you are enjoying your break.

Treating all colleagues with respect, and discussing the management of patients with those who are expected to carry it out, will help you get on better with others and get things done quicker.

Communication, communication, communication

We all know that good communication is of the upmost importance. However, multiply that by a million in EM. Due to the critical nature of patients, capacity and time restraints, everyone wants to know what is going on with your patient. Keep quiet and pretty soon you will have the nurse in charge, consultant and bed manager breathing down your neck wanting to know why your patient has not been referred or discharged.

If you have questions, get them out early on. Most registrars and consultants are very approachable and keen to help; however, you won’t be thanked for asking for advice for a patient you have been seeing for the last three and a half hours.

Telling your colleagues what you are doing will put them at ease, speed up treatment, and confirm you are doing the right thing. This also applies to patients – let them know what you are doing so they don’t feel left out.

Decision time

For most junior doctors, this is the first time they will have to start making decisions on the management of patients. You will be using your knowledge to assess and treat patients and make them better. Remember you trained for five years to do this, not to dictate discharge letters and write in the notes on ward rounds.

No-one is expecting you to know everything. Simple immediate, appropriate management is the name of the game, so do the basics and if you are unsure, ask for help early on.

Take a focused and appropriate history and examination. Think about the investigations you are doing and how they are going to affect your management. If they aren’t going to, then maybe you should not be doing them.

Read up on local protocols and guidelines – they will provide you with safe, appropriate and legally–defensive advice on treating many diseases. They are ideal for treating straightforward cases without bothering your busy seniors, but remember they are just a guide.

Always try to have a diagnosis and initial management plan in mind before discussing a patient with a senior, especially a consultant – they will ask you. I heard one consultant tell an SHO “you have your own GMC number, I am not deciding for you”. Remember, although seniors in EM tend to be the most helpful and approachable of all specialties, their patience will soon wane if they are asked to review all your patients.

Documentation

Time is not on your side, and often you will do many things in the heat of the moment.  However, it is important to keep your notes concise and precise. You may not be writing pages and pages, but you must document your assessment and treatment and the reasoning behind it.

Good documentation is your best defence should something untoward happen or a complaint be made. Remember to record not just your history and examination, but any discussion that you have with seniors or other specialties, and also that you have considered differential diagnoses.

When handing over at the end of your shift, you should give a clear plan of what is to happen with your patient. Handing over a patient should not be an excuse to hand over the decision-making. A clear plan also protects you when leaving your shift and makes sure that your management is followed through.

Work hard, but take your breaks

You may have done a wonderful job with your first patient of the day, but that does not mean that you can sit and wait for the investigations to be done. You will be expected to deal with more than one patient at a time. While you are waiting for the bloods you can start assessing other patients, or reviewing the previous results. But be sensible and don’t overload yourself or you will miss things, delay treatment or get things wrong, and patients’ management will suffer.

Remember to take breaks. It is up to you to do so; noone else will remind you. Check with colleagues so you do not all disappear at the same time, but do not be tempted to wait for a quiet moment, as some days it will never come.

As important as it is to arrive on time, try to make sure you leave on time too. This means being organised towards the end of your shift. If any patients need to be handed over, do so in good time to an appropriate colleague. If it gets to ten minutes until the end of your shift, it is probably best if you avoid seeing a new complex case, so ask if you can help with any jobs, or ask your seniors if there are any patients that it will not take too long to see.

There will be times when you stay longer, due to a busy department or a complex patient; however, be sure to log your hours, and make sure you will be paid for the extra time.

Enjoy it

EM may be something you never considered as a career, but make the most of your time there and you will really enjoy it. This is a time when you can grow as a doctor, in confidence and capability.

You will gain a wide variety of medical experience and skills you will not get anywhere else, from suturing to psych assessments.

You will develop new and better ways of working as a team, dealing with patients, and most importantly you will go from a TTO–writing and ward round–documenting encyclopaedia to a thinking and decisive doctor. Be warned you may find yourself not wanting to leave.

….oh, and there will be blood.

Having the right indemnity is vital for every specialty, but none more so than emergency medicine. If something does go wrong, or you need urgent medicolegal advice, MPS has a 24-hour medicolegal helpline that is available to all its members. Become a student member for free.

As a junior doctor, prescribing is one of the most risky new responsibilities you will take on, and as a student it’s one of the key areas that could come up in exams. Be prepared by making sure you know the safe guidelines around drug legislation.

Prescribing should always set off hazard warning lights in your mind. Danger areas include transferring information to new charts, team handovers, over-prescribing, forged prescriptions and prescribing for the wrong patient.

Top tips:

• If you are unsure, always ask. Don’t feel pressured to do anything beyond your competence – ­always get a senior to help, ask ward pharmacists or the GP. Clarify everything – it’s always better to admit you didn’t hear properly than to try and guess a prescription.
• Be especially careful during team handovers, when good communication is vital.
• Check and double-check brand names, doses and frequency. Always check for patient allergies, and other medications the patient is taking including prescription, over-the-counter and alternative medicines. And remember to check for any existing medical conditions.
• Make sure you are up to speed on current guidance from the British National Formulary (BNF). BNF is your prescribing bible, and it’s available online if your copy goes walkabout.
• Clear labelling is vital, especially during team handovers. Prescriptions should clearly identify the patient, the brand, the dose, frequency and start/finish dates, etc, be written clearly or typed, and be signed by the prescriber.
• Most prescriptions are now computer-generated; however, there are some pitfalls to be aware of if writing by hand. If you’re of the iPod generation and are evolving keypads for thumbs, it may be time to brush up your handwriting! Always date the prescription and include the patient’s full name and address, and for patients under 12, their age or date of birth. Clearly state the drug, dose, strength, route and frequency using indelible ink and write drug names in full. If you make a mistake, draw a line through and initial the change.
• Remember – the person who signs the prescription is the one who will be held accountable if something goes wrong. If you prescribe at the recommendation of a nurse or other healthcare professional who does not have prescribing rights, you must be satisfied the prescription is appropriate for the patient.

Too close for comfort

Prescribing for yourself, friends and family is another area fraught with potential problems. ‘Physician, heal thyself’ goes the proverb. However, modern medical guidelines advise that you should avoid treating yourself or anyone close to you.

• The GMC demands that, wherever possible, doctors should avoid treating those with whom they have a close personal relationship, and should be registered with a GP outside their family.

However, this can be surprisingly difficult to put into practice when faced with demands from family and friends. Think about how you might react to the following situations:

• A worried friend asking for some Tamiflu “just in case”.
• Non-medical colleagues on the ward asking for antiemetics the morning after a big night out.
• A stressed-out relative asking you to prescribe antibiotics for your young niece who has a fever.

These requests may seem innocent at the time, but the unwitting doctor may end up facing the GMC.

Right to know

Remember that the principle of informed consent applies as much to prescribing medication as it does to surgical procedures. Patients should be fully informed about:

• Their condition
• The reason for the recommended treatment
• What to expect in terms of improvement
• Symptoms to report and when they should come back
• The need for any monitoring and review
• Any possible side effects
• Potential adverse effects, for example if they should avoid driving or handling dangerous machinery
• Possible interactions with other drugs, including over-the-counter medicines and alcohol.

Making it childproof

While all the above advice applies to both children and adults, special care is needed when prescribing, preparing and administering drugs to children. Important points include:

• Drugs that are relatively innocuous in adults may not be in children. Variations in height, weight and body mass can make them more susceptible; or they may quickly accumulate toxic levels as a result of slower metabolism and excretion.
• In many cases referred to the Medical Protection Society, mistakes occurred because the doctor failed to check the appropriateness of the drug and its route of administration in children or infants, or to prescribe the correct dose.
• Be especially careful when calculating doses – get a colleague to check your maths if possible.
• Make sure you give the child’s parents or guardian all the relevant information. Always warn parents about side-effects, especially if they could be upsetting for the child.
• Remind parents of the importance of storing drugs in their labelled containers and out of the child’s sight and reach.

For more information about prescribing, check out the factsheets and articles at www.medicalprotection.org.uk, contact an MPS adviser on 0845 605 4000 or email querydoc@mps.org.uk

Google body: getting a good look at the vasculature and internal organs in 3D

Google Body is here. And boy, although it hasn’t yet it made an impact as far as we can see in the medical community, we like it, and we like it a lot.

Over the years as educationalists contributing to medical education, things come and go. Innovations are frequent, and new developments are normally hamstrung by copyright issues, usability issues, problems with institutional subscriptions, and restricted access to resources.

What is google body? One of our contributors explains…

Google Body lets you do several things, but basically its your own detailed 3d medical body, which you can zoom rotate, and add and remove anatomical layers with ease. Its so simple. I didn’t need any instructions, and I’m pretty sure  todays crop of web savvy medical students won’t either. Google don’t specifically say who this is being marketed towards, but superficially it seems perfect for the medical students. I love it. I think you will love it too

Lets consider whats possible. Take a view of the shoulder. The nervous innovation, vascular supply, bursa, tendons and glenoid fossa are all clearly on view. Rotation is simple. Zooming in and out is simple and straightforward. Moving through the different soft tissue plains and adding and removing nervous tissue, bony anatomy, vascular system in what is a very user friendly navigation system.

As a group of educationalists, the potential for medical student and patient education is really fantastic, and whilst the items remain free, we’re all for it.

It really is the next best thing to a three dimensional model. We have been commenting on Google body through our Twitter account, under the hash tag #googlebody. We would be interested to hear medical students opinions on this, and a simple rating scale is below if you want to register your opinion on it, or post a comment below on whether you think it can be used as a good resource for medical students.

What does your score mean on our burnout self assessment?

• 0-4 Minimal signs of burnout as a student.
• 5-8 There are some factors here supporting a level of burnout.
• 9-12 You are exhibiting several features of burnout, and this could become a serious problem.
• 13+ You are exhibiting multiple signs of burnout.  Talk to someone, soon

Now, see how you score against other medical students by entering your score below and clicking submit:

What can you do about burnout?

Nina Feghali, A General Practitioner and Contributor to Medical Educator gives her opinion. Nina was not involved in the construction of the burnout survey.

“If you are concerned you have burnout, the first thing is to talk to someone: be it a friend, colleague, fellow student, member of family, personal tutor, head of year.
It’s generally going to be up to you to make that judgement, as to who is going to be the most appropriate person. Don’t shy away from this and if you do recognise signs of unprofessional behaviour, this is even more important. Acknowledging there is a problem is often the first step to solving it. Whilst I am always sceptical of self-assessments like this, they can provide important pointers. The example presented here simply tests a number of constructs associated with burnout. Remember burnout is common (over half the students studied in the JAMA paper), but it has also been linked with suicidal ideation, and a lack of empathy, and here, poor professionalism. Think carefully about this, and seek help if you are concerned.”

Disclaimer: This is an informal score, intended for medical students, and does not represent medical advice. This score has not been validated, but it is free to use, and modify.  This means you can use it yourself under a Creative Commons Licence (Attribution-Non-Commercial-Share-Alike). This means you can use it, edit it and share it, as long as you acknowledge the original source.

1. Medical Protection: The Medical Protection Society

The MPS has a range of online resources and clinical information to help guide medical students and healthcare professionals through their medical training. One thing we like is their magazine for newly qualified junior doctors which are handy for a quick read through relevant junior doctor experiences of life at work. New Doctor magazine can be found here, and Medical Student pages (UK) here.

2. Mnemonics: Medical Mnemonics

We love Mnemonics. Take this one for joint pain.

SOFTER TISSUE:
Sepsis
Osteoarthritis
Fractures
Tendon/muscle
Epiphyseal
Referred
Tumor
Ischaemia
Seropositive arthritides
Seronegative arthritides
Urate
Extra-articular rheumatism (such as polymylagia)

They missed trauma out but hey, nobody’s perfect.

3. Anatomy Guides: Cross sectional Anatomy from anatomy atlases .

We think this picture is of a brain. It’s definitely not the glenohumeral joint.

4. Radiology Help: IMIAIOS

We like this sitter from IMAIOS, who provide detailed pictures like the one you can see here of the famous Scottie dog. We thought it looked like a lumbar spine. How wrong we were.

By the way, you won’t see many more lumbar spine radiographs because your local radiologist will probably have a heart attack if you try to request one! This is because they are notoriously useless at picking anything important up, other than fractures.

5. Stats Advice: BMJ Stats Pages

The BMJ weigh in with a great free resource which requires no subscription. The BMJ really are helping doctors make better decisions (we’re aiming to help you as a medical student make the best decision).

6. iPhone App: IResus

We love this app from the developers at Imobilemedic.com.  You might get a few funny looks from doctors over45 at the next cardiac arrest if you whip this out, and remember not to spill your coffee on your iPhone.

7. Apps for all Smartphones: Med Calc

Thought the Anion Gap was a tourist attraction north of Watford? We’ve got new for you….

If you need to work out a BMI, GCS or Disease Activity score quick? Check out Med Calc… It works on most smart phones. As one contributor said: “I use this most days at work”*

We are fairly certain this is just to show off, but we love this app.

8. General Information: GP Notebook

Most of the GPs that we deal with from medical educator would be doing well to be dealing with most of the complex stuff listed on here. Need to know the classification system for bone tumours? Look no further.

9. Quick information: Wikipedia

Wikipedia is still top of our list for those obscure things you need to know about. As students you always need to be sure to check your sources, however there comes a time when you need fast reliable information, or when you need to read round a topic.  The Journal Nature found that Wikipedia was as good as the Encyclopaedia Britannica across a range of scientific areas. That’s good enough for us, this represents web2.0 in action!

10. Free MCQs & video: Medical Educator

You didnt think we would leave ourselves out did you? If you don’t know already, signing up is completely free and gives you access to loads of our sample multi-questions, videos and podcasts.

Got any other top free resources that you know, use and love? Leave a comment and share the joy!

At first, the students dont see themselves as Doctors but through the blogging process they become more reflective and get used to using the vernacular. From the article:

“When students from ethnic minority communities and disadvantaged economic backgrounds dream of becoming doctors, they sometimes struggle to envision themselves within that world. The contrasts between hometown, university, medical school, and hospital rounds can be overwhelming.”

“Weekly blogging is an integral part of my students’ pre-medicine internship. Through this creative, reflective process, they gradually see themselves as doctors and nurses, redefining their identities.”
Source: Arizona Daily Star

Its an interesting approach and yet another example of new technologies being used in learning and medical education. Have you got help from blogging your personal learning experiences? We’d love to hear from you.