Archive for the ‘Uncategorized’ category

November 19, 2012

Some things to think about when you next go to the wards.


I recently took a group of medical students to see Mrs Cole*. She was 88 and was in hospital due to a severe exacerbation of COPD. She was kind enough to let us talk to her and listen to her lungs, despite being quite breathless. As we talked I perched on the edge of the bed and, as I often do, held her hand.  She grasped it tightly and wouldn’t let go. I finished the teaching session, sent the students off to their lecture, and stayed with Mrs Cole longer than I had intended. It felt like she was clinging to me as we talked; clinging to my youth, my health, and my carefree existence.

I couldn’t offer her much: we were treating her exacerbation but no drugs could reverse her lung damage. No words could allay her very real fears for the future. But I felt what I could…

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Empyema and Pleural Drainage

December 23, 2009

Empyema: This is defined as collection of pus in a naturally occurring cavity and is a complication of pneumonia. Nb Empyemas do occur in the gall bladder and rarely an intracranial subdural empyema.

What is the difference between and abscess and empyema:

Empyemas are accumulations of pus from a pre-existing anatomical cavity


Abscess: accumulations of pus in a newly formed structure, formed by adjacent healthy cells in an attempt to keep the pus from infecting neighbouring cells

The four steps to Empyema:

  1. 1. Pneumonia
  2. 2. Simple parapnuemonice effusion
  3. 3. Complex parapneumonic effusion
  4. 4. empyema
  1. Pneumonia
  1. Simple parapneumonic effusion (a pleural effusion being excess fluid that accumulates in the pleural cavity results from inflammation of the pleura by the adjacent pneumonia infection. This infection causes increased capillary permeability and exudation of fluid into the pleural space. Initially the pleural fluid is sterile, so will appear clear with:
  • low white cell count
  • lactate dehydrongenase, LDH (low levels in a transudate – passive secretion and high levels in exudate as a result of inflammation)
  • normal glucose and pH.

This simple parapneumonic effusion appears on a CXR or USS as a free flowing effusion.

  1. This develops into a complicated paraneumonic effusion as the fluid is invaded by the bacteria from the adjacent pneumonia. This leads to:
  • Increased numbers of neutrophils
  • Decreased glucose levels
  • Pleural fluid acidosis
  • Elevated LDH

It is classified as complicated because it requires drainage for resolution

  1. Empyema Thoracis: This develops as the complicated parapneumonic effusion fails to resolve and there is frank pus accumulation in the pleural space. The patient will appear:
  • acutely unwell with a high fever
  • elevated neutrophils =  granulocytois
  • marked elevation in LDH > 1000U/l
  • Marked pleural fluid acidosis
  • Marked decreased glucose level

Laboratory studies indicate that preexisting pleural fluid is required for the development of empyema because it is not seen after direct inoculation into a dry pleural space. The pus is seen after is has been removed by drainage of which there are various options which will be discussed bellow.

Treatment: IV augmentin TDS for 5 day + drainage

Nb Hippocrates in 500BC recognised the serious problem of empyema and recommended treating it with an open drainage

Risk factors for developing and empyema from pneumonia:

  • Low albumin <30 g/l
  • Low sodium <130 mmol/l
  • Platlet count >400
  • IV drug use
  • Hx of alcohol abuse
  • Hx of COPD

Pleural drainage:

  • Thoracocentesis: a procedure to remove fluid from the pleural space and then used diagnostical to establish the cause of the pleural effusion.
  • Chest drain (tube thoracostomy): position tube under USS guidance in a dependent part of the empyema. The key to this procedure is  prompt drainage. There are two techniques:

Recent studies have shown that thrombolytic therapy (streptokinase) for complicated parapneumonic effusions have been effective if administered early and at this stage show a 70-90% success rate in halting the progression to empyema

  • VATS – videa assisted throrascopy, with the patient under local or general anesthesia to allow direct visiulisation, via an endoscope so minimally invasive, of the empyema so it can be drained completely or decortication = removal of inflamed pleural layer. Most often used in patients with multi-located empyema

Xmas Parties

December 18, 2009

Xmas Party number 1 tonight – tonight DundeeChest was the “Plus 1”.  An opportunity to talk to some GP trainees, and also a St Andrews and Edinburgh medical student.  She was intrigued by the DundeeChest idea, I think.  Enough to google us?  I suspect so.  I’d like to think the word might spread across to Lothian, we might get a few more hits, and perhaps a few more regular readers, or, perhaps, some contributions?

So, Kerry, if you’re reading this; welcome to DundeeChest!  Register, and get posting.

And Merry Christmas.

Prone Prune.

December 3, 2009

For those of you lucky enough to come along to any of the oxygen talks I’ve done recently, will have heard be tell you that increasing oxygenation beyond SaO2 of 90% doesn’t seem to improve survival in ICU patients.  One of the big topics in ARDS management has been proning of patients to improve V/Q matching, and improve tissue oxygenation etc etc.  Here’s a paper in JAMA this month showing it doesn’t work.  Take with usual pinch of salt, of course.

Will we all become GPs?

October 29, 2009

Laura sent me an interesting link to a blog.

To summarise, it explains how there is a shortage of primary health physicians in the US. The main contributing factor is money, family practitioners get paid on average 55% less than non-primary care specialties and when you are trying to pay off loans of about $180,000, its not unreasonable to go for the job that is paid 55% more. The reasons for the differences, which underpins a fundemental difference between the US and the UK, is the market.

The health sector in the US operates in a market driven system, capitalism. Whereby the price is never static, its whatever someone is willing to pay for it. Thus, radiologist 5 years after residency can be expected to earn $325,00 nearly double that of a family practitioner because the customer is willing to pay more for the services of the radiologist than the family practitioner.

Here in the UK the opposite is happening, more trained medics are becoming GPs. This, unlike in the US, is not about money because we have a socialist approach in the NHS. There is no market, which is the main problem that opponents have of the NHS. Salaries for consultant and GPs are fairly similar and are equally bellow that of other stressful jobs that require far less training. This is because stressful jobs such as banking and law are market driven, so they will get paid what ever the market will pay them, there success should represent there payment. However this is not the case in the NHS, you can be a very average doctor and get paid the same as a very good one that reach targets and pushes the boundaries because there is no monetary incentive to be better. It goes on through out the NHS, from drugs to toilet roll, they all get procured inefficiently because there is no real incentive to do it differently.

So if it is not about money, what is it about? Well lifestyle and decreased training time play a big part  but a big problem is that there aren’t enough consultant positions and because there is no market there is little incentive to slave away to become a consultant. I have a friend who has wanted to be a hospital physician for a long time, he is a very clever chap and has tried, many times in vain, to bolster his CV in anticipation. However, he may soon be faced with the prospect of becoming a GP because of the lack of consultant post. I am not saying this is bad but this wasn’t what fits his skill set.

One would have thought that being market driven, the US would be more efficient but it spend more per capita on health care than we do. However, the NHS is deeply inefficient and there are things to be done about it. Maybe as the NHS becomes more efficient more consultantships will be created but until that happens I am afraid it seems that we will become GPs.



October 28, 2009

I think everyone should see the following program ‘The World’s Greatest Money Maker‘ available on the BBC iPlayer.

It is about how the guy made money but essentially it documents how this super rich guy lives a normal life and how in a capitalist world is best to look after those around you and those who haven’t been given as many opportunties.

It think this is a very salient point for all and espcially medics


Santa’s list

October 27, 2009

Please can someone get these for me for christmas

It isn’t the most reliable source but a friend was looking through Gizmag and we found some interesting stuff.

1- a portable ultrasound device, real handy for those quick chest drains I like to insert on the run

2- 3D interactive autopsy table

I have been good this year Santa