pacientii de oncologie

Am terminat oncologia in Ader Hey in August. Am vazut destule cazuri de cancer, cateva dintre ele avand o evolutie trista. Azi, pentru ca eram in Aldey Hey cu alte probleme, m-am intalnit cu o colega care inca lucreaza la oncologie si am aflat ca trei dintre pacientii pe care i-am vazut si eu de cateva ori au murit. Ma asteptam la unul dintre e sa moaa, dar nu si la ceilalti doi. Si am aflat ca unii la care ma asteptam sa nu mai fie in viata acum, sunt bine.

Groaznic este cancerul la copii...

 

Oncologie pediatrica

Am facut 3 luni de oncologie pediatrica la Alder Hey. Tocmai am terminat stagiul saptamana trecuta.
Interesante cazurile, dar si destul de tragice. O durere de cap... tumora cerebrala....o umflatura pe brat...rhabdomiosarcom...oboseala si ceva ganglioni...limfom.....si tot asa.
Nu as face specialitatea asta. Prea vezi aceeasi pacienti..over and over again. Si e si destul de trista, cu toate ca rata de vindecare este de 97% la ALL :-)

guideline de swine flu in Alder Hey

Current

Swine Flu News

  

This information is designed to be used by staff as a source of information for themselves, patients and visitors to respond to the challenge of swine flu outbreak. As the national and local situation develops this information will be amended.

 

The strain of Influenza A (H1N1), also known as swine flu has now spread to more than 100 countries, in the United Kingdom figures are continuing to rise and currently there are over 8,512 cases. All of the signs are that the virus will continue to spread for some time.

 

Swine Flu – Movement from containment to treatment phase

 

We are writing to let you know that Andy Burnham, the Secretary of State for Health, has announced that it is time for the health service to move from containment phase of swine flu into a treatment phase. This is because scientists expect to see rapid rises in the number of cases.  It has always been known it would be impossible to contain the virus indefinitely but this has provided the time to learn more about this new virus, to build up antiviral and antibiotic stockpiles, and to start to develop a vaccine.

 

The treatment phase means that:

• Doctors will be able to diagnose Swine Flu on the basis of symptoms rather than waiting for laboratory testing; so swabbing in the community will stop
• Primary Care Trusts will now begin to establish antiviral collection points where necessary, allowing 'flu friends' to collect antiviral drugs as part of the primary care response to this phase.  (List in A&E)
• All contact tracing will now cease, and we will stop giving antiviral

drugs to people who may have been exposed to the virus "contacts" (unless they are deemed to be at particularly high-risk of contracting it)

• All those who have contracted the illness will continue to be offered

antiviral treatment. However, it will remain a matter of clinical discretion as to whether to prescribe treatment or not.

 

The Department of Health will be purchasing sufficient vaccine doses to vaccinate the entire population with the first deliveries arriving in August, and at least 60 million doses are expected by the end of the year.  Decisions are yet to be made about who will be prioritised to receive the first doses of the vaccine, but it is anticipated that frontline staff will be considered alongside other high priority groups in order to protect them, their families and their patients.

 

So what does this mean for Alder Hey NHS Foundation Trust?

 

Staff

Staff who think they may have swine flu should follow the normal sickness procedure and advise your Line Manager.  If you have flu symptoms, please stay at home.

You will be advised by your GP/ Occupational health when you should return to work.  If you do not have flu then follow the normal sickness guidelines for coming back to work.

 

You are only infectious when you have flu symptoms, so you should come to work as normal even if you have been in contact with someone with Swine Flu.  Speak to your Line Manager if you are uncertain about your own circumstances.

 

Staff who would like further information about the Department of Health guidance can visit www.dh.gov.uk/swineflutreatmentphase

 

General public

If people think they have Swine Flu, they should first

 

 

1.         People should check their symptoms either

                        Online at www.nhs.uk

                        NHS Direct (0845 46 47)

                        Swine Flu information line on 0800 1 513 513.

                       

2.         If they are still concerned, they should then call their GP, who can provide a diagnosis over the phone.

If swine flu is diagnosed then they will be given a voucher to pick to antiviral treatment, this may be a local pharmacy or a community centre, (not all pharmacies will have stocks of antiviral treatment)

 

3.         They Should NOT attend A&E departments.

 

In the future, as cases rise further, we will move to a system where cases are diagnosed and dealt with by the National Pandemic Flu Service. This will take the pressure off GPs by allowing people to be diagnosed and given their antiviral vouchers either online or via a central call centre.

 

The UK has now moved from containment phase to treatment phase, this means that GP's will no longer be testing patients for this strain of flu but will be offering antiviral treatment on clinical assessment.

What treatment will they be given?

 

The treatment for influenza is to alleviate the symptoms and may shorten the

duration time of illness, they will not stop the illness altogether.

 

Only those who have symptoms will be given antiviral treatment after

assessment by their GP.

Do we treat any patients who attend A&E?

 

Any patient who attends A&E with suspected swine flu or who are contacts of

a case of swine flu should be directed to contact their GP or NHS Direct.

We are only to treat patients who require admission.

 

What do I do if I think I have Swine Flu?

 

If you have a high temperature and have two or more of these symptoms

Ø      Pyrexia >38

Ø      Aches and Pain (particularly joints)

Ø      Sore Throat

Ø      Runny Nose

Ø      Headache

Ø      Vomiting/diarrhoea

Ø      Cough

 

You may have swine flu.

 

Staff

 

If you develop symptoms at home:-

1.                    DO NOT come into work.

2.                    Follow the usual sickness reporting procedure

3.                    Ensure you tell your line manager that you have symptoms of flu.

4.                    Follow guidance for patients to get your antiviral treatment if needed.

 

If you develop symptoms at work;-

 

1.                  Inform line manager immediately

2.                  Line manager to send directly home.

3.                  Call your GP/swine flu number from home

 

Staff who are contacts of someone with swine flu but have no symptoms should work as normal.

 

 

Frequently asked questions regarding swine flu on the wards

 

INFECTION CONTROL

 

1) Who needs to be isolated?

Any patient with a clinical diagnosis of swine flu regardless of any swab result

 

2) Do children who have been in contact with a case of swine flu need to be isolated?

If they have no flu-like symptoms, they can be nursed on an open ward.  If symptoms of flu develop, they should have a medical assessment and be moved into isolation. (Refer to flu algorithm for diagnostic criteria)

 

3) How long do patients with swine flu need to be isolated?

Until at least 7 days from the beginning of their illness. 

After day 7, patients who are asymptomatic, can be moved out of isolation.  Immuno-compromised children may need to be isolated for longer.

 

Antiviral treatment

 

4)  Who should be given antiviral treatment?

All patients who meet the clinical criteria for a diagnosis of swine flu.

In a < 3 months-old child, please discuss with microbiologist prior to starting antiviral treatment

 

5) Who should be given antiviral prophylaxis?

People belonging to a "high risk group" who had a significant contact with a known swine flu case

Prophylaxis of children below 1 year of age should be very carefully considered.

 

6) What are the high risk groups?

Some people are considered to be at greater risk of becoming more seriously ill from swine flu than others.  These high risk groups are:

People with    -     Chronic lung disease

-         Chronic heart disease

-         Chronic kidney disease

-         Chronic liver disease

-         Chronic neurological disease

-         Immunosuppression

-         Diabetes mellitus

Patients who had drug treatment for their asthma within the past 3 years

Pregnant women

Children under 5 years old

People aged 65 years and older

 

7. When will vaccination be available?

 

Vaccine is expected in August.

Plans are in place to offer vaccination to all front line staff and high risk vulnerable patients.

 

 

 

 

 

 

 

 

 

INFECTION CONTROL ADVICE

 

General Advice

 

1.                  Patients should be nursed in isolation cubicle.

2.                  Staff attending to patient should wear apron and mask according to chart below and ensure good hand hygiene practices.

3.                  Patients who need to attend another department in the Trust should wear a surgical mask whilst being transported.

4.                  If there is a risk of splashes to the eyes then eye protection should be worn.

5.                  Staff who are in one of the high risk category as shown above should not be asked to look after definite positive patients, or those who fit the criteria i.e. 2 or more of the symptoms, Staff who are in one of these high risk categories are asked to ensure that occupational health know their status, if required during the pandemic redeployment may be needed.

 

 

Aerosol generating procedures.

 

When undertaking aerosol generating procedures staff should don apron, gloves eye protection and FFP mask as shown on chart below

 

What face mask should I wear?

 

For confirmed or suspected cases admitted to a clinical area – i.e. everyone with flu like symptoms:

 

Patient isolation in cubicle

Good hand hygiene is essential!

 

o       Note :

§         Other than direct clinical care of the patient, a contact is defined as having been  within a metre of the patient for greater than 1 hour

§         If asymptomatic you are not infectious

 

·        No mask

o       Staff not giving direct medical care

o       Domestics cleaning cubicles (aprons and gloves)

o       Visitors  (if symptomatic should NOT visit, if asymptomatic they are not infectious and do not require face mask)

 

 

·        Surgical face mask    (+ gloves and yellow apron)

o       Staff giving  direct medical or nursing care

 

 

 

·        FFP3 mask (+gown, gloves and eye protection.

Only need to be worn when performing Aerosol Generating Procedures: 

                                                                                                

(Intubation, manual ventilation and suctioning

Cardiopulmonary Resuscitation (CPR)

Bronchoscopy

Nebulisation if it is necessary to stay with the child)

 

PICU/HDU;

Non-invasive positive pressure ventilation, High frequency oscillating ventilation, bi-level positive airway pressure (BIPAP).

 

NB: - Nasopharyngeal aspiration (NPA) is not classed as aerosol generating procedure and surgical face mask and gloves should give sufficient protection.

 

 

           

Environment

 

The patient area should be cleaned at least daily and kept free from dust.

Equipment which is not going to be used should be removed from the area.

 

 

online procedure guidelines

Un excelent website pentru proceduri pediatrice este cel de la Royal Children's Hospital Melbourne. Cautam un video pentru aspiratia suprapubica, dar era destul de dificil de gasit pe google. 

7 nopti

Tocmai am terminat un set de 7 nopti pe saloane in Alder Hey. N-am avut nici un crash-call.

Au implementat un sistem de clinical supporting nurses care stiu sa puna canule si pot sa rescrie drug-charts, iar toate bleepurile de pe saloane tre sa treaca pe la ele, asa ac e mult mai simplu. Am primit cam 15 bleepuri pe noapte, ceea ce e un numar foarte rezonabil.

Ce am vazut interesant:

- hidrocephalus congenital - copil de doua zile la care stiau de diagnostic de la 28 de sapt intrauterin, dar au vrut sa continue sarcina. nasterea a fost la 39 de sapt. la doua zile RMN-ul arata un strat subtire de tesut cerebral pe niste ventricule imensa de dilatate

- spina bifida reala - 1 zi de la nastere. Astea doua cazuri le-am vazut ca-mi bagam eu nasul pe la neurochirurgie :-)

- sindrom West pe phenitoina iv (CVL) la care era foarte de greu de contolat nivelele ( normal ar trebui ca nivelul trough/predose sa fie 15-20 , dar in cazul fetitei asteia trebuiau sa fie 25-30 ca sa-i controleze epilepsia). De azi o sa o inceapa pe o dieta ketogenica, ca ultima solutie pentru epilepsie.

- endocardita bacteriana la un copil de 4 ani - la care in fiecare noapte ii ajustam potasiul cu infuzii pt era pe diuretice si pe vanc, gent si amfotericina ( si astea pot sadea potasiul)

- sugar de 8 zile cu TGA, stabil pe  prostaglandin oral care facuse o temperatura de 38.3 in dimineata dinaintea operatiei. Era OK la examinare si probabil ca temperatura se datora prostaglandinei (este cel mai frecvent efect advers).

- baiat de 14 ani cu Duchenne's terminal pe BiPAP, cu insuficienta cardiaca - se purtau discutii cu familia si membrii echipei multidisciplinare in legatura cu planurile pentru sfarsitul vietii

- baiat de 4 ani cu prune belly syndrome - era in spital pt ca avusese a doua operatie de orchidopexie

- peritonita bacteriana la o fata de 14 ani cu peritoneal dialysis cu CKD end-stage datorita refluxului vezico-ureteral cand era mica

- un baiat de 10 anicu o boala reumatologica inca nediagnosticata care avea dureri asa de intense de abdomen incat era pe PCA (patient cotrolled analgesia) de fentanyl si pe infuzie de ketamina.

- am mai invatat ca poti opri infuzia cu imunoglobuline ca sa administrezi alte medicamente IV pentru scurt timp daca nu ai si alta linie.

 

Ieri noapte am avut cu registrarul Anand un CBD - Case Based Discussion despre o fetita de 3 ani cu probleme cronice datorate paraliziei cerebrale (cerebral palsy) - gen aspiratii repetate, fundoplicatie, si ne-am referit si la cum identifici o infectie intr-un astfel de pacient - am incercat sa vedem cum poti sa-ti dai seama de unde provine febra folosind un minim de resurse. De exemplu cea mai simpla analiza de sange care poate fi facuta si in cabinet este frotiul de sange periferic. Daca de pilda pe frotiu ar aparea neutrofile toxice (multisegmentate, granulatii toxice), left shift, atunci probailitatea mare ar fi ca febra este datorata unei infectii bacteriene. A face un frotiu de sange si a-l citi ar fi un lucru destul de util.

 

Probabil ca am uitat deja multe dintre cazurile pe care le-am vazut :-)

 

F1 and F2

N-am dat rezi in Ro. Am inceput direct in uk cu F1. Am facut cate 4 luni de medicala (gastro), chirurgie si a&e (accident and emergency) (in Aberystwyth) apoi in F2 obs&gynae, pediatrie si medicala (in Wrexham).
In ST1 am facut 6 luni de pedi generala combinat cu neonat (Whiston), apoi 3 luni de urgente pediatrice, iar acum oncologie pediatrica (Alder Hey). Pot spune ca din tot ce am facut am invatat ceva si a fost foarte util.

May bank holiday

Ieri am lucrat de la 6pm la 2am. Nu a fost prea aglomerat. Am vazut un baiat de 8 ani nigerian cu tricuspid atresia care avusese un BT shunt pe la 6 luni si un modified Fontain la 4 ani, iar acum ar fi trebuit sa aiba Fontain-ul facut, dar maica-sa nu prea vroia. El obosea din ce in ce mai rau, saturatiile erau pe la 70%. Venise la sp. pt ca obosea asa de tare si ca avea durere in piept. Durerea probabil ca era de la flow-ul redus de sange catre plamani.
Am mai vazut un baiat da 10 ani nou diagnosticat cu boala ticurilor  :-) Trimis de GP pt ca avea miscari involuntare - duh!
Un coleg a vazut o fetita de 2 ani cunoscuta cu sindrom Rett care avea amigdalita.
Iar azi unul dintre coonsultanti ne-a chemat sa ne arate un caz interesant - un copil de 2 care venise in decurs de o luna cu o a doua fractura de tibie, la acelasi picior... Destul de curios - de obicei inseamna fie NAI (non-accidental injury) fie o boala de colagen. In cazul fetitei asteia era o boala de colagen, usor diagnosticata cand s-a uitat la culoarea sclerelor - gri-albastrui, la fel ca ale mamei ei. probabil are osteogenesis imperfecta type I. 

Nobody's perfect

.:reflective practice from the Portfolio:.

Describe the event:

I saw an 8 year old boy complaining of headache and left ear pain for two days. I took a history and examined him, looked in the ears, at his dentition, feeling the cervical lymph nodes and the parotid area. He was swollen and exquisitely tender over the left anterior cervical lymph nodes. I didn't come to any conclusion, as the ears were fine and the teeth didn't show any abscess.
So.. I went to ask one of my seniors about what to do next. I was thinking of a developing abscess in one of the cervical lymph nodes and thought of asking for an ultrasound of the neck the next day.
When the senior came to have a look he asked me if the throat is OK and I said yes, then realising I haven't actually looked in the throat. And of course the patient had a very enlarged left tonsil with pus points on it, thus giving the diagnosis of bacterial tonsillitis.

What did I think and feel?

I couldn't believe my stupidity in forgetting to look in the throat but actually thinking I have done it. I felt so ashamed that I missed such a simple diagnosis because of an examination blunder that I cannot really explain to myself.
I went back to the notes and there was actually written by me that the throat was clear (??).
I then realised that was has happened is actually a very good thing - It's a "tap on the shoulder" to remind me that anyone can make mistakes and forget things. Also it's a good reminder that examination should be thorough and very organised.

What were the context / factors which had an influence on the event?

It was 10 pm and I was probably a bit tired, having seen all day patients in the minors area. This was the first patient I was seeing in the minor illnesses area.

Looking back what could I have done differently?

Not knowing exactly why I thought I actually examined he throat I don't know what I could have done differently. Maybe drink a cup of coffee during the evening break.

What were the key learning point(s) from this event?

1. anyone can make a mistake
2. do the examination and write the notes in a very organised manner
3. ask if you don't know. Someone else might see things which are blatantly obvious but invisible to your eye and clinical acumen.

Noonan's

Azi am vazut o fetita de 10 ani cu Noonan's. Venise de fapt pt amigdalita, dar a fost interesant pt ca era prima data cand am vazut Noonan's in realitate. Arata ca un pacient cu Turner's - scunda, webbed neck, wide spaced nipples. Avea o sternotomie mediana de cand fusese operata la 1 an pt stenoza pulmonara. Avea si hearing aids si folosea limbajul semnelor.

P.s. la cultura exudatul faringian (throat swab) era pozitiv pt GAS (group A streptococcus). Ii dadusem Penicilina V oricum pt ca amigdalita parea bacteriana atunci cand o vazusem. 

Marele "mimicator"

Aseara, cand sa vad ultimul pacient, intrand in cubicul m-a frapat cat de rau arata (unwell). Un baiat de 6 ani, cunoscut cu hipopituitarism congenital, care lua cortizon, tiroxina si hormon de crestere(GH). Vomitase ieri de vreo 8 ori si fusese vazut dupa-amiaza in A&E si trimis acasa cu diagnosticul de URTI. Parintii ii marisera doza de cortizol (de la 2.5 mg bd la 5 mg qds).
Cand l-am vazut eu arata pamantiu (fusese pus in categoria verde - triaged green). Timplu de reumplere capilara era 6 secunde si el era cam ametit si zicea ca nu simtea bine. Colegul de la medicala a pus repede o canula - super noroc, pt ca pacientul era foarte shut down periferic. I-am dat fluide si hidrocortizon iv (plus albumina si antibiotice) si dupa 10 min era mult mai bine, CRT scazand la 2 sec.
Un CXR a aratat ca avea pneumonie lobara - interesant pt ca nu avea semne ori simptome (nici febra), dar explicabil prin hipopituitarismul lui.

p.s. : a fost externat dupa cateva zile- bine, pe antibiotice si steroizi oral.

Pleoape violete

Foarte interesant caz, un coleg mi-a cerut pararea- o fetita mulatra de 6 ani care sa prezentat cu durere de coate si genunchi si o eruptie. Semnele vitale erau normale. Istoria era ca genunchii si coatele o dureau de vreo 2 luni, dar mai tare in ultimele doua zile, de cand aparuse si eruptia.
La examenul fizic - genunchii erau rosii si inflamati, usor durerosi la palpare; eruptia era pe abdomen mai mult si cate pete pe pulpe - maculara, rozalie, cu marginile bine definite, cu unele leziuni confluente; interesant avea si o coloratie violeta a pleoapelor superioare.
Analizele de sange - hemoleucograma normala, profil biochimic normal, ESR 25 (mare).
Eu am crezut ca este ceva autoimun (gen lupus sau dermatomiozita), din pacate nu au facut nici un test de imunitate (ANAs etc).
Urmeaza sa fie vazuta in clinica in vreo 2 saptamani.

Atentia conteaza

Azi am vazut un posibil caz de pemphigoid la o fetita de 13 ani care de 6 luni avea niste leziuni buloase pe diverse parti ale corpului care apareau ca niste pete rosii (asemanatoare cu eczema) care o gadilau si evoluau in bule cu lichid limpede in ele masurand aprox 2cm diametru, care dispareau in aprox o sapt si nu lasau cicatrice, ci doar o usoara discoloratie a pielii. Urmeaza sa aiba un consult dermatologic pt stabilireaa diagnosticului.
Am mai vazut o fata da 15 ani care avea sore throat de 1 luna si ganglioni cervicali umflati. In timpul consultatiei maica-sa mi-a spus ca ea si tatal fetei sunt HIV positive... si ca fata ar dori sa fie testata pt HIV. Eu i-am facut un test pt mononucleoza (monospot) si i-am zis sa mearga la clinica de infectioase de adulti pt testul de HIV. --> monospot negativ
Foarte interesant a fost si cazul unei fetite de 3 luni cu episoade de plans in timpul noptii, dificil de oprit de catre parinti. Copilul avea cleft palate, care fusese ratat la baby check (cu toate ca era destul de mare) si mai avea si alte malformatii: coloboma, low set ears, gura triunghiulara si clinodactilie (degetul 5) si tinea si mainile in extensie cu wristurile flectate. Am pus diagnosticul posibil de reflux (GORD), dar le-am zis ca ar putea fi parte din sindromul genetic (nu stiau inca exact ce sindrom are).

Funny head

Azi am vazut un sugar de 6 luni cu plagiocephaly. Statea cu capul intors spre dreapta mai tot timpul si ii era destul de greu sa intoarca complet capul catre stanga. Avea si o usoara diferenta in modul cum tinea mainile si apuca obiecte. Prefera sa foloseasca mana dreapta. Cand era pus pe burta nu folosea mana stanga sa se ridice. L-am referred la community paeds pt un developmental assessment.
Am mai vazut un baiat de 14 ani cu mycoplasma pneumonia (avea si astm sever, dar nu in criza) - febra, tuse, crepitatii bilateral si un CXR tipic. L-am inceput pe amoxicilina si claritromicina oral.

The fifth ...element

Azi am vazut un caz de slapped cheeks disease (aka fifth disease/erythema infectiosum) la un baiat de 6 ani care avea un rash confluent maculopapular intens pe obraji si mai rar pe brate si antebrate. Nu avea nici un alt simptom.

Uitasem... cyanotic spell

Am vazut un caz de "cyanotic spell" in Fallot's Tetralogy saptamana trecuta. Era o fetita de 5 luni care plangea, era cianotica (buzele), saturatii de 30%, cunoscuta cu FT. Facea un lucru interesant - cum statea pe spate, isi ducea singura genunchii la barbie pana cand se termina criza (adik saturatiile cresteau pe la 95%) apoi ii lasa jos si saturatiile scadeau din nou. I-au dat diamorfina intranazal apoi, pt ca nu se terminase criza, propranolol intravenos cu care i-a trecut.
Ce interesant cum descoperise ea singura ca sqattingul ii face bine :-)

Hypoglycaemia work-up

Asa trebuie sa investigam hipoglicemia la Alder Hey (la pacienti non-diabetici)

Blood sugar <>

PLEASE:

• FILL ALL ENCLOSED TUBES
• FILL CIRCLES ON SCREENING CARD
• PUT ONE ORANGE TUBE ON ICE (AMMONIA)
• RING LAB TO TELL THEM A HYPOGLYCAEMIA WORK UP IS COMING
• OBTAIN FIRST VOIDED URINE AFTER PRESENTATION

REQUEST:

• GLUCOSE, LACTATE
• INSULIN, CORTISOL, GROWTH HORMONE
• AMMONIA (ON ICE)
• KETONES, FREE FATTY ACIDS
• AMINO ACIDS
• U & E
• ACID-BASE (GAS TUBE)
• CARNITINE, ACYL-CARNITINE (SCREENING CARD)
• URINE ORGANIC ACIDS (DIP FOR KETONES ALSO)

Mai multe detalii pe www.metbio.net - sau fiserul pdf aici

linkuri interesante

Medical info online:

http://www.cks.library.nhs.uk/ - da click pe dynamed - textbook updatat frecvent cu referinte excelente

http://wales.mapofmedicine.com/

http://www.medscape.com/index/section_1668_0 - cazuri pediatrice

www.medicines.org.uk - informatii detaliate despre medicamente

www.bnf.org.uk - British National Formulary

www.bnfc.org - BNF pediatric

www.doctors.net.uk - comunitate a medicilor cu UK Registration

www.nejm.org - New England Journal of Medicine

www.paediatrics.info - site cu guidelines si MCQ-uri

http://nww.doctoronline.nhs.uk/masterwebsite1Asp/ - information leaflets

http://www.yourchildshealth.nhs.uk/ - paediatric information leaflets

http://www.labtestsonline.org.uk/ - info about lab tests

http://newborns.stanford.edu/PhotoGallery/ - galerie foto pediatrica

http://www.hawaii.edu/medicine/pediatrics/pedtext/ - problem based learning pediatrie

http://www.pediatriceducation.org/ - cazuri de pediatrie

http://www.toxbase.org/

http://www.searchmedica.co.uk/ - cautare medicala

http://www.rcpch.ac.uk/Examinations/MRCPCH-Part-2/Part-2-Structure-and-Specimen-Papers - MRCPCH part 2 specimen papers

http://www.drugs.com/drug_interactions.php - drug-drug and drug-food interactions

http://pediatricradiology.clevelandclinic.org - Pediatric radiology teaching

http://learning.bmj.com - unele module gratuite

http://www.wiganleigh.nhs.uk/Internet/patient_information/Leaflets/intro.asp - patient information leaflets

http://www.clinicalanswers.nhs.uk/index.cfm?cv1=3 - Q&As paeds and others

http://www.rch.org.au/clinicalguide/cpg.cfm?fuseaction=home.titles - clinical guidelines from The Royal Children's Hospital - Melbourne

http://www.merck.com/mmpe/sec19.html - paediatric chapter of Merck online

http://www.elib.scot.nhs.uk/portal/elib/pages/index.aspx - NHS Scotland e-Library

http://www.bestbets.org/database/browse-by-topic.php?CategoryID=236 - best evidence topics in paediatrics

Journals

http://www.sciencedirect.com/science/journal/17517222 - Paediatrics and Child Health (formerly known as Current Paediatrics)\

http://clinicalevidence.bmj.com/ceweb/index.jsp - BMJ clinical evidence (use Athens login)

Ce cazuri am mai vazut

Scriu dupa 1 an :-)

Tocmai am terminat o saptamana de nopti in A&E la Alder Hey.. multi pacienti peste noapte, dar incredibil, mai toti simple raceli si gastroenterite. Nu am avut nici urgenta reala. Ma gandeam oricum ca daca vine cineva collapsed sa pun un intraosseous needle, cu toata cu nu vazusem inainte in realitate cum se face.
Ce-am vazut interesant:
- un baiat de 12 ani cu un collapse; incidental am descoperit la el un second degree AV block Mobitz type 1; dupa ce a fost internat s-a descoperit si ca avea hipotiroidism sever, cu toate ca nu avea caracteristici (doar ca era putin obosit si avea BP-ul destul de scazut 70/50)
- un sugar cu sindr Beckwith-Wiedemann; avea limba mare si o cicatrice pe abdomen de la un gastroschizis reparat la nastere (traiesc OK, caracteristicile tind sa dispara dupa copilarie, au o rata crescuta de a face cancer in copilarie - de 600 de ori fata de medie)
- un sugar de 1 an cu cardiomiopatie dilatativa; avea tuse de vreo 4 luni, fusese tratat cu antibiotice de cateva ori de GP, fara succes; de la percentila 50 la nastere greutate, scazuse la sub percentila 2 la 1 an; diagnosticul fusese pus incidental de cineva care se gandise sa-i faca un CXR; acum era pe tratament (furosemid, captopril, digoxin) si avea un rash, probabil secundar tratamentului
- baiat de 13 ani cu mutiple petesii si echimoze pe tot corpul care se simtea bine; am banuit ca e ITP inca de la inceput, iar FBC-ul mi-a confirmat diagnosticul - platelets erau 1 ! L-am admis pt ca asa a zis consultantul, insa eu nu as fi facut asa.

Prima punctie lombara la un copil

Yahooo! Azi am facut prima punctie lombara la copil. Un sugar de 3
saptamani, cu febra 38.5 -> Full septic screen (bloods for FBC, U&Es,
CRP, BCs; urina - cateterizat; CSF). Registrarul meu a fost foarte
helpful si m-a ghidat pas cu pas; si am avut si noroc, tinand cont ca
sansa de reusita este doar de vreo 50%.
Sunt curios sa aflu maine rezultatele.

When does a case need to be reviwed by a senior?(either directly or by discussion)

When a child is referred they will either be admitted or sent home
after adequate assessment of their problem. What constitutes
"adequate" assessment cannot be prescribed in advance for all
situations. The most important guarantee that any problem has been
adequately assessed will be the competence of the person doing the
assessment.

When you have assessed a problem you need to reflect on your level of
competence in dealing with the, a) child, b) the family and c) the
medical condition. If you are happy on all 3 counts then you need not
ask the Registrar for advice before making a decision about
admission/discharge. We do not want to have one rule for all
situations but would expect people to practice safely.

Whether an individual SHO is happy to make the decision will differ
depending on how long they have been in this post, whether or not they
have previous paediatric experience (and how much, of what?), how many
similar cases they've dealt with before and how good their clinical
and communication skills are. One SHO will ask them about a problem
where a second one wouldn't. This is what the Registrars themselves
will expect to happen.

At the beginning of a job, even experienced SHOs should at the very
least discuss all cases with the Registrar in order to allow them to
gauge your competence. How long this continues will then decided by
explicit discussion between individual SHOs and Registrars. If the
Registrar wishes to know about all cases, their view supersedes that
of the SHO.

We all have to recognize our levels of competence and practice safely.
If you feel any hesitation about making a decision, you should err
on the side of safety and discuss the child with the Registrar.

Remember that if a child has been referred in by their GP, it is a
courtesy to phone the GP and explain why admission was not necessary.

Consider also that some families have come a considerable distance and
may be exhausted. This would be a consideration for families from
anywhere west of Corwen.

This advice applies equally well to inpatients reviewed by SHOs
because of a change in their condition (either improvement or
deterioration).

Remember that you must always discuss a child with your Registrar if
your assessment is that the child has a serious condition, even if you
are entirely happy with your assessment and further management.

All of what has been said above can be translated to the dilemma of a
Registrar considering whether they need to discuss a child with a
Consultant. Consultants have the same sorts of decisions to make when
they consider whether they need to talk to a tertiary specialist.
Every doctor has to be reflective about their own competence and
practice safely. We hope that this guidance will both support you in
asking for help when you need it, but also practising your skills when
you are more experienced.