TIPS for Emergencies

Dr. James Manos (MD)

April 17, 2020

                            TIPS for Emergencies

Image (public domain): This is the main patient area inside the Mobile Medical Unit in Belle Chasse, Louisiana. This configuration is an emergency department with minor surgery capability. Author: Robert Kaufmann. Date: October 25, 2005. Source: This image is from the FEMA Photo Library. Uploaded by the user Wikipedia Link: https://ro.wikipedia.org/wiki/Fi%C8%99ier:FEMA_-_18213_-_Photograph_by_Robert_Kaufmann_taken_on_10-25-2005_in_Louisiana.jpg

(You may print these pages)

Patient name: Age: LMP (last menstrual period) (women of childbearing age):

Weight (especially if child): Address: Cell phone:

HISTORY 

Subjective symptoms?/ First time?/ When did it start?/ Has it worsened?/ Other in the family or environment with the same symptoms? Hazards? Need for decontamination? / Count pain from 1 to 10 scale. // Any rash recently, e.g., measles encephalitis. 

Vitals

Pulse, respiratory rate (RR), blood pressure (BP), temperature (T), glucose (initially with finger stick), SaO2 (oxygen saturation)

High temperature: malignant hyperthermia (e.g., from the anesthetic halothane or the depolarizing muscle relaxant succinylcholine); people taking neuroleptics may develop malignant neuroleptic syndrome with hyperthermia; those who abuse illicit drugs, including cocaine and amphetamines such as Ecstasy, may also have hyperthermia)

(S)AMPLE

Signs  & Symptoms

Allergies (including drugs, bees, nuts, seafood, etc.)

Medications (anything, including non-prescribed drugs, herbs & lifestyle such as for sex (especially in case of myocardial infarction) or obesity (amphetamines?)

Past medical history (PMH)

Last meal (When? What? Any others with the same symptoms?)

Events and environment-related (e.g., to injury) (What happened? kinetics on traffic accident):

Α (Airway & cervical immobilization when needed)

1. Airway (Patent & Safe? Threatened? Obstructed?)

2. Do you suspect any cervical injury? (If yes, place a collar). A person riding a motorbike and involved in a traffic collision wearing a helmet also needs a collar after the removal of the helmet by skilled rescuers.  

3. Tracheal position (in the middle? Deviation? (tracheal shift towards the opposing side in tension pneumothorax)    

4. Jugular Veins Distension (JVD?) (Congestive Heart failure? Cardiac Tamponade? Tension Pneumothorax?) It may not appear in severe hypotension, e.g., from hypovolemia.

5. Kussmaul’s sign (increased JVP during inspiration) (cardiac tamponade? constrictive pericarditis? restrictive cardiomyopathy?) Beck’s triad in cardiac tamponade: hypotension, jugular vein, distention, distant, and muffled heart sounds.

B (Breathing)

1. Respiratory rate (RR)

2. Depth of breaths (shallow?)

3. Labored breathing (Accessory breathing muscles? Intercostal, sternal, and subcostal retraction or recession?)

4. Paradoxical breathing (‘seesaw,’ rocking, with the belly)? Nasal flaring? Head bobbing or grunting on babies?)

5. Bilateral equal chest expansion? (pneumothorax?)     

6. Decreased chest expansion (asthma/COPD?)

7. Lung auscultation: Bilateral equal breath sound (apices & bases)? (if not, consider pneumothorax)

8. Lung percussion (dullness? Stony dullness? //// Hyper-resonance? (consider pneumothorax) tympany? (consider tension pneumothorax)

9. Oxygen saturation (SaO2)

10. Place oxygen mask or nasal cannula (keep saturation > 90%)

Notes

1. Blood with chocolate, brown color may indicate methemoglobinemia. There is cyanosis with falsely normal arterial oxygen tension (PaO2), but the oxygen saturation may be low or overestimated. The key feature is the disparity between those 2. Pulse oximetry measurements with low levels of methemoglobinemia often result in falsely low values for oxygen saturation and are often falsely high in those with high-level methemoglobinemia. Cyanosis does not improve with the administration of Oxygen. 

2. In the case of carbon monoxide (CO) poisoning, carboxyhemoglobin causes pulse oximeters to register artificially high oxygen saturation (Spo2) values. Blood gas oxygen tension (PO2) measurements tend to be normal. A carboxyhemoglobin (HbCO) measurement is essential for determining exposure. Do not forget to check the ECG & cardiac markers.

There are special pulse oximeters that measure methemoglobin and carboxyhemoglobin (HbCO)

3. Cyanide poisoning may occur from smoke inhalation of burned wool, paper, cotton, silk, and plastics and consuming stone fruit seeds of Prunus species such as bitter almonds. Patients with cyanide poisoning present with respiratory distress and normal oxygen saturation, while the arterial blood gases ABGs may show anion gap metabolic acidosis. Cyanide toxicity is characterized by normal arterial oxygen tension and abnormally high venous oxygen tension, resulting in a decreased arteriovenous oxygen difference (less than 10%). 

C (Circulation)

1. Pulse Rate 

2. (first, the radial, if undetectable, try carotid – shock? Cardiac arrest?)

3. Pulse irregular? (atrial fibrillation (irregularly irregular) or flutter?)

4. Is pulse fast and thready? (hypovolemic shock?)

5. Pulsus paradoxus (decreasing pulse or systolic pressure fall > 10 mmHg during inspiration)? (cardiac tamponade? Constrictive pericarditis? Severe asthma? Tension pneumothorax? Pulmonary embolism?

6. Puslus alterans? (heart failure due to increased resistance to LV ejection, as occurs in hypertension, aortic stenosis, coronary atherosclerosis, and dilated cardiomyopathy)

7. Postural (orthostatic) hypotension (supine for 3 min, then erect for 1 min, increase on Heart Rate >_ 30 bpm, or decrease of Systolic BP> 20 mmHg or if Systolic BP < 90 mmHg)? If yes: Hemorrhage or severe dehydration? (it may be an early sign) Autonomic neuropathy? Medications?  

8. Dehydration? Initial signs/symptoms include thirst, dry tongue/buccal mucus membranes, decreased skin turgor, and reduced urine output. Severe dehydration signs include tachycardia, fast–thready pulse, little or no urine output, sunken eyes or fontanelles, orthostatic hypotension, hypotension, decreased capillary refill, mottled skin, and coma. The skin may be dry on the elderly, not necessarily indicating dehydration. The mouth may be dry (xerostomia) from Sjogren's syndrome or anticholinergic medications, including TCAs (tricyclic antidepressants).  

9. Difference in BP/ Radial pulse delay between upper extremities? (radio-radial delay). Causes include aortic dissection, subclavian artery stenosis, coarctation of the aorta, atherosclerosis (elderly), peripheral arterial disease (PAD), and other cardiovascular conditions.

Brachioradial delay? The right brachial and right radial pulse are simultaneously palpated. The radial pulse is felt after the brachial pulse in severe aortic stenosis. 

10. Delay in pulses between upper and lower extremities (radio-femoral delay). Causes include aortic dissection, coarctation of the aorta, thrombosis/embolism/ atherosclerosis of the aorta/ aortoarteritis, peripheral arterial disease (PAD), and other cardiovascular conditions.

Also, if the BP of the legs (lower calf) is higher than the BP of the arms, this may indicate aortic regurgitation. If it is lower (as in ankle-brachial index in PAD), the same causes as the pulse delay between the upper and lower extremities may be responsible (See (10)). 

11. Difference in femoral pulses between two lower extremities? (ruptured aneurysm? atherosclerosis?) Note: The presence or absence of femoral pulses cannot be relied on in establishing a diagnosis of a ruptured abdominal aneurysm since femoral pulses have been known to remain unchanged even though there was a rather massive extravasation of blood at the site of rupture. Pulsatile abdominal mass (abdominal aneurysm), groin mass (femoral aneurysm?), or popliteal fossa (popliteal artery aneurysm). 

13. Flank ecchymosis (Grey Turner sign)? (represents retroperitoneal hemorrhage)(Acute pancreatitis? Retroperitoneal hemorrhage? Aortic rupture from ruptured abdominal aortic aneurysm? Blunt abdominal trauma? Ruptured ectopic pregnancy? Spontaneous bleeding from coagulopathy?) Cullen's sign (hemorrhagic discoloration of the umbilicus) (Acute pancreatitis? Hemorrhage from blunt abdominal trauma? Aortic aneurysm rupture? Ruptured ectopic pregnancy?)

14. Heart auscultation: heart sounds (Audible S3/ S4? Loud S1/S2? Soft S1/S2? Normal splitting of S2? Widely or Reversed Splitting of S1?) Mid-systolic click? Ejection click? S3?S4? (gallop).

15. Murmur (diastolic? systolic? Continuous? Expands at the axilla or carotids?)? Thrill? Carotid bruits?

16. Apical impulse (displaced? Apical thrust? Double systolic? Sustained lift? Dyskinetic?)

17. PR (per rectum) examination in case of suspected gastrointestinal hemorrhage.  

18. Connect the patient on a monitor: 12 lead ECG (in the case of a cardiac arrest, you attach pads/paddles of the defib – ‘quick look!’)

19. IV access, take blood for Labs (also blood pregnancy test if indicated; blood type & crossmatch if hypovolemia)

20. Urinalysis (stick) (increased urine protein in pregnancy or early puerperium may indicate pre-eclampsia)                                  

                   

21. Glucose finger stick (hypoglycemia may mimic stroke)

22. Is Capillary refill time (index) prolonged? (> 3 min) (normal range<_3) (prolonged: hypovolemic shock?)

23. Color and temperature of the skin (cold & clammy? (hypovolemic shock?) /// Peripheral cyanosis? Central cyanosis (mouth, tongue)?)

24. Signs of cardiac failure (ankles edema, basal rales at lungs, jugular vein distension, pulsus alterans, and on children liver enlargement)?

25. ΑΒGs (arterial blood gases)

D (Disability) 

AVPU (Alert/ responds to vocal stimuli/ to pain/ unresponsive) or GCS.

Also, pupils' size & reaction. Opioids and organophosphates will cause small pupils (pinpoint on opioids; pontine hemorrhage also causes pinpoint pupils).

LOC (level of consciousness): Confusion? Stupor? Comma? Do not forget the Babinski reflex (plantar) in comatose patients to exclude, for example, a stroke. 

Abnormal posture of flexion or extension?

Note: blood ammonia levels may be requested to investigate unexplained neurological dysfunction (including inherited errors of metabolism and hepatic encephalopathy).

GCS (Glasgow coma scale)

Eye Opening (E4). 

Response to pain is checked by pressing the patient’s nail bed with a pen. If there is no response, try supraorbital pressure and sternal pressure. Be careful about eye drop use, eye operation, or fake eye!

4 0 – 1-year old: spontaneously; > 1-year-old: spontaneously

3 child: to sound; adult: to verbal command (in response to voice but not 

 necessarily to ‘open your eyes’)

2 all ages: to pain

1 all ages: no response (does not open eyes)

NT: not tested, e.g., severe trauma to eyes, enucleation. 

Best Verbal Response (V5)

5 0 – 2-year-old: coos and babbles; 2 – 17-year-old: orientated and appropriate; adults: oriented to time, person, and place, converses normally

4 children: irritable cries; 2 – 17-year-old: confused; adult: confused and disoriented but able to answer questions

3 <2-year-old:  cries in response to pain; 2 – 17-year-old: incomprehensible words; adult: inappropriate words

2 <2-year-old: moans in response to pain; 2-year-old - 17-year-old: incomprehensible sounds

1 all ages: no response (makes no sounds)

NT: not tested, e.g., intubation, non-oral language disability, linguistic barrier

Best Motor Response (M6).  

The motor response may be, e.g., ‘raise your hand.’ It is the better response of any limb. Be careful of paralysis and grasp reflex.

6 0 – 2-year-old: moves spontaneously and purposefully; >2-year-old: obeys commands

5 <2-year-old: withdraws to touch; >2-year old: moves to localize pain 

4 all ages: flexion/withdrawal from painful stimuli

3 all ages: decorticate posture (abnormal flexion)

2 all ages: decerebrate posture (abnormal extension) 

1 all ages: no response (makes no movements ) 

NT: not tested, e.g., paralysis/hemiparesis (acquired causes such as post-stroke, post-neurological injury; congenital/innate such as cerebral palsy)

Score: min 3, max 15. If GCS<_8 the patient needs intubation (RSI rapid sequence intubation if GCS > 3).  In the case of head trauma, GCS <_8 indicates a severe injury, GCS 9 –12 moderate injury, GCS 13–15 minor injuries. 

Tracheal intubation and severe facial/eye swelling or damage make testing the verbal and eye responses impossible. In these cases, the score is given as 1 with a modifier attached (e.g., "E1c", where "c" = closed, or "V1t" where t = tube). Often, the 1 is left out, so the scale reads Ec or Vt. A composite might be "GCS 5tc". This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for "abnormal flexion."

Stroke assessment

Confusion/ decreased LOC (Level of consciousness)? Limb weakness/ paralysis? Slurring speech? 

Cincinnati Prehospital Stroke Scale

1 of the following suggests the possibility of stroke:

a) Facial droop (‘smile’)

b) Arm drift (‘raise both arms with your eyes CLOSED’)

c) Speech (slurred, mute, inappropriate words, dysarthria).

3. Symptoms NOT improving spontaneously (differential diagnosis with TIA transit ischemic attack).

ABCDs, glucose finger stick, check electrolytes, and BP. Do not give D5W (5% dextrose)

E (Expose/ Environment) (+call Expert!)  

Remove the patients’ clothes. Check the skin for injury, rash, petechiae, hives, etc. In the case of trauma, skilled rescuers should Log – Roll (with the spine aligned) the patient and check the back. Then, with blankets, prevent hypothermia.

Other Signs

Dark or tea-colored urine with positive Hb urine stick? (rhabdomyolysis) (increasing amounts of blood by urinalysis progressively raises the probability of myoglobinuria, especially in the absence of hematuria)     

Delay of expected LMP (Last Menstrual Period): Ectopic? Molar pregnancy?   

Fetor/ odor, e.g., hepatic (like sweet musty); Ketotic in diabetic ketoacidosis (like fruit); cyanide poisoning (like almond), ammonia in chronic kidney failure/ uremic (like urine or fishy), hydrogen sulfide poisoning (like a rotten egg), phosgene poisoning (like mown hay). 

Kussmaul respiration (Diabetic ketoacidosis?)

Cheyne Stokes respiration? 

Babinski (upgoing plantar)? (Stroke?)  

Ocular movements, convergence & adaptation (stroke?) 

Lateralizing signs? (stroke?))

Meningeal (meningitis) signs?

Nystagmus/ vertigo? (Ear? Central nervous system?)

Asterixis (flapping)? (liver failure?)

PR (per rectum) examination (rectum, prostate, sphincter tone)

Treatment - Medications 

Date, time, and place of examination

Doctors’ name and signature

Reference:

BIBLIOGRAPHY

1) Longmore M., Wilkinson I.B, Davidson E.H., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 8th edition, 2010.

2) Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw Hill - LANGE, 6th edition, 2008

3) Ramrakha P., Moore K., Oxford Handbook of Acute Medicine, Oxford Medical Publications, 2nd edition, published 2004, reprinted 2005.

4) ALS (Advanced Life Support), European Resuscitation Council, 5th edition, The Image Factory, Belgium,2006.

5) EPLS (European Pediatric Life Support), European Resuscitation Council, 3rd edition, The Image Factory, Belgium, 2006.

6) Llewelyn H., Aun Ang H., Lewis K., Al–Abdulla A., Oxford Handbook of Clinical Diagnosis, Oxford Medical Publications, 2006.

7) Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008.

8) Richards D., Aronson J., Oxford Handbook of Practical Drug Therapy, Oxford Medical Publications, 2008.

9) ATLS (Advanced Trauma Life Support), American College of Surgeons – Committee on Trauma, Students Course Manual, First Impression, 7th edition, 2002.

10) PHTLS (Prehospital Trauma Life Support, basic & advanced), Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in association with The Committee of Trauma of the American College of Surgeons, 5th edition (revised), Mosby, inc, 2003.

11) ALSO (Advanced Life Support in Obstetrics), American Academy of Family

Physicians, 4th edition (revised), 2006.

12) Kasper D.L., Braunwald E., Fauci A.S., Hauser S.L., Longo D.L., Jameson J.L., Harrison’s Manual of Medicine, McGraw–Hill, 16th edition, 2005.

13) Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.

14) Wyatt J.P., Illingworth R.N., Graham C.A., Clancy M.J., Robertson C.E., Oxford Handbook of Emergency Medicine, Oxford Medical Publications, 3rd edition, 2006

15) Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.

16) ACLS (Advanced Cardiac Life Support), American College of Emergency Physicians, Study Guide, 2nd edition, Jones and Bartlett Publishers, 2007.

Links  

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058018/

https://www.sciencedirect.com/topics/neuroscience/cyanide-poisoning

https://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2018-0475-OA

https://www.medscape.com/answers/204178-70238/what-is-the-role-of-pulse-oximetry-in-the-workup-of-methemoglobinemia

https://jamanetwork.com/journals/jamapediatrics/article-abstract/514678

https://emcrit.org/ibcc/methemoglobinemia/

https://www.sciencedirect.com/topics/veterinary-science-and-veterinary-medicine/capillary-refill

https://journals.lww.com/anesthesia-analgesia/fulltext/2011/07000/capillary_refill_time___is_it_still_a_useful.21.aspx

https://www.bjanaesthesia.org.uk/article/S0007-0912(17)48117-7/pdf

https://www.sciencedirect.com/topics/neuroscience/carboxyhemoglobin

https://www.uptodate.com/contents/carbon-monoxide-poisoning

https://www.ncbi.nlm.nih.gov/books/NBK513297/

https://www.sciencedirect.com/topics/medicine-and-dentistry/hypovolemic-shock

https://care.diabetesjournals.org/content/37/11/3124

https://www.ahajournals.org/doi/full/10.1161/JAHA.119.011991

https://emedicine.medscape.com/article/1175139-clinical

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5615427/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1031608/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716484/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127586/

https://www.annalsthoracicsurgery.org/article/S0003-4975(10)66558-7/pdf

https://fpnotebook.com/cv/valve/artcstns.htm

TIPS for patients in shock

Dr. James Manos (MD)

April 15, 2020

                      TIPS for patients in shock

Image (free to use): The Trauma Room in the E.R. of the University Hospital in Mannheim, Germany (September 4, 2009). Author: Belle Chasse, LA, October 25, 2005. Author: Director84. Uploaded by: Director84. Source: Wikipedia. Link: https://en.wikipedia.org/wiki/File:Schockraum_Uniklinik_MA.jpg

Investigations on patients with shock

Vitals (pulse, respiratory rate (RR), blood pressure (BP), temperature (T), glucose (initially with finger stick), SaO2 (oxygen saturation)

Blood glucose (initially fingerstick measure) 

ABGs (arterial blood gases) (e.g., if oxygen saturation is abnormal)

Place on a monitor (in Europe: Right for Red, YelLow for Left, and Green for splEen) & perform a 12 lead ECG. 

ECG (including V4R, if suspected right ventricular infarction) 

Limb electrodes mnemonic: ''Ride Your Green Bike''

Red: Right-arm – ulnar styloid process at the wrist

Yellow: Left-arm – ulnar styloid process at the wrist

Green: Left leg – at the ankle – medial/lateral malleolus

Black: Right leg – at the ankle – medial/lateral malleolus.

Blood for lab tests (also type & crossmatch if needed) 

HISTORY 

Subjective symptoms?/ First time?/ When did it start?/ Has it worsened?/ Other in the family or environment with the same symptoms? Hazards? Need for decontamination? / Count pain from 1 to 10 scale. // Any rash recently, e.g., measles encephalitis. 

(S)AMPLE

Signs & Symptoms 

Allergies (including drugs, bees, nuts, seafood, etc.)

Medications [anything, including non-prescribed drugs, herbs & lifestyle drugs such as for sex (especially in case of myocardial infarction in which PDE5 inhibitors, such as Viagra (R), may cause severe hypotension if nitrates are administered for chest pain) or obesity (amphetamines?)]

Past medical history (PMH)

Last meal (When? What? Any other with the same symptoms?)

Environment/ Events (e.g., surrounding the time of injury) (e.g., (What happened? // kinetics on traffic accident)

Imaging tests 

Chest X’ Ray (CXR) [(pneumothorax? (perform both inspiration and expiration XCR; on an expiratory film, a pneumothorax will appear relatively larger, taking up a larger percentage of the thoracic cavity), cardiomegaly? Widened mediastinum? Subcutaneous emphysema?], abdominal X’ Ray (AXR) (free air?), echocardiography (transesophageal echocardiography for aortic dissection), Focused assessment with sonography (FAST) in trauma, CT/ MRI.

Labs

CBC (FBC) (complete/ full blood count), BUN, creatinine, electrolytes (potassium K, sodium Na, magnesium Mg, phosphate P, calcium Ca – ionized or corrected for low albumin), coagulation studies (platelets, PT, APTT, INR, D’ Dimers), LFTs (lever function tests), CK, cardiac enzymes & markers (especially troponin), LDH, ESR, CRP, amylase (if increased check urine amylase), lipase (more sensitive than amylase for pancreatitis), serum lactate (may spuriously increase if the sample is hemolyzed), urine color (increased CPK with dark indicate rhabdomyolysis), urinalysis, cultures (in suspected sepsis take samples for cultures: blood, midstream urine, feces (if diarrhea), throat/ vagina/ sputum/ wound swab; also gram Stain, sensitivity to antibiotics), pregnancy test (childbearing age women – a positive test may also indicate ectopic or molar pregnancy), toxicology (aspirin, paracetamol, antiepileptics, digoxin, lithium, illicit drugs, etc.), drug levels (e.g. anticonvulsants, gentamycin, vancomycin, etc.), +_HbCO levels, +_ TFTs (thyroid function tests), cortisol/ ACTH levels, blood type & crossmatch (ask 4 – 6 units). 

Notes

1. Blood with chocolate, brown color may indicate methemoglobinemia. There is cyanosis with falsely normal arterial oxygen tension (PaO2), but the oxygen saturation may be low or overestimated. The key feature is the disparity between those 2. Pulse oximetry measurements with low levels of methemoglobinemia often result in falsely low values for oxygen saturation and are often falsely high in those with high-level methemoglobinemia. Cyanosis does not improve with the administration of Oxygen. 

2. In the case of carbon monoxide (CO) poisoning, carboxyhemoglobin (HbCO) causes pulse oximeters to register artificially high oxygen saturation (Spo2) values. Blood gas oxygen tension (PO2) measurements tend to be normal. A carboxyhemoglobin measurement is essential for determining exposure. Do not forget to check the ECG & cardiac markers.

There are special pulse oximeters that measure methemoglobin and carboxyhemoglobin (HbCO).

3. Cyanide poisoning may occur from smoke inhalation of burned wool, paper, cotton, silk, and plastics and consuming stone fruit seeds of Prunus species such as bitter almonds. Patients with cyanide poisoning present with respiratory distress and normal oxygen saturation, while the arterial blood gases ABGs may show anion gap metabolic acidosis. Cyanide toxicity is characterized by normal arterial oxygen tension and abnormally high venous oxygen tension, resulting in a decreased arteriovenous oxygen difference (less than 10%). 

What to rule out on shock:

A. HYPOVOLAEMIC SHOCK

If the patient is shocked, then has cool and clammy skin (e.g. nose, toes, fingers), tachycardia (> 100 bpm), prolonged capillary refill time (more than 3 sec), hypotension (Systolic BP < 90) if blood volume loss is > 30% (> 40% on children!), postural hypotension (a drop of Systolic BP> 20 mmHg on standing), confusion, decreased urine output (< 30 ml/h). 

TIPS:

1. For < 15% blood loss early indicator is pale skin; for 15 – 30% will be additionally clammy and cool skin, tachycardia (>100 bpm), increased diastolic BP with narrowed pulse pressure (systolic BP – diastolic BP), delayed capillary refill (normal if <_3 sec, prolonged if >3sec).  

2. Tachycardia may be obscured in hypovolemic shock if the patient takes beta-blockers.

I. Blood loss.

Causes

a) Traumatic blood loss.

1. Exsanguination, e.g., severe bleeding, scalp lacerations (especially in children), etc.

2. Hemoperitoneum.

3. Hemothorax.

4. Fracture, especially of the femur and pelvis. 

TIPS: Stop any visible hemorrhage and check for bleeding in the chest and abdomen. Perform CXR (chest X-ray), and FAST/ ultrasound. Check for pelvic or long-bone/ pelvis fracture. If so, do immobilization and consider PAST (anti-shock trousers). Consult an orthopedic surgeon.

b) Non-traumatic blood loss.

1. GI (gastrointestinal) bleeding.

2. AAA (Abdominal aortic aneurysm) rapture.

3. Ectopic pregnancy rapture.

TIPS

1. Any difference between the pulses/ blood pressure estimation between the upper extremities (aortic dissection? subclavian artery stenosis?) and also between the upper and lower extremities (aortic dissection? aortic coarctation?). Consider abdominal aortic aneurysm if pulsatile abdominal mass and/ or if there is any difference in femoral artery pulses. Perform ultrasonography.

2. Is there hematemesis or melena? Perform PR (per rectum) examination. Is fluid on the nasogastric (NG) tube bloody? Emergency gastroscopy may be needed.

II. VOLUME LOSS

Causes

1. Burns.

2. Heatstroke with dehydration.

3. Skin integrity loss.

4. Vomiting (dehydration).

5. Diarrhea (dehydration).

6. Decreased fluid intake (elderly, dementia, disability/ no access).

7. DKA (Diabetic ketoacidosis) with dehydration. Rule it out, especially on children (fruity breath odor?). On the elderly, rule out the hyperosmolar hyperglycemic state (HHS) characterized by severe hyperglycemia, hyperosmolality, and dehydration in the absence of ketoacidosis

8. Third space accumulation, e.g., ascites (e.g., on heart failure, nephritic syndrome, protein loss enteropathy, malnutrition). 

B. CARDIOGENIC SHOCK

The skin may be pale and cool (‘cold & wet’), but sometimes there may be a ‘wet & warm’ type from SIRS). 

Causes

a. Dysrhythmia.

1. Tachyarrhythmia.

2. Bradyarrhythmia.

b. Cardiomyopathy.

1. MI (myocardial infarction).

2. RV (right ventricular) infarction (Always on an ECG, place a V4R i.e., V4 lead on the right). Avoid nitrates, diuretics, and morphine, which will decrease blood pressure steeply!

3. Dilated cardiomyopathy

c. Mechanical problems

1. Aortic regurgitation from an aortic dissection.

2. Papillary muscle rupture after a myocardial infarction (MI).

i. Ventricular aneurysm rupture.

ii. Free wall ventricular rupture.

For patients not in cardiac arrest (i.e., for patients with a pulse), cardiovert any unstable tachyarrhythmia with synchronized mode. Place transcutaneous pacing for unstable bradyarrhythmia (until official IV pacing is performed if recurrence).

For cardiogenic shock, give oxygen 100% high flow; consider if thrombolysis is needed (e.g., massive PE pulmonary embolism; ischemic stroke); consider under consultation gentle fluid challenges (e.g., 250 cc fluids) if no pulmonary edema. CPAP or intubation and mechanical ventilation (e.g., severe pulmonary edema; inotropes; Intra-aortic balloon pump, PCI (on MI). Consult early a senior cardiologist. The main TIP before any intervention (especially diuretics, nitrates/ nitroglycerin (TNG), and morphine) is to check for hypotension that will deteriorate. For the same reason, ask for any drugs, including lifestyle medication for sex (Viagra, Cialis, Levitra)! Is there any known drug allergy?   

C. DISTRIBUTIVE SHOCK 

The skin is warm and red!

Causes

1. Anaphylactic shock. Laryngeal edema, stridor, wheezing, hives, urticaria, angioedema (ACE inhibitors? hereditary angioedema? – in the latter, give FFP fresh frozen plasma or c1 esterase inhibitor). Give IM adrenaline, fluids (crystalloids), raise legs, give 100% oxygen high flow, give β’ agonists (salbutamol) on wheezing, hydrocortisone.

2. Septic shock. Suspect SIRS (systemic inflammatory response syndrome) if >_ 2 of the following: T (temperature) > 38 or < 36 degrees Celsius, HR (heart rate) >90, RR (respiratory rate) > 20/min (or hypocapnia), WCC (WBC) > 12,000 or < 4,000 or > 10% bands. Sepsis is SIRS with infection. Septic shock is sepsis with hypotension (SBP< 90 mmHg) despite fluid resuscitation.

In case of an erythematous rash, exclude TSST1 toxic shock syndrome toxin 1 (keep in mind that toxic shock syndrome may occur after tampon use on women and in nasal packing left for time).

3. Neurogenic shock (spinal cord lesion, surgery, spinal trauma). On trauma, exclude first hypovolemic shock (bleeding in abdomen, chest), which is commoner. Neurogenic shock is characterized by hypotension, bradycardia, motor/ sensory level, decreased rectal tone, and warm skin. The TIP here is bradycardia. In neurogenic shock, there is hypotension, while in case of increased intracranial pressure (e.g., head trauma), bradycardia will be accompanied by increased BP and irregular, decreased respirations (Cushing triad).   

4. Toxins. Consider decontamination (eyes, skin: meticulous washing), hazards (decontamination in a designated spot), clothes removal, antidotes, gastric lavage? / Whole bowel irritation? / Active charcoal? Dialysis? The key here is to administer antidotes when needed. Intravenous lipid emulsion may help in some cases.

Opioids and organophosphates will cause small pupils (pinpoint on opioids; pontine hemorrhage also causes pinpoint pupils).

CO (carbon monoxide) may cause a headache as an early symptom. Sometimes, the patient may have cherry-red lips.  

Organophosphates are used as insecticides, medications, and nerve agents. Symptoms include increased saliva and tear production, diarrhea, vomiting, small pupils, sweating, muscle tremors, and confusion.

5. Drugs – vasodilation e.g., β’ blockers or calcium channel blockers. These may cause shock without tachycardia (especially if given both).

Endocrinological problems.  

6. Adrenal insufficiency (recent abrupt stop of cortisone, or not increasing it in stress situations such as surgery or trauma?).

7. Thyrotoxic coma (it may also cause hyperthermia and atrial fibrillation (AF)).

8. Myxedema coma (it may also cause hypothermia and bradycardia).

9. Hypoglycemia (it may mimic stroke and cause focal neurological signs such as hemiparesis). Before the official Lab tests, always perform a ward finger stick test initially.

10. Hypopituitarism (in pregnancy, consider Sheehan’s syndrome from severe blood loss during delivery). 

D. OBSTRUCTIVE SHOCK

Causes

1. Tension pneumothorax: unilateral decreased breath sounds, tracheal deviation (away from the pneumothorax; late sign!), unilateral hyper-resonance of the hemithorax on percussion, and also jugular vein distension (JVD) – if not hypovolemic!). Don’t wait for a CXR (chest X-ray)! Perform needle decompression, and next insert a chest tube. For a CXR, remember that an expiratory film, if feasible, may show a pneumothorax better.

2. Pericardial disease.

i. Cardiac Tamponade. JVD (jugular veins distension), muffled heart sounds, Kussmaul's’ sign (an increase of JVP on inspiration), low ECG voltage, electrical alternans on ECG, pulsus paradoxus (decrease of Systolic BP and pulse on inspiration). Trauma is a common cause. It may also be iatrogenic. Other causes are less common (renal failure - uremia, lung cancer, TB, etc.). Perform FAST/ ultrasound.

ii. Constrictive pericarditis.

3. Massive pulmonary embolism (PE). Hypoxemia, right ventricular strain on ECG, acute right ventricular overload, chest pain, cyanosis, syncope, hypotension, tachypnoea, tachycardia, JVD (jugular vein distention). Give unfractionated heparin IV. If massive, consider thrombolysis (e.g. with rTPA alteplase) or embolectomy (by a surgeon). Do D’ Dimers. Negative D – Dimers usually rule out a PE (negative predictive value). Check leg & pelvis veins for DVT (Deep Vein thrombosis) with a Doppler/ plethysmography. Risk stratification is the key to assessing pulmonary embolism/ DVT risk!

4. Auto-PEEP from mechanical ventilation!

GENERAL TIPS

Warm skin? If so, consider sepsis, neurogenic shock, anaphylactic shock, or medication overdose.

Rule out Poisons/ medication overdose or adverse effects/ illicit drug abuse, sepsis, and Adrenal Insufficiency.

JVD (jugular vein distension): exclude tension pneumothorax, cardiac tamponade, massive PE (pulmonary embolism), and CHF congestive heart failure (for heart failure, check for calf edema and fine lung crackles – end respiratory crepitations/ rales, especially at lung bases). JVD may not be visible in case of severe hypotension.  

ABGs (arterial blood gases)

Venous blood PH is usually 0,01 – 0,03 lower than arterial blood PH. Also, usually, PCO2 is 6 mmHg higher, and bicarbonate is 2 meq/L higher if using venous blood.

Anion gap is ([Na] + [K]) – ([Cl] + [HCO3]). Increased anion gap occurs on DM (diabetes mellitus), alcoholics, starvation, lactic acidosis, renal failure, exogenous toxins metabolized to lactate (cyanide – CN, CO, ibuprofen, strychnine, toluene, iron – Fe and INH - isoniazid), or exogenous toxins metabolized to acids (aspirin, methanol, ethanol, ethylene glycol, paraldehyde and rarely with isopropanol), severe hypotension, seizures, and hypoxemia.

Increased osmolar gap may occur in diabetic ketoacidosis (DKA; especially in children) and ethylene glycol, methanol, or ethanol, isopropanol poisoning. Osmolar gap ΔOsm = measured Osm – Calculated O

Delay in pulses between upper and lower extremity (radio-femoral delay) (Aortic dissection? Coarctation of Aorta? Thrombosis/embolism/ atherosclerosis of aorta/ aortoarteritis?) 

Brachioradial delay? (right brachial pulse and right radial pulse are simultaneously palpated: radial pulse is felt after the brachial pulse in severe aortic stenosis)

Is there any difference in femoral pulses between the two lower extremities? (Ruptured aneurysm? atherosclerosis?) Note: The presence or absence of femoral pulses cannot be relied on in establishing a diagnosis of a ruptured abdominal aneurysm since femoral pulses have been known to remain unchanged despite massive extravasation of blood at the site of rupture. 

Pulsatile mass? Pulsatile abdominal mass (abdominal aneurysm?) or groin mass (femoral aneurysm?), or popliteal fossa (popliteal artery aneurysm). 

Grey Turner sign (flank ecchymosis; represents retroperitoneal hemorrhage; examples with a positive sign are acute pancreatitis, retroperitoneal hemorrhage, aortic rupture from a ruptured abdominal aortic aneurysm, blunt abdominal trauma, ruptured ectopic pregnancy, spontaneous bleeding from coagulopathy?) 

Cullen's sign (hemorrhagic discoloration of the umbilicus; examples with a positive sign are acute pancreatitis, hemorrhage from blunt abdominal trauma, aortic aneurysm rupture, ruptured ectopic pregnancy)

Hyperthermia: Heatstroke may cause hyperthermia. Other causes of hyperthermia may include illicit drugs of abuse (e.g., cocaine, ecstasy), neuroleptic malignant syndrome, malignant hyperthermia from anesthesia (e.g., from the volatile anesthetic halothane or the depolarizing muscle relaxant succinylcholine), sepsis, thyrotoxicosis, pheochromocytoma, status epilepticus (prolactin levels will NOT be increased), psychotropics (SSRIs, TCAs, MAO-inhibitors) with serotonin syndrome, etc. Hyperthermia may be combined with rhabdomyolysis, especially in the case of illicit drug abuse.

Thanks for reading!

Reference:

Bibliography 

1) Longmore M., Wilkinson I.B, Davidson E.H., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 8th edition, 2010.

2) Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw Hill - LANGE, 6th edition, 2008

3) Ramrakha P., Moore K., Oxford Handbook of Acute Medicine, Oxford Medical Publications, 2nd edition, published 2004, reprinted 2005.

4) ALS (Advanced Life Support), European Resuscitation Council, 5th edition, The Image Factory, Belgium,2006.

5) EPLS (European Pediatric Life Support), European Resuscitation Council, 3rd edition, The Image Factory, Belgium, 2006.

6) Llewelyn H., Aun Ang H., Lewis K., Al–Abdulla A., Oxford Handbook of Clinical Diagnosis, Oxford Medical Publications, 2006.

7) Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008.

8) Richards D., Aronson J., Oxford Handbook of Practical Drug Therapy, Oxford Medical Publications, 2008.

9) ATLS (Advanced Trauma Life Support), American College of Surgeons – Committee on Trauma, Students Course Manual, First Impression, 7th edition, 2002.

10) PHTLS (Prehospital Trauma Life Support, basic & advanced), Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in association with The Committee of Trauma of the American College of Surgeons, 5th edition (revised), Mosby, inc, 2003.

11) ALSO (Advanced Life Support in Obstetrics), American Academy of Family

Physicians, 4th edition (revised), 2006.

12) Kasper D.L., Braunwald E., Fauci A.S., Hauser S.L., Longo D.L., Jameson J.L., Harrison’s Manual of Medicine, McGraw–Hill, 16th edition, 2005.

13) Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.

14) Wyatt J.P., Illingworth R.N., Graham C.A., Clancy M.J., Robertson C.E., Oxford Handbook of Emergency Medicine, Oxford Medical Publications, 3rd edition, 2006

15) Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.

16) ACLS (Advanced Cardiac Life Support), American College of Emergency Physicians, Study Guide, 2nd edition, Jones, and Bartlett Publishers, 2007.

          Links  

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058018/

https://www.sciencedirect.com/topics/neuroscience/cyanide-poisoning

https://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2018-0475-OA

https://www.medscape.com/answers/204178-70238/what-is-the-role-of-pulse-oximetry-in-the-workup-of-methemoglobinemia

https://jamanetwork.com/journals/jamapediatrics/article-abstract/514678

https://emcrit.org/ibcc/methemoglobinemia/

https://www.sciencedirect.com/topics/veterinary-science-and-veterinary-medicine/capillary-refill

https://journals.lww.com/anesthesia-analgesia/fulltext/2011/07000/capillary_refill_time___is_it_still_a_useful.21.aspx

https://www.bjanaesthesia.org.uk/article/S0007-0912(17)48117-7/pdf

https://www.sciencedirect.com/topics/neuroscience/carboxyhemoglobin

https://www.uptodate.com/contents/carbon-monoxide-poisoning

https://www.ncbi.nlm.nih.gov/books/NBK513297/

https://www.sciencedirect.com/topics/medicine-and-dentistry/hypovolemic-shock

https://care.diabetesjournals.org/content/37/11/3124

https://www.ahajournals.org/doi/full/10.1161/JAHA.119.011991

https://emedicine.medscape.com/article/1175139-clinical

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5615427/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1031608/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716484/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127586/

https://www.annalsthoracicsurgery.org/article/S0003-4975(10)66558-7/pdf

https://fpnotebook.com/cv/valve/artcstns.htm

AVOID the UK, Australia and the USA for specializing in medicine

Dr. James Manos (MD)

April 12, 2020

Why should a doctor better AVOID choosing the UK, Australia, or the USA for specializing in medicine?

Image (free to use): A medical professional wearing a surgical mask during a surgical operation to remove a hemangioma (at the California Pacific Medical Center) (February 8, 2007). Uploaded by the user:  Artur Bergman. Source: CPMC Surgery; Wikipedia. Link: https://en.wikipedia.org/wiki/File:CPMC_Surgery_(412142792).jpg

Abstract

Although an Australian, I advise international medical graduates against choosing the UK, Australia, and the USA to specialize in medicine as they do not show they need them! From this advice, specialists are excluded. Regarding the UK, the NHS system is on the verge of collapse, while they currently ask for experienced doctors even for junior posts! In Australia and the USA, foreign graduate doctors who wish to specialize there must take costly exams regardless of graduating from a Western or a developing country! The success rate in Australia is low, while the fees are exorbitant. Doctors should choose other Western countries that really need them, such as Sweden! 

Contents

a) The British National Health Service (NHS) is on the verge of collapse!

b) Why you should NOT choose the UK for specializing in medicine!

c) Why you should NOT choose Australia and the USA for specializing in medicine!

d) Private vs. Public healthcare: Which system is to the benefit of the patient?

e) Is there an optimal Western healthcare system?

a) The British National Health Service (NHS) is nearing collapse!

Overview

In the British National Health Service (NHS), things are predicted to deteriorate, as it is financially unsustainable, and some speak even about its (semi)privatization, as in the USA! In March 2016, junior doctors in the UK went on strike, complaining about pay cuts and exhausting working hours. In many Western countries, problems still show that healthcare systems are not flawless. In the UK, a junior doctor is paid annually only 32,400 dollars! With this meager income, a junior doctor should pay numerous obligations, such as paying nearly 1,000 dollars to rent a small apartment in London. 

The NHS has many problems. The most significant is underfunding. Another significant issue is that many posts, covered mostly by international doctors, are service instead of training. Hence, they are not educational, approved by the Dean, but we have a service type of doctor like an employee of a supermarket! 

It is doubtful whether the NHS in the UK is the best healthcare system. I am not sure if they are even satisfying! The question is, who does the rating? A healthcare system evaluation should be performed by independent international authorities such as the World Health Organization (WHO) rather than local, such as NICE in the UK.

Regarding the NHS in the UK, although its myriads of ‘standards,’ it has many flaws, such as the long waiting lists for surgeries, as well as the fact that most foreign doctors run the system offering service instead of sustaining official (having the educational and Dean’s approval) training. Another significant issue is the recent underfunding of the system, which has worsened after Brexit. Already, the wages and working conditions of junior doctors have caused frustration!

According to Public Health England’s annual health profile, British women have the lowest life expectancy in Europe at birth, at 83 years! The longevity in the UK is ranked 17th out of 28 European Union (EU) nations! Women born in England can expect, on average, to spend 19.3 years, 23 percent of their lives, in poor health! Statistics for men in the UK are slightly better.

The flaws of a Public Healthcare system

There is controversy over the ideal system; some argue it should be public, while others insist it should be private. In the US, contrary to common belief, the Medicare system is a public-private partnership, while the decisions to pay claims are made by private companies! Contrary, in the UK, the NHS is public. Both systems have flaws. Most important is their underfunding. The overpopulation in Britain and the increased demand to treat senior citizens with infirmities have brought the NHS system to its knees. Things in the UK are getting worse. The waiting lists for visiting a specialist and surgery are often so long that a patient may seek another European hospital overseas with a shorter waiting list.

Another consideration is that the UK healthcare system still has many problems, with underfunding being the most important. Guidelines and protocols differ in the UK. For instance, I read somewhere that the death of a patient in a ward can be confirmed without an electrocardiogram! In any case, although the UK system has myriads of standards, it is doubtful if they are all followed.  

The lack of a second medical opinion and avoidance of surgeries in the elderly! 

Often, people diagnosed with cancer or another severe disease, acute or chronic, do not seek a second medical opinion as either they neglect it or rely on and trust the first and single medical advice. 

Senior patients also have the right to a second opinion regardless of age, especially for life-threatening conditions. This is especially important when urgent or elective surgery is excluded. Otherwise, we can speak about a subtle form of euthanasia!  I recall a documentary about a senior British man who visited the ER suffering from mesenteric ischemia. Although this is fatal unless treated surgically, he was excluded from surgery due to various medical conditions (including epilepsy), i.e., comorbidities. Of course, he died. However, in this case, the patient had no choice but surgery, as no surgery condemned him to death. Things here are complicated, as many surgeons are assessed for their mortality rate and would avoid operations with a high mortality risk! But it should be the patient who should come first, not the statistics! 

I once asked a Southern European surgeon who works in the NHS if the elderly with cancer are treated as in his country. He replied that a surgeon in the UK might be reluctant to bring a senior patient into the operating room. However, in other countries, surgeons may be less reluctant! From my perspective, a relatively good cardiovascular condition and the lack of severe comorbidities should be considered in the elderly so that they are not excluded from surgery, at least in emergencies. 

Cardiovascular health should be investigated with ECG, Echocardiography, and pulmonary function tests, especially FEV1. That is especially important for life-threatening diseases such as cancer and CABG (coronary artery bypass) for heart problems. Of course, the patient will take the mortality risk. But the problem here is that if the mortality ratio of each surgery is documented, a surgeon will not be happy if a senior patient dies in the operating room (OR). Consequently, surgeons will discourage or refuse operations on elderly patients who otherwise are fit for surgery. That is a shortcoming of reporting mortality rates in operations.   

Doctors wearing casual clothes!

In the UK, you can see doctors without white coats or scrubs (like those surgeons wear). They simply carry a label with their name! Obviously, it is not for the benefit of the doctor's sanitation to wear casual clothes. A white coat protects the physician as well as the patient. From my perspective, wearing casual clothes with only an ID tag signifying that a person is a doctor is unacceptable. In the ER, at least an apron should be used for protection. 

They removed the lab (white) coat in the UK in 2007. But there are no convincing reasons for not wearing scrubs that are amazingly comfortable, speaking from my own experience!  Also, the UK has banned crocks (hospital-comfortable open shoes) since 2011! 

Doctors assessed strictly with an appraisal and revalidation system! 
Complaints against doctors just by clicking an option on the General Medical Council's webpage!

The appraisal and revalidation system has efficiently worked in the UK and should be an example for all countries. But the way that anyone can easily make a complaint by merely clicking the option on the General Medical Council may have, as a consequence, a doctor to incline to ''defensive medicine'' with an additional cost of unnecessary lab or imaging exams and interventions! 

Cost-effectiveness at the expense of human life?

A characteristic case of cost-effectiveness was during the coronavirus COVID-19 crisis that became a pandemic in the Spring of 2020. The UK delayed enormously imposing a lockdown, as it found it cost-effective not to do so! But when the death toll rose significantly, and even the Prime Minister was hospitalized in the ICU with pneumonia from the virus, it was then when they started some restriction measures! 

Notwithstanding, cost-effectiveness is mandatory as the health systems have already been brought to their knees because of the aging population. They struggle to provide expensive drugs, especially immunotherapy, which costs more than five hundred dollars per dose, while gene therapy, which costs 2 million dollars per dose, is inaccessible. However, this should not be done at the expense of the patient's safety, such as was in the controversy over depriving British patients of interferon for Multiple Sclerosis in the NHS. At the same time, in other European countries, it was widely used. A recent example is the new expensive meningitis group B vaccine that many health systems cannot afford, so families purchase it at their own expense. Concisely, cost-effectiveness should always be sought, but we should keep in mind that in medicine, humans come first, not the economy!

b) Why you should NOT choose the UK for specializing in medicine!

Overview

If you live in a Western country, you will waste your time if you choose the UK to practice medicine! Many people working in the NHS want to leave the system and travel overseas to a country with a better healthcare system! As I explained above, the NHS is on the verge of collapse or privatization! Regarding the NHS system, it is on the brink of collapse. Currently, hospital vacancies ask for experienced doctors, even in junior posts!

Competition

Competition for a medical post is very high, and the typical example that comes first to my mind is the UK, where there may even be some hundred applications for a single hospital post. In the last decade, competition has increased dramatically from international doctors, and this was aggravated by the migration surge towards Europe, referring to migrants from Europe (such as from the Balkans and Southern Europe) or migrants coming from countries outside Europe, such as from the Middle East, Asia, Africa, and even from South America!

So, foreign doctors participate as well in the reckless competition for the available hospital posts that, in this way, they become international! Because of the abundance of applicants, most of the available vacancies have been covered, while recently, most jobs appeal to higher-level doctors, specialists, and consultants. This is most striking in the UK.

Training (vs.) Service posts: wasting time on irrelevant, non-training posts until obtaining a specialty!

A problem standard in the UK is that most posts are not educational and Dean-approved but are service posts and consequently do not count in the estimation of the training years for completing a specialty! Most of the vacancies in the UK are LAS (locum appointment for Service) rather than LAT (locum appointment for Training). There is controversy over this matter, as some claim it is better not to have service posts, as all posts should be training. Doctors need training. There is controversy over the fact that posts that are not educational and Dean-approved do not count toward the overall period of medical practice. Regardless of service or training, all working years should be a specialization period.

Most NHS medical posts in the UK are service posts, so they do not have the educational and Dean's approval as training posts. So, even though the hospital says that they have a training aspect, it may or may not be a training post officially! That means that many doctors in the UK work in various service posts that are often irrelevant to the specialty they wish to practice. For instance, a doctor wanting to specialize in gastroenterology may practice medicine at various clinics, such as the emergency department, as most vacancies are clinical and require experienced doctors even at the Foundation Year 2 level! Usually, they demand recent NHS experience! Thus, a doctor in the UK may spend an overall 7 - 10 years on becoming a specialist, while in other countries, it may take only 5 to 6 years for most specialties!

Four-month contract, underpayment, and costly accommodation!

Another problem in the NHS of the UK is that most contracts are for four months to a maximum of one year. That means that usually, after four months, a doctor must change hospitals or reapply to the same one! Consequently, the medical training period is interrupted every 4 months until the adjustment to a new hospital.  

Additionally, many junior doctors complain that their wages in the UK remain low despite their strikes. But even for higher levels, the salary is not satisfactory concerning the highest wages in other Western countries or even the Middle East (such as in Dubai). Also considerable is the inflated cost of living in the UK, especially in London, where someone may pay nearly 1,000 dollars monthly to live in a small apartment! On the contrary, in the US, accommodation is more affordable to medics, while some may reduce costs by living with a roommate.

Overqualified doctors for junior posts!

The extreme number of international applicants in countries such as the UK means that many vacancies, even those involving junior doctors, are covered by overqualified doctors, even specialists! Qualifications such as MRCP exams and extensive experience are often desirable for posts referred to junior doctors, but they should not, as these are higher-level qualifications! 

A striking example that came to my attention was a service post (LAS) of Foundation Year 1 in general surgery in the UK that asked a trainee with clinical skills such as venipuncture, insertion of central lines, peritoneal drains, etc. These skills, of course, are extreme for a junior doctor on a foundation year one level. Referring to Foundation Year 1 posts, some vacancies require previous NHS experience. However, these posts apply to medical interns who are about to practice in hospitals without experience! Notwithstanding, as the number of medical graduates is high, especially from India, Pakistan, and Southeastern Europe, employers often ask for previous hospital working experience! 

All the above are related to the abundance of international doctors who apply for medical positions worldwide. Hence, hospitals are happy to use overqualified doctors for low-grade medical jobs, usually service posts, as the training educational and Dean-approved posts are the minority!  

The low wages of the medical staff and, in some cases, the unpaid overtime!

The salary of the medical professionals working in hospitals should be satisfactory. Otherwise, without a financial incentive, doctors feel frustrated, and their performance remains low.  In the UK, a junior doctor is paid only 25,000 pounds annually, nearly 32,400 dollars! With this meager income, a junior doctor should pay his or her numerous obligations. In the British NHS, things are predicted to deteriorate, as it is financially unsustainable, and some speak even about its (semi)privatization, as in the USA! 

In the last years, there has been a massive wave of medics from developing countries as well as from many developed countries (such as from Southern and Eastern Europe) aiming to work in developed countries such as in Southern and Central Europe and North America where they seek better wages in advanced health systems. 

Another issue is that some doctors may work overtime, but this extra workload may not be paid. 

Bank doctors with a ‘parachute landing fall’ to hospitals ‘when’ and ‘if’ they need them!

The new trend in the UK is the post of 'bank doctors.' No, they are not related to banks and finance! They are doctors who 'land with their parachutes' whenever and if needed ('when and if') to cover somebody's days off or leaves or in case a doctor is necessary for a specific clinic. So, these doctors do not have a particular residence, which raises the concern that a doctor comes to work in a hospital unfamiliar to them. Additionally, the bank post may be without a contract, meaning that the doctor can be easily fired!

Pre-interview via Skype or direct live interview?

When someone who has applied for a vacancy in countries such as the UK is called for an interview, it is prudent to ask for a video call pre-interview via Skype. This choice will prevent the applicant from wastefully spending money to travel to the UK and learning at the interview that they do not meet the elevated expectations of the hospital because most posts are covered by overqualified international doctors with sustained experience.

Vacancies for UK hospitals (application forms): could you tell me your ethnic origin, religion, and sexual orientation? 

When someone wishes to apply as a doctor for a hospital post in the UK, filling out the application form will meet the 'weird' question about their sexual orientation, religion, and ethnic origin! Recently, some vacancies ask asked if you intend to change sex, although changing sex is usually accompanied by changing the ID documentation.

The GMC (General Medical Council) asks the same to enroll as a doctor in the UK. For this article, I called the GMC and asked them why they asked these things, and they replied that they do it for statistical reasons to register the diversity. They assured me that this information was confidential. However, I still have not realized the necessity to ask these kinds of questions in the application form for a hospital post, and my consideration is primarily how an employer will assess this information. Apparently, this information is given to protect applicants from discrimination. But this should be obvious to everyone, regardless of providing or not this information. Protection should be provided anyway.

Difficult exams and certifications

Certifications, such as the MRCP (and FRCS for surgeons) in the UK, make things difficult for someone who wishes to complete a specialty and become a consultant. In the US and Canada, the USMLEs (steps 1, 2 & 3) tests are mandatory for someone who wishes to study medicine there. These difficult exams discourage many international students who want to live the American dream.

In the UK, most posts require NHS experience; many ask applicants to have passed the MRCP test (it has fees). Moreover, in the UK, the GMC (General Medical Council) needs, in some cases, the PLAB test. To prove English language proficiency, they need a remarkably high overall score of 7.5 and a minimum of seven on each of the four modules of the IELTS exams to enroll non-native speakers. However, it is not easy to achieve in ''writing part 2,' i.e., the essay! Surprisingly, the GMC does not recognize the US TOEFL exams, as if in the USA, they are speaking Chinese! Obviously, this happens because the IELTS was created by the UK and Australia! It should be mentioned that in the IELTS exams, the exam graders spare high grades in the essay, at least those equal to or higher than seven, which is the required grade in the ''writing'' part! 

c) Why you should NOT choose Australia & the USA for specializing in medicine!

Overview

Many international doctors, including those working in the NHS, consider Australia a place to specialize in medicine. This decision may be the right choice for specialists. But the decision for international medical graduates to take exams to specialize in Australia is a waste of time and money! The same is true for taking the USMLEs to practice medicine in the USA. 

Australia

A doctor from Finland who now practices medicine in Australia as a GP recommends choosing another country! You may read her daunting experience on What is some advice about an AMC (Australian medical certificate) especially sources of studying?

If you wish to take exams to specialize in medicine in Australia, you will waste your time and money! The pass rate for the MCQ exams is 58 percent. If you pass them, you will have only a 28 percent possibility of passing the clinical exams! The MCQ exams are supposed to equal the level of an Australian graduate. But this can be doubted, as these exams ask for information that only a generalist would know, not even a GP or an internal medicine doctor! They ask for things from all fields, including surgery, general practice, internal medicine, pediatrics, psychiatry, obstetrics, and gynecology. The MCQ tests are delivered in a 3.5-hour session. That means you will have 84 sec to answer each of the 150 questions that may be difficult! For example, you may even be asked to interpret a CT scan! That means whether an Australian medical graduate has an excellent theoretical and clinical knowledge of all specialties or the exams are an excuse for the AMC to decrease the passing rate to a dwindle! The latter seems more reasonable. 

The AMC in Australia accepts without exams only medical graduates who have practiced medicine for at least one year in the UK. It also accepts medical graduates from New Zealand, Canada, or the US who do not need to take exams. They may ask some candidates to pass the PLAB test. But medical graduates from countries other than the above are asked to sit written (like USMLEs in the US) and clinical (like PLAB test but harder) exams that are costly. Obviously, the system does not give a damn if you come from a Western country, as you will take costly exams along with medical graduates from developing countries. 

In other words, it is as if they consider European medical graduates incompetent, asking them to take exams along with candidates from developing countries, including India, Pakistan, Bangladesh, countries of Africa, non-EU members from the Balkans, etc. Also, as mentioned, the success rate is low, and the whole preparation to take exams means a waste of time and money.

The total cost for this venture (exams, books, traveling to Australia for the clinical test, and paying all the required fees) with a low probability of success is at least 5,000 US dollars! Additionally, the system requires one year of clinical practice in Australia! But these posts are scarce. Perhaps it was something like rural service in the past, but recently, vacancies can be found everywhere, not only in the provinces. The Australian Medical Council, apart from IELTS, recognizes TOEFL (IBT), but it needs an extremely high mark on the ‘’writing’’ section (essay). It should be mentioned that the British and Australians have created the IELTS test, which explains why they prefer their exams to other international ones! In the IELTS exams, the exam graders spare high grades in the essay, at least those equal to or higher than seven, which is the required grade in the ''writing'' part! 

The USA 

It is doubtful whether the US healthcare system is the best. It may not even be satisfying! The question is, who does the rating? The evaluation of a healthcare system should be performed by independent international authorities, such as the World Health Organization (WHO), rather than local, such as NICE in the UK.

In the US, the Medicare system is manipulated by insurance companies that aim to spend less on patients’ treatment. This tactic adversely affects their health when important lab and imaging tests and interventions are omitted! Additionally, before the ‘Obama Care’ in 2010, uninsured patients had no access to healthcare, while those treated for emergencies were dumped from the hospital after recuperation! US resident doctors (not specialists) are also said to be treated like slaves!

The latest statistics in the US show, as in the UK, that the figures are unsatisfactory. Americans' new average life expectancy is 78.7 years, ranking the US behind other developed nations and 1.5 years lower than the Organization for Economic Cooperation and Development (OECD) average life expectancy of 80.3!

In the US, before Obamacare, uninsured patients were dumped from hospitals after receiving first aid! Statistics show that healthcare expenditure in the US is the highest compared to other countries. However, a considerable proportion of the population, including children and the impoverished, are uninsured or ''under-insured''! For example, this may be an individual's choice to work without insurance in a job or as a freelancer, with the former being illegal and the latter a reckless decision that the uninsured will understand eventually when he or she becomes old or if an unexpected illness or injury comes.  

Putting all together, an ideal system is between private and public, with cooperation in receiving patients and undertaking lab and imaging exams. 

The USMLE exams to practice medicine in the US

In the USA, international medical graduates need to sit the USMLE exams, which are costly. As in Australia, the system does not give a damn if you come from a Western country, as you will take the extravagant exams along with medical graduates from developing countries! The rate of success is better than in Australia. Nevertheless, the whole preparation to take exams is a waste of time to prepare for the 2 steps and a waste of money to pay the fees.

d) Private vs. Public healthcare: Which system is to the benefit of the patient?

Let us imagine a patient who suffers from a medical problem and is hospitalized. In a public hospital, the patient will be treated well. Still, when the hospital is overcrowded, less attention may be paid, and earlier discharge may occur, as every empty bed is valuable! Suppose the patient needs to be hospitalized in an ICU (intensive care unit). In that case, specific criteria may exclude him or her, such as extreme age, ominous prognosis, if the illness is incurable, etc. 

Suppose the same patient is hospitalized in a private hospital and can afford to pay his or her expenses without the interference of a private insurance company. In that case, the patient can receive optimal treatment in a well-organized private hospital with more skilled doctors (mostly specialists), and ICU admission criteria may be less strict! However, in case the private hospital's expenses are paid by a private insurance company, then healthcare may be suboptimal, as the insurance company will cut many costs that are not always unnecessary. That means the patient will receive at least the basics. However, depriving the patient of the expensive lab and imaging tests or access to the ICU (in which the daily cost is enormous, for example, it may be $ 3,000 per day) may affect the outcome. 

As mentioned above, the ideal system may be between a private and a public healthcare system. But as public or private insurance is associated with pensions and healthcare, things are more complicated, and since the population is aging, it may render unsustainable as in the UK! 

e) Is there an optimal Western healthcare system?

I am unsure if there are any satisfying Western healthcare systems, as the problem is who does the rating, i.e., if it is independent. In any case, countries such as Scandinavia, Canada, Australia, and New Zealand allocate public funds from taxation to finance their national health system to which everyone has free access. These countries have succeeded in providing a satisfying level of effective healthcare for their citizens, not theoretically as in the UK. In contrast, the NHS system still has many problems, with underfunding being the most important. 

Conclusion

Although an Australian, I advise international medical graduates against choosing the UK, Australia, or the USA to specialize in medicine as they do not show they need them! From this advice, specialists are excluded. Regarding the UK, the NHS system is on the verge of collapse, while they currently ask for experienced doctors even for junior posts! In Australia and the USA, foreign graduate doctors who wish to specialize there need to take costly exams regardless of graduating from a Western or a developing country! The success rate in Australia is low, while the fees are exorbitant. Doctors should choose other Western countries that really need them, such as Sweden! 

Thanks for reading!