Hierarchy Of Evidence

Evidence-based medicine is the conscientious and judicious use of current, best research evidence to optimise management plans.
Here’s the order of importance.

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That’d be all.

- Ashish Singh

Reference(s):
1. Evidence based medicine: what it is and what it isn't by Sackett et al, 1996.

Unique iris behavior in bleeding

Iridodialysis bleeds profusely as the circulus major arteriosus lies near it's root.
Conversely, sphincterotomies or YAG iridotomies hardly bleed. Why? Because the vessels in the iris away from it's root are intertwined within it's musculature. The muscles contract immediately, halting any hemorrhage.

-Sushrut 

Burnout Advice.... Jay's 2 cents s/p reading Ikan's post

Burnout is a very common thing among us medicos. That spans from being a medical student upto a resident or even a consultant sometimes!

We feel stupid most of the times and some of our seniors have that bad habit of making the juniors feel bad.

But trust me, you WILL become as good as them, and even better! Medical field needs experience and alot of reading. Med school teaches us maybe 1/10th of what we should know as a doctor. And the remaining we learn on the job.

There is always more to learn more to read and more to understand but medicine is not a lonely game. Always refer, and ask! In Medicine, 2 brains are always better than 1 brain. Don't feel shy or bad to ask for help.

Use your head! If they belittle you, tell yourself you will learn it. Smile and move on.

For me each time I lose motivation, I watch an episode of a Medical TV series. It could be HouseMD, The Resident, New Amsterdam, Good Doctor, Chicago Meds, or any random episode I find in Youtube.
Watching them gives me the feeling of impact I can have in others' lives.

I also go through Youtube videos from famous Medical youtubers, few of my favorites are Jane and Jady, TheStriveToFit, Ali Abdal, DoctAura etc. They have amazing study tips and other medical related things that can give you the motivation to read and learn.

Sometimes I go through #Studygram handle in Instagram. There are many colourful notebooks and workspaces, it really inspires me and gives me a free mind to study.

I also like to read the study tips written by my fellow authors. They have eye opening and motivational tips that really makes me go sit and get that one chapter done.

If all these don't work, just listen to your favorite songs and move your body a little bit when your room mates are not watching! 😂 It definitely gives some positivity to shrug off that sad burnout feels.

Yes! I find most of my inspiration and motivation by online activities rather than going out and resting under the trees. One reason being Im not a very outgoing person and another being I have very little time as a Junior Intern.

And also it helps to clean your room. And cooking a meal for you and/or your family/partner. It would leave you with a clutter free environment and a tasty meal to eat. And if things go well, a lot of praising for your yummy food by others with make your self esteem get better too.

Then get a yummy dessert or make one. Sometimes I just eat a slice of custard cake on my way home, or cook a simple bread pudding and share with my roomies. Although they jump into finish it
and finally leaving me a little piece. ( Those two a-holes!!! 😂😂)

You don't need a trip to beach or hike to mountain, but sometimes sleep on a cozy bed with newly washed sheets, after a warm bath, applying your favorite night lotion, a drop of nice smelling essential oil behind your ears and wearing relaxing clothes will refresh you too.

These are few of my techniques to feel good after a toxic day with disastrous rounds.

Confession : I have had my fair share of bad days. I was punished for silly mistakes. I was sanctioned with extension of duty and forced to work extra hours to compensate for it. But we gotta accept our short comings, learn from our mistakes and move on. We at Medicowesome are not saints or gods to dictate how you should live and everyone of us had made errors, said wrong things in rounds, got shouted at, failed exams, and some of us even went through psychiatric help to get over any of the depressive periods we had

But what is most important is, NONE of us gave up! I take this time to thank my Medicowesome family for helping each other and even helping me rise up in such times when I was so low. Behind the groups and the blog, we are an amazing group of friends although many of us have never met each other. Medicowesome is my support group, and we all need one including you. Find your supportive group, and for the records don't forget we at Medicowesome as also on your back, ready to hold you up.

Stay strong and comment or message us about your methods of tackling a toxic day or a burn out session. So we all can learn from it.

Keep it up! Take care and always....be awesome!

With love,
-Jay

Residency and burn out advice

Here's a conversation I had with a friend of mine. She's a resident in a busy government hospital in Mumbai.

I still feel like Jon Snow (I know nothing). I feel like I'm stuck at the basics. And seniors expect a lot. It is somehow unfathomable to me that someday I will be even one tenth as smart as them. Morning rounds as a massacre. It's like beheading my already non existent self confidence. I feel so stupid everyday. I have no energy to study.

I'm trying so hard to not let it get to me but everyday I get to hear criticisms either from professors or immediate seniors. I wasn't born stupid Nakeya but everyday I feel like I've bitten off more than I can chew and chosen a career that's too difficult for me. I feel thoroughly demotivated these days. Like I'm just working because I have to. I feel like I've lost interest only to improve and be better everyday.

Me:
It's OKAY to feel stupid. I think it's everyone of us. It's a part of learning. Indian culture has not developed a way to give constructive feedback... So you got to modify the words they say and take it in a way that motivates and inspires you. It's... I'm pretty sure it's just the culture that makes you feel more stupid than you should feel. The career is not difficult. The training is. You're not stupid. The way they teach is!

We do this thing every week - We share our humanistic experiences with everyone. It could be as simple as holding grocery bags for an old lady.  It really helps. We tend to think about the things we did wrong and belittle ourselves. But we need to think about the good things we did. The things we did right. Made a baby smile when they were sick. Made a correct medical decision. Got the IV in the first go. We need to celebrate the little things.

Take time off from medicine and rest whenever you get a chance.

-IkaN

Asking Questions

History taking in medicine is science just as much as art. Here are some tips.

DOs

Open questions: ‘How are you?’ ‘How does it feel?’
The direction a patient chooses offers valuable information.
‘Tell me about the vomit’
‘It was dark’
‘How dark?’
‘Dark bits in it’
‘Like...?’
‘Like bits of soil in it’
This information is gold although it does not cast in the form of coffee grounds.

Patient-centred questions: Patients may have their own ideas about their symptoms, how they impact and what should be done. This is ever truer as patients frequently consult Dr. Google before their physicians. Unless their ideas, concerns and expectations are dealt with, your patient may never be fully satisfied with you or be fully involved in their own care.

Considering the whole: Humans are not self sufficient units; we are complex relational beings, constantly reacting to events, environment and each other. To understand your patient’s concerns, you must understand their context: family, friends, work, dreams and fears. A headache caused by anxiety is best treated not with analgesics; but by helping the patient access support.

Silence and echoes: Often the most valuable details are the most difficult to verbalise.
Trade secret: the best diagnosticians in medicine are not internists, but patients. If only the doctor would sit down, shut up and listen, the patient will eventually tell him the diagnosis.
While powerful, silence should not be oppressive- try echoing the last words said to help your patient vocalise a particular thought better.

DON’Ts

Closed questions: Permit no assumptions. Take no subtle information for granted. Let the patient paint you a picture.

Questions suggesting an answer: The doctor’s expectation and hurry to get the evidence into a pre-decided format have tarnished the patient’s story enough to render it useless.

- Ashish Singh

Pathophysiology: Diabetic Ketoacidosis

Hello guys, here’s a whiteboard summary of how DKA happens.

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- DKA is a medical emergency. It’s a complication of type 1 diabetes.
- DKA has a triad of hyperglycemia, ketosis [metabolic acidosis] and dehydration.
- Main ketone bodies are beta-hydroxybutyrate and acetoacetate. Acetone is only a minor ketoacid.
- Lactic acidosis also contributes to metabolic acidosis.
- More glucose in blood leads to more glucose filtered into urine causing osmotic diuresis.


- Ashish Singh 

Burkitt’s Lymphoma types

There are three types of Burkitt’s Lymphoma: Endemic (African), Sporadic  (non-endemic) and immunodeficiency-associated.

Molecular mayhem - AML relapse after HSCT

For many hematological disorders including AML, CLL, ALL HSCT is the only viable therapeutic option when cytogenetics are not conducive for chemotherapeutic agents. However subsequent relapses are not uncommon which are due to subtle molecular alterations because of underlying and acquired mutations.

WhiteBoard Summary: Lichen Planus

Hi guys, let’s talk dermatology.

Lichen Planus is a papulosquamous disease that affects skin, nails and mucous membrane, caused by cell-mediated immunity of unknown aetiology. Here’s a (not-so-white) whiteboard summary.

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- Morphological variants can be hypertrophic, atrophic, erosive, follicular, annular, vesicular, bullous, actinic or pemphigoid.

- Lichenoid reaction can be caused by drugs (thiazides, antimalarials, penicillamine, gold) and even in Graft vs. Host disease.

- Those with steroid resistance/ intolerance are treated by hydroxyquine, methotrexate or sulfasalazine.

- Psoralens can also be used along with UV-A radiation.

- Patient education regarding self-limiting and recurrent nature of the disease is important.

- Ashish Singh

Pathophysiology: Multiple Sclerosis

Hey guys, let’s look at the fundamentals of multiple sclerosis.

Multiple sclerosis is an autoimmune disease of the CNS characterised by

- chronic inflammation

- demyelination

- reactive gliosis/ scarring

- neuronal loss

with a course that is relapsing-remitting or progressive

and lesions that are disseminated in time and space.

Here’s how it happens:

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- Ashish Singh

Antibiotics: Action and Resistance

A series of fortunate events - including a cancelled holiday and an unpredictable British summer - in 1928 began the antibiotic revolution, when Alexander Flemming’s observation that a contaminating Penicillium colony caused lysis of Staphylococci.

Here’s a pictorial summary of various sites of action of modern-day antibiotics.

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However, the capacity for prokaryotic bugs to develop resistance far outweighs the human capacity to develop new antiobiotic drugs.

Antibiotic resistance can be:

- Intrinsic: Inherent structural or functional characteristics, eg: vancomycin cannot cross the outer membrane of Gram negative bacteria.

- Extrinsic: Acquired through years of mutation and/or transfer of resistance properties. This evolutionary phenomenon is accelerated by selection pressure from antibiotic use, eg: beta lactamase producing Gram positive bacteria.

- Ashish Singh

WHO Pain Ladder

Humans are the most exquisite devices ever made for experiencing pain; the richer our inner lives, the greater the varieties of pain there are for us to feel.
As physicians, never forget how painful pain is, nor how fear magnifies pain. Try not to let these sensations, so often interposed between your patient and recovery, be invisible to you as he/ she bravely puts up with them.

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- ALWAYS GO UP THE PAIN LADDER, IF PAIN PERSISTS/ INCREASES.
- Simple analgesics are non-narcotic.
- Review and chart each pain carefully and individually.
- Identify and treat underlying pathology, wherever possible.
- Adjuvants:
1. Neuropathic pain: Gabapentin, Pregabalin, Amitriptyline, Duloxetine, Steroids
2. Bone cancer pain (primary or mets): Radiotherapy, Bisphosphonates
3. Intestinal/ Renal colic: Hyoscine butylbromide
4. Muscle spasm: Baclofen
5. Brief pain relief: Nitrous oxide (usually with oxygen)


- Ashish Singh

Mnemonic: Incubation Period of Hepatitis

Hey guys, here’s a simple little mnemonic to remember the incubation period of various hepatitis infections.

Rule of 4 to 8:

Hep A - 4 weeks

Hep E - 5 to 6 weeks

Hep C - 7 weeks

Hep B/D - 8 to 12 weeks

Pay attention to the order of Hep infections from 4 to 8.

Why A&E first? That’s because they enter through the mouth (feco-oral mode of transmission) and your mouth is the first part of your GI.

Remember, Hep D co-infects or super-infects Hep B.

- Ashish Singh