What do you think?

Most viewed discussions

The most viewed discussions on doc2doc this month

Comment: The Ebola Frontline

Posted in Public health at Thu, 23 Apr 2015 17:56:21

Mukhtar Ali

Posts: 938
Joined: 14 Nov 2010

This isn't from  MSF's Frontline Blogs page, but from the pages of the Observer, in the Sunday newspaper's magazine section, about the work at the centres run by the US charity, Samaritan's Purse  in Monrovia and by MSF in Sierra Leone .  You can read the whole report at:  http://www.theguardian.com/society/2014/aug/24/ebola-the-frontline-liberia-sierra-leone

It includes several interviews, with a doctor, a public health specialist, a nurse, one who has lost their entire family to Ebola and to a survivor, their first in Monrovia.   I'd like to copy here the last, becauue I think it encapsulates the predicament of so many in West Africa.    May I introduce you to Harrison Sakela?

The survivor

‘I decided to treat her myself: I bought some medicine and a drip’: Harrison Sakela, Liberia. Photograph: Carilla Doe

Harrison Sakela, Liberia
I kept hearing the word “Ebola” but I hadn’t seen what the illness could do to a human body until my mother got sick. She had travelled to a funeral in Sierra Leone and met someone who had it. I was teaching a class, like any normal day, when I was told that she was unwell, so I went to see her in Sierra Leone and it was obvious that something was very wrong.

I decided to treat her myself: I bought some medicine and a drip. I spent about three days trying to help her but she wasn’t responding. At the last stage, she wouldn’t look people in the face. She was toileting every two to three minutes. She refused to eat food. It took her two weeks to die.

Within a week of coming back from Sierra Leone, I began feeling very weak. My head was hurting, I had a fever. I was not even able to cross the road. A Samaritan’s Purse health facility worker saw me and asked me to come to the centre. I agreed straight away and tested positive for Ebola that day. I had severe diarrhoea and was very weak, but I never vomited blood like others had. A week later they tested my blood. It came back negative for Ebola and they discharged me. I came out and I am all right. Now I am the Ebola ambassador.

I have lost five family members to Ebola: my mother, father, sister, niece and my niece’s daughter. I have no one now, so I’ve decided to stay on at the treatment centre and work here as a security guard.

Most people in my community are ready to accept me again, although some people are saying that the Liberian government is giving me money to say that Ebola is real. Ebola is real. I have experienced it. The people of West Africa need to stop denying it exists

To support the work of Médecins Sans Frontières or Samaritan’s Purse, please visit: msf.org.uk and samaritans-purse.org.uk

Performers List problems

Posted in Careers at Fri, 24 Apr 2015 03:52:55

peter lacey

Posts: 5
Joined: 11 Apr 2015

I returned end of January from 15 yrs in NZ as a fulltime GP ( UK trained MRCGP FRNZCGP - fully and annually revalidated in NZ ) and was told prior to my departure from NZ by East of England Area Team that I would only need to complete the requirements of the Performers List application ( which is a 29 page document), show them original documentation on arrival and could start work. (GMC registration was straightforward and sensible.)

I arrived and found that the team dealing with me had been re-deployed a week before and that I had to start the process all over again, CV, Police check and OH check including repeated bloods and an archaic Mantoux test which took them 3 weeks to organise. After that they said that I would be signed onto the Performers List and I could start work at the Practice that had recruited me from overseas and who were desperate for me to start. During this time  I had a 3 week induction training at the practice and did all my IG, safeguarding, ICE , Emis Web, QOF, DrFirst etc. training and sat in with all the clinical staff and admin staff and went out on visits with the outreach teams.

Once the OH bloods and Mantoux were done and I was signed off 'fit to practice with an EPP certificate' we heard nothing  from the Performers List team - so I got in contact and they then said it had to go to a Panel Meeting which was a week later - now I have been out of work for 10 weeks since leaving NZ .

At the Panel meeting on Thursday despite acknowledging that I was a well qualified and experienced GP working in an equivalent GP situation in NZ  they decided that  I have to do the new I+R scheme which doesn't start til 1st April  - this means unemployment til at least June when I can pay to do the MCQ as a first hurdle. This may be followed by simulated surgery assessment and then being placed under supervision for 3-6 months in a Practice not of my choosing anywhere in East of England and Midlands.

I am a single parent mum to 4 still financially dependent- on-me children. Two of my children are with me in the UK, two completing Uni education in NZ and were going to follow. I have a shipping container of goods about to arrive in the country in the next week or so and an offer in on a house based on my estimated earnings as a Partner in the Practice and close to the surgery . I am now unemployed and will soon be homeless as I am renting a holiday cottage.

On reviewing the situation I am not the only UK trained GP returning from Aus/NZ/Canada who is undergoing or has had to go through this blatant discrimination against UK GP's working overseas and this humiliating and resource wasting process.

The UK is short of 8000 GPs - so why are they making it worse by turning away/stonewalling experienced UK trained GPs who are motivated to return from Australia and New Zealand because they miss the good things about the UK and family and friends ? The Practice that recruited me are not only embarassed and disappointed but are overwhelmed themselves due to the recruitment crisis and have been  3 doctors down since last September and were eagerly awaiting my starting work with them. Week after week has been a rollercoaster of being told ' once you have done this ....you can start , followed by no... didn't we say ? you also have to do this .....'

I am saddened and disgusted. 

Question of the week: How would you treat this patient with possible TB?

Posted in Respiratory medicine at Tue, 21 Apr 2015 20:03:19

Dr Z Ali

Posts: 1
Joined: 21 Apr 2015

A 21 year old dental student visits his GP with an enlarged cervical lymph node.  The GP refers him on to a local surgical out patient department, the surgeon elects to carry out an excision.  The excision is uneventful, the node is sent for histopathology, in formalin as usual.  No specimen goes to microbiology.

Acid Fast Bacilli are seen on the histological specimen, so the patient is referred to the ID clinic.

He had a BCG vaccination at the age of 12, developed a large scar (15mm) following a "good" reaction to the vaccine.  He has been well, with no respiratory symptoms at all.  He has no other lymphadenopathy.

How do you want to treat this patient?  Does he have TB?  Does he need to be treated?  With what? For how long?

Clinical question of the week: ST elevation without obstructive coronary disease

Posted in Cardiology at Sat, 25 Apr 2015 16:07:19


Posts: 18
Joined: 13 Nov 2014
A previously fit 42 year old woman developed severe chest pain after an argument with her partner. On arrival to A&E her ECG showed marked ST segment elevation in the septal leads. She was transferred for emergent coronary angiography but this demonstrated no obstructive coronary disease. Her chest pain and ecg changes resolved after a few hours with no q waves. and serum troponin was very elevated. Her ECHO showed severe LV impairment with anterior and inferior akinesia immediately after the coronary angiogram but normalised 2 days later.

Amantadine for Irritability After Traumatic Brain Injury

Posted in General at Fri, 24 Apr 2015 15:14:34

Mukhtar Ali

Posts: 938
Joined: 14 Nov 2010

Amantadine, a readily available, inexpensive, easy-to-administer medication, was effective for irritability in outpatients with chronic, moderate traumatic brain injury. Aggression in the whole group might not have significantly improved because of a ceiling effect. Although clinicians have several pharmacologic options for treating irritability, this study is the most rigorous completed thus far. Results of a multicenter, randomized trial should be available soon and, hopefully, will confirm these findings. Amantadine must now be considered a first-line medication for irritability after TBI.


Clinical question of the week: 16yo with sexual exhibitionism, dysarthria, and drooling

Posted in Psychiatry at Thu, 23 Apr 2015 12:53:00


Posts: 3
Joined: 07 Aug 2011

A 16 years old male was in school and his classmates told him that the way he looks at them is different, then he presented with jaundice, abdominal pain. He also presented with declining school performance, sublte personality changes, impulsiveness, labile mood, sexual exhibitionism and inappropriate behaviour. During history taking, the family mentioned that another member had similar manifestations earlier. On examination, he has dysarthria and drooling of saliva. Investigations revealed low levels of ceruloplasmin, elevated aminotransferase.

What would be the possible test that would help to reach the diagnosis? if possible what would be the diagnosis?


MRCGP practice question from OnExamination: Chronic knee pain

Posted in General clinical at Sat, 25 Apr 2015 08:45:57


Posts: 923
Joined: 13 Oct 2009

A 68-year-old female patient is seen as an emergency appointment.

She has chronic problems with knee osteoarthritis and was seen at the practice four days ago. She was diagnosed several years ago when she first presented with knee symptoms and last had x rays at that time which showed moderate degenerative changes.

She had attended surgery four days ago as her knee symptoms had steadily deteriorated over recent months and her pain was not being controlled by over-the-counter paracetamol and ibuprofen. She was also referred for an up-to-date routine knee x ray which is pending. She was prescribed co-codamol 30/500 tablets to use hopefully to provide better control of her pain symptoms.

She reports that her knee is still giving her a lot of pain and that over the last few days she has been taking eight co-codamol 30/500 tablets a day to provide pain relief. She also says that she has continued to use maximal doses of over-the-counter paracetamol and ibuprofen. On further discussion, her knee has not deteriorated since she was last seen and there is no erythema, increased temperature, or new swelling. Her mobility is the same as when she was last seen at the practice.

Liverpool CCG "rethinks" funding for homeopathy

Posted in News & media at Sun, 26 Apr 2015 15:22:48


Posts: 1512
Joined: 09 Dec 2011

The BMJ reports that Liverpool CCG, prompted by a challenge from the "Good Thinking Society" have agreed to reconsider the £30,000 it budgets for homepathic remedies every year.  http://www.bmj.com/content/350/bmj.h1973

The rapid responses so far have defended homeopathic treatments on the usual points, that it does work, sometimes, and patient autonomy.

Does your CCG approve of homeopathy and spend serious money on it?


Poll about smoking in cars

Posted in General clinical at Wed, 22 Apr 2015 17:24:40


Posts: 1
Joined: 22 Apr 2015

The thread Smoking Banned in Cars is too interesting to go without a poll

Fancy quizzing a future UK health secretary?

Posted in BMJ at Sat, 25 Apr 2015 22:26:04


Posts: 275
Joined: 29 May 2013

If you were in the same room as health secretary Jeremy Hunt, Labour health shadow Andy Burnham. Lib dem health spokesman Norman Lamb and UKIP's Louise Bours, what would you ask them?

The BMJ is co-hosting a live health hustings at The British Library, London, from 11am on April 21. If you're in town we have a few spare tickets. Email rcoombes@bmj.com for more details.

Alternatively post your question below, and log on to www.healthdebate.net next week to watch the live webcast to find out if we were able to include it.

How did you make the most of your medical elective?

Posted in Student BMJ at Tue, 21 Apr 2015 09:26:10

From Twitter

Posts: 33
Joined: 19 Jan 2015


I hope you are all well on doc2doc - sorry it has been so long since I last posted! 

We are working on an article for Student BMJ about making the most of being on your medical elective. We are looking for medical students to tell us how they made the most of their experience - with practical tips - but also perhaps things you wish you had done or mistakes you made. 

We are on the search for 3 students to write a couple of paragraphs on this subject (350 words max). The best submissions will be published in the May issue of Student BMJ!


Doctors standing for election as MPs

Posted in Careers at Fri, 24 Apr 2015 13:17:26

P English

Posts: 65
Joined: 29 Jun 2009

BMJ Careers has just published a piece about the motivations behind doctors entering politics and whether more medics should be standing for election as MPs.

In the UK’s general election next month, there are 30 doctors standing as candidates:

11 for the Conservative party

Six for the Labour party

Two for the Liberal Democrats

Four for the UK Independence party (UKIP)

Seven for the National Health Action party (NHAP)


In the article a former GP and Conservative MP is quoted as saying: "The ability to prioritise, to work collaboratively, to be able to explain, to be comfortable communicating with people who are very angry, and to be able to speak in public and explain what you are doing—all are skills that many doctors use every day and perhaps they don’t realise that they have had all the training needed to be an MP.”

It is also mentioned that doctors and manual workers are under-represented in UK Parliament, while barristers, journalists and career politicians seem to be massively over-represented. Is this the same worldwide?

Would you consider standing for election as a member of parliament for your country? Do we need more doctors in parliament to influence political decisions on healthcare and to represent doctors and other frontline workers?

Recurrent Diverticulitis Investigation

Posted in General clinical at Fri, 24 Apr 2015 20:46:37


Posts: 6
Joined: 11 Nov 2013


I am a family medicine resident in Canada and working in a rural community. I would like to know the approach others take in investigation of recurrent diverticulitis. I've had a few patients during my training that present multiple times with diverticulitis. I will usually obtain a CT scan to ensure the diagnosis but I am wondering if this is really required in a patient that is vitally stable (aside from being febrile) but in significant pain. If it were a patient that you would likely treat as an outpatient based on a mildly elevated white count and stable vitals, would you still obtain the CT scan for verification or just treat with antibiotics and close follow-up?


What should a seven day NHS include?

Posted in News & media at Tue, 21 Apr 2015 19:04:24


Posts: 88
Joined: 15 Jan 2010

We have recently published an article in BMJ Careers on seven day services may (or may not) work in the NHS http://careers.bmj.com/careers/advice/view-article.html?id=20021742

The consensus from the profession seemed to be that seven day services ought to focus on emergency care only, rather than atempting to provide a truly 24/7 "Tesco" type service. However, to be honest there is still not a huge amount of clarity on what "seven day services" actually means.

How do you think a seven day service should work?

How does it work in other countries? 


Doctors who are body builders

Posted in Public health at Sat, 25 Apr 2015 12:19:12


Posts: 388
Joined: 14 Dec 2010

I came across an athletic doctor, who seems to be doing an excellent job as a body builder. I was surprised to find that a patient and his carers, having troubles to accept the concept of a muscular doctor. They had arguments like he does not look like a doctor, doctors can be slim or overweight, leaning towards if he has time for body building when does he study.

I wonder what are your opinions about the stereotype of the image of a doctor.

Fundus Examination

Posted in General clinical at Wed, 22 Apr 2015 01:21:03


Posts: 712
Joined: 21 Feb 2012

These fudus images were taken from a 20 years old patient presented with cough and blood stained sputum

what is the diagnosis ?


ECG from the grand round

Posted in General clinical at Sat, 25 Apr 2015 01:18:56


Posts: 712
Joined: 21 Feb 2012

This is the ECG of a 59 year old patient, who presented with chest  pain and palpitation

what does it show ?


Should surgical training include involvement in a clinical trial?

Posted in General clinical at Sun, 26 Apr 2015 07:26:52

John D

Posts: 3514
Joined: 01 Feb 2010

This is the latest Head to Head question from The BMJ


Arguing "Yes" is Morton Dion, professor of surgery, Academic Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham

His arguments include:

  • Without a sound evidence base, surgical practice will evolve in a sporadic and haphazard fashion.
  • Surgical care extends well beyond the operating theatre. Advances in perioperative care developed in the past decade, including optimisation before operations and better recovery,have been translated into routine clinical practice.
  • Audit isn't enough. Clinical audit is designed to eradicate poor practice, but clinical research is essential to determine and disseminate best practice
  • Participation in clinical research provides the tools for continued education throughout a consultant’s career and should be seen as essential to continued professional development.

Arguing "No" is Colin D Bicknell, clinical senior lecturer and honorary consultant vascular surgeon, Imperial College, London

His arguments include:

  • Surgery is a craft specialty, and training in the technical and team skills needed to provide the best quality surgical outcomes and lead a theatre team must be the primary aim of training.
  • An ability to critically read and appraise clinical research is indeed mandatory. This should be taught and examined, but this does not mandate involvement in a clinical trial.
  • To say that participation should be compulsory we would have to provide effective training in these domains by ensuring the quality of trial methodology and prove that these skills could not be learnt as effectively elsewhere.
  • There are not enough high quality clinical trials for all surgical trainees to be part of the study management team.

Does the patient know best?

Posted in Quality & Safety at Thu, 23 Apr 2015 04:16:48


Posts: 1265
Joined: 07 Sep 2009

At 1530 today the International Forum in London is hosting its first formal debate.  Speakers will argue for and against the motion that “the patient knows best”. The audience will get the chance to vote and contribute before and after the argument. 

Speakers for the motion:

1.       David Grayson, Consultant Otolayngologist, Ko Awatea, New Zealand

2.       Paul WicksVice President  of Innovation at PatientsLikeMe.com

3.       Surina Taneja, medical student and member of the debating section, UCLU Medical Society, UK

Speakers against the motion:

1.       Brian Robson, Executive Clinical Director of Healthcare Improvement Scotland

2.       David GilbertDirector of InHealth Associates and writer of futurepatientblog.com

3.       Kirtana Vallabhanenimedical student and member of the debating section, UCLU Medical Society, UK

AdjudicatorsThos Thorogoodstudent debater, and Tessa RichardsSenior Editor/ Patient Partnership, The BMJ

ChairTim BrooksChief Executive, BMJ


You can watch the debate live at 1530 by clicking here



Where do you stand on this?

Watch quality and safety sessions live from the International Forum this week

Posted in Quality & Safety at Wed, 22 Apr 2015 08:51:37


Posts: 1265
Joined: 07 Sep 2009

Now in its 20th year the International Forum is an annual gathering of healthcare professionals in quality improvement and patient safety. It starts tomorrow at ExCel, London. We’re looking forward to meeting those of you who are attending. For anyone who can’t make it, you can watch the following sessions live on the International Forum website:


Wednesday 22 April 2015

09:15 - 09:30 Welcome and opening of the Forum. Fiona Godlee, Editor in Chief, The BMJ

09:30 - 10:30 Keynote 1: Inspiring a new generation of healthcare improvers. Maureen Bisognano, President and Chief Executive Officer of the Institute for Healthcare Improvement

11:00 - 12:30 Connecting and inspiring for change (part a): Can social networks support minimally disruptive medicine through promoting connections and mobilising resources outside of formal medical care? Anne Rogers, Professor of Health Systems Implementation, University of Southampton and Research Director of the NIHR CLAHRC Wessex, England

(part b): Quality Mindset: Health & Care Radicals Inspiring Industrial Quality Improvement. Celine Schillinger, Head, Innovation and Engagement, Sanofi Pasteur Quality, USA

13:30 - 15:00 National strategies for improvement (part a) In treating illness, are we forgetting about creating wellness? Harry Burns, Professor of Global Public Health at Strathclyde University, UK

15:30 - 16:30 Developing a world class digital health service. Dr Paul Rice, Head of Technology Strategy, NHS England, UK

16:45 - 17:30 Keynote 2: Providing practical, emotional and educational support to vulnerable inner-city children and young people. Camila Batmanghelidjh, Founder and Director, Kids Company, England


Thursday 23 April 2015

09:15 - 10:30 Keynote 3: Ebola: The Global Impact. Professor David Heymann, Chair of Public Health England, Head of the Centre on Global Health Security at Chatham House, London and Professor of Infectious Disease; Colin Brown, Royal Free London NHS Foundation Trust, England; Stephen Mepham, Consultant in Microbiology and Infectious Diseases, Royal Free London NHS Foundation Trust, UK; Jean-Jacques Muyembe-Tamfum, Professor of Microbiology, Kinshasa University Medical school and Director General of The National Institute for Biomedical Research, Kinshasa, Democratic Republic of Congo, Africa

11:00 - 12:30 Inspiring large scale community projects (part a) Everyone's Involved and No One's in Charge: Strategies for Multi-system Problem Solving in Population Health. Rosanne Haggerty, Founder and President of Community Solutions, USA

(part b) Project ECHO: Moving Knowledge Not People. Sanjeev Arora, MD, Founder of Project ECHO, USA

13:30 - 15:00 Inspired transformation: How to ignite energy for change. Helen Bevan, Chief Transformation Officer, NHS Improving Quality, England; Göran Henriks, Chief Executive of Learning, Qulturum, Jönköping, Sweden

15:30 - 16:30 The BIG DEBATE: our motion: “the patient knows best”

 Speakers for the motion: David Grayson, Consultant Otolayngologist, Ko Awatea, New Zealand; Paul Wicks , Vice President of Innovation at PatientsLikeMe.com; Surina Taneja, medical student and member of the debating section, UCLU Medical Society, UK.

Speakers against the motion: Brian Robson, Executive Clinical Director of Healthcare Improvement Scotland; David Gilbert, Director of InHealth Associates and writer of futurepatientblog.com; Kirtana Vallabhaneni, medical student and member of the debating section, UCLU Medical Society, UK

Adjudicators: Thos Thorogood, student debater and Tessa Richards, Senior Editor/ Patient Partnership, The BMJ

Chair: Tim Brooks, Chief Executive, BMJ

16:45 - 17:30 Keynote 4: A story about fruit flies, balloons, toys and our future: What can healthcare learn from Google's global innovation and customer-centric approaches Alfred Biehler, Head of Customer Advocacy, Google for Work, Google, UK


Friday 23 April 2015

09:15 - 10:15 Keynote 5: A Story of Suffering, Recovery, Determination and Self-Belief. Martine Wright, Paralympian; Survivor of the 7/7 London Bombings; Patient Spokesperson

10:45 - 11:45 Improving Care for Athletes – lessons from The Glasgow 2014 Commonwealth Games. Liz Mendl, Consultant, Performance Sport and Medical Services, UK; John MacLean, Medical Director, Sports Medicine Centre, Hampden Park, Glasgow; International Team doctor for The Scottish Football Association; Sarah Mitchell, National Programme Manager for the AHP National Delivery Plan, Scottish Government, Scotland

12:00 - 13:00 H1: Robotic and animal innovations changing healthcare (part a) Designing Technology for Working Dogs: an Interspecies Perspective on Human Wellbeing. Clara Mancini, Lecturer in Computing and Head of Animal-Computer Interaction, The Open University, England

(part b) PARO robot harp baby seal in action at Danish elderly homes, the important factors.  Jakob Iversen, Senior Project Manager, Health and Human Interaction Technologies, Danish Technological Institute, Denmark

14:00 - 15:00 Making better lives with Cycling Without Age. Ole Kassow, Founder, Cycling without age, Denmark

15:15 - 16:15 Keynote 6: Old Myths and New Designs: The New Simple Rules for Health Systems. Donald M. Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement; Former Administrator, Centers for Medicare and Medicaid Services

Patient Feedback important for doctors/hospitals?

Posted in Quality & Safety at Thu, 23 Apr 2015 13:34:12


Posts: 1
Joined: 23 Apr 2015

As a medical service provider, is it important for doctors, hospitals, nurse practitioners to know how the patient felt about the service provided by their doctor, doctor's office, nurses?

GMC alert: New legal requirement from the Competition and Markets Authority

Posted in News & media at Wed, 22 Apr 2015 08:38:38


Posts: 1265
Joined: 07 Sep 2009

Dear Doctor

I am writing to alert you to an Order from the Competition and Markets Authority (CMA) that came into force on 6 April 2015. The Order follows a lengthy investigation into the independent healthcare market, which found widespread use of incentive schemes to encourage doctors to treat or refer their patients for tests at particular facilities.

The CMA Order, which is in line with GMC guidance, states that:

a referring clinician is prohibited from requesting, agreeing to receive or accepting any direct incentive from, or any obligation from, a private hospital operator to give preference to the facilities of that private hospital operator when treating patients or referring patients for treatment or tests.

The CMA also found that some patients did not receive clear and timely information about fees. GMC guidance on Financial and commercial arrangements and conflicts of interest is unequivocal on this: doctors must be honest and open in any financial arrangements with patients, and doctors who charge fees must tell patients about their fees, if possible before seeking their consent to treatment. We are obviously concerned that some doctors may not be following this guidance.

If you think the Order (pdf) could affect your practice, you may want to read it in full and consult the further briefing on our website. If you are concerned in any way, you may also want to discuss it with your defence organisation.

Over the next week we will be emailing licensed doctors throughout the UK on this issue. I will also be contacting the chief executives of organisations that operate independent hospitals or private patient units to ask them not to put doctors in a position where they risk breaching Good medical practice. We will expect hospitals to inform us about incentive schemes that raise questions about compliance with our guidance.

Any scheme which gives a doctor a financial incentive that could affect their clinical judgement or referral recommendations is unacceptable. Wherever possible doctors should avoid conflicts of interest but, where there is a conflict, it should be declared to anyone affected, formally and as early as possible. If in doubt about whether there is a conflict of interest, the advice is to act as though there is.

If you have any comments or queries about this issue, you can call our Contact Centre on 0161 923 6602 or send me an email. At the end of this email, I have included a comprehensive list of our guidance and supporting resources which I hope you will find helpful.

Best wishes,


Niall Dickson

Cheif Executive and Registrar

General Medical Council

Diminished Capacity and Criminal Law

Posted in BMJ at Sun, 26 Apr 2015 17:50:36


Posts: 1512
Joined: 09 Dec 2011

The Director of Public Prosecutions announced earlier this week that an 86 year old Peer would not be tried for 22 historical child sexual abuse charges. This decision has caused a furore amongst alleged victims, Police, media, Politicians and some lawyers. Whilst satisfied the evidence was such there was a realistic prospect of conviction it fell short, say the CPS, of being in the public interest because the accused has Dementia. He could not therefore, instruct counsel and follow the proceedings nor was he any threat to the public. This decision reflects the increasing number of cases coming before the courts where elderly men face accusations of abuse occurring years or decades before. Not only may the accused be aged or infirm but witnesses and alleged victims must rely on fading memories and recall.

These cases require a scrupulously straight bat amongst Doctors and Lawyers but for alleged victims the case in point is deeply dissatisfying. There is no doubt that this case has been mishandled for the better part of thirty years by Police, CPS and the ‘establishment’. On the assumption that the medical facts are clear I cannot see how the DPP could reach any other decision but, it might have appeared more transparent if a Judge had determined in court the defendants capacity to stand trial based on the Doctors evidence in person. Justice must not only be done but seen to be done.

Unfortunately because of well publicised cases in the past there is a distrust amongst some about the diagnosis of Dementia being made on defendants only to find the accused ‘recovers’ rather well when legal proceedings have stopped. Lawyers for alleged victims have been quick to say that the Peer signed documents in the last few weeks concerning his assets and attendance in the House of Lords which raise questions about his own lawyers claims of his incapacity. Suffice to say assessing diminished capacity, fluctuating capacity etc is not an exact science.

Any thoughts?


Killer Krokodil Hits The Streets With A Vengeance!

Posted in General clinical at Mon, 27 Apr 2015 11:32:19


Posts: 388
Joined: 14 Dec 2010

Has anyone yet seen a patient who uses/abuses the--still quite new--toxic substance generically known as desomorphine a potent/powerful opioid? The drug, which has it's origins in Russia, was nicknamed Krokodil and pronounced cro-co-dile because it causes a user's skin to turn scaly and green, eventually leading the skin to rot and even drop off. And, that is sadly NO exaggeration. About a month ago EMS brought a patient to my ED (A&E) s/p being found--obtunded; semi-conscious and "shocky"--in a local park/playground. At first we resuscitated him as an overdose maintaining Airway; Breathing; Circulation. But upon secondary evaluation the 27 y/o man began sloughing off massive layers of skin sticking to his clothing which was rapidly removed for evaluation and debridment. This poor man looked as if he had 2nd-3rd degree, thermal burns on all of his extremities. My first thought was, is this some kind of flesh-eating organism causing necrotizing fasciitis? Indeed, the patient had greenish color; scaly epidermis. At a later time, one of our stellar ED nurses tried to replace a chuck and gauze used to contain the sere-sangenous oozing of his dying skin, and as she carefully unwrapped the gauze bandage, about approx. 2 - 3 pounds of skin; muscle and ligamentous tissue sloughed off the bones, leaving the posterior proximal forearm with a gaping hole such that I observed the quadrator muscle between the now exposed radius and ulna.

As best as we could we tried to address his massive wounds, and I kid you not, at one point I thought his diagnosis could be Leprosy...Not that I have actually seen a lot of Leprosy in my medical career. So we treated him for sepsis; cellulitis; osteomylitis; opioid OD; AKF and dehydration. Sadly, the long story short is that after one day of impatient admission, and just before surgery to debride and graft his massively infected; gaping defect(s) the patient pulled the two large-bore IVs from his arms and just casually walked out AMA. Two days later he was found deceased from an apparent OD in the same park he originally came from. Not that I, nor any of my staff were surprised, just frustrated we couldn't have somehow done more to "attempt" to save his life.

A leading medical toxicologist here in the US, and co–medical director at the Banner Good Samaritan Poison and Drug Information Center in Phoenix, Arizona, told Medscape Medical News in an interview that "this [Krokodil] is a 'very frightening drug' that clinicians need to be aware of."

So, has anyone else seen this yet? Comments? Questions?

Free clinical examination (OSCE) guides with HD video demonstrations

Posted in General clinical at Mon, 27 Apr 2015 11:15:00


Posts: 1
Joined: 27 Apr 2015

Hey guys,

I'm Lewis, a junior doctor in the UK. I founded www.geekymedics.com which is a free medical student revision resource. I've been producing lots of clinical examination guides, with associated videos and thought it might be useful to people preparing for clinical exams. I'd also love to hear your feedback.

The examination guides are located here http://geekymedics.com/category/osce/

Hopefully you guys find it a valuable resource :)