Endocrinology : Addison's disease: Etiology, Incidence, Signs & Symptoms & Acute Addisonian Crisis:

 Addison's disease: Etiology, Incidence, Signs & Symptoms & Acute Addisonian Crisis:

Addison's disease, also called adrenal insufficiency, is an uncommon disorder that occurs when the body doesn't produce enough of certain hormones.

Eiology :

In Addison's disease, the adrenal glands, located just above kidneys, produce too little cortisol and, often, too little aldosterone.

Incidence

Addison's disease occurs in all age groups and both sexes, and can be life-threatening.

Treatment involves taking hormones to replace those that are missing.

Symptoms

Addison's disease symptoms usually develop slowly, often over several months.

Often, the disease progresses so slowly that symptoms are ignored until a stress, such as illness or injury, occurs and makes symptoms worse.

Signs and symptoms may include:

Extreme fatigue.

Weight loss and decreased appetite.

Darkening of skin (hyperpigmentation).

Low blood pressure, even fainting

Salt craving

Low blood sugar (hypoglycemia)

Nausea, diarrhea or vomiting (gastrointestinal symptoms)

Abdominal pain

Muscle or joint pains

Irritability

Depression or other behavioral symptoms

Body hair loss or sexual dysfunction in women

Acute adrenal failure (addisonian crisis)

Sometimes the signs and symptoms of Addison's disease may appear suddenly.

Acute adrenal failure (addisonian crisis) can lead to life-threatening shock.

Emergency medical treatment should be sought if the patient if you experiences the following signs and symptoms:

Severe weakness

Confusion

Pain in lower back or legs

Severe abdominal pain, vomiting and diarrhea, leading to dehydration

Reduced consciousness or delirium

Low blood pressure

High potassium (hyperkalemia) and low sodium (hyponatremia)

Geriatrics : Alzheimer"s Disease

 Alzheimer's disease

Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. 

In most people with the disease—those with the late-onset type—symptoms first appear in their mid-60s. 

Early-onset Alzheimer’s occurs between a person’s 30s and mid-60s and is very rare. 

Alzheimer’s disease is the most common cause of dementia among older adults.

Origins and history:

The disease is named after Dr. Alois Alzheimer. In 1906, 

Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness. Her symptoms included memory loss, language problems, and unpredictable behavior. 

After she died, he examined her brain and found many abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now called neurofibrillary, or tau, tangles).

These plaques and tangles in the brain are still considered some of the main features of Alzheimer’s disease. 

Another feature is the loss of connections between nerve cells (neurons) in the brain.

 Neurons transmit messages between different parts of the brain, and from the brain to muscles and organs in the body. 

Many other complex brain changes are thought to play a role in Alzheimer’s, too.

This damage initially appears to take place in the hippocampus, the part of the brain essential in forming memories. 

As neurons die, additional parts of the brain are affected. By the final stage of Alzheimer’s, damage is widespread, and brain tissue has shrunk significantly.

Clinical Features:

Memory problems are typically one of the first signs of Alzheimer’s, though initial symptoms may vary from person to person. 

A decline in other aspects of thinking, such as finding the right words, vision/spatial issues, and impaired reasoning or judgment, may also signal the very early stages of Alzheimer’s disease. 

Mild cognitive impairment (MCI) is a condition that can be an early sign of Alzheimer’s, but not everyone with MCI will develop the disease.

People with Alzheimer’s have trouble doing everyday things like driving a car, cooking a meal, or paying bills. 

They may ask the same questions over and over, get lost easily, lose things or put them in odd places, and find even simple things confusing. 

As the disease progresses, some people become worried, angry, or violent.

How Long Can a Person Live with Alzheimer’s Disease?

The time from diagnosis to death varies—as little as 3 or 4 years if the person is older than 80 when diagnosed, to as long as 10 or more years if the person is younger.

Although treatment can help manage symptoms in some people, currently there is no cure for this devastating disease.

How Is Alzheimer's Disease Treated?

Alzheimer’s disease is complex, and it is unlikely that any one drug or other intervention will successfully treat it. 

Current approaches focus on helping people maintain mental function, manage behavioral symptoms, and slow down the symptoms of disease.

Treatment for Mild to Moderate Alzheimer’s

Medications called cholinesterase inhibitors are prescribed for mild to moderate Alzheimer’s disease. 

These drugs may help reduce some symptoms and help control some behavioral symptoms. 

The medications are Razadyne® (galantamine), Exelon® (rivastigmine), and Aricept® (donepezil).

Scientists do not yet fully understand how cholinesterase inhibitors work to treat Alzheimer’s disease, but research indicates that they prevent the breakdown of acetylcholine, a brain chemical believed to be important for memory and thinking. As Alzheimer’s progresses, the brain produces less and less acetylcholine; therefore, cholinesterase inhibitors may eventually lose their effect.

Treatment for Moderate to Severe Alzheimer’s

A medication known as Namenda® (memantine), an N-methyl D-aspartate (NMDA) antagonist, is prescribed to treat moderate to severe Alzheimer’s disease.

 This drug’s main effect is to decrease symptoms, which could allow some people to maintain certain daily functions a little longer than they would without the medication. 

For example, Namenda® may help a person in the later stages of the disease maintain his or her ability to use the bathroom independently for several more months, a benefit for both the person with Alzheimer's and caregivers.

The FDA has also approved Aricept®, the Exelon® patch, and Namzaric®, a combination of Namenda® and Aricept®, for the treatment of moderate to severe Alzheimer’s disease.

Namenda® is believed to work by regulating glutamate, an important brain chemical. When produced in excessive amounts, glutamate may lead to brain cell death. Because NMDA antagonists work differently from cholinesterase inhibitors, the two types of drugs can be prescribed in combination.

Geriatrics : FRAILTY

 FRAILTY

Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. 

Frailty is a condition associated with ageing, and it has been recognized for centuries.

Causes

Sarcopenia

Sarcopenia is the degenerative loss of skeletal muscle mass, quality, and strength associated with aging.

The rate of muscle loss is dependent on exercise level, co-morbidities, nutrition and other factors. 

Sarcopenia can lead to reduction in functional status and cause significant disability from increased weakness. 

Osteoporosis

Osteoporosis is an age-related disease of bone that leads to an increased risk of fracture.

 In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is disrupted, and the amount and variety of proteins in bone is altered. 

Osteoporosis is defined by the World Health Organization (WHO) in women as a bone mineral density 2.5 standard deviations below peak bone mass (20-year-old healthy female average) as measured by DXA; the term "established osteoporosis" includes the presence of a fragility fracture.

Muscle weakness

Muscle weakness, also known as muscle fatigue, (or "lack of strength") refers to the inability to exert force with one's skeletal muscles. 

Weakness often follows muscle atrophy and a decrease in activity, such as after a long bout of bedrest as a result of an illness. 

There is also a gradual onset of muscle weakness as a result of sarcopenia – the age-related loss of skeletal muscle.

Mechanism

It has been suggested that the biological underpinnings of frailty are multifactorial, involving dysregulation across many physiological systems.

A proinflammatory state, sarcopenia,  anemia, relative deficiencies in anabolic hormones (androgens and growth hormone and excess exposure to catabolic hormones (cortisol), insulin resistance,glucose levels,compromised altered immune function, micronutrient deficiencies and oxidative stress are each individually associated with a higher likelihood of frailty. 

Diagnosis

The most widely used frailty scale consists of five items:

Unintentional weight loss >4.5 kg in the past year

Self-reported exhaustion

Less than 20th population percentile for grip strength

Slowed walking speed, defined as lowest population quartile on 4-minute walking test

Low physical activity such that persons would only rarely undertake a short walk

A healthy person scores 0; a very frail person scores 5. 

Compared to non-frail elderly people, people with intermediate frailty scores (2 or 3) are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to their own homes.

 Frail elderly patients (score of 4 or 5) have even worse outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-frail elderly people.

Linda Fried / Johns Hopkins Frailty Criteria

A popular approach to the assessment of geriatric frailty encompasses the assessment of five dimensions that are hypothesized to reflect systems whose impaired regulation underlies the syndrome. These five dimensions are:

Unintentional weight loss,

Exhaustion,

Muscle weakness,

Slowness while walking, and

Low levels of activity.

Rockwood Frailty Index

Another notable approach to the assessment of geriatric frailty  is Rockwood Frailty Index ,in which frailty is viewed in terms of the number of health "deficits" that are manifest in the individual, leading to a continuous measure of frailty. This approach was developed by Dr. Rockwood and colleagues at Dalhousie University.

Surgical outcomes

Frail elderly people are at significant risk of post-surgical complications and the need for extended care. Frailty more than doubles the risk of morbidity and mortality from surgery and cardiovascular conditions.

Assessment of older patients before elective surgeries can accurately predict the patients' recovery outcomes  

https://academy.zenva.com/?a=321

Thyrotoxic crisis : Investigations & Management :

Investigations :

ECG will show Sinus Tachycardia but Atrial fibrillation or other arrhythmias may be present.

Thyroid function tests would show Hyperthyroidism.

Thyrotoxic crisis is mainly a clinical diagnosis.

There are no specific lab investigations to diagnose thyrotoxic crisis.

The levels of thyroid hormones maybe the same as in uncomplicated hyperthyroidism.

Treatment should be started immediately as soon as clinical  diagnosis of thyrotoxic crisis has been made.

And time should not be wasted in confirming the diagnosis by lab investigations.

Management:

Thyrotoxic crisis is a life threatening condition with mortality of upto 20 – 30 % reported.

Aside from basic resuscitation give specific treatment for thyrotoxic crisis on clinical suspicion.

Hyperthyroidism :

The patient in thyrotoxic crisis requires both of the following :

Propylthiouracil or carbimazole :

Propylthiouracil is the preferred drug as it both blocks the further synthesis of thyroid hormones and inhibits peripheral conversion of T4 to T3.

However it is often not immediately available on the wards whereas carbimazole usually is.

If propylthiouracil is available ,give a loading dose of 600 mg to 1 Gm orally or via nasogastric tube and then 200 mg every 6 hours.

If PTU is not available, carbimazole 20 mg shoul be given followed by 20 mg three times a day.

Lugol”s iodine : Saturated solution of potassium iodide :

5 drops every 5 hours beginning 4 hours after starting PTU / Propylthiouracil / carbimazole not before , as thyroid hormone stores may be increased) to inhibit further rrelease of thyroxine.

Supportive measures particular to Thyrotoxic crisis :

Hyperpyrexia:

Peripheral cooling measures and Paracetamol

Aspirin should not be used as it can displace thyroid hormones from its binding sites.

Tachycardia :

Give propranolol 1 mg iv repeated every 20 minutes as necessary upto total of 5 mg or give 40 – 80 mg PO four times a day.

Be cautious in case of patient having Cardiac failure.

Esmolol is a short acting beta blocker and can be used as an infusion for immediate management of sympathetic overactivity.

Atrial fibrillation :

Consider digitalization but note that higher doses of digoxin than usual may be needed due to relative resistance to the drug.

Steroids : hydrocortisone 200 mg iv then 100 mg every 6 hours or dexamethasone 2 mg po four times daily .

Treat possible precipitating causes :

Start broad spectrum antibiotics if there is any suggestion of infection.

Endocrinology : Thyrotoxic crisis

Thyrotoxic crisis :

Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis.

Clinical features of thyrotoxic crisis / Storm:

Weight loss

Heat intolerance

Sweating

Palpitations

Tremor

Diarrhoea

Anxiety

Agitation

Irritability

Precipitating causes of Thyrotoxic crisis:

Withdrawal of Antithyroid drug therapy

Infection

Radio iodine treatment

Iodinated contrast dyes

Thyroid surgery

Child birth

Clinical Examination :

Following features would be observed :

General :

Agitation

Anxiety

Restlessness

Tremor

Warm skin and moist

Hyperpyrexia

Cardiovascular compromise :

Sinus Tachycardia : Hewart beat greater than 140 bpm in thyroid crisis.

Fast Atrial fibrillation or supraventricular tachy cardia is also common.

Neurological features :

Altered consciousness

Frank psychosis

Delirium

Seizures and

Coma may be present.

Findings suggestive of Thyroid pathology include the following :

Signs of Graves disease :

Exophthalmos

Lid retraction

Lid Lag

Goitre :

Smooth Vs nodular

Any associated bruit

Vitiligo associated with Auto immune Thyroid disease.

Geriatrics : Capacity Assessment

What is capacity?

Capacity means the ability to use and understand information to make a decision, and communicate any decision made.

A person lacks capacity if their mind is impaired or disturbed in some way, which means they're unable to make a decision at that time.

All adults are presumed to have sufficient capacity to decide on their own medical treatment, unless there's significant evidence to suggest otherwise.

Examples of how a person's brain or mind may be impaired include:

Mental health conditions – such as schizophrenia or bipolar disorder

Dementia

Severe learning disabilities

Brain damage – for example, from a stroke or other brain injury

Physical or mental conditions that cause confusion, drowsiness or a loss of consciousness

Intoxication caused by drugs or alcohol misuse

Someone with such an impairment is thought to be unable to make a decision if they cannot:

Understand information about the decision

Remember that information

Use that information to make a decision

Communicate their decision by talking, using sign language or any other means.

Geriatric Assessments : Abbreviated Mental Test Score / AMTS

 Geriatric Assessments : Abbreviated Mental Test Score / AMTS

This is a set of ten questions designed to give the examiner a rough idea of the mental state of the patient.

Total score : 10

The questions, and their conditions for one point each, are:

1) Age - must be correct.

2) Time, without looking at a timepiece, correct to the nearest hour.

3) 42, West Street - given as at test of immediate memory and retested at the end.

4) Month - must be exact.

5) Year - exact, except in Jan or Feb when last year is OK.

6) Name of place, or type of place or town ("in hospital" is insufficient .

7) Date of birth - exact

8) Start of WWI, exact - 1914

9) Name of the present monarch.

10) Counting backwards from 20 to 0, can prompt to 18 and patient may self-correct or hesitate.

Check the address recall from point No 3.'

Assessing / Interpretation of the AMTS :

The patient scores one point for each correct answer in the mental test score as long as the criteria are fulfilled, e.g. the time is given correct to the nearest hour.

A score of 8 to 10 is normal - note that it is very easy for a patient not to know the time.

A score of 7 is probably abnormal, and any less is definitely abnormal.

The score is invalid if the patient:

is delirious

has an affective disorder.

Notes:

There is evidence that clinicians use variants on these questions when undertaking a 10-point mini-mental test score.

The above AMTS is based on the format taught to Oxford University medical students .

The stated AMTS varies from the original by questioning about month when the original mini-mental test asked about recognition of two people - score if roles of two people correctly recognised - for example, doctor and nurse

Astronomy : Did Meteorites bring water to the earth

Astronomy : Did Meteorites bring water to the earth

In previous article, we had discussed about the origin of life on earth that it was made possible by chemical reactions in the space and building blocks of life was found in the meteorites that have fallen on the earth.

Now another astonishing discovery that supports the role of chemical reactions in the space and its role in originating and evolution of life on earth has been made.

Scientists have discovered that there is a high probability that water which forms the basis of creation of life on earth might have been brought to earth by meteorites from space.

A meteorite is a solid piece of debris from an object, such as a comet, asteroid, or meteoroid, that originates in outer space and survives its passage through the atmosphere to reach the surface of a planet or moon.

Meteorite

Meteorite

According to the article by new scientist , link given below , some of the meteorites that fell on earth recently had contained in them liquid water within the past million years. This may imply that space rocks brought water to the surface of the earth throughout the history of the earth.

These meteorites were once a part of asteroids that were formed 4.5 billion years ago.

According to a research conducted by Mr Simon Turner , when ice melts in a meteorite, the water and water soluble elements move from one part of the rock to another. Hence evidence of presence of water soluble elements such as uranium and comparing  their concentration with non water soluble elements  can help in detection of eveidence of presence of water.

Full link in New Scientist Magazine is below :

https://www.newscientist.com/article/2264333-meteorites-may-have-brought-water-to-earth-in-the-recent-past/?fbclid=IwAR1q7g8fQGJ5kLOft8nKm-_d93QtD-1Z54wCPJbFjPQajzEDP6kq8iYT14c

 

Asteroids

Asteroids are rocky worlds revolving around the sun that are too small to be called planets. They are also known as planetoids or minor planets.

 There are millions of asteroids, ranging in size from hundreds of miles to several feet across. In total, the mass of all the asteroids is less than that of Earth's moon.

Asteroid

Counseling scenario : Counsel a relative of a critical patient regarding his critical condition and plan of management.

Counsel a relative of a critical patient ( Advanced Congestive Cardiac Failure ) regarding his critical condition and plan of management.

You are a junior doctor working on evening cover for a General Medial / Acute Medicine Ward.

Mr H is a 76 year old man who has been admitted 6 days ago with exacerbation of congestive cardiac failure.

He was started on treatment with oxygen , diuretics , and vasodilators .

However there is little response and he stays short of breath ad hypoxic despite being given supplemental oxygen.

His GCS has dropped to 7 and he appears drowsy.

The consultant on call reviewed him during ward round and decided that in the event of a cardiac arrest , he should only be treated conservatively and no CPR / cardio pulmonary resuscitation should be provided.

This was discussed with his son who also agreed.

At night his daughter arrives and speaks to you saying she wants her father to be resuscitated and transferred to ICU / intensive Care unit.

Your task :

Explain to the daughter that shifting the patient to Intensive care unit would not be appropriate and CPR would be ineffective as well.

Main points to explore :

What does the daughter believe will happen to her father ?

Why does she want her father to be transferred to the Intensive Care Unit ?

Main points to establish :

What does she know about her father”s condition and his previous state of health.

She does not live with him and may not be aware of his previous condition.

Explain to her what treatment has been given to her father.

He has been treated actively with oxugen , vasodilators and diuretics but has deteriorated despite this.

Be clear and explicit about his prognosis:

Tell her , her father is dying and there is no treatment that can reverse his condition or improve his prognosis. Not even ITU intervention or CPR in case of cardiac arrest.

Tell her about the management plan / ceiling of Care :

Her father will be given treatment to alleviate / relieve his symptoms and keep him pain free and comfortable and dignified.

This includes ward based care such as oxygen and diuretics.

Remove the misconception of the relative that no  treatment will be given at all.

Daughter may ask:

Why are you not admitting my father to the ITU :

Explain I am sorry to say your father has advanced Congestive Heart failure.

We have given him treatment with Oxygen , Diuretics and medications in order to help his heart beat more stronger and take the fluids out of  his body to reduce the pressure on his heart but it seems like these treatments are not working and his heart is continuing to fail.

Any intensive treatment such as intubation and CPR will most likely not work.

So we will continue to give him best medical care and keep him pain free.

Any intensive treatment and CPR would unlikely to succeed but will give more distress to the patient.

Address her concerns and be polite and give her time to understand the situation.

Daughter may ask : 

Is there nothing else you can do for him / Do to help him?

Tell her that we can make his breathing easier for him , make sure he is comfortable , dignified and pain free.

Daughter may say :

You are doing this because that’s what my brother / other relative wants,

Explain, this is not the case . This is a medical decision and has been made by the medical team headed by an experienced Consultant.

Although we have told your brother about this and he has agreed to this plan of action.

Relative may ask : Can I speak to someone more senior about this ?

Explain : The consultant who had made this plan of management for your father may not be available at this time , but I can arrange for the Registrar to speak to you or someone from the ITU team.

But they are most likely going to tell you the same plan which I have already told you.

However if you need to ask anything which I have been unable to answer , we can arrange your meeting with them.

Astronomy : Did Chemical reactions that led to creation of living cells and life took place in space and on stars?

There a lot of complex discussions regarding the origin and creation of universe and life forms and living things in it including humans.

These mainly include religious and scientific views.

Most of the time there is an overlap between these two views as well.

There is a little doubt that the formation and development of the Universe and its subsequent life forms / living things was a complex process.

If we analyze the complexity of the universe, it came into being by mixture of different elements and chemicals and compounds.

These elements  are found in both living and non – living things.

Eg calclium can be found in bones and teeth  of human beings and it entes the body by consumption of calcium containing foods. Similarly egg shell which is a non living object also has calcium. 

Haemoglobin which is found in red blood cells of human beings  / living things has iron. Iron is also found in non living objects such as utensils. These elemenst are found all over the universe and have vital part in both living and non-living objects.

Similarly a lot of chemicals are formed from combination of more basic chemicals.

Before the creation of complex Universe and human civilization including complex life forms in Oceans and seas like fish and whales and air like birds,and land , a lot of basic chemicals were created in the Universe as a result of complex chemical reactions.

These simple chemicals then combine to form more complex chemicals that resulted in creation of a genius atmosphere that led to origin of life on land ( which includes ours and other land creatures(,sea and water.

There is little doubt that all the Universe is functioning under  complex laws of physics and other sciences and creation of life forms was the result of calculated chemical reactions and creation of elements and chemicals over a period of time which probably took place in the space and on environment of stars over a span of millions of years , as now scientists are discovering from research done in Universes and Meteors.

On 23 April 2019 , an asteroid broke up into numerous pieces in the sky.The research on the components of  these fragments gave amazing results suggesting that they contain complex amino acids and other chemicals that ultimateluy led to creation of the life on the universe.

 

Clays in a 44-millimeter-wide Aguas Zarcas fragment may hold amino acids, along with stardust that predates the Sun. LAURENCE GARVIE/CENTER FOR METEORITE STUDIES/ARIZONA STATE UNIVERSITY

The results of this study is given in the article below :

https://www.sciencemag.org/news/2020/08/unusual-meteorite-more-valuable-gold-may-hold-building-blocks-life?utm_campaign=ScienceNow&utm_source=Contractor&utm_medium=Facebook&fbclid=IwAR08PXFaIXu-Pc4ZycEJpmuTNXvUBTrO1GJcVCXUsDz1uGqFkWjQiPBqFe0

Some important points from this article are given below :

On 23 April 2019, an asteroid the size of a washing machine broke up in the skies over Costa Rica. Dozens of fragments , chock full of primordial carbon ,l anded along a 6-kilometer-longswath between the villages of La Palmera and Aguas  Zarcas .

Aguas Zarcas, as the fragments would soon collectively be called, is a carbonaceous chondrite, a pristine remnant of the early Solar System. The vast majority of meteorites are lumps of stone or metal. But true to their name, carbonaceous chondrites are rich in carbon—and not just boring, inorganic carbon, but also organic molecules as complex as amino acids, the building blocks of proteins. They illustrate how chemical reactions in space give rise to complex precursors for life; some scientists even believe rocks like Aguas Zarcas gave life a nudge when they crashed into a barren Earth 4.5 billion years ago.

From the beginning, the inky Aguas Zarcas resembled a legendary carbonaceous chondrite that exploded in 1969 over Murchison, an Australian cattle town. Geology students helped collect about 100 kilograms of Murchison, and a local postmaster mailed pieces of it to labs across the world. To date, scientists have recognized nearly 100 different amino acids in it, many used by organisms on Earth and many others rare or nonexistent in known life. Hundreds more amino acids have been inferred but not yet identified.

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Counselling Station : Counselling a patient"s relative regarding his critical condition and ineffectivity of CPR ; You tube link

 Counselling Station : Counselling a patient"s relative regarding his critical condition and ineffectivity of CPR ; You tube link

https://www.youtube.com/watch?v=zPDM8Tkq4Lg

Counselling Station : Counsel relative of a deteriorating patient with low chance of recovery that CPR would not be effective in management plan

You are a junior Medical doctor on call for ward cover.

Mr X , an 80 year old man has been admitted to the hospital with a dense left hemispheric stroke  resulting in aphasia and  a right sided hemiparesis.

He has a background history of prostate ca , left ventricular failure , atrial fibrillation and COPD / chronic Obstructive Pulmonary Disease.

His GCS has fallen to 7 / 15 ,

E 2 , M 4 , V 1which is presumed to be due to extension of his stroke.

The patient has been reviewed by the Consultant who feels that ICU care / Intensive care unit is inappropriate for this patient and the patient should not be resuscitated in case of cardio pulmonary arrest.

Your task :

Explain to the family what has happened and why it would be inappropriate to attempt resuscitation  in the event of cardio pulmonary arrest.

Key issues to explore :

Obtain as much information as possible about patients co-morbidities and functional level  before his stroke.

This can be done by asking the staff / nurse taking care of the patient.

It is also important as this will help build trust of the relatives in the doctor as they will trust a doctor who knows their patient more than just another doctor who thinks he was just another patient who had a massive stroke.

Ceiling of care

The scenario says ITU / ICU or invasive care is not appropriate

It is important to establish a ceiling of care eg if the patient develops a chest infection , can he be given intravenous antibiotics ? ie Ward based care

Hence it is important the medical and nursing teams reach an agreement of which treatment can or cannot be given  before proceeding to the relatives for a discussion.

What does the family know already and what are their expectations.

It could be that they were expecting Mr X will make a full recovery soon and go home.

Setting

Ideally there should be 

A quiet room adjacent to the ward

Room should have plenty of tissue papers supply

A landline telephone

Leave your bleep with another colleague to avoid distrurbance

Keep your mobile off

Take a senior ward nurse with you for your own support and that of the family as well.

Good lighting

Introduction

Introduce yourself to the family

Your role in the hospital care team

Also introduce any nurse accompanying you.

Check Identity of the patients family

You should make sure you are speaking to the correct family and establish the relationship of the family members with the  patient.

Explain to the family members what happened correctly and exactly .

Patient had a massive stroke and now has become paralyzed and is unable to speak and despite the best possible management deteriorated quickly and is now in a subconscious state.

Be clear and explicit about your treatment plan:

We will ensure he is comfortable by giving him proper intravenous fluids and make sure he is not in pain by giving analgesics.

We need to maintain his comfort and dignity.

Be explicit about the limits and level of care your consultant thinks will be best for him.

Eg CPR would unlikely to be of any use, rather will cause pain and distress to the patient.

Also intubation and invasive ventilations will not be suitable for him as well.

Usually many people themselves do not want any painful or distressing treatment in last stages of life of the patient and are very understanding in this matter.

Give the patient and their damily plenty of time to understand the information given and answer to any concerns or questions they may ask.

Discussion

Why has this happened:

As a result of stroke / CVA, a part of patients brain has stopped functioning following loss of blood supply as a result of blood vessel occlusion or haemorhage

As a result brain stops its normal function s and patient is unable to speak and has developed weakness of his body ( right side in this case).

With time the brain may become more swollen and the patient becomes unconscious and will deteriorate further.

Is he going to get better:

I am afraid to say that I do not think so

He has had a very massive stroke and things are likely to get worse.

Although I would be delighted if I am wrong.

But I honestly believe he would probably deteriorate and may even die soon.

Is he in any pain?

I don’t think he is in pain

He is unconscious and not aware of what is happening nor be able to feel any pain.

Our priority is to keep him comfortable and pain free.

If we had believed or though he is in pain, we would have given him analgesics and pain killers to prevent any distress or pain.

If he gets worse, will you resuscitate him ?

Usually CPR / Cardio pulmonary resuscitation and ventilator support is given only in case of patients who have a reversible condition and there is a chance of recovery

However in his case considering the massive stroke and reduced recovery potential as well as advance age, it is unlikely that any of such modalities will cause any improvements.

Rather these interventions will cause him more pain.

Our priority at the moment is to make sure to keep him pain free and comfortable so we will not proceed with CPR.