The Unofficial Guide to Medicine

Introduction Basic Patient Assessments 13

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Step-By-Step Illustrated Guides to Over 50 Core Practical Skills, with Accompanying Mark Schemes, and Typical Exam Questions FIRST EDITION Emily Hotton and Zeshan Qureshi

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Blood Tests Paediatrics

Practical Skills

General Skills

The Unofficial Guide to

Urology

Medicine and Surgery

Medication Administration

Acute Patient Management

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THE UNOFFICIAL GUIDE TO PRACTICAL SKILLS FIRST EDITION Emily Hotton Zeshan Qureshi

Introduction

ISBN 978-0957149960 Text, design and illustration © Zeshan Qureshi 2014 Edited by Emily Hotton and Zeshan Qureshi Published by Zeshan Qureshi. First published 2014 All rights reserved; no part of this publication may be reproduced, stored in a retrieval system, transmitted in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publishers. Original design by Zeshan Qureshi and Emily Hotton. Front cover design by Zeshan Qureshi, Emily Hotton, and Tom Green. Page make-up by Anchorprint Group Limited Illustrated by Anchorprint Group Limited, Peter Gardiner: medical illustrations (clinical skills limited) and Martin Burnett: clinical photographs (UK Media Solutions) A catalogue record for this book is available from the British Library. Publisher and Chief Editors’ Acknowledgements: We would like to thank all the authors for their hard work, and our distinguished panel of expert reviewers for their specialist input. We are extremely grateful for the support given by medical schools across the UK. We would also like to thank the medical students that have inspired this project, believed in this project, and have helped contribute to, promote, and distribute the book across the UK. Thank you to Matt Harris, Andrew Strain, Baldeep Sidhu, Kyle Gibson, and Reza Jarral for their contributions to the Practical Skills chapter of the Unofficial Guide to Passing OSCEs upon which this book has been developed. Thank you to Ruth Harrison, Srikant Ganesh, Abiola Adeogun for acting as models. Particular thanks go to Natalie Blencowe, for her constant advice and support. We also want to make a special mention to Dr and Mrs Hotton, who have been truly invaluable in providing energy and support to see this project through. Thanks also go to the Bath Academy, at the University of Bristol for the equipment and facilities for the images. The authors and publishers would like to thank the following for permission to reproduce their images: Reproduced by the kind permission of the Resuscitation Council (UK): Fig 3.7, 3.10, 3.13 Dr David Pothier (www.earatlas.co.uk): 3.70, 3.71, 3.72, 3.73, 3.74, 3.75 Pamela Gulland/Hannah Collinson: ECG 1-6 (Station 3.9) Dr Richard Mansfield: Fig 3.56, 3.60, 3.61 Dr Ed Friedlander: Fig 3.66 NHS Lothian: Fig 3.65, 3.68 NHS Fife: Fig 3.64, 3.67 CME Medical UK Ltd: Fig 4.16 Commissioned photographs by: Katrina Mason: All images: station 5.13 Martin Burnett (www.martinburnettphotography.co.uk): All other photographs Commissioned medical illustrations by: Peter Gardiner ([email protected]) Although we have tried to trace and contact copyright holders before publication, in some cases this may not have been possible. If contacted we will be pleased to rectify any errors or omissions at the earliest opportunity. Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property that may occur as a result of any person acting or not acting based on information contained in this book Printed and bound by Cambrian Printers in UK

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Introduction

Introduction ‘The Unofficial Guide to Practical Skills’ follows on from the huge success of ‘The Unofficial Guide to Passing OSCEs’. This book covers the core clinical competencies for new graduates, as well as additional practical procedures that are expected to be performed by junior doctors. Written by recently qualified foundation doctors, with review by senior clinicians, we have ensured that all procedures follow current guidelines. This book has detailed explanations of over 50 practical skills stations. Each station includes a corresponding mark scheme, associated questions and answers as well as further areas to explore. The aim is to give you a comprehensive overview of all procedures, even if you have yet to witness them in your training. Covering both basic and more advanced practical skills, we hope this book will prove to be a handy study companion for your undergraduate and postgraduate training. Practical procedures can be nerve-wracking to perform, both under the close scrutiny of OSCE examiners and pressures of daily clinical practice. The following simple measures are central to performing practical skills proficiently and effectively: ... take time to prepare yourself for the procedure ... ensure you are familiar with the method and equipment you need ... make sure that correct infection control measures are undertaken, from hand washing to use of personal protective items ... always identify the patient you are about to perform a procedure on and obtain the appropriate consent ... check the patient understands your explanation and allow time for them to ask any questions ... be confident in your ability ... use the experience of your peers ... if you are having difficulty, seek help With this textbook, we hope you will become more confident and competent in these skills both in exams and in clinical practice, but we hope that this is just the beginning. We want you to get involved, this textbook has been written by junior doctors and students just like you because we believe: ... that fresh graduates have a unique perspective on what works for students. We have tried to capture the insight of students and recent graduates to make the language we use to discuss this complex material more digestible for students. ... that texts are in constant need of being updated. Every student has the potential to contribute to the education of others by innovative ways of thinking and learning. This book is an open collaboration with you. You have the power to contribute something valuable to medicine; we welcome your suggestions and would love for you to get in touch. A good starting point is our facebook page, which is growing into a forum for medical education, search for “The Unofficial Guide to Medicine” or enter the hyperlink below into your web browser. Please get in touch and be part of the medical education project Emily: [email protected] Zeshan: [email protected], @DrZeshanQureshi Facebook: http://www.facebook.com/TheUnofficialGuideToMedicine?fref=ts

The Unofficial Guide To Practical Skills

Introduction

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Introduction

foreword This book is the latest addition to ‘The Unofficial Guide to…’ series, giving high quality advice and guidance to medical students through their transition into doctors. Previous books in the series have focused on tackling the nuances of OSCE stations. However, ‘The Unofficial Guide to Practical Skills’ aims to reflect the recent emphasis, by the General Medical Council (GMC), on practical skills. Approaching practical stations in exams can be challenging. Many medical students struggle to get hands-on experience of practical procedures during time on the wards. In addition, doctors have their own methods for a given skill and contrasting advice can be given. Although a breadth of opinion is good to allow you to develop, it can be a hurdle under exam pressure. This book provides an interactive framework from which to hang this array of knowledge. Directing you through a wide range of scenarios, from knee joint aspirations and ascitic taps to administering oxygen, with skill specific mark schemes, it gives you a clear structure from which to hone and perfect your practical skills. The once daunting prospect of approaching practical skills can now be overcome by using this refreshingly comprehensive and user-friendly guide. Including both skills focused upon by the GMC and an array of additional skills essential in the armoury of a junior doctor, this book really is the must have! Best of luck with all your practical skills!

Robert Miller, Final Year Medical Student, University of Bristol

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Introduction

Introduction

how to use this book This book has been created for you. We aim to ease the stress of studying and assist in making learning enjoyable to help you become a better clinician. The book is split into eight chapters, following a logical order from simple procedures to those that are more challenging.

Each practical skill station has a method outlining how to perform the skill as well as detailed objectives, general advice and facts dispersed throughout. This is followed by a matched mark scheme and a series of questions. This format allows for individual study or group work. There are three roles that may be adopted: the patient; the examiner and the candidate. The roles of the patient and examiner can be combined if working in pairs.

Scenario These are real life instructions that would be found in OSCEs or on the wards. Take your time to read the passage and note any salient points. In OSCE scenarios you will not be able to ask the examiner any questions regarding the passage, so carefully reading it before starting is paramount.

Mark Scheme This is a checklist of points that are important to cover in each station. It is not based on any specific university mark scheme, but covers principles we believe are important to address. The examiner can tick off points in the boxes as they are covered. These mark schemes can be used several times to gauge progress over a period of time.

Questions and Answers for Candidate These questions can be asked to the candidate with model answers provided.

Q&A

Additional Questions to Consider These are other questions surrounding the theme of the station. They are ones to consider, discuss and think through further to those provided.


How to use this book

5

Introduction 6

Abbreviations and symbols ⁰

degrees

kPa

kilopascal(s) pressure

ABPI

ankle brachial pressure index

L

litre

AMD

age-related macular degeneration

LA

local anaesthetic

ß

beta

LFTs

liver function tests

BE

base excess

LP

lumbar puncture

BiPAP

bilevel positive airway pressure

m

metres

BMI

body mass index

MC&S

microscopy, culture and sensitivity

BP

blood pressure

mg

milligram(s)

cm

centimetre(s)

MI

myocardial infarction

cmH2O

centimetre of water

min

minute(s)

CO2

carbon dioxide

mL

millilitre(s)

COPD

chronic obstructive pulmonary disease

mmHg

millimetres of mercury pressure

CPAP

continuous positive airway pressure

mmol

millimoles

CPR

cardiopulmonary resuscitation

MRSA

methicillin-resistant Staphylococcus aureus

CRP

C reactive protein

NPDR

non-proliferative diabetic retinopathy

CSF

cerebrospinal fluid

NTT

non touch technique

CT

computed tomography

O2

oxygen

CVP

central venous pressure

OP

oropharyngeal

DKA

diabetic ketoacidosis

PaCO2

arterial partial pressure of carbon dioxide

DLCO

diffusion capacity of the lung for carbon monoxide

PaO2

arterial partial pressure of oxygen

ECG

electrocardiogram

PCI

primary coronary intervention

EDTA

ethylenediaminetetraacetic acid

PEA

pulseless electrical activity

FBC

full blood count

PICC

peripherally inserted central catheter

FEV1

forced expiratory volume in one second

PPE

personal protective equipment

FiO2

inspired oxygen concentration

PT

prothrombin time

FVC

forced vital capacity

SaO2

arterial oxygen saturation

GCS

Glasgow Coma Score

SAAG

serum-ascites albumin gradient

Hb

haemoglobin

SBP

spontaneous bacterial peritonitis

HCO3-

bicarbonate

STEMI

ST elevation myocardial infarction

HAS

human albumin solution

TB

tuberculosis

ICP

intracranial pressure

TLCO

transfer factor of the lung for carbon monoxide

ID

identification

U&E

urea and electrolyte

IJV

internal jugular vein

USS

ultrasound scan

INR

international normalised ratio

VF

ventricular fibrillation

IV

intravenous

VT

ventricular tachycardia

kg

kilograms

WCC

white cell count

Introduction

Introduction

Contributors Editors Emily Hotton Zeshan Qureshi

Foundation Doctor (University of Bristol) Academic Clinical Fellow - Paediatrics (University of Southampton)

Senior Advisor Dr Natalie Blencowe

NIHR Doctoral Research Fellow and Honorary Specialty Registrar, Surgery, University of Bristol

Srikant Ganesh Foundation Doctor (University of Bristol) Chest Drain Diagnostic Ascitic Tap Diagnostic Pleural Tap Instruments Proctoscopy Surgical Gowning and Gloving Suturing

S.Ganesh

Andiran Anduvan Core Medical Trainee (Charles University, Prague) Diagnostic Ascitic Tap ECGs Otoscopy Spirometry Therapeutic Paracentesis

A.Anduvan

Practical Skills Authors

James Hayward Foundation Doctor (University of Bristol) Administering Oxygen Airway Management Central Venous Lines Immediate Life Support Intravenous Cannulation Lumbar Puncture Setting Up a Giving Set


J.Hayward

Ruth Harrison Foundation Doctor (University of Bristol) Death Certification ECGs Female Urethral Catheterisation Fundoscopy Inhaler Technique Local Anaesthetic Administration Male Urethral Catheterisation Peak Flow

R.Harrison

N.Hall

Nikki Hall Opthalmology Trainee (University of Edinburgh) Fundoscopy

Contributors

7

Emily Hotton Foundation Doctor (University of Bristol) Ankle Brachial Pressure Index Arterial Blood Gas Blood Cultures Blood Glucose Blood Pressure Blood Gas Interpretation Blood Transfusion Body Mass Index Choking Drug Administration via Nebuliser Hand Washing Heart Rate and Respiratory Rate Infection Control Intradermal Injections Intramuscular Injections Intravenous Drugs Knee Joint Aspiration Lying and Standing Blood Pressure Manual Handling MRSA Swab Nasogastric Tube Insertion Nutritional Assessment Operating a Syringe Driver Oxygen Saturation Phlebotomy Preparing Baby Formula Milk Simple Dressing Change Sizing and Fitting a Hard Collar Subcutaneous Injections Suprapubic Catheterisation Urinalysis

E.Hotton

Introduction

Practical Skills Authors Continued

K.Mason

Katrina Mason Core Surgical Trainee (University of Bristol) Suturing

Senior Reviewers Dr Steven Alderson Dr James Andrews Ken Arber Dr Patrick Byrne Frances Haig Elizabeth Hotton Dr Chris Lang Sophie Macadie Tracey Murphy Dr David Tate Mr Jonathan Wyatt

National Medical Director’s Clinical Fellow to Health Education England Medical Registrar, Wellington Regional Hospital, NZ Clinical Education Facilitator, University Hospitals Southampton Consultant Physician and GP, Belford Hospital Fort William Clinical Education Facilitator, University Hospitals Southampton Sister and Unit Manager, Mount Edgcumbe Hospice, Cornwall Consultant Cardiologist, Edinburgh Royal Infirmary, Edinburgh Clinical Education Facilitator, University Hospitals Southampton Clinical Education Facilitator, University Hospitals Southampton Gastroenterology Registrar, Royal United Hospital, Bath Emergency Department Consultant, Royal Cornwall Hospital, Truro

Student Reviewers Alexander Curtis Vanessa Hayter Amelia Holloway Katherine Lattey

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Introduction

University of Bristol University of Bristol Peninsula Medical School Brighton and Sussex Medical School

Introduction

contents 1. Basic Patient Assesments

5. Medicine and Surgery

1.1 Heart Rate and Respiratory Rate .............................. 12

5.1 Simple Dressing Change.......................................... 122

1.2 Oxygen Saturation..................................................... 14

5.2 Spirometry.............................................................. 125

1.3 Blood Pressure.......................................................... 15

5.3 Knee Joint Aspiration............................................... 128

1.4 Lying and Standing Blood Pressure........................... 18

5.4 Nasogastric Tube Insertion...................................... 130

1.5 Ankle Brachial Pressure Index................................... 20

5.5 Diagnostic Pleural Tap............................................. 133

1.6 Blood Glucose........................................................... 22

5.6 Chest Drain............................................................. 137

1.7 MRSA Swab............................................................... 24

5.7 Diagnostic Ascitic Tap.............................................. 144

1.8 Body Mass Index....................................................... 26

5.8 Therapeutic Paracentesis......................................... 147

1.9 Nutritional Assessment............................................. 28

5.9 Lumbar Puncture..................................................... 152

2. Blood Tests 2.1 Phlebotomy............................................................... 32 2.2 Blood Cultures.......................................................... 36 2.3 Arterial Blood Gas..................................................... 39 2.4 Blood Gas Interpretation........................................... 42

3. Acute Patient Management 3.1 Immediate Life Support............................................. 48 3.2 Choking..................................................................... 54 3.3 Sizing and Fitting a Hard Collar................................. 56 3.4 Airway Management................................................. 59 3.5 Administering Oxygen............................................... 63 3.6 Intravenous Cannulation........................................... 66 3.7 Setting up a Giving Set.............................................. 72 3.8 Blood Transfusion...................................................... 75 3.9 ECGs.......................................................................... 80 3.10 Fundoscopy............................................................... 91 3.11 Otoscopy................................................................... 95 3.12 Central Venous Lines................................................. 97

5.10 Proctoscopy............................................................ 156 5.11 Instruments............................................................ 159 5.12 Suturing.................................................................. 163 5.13 Surgical Gowning and Gloving................................. 168

6. Urology 6.1 Urinalysis................................................................ 176 6.2 Male Urethral Catheterisation................................. 180 6.3 Female Urethral Catheterisation.............................. 184 6.4 Suprapubic Catheterisation .................................... 187

7. Paediatrics 7.1 Peak Flow............................................................... 192 7.2 Inhaler Technique.................................................... 194 7.3 Preparing Baby Formula Milk.................................. 197

8. General Skills 8.1 Hand Washing......................................................... 202 8.2 Infection Control..................................................... 204

4. Medication Administration

8.3 Manual Handling..................................................... 206

4.1 Intramuscular Injections.......................................... 102

8.4 Death Certification.................................................. 208

4.2 Subcutaneous Injections......................................... 105 4.3 Intradermal Injections............................................. 107 4.4 Local Anaesthetic Administration............................ 109 4.5 Intravenous Drugs ................................................. 112 4.6 Drug Administration via Nebuliser........................... 115 4.7 Operating a Syringe Driver....................................... 117


Contents

9

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Some doctors choose to infiltrate the superficial skin with local anaesthetic prior to performing the arterial puncture. 1-3 mL of lidocaine 2% can be infiltrated to assist with pain control

Arterial blood samples can also be taken from the femoral and brachial arteries

‘If filling stops prior to the syringe being full, retract the needle slig htly. Most commonly, this occurs because the needle has pierced the posterior arterial wall, preventing further filling. By retracting the needle, the bevel will be placed inside the artery, allowing for filling to occur. Most blood gas analysis machines only require 1 mL of blood’

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What cannula would you use for a blood transfusion?

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Station 3 // Preparing Baby Formula Milk

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