Prostatitis

There are four main types of prostatitis and each of these is managed differently. In the emergency department, we are most likely to see acute bacterial prostatitis,but might also see chronic infection and pain.

Acute Bacterial Prostatitis
Acute prostatitis is a common disease amongst men over 50 years of age, especially those who are immunocompromised, like in diabetes or HIV/AIDs.  CKD causes immunocompromise - but I couldn't find any obvious links to CKD and prostatitis!

It often presents with frequency, urgency and dysuria. In women, we might attribute these symptoms to a UTI, but UTI is rare in men without anatomical abnormalities, until the prostate starts to get bigger, increasing the frequency again. We should consider doing a scrotal, genital and rectal examination in any man diagnosed with a UTI, to check there isn't something else.

There might be obstructive voiding symptoms in >80% of patients. 38% of people get perineal discomfort which may present as back or rectal pain.
Some people get systemic features. Can get fever in 60% - 86%, maybe with rigors, malaise and myalgias.

Cause - 
Prostate biopsy - happens in 2% of cases - http://www.ncbi.nlm.nih.gov/pubmed/20577611
Resistance to prophylaxis - http://www.ncbi.nlm.nih.gov/pubmed/21782225
E-coli being the most common pathogen.
Can spread by incomplete voiding.

Sneezing whilst voiding - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556327/
Sexually transmitted

What examination--> 

Examination - Look for signs of urinary retention. If in retention, go for an SPA
Classically described as ecquisitely painful and boggy, actually you only get a  painful prostate in 68%. Pain or symptom reproducability is probably the most important symptom.    http://www.ncbi.nlm.nih.gov/pubmed/15822390.


Investigations - 
Urinalysis - send sample off for culture.
               Leucocytes and nitrites have a great positive predictive value, but not a great negative predictive value. http://cid.oxfordjournals.org/content/46/6/951.long

 Do NOT do prostatic massage to get a sample - may make things worse!
 Blood cultures - positive in 8 - 21% of cases http://www.ncbi.nlm.nih.gov/pubmed/20237098  http://www.ncbi.nlm.nih.gov/pubmed/17969797
 CRP raised in most cases
If there's microhaematuria on the dip, make sure it gets repeated as it might be a sign of cancer.
 PSA - not clear role, but has a high negative predictive value - http://bestbets.org/bets/bet.php?id=1585
PR without prostatic massage makes minimal difference to the serum PSA value and generally does not cause a clinically significant increase in PSA levels. However, some studies have found that there may be a minority of men in whom the procedure raises PSA. [ 6 ] For this reason some experts recommend that blood for PSA testing should be taken before DRE.

Urethral catheters are allowed in "experienced" hands but pre-treatment with appropriate antibiotics is mandatory. If the catheter is difficult to pass, a suprapubic is indicated.

So how do you tell if someone has prostatitis, or just a UTI? And like many things, there's no real answer. If they've got a painful or boggy mass on examination, then the answer is easy! If they haven't...could it still be prostatitis? Generally, yes it could be. The patients are normally significantly unwell - the risk of bacteraemia is increased in severe UTIs like pyelonephritis and prostatitis. I think it's reasonable if you have a really really sick ?urinary sepsis, to assume prostatitis until proven otherwise.
Review after 7 days 

Treatment - antibiotics
- Broad spectrum (cephalosporin) plus gentamycin if patient is systemically unwell.
- If oral antibiotics are appropriate, use
o Ciprofloxacin 500mg BD for 28 days or
o Ofloxacin 200mg BD for 28 days
- If patient is allergic to quinolones, consider trimethoprim (200mg BD for 28days) as an alternative. It needs to be for a long time because the prostate has quite a poor blood supply.


Laxatives - if defacation uncomfortable
Rest
NSAIDs
It is possible to add on an alpha blocker such as tamsulosin which has been proven as an beneficial adjunct for symptom relief.
Hydration

A referral to the Urology Team should be made upon discharge.

If fails to respond, arrange trans-rectal USS or CT of the prostate to R/U prostate abscess. Prostatic abscesses are relatively uncommon due to clinical practice due antibiotic therapy. Like prostatitis, common presenting features are dysuria, fever, suprapubic pain +/- urinary retention. Urine examination usually reveals pus cells.  The organisms usually involved include:
Escherichia coli
Staphylococcus spp
Gonococcus spp: rare


You should delay PSA testing for six weeks after treatment for a urinary tract infection.
Ciprofloxacin is the antibiotic which the Prostatitis Expert Reference Group (PERG) recommends as first line treatment for chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome. It has excellent penetration into the prostate, good bioavailability and good activity against typical and atypical pathogens. Treatment should be guided by bacterial cultures and sensitivities once these are known. You should continue treatment for at least four weeks. Options for second line antibiotics include trimethoprim or a tetracycline such as doxycycline.



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The chronic forms of prostatitis are common and debilitating and between 35 to 50% of men report symptoms suggestive of prostatitis at some time in their life.
Prostatitis is a common urological diagnosis in men under 50 years old and is most prevalent in men aged 36 to 50 years.


Four main domains of symptoms of chronic prostatitis/chronic pelvic pain syndrome [ 1 ]
Pain
Lower urinary tract symptoms
Psychological issues
Sexual dysfunction
and these are beyond the remit of this podcast.



http://emedicine.medscape.com/article/2002872-treatment#d10
https://cks.nice.org.uk/prostatitis-acute#!diagnosissub
http://www.racgp.org.au/download/Documents/AFP/2013/April/201304dickson.pdf
http://www.primarycareurologysociety.org/downloads/2015presentations/Jon%20Rees%20Prostatitis.pdf
https://uroweb.org/wp-content/uploads/19-Urological-infections_LR.pdf
http://www.rcemlearning.co.uk/modules/acute-urinary-retention/
http://radiopaedia.org/articles/prostatitis
http://radiopaedia.org/cases/acute-bacterial-prostatitis-and-abscess
http://wikem.org/wiki/Prostatitis

http://learning.bmj.com/learning/modules/flow/ICH.html?execution=e1s1&moduleId=10051979&status=LIVE&action=start&_flowId=ICH&sessionTimeoutInMin=90&locale=en_GB&shouldStartAtQuestionSection=false

Trachy

There are a few potential problems for trachys - bleeding, obstructing and needing to insert one. All of these could present to the emergency department.

Tracheotomy is an incision in the trachea and comes from two Greek words: the root tom- meaning 'to cut', and the word trachea.

Tracheostomy, including the root stom- meaning 'mouth' - refers to the making of a semi-permanent or permanent opening, and to the opening itself.

Laryngectomy is the surgical removal of the larynx, usually completely and permanently. The remnants of the trachea are stitched to the anterior neck. There is no connection from the nose or mouth to the lungs, so traditional airway manipulation will not work.

If a trachy has been inserted, the upper airway anatomical dead space can be reduced by up to 50%, The natural warming, humidification and filtering of air that usually takes place in the upper airway is lost.

Bleeding Trachy
- Hyperinflate cuff
- Silver nitrate if local bleeding
- Pressure over sternal notch

Respiratory Distress - "DOPES"
Displacement
Obstruction
Patient - bronchospasm, pneumothorax
Equipment - is cuff OK?
Stacked - are breaths being stacked?

Following the emergency guidelines can be very helpful.

References
http://foamcast.org/2015/10/07/episode-35-the-trachea/
http://www.tracheostomy.org.uk/
http://portal.e-lfh.org.uk/myElearning/Index?HierarchyId=0_132_132&programmeId=132
http://emcrit.org/podcasts/surgical-airway/

Pericarditis...and Cardiac Tamponade

I have seen a fair few patients that I have diagnosed with pericarditis. It seems that I've probably over-diagnosed it in quite a lot of people! 5% of patients presenting to the ED with non-ischaemic chest pain have acute pericarditis - so my numbers are probably right.

The Pain 
- Relieved by leaning forward
- Can radiate to the trapezius ridge as the phrenic nerve travels

Signs
- Pericardial friction rub in 85% of cases
- Rub still heard on breath holding

ECG
- Diffuse concave or saddle shaped ST changes, with ST elevation in 90% of cases, typically leads Ι, ΙΙ, V5 and V6
- Associated ST depression in aVR and V1 is seen in 64% of cases [6].
- PR depression
- Look carefuly at V6. If ST elevation to T wave height ratio is greater than 0.25, acute pericarditis is more likely than BER.

 Diagnosis - needs 2/4
Characteristic chest pain
Pericardial friction rub
Suggestive ECG changes
New or worsening pericardial effusion

High Risk features
Temperature greater than 38ºC
Raised WCC
Large pericardial effusion
Cardiac tamponade
Acute trauma
Immunosuppression
Oral anticoagulants
Failure of NSAID therapy
Recurrent pericarditis
Troponin levels are elevated in 30-70% of patients with 'pericarditis'; they offer no prognostic information.

Pericardial Effusion
A true diagnosis needs relief of symptoms from pericardiocentesis.
Signs - Pulsus paradoxus is an exaggerated fall in systolic blood pressure of 10 mmHg or more during inspiration.
The Beck triad is present in only a minority of patients

References
http://sinaiem.org/cardiac-tamponade/ 
https://radiopaedia.org/articles/cardiac-tamponade 
http://www.rcemlearning.co.uk/modules/acute-pericarditis/ http://www.rcemlearning.co.uk/references/pericarditis/ 
https://coreem.net/core/pericarditis/ 
http://www.emnote.org/emnotes/ecg-findings-of-pericarditis

Management Part 5 - general

Your Department Overview
You are always likely to be the lead
Notice the dates
Look at how many Consultants there are in the department and if this is right for CEM guidance
Prepare a one liner about the department eg TU med
Always then do a shift walk / speak to SpR / NIC
Comment on anything that is abnormal
If you are running late, ask the day registrar to ring the night registrar
If you delegate say you will be available all the time so anyone can work under my direct supervision
Always signpost your diary - say I will deal with the urgent things first...
Always be prepared to cancel things in your diary eg. the drains if there's a majax
Don't say juniors - say medical or nursing staff

Content
If there's targets, look at how far through the year we are and how close to target we are
If there's name and shame state this is a dysfunctional department
If there's audits, look at who does the audit
If they mention patient details, do you have enough identifiers?

Emails
Look at who they came from and when
The CEO is automatically important
Always look at who is CC'd
Bring in comissioning

Rules
You can't discipline Nurses
Matron can't discipline medics

FY2 teaching
Look at who is staffing the department

Reference Request
We must have known for 36 months
Find out who was supervisor
Review appraisals
Assume it was you that you were their supervisor
Give an accurate reference

Incident Forms
Say that all incident forms will be appropriately assigned. From this report, it would not be assigned to me but if it was... ...

Teaching
Always mention teaching - mention the teaching programme/ induction. If the FY2s are at teaching, who is running the department.
Look at the topics - if there is something like "foolish mistakes by patients" state that this is degrading.

Late Night Swaps
State it is against policy
But that you would try to help
Remind people on induction of the policy, and resend policy.

Forging Signatures
Locum agency to investigate
?Signature record with the secretaries
Say the locum isn't coming back

Medication Shortage
Shortage does not = gone
Can we stockpile
Keep pharmacy link in the loop
Email / poster in the back of the loo
Tell Nurses there is a shortage
Physically stick the sign in the resus cupboard

Bomb Threat
Gather some information - is it real?
Escalate to all co-located services - NIC, duty manager.
State there is a policy
Police liason officer

Doctor being bullyed
SUI
Bullying policy
Phone the doctor
Time of shift swapping
Having worked with these 2 FY2s I will have an awareness of their characteristics...
Sisters is a Nursing Issue
Get a copy of the notes, add my notes. Store in "incidents file"

Fascia Iliaca Blocks

Fascia Iliaca blocks are really useful for analgesia for hip fractures. We should be performing them!

Fascia Iliaca or Femoral?
My understanding of this is if we're using a landmark approach, and we use a femoral nerve block the risk of not being in the right soft tissue plane is high. This means that a fascia iliaca block us more likely to be beneficial. The evidence, which I haven't appraised myself, suggests that there's not a significant amount of difference between them all.

Anatomy 

If you look here you can see that the femoral nerve sits, and is enclosed between the fascia lata and the facia iliaca. If you go just lateral to it, you don't know whether you are above or below the fascia iliaca. If you do a fascia iliaca compartment approach, you know you are in the right space.

The podcast from Anatomy for EM is excellent at running through this.

The fascia iliaca compartment contains the three main nerves we are interested in blocking - the femoral nerve, lateral femoral cutaneous and obterator. They provide analgesia for all of the leg except the posterior bit - which the sciatic nerve covers.

Contraindications
· Patient refusal
· Anticoagulation
· Previous femoral bypass surgery
· Inflammation or infection over injection site
· Allergy to local anaesthetics
· Previous femoral bypass surgery

Anaesthetic
We need to use large amounts of local anaesthetic to perform this. 30-40ml should be used for every adult sized patient, and anaesthetic adjusted accordingly.

Our maximum doses are:
Bupivacaine        2mg/kg
Lidocaine            3mg/kg

We normal use 0.25% bupivacaine to provide maximum volume. For a 80kg patient, this would be 160mg which is 60ml of 0.25% bupivacaine. Which is quite a lot. Bupivacaine often works slowly but lasts for a while.

Landmarks 
Place one middle finger on the ASIS and the other middle finger on the pubic tubercle.
Draw a line between these two points.
Divide this line into thirds.
Mark the point 1 - 2 cm caudal from the junction of the lateral and middle third.
This is where you are aiming for.

Ultrasound
Ultrasound for blocks isn't yet common practice. I use it to help avoid accidental intravascular injection - put the probe on where I'm going to inject, and double check.

You can see the two fascial layers on ultrasound, and see the local anaesthetic expand. This video demonstrates the use of ultrasound wonderfully.

Complications
Failure
Infection
Accidental intravascular or intraneural injection
Local anaesthetic toxicity

Links and References
http://www.propofology.com/infographs/fascia-iliaca-block 
http://learned.rocks/cooked-resourced/2016/8/15/nerve-blocks 
http://www.rcemlearning.co.uk/modules/fascia-iliaca-block/ 
https://songsorstories.com/2016/07/31/pop-pop-phew-sounds-to-go-with-blocks/ 
http://www.thegasmanhandbook.co.uk/fascia-iliaca-block.html 
http://stemlynsblog.org/fib-virgil/ 
http://bestbets.org/bets/bet.php?id=2673 

Management part 4 - Complaints

Complaints are unfortunately comment and cost the NHS a lot in time to investigate, and litigation costs. GMC guidance says patients are allowed to complain, and their complaints must be investigated and not bias the care they are provided.
Formal complaints must be made within six months of the event, or the patient becoming aware of the event up to a maximum of a year of the event, by the patient or relative.
The trust has 3 days to acknowledge the complaint, and 25 working days to reply with a response (10 days in primary care).
Always mention PALS

There are three types of claim:
•Category A Claims: below which the trust bears the costs of any settlement (eg £20 000-250000).
•Category B Claims: claims over and above this are settled by the CNST in part (20%)
•Category C Claims: above this threshold (£500 000) settlement paid in full by CNST

To exist, medical negligence requires:
-  Duty of care existed
-  Duty was breached (Bolam/Bolitho tests)
-  Harm occurred as a result of the breach

To get compensation, a patient needs to prove:
That the treatment fell below a minimum standard of competence; and
That he/she has suffered an injury; and
That it is more likely than not that the injury would have been avoided, or less severe, with proper
treatment

 There are six main components of good complaints handling. 

1) Getting it right
2) Being customer focused
3) Being open and accountable
4) Acting fairly and proportionately
5) Putting things right
6) Seeking continuous improvement

When dealing with a complainant, the 3 Rs can be helpful.
Regret
Reason
Remedy

Complaints from GPs
This is not a complaint it's colleague to colleague
Can ring the emailer back, acknowledge mistake, praise their system and make it positive ?audit
Involve GPs in plans/ audit
Local resolution
Datix


http://michael.gradmedic.org/medicine/medicolegal.html#negligence
http://fcemprep.blogspot.co.uk/2014/09/the-fcem-management-viva-basics.html?m=1 

Management Part Two - Disciplinary and Policies

·         Warnings

·         Verbal

·         Written

·         HR issues

• Grievance is an ‘Employee’s complaint’ against management.

• Discipline is a ‘Management’s complaint’ against an employee.

Clinical Issues

- Follow Trainee in Difficulty advice

- NCAS involvement may be necessary 

- An informal route may be decided on 

      Retraining, re-skilling, e.g. workshops, e-learning, 

      Counselling, rehabilitation, e.g. NHS Practitioner Health Programme

      Supervision or development support programme e.g. supervised practice, formative work-based assessments 

       Mentoring or coaching, career guidance

- If needs investigating medical director appoints case investigator. 

- Complete within four weeks 

- If need formal capability hearing, need 20 days notice, 2 members of trust board and one practitioner from outside the Trust. Advice from HR, senior Clinician from outside the trust.

-  Outcomes could be agreement for improvement, formal written warning, final written warning or dismissal. Dismissal needs to be reported to the GMC. 

Referral to the GMC

If:

a. The doctor’s ill health is posing, or may pose, a risk to patients;

b. The doctor refuses, or has failed, to follow advice and guidance from his or her own doctor, occupational health adviser or employer.

c. The doctor’s conduct has led to the involvement of the police and/or the courts or raised other concerns.

Holiday Leave

The annual entitlement under Agenda for Change for each full-time member of staff is:

On appointment              27 days + 8 General Public Holidays

After 5 years service 29 days + 8 General Public Holidays

After 10 years service 33 days + 8 General Public Holidays

Whistleblowing

If concerns speak to CD. If still have concerns anyone can speak to the board.