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EMERGENCY MEDICINE
Liverpool Hospital
The Weekly Probe
10th February 2014
Volume 17 Issue 3
Paediatric Short Stay unit - The Paediatric Short-stay Unit commenced operations yesterday,
07:00-22:00 Monday-Friday with 4 beds.
There will be a Paediatric Consultant and Registrar attached to PSSU, and they will have a contact
number (to be confirmed) to call to refer patients.
Suitable patients are those likely to be discharged but are requiring further treatment beyond 4 hours
in the ED.
Suitable diagnoses include Asthma, Gastroenteritis, Bronchiolitis, Ingestions/Poisonings, Croup,
Awaiting results of procedures, Minor Head Injuries, Post sedation recovery, Unsettled babies, Mild
allergic reactions, No toxic Febrile Child.
Please contact the PSSU registrar as first point of contact to accept admission to PSSU.
In the evenings there will be a restriction on acceptance to the PSSU after 6pm, as the children need
to be discharged/admitted from the unit by 22:00pm.
With recent commencement of a new Paediatrician there will also shortly be running an Acute Ward
Review Clinic 5 days a week in the afternoon, as well as ED focused Paediatrician who will be
available to assist in ED
Meningitis Care Sets - The Microbiology lab has created a care set for acute meningitis to be used
when sending CSF. This care set is designed around a new multiplex PCR assay we have for
detecting pathogens in CSF (it covers Neisseria meningitidis, Streptococcus pneumoniae, HSV 1 and
HSV 2, VZV and Enterovirus). The care set also includes protein and glucose testing and Microscopy
and culture. There is an option for including Cryptococcal antigen, although this is not performed
unless specifically requested.
To select go to Orders and search for terms including “CSF acute meningitis panel” then select or
deselect what you need within the panel.
Preparation of medications for Procedural Sedation – on the Intranet site under Sedation there is
a new guideline for the Preparation of Medication for Procedural Sedation. Please make yourselves
familiar with this policy as it contains changes regarding the shared responsibility of preparing these
high risk medications.
Fitness to Drive – We occasionally see patients who present with a illness which makes it
dangerous to drive. Regardless of advice , some continue to drive, with risks to the patient and most
importnantly the public.
On the Liverpool ED intranet site under “administrative” then “Medicolegal and Death” is information
for clinicians on what advice we should be giving for such drivers (eg post seizure, hypo etc) and
forms o who to notify if you want to report the recalcitrant driver. Also at
http://www.austroads.com.au/assessing-fitness-to-drive/
However some further info from the Ministry of Health this week on such issues.
The Ministry of Health’s policy, based on common law and ethical principles, is that the duty of
confidentiality owed by medical practitioners to their patients must be preserved except where:
 disclosure of health information occurs with the consent of the patient or
 where there is a lawful justification for disclosing the information without the consent of the pt.
One context in which disclosure of health information to third parties arises is medical assessment of
patients for fitness to hold a licence to drive. This is generally done to assist the relevant licensing
authority (Roads and Maritime Services in NSW) to determine whether or not a patient is fit to hold a
licence or to hold a conditional licence.
Information regarding this process can be found on the RMS website, which includes a standard
“Medical Condition Notification Form”. This form can be completed by the medical practitioner in
consultation with the patient, and submitted to RMS.
There may be circumstances in which a medical practitioner may hold concerns about a patient’s
fitness to drive and/or that the patient is a potential danger to the public if permitted to drive in any
circumstances, or is permitted to drive without being subject to conditions. In this event where
possible medical practitioners should encourage patients to either self-notify the medical condition to
RMS or to consent to the medical practitioner notifying RMS of the practitioner’s concerns via the
submission of a completed “Medical Condition Notification Form”.
Where the patient does not comply with the medical practitioner’s advice, legislation in NSW provides
protections for medical practitioners who directly report the matter to RMS.
Section 275(4) of the Road Transport Act 2013 (NSW) provides as follows:
An individual does not incur civil or criminal liability for reporting to the Authority [ie RMS], in good
faith, information that discloses or suggests that:
(a) Another person is or may be unfit to drive
(b) It may be dangerous to allow another person to hold, to be issued or to have renewed, a driver
licence or a variation of a driver licence.
The above provisions are discretionary reporting requirements only. There is no mandatory
reporting requirement for medical practitioners in relation to drivers who may present a risk to the
public. In considering whether to make report directly to RMS, medical practitioners should ensure
that:
• They are acting in good faith – that is, they are acting out of a bona fide concern for safety concerns
regarding the driver concerned
• The health information they disclose to RMS is limited to information that is relevant to the issue of
the driver’s fitness to drive or that allowing the person to hold a licence may be dangerous.
Situations that may result in a medical practitioner reporting a patient to the RMS include
where the patient is:
• Unable to appreciate the impact of their condition
• Unable to take notice of the health professional’s recommendations due to cognitive
impairment
• Continues driving despite appropriate advice and is considered likely to endanger the
public.
In the event that the medical practitioner decides to directly report a patient to RMS, it is good
practice to advise the patient that the practitioner is doing so.
Medical practitioners may, if they wish, when directly reporting a patient to RMS, use a copy of the
approved “Medical Condition Notification Form”. A copy of the form, and more information from RMS,
can be found at:
http://www.rms.nsw.gov.au/licensing/healthmedicals/health_professionals.html
The “Assessing fitness to drive” booklet also has the contact info for interstate licensing boards where
the info can be sent (eg interstate epileptic truck driver who refuses to take his meds)
http://www.austroads.com.au/assessing-fitness-to-drive/
SHIP Pathway This is a reminder regarding Mental Health patients being medically cleared, please
document medical clearance using the form.
If clinically indicated, consider CT brain for first onset psychosis to exclude intracranial pathology.
There was a patient that was admitted to PECC with new onset psychosis who had a brain tumour
with changes in behaviour.
Regarding the SHIP pathway (Self Harm Intoxicated Patients), this has been revised and finally
approved as a hospital policy and is now available in the hospital intranet, (search SHIP) and will also
update on the ED intranet website for easy access. A copy is also on the wall in acute staff area.
Please be mindful of the exclusion criteria such as patients requiring cardiac monitoring, evidence of
serious intoxication requiring HDU/ICU care, monitored bed or need for antidote such as NAC for
Paracetamol overdose or Naloxone for opioid overdose, patients with evidence of mod-severe liver
failure/encephalopathy, head injury patients, or persistently aggressive patients, these patients
SHOULD NOT be under the pathway.
Editor: Peter Wyllie
Please inform PECC if patient is suitable and admitted under this pathway so they can in turn make
initial (limited) psych assessment, who will then hand over to C/L team who will review patient in
MAU once sober and can make a full assessment.
THIS WEEK
Deep Brain Stimulation (DBS)
Keratoconus
Next Week
Joke / Quote of the Week
The Week Ahead
Deep Brain Stimulation
A colleague at RNSH treated a 50yo cyclist who came off his bike, smashed his helmet and was
amnesic and bruised and battered. The complicating issue was that he had a deep brain stimulator in
place to manage his Parkinson's disease tremor.
What are the implications of this to us in the ED ?
Deep Brain Stimulation is not what you get from reading the latest edition of Ralph magazine or
watching a episode of Big Brother, but it is a technique whereby electrodes are inserted into deep
white tissue (thalamus, globus pallidus etc) as part of the treatment of essential tremor, Parkinson's
disease, cerebral palsy, dystonia, ataxia, spasticity or Tourette's Syndrome.
Electrical signals are then transmitted from a box implanted inferior to the clavicle (similar to a
pacemaker yet often on the right side) via wires to the above regions.
There are 2 main providers in Sydney- Medtronic and St Jude. According to the Medtronic rep there
were ~ 80 Medtronic devices implanted last year, most via the private hospital system. So this is a
relatively infrequently used device but something we may encounter in the ED.
However there are some implications to the ED if such a patients presents to the ED.
You cannot tell if the device is on or off
o The patient should present with a hand-held controller which will advise you if the device
is working or not
o The patient may not be able to communicate if the device is malfunctioning , making the
assessment more difficult
o The device may be turned on or off via electrical impulses or magnets. These include
 Theft detectors
 Airport security devices
 Large stereo speakers with magnets
 “Items with magnets (eg refrigerators, freezers, power tools) may cause the
neurostimulator to turn off “
-
Components may fail including the rechargeable battery which patients are instructed to check ) or
cables which may become displaced or fracture.
-
ECG interference may be seen – if unsure turn device off
-
Imaging implications
o Xrays are OK
o Recommendation to turn the device off prior to CT- however consider the clinical context
o Ultrasound

therapeutic (for the patient not the doctor) ultrasound should not be provided
adjacent to the device
 However most importantly diagnostic ultrasound “ poses no electrical interference
problems .. however the transducer should not be placed directly over the
implanted neurostimulator
Editor: Peter Wyllie
-
Resuscitation
o Defibrillation may damage the device or cause tissue damage however survival is more
important
o However position pads as far away from the device as possible and angle the paddles if
you are using them perpendicular to the leads. That is, use pads in the anterior-posterior
position.
-
Surgical considerations
o recommendation to turn device off prior to surgery – if diathermy required, then use
bipolar rather than monopolar diathermy
o Lithotripsy should be avoided
Most importantly, if you have any questions or problems, contact the patient’s treating
neurologist and or the device rep, contact details on the patients card or via white pages ,
similar to what we encounter with pacemakers.
Refs : Medtronic DBS product information
Keratoconus
A 30yo man presented with an acute deterioration in his vision – he could count fingers on the
involved eye c/w 6/9 on the other eye. Below are a picture of his eyes – note the conical shape of his
cornea and the marked corneal clouding (oedema).
Keratoconus (KC) is a progressive, noninflammatory, bilateral (but usually asymmetrical) disease of
the cornea, characterized by corneal thinning that leads to corneal surface distortion. Visual loss
occurs primarily from irregular astigmatism and myopia and secondarily from corneal scarring.
Commonly recognized ocular associations include keratoconjunctivitis, retinitis pigmentosa, and may
be associated with connective tissue disorders (eg, Ehlers-Danlos and Marfan syndromes), mitral
valve prolapse, atopic dermatitis, and Down syndrome. Particular risk factors include atopic history,
especially ocular allergies, rigid contact lens (CL) wear, and vigorous eye rubbing. Can occur or
progress at any age.
History: -Patients often report decreasing vision (distortions, glare/flare, and monocular diplopia or
ghost images) with multiple previous unsatisfactory attempts in obtaining optimum spectacle
correction. When hydrops develops, patients report sudden loss of vision and some ocular discomfort
in one eye but usually not much pain or conjunctival injection.
The ocular manifestations of keratoconus are limited to the cornea. They include steepening of the
cornea, especially inferiorly , thinning of the corneal apex, and changes in Bowman's layer. A ring of
iron deposition accumulates in the epithelium at the base of the cone (Fleischer ring). The steepening
Editor: Peter Wyllie
of the cornea leads to clinical signs, which include protrusion of the lower eyelid on downgaze, and a
light beam from the temporal direction across the cornea causes a arrowhead pattern on the nasal
side. In some patients who have keratoconus, acute rupture of Descemet's membrane on the inner
side of the cornea (acute hydrops) may occur and result in acute overhydration of the cornea and
accumulation fluid within the corneal stroma. The overlying corneal epithelium may become
oedematous, and fluid may leak through the corneal epithelium.
Treatment. – early - glasses then rigid contact acuity becomes inadequate. When contact lenses no
longer provide adequate acuity, contact lens comfort becomes inadequate, or the steepness of the
cornea is such that lenses cannot be maintained in position, surgical treatment is indicated
(keratoplasty) Acute treatment of hydrops is palliative; many corneas flatten secondary to hydrops,
and both visual acuity and contact lens application may improve following such events.
Refs Yanoff – Opthalmology
NEXT WEEK
56yo man presents with 2 days of progressive pain in his right leg.
What is going on and what do we need to do ?
JOKE / QUOTE OF THE WEEK
The caption on this one read “No time for gym? No worries” I thought this one reminded me of Alex
post exams
Editor: Peter Wyllie
Please forward any funny and litigious quotes you may hear on the floor (happy to publish names if
you want)
THE WEEK AHEAD
Tuesdays - 11.30-2.30 Intern teaching -Thomas & Rachel Moore
Wednesday
0800-0900 Critical Care Journal Club. ICU Conf Room / 12.30-1.30 Resident MO in
Thomas & Rachel Moore
Thursday 0730-0800 Trauma Audit. Education Centre / 0800-0830 MET Review Education centre /
1300-1400 Medical Grand Rounds. Auditorium.
Editor: Peter Wyllie