Education

Surgical emergencies: multiply injured patients

Ashok Handa, Kevin Turner, and Adam Jones explain the principles of advanced trauma care

call to casualty to attend to a mul-

A tiply injured patient causes anxiety

in most doctors and sets their
pulse racing. Fortunately, most hospitals
now have a trauma team, and as a house
officer in surgery you will be called to help
your registrar or senior house officer
rather than to deal with patients on your
own. In general, most accident and emer-
gency departments will have some warn-
ing from the ambulance service and will
call you to the resuscitation room to pre-
pare for the arrival of the patient(s).
Multiple trauma, mostly from road traffic
accidents, is the leading cause of death

among people aged up to 40 years. It is the
third highest cause of death in all age
groups. In the United Kingdom this is
equivalent to 14 airline crashes per year and
costs around £600 000 per patient. In 1988,
the Royal College of Surgeons of England
adopted the course in advanced trauma life
support (ATLS) from the American College
of Surgeons1 after the report by its working
party showed a cause for concern in the
management of multiply injured patients
in Britain. Now ATLS training forms the
basis for the management of multiply
injured patients in most hospitals.
In order to perform their role effective-
ly, new house officers should understand
the process of ATLS and the principles of
care. There is little time for teaching during
the management of a multiply injured
patient. The purpose of this article is to
outline management principles, so that
you can understand what is going on.
Detailed aspects of management can be
learned later.
The chain of care
The outcome in a multiply injured patient
depends on a number of people and agen-
cies working together towards the same
goals. The first link is the prehospital care
provided by the paramedical service and
the information the team provides to the
trauma team on the mechanism of injury,
initial condition, and subsequent changes
in the patient. The second link is the
Paramedics loading an injured man into an ambulance with a splint and neck brace
reception, resuscitation, and initial assess-
ment in casualty. The third link is the
emergency investigation, surgery, and
intensive care. The final link is the defini-
tive care in the initial hospital or after
transfer for specialist care.
There is a tri-modal distribution of
death.
● Death within minutes—usually lethal
injuries resulting in death at the scene of
the accident
● Death in the first hour—life threaten-
ing injuries requiring urgent attention
● Death in days/weeks—resulting from
the complications of initial injuries sus-
tained
Emergency management is aimed at
reducing death from life threatening
injuries.
Trauma teams—who should be
present?
The ideal trauma team consists of a mini-
mum of four doctors and two nurses. The
members should include the following.
● Surgical registrar/senior house offi-
cer/house officer
MAURO FERMARIELLO/SPL
● Orthopaedic registrar/senior house
officer
● Anaesthetist
● Accident and emergency registrar/
senior house officer
● Two accident and emergency nurses
A team leader should be chosen in the
preparation phase, although most hospi-
tals have a protocol of one of the registrars
being the team leader. Other members of
the team with vital roles are the following.
● Radiographer
● Laboratory staff
● Porters
● Specialist surgeons
● Paramedics/ambulance crew
Initial assessment
Although the assessment is outlined as a
longitudinal progression, many of these
activities occur simultaneously. The initial
assessment consists of the following.
● Primary survey
● Resuscitation
● Detailed secondary survey
● Initiation of definitive care
The primary survey and resuscitation

186 STUDENT BMJ VOLUME 8 JUNE 2000


run concurrently with intervention for
problems as they are encountered. With
the full team present, several problems can
be addressed at once.
Primary survey
This is a logical sequential assessment of
the patient’s vital functions with identifi-
cation and treatment of life threatening
conditions. This constitutes the ABC of
trauma care.
● A: Airway maintenance with cervical
spine control
● B: Breathing and ventilation
● C: Circulation
● D: Disability (neurological status)
● E: Exposure
A: Airway maintenance with cervical
spine control
This will normally be undertaken by the
anaesthetist. The principles are to establish
an airway while maintaining control of the
cervical spine. Patients should be laid flat
and neck extension avoided. Stabilise the
neck by fitting a rigid collar and tape the
forehead to the sides of the trolley.
Remember: all multiple injuries have a
cervical spine injury until proved otherwise.
B: Breathing and ventilation
A patent airway does not ensure ade-
quate ventilation. The patient’s chest
should be exposed to assess breathing
movements. Briefly examine the chest,
looking for any injuries to the chest wall
that may compromise ventilation. Check
for good bilateral air entry. Some injuries
should be identified and treated imme-
diately before moving on. These are ten-
sion pneumothorax, massive haemo-
thorax, flail chest, and open chest
wounds. A useful mnemonic for air-
way/chest injuries is ATLS-FC (Box 1).
Give 100% oxygen through a mask or
intubate if necessary.
Box 1—ATLS-FC: life threatening chest
injuries
A Airway obstruction
T Tension pneumothorax
L Large (massive) haemothorax
S Sucking chest wound (open
pneumothorax)
F Flail segment (and underlying lung
contusion)
C Cardiac tamponade
C: Circulation with haemorrhage
control
Assess blood volume and cardiac output
from clinical examination. Cerebral circu-
lation may be impaired resulting in altered
level of consciousness. In a multiply
injured patient blood loss is the common-
STUDENT BMJ VOLUME 8 JUNE 2000
How much blood has my patient lost? It’s a game of tennis
0-15% 15-30%
Pulse <100 >100
Blood pressure Normal Normal
Respiratory rate 14-20 20-30
Note that you may see a drop in blood pressure only after significant blood loss. Young
patients maintain their blood pressure better than old people. Don’t be reassured by a
normal pressure in a young patient—they may have lost a lot of blood.
est cause of diminished conscious level.
The skin colour is a good indicator of cir-
culating volume, and pale, ashen skin indi-
cates at least a 30% loss in blood volume.
The pulse (carotid or femoral) is a good
indicator of blood loss, and rapid, thready
pulses are early signs of hypovolaemia.
External, severe haemorrhage should be
identified and controlled by direct manu-
al pressure on the wound.
Pulse, blood pressure, and respiratory
rate can give you some idea of the amount
of blood loss. Remembering how a game
of tennis is scored can help (Table)!!
D: Disability (neurological status)
A rapid assessment of the neurological
state can be made by seeing if the patient
is speaking to you, by looking at the pupils
and assessing the level of consciousness.
A simple mnemonic is AVPU (Box 2).
Box 2—AVPU
A Alert
V Responds to vocal stimuli
P Responds to painful stimuli
U Unresponsive
The Glasgow coma score (GCS) is more
comprehensive but is often left until the sec-
ondary survey. The GCS was described in
detail in last month’s article on head injury.
E: Exposure
FULLY undress the patient to allow a
thorough examination, but keep him or
her warm by then covering with blankets.
Resuscitation
Your patient should be resuscitated while
the primary survey is being conducted.
The aim of resuscitation is to achieve good
tissue perfusion. This includes establishing
that the airway, ventilation, oxygenation,
and circulation are all adequate. You need
to be vigorous with shock treatment and
to manage any life threatening injuries as
they are discovered. The following is the
minimum management in most cases.
● Oxygenate with 100% oxygen
● Insert two cannulas (14 gauge) in the
antecubital fossae, crossmatch blood
● Infuse 2 litres of Hartmann’s solution
rapidly
Education
30-40% >40% (game over)
>120 >140
Decreased Decreased
30-40 >35
● Send blood samples for full blood
count, urea and electrolytes, glucose
● Record vital signs (temperature, pulse,
respiration, and blood pressure)
● Pulse oximetry
● Electrocardiogram monitor
● Urinary catheter—unless contraindi-
cated
● Nasogastric tube—unless contraindi-
cated
● Arrange x ray films: lateral cervical
spine, chest, anterior-posterior pelvis
Secondary survey
This is a detailed head to toe examination
of the patient undertaken after the patient
has been resuscitated and stabilised. It may
be interspersed with x rays and other pro-
cedures such as catheterisation. It should
be undertaken by an experienced doctor
and needs attention to detail. The sec-
ondary survey has been summarised as
“tubes and fingers in every orifice.”
Remember this may be the only FULL
examination the patient gets throughout
his or her inpatient stay and thus should
be very detailed. It is not unheard of for a
patient not to thank you for saving his or
her life but to sue you for missing a mallet
finger deformity.
A full history should also be obtained
from the patient if possible or from the
ambulance crew or relatives. The
mnemonic AMPLE is a good way to
remember what you should ask about
(Box 3).
Box 3—An AMPLE history
A Allergies
M Medication
P Past medical history
L Time of last food or drink
E Events and environment related to
injury
Definitive care phase
During this phase the comprehensive care
of the patient is planned and includes frac-
ture stabilisation, operative intervention,
and the transfer of the patient to a refer-
ral centre for specialist attention if
required. The patient should only be trans-
ferred if stable and with appropriate med-
ical escort, usually an anaesthetist.
187
Education

Re-evaluate Self test questions

Box 4—Points to remember
● Call for help: doctors, nurses, others
● Remember the ABC
● Give 100% oxygen
● Hypotension=hypovolaemia
(in trauma)
● Two big peripheral lines and 2 litres of
fluid
● Crossmatch early
● Cervical spine is fractured until proved
otherwise
● Do NOT leave the patient (for example,
for an x ray film)
● Ask for history of events from
ambulance crew
● Must have x ray films of lateral cervical
spine, chest and anterior-posterior
pelvis
● Keep records and look at the time
● Re-evaluate constantly
● Take an AMPLE history
Documentation
The team leader must ensure that this is
clear and concise. Documentation should
be detailed, chronological, and must
include time of arrival and names of those
present. Medical record keeping is an
essential part of good medical practice.
Vital signs can change rapidly. Throughout
the assessment of a trauma patient
remember to re-evaluate your findings.
You may discover something that you had
initially missed. Impaired consciousness is
the most common cause of a diagnosis
being missed.
Conclusion
Managing multiply injured patients can be
a scary experience. The advent of trauma
teams and use of the ATLS process provides
a framework and results in effective, rapid
management of these patients (Box 4). As
part of a trauma team you will quickly learn
to assess and resuscitate trauma patients and
have an impact on their outcome.
Ashok Handa clinical lecturer,
Nuffield Department of Surgery, John Radcliffe
Hospital, Oxford
Kevin Turner research fellow in urology,
Molecular Oncology Group, Institute of Molecular
Medicine, John Radcliffe Hospital, Oxford
Adam Jones specialist registrar in urology,
Churchill Hospital, Oxford
1 American College of Surgeons. Advanced trauma life sup-
port course manual. Chicago: American College of
Surgeons, 1997.
2 Skinner D, ed. ABC of major trauma. London: BMJ Books,
2000.
3 Royal College of Surgeons of England. Report of the working
party on the management of patients with major injury.
London: Royal College of Surgeons of England, 1988.
(1) What does the primary survey consist of?
(2) What percentage of blood loss results
in hypotension?
(3) Which life threatening chest injuries
must be treated immediately?
(4) What is the primary aim of
resuscitation in a multiply injured patient?
(5) When and why is a secondary survey
necessary?
hroughout his or her inpatient stay.
FULL examination the patient has
identify all injuries and may be the only
detailed head to toe examination to
resuscitated and stabilised. It entails a
patients after the patient has been
(5) A secondary survey is essential for all
(4) Airway and cervical spine control.
segment, and cardiac tamponade.
haemothorax, open pneumothorax, flail
(3) Tension pneumothorax, massive
loss and needs aggressive treatment.
relatively late sign of shock from blood
(2) At least 30%. Hypotension is a
E: Exposure
D: Disability (neurological status)
C: Circulation
B: Breathing and ventilation
A: Airway and spine control
(1) The ABC of trauma:
Answers

Selling yourself short

Have the fates ever conspired against you so much that you
cursed existence? Have you ever wondered what was the point?
I have, and I did until the week before half term in lower six form.
Since then, I haven’t blamed anyone or anything but myself. .
Sarah Roe is a primary and secondary school filled with the
best teachers and the best children who have the best parents that
I have ever had the privilege to meet. I only worked there for a
week, but like so many things that change your life—the encour-
aging words from your teacher or the smile from the girl across
the class—time stands still and your memory grabs hold of every
detail.
Let me talk about the children first. I don’t think many people
can give an example of a more enchanting experience than that
of making a child giggle. The way a grown, stern business man
can regress to a babbling, drooling, gaga- and googoo-ing infant
shows the extent of this appeal. The kids at Sarah Roe were mag-
ical in this way. They emanated so much love, so much zeal for
life. A smile would greet you in the morning, a hug for getting the
bike out of the shed, and a wave as they left in their school buses.
They gave so much in the way of this “happy” currency, and, what
is more, they never asked for a penny in return. In a world, where
pure selflessness is so seldom, this pocket of joy seemed like some
fantastic hallucination. Their faces and names still act like a candle
in my mind when I am consumed by dark and dreary thoughts.
They are my inspiration, their love of life my aspiration.
In the children, I saw a model of outlook and perspective,
whereas in the parents and teachers I saw determination and will.
Some of the parents were not coping well, and their lives were
full of sacrifice. But in a world where the whine of a man tran-
scends the whine of any fire engine or ambulance, these parents
kept quiet. Actually, no, they did not keep quiet, they spoke a lot.
They spoke of how wonderful this and that was, and how great
that and this is. How they can’t wait until that happens or when
such and such comes over. Initially this blissfulness seemed no
more than a facade, and on my first day, armed with scepticism
and pessimism I began to hack away at it. To no avail; behind
their facade there was another, and another, and yet another. By
day three, I had concluded that these people must be sincere.
This struck me hard, and as I recoiled from the blow I saw the
sanguine, gratified faces of the people I had tried to scorn.
Sarah Roe is a school for the mentally and physically hand-
icapped. So you see, these people, both the children and their
parents, have the most right to complain, the most right to
curse. But they don’t. They live their lives to the best of their
potential, persisting through periods of misfortune while all the
time treasuring the good that crosses their paths. Such a lesson
in life was a blessing—who is happier, the man with everything
who wants more or the man with nothing who wants nothing?
Thank you, Sarah Roe, and thank you, Omar. Omar was a
tetralingual nine year old with a severe motor disorder, who
befriended me. We continued to keep in touch until he had to
leave to go back to Pakistan.
Ajmal Hussain fourth year medical student
University of Southampton

188 STUDENT BMJ VOLUME 8 JUNE 2000

 Education

Eating disorders: essential information

Paul Robinson provides an overview of the three main conditions

he eating disorders anorexia ner-

T vosa, bulimia nervosa, and binge eat-

ing disorder have become major
health problems, particularly among young
women, since the 1950s.1 The full disorders
affect 1–2% with atypical and less severe
eating disorders much more common.
Their standardised mortality ratio is among
the highest for any psychiatric condition.2
The common factor among all eating dis-
orders is dissatisfaction with body shape
and consequent dietary restriction. The dif-
ferences reside in the degree to which diet-
ing is effective and the lengths to which suf-
ferers will go to achieve weight control. (See
Box 2 for diagnostic criteria.)
Anorexia nervosa is present when
weight loss is severe (BMI <17.5) and when

amenorrhoea due to weight loss induced
hypothalamic hypogonadism appears.
Bulimia nervosa is present when episodes
of massive overeating occur (usually in
response to dietary restriction), and is asso-
ciated with inappropriate compensatory
behaviours (see Box 3) aimed at minimis-
ing the effects of overeating on weight.
Both conditions require an abnormally
intense hatred of fat, a feeling that one is
fat, and a dislike of one’s own body. The
first two predominate in anorexia nervosa,
and the third in bulimia nervosa. The diag-
nosis of binge eating disorder has been
applied to people, usually obese, who
engage in binges (bulimic episodes) with-
out the behaviours listed in Box 3. The
three conditions overlap and underweight
patients who overeat and vomit have
anorexia and bulimia nervosa, and patients
who overeat go through periods in which
they may not engage in vomiting, etc and
times when they do, and so pass from one
category to another.
Epidemiology3 4
The group at highest risk are young
females between the ages of 15 and 30,
with anorexia nervosa striking a somewhat
younger age group and bulimia nervosa a
rather older group. The sex incidence is
one male to between 10 and 20 females.
Anorexia nervosa is overrepresented in
social classes one and two (professional
and managerial) but bulimia nervosa
appears to be distributed through all class-
es equally. Bulimia nervosa has had a
prevalence in young women of 0.5-1.1%
and anorexia nervosa 0.1-0.7%. Estimates
of the prevalence of all clinically significant
eating disorders, including those that just
MARTIN HASWELL
A common factor among all eating disorders is dissatisfaction with body shape
fail to meet full criteria (eating disorders with a strong emphasis on thinness, includ-
not otherwise specified, EDNOS) are that ing ballet, modelling, and being a racing
8.7% of females in the general population jockey, can predispose to eating disorder
are affected. symptoms and, in an otherwise predis-
posed individual, a full blown eating dis-
Aetiology order. The most powerful factor is female
There appears to be a genetic element,5 sex, with a male to female ratio of at least
although the nature of what is inherited 1 to 10. This is usually attributed to the
remains to be clarified. Early experiences, greater social pressure exerted via the
particularly family over-protectiveness,6 media and peer pressure on women to be
may be important in some cases, as may thin, although other factors, such as
the opposite: various types of abuse and women’s changing role in society,8 play an
neglect.7 Engaging in training or careers important part.
Box 1—Case description
An 18 year old woman collapses in the street and is brought to A & E by ambulance. She
is found to be emaciated, and has scars of cuts on her left arm. She also has enlarged
parotid glands and blood tests show a high paracetamol level and hypokalaemic
alkalosis. In A & E she develops a ventricular arrhythmia which responds to a
potassium infusion and she is treated for paracetamol poisoning. After a few days on a
medical ward she recovers enough to give a history of weight loss, bingeing, and
vomiting for several years. She refuses to eat and her weight declines to a body mass
index of 12.5. She develops severe muscle weakness, a raised creatine kinase level, and
thrombocytopaenic purpura. A muscle biopsy shows type 2 fibre atrophy and a bone
marrow biopsy is hypocellular. Nasogastric feeding is instituted, and she is offered small
meals. She recovers some strength, but manages to get hold of a large amount of bread
and chocolate on which she binges, and develops abdominal swelling and severe
vomiting. Abdominal x ray confirms gastric dilatation and she is treated conservatively
with nasogastric suction and intravenous fluids. She is disoriented and has paranoid
ideas about staff on the ward. She gradually recovers and, with constant psychiatric
nursing care, agrees to take fluids and then food by mouth.
A full history reveals that she was a victim of a sexual assault by a stranger at the age of 10,
and that symptoms of depression, anorexia nervosa, and bulimia nervosa coincided
with the onset of puberty at 14. She had been amenorrhoeic for three years, and a bone
mineral density scan showed moderately severe osteoporosis. Further treatment
consists of individual and family therapy, attendance at a day service, and fluoxetine
medication.

STUDENT BMJ VOLUME 8 JUNE 2000 189

Education

Clinical features of eating

disorders Box 3 Inappropriate compensatory behaviours used after eating in anorexia
Eating disorders can present to a doctor and bulimia nervosa
with symptoms referable to almost any sys- Behaviour Comments
tem. A case description, which should be
Severe dietary restriction In restricting type anorexia nervosa
read with reference to Box 4, is shown in (including prolonged starvation)
Box 1.
Excessive exercise
The key diagnostic features of each of
the three conditions are given in Box 2. Self induced vomiting Most common behaviour
Patients may conceal the true nature of Laxative abuse Uncertain whether it leads to reduced nutrient
their illness by convincing doctors to absorption
engage in fruitless and expensive investiga- Abuse of enemas
tions. Thus, patients with eating disorders Diuretic abuse Seen in medical personnel
may be investigated for malabsorption, Anorectic drug abuse Prescribed or “street”
pituitary disease, gastric problems, and food (including amphetamines)
allergies. The last can be particularly Thyroid hormone abuse Seen in medical personnel
unhelpful, because patients diagnosed as
Neglect of insulin in diabetics Extremely difficult to manage
allergic to, say, grains, will then be able to
avoid them with a medical blessing and lose
weight. Treatment of infertility due to
anorexia nervosa with assisted conception therapy, medical and psychiatric monitor- ble predisposing, precipitating, and per-
also raises ethical objections, in view of the ing, support, and specific therapy for the petuating causes of the disorder, and a
problems faced by the children of women eating disorder. mental and physical examination to sup-
with active eating disorders. Assessment includes attention to infor- plement historical information and allow
mation needed to make a diagnosis (Box diagnoses to be postulated.
Prognosis and management 2), definition of any complications present Engagement in treatment is a very
The keys to management are medical and (Box 4), a history from the patient and important area that has given rise to the
psychosocial assessment, engagement in family to allow a formulation of the possi- technique of motivational enhancement9
in which the level of motivation is assessed
Box 2 Diagnostic criteria for eating disorders and patients are moved as far up the scale
in the direction of higher motivation as is
Anorexia nervosa (ICD 10)16
1 Self imposed weight loss due to dieting, vomiting, or other means leading to <85%
possible.
expected weight or a body mass index of <17.5. In younger patients, lack of expected Medical monitoring requires the use of
growth. reproducible ways of measuring physical
2 Abnormal attitudes to food and weight. Preoccupation with desire to be thinner. Feeling state so that care can be shared between pri-
fat even though underweight. mary and secondary care, the patient, and
3 Endocrine disturbance. Loss of menstrual periods in females. Loss of libido, sexual family. Three physical tests that are sensi-
interest, and erectile function in males. Primary amenorrhoea and delayed puberty in tive to muscle and cardiovascular function
prepubertal children. are the sit-up, stand up, and postural dizzi-
Bulimia nervosa (ICD 10) ness tests (Box 5). In addition, serum potas-
1 Persistent craving with episodes of overeating. sium, especially if vomiting or laxative abuse
2 Counteracting the “fattening” effects of food by self induced vomiting, purgative abuse, is present, blood count, creatine kinase (for
starvation, appetite suppressants, thyroid preparations, diuretics or, in diabetics, neglect myopathy) and liver function tests can be
of insulin.
monitored if BMI <13. Consider admission
3 Morbid dread of fatness. Self imposed weight threshold below a healthy weight. Often a
(psychiatric or medical) if physical measures
previous overt or cryptic episode of anorexia nervosa.
are deteriorating. Note that weight or BMI
Binge eating disorder (DSM IV)17 alone may be completely unreliable in a
1 Recurrent episodes of binge eating involving
patient who may drink up to 4 litres of
a) eating, within a discrete time period (eg <2 hours) an abnormally large amount of food
water before weighing. Psychiatric moni-
b) a sense of lack of control over eating.
2 Marked distress about binge eating. toring should form part of follow up so that
3 Binge eating on at least two days per week for six months. depression is identified and treated, either
4 Not associated with regular use of inappropriate compensatory behaviours. through improvement of the eating disor-
der or using antidepressant medication.
Fluoxetine has been studied most in bulim-
Useful websites ia nervosa10 and may be the drug of choice
http://www.bbc.co.uk/health/womens/hevbod_eatingdisorders.shtml for depression in this disorder.
Characteristically informative BBC site on eating disorders.
http://www.rcpsych.ac.uk/public/help/anor/anor_frame.htm Osteoporosis appears to respond to weight
Royal College of Psychiatrists’ leaflet on eating disorders. gain, but no other treatment (including hor-
http://www.mentalhealth.org.uk/eat.htm mone replacement) has been shown to
The Mental Health Foundation’s leaflet for sufferers
http://www.gurney.org.uk/eda reverse the disease, in the absence of weight
The Eating Disorders Association site restoration.11
http://www.mentalhealth.com Support to the patient and the family in
US psychiatry site with a large amount of information on mental health problems, with a
US slant. the form of individual sessions and support
http://www.something-fishy.org/ groups can be provided by statuary or vol-
Large site covering every aspect of eating disorders, mainly for sufferers. Includes a chilling
memorial page to victims of eating disorders. untary bodies (for example, the Eating
Disorders Association, Norwich).

190 STUDENT BMJ VOLUME 8 JUNE 2000

 Education

Box 4 Some of the ways in which eating disorders can present to doctors1
System Symptom/condition Mechanism
Psychiatric Depression Low weight
Bulimia
Co-existing depressive illness
Obsessive-compulsive disorder Low weight, obsessional traits
Deliberate self harm Depression, personality disorder
Psychosis Refeeding, stimulant abuse,
Co-existing psychotic illness
Alimentary Dental erosion Gastric acid, carbonated drinks, bingeing on sweet foods
Parotid enlargement Vomiting, bingeing, chewing and spitting food
Haematemesis Pharyngeal damage, oesophagitis
Mallory Weiss
Prolonged gastric fullness Delayed gastric emptying
Distorted interoception
Abdominal pain Gastric dilatation/perforation
Diarrhoea/constipation Laxative abuse
Prolapse Laxative, enema abuse
Paediatric Failure to grow in weight height or both Anorexia nervosa in child OR in mother
Endocrine Amenorrhoea Hypothalamic hypogonadism
Infertility Hypothalamic hypogonadism
Polycystic ovaries in bulimia nervosa
Problems with pregnancy, low birth weight Malnutrition
Rheumatology Osteoporosis Low oestrogen, malnutrition, ?high cortisol
Cardiology Low blood pressure Cardiac wasting, dehydration
Arrhythmias Hypokalaemia, low phosphate in refeeding
Haematology Pancytopaenia, purpura Low weight, bone marrow depression
A&E Overdose, deliberate self harm Depression, personality disorder
Collapse Cachexia, GI bleed, acute abdomen
Infectious diseases TB Depressed immunity
Neurology Delirium Refeeding, Wernicke’s encephalopathy
Myopathy Nutritional myopathy (type 2 fibre degeneration)
Neuropathy Unknown
Pressure palsy (eg ulnar, peroneal) Wasting, pressure on vulnerable nerves
1
Mnemonists might like PAPER CHAIN as a help in remembering this list

suburban health districts in south west London, UK. Int

Box 5 Medical monitoring in anorexia nervosa
Name Address
DOB Phone
GP Hospital
Contact
Date BMI Squata Sit-upb
a) ability to rise from squatting (0 unable to rise even with help from hands, 1 can only rise
with help from hands, 2 some difficulty, 3 no difficulty)
b) ability to sit up from lying flat (no pillow, firm surface; scale as for (a))
c) dizziness on standing up from a lying posture (0 no symptoms, 1 transient, 2 persistent, 3
unable to stand because of dizziness)
A few specific therapies have been sub-
jected to controlled studies, including fam-
ily therapy in anorexia nervosa12 and cog-
nitive behavioural therapy and interper-
sonal therapy13 in bulimia nervosa. The
value of inpatient care for anorexia ner-
vosa has not been established, although it
is unavoidable if weight loss or other com-
plications are life-threatening. The Mental
Health Act (1983)14 can be used to admit a
patient with an eating disorder to hospital
and, under the act, feeding is regarded as
treatment, so can be given against the
patient’s will, in the rare circumstances in
which this is necessary to save life.
Prognosis for normal weight bulimia
nervosa appears to be favourable, with the
majority improving after 10 years,
Hospital Number
Stand upc Other Tests (K, Na,
symptoms, creatine kinase,
signs etc)
although treatment accelerates recovery.
For anorexia nervosa the outlook is less
optimistic, with a mortality of 5-20%,15 and
recovery in about one third of patients.
With earlier detection and more specific
treatment, these rather gloomy figures
should improve.
Dr P H Robinson, consultant psychiatrist, Eating
Disorders Service, Royal Free Hospital
paulhrobinson@hotmail.com
1 Robinson PH. Recognition and treatment of eating dis-
orders in primary and secondary care. Aliment Pharmacol
Ther 2000;Apr 14: 367-77.
2 Harris EC, Barraclough B. Excess mortality of mental
disorder. Br J Psychiatry 1998;173:11-53.
3 Gotestam KG, Agras WS. General population-based epi-
demiological study of eating disorders in Norway. Int J
Eat Disord 1995;18:119-26.
4 Rooney B, McClelland L, Crisp AH, Sedgwick PM. The
incidence and prevalence of anorexia nervosa in three
J Eat Disord 1995;152:299-307.
5 Gorwood P, Bouvard M, Mouren-Siméoni MC, Kipman
A, Adès J. Genetics and anorexia nervosa: a review of
candidate genes. Psychiatr Genet 1998;8:1-12.
6 Shoebridge P, Gowers SG. Parental high concern and
adolescent-onset eating disorders. Br J Psychiatry
2000;176:32-137.
7 Welch SN, Fairburn CG. Childhood sexual and physi-
cal abuse as risk factors for the development of bulimia
nervosa: a community-based case control study. Child
Abuse Negl 1996;20:633-42.
8 Katzman MA, Lee S. Beyond body image: the integration
of feminist and transcultural theories in the understand-
ing of self starvation. Int J Eat Disord 1997;22:385-94.
9 Treasure JL, Katzman M, Schmidt U, Troop N, Todd G,
de Silva P. Engagement and outcome in the treatment of
bulimia nervosa: first phase of a sequential design com-
paring motivation enhancement therapy and cognitive
behavioural therapy. Behav Res Ther 1999;37:405-18.
10 Goldstein DJ, Wilson MG, Thomson VL, Potvin JH,
Rampey AH Jr. Long term Fluoxetine treatment of
bulimia nervosa. Br J Psychiatry 1995;166:660-666.
11 Grinspoon S, Herzog D, Klibanski A. Mechanisms and
treatment options for bone loss in anorexia nervosa.
Psychopharmacol Bull 1997;128:399-404.
12 Eisler I, Dare C, Russell GF, Szmukler G, le Grange D,
Dodge E. Family and individual therapy in anorexia ner-
vosa. A 5-year follow-up. Arch Gen Psychiatry
1997;54:1025-30.
13 Fairburn CG, Jones R, Peveler RC, Carr SJ, Solomon RA,
O’Connor ME, Burton J, Hope RA. Three psychologi-
cal treatments for bulimia nervosa. A comparative trial.
Arch Gen Psychiatry 1991;48:463-469.
14 Mental Health Act Commission (UK). Guidance on the
treatment of anorexia nervosa under the Mental Health
Act, 1983. Mental Health Act Commission, Nottingham,
1997.
15 Ratnasuriya RH, Eisler I, Szmukler GI, Russell GF.
Anorexia nervosa: outcome and prognostic factors after
20 years. Br J Psychiatry 1991;158:495-502.
16 World Health Organization. The ICD-10 Classification
of Mental and Behavioural Disorders, 1993.
17 American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders: DSM-IV, 4th
edn. American Psychiatric Press, 1994.

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Career focus
Surviving (and even enjoying) medicine
Being attracted to medicine and having a propensity for burnout are two sides of the same coin.
Abi Berger has some tips to help doctors revitalise their lives
H
ands up if you recognise any of the
following psychological traits: per-
fectionist, overly conscientious, ten-
dency to seek approval (“people pleasing”)
and need to control others, great sense of
responsibility, chronic self doubt, uncom-
fortable with praise, and ability to delay grat-
ification. It’s a given that most people who
enter medicine will hold many of these char-
acteristics.
It’s not something that happens to us at
medical school—although a lot of what
happens there does account for later prob-
lems—it’s what we medics tend to bring
with us. It’s what attracts us to medicine in
the first place. Acknowledging this helps.
Acknowledging it early enough, and
adopting self caring practices, will help to
ensure that we do not burn out and that
we remain safe and competent at our jobs,
and we may even reverse the trend of seek-
ing early retirement. Most doctors suffer
from an episode of depression at some
point in their career, and every medical
school should include lectures on “burnout
prevention” alongside those on anatomy
and physiology.
According to a recent US conference on
physicians’ health in South Carolina,
organised by the American and the
Canadian Medical Associations, we doctors
are sitting ducks for becoming burnt out.
With thanks to some of the conference
speakers, here are five practical tips on
how to survive, succeed, and sustain inter-
est in a career in medicine.
Tip 1: Make sure you do things
other than work
According to Douglas Graham, a doctor
with over 20 years’ experience of working
with the Physician Support Program in
British Columbia, the top five “soul killers”
are isolation, fear, anger, exhaustion, and
shame. A single night on call can easily
provide opportunities for all five. One way
to recover from such onslaughts is to pur-
sue—not just think about pursuing—tried
and tested antidotes. This does not mean
alcohol. It does mean making time for
196
Burnout beating behaviours
● Book time off work for a holiday (even if you don’t yet know what you will do
with the time)
● Remember the Tarzan rule: don’t let go of one swinging branch before gripping the
next—for example, make sure the next holiday is booked before the first is over
● Anticipate and prepare (if you’re giving a lecture, remember that you need time to
prepare it and to arrange your slides, not just time to give the talk)
● Don’t take work home (if you really have to, decide when and where you will do it,
and warn your family)
● Find at least one good friend; stick around people who are “good” for you
● Create “people” breaks in your week; this includes partners and children
● Find opportunities to laugh more often (someone has calculated that children laugh
500 times a day on average, but adults only manage it five times daily)
● Relax regularly—don’t wait until it becomes a necessity
● Financial planning: do it, and keep it simple and basic (avoid the Christopher
Columbus strategy—you don’t know where you’re going or what you’ll do when
you’ll get there)
● Eat, exercise, and take time out to go to the toilet during the day—how many times
do we find we haven’t even given ourselves the luxury of this?! (Mamta Gautam)
things you enjoy–friends, exercise, eating, and work that you can control, and also
and finding quiet time for yourself. Making those that you can’t. Now address the
daily “to do” lists that prioritise these activ- issues that you can influence. Stress arises
ities—and posting them on the fridge and when we cannot integrate the dream of
ticking them off—is one way to make them being a doctor with the reality of the job.
more likely to happen. Ask yourself if you would like to prac-
These are not added extras, but essen- tise medicine full time, part time, or not at
tials. If we don’t quite get around to doing all. Now ask yourself if the answer you gave
them, not only are we letting ourselves was an honest one, or the one you think
down, but we will be failing our patients. others want to hear. Then make plans on
(If you don’t look after number one, you how to convert the dream into reality. It
cannot look after number two, three, or may well be a middle to long term plan,
four.) depending on what stage you are at. Do
not lose sight of your ideal, but be pre-
Tip 2: Create your dream work pared to review the plan regularly—at least
schedule annually.
Remembering that we have options in life
is critical. None of us was forced into med- Tip 3: Learn to say no (and not
icine. None of us is forced to stay in it, once feel guilty about it)
we’re qualified. We all have the option to This is harder than it sounds. Mamta
change our mind, yet many doctors (and Gautam, a consultant psychiatrist from
many others besides) feel trapped and Ottawa who sees only doctors as patients,
unwittingly adopt the role of victim when it got 200 people at the recent conference to
comes to their career. follow these instructions: 1. Open mouth;
If you find yourself asking the question 2. Say “no”; 3. Close mouth (this last is the
“how did I get here?” it’s time to assume hardest bit—doctors have a tendency to
greater responsibility for your decisions. add things like “but I’ll do it anyway”
Remember that we have more control before closing their mouths).
than we think. Identify those aspects of life Next, acknowledge the feeling of guilt
STUDENT BMJ VOLUME 8 JUNE 2000
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that often follows saying

“no,” and then let it go.
Gautam argues that the
things that really make
you feel guilty are proba-
bly the best things for you
to do. (Note: she was refer-
ring to situations where
you might feel guilty from
an overriding sense of
responsibility, like feeling
guilty about taking time off
work when you are ill; she
was not referring to feeling
guilty about committing a
bank robbery.)
Tip 4: If you need help,
go and get it
This probably sounds
trite, but we find it easy to
tell patients to do this, and
for some reason find it vir-
tually impossible to apply
it to ourselves. Doctors
with problems cause prob-
lems for other people.
Doctors who drink too
much, work too hard, take
illicit drugs, become
depressed, get ill (the list of
“impairments” goes on
and on), and do not do
anything about it are self
harming but also harmful
to others. Self medication
is as dangerous as ignor-
ing the problem.
The problems are mul-
tiplied when an individual
is so impaired that they
refuse to acknowledge
that they have a problem. Tip 5: Seek peer support is more lonely to withhold ourselves from
It is easy to recognise problems in other This is something that some GPs in the support through fear of stigma. It is impor-
people, much harder to recognise them in United Kingdom have been doing for a tant not to deny yourself or your needs.
ourselves, and hardest of all to do some- long time—with or without facilitators. It
thing about them. This last is as much to rarely happens within any other specialty. 12 Steps to sanity
do with our inherent qualities as with the It is even rarer in the United States. All five tips, and their derivations, are
messages we pick up at medical school. Meetings of doctors that work on the “one- referred to indirectly by Michael
Daniel Chapman and his colleagues, upmanship” principle are self defeating, Kaufmann in his “12 steps for medical pro-
from Atlanta, Georgia, carried out a review and informal whingeing en masse is prob- fessionals.” Based on the Alcoholics
of all research papers published in nation- ably not that helpful. Anonymous original 12 step programme,
al medical journals between 1989 and According to William Zeckhausen, a pas- the programme that Kaufmann, who is
1999 about “impaired” physicians, and toral counsellor from New Hampshire who medical director of the Ontario Medical
came up with the following messages for has provided leadership for a number of Association’s physicians health pro-
such physicians: physician support groups, finding a group gramme, has come up with for doctors has
of colleagues to meet with on a regular basis been circulated to over half the doctors in
● I am aware of your behaviour and am and developing within this group the secu- Canada. He also provides a second list that
concerned rity to share feelings and concerns (about encapsulates some of the less helpful mes-
● You are not alone patients, work, family problems, or anything sages we still seem to pick up at medical
● Help is available else) can greatly reduce a sense of isolation school. You don’t have to have a problem
● There’s every reason for optimism and enhance a sense of wellbeing. If you to find solace in his 12 steps. You simply
● Seeking help now does not mean you don’t want to join or create a group, at least need to be a practising doctor.
are a “bad” doctor—it will just make find a mentor.
you a better one It is a truism that the higher up the career Abi Berger, science editor, BMJ
● Dr Kaufmann’s 12 Steps for medical professionals is
Not seeking help can have serious ladder we go, the more we stand to benefit reproduced on the BMJ’s website
consequences. from peer support. It is lonely at the top. It (bmj.com/content/vol320/issue7243/#CAREER).

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