RMO Course Material (1)

8/11/2019 RMO Course Material (1)

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SUPPLEMENTARY MATERIALSfor RESIDENT MEDICAL OFFICERS

by Grzegorz Chodkowski, MDJacob Stephanus Drotsk, MD


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NES Healthcare 2007

All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system or transmitted,

in any form or by any means, electronic, mechanical, photocopying, recording or otherwise

without the prior permission of the copyright owner.


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RMO Course 2007 3

Index

Educational Objectives of the RMO course . . . . . . . . . . . . . . . . . . . . . . . 5

RMO Duties and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Medical Supplies and Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Emergency equipment for RMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Early Warning Scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

The Most Common Medical Abbreviations . . . . . . . . . . . . . . . . . . . . . . 19

Body Parts (Medical/Colloquial) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Physical activities (Medical/Colloquial) . . . . . . . . . . . . . . . . . . . . . . . . . 27

Needle Stick Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

How to Learn English . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Dialogue 1 Patient in Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Dialogue 2 Cannulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Dialogu 3 Catheterisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Glossary of Plastic Surgery Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Surgical terminology for RMOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Glossary of Job Titles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Job titles/grades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Drug Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Drug Dosage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Helping patients to cope with tablets . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

The Most Common TTOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Tips on writing TTOs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

History Taking Mnemonics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

History Taking Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Physical Examination Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Presenting During Ward Rounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Ortopaedics post-op notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Arterial Blood Gas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Blood Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Cohort Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Pain Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70ECG Monitoring and rhytm strips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Drug Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Acute Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Cannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Venepuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Venepuncture Vocabulary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Emergency Scenarios. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

PCA Pumps Patient Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

PCA Pumps for the RMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

SI Conversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Laboratory Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Sample hospital documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102


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4 RMO Course 2007


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Educational Objectives of the RMO course

1. To share information regarding the duties of a Resident Medical Officer.

2. To experience practical Basic Life Support based on the new UK Guidelines (2005).

3. To have hands-on training in the safeguarding of the airway with insertion

of various airway devices.

4. To gain knowledge regarding defibrillasation and ECGs and BNF pharmacology.

5. To master prescription facts about important emergency and non-emergency drugs.6. To have hands-on practical experience in venepuncture and cannulation techniques.

7. To gain knowledge regarding arterial blood gas sampling, blood Transfusions

and chemotherapy.

8. To master the practical skills of male and female catheterization.

9. To gain practical experience of the setting of a PCA machine and an Infusion pump.

Skills and knowledge that will be acquired during the course

1. Acquire knowledge of the duties of a Resident Medical Officer

and medical English.

2. Adult, child and baby CPR skills.

3. Intubation skills and airway insertion techniques.

4. Correct use of defibrillators and AEDs.

5. Acquiring and reading ECGs.

6. BNF knowledge regarding emergency and non emergency drugs.

7. Venepuncture and cannulation skills.

8. Knowledge regarding arterial blood gas sampling, blood transfusion and Chemotherapy,Early Warning Scores (EWS), Prescription and medical note writing.

9. Urethra catheterization skills.

10. PCA and infusion pump settings.

Reading material provided 4 weeks prior to the course include:

1. RMO Course Manual

2. Beginner to Specialist

3. ECG Made Easy

4. BNF

5. Medical IELTS

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6 RMO Course 2007

RMO Duties and ResponsibilitiesEmergency to be familiar with the location and use of emergency equipment

to demonstrate competency in ACLS/PALS

to respond immediately to clinical emergencies / lead the resuscitation team

in an emergency situation undertake emergency investigations and procedures

in accordance with hospital policy and as directed by the patients Consultant

Ward Duties be present and contactable within hospital premises at all times to clerk and assess patients on admission according to the hospital policy

to maintain individual contact with patients, carrying out ward rounds and other duties

detailed by the individual hospital

to attend communication (handover) rounds as require

to update clinical notes on all patients attended according to best practice

for record keeping

to respond promptly to the request of all medical staff

(Consultants and other doctors, nurses) to see any patients within the hospital

and to advise or start any treatment as indicated undertake specific medical procedures on patients within all departments in the hospital

as requested by medical and nursing staff: cannulation, commencing i.v infusions, urinary

catheterisations, administration of i.v drugs, ECG, phlebotomy, etc.

to check blood sample results and take necessary actions

to assist with pre-operative /admission and outpatient clinics, if requested

to prescribe medicines to take home and complete discharge letters

as requested according to local policies

before going off duty ensure written appropriate communication to the oncoming RMO

specifying any requirements of individual patients

Responsibility to Consultants inform Consultants of any change in the condition of their patients

and any emergency procedures undertaken

in a routine situation initiate requests and treatments with the prior consent of the

patients Consultant

in the event of death of a patient inform the Consultant, and the patients GP

(if the Consultant is unable to do so)

advise the Consultant immediately who threatens to discharge themselves

against medical/nursing advice

see and examine discharged post-operative patients, on requests of the consultant


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RMO Course 2007 7

Other dutiesRMOs must not routinely perform the role of surgical assistant in the OperatingDepartment, but are required to respond in the event of an urgent/emergency situation

dispense drugs from the pharmacy as required following the local hospital policy

to examine a sick/injured member of hospital staff and offer appropriate advice in respect

of treatment RMOs are expected to look smart and presentable at all times, wearing

a white coat and a name badge when attending patients

Administrative Duties comply with the hospital consent and confidentiality policy

maintain comprehensive clerking notes and treatment records for all patients read understand and adhere to hospital policies and procedures

complete hospital administrative documentation as required

ensure correct procedures are carried out in respect of patients discharging themselves,

deaths in care and coroners requirements

Health and Safety and Quality Assurance be familiar, understand and adhere to all Health and Safety regulations including

evacuation policy and the RMOs role in such an event participate/assist/attend in-house trainings as requested. This may include: fire safety,

infection control, manual handling, blood transfusion

be aware of the promotion of effective customer care and public relations in order

to promote the good reputation of the hospital


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Medical Supplies and ToolsHere is a list of some of the most common supplies found in doctor's offices, operating

rooms, and medical kits. Write describing words down from your native language next to

the text.

antiseptic liquid used to sterilize (clean) the surface of the skin

adhesive wound dressing a cloth covering for a wound or sore

bandage a cloth covering that is placed over a wound to preventbleeding, swelling and infection

bandage scissors tool used to cut bandages

blood pressure monitor a tool that measures the force of blood flow througha person's body

dressing protective covering that is placed over a wound

elastic tape a thin roll of stretchy material that is sticky on one side

eye chart a poster of letter, word, and number combinations of

various sizes used to test a person's eyesight

forceps instrument used during operations and medicalprocedures(assists the doctor in pulling, holding, and retrieving)

gauze thin, netted material used for dressing woundsgauze pad

gurney a metal stretcher with wheels

hypodermic needle sharp pointed metal piece that pricks the skin

(attached to a syringe), used for taking bloodor administering medicine

IV bag the pouch that contains liquids to be pumpedinto a patient's body

medicine cup small plastic measuring cup

microscope equipment that makes small things appear largerthan they are

otoscope a device used for looking into a patient's ears

oxygen mask equipment that fits over the nose and mouthand supplies oxygen

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Emergency equipment for RMO

Bag valve mask

ResuscitatorAn obsolete term for an apparatus that forces gas (usually O2) into lungs

to produce artificial ventilation.

Ambu bagProprietary name for a self-reinflating bag with nonrebreathing valves to provide positive

pressure ventilation during resuscitation with oxygen or air.

Oxygen cylinder

Oxygen mask

Nasalcanula

Oropharyngeal airway

Oropharyngeal passage

FaucesAnatomy the narrow passage from the mouth to the pharynx, situated between the soft

palate and the base of the tongue; called also the isthmus of the fauces. On either side

of the passage two membranous folds, called the pillars of the fauces, inclose the tonsils.

IntubationProcedure the insertion of a tube into a body canal or hollow organ, as into the trachea

or stomach.

IntroducerAn instrument, such as a catheter, needle, or endotracheal tube, for introduction

of a flexible device.

Synonym: intubator.

Stylet/introducer

DefibrillatorEquipment a device which delivers a measured electrical shock to arrest fibrillation

of the heart (ventricle).

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Automated external defibrillatorSudden cardiac arrests can happen to anyone at any time and therefore any building that

hosts a large throughput of people on a regular basis should carry out a risk assessment

in line with the resuscitation council guidelines for treatment of cardiac arrests victims.

In reality, cardiac arrest impacts all age groups, genders, and levels of fitness. For many

victims there are no outward signs of a problem until it is too late. It can strike at anyone,

anytime, anywhere.

Sudden cardiac arrest (SCA) causes the hearts normal rhythm to suddenly become chaotic.

The heart can no longer pump blood effectively and the victim; collapses; stops breathing;

becomes unresponsive; and has no detectable pulse. SCA can strike anyone and at anytime.

Although the risk of SCA increases with age and in people with heart problems, a large per-

centage of the victims are people with no known risk factor. SCA is an electrical problemwith the heart and should not be confused with a heart attack which is a pumping problem.

Sometimes a heart attack, which may not be fatal in itself, can trigger a sudden cardiac

arrest.

Defibrillation is the only treatment proven to restore a normal heart rhythm. When used

on a victim of SCA, the automated external defibrillator (AED) can be used to administer

a lifesaving electric shock that restores the hearts rhythm to normal. AEDs are designed

to allow non-medical personnel to save lives.

If the victim receives defibrillation within three minutes the chances of survival are 70%.

Every minute that the heart is not beating lowers the odds of survival by 7%.

After 10 minutes, the chances of survival are negligible. CPR can buy a little time

but ultimately SCA requires a shock to restore a normal rhythm.

AED defibrillators uses advanced biphasic technology.AEDs are very simple to operate and can be used by either medical or non-medical person-

nel. Voice prompts guide the rescuer through the steps involved in saving someones life,

including calling an ambulance and performing CPR in compliance with new 2005Resuscitation Council guidelines. The AED is self-contained with pre-connected pads and

a lit status indicator. It also features an audible alarm if an internal problem is detected

when performing self-tests. A computer inside the unit analyses the patients heart rhythm

and determines if a shock is required to save the victim. If a shock is required, the AED uses

voice instructions to guide the user through saving the persons life. Safeguards designed

into the unit means that non-medical responders cant use the AED to administer a shock if

the system determines that no shock is required.

Everyday, lives could be saved by the prompt delivery of a life-saving defibrillation shock

from AEDsNow there is something that can be done to improve the odds for your students,

staff and guests that is easy to use and inexpensive to buy.

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Automatic External Defibrillator TrainingAlthough Guidelines 2005 contain recommendations for changes in the sequence of shock

delivery, there are no fundamental changes to the sequence of actions, since users should

be taught to determine the need for an AED, switch on the machine, attach the electrodes,and follow the prompts.

The main guideline changes are: Place the axillary electrode pad vertically to improve efficiency.

If possible, continue CPR whilst the pads are being applied.

Program AEDs to deliver a single shock followed by a pause of 2 min for the immediate

resumption of Compressions and then ventilations.

LMA Laryngeal Mask Airway1. Laryngeal Mask Airway will be referred to as LMA

2. Ensure Basic Life Support is on going

3. Collect together the items needed to insert LMA

a) Working Suction

b) Bag Valve Mask with Oxygen attached (BVM)

c) Gloves

d) LMA size 4 (Reusable LMAs should have had the cuff over inflated

on return from TSSU to ensure no herniation has occurred)

e) 50ml syringef) Lubrication Gel

g) Stethoscope

h) Bite Block

i) Tape to secure LMA in place

4. Put on Gloves

5. Check the interior and exterior of the LMA (for reusable LMAs Flex the tube to ensure no

kinks occur)

6. Deflate the cuff fully ensuring correct shape

7. Prepare the syringe with 30mls of air8. Apply lubricant to the rear of the LMA only

9. Hold LMA like a pen, ensuring the black line is facing you

10. Ensure head is in position Neck flexed, head extended

11. Ask assistant to remove ventilation and count for 30 seconds.

12. Insertion of LMA should take no longer than 30 seconds

13. Follow the palate of the mouth, centrally, pushing the LMA into the oropharynx, once

resistance is felt, stop, index finger should have disappeared into the mouth

14. Once in place hold the LMA with the other hand before removing finger from the mouth

15. An attempt to push the LMA further into the hypopharynx can now be made.

16. Let go of the LMA

17. Inflate the cuff, watching to see the LMA move

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18. Attach BVM and ventilate ensuring Oxygen is attached. The chest should rise. If no rise

of the chest remove and re-insert.

Ensure oxygenation is taking place if reinsertion is going to be delayed

19. If chest rises, listen to lungs and stomach to confirm placement (if listening to lungs isnot something you usually do, now is the time to start practicing on your colleagues and

patients)

20. Insert Bite block and tie in place

21. If there is no air escaping at the mouth asynchronous chest compressions and ventila-

tions may be performed

Removal after successful resuscitation

Remove LMA still Inflated with suction available

Apply oxygen via non re breathing mask

Combi tube

Combitube Protocol

Indications for Combitube UsePatient is unconscious and unable to protect own airway; no apparent gag reflex.

Contraindications

1. Patients under 70 lbs. and under 5 feet tall.2. Responsive patients with an intact gag reflex.

3. Patients with known esophageal disease.

4. Patients who have ingested caustic substances.

5. Known or suspected foreign body obstruction of the larynx or trachea.

6. Presence of tracheostomy

Procedure PrehospitalCardiorespiratory/Respiratory (Pulse Present) Arrest

a. The first priority is to defibrillate the patient in cases of ventricular fibrillation.The AED should be applied first, using conventional airway management, following

the AED protocol.

b. The Combitube should be placed during the two minutes of CPR between sets of AED

analyses. (This may somewhat delay subsequent AED analysis).

c. Hyperventilate the patient prior to Combitube insertion for 10-15 seconds using either

a BVM or Mouth-to-Mask device with supplemental oxygen.

d. Insertion done quickly between ventilation

I. Except in cases of suspected cervical spine injury, hyper-extend the head

and neck.

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II. In cases of suspected cervical spine injury, c-spine precautions will be taken at all

times.

III. Patent airway and ventilation should already have been established by other basic

methods.IV. In the supine patient, insert the thumb of a gloved hand into the patient's mouth,

grasping the tongue and lower jaw between the thumb and index finger, and lift

upward.

Caution: When facial trauma has resulted in sharp, broken teeth or dentures, remove

denture and exercise extreme caution when passing the Combitube into the mouth to

prevent the cuff from tearing.

V. With the other hand, hold the Combitube with the curve in the same directions as the

curve of the pharynx. Insert the tip into the mouth and advance carefully until the

printed ring is aligned with the teeth. Caution: DO NOT FORCE THE COMBITUBE.

If the tube does not advance easily, redirect it or withdraw and reinsert. Have suctionavailable and ready whenever withdrawing tube.

VI. If the Combitube is not successfully placed within 30 seconds, remove the device and

hyperventilate the patient for 30 seconds using basic methods, as described in C

above, before re-attempting insertion.

e. Inflation of Combitube

I. Inflate line 1, blue pilot balloon leading the pharyngeal cuff, with 100ml of air using

the 140ml (cc) syringe. (This may cause the Combitube to move slightly from the

patient's mouth).II. Inflate line 2, white pilot balloon leading the distal cuff, with approximately 15ml of air

using the 20ml (cc) syringe.

f. Ventilation

I. Begin ventilation through the longer blue (distal) tube (Number one). Watch for chest

rise. If auscultation of breath sounds is positive and auscultation of gastric air sounds

is negative, continue ventilation.

II. If no chest rise, negative lung sounds, and/or positive gastric air sounds with ventila-

tion through the distal tube, begin ventilation through the shorter clear (proximal) tube(Number 2). Confirm ventilation with chest rise, presence of auscultated lung sounds,

and absence of gastric air sounds.

III. If there is no chest rise or positive lung sounds through either tube, remove the

device, hyperventilate the patient 20-30 seconds as described in C above, and repeat

the insertion/inflation/ventilation procedures.

IV. Continue to ventilate the patient through the tube which resulted in lung sounds using

a BVM or a manually triggered oxygen delivery value.

V. REASSESS TUBE PLACEMENT FOLLOWING EVERY PATIENT MOVEMENT.

g. If two consecutive attempts at intermediate airway placement fail to result in a proper

placement and ventilation, do not attempt placement again. Ventilate the patient using

basic methods and equipment.

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h. Removal of Combitube at direction of Medical Control or when attempting reinsertion,

or if the patient awakens. Remove combitube as follows:

I. Have suction readyII. Deflate blue tube Number 1

III. Deflate white tube Number 2

IV. Remove combitube

V. Be prepared for vomiting

NOTE ON SUCTIONING THROUGH THE COMBITUBE: When suctioning the patient through

the Combitube, always introduce the suction catheter through Tube Number 2 (white).

Because the Combitube will usually be in the esophagus 80%, most through the tube suc-

tioning will be gastric suctioning and will result in decreased gastric distension. In the event

that the Combitube is in the trachea 20%, suctioning of the patient's airway will result.

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Early Warning Scores (EWS)

What is an Early Warning Score?

In the United Kingdom Early Warning Scores (EWS) are now commonly used for the assessmentof unwell hospital patients. The Early Warning Score is a simple physiological scoring system

that can be calculated at the patient's bedside, using parameters which are measured in the

majority of unwell patients. It does not require complex, expensive equipment to measure

any of the parameters. It is reproducible1 and can be used to quickly identify patients who

are clinically deteriorating and who need urgent intervention. EWS can be used to monitor

medical, pre and postoperative surgical, and Accident and Emergency patients.

Early warning scores are sometimes also referred to as Patient at Risk scores (PARS)

or Modified Early Warning Scores (MEWS).

How do you calculate an Early Warning Score?An EWS is calculated for a patient using five simple physiological parameters. Mental

response, pulse rate, systolic blood pressure, respiratory rate and temperature. For

patients who are postoperative or unwell enough to be catheterised a sixth parameter,

urine output, can also be added. The idea is that small changes in these five parameters

will be seen earlier using EWS than waiting for obvious changes in individual parameters

such as a marked drop in systolic blood pressure which is often a pre-terminal event.

Of all the parameters, respiratory rate is the most important for assessing the clinical state

of a patient, but it is the one that is least recorded. Respiratory rate is thought to be themost sensitive indicatory of a patients physiological well being. This is logical because

respiratory rate reflects not only respiratory function as in hypoxia or hypercapnia,

but cardiovascular status as in pulmonary oedema, and metabolic imbalance such as

that seen in diabetic ketoacidosis (DKA).

When and why to use an Early Warning Score?An EWS score should be calculated for any patient that nursing staff are concerned about.

It gives a reproducible measure of how at risk a patient is. Patients who have sufferedmajor trauma, or have undergone major surgery, can be started on an EWS observation

chart as soon as they arrive on the ward to monitor their clinical progress, and give early

warning of any deterioration. Repeated measurements can track the patient's improvement

with simple interventions such as oxygen or fluid therapy or further deterioration. Serial

EWS readings are more informative than isolated readings as they give a picture of the

patient's clinical progress over time.

The scoring system was developed because not all unwell patients can be monitored on

intensive care or high dependency units. It allows deteriorating patients to be identified,

before physiological deterioration has become too profound. Once an unwell patient has

been identified, with an EWS score of 3 or more, this should stimulate a rapid assessment

of the patient by a ward doctor or, if available, the intensive care unit (ICU) team. The result

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of the review should be the modification of patient management to prevent further

deterioration. If deteriorating patients are identified early enough, simple interventions

such as oxygen, or fluid therapy, may prevent further deterioration and imminent collapse.

The use of EWS has been shown to be effective in reducing mortality and morbidityof deteriorating patients as well as preventing ICU admissions.

What should happen if a patient has an Early Warning Score of 3 or more?Studies have indicated that score of 3 or more requires urgent attention4,6. The level of

response is dependent on the facilities available. In many UK hospitals a score of 3 triggers

an immediate review by a ward doctor. If no improvement is seen the most senior ward

nurse can then call a senior doctor. This gives the ward nursing staff the authority to refer

upwards to more senior members of staff if a patient's clinical situation is not improving.

Some UK hospitals have gone further and a score of 3 results in an immediate call, by the

nursing staff, directly to the Intensive care unit registrar for a ward review. Other hospitalshave been more cautious and use a score of 4 or even 5 as a call out trigger4.

Case Histories1. A 60-year-old man arrived in hospital with increasing shortness of breath. He had no

chest pain. He had a past history of a myocardial infarction and was awaiting coronary

artery bypass surgery; he was also a known asthmatic. On arrival in hospital he was

alert with a respiratory rate of 30, a pulse rate of 130 and a blood pressure of 108/60,

his temperature was 38.5C. He therefore had an EWS score of 5. He was assessed

by the emergency doctors. A salbutamol nebuliser and oxygen therapy were given.After 15 minutes, on clinical observation, he looked better. His respiratory rate had

dropped to 24, his pulse rate was 124 bpm, temperature remained the same but his blood

pressure had dropped to 95/55mmHg. Therefore despite looking better his EWS score had

risen to 6, suggesting he was still deteriorating. The intensive care team were called and

he was admitted to the high dependency unit for observation and treatment. He was

found to be septic from a chest infection. This case shows that subjective judgements

made on appearance only can be misleading. More objective judgements are often made

on the basis of physiological parameters.

2. A 72 year old patient arrived in recovery after a Whipple's resection of his pancreas for

a pancreatic tumour. He had lost 3 litres of blood intra-operatively and was receiving

a blood transfusion in recovery. Initially in recovery he was alert with a heart rate

of 70bpm, a respiratory rate of 15, a blood pressure of 110/70mmHg, and a urine output

of 20ml/hr. His EWS was 1. Over the next 3 hours in recovery he became more tachycardic

and hypotensive. He was alert with a heart rate of 105, a respiratory rate of 20, a blood

pressure of 95/50 and a UO of 10ml/hr. His temperature was not recorded. Therefore his

EWS can be calculated as having risen to 4. Despite this a doctor did not review him, and

he was sent back to the ward. By midnight he was drowsy, had a respiratory rate of 30,

temperature of 38.5C, heart rate of 120bpm, blood pressure of 90/50mmHg and his urine

output was negligible. This made his EWS 11. He was finally reviewed, actively resuscitated

and taken immediately back to theatre for an exploratory laparotomy. Two litres of blood

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and clot were found in his abdomen from a bleeding artery. He was in hypovolaemic

shock. He was sent intubated to the intensive care unit and remained there overnight.

If the EWS protocol had been followed this patient should have never left recovery.

All the signs were there from a very early stage that he was deteriorating.Early intervention would have prevented the development of hypovolaemic shock

and possibly an ICU admission.

Taking the lead in resuscitation

It will be expected of the RMO as the only doctor in the hospital to take the lead and the

responsibility for all resuscitations. A dedicated team will assist the RMO with resuscitation.

Leadership during stress full situations call for a calm open minded knowledgeable RMO It

is therefore of utmost importance to know the emergency protocols, the staff that will assistyou, the hospital floor plan and where the emergency equipment is based in the hospital.

What makes an effective leader? A person with leadership skills has the ability to take

initiative, make swift, concise decisions and accept responsibility for their actions. They are

also the type of person you probably want on your resuscitation team when faced with a life

or death situation in the hospital. Resuscitation requires coordination and cooperation

between professionals. When it gets down to it, we believe that there has to be a leader

(on the resuscitation team) because someone must be able to make quick decisions.

When a team leader is not identified during resuscitation, several scenarios can occur.For example, they have observed more than one person doing a single task, such as

preparing medication, no one giving a heart rate or assisting with oxygen during intubation,

and no one coordinating compressions and ventilation. The leader is the person who says

to a specific individual, Can you listen for breath sounds? or stops an intubation attempt

which has gone on too long. Someone in the hospital has to make sure that the overall plan

is being followed rather than having each person think independently, leaving some tasks

uncompleted and some done multiple times.

Specific functions for the leader and team members must be delegated before the actualresuscitation begins. After selecting a leader, and before the actual resuscitation, the team

should review member tasks and relevant basic and advanced life support guidelines pertinent

to a specific task, such as defibrilization.

Its important to note that, overall, the process must also include prompting

and supporting each individual with positive feedback, providing objective

input and allowing time for a debriefing period after the actual resuscitation is completed.

People can shift and change roles, but when they step into the leadership

position, they need to focus on overall priorities. Problems that arise in the absence of

a leader involve losing awareness of the overall situation. Thats the biggest single issue

that weve identified.

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A good leader is experienced, decisive and positive, and possesses the ability to know when

a specific action is needed, as well as when they personally need to perform this action.

Finer and Rich have identified the following six attributes of a well functioning team:

Good Communication

Adaptability

Flexibility

Coordination

Initiative

Team Spirit

During resuscitation, someone saying good job means a tremendous amount

to the people on the team. This sort of thing show people what positive reinforcement cando resuscitation, such as trauma resuscitation and adult cardiac arrest, theres always

someone running those codes. Thats the norm and expectation in these resuscitations,

but its not really the expectation in neonatal resuscitation, Rich said. With a newborn,

you are also faced with a variety of possible scenarios. We believe there are a lot of lessons

to be learned from other resuscitation circumstances and are amazed at the applicability

of these lessons to neonatal resuscitation.

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RMO Course 2007 19

The Most Common

Medical English AbbreviationsAbbreviation English Your own language

a. lat. anno

ABCD Airway Breathing Circulation Defibrillation

Ab, abor abortion

ACLS acute cardiovascular life support

ACS Acute Coronary Syndrome

AED automated external defibrillator

AD lat. auris dextra

AHA American Heart Association

AI artificial insemination

AIDS acquired immunodificiency syndrome

AIHA autoimmune haemolytic anaemia

ANS autonomic nervous system

AXR abdominal X-ray

BD lat. bis in diem (twice daily)

BLS Basic Life Support

BMI body mass index

BP blood pressure

BT bone tumour

Bx, bx biopsy

CA, Ca cancer, lat. carcinoma

CAD coronary artery disease

CF cancer free

CHF Coronary Heart Failure

CISD Critical Incident Stress Debriefing

CLL chronic lymphocytic leukaemia

CN cranial nerveCNS central nervous system


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20 RMO Course 2007

CPR cardio-pulmonary resuscitation

CPSS Cincinnati Prehospital Stroke Scale

C-sect caesarian section

CSF cerebrospinal fluid

CSM Carotis Sinus Massage

CSU catheter specimen of urine

CVA cerebrovascular accident

CVP central venous pressure

CVS cardiovascular system

Cx CircumflexCXR chest X-ray

Dg. lat. diagnosis

DNR do not resuscitate

DOB date of birth

DOPES Displaced Obstructed Pneumothorax Equipment Stomach Distension

DU duodenal ulcer

DVT deep vein thrombosis

dx. lat. dexter

EBL estimated blood loss

ECC Emergency Cardiovascular Care

ECG electrocardiography

EDD eosaphegal detector device

EUA examination under anaesthesia

Ez eczema

FBC full blood count

FDIU fetal death in utero

EF Ejection Fraction

EMD Emergency Medical Departament

EMS Emergency Medical Services

EMT Emergency Medical Technician

FBAO Foreign Body Airway Obstructionfra. lat. fractura


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RMO Course 2007 21

FX, Fx fracture

GA general anaesthesia

GI gastrointestinal

GI and GII lat. gravida I and gravida II

ging. gingiva

GP General Practitioner

gr. lt. Gradus

GU gastric ulcer

Gyn gynecology

h. herniaH/ct haematocrit

Hb. haemoglobin

HD haemodialysis

HDU high dependancy unit

HGH human growth hormone

HHH Hazards-Hello-Help

HIV human immunodficiency virus

ICD Implanted Cardioverter Defibrillator

ICP Intra Cranial Pressure

IDDM insulin dependent diabetes mellitus

IM, i.m intramascular

in dec. lat. in decursu

in st. lat. in statu

INR international normalised ratio

(clotting time)

IOFB intra-ocular foreign body

IUC idiopathic ulcerative colitis

IUD intra-uterine death

IV, i. v intravenous

IVF in vitro fertilization

IVI intravenous infusion

KUB kidney, ureter, bladdersLA local anaesthesia


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22 RMO Course 2007

La labial

LAD Left Anterior Descending

LaG labia and gingiva

LAPSS Los Angeles Prehospital Stroke Screen

LCA Left Coronary Artery

LFT liver function test

LLL left lower lobe

LLQ left lower quadrant

LMA Laryngeal Mask Airway

LMWH Low Molecular Weight HeparinMAT Multifocal Atrial Tachycardia

m. lat. modo

MCP multidisciplinary care pathway

MD muscular dystrophy

MD medical doctor

med. medial

meta. lat. metastases

MFT muscle function test

MRI magnetic resonance imaging

MRI magnetic resonance imaging

MSU midstream urine

my myopia

N&V nausea and vomiting

n. s lat. non specificata

NAD no abnormality detected

nas. nasal

NBM nil by mouth

NEC not elswhere classified

NG tube naso gastric

NHS National Health Service

NIDDM non insulin dependent diabetes mellitus

NIHHS National Institute of Health Stroke Screen

NMR nuclear magnetic resonance


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24 RMO Course 2007

PR per rectum

PRN lat. pro re nata (as&when required)

prob. lat. probabiliter

pros. prostate

PU peptic ulcer

PV per vagina

PVC Paroxysmal Ventricular Contraction

PSVT Paroxysmal Supra Ventricular Tachycardia

PWB partial weight bearing

qa lat. quoadQDS lat. quarter in die summendus (four times daily)

RA rheumatoid arthritis

RBC red blood count / red blood cell

RCA Right Coronary Artery

RE rectal examination

RMO resident medical officer

RT radiotherapy

RTA road traffic accident

RTW return to ward

RUQ right upper quadrant

S.A, Sa sarcoma

SAH Sub-Arachnoidal Haemorrhage

s.f sub forma

SC. subcutaneus

sin. sinister

SM sclerosis multiplex

SPP suprapubic prostatectomy

ss. lat. subsequens

ST skin test

st. post status post

susp. lat. suspicio

syph. syphilis

T temperature


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T tumour

t terminal

Tb, Tbc tuberculosis

TCI to come in

TCP Transcutaneus Pacing

TDS lat. ter in diem summendum (three times daily)

TED anti embolic stockings

TEE trans oesophageal echocardiography

TLD thoracic lymph duct

TNM tumour, node, metastasesTSH thyroid stimulating hormone

TTA to take away

TTO to take out

Tu tumour

TURP transurethral resection of the prostate

U&E urea and electrolytes

UC ulcerative colitisUG urogenital

UFH Unfractioned heparin

UGI upper gastrointestinal

URTI upper respiratory tract infection

USG ultrasonography

UTI urinary tract infection

utr. lat. utriusque

VAIN vaginal intraepithelial neoplasia

VD veneral disease

VE vaginal examination

VF Ventricular Fibrillation

VT Ventricular Tachycardia

WBC white blood Mount

WPW Wolf Parkinson White

WR Wasserman reaction (test for syphilis)

XR X-ray

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26 RMO Course 2007

Medical Colloquial

anus back passage

bowels gut(s),innards, insides(s)

breasts bosom, bust, chest

buttocks behind, bottom, botty, posterior, rear, seat

cervix neck of womb

elbow funny bone

foot Tootsy

genitals down below, private parts

groin and skin crotch, crutchcov. genitals

hand mitt, paw

head bonce, nut napper

heart engine, ticker

intestines bowels, guts, innards, insides

little finger finky

lungs bellows, tubes

neck (a) nape, cruff

oesophagus gullet

spine backbone

stomach belly, tummy, guts, innardsthroat gullet

trachea windpipe

umbilicus belly button, navel

urethra pipe

urinary system waterworks

uterus womb

uterine tubes tubesvagina birth canal, down below, front passage,private part

Medical/Colloquial English

Body Parts


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RMO Course 2007 27

Medical Colloquialto belch to burp

to copulate to have sexual intercourse, to have sex, to make love, to be intimate,to go to bed with, to sleep with, to go with, to perform

to defecate to open the bowels, to do a motion, to go to the toilet, to do numbertwo, to poop

to die to pass away, to depart, to conk out, to croak, to go to Part 4, to kickthe bucket, to peg out, to pop off,to pop ones clogs, to snuff it, to

turn up ones toes,to pass flatus to break wind, to fluff, to poop, to fart

to hit to bash, to belt, to biff, to bop, to give a bunch of fives(punch),toclobber, to clonk, to clonk, to clout, to crown(on the head),to floor(to the ground),to knock out (on the head causing loss of conscious-ness), to take a pop at, to sock, to smack, to stick one on, to thump,to wallop, to whack

to beat up to do over, to duff up, to dust up, to give a hiding, to knock about, togive a pasting (to paste), to rough up, to sort out, to thrash

to lose consciousness to pass out, to black out, to conk out, to flake out, to zonk out

to menstruate to be indisposed, to be on a period, to at the time of the month, tohave ones monthly,

to be pregnant to be expecting, to be having a baby, to be in the family way,

to regain consciousness to come to, to come round

to have stomach ache the collywobbles

to urinate to pass water, to do number one, to spend a penny (women), to tid-dle (childish), to tinkle (women only), to wee-wee (childish), to pee,

to piddle,

to vomit to bring up, to be sick, to puke

Activities


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28 RMO Course 2007

Needlestick Injury

A needlestick injury is any injury where the skin has been breeched with an infected sharp.This can include grazes as well as puncture wounds.

Similarly, splashes of blood or blood stained fluid into the eye is considered as carrying the same

risk but of a different order.

Following a mucocutaneous exposure, via the mucous membrane, the average risk is estimated

to be less than one in one thousand.

Where intact skin is exposed to HIV infected blood, no risk of HIV transmission is considered.

With HIV/AIDS, the chance of contracting the infection from a needlestick injury in one in 300,

whereas with hepatitis C it is one in 30 and hepatitis B it is one in three.

More than a third of all incidents happen after the completion of procedures such as cannulation

and phlebotomy, often as a result of resheathing needles. Health professionals should not under

any circumstances resheath needles.

Sharps bins should never be more than two thirds full.

A Needlestick Injury is an Emergency

Stop what you are doing immediately

Force the wound to bleed

Wash under running water

Report immediately to your immediate manager

Report to Ocuppational Health/ Accident and Emergency (as per protocol)

Needlestick Injury and Post Exposure Prophylaxis (PEP)

Consider with the Accident and Emergency clinician/Occupational Health clinician whether

or not to take PEP.

This is a short course, generally around three months, of anti-retroviral triple therapy which is

thought to be of value in preventing seroconversion when an individual has been expose

to the HIV infection.


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RMO Course 2007 29

The most usual regime offered is a three drug combination of:*AZT

*3TC*Indinavir or Nelfinavir

These drugs are started immediately. A case control study amongst healthcare workers exposed

to HIV has found that the administration of AZT for four weeks after exposure was associated with

an 80% reduced risk of seroconversion.

AZT treatment at this stage is believed to block the infection of immune system cells by HIV, so

prompt AZT treatment is likely to block the establishment of HIV infection in an individual who has

been exposed to the virus. It is assumed that a combination of two or three drugs may be even

more effective than AZT alone at blocking HIV infection.

The Decision to commence PEP

Risk assessment:

Was the donor patient HIV positive?

Was the patient known to have a high viral load at the time of inoculation?

Was the injury received a deep injury from a large diameter needle?

Despite the benefits of PEP, there is evidence that the standard regime of AZT, 3TC and Indinaviris poorly tolerated.

Nine out of 18 healthcare workers at three London hospitals who commenced this regime stopped

or changed therapy due to side effects within four weeks.

Six of the nine who started Indinavir required more than two weeks off work. Among the other 9,

only one required more than 7 days leave. There were no discontinuations among the five people

who received saquinavir.

PEP Department of Health guidanceIf exposed in the course of your work you may well have access to triple therapy on site which

could save time.

Local policy will include instructions to inform occupational health in the instance o exposure.

Training on prevention of needlestick injuries and post exposure procedures, including AZT

treatment, should also be included.

Ideally administration of PEP, should commence within1hour of exposure. If not at least

within 24 hours of exposure.

All NHS Trusts should have a post-exposure policy. Starter packs of triple therapy should

be available on site for use following occupational exposure.


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30 RMO Course 2007

How to learn English

List of Useful Websites

General English

www.esl-lab.com

listening exercises

accent.gmu.edu/searchsaa.php

a collection of listening exercises witha variety of acents

www.focusenglish.com/dialogues/conversation.html

a collection of dialogues on different topics

www.tolearnenglish.com/english-videos.php

free audio and video materials with tapescripts

www.angielski2.host.sk

free komputer programs for learning english

ebib.oss.wroc.pl/2005/65/slowniki.php

a collection of free computer dictionaries and translators

www.elllo.org

listening exercises

www.fullbooks.com

hundreds of books to read

www.gutenberg.org/browse/categories/1

a collection of books to listes e.g Sherlock Holmes

Medical English

www.englishmed.com

the most comprehensive website on learning Medical English

www.flashandbones.com

Medical Picture and exercises, great for learning Medical vocabulary


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RMO Course 2007 31

www.englishforums.com

a forum for all English language learners around the Word. On the website a big part

on medical English.

www.medicalstudent.com

the greatest collection of Medical links on Internet

www.ugent.be

internetowy sownik zwrotw i terminw medycznych Uniwersytetu w Gandawie; take

odpowiedniki znaczeniowe w innych jzykach europejskich

www.bbc.co.uk

high class resources for all learning English and Medical English

(www.bbc.co.uk/health)

www.patient.co.uk

a service created by Medical Professional for patients, including hundreds of disease

and drug leaflets (also audio), links etc. Not to miss !

www.nice.co.uk

National Institute for Clinical Excellence an independent organisation setting

standards In disease prevention and treatment In the UK

www.bmj.com

a must for all thinking of working in the UK the language of UK doctors

Internet Dictionaries

Zagraniczne

http://dictionary.cambridge.org/

www.m-w.comwww.alphadictionary.com

www.wordsmyth.net

www.onelook.com

www.dictionary.com


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32 RMO Course 2007

Dialogue 1 Patient in PainDOCTOR: Ah Mr Dixon what seems to be the problem?

PATIENT: Its my back Dr its killing me

DOCTOR: Which part your back?

PATIENT: Right at the bottom, down here

DOCTOR: Ah I see, your lower back. What sort of pain is it?

PATIENT: Its like knife, it comes and goes. But even when its not too bad, it hovers inthe background, if you see what I mean Dr

DOCTOR: Umm, so does anything make it worse?

PATIENT: Yeah, definitely, lifting. Before this happened I really enjoyed building, Ive gotmy own business, but since my fall, I fell of the roof, Ive become an officeboss. I hate not being out there, you know the banter with the lads. Its sofrustrating, I want to do it but my body isnt willing.

DOCTOR: Yeah I appreciate how frustrating it must be for you. Im just looking at thepain chart you filled in, you have problems walking sometimes?

PATIENT: On a good day, I havent any problems with walking but on a bad day I cantmanage 50yards. Well and as for sitting, thats a nightmare, I can only sitfor 10 minutes then I have to stand up to relieve the pressure. My wife boughtme this special cushion from one of those mobility shops. It helps a bit, but

its still there.DOCTOR: Right, I see, what about sleep, do you manage to get any sleep at all?

PATIENT: Well sometimes I can sleep like a log but when the pains bad, I cant get tosleep at all, and even then when I do the pain wakes me up 2 or 3 times a night.

DOCTOR: So the pains so bad it disrupts your sleep.

PATIENT: Too right.

DOCTOR: I see. Does anything relieve it at all?

PATIENT: Well those pain killers are useless, I dont know why I bother to take them at

all! When its really bad, I have to lay on the floor or in my bed, on my right orleft side, with my knees bent up to my chest, sort of curled up in a ball. Afterabout 30 minutes the pain is loads better.

DOCTOR: Yes I see, it must be very difficult when your trying to run a business. Haveyou noticed if theres a pattern to your pain at all?

PATIENT: Umm, no not really Dr, thats the problem I cant plan anything at allbecause I never know from one day to the next if Ill be well enough or not.

DOCTOR: Yes, Ive read your chart, it looks as if this pain is affecting every aspect of yourlife.

PATIENT: God yeah Dr, my family stay well clear of me when Im in a lot of pain, Im likea bear with a sore head.

DOCTOR: [small laugh] Well its understandable Mr Dixon, long term pain would affectanybody.


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RMO Course 2007 33

Dialogue 2 - Cannulation

DOCTOR: Hello Mrs Dixon, how are you today ?PATIENT: Well I'm a bit better than yesterday, but Im not my usual self Doctor,

not by along chalk.

DOCTOR: I see, well try not to worry Mrs Dixon we' re going to be carrying out a lot oftests and investigations this week, to find out what the problem is.So you need a drip Mrs Dixon, because youre not eating or drinking properlyat the moment. So I'll need to insert a cannula, before we can start the drip.

PATIENT: I see Doctor, I thought you might have to.

DOCTOR: So is that alright Mrs Dixon ?

PATIENT: Yes of course Dr, if it needs to be done, that's that Dr.DOCTOR: Ok Mrs Dixon, how are you with needles, have you ever felt faint or passed out

before ?

PATIENT: No Dr, I don't find it too bad.

DOCTOR: Where would you be more comfortable, sitting in the chair or sitting on the bed?

PATIENT: I'll sit on the bed Dr.

DOCTOR: First I need to pop a pillow under your arm Mrs Dixon, just to support it. NowI just need to look at your arm Mrs Dixon, so I can find a good vein. Oh yes, I'llput it in this one. Try and not move Mrs Dixon until its done. First Mrs DixonI'm going to put this tourniquet, around your arm, It'll feel a bit uncomfortable.

PATIENT: Don't worry Dr I've had this before.

DOCTOR: Alright Mrs Dixon, I'm just going to clean the area a little, it might feela bit cold.

PATIENT: That's fine Dr.

DOCTOR: I'm going to stretch your skin a tiny bit, just to stabilise the vein a little. OK,that's fine, well done. When I insert the cannula you'll feel a sharp prick, itsuncomfortable, but its not for long. Here we go, Ok that's good I'm just pullingit back a little to make sure its in the right place. Smashing, I'm going torelease the tourniquet now. That's good, just stay still abit longer. Right nowI,m going to press on your vein a little, while I remove the needle. Ok, I'mattaching this 3-way tap, and I'm going to flush it with a little fluid. Oh yes,we're almost done Mrs Dixon.

PATIENT: Phew, I'm glad that's over with, you always think that it will be worse thanit actually is !

DOCTOR: That's it Mrs Dixon, I'm putting this dressing on it, so it stays in place.

PATIENT: I see Dr, yes thats feels fine.

DOCTOR: Good well attach the drip now.


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34 RMO Course 2007

Dialogue 3 - Catheterisation

DOCTOR: Hello Miss Grey, how are you today?

Miss GREY: I still can't manage to pass water Dr.

DOCTOR: I see, well after discussing it with Dr Bart, we feel that a catheter would bethe best option at this point. At least then, you won't feel as bloated and it'llcertainly relieve your stomach pain.

Miss GREY: Well anything is better than feeling like this Doctor, but does it hurt?

DOCTOR : Well its not painful as such, just a little uncomfortable.

Miss GREY: Ok Dr if you think it'll help I'll have it.

DOCTOR : Well its only temporary until we find the root of the problem.

Miss GREY: Umm

DOCTOR : Well, I'll just draw the curtain, so its private. I'll need you to lay on yourback. This is a sterile procedure, so I'll be using a special pack. I'll weargloves, and clean you down below, then till insert the catheter. Once I'msure its in the right place, I'll then fill up the small balloon with sterilewater, you won't feel this at all, but it stops the catheter falling out.Finally I'll attach the catheter bag, so the urine can drain out freely.

Miss GREY: Alright Dr that doesn't sound too bad.

DOCTOR : I appreciate that its a bit embarrassing for you, but it will be over

in minutes.

Miss GREY: Alright Dr, I'll lay on my back.

DOCTOR : That's right, but could you bend your knees and just let your legs open.Good that's fine, Ok I'm just going to clean you down here, it might feela bit cold.I have the catheter tray down here, so if you can stay as still as you can.Ok, I'm lubricating the end of the catheter, so it'll go in easily, it may feela little uncomfortable. Good well done, its in, now just take a deep breathfor me. There we go I've filled up the balloon, so it shouldn't come out.Right, I'm attaching the bag, and its draining clearly.


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Glossary of Plastic Surgery and Surgical Terms

Since Plastic Surgery constitutes a high percentage of the operationscarried out in Private Hospitals you might find these terms helpful.We also recommend that you familiarize yourself with the most commoncomplications regarding these procedures.

Abdominoplasty (Tummy Tuck)Sometimes after multiple pregnancies or large weight loss, abdominal muscles weaken, and

skin in the area becomes flacid. Abdominoplasty can tighten the abdominal muscles and, in

some instances, improve stretch marks. In both men and women, the procedure will remove

excess skin and fat. Generally, an incision is made across the pubic area and around theumbilicus (navel). When skin laxity and muscle weakness is confined to the lower part of the

abdomen, a modified abdominoplasty that limits tissue removal and muscle repair to the area

below the umbilicus may be performed. This usually leaves a shorter scar and no scarring

around the navel.

Alpha Hydroxy AcidsAlpha hydroxy acids are derived from foods, such as fruits and milk, and can improve

the texture of skin by removing layers of dead cells and encouraging cell regeneration.

Augmentation Mammoplasty (see Breast Augmentation)

Blepharoplasty (see Eyelid Surgery)

Breast Augmentation (Augmentation Mammoplasty)Breast augmentation is typically performed to enlarge small breasts, underdeveloped

breasts or breasts that have decreased in size after a woman has had children. It is accom-

plished by surgically inserting an implant behind each breast. An incision is made either

under the breast, around the areola (the pink skin surrounding the nipple) or in the armpit.A pocket is created for the implant either behind the breast tissue or behind the muscle

between the breast and the chest wall.

Breast Lift (Mastopexy)Frequently, a woman elects this surgery after losing a considerable amount of weight,

or losing volume and tone in her breasts after having children. The plastic surgeon relocates

the nipple and areola (the pink skin surrounding the nipple) to a higher position, repositions

the breast tissue to a higher level, removes excess skin from the lower portion of the breast

and then reshapes the remaining breast skin. Scars are around the areola, extending verti-

cally down the breast and horizontally along the crease underneath the breast. Variations on

this technique, in some cases, may result in less noticeable scarring.

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36 RMO Course 2007

Breast Implants (Textured-Surface)The shell of textured-surface breast implants are made with the same silicone elastomer

that is used for the shell of other types of breast implants, but a special manufacturing

process creates a textured surface.

Breast Reduction (Reduction Mammoplasty)Breast reduction is normally classified as a reconstructive procedure, since oversize breasts

interfere with normal function and physical activity. However, there is an important aesthetic

component to the operation, since the plastic surgeon can improve the shape of the breasts

and nipple areas. Breast reduction involves removing excess breast tissue and skin, repositioning

the nipple and areola (the pink skin surrounding the nipple) and reshaping the remaining

breast tissue.

Buccal Fat PadBuccal fat pads are located above the jawline near the corner of the mouth. They can be

removed in individuals with excessively round faces to give a more contoured look, sometimes

referred to as the waif look. However, plastic surgeons warn that, in some individuals,

removal of the buccal fat pads can lead to a drawn, hollow-cheeked look as aging progresses.

Buttock LiftExcess fat and loose skin in the buttock area can be reduced by performing a buttock lift in

combination with lipoplasty (liposuction). Incisions required for skin removal can often be

hidden in the fold beneath the buttocks.

Calf AugmentationIncreased fullness of the calf can be achieved using implants made of hard silicone which

are inserted from behind the knee and moved into position underneath the calf muscle.

CannulaA hollow tube attached to a high-vacuum device used to remove fat through liposuction. The

plastic surgeon manipulates the cannula within the fat layers under the skin, dislodging the

fat and vacuuming it out.

Capsular ContractureCapsular contracture is the most common problem associated with breast implants. It

occurs when naturally forming scar tissue around the implant shrinks and tightens, making

the breast feel firmer than normal and sometimes causing pain and an unnatural appear-

ance of the breast.

CelluliteCellulite is the dimpled-looking fat that often appears on the buttocks, thighs and hips. While

there is no treatment that will eradicate this problem, aesthetic plastic surgeons are exploring

new techniques which may improve the condition. One method is to cut the fibrous tissue that


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binds the fat down in these areas and creates the lumpy appearance, and then to inject fact

withdrawn from elsewhere in the body to smooth out the unevenness. Another technique, called

the cellulite lift, surgically removes excess skin and fat, leaving a thin scar that may extend

around the full circumference of the abdomen but is placed discreetly within bikini lines.

Chemical PeelFine lines and wrinkles around the mouth and on the forehead and cheek areas may be

improved with a wide range of skin treatments. A chemical peel solution is applied to the

entire face or to specific areas to peel away the skin's top layers. Several light to medium-

depth peels can often achieve similar results to one deeper peel treatment, with less risk

and shorter recovery time. Peel solutions may contain alpha hydroxy acids, tricholoracetic

acid (TCA) or phenol as the peeling agent, depending on the depth of peel desired and on

other patient selection factors.

Chin Augmentation (Mentoplasty)Chin augmentation can strengthen the appearance of a receding chin by increasing its

projection. The procedure does not affect the patient's bite or jaw. There are two techniques:

one is performed through an incision inside the mouth and involves moving the chinbone,

then wiring it into position; the other approach requires insertion of an implant through an

incision inside the mouth, between the lower lip and the gum, or through an external incision

underneath the chin.

Collagen InjectionsCollagen is an injectable protein that can be used to treat facial wrinkles. Patients to be treat-

ed with collagen should first be tested for any allergic reaction. The results of collagen injec-

tions are not permanent, and treatments must be repeated periodically to maintain results.

DermabrasionDermabrasion is a procedure in which a high-speed rotary wheel, similar to fine-grained

sandpaper, is used to abrade the skin. It may be recommended when there is extensive sun

damage and heavy skin wrinkling. In addition, dermabrasion can be used to improve the tex-

ture of pockmarked skin resulting from severe acne or chicken pox. Following treatment, theskin should appear firmer and smoother, but permanent pigment changes may occur.

Earlobe ReductionA simple, 30-minute procedure, earlobe reduction can be performed in a plastic surgeon's

office or at the same time as a facelift operation. The earlobe should not comprise more

than 25 percent of the total length of the ear. In cases where it exceeds this dimension,

an L-shaped wedge is cut away, the earlobe edges are brought together and sutured.

Eyelid Surgery (Blepharoplasty)Aesthetic eyelid surgery can brighten the face and restore a more youthful appearance

by reducing the fat that causes bags beneath the eyes and removing wrinkled,

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drooping layers of skin on the eyelids. Blepharoplasty is often performed along

with a facelift or with other facial rejuvenation procedures. Incisions follow the natural

contour lines in both upper and lower lids, or can be done through the lining

of the lower eyelid, providing access to skin and fatty tissue. The thin surgical scarsare usually barely visible and blend into the eyes' natural lines and folds.

Facelift (Rhytidectomy)A facelift can reduce sagging skin on the face and neck. Incisions are placed in the hairline

and then pass in front of and behind the ears; the exact design of incisions may vary from

patient to patient and according to the surgeon's personal technique. For younger patients,

more limited incisions may be appropriate. When necessary, removal of fatty deposits

beneath the skin and tightening of sagging muscles is performed. The slack in the skin

itself is then taken up and the excess removed. Scars can usually be concealed by hair and

makeup.

Fat InjectionsFat withdrawn from one body site can be injected into another for example, to smooth lines

in the face or build up other features such as the lips. In most cases, a percentage of injected

fat is resorbed by the body, and the procedure must be repeated. Injection of fat to enlarge

the breasts is a dangerous procedure and is not recommended because of the possibility of

dense scarring that may seriously hinder accurate interpretation of both breast self-exams

and mammograms.

FibrelFibrel is a synthetic substance which is an alternative to collagen and fat injections for the

treatment of facial wrinkles. As with collagen and fat, fibrel treatments must repeated at

intervals to maintain correction.

Forehead Lift (Brow Lift)The forehead lift is designed to correct or improve skin wrinkling, as well as loss of tone

and sagging of the eyebrows that often occurs as part of the aging process.

The procedure may also help to smooth horizontal expression lines in the foreheadand vertical frown lines between the eyebrows. Incisions are placed behind the hairline

above the ear and pass over the top of the head. In some cases, incisions may be placed

in front of the hairline.

Some patients may have the procedure performed with the use of an endoscope,

requiring much shorter incisions. Improvements are made beneath the skin and on the

deep muscles; skin and muscle are then tightened to give a fresher, more youthful

appearance.

Hydroxyapatite GranulesHydroxyapatite granules are a bone substitute made from coral that can be used

to enhance facial contours, such as forming more prominent cheekbones. The substance

also has reconstructive uses in craniofacial surgery.

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This is usually accomplished through incisions placed behind the ears so that subsequent

scars will be concealed in a natural skin crease. Otoplasty can be performed on children

as early as age five or six.

Peel: Buffered PhenolBuffered phenol offers yet another option for severely sun-damaged skin. One such formula

uses olive oil, among other ingredients, to diminish the strength of the phenol solution.

Another slightly milder formula uses glycerin. Buffered phenol peels may be more comfort-

able for patients, and the skin heals faster than with a standard phenol peel.

PhenolThe chemical phenol is sometimes used for full-face peeling when sun damage or wrinkling

is severe. It can also be used to treat limited areas of the face, such as deep wrinkles around

the mouth, but it may permanently bleach the skin, leaving a line of demarcation betweenthe treated and untreated areas that must be covered with makeup.

PlatysmaThe muscle which, when tight and firm, gives the neck underneath the chin and jawline its

youthful contour. The platysma muscle can be tightened during a facelift or as a separate

procedure.

Reduction Mammoplasty (see Breast Reduction)

Retin-ARetin-A cream may be applied to enhance the overall texture of the skin and is often

prescribed as a pre-treatment prior to a facelift or chemical peel.

Rhinoplasty: OpenThe open rhinoplasty technique can sometimes benefit patients who need more complex

correction or are undergoing a secondary rhinoplasty procedure. A small incision is made

outside the nose across the columella (the tissue that divides the two nostrils). This enables

the plastic surgeon to turn the outer tissue of the nose back, providing visualization of thestructures inside. Additional incisions, like those used in the traditional closed approach, are

made inside the nose as well. The scar resulting from the incision on the outside of the nose

eventually becomes barely visible.

Rhinoplasty (Nose Reshaping)Rhinoplasty is usually performed to alter the size and shape of the bridge and tip of the nose.

Reshaping is generally done through incisions inside the nose, but there may also be an

incision passing across the central portion of the nose between the nostrils. It is sometimes

necessary to narrow the base of the nose or reduce the size of the nostrils, which involves

removing small wedges of skin at the base of the nostrils. The nose is reduced, or sometimes

built up, by adjusting its supporting structures, which is done either by removing or adding bone

and cartilage. The skin and soft tissues then redrape themselves over this new scaffolding.

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Rhytidectomy (see Facelift)

Superficial Syringe Liposculpture

Use of a syringe to withdraw fat, instead of vacuum suctioning pumps, allows for less bloodloss and speedier postoperative recovery. Superficial syringe liposculpture is performed on

the layer of fat just beneath the skin.

Tattooing (Cosmetic)Cosmetic tattooing, or micropigmentation, can be used for permanent eyeliner, eyebrows or

lip color. It can also be used for permanent blush and eyeshadow, though this is infrequent.

Other uses by plastic surgeons include recreating the coloration of the areola around the

nipple following breast reconstruction; restoring the color of dark or light skin where natural

pigmentation has been lost through such factors as vitiligo, cancer, burns or other scarring;

and eliminating some types of birthmarks or previous tattoos. Micropigmentation should beperformed only under medical supervision by appropriately trained personnel.

TCATrichloroacetic acid is used for peeling of the face, neck, hands and other exposed areas

of the body. It has less bleaching effect than phenol, and is excellent for spot peeling

of specific areas. It can be used for deep, medium or light peeling, depending on the

concentration and method of application.

Thigh LiftA thigh lift can be performed to tighten sagging muscles and remove excess skin in the thigh

area. Because a thigh lift leaves noticeable scars in the inner or outer thigh area that some

patients find undesirable, it is not a frequently performed procedure.

Tissue ExpansionTissue expansion is a technique in which skin or other tissue is stretched using inflatable

balloons. It can be of particular value in performing breast reconstruction, breast enlarge-

ment or treatment of male pattern baldness.

Transconjunctival BlepharoplastyTransconjunctival blepharoplasty (eyelid surgery) is performed by making an incision from

inside the lower eyelid. It avoids any scarring on the lower lid. It is a useful technique when

only fat, and not skin or muscle, needs to be removed from the eyelid area.

Varicose veins twisted, widened veins caused by swollen or enlarged blood vessels.The blood vessels have enlarged due a weakening in the vein's wall or valves.

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Surgical Terminology for the RMO

ectomy - means the surgical removal of something for instance the appendix

in an appendectomy or appendicectomy

otomy means the surgical or slicing of a body part, for instance Laparotomy an operation

to open the abdomen/stomach

stomy is the creation of an artificial opening, as in a Colostomy an opening through

the wall of the abdomen for the colon to divert waste through

pathy suffering or disease as in neuropathy which is disease of the nerve

itis means inflammation as in Gastritis which is inflammation of the stomach

emesis is to vomit as in Hematemesis vomiting blood

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Glossary of Job Titles for Doctors

(source: www.nhs.org.uk)SummaryDoctors are the primary managers in the treatment of most patients. They examine symp-

toms, consider a range of possible diagnoses, test the diagnosis, decide on the best course

of treatment and monitor the progress of that treatment.

All doctors, in the NHS or private practice, must be registered with the General Medical

Council (GMC) to undertake clinical practice in the UK. Doctors, particularly in the hospital

setting, are often known by the specialist area in which they practise, for example an anaes-

thetist or an obstetrician, but will practice at a certain grade depending on their level oftraining and experience.

Doctors start as medical students and, typically, continue training until they become

a consultant or GP general practitioner. Doctors are assessed and examined during their

training, with the ultimate aim being the award of a certificate of completion of training fol-

lowed by entry on the GMC's specialist register or general practitioner register. Doctors from

overseas can also gain entry to the specialist or general practice registers providing they

have the right qualifications, training and experience. Entry on either of these registers is the

marker that says the doctor can act as an independent doctor in the NHS.

The doctors listed in this section of the glossary are all medically qualified and will usually

use the title Dr before their name. However, doctors that perform surgery may, due to histor-

ical reasons, use the title Mr or Mrs, for example, instead. A doctor could also be a university

Professor and use that title instead of Dr.

Academic doctorsAcademic or clinical academic doctors are those who often work in hospital or general

practice but also spend time teaching or researching at a university. As well as performingthe usual duties of a doctor, academic doctors are responsible for teaching new generations

of doctors and/or undertaking research in order to forward the science of medicine. Common

job titles for academic doctors are: clinical academic fellow, clinical lecturer, clinical

research fellow, lecturer, senior lecturer, professor or reader. Academics who are professors

or senior lecturers will normally have a consultant contract at a hospital or be a GP general

practitioner. A doctor in a post such as clinical lecturer will also normally also have duties

as a specialist registrar or GP registrar.

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Medical studentsMedical students typically undertake a five-year course of study to become a doctor two

years studying basic medical sciences followed by three years of more clinical training

during which they work in hospital wards under the supervision of consultants. If the hospitalor practice you attend is one where teaching takes place, you may see medical students

accompanying qualified doctors on, for example, ward rounds or in out-patient clinics.

As a patient, you should be asked whether you mind a medical student(s) being present.

Following success in final examinations, newly qualified doctors receive their primary medical

qualification typically denoted in the UK by one of the following: MBBS, MBChB, BM, MB BCh.

Junior doctorsJunior doctors are doctors in training usually in hospital or in general practice. They will

have been through medical school and have obtained registration with the General Medical

Council, but are not yet trained to a level which allows them to work as a consultant or gen-eral practitioner. However, as they progress through training and gain experience their

responsibilities increase, but they are always under, though not necessarily directly, the

supervision of a senior doctor. On completion of training they gain a certificate of completion

of training and gain access to the General Medical Councils specialist register, for those

completing specialist training, or general practitioner register for those completing training

as a general practitioner. All postgraduate training in the UK is overseen by the Postgraduate

Medical Education and Training Board. Junior doctor grades are foundation year 1,

foundation year 2, GP registrar, senior house officer and specialist registrar.

Senior doctorsSenior doctors are consultants or general practitioners. They are allowed to practice inde-

pendently (ie without supervision), and will have been fully trained or have gained an appro-

priate level of experience. Before a doctor can become a consultant or general practitioner

they need to be listed on the General Medical Councils specialist register, for hospital and

other specialists, or the general practitioner register for general practitioners.

Staff and associate specialist grade doctors

Staff and associate specialist doctors are neither junior nor senior doctors. Doctors at thisgrade are hospital doctors who will normally have spent some time as a junior doctor but will

not have formally completed training in the UK or have not yet been judged to have acquired

an equivalent level of experience to be registered on the General Medical Councils specialist

register. The main job titles for these doctors are staff grade or associate specialist.

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Job titles/grades

Associate specialistLocation: HospitalDescription: An associate specialist is a doctor who will have trained and gained experience in

a medical specialty but has not yet attained the status of a consultant. They will often work without

direct supervision, but will be attached to clinical team lead by a consultant in their specialty.

Training: An associate specialist will have undertaken some specialist training and will

almost certainly have attained the professional qualifications to be a member or fellow of the

relevant medical royal college or faculty.

ConsultantLocation: HospitalDescription: A consultant is a doctor who is fully trained in a particular specialty area and has

the ultimate responsibility for the clinical care of patients. Most consultants work in hospitals in

multidisciplinary teams which will include nurses and other healthcare professionals as well as

other doctors. Consultants are responsible for the education and supervision of junior doctors in

their team and also for the supervision of staff and associate specialist grade doctors.

Training: Completion of a specialist training programme (or assessed as equivalent) leading to entry

to the General Medical Councils specialist register, plus continuing professional development.

Foundation year 1 (alternatives: house officer, pre-registration house officer),Foundation year 2 (alternative: senior house officer)Location: General practice, Hospital

Description: Foundation year doctors are newly qualified medical graduates who undertake

a two-year programme of training in order to gain practical experience of being a doctor and

gain the general competencies required to be a good doctor. They undertake supervised

training in hospitals and sometimes in general practice. After the first year of foundation

training the doctor will become fully registered with the General Medical Council. After the

second year of foundation training the doctor will decide whether to enter training in a spe-

cialist area of medicine or as a general practitioner.Training: The foundation training programme

GP general practitionerLocation: General Practice, Health centre

Description: General practitioners have overall responsibility for the management of patient

healthcare, including the diagnosis and treatment of health problems and referring patients

for specialist treatment where necessary. They are increasingly responsible for monitoring

their patients health on a regular basis. Some general practitioners develop an interest

in a special area, for example, dermatology, epilepsy, mental health or sexual health.

Training: Completion of a general practitioner training programme (or assessed as

equivalent) leading to entry to the General Medical Councils general practitoner register,

plus continuing professional development.


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GP registrar general practitioner registrarLocation: General practice, Health centre

Description: A GP registrar is a general practitioner in training. During this time,

under the guidance of a GP trainer, they will learn about how general practice is organisedand managed and will see patients both in the surgery and at home. GP registrars also have

the opportunity to gain extra skills in areas such as womens health and drug misuse.

Training: Following foundation training, at least three years of further training in approved

training posts including at least one year training in a general practice or health centre

under the guidance of a GP registered as a trainer. The period of training done in hospital

will be as a senior house officer. Successful completion of training will lead to entry

on the General Medical Councils general practitioner register.

Senior house officerLocation: HospitalDescription: A senior house officer is the first rung of training in hospital after foundation

training. They train in a specialist area and learn the basic skills and knowledge of that

specialty, and will work towards, or have obtained, some professional qualifications.

As senior house officers gain experience they may manage some patients with basic

complaints which they are competent to treat, but will always, though not directly,

be supervised by a consultant.

Training: Following foundation training, normally one to two years' further basic training

in approved training posts often leading to a professional qualification, or part of, from the

relevant medical royal college or faculty.

Specialist registrar (alternatives: registrar, senior registrar)Location: Hospital

Description: A specialist registrar is a doctor in the advanced stages of training towards

becoming a consultant. They will have increased clinical responsibilities and though always,

though not directly, supervised will see and manage patients with complaints that they are

competent to treat. A specialist registrar will have attained or be in the process of attaining

all the professional qualifications required for their specialty area.

Training: Following basic training as a senior house officer, normally between four to sixyears of further training, depending on the specialty, in approved training posts leading

to a professional qualification from the relevant medical royal college or faculty and, on

successful completion of training, entry on the General Medical Councils specialist register.

Staff grade (alternatives: hospital doctor, trust grade doctor)Location: Hospital

Description: Staff or trust grades are doctors who work in a specialist area and undertake

clinics and perform procedures under the supervision of a consultant.

Training; They are not trainees but will have done some training and are likely to have

a professional qualification, or part of, from the relevant medical royal college or faculty.

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Specialty doctors and related royal colleges and facultiesThe medical royal colleges and faculties are the professional

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