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Are we allowed to be recorded?

17/5/2019

I attended a recent study day, and one of the speakers was from the GMC. The GMC has numerous publications, and it can be challenging to keep up with all the guidance. We discussed 2 topics, one which I knew nothing about and thought I'd share.

Patients recording NHS staff in health and social care settings

Click here to download a copy of this guidance.

I did not know any of this!

Unlike medical professionals, who are expected by the GMC to obtain patients' consent to make visual or audio recordings, patients do not need their doctor's permission to record a medical consultation or treatment (overt / covert; video / audio).
- While a patient does not require permission to record their consultation, common courtesy would suggest that permission should be sought in most cases.
Patient recordings which are made either covertly and overtly in order to keep a personal record of what the doctor said are deemed to constitute personal ‘note taking’ and are therefore permissible.
The position may, however, change once a recording is no longer used as a record of the consultation, for example where the recording is disclosed or publicised in a modified way which is not connected to the consultation.
- Any such disclosure or publication, depending on the nature and context, may attract a civil action for damages and may also be a criminal offence.

Doctors' use of social media

This is an important guide to be aware of, as social media is increasingly becoming more and more part of our daily practice. The use of social media is not limited to Facebook! There are very few teams now that do not make use of a messaging app, and we should make sure we maintain patient confidentiality.

Click here to read the full guidance.

Social media include blogs and microblogs (such as Twitter), internet forums (such as doctors.net), content communities (such as YouTube and Flickr), and social networking sites (such as Facebook and LinkedIn)
The standards expected of doctors do not change because they are communicating through social media rather than face to face or through other traditional media.
Using social media has blurred the boundaries between public and private life, and online information can be easily accessed by others. You should be aware of the limitations of privacy online and you should regularly review the privacy settings for each of your social media profiles

There are many new apps available marketing themselves as "NHS compliant", "GMC compliant" for communication use between clinical teams. They may well replace the bleep / referral system one day!
Have a look:
https://www.siilo.com/
https://forwardhealth.co/
https://www.hospify.com/
These may well be a better option than WhatsApp...

NBothma

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Atrial Fibrillation

16/5/2019

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I started this morning innocently reading a recent blog post by the St Emlyn's Team with the intention of screening large numbers of recent blog posts as part of my weekly CPD update. Low and behold, it is 5pm and I am still stuck on this one post and topic: ATRIAL FIBRILLATION. I should have known reading something about AF would not be a simple task!

I am sure I am not the only person who feels a little overwhelmed from time to time when faced with decision making in the management of AF. I guess it is because it does not fit in a neat box of a single answer for every event.

I thought I would summarise a few key points I have reviewed today:

1. Definitions

Atrial Fibrillation (AF) is an atrial tachydysrhythmia characterised by predominantly uncoordinated atrial activation with consequent deterioration of atrial mechanical function.
The p waves which represent depolarisation of the atria, are absent during atrial fibrillation and the heart rhythm is irregularly irregular.
Correct description is AF with fast / slow / controlled ventricular response

2. Aim of treatment

Prevent complications (thromboembolic events - stroke)
Alleviate symptoms (minimise circulatory instability)

3. Priorities

Assessment of time of rhythm onset
- It is important as it allows the clinician to determine whether a rate or rhythm control strategy is in the patient's best interest.
  A safe time frame for rhythm control (cardioversion) is 48 hrs from onset.
Assessment of precipitating events
- 'PIRATES'
  - PE; Ischaemia; Resp disease; Atrial enlargement; Thyroid disease; Ethanol; Sepsis
- Where there are identifiable precipitants of atrial fibrillation they should be treated.
- There has been shown to be a 6 fold adverse event rate when treating AF secondary an acute underlying medical illness in the ED.
- AF usually improves / resolves if treatment is directed at precipitant.
Assessment of haemodynamic consequence
- Most pts with AF are CV stable
- 2 uncommon groups may become unstable
  - Poor LV function
  - AF with rapid ventricular response > 150 bpm
Assessment of stroke risk
- Formal stroke risk assessment using the CHA2DS2-VASc score
  - Consider anticoagulation for men with a CHA2DS2-VASc score of 1
  - Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above
- Bleeding risk should be assessed using the HAS-Bled Score

4. Management

RATE CONTROL vs RHYTHM control

AFFIRM Trial (2002): showed no benefit in rhythm control vs. rate control in terms of morbidity and quality of life, but patients deemed not likely to tolerate being in AF were excluded from the study (thereby negating any possible benefit shown in these patients).
40-70% of patients will spontaneously convert back to NSR at 24hrs
Early or delayed cardioversion in recent onset AF NEJM (2019): In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was non-inferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.
Which patient would you treat with rhythm control in the ED?
- stable, low risk for short term stroke
  - clear onset < 48hrs
    - Immediate anticoagulation in ED not always required but should be considered in those deemed high risk for stroke as per the CHADS2VASC score.
  - > 3 wk of NOAC / therapeutic Warfarin
- If onset >48 hrs and ≥ 2 CHADS-65 criteria: consider rate control or TOE-guided CV
- treatment options
  - electrical (150J biphasic)
  - chemical
    - Flecainide
      - If no underlying structural heart disease
      - IV or PO
    - Amiodarone

MEDICATIONS FOR RATE CONTROL
NICE: Offer a beta-blocker or a rate-limiting calcium-channel blocker (diltiazem [off-label use] or verapamil). The choice between a beta-blocker and a calcium-channel blocker will depend largely on the person's comorbidities.

Beta-blocker (works in 70% of patients):
- metoprolol 2.5 - 5mg IV q20min up to 15mg, followed by 25-50mg PO
- consider using if patient has HTN, CAD, diabetes, prior MI or hyperthyroidism
- do NOT use in asthmatics or patients in acute heart failure
Magnesium Sulfate
- The LOMAGHI study (2018): A double-blind, randomized controlled trial. Intravenous MgSO4 appears to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control. Similar efficacy was observed with 4.5g and 9g of MgSO4 but a dose of 9 g was associated with more side effects.
- Consider administering magnesium 2-4 g IV over 30 min as an adjunctive therapy
Digoxin
- is second line, as slow onset
- caution in renal failure
- consider first line if hypotension or acute HF

IS TROPONIN NECESSARY FOR ALL ACUTE AF PATIENTS IN THE ED?

In an unpublished review of charts at the University Health Network, 86% of patients had troponins drawn, 14% were positive and 5% of patients were treated as ACS – most of these had hypotension, signs of heart failure, or ECG changes after conversion or rate control
Ischaemia may be the result or the cause of AF so consider doing troponins when there are clinical features of ACS present or risk factors for CAD.

AF WITH WIDE QRS

Differential
- AF with aberrancy (LBBB or RBBB)
- AF with pre-excitation (WPW)
  - QRS morphology bizarre, polymorphic, much faster AF
  - NEVER give AV nodal blocking agent (beta-blocker, calcium-channel blocker, adenosine, digoxin and even amiodarone)
  - Treatment: electrical cardioversion

References

NBothma

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Are we allowed to be recorded?

Patients recording NHS staff in health and social care settings

Doctors' use of social media

Atrial Fibrillation

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Are we allowed to be recorded?

Patients recording NHS staff in health and social care settings

Doctors' use of social media

Atrial Fibrillation

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The Derrifoam Blog

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