GIST-related malignant ascites with large-volume paracentesis complicated by myocardial infarction and tumour rupture.

This paper describes a patient with an inoperable gastrointestinal stromal tumour with moderate volume malignant ascites. A large-volume paracentesis caused haemodynamic instability and a myocardial infarction. An indwelling right-sided peritoneal catheter was inserted following further ascites build-up. The patient experienced spontaneous acute rupture of tumour and subsequent loculated ascites. An additional second catheter was inserted to the left side of the abdomen following reaccumulation of ascites following liquefaction of cyst contents and successful one-off drainage on the left side of abdomen. This is the first case report of a patient with two indwelling catheters: we describe learning points pertaining to those as well as the rupture of gastrointestinal stromal tumours. Haemodynamic instability after paracentesis in malignant-related ascites has also not been described.

Screening for delirium in specialist palliative care inpatient units: perceptions and outcomes.

OBJECTIVES: The UK National Institute for Health and Care Excellence (NICE) indicate that palliative care patients are at high risk of delirium and should be screened for it using the short confusion assessment method (short CAM). This study aimed to assess the perceptions of the short CAM for delirium screening amongst health-care workers in specialist palliative care inpatient units (SPCUs) and to investigate its use as a screening instrument. METHODS: Patients in 5 SPCUs in the North East of England were screened for delirium using the short CAM and a staff survey assessed the acceptability of the short-CAM in this setting. RESULTS: Of the 63 staff surveyed, 79.4% felt screening for delirium was important and 59.3% found the short CAM 'not at all' burdensome to complete. However, only 40.7% felt that the short-CAM often accurately reflected patients' conditions and none felt it always accurately reflected patients' condition. Of 298 patients screened, 20% screened positive on the short CAM. Malignant and intra-cerebral diseases were significant independent predictors of a positive screen. Hospice length of stay and in-hospice mortality were higher in those with a positive result (66.7%) than in those without (38.2%). CONCLUSIONS: Health professionals deem delirium screening to be important in SPCUs, but may not support routine use of the short CAM. This could reflect a limited perceived impact on care and lack of confidence in this tool to reflect a complex patient group.

Excellence in cost-effective inpatient specialist palliative care in the NHS - a new model.

There is little in the literature describing hospital specialist palliative care units (PCUs) within the NHS. This paper describes how specialist PCUs can be set up within and be entirely funded by the NHS, and outlines some of the challenges and successes of the units. Having PCUs within hospitals has offered patients increased choice over their place of care and death; perhaps not surprisingly leading to a reduced death rate in the acute hospital. However, since the opening of the PCUs there has also been an increased home death rate. The PCUs are well received by patients, families and other staff within the hospital. We believe they offer a model for excellence in cost-effective inpatient specialist palliative care within the NHS.

'I see you're angry': actor-reported anger scores.

BACKGROUND: Teaching communication skills using role-play addresses an important learning need for medical students, with the debriefing process being central to the learning that occurs. In this work we examine the feasibility of using actor-reported 'anger scores', during a challenging communication scenario, as a tool to stimulate debriefing. METHODS: This teaching session was delivered to 10 groups of final-year MBBS (Bachelor of Medicine and Bachelor of Surgery) students at Newcastle University. One student from each group took on the role of the foundation year 1 (F1) doctor and had 10 minutes to talk to an angry relative (actor), who was unhappy with the care her mother had received. During the scenario the actor recorded her level of anger on a 10-point Likert scale (1, 'no anger'; 10, 'extreme anger') at 1-minute intervals. Once the scenario was complete, the in-room tutor graphically presented these scores against time. During debriefing, students were asked to examine the graph produced: fluctuations in anger levels were identified, discussion was held regarding possible precipitants for the changes seen and strategies were developed for tackling future such incidents. RESULTS: Examples of graphs produced during the session are presented, including annotations highlighting the discussion topics that arose. Feedback on the session from both students and actor was positive, with no reports that the scoring process interfered with the fidelity of the scenario. DISCUSSION: We believe that actor-reported 'anger scores' provide a quick, simple and cheap method of producing a visual aid to the debriefing process that, in the context of a challenging communication scenario, provided a stimulus for discussion.

Simulation and stress: acceptable to students and not confidence-busting.

BACKGROUND: Newly qualified doctors frequently feel unprepared for clinical practice. 'Performing under stress' has been cited as a particular barrier in this transitional period. Conventional views on training using simulation state that it must take place in a controlled environment to benefit learning; however, we attempted to create a high realism 'high-stress' simulated scenario to try and prepare students for stressful situations in future practice. METHODOLOGY: Simulation stations were designed for final-year students. High realism was incorporated, as were factors designed to generate increased stress for students. Examples of this were that tutors did not prompt students during simulations, all bloods had to be taken to a 'lab', incomplete or incorrect requests were rejected and results were received in real time. All requests for senior help had to be made properly by telephone to a 'registrar'.Students completed a questionnaire rating knowledge and confidence of various session outcomes before and after the session, and rated the overall session out of 10. They also provided free-text comments. Before and after scores were compared with a Mann-Whitney U-test. RESULTS: Forty students completed the session. Overall, the session was evaluated highly by students (with a mean score of 9.6 out of 10). There was no significant difference between the pre- and post-session scores. The free-text comments reflected the utility of the enhanced realism and stress. DISCUSSION: From the students' comments we appear to have successfully created the 'stress' we set out to achieve. We were concerned that incorporating significant stress may have a negative impact on learning; however, students did not report a decrease in confidence following the session.