Medical Skills Courses by Dr Mike Smith

Linda Scott - Tuesday, June 06, 2017

I was a late convert to General Practice.

Until 2007, I had done many years as a Plastic Surgery Trainee, but a series of epiphanies and a few hospital jobs later, I found myself in my registrar year at a wonderful practice in Hertfordshire. It was genuinely wonderful.

I got to have meaningful conversations with patients, staff and my family. I felt like I was part of a team rather than part of a large, overbearing organisation. I loved it.

However, I did miss the practical hands on tasks of surgery itself. I was told I was quite good at it.

So, imagine my delight when I was asked to do a ‘minor ops list’ by my practice. A list of my own, with my own room, my own assistant and more importantly my own patients. This was a chance to be a surgeon again.

I went through my checklist:

  • Tottenham Hotspur Scrub hat – check 
  • Personalised surgical scrub top – check
  • Surgical Marker Pen – check
  • Personalised consent form – check
  • Cheesy 80’s music to play in the background (Electric Dreams by Phil Oakley being a personal favourite) – check
On the day of the list, I was excited. I had the minor ops room set up in my style. I was going to show these GPs how minor surgery was really done. I was going to add a touch of Hollywood glamour to Welwyn Garden City.

I strutted into the room.

Within seconds the wind was taken out of my sails. It was then that I realised that the world of General Practice minor surgery was very different environment, and I was going to have to learn, relearn and adapt very quickly.

The first thing that struck me was the patient. She was in her 70’s and was having a premalignant lesion removed from her trunk. She was fully dressed and wasn’t even close to being ready for an operation. There was no hospital gown and she wasn’t quite sure why she was here. I spent a further 10 minutes explaining the procedure, 10 minutes helping her undress, and then 10 minutes talking about how lovely Dr B (the senior partner was) and how he was the one who usually saw her.

After 30 minute I hadn’t even put knife to skin. It was at this point, the lady decided she didn’t want the procedure.

At least the next patient went better. I managed to get to the point of operating on him. Admittedly, there was no operating table, very little surgical equipment and questionable lighting, but at least I had managed to cut an ellipse of skin from him.

At this point I glanced over to my assistant, the lovely nurse Lynne, and made a waving gesture with my hand. Now anyone who has done any amount of surgical training knows what this gesture means (for those of you in doubt, it means ‘Please pass the diathermy’). However, Lynne just smiled back at me. I waved again for the diathermy. She smiled and waved back.

At this point I decided to ask her outright “please pass the diathermy.”

The dia-what?”

“The thing you use to stop the bleeding,’ I helpfully explained.

“Oh! I know what you mean”, and she quickly trotted off to the store room and came back with an old wooden box. She then proceeded to take out an even older wooden box with a lead coming from it with a red-hot attachment at the end. She gave it to me. I used it.

The smell of burnt flesh was only beaten by the chunk of skin that was ripped away by this attachment. This certainly wasn’t a diathermy (I later found out it was an electrocautery machine.) It bled like stink. I grabbed some wet gauze and applied pressure, the whole time trying to look in control of the whole procedure.

As I stood there, applying pressure to the wound, looking at Lynne cleaning the tip by burning off the excess flesh, I realised that Primary Care Minor Surgery was different. It wasn’t more dangerous, it wasn’t worse, it was just different.

So, what did I want to do about it?

I decided over the next year that I would, with the help of the RCGP and my professional colleagues, try and learn as much about Minor Surgery in General Practice as possible, whilst weaving in the techniques, skills and evidence from my surgical training. With this information, we would write a handbook, write a course, get it CPD accredited and approved by the professional bodies. We would take pride in delivering the courses ourselves, knowing that we were driving up the standards of minor surgery for patients and practices alike, whilst having fun in the process. And so MEDICAL SKILLS COURSES was born……..

A decade later, thousands of delegates later, and many wonderful moments later, we find ourselves partnered with NB MEDICAL, the most reputed and largest General Practice educator in the country, educating GPs in exactly what they need to know to deliver high quality and evidence based practice……..a philosophy we wholeheartedly agree with!

And as for my practice nurse in 2007?

Thanks Lynne. For teaching me a valuable lesson about the beauty of General Practice, and thanks for showing me how GPs can be amazing at minor surgery.

For more information on our Minor Surgery and Joint Injection courses for GPs please click the link below……..its easier than you think……

Medical Skills Courses

Dr Mike Smith MBBS MRCS(Eng) MRCGP

 

​SGLT2 Inhibitors – The Panacea for Type 2 Diabetes?

Linda Scott - Tuesday, June 06, 2017

SGLT2 inhibitors (SGLT2i) exert their glucose-lowering effect in an insulin-independent manner, by reducing renal glucose re-absorption, leading to increased excretion of glucose in the urine. Around 300kcal of glucose is excreted daily, therefore, in addition to improvements in glycaemic control, this class of drug can also lead to weight loss.

During May 2017, NICE revised their 2015 T2D guideline placing greater emphasis on the use of SGLT2i as second-line therapy options alongside gliptins, pioglitazone and sulphonylureas (SUs). NICE also advocate the use of SGLT2i in triple therapy. Furthermore, NICE also suggest we consider SGLT2i as alternative first-line therapy if metformin is not tolerated or contraindicated. SGLT2i are also licensed to be used alongside insulin in those with T2D.

Moreover, draft SIGN diabetes guidelines published May 2017 preferentially place SGLT2i as add-on therapy to metformin if hypoglycaemia is a concern, or weight loss is considered to be potentially beneficial. So, pretty much everyone then. Notably, SIGN suggest we use an SGLT2i with proven cardiovascular (CV) benefit as add-on therapy to metformin in those with T2D and established CV disease.

This latter recommendation was driven by the EMPA-REG OUTCOME trial published during 2015 which demonstrated a reduction in CV & all-cause mortality with empagliflozin. Additionally, during March 2017, CVD-REAL, a retrospective study of >300,000 individuals with T2D who were newly prescribed SGLT2i demonstrated a reduction in all-cause mortality as well as hospitalisation for heart failure.

So far, so good. But what adverse effects of SGLT2i do we need to be aware of?

The commonest side-effects encountered with SGLT2i are urinary symptoms (polyuria, dysuria & UTIs) and mycotic genital infections due to the increased glycosuria. Thirst, dizziness and constipation can also occur due to volume depletion.

SGLT2i themselves have a very low risk of hypoglycaemia, however this risk is much higher if used alongside SUs or insulin.

Importantly, all currently available SGLT2i can only be initiated if eGFR>60 so this class of agent is not an option for our many patients with co-existing CKD.

During May 2017, the FDA confirmed an increased risk of leg and foot amputations (mostly affecting the toes) specifically with canagliflozin; the underlying mechanism is unclear and requires further investigation.

Finally, during April 2016, the MHRA issued guidance regarding SGLT2i and the risk of euglycaemic diabetic ketoacidosis (DKA). This is a rare phenomenon (1:1000 – 1:10,000); however, we must warn patients of symptoms of DKA and test for raised ketones in patients with symptoms of DKA even if glucose levels are near normal. Finally, we need to emphasise the importance of sick day rules with SGLT2i and advise patients to stop them alongside metformin during periods of illness.

So, as we can see, SGLTi are not the panacea for T2D, but are a very useful addition to our armamentarium to tackle T2D.

Come along to one of our NB Medical Diabetes for Primary Care courses to find out more about SGLTi and all aspects of the primary care management of T2D http://www.nbmedical.com/diabetes-gp-update-courses

Kevin Fernando



Locum Organiser