Good morning and welcome to your Tuesday dose of Your Daily Meds.
Bonus Review: What are some functions of the Hypothalamus.
Answer: It does a few things -
* Control of water balance
* Temperature regulation
* Control of anterior pituitary hormones (neuroendocrine function)
* Production of posterior pituitary hormones (more neuroendocrine function)
* Appetite and satiety
* Role in behaviour and emotions
Quick Question:
In the physical examination of the neonate, which of the following describes a common newborn rash, manifesting as pustules with an erythematous base, often with a widespread distribution?
* Erythema toxicum
* Milia
* Pustules
* Lanugo
* Naevus simplex
Have a think.
Scroll for the chat.
Ethics Case:
You are a motivated little Emergency Department Doctor.
You have just met a 15-year-old female who attempted suicide last night by swallowing button batteries.
The girl was brought to the Emergency Department under the Mental Health Act’s Emergency Examination Authority, so if she had tried to leave during the morning, she would have been detained. But she had not tried to leave, she was calm and cooperative.
Her parents are completely uncontactable.
You know that these button batteries are very corrosive so you erect x-ray the abdomen.
The batteries are still in the region of the stomach. They are potentially retrievable endoscopically before they can cause harm.
You discuss all this with your ED Consultant, then you call the Gastroenterologist on call.
“Sure!” she says, “If you could consent her for the Endoscopy, I’ll do it on my morning list within the next couple of hours.”
You discuss the risks of Endoscopy and Sedation with the young girl versus the risks of leaving the batteries in situ and watching and waiting.
The girl is receptive to your explanation, she seems to be able to understand, retain, consider, use and communicate her wishes and consents for Endoscopy.
You take the signed consent forms to the Day Procedure Unit.
“No”, says the Nurse in charge. “She is under sixteen - you will need to contact the Child Guardian.”
Now, I ask you. What are your thoughts here?
Do you punch on with this Nurse, or do you go and jump into the pre-recorded telephone cue of another government bureaucracy?
Or do you do something else?
Scroll for the chat.
Bumpy Babies:
Erythema toxicum is a common newborn rash manifesting with pustules with an erythematous base. The rash can have a widespread distribution that may change over a period of several hours. Differentiating infected lesions can be accomplished by microscopic examination of the vesicle contents which contain eosinophils in cases of erythema toxicum.
Milia occur particularly over the neonatal nose and are small sebaceous cysts that disappear by several months of age.
Pustules may be present from birth in congenital candida infection or may appear later with Staphylococcus aureus skin infections. Erythema toxicum is a more common differential diagnosis.
Lanugo is the fine downy hair covering the skin of the shoulders, upper arms and thighs of the neonate. It may be more evident in premature babies.
Naevus simplex, birth marks, are superficial vascular naevi commonly found on the occiput, over the eyelids or between the eyebrows of the neonate. They tend to fade over several months, often disappearing in the second year of life.
What To Do…?:
Well, you could calmly explain the concept of Gillick Competence to the Nurse.
But that did not go down so well.
You could tell on that Nurse to your boss.
That works better.
But the best result was to have the Gastroenterologist, the actual proceduralist doing the procedure, to consent the patient again in Endoscopy suite, just to be sure.
Remember, just because you happen to be a medico-legal-ethics nerd, doesn’t mean that other people are. And when you are having a busy day in the ED, you can’t be having stand up arguments citing decisions from the House of Lords when you have other jobs piling up.
Remember more that people who have tried to kill themselves can still have capacity to make the decision for life saving or condition-altering treatment. Like it or not.
Because capacity is context-dependent. And someone with “…sufficient understanding and intelligence to understand fully what is proposed” has capacity to make their decision, wether you agree with that decision or not; regardless of arbitrary age cutoffs.
(Also, just quietly, a 103-year old fellow with an acute delirium on top of his dementia very likely does not have capacity to consent for an Endoscopy……..even though he is over the age of sixteen…but I didn’t drop that bomb…)
Anyway this was a real case. So there.
Bottom line: People that have done silly things are still autonomous individuals (once particular conditions that would actively hinder their autonomy have been excluded) so are free to make their own decisions, in so far as they have the capacity to do so.
Bonus: Why is it that the posterior pituitary has neural connections with the hypothalamus, but the anterior pituitary has vascular connections with the hypothalamus?
Answer in tomorrow’s dose.
Closing:
Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!
Luke.
Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.
Just credit us where credit is due.
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