August 2018
In our 102nd edition, Richard carries on with the second part in his series on errors and bias, Louise reviews Nice's latest on hearing loss and ear wax, Judith on why medicine can have a sting in its tail, Liz sheds more light on tiers and Nigel has five top financial tips for you.
The Sessional GP
Supporting sessional GPs to improve patient care
image © Claire de Mortimer
Learning from errors and mistakes in healthcare
In the first part of this three article series on errors and mistakes in general practice, we explored the psychological basis for errors and biases in human behaviour that lead to mistakes occurring. In this second instalment, we think about the psychological limits that contribute to mistakes, and how we can use these insights to build a safer, open learning culture in medicine based around the principles of Black Box Thinking. Published in 2015, Black Box Thinking by Matthew Syed explains the inextricable connection between failure and success, comparing the psychology, culture and institutional responses to failure and how mistakes are managed in two safety critical industries: airline and healthcare. The book opens with this startling statistic; in 2013, out of three billion airline passengers across the globe, 210 people died in air accidents compared to 400,000 preventable deaths in the US healthcare system alone. This is the equivalent of two jumbo jets full of passengers being killed by preventable accidents every day. Why is this happening? And why does it continue? A routine operation The harrowing story of a routine operation provides some clues to the institutional and attitudinal differences between these industries. In March 2005, Martin Bromiley took his wife Elaine to their local hospital for a routine sinus operation. The first two minutes after having administered the anaesthetic were hampered by jaw muscle contraction, making oxygenation impossible using various laryngeal masks. As Elaine’s lips began to turn blue, her oxygen saturation fell to 75%. An oxygen mask for two minutes made no difference, so the anaesthetist switched to tracheal intubation. But he couldn't see the airway. After a further eight minutes, Elaine’s sats had now dropped to 40% and her pulse to 50. A second anaesthetist, and the surgeon, arrived to assist, with three nurses on standby, one of whom had clearly grasped the severity of the situation, grabbed a tracheotomy pack and made it clear to the anaesthetist that she was ready to assist. But the anaesthetists struggled on with attempts at tracheal intubation, eventually succeeding and getting oxygen saturation back up to 90%. This had taken 20 minutes. Martin was called, and informed that there had been a tragic complication, a one-off, and the team had done everything they could. The feeling was that this was an inevitable, unavoidable and rare complication with bad luck all-around. Elaine was severely brain damaged and died two weeks later. Martin wasn’t angry; he didn’t blame the clinical team, but he did want answers. He did not accept that this was a rare and inevitable situation. And that was because, crucially, Martin came from an industry that took a very different approach to ‘accidents’; he was a pilot and, as he learned more about what had happened to Elaine, he realised there were close similarities to previous airline ‘tragedies’. Flight UA173 In 1978, United airlines flight 173 was approaching the runway in Portland Oregon, and deployed its landing gear ready for final approach. But the landing gear light, indicating that the wheels had been lowered, didn't light up.The plane was immediately put into a holding pattern so that the crew could check whether the wheels were down or not. Like all aircraft, UA173 had two flight recorders - black boxes, one for cockpit audio and the other for data. They would later reveal how the captain continued to search for reasons why the landing gear light hadn't lit up. Were the wheels jammed? Or were they down but the light was just not working? The flight engineer could be heard regularly reading out the plane’s fuel reserves, which had minutes left before the engines would fail. But the captain continued to be immersed in searching for the cause of the problem rather than risk landing without full landing gear. When the flight engineer, by now in great distress, finally told the captain that they needed to land immediately as the fuel had run out, they were still eight miles away from the runway and circling over a busy city. The captain can be heard to be clearly surprised, and replied that he believed they still had several minutes of fuel left. The plane crashed killing eight people, including the flight engineer who had tried to raise the alarm with his superior officer. The response to this incident, compared to that of Elaine Bromiley, is striking in itself: there was a statutory, immediate investigation into the crash. Historical and real-time data was used, including data from the the Black Boxes, enabling comparison with historical incidents. Everyone involved freely gave cooperation, as the immediate assumption was there must be a system problem. Any evidence given to the independent enquiry was inadmissible in a court. Within weeks of the report being completed, its findings were disseminated throughout the entire aviation industry, with recommendations for change to protect air crews and their passengers in the future, with checklists, tools and training simulations. In the time since these changes have been implemented, the spate of crashes that were so typical of the 1970s have declined significantly. This is Black Box Thinking in action, and the perfect illustration of an open loop evolving learning system. “So that others may learn, and even more live” In contrast, thirty years later in the NHS, Martin Bromiley had faced an uphill struggle in trying to learn what happened to his wife and apply that learning to protect others. When the report he fought for was finally published, the findings and recommendations were startlingly similar to the Flight UA 173 case 30 years earlier, revealing a system that did not allow for the limits of human psychology. The powerful effect of social hierarchy, which had prevented both the flight engineer from assertively challenging his captain about the fuel reserves and the nursing staff from shouting for a tracheotomy, were clearly evident. The other signature was the narrowing of perception and loss of awareness of time passing that affected the captain of Flight UA173 as he focused on solving the problem of the landing gear, and the anaesthetists who intently and repeatedly tried tracheal intubation, and were later horrified to learn that their patient had been severely hypoxic for a full 20 minutes. Martin went on to found the Clinical Human Factors group, a charity dedicated to preventing these types of medical errors happening. As a result of his work, anaesthetic training and procedures have been transformed with simple but powerful use of regular time checks during emergencies, clear definitions of team member roles and the breaking down of social hierarchies to allow any team members to call out a risk or obstacle that could harm a patient. Martin receives weekly messages from clinicians from around the world that his work on challenging failings, that were once seen as inevitable and acceptable complications, has deeply affected their training, and saved ‘incalculable’ lives from harm and death. A humbling example of an open learning culture in one corner of healthcare. Failure and error in healthcare But on the whole, how well has healthcare since progressed towards adopting Black Box Thinking and a ‘growth’, open-loop, open culture? There has been some rhetoric around developing a no-blame culture, but the culture still remains doggedly stuck with individualising blame for the failures of an over-stretched system with doctors and healthcare staff being held personally, and even criminally, responsible for system failings. The prevailing attitude to error seems best summed up by Professor James Reason, professor of psychology at the University of Manchester, and a leading researcher and thinker in human error, who was involved in formulating the Swiss Cheese Model of error causation and prevention. “This is the paradox in a nutshell: healthcare by its nature is highly error-provoking - yet health carers stigmatise fallibility and have had little or no training in error management or detection.” So why are health carers bad at learning from errors? It’s worth examining Professor Reason’s Swiss cheese model to appreciate the attitude to error that should flow from this. The Swiss cheese, representing the layers of error protection, and the holes the gaps that can allow errors through, recognises the absolute certainty that human beings will make mistakes, and so seeks to design systems and environments that work around our human nature to reduce the risk of error as far as possible, protecting both the workforce and patients from errors. As we’ve seen in the case of UA173, the assumption is that if an error occurs, it must be because there is an unacceptable alignment of the holes in the error protection layers which needs identifying and closing. So what stops us applying this approach in healthcare? The external factors There exists amongst the public, and even within our profession, a powerful instinct to condemn errors. Especially in high stake situations where the outcome of decisions or actions befalls a third party - in the case of healthcare, a patient. This stems from the very human tendency we have to leap to conclusions based on incomplete evidence - the What You See Is All There Is (WYSIATI) described by Kahneman - and a collective Hindsight Bias that judges professionals on outcomes, not their thought process or actions in the scenario they found themselves at the time. As humans, it is psychologically more satisfying to create simple narratives when faced with complexity. And when there is a highly complex series of interacting, multi-system failures, our drive is to instead seek a simple solution, preferably embodied in a culprit we can blame and deal with to restore our sense of the world being controllable. As we saw in the previous article of this series, this is our deep System One (S1) need for coherence and stability. The internal factors The public like their doctors to be infallible when they need us and things go well. How often have you heard a patient attribute great healing powers to an individual clinician, despite the enumerable factors in that patient’s journey that actually contributed to the patient’s recovery? The flip side is that, when something does go wrong, we are quickly held “accountable” for factors not within our direct control. As individual doctors, and as the medical profession, we have to accept that we ourselves may contribute to this illusion of infallibility which can quickly sour to total fallibility. As GPs, we tend to be individuals who are high achieving in our early lives: we excel at school; we are told we are inherently clever because we hit targets; and then we go to medical school where the pressure is ratcheted up by being surrounded by more people like us, who got even better grades than us. We learn to judge ourselves on outcomes. If we fail at something, we are judged by others, but we also judge ourselves, and it can feel like a personal failing, not a valuable experience to learn from. We spend our formative years in this feverish environment with little or no experience in the true complex nature of failures and how we can learn from them. The irony being that we are studying medicine which has progressed through application of the scientific method - the supreme example of an open learning culture with progress and success evolving through a series of failures and negative outcomes. But none of this seems to rub of on us when it comes to considering our own performance and practise and, more widely, how the fruits of medicine are delivered in health care settings. And then we are doctors: a group of individuals with little or no training in error causation and management, and a heightened internal fear of failure, working in a system that does not recognise our limits as humans. Bad outcomes are either someone else’s fault, hopefully not ours, or they are just one of those unfortunate things that happen occasionally - precisely the attitude that met Martin Bromiley when his wife died. And it is all entirely subconscious; it’s not about consciously covering up errors to avoid external consequences. Adding to the psychological arsenal of WYSIATI and hindsight bias discussed in the first article is another phenomenon talked about by Kahneman, that of cognitive dissonance. Cognitive dissonance This stems from our instantaneous, automatic S1 thinking and is a powerful mechanism for hiding our failures and errors from ourselves to protect our self-esteem, our sense of being “competent”. It is so subconscious that we often don’t realise that we are denying errors. Like a person with dementia, incapable of making new short-term memories, we just don’t see the failure in the first place. Take the example of the clinical team in the case of Elaine Bromiley. They were not being dishonest when they initially explained her death as a rare, but unavoidable, complication. Perhaps many of us at first glance would have agreed. But as we’ve seen, opening up to the idea that this needed investigation revealed areas where system improvements were needed. This caused a leap in progress which has protected both patients and the doctors, who are often the “double victims” in poorly designed systems. In out third and final article on errors and biases in healthcare, I’ll illustrate the points we’ve made with a story of a locum session that culminated in the locum being blacklisted by a practice through a series of unfortunate events that, had a Black Box Thinking approach been made, the practice may instead have evolved new processes which would have improved the working environment for all their staff and locums, and improved patient safety. Dr Fieldhouse is chairman of the National Association of Sessional GPs chairman@nasgp.org.uk
By Richard Fieldhouse @rafieldhouse
the plane truth
"There has been some rhetoric around developing a no-blame culture, but the culture still remains doggedly stuck with individualising blame for the failures of an over-stretched system with doctors and healthcare staff being held personally, and even criminally, responsible for system failings."
pension tier and indemnity non-tax thresholds
"To keep it as simple as possible – just don’t have a three month gap in locum work! Even one session is enough to give continuation for this purpose."
The implications of which can burn holes in your pockets.
By Liz Densley @honey_barrett
My last article looked at tax thresholds which can affect GPs. One of our readers pointed out that I had not included non-tax thresholds which will also affect ‘take home’ income, so this month I’ll discuss some other thresholds. Pension tier rates You are probably aware of the pension tier rates, but not necessarily the implications. They do not work like tax rates where each band of income has its own rate. The rate is determined by pensionable income and is chargeable on the whole amount. So for example, if your pensionable income is £70,630 you would pay at 12.5%. If you earned £1 more, then you would pay at 13.5% - so you’d pay an extra £706 of pension contributions – without earning any additional pension. What’s more as a GP locum or salaried GP you cannot just incur additional expenses to reduce pensionable income because all of a salaried GPs income (up to full time) is pensionable and 90% of a locum’s fees are pensionable. For a GP principal it is impossible to know before the end of the year exactly what pensionable income is – as it is calculated by apportioning both income and expense shares from the annual accounts. Annualisation rules To make it even more complicated to work out, you also need to consider the annualisation rules. For sessional GPs in the 2015 scheme, if you do not have pensionable salaried income for the whole pension year (that is to 31st March each year) so you have a gap of more than a month in your employment or if you have a three month gap in locum income – then you have to gross up your income for a whole year to determine what tier rate you pay. This annualisation process is highlighted on the Type 2 pension certificate each year (but unfortunately the forms provided do not give the correct answer in all cases….). Hopefully the 17-18 forms will follow the rules correctly for all situations. To keep it as simple as possible – just don’t have a three month gap in locum work! Even one session is enough to give continuation for this purpose. There are separate annualisation rules for GP principals in the 2015 scheme which are worked through in the main certificate of pensionable pay each year (and that form did seem to work last year according to the rules). Action point for freelance GPs Keep a running total of pensionable income so that you can see if you are likely to be close to any tier rate bands by the end of the year. It may be better to turn down a session than pay an uplifted pension tier. Action point for GP principals Make sure your partnership agreement is flexible enough for you to adjust profit share for holiday. Then if a full profit share would take you just over a tier rate, you could reduce your share for an extra day’s holiday to take you under again. Seniority payments for GP Principals: Whilst these payments are reducing and will cease in a couple of years altogether, it is still worth thinking about. For GP principals, to get the full seniority payment you have to have pensionable income of at least 2/3rds of the national average. The national average is only known some years after the event, so you cannot look at this with any degree of accuracy. We’ve seen more GP principals recently, cut down sessions in the practice and top up with freelance work. Just be aware that if you reduce your practice income – either by reducing sessions or by having a low profit year – you could also lose some or all of your seniority money. Indemnity cover This is normally based on the number of sessions you work in a year of cover – and whether you are doing out of hours work. So if you work a session that takes you over the limit, that session could result in a large additional indemnity payment – so you could find you are actually working a few additional sessions for absolutely no net income at all. Action point: keep a record of sessions to make sure you don’t inadvertently exceed what you are insured for (but equally don’t insure for more sessions than you need to) – and be aware that this will be based on the year of cover rather than the fiscal or pension year. Liz Densley is medical specialist Director with Sussex Chartered Accountants, Honey Barrett and secretary of aisma (the association of independent specialist medical accountants). Contact her on 01424 730345 or at liz.densley@honeybarrett.co.uk
is laughter the best medicine?
The use of humour is believed to have several positive psychological and physiological effects on health. Many doctors and patients believe it has a place in the consultation. Dr Rachel Birch, medicolegal adviser at Medical Protection, addresses this issue in more detail and presents a case where humour had unintended consequences. In recent years it has been recognised that the use of humour may well have a positive impact on patients. In fact, in some parts of the world, “laughter therapy” is even being used as a new form of complementary treatment. Many hospitals employ clowns to cheer up patients and visitors and to try to lessen the impact of illness and being in an unfamiliar environment. Laughter may provide clinical benefits to patients, including lowering blood pressure, reducing stress hormone production, elevating mood, reducing pain and lowering anxiety. As humans, many of us use humour to cope with difficult situations and express our true feelings, fears and frustrations. As doctors, I am sure we can all recall busy shifts where laughter was the glue that held the team together and enabled us to cope with challenges. Could it be that humour could help patients too? Whilst some articles report that patients would like healthcare professionals to use humour, others outline the potential risks that patients could become distressed or offended. It is clearly something that should be judged on a case by case basis, as the following case scenario illustrates: Case scenario Dr K had been working as a part-time sessional GP for the past 6 months. Mr A came to see her in her morning duty doctor surgery. She had met him twice before, presenting with recurrent chest infections. He was a jovial man who worked as a teacher, and had previously joked that he caught his infections from the young children at the school. He presented with breathlessness, cough and a raised temperature. Examination revealed him to have a further chest infection and Dr K explained to Mr A that he would require antibiotics. As she handed him the prescription she joked that he should perhaps wear a face mask at work so that the children couldn’t cough and splutter on him. One week later Mr A came to see his usual GP, Dr F. His infection had resolved but he was concerned about the number of infections he was getting. He was worried he could have lung cancer as his father had died from this. He also complained about Dr K’s “light-hearted attitude” to his symptoms - he did not want to make a formal complaint but wanted Dr F to talk to Dr K about this. Dr K arranged further investigations and fortunately Mr A did not have lung cancer. Dr K raised Mr A’s comments with Dr F, and Dr F was sorry that Mr A had interpreted that she wasn’t taking his health seriously, at a time when he was very worried. Two weeks later Mr A came to see Dr F again in the duty doctor session, with a further chest infection. Dr F apologised for upsetting him with her comments and he accepted this, before concluding his consultation with a funny story… As this case demonstrates, an attempt at humour can backfire if the situation is wrong. Mr A was probably already worried about underlying malignancy when he came to see Dr K. He didn’t mention it to her, but it is possible that there were cues that she could have picked up on. If patients are stressed or angry, comments that would usually make them smile could be felt to be insulting or insensitive. Pain and feeling unwell also can have dramatic effects on patients’ judgement of and tolerance for humour. Remember that patients may use humour to mask concerns about their health, so a joke made during a consultation may actually be a cry for help. It is very important to be aware that what is funny to one person may not be funny to others. Cultural and religious beliefs may also come into play. The General Medical Council advises doctors to be polite and considerate to patients, to respect their dignity and not to express personal beliefs in a way that is likely to cause patients distress. It is important to any attempts at humour do not go against such advice. In some cases, although not all, it may be easier for a GP who knows the patient well to gauge when to use humour and when to avoid it. They may be party to relevant background information, such as family members being unwell or work stresses. The RCGP ran a workshop at their 2016 Annual Conference helping doctors to recognise aspects of their own emotions and personalities and how they can be best used for the benefit of patients. Our own personal sense of humour is an essential part of our personality. It may be that, with further self-awareness within our training, humour becomes more common as a communication tool within the consultation. Learning points for sessional GPs Think first before you introduce humour into a consultation - how well do you know the patient? Whilst some patients may welcome humour and find it assists their communication with GPs, others may perceive that they are not being taken seriously. Pain and distress can affect a patient’s experience of humour. Patients may use humour to try to express what they are really feeling. Reflect on your own personality and how this can have a positive effect on your consultation style.● Rachel Birch rachel.birch@medicalprotection.org
By Rachel Birch @MPSdoctors
We all like a laugh, but it's not always the general panacea we think it is.
"Whilst some patients may welcome humour and find it assists their communication with GPs, others may perceive that they are not being taken seriously."
"Not many really understand the difference between a surgeon and a GP, and some policies will only pay out if you are unable to perform ANY job…including scanning things at the supermarket checkout!"
By Nigel Farrar www.legalandmedical.co.uk
Being a locum has many advantages: greater flexibility, autonomy and variety. But there are some disadvantages too: peaks and troughs in income, difficulties with getting a mortgage and uncertainty about your financial situation if you fall ill or die, to name just a few. Modern life can compound matters too. A recent report has found that 1 in 4 families are now single parent households. Sadly, being a GP doesn’t make you immune to such statistics either and increasingly I am being asked for advice about this very situation. But fear not. Here are my five tips to make your finances as a locum run more smoothly in the future. 1. Who’s going to look after you and your family financially if you fall ill and can’t work or you die? The NHS Pension scheme is still a good starting point for many doctors, but you do not qualify for any sick pay at all, and unless you die while in role during a contractual locum job you won’t qualify for death in service. So what can you do to ensure you and your loved ones are taken care of no matter what? A suite of protection policies is an essential part of your basic financial planning as a locum. Ensuring your mortgage and any other debts are cleared in the event of your death, plus a sum for your family to use in the future, is a basic need and is surprisingly affordable. But beware not all policies and providers are the same. Also it’s worth considering a policy that offers guaranteed premiums as opposed to reviewable, so you won’t suffer increased costs in the future that could tempt you to cancel the policy. Things are more complicated if you fall ill either in the short or long term. You have two options here. Ideally take both. Critical Illness is a lump sum payable on diagnosis of a defined list of critical illnesses. What qualifies as a ‘critical illness’ varies company to company, so take your time to understand what your policy will offer you. The best ones also cover your ability to perform the duties of your normal occupation, so a specialist knowledge about your type of medical practise is vital in a provider here. Not many really understand the difference between a surgeon and a GP, and some policies will only pay out if you are unable to perform ANY job…including scanning things at the supermarket checkout! Income protection is a replacement regular income when you are ill and unable to work. As you will receive zero sick pay as a locum, you need to consider a policy that pays out sooner than your employed counterparts. Policies can start immediately after falling ill or after a set time period such as 4, 13 , 26 or 52 weeks. The longer you wait for payment, the cheaper the premium. Again career specific understanding by providers is so important. Take expert advice from a specialist IFA like Legal and Medical to fully understand the ones that will suit you best. 2. Set aside a ‘rainy day’ fund It seems like an obvious one but it’s surprising how many people I meet that don’t do this. Decide on a sum, maybe a few months outgoings, and put it away in a bank account. This will also help you to choose an income protection that pays out a little later and is therefore a bit cheaper as you have this to fall back on too. 3. Mortgages I get asked more questions about getting a mortgage as a locum than any other topic. It’s always a bit less straightforward than for other doctors, as you generally need at least two years accounts before most companies will lend to you. However there are a few that will consider you after you hold one full year’s accounts. If you are planning to buy a house, inform your accountant before finalising your accounts. Generally your accountant’s objective is to legitimately minimise the tax you pay, but in doing so will reduce your taxable income. When you want to get a mortgage your objective is to show that you can comfortably afford the mortgage repayments and your accounts along with your bank statements will need to evidence this. Child maintenance is also a bit tricky when applying for mortgages. Often maintenance forms an integral part of your family’s financial situation. Some lenders will totally disregard it if you are receiving it but will fully take it into account if you are paying it when calculating your affordability. That always strikes me as rather unfair! Other lenders will take the receipt of maintenance into account but not fully. 65% is sometimes used. But they may also then limit the term of the mortgage to the timescale you will be in receipt of the maintenance, e.g. until your youngest is 21. With most of us trying to stretch our mortgage terms until retirement, this can cause issues. It can be a minefield that eats up hours of your time and can feel a little bit like a wild goose chase at times, so why not shorten this process by speaking to us. We have seen this many times before and can help to select the right mortgage for you. 4. Childcare vouchers Juggling childcare and work is mind boggling and very expensive at times. So unless you have an adoring grandparent or two on tap make sure you are claiming all the government help you can especially if you have a 2,3 or 4 year old as you may qualify for free childcare session. 5. Keep up to date on your NHS pension scheme As a locum you faithfully send away your forms and payments to the NHS Pension scheme and hope it’s all going to the right place and being credited to you! Once a year every pension scheme has to provide its members with a statement of benefits. The NHS Pension Scheme is no different. An online total rewards statement is the easiest way, but some doctors struggle to get access. This statement is your annual method of checking you are on track and being credited appropriately so it’s a vital part of your financial housekeeping. They can be as clear as mud when you do get them we ask all our clients to forward a copy to us. It holds so much useful information and we are always happy to ‘translate’ what yours means for you and your future. So there you have it. A few simple things everyone can do to make their financial lives less complicated and add some calm to a sometimes manic life! Legal & Medical Investments Ltd is registered in England & Wales No. 3429678 Registered Office; Splatford Barton, Kennford, Exeter EX6 7XY Tel: 01392 832696. www.legalandmedical.co.uk We are authorised and regulated by the Financial Conduct Authority. Entered on the Financial Services Register under reference 185193. The Financial Conduct Authority does not regulate offshore investments, tax advice, estate planning and some forms of mortgages. The tax reliefs referred to on our articles are those currently applying in the United Kingdom to UK Tax Residents. These tax reliefs are liable to change. The value of any tax relief available will depend upon the individual circumstances of the taxpayer.
five financial tips for gp locums
Make sure your hard-earned income is working as hard as it can for you.
© Claire de Mortimer,detail, watercolour
When venom is man's best friend
Did you know that captopril was derived from the venom of the deadly Brazilian pit viper? Since it went on the market in 1981 captopril and its successor ACE inhibitors have probably saved many more lives than have been lost to pit vipers. I’ve watched snake charmers capitalising on our fear of snakes, and I have observed blood trickling for an hour from my leg where a leech had fastened itself, but I have only ever seen one venomous snake in the wild. Walking along a Cornish beach after a weekend on call, I came across an adder sunning itself on the sand. In Britain the only deaths from snake bite in the last 40 years have been from exotic pets. But, as makers of horror films know, snakes alarm most people, a response which may have proved evolutionarily advantageous for our forebears. Some creatures are merely poisonous – passively producing a toxin to defend themselves, for instance, when you tread on them. A venomous beast is one which actively wounds another animal and inserts a toxin designed to achieve its aim of acquiring a meal. Apparently, we are never far from one. Most phyla in the animal kingdom have venomous members, even mammals. The slow loris is cuddly-looking, but if you are tempted to hug it when it stretches out its arms, be aware a venom gland in its elbow produces a nasty allergic reaction. Few, if any, animals evolved their venom to attack humans; we are collateral damage in an evolutionary arms race. There are no accurate statistics, but venomous snakes probably kill more than 100,000 people every year and 400,000 undergo amputation. Deaths due to scorpions, already high, are likely to increase now that they have discovered the advantages of city living. The venomous animal overwhelmingly responsible for most deaths is the malarial mosquito. But it isn’t just blood feeders that use anticoagulants and analgesics. Venoms are a mixture of hundreds of compounds, each of which is tailored to meet the attacker’s objective. Add vasodilators and hyaluronidases and venom will more easily reach its target tissues, where neurotoxic, cytotoxic, cardiotoxic compounds act to disable or kill the prey. No wonder that man has used venomous animals to his own ends, from ancient tribes in Iraq who threw pots of scorpions at their enemies to radical pastors demonstrating God’s power, and their own, by handling rattlesnakes – until the rattler demonstrates its power by biting them. No wonder that most cultures have traditional remedies – ineffective and some downright dangerous. And modern snake oil salesmen still sell protection and treatment. Inevitably rural people in poor countries suffer most, because their lifestyle exposes them to venomous animals. Health services are a long way off and an appropriate antivenom, even if available, is prohibitively expensive. Antivenoms are now on WHO’s list of essential medicines, and, in response to pressure from affected countries, envenoming has been raised to the status of a neglected tropical disease. But however sound WHO’s advice for managing the problem, for many countries implementation is unrealistic. To produce an antivenom, you need the venom. There are well-established techniques for milking snakes, but how do you obtain venom from small sea creatures? Then, you have to analyse those hundreds of compounds. Then, making the antivenom currently involves injecting horses and collecting the immunoglobulins they produce. Testing the antivenom isn’t straightforward either, because what kills a human may not damage other animals. Add the problems of cost and the distribution of appropriate antivenoms to areas where venomous snakes abound. Making antivenoms isn’t profitable, but venoms are a treasure trove for scientists and, as captopril shows, a potential goldmine for pharmaceutical companies. Probably more than quarter of a million species are venomous. Where to start looking? At victims’ sufferings and deaths, and at traditional communities’ use of animal toxins. These days traditional knowledge is protected, at least in theory, by biopiracy laws. The sodium channel blocker tetrodotoxin has been invaluable in research on nerve conduction since the 1950s. One source is the pufferfish, a popular delicacy in Japan where chefs require a licence to cook it. (Even so, one professor of physiology declined to taste it.) Calcium channel blockers from spider venoms are a tool in cell membrane studies. And kraits have aided neuroscience research as the α-bungarotoxin in their venom binds to nicotinic acetyl choline receptors at the neuromuscular junction. More generally, studying how venoms achieve their aims can help us understand the pathways involved and so design better therapies. And much might be learned from studying the ingenious devices that animals have evolved to penetrate cuticle, hide or scales to insert venom into their victims. Even when a compound in a venom has been characterised and revealed potentially clinically useful properties, there is a long road to develop a safe and effective medication. But some drugs have made that journey. The glucagon agonist exenatide was developed from a chemical in the venom of the Gila monster, a New World lizard. Eptifibatide, derived from an anticoagulant in the venom of a rattlesnake, and tirofiban, from saw-scaled viper venom, are i.v. antiplatelet drugs. Some patients with severe chronic pain benefit from intrathecal ziconotide, developed from cone snail venom. There is a lot of interest in exenatide’s neuroprotective effects for Parkinsons Disease, cobra venoms for multiple sclerosis, motor neurone disease and cancer, and a sea anemone neurotoxin for psoriasis. Bee venom penetrates the blood-brain barrier so could be a vehicle for therapies. So does chlorotoxin, a paralytic in the venom of the aptly named deathstalker scorpion, and it shows a preferential attachment to glioma cells. With a fluorescent marker attached, it is undergoing phase II clinical trials of its potential as a diagnostic aid and a guide for the neurosurgeon’s scalpel. And a spider venom constituent which induces priapism could lead to a treatment for erectile dysfunction. The tiny emerald cockroach wasp has perhaps the most disturbing modus operandi. It turns its much larger cockroach victim into a zombie, alive but passive, which can be led by its aggressor to its nest and where it lays its eggs in its victim to serve as a living larder for its larvae. It’s not, I trust, the horror story scenario that fascinates scientists, but the zombie state it produces. It resembles encephalitis lethargica, so the wasps’ venom might provide shed light on dopamine and other pathways which are affected by movement disorders. The research is expensive and challenging. Being peptides, most toxins are broken down by digestion, so they need substantial modification before they can be used orally. But, venomous animals are a source of unlimited opportunities for medical development. Like the snake charmer’s cobra they excite our awe and fear. But let us, safe in Britain, not forget those for whom venomous animals are a daily threat. They need antivenoms. The Natural History Musuem’s website has information and links about venomous animals. Judith Harvey judith.harvey12@gmail.com
By Judith Harvey @judithharvey12
a viper’s nest
"No wonder that man has used venomous animals to his own ends, from ancient tribes in Iraq who threw pots of scorpions at their enemies to radical pastors demonstrating God’s power, and their own, by handling rattlesnakes – until the rattler demonstrates its power by biting them."
Hearing loss and ear wax are the bread and butter of general practice
"GP surgeries should be offering irrigation for wax removal, or aural probing."
hearing loss and ear wax
By Louise Hudman
This is a new guideline from NICE on managing hearing loss and ear wax, published in June 2018. Exciting? Well, there are a couple of good bits in here, especially given how common a problem this is. Some top tips that were new for me: Consider an urgent referral to ENT for someone of Chinese or South East Asian origin with hearing loss AND a middle ear infusion, which is not due to an URTI. Consider referring patients with newly diagnosed dementia, or people with learning disabilities for a hearing assessment every 2 years. Also consider referring at diagnosis for people with dementia and on transfer to adult services for people with a learning disability. NICE advises that we should NOT be advising patients to use home syringing kits. See below for more detail on why this is. GP surgeries should be offering irrigation for wax removal, or aural probing. Drops don't have to be used for several days before irrigation. Studies suggest that using drops immediately before irrigation is safe and effective. If irrigation is unsuccessful, then water can be instilled 15 mins before a second attempt, or a 5 day course of drops can be advised. What drops to suggest patients use? NICE advises that any can be used, even hydrogen peroxide, which has gone out of fashion a bit. See below for more detail on this (I know it's a bit trivial, but it always really annoys me that I don't know the evidence base for something we advise on all the time). Hearing loss and when to refer Sudden or rapidly worsening hearing loss Patients should be referred whether it is unilateral or bilateral if it is not explained by external or middle ear problems. Sudden loss (i.e. developed suddenly over 3d or less) in the last 30d – refer immediately (within 24 hrs) to ENT or ED. Sudden loss > 30d ago – refer urgently (within 2w) to ENT or an audiovestibular service. Rapidly worsening loss (ie 4 to 90d) refer urgently (within 2w) to ENT or an audiovestibular service. Hearing loss with other signs or symptoms Refer immediately (to be seen within 24 hrs) to ENT if: Acquired unilateral hearing loss AND altered sensation OR facial droop on the same side. NB If stroke is suspected then obviously manage as that. Hearing loss in immunocompromised patients with otalgia AND otorrhoea IF treatment hasn’t worked within 72 hrs (beware malignant otitis externa). Consider an urgent referral (within 2ww) to ENT if: Chinese or South East Asian origin with hearing loss AND a middle ear effusion, not associated with URTI (nasopharyngeal tumours are more common). Consider referring patients to ENT or an audiovestibular service if they have: Unilateral or asymmetric hearing loss. Hearing loss that fluctuates and isn’t associated with an URTI. Hyperacusis (that is causing significant distress and interferes with daily activities). Persistent tinnitus that is unilateral, pulsating, distressing or has changed significantly. Vertigo that hasn’t fully resolved or is recurrent. Hearing loss that isn’t age related. Consider referring patients to ENT, if after the removal of wax, or the treating of infection, they have any of the following: Partial or complete blockage of the ear canal that prevents examination or impression taking. Pain that has lasted more than 1 week, despite treatment. Otorrhoea (not wax) that has not responded to treatment or has recurred. Abnormal appearance of the drum (e.g. inflammation, polyp formation, perforation, abnormal bony or skin growths, swelling of the outer ear, blood in the ear canal). Middle ear effusion that persists after or occurs in the absence of an URTI. Ear wax Such a common problem and one which causes a surprising amount of distress and time spent consulting with us. I was particularly interested in this bit as quite a few practices seem to be stopping doing irrigation and advising more self-management. A note of caution... most of the studies done in this area are on small numbers of people and are of low quality. It can therefore be quite hard to draw robust conclusions. Ear irrigation vs home syringing NICE advises that we should be offering irrigation where wax is causing a problem. Benefits of GP ear irrigation vs home syringing: It is more effective (there are fewer consultations in the following 2 yrs for ear wax). It is more comfortable for patients. It gives better hearing afterwards (by about 10dB). However, the studies have not been large enough to show whether there are any significant harms from home syringing and it is probably more cost-effective as the benefits of irrigation are small. NICE advises that we do not suggest home syringing to patients. This is partly because its safety has not been proven. It is also because they felt that in general we advise patients not to insert anything into their ears and yet advising home syringing goes directly against this advice. Ear drops immediately before irrigation Traditionally we have advised patients to use drops for at least 5d before irrigation. However there is no high quality research that shows any benefit of using drops for several days before irrigation compared to using them just immediately before irrigation. Only having to insert drops immediately before irrigation may benefit some groups (e.g. the elderly) who could struggle to insert drops. It may also reduce the number of unsuccessful irrigation attempts, as drops can be inserted immediately before the procedure. If unsuccessful, evidence suggests that instilling water into the ear and leaving it for 15 mins also improves the chances of success. Ear drops for wax removal This is one of those scenarios where drop A is better than drop B in study 1, drop B is better than drop C in study 2 and drop C is better than drop A in study 3, i.e. all a bit of a nonsense. Olive oil - There weren't any decent studies done that NICE could find on using olive oil on it's own for wax clearance. There is evidence for it's benefit in use before irrigation. Hydrogen Peroxide - There is some evidence that it can cause irritation and some evidence of increased harm if used before irrigation. However NICE felt that there wasn't enough evidence to give a negative recommendation about it. So what should we be advising? The evidence does suggest that using drops on their own is effective and that they are effective if used before irrigation. Water, olive oil and sodium bicarbonate all have good evidence for use before irrigation, though sodium bicarbonate doesn't have evidence for any benefit if used only immediately before irrigation. NICE advises that it is difficult to conclude that there is a clear advantage of one drop over another. They suggest considering cost and patient factors when giving advice. Louise Hudman louisehudman@gmail.com
www.nasgp.org.uk
Promises, promises
This magazine is supported by an educational grant from the Medical Protection Society.
