A-Z Guide to the NHS - Atrial Fibrillation, ABG, Adverse Drug Reactions, & Autoimmune diseases

[Music] hello and uh welcome to another video today with myself dr james gill however i'm going to be joined by a guest today andy stein so we're in the times of covert so we are socially distanced two meters apart for this interview with dr andy stein one of the acute and renal physicians at uh one of the super hospitals around here and we're going to be trying something new this is one of andy's big ideas and he has an awful lot of them um we're going to try and do an a to zed or perhaps an abc of the nhs looking at what words we're usually using behind the scenes in the nhs and medically speaking and we thought we'd try and address some of those and see you know if we can do something to help everyone at home understand a little bit more about how the nhs works and what we see in it so this is going to be an evolving series and it's going to be vital that we get some input from yourselves on how things are going and how we can change what we're going to be covering over hopefully the next few months to benefit and provide you guys more effective information and help so andy um just fill us in some of your background so uh james as you know i'm a hospital doctor i'm what's called a consultant physician and i work at a big hospital in coventry called uhcw i've been there a long time 20 years and i've known you quite a long time as well okay so to be fair um andy is he's underselling himself here he's one of the big dogs okay and part of that is that he's involved in the medical school he taught me when i was here as one of the students he is involved in so many of the committees and things and the renal team are always looked at as some of the most skilled in a hospital because of how they deal with the whole patient and because as i'm sure you'll rightly say you know the kidney is so very vital to everything not just the ability to produce we well i would say that wouldn't i the kidney is my favorite organ the organ that i've spent my life studying and treating patients with but it is only one organ and most human beings also need a heart and some lungs and a brain i know i know plenty of consultants that don't have heart they deal quite well without them okay let's move on to the uh a to z of the nhs and we're going to do a's today so first what are we going to go with for the first well we're going to start off with atrial fibrillation move on to arterial blood gas that one's going to be stabby yes then adverse drug reactions and then finally my favorite subject which is autoimmune disease that sounds good to me now i'm particularly interested how that autoimmune side of things is going to go because that's quite a complicated um an area so that that'll be a really interesting one i think okay would you like me to start with that one or start with atrial fibrillation no we we want you know we want to hold that in reserve that that's going to be okay our jewel on this one so let's start at the top then with our atrial fibrillation shall we andy what is an atrial fibrillation atrial fibrillation or as we in the trade call it af it's the commonest disturbance of the heart rhythm but to understand it you have to understand what normal is so the normal human heartbeat is 60 to 80 beats a minute and it's regular like this so a sinus rhythm what we call sinus rhythm but in some people you can develop a fast or sometimes slow irregular heartbeat and that would feel more like this it's random and some patients can feel they've got it but many patients don't feel they've got it so a lot of the public have this and don't know in other words it's a silent arrhythmia so when you say a lot of patients can have it and some don't they're the patients correct me if i'm wrong who come to me in the gp surgery and say i can feel my heart beating they'll talk about palpitations that's correct is it yeah that's right so um they will feel an abnormal sensation in their chest which is called a palpitation in what because you normally don't really feel your heartbeat but if it's irregular sometimes you can and they feel a sort of fluttering uh around where the heart is so as you said we can have that regular heartbeat one two one two or an irregular one one two four five one two all over the place but apart from one sounding much nicer and regular what does it matter it matters because atrial fibrillation is a risk factor for stroke in fact 20 of patients who have a stroke have atrial fibrillation as a cause of that stroke now as you know and as i know and hopefully most of you know a stroke can be a devastating disease and i think this is the bit that we really want to hammer home today with regard to atrial fibrillation there are lots of reasons you can have a stroke but atrial fibrillation 50 of those patients have catastrophic strokes it's a huge huge problem in fact that stroke could be devastating to the point of causing your death which is generally a bad thing it can make you unconscious it can give you complete weakness or paralysis down one side of the body it can affect your vision it can affect your voice it can affect your language so a stroke is a really bad thing and there's anything we can do to prevent it it's a good thing and i think that's really really important to highlight that with regard to atrial fibrillation we can recognize this disease we've got treatments for the disease so not only can we control the problem with the heart but we can reduce greatly the number of people that have a stroke as a result of this problem and the reason we need to do that is it's very very common in fact about a million people in the united kingdom have af and many of them don't know they're in f and that's because the af is not either particularly fast nor particularly slow that's bad but when you look at the over 65s in fact seven percent of people over 65 have af that's a large number of people really large so we don't want them to have strokes now i imagine we'll be covering stroke when we do the s's hopefully and that's going to rely on you guys because we need the feedback on this video if it's good if it's working well if you're getting something out say down below we can adjust these because we've got you know hopefully a whole alphabet's worth of these to do before i tell you how we prevent a stroke the first thing you have to do is make the diagnosis which is relatively easy an experienced doctor can make the diagnosis by examination though you would always do an ecg to confirm the diagnosis most patients probably don't need to be referred to a specialist a cardiologist most could be dealt with by most doctors like yourself a gp or myself a physician and there's two types of drug that a patient may well need the first type of drug is to control the fast irregular heart rate and we use a very traditional drug called digoxin and then another drug called a beta blocker and an example of that would be bisoprolol for example actually i think this is because we're going to talk about adrs in a minute adverse drug reactions wasn't van gogh on digoxin we'll see i think so because doesn't de-jockson give you a yellow tinge to your vision can it yes and i think that's why all of van gogh's paintings have a yellow tinge to it because who is on digoxin really and does that explain why he cut his own ear off oh that's psychiatric i don't do that not our problem not our problem anyway moving on from van gogh to the modern age um we've talked about controlling the heart rate with drugs like digoxin and bisoprolol and then we've talked about the tendency for patients and af to have a stroke but we can stop them having a stroke by giving a drug to thin the blood traditionally we use an old-fashioned drug called warframe i'm not a big fan of warfarin rat poison we've got much better stuff today so now we can see the difference between my age and james's age through most of my career warfarin's been the only drug available and so we thought it was okay but when i say okay to be honest it's a nightmare the patient has a regular blood test to make sure that the blood levels of warfarin are neither too high nor too low the patient must avoid alcohol and there are loads of other drugs that interact with warfare in other words effect warfare and either making warfarin too powerful or not powerful enough so it's a bit of a nightmare warframe and with that i just want to give a contrast to my broad brush stroke that warfarin is a a horrible drug there are patients that need warfarin and that that's fine when it comes to a patient as doctors we choose the best thing for each individual patient and there are some patients that can't use the newer medications for whatever reason in which case we're choosing our water in there because it's the best option for that patient so it definitely does have a good role and is vital for many patients it's just that we do have other better medications where they can be used so one of those better medications and the newer drugs is called a noack noac or doak d-o-a-c these are tablets like warframe but they have one huge advantage you don't have to have regular blood tests they're also more consistent in many ways so we can predict roughly how thin the patient's blood will be without the regular blood tests and it it gives a patient more freedom for their life so you can eat a diet without worrying about interacting with you know your medication in terms of the way it will with warfarin no axe life is easier i think yeah they're a really great advance so our patient with atrial fibrillation um or most patients with atrial fibrillation will end up on a drug to control the heart rate and also a drug to thin the blood and if we can do that we can in most of them prevent them from having a stroke which is a good idea hence why as andy said at the start there so many patients may have atrial fibrillation and not know about it so what's one of the things that a patient might experience having atrial fibrillation that might be the reason for them to come and talk to us good question um like you say often they don't know and it's something a doctor may pick up on a routine examination but if they do have a symptom it could be palpitations that's when they feel their heart rate and they may even feel it being fast and irregular and tell you so they may be short of breath though that's unusual unless the heart rate is very fast or they may just feel generally weak and not right and i think that gives an idea about how vague some of these things can be but even the palpitations we've all got our hearts beating away in our chest but we're not aware of that fact if i blast up the hill here at the medical school i'm going to be aware of my heart beating my chest and that's fine but if you're sat at rest and you can feel your heart in your chest that might be a good reason to have a chat to somebody one of my concerns about covid and when this covered world is most of our appointments are now virtual in other words on the telephone or sometimes on a video and it does concern me that doctors like you and me are not examining the patients as much as we used to because sometimes things like af are picked up on routine examination and i expect you pick that up many times in your general practice you're absolutely correct with that and that's why i say we need to speak to you we need to hear from you there's lots of things that we will pick up but at the moment if there is something unusual if there's something that doesn't feel right don't sit on it speak to your doctors yes we've got a lot of telephone triage we've got a lot of viewing people but the practices are still open and if needed we will see you and we will put a hand on your arm we'll check your pulse we'll listen to your chest we will care for you but we can't do it if we don't know that you've got a problem absolutely and i think the public should know that hospital doctors like myself gps like you are going to work we are seeing patients yes there are small risks to us but we're using ppe and other things to reduce the risk of kovi but we are still there and it's very important the public come forward if they have a complaint i think they might have atrial fibrillation or in fact anything well i think that's probably a good point to move from atrial fibrillation because we're going into a bigger c covid which i think will probably a video all on its own so what else have we got on the list so next on my list is something slightly painful painful uh in many ways called abg or arterial blood gas these were the bane of my life as a junior doctor not because i'm not good at them i was fabulous i just don't like causing pain to people yeah uh pain is a strange thing we don't really understand pain we've all had pain we've seen patients with pain we know it's not nice but one thing as a doctor you don't want to do is cause pain and unfortunately uh when one does an abg as you've done in the past and i've done a few well a few thousand um you do cause pain and maybe we'll talk about in a minute why they cause pain but first of all let's talk a bit about what an abg is an arterial blood gas so this is when a doctor like myself or yourself or a nurse takes a sample of blood from an artery now most blood is taken from a vein and i expect you do that don't you james yeah and i still do that when needed in the practice as even as a doctor i think it's important to keep my skills up and it's actually nice to be able to do something there and then for the patient but i won't be doing an abg in the practice because it's quite different so when james in his general practice takes a normal blood sample it's from a vein usually in this area which doctors call the anti-cubital fossa or elbow and he will take blood quite simply with little pain to yourself the patient he will not do an arterial blood sample and that is usually done in hospital by somebody like me or one of my many hundreds of juniors because i haven't done one for 20 years and we take this from an artery here called the radial artery ouch and i think that ouch is probably for two reasons as we say going into a vein doesn't hurt particularly there's a small scratch yes but the veins are relatively thin whereas the arteries have got a much thicker wall so piercing the needle through is much more painful but because the um the artery there is sitting so close to the bone it's not unusual to actually go into the artery through the artery and scratch the bone on the other side whereas that's not going to happen when we're doing a venous blood sample instead sadly i've done that many times to a patient and i don't like doing it but you certainly learn a few new swear words when you do that to a patient anyway but something so painful why you know why would we do this is it really that important well yes it is when either a patient is obviously extremely unwell or you think they might be extremely unwell one way to confirm that impression is to do an abg and that gives you three important pieces of information and they are the level of oxygen in the blood the level of carbon dioxide and the ph that's the mark of acidity of the blood those three things really tell you a lot about the patient how unwell they are other things also come out of it like the amount of glucose and something called lactate in the blood something called potassium which is a mineral in the blood but it's primarily the oxygen the carbon dioxide and the ph so what do you do well you get a little kit uh you attach a sharp needle to a syringe a small syringe you ask the patient to do that you may even have a nurse to hold the patient's hand down and then you put the needle in there um now because of the pressure of the blood in the artery you actually rarely need to suck blood out it actually forces uh itself out into the syringe then comes the hard bit which is removing it and then stopping the bleeding where the needle went in so you need to be quite quick and put some more dressing and at this point it's helpful to have an assistant who can put their finger on the dressing so we've all had blood samples taken and frequently we'll get a bruise under the skin that's simply because blood has leaked into that area it's called extraversation but we can prevent that when i'm doing a blood test myself on patients at the practice as soon as i remove the needle i make sure they press down as hard and as long as they can to reduce the chance of getting a bruise and that's just as andy was saying after the abg has been taken by putting pressure on there we're hopefully going to reduce the chance of getting that painful bruise there as well so what do you do next you take your sample away to a machine an abg machine which hopefully is nearby though i must admit i have worked in hospitals when it's another building you have to run across the car park in the snow with your syringe to put it into a machine in another building but fortunately uh that doesn't happen very much in the modern age um and then you put the sample of blood into the machine wait a few seconds and then you get a readout usually in the form of a small bit of paper telling you the patient's oxygen carbon dioxide ph and other things so that's what it's all about when do we do them well basically when a patient is very sick um you wouldn't normally have an arterial blood gas but it's a very good test what i call a trouble up meal test whereby if you think a patient is definitely very sick or you think a patient might be very sick but you don't know really what's wrong with them it's a very good test to start with because if the oxygen levels are down or the co2 levels are up or the ph the acidity of the blood is down the ph down means that the blood is acidic that's a sign of very bad ill health i mentioned earlier the thing called a lactate that is an extremely good sign of ill health and if that significantly raised the patients in serious trouble and as a junior doctor you would know to call the cavalry at that point and that's why we often find the abg machine in three places in the hospital on the surgical admission ward in the a e department and an itu because that's where we've got the sickest patients so i think that's about it for abg's we probably haven't got time today to go into the nuances of what you do if the oxygen is down or the co2 is up but i think you get the general picture of what it's all about okay so we've got atrial fibrillation we've got the slightly squeeze inducing abg what else is on our list so the next one um is something i feel quite passionate about and that's an adr an adverse drug reaction it's not just a side effect it is it's kind of fancy name for a side effect of a drug and it's if you like the technical doctor's name um and if you remember from your hippocratic oath that you took in the uh fifth century bc i've not got that much grey uh you will remember something about do no harm and unfortunately back in the 5th century bc in athens and now there's a very dangerous thing that a doctor has in the armory and it's this and we use pens hopefully with clear writing utter rubbish last air medical school congratulations here's your graduation lump hammers to the fingers none of us can write that's why we type everything now it's a lot safer than we started typing if only we could spell anyway so this is a very dangerous thing and why in your hippocratic oath you said do no harm and that's the problem with many drugs that are used in western medicine both in an acute setting when a patient is very ill on a general practice setting that they really all have risks as well as benefits so that's what an adr it's an unpredicted or sometimes predicted adverse in other words abnormal drug reaction now you say that about having a benefit and a disadvantage i'm sure the one that everyone at home is used to is vomiting and diarrhea after you've had an antibiotic we've given you that antibiotic to try and clear up an infected cut or perhaps dealing with a chest infection but we've given you new symptoms as a result of the positive effect that that's having so with the antibiotic we're killing the bacteria but probably also decimating your good bacteria in the gut which is why you end up with a bit of a dicky tummy there's an adverse drug reaction that i've seen several times when i was a junior doctor and a middle grade doctor long ago and it relates to a very common drug which many of you would have taken called paracetamol as you know paracetamol is a very good drug most of you will have taken it at some point in your lives it's a very commonly used drug you use it for headaches fevers flu-like illnesses hangovers you've never had one of those james um and also you probably would have given it to your children to help them sleep at night if they've got a fever for example in the form of calpol but the big butt is in overdosage and you may not deliberately take an overdose it can kill you it's actually quite shocking how easy it is to overdose with paracetamol so the usual dose is two tablets four times a day so eight in total i personally have had a patient who has died from taking 10 tablets of paracetamol just that small difference now admittedly they'd done 10 a day for a few weeks but nevertheless most people would think that's not a big difference but paracetamol the dose is very specific so my story about paracetamol and it's quite a sad one it's about a young woman in her late teens that i looked after some years ago who had an argument with her boyfriend now we all have arguments with our boyfriends girlfriends husbands and wives but it's important not to take paracetamol she didn't really want to die what she wanted to do was to get her boyfriend back so she took quote too many paracetamol but it wasn't that too many it was only 20-ish tablets in a 24-hour period and she woke up a week later having had a liver transplant so that's pretty devastating uh for a young woman in fact for a person of any age the story goes on um she got out of hospital she was put on various drugs including a drug called cyclosporine to prevent her rejecting the liver um and then a couple of years later went into kidney failure had dialysis treatment and i looked after her when she'd had a kidney transplant so this young woman made a mistake several years earlier in her life and ended up with initially a liver transplant secondary to a paracetamol overdose and a kidney transplant secondary to cytosporine so we've actually got the two adrs there we've got the paracetamol with its liver toxicity and the cyclosporine with the renal toxicity absolutely now most adrs are not that bad but it's very important for all the doctors and nurses out there to report adrs and in the uk we have a system which used to be called the yellow form and there's a book that most doctors carry or have near to them in some form at all times called the bnf the british national formerly and this is a list of all drugs you can prescribe in the uk and at the back of the book there is a yellow form which you can rip out and send to the authorities it's important both to record new side effects or known side effects and send that form off there's also a fancy cyber way of doing i'm sure a youngster like you would prefer to do but it doesn't really matter whether it's a paper form that you send off or a cyber form that you send in an email or whatever it's important that we all do it that's how the authorities and drug companies learn about the side effects of drugs and part of that is almost mathematical so there's a medication called ramipril it's a very good antihypertensive medication anti-blood pressure medication and it also has some kidney benefits where it protects from the kidney this is a great medication when it came out everybody loved it but some people subsequently developed a cough but it would happen months and months later after that medication was initiated and it was only through the yellow card system where people reporting you know this patient is on ramapan and has a cough that they are actually to make the connection that it was the ramipril causing the cough and i have seen this in the last couple of months i've had a gentleman who has had a cough for about nine months and we've not been able to find a cause from it but before he came to our surgery he was started about 12 months ago on ramipril so we've ruled out all the other possible causes we've stopped the ramapril and his cough has improved so that yellow card system has been vital to pinning down side effects that aren't often obvious that's probably enough on adrs i think we should move on to our final a which is my favorite one auto immune disease before we can understand autoimmune disease we need to pause and think about what the immune system is so the immune system is probably the most important bit of the body and you have to have great faith in it because you can't see it you can't touch it you can't feel it but it saves your life every minute of every day now we've all had sore throats and we get lumps in the neck these are glands or nodes and they go down when the sore throats better we also have these glands or nodes in our armpits and in our groins we also have a liver over here a spleen and in the blood there's an army of white blood cells which are like the soldiers of the immune system and their guns are called antibodies and cytokines and things like that and that immune system exists in us all works 24 hours a day and protects you against foreign invaders those foreign invaders could be for example cancer cells they could be infections like covid or they could be foreign bodies like a splinter a piece of metal or thorn in your finger for example either way those things are not welcome in your body and your body has to try to get rid of them so one of the ways i've thought about the lymph nodes or the the glands as you say is as you say they're trying to your immune system is trying to repel a foreign invader so they send the soldiers the white blood cells out but they need barracks which is what the lymph nodes essentially work as like a staging ground to go forwards so we can find that patients will have lymph nodes in certain areas which we can then work backwards to try and say well hold on do they have a problem in this region of the body absolutely now most of the time as i say the immune system is a good thing but it can turn on the human body and what's interesting about the immune system is actually why it doesn't how it knows not to attack your nose or my foot but that's a story for another day we actually don't really understand how it knows what is you and what is not you what we do know is the immune system can go wonky and become overactive and start sending its soldiers to send antibodies to other bits of the ball of the normal body in other words to attack your normal body now that sounds you know major league medicine but actually autoimmune diseases are much much more common than people think think of people who you know yourself who have had eczema or allergies or asthma all of these are one form or another of an autoimmune disease so they can be very very common they're always annoying or unpleasant but as we'll see now there can be some devastating autoimmune diseases absolutely so you can have a mild autoimmune disease like you say eczema asthma psoriasis these are quite easy to treat or may not need any treatment but autoimmune disease can be a lot more serious you can have autoimmune disease of the thyroid gland of the pancreas land which is here and that causes diabetes of the joints such as rheumatoid arthritis of the bowel causing ulcerative colitis and crohn's disease crohn's disease is a really horrible disease i wouldn't wish that on anybody and you can also have autoimmune disease of my favorite organ the kidney okay now you say about autoimmune conditions of the kidney i mean that that's some major league medicine there um can you give us any simple examples of the autoimmune disease of the kidney simple i'm not simple normally goes with kidney that goes with kidney there are some very rare diseases um with very long names like vagueness granulomatosis and polyarteritis nedosa which fortunately you're very unlikely to see we see very rarely there are some slightly more common ones one called lupus that you may have heard of i think we've all watched house but we know that lupus is a bad diagnosis sorry i couldn't resist lupus is one of my favorite diagnosis actually and in fact uh when there was a review in other words a show done by the medical students they were very naughty and did a sketch on one of my wardrobes apparently they said i was a bit like house and i used to diagnose lupus apparently on every single patient on every single ward round even if they had a sprained ankle or an ingrowing toenail but that's uh another story back to autoimmune disease so the common aspects to these rare autoimmunities of the kidney is that the immune system is overactive and it sends antibodies cytokines and other guns if you like guns and bullets to the small blood vessels inside the kidney and that can cause either short-term kidney failure long-term kidney failure or another rare kidney disease called nephrotic syndrome okay so in terms of those major league renal issues is that something that patients can recover from yes and no some of them are very serious indeed and we don't really have any effective treatments for and unfortunately the patients end up on long-term dialysis and they need a transplant but there is a subgroup that are very treatable and if you get to the patient early if you make the diagnosis early if you use strong drugs like cyclophosphamide that's a drug with a very long name azathioprine mycophenolate and a steroid called penicillin you can actually cure the patient of the autoimmune disease now one of the things that you said uh early on about the immune system using antibodies and bullets we do have new and developing drugs that we're using against autoimmune diseases using those antibodies you know what what are those are you working with yes we use a few of those drugs they're not used as commonly in kidney medicine they're used more commonly in problems of the gut and bowel for example osteocolitis crohn's disease and in rheumatoid arthritis for example and they're generally known as the biological agents and most of those drugs have to be given intermittently like once a week or once a month for example we use them a bit in my kidney world but we're not in in many patients okay so i think that you know we appreciate from what you're saying that the autoimmune diseases are of complete range and as with all of these things and i i want to have this as an underlying message here we're talking today about this you know the approach the abc of the nhs because we want to help you guys get more out of your nhs if you understand about the things that we do and you understand some of the words that we're using perhaps formal words you're more likely to be able to say hold on that applies to me i need help with that so if you do have issues with you know the simple autoimmune diseases eczema asthma psoriasis and things like that don't sit at home and suffer with them saying it's just eczema talk to us we can help so i think that's probably a good place to wrap up this the first letter of our 8 abc on the nhs please give us some information on how this you know you'd like this series to evolve if you'd like this series to carry on for that matter you know what's been useful to you what can we do to improve it and well essentially you know give us other things that you might want us to cover we've got our lists here but ultimately we're doing these videos for yourselves at home well on that thank you andy for giving us this time today and hopefully we'll see you on the next one thank you very much james take care everybody