Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good evening everybody. Uh It's great day everyone joining on um live with us tonight on Middle Primary Care Network. Um Apologies for the slightly delayed start. We were fighting some gremlins in the system. Um But we're, we're good to go now. We're good to go. We're live and it's great to be with you. Uh It's my absolute pleasure to introduce a colleague I worked with last year, an expert in palliative care. Doctor Jane mccauley who is a consultant in palliative care medicine in the Southern Trust in Northern Ireland. And as always, thank you so much for given your time to take our session tonight with registrations as always from right across the world and uh more people that are on the call be catching up with us after. Um I have popped a little message in the chat there just as a way of introduction. I direct you towards the metal uh where you can register for upcoming events, get your certificates for tonight and for future events and see what we have coming up in the schedule schedule. Um As usual, we will run the session fairly uninterrupted um for the first part. Um but I will be keeping an eye on the chat. So please submit any question that you have as we go through and I will corral them off to the side and we can have some discussion towards the end of this evening's talk without any further ado I am going to pass over to Doctor mcauley. Doctor mcauley. I am going to switch my camera and my golf just as it's not distracting, but I am here in the background and watching and listening. Thank you so much. So good evening, as I was saying, my name is Doctor Jane mcauley. I'm a palliative medicine consultant in the Southern Trust in Northern Ireland. And I hope the discussion uh opportunity for question answers and the, the slides today are some, some use to you. So today I'm going to look at palliative care emergencies. So what are we thinking about emergencies in palliative care? It's not sometimes not something you associate with palliative care. So we're gonna think what it, what it could they be, how do you recognize them? And then from a primary care's perspective, what action are you needing to take? So, the thing emergencies I'm talking about today are spinal cord compression, superior vena caval obstruction, major hemorrhage, and then we're gonna touch on hypercalcemia. Although it's not a, I suppose a classical emergency. It's something that if we miss it can, if it's allowed to go really, really high, turn into emergency. So it's something just even to raise the awareness and know the initial management for so that we can prevent it becoming uh an acute emergency. So spinal cord compression going to look at first and you, you know, the the spinal cord runs from the cervical right down to L1 L2 and then it splits into those lower motor neurons for forming the cauda equina. Thinking about the incident. It's not a rare thing, That's the important one and that's why I've put it first. Uh So if this is the only one that you take home today, this is the important one. It's about 5% of all cancer patients and very much the figures for cancer patients, maybe a third of all people will develop cancer at some point in the western world. Um 5% of that is not a small number who you should be highly suspicious of and have a real index of monitoring for are those patients that are known to have vertebral metastases. So, those patients are particularly at risk, you see a doubling of the incidence to 10% and the most common malignant causes are no big surprise. It's the ones that commonly metastasize to bone. So, breast prostate cancer, lung cancer, renal cell carcinoma, myeloma, and lymphoma. So, these are what patients with these cancers, if they're complaining of back pain or symptoms of weakness. These are patients, you should always be thinking spinal cord compression until it's ruled out thinking of a little bit of the pathophysiology, what's going on, what's causing the compression on the cord, the cord runs through a very narrow canal. So it doesn't really take much for pressure to, to cause the, the impingement on the cord. So it can purely even just be edema, swelling of the, the tissues around. Um from the tumor pressing in can be ischemia. There's quite a rich plexus of blood vessels. And if that's impaired by the tumor growing and interrupting the blood supply, you can have infarction of the cord or ischemia of the cord and then there can be that pressure. So if you get collapse of the vertebra, uh some of the of the bone is propelled back into the spinal cord or even um instability of the of the vertebral column. You can see how you spinal cord compression could happen. Also thinking about the sights, I think there's something that we commonly did when I was a houseman. Uh whenever we were thinking about things coqui was the one that always stuck in our minds. And anybody come in and that we were thinking spinal cord compression, we did a lumbar X ray. Well, that really rose out very little. Um the commonest site as you can see from the slide is thoracic, 70% of patients with spinal cord compression, the site will be thoracic but actually 20% will have multiple sites at the time of presentation. And that can give you quite a mixed and quite confusing uh clinical picture. So always having that index of suspicion and trying to tease out what's going on. So an X ray, a plain film X ray is never going to rule this out. Uh and actually, it's quite often the thoracic spine, we should be thinking of not the lumbar spine, early diagnosis is crucial to prognosis. So really what I'm going to be referring to throughout the majority of this bit of the talk will be the nice guidance for treating and managing malignant spinal cord compression. And it was updated in 2023. So we're going to, I'm using that updated guidance and they're very much focused on that early diagnosis. So they're saying even with the the previous guidance being in place for for over a decade, still patients are experiencing significant delays from the time when they first developed symptoms through referral. So by the time they're presenting maybe to ed uh to the emergency department, they, when you ask in the history, they have had symptoms that were clearly them developing the the spinal cord compression maybe weeks, months beforehand. Uh and it's trying to pick that up early to try and maintain neurological function for nearly half of the people with malignant spinal cord compression are unable to walk at the time of diagnosis. So there's clearly a window of opportunity that has been missed. So early detection, early treatment and care can actually reduce developing an avoidable disability or even premature death. So the very much the focus is on high index of suspicion, both for the clinicians but obviously for the patients because if they don't present to the clinician, you can do very little. Um it's actually them being aware of the risk and knowing when to present and what symptoms that they should be watching out for. So this is the guidance. You'll be glad that I'm not going to be reading this slide, but it's just a signpost you to that guidance, you Google it, it will pop up and you can see that. And I think also, er, you'll have copies of the slides so you can, uh, you can actually click on the, on the, the slide and, and, and look at it yourself. Um, but actually I would just signpost you to the guidelines online because that's is, but the rest of my slides are really uh based on this. So hopefully we'll be able to clarify the key points. So, one of the box, the, the first box in that table, we're very much looking at the symptoms and signs of spinal cord compression. So the symptoms and signs that you're wanting your junior doctors to be looking out for an ed and yourselves looking out for in primary care. So somebody's presenting or even symptoms that you're going to discuss with a patient who's worried that uh maybe about uh they've now been diagnosed with bone metastases. And you're saying, well, actually, you know, you need to come back to me if the this this these things happen, come back early or present if it's over a weekend to an ed department for investigation. So key things, any bladder are bile dysfunction. This can be an early sign um with claudia coa much much later sign. If it's higher up in the spinal cord, any gait disturbance or difficulty walking, that can be an early sign of loss of power. They just feel things are off. They're just not, you know, they don't feel they've got the same strength and sometimes the patient will be aware of that change before you can even pick it up. Clinically. We certainly remember a patient who was saying my knee feels weak, my knee feels weak, we could find nothing. Uh And 2012 hours later, he had uh the classical signs of, of, of of spinal cord compression, limb weakness. Again, you're trying to pick things up before that. But certainly, if they're presenting with limb weakness, then you're going to be picking that up and, and investigating that very urgently, any neurological signs of spinal cord or ca equina, sorry, that's spelled wrong. Uh And then any numbness, parsia, sensory loss in the lower limbs or radicular pain. So that pain in the back going around in a radicular pattern, that's suggesting that there is compression of the and affecting some of the nerves in the spine. Clinical features, these very much depend on the level that the cord is going to is being impacted on being compressed. Obviously, if you're having multiple levels and some are above L1 and some below, you can see where you get this mixed picture. But classically, if the lesion that's causing the cord compression is above the lumbar spine, the first lumbar spine, you're going to get the upper motor in your own signs, back pain present in 90%. So that is a very good clue. And if they're describing it is increased on coughing or they're able to really localize it and describe it in that radiation round in a radicular pattern, you should also have muscle weakness, sensory loss, maybe increased tone and then you're checking the reflexes with the upper motor neurone pattern. So, brisk reflexes, the sphincter dysfunction is late. Sometimes we learn all about caudal and we don't actually learn about the commoner presentation, which is the thoracic spine, spinal cord compression. Uh if someone is affected at the thoracic spine and is presenting with as complaining of sphincter dysfunction, they've really lost most of their power and off their feet and in a very difficult situation. So, the sphincter dysfunction is very late in an upper motor neurone presentation of your spinal cord compression. If the lesion is below L1 into the cao you're going to get those lower motor neuron signs. So they complain more of classical sciatic pain going down the back of the leg saddle anesthesia. They may not complain of this, but this may be something you examine and test for. So that checking the sensation around the anus and onto the, the cheeks, reduced tone. Again, you're maybe having to check anal tone and, and actually getting them to, uh, and make sure you're chaperoned when you're doing that, looking at the planters, they can be absent or downgoing and something that can be missed can be urinary retention. This certainly is something I've experienced where I was meeting a patient for the first time. And we looked at the signs of you've, you've got um called her, she clinically had lost power. It was all in keeping with that. And when we went back to the notes, she had been catheterized about five days earlier because uh she'd gone into urinary retention and that hadn't been noticed or picked up. The nursing staff had just popped the catheter in. Nobody really had picked up. This was a change and she hadn't complained of any other signs at that point. And then it was five days later that she began to complain of the, of the weakness and it was all there. So just having that index of suspicion, particularly in a patient with cancer who has bone metastases. Nice guidance. So what is it saying, saying to treat it as an emergency? And if you're in uh England and Wales you will have these malignant spinal cord coordinators. Uh, we don't actually have that in Northern Ireland and you may well not have that in your own, uh, part of, in your own country. But if you do have that person coordinator, that's the person you're going to contact, to organize all of the, the care in, in my, uh, place of work. I'm usually speaking to the oncology registrar on call in the cancer center that's closest to us. So you're really wanting uh maybe uh Australia or um America candidate, you might actually be speaking to uh surgical teams, spinal surgical team. So know your own pathway is what I'm saying, know your own er, services and know what you find that out. So, um if you're in primary care, you're going to have to treat that as an emergency and get these people into a acute hospital setting where they can get rapid investigation and their case discussed uh by the key people for that. What you should be thinking of is, uh, is if there's any signs of spinal instability, you should be um trying to have, keep them as immobile as possible, so they don't cause more damage. So that could be bed rest log rolling, er, until the investigations can be happening. What you can do is start uh dexamethasone 16 mg daily. And you're saying, why would I do that? Going back to the pathophysiology where we talked about edema uh and swelling in the tissue, in the normal tissues causing increased pressure on the spinal cord. The high dose steroids can reduce some of that swelling. And by a little bit of time, a little bit, take a little bit of pressure. Now, it obviously won't have any impact on the tumor or any bone that has maybe uh moved or changed. If it's diagnosed lymphoma, it might have an impact. Uh but it's mainly the swelling in the narrow tissues, but sometimes that is enough, uh, just to buy a little bit of time cause once the nerve is permanently damaged, it's permanently damaged, you want to assess pain and insurance, analgesia is prescribed, that's key to getting the person to the, to the right place. They won't be able to, uh, lie down an MRI scanner or even, you know, transfer into, into that setting if they're too sore. So you need to get them well, pain controlled and at avail of the, of the proper investigations. And certainly the nice guidance is very much saying, carry out your MRI with our, of having that clinical suspicion. If MRI is contraindicated, they have a pacemaker or a metal in their eye or something like that, then you're into to speak, speaking, uh, the team will speak to radiology and it might well be act up there, I think. And this is just a picture of an MRI just to let you see what that would look like. Obviously, you got multiple levels. It's imaging the vertebral column really well. You can see the cord, you can see the fluid around it, it's bright white and you can see the two areas where it's being impinged on. And that obviously would be a multiple level and would need treatment quite urgently. Spinal stability was a big bit in the uh the uh new information, I suppose in the this new nice guidance, giving us a bit more detail about that because it was mentioned in the first one. But this certainly helped. I thought this was an improvement in, in this current version. Uh it talked about considering CT so yes, you're going to do an MRI uh to get the diagnosis. But your spinal team surgeons might want a CT to assess the spinal stability if they're planning surgery. So to actually look at the building blocks and helps them with their surgeries, that might be something they might want also is we can use a score and that's in the guidance to work out because when you're, if you're speaking, uh if the team are speaking to er surgeons, they will be asking for clinical information. And this validated score means you're actually talking in the one language. Uh And it's part of that holistic clinical assessment. So that's very important to have a scoring system and that's in the guidance. So you can look that up if you're interested immobilizing the patient. So if you're having to get a patient to hospital. How are you going to get that done in a way that they don't worsen the spinal cord compression, particularly if they've got weakness already and their signs and symptoms in keeping with instability and you're needing that specialist advice. So it's very much, the guidance is very strong on that if they've got severe to moderate pain on movement and you're really feeling that they're appropriate for them to be being investigated urgently making sure that, that you're immobilizing them, log rolling them bed rest all of those things to try and reduce the impact until you can get treatment on board. Again, this is just signposting you to this. You can look at it on the slides later on if you want or Google the, the nice guidance and this is the, the table giving you a wee bit more detail about the radiotherapy and the invasive interventions that would be planned. So patients when you're discussing them, uh when they've had their MRI scan back and what the team would be discussing whether surgery is appropriate or suitable. And if it's not, would they be for radiotherapy? And if they're not for radiotherapy, then how are we going to manage things? Maybe just even with spinal supports and things like that. So all of these options need to be considered. And as you imagine needs a multi professional, multidisciplinary team to manage something as complicated as this, how things are managed. Certainly in my setting, radiotherapy would still be what the majority of patients receive the very, uh, advanced cancer usually and they may not fit for, for surgery. We do aim to deliver that within 24 hours of the diagnosis being made. And certainly, um, we're trying to prevent power being lost if they have lost power already, all power has been lost, uh, for more than two weeks and they're pain free. The decision might be made that radiotherapy is not going to be of clinical benefit or if the person is too frail, uh they're not going to survive long enough, but the majority of patients will proceed for radiotherapy even just to improve the pain. As you're probably aware, radiotherapy is a good uh treatment for bone pain from metastatic disease. It gets for improvement with about 80% of patients will get a good benefit from radiotherapy for pain relief alone, surgical de decompression. If someone has better prognosis, very limited stage of disease, maybe someone that doesn't have a diagnosis that might, it might be appropriate to decompress and get histology at the same time, if they feel that the prognosis might be well over three months, uh if they still have function that that is, that is your feeling are going to save that function and they're fit and willing for surgery again, involving the patient in the conversation. They may not want to proceed with that. If radiotherapy surgical decompression isn't an option. And they're having spinal instability, pain on movement. Uh You can consider things like the halo vest which provides external spinal support as a palliative care consultant, you would expect me to be more focusing on the symptom management. So certainly I feel that's really equally important to all of the the measures we've been discussing to date. And pain management is really crucial thinking about not just about uh painkillers, analgesics, but also things like bisphosphonates, particularly in breast cancer and myeloma. They can strengthen the bones, reduce pain, reduce fracture risk. And tou is may be a a newer agent for solid tumors with bone pain, but not, not prostate cancer. Thinking about bowel management, this spinal cord compression, if it's not picked up early enough, uh it really is a spinal insult and your bowel management really depends on the level of the involvement. So if it's above L1, the local sacral reflex is preserved. So you will have that local reflex. So you're really aiming to keep the stool quite soft, to firm and then having regular pr intervention to trigger that local reflex to bring about the bowels moving. If it's below that, that's a really difficult situation to manage because you, you have an atonic bile, you've lost that local reflex and sometimes a manual vaccination may be the necessary approach to that. And that's a very tricky difficult thing for a patient to manage with, with dignity. And that's something that you really are trying to prevent. So a lot of the nice guides are trying to prevent being in this situation. And as you can imagine, if the person is left with quite a lot of disability, that psychological support is really key. Somebody's been walking about really fit well driving and now they have lost power. They may be having trouble with bladder and bowel function. There's a lot of psychological support that's needed to provide to help them with that situation. Rehabilitation. So very much involving the multidisciplinary team, the physiotherapist and the occupational therapist. That's something that would be very much key to, to rehabilitation, key role in trying to maximize potential function and independence and in our team as well. The social worker maybe looking at care at home, thinking about maybe respite if the family have taken on a significant amount of the care, if there are periods of time that you can offer respite so that they can go in somewhere and to allow the family to do maybe important things or just get a wee bit of rest from the care and psychological support as well for the patient and the family. Why is it important to involve your physiotherapist and your occupational therapist? Very much. The team uh in my hospital would be saying that, you know, they want to be looking if somebody is needing to manage stairs, if they're needing mobility assessments, thinking about the transfers, even continence issues or pressure care they really should be involved and they may actually be the the person that's picked up this diagnosis. So maybe they've been asked to see somebody in the community because the person is struggling with mobility. So actually, if, if they're uh they may be the first professional to actually think this is what's going on a and actually flagging that as a concern. I think this person might be developing cord compression, social worker, Again, they may be the person that uh certainly our team, we have a community social worker and they may well be being asked to see a patient uh because they're not able to manage their activities of daily living and they actually have to have an index of suspicion as well and be aware that that might be something that needs to be seen urgently and referred on to their general practitioner being also a resource for the family. If they're needing increased cars at home to provide support or maybe increased to already a care package that is already there. If that, if the person can't be managed at home, it might be looking at a permanent placement, be that in a nursing home or a different care facility and also the really crucial support uh trying to help people adjust to the major changes and losses that they have. It might be practical, it might be financial. Um And actually looking at some pre bereavement work is a key, a key role as well. And what's the outcome of all the crucial even with the best will in the world. If someone is not walking at the time of diagnosis, they may well not improve. 67% of those patients will not see a functional improvement even with the best treatment. While if this can be picked up early, 81% of those walking at the time of diagnosis will be walking at the time of discharge. So you can see the huge difference that uh picking it up early while they still have significant function. Loss of sphincter control is a very bad prognostic indicator. And place of care obviously is crucial when the acute care is is is over home is obviously where the patient wants to be for as long as possible. And that's why it's really key to use as much function uh to stabilize and use what function they have to keep them as independent as possible. But sometimes nursing home replacement is necessary if they cannot be managed. Uh they don't have care around the clock to manage them uh safely hospice. We are fortunate enough to have inpatient hospice facilities. Uh and that might be a place that someone may go, particularly if they've got specialist physical or psychological needs. This is really a major life change with a very poor prognosis so that it's really crucial that there's good communication between the inpatient acute setting and the primary care setting about what has happened and what the person's needs are at the time of discharge and median survival. Again, median survival, obviously, with a range of diagnoses, you're gonna have maybe a significant range, but 7 to 10 months would be the median and less than a third are alive at a year. So this is very, very much advanced disease territory. So you're thinking primary care, I'm a GPI don't organize MRI scans or I don't do all of this. So why do I need to know about this? Why are you telling me about this or from the nice guidance perspective, you're very much the most important person in this in this story because having that high index of suspicion, supporting the patient um with having also a high index of suspicion and reporting any symptoms and clinically assessing them urgently treating them as urgent. So phone in and say I'm actually noticing this these weakness or bile symptoms, taking those seriously and clinically assessing them, particularly if there's spinal instability symptoms or neurological signs. And if they're positive, getting the steroids started early buying as much time as possible treating pain, so they can manage to move to hospital and maybe get into for urgent investigation and then arranging that urgent admission through in my situation. It would be uh for investigation, obviously knowing your own pathway in whichever country you're in is really really crucial. And actually suggesting to, to the people transferring the person that spinal precautions may be needed because obviously you don't want someone in the transfer to further acute investigation for, for that to worsen and actually them to, to become seriously more impaired. I'm gonna move on to uh S VC obstructions which appears by vena cava obstruction. And we'll take questions on the end if that's ok. So super venous caval obstruction, 50% of uh will be the first presentation of an actual uh cancer diagnosis etiology. When we look at that, no big surprises that the commonest one is lung cancer. So a big lung mass of the apex of the lung where the superior vena cava is, is trying to get into the heart. Uh will obviously, if it becomes big enough cause obstruction and then you get that back pressure in the super vena cava system and they present with, with the classical symptoms and signs. But it's obviously, the prognosis is very different. Uh if someone's diagnosed with a lung cancer and with a lymphoma. So if half of the patients are presenting with no diagnosis, it's really crucial that we get an accurate histological diagnosis prior to treatment. If that's at all possible. Obviously, if you've got a lung cancer, if you've got a lymphoma, one is, has a much better prognosis than the other. And you don't want to miss something like that when you look in the literature, um there are 12% can present with uh a benign. I've never seen anybody present with a goiter or with an aortic aneurysm. Um most patients, it's really something more sinister like lymphoma or lung cancer. And what are you, what symptoms are we looking at in that classical syndrome symptoms? What really come from that back pressure and the tissue is becoming really quite edematous. So shortness of breath because of the tracheal edema, headache because again of cerebral edema, visual changes, dizziness, syncope, they may notice or the family may notice that they've got their face and their eyes actually have got quite puffy and droopy and neck, arm and hand swelling. The signs are in keeping with that. So they may actually have tachypnea. The respiratory rate is up. You can see that there's arm edema, hand edema, periorbital edema. There's a classical dilated collateral superior chest veins. If the obstruction has been there for a couple of days, the body tries to open up all the wee byroads, all the wee small ways back to the heart and these collateral veins try to open up. So it's very much if you're thinking about that, open up the shirt and have a look at the chest cyanosis, nonpulsatile, distension of the neck veins makes sense. But it's something that you never see because if their face is so puffy, their neck is so puffy, you're rarely seeing the JVP to actually know whether it's pulsatile or not. And this is just a picture of letting you see the collateral circulation. Usually the obstruction has to be there for at least a, a day or so for this to start to open. But these are these tiny little twisty veins that are not used to the traffic that they're getting. But the body is trying to get the blood back to the heart investigations, simple things like a chest X ray ct scan. And if this is a presentation, no diagnosis already, you're going to do specialist referral. Um they will need tissue diagnosis. And this is a picture of the chest X ray showing a tumor of the lung, which really you can understand why superior this patient would present with superior vena caval obstruction. And this is the chest X ray of the gentleman with the collateral veins that we've seen just in the for the previous slide. So how are you going to manage that very much? It's the symptomatic management while all of the other things are happening? So you want to manage them in an upright position. So they feel more comfortable, oxygen might be required. And again, if the analgesia and angiolytic might be helpful if they're sore. Obviously, you're going to go with angiolytic. If they're very anxious, distressed, uh analgesia like low dose opioids and benzodiazepines for angiolytic may be helpful. There's no huge evidence for dexamethasone, but it's something that we still do. We'll go with high dose dexamethasone. Again, try to reduce any swelling around the presumed tumor and allow any flow through and you're going to seek an oncology opinion, uh would radiotherapy or chemotherapy be an option? And again, you need to be in a situation where you're able to tell them histology for that to be, to be possible. Certainly, in your uh interventional radiology, if that is an option for stenting, that can provide quite rapid relief of the symptoms while you're getting what the histology. So it depends what's available to you in your area, what may happen for the patient. And this is just a picture of a quite a long stent that has been passed into the super A CAVA to open up on obstruction. So what does that mean for me, for me as a general practitioner, being aware of what the clinical signs and symptoms are of the superior vena cava and being able to clinically assess those and then describe them to whoever you're referring that patient to. If it's positive, you can start the steroids, dexamethasone, 16 mg, tries to reduce any swelling and, and allow the flow through treating any symptoms. So you can, if they're very short of breath, very anxious, you certainly can get some analgesia and some angiolytic on board and then arranging that urgent admission for investigation if that's appropriate. Moving on to the palliative management of major hemorrhage in advanced cancer. That's something that has become uh more topical in. Certainly, the UK and most trusts will have a policy in place for managing uh a terminal hemorrhage. Where palliative management is appropriate situations such as a tumor eroding into the carotid artery or somebody is going to bleed out very, very quickly or they can be bleeding from the tumor, something very vascular like a sarcoma or a gastric tumor can bleed very briskly and someone can die very, very quickly. And all of this can be exacerbated by a bleeding tendency. Say someone has low platelets, uh they have invasion of the bone marrow, they have low platelet count. They have D IC again related to their malignancy. So they've got disseminated uh coagulation. So their bleeding and clotting uh is going on at the same time if they have kidney failure and significant uremia and most patients are on Apixaban, that's rare to find a patient that's not on Apixaban nowadays. Um So thinking about these things, should they or should they not be on? And they on the anticoagulants at this stage, but that certainly can make a small bleed, a major bleed. If it's a nonmajor hemorrhage, you're gonna do your usual things you're going to be thinking of. Is there an oncology or a systematic or a local measure that I can do to control a sort of minor bleed? Might be thinking about maybe palliative radiotherapy depending on where the bleeding is happening. We would sometimes use oral or even IV transam acid to try and stabilize any clots that are formed depending on where it is. You might be using maybe local measures such as adrenaline soaks in the dressings. But we certainly in most of our hospitals in Northern Ireland would have what we call the major hemorrhage uh protocol for the when the patients that are appropriate for the palliative manage of major hemorrhage. So what does that mean for you? I think it's being aware that that the palliative management uh plan may be appropriate for the patient. So it's actually maybe reviewing the notes or discussing with the patient. It's the lead clinician and the multiprofessional team that have been involved in the patient's care that will have with the patient and the family will have had these discussions and hopefully documented this. So is resuscitation and acute active management the most appropriate thing. So if this person bleeds out in the community is a rapid uh urgent admission appropriate for resuscitation and all active intervention, well, then that goes ahead. But if things have been discussed, the patient and the family are aware that actually resuscitation and acute active management is not appropriate for them and that there's a palliative management plan uh in place and that this is uh what the next you guys are talking about. So it's where the team that have been managing the cancer are feeling it's appropriate, the patient and family are feeling appropriate that there's no going to be no urgent drama. It's support in the setting they're in and that does take into account the stage of illness, the treatment options, but particularly treatment, patient choice as well. Ok. How do you prepare for a major hemorrhage? As you would imagine, the sensitive communication with the patient and the family is really crucial. Uh You need to prepare them if this is likely, but you don't want to scare them and disempower them. Uh completely, we could often would liaise with our out of hours services be that primary care. Um be that uh the ad department have, would have that flagged on the electronic system. I asked that's our Northern Ireland ambulance service. So whoever you provides your ambulance service to get to take people urgently to hospital there, that they would have a, a document communicated with them to make them aware that this is what has been decided for this patient equipment. It's really important if you can get that equipment in the house because it's a major hemorrhage is quite a lot of blood volume and how you manage that safely. So having gloves, uh protective equipment, waste bags, dark tws, dark sheets, anything that can sanitize if it does happen and we talk about medication depending on which site is, it's happening. Be it? Buckle Midazolam or Im Midazolam, we would try and have that in the house again. Buckle Midazolam could possibly be used by the family if they're trained. Im Midazolam is obviously only going to be used if there's a healthcare professional present an analgesia may or may not be there uh be appropriate. Again, this is something that you can look at uh on your slides later on if you're looking. But we as part of our protocol did an ABCD uh because we felt that was um something that was useful and with something that would stay in, in the junior doctors minds, the a very much is the awareness, the preparation. So it's engaging in the sensitive discussions with the patient and the family, looking at maybe an advanced care plan and documenting that individualized management plan. So it's there for everyone to see the primary care team can see it your out of hours, your ambulance service can see that prescribing if a crisis dose is appropriate of them, Dazla and making sure the patient and family and everybody knows that that, that that's there and preparing the patient's environment. So dark toils might be the only thing that is useful. Um And having those waste bags that they get if, if uh to dispose of blood stained uh material, we do have uh an information form is uh uh an example of one. and we can fill that in and if that goes to the ambulance service. So they're aware of the patient. If there's nothing else you remember, this is probably the key thing. If you're in this situation, it's very easy to panic, very easy to feel. I must go and find do this, do this, do this if it's a true major hemorrhage from a major blood vessel. That patient has usually seconds. And the only thing that you sometimes can do is be with them, uh be present with them and hold them in a position that is most comfortable for them. So if they're bleeding, they're vomiting or is coming up from the respiratory tract, getting them to the most comfortable position, you can get them into and try and remain as calm as possible. If there's other people there, then getting them over the phone for help and support the family. But if nothing else sticks with you, remembering if you're in that clinical setting, making sure you're there because if you go somewhere, the patient will be gone and they really do need somebody to be present with them. C is for calm and comfort. So calling for help, not leaving the person, but calling for help, trying to comfort them, using the dark tiles or dressings. If they're there, positioning the person in the most appropriate position and obstructions there are needed. If you're a trained healthcare professional, which you obviously are. If it's there in the house, you could give im Midazolam 10 mg every 15 minutes with a maximum of 30 mg. Bucco Midazolam might be present if the patient uh if it's gonna bleed from a situation where the family could use the buckle root and again, 5 to 10 mg to the same dose, the maximum dose and then clinical waste bags for the used uh stain material and D is for the debrief. Again, you're thinking of how are we going to manage the environment, immediate support for the family, immediate support for the professionals, many professionals are present in that something they will remember for their entire professional career and sometimes psychological support and brave counseling if that's available is really, really important where, where time getting short. So I'm just gonna move on to the last piece of the talk, which is malignant hypercalcemia. Again, this is commonly associated with those types of cancer that metastasize to bone. But we have seen hypercalcemia in patients that don't have known bone metastases where the cancer is obviously interacting with the host and the cytokines and maybe producing something that is parathormone like uh and driving a hypercalcemia without uh bone metastases. So it isn't a, it's a very strong association but it's not 100%. So even when somebody doesn't have bone metastases, think hypercalcemia management, it's very much uh similar management as you can manage any hyperosmolar condition. So you're thinking fluid replacement first, the person has got quite dehydrated because the body is trying to get rid of the calcium and it does that by trying to pee it. So they're peeing a lot and they've got can get quite dehydrated if it's not been picked up early, bisphosphonates would be the first line of what we would consider using. Again, caution if they're in renal failure, you might not be able to give it or you might have to adjust which, what drug you use and what dose you use. Don't check the calcium too early. It will sometimes go up before it comes back down and you really shouldn't be retreating, retreating uh before seven days. Uh because the bisphosphonate might still work. We would see resistance relatively commonly, particularly in lung cancer for whatever reason. And you can retreat again, not within the week, a repeat dose of the bisphosphonate. That might be a repeat dose uh at the same dose or even a higher dose. We would really discuss that with pharmacy and uh clinical pathology. Sometimes douma is one that also we use particularly um if renal failure is a problem as well, very poor, poor prognosis, independent, poor prognostic indicator, 80% of patients with malignant hypercalcemia will die within that first year, particularly those patients with lung cancer, obviously, very poor prognosis. So, what does that mean for me particularly thinking about having a high index of suspicion, the patients confused or nauseated. Think about a uni and a corrected calcium depending on what your lab is giving out, make sure it's corrected calcium. Our lab will give us a corrected calcium in the er, but in the olden days, I do remember having to sit and work it out. Uh And because our patients have advanced malignancy, the albumins can be low. So if you're getting a calcium that's not corrected for the albumin. You need to do that calculation because you could be looking at what looks normal. But then when you take into the low albumin into account, it actually is high. So just check is it corrected calcium? And if it's not do the calculation, you're usually going to be using IV fluids and IV bisphosphonates. Again, that's going to be likely inpatient uh care, which depends on your setting. You may have the facility to do that particularly for patients known to our service. Sometimes some uh home treatment teams can do that in, in the home setting. So it's worth knowing what's available in your setting. Or patients may have access to day treatment centers as well where they can go up, get the fluids and then go up the next day and get the bisphosphonate. So given poor prognosis, patient wants us to be at home as much as possible, there may be other options. So knowing what's available in your area. So uh that's the end of my presentation. So just any time for questions, that was absolutely fantastic. Um I have heard Doctor mcauley teaching before in my foundation year one teaching last year. And every time we had a talk, I took away something different and the same things happened tonight, I didn't know that thoracic spine, metastatic, um spinal cord compression was so common. Um in ad where I'm currently working in the emergency department there are so many pr exams done for query spinal cord compression. Um And the fact that that that sphincter tone is such a late presentation factor. You know, the fact that that it may not even be there. It's just um so and the picture of the sec o the collateral circulation on the chest wall, all that also kind of took me by uh by surprise. Um I am going to pull down the slides and I'm going to pop, pop up on the screen, some questions that have come through as the talk has progressed. But to the audience, I'd I'd invite you to pop any further questions in the chat and we will endeavor to, to look at them. So first question came through um when we were talking about spinal cord compression. So Baa has asked in the end of life care patient where your set of care would be perhaps at home or at the very maximum in hospice. Um Would we, would it still be warranted to discuss a suspected metastatic spinal cord compression with the coordinator? It depends what's set up in your setting. I think sometimes it's a bit uh like you might be discussing it. So they're aware, uh It's a bit like do you discuss somebody had a cancer MDT when you know they're not fit for anything. Uh It just means that they're at least their numbers are recorded. You get an idea of, you know, if you're only getting a slanted view of everybody that comes is fit. You don't realize there's a cohort that's been maybe missed. Um, so it's useful if you're in a system that is auditing that. So if you're in a system that's auditing those numbers, it's worth letting them know. Uh, we don't even have them. You know, the first game has come out about 2007 and we still haven't got one. We're still sort of phoning the oncology reg and then trying to speak to spinal teams. And then there's this three way conversation of madness that doesn't work for anybody. Um So we, we don't have that luxury. Uh They may or may not want to hear. But I think sometimes if they're auditing that, uh and they're having a quality improvement type cycle, it does no harm for them to be aware. Again, they're probably wanting to know when you, when you know what is spinal cord compressions, they're probably, probably only counting the ones that have an MRI scan. So if they're really not fit for investigation, I probably wouldn't be phoning or bothering anybody. But again, you'll be speaking that over with the patient with the family. If there's any index of this mightn't be right, discuss it with her oncologist. Uh Just to make sure you're on the right side, undocumented. It's, of course, it's that being in the knowledge of advanced care plan and what's appropriate, not, we had a patient like that, that I had assessed an ed and that three way conversation can be quite difficult between us in primary care, the emergency department, the oncology team, the Acute Oncology Service, and then the spinal team and then also the cancer center who then facilitated radiotherapy for that patient is, it can be quite a complex uh communication. We're very envious of if, if, if it works in the rest of the UK, this mythical creature called a coin, I'm sure she doesn't work at the weekends and that's when most of them turn up. So it's always the middle of the night. It is. Um We will move on re has mentioned about um palliative management. Would you suggest giving 60 mg? I assume this is all dexamethasone empirically. Even if we don't have an MRI proven spinal cord compression, I would, I would, it's tricky then that you're going, what do I do? But if you like to 16 mg, you get a bit of improvement, you know, it might help pee and it might take a wee bit of pressure off, then you know, it doesn't work three days, stop it, you know, give it a try. If you have a name of what you're looking for, if it doesn't help, then stopping it. If you are seeing an improvement, then you're gonna be gently weaning it. Um And then even if they're pure end of life care and have a lot of pain and are fit to go up for one fraction of radiotherapy. I'd still be having a conversation with the oncologist and saying, I think they've got, well, usually they like them to have about six weeks, 4 to 6 weeks and they're good fit to come. If they're really in the last week, 10 days, then obviously, no, you wouldn't be thinking of that conversation. But, um, it certainly, it might help him if you're putting 16 MGS, you probably need to be thinking about monitoring blood sugars a wee bit. Uh that might be BMS or that might be blood or urine samples depending on your, your setting. But certainly, yeah, at least once a day checking that you haven't knocked your blood sugars up. Of course, of course, there are um some lovely comments just to mention coming through in the chat about the, the great talk and the qualities just to share them with you and we will, we will share them out with you after. Um, some folks have mentioned about the audio drop and it hasn't at my end and not to worry if you need to. Um, because it's ok at my end, the recording will be done. Um So you will be able to catch up on those bits. Um uh forgive the pronunciation. Um, has asked, should we have a high index of suspicion for someone in remission of their cancer to still have some of these complications? And this came through in the spinal cord compression, part of the lecture as well. Certainly, depending on the type of cancer. Breast cancer. Yes. I, and a very long time ago did six months as an oncology reg it wasn't fun. But you, I did a breast clinic and every patient that said that a sore back, you were having to take that very, very seriously. They were cancer free from their point of view, but a sore back. That's a nice guidance. Yeah, you're gonna have to MRI that, um, you know, not necessarily the 24 hour rule, but you are, those folks are high risk, high risk of coming back. And if that's the first presentation and you pick it up early, you might prevent them losing the ability to walk, manage their bile. So you wouldn't want to be missing it and then they come back in two weeks and say, you know, you missed this and I, I'm left with a really a difficult situation. So, yeah, I think particularly ones that are high risk of coming back. I don't think you can ever rule breast cancer out of coming back. Uh If somebody's maybe 1015 years out of one that's highly unlikely to come out, it begins to drop further down. Uh But something that's highly likely to come back, there are features that make it highly likely to be recur always have that index of suspicion, at least do your neurological examination and give them, I suppose the safety net if, if you notice this, this and this, if this gets worse, if this hasn't settled. Um, yeah, we did worry when the first nice guidance came out, we thought we were just going to be using. Everybody's going to be MRI every three weeks hasn't been probably as bad as that. But I think in the current days, I think you really do want to be doing an MRI if you're in the setting where at high risk, of course, of course, of course, um to his game, uh came in with a question this time with relation to major hemorrhage. If a patient was in their advanced care plan, let's say, deemed not for transfer to a hospital and a family member is not comfortable administering, uh managing that. Is there any tips of managing that at home in the home setting? I guess, maybe covered some of those things in the talk? But the medication, if it's a true major hemorrhage medication really isn't the biggest part. We certainly spent a lot of time trying to get I um, Midazolam because you, you need two nurses in a hospital setting. You know, two nurses, the keys that you haven't a hope of getting that. So we spent a lot of time with our pathway trying to get it into an aseptic box so that it could go in the medicines trolley or be it. We had some medicines in, in the patient's locker in certain wards and things. So we spent a lot of time doing that. We always thought it was easier at home because usually medicines are in a box under the bed and the most random cupboards and things. Um, if the family don't want to give the medication, it's not the biggest thing. And quite often if they're bleeding from a site BTA quite often isn't something that can be done practically. So if they're not comfortable, it's quite often putting in the support for them that they can manage, it might well be giving them uh in our policy. We have a list of phone numbers. So we would be saying, well, if it's 9 to to 5 ring this number, if it's this and trying to give them contact numbers because most people have their phone on them even around the house, so they could phone. But you would be saying just stay with them, have the dark towels close to the bed, get them propped up uh into the most comfortable position, try and stay calmer. It does not happen that often. Thankfully, I've only been there once, twice, twice. You'll remember it if you're there, you'll remember it for the rest of your days. Um And you imagine if that was a family member. So quite often from a primary care perspective, it's the support of the family member afterwards. Uh That's probably the key thing because for the patient, they're usually gone. If it's carotid artery or something, a major vessel, they're gone within minutes. Uh So it's actually getting into a comfortable position, staying with them and maybe dark tiles to try and screen the worst, the worst of it. And then, uh I still remember how, how glowingly the GP was prescribed for one lady uh because they just came out and helped them with the tidy up and I'm not suggesting you all go out and help with the tidy up, but they knew them, they came out and they helped all of the stuff away, they cleared away all the stuff and just made sure it was gone and they, that was something like that was so much appreciated. It's not something you can write in a policy but simple things like that obviously uh make a difference, makes such a difference. I mean, that ABCD being there. Um Again, I'm only obviously fairly more junior, but I've prescribed several crisis doses of Midazolam thankfully never had to use them. Um But yeah, just being there and the effect of that, um VAC has mentioned about what level of calcium would be considered hypercalcemic. Would it be even if it was 0.1 over the uh upper limit of normal, we tend to go, my units might not be your units. But um I tend to treat if they're symptomatic and they don't have to be that symptomatic over 2.82. Sometimes people would treat a wee bit lower pli care tends to, uh, oncology might push you to be over three. but we find my population is very frail, very elderly. Little alterations in the biochemistry can really make them very confused, muddled. You know, they can be symptomatic at 2.8 and you'd rather not wait till they get to three because even when you get the numbers back, it takes them maybe a week to settle just from more vulnerable drains. Uh, and you've had that bit of dehydration with it and the, you know, so I would tend to treat earlier. Um I know sometimes the oncology guidance that comes out maybe is a wee bit higher, but then we managed to persuade them to bring it down a wee smidge for us. Um Just because we, we see, we see the impact we're asking the questions. Are you nauseated? Are you thirsty? Are you a bit muddled? And they generally are? So 2.82 0.8 would be my, I couldn't tell you what the equivalent of it. Yeah, but three does seem high. That that did seem high. Surely do I think we maybe have answered this about the duration of dexamethasone in the empiric setting. I think you said about 72 hours. Kind of until that, that if I would be guided by your oncologist usually is what happens. We usually stick it in, they get their MRI scan, it's negative, you stop it. Um It's positive I would leave it until the treatment is done. I probably wean it a bit slower and probably, sometimes it has it down quite quickly. But I'm always worried if they get response and they get necrosis of the tumor, you might actually get more edema around that acute period of time. Um, but certainly there should be a plan for it to come down. I think that's the key thing. I wouldn't get too hung up if it's five days or two weeks. As long as there are a plan that it is going to come down and possibly stop. Uh, what you tend to see sometimes is people are on it long term and people have forgotten to have a, a plan for it and then you end up with all the complications. So it depends what you started for in the empirical setting where you're not sending for anything and they benefit. You're gonna be very slowly bringing that down, uh, because you don't want them to get sore again. Uh, and you've nothing that has intervened, but if there's something that has intervened, you're gonna ask your oncologist, what do they advise? Um, if they're going for surgery again, I would think you'd probably get it out fairly quickly because they're gonna be in the situation of healing and again, discuss that with them, they'll be making those decisions themselves, but surgically decompress something. But then you're in, in a different setting, the role its role should hopefully be away. Sure. Sure. Um There are a couple of duplicate questions or uh questions that we maybe have answered already. So, in the interest of time, I think I will make this our, our last question of this evening. Um Yvonne has asked about with regards to major hemorrhage. Does I am Adaza need to be prescribed or would we jump in the same way as we do in the likes of a cardiac arrest? Um, and, and sort of retrospectively look at that, uh, if a nurse is gonna give that, she would need that prescribed. Yeah, if you're a GP and you're standing there, you give it, you know, you're there, you've got it. But it, if you're in the situation where it's in the house, it should be prescribed, it shouldn't be in the house unless it's prescribed and we would have a, a chart and, you know, there'll be a system in, in primary care in where that could be easily prescribed and then the nurse can give it to you the prescription. Um Getting it from the pharmacy would go alongside the chart being in the house so that the nurses could give it. Now, if you're in emergency situation where you're there with your doctor's bag and you have the drugs and you say this is a major hemorrhage and I know that they're not for red lighting out for treatment and you're clear about that and clear, they're not for resuscitation and all of that and you have the drugs and you, you know, you can do that, um, and then write it up again, you know, in the documentation. But that's because you're a doctor and you're, you're treating the thing. Um, certainly if you're a nurse, I would be making sure only giving something that is prescribed. Oh, absolutely. Um, something at a point of interest for, for folks, maybe not in Northern Ireland on the call. We're going through a, a kind of move from uh paper prescribing to electronic prescribing at the minute. And that's causing some uh some interesting things and these questions do come up. Can I get without prescribed? Is it prescribed on the system? You know, so we get a lot of that for sure. Um Yes, Yvonne has just added on here um that she works in the community as a nurse and often Midazolam is prescribed for breakthrough but not an emergency. That's a really interesting one. Yvonne as an F one. I remember co prescribing Midazolam um on P RN sections or as required sections for an agitation dose and then a crisis bleed dose. And it was, it was a case of just having that communicated so that so that the team administering would know that this is the dose for agitation and this is only for use in a in a terminal bleed thoughts on, on that document calling just to close again. I think it's that situation where if everybody is in, in agreement that that's the appropriate thing. It's not for red lights, they're not for resuscitated, but it hasn't been prescribed. But everybody's clear that, that palliative management, I think the big thing is, is the palliative management plan, the right plan. So that's the right plan. And the drugs haven't been prescribed, but you could give Midazolam five that's in the house and it is prescribed, you could give it. It's not ideal because if you give it subcut, that person is shut down peripherally, they're unlikely to absorb much of it. That's why it's the only one we talk about. I would give everything subcut. We, we don't give anything I am except this and that's because you're going into deep muscle in the hope that no matter how shut down they are, you'll get a bit more absorption. So you're going subcut and they're very peripherally shut down. It's half the dose you're wanting and it's subcut, but it's better than nothing. But I wouldn't go looking to do that or looking for those drugs. If I was the only person there, I'd be with the person talking to the person covering the blood as much as possible with tiles, keeping them in a comfortable position, talking to them. That's more key than the drugs. Because if I'm hunting for drugs and hunting for a prescription, I'm doing the wrong thing. Um, unless there's somebody else there to do the the talking and the prompting. So being there and being with the person is more key than any of the medicines. Absolutely brilliant. Um I will call a close on the Q and A there. Um We started a couple of minutes late, we're finishing a couple of minutes late. Um but folks can I thank you all coming along. Um Can I on behalf of everyone here, all 100 and 40 at maximum I think we had tonight. Um Can I express a massive thank you to Doctor mcauley for taking your time this evening? Um, a fantastic presentation, some lovely comments coming in the chat there. Um I'm going to share the feedback form which will have gone into the chat. You should also get that via email. Please fill the feedback form out. We provide our speakers with the feedback from these talks and they use them to inform their future teaching and they use them for uh appraisals, various different things um that are ahead of me for a little while yet. Um But um we're glad that you enjoyed tonight. Thank you for all your lovely comments. Um I am going to just pop up in a couple of links to the chat about our upcoming events. We will have Doctor mcauley back with us caring another topic um later on this year. But the next upcoming events just popping in there now is uh CO PD management with uh Steve Holmes and that's on the first of October. Um So just next week and the week after that, uh we have Christopher Dukes, er, chatting to us about mastering shoulder pain in primary care and that's the link for that just going into the chat as well. Um Folks, once again, thank you for coming uh catch up content, including the recording and slides will be available shortly on the event page. Thank you, Doctor mcauley and we will see you all soon.