Your news, your voice, your Acute & General Medicine
Take a sneak peek at the 2018 programme
2018 hands-on training preview
Poster Zone - SPECIAL COMMENDATIONS
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Guest editor:
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February 2018 • Issue 19
English medics lead the way in treating acute kidney injury
This is because the care of patients with this syndrome was galvanised eight years ago after a national investigation showed there was poor recognition and treatment of AKI, a lack of senior reviews and poor evidence of critical care outreach.
Dr Thomas, who is Clinical Director for Professional Education, Heart of England NHS Foundation Trust, said acute and general physicians need to know how to treat AKI because it is common, representing about 20 per cent of admissions of sick patients and is an important cause of morbidity and mortality. It causes about 40,000 excess deaths per year, compared with 35,000 deaths from lung cancer.
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England is one of the best developed nations for treating acute kidney injury (AKI), Dr Mark Thomas, Consultant Physician and Nephrologist, told Acute & General Medicine delegates.
Dr Mark Thomas, Consultant Physician and Nephrologist
The inherent instability and unpredictability of acute coronary syndrome makes these patients challenging to diagnose and treat.
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Dr Unni Krishnan, Honorary Consultant Cardiologist
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But data on patients with 30 day major adverse cardiovascular events
(MACE) such as a heart attack or death from a heart attack, after presenting with ischaemic symptoms, shows that some patients are missed.
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Acute coronary syndrome is easily missed in the emergency department Less than 10-15 per cent of patients presenting with chest pain to the emergency department have acute coronary syndrome (ACS), Dr Unni Krishnan, Honorary Consultant Cardiologist, Cambridge University Hospitals NHS Trust, told Acute & General Medicine delegates.
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Contents
EDITORIAL TEAM Francesca Robinson
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Early intervention improves patient outcomes in haematological emergencies
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Sneak peek at the 2018 programme
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World’s first single use videoscope at AGM
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Medical problems in pregnancy
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Poster Zone Special Commendations
ACUTE & GENERAL MEDICINE TEAM Sarah Bray - Marketing Manager Bertie King - Delegate Relationship Manager Yemi Ibidunni - Show Manager Mike Broad - Programme Director CONTACT US 14 Exhibition House Addison Bridge Place Kensington W14 8XP
Your news, your voice, your Acute & General Medicine In 2018 we’ll be introducing new sections to the newspaper that are all about you! If your team has done something innovative to improve patient care that’s worth sharing, or you have a newsworthy story from your Trust or ward - we want to hear about it:
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Welcome
• Send us your good news stories and we’ll feature you in the Summer or Autumn newspaper sent to over 70,000 doctors from across the world. Sponsorship Statement LONDON
AGM is for healthcare professionals only. The seminars at AGM have been brought to you by CloserStill Media in association with our partners and sponsors. The views and opinions of the speakers are not necessarily those of Closer2Medical or of our partners and sponsors.AGM’s association partners have helped develop the programme. Sponsors have not had any input into the programme except where an individual session states it is sponsored. The session topic and speaker have been developed by each sponsoring company.
• Confessions of a hospital doctor - each issue we will choose the funniest ‘confession’ and publish it anonymously. Send your articles to: training@closerstillmedia.com Enjoy the read! Sarah Bray Marketing Manager Acute & General Medicine
MORE THAN DEFENCE
When we spoke to you at this year’s conference
of you said that you think patients are more likely to submit a complaint now compared to 10 years ago.
Peace of mind is knowing that an experienced team of over 100 medicolegal advisers and specialist lawyers are on hand to advise and support you.
visit medicalprotection.org call 0800 561 9000 The Medical Protection Society Limited (MPS) is a company limited by guarantee registered in England with company number 36142 at Level 19, The Shard, 32 London Bridge Street, London, SE1 9SG. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association. MPS® and Medical Protection® are registered trademarks.
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Top 10 considerations when treating AKI: Consider the risk of AKI and minimize it with early detection.
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Small rises in creatinine signal subtle acute kidney injury and an increased risk of mortality.
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Don’t regard a systolic blood pressure of 120 mm as necessarily normal. ‘We are a high blood pressure society. Ask patients what medication they are on and what their GP says their normal blood pressure is,’ said Dr Thomas.
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There are a range of drugs that are nephrotoxic-suspend them. These drugs include acyclovir, warfarin and statins.
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Tell patients about the ‘sick day rules’.
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The kidney is vulnerable to ischaemia.
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Vasodilatory prostaglandins and angiotensin II help maintain GFR (glomerular filtration rate) the face of hypovolaemia.
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Early intervention improves patient outcomes in haematological emergencies
The kidneys protect themselves using autoregulatory reflexes. They are used to blood pressure within a certain range, so find out what the normal blood pressure is for your patient.
Five clinical scenarios of malignant and nonmalignant haematological emergencies which could present to the acute medical team were explained to Acute & General Medicine delegates by Dr Fiona Dignan, Consultant Haematologist, Manchester Royal Infirmary.
AKI and CKD are closely interrelated conditions. If you have had AKI you are more prone to developing chronic kidney disease (CKD) in the future. Diabetics are particularly at risk.
Acute chest syndrome in sickle cell disease is one of the most common haematological emergencies. Dr Dignan said the important things to remember with these patients were to: watch for acute chest syndrome in acute sickle cell crisis especially if there are symptoms of chest pain, respiratory symptoms or fever; review the patient frequently as acute chest syndrome often develops after admission; monitor O2 sats on air and involve the haematology team at an early stage.
Warn patients and their GPs on discharge that AKI can recur for at least 2-3 three years and can cause chronic kidney disease. The kidney function of patients who have had AKI should be monitored.
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Febrile neutropenia is another common emergency. These patients should be offered empiric therapy immediately, they should be examined and their history taken. Tests should include FBC, U+Es, albumin, CRP, lactate and blood culture, line cultures, urine dipstick, chest X-ray and throat swabs in accordance with the NICE 2012 guidelines. Spinal cord compression is another fairly common emergency but is often missed. This is because symptoms of low back pain are common, 23 per cent of patients with spinal cord compression have no previous history of cancer. One study showed that it took two months to make a diagnosis.
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Dr Fiona Dignan, Consultant Haematologist
It is important to recognise spinal cord compression early because patients are at risk of paralysis. Almost half of patients cannot walk by the time of diagnosis and this is a concern because motor function has been shown to correlate with prognosis. Treatment before paralysis is clinically and cost effective. Dr Dignan also discussed thrombotic thrombocytopenic purpura and acute promyelocytic leukaemia, which are less common haematological emergencies. She said it was important that acute and general physicians knew about these conditions because early intervention could improve patient outcomes.
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Acute coronary syndrome is easily missed in the emergency department Clinical assessment should be central to decisionmaking although risk scores can be used to help the process. A risk score can reduce length of hospital stay and the number of investigations in patients with suspected acute coronary syndrome. However risk score performance was not shown to be any different from clinical judgement in a trial with an unselected cohort presenting to the emergency department with chest pain. Other studies have shown that risk scores do not affect clinicians’ practice – they can remain hesitant to send patients home despite a low score. ‘What was most interesting for me was that this trial showed that we are all creatures of habit. We have our clinical gut feeling and we lean towards a decision based clinical judgement rather than a decision based on a score. I think that is reassuring,’ said Dr Krishnan.
A troponin assay can be a helpful prognostic tool. It is a marker of cardiac myocyte damage, not atherosclerotic plaque rupture. Normal populations have detectable troponins so sampling should be done at least two hours after symptoms. This test should not be used to override other indicators of risk. It is a helpful prognostic tool. Dr Krishnan said that in his opinion medical therapy should the mainstay of treatment for acute coronary syndrome, rather than stents. He summarised: take a history looking at the onset and character of the pain; pretest probability; get more data; repeat the ECG and compare it with any previous tests. Then ACS treatment should start before the troponin result arrives and the test should be repeated if it was done less than two hours from the onset of symptoms. ‘If there is haemodynamic instability, consider bedside imaging, then escalate treatment appropriately (intravenous therapy) and involve tertiary centre. If in doubt about a coronary artery dissection get a CT scan of the aorta,’ he said.
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A sneak peek at the 2018 session and speaker line-up
EXCLUS
IVE
2018 Programme Preview ELDERLY MEDICINE SESSIONS
NEPHROLOGY SESSIONS
• Managing the Frail Patient • Dealing with Delerium • Inpatient falls: reducing the numbers and harm
• Sodium and potassium disorders
CRITICAL CARE SESSIONS
DIABETES & ENDOCRINOLOGY SESSIONS • Endocrine Emergencies
• Sepsis - the silent killer • Legacy after Critical Illness - from survival to living
GASTROENTEROLOGY SESSIONS
CARDIOLOGY SESSIONS
• Managing IBD
• ECG Masterclass • Acute Heart Failure
HEPATOLOGY SESSIONS
ACUTE MEDICINE SESSIONS
• Update on NAFLD
• Deterioration – the need for collaboration
RESPIRATORY SESSIONS
NEUROLOGY SESSIONS
• Acute Respiratory Presentations • COPD update for the generalist
• Headaches - when to worry • Parkinson’s: management on the take and on the wards
HOT TOPICS SESSIONS
EMERGENCY MEDICINE SESSIONS • • • •
• • • • •
USS at the front door – interesting cases Acute oncology at the front door Unusual cases in ED Early diagnosis of acute coronary syndromes
Poisoning and overdose Ambulatory Care - preventing every day admissions’ HIV: the challenge of acute management Human factors and the dangers of handover Superbugs - what you need to know at the front door?
THE FULL 2018 PROGRAMME WILL RELEASED IN THE SPRING
2018 speakers include... DR FRANCESCA SWORDS
DR SIMON FYNN
PROF SUNIL BHANDARI
DR POOJA DASSAN
PROF ANDREW CLARK
DR OMAR USMANI
Consultant in Endocrinology, Norfolk and Norwich University Hospitals Foundation Trust
Consultant neurologist at Imperial College Healthcare NHS Trust and London North West Healthcare NHS Trust and is an Honorary Clinical Lecturer at Imperial College
Consultant Cardiologist and Clinical Director for Cardiology at Papworth Hospital, Cambridge
Chair of Clinical Cardiology, Honorary Consultant Cardiologist, Castle Hill Hospital, University of Hull
Consultant in Nephrology at Hull and East Yorkshire Hospitals NHS Trust and Honorary Professor at Hull York Medical School
Clinical Senior Lecturer and Consultant Physician at the National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital
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2018 HANDS-ON TRAINING PREVIEW
World’s first single-use videoscope at Acute & General Medicine
Topics covered at Acute & General Medicine include: • Current Challenges in Airway Management
Ambu bring efficient healthcare solutions to life within our fields of excellence: Anaesthesia, Patient Monitoring & Diagnostics and Emergency Care. Millions of patients and healthcare professionals worldwide depend on the functionality and performance of our products. The manifestations of our efforts range from early inventions like the Ambu bag to our latest landmark solutions such as the aScope™ – the world’s first single-use videoscope. Our commitment to bringing new ideas and superior service to our customers has made Ambu one of the most recognised medicotechnical companies in the world. Ambu are delighted to be demonstrating the innovative Ambu® aScope™ 4 Broncho singleuse at Acute & General Medicine 2018, flexible videoscope that challenges conventions in flexible optical intubation, offering immediate accessibility, a higher level of practicality and no risk of crosscontamination. The scopes are compatible with the high-resolution monitor, Ambu® aView™, which enables easy navigation and fast identification of anatomical landmarks. Ambu are dedicated to improving patient safety and determined to advance single-use
devices which is why we believe it is important to implement NAP4’s recommendations of regular multidisciplinary training for difficult airway management after purchasing suitable equipment to manage difficult airways.
• Overview of clinical evidence and current guidelines
Our dedicated staff will be on-site at Acute & General Medicine to offer Difficult Airway Workshop training sessions which provide opportunities to learn more about the benefits of using advanced single-use visualization equipment for management of the difficult airway and to learn how the aScope™ system is suitable for a wide range of endoscopic procedures in the OR, ER and ICU.
• Cost efficiency of single-use scopes
Delivered by experienced Ambu Clinical Educators, you will learn how aScope™ 4 Broncho can enhance patient safety, reduce infection risk at hospitals and help to control costs. Instantly improve your advanced airway skills through hands on practical demonstrations, delivered in accordance with clinical consensus guidelines as stated by the National Tracheostomy Safety Project and the Intensive Care Society, as recommended in the NCEPOD report.
• Clinical use of single-use scopes • Hygiene, advantages and disadvantages of single-use scopes • Practical demonstrations of Ambu aScope 3 system • An overview of where Ambu products fit in to difficult airways
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Your conference will give you access to world-class hands-on training at Acute & General Medicine 2018.
2018 HANDS-ON TRAINING PREVIEW
2018 Hands-on training will include: MORE ULTRASOUND Workshop Stations MORE NON-INVASIVE VENTILATION Workshop Stations MORE DIFFICULT AIRWAY Workshop Stations MORE ECG Workshop Stations WITH MORE TO BE CONFIRMED SOON!
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that yielded inaccurate results, and required the use of statistical variables for correction of measurements. However, the Empirical data used in the formula were highly specific and could not be applied universally, and in turn affected overall precision. The InBody Test provides a comprehensive view of body composition balance. Body water, proteins, minerals, and body fat, which are the components of the human body, closely relate to the status of our health. Using the method of quantitative analysis, these elements of body composition and body composition analysis provide basic information required for assessing the status of the body. The InBody utilises the BIA Method. First used in the late 1960s, the bioelectrical impedance analysis (BIA) method measures body water by obtaining the impedance index. The impedance index is obtained by applying a small alternating current on the body, based on the principle that the body contains water and that the level of electric resistivity, i.e., resistance, changes according to the amount of water in the body. In the late 1980s, the BIA method was a singlefrequency whole-body impedance measurement
worldwide. The InBody is mentioned in hundreds of research papers published every year across various fields such as nutrition, sports and obesity.
The InBody technology overcomes limitations of early BIA. Motivated through Understanding the cause of BIA’s inaccuracy as a limitation in technology, the solution for the limitation could be solved through technological innovation. In 1996, Dr.Cha developed the InBody, “world’s first commercial BIA body composition analyser, capable of both direct measurement of body segments and multi-frequency measurement”. Today, the advancement to BIA technology brought out by the InBody with exceptional precision and ease of use is widely recognised by experts
Should you require an InBody demonstration, please contact us on uk@inbody.com or visit us at Acute & General Medicine 2018 to arrange an appointment
Medical problems in pregnancy what other therapies have I got and can this woman manage without this drug in pregnancy?’ Professor Nelson-Piercy also warned that it was no good giving a patient a drug if she was not on board with the treatment, otherwise she would not take the medication. Counselling and making a collaborative decision with the patient about treatment was important.
She said that pregnant women were more predisposed to certain acute medical problems and those with chronic medical conditions could find their symptoms get worse or flare up during pregnancy. It was important to understand that pregnant women could suffer pregnancy specific medical problems.
The most recent Confidential Enquiry into mother’s deaths showed that two thirds of mothers who died in pregnancy died from medical and mental health problems and only one third from direct complications of pregnancy such as haemorrhage and preeclampsia. Cardiac disease (acute coronary syndrome, aortic dissection and cardiomyopathy) was the leading cause of maternal mortality in the UK and venous thromboembolism, the commonest direct cause of maternal death.
Pregnant and postpartum women deserved the same attention to diagnosis and treatment and appropriate management plans as the nonpregnant patient. ‘As physicians we tend to be overcautious denying investigations and denying relevant treatments and therefore errors of omission are very common,’ she said. She warned that most drugs do not have a licence for use in pregnancy. Many physicians were cautious about giving women drugs in pregnancy. ‘If you are not sure that a woman should take a drug you have got to ask what are the consequences of not treating the disease,
Women with pre-existing medical and mental health problems should be given pre-pregnancy advice and joint specialist maternity care. ‘Whatever specialty and whatever chronic medical condition you treat, the best outcome for the baby is to control that disease. If you don’t treat the medical condition you increase the risk of infertility, miscarriage, preterm delivery and pre-eclampsia and that is bad for the baby,’ said Professor Nelson-Piercy.
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Medical problems in pregnancy cause more deaths than obstetric problems and yet many physicians are unfamiliar with pregnancy and how it influences the management of medical disorders, Prof Catherine Nelson-Piercy, Professor of Obstetric Medicine, Guy’s & St Thomas’ Foundation Trust, told Acute & General Medicine delegates.
Profesor Catherine Nelson-Piercy, Professor of Obstetric Medicine
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Acute & General 2017 Medicine Poster Zone Thank you to all of our Poster Zone presenters who made the 2017 presentation area the biggest and most valuable yet! A big congratulations to the following abstracts who received a Special Commendation by the judges...
A rare cardiac complication of intravenous drug use Gould, J. Guy’s & St Thomas’ NHS Foundation Trust INTRODUCTION A 35-year-old male presented with central pericarditic chest pain and fevers. He had no past history but used intravenous (IV) drugs 14 years ago.
Reducing time to endoscopy from suspected colorectal cancer GP referrals to ensure compliance with the 62-day cancer pathway Siddiqui, Z. Aya, H. Ahmed, R, Sorelli, P. King’s College Hospital / Lewisham and Greenwich Trust BACKGROUND The 62-day cancer pathway set out by the NHS promotes prompt cancer diagnosis and treatment. At Queen Elizabeth Hospital (QEH), Woolwich, the main delay in the colorectal cancer pathway was from GP referral to first investigation. AIM(S) Our aim was to ensure that at least 90% of patients referred by GPs on the suspected colorectal cancer pathway to QEH were investigated by endoscopy within 14-21 days, by February 2017. Read the full abstract via www.agmconference.co.uk/ poster-zone-abstracts-2017
On examination, vitals: BP 128/84 mmHg, HR 130bpm, SpO2 90% on room air, RR 30 breaths per minute. There were no audible heart murmurs, pericardial or pleuritic rubs and no peripheral stigmata of infective endocarditis or signs of recent IV drug use. A 12-lead ECG showed widespread subtle ST segment elevation. A computed tomography pulmonary angiogram (CTPA) demonstrated a segmental pulmonary embolism and a moderate global circumferential pericardial effusion. He subsequently admitted that due to boredom from unemployment, he had attempted to aspirate blood from his left groin with a 14-year old needle he had wiped clean by hand. He intended to create euphoria without injecting drugs but his wife interrupted him and hit him. He kept hold of the needle and syringe but in falling onto his side was concerned he had lost a needle fragment in his left groin. Further inspection of his left groin did not reveal a needle remnant and neither did a pelvic radiograph or ultrasound scan. Read the full abstract via www.agmconference.co.uk/ poster-zone-abstracts-2017
The importance of the follow-up CXR post diagnosis of Community Acquired Pneumonia Rochester, A. Stafford, N. Mankragod, R. Locum AIM Given that approximately 1% of patients with community acquired pneumonia (CAP) will have an undiagnosed lung malignancy corresponding to the initial radiological changes, we wished to identify the proportion of patients admitted to Maidstone District General Hospital with radiologically-confirmed CAP over a three-month period who underwent review and/or repeat imaging at 6-8 weeks, as per British Thoracic Society (BTS) guidelines.1,2 Read the full abstract via www.agmconference.co.uk/ poster-zone-abstracts-2017
Gastric Bypass-related Hyperammonaemia a case report Chok, Y. Soong, N. Gannon, D. Colchester General Hospital CASE A 53 year-old lady was admitted following a collapse. Two weeks ago, she underwent an emergency gastrectomy and Roux-en-Y gastric bypass surgery for gastric outlet obstruction secondary to peptic ulcer disease. Physical examination revealed GCS of 8/15, erythematous abdominal surgical wound and bilateral extensor plantar reflexes. Initial blood investigations showed raised CRP, low albumin and mild anaemia. Despite treatment for sepsis, she remained encephalopathic. Subsequently, serum ammonia level was sent and it was markedly elevated. She also has low/low-normal plasma amino acids, low zinc level and elevated plasma glutamate. The diagnosis was revised to Gastric Bypassrelated Hyperammonaemic (GaBHA) encephalopathy. She was treated with protein restriction, intravenous glucose and oral lactulose, and she responded well. Her conscious level improved as her ammonia level fell. She was discharged home well, but was lost to followup. We later learned that she was admitted to another hospital where she unfortunately passed away. Her ammonia level was again markedly raised. Read the full abstract via www.agmconference.co.uk/ poster-zone-abstracts-2017
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‘This is the third time I have come to the conference. It is a well organised event with a good overall general medical content and is very useful for a general update.’ Consultant Physician, Royal Liverpool University ‘I think this conference is really amazing because in just two days you can get an overall update in many different topics aspects of medicine. The speakers are excellent.’ Respiratory Consultant Portsmouth Hospitals
‘The lectures at Acute & General Medicine are absolutely great and help delegates to improve their overall knowledge of acute medicine and learn about everything that is new in all the different specialties. In two days you can get a good all round update.’ Acute Medicine, Medway Hospital, Kent ‘I have come from Latvia as Acute & General Medicine had good reviews. There are a broad range of topics and it’s a great event for learning about new things. I have done all the hands-on training sessions. I wish it lasted longer than two days.’ Riga Eastern Clinical University Hospital, Latvia
Straight from the doctors mouth...
‘I’ve been coming to the conference for last five years because it’s really good value for money. You get good medical updates in all the topics that are relevant for the acute physician. I come each year to top up my knowledge.’ Consultant Accident and Emergency UCLH
Follow us @agmconfuk #agmconfuk
‘I have come from Sri Lanka to attend this conference because of the quality of the education that it offers. There are a lot of interesting topics and the speakers are all very good. I am also interested in technology and have been touring the exhibition stands to see what new products and services are available.’ Consultant Physician, Sri Lanka
‘Acute & General Medicine is really good for keeping up to date with acute medicine which is really relevant for me. I also love the hands-on sessions. I have done the airway training and it will be really useful for my work in the AMU. There is a really good mixture of people here and I’ve met up with a quite a number of doctors I used to work with.’ Physician Associate, Hillingdon Hospital
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