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The 4-hour standard. Why can’t you get it right?

10 Jan, 17 | by scarley

please-get-it-right

If you were hoping for a solution to flow in the ED then this is not the post for you. Rather it’s an appeal and a cry of pain from all UK clinicians who work in emergency departments for politicians and journalists to understand what the 4-hour target is.

It is the percentage of patients seen and DISCHARGED OR ADMITTED within 4 hours.

Journalists regularly mistake this as the time that people wait to be seen in the ED which of course is entirely different. Yesterday Jeremy Hunt was questioned in the commons about the current crisis in the ED and even the opposition front bench mistook the 4 hour standard as wait to be seen and not the time it takes for us to completely sort patients out and either get them home or into a hospital bed.

Even Wikipedia is unclear on the matter, and so it’s perhaps not surprising that everyone is confused. The King’s fund does much better and has some excellent research in the area.

Does this matter? Well I would argue that it does. From a public perception if we are failing to even assess people within 4 hours that does indeed sound awful. The idea that we have to complete the ED journey within 4 hours must surely be understood as a more challenging task. If it were just a wait to be seen then in all honesty we’d be running at well over 100% already (if you include triage which you should).

So. An appeal that perhaps no journalist or politician will read. Please get it right and stop emergency clinicians shouting at the TV or radio every time you get it wrong. We’re under enough stress as it is.

vb

S

@EMManchester

https://twitter.com/deanoburns/status/818745470281465856

How to write off your paperwork. EMJ Blog.

29 Dec, 16 | by cgray

how-to-write-off-your-paperwork

Emergency medicine is one of those specialities where physicians of all grades have to make their own notes, even the consultants. Medical and surgical bosses have juniors to scribe at the ward round, secretaries to type up dictated clinic letters, assistants to type op notes (most of the time). EM consultants, like their junior colleagues, still need to put their own pens to paper, or fingers to keyboard.

There are two general ways to make notes in the ED. You can do it whilst talking to the patient, which creates the most contemporaneous notes, allows you to use the patient’s own words, and means you can easily recant the story back to them to confirm details, though can sometimes create the impression that you aren’t giving the patient your full attention. I am a big fan of this approach, writing quickly means I can document almost as fast as I can talk. In my opinion, I forget fewer questions, meaning I can carry on with other tasks without having to return to the patient when I remember later on. It’s an approach that works well for me and my very short attention span, though only really works when I’m in a department with paper documentation. Alternatively notes can be completed after seeing the patient, when you can rearrange everything you have learnt into a sensible and concise narrative. However, writing at the desk puts you in the line of fire of technicians asking you to check ECGs, or other colleagues asking your opinion on their patients, to name a few examples. These interruptions have the potential to cause confusion in the history and examination you are trying to commit to paper, and details can be missed or altered.

I would miss doing my own paperwork in the emergency department – I write small and fast, (and reasonably legible) and my note taking helps to put my thoughts in order to make differentials and come to conclusions. However, I’m sure many of you have wondered how much quicker and efficiently you could work if you had someone to write notes for you. Maybe you even have a scribe – I know of people that do, and it seems to be reasonably popular in the US.

Scribes can help those who adopt either approach, and whether electronic or paper. They allow contemporaneous note taking, so that the clinician can focus on the patient, listening to their answers carefully rather than just planning the next question. It can be easy to miss cues from the patient when you are documenting at the same time. They also mean that time isn’t spent documenting at the nurses station, allowing a better focus on other tasks – not missing that subtle MI on the ECG you’ve been shown because you’re still trying to remember how to spell “Sjögren’s”. However, as I’ve already mentioned, sometimes you need to write the notes yourself, for those more complicated patients where writing it out helps with problem solving.

In this month’s EMJ, Katherine Walker and team from Melbourne have put together an observational study and cost analysis to determine the feasibility of training medical scribes in the ED. They took 10 trainees, put them through a 1 month pre-work course followed by 2-4 months of training and clinical sessions facilitated by emergency physicians. Only 5 trainees became competent, and required 68-118 hours of clinical work to do so. They found training scribes to be a feasible exercise, and crucially did not find any loss of productivity in the physicians who trained them. Medical students became competent more quickly than pre-med or non-medical students, and only medical/pre-medical students made it through the whole programme. There is little information on how scribes were selected to go forward to each part of the scheme, and also what the criteria were for applicants to be offered an interview. There was an overall loss in money from the programme, which had not been recuperated by the end of the study. Longer periods of observation would be needed to identify how long it would take for training costs to be outweighed by productivity savings, if at all.

As always we’d recommend you read the paper yourself to get the full results and to be able to draw your own conclusions. A reply from a senior scribe, Nicholas Rich, also provides a useful commentary and some further reading.

It’s an interesting concept, one that doesn’t appeal to me personally, but maybe it does to you. Have you got a scribe? Do they improve your productivity and patient interaction? We’d love to know.

vb

Chris
@cgraydoc

#FOAMed, credentials and a view from the college (sort of).

10 Dec, 16 | by scarley

156r09lpI found an amazing tweet on my timeline today that taught me many things. Firstly, I was not aware that students were publishing their own theses online and as an open access resource (this is fantastic), and secondly the topic in question is of great interest to me and everyone here, that is the development of #FOAMed.

Chris Walsh is a super chap who is head of e-learning at the Royal College of Emergency Medicine. He is an extremely intelligent man with a strong academic track record, initially in the humanities, and now also in the field of medical and digitial education.

He has now published his MSc thesis online looking at the development, current state and future direction of e-learning resources for the RCEM.

Click here to read the thesis online.

I am very interested in the view from a senior member of the college as my relationship with the college over e-learning has been difficult at times. As an advocate of #FOAMed I’ve always struggled with the requirements to meet the limitiations and restrictions of an overarching organisation whilst maintating the freedom, speed and open discussion that #FOAMed creates. This is a theme in the thesis and I found Chris’s analysis of #FOAMed as a dialogic process fascinating. This work also aludes to the changing relationships between organisations, traditions, curricula, members, technology and delivery. It’s complex and fascinating.Chris has used a mixed methods technique to look at the impact and future direction of e-learning for the College and for #FOAMed. The perspective is clearly from his position, and thus the influence of the College perspective is very clear, but there are many interesting elements for any producer or consumer of #FOAMed.So what are the main themes? Obviously this is my interpretation and you really should read the whole document.

    #FOAMed is here to stay.#FOAMed engages and invigorates elements of the EM community but some are not engaged.There is a desire amongst some for credentialing of activity related to #FOAMed (though the strength There is some confusion between e-learning and #FOAMed type activities and credentialing.The RCEM is developing a system to credential #FOAMed learning.There is a belief and understanding that #FOAMed will be incorporated into formalised learning and continuous professional development.

There are many other questions too of course. This study is based on small samples and almost all the interviews were conducted with those involved in college work. The survey data was sought through social media spaces which is good as they are #FOAMed consumers, but also limits the findings to those who are already engaged in this style of learning. The perspective is thus largely one of the college establishment and as a result may be a self-fulfilling one. However, I’m not sure that matters that much as the project is really aimed at those groups as opposed to those who are not currently engaged with College resources. It does therefore study a specific, but relevant

So. Follow the link above to read the thesis (or at least read the abstract), follow Chris Walsh on his twitter account, and if you feel inclined I’m sure he would be delighted to hear your thoughts.

My final question is in regard to the proposed credentialing of #FOAMed activity into an online CPD portfolio.

The question is whether users will be able to record activity from non RCEM #FOAMed sites, or will it be limited and paywalled by the college. As a #FOAMed advocate I’m clearly keen to support learners to be able to record #FOAMed CPD from any blog or podcast.

That may not be a decision that Chris will personally make, but I’d love to know the answer (and hope it’s the right one).

The bottom line is that this is a great piece of work that takes our understanding of College based learning further and deeper than we have previously seen.

vb

S

 

What do Emergency Medicine and Donald J. Trump have in common?

7 Dec, 16 | by rlloyd

trump-01

Illustration by A3 Studios

*Caution: Emotionally-charged post, pinch of salt required… personal feelings only and not the editorial view of the EMJ/BMJ.

On the morning of the 9th November 2016, I woke up to the earth-shattering news that Donald Trump had been elected President Elect of the United States. It’s a moment I’ll never forget.

Rain pounded menacingly against my bedroom window, all my social media outlets exploded with sentiment of anger and sadness, and my American fiancé lay next to me in floods of tears.

I, like many (urm… all) of my friends and family, and seemingly the majority of the #FOAMed community, am horrified by the Trump phenomenon. His hateful, divisive rhetoric is unlike anything I’ve previously encountered in a public figure, let alone the new leader of the free world. Appropriately, and frighteningly, he has drawn comparisons with some of modern history’s ugliest dictators, such as Hitler and Mussolini. Mind-bendingly hideous stuff.

Throughout his campaign, Trump would verbally decapitate anyone who dared to undermine him. Cutting personal insults and sinister threats (‘I’ll throw her in jail when I’m in the White House!’) were par for the course, and reflective of an insecure man with astonishingly thin skin. Of course most of the time it was his rival Hillary Clinton in the firing line, but even fellow Republicans took some damage if they decided to be critical.

If his foul-mouthed tirades were a shrewd strategic move for diverting attention from his lack of political acumen and poor grasp of the Presidential job description, then arguably, the man’s a genius. Decipherable policy specifics were sparse, but unashamed fascism seemed to be a common theme, exemplified by absurd proposals to build a wall on the US-Mexico border and ban all Muslims from entering the US.

I’ve lost count of how many times I felt convinced of his self-destruction. Whether it was accusing all Mexican immigrants of being ‘rapists’, jokingly inviting a Clinton assassination attempt, or the release of a video where he openly boasted of sexual assault, he somehow kept on surviving. And then he won the keys to the White House. Ugh.

I am no journalist. Nor am I a political analyst. I’m a blogtastic British junior doctor training to be an Emergency Physician, and therefore pretty far removed from the whole debacle (*wipes sweat off brow*). Having said that, witnessing Trump’s ascendancy has triggered an important work-related reflection that I feel the urge to share.

Where is our basic human decency?

The Trump campaign suffered from a disease which stripped it of basic human decency. Depressingly, this reminded me of the alarming regularity that I witness unnecessary rudeness and outright bullying in the ED environment. Unpleasant, heated exchanges are a daily occurrence (certainly where I work anyway). Where does the hostility come from?

We’re bloody busy

The influence of workload cannot be emphasised enough. The ED is inevitably the busiest department in every reasonably-sized hospital, and it remains so 24 hour-a-day, 7 days-a-week (despite what our Health Secretary might have the tabloid newspapers believe).

When you consider that in 2015-16 there were 22.9 million visits to the 136 existing EDs in the UK, I think it’s fair to say overburdened is an understatement (by developed world standards of course) (1). Stress levels can reach fever pitch at the sight of a an overflowing waiting room, a seemingly never-ending list of ‘unclicked-on’ patients on a computer screen, or a growing congregation of paramedics indicating that pregnant ambulances are queuing up.

All of these are inevitable features of working in a UK ED, and with the added pressure to have patients ‘sorted’ in under four hours (i.e. discharged or warded), it’s understandable that some might become irritable and combative. It doesn’t matter if you are a native ED doctor, nurse or visiting specialist, the feeling is contagious; it’s a pressure-cooker workplace, and too often I see people releasing their personal pressure-valves by taking out frustrations on colleagues.

Of course, all of the emotional demands of working in such an over-stretched environment are heightened when dealing with particularly sick and unpredictable patients. As such, the resuscitation room tends to be the arena where I am most stunned by the way colleagues address each other.

False inferiority complex

There is no department where tribalism is more evident than the ED. It’s a bubbling cauldron of inter-specialty and multidisciplinary interaction.

As emergency medicine practitioners, we’re arguably the only nominal generalists in the hospital setting. This means that in the eyes of some of our specialty colleagues, we’re ‘second best’ at managing many of the pathologies we see. We can commence management of acute coronary syndrome, but we’re not cardiologists; we can intubate, but we’re not anaesthetists; we can even crack chests, but we’re not cardiothoracic surgeons.

This, of course, is a total fallacy. Emergency physicians might seem like generalists at surface-level, but the reality is that they ‘specialise’ in appropriately differentiating the undifferentiated. Where neighbouring specialties anchor towards diagnosing familiar pathologies (e.g. the cardiologist quickly labelling a patient’s chest pain as myocardial ischaemia), emergency physicians won’t jump to premature and potentially dangerous false conclusions, and remain open to multiple possibilities until firm evidence presents itself. In the initial phase of managing patients fresh from the community, across the spectrum of acuity, the emergency physician possesses the safest, and most expert pair of hands.

Unfortunately this isn’t always recognised by our specialty colleagues, who can overlook the inherent challenges of the emergency medicine landscape, and occasionally be quick to patronise, condescend, and even ridicule when being referred to, particularly when by a junior person.

In the more vulnerable amongst us ED folk, this can breed a false inferiority complex and erode confidence. Seniors are more likely to react with verbal pugilism if they feel disrespected.

Conflict is further cultivated by the unfortunate reality that much of our job involves giving someone else more work to do, which naturally fosters resentment on their part.

Of course, the outcome of inter-specialty collisions in the ED don’t always end in tears, and I appreciate that I might be painting a overly grim picture. However, in my experience the referral process can turn ugly very quickly, particularly when other stressors are in play (e.g. being particularly busy).

Blame culture

Doctors aren’t supposed to make mistakes. However, it’s undeniable that healthcare (especially the ED) is highly error-prone. It’s an unpredictable, dynamic environment with an extraordinary amount of moving parts.

The hallmark of a good system is a strong culture of learning from failure. The ultimate example is the peerless aviation industry, whose safety model has become the stuff of legend – they jump up and down with excitement when a plane crashes because it represents an opportunity for precious learning (2).

In stark contrast, it’s no secret that the healthcare industry hasn’t exactly covered itself in glory when it comes to promoting patient safety. From the Mid-Staffordshire Enquiry to the Harold Shipman scandal, our history is littered with examples of system failures that should have been thwarted earlier through a healthier culture of incident reporting and institutional change management.

I’m not saying we’ve had no success stories, I’m merely suggesting that there’s an awful lot of room for improvement. There’s the tragic case of Elaine Bromiley, whose death in the anaesthetic room prior to a routine sinus operation prompted an independent investigation which led to a global revolution in patient safety measures around airway management (3). It’s worth noting that the investigation was driven by Elaine’s inspirational husband Martin – a commercial airline pilot.

There are plenty of historical and structural reasons for our suboptimal safety culture, but arguably the most important factor is that society puts doctors on a pedestal, and assumes invincibility. Error is heavily stigmatised in our workplace because the public expects perfection. So when the inevitable mistakes do occur and we fear being implicated, a strategy for deflecting attention is to turn on each other. Even when there is no risk of being implicated, we still can’t resist the urge to point the finger of blame (or gossip about the incident behind the back of the guilty party) because somehow it soothes open wounds from previous public humiliations.

When it comes to mistakes, our institutional focus is on who did it, and not what can be learnt from it. Opportunities for progression usually descend into fruitless professional witch-hunts. And this culture is ingrained in us all from medical school.

The ‘patients lives are on the line’ card

Trump exonerated himself from his revolting campaign narrative by playing the ‘political correctness’ card. He fooled the electorate, and branches of the media, into thinking his verbal excrement was acceptable (even attractive) because he wasn’t a career politician and therefore didn’t ‘play by the rules’. No other presidential candidate in US history would have got away with some of the things he’s said, but he was ‘sticking it to the establishment’, so it was OK.

In a similar vein, I believe that it’s become acceptable for collegiality and decency to be left at the door of the ED because the ‘patients lives are on the line’ card gets played. The stakes are far too high for us to care about the way we treat each other.

This attitude is helped along by our very rigid, arguably militaristic hierarchical structure.

There is no doubt that a hierarchy is crucial for ultimate decision-making accountability, but it gets abused too often in my opinion. Of course some are more guilty than others, but if a senior person is feeling particularly under pressure (or, dare I say it, out of their depth), it’s all too easy for them to take out their frustrations on a defenceless junior staff member – riding the authority gradient. And it’s totally acceptable to do so, because it’s a patient’s life at stake of course.

I’m not just talking about consultants and senior nurses, it spans the entire spectrum of ED staff. I’ve witnessed a rookie doctor rotating through the ED viciously bark at student nurses for taking ‘too long!’ to attach the monitoring to a perfectly stable patient in majors – unacceptable, and an abuse of authority even at the most junior level.

Misplaced self-importance anaesthetises basic manners. We weaponise the inherent moral high ground of doctoring in much the same way that Trump weaponised being ‘un-PC’. We’re getting away with behaviour that we shouldn’t.

The irony of playing this ‘card’ (so to speak) is that our patients ultimately suffer because our multidisciplinary teammates are less willing to go the extra mile for someone they don’t like. Truly toxic stuff. Are we that self-righteous? Are we that arrogant?

Why are we not holding ourselves to a higher standard?

I am not proclaiming to be mightier than thou. I have fallen foul of high stress, surfed the authority gradient and hidden behind the fallacy that I’m making regular life and death decisions as much as the next junior emergency medicine trainee. I can recall multiple times where I’ve been unacceptably rude to colleagues, and even remember an occasion where I made a nurse cry and run out of resus. I was remorseful about those moments, but only transiently. There was always something ‘terribly important’ I could distract myself with, ridding me of the shame I felt for being a b*****d to a colleague for no valid reason.

However, those I verbally abused will not have recovered so quickly, and are now more likely to treat their future juniors as I did them on those occasions. This is the vicious cycle of bullying that I’m sure every doctor reading this post will relate to on some level, whether they can admit to it or not.

Why are we not holding ourselves to a higher standard? As front row spectators to the fragility and preciousness of human existence, surely we of all people should have more respect for each other.

We musn’t be fooled into thinking that just because we have different skillsets or seniority that we aren’t singing from the same hymn sheet. No matter what it says on your hospital name badge, we all have the same job description: help make people better.

We deal in the currency of human life, which in my opinion is the greatest professional privilege that there is. No matter how bad our day seemingly is, or how much pressure we feel under, you can bet your bottom dollar that you need to look no further than the frightened, desperate person staring back at you from the trolley to find someone worse off. That dose of perspective is a gift, and it alone should do the job of warding off Trump-like demonstrations of contempt for our colleagues.

Of course, Americans voted for Trump in their droves (in much the same way that Brits voted for ghastly Brexit). Why? That’s not for me to say; I’ll leave that to the politicos. What I can say with some certainty is that a massive proportion of the Western world feels a potent combination of embarrassment, sorrow and anger that we’ve allowed such a harmful situation to escalate.

Is this not the very same cocktail of emotions that we feel after a hostile exchange in the ED? We must strive to be better at checking ourselves before forgetting our basic human decency and engaging in needless workplace warfare.

We’re better than this.

Do the right thing

As medical professionals, our knowledge-base and skillset give us almost supernatural status in the eyes of the public. Being a doctor is more than a job, it’s a title. But that’s not why they’ll allow us to slice into their bodies, poison them with medications, and have access to their most hidden secrets. They allow us these privileges because we’re supposed to be fundamentally good people who’ll always act in their best interests no matter what the cost. We, more so than anyone else in wider society, are deemed to be the custodians of doing the right thing.

That should be something we carry with us at all times in our workplace, regardless of who we are speaking to, or the nature of the scenario. There is no place for Trumpism in the ED.

Robert Lloyd
@PonderingEM

NB: I appreciate that the content of this post is emotionally-driven, opinion-based, and potentially controversial. Please feel free to commentate/agree/criticise in the comments, it would be great to generate some discussion around the topics brought up.

References

  1. Accident and Emergency Statistics: Demand, Performance and …
  2. Black Box Thinking. By Matthew Syed.
  3. What can we learn from fatal mistakes in surgery. By Kevin Fong, BBC News.

Many thanks A3 Studios for the amazing accompanying graphic.

Live and let die

30 Nov, 16 | by cgray

lald

Everyone dies. It’s a sad fact of life and a tough part of any healthcare professional’s day. Some deaths are unexpected, and hit us hard. Thankfully, there are those that we know are coming, and this gives us the opportunity to try to give that person a peaceful and comfortable end of their life, and for their family to be present and informed when it happens, or at the very least to have that choice.

If something acutely changes, or the person deteriorates suddenly, it can sometimes be very difficult for carers or families. Despite plans for end-of-life care to take place at a nursing home, it’s not uncommon for an ambulance to be called to attend. Transferring the patient to the emergency department can be inappropriate, and have negative consequences on both care of the patient, and the experiences of them and their family in the last few hours of life. In a busy emergency department, it can be difficult to provide the dedicated medical care and emotional support that is often needed. Often we try to get the patient back home or to a ward, where the atmosphere is a bit more relaxed, but with bed pressures and if death is imminent, this can all be very difficult to achieve, though I’d like to think we try our utmost.

In October’s EMJ, Georgina Murphy-Jones from the London Ambulance Service, and Stephen Timmons from the University of Nottingham have explored how paramedics make decisions regarding transfer to hospital for nursing home residents nearing the end of their lives. As they highlight in their paper, it’s difficult to know exactly how often this occurs, but these calls are complex, and there are often multiple factors in play to consider. Face-to-face interviews were conducted with six paramedics, which were recorded, transcribed and analysed to identify themes.

It’s a fantastic paper, and really gives a good insight into how paramedics think in these situations. It can be all too easy to blame our pre-hospital colleagues for bringing patients into hospital when they have an end-of-life plan to avoid hospital admission, and die at home or another preferred place. However, it’s important to remember that whilst emergency physicians operate in an information-light, time-critical environment, paramedics and ambulance technicians often have less facts than we do, and have to make decisions more quickly.

There are some really good take home messages here from the identified themes, and food for thought for your next end-of-life encounter.

  • Paramedics find it difficult to understand patients’ wishes – in the experience of those studied, these wishes were inadequately documented or limited in content, sometimes just confined to a DNACPR decision. When nursing home staff were asked about their patients, they often did not know them or their wishes well. This made it difficult in an end-of-life situation to make a decision, as quite often the patient themselves was too unwell to express their desires verbally.
  • Evaluating best interests is difficult – when patients lack capacity to make a decision, paramedics have to make it for them. It’s difficult to do this, particularly if this is the first time you’ve met someone and have limited information. Paramedics have to weigh up the risks versus the benefits of leaving the patient at home, or bringing them into hospital, and this can be even more difficult taking into account the next point.
  • Everyone wants to have an input – decision to convey or leave at home is influenced by nursing home staff, relatives, and other pre-hospital professionals. There can be a lot of pressure from nursing home staff to transport the patient, even if alternate decisions have already been made and documented around end-of-life care. Paramedics who took part in the study described situations of conflict between staff, relatives, and patients, and the difficulties they face in trying to keep the patient at home when other parties disagree, even if the patient themselves does not wish to go to hospital.

It’s obviously hugely difficult for paramedics to make these decisions, but the overriding theme here is communication. So what can we do to help?

Document everything

In order to understand patients’ wishes, make a best interests decision, and weigh up input from all parties, paramedics need to know the facts. Information about the patient, their condition, their decisions about end-of-life care, discussions with their family, and communication with other professionals involved in their care should be documented and easily accessible. It should be easy to see what the patient wants to happen towards the end of their life, and in what cases the patient should return to hospital.

Talk to the family

Dying relatives are hard. As a family, you want to do everything you can to help your relative. Sometimes, it’s hard to feel like you’re doing everything possible unless you call an ambulance, even if your family member is already in a nursing home, being cared for. Talking to families, not just about the decision to send the patient home to die, but also about what will happen later on once the patient is actually in the nursing home, is crucial.

Empower the nursing staff

From the paper, it seems that there were instances of nursing staff not feeling able or qualified enough to nurse patients who are dying. If we send patients to a nursing home to spend the rest of their life being cared for there, we need to be sure that the nursing home have the capability and experience to do so. This ties into the first two action points also. If we document clearly the plan, and inform the family as well, the nursing home staff will have a much easier time looking after our patient, with less ambiguity. If your patient is being discharged, phone the nursing home, speak to the manager, and let them know what’s going on. The GP needs to know as well!

Support your paramedics

Not only to help them make decisions in the nursing home, but also when these patients do arrive in our ED. They’ve had to make some tough choices, usually under pressure from staff or family members, and some that they might be disappointed with because they feel it’s not the best thing for the patient. But, they’ve done what they can, in the time they had, with the information they had. We need to support them through these difficult decisions, not criticise them.

 

Much to think about regarding end-of-life care, and hopefully from reading the paper, and assessing needs in our own practice, we can try to ensure more people can achieve the death they want, in the place they want to die.

vb

Chris
@cgraydoc

Nuances of Neurogenic Shock

4 Nov, 16 | by rlloyd

nuances-of-neurogenic-shock

Even when the mechanism is highly suggestive for significant spinal injury, the shocked major trauma patient is haemorrhaging until proven otherwise; cue blood products and damage control resuscitation.

When there is no evidence of external haemorrhage in the primary survey, the EFAST is negative, and the trauma series CT shows no evidence of bleeding, a diagnosis of neurogenic shock can be considered, particularly if there is obvious focal neurological deficit.

It should always be a diagnosis of exclusion due to it’s rarity; mislabelling a hypovolaemic trauma patient with neurogenic shock will result in a bad outcome very rapidly. Having said that, the nuances of managing neurogenic shock run against the grain when compared to other major trauma principles. Thus, a sound understanding of the underlying pathophysiology is crucial if one fancies him/herself a half-decent traumatologist.

What is neurogenic shock?

Neurogenic shock is distributive in nature, much like septic or anaphylactic shock. It occurs exclusively in patients with spinal cord injuries, and results from loss of sympathetic tone to the heart and vasculature. The unopposed vagal innervation results in a deadly triad of hypotension, bradycardia and peripheral vasodilation.

Sympathetic outflow originates from the lateral horn of spinal cord segments T1 to L2 – the ‘sympathetic cord’. As sympathetic innervation of the heart arises from T1-T5 it is theorised that neurogenic shock can only occur when the spinal cord injury is at T5 or above.

In the haemorrhagic, hypovolaemic major trauma patient, a restrictive fluid regimen is employed as per principles of permissive hypotension; and the fluid of choice should always be a blood product. In contrast, managing the neurogenic shock patient is pretty similar to managing septic shock, minus the antibiotics.

The goals of therapy are to restore and maintain tissue perfusion, and in doing so, prevent secondary cord injury. Unlike other types of distributive shock where the vasculature is ‘leaky’, neurogenic shock is purely vasoplegic with no hypovolaemic component. Therefore, the mainstay of therapy is judicious crystalloid with early vasopressors. Overzealous fluid administration can result in iatrogenic pulmonary oedema.

In real life, these patients are rarely ‘either or’. The multiply injured will usually be juggling haemorrhage, pain and anxiety, which wreak havoc on the vital signs, obscuring the characteristic bradycardia/hypotension combination one would expect to see in neurogenic shock.

It is complex, life threatening, and notoriously difficult to identify.

Recent EMJ paper – Taylor et al, October 2016

An interesting recent EMJ publication tackles this issue by exploring the nature of neurogenic shock presentations in a UK-based major trauma centre over a 3-year period. Appropriate patients were selected from the hospital’s TARN database, and their clinical notes were subsequently interrogated.

Out of 33 patients identified as sustaining a spinal cord injury, only 15 experienced neurogenic shock. This was despite a pretty wide net being cast in terms of criteria; an episode was defined as: systolic blood pressure <100mmHg and heart rate of <80bpm recorded concurrently.

Naturally, this tiny study group prevents any concrete conclusions being drawn from the data, but it’s reflective of the remarkably rare nature of neurogenic shock – which in itself is an important point to appreciate.

Vital signs were looked at from the prehospital and ED environments, which is unique to this study – previous similar publications have only investigated patients in spinal injury units. As such, they found that time of presentation was highly variable in these patients. The earliest appearance of neurogenic shock was 13 minutes post-injury, and the latest appearance was 263 minutes post-injury. In many of the patients that presented later, they had normal vital signs prior to going into neurogenic shock.

Four patients had anatomic lesions below T5 (1 at T9, 3 at L1), which contradicts the theory that neurogenic shock can only occur from spinal cord injuries at T5 and above. The authors suggest that this is explained by the fact that the whole length of the sympathetic cord supplies innervation to the vasculature, and interruption at any level has the capacity to induce shock, independent of heart involvement (i.e. entirely vasoplegic). Two-thirds of patients had cervical cord injuries.

Perhaps predictably, patients with complete spinal cord injuries were significantly more likely to experience neurogenic shock when compared to those with incomplete injuries. However, the authors were unable to identify any clues that predicted severity of neurogenic shock (judged by presence of marked/persistent bradycardia or hypotension); this included type of injury (i.e. complete or incomplete) and vitals when neurogenic shock first presented. However, it’s worth remembering how small the studied cohort was.

Take-home message 

Neurogenic shock is an elusive diagnosis to confidently make, particularly when there is a cloudy ‘mixed-shock’ picture. We must remember to consider it in patients with a suggestive mechanism of injury, and appropriately tailor management when it’s likely to be in play.

It’s unpredictable, variable in onset and should be considered in shocked patients with any type of spinal injury, regardless of anatomical level. Awareness of these nuances will improve outcomes.

Presentation of neurogenic shock within the emergency department. Matthew Pritam Taylor, Paul Wrenn, Andrew David O’Donnell. Emerg Med J doi:10.1136/emermed-2016-205780

Robert Lloyd
@PonderingEM

The weekend effect: Part 2 – a traumatic time!

29 Oct, 16 | by cgray

the-weekend-effectpart-2-a-traumatic-time

If you haven’t already, listen to Ellen Weber and Chris Moulton talk about the background to the weekend effect. Click HERE.

The UK Junior Doctors’ contract changes imposed by the government in order to shape their poorly defined ‘Seven Day NHS’ caused much debate and consternation surrounding the ‘weekend effect’, which seemed to be the main selling point for their demoralisation of a large proportion of the clinical workforce. Patients admitted over the weekend have been shown in several studies to fare worse than those admitted during the week (though indeed other studies suggest the opposite, or no difference at all!). The reasons for this are unknown however, and further research is being done to try to ascertain the cause of the ‘weekend effect’, whether particular patient groups are more at risk, and what, if anything, can be done to improve care. There is currently no evidence that doctor staffing levels are the cause and many feel that the effect simply reflects that patients who present over the weekend are, on average, more unwell. Other factors could include coding practice, or the availability of diagnostic resources at the weekend. However, all agree that if this effect truly exists, it’s important to establish why, as this will then determine whether it can be modified through changes to service provision or structure, in order to treat our patients better.

David Metcalfe and team from the University of Oxford are one group looking into this. Published on the EMJ website earlier this morning is their paper on the weekend effect in major trauma.

metcalfeabstract

The abstract is here, but as always we’d advise you read the full paper to draw your own conclusions.

Major trauma networks have been around for four and a half years now, with the most severely injured patients preferentially triaged to the major trauma centres (MTCs). Patients arriving at these hospitals are usually managed from the start by a consultant-led trauma team, whether it’s 10am on a Tuesday, or 3am on a Sunday. Access to imaging, diagnostics, surgeons, and emergency operating staff and space are also a necessity for these centres, and MTCs are rewarded under a best practice tariff (BPT) for meeting quality standards.

Who was studied?

49,070 major trauma patients (adult and paediatric) presenting to the 22 MTCs around the UK. The inclusion criteria were admission for at least 3 days, requirement for high-dependency care, or death following arrival at hospital. Data were gained from the Trauma Audit & Research Network (TARN) database from the time the BPT was introduced, and for each hospital only from after the period they were operational as an MTC. From this the authors hoped to gain more complete data, as this improved after the BPT was put in place.

The group also subdivided patients later according to injury severity score (ISS), and whether they presented during the day (0800 to 1700), night (1700 to 0800), weekday, or weekend (Saturday or Sunday).

What did they find?

If we took the total data collected by the team, and condensed all these patients down so that they all presented to major trauma centres in just one week, 327 patients per hour would have turned up during weekdays, 333 per hour on weekend days, 210 per hour on week nights, and 419 per hour on weekend nights. Of course, the reality is much less, as these data were spread out over the period of the study, but these numbers give a good indication of major trauma frequency across the week.

Major trauma occurs more frequently on the weekend, and the patient characteristics demonstrate that those presenting at night are generally younger, with a higher male:female ratio. Less patients were conveyed via air ambulance at night, likely as a result of flying restrictions at these times.

Aside from a shorter length of stay in patients admitted during weekend nights compared with weekend days, there were no significant differences in the primary outcomes of length of stay, mortality, risk-adjusted excess survival rates, or Glasgow outcome score when comparing groups.

The study found that patients presenting with major trauma at night were more likely to be transferred into a Major Trauma Centre at night, which likely reflects daytime availability of diagnostics and specialist input at trauma units. There was no difference when comparing weekday to weekend day, however. There were also no significant differences found in the ISS >15 subgroup in any of the outcomes.

They found no evidence of a ‘weekend effect’ in this major trauma population.

What conclusions can we draw?

This is a large population multicentre observational study, with good data completeness, clear inclusion criteria, and clear outcome measures. There are no significant findings when comparing various groups, and the outlined definitions of day vs night are consistent with normal rota patterns.

The major trauma network is intended to provide well-staffed and resourced hospitals with senior specialists available 24/7 in order to provide severely injured patients with expedient access to necessary investigations and treatment, facilitating the best possible outcome. Whilst there is no evidence of a ‘weekend effect’ in patients presenting to MTCs, this does not mean that it does not exist elsewhere. If a difference had been found, however, this would suggest that staffing and resourcing in the hospital make little difference and that there are other forces at work.

Further work is needed on other populations, but it is reassuring that, unlike data from the US that trauma patients admitted at night are more likely to die, a large scale study of the UK major trauma centres has shown equivalent outcomes throughout the 24/7 hours of operation. It’s a fantastic achievement and one that all those working in centres across the country should be proud of.

vb

Chris
@cgraydoc

 

If you haven’t been keeping up with the recent body of evidence surrounding the ‘weekend effect’, the Vice-President of the Royal College of Emergency Medicine, Chris Moulton, has provided a fantastic commentary to the Metcalfe paper. He’s also managed to give us a history lesson on the origins of the weekend at the same time. It makes for great reading.

The weekend effect. Part 1.

28 Oct, 16 | by scarley

the-weekend-effect

Chris Moulton VP of the Royal College of Emergency Medicine and Ellen Weber discuss the weekend effect. This is well worth a listen to get behind the headlines and politics of a controversial meme in healthcare.

What is it? Is there an effect and what can we do about it?

Click on this link to read more about the paper on Chris Gray’s blog.

 

vb

S

 

Primary Survey: November 2016.

22 Oct, 16 | by scarley

primary

Richard Body, Associate Editor

The Manchester derby for paediatric early warning scores

There is clearly a need for a validated physiological early warning score for specific use in the paediatric emergency department (PED). In this issue, Cotterill et al compare two paediatric early warning scores developed in Manchester: the Royal Manchester Children’s Hospital Early Warning System (ManCHEWS) and a modified version, the Pennine Acute Trust Paediatric Observation Priority Score (PAT-POPS). The modified score incorporates the original physiological scoring system but also takes account of the nurse’s judgement and specific elements of a patient’s background. This Manchester derby was a close call: but will the marginally superior accuracy of PAT-POPS for predicting hospital admission ultimately win over the simplicity of ManCHEWS?

Future emergency care: the (citizen’s) jury has spoken

In Queensland, Australia, Scuffham et al took an extremely interesting approach to patient and public involvement. They convened a citizen’s jury to deliberate on matters relating to the delivery of emergency care. The jury’s verdict is intriguing and highly relevant to the future of Emergency Medicine. The participants were clearly amenable to alternative models of emergency healthcare delivery including care provided by allied health professionals and decisions not to transport patients to hospital from the pre-hospital environment.

What is ‘productivity’?

If you sometimes feel that measuring productivity in the Emergency Department has the potential to create a dehumanized production line (and even if you don’t), this month’s paper by Moffatt et al is a ‘must read’. In a series of semi-structured interviews with healthcare practitioners working in an Emergency Department, this team explores their feelings about the notion of ‘productivity’. The findings are heartening and are sure to kindle a warm feeling in the heart of any emergency physician. Hopefully this important work will lead to greater recognition of the need to retain compassion in our practice, promote an appropriate balance between ‘care’ and ‘efficiency’ and avoid the “sausage factory” mentality, to quote one of the participants.

A SuPAR new biomarker of serious illness?

In Emergency Medicine we are becoming accustomed to the use of biomarkers that may lack specificity for any one particular condition, but that provide important prognostic information. Lactate could be considered one such biomarker, and its interpretation has become an important skill for emergency physicians. This may suggest that we are at the dawn of a new era for biomarkers. Our traditional ‘binary thinking’ about diagnostics, whereby tests can simply tell us whether a patient does or does not have a particular disease, is beginning to seem crude and outdated. In this issue, Rasmussen et al measured SuPAR at the time of admission to an Acute Medical Unit in a cohort of over 4,000 patients. SuPAR was shown to predict mortality and the need for hospital re-admission even after adjustment for confounders. The findings are impressive, and this work must lead on to further research to identify how this interesting non-specific biomarker can be used to guide real life healthcare decisions.

Health inequality and the global importance of emergency care

We know surprisingly little about the relationship between emergency care provision and the impact of emergent conditions on health, internationally. Of course, emergency physicians might expect that failure to provide adequate emergency care would lead to greater mortality and morbidity from such conditions. In this issue, Chang et al quantify this problem. In an analysis from 40 countries, they found that all fifteen of the major global causes of mortality and morbidity can present emergently, and identified that insufficient access to emergency care is clearly associated with higher mortality and morbidity. This makes sobering reading as a demonstration of global health inequality, and highlights the pressing need to develop Emergency Medicine internationally.

vb

Rick Body

@richardbody

How Junior Doctors Think: A Guide for Reflective Practice

19 Oct, 16 | by rlloyd

how-do-junior-doctors-thinkl_

In the UK, junior doctors will rotate through emergency medicine in their second year post-graduation (Foundation Year 2). They’re granted autonomy to make independent decisions and ‘own’ patients for the first time.

Elsewhere in the hospital, a junior’s role is largely secretarial, and generally within the confines of ‘normal working hours’. In the ED, the hours are brutal, the pace is relentless, and the sudden spike in responsibility ED is daunting. The learning curve is steep, but rewarding.

‘My first shift in the ED was the first time I felt like a real doctor.’

Perhaps the most unique element is the density of decision-making. Each shift serves up a broad menu of undifferentiated patients ‘fresh’ from the community, often requiring multiple investigations/interventions. When you consider the wider landscape of an ageing population, over-burdened health service, and the much maligned 4-hour target, it’s an undeniably tough job for rookies; a pressure-cooker workplace that’s fertile ground for misdiagnosis and clinical error.

Therefore, in the interests of patient safety (and junior doctors overall wellbeing) it’s important to understand the mechanisms by which junior doctors collect/process information, and make decisions. Otherwise known as ‘clinical reasoning’.

Published in the EMJ in June 2016, Adams et al have qualitatively investigated clinical reasoning in junior doctors rotating through the ED for the first time. Thirty-seven doctors were interviewed and took part in focus groups. Questions and discussion were based around retrospective recall of two cases (one straightforward and one difficult case).

The authors used ‘dual cognition theory’ (DCT) as a framework. DCT describes two distinctive cognitive approaches to decision-making: ‘Type 1’ thinking (T1) is automatic and intuitive; ‘Type 2’ (T2) is deliberate and analytical.

This system was, of course, pioneered by Daniel Kahnemen in his book ‘Thinking Fast and Slow’ (essential reading). Below is a video which provides a useful visual explanation.

Key findings from the paper:

  1. There are 3 phases of clinical reasoning in junior doctors – each is briefly explained below, but for more complete explanations please read the original paper.
  2. During all 3 phases, both thinking pathways (T1 and T2) were working in parallel.

*Please note: indented sentences in italics are my own interpretation of the research, not actual quotes from the data.

Phase 1: Case Framing

Initially, a decision needs to made whether to go into clerking mode (i.e. systematic enquiry) or ‘resuscitation’ mode (call for help, ABC approach etc).

The information processed to make this decision are clues from the patient demographics, triage note and ‘end-of-the-bed-o-gram’.

Phase 2: Evolving Reasoning

The next phase involves establishing a diagnosis. This happened in two ways:

1) Diagnosis instantly recognised (T1 predominant)

Usually from a single cue in the assessment.

‘This patient has right iliac fossa pain. It’s probably acute appendicitis.’

These reflex diagnoses are then interrogated for error via:

  • Screening for ‘red flag’ features
  • Diagnostic timeout’ to organise thoughts
    • Reflection whilst writing patient notes
    • Informal discussion/presentation to a colleague
  • Begin another task, allow opportunity for spontaneous thought (passive diagnostic timeout)

2) Diagnosis not recognised, further analysis commences (T2 predominant)

With no immediate diagnosis reached, ‘hypothetico-deductive reasoning’ is employed. This is where multiple possible hypotheses are generated, and then the history, physical examination, and investigations are used to test these hypotheses, with a view to eliminating them one-by-one.

The ‘SOCRATES’ mnemonic is a useful tool for challenging hypotheses in chest pain patients.

‘Site? Onset? Character? Radiation? Associated symptoms? Timing? Exacerbating/relieving factors? Severity?’

Ongoing observation is also employed to test diagnostic hypotheses, and to screen for an evolving clinical scenario.

‘The inflammatory markers are higher than I thought they’d be. This patient is likely to be septic. Let’s start IV antibiotics and refer to the medics.’

Phase 3: Ongoing Uncertainty

This was predictably common in an inexperienced cohort of doctors, and dealt with via:

  • Delaying discharge and continuing to observe
  • Simplifying the overall decision: ‘is this patient too unwell to go home?’
  • Sharing responsibility
    • With seniors
    • With peers via informal discussion
    • With patients via safety netting

Three points I’ve taken from the paper…

1) Inexperience can lead to ‘misframing’

T1 judgement was the dominant thinking pathway during ‘case framing’, particularly when it came to first impressions – a ‘gut-feeling’ assessment of acuity.

A lack of experience might prevent juniors from picking up on subtleties (e.g. sweating, mild agitation), or get falsely reassured by certain details (e.g. normal vital signs) that a senior doctor would not, and ‘misframe’ the patient’s level of acuity. Clearly, this has the potential to be detrimental to patient outcomes.

For this reason, focused reflection on this crucial phase of the assessment via case-based discussion with a senior colleague is critical. It will encourage juniors to gain some insight into how their own intuitive thoughts play a prominent role, and perhaps encourage them to interrogate those thoughts for biases.

‘Did you make any assumptions about this patient before seeing them?’

‘Were there any clues or triggers when you first saw them that changed how you felt about the case?’

‘Can you think of any other clues that might subtly point to the patient being more unwell than the triage note suggests?’

2) Diagnostic time-outs should be encouraged

It was established that junior doctors would utilise diagnostic time-outs whilst writing notes or via informally presenting to peers. This is an important part of the clinical reasoning process, particularly in complex patients. It can safeguard against premature ‘closure’ of a case (i.e. jumping to conclusions, and then sticking with them incorrectly) .

Again, this part of the process needs to be reflected on, so that it’s utility is appreciated.

‘It was when I was writing the notes about the 68 year-old male that I thought had renal colic, that the possibility of ruptured AAA came into my head. It’s a useful moment to think about the case.’

Diagnostic timeouts should be encouraged by higher ups, despite being potentially time-consuming, and particularly if the shop floor is manned heavily by junior doctors (a not-uncommon scenario). Despite the overburdened and target-driven climate of UK  emergency medicine, departments must avoid falling into the trap of pushing their staff to work faster. Patients are safer when junior doctors are given the chance to slow down and think.

3) Juniors should be given protected time for case follow-up

The transient nature of our patient encounters in the ED can lead to an ‘out of site, out of mind’ culture, where we fail to follow-up uncertain or particularly interesting cases. Again, this is re-enforced by the pressure to work quickly. This represents a glaring missed opportunity for learning, and the lack of diagnostic feedback potentially leads to the propagation of flawed clinical reasoning, particularly in inexperienced doctors.

Perhaps juniors should be given protected time to follow-up on cases they’ve seen (read discharge summaries/visit ward/call patient at home if discharged). They could then log this process, and formally reflect on notable cases with a supervisor.

This paper has highlighted that junior doctors have a tendency to make judgements on single cues, as opposed to pattern recognition, and can draw premature conclusions from insufficient clinical information. There is no doubt that regular feedback on real cases will serve as a powerful tool to improve clinical reasoning. It will gradually nudge them towards the realm of expertise.

Much like the encouragement of diagnostic timeouts, the key is likely to be departmental culture change. This will require brave consultants and senior nurses.

Final Thoughts

This paper should serve as a guide for junior doctors (and their supervisors) for more focused, effective reflective practice.

It’s not just about reflecting on the pathology encountered and decisions made, it’s also about the clinical reasoning process that led to those decisions. The journey is just as important as the destination. Junior doctors should be reflecting on how they think.

Additionally, departments should strive to create a healthy environment for regular reflective practice, and not to prioritise targets over the development of junior doctors clinical reasoning skills.

The Paper

Clinical reasoning of junior doctors in emergency medicine: a grounded theory study
E Adams, C GoyderC HeneghanL BrandR Ajjawi
Emerg Med J emermed-2015-205650
Published Online First: 23 June 2016 doi:10.1136/emermed-2015-205650

Many thanks to Dr. Emily Adams, the primary author, for her assistance in the creation of this blog post.

Robert Lloyd
@PonderingEM

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