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The Role of IO in Trauma: A #FOAMed Debate

11 Oct, 14 | by rradecki

The Emergency Medicine Journal recently published a review of intraosseous access experience from the Royal Army Medical Corps. This review documents 1,014 IO devices and 5,124 infusions of blood products, medications, and fluids. There were no major complications, and the rate of minor complications was extraordinarily low – the most frequent being device failure, occurring approximately 1% of the time.

But, what is the role of intraosseous access in trauma?

Who is Dr. Brohi, you may ask? Just the head of the LondonTIER, Professor of Trauma Sciences in the Blizard Institute, Barts and the London School of Medicine & Dentistry, and Consultant Trauma & Vascular Surgeon at Barts Health NHS Trust. Someone whose opinion is worth a listen. If you have any doubts, watch him speak at SMACC GOLD.

To say his comment spurred a rivulet of FOAM would be an understatement. To see the entire thread of responses and branching conversations, start here and don’t stop scrolling. But, a few of the highlights:

What do you think?  Do you agree – the IO is, as used by the Royal Army Medical Corps (RAMC), a temporary tool prior to definitive access in a trauma center?  Or, do you find utility, even in the setting of a fully capable trauma resuscitation?

Highlights from the October issue of EMJ

10 Oct, 14 | by scarley

EMJ_100x100Emerg Med J 2014;31:793 doi:10.1136/emermed-2014-204282

Highlights from this issue

  1. Ian K Maconochie, Deputy editor

Conducting emergency research when consent and consultation are a challenge (editor’s choice)

Studies in patients with emergency conditions that render them unable to give consent have been very difficult to conduct owing to ethical considerations. The guidance offered in the commentary by Gavin Perkins should bring significant benefit to this under researched population, an example of which is seen in this month’s editor’s choice: Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for pre-hospital traumatic pain randomised controlled trial. This is a follow up report on trauma patients who participated in a randomised trial of pain relief in the pre-hospital setting. The initial paper found that ketamine had significantly better analgesic effects than morphine; however regardless of treatment, persistent pain is still a big problem for many patients at 6 months, affecting quality of life.

Comparison of intubation modalities in a simulated cardiac arrest

Advances in intubation techniques include video assisted devices (VAD). This study looked at how long the procedure takes with 2 different modes of intubation, either direct laryngoscopy (DL) or using VAD, with and without bougie.

Twenty emergency physicians with prior training in these modes of intubation intubated a mannequin with a difficult airway on a hospital bed whilst continuous CPR was delivered.

Did the VAD improve time to intubation, and when a bougie was used, was this quicker than DL?

VAD was quicker than DL (median 20.6 seconds, IQR 17.7–27.1 as compared with 27 seconds, IQR 20.3–35.4.) However, using a bougie with the VAD added considerable time: 60.1 seconds (IQR 39.1–99). This important result leaves some questions: is a bougie really useful in this situation? Is its use deleterious? Maybe a future study looking at bougie use in the difficult airway in adults and children should be planned.

The effect of elevated serum alcohol on the outcome of severely injured patients

This retrospective cohort study looked at 184 criteria-selected patients admitted to Trauma Unit at the University Hospital between October 2008–December 2009 with injury severity scores above 17. Patients were stratified into 2 groups: blood alcohol level positive (BAL+) with >5% level of alcohol, and those with lower/no blood alcohol level (BAL–).

Injury severity scores were similar in the groups, but there was more traumatic brain injury in the BAL+ patients.

There was no significant difference in mortality between the 2 groups, the causes being similar in both. Nor were there significant differences in length of stay in hospital and ICU, or duration of ventilation.

Does this mean that alcohol has no effect? The jury is still out. Similar studies are needed from multiple centres with aggregated data to address this question.

The sad truth about the SADPERSONS Scale: an evaluation of its clinical utility in self-harm (reader’s choice)

This SADPERSONS score, devised in the US in 1983 for medical education, is supposed to help identify individuals at risk following a suicide attempt. Despite prior studies showing a lacklustre performance, the score continues to be used in EDs. The study in this issue followed 126 consecutive individuals of all ages presenting to a large UK general hospital with self-harm (including poisoning), to see if they re-presented to the ED within 6 months. All patients were also assessed by the specialist self-harm team. Using the previously recommended cut-off score of ≥7, SADPERSONS failed to identify 80% of subsequent self-harm and 50% of those who needed further secondary management. The authors conclude that use of the score by itself is insufficient to ensure that optimal care can be delivered.

A population based study on the night-time effect in trauma care

This retrospective study reviewed 1940 cases in the Emilia-Romagna area of Italy (with 4.5 million inhabitants), which has had a centralised trauma system since 2006 Out-of-hours and in-hours mortality of trauma patients was examined including, unusually, patients transferred from to the major trauma centre from the 84 satellite hospitals in this region.

There were fewer secondary night–time transfers but with an increased risk of mortality in this group. Another interesting finding is that only 40% of patients with severe trauma came to the major centre, a figure which the authors say, is paralleled in other health systems in the world.

The night-time effect on mortality is attributed to the ‘lack of homogenous transfer protocols and of a standard level of pre-hospital care around the clock’. It would be interesting to see what the impact of addressing these issues might be and to hear from other health systems if similar problems are found in trauma care networks.

Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study

Does a triage system plus a co-located GP unit reduce costs in delivering care? The answer appears that it does. In this study from Switzerland, the cost reduction overall was a staggering 417 000 Euros. Can you show cost reduction if you have a similar system in place?

Randomised trial comparing the recording ability of a novel, electronic documentation system with the AHA paper cardiac arrest record

Sixteen anaesthetists were asked to view pre-recorded PEA or VF arrests and document what happened using paper and electronic systems. There were fewer missed events, less irrelevant information noted and fewer mistakes made in documenting those events using the electronic system. It seems the quality and meaning of the data is enhanced by an electronic recording system.

An evaluation of the referral process in the emergency department

This is an area fraught with misunderstanding and potential upset if things go wrong! Miscommunication is frequently cited in serious events, but is commonplace in delivering healthcare. This study looked at how ED and non-ED clinicians felt about referring patients and offers some solutions to this key area of patient care.

And still more…

In addition to the other articles and features in the October issue, EMJ will be publishing an on-line issue with free, full-text access to all articles for the next three months. Find it from September 30th here

Support EM in Africa

9 Oct, 14 | by scarley

Screenshot 2014-10-09 09.16.06Emergency Medicine is an emerging specialty the world over and we at St Emlyns and the EMJ are alwayts keen to promote innovation and learning wherever it takes place. In the past we have wholeheartedly supported the fantastic “Developing EM Conference” and its aims. Teaching and learning collaboratively across geographical borders is a challenge; teaching and learning across huge resource disparity is an even bigger one.

This month we have the opportunity to support another intervention for worldwide EM.
The African Federation of Emergency Medicine relies on financial support to assist delegates to attend its meetings. The second AFCEM conference is not far off but donations have been hit heavily in the wake of Ebola.

If you’ve ever been to a medical conference you know how amazing it feels to meet like-minded clinicians, to share knowledge and experience, build friendships and partnerships and to problem-solve together. African EM clinicians need your help in order to be able to attend the AFCEM 2014 AFCEM meeting in Addis Ababa next month.

Please support an African delegate – any financial contribution will help. You can AFCEM Support a Delegate Support a Delegate here.

You can read more about how this can make a difference in Help African EM Now! – LITFL this great piece by  Katrin Hruska on Twitter  over at Life in the Fast Lane.

Support an African delegate – together we can build EM the world over.

UPDATE – As of this today we have managed to assist 6 delegates to the conderence – let’s make it many many more




Natalie May

Consultant in Emergency Medicine

Royal Manchester Children’s Hospital


This post first appeared at St.Emlyn’s

Exit Block Kills: College of Emergency Medicine launches new campaign

9 Sep, 14 | by scarley

Launched at the UK College of Emergency Medicine conference in Exeter today. Cliff Mann launched the latest campaign following from the CEM 10.

The bottom line is that crowded emergency departments harm patients.

Watch the video to learn more.


This month’s primary survey from EMJ

8 Sep, 14 | by scarley

EMJ_100x100Highlights from this month’s issue

  1. Steve Goodacre , Deputy Editor
  2. Ellen J Weber,  Editor in Chief


Restart a Heart

What do you have planned for October 16? Perhaps it’s a shift, or a few meetings, or a day of walking? All important, but perhaps you can spare a few minutes that day to encourage someone you know to take a CPR class? Or you can call the school your children go to and ask when they are going to start teaching CPR (and volunteer to help!). October 16 is European Restart a Heart Day, and in anticipation, we’ve included four articles in this issue—commentary and research—from international authors highlighting failures and opportunities to improve on bystander involvement in emergencies. Professor Tzi Bun Ng discusses the tragedy of a middle-aged woman who collapsed in a busy Chinese subway station but neither bystanders nor station employees came to her aid. The study by Vaillancourt, and. a systematic review by Zhimin He et al provide data on teaching first aid and resuscitation to the oldest and youngest among us. Andrew Lockey provides a commentary making a very good case for teaching CPR in schools.

Predicting ambulance journey times

Reconfiguration of emergency services is a topic that regularly attracts a lot of attention in EMJ. The potential benefit to patients from centralising specialist care needs to be balanced against the potential harm caused by increasing ambulance journey times. This means that before services are reorganised we need to estimate the impact of reorganisation upon ambulance journey times. An obvious way of doing this is to use commercially available Geographic Information Systems (GIS) software to estimate journey times, but do these estimates provide an accurate reflection of emergency ambulance journey times? McMeekin and colleagues compared GIS predictions to recorded times for 10 156 emergency ambulance journeys and found that the mean prediction discrepancy between actual and predicted journey times was an under prediction of 1.6 min. This difference is unlikely to be clinically significant and suggests it is reasonable to estimate journey times for service planning using generic GIS software. However, if you are thinking of using GIS software to predict the journey time of a specific patient to your hospital, then it might be worth bearing in mind that an average may not reflect substantial variation in the individual data.

Laryngeal mask airway or endotracheal intubation?

Endotracheal intubation may be seen as the gold standard for securing and protecting the airway but high failure rates and the risk of complications have led to concerns about use in the pre-hospital setting. As a consequence the laryngeal mask airway has been suggested as an alternative. Bosch and colleagues evaluated the use of a laryngeal mask airway in 50 patients in the Dutch ambulance service and report a 100% success rate with 98% success at the first attempt. This suggests potential for the laryngeal mask airway to provide better airway control than endotracheal intubation but randomised data are clearly required to determine comparative effectiveness. The scene is set for a trial of pre-hospital airway management—is anyone bold enough to take on the challenge?

Point of care testing—is it worth the cost?

Point of care devices can provide quicker availability of results and shorten emergency department length of stay but usually incur increased costs compared to laboratory testing. It is tempting to assume that a point of care test that provides results an hour earlier than the laboratory will reduce length of stay by an equivalent amount. However, randomised comparison is required to test this assumption. Asha and colleagues randomised 811 patients to receive either point of care or laboratory testing and found that point of care testing was associated with mean reductions of 26 minutes in time to disposition decision and 20 minutes in emergency department length of stay. Mean pathology costs were $12 higher in the point of care group, so $113 was being paid per hour saved in time to disposition. This adds up to a lot of dollars but also a lot of potential time saved across an emergency department population. Careful consideration is required to decide whether such expenditure is worthwhile.

Diuretic administration in acutely decompensated heart failure

Intravenous diuretics are often used in acute heart failure. The intense urine output achieved after administration is often viewed with satisfaction by the clinician, if not the patient. Llorens et al aimed to determine the effect of different administration strategies upon diuresis and a number of secondary outcomes in a randomised controlled trial of 109 patients with acutely decompensated heart failure. They found that continuous infusion produced a greater 24 hour diuresis than bolus administration but was more likely to result in hypokalaemia. There were no significant differences in improvements in clinical symptoms or signs between the three groups. This raises the question of whether there is any causal association between producing a substantial diuresis and improving relevant outcomes in acutely decompensated heart failure.

Lumbar puncture for suspected subarachnoid haemorrhage

This is another topic that engenders strong debate, often between those with contrasting perspectives of the problem. Emergency physicians see a large unselected group of patients often indiscriminately investigated with CT and doubt whether all those with negative CT really need lumbar puncture. Neurologists and neurosurgeons see the highly selected group with positive tests, including those with negative CT but positive lumbar puncture, and conclude that failure to perform lumbar puncture is unthinkable. Stewart and colleagues add some more data to inform the debate. In a cohort of 244 patients investigated for suspected subarachnoid haemorrhage they found that the sensitivity of CT for subarachnoid haemorrhage was 93.8%, rising to 95% if limited to scan performed within 12 hours of ictus. This suggests that CT alone is inadequate to rule out subarachnoid haemorrhage when it is suspected. The question remains though—when should we suspect subarachnoid haemorrhage? The prevalence of subarachnoid haemorrhage in the study cohort was 29%. If clinicians were able to select such a high prevalence cohort for investigation the debate about lumbar puncture would become largely irrelevant.

Is the Opioid Epidemic Just an American Problem?

3 Sep, 14 | by rradecki

Many problems among developed countries are unique to the United States. Gun violence is at levels comparable to locations of civil unrest around the world, and we are proud of our world leadership in obesity. Our dysfunctional healthcare incentives and payment system, despite many examples of innovative excellence, shows starkly different health status based on socioeconomic standing.

Opioid abuse and overdose is a rapidly increasing issue in the United States.  Even more damning is the obvious: all the opioids in circulation are at some point prescribed by physicians.  There are no fingers to be pointed except at ourselves.   Opioid abuse has given rise to increased heroin use and sporadic clusters of deaths, as unfortunate addicts find their typical supplies laced with fentanyl or acetyl-fentanyl, each far more potent concoctions.  Naloxone auto-injectors have recently gained notoriety – but, while these are life-saving in the appropriate circumstances, the devices cost several hundred dollars and address the symptoms of the epidemic, not the root causes.

The Academic Life in Emergency Medicine recently hosted an excellent Google Hangout discussing the challenges associated with opioid prescribing – balancing the alleviation of suffering with downstream diversion and other complications. Resident authors from the Harvard-Affiliated Emergency Medicine Residency were joined by clinical toxicologists from Toronto and Washington, D.C., to discuss appropriate analgesia in the Emergency Department. Surprisingly, many resident respondents felt this aspect of practice was highly neglected in their training.  The video discussion, the comments section, and the accompanying Twitter feed highlight questions and responses from all levels of training and expertise.

One of the other interesting question posed, however, was – how are prevalent are opioid prescribing and abuse issues outside the U.S.? Are you evaluated on patient satisfaction – and pressured to give opiates as a result? Are prescription databases widely available to screen patients at risk for abuse or diversion? How was your analgesic education handled?

Developing EM in Brazil 2014

31 Aug, 14 | by scarley

The following video tells us more about the fantastic project that is ‘Developing EM’. I found it on the excellent (and must visit site PHARM).

Bishan Rajapakse interviews Lee and Mark on what they hope to develop both in Brazil and in future conferences.

Please listen and consider attending in the future.

This year’s conference is in Salvador de Bahia from September 8-12th and although it might be a little late to get there this year please check out the website and consider making a late dash this year, or make time for 2015.



PS – Bishan is famous for many things and is a real talent. Check out this clip to see what he gets up to in his free time….

Highlights from the August EMJ

8 Aug, 14 | by scarley

Ellen Weber

Ellen Weber

Ellen J Weber, Editor in Chief

From DRC to DAR

Last fall, I had the extraordinary opportunity to spend two months at Muhimibili Hospital in Dar Es Salaam, teaching in the first emergency medicine residency in Tanzania. During this time, I was reminded of what a privilege it is to be a physician, and how lucky I was to grow up in a country where the path to medical school was straightforward, my life relatively stable, and my work, although stressful and chaotic, secure. This month, the view from here features an interview with an inspiring young physician who has travelled a far more dangerous and circuitous path. Dr Mudenga Mutendi Muller describes his experiences in a hospital during the war in Goa, assuring safety for his family, then leaving his home country to begin EM training in Tanzania. More of our interview can be heard in our podcast at:

An old medication raises new possibilities–and questions

Methoyxflurane, an inhaled anaesthetic agent used in the 1960’s and 1970’s, has analgesic properties at sub-anaesthetic doses and has been used for pain management in Australia in pre-hospital and emergency care for many years. However, there are few randomized trials and it is not licensed in the US or UK. This month, Coffey et al report the findings of a multicenter placebo-controlled trial of methoyxflurane for pain in ED’s in the UK. Readers may ask why a comparison to placebo was necessary and how the results should be interpreted when other active agents exist. In a related commentary, Simon Carley and Richard Body discuss the issues.

You are getting sleepy–aren’t you? (Editor’s choice)

Oral midazolam for sedation of young children needing laceration repairs is unreliable, and has led many of us to IV or IM ketamine. But what about combining oral midazolam and oral ketamine? A double blind randomized trial by Barkan et al found that children given both agents had deeper sedation, and required less IV sedation, than those administered midazolam alone, although VAS scores for the two groups, as assessed by the investigators and parents, were not different. Another arrow in the quiver for pediatric sedation? Perhaps, but be aware that the children receiving both ketamine and midazolam stayed nearly an hour longer in the ED.

That CT scan may not be what parents want after all…

Two young parents bring their only child into the ED after he fell off a chair and hit his head. They are worried. After examining the child, you consult your head injury guidelines and, using your best bedside manner, make a recommendation to the parents. Have you convinced them? It depends. Seriken et al found that among parents of young children with minor head injuries, those with more education were less reassured at the end of the visit, and mothers were less reassured than fathers. Interestingly, parents whose child had a CT were no more reassured than those that didn’t, while neurosurgical consultation had a positive impact. The study was conducted in Turkey, but its findings hit home with me.

Its not about catching babies

A review of 66 obstetric cases retrieved by physician-led helicopter teams in Sydney reveals some staggering data on the skills needed for these critical transports. Two thirds of cases involved haemorrhage, followed by eclampsia. Nearly all patients required mechanical ventilation; retrieval physicians intubated in 23 cases and established central lines in 30 patients. The authors conclude that “Exhaustive training in obstetric emergencies may not reflect the learning needs of physicians in services such as ours” and propose a training curriculum.

Is it time to put mannitol on the bottom shelf? (Reader’s choice)

Mannitol has been the go-to osmotic agent for lowering intracranial pressure (ICP) in head trauma for nearly a century, but its primacy is being challenged by hypertonic saline. In a meta-analysis confined only to randomized studies of these agents for traumatic brain injury, Rickard et al found no significant difference in ICP-lowering ability, although the trend favored hypertonic saline. So is it time to shelve the mannitol? Unfortunately, more study is needed.

How happy are patients with Emergency Care Practitioners?

Emergency Care Practitioners (ECP) are nurses and paramedics with advanced training who work in a variety of care settings in the UK. O’Keefe et al report on a postal questionnaire sent to patients seen by either an ECP or more typical provider in these settings, which found that more patients seeing ECP’s were highly satisfied than those who saw the usual type of care provider. Although the study is limited by a modest response rate (38%), its findings are consistent with several studies of nurse practitioners and physicians’ assistants in other countries.

A starting point for ruling out scaphoid fractures

You know the drill. A patient has fallen on an outstretched hand, they have snuff box tenderness—and a negative X-ray. Plan: immobilize and repeat X-ray in 10 days. Perhaps. In a prospective study of 154 patients with wrist injuries and negative films, Bergh et al found that they could combine 3 exam findings into a clinical scaphoid score that predicted all 13 scaphoid fractures found on MRI. Caution: The NPV of 96% is hopeful, but will vary with prevalence of fracture. And the rule still needs validation in another population of patients and physicians.

Why do we call it ‘Teaching’?

4 Aug, 14 | by scarley

A Reflection on Teaching and Learning Culture in UK Emergency Medicine


One of the things that most amuses my school teacher friends is my insistence on referring to postgraduate educational opportunities as ‘teaching sessions’, e.g. ’I’ve got regional teaching this afternoon’. I’m not alone here in referring to ‘teaching’ – it’s common amongst doctors and medical students alike.

And an all too commonly heard moan for doctors, (I’ve done it myself, many times), is that they aren’t getting enough ‘teaching.’ At the recent College of Emergency Medicine and British Medical Association joint seminar held as part of the Emergency Medicine Trainees Association 2014 conference a recurring theme was a perceived need for more shop-floor teaching.

This is all anecdotal of course, but there is very little evidence out there regarding trainees views on this topic. The GMC National Training Survey[i] is a good place to start, but when you look at the actual questions and how the scores are calculated, it becomes clear that a score of 70-ish for local teaching (which it has been steadily since 2012) means very little, being calculated as it is from a combination of questions like ‘How many hours a week do you receive local specialty specific training?’ (What does this mean? Shop floor supervision? Small group seminars?), and ‘Who carries out local specialty specific training?’ (Senior doctors scores highly here but is that a true marker of quality? Does being a Consultant automatically make you an excellent teacher?) We are also asked to rate the quality of our teaching sessions, but against what standard? In summary, this survey is not an especially valid way of evaluating the quality of a teaching programme.

What do we actually mean when we say ‘teaching’? As postgraduate learners, we have a wealth of opportunities available to us, from organised lecture programmes and seminars, to shop-floor supervision to simulation courses.

Calling these varied learning opportunities ‘teaching’ turns them into passive activities and implies the spoon feeding of facts and transfer of knowledge direct from our teachers to our brains. It absolves us of our responsibility as learners to make the most of them.

The complaint of ‘not enough teaching’ is generally used to refer to shop floor learning, where a trainee is directly supervised doing something by a senior, (for example leading a team or performing a procedure), hence the regular comparisons with the one-to-one training that junior anaesthetists receive. That juniors in emergency medicine have senior supervision available for absolutely every single patient that they see seems to pass us by. That senior anaesthetic trainees practice independently for much of the time without constant one-to-one supervision also seems to escape us.

In actual fact, we do receive a significant amount of this kind of teaching. In the departments I have worked in, there has been consultant presence on the shop-floor for the vast majority of time in-hours. My current department has consultants on the floor for 16 hours a day. Supervision is therefore available to me for the vast majority of my working hours. Are we counting those ‘Can I just ask you about?’ and ‘What do you think of this?’ as being ‘teaching’?

As well as this, the College of Emergency Medicine has an exhaustive list of workplace based assessments that we are all required to complete. They are near universally despised, yet they represent direct hands on supervision opportunities, or to put it another way; ‘teaching’. Why then do we hate these assessments? Rather than seeing them as irritating tick box forms, can we reframe them as empowering us to request direct training and feedback on our performance?

And what exactly do we want ‘teaching’ on/about? If you’re a surgeon, then understandably you want to spend lots of time performing surgery, learning the craft of each procedure. If you’re a gastroenterologist, then the hours spent as a general medical registrar probably seem less relevant to your career compared to the endoscopy lists and clinics. This just doesn’t apply in emergency medicine. As an EM doctor, every single patient that we see on every single shift is a potential learning opportunity. We cannot just see the critically ill – our speciality is far broader than this. We need to be happy with the bread and butter of our specialty, not just the jam. Head injuries, elderly patients with falls, acute confusion, intoxicated patients both drugs and alcohol, febrile children, vague chest pain, dizziness, non-specific abdominal pain, deliberate self-harm, red eyes…It’s all on our curriculum and forms the vast majority of our workload[ii],[iii].

As senior emergency medicine doctors, we do not need to be directly supervised seeing these patients, but we should not dismiss them as non-learning or pure service provision events. There is no substitute for seeing large volumes of real patients and building up a bank of experience. Experience is what tells you that the ‘drunk’ patient with confusion has a subdural haematoma, or that the ‘back pain’ is an abdominal aortic aneurysm beginning to rupture (but experience is not everything – see below!) And sending a patient home reassured, happy and without what they thought came for (scan, antibiotics, xray) is as much an art as running a really slick arrest call.

Also on our curriculum are a whole range of managerial and leadership skills. Whether we like it or not, managing patient flow, supervising juniors and maintaining an overview of the department will form part of our job as ED Consultants. While we might prefer to be in resus seeing that interesting trauma, learning how to run the floor is essential, and can only be learned through practice. Maybe it’s not such a bad thing to be asked to run the show while the boss is in resus doing the fun stuff sometimes? It all depends on whether you see doing that as a key part of your role and important for you to practice or not.

And practice is the key word here. ‘Practicing’ medicine is what we are licensed to do. We cannot learn our craft solely through our computer screens, high fidelity simulators or textbooks. It is widely believed that to become expert in something, approximately 10 years of practice is required[iv]. Yet many people play sports or musical instruments for years without achieving mastery. Experience alone is not enough:

‘You have not had thirty years’ experience, Mrs Grindle-Jones,’ he says witheringly. ‘You have had one year’s experience 30 times.’[v]

Deliberate practice is required in order to become expert[vi]. Deliberate practice means thinking about what we are doing with each and every patient. It’s about seeking out feedback, following up cases, reading around. About thinking ‘Next time, I’ll do that a bit differently’. The responsibility for this lies with us. Our teachers are there to assist us in this process, not to do it for us.

I believe it is time for us to take control of our own learning. Complaining that we’re not getting enough ‘teaching’ isn’t good enough. We are surrounded by learning opportunities and it is up to us to make the most of them. What do you think?



Sarah Payne




[i] GMC National Training Survey, General Medical Council; 2014 (accessed 30/7/14)

[ii] The Older Person in the Accident and Emergency Department, British Geriatrics Society; 2008

[iii] Health and Social Care Information Centre, Focus on Accident and Emergency, UK Government Statistical Service; 2013

[iv] Ericsson, KA. The Road to Excellence, Lawrence Erlbaum Associates;1996:10

[v] Carr, JL. The Harpole Report, Quince Tree Press ; 1972: 128

[vi] Ericsson, KA. The Road to Excellence, Lawrence Erlbaum Associates;1996: 21, 33

The Science Behind Telling “Sick” From “Not Sick”

31 Jul, 14 | by rradecki

Jeff Kline contributed a very interesting article to the Emergency Medicine Journal last week – offering up a bit of a potential science behind the “gestalt” in medicine. We’ve seen multiple examples where clinician gestalt performance is very similar to carefully-derived, evidence-based, risk-stratification criteria. Specifically, the diagnoses of “acute coronary syndrome” and “pulmonary embolism” have been evaluated in the past – and only the newest attribute-matching tools have offered any promise regarding improving upon simple clinician judgement.

This newest study from Kline, et al, evaluated 50 patients in the Emergency Department and their facial reactions to visual cues. It turned out, the 18 patients from this cohort ultimately diagnosed with significant cardiovascular syndromes displayed significantly decreased expressive variability when prompted with multiple stimuli. The reasonable conclusion, therefore, is patients with serious diagnoses may exhibit measurable, reproducible behavior changes. A small study, to be sure, but hence the idea – there is something encoded in our emotional intelligence helping us evaluate “sick” from “not sick” in the Emergency Department.

Supposing this observation holds up to further scrutiny, the results do not surprise me at all. Part of clinical training in Emergency Medicine involves simple voluminous exposure to as many patients as feasible. The behaviors of each different patient, their clinical features, and their outcomes become encoded in this entity, the clinician “gestalt”. And, what this study reflects is something we all recognize – a patient is not simply a collection of risk factors, or a Revised Geneva Score – the physicality associated with how a patient exists in the examination room provides additional information. The intuition of the experienced clinician, then, may be based as much in reading patients’ faces as it is synthesizing clinical knowledge.

This has interesting implications for other developments in medicine, as well. The time pressures in Emergency Medicine, or in other outpatient settings, that simply cut down on time spent with each patient, may detract from the quality of the evaluation. Telemedicine, another technological advance aimed at diluting and expanding coverage, may suffer as a result of diminished communication of these critical nonverbal cues.

Regardless, this study is quite unique in the spectrum of Emergency Medicine research, and hopefully inspires a follow-up generation of research.  Or, alternatively, what would you say forms the basis of our “gestalt”?

Link: “Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting






Ryan Radecki

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