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What’s the point of a log roll? EMJ

26 Aug, 16 | by scarley

Screenshot 2016-08-22 08.27.02

A very interesting paper in this month’s EMJ on the utility of log rolling trauma patients. Why interesting? Well, because I think the evidence for the lack of utility in log rolling has been around for some time and yet it persists in practice.

It’s unclear why, perhaps it’s the big scary guidelines that still suggest that we need to take our unstable trauma patients with potential spinal injuries and then flip them on their side to try and shake off some clot and jiggle the broken bones around a bit. Harsh? Perhaps, but I think all trauma clinicians wil have seen physiological deterioration with poor patient handling.

This paper further provides evidence for safe handling and we should all read and carefully consider our response to the question ‘has the patient been rolled’.

In my practice if I really need to have a look at the back then I’ll raise the patient very carefully by 20 degrees, just enough to put a scoop stretcher in, or to feel for foreign matter or obvious injury. If they are going for CT then nothing else is needed.

Whilst we are at it, let’s challenge the mandatory rectal in trauma. It has a poor sensitivity and specificity and let’s face it. The patient is already having a bad day without you putting a finger in their anus.

Screenshot 2016-08-22 08.22.35

With such poor sensitivity it’s not going to stop you from doing further investigations and even if positive you’re still going to do further investigations. I think it’s difficult to justify during the primary survey. For patients undergoing CT then these clinical tests can wait.

Let’s leave the log rolling to these experts.

vb

S

@EMManchester

 

What is the purpose of log roll examination in the unconscious adult trauma patient during trauma reception? http://emj.bmj.com/content/33/9/632.short?rss=1

SCANCrit on log rolls and rectals. http://www.scancrit.com/2014/04/10/log-roll-finger-bum/

Log-rolling a blunt major trauma patient is inappropriate in the primary survey. http://emj.bmj.com/content/early/2013/10/17/emermed-2013-203283.full.pdf

Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. http://www.ncbi.nlm.nih.gov/pubmed/16394903

Poor test characteristics for the digital rectal examination in trauma patients. http://www.ncbi.nlm.nih.gov/pubmed/17391807

Primary Survey September 2016: EMJ

24 Aug, 16 | by scarley

This month’s primary survey from the EMJ.

Emergency Triage and Treatment Course in primary care health centres in Guatamala

Emergency triage Assessment and treatment (ETAT) course was developed by WHO in 1999 as part of its Integrated Management of Childhood Illnesses program for improving outcomes for children. It has been devised as a hospital based system for health services of limited resource settings.

This study took ETAT and introduced into the primary care setting, making it a self-sustaining locally led course in a district within Guatamala. The course comprised 5 modules that cover Triage, Airway/breathing, Circulation, Coma/convulsions and Dehydration which took 16 hours in total. Two courses were delivered in October 2012, and subsequently candidates were asked to undergo a written test and a survey about their confidence prior to the course and immediately thereafter, and then again at 3 months, 6 months and 12 months after the course. They were asked to take part also in a clinical skills assessment. During this time, a quality improvement program was established to identify and remedy problems that were found to be significant for candidate performance and learning.

There was an improvement in knowledge, from the pre-course to post course tests that was sustained in all subsequent tests. The clinical skills retention, assessed at 3, 6 and 12 months, all scored highly.

There was a boost in confidence before and after the course although this did start to reduce over time (but not to statistically significant standards). The level of confidence remained than that determine in the pre-course assessment.

This paper highlights that ETAT which has been shown to improve care for children in the resource limited care setting and shows that with planning and the use of QI programs, clinical skills knowledge and even confidence in a range of health care practitioners can be enhanced.

Point of care lung ultrasound in young children

This study had a ‘novice’ ultrasound operator look at the lungs of children triaged as having a respiratory problem such as wheeze or respiratory tract infection. The images were captured before any treatment was given to the children; these images were evaluated by an expert in ultrasound to determine if there were any of the following:

  • 3 or more B lines per intercostal space, consolidation+/− pleural abnormalities

  • Any of these features being present counted as a positive ultrasound.

None of the children with asthma had a positive ultrasound, whereas in pneumonia, all were positive. In children with asthma and pneumonia about half of he cases were positive as was the case in children with bronchiolitis. However, caution must be applied about just using ultrasound as the numbers in the study are small and more validation studies are required.

On a roll!

Why do log rolls in the unconscious adult patient? This retrospective study over 2 years looking at GSC 9 or less +/− intubated patients from the Alfred Trauma registry with major trauma (ISS >12) and compared the log roll findings with the CT/MRI reports on the presence or absence of thoracolumbar injury. Out of the 403 patients, about 85% did not have any abnormal findings on log roll. Out of the patients who had a thoracolumbar fracture(s), 72.5% had a normal log roll. Lesions seen included abrasions, bruising, haematoma, open wounds, foreign bodies and burns which were important in some instances for acute patient management. Using palpation in this group of patients to find any abnormalities is questionable. For determining thoracolumbar fractures, palpation has a specificity of 98.8% but a sensitivity of 8.5%. The authors therefore recommend that visual inspection is important but that palpation may not be as helpful, especially when patients may go onto have CT/MRI imaging to rule in or out thoracolumbar fractures. It should be noted that this idea needs further prospective studies to confirm or repute the proposal!

Sawbones? A potential life-saving intervention

Fortunately pre-hospital limb amputation is not common but when needed, it can be life-saving. The study used cadaver limbs, donated for medical research purposes, to see which was the most effective tool/technique to perform an amputation. Four devices were examined for the time from knife to full amputation, the number of attempts required, and perceived risk to the rescuer or “patient” during the procedure.

After the procedure, an assessment was made of the damage to the soft tissue, skin and bone, by 6 independent clinical rates according to a 5 point scale, with 5 being the most favourable result.

Ninety one seconds was the longest time taken to effect amputation, and all 4 techniques/tools had their advantages and disadvantages—a really important topic to improve patient care in difficult situations, showing practical aspects about a life-saving procedure.

Good communication makes for less ‘traumatised’ patients

Good interpersonal skill can reduce patient worry as seen in this study of acute coronary syndrome patients. The incidence of subsequent posttraumatic stress reactions decreases according to patient perception of communication with their clinician. It is important to think about how we conduct ourselves as this impacts greatly on how much better our patients can become!

“Delayed discharges and boarders”….

An ebb and flow of patients would be ideal, but as this paper shows that delay in the discharge of patients backs up patients in ED. The authors show this in their setting, in a busy hospital in Dublin and, in the discussion, show that this is a commonplace problem in many different countries throughout the world. How social and community care can improve their ‘joined-upness’ with hospital based care is essential for delivering optimum patient care.

Ian K Maconochie

Click here to go to the journal site.

Should More Emergency Physicians be ‘Piloting British Airways’? The Musings of a Trainee: EMJ

22 Aug, 16 | by rlloyd

musings

Emergency physicians (EPs) routinely manage the sick, undifferentiated patients in whom life-saving interventions need to be executed rapidly. Our Royal College defines emergency medicine as ‘the specialty in which time is critical.’

In severe illness or injury, ‘A’ comes first. Securing a definitive airway is the gateway to the rest of critical care; without one, our sickest patients will usually be carried out of the resuscitation room in body bag. For this reason, emergency airway management must lie within the skillset of the emergency physician.

Rapid sequence induction (RSI) and tracheal intubation are, appropriately, considered core skills for EM trainees in the UK. The second year of ‘Acute Common Care Stem’ (ACCS) core training – the route to advanced EM training – consists of six-month rotations through anaesthesia and intensive care, allowing for ample exposure to critical illness, and development of advanced airway skills.

Despite this, frustratingly, EM-led RSI is a contentious issue in the UK. In 2010, Benger and Hopkinson published a survey in the EMJ that examined the practice of ED RSI across the UK over a 2-week period (1). It revealed that anaesthetists carried out the procedure a whopping 80% of the time (actual percentage likely to be even higher as only particularly ‘airway-keen’ EDs contributed). This starkly contrasts with Australasia and the US, where EM-led RSI is standard of care, with anaesthesia backup made available if difficulty is predicted.

Silo-culture and tribalism remain prominent in UK EDs in 2016, with anaesthetists usually assuming full ‘pilot duties’ when it comes to the airway. However, the landscape is changing, particularly in prominent teaching hospitals – in large part due to a new generation of EPs who’ve completed ACCS.

Additionally, there is some solid literature that suggests EM-led RSI is safe and effective, as long as practiced within a supportive system. Let’s have a look.

Stevenson et al, 2007 (2)

This EMJ publication is a single-centre prospective observational study which investigated the nature of ED RSI practice at a district general hospital in Scotland (Crosshouse Hospital, Kilmarnock) over 3 years. Data was collected via a questionnaire filled out by the intubating doctor immediately after the procedure. The authors were most interested in who was performing the procedure, and whether a specialty was implicated in airway-related complications (categories: desaturation, hypotension, aspiration, oesophageal intubation, cardiac arrest). In short, they wanted to know EPs were worthy of wielding laryngoscopes.

Over the 40-month period, 199 ED RSIs were performed. EPs carried out 44% of these – far higher numbers than contributing departments to Benger and Hopkinson’s survey (published 3 years later). Anaesthetists achieved superior laryngoscopic views and higher rates of first pass success (91% versus 82%) but promisingly, there was an identical overall success rate (97%), and almost identical complication rates.

The crucial detail from this paper is that the department had high instances of senior presence from both specialties during ED RSI. This suggests a supportive training environment, and a collaborative approach to emergency management. Ongoing inter-specialty synergy has probably further propagated safe EM-led RSI in this department in the years since the paper was published.

Kerslake et al, 2015 (3)

A more recent publication which supports EPs at the head-end is this paper from Resuscitation. Similarly, it is a single-centre prospective observational study, where 12 years of ‘ED Intubation Registry’ data was analysed.

Interestingly, this hospital (the Royal Infirmary of Edinburgh – a large, urban teaching hospital) has a protocol dictating that a senior anaesthetist is contacted to supervise all ‘drug-assisted intubations’ (invariably RSI). The anaesthetist only steps in if added expertise is required due to a predicted/encountered difficult case.

78% of 3738 tracheal intubations were performed by EPs – unprecedented numbers in the UK. EPs were found to achieve similar laryngoscopic views, but lower first pass success over the whole 13 year period. In order to reflect modern practice, the authors performed a subgroup analysis on intubations performed since 2007, which demonstrated improved EP performance – first pass success matched the anaesthetists (88% versus 87% respectively). This is probably a reflection of ACCS training being introduced relatively recently.

This paper demonstrates indisputably excellent numbers, and is further evidence that appropriately trained EPs, when part of a collaborative system, are fully competent airway practitioners. By formally protocolising dual specialty involvement with ED RSI, rapid progress has clearly been made at this institution.

National Audit Project 4, 2011 (4)

nap4

NAP4 was a very high profile publication from the Royal College of Anaesthetists which captured detailed reports of major complications from airway management across the UK over 1 year. Reports included cases from the ED and ICU as well as the anaesthetic environment. NAP4 has been widely discussed around the world because the lessons from it have been so valuable for all airway practitioners.

A headline finding from NAP4 was that out-of-theatre airway management is associated with a significantly higher complication rate than the anaesthetic room (at least one in four major airway complications occurred in the ED/ICU). Furthermore, these complications were far more likely to be fatal.

Close inspection of the paper revealed some eye-opening analysis with regards to events in the ED: Many complications were avoidable, and could be attributable to the visiting (often junior) anaesthetist being unfamiliar with the environment.

Analysis of the ED-based events included mention of:

  • Communication breakdown in the resus team.
  • Lack of team-based contingency planning (‘failing to plan for failure’).
  • Failing to locate/use appropriate equipment (e.g. waveform capnography).
  • Failure to follow usual protocol due to high stress levels and novel distractions.

In order to combat these examples of avoidable error in the ED, NAP4 recommend:

  • Development of excellent communications between specialities involved in emergency airway management – this encourages cross-specialty planning for commonly encountered airway problems.
  • Joint training of EM/anaesthetics/ICU staff. Ideally simulation and team training.
  • Regular audit of emergency airway management in resus.

Crosshouse Hospital and the Royal Infirmary of Edinburgh have demonstrated that adherence to NAP4s recommendations is more achievable with a collaborative approach to emergency airway management.

Opportunity for EM to take a leading role

Here in the UK, the reality is that most of us probably work in hospitals without protocolised co-operation and support from anaesthetics, and find ourselves frustrated by an institutional reluctance to us utilisating our skill-set.

If EPs/EM trainees can take a leading role in the pursuit of a closer relationship with the anaesthetics department, then perhaps the process of ushering in culture change can happen more rapidly, even in the traditionally less progressive hospitals.

The key is building better communication channels with the anaesthetics department. ACCS trainees have an important role, as they are perfectly placed to ‘start the conversation’ whilst working in theatres and ITU. Joint training initiatives can be lobbied for, and enthusiasm can be expressed.

Even if local policy dictates that anaesthetists are the only practitioners permitted to perform ED RSI, EM can still take the lead with auditing/surveying practice. This will foster improved communication and joint teaching (might stimulate creation of EM/critical care joint audit meeting).

Screen Shot 2016-08-15 at 01.58.09Surveying ED RSI practice via a questionnaire filled in by the intubator post-procedure is a project that I have initiated at my own hospital. The project was inspired by the papers mentioned in this post, and the Australia New Zealand Airway Registry, which I was exposed to whilst working in Melbourne. If emergency clinicians can identify opportunities for improving ‘anaesthetics practice’ in the ED then attitudes might start to change.

EM-led quality improvement projects involving airway management will almost certainly be welcomed by anaesthesia, being the leading specialty that they are for pioneering patient safety initiatives. For EM trainees keen to manage airways (like myself), demonstrating a persistent interest (i.e. beyond the 6-month anaesthesia rotation) should be considered as important as demonstrating competence, as it will be that interest which stimulates local, and UK-wide culture-change.

The appropriateness of an ED doctor at the head-end has been a circular (and boring) debate for years. Anaesthetists will always maintain a greater level of technical prowess when it comes to advanced airway management for obvious reasons. However, an EP who has demonstrated competence and ‘currency’ is perfectly qualified to manage the airway, and will have the advantage of more familiarity with the resus environment, and the luxury of initiating proceedings without delay. Bottom line? The ‘anaesthesia versus EM’ argument is moot – specialty is irrelevant when it comes to these patients, it is the skillset which matters. Anaesthetics? EM? ITU? We are all resuscitationists.

Final thoughts

It is worth remembering that EM is a specialty which struggles to retain trainees in the UK. An enormously attractive aspect of working in A&E is the critical care element, but all too often, our time in resus gets trumped by pressures to meet targets (‘the anaesthetist has arrived, go back to majors and pick up another patient’). The ability to manage the airway is symbolic of a true resuscitationist, and empowering trainees with that responsibility will galvanise those already in training, and attract more junior doctors to our great specialty. In the long run it will pay off.

Robert Lloyd
@PonderingEM

Worth Reading/Listening

‘RSI in the ED; should EM be taking the lead?’ – HEFTEMCast (podcast)

‘JC: ED RSI – you can do it’ – St. Emlyn’s (blog post)

‘John Hinds on Airway at RCEMBelfast’ – RCEM FOAMed Network (podcast)

‘NAP4 Major Airway Complications in Emergency Departments’ – Professor Jonathan Benger (lecture)

 

ADD-ON (23/08/16): An Important Tweet…

The day following publication of this post, a leading voice in the world of EM tweeted this:

On 1 December 2015, the Royal College of Anaesthetists and the Royal College of Emergency Medicine released a joint statement on emergency airway management (5). It echoes the recommendations made by the NAP4 report, and is very progressive with regards to the role of the emergency physician, and the importance of interdepartmental training. The statement dovetails beautifully with the points made in this blog, and is essential reading. Here is a snippet:

‘Opportunities for the maintenance of rapid sequence induction and tracheal intubation skills by emergency physicians should be provided within each acute hospital.’

Many thanks to both colleges for making their position clear on such an important issue in UK EM, and to Dr. Reid for bringing this to the attention of the author!

 

References

  1. Benger J, Hopkinson S. Rapid sequence induction of anaesthesia in UK emergency departments: a national census. Emerg Med J. 2011 Mar 1;28(3):217–20
  2. Stevenson AGM, Graham CA, Hall R, Korsah P, McGuffie AC. Tracheal intubation in the emergency department: the Scottish district hospital perspective. Emerg Med J. 2007 Jun 1;24(6):394–7 
  3. Tracheal intubation in an urban emergency department in Scotland: A prospective, observational study of 3738 intubations
  4. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011;106:632-642.
  5. Emergency Airway Management: A joint position statement from the Royal College of Emergency Medicine and the Royal College of Anaesthetists

Smile if you’re having a PE. EMJ

16 Aug, 16 | by scarley

This week we have a new study from the fabulous Jeffrey Kline looking at whether the probability of a patient’s smile affects the likelihood of a positive diagnosis for PE.

Jeff has an amazing track record in PE research. He’s also a competitive bodybuilder which has nothing to do with PE, research or this article, it’s just that I am really impressed.

At first glance this may seem a bit weird and perhaps you were going to look at whether SMILE was an acronym for some new scoring system, but no. We are really talking about smiles from the patient. I find this stuff fascinating as I’m a great believer that we pick up subtle clues from patients that influence our perception of illness and thus affect our decisions. No doubt you will all have experienced the patient who ‘looks sick’ but the numbers are OK. That sixth sense, gestalt, judgement, whatever you wish to call it is important. It changes what we do and how we think but there is a paucity of research out there.

You may already have read Jeff’s work on facial expression in cardiovascular disease and if not you probably should which suggests that patients do have different facial reactions depending on their underlying diagnosis. Maybe there is something in this.

In this EMJ paper the question of the smile is examined. The abstract is below (but read the full paper please). Does it make a difference. Well yes and no would be a fair conclusion. It changes the way that we think but perhaps not what we do.

Screenshot 2016-08-13 13.52.08So, an interesting insight into some of the art of emergency medicine? Perhaps. We’d love to hear what you think.

vb

S

@EMManchester

 

 

 

Medical Challenge 2016. EMJ

13 Aug, 16 | by cgray

If you were at SMACC this year, or the last college conference, you’ll be aware of developments in pre-hospital schemes throughout the UK. In particular, Northern Ireland is undergoing a pre-hospital revolution. Plans afoot for a HEMS programme, increasing awareness and involvement from doctors, and university schemes forming to enable students to gain experience and skills in pre-hospital care. One such programme, at Queen’s University Belfast, won a medical competition led by the British Army in Northern Ireland, which is a fantastic achievement. I had a chat with Stephen McKenna, a nursing student from Queen’s University Belfast, to find out what the medical challenge is, and a bit more about the pre-hospital care programme at the university.

Chris: Hi Stephen, thanks for talking to me. Tell me about your group.

Stephen: We are the Pre-Hospital Care Society, a society set up at Queen’s University Belfast by pioneering medical students in 2014 in response to the growing interest in pre-hospital care, particularly emergency care. We’ve grown in membership and our new committee now includes both nursing and medical students, which is reflective of those involved in pre-hospital care. Our main aim is to raise the profile of pre-hospital care in NI, as well as to teach life saving skills to members of the public where possible.

The QUB pre-hospital team recently won the medical challenge, can you tell me a bit more about the challenge itself?

The medical challenge is a yearly event organised by the Army. It runs over an entire day and involves a series of mini medical scenarios, most often under pressure and in an environment that you just wouldn’t get in a hospital or university. We had everything from catastrophic bleeds, cave rescues and gun shot wounds – all obviously staged!

How did you hear about it?

This is a popular event in the NI medical calendar. Each year, hospitals from across NI submit a team to take part. I did it last year and was determined to get members from the society involved this year, because it’s a unique experience. Spaces are limited as many teams want in on the action. The Army have provided us with invaluable support throughout the year and they made sure we knew the event was running.

What was your role on the team?

As the old saying goes, there is no ‘I’ in team, so with that in mind it was a team effort from the outset! I merely organised the teams before we set out. Although only one leader was needed, we decided that everyone should have the chance to lead a scenario. We selected the person with the relevant skills to lead the team each time. We feel this was a critical decision which led to the win. In a pre-hospital environment, the most appropriate person should always be in charge!

ABC_2767 (1400x1063)

How did your team prepare, did you have support from healthcare professionals?

Throughout the year we run free training events for our members. Everything from catastrophic bleeding workshops, lectures on frostbite, and using trauma equipment at accidents. This meant we were well skilled and prepared from the outset. Our team was made up of students, junior doctors and a paramedic! You can’t get a better skills mix than that.

What was it like on the day, what did you have to do?

Full on! The scenarios are based around a military theme so you can imagine the stress we faced. Each scenario was timed, so we had to act quickly, communicate efficiently and work as a team. We had a brief before each task and were assessed by leading trauma specialists on how well we completed it, and more importantly if the casualty survived!

ABC_2826 (934x1400)

How did you celebrate your win?

What happens on camp, stays on camp! But let’s just say the army’s hospitality wasn’t wasted on us!

What’s next for the pre-hospital group from QUB?

Our newly elected committee has planned an array of exciting events. We have so many fantastic sessions lined up, even a maternity evening! The support from professionals in Northern Ireland has been overwhelming. We have a great network of people who have offered their skills and expertise. We’re currently planning one of our biggest and most exciting events to date – a ‘sim-lecture’ on campus. We’ve organised a live casualty extrication demo from a simulated car crash on campus, where we aim to highlight the importance of road safety and the work of pre-hospital emergency responders. This event will be built into the Freshers’ week and has been kindly supported by the university and students union. Watch this space!

Stephen and the group are always keen to hear from anyone who’d like to talk at their events, so get in touch if you can help.

 

Thanks to Stephen and the committee for providing photographs, which have been used with permission.

Chris

@cgray

The other side of the ECG. EMJ

8 Aug, 16 | by scarley

Last week I was wandering through Amsterdam when I came across a tweet which stopped me in my tracks. A real game changer, a shock, a wake up call and a surprise. Rob Rogers (aka @EM_Educator) tweeted a really interesting ECG. Take a moment to have a look and consider the diagnosis.

Of course, you’ll have seen ECGs like this before, an inferior AMI with lateral and posterior involvement. It’s a biggy! You may well have thought…’I’m glad that this isn’t mine’. The thing is, for Rob that was not an option. This is Rob’s ECG from his hospital bed, tweeted about 24 hours after he attended. Take a moment to think about that. If you’re an emergency physician like me then you’ll have seen ECGs like this, you’ll have had those conversations with patients in the few minutes between diagnosis and thrombolysis, or the move to the cath lab. How different would it be if it was you?

Rob is just 45 years old, an emergency physician like you and me (I’m 48).

Rob is a medical education genius, he’s devoted many aspects of his career to helping others learn and to be better clinicians. He’s runs teaching courses, websites and conferences and I suppose that his tweeting of his ECG is another incredibly brave aspect of that. The altruism in sharing his story such that others can learn is amazing.

Now, his story has two good endings.

Here’s the first, a great result in the Cath Lab.

The second is his excellent podcast telling the story of his MI and how he has changed the way he looks at the world. Have a listen and think about his story, his journey, your journey and perhaps consider what it might be to be on the other side. Stop and think about your life, values and commitment to looking after yourself. This stuff matters.

At some point in the future it’s almost inevitable that we will all find ourselves in the hands of colleagues and friends. In education our ambition is to develop and train those who will look after our patients, but as ROb describes that might also mean looking after you or me. This is not a completely new concept to me as  I vividly remember one of my heroes (Chris Moulton) who taught me so much as a registrar telling me that investing in education is one of the best ways to improve the care that he might one day need. It was a little tongue in cheek, but there is some truth in this and when you listen to Rob talking about the excellent care he receved then all of that would be a consequence of someone (perhaps even Rob) investing in their training, skills and wisdom.

Education – pay it forward –  you might get it back in heaps later.

Rob has been incredibly brave to share his story, to give us all for thought, and for many of us to hear his wake up call.

To Rob from all of us in the Social Media, #FOAMed and Emergency Medicine world, the very best wishes and a speedy revovery.

vb

S

@EMManchester

This blog first appeared on St.Emlyn’s

Primary Survey August 2016. EMJ

4 Aug, 16 | by scarley

Richard Body, Associate Editor

Editor’s choice: Nurse versus computer for paediatric triage

This month, Takahashi et al present a retrospective cohort study evaluating the impact of allowing nurses to change the triage priority assigned by the computerised Japanese Triage and Acuity algorithm (JTAS), which is based on the patient’s presenting complaint, historical factors and physiological parameters. In particular, the nurses could assign a lower triage category if they felt that the triage category was inappropriately high based on physiological parameters recorded when a child is distressed or looks otherwise well. The re-categorised triage priorities more appropriately predicted the need for hospital admission. This study presents early evidence to suggest that the ‘gestalt’ of experienced triage nurses could be used to avoid over-treatment and it provides an excellent platform for future work that is designed to evaluate safety outcomes.

Graphic

Head injury: after the ‘golden hour’ come the danger hours?

It might seem reassuring when patients present late after a head injury. If a patient is going to have an intracranial haemorrhage, in usual circumstances we expect it to become apparent in the first 24 hours after injury. Marincowitz et al investigated the incidence of traumatic abnormalities in 101 late presenters. They also evaluated the performance of the National Institute for Health and Care Excellence (NICE) criteria for computerised tomography (CT) scanning in that group. There were two very interesting findings. First, an astounding 9.9% of late-presenting patients had a traumatic abnormality, 3% required neurosurgery and 1% died. We should bear in mind that the sample size is small and there is potential for selection bias: only patients who underwent CT scanning were included. We therefore wouldn’t expect such a high incidence in undifferentiated late-presenting patients, so it is important that clinicians don’t over-react to this initial finding.

Second, however, is the fact that the NICE criteria for cranial CT scanning missed 30% of traumatic abnormalities. While you may react to that figure by questioning the clinical significance of those injuries, when you read this paper you should note that 25% of patients who required neurosurgery or died were also missed by the NICE criteria. This work therefore appears to clearly demonstrate the need for a bespoke clinical decision rule to guide the management of patients who present >24 h after head injury.

Paediatric procedural sedation: is the UK falling behind?

The literature on procedural sedation for children in the Emergency Department extends back at least 25 years. As long ago as 1998, McGlone et al described the use of ketamine as an alternative to “brutacaine” in the Journal of Accident & Emergency Medicine.1 The benefits of avoiding hospital admission and general anaesthesia are readily apparent. It is alarming, therefore, that the qualitative analysis of focus group data by McCoy et al this month reveals that emergency physicians in the United Kingdom are still experiencing many barriers in delivering this service. In a linked editorial, Krauss and Green provide a number of helpful tips for Paediatric Emergency Departments in the United Kingdom, based on their experience in the United States where procedural sedation protocols are long established. Both papers clearly highlight a pressing need to develop practice in parts of the United Kingdom. They call for a national response to improve training and competency assessment for this important skill.

Do nice doctors get sued?

According to an old medical myth, less skilled surgeons may make up for what they lack in technical ability by being excellent communicators. In this issue of the journal, Smith et al report an innovative randomised controlled trial in which patients in an Emergency Department waiting room were each shown a video of a doctor-patient encounter but were randomised to see a video that included some empathic statements made by the doctor or one that did not. The patients viewing videos of an ‘empathic’ doctor were less likely to report that they would sue the doctor if something went wrong. It seems, therefore, that nice doctors are less likely to be sued. However, before we step up our communication skills training at the expense of honing clinical skills, we should read the full paper and exercise caution. Nice doctors may have been slightly less likely to be sued but the difference was small and some patients would still have sued the ‘nice’ or ‘empathic’ doctors.

The human side of pre-hospital research

Most readers are likely to be familiar with PARAMEDIC, a large cluster randomised controlled trial evaluating the use of a manual compression device in pre-hospital cardiopulmonary resuscitation.2 The trial enrolled 4,771 patients in the pre-hospital environment, which was a huge success. In this issue of EMJ, Pocock et al explored the human factors that influenced delivery of the trial by paramedics. The findings of this survey provide some fascinating insights into the requirements for successful research delivery. This paper is therefore essential reading for anyone contemplating undertaking research in this highly challenging environment.

References

Learning from Major Incidents

1 Aug, 16 | by cgray

Major Incidents

In this month’s EMJ, David Lowe, Jonathan Millar and colleagues from Glasgow Royal Infirmary (GRI) and the University of Glasgow share their experience gained from the tragic events that unfolded in their city in 2013 and 2014. The first –  where a police helicopter crashed into the Clutha Vaults pub due to a fuel management issue – led to ten deaths and several seriously injured, while the second caused 6 deaths and 15 injured when the driver of a bin lorry crashed after blacking out at the wheel. Many of those injured were taken to GRI, and in the aftermath of these incidents, lessons were learnt and action points generated. Ten key lessons are included in the article, and with many major incidents occurring throughout Europe and the rest of the world in recent months, it’s sadly all too possible that you may have to declare one in your department in the near future. Reading about and learning from the experience of others can help you to refine your own disaster management plans.

Whilst some of the points may have already entered your mind, such as early allocation of roles, and having an effective command and control structure to co-ordinate resources both in the ED and in the rest of the hospital, there are some less obvious, but equally key points for learning. In a smaller hospital, particularly if you have a major trauma unit nearby, trauma may be a rare sighting, and on activation of the trauma team the response may be slow with some members unclear of their responsibilities. The Glasgow team recommend a low threshold for activation of the trauma team, as this will not only help members to become more familiar with the process and each other, but also raises awareness of trauma care in the hospital.

Another change involves drug preparation. It was found that in a major incident, multiple patients may need an RSI, analgesia, sedation, or other key medication such as tranexamic acid. This can lead to several doctors or nurses all trying to access the same medications at one time. They have implemented a protocol that on activation of the major incident plan, designated staff will draw up a number of drugs bundles which can then be accessed quickly by the trauma teams, without a fight at the drugs cupboard or the fridge.

The article has a number of other fantastic learning points and is well worth a read. If you have access, you can also read the reply by Sophie Hardy which explores the difficulties with sharing major incident experience, and a link to the website majorincidentreporting.net which is a global initiative to aid this. On the same subject, if you haven’t already read the paper (published in the Lancet in November 2015) by Martin Hirsch, Pierre Carli and colleagues on the response to the multisite terrorist attacks in Paris, then please do. You can also see Youri Yordanov, one of the authors of the paper, give one of the keynote lectures at this year’s RCEM Scientific Conference in Bournemouth in September, where he will be speaking on the lessons learnt from Paris.

vb

Chris

4-hour standards and staffing. Can we square the circle?

22 Jul, 16 | by scarley

TargetsFinanceSafetyStaffing

It’s been a turbulent and highly unpredictable few weeks in the UK. The Brexit vote to leave the EU, a new Prime Minister and the main opposition Labour party seemingly at war with itself have dominated the headlines. In amongst this we have seen the retention of Jeremy Hunt as Secretary of State for health  amidst a brutal cabinet reshuffle.  I think it’s fair to say that this was not a popular choice for many NHS workers, but perhaps it does mean that we have a degree of predictability and continuity.

Or do we?

Yesterday I gave a talk at our local trainee’s day about the future of emergency medicine. I suggested that financial pressures in the UK may lead to a change in the targets that currently dominate departments and the experience of those working in them. The 4-hour target (standard as it is formally known) requires emergency departments to admit or discharge 95% of patients within 4 hours. We’ve not been meeting it for some time (and in fact some hospitals have more bespoke targets but let’s not get picky here). Have a look at the graph below, it does not read well.

Perhaps this is a time to bury bad news and so it was that we heard about a revision/relaxation of the standards for hospitals already in crisis. Some will welcome this, but beware, those of us who remember a time before targets a very much aware that they have driven substantial investment in emergency services and in particular staff. Not enough I grant you, but it has had a significant influence.

Similarly concerns around safe staffing followed reports into patient safety events at Mid Staffs hospital leading to increases in staffing and the stretching of NHS budgets. Many hospitals recruited extra staff to meet safe levels following internal reviews or external reviews from organisations such as the CQC. A safe hospital is not a cheap hospital, and safety relies on trained, motivated and capable staff to look after our patients and each other. This is especially the case in emergency care where staffing is a large part of the budget.

You don’t need to read the entire Francis report on Mid Staffs, but it has been highly influential. The tweet below from Shaun Lintern (who is well worth following) rather sums up that report, essentially it raised the major concern that financial and admin targets can pervert the delivery of safe and effective care. Clearly we don’t want to repeat this.

The double whammy yesterday was the less well publicised report from NHS Improvement stating that many UK hospitals had over recruited and would thus have their budgets cut as a result. The report lists trusts who have allegedly overspent in line with increases in activity or inflation. The methodology has been questioned and the reaction from trusts has been fierce.  Click on the link in Shaun Lintern’s tweet to read the hospitals named. You may well recognise them. I certainly know many well and I can assure you that they are not awash with staff. Many are in significant difficulties facing the constraints of finance, targets amidst a desire to care for patients and keep them safe.

It is difficult to see how emergency care services will balance the financial requirements announced yesterday together with a need to maintain patient safety and deliver a quality service. It is even more difficult to see who will be blamed when the equation cannot be met. I suspect that the NHS senior management will be happy to devolve that to trusts and departments, but we shall see.

For now, for anyone celebrating the death of the 4-hour target, beware, it’s bound to be replaced by something else and that may be even less palatable.

vb

S

@EMManchester

The views expressed here are mine and do not represent the position of the EMJ or BMJ publishing.

What’s the future of medical journals?

10 Jul, 16 | by scarley

The future of medical publishing

I had the pleasure of joining a panel discussion at the recent SMACC conference on the future of medical journals. I was delighted to share the stage with some real big hitters such as Richard Smith (ex editor of the BMJ) and Jeff Drazen (current editor in chief of the NEJM), together with some amazing researchers such as Sara Bassin Flavia Machado, Kathy Rowan, John Myburgh, Simon Finfer and Kath Maitland.

As with all panel discussions there was a degree of entertainment generated by our host Simon Finfer, but this is a significant matter. Journals and the publishing process have a huge role and influence on the conduct, funding and dissemination of science. The panel was assembled with deliberately discordant views to challenge the status quo and to look to what may be a fabulous, or perhaps a more dystopian future.

Richard Smith is a vociferous proponent of a post journal world and you can read his thoughts here. It’s really worth a read as a challenge to how we deliver knowledge from primary research out to those that actually need it and then out to practice, and more importantly to those that will benefit from it i.e. our patients.

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I found myself at one end of the on stage sofas with Rob MacSweeney who many of you will know from the Critical Care Reviews website, and with whom I share many views. I think we played our role as challengers to the status quo pretty well. Rob in particular is a fantastic exponent of getting research to the bedside in an ethical and fair way. If you’re not following his blog, and getting his newsletter at critical care reviews then follow the link and think about joining in.

There was too much on the day to summarise here, but I’d ask you to have a think about some of the ideas raised on the day. Right or wrong the panel were challenged on the following.

  1. Publishing in high impact journals is a key to academic promotion. Should it be?
  2. Universities are using a proxy measure (impact factors) to determine promotions. That’s outsourcing a really important measure to a system that has huge flaws.
  3. Similarly, funding organisations measure success in terms of publications in high impact journals. Journals thus have a huge influence on research funding priorities and success. Is this right?
  4. Peer review has been repeatedly shown to have huge flaws, fails to detect fraud, fails to detect poor quality and is prone to interpersonal bias and politics. Can we find a better way?
  5. Social media has the potential to produce post publication review, but is it any good, and can we collate it?
  6. Should we have open publishing, followed by widespread open peer review and then publication, and would this be better at detecting fraud, bias and error?
  7. Some journals make their papers open access after a period of time (e.g NEJM) and this is a good thing, but it would be better if it was sooner. Should all funding agencies demand open access (as many now do)?
  8. The relationship between researchers seeking publication, impact factors, promotion and future funding is complex and arguably at risk of a ‘mutualism’ relationship that does not directly benefit patients. How do we break that relationship (and do we need to)?
  9. Many journals believe that they are providing a service by filtering the poor quality out and only presenting research that is worthy of attention. The question was raised as to whether we need ‘other people’ to do this for us. Do we really need journal editors to be our filters and guides or can we do it for ourselves?
  10. Patients enter trials on the understanding that they will benefit healthcare in the future. Is it therefore unethical that that information is behind a paywall and not widely distributed?

We covered many more topics and I’d recommend a listen when it is eventually released from the SMACC website. For me, straddling the traditional world of journals as an EMJ editor, and also as proponent the new world of #FOAMed it was fascinating. I think it’s increasingly difficult to see how journals can survive in their current format with the rise of easy e-publishing and the ability to engage with a much broader audience across the internet. However, thinking that journals will remain as they are and not adapt to a changing world would be similarly naive. Journals will have to adapt and change and I’m sure they will.

My thoughts are that the role of journals as sole publishers of original research will diminsh, taken over by an open publication, hive-mind reviewed, open multi peer review process (I can dream). This will not mean that journals will die. Arguably there will be an increasing need for the  collation and interpretation of science, and arguably this will be a more effective and useful service for readers. The signs of such a change are already here. For example the BMJ has changed format over the years and now serves original research in a more summary style within the paper version. The detail is available, but not in the paper copy. It seems that accessibility, engagement and interpretation are increasingly valued, and that’s no bad thing. Here at the EMJ the primary survey and the podcasts serve a similar purpose and they are popular.

What then is the future of medical publishing? I’m not sure but I’m fairly confident that the status quo will not continue. What do you think?

vb

S

EMJ Editor and Editor at St.Emlyn’s virtual hospital, blog and podcast.

PS. The debate was fuelled by some rather fabulous on stage drinks. The 25 year old Bushmills as recommended by Rob was truly stunning.

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