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Help set UK EM research priorities

24 Sep, 16 | by scarley

the-james-lind-research-priority-setting-exercise-needs-you-to-get-over-the-line

Hopefully you already know about the James Lind Alliance 1–4. If not have a look at the St.Emlyn’s blogs and podcasts, but in brief the Royal College of Emergency Medicine is working with the JLA to set the most important research priorities in emergency medicine. The process has been running since the middle of last year and after a lot of work led by Professor Jason Smith and Richard Morley we are down to the last 60 questions.

We need your help in prioritising the final questions.

We need professionals and the public to follow this link to a survey that will finalise a list of questions that will then go through to a final round in January where the top 10 research priorities will be set.JLA flyer for download

We need everyone to help complete the survey, both patients and professionals.

FOLLOW THIS LINK  – https://www.surveymonkey.co.uk/r/JLAEMPSP

Download this flyer and share in your department. Show it to friends, family, patients, professionals and get everyone involved.

Past processes have shown that if the JLA recommends a research priority then it significantly increases the likelihood of getting the projects funded. In other words this really matters and could shape UK EM research for the next decade.

So please. Have a look and complete the survey today.

Thanks

S

@EMManchester

On behalf of the JLA steering group.

1.
James Lind Alliance and RCEM needs you. stemlynsblog.org. http://stemlynsblog.org/james-lind-and-the-rcem-needs-you-and-you-and-you-st-emlyns/. Published October 2015. Accessed September 24, 2016.
2.
James Lind Alliance: Emergency Medicine. jla.nihr.ac.uk. http://www.jla.nihr.ac.uk/priority-setting-partnerships/emergency-medicine/. Published 2015. Accessed September 24, 2016.
3.
Smith JE, Morley R. The emergency medicine research priority setting partnership. Emergency Medicine Journal. 2015;32(11):830-830. doi: 10.1136/emermed-2015-205353 [Source]
4.
James Lind Alliance Update. stemlynsblog.org. http://stemlynsblog.org/james-lind-alliance-update-st-emlyns/. Published December 2015. Accessed September 24, 2016.

Extending primary care reduces attendance – or does it?

13 Sep, 16 | by scarley

do-more-gp-appointments-lead-to-fewer-ed-visits_The debates around 7-day services, job contracts, scope of practice and emergency medicine overcrowding can sometimes feel like a maelstrom of fact, figures, spin and deceit. Even those of us working in emergency medicine find it difficult to determine the quality of what we hear through news channels and so it’s always good to read some science about really important issues that affect us.

A recent study in PLOS ONE has looked at the impact of extending primary care (GP) hours in Manchester, which also happens to be my home town. Over a one year period NHS Greater Manchester spent £3.1 Million pounds enabling groups of GPs to extend their services in the hope that they would reduce pressure on ED services.

screenshot-2016-09-13-12-06-15

This paper has already attracted interest and will no doubt be used by politicians and politicos to further their agendas. We on the other hand will be left to pick up the pieces.

They determined this by comparing attendance rates between GPs with the additional funding vs those without, and at first glance it looks like a success. The claimed rate of a 26.4% reduction in emergency department visits is a very tempting headline, but I was in Manchester in 2014 and I can assure you that we did not see fewer patients. The result is of course a relative risk and these are well known for being difficult to interpret and susceptible to making results appear more dramatic than they really are.

Let’s delve a little deeper from an emergency physician’s perspective.

  1. This is a really complex analysis and it’s tricky to find the raw data.
  2. They estimate that they had to provide 33,159 appointments to achieve 10,933 fewer ED attendances. So you have to offer 3 GP appointments to prevent a single ED visit.
  3. These were for minor problems (so it would not affect the more severe end of the ED)
  4. The analysis is complex as they are trying to compare reported attendance against trends but the suggestion of a 26.4% relative reduction is offset in my mind by the reported ED attendance rates per 1000 patients. In the control group it was 32.3 vs 29.4. Although statistically significant on their analysis I’m not convinced that we would notice.
  5. I am really struggling to understand how they came to the conclusion that there was a 3.1% reduction in ED attendances. It is stated in the paper but I just can’t see the baseline data to explain this (maybe it’s just me). They do state that it was a not a statistically significant finding.
  6. They do admit that a formal cost analysis was not done but do claim that costs have reduced in the EDs by £767,976 over the study period. I think this must refer to the ED costs WITHOUT taking into account the £3.1 Million spent. If I was reporting this I think I would subtract one from the other and call it roughly a £2.3 Million pound loss.
  7. No health outcomes were assessed and there was an assumption that admitted patients were ‘appropriate’ and not included in the analysis. I don’t like differentiating patients into appropriate and inappropriate on the basis of whether they were admitted. Anyone working in an ED knows that admission is not a good determinant of this.
  8. I would really like to see the data on ED attendances during the study period. Did this intervention really have any impact on what the local EDs saw in terms of patients numbers?

This paper has led to headlines suggesting that the funding really did cut ED visits such as this on the BMJ site, but I’m really not sure that it does.

What does this mean for us? It tells me that reducing ED attendance is complex and that simple measures such as extending opening hours do not always have the dramatic effect that politicians and some medical leaders predict.

It tells me that Emergency Departments provide really cost effective care, or does it. Rather it might just tell me that EDs are chronically underfunded and are providing care on the cheap.

I’ll leave it to you to decide, read the paper and get back to us.

Good luck with understanding the stats section.

vb

S

 

BMJ Blogs Extending primary care hours cuts emergency department visits. http://www.bmj.com/content/354/bmj.i4818

Associations between extending access to primary care and emergency department visits. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002113

ECG Marksmanship: Posterior Wellen’s Syndrome

9 Sep, 16 | by rlloyd

posterior-wellens-syndrome-2

One of the most rewarding elements of emergency medicine is spotting a potentially catastrophic situation at an early stage, and proceeding to ‘nip it in the bud’ before things start getting hairy.

To coin a military analogy: a battalion might be perfectly capable of neutralising the enemy in close-quarters combat, but in an ideal world, a shrewdly placed sniper will take care of business ahead of time. No need for bayonets if you’ve got a man on the roof.

The emergency physician acts as the sniper when Wellen’s Syndrome is spotted on the 12-lead ECG. A pain-free, haemodynamically stable patient might be moments away from a ‘widow-maker’ infarct, but if the subtle precordial biphasic T-waves are picked up, the enemy lesion can be taken out from range via percutaneous coronary intervention (PCI), sparing the patient’s anterior myocardium. No drama.

What is Wellen’s Syndrome again?

It was first discovered in 1982 by Hein J. J. Wellen, and describes characteristic T-wave changes in the right precordial leads (V1-V3) that represent critical stenosis of the left anterior descending (LAD) artery.

Most cases (approximately 75%) of Wellen’s Syndrome have a ‘Type B’ pattern – deep and symmetrically inverted T-waves. This is an easy spot, and should ring alarm bells even at novice level.

wellens1_1

Wellen’s Type B (Image from ‘Life in the Fast Lane’)

A minority of cases (approximately 25%) will have ‘Type A’ pattern – biphasic T-waves. These are often more subtle, and easily overlooked, particularly if the patient is clinically well.

Wellen's Type A (Image from 'Life in the Fast Lane')

Wellen’s Type A (Image from ‘Life in the Fast Lane’)

The physiological basis for Wellen’s is spontaneous reperfusion of a previously occluded artery. Often patients will present to the ED following a bout of severe chest pain which has resolved. Classically, the ambulance ECG will demonstrate an impressive STEMI, which has disappeared once the patient has arrived in resus, pain-free. Despite being symptomatically better, these patients will have an active thrombus and are high risk for re-occlusion and STEMI. They need aggressive medical management, with a view to urgent angiogram/PCI.

Wellen’s waves are not exclusive to the anterior leads. They have been shown to correlate with spontaneous reperfusion in the left circumflex (LCx) and right coronary artery (RCA) when ECG changes are seen in the inferior and lateral lead distribution.

Interesting recent EMJ article – Driver et al, August 2016

Until recently, the literature has not described the ECG appearance of posterior MI (PMI) reperfusion.

An article published online first in the EMJ last month takes on this very challenge. Tellingly, one of the authors is Stephen Smith, author of ‘Dr. Smith’s ECG blog’ – one of the most prominent ECG #FOAMed resources available.

The classical acute PMI ECG demonstrates new ST depression in the right precordial leads – a mirror image of ST elevation in the hypothetical posterior leads (V7-V9). The posterior myocardium is supplied by either the LCx or RCA, depending on the patient’s anatomy.

The authors of this paper hypothesised that spontaneous reperfusion of the offending artery in acute PMI patients would result in Wellen’s waves (deep T-wave inversion) in the posterior leads, which would correlate with an increase in positive T-wave amplitude in the right precordial leads – again, the mirror image concept.

It was a retrospective observational analysis of 72 patients with LCx or RCA occlusions who underwent PCI – mimicking spontaneous reperfusion. Forty eight patients met criteria for PMI – ‘presence of right precordial ST depression, maximal in leads V2 and/or V3, not explained by QRS abnormalities’. Twenty four patients did not meet criteria – i.e. they had occluded their LCx/RCA, but the posterior myocardium was not infarcted.

Post reperfusion:

  • PMI patients had a greater increase in V2 and V3 T-wave amplitude when compared to non-PMI patients (p=0.0005 and 0.03 respectively).
  • PMI patients had greater maximal T-wave amplitude in lead V2 (p=0.04) when compared to non-PMI patients.

The authors believe they have described an ECG finding for PMI reperfusion that is ‘analogous’ to typical Wellen’s waves. ‘Posterior Wellen’s Syndrome’ is born.

Of course there are the inherent limitations of a single-centre study with a small patient population, but nonetheless the paper is compelling reading. It’ll make you a more accomplished ECG marksman, taking better aim from the roof of your department.

For me, the take-home point is to always carefully consider treating and admitting a patient with resolved ischaemic-sounding chest pain and unusually big right precordial T-waves (however subtle) – particularly if they have risk factors for coronary artery disease. At the very least previous ECGs should be hunted down and interrogated.

As always, would love to hear others thoughts on the paper.

Robert
@PonderingEM

The Paper

Driver BE, Shroff GR, Smith S. Posterior reperfusion T-waves: Wellens’ syndrome of the posterior wall. Emerg Med J. 2016 Jul 29.

Additional resources used

Dispatching stress in the EOC #IAM999

5 Sep, 16 | by cgray

ou're never making just one decision_(1)

In this month’s EMJ, Astrid Coxon and team have published a study looking at the experiences of staff working in local Emergency Operations Centres (EOCs). Broadly, staff who work there are in two groups. There are call takers who answer 999 calls from members of the public, process the information they receive, triage it, and pass it to the dispatch team, and in some cases stay on the phone line to talk to the caller or give emergency medical advice. The other group are the dispatchers. They take the information from the call takers, and liaise directly with the frontline crews to co-ordinate and prioritise the medical response to the huge volume of calls that come in every day.

The study looked at this second group, who are largely invisible to the public, and aimed to identify key stressors in the workplace, so that these could be managed and reduced where possible. They hope that this could have a positive impact on the well-being of the staff, reduce sickness absence, and decrease staff turnover. The main factors found involved resources and pay, interpersonal difficulties, and feeling overworked and undervalued – themes that I’m sure many in all areas of healthcare can relate to. You can read about some of the ways the participants in the study felt that stress could be reduced, as well as some of the authors’ suggestions, in the EMJ or on the website.

This article, as well as the recent #IAM999 campaign on Twitter and other forms of social media, reminds us how crucial it is to remember that before our patient turned up nicely packaged by the paramedics, and indeed before the paramedics even arrived on scene, there was someone on the other end of the phone, supporting and giving advice to a worried patient, concerned relatives, or a distressed bystander. They may have been listening to the last words someone would ever say, or helping a child try to resuscitate their mother or father.  There are so many people who work behind the scenes in pre-hospital and emergency medicine. Their support and work are a huge part of the process that has led to your patient arriving in the ED, but too often we forget that this bit actually exists. It’s reassuring that work has been done to try to assess stress in these people, and to look for ways they themselves, as well as the organisation they work for, can make changes to reduce this.

It can’t be an easy job, particularly when, like ED doctors and nurses, time is rarely taken to process what’s happened before moving onto the next poorly patient. However, it’s a rewarding job, and one that can make a huge difference to the lives of patients and their families.

As Sam, who participated in the study, said, “I can honestly say I go home at the end of every single day and I’ve made a difference to at least one person…”.

And for me at least, that’s what emergency medicine, from the first 999 call, to the patient leaving the department, is all about.

vb

Chris

@cgraydoc

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!

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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

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