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Are nurses always right?

15 Feb, 17 | by cgray

Are nurses always right?

As a junior doctor, I have had, and still have some fantastic senior colleagues to work with, who generally give important and valuable advice. Over the placements and years, their advice is slowly turning me into the doctor that I aspire to be, an amalgamation of all the good bits from every doctor I have worked with so far along the way. I say doctor, but really I’m talking about all the other people that play a part in the hospital experience. Physiotherapists, pharmacists, health care assistants, porters, and so many more. Most of all, the many brilliant nurses I’ve had the pleasure of working alongside.

When I first started out as a doctor, the single biggest piece of advice that was given to me, and that still holds true today as one that I pass on to those unlucky enough to be my juniors, is to listen to the nurses. Make friends with the nurses. Don’t get on their bad side. Pay attention to what they say. That advice has saved me and saved my patients more times than I can count.

Because, nurses are always right. Aren’t they?

It’s a brave team that would design a study to pit nurses against a scoring tool, but that’s exactly what Allan Cameron and team from Glasgow have been up to. The Glasgow Admission Prediction Score (GAPS) was developed to estimate the probability of a patient being admitted, based on data collected at triage such as the patient’s age, early warning score, and triage category. The tool has been validated with good results, and could be used to help to optimise flow within the ED through early identification of those more likely to need a hospital bed.

This study, published in the January EMJ, aimed to compare GAPS to the triage nurses’ gestalt on likelihood of admission. To assess the latter, a visual analogue scale (VAS) was used, onto which triage nurses would mark how certain they were of patient admission/discharge. Previous studies on the topic have shown that when nurses are confident of the outcome, they’re usually right, and this study was no different. As always, we’d recommend you take a look at the paper itself to draw your own conclusions from the results.

3844 attendances to a single emergency department were studied, however a portion were allocated direct to a minors or resuscitation area, bypassing triage, and further patients were excluded from being under 16 or leaving before treatment was complete. Only 9 patients out of the 2091 that were triaged had insufficient data completion, which is a respectable figure. Of the 1829 attendances suitable for inclusion, 745 were admitted (40.7%), which seems high, however as stated this did not include a large number of minors patients who were more likely to have been discharged.

Nurse gestalt was found to be more sensitive than GAPS (81.2% vs 71.8%) but less specific (77.4% vs 86.6%). There was no correlation between nurse seniority and accuracy of predictions. Whilst the GAPS was more centrally distributed, results from the VAS showed peaks at 0-5% and 95-100% certainty of admission. This was the case for 781 patients. In these patients, nurses performed significantly better than GAPS, correctly predicting outcome in 92.4% (722). Excluding these patients though, GAPS provided a more accurate assessment.

In practice, the team found that the most accurate way to predict likelihood of admission was GAPS, but with the triage nurses able to override the tool where they were confident (>95%) as to whether the patient would be admitted or discharged. The authors admit that more work is needed, but maybe we’ll see admission prediction scores in use in the future.

Interestingly, there is no mention on whether those patients discharged home were followed up to see if any were admitted in the following days. Maybe the nurses’ gut feeling wasn’t wrong after all…

vb

C
@cgraydoc

Live and let die

30 Nov, 16 | by cgray

lald

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

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

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

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

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

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

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

Document everything

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

Talk to the family

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

Empower the nursing staff

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

Support your paramedics

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

 

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

vb

Chris
@cgraydoc

The weekend effect: Part 2 – a traumatic time!

29 Oct, 16 | by cgray

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

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

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

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

metcalfeabstract

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

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

Who was studied?

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

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

What did they find?

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

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

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

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

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

What conclusions can we draw?

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

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

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

vb

Chris
@cgraydoc

 

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

Become an EMJ reviewer

18 Oct, 16 | by scarley

peer

The EMJ, like most journals relies on peer review to help the editorial team make decisions on submitted papers.You can have a look at the list of people who have reviewed for us here, and we are always looking for more.

Now peer review has had some tough times of late. Ex editors of major journals have described it as ‘A flawed process at the heart of journals’ and it is true that it is not a perfect process. However, it has also been argued, also by Richard Smith that it there is no obvious alternative and that is respected by the scientific community.

Personally I am a sceptic when it comes to peer review and am increasingly an advocate of a blend of pre and post publication review. I particularly like the idea of post publication review facilitated through social media and of course we encourage letters and comments through any of our social media outlets on papers published in the EMJ.

However, for now, peer review is here to stay prior to publication and that means we need the brightest and best people to help us make decisions for the EMJ. So, if you are good at critical appraisal, if you have expertise in an area of EM practice and/or research design and if you want to help the EMJ publish the best papers then get in touch.

Contact us here and send us your details. Help us make the world a better place.

vb

S

@EMManchester
Peer review: a flawed process at the heart of science and journals Richard SmithJ R Soc Med. 2006 Apr; 99(4): 178–182. doi:  10.1258/jrsm.99.4.178 PMCID: PMC1420798

BMJ Blogs on peer review

Why Are Wee Waiting?!

30 Sep, 16 | by cgray

Why are wee waiting?

As anyone who has worked in an emergency department that caters for our younger patients knows, at any point during the day you can almost guarantee that there’s a parent somewhere, clasping a bowl to their child, waiting for them to wee.

The clock is ticking, the managers are on your back, and all the while you’re at the mercy of a tiny bladder.

Wouldn’t it be so much easier if there was some easy (and non-invasive!) way to just get that baby to pass urine quicker?

Published online at the EMJ last month, Jonathan Kaufman and team from the Children’s Hospital in Melbourne, Australia have designed and trialled a possible solution called the Quick-Wee method. This was developed through anecdotal reports of children voiding during perigenital cleaning, which the team hypothesised stimulates newborn cutaneous voiding reflexes. Their technique is to perform ten seconds of perigenital cleaning with sterile saline-soaked gauze, then rub saline-soaked gauze suprapubically in a circular motion for up to five minutes. It’s a technique that requires just a single member of staff, and one that they hope can decrease the time it takes to get a clean catch urine sample.

This was a single centre, feasibility study, and therefore all patients had the technique performed and there was no control group. Room temperature saline-soaked gauze was used in half the patients, with cold saline used for the remainder, as it was thought that temperature might have a role here too. The researchers looked at outcomes of voiding within five minutes, successful catch, and parent/clinician satisfaction on a five point Likert scale.

Previous studies have determined an average time to void of between 25 and 60 minutes, with only around 12% passing urine within five minutes. In this study, of 40 children aged between 1 and 24 months old, twelve children (30%) had successful voids in under five minutes, and all of those were under 12 months old. Cold gauze appeared more effective, but not significantly so, and all involved were reportedly satisfied with the technique.

This is a small study, but one that appears to show improvement compared with just waiting with a pot. It’s a technique that is technically easy, and could be performed by a parent or guardian rather than a healthcare professional. The protocol for their randomised controlled trial has already been published, and it will be great to see the results of this once the study is complete.

You can see Dr Kaufman present the team’s findings at the Australasian College of Emergency Medicine Annual Scientific Meeting 2015 here.

vb

Chris

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

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.

Conference season

24 Jun, 16 | by scarley

Are conferences dead_

Having just returned from Dublin and the SMACC conference, and a few weeks earlier having travelled to the wonderful IFEM conference in Cape Town it’s time to reflect on the worth of the travel, expense and family disruption that ensues. Our work families too have to pull extra shifts and adapt to those of us lucky enough to get away for a few days away from the department.

In an era of web based technologies, podcasts, vodcasts and associated social media it’s questionable whether we need conferences at all. There are surely cheaper, less expensive and more convenient ways of communicating and in an era of social media it is ever easier to make those connections across the planet.

We should of course not forget the enormous environmental impact of many conferences, notably those large international conferences where 100s of tons of jet fuel are burned into the atmosphere to fuel knowledge dissemination that might so easily have been delivered online.

This is a theme we touched on in the EMJ in a paper looking at the future of conferences where the case for future more environmentally aware and better disseminated conferences was explored.

Innovation in the field of medical conferences.

So are conferences dead?

My experience last week and in South Africa would suggest not. Take the SMACC conference which has gained a bit of a reputation for blending social media, education and entertainment. The participants are almost all involved in online learning and so might be expected to shun the traditional travel to meet and great type affair.  Yet it is precisely this audience of online engaged clinicians who seek out the ability to meet, to network, to share, to laugh, cry and share together. This year the conference sold out in a matter of hours with competitions being held for the remaining tickets. The interest and anticipation to meet with like minded enthusiasts from across the globe was palpable and at times a little over the top and uncomfortable. The demographic was young, multicultural and multiprofessional. This is not typical behaviour for medical conferences, and perhaps is more akin to pop concert tickets. It’s a situation that makes some feel uncomfortable, but there is no doubt that it is engaging a worldwide population of learners.

A paradox perhaps, that the conference espousing an online socially connected world is one that sells out in hours and has a waiting list of those wanting to attend.

I’ve not quite got my head round this yet, but I think there may be at least two elements at work. Firstly there is a natural human desire to connect and conferences allow that, online interactions are good, but they are not the real thing and it’s great to meet in person, to explore ideas and to satisfy a human need to put faces to names. Secondly, although I find the online education world fascinating, there is only so much it can do. A live presentation of high quality is unsurpassed as a learning experience and you simply can’t do some things online.

Take the on stage discussion at SMACC on the future of medical journals as discussed by Richard Smith (ex BMJ editor). That was a great session that simply could not work as well in any other setting. A blend of science, politics, fun and entertainment with some really important discussion points and views.

Richard Smith: What will the post journal world look like?

So, the conference is far from dead, but it is changing. It’s role as a prime means of delivering information is perhaps waning, but as an opportunity to form and build social links, collaborations and understanding it is surely on the rise.

So I guess I’ll probably see you in an auditorium soon. If you do then say ‘hi’. After all, the people are just as important as the presentations. Collaborations, discussions and developments come from interaction, not from powerpoint.

vb

S

 

DOI: I’ve had supporting expenses to travel to many conferences, including SMACC last week. I am unbelievably lucky and priviliged to do so. I’ve actively supported a range of innovative conferences and believe that the old model of boring lectures given by boring speakers on boring subjects is a waste of time.

OT in the ED

2 Jun, 16 | by cgray

“Occupational therapists help people to do the things they want to do”

In this month’s EMJ, Kirstin James details the work that occupational therapists (OTs) have been carrying out up and down the country’s emergency departments to facilitate a return to normality after an illness or injury. She tells the story of an 87 year old lady called Mrs MacDonald, well known in various guises throughout our profession, and how she assessed her physically, cognitively, and socially to determine her ongoing needs after a fall and humerus fracture. By carrying out her assessment and determining the patient’s needs, Kirstin could enable Mrs MacDonald to go home. She organised care visits by the crisis team whilst more permanent arrangements were being made, procured equipment to make it easier for Mrs MacDonald to get around the house and go to the toilet, and made sure she had the support she needed.

Kirstin made it possible for Mrs MacDonald to do the things she wanted to do, and to do them in her own home rather than a hospital bed.

Whilst my local ED doesn’t have direct occupational therapy input, we can admit patients to our observation unit to be assessed by a multidisciplinary team comprising of physiotherapists, OTs, and discharge co-ordinators who can facilitate access to community nursing and other services. Once they have been assessed, a decision can be made on whether the patient is safe to go home that day (with or without further assessment in the near future), or that they need measures put in place before they go home. Sometimes these measures take time and, after discussing it with the patient, it may be better for them to be admitted to one of the main hospital wards to allow this to take place.

Kirstin’s article is a fantastic reminder that our work in emergency medicine isn’t just about fixing a medical problem. We also have to consider the impact that this medical problem is going to have on our patient when they get home. Are they still going to be able to eat, drink, move around their house, go to the toilet? What help do they need to allow this to happen? Who else is, or can be, at home with them? Thinking about these issues early on may help the patient to get better more quickly, and avoid further ED attendances and subsequent hospital stays.

If you don’t know how to access occupational therapy in your ED, find out! And if you do know, let us know what happens where you are. We’d love to hear.

Chris

 

Reference:

James K. Occupational therapists in Emergency Departments. Emerg Med J 2016;33:442-443.

The Balance of Risks and Harms in Trauma Immobilization

11 Dec, 15 | by rradecki

In a recent online-first publication in the EMJ, McDonald et al canvas the literature regarding selective immobilization protocols in trauma. Their most significant finding, unfortunately, is the low quality of the evidence and the high degree of bias present across included studies. This limits the authors’ attempted analysis of sensitivity and specificity of selective immobilization protocols.

From a qualitative standpoint, however, their data bears examination. The included studies or prehospital immobilization range in size from 3 to 504 spinal injuries. Within these cohorts, 76 patients were identified with injuries who did not undergo immobilization. None of these patients had any reported neurologic deterioration in spine of their missed immobilization.

This small snapshot ties into another recent publication, in AEM, looking specifically at cases of neurologic deterioration in the context of failed prehospital immobilization. These authors identify 41 qualifying cases across 12 studies. Most patients had normal function at the scene, but many had substantial disability or death following a period of non-immobilization.

This leads, then, to two related questions raised by each of these authors. The first: how do we reform our prehospital protocols to reduce unnecessary immobilization, while potentially still capturing those few with spinal injuries. The second: how much benefit does pre-hospital immobilization convey regarding long-term outcomes? McDonald et al report their sensitivity and specificity based simply on the presence of an injury, but, long-term disability is the patient-oriented outcome. To truly address and refine pre-hospital immobilization strategies, further study should be designed and powered to detect – if possible – the presence of subsequent neurologic deterioration. Only then, when deterioration rates can be compared between the immobilized and non-, will we have a better grasp of the value of continued, dogmatic, pre-hospital trauma care.

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