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Primary Survey March 2017

23 Feb, 17 | by scarley

It’s March 2017 and time for a quick review of the best of the EMJ this month

Under pressure: does cricoid improve laryngoscopy?

Whether or not we should use cricoid during emergency intubation is fast becoming one of the greatest modern controversies in Emergency Medicine. While we await data from randomised controlled trials, in this month’s issue Caruana et al have provided some important new evidence. In a retrospective analysis of 1195 patients undergoing pre-hospital intubation, cricoid pressure was not found to be associated with difficult laryngoscopy. After propensity score matching, there were no apparent differences in the incidence of complications with or without the use of cricoid pressure, other than an increase in the proportion of patients sustaining airway trauma when cricoid pressure was used. Ultimately we now have further reason to question the routine use of cricoid pressure, but is it sufficient to change your practice?

Statistics made much easier!

Reading the phrase ‘propensity score matching’ may have just made you feel a little uncomfortable. If so, you’re not alone. Most emergency physicians could do with a little help when it comes to interpreting some of the more complicated statistical analyses we encounter in the literature. If you feel that way, I’m sure you’ll be pleased to see that this month we have the first in an occasional series of articles on statistical concepts that go beyond the basics. These articles aim to provide a helpful tutorial to readers to increase their skills of critical appraisal for the future. To help illustrate the concepts, we will link them to original articles that we publish. This month, we’ve linked to the work by Caruana et al, which is free to access as the editor’s choice.

Who calls ambulances and doesn’t wait?

Most of us can appreciate that calling for an emergency ambulance is not to be taken lightly. When emergency services are facing severe and increasing pressure, it can be extremely frustrating to observe that some patients arrive in the Emergency Department by ambulance but don’t wait to be seen. In this issue, Doupe et al explore the characteristics of patients who do just that. Compared with other patients, they found that patients who called an ambulance and did not wait were more likely to have a history of substance abuse ad to live in low income areas. Identifying the characteristics of patients who exhibit this behaviour will help emergency physicians to create individual management plans to deal with apparently unhelpful patterns of seeking healthcare.

A new device to help metrics for ED weighting

Rapidly and accurately estimating the weight of children presenting to the Paediatric Emergency Department is highly important for drug dosing but often challenging. Emergency physicians commonly use formulae or aids such as the Broselow tape. This month, Jung et al report on the accuracy of a novel ‘rolling tape’ electronic device with wireless transmission. They demonstrate that its use enabled faster and more accurate weight estimation than the Broselow tape. However, they go further still: using the rolling tape led to faster orders for resuscitation drugs and defibrillation in cardiac arrest. Could this revolutionise how we measure patients’ weight in the Paediatric Emergency Department?

The trajectory of an academic emergency physician

If you’re a research active emergency physician, you may be interested in tracking your academic progress in relation to other emergency physicians. Is your progress fast or slow? In this issue, Miro et al explore whether we can develop a guide to the progress of researchers in Emergency Medicine. They tracked the h-index of a selected group of academic emergency physicians. The h-index tries to combine an author’s impact with their productivity. If an author has, for example, 5 articles that have been cited 5 times or more, then their h-index is 5. Miro et al have derived a formula to track the rise in h-index for ‘fast’, ‘medium’ and ‘slow’ growth academics. Where do you fit in? Don’t be discouraged, though. All the authors included in this sample were highly reputable academic emergency physicians. Even those in the ‘slow growth’ category may therefore be elite researchers. You may, however, find that this article spurs you on!

Can doctors measure pain in children?

Brudvik et al report a fascinating study in which they asked children to score their pain in the Paediatric Emergency Department, while doctors and parents were asked to estimate the score. How do you think we did? Read the full article to find out the detail, but you may be surprised to find out how much we under-estimate pain and how often we withhold analgesia, even for children with severe pain. It’s a sobering reminder that the pain of an individual is a very personal experience and cannot be accurately measured by others.

vb

Rick Body

PDF

http://dx.doi.org/10.1136/emermed-2016-206657

BBC visit UK emergency department and experience Winter pressures

7 Feb, 17 | by scarley

It’s not really news that UK Emergency departments are under pressure, but those realities are often hidden from the general public. However, in the last week the BBC was granted access to the Royal Blackburn hospital to see first hand how it feels to deliver emergency care in an overcrowded environment.

Follow the link below to see the BBC review.

http://www.bbc.co.uk/news/health-38885775

vb

S

The One-Upping Blind spot.

2 Feb, 17 | by scarley

Sometimes you see things on twitter that upset you. This week I noticed this post from the excellent Shaun Lintern on ‘one-upping’ in hospitals. It’s not a phrase I’ve heard before but it essentially means putting an extra patient on wards above their intended capacity.

Ruth May is the executive director of nursing for the NHS Improvement agency. She is quoted as saying that one upping is not acceptable and that it poses a significant risk to patients. There is little to argue with this but stop and think, what are the consequences for the whole system if one area declines to accept any risk? Does the risk vanish, or does it simply move elsewhere? I suspect that you, like me know that it is the latter.

If one upping is unacceptable does NHS Improvement have any idea what it’s like to work in a UK ED at the moment? Never mind one upping, try 10,11,12,13,14,15 upping your trolley patients. It is so common as to be routine practice in the UK.

Those numbers do not take account of the patients in the waiting rooms who should be on trolleys, but who are on chairs as we’ve run out of trolleys for them to lie on. Is it acceptable to have to give IV opiates to a patient sat on a chair in a corridor with renal colic? Of course not, but that real example is a manifestation of what overcrowding means. It’s incredibly risky for patients as we know that overcrowding causes increased numbers of deaths. Make no doubt about it, overcrowding causes death and disability in our patient populations in the ED.

Ruth May does not state whether her comments apply to the ED and I’m sure she knows about EM overcrowding, but her comments are likely to prevent the sharing of risk across hospitals and services. This could lead to more harm as we know that sharing risk is a positive patient safety move. You should be familiar with Full capacity protocols which are designed to share the load and to avoid the harms that overcrowding causes, but they are yet to catch on in the UK.

Also see www.hospitalovercrowding.com

How on earth can it then be logical to concentrate all that risk in one place, the ED, rather than spread the risk across wards and departments? How can it be wise to ask my team to look after multiple patients on trolleys in corridors as opposed to asking a number of wards to take one extra patient.

It’s illogical, unsafe and dangerous and yet it’s a common strategy in many trusts. The comment above from a UK colleague about crowding this winter will be familiar to many. Corralling the risk in an overcrowded ED is indicative of a hospital that has chosen to concentrate the risk in a single place. It’s bad for patients and it’s bad for staff who burn out as they cope with a deeply unfair, grossly differential and unsustainable workload.

My plea is that when we hear talk of avoiding one upping that it does not inadvertently lead to even greater levels of harm in the ED.

We need strong and vocal leadership to stop this from happening.

vb

S

Primary Survey Feb 2017

30 Jan, 17 | by scarley

Highlights from this issue
Ellen J Weber, Editor in Chief

 

Teaching how to think
Somewhere between entering medical school and leaving specialty training, a young doctor makes a transition from being a complete novice to a physician capable of making diagnostic and treatment decisions more or less independently. How exactly does that happen?

Two articles in this month’s issue, along with a commentary by Damien Roland, attempt to shed some light on this murky metamorphosis. The study by Bowen et al examines  a cross-section of clinicians at different phases in their careers, looking at how decisions are made. In this study, 15 Paediatric Emergency clinicians (consultants, trainees and nurse practitioners) were interviewed about their decision making when treating  patients under 5 with respiratory illness. Junior clinicians were more risk averse, and relied heavily on guidelines and second opinions; experienced physicians appeared to use more tacit knowledge and take more risks.

In this month’s Editor’s Choice selection, Adams et al, studied 37 junior EM doctors who were asked to recall two recent cases and discuss how they approached their clinical decision making. In the language of dual-cognition theory, the authors found that the trainees essentially described that throughout the diagnostic and disposition process, they used so-called Type 1 thinking (intuitive), countered by Type 2 (analytical) thinking to keep themselves and their patients safe. A high level of diagnostic anxiety was seen in this group of doctors. The authors suggest that teachers could do more to prevent premature closure, speed up learning of pattern recognition to decrease cognitive loads, and routinely employ methods of reflection after a case to improve awareness of the reasoning process. They provide a helpful set of questions for the teacher of emergency physician to walk the learner through this process. To bring this all together, Dr Roland’s commentary ‘Have we forgotten to teach how to think?’ challenges us all to consider if we are paying enough attention to this aspect of the transition from novice to expert.

Smile, though your heart is breaking
Arguably, the antithesis of thinking is acting on instinct, or gestalt. Much has recently been made of physician gestalt, with several studies suggesting that physician gestalt is about as good as many tests or decision rules. Jeffrey Kline, who most of us know for his work in pulmonary embolism (PE), and specifically the PERC rule, has an avocation in physician gestalt, questioning what it is about our patients that gives us this ‘sixth sense’ about whether they are sick or not. Some will remember Dr Kline’s EMJ publication in which he demonstrated that patients who are sick (in that case, have a PE or a serious cause of chest pain) have less facial reaction to stimuli than those who are well. Based on this finding, he hypothesized that patients who do more smiling – and physicians perceive as smiling – are less likely to have a serious diagnosis. In this month’s issue, we reveal the results of a study by Kline and colleagues of 208 patients about to undergo a CT scan for pulmonary embolism.  The pretest probability of a PE was estimated using the gestalt method (visual analogue scale, 0%–100%), the Wells score (0–12) and physicians’ impression of whether the patient smiled during the initial examination (smile+). Patients’ faces were also analysed with an automated neural network-based algorithm for happy affect. Without being too much of a spoiler, let’s just say ‘don’t let that smile fool you’. The results may have you rethink your initial  impression of that chipper patient in room 3.

Is it time to embrace the Shock Index?
The Shock Index was introduced in 1967 as a prognostic marker for hemorraghic and infectious shock. It has shown promise as a marker of high risk patientsin several ED studies since then, having  an association with increased lactate, and, in another study, increased incidence of post-intubation hypotension. But the Shock Index has not generally been adopted into routine EM practice. Balhara and colleagues from The Johns Hopkins University School of Medicine studied over 58 000 patients seen in their ED over 12 months, and demonstrated that increasing values of the Shock Index were associated with an increasing likelihood of admission and mortality. An SI of >1.2 was a strong predictor of both inpatient admission and mortality. The Shock Index is remarkably simply to calculate: heart rate/systolic BP. If you can calculate a MAP, you can certainly calculate a shock index!

Candy is dandy, but glucose is quicker
This systematic review by Carlson and colleagues answers the question of whether dietary sugars are as good as oral glucose for patients with hypoglycaemia (and no IV). The simple answer is no, they are not. However, knowing the ‘bottom line’ should not dissuade you from reading this interesting paper, which looks at the effects of some of your favourite confections.

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Ellen Weber

EMJ Editor

The ‘Deliberate Practice Mindset’

27 Jan, 17 | by rlloyd

Performance improvement is an interest of mine. I have previously blogged and podcasted about the strategies I employed to lift my game (from rock-bottom) when working in an extreme environment – a South African township ED.

I first became aware of ‘deliberate practice’ after reading an excellent St. Emlyn’s post last year. I had never encountered the concept before, but it resonated with me because it resembles certain aspects of how I’ve approached self-improvement in a professional setting, particularly when desperate to prove myself in South Africa.

The psychologist who originally described deliberate practice, Dr. Anders Ericsson, has recently published a book – Peak. It explores the ‘science of expertise’, for which he is the world’s leading expert – the expert on experts.

I thought I’d discuss a few of my take-home points from the book.

The ‘gift’ fallacy

“I am not talented, I am obsessed” – Conor McGregor, UFC lightweight champion

Too often, wider society’s assumption is that elite performers are naturally ‘gifted’. They have been magically blessed with superhuman ability. According to Ericsson, this is false.

No-one is born with an innate ability to perform at expert level, in any domain. All exceptional performers, regardless of field, have had to push themselves through a very intense practice regime to get to where they are. They have learnt how to be brilliant.

Ericsson repeatedly makes the point that in his 30+ years of studying an extraordinarily wide range of expert performers, from grandmaster chess players to professional tennis players to concert violinists, he is yet to encounter a genuine ‘prodigy’ – somebody born with prerequisite skills for expert performance.

MozartEricsson’s favourite example of the ‘God-given talent’ fallacy is legendary composer Wolfgang Amadeus Mozart. From an astonishingly young age, Mozart wowed audiences in concert halls across Europe with his apparent mastery of multiple musical instruments, and was labelled a child prodigy. Not so much, it turns out. The history books reveal that Wolfgang could barely walk before commencing a comprehensive training regime designed by his father, a pioneer in musical training. Furthermore, Ericsson claims that if he were around today he would barely stand out from the crowd. In fact, it’s been demonstrated that Suzoki Method-trained child musicians are often able to perform to a higher level than Mozart was ever capable of achieving.

A key component of Mozart’s prodigious skillset was thought to be his possession of perfect pitch – the ability to accurately name a musical note upon hearing it in isolation. The assumption was that it spontaneously emerged from birth and was un-teachable. It has since been proven that anyone can be trained in perfect pitch, particularly if they’ve received appropriate training between the ages of 3 and 5 years. Intriguingly, it is now acknowledged to be fairly common for children born in countries where tonal languages (e.g. Mandarin) are spoken to possess perfect pitch if musically trained. No magic involved.

The only exception to the rule that natural talent is bogus is when it comes to height and body size. Specific phenotypes are essential for certain sports – you need to be tall to slam dunk a basketball, and being short confers a big advantage for competitive artistic gymnastics. No specialised training regime will lengthen or shorten your bones.

We’re all endowed with the same ‘gift’ – the ability to adapt and improve if we train ourselves correctly (i.e. effective practice). Excitingly, Ericsson’s key message in Peak is that a common set of general principles lie at the heart of effective practice for any human endeavour… all walks of medicine included.

All practice is not equal – avoid naive practice (and forget the 10, 000 hour ‘rule’)

The most common approach to improving performance is ‘naive practice’.

This is where one spends a significant amount of time engaging in the activity, with the hope that stockpiling experience alone will improve performance, and move them closer to the realm of expertise.

“All I need to do is see 15 Majors patients per shift for the next 10 years and I’ll become a world-beating Emergency Physician” – hapless emergency medicine trainee destined for mediocrity

This is aligned with the 10, 000 hours ‘rule’ as per Malcolm Gladwell in his book Outliers. The proposed theory is that 10, 000 hours of generic practice yields expertise, with emphasis on time spent practicing as opposed to the nature of the practice itself. No specific component of the activity is isolated and focused on (e.g. putting in golf, or needle manipulation in central venous access), one just keeps doing the task over and over again. Outliers has been an immensely popular publication, and the 10, 000 rule a widely-disseminated concept. It sounds cool, and it satisfies the basic human desire for cause and effect.

In reality, this theory is fundamentally flawed. In order to change behaviour (i.e. improve performance), you need to engage in effective training. Ericsson calls this ‘purposeful practice’.

Interestingly, it is Ericsson’s original work, examining concert violinists in training, that inspired Outliers, and he levels a reasonable amount of hostility towards Gladwell in Peak, with accusations of corrupting lessons from the research. The best violinists out of the trainee group had all spent approximately 10, 000 hours by the age of 20 in solitary practice, as compared to the more inferior (but still relatively elite) trainees who had a few less thousand hours on the clock. It was this finding which prompted Gladwell to jump to the conclusion that 10, 000 hours was the magic number, yet the few that went on to win international music competitions did so at 30+, when they had put in 20,000 to 25,000 hours of practice.

“The greats weren’t great because at birth they could paint, the greats were great because they paint a lot” – Macklemore, rapper

It might be mired in controversy, but the 10, 000 hour rule does serve one crucial purpose – it reminds us that a massive volume of practice is required to achieve peak performance. No elite performer in any field has not dedicated a significant slice of their life towards achieving their goal. The path to greatness is not easy.

Purposeful Practice (core of Ericsson’s deliberate practice)

Exactly what it says on tin – this is practicing with a purpose. The mission is to improve, and you are practicing for that sole reason. Every time you practice, you are asking the question: “How can I do this better?”

A specific component of the skill is isolated (a component that one is poor at/can’t do) and then targeted for improvement via training activities. There are four principles of purposeful practice:

1.     You need to establish a (reachable) specific goal. Vague overall performance targets like ‘succeed’ or ‘get better’ won’t cut it.

2.     You must be maximally focused on improvement during practice. It must be intense, uninterrupted and repetitive (‘drilling’). Not particularly pleasant, but highly rewarding.

3.     You must receive immediate feedback on your performance. Without it, you can’t figure out what you need to modify or how close you are to achieving your specific goal.

4.     You must get out of your comfort zone, constantly attempting things that are just out of reach.

Take chest drain insertion for example. You isolate one part of the procedure that you know needs improvement – e.g. surgical hand-ties (to suture the chest drain to the skin):

Goal: Be fast and efficient at single-handed surgical hand-ties by the end of the training session.

Focus: Watch a training video explaining how best to perform the tie a few times; then practice tying knots round a kitchen utensil using the taught technique multiple times.

Feedback: Compare your performance to that on the training video, or ideally get personalised feedback from a supervisor.

Exit comfort zone: Experiment by performing the technique under time pressure or give yourself less suture thread to work with.

A hallmark of purposeful practice is that performance level during training tasks is not initially at the desired level – there is a gap. By the end of a phase of training, there needs to be something measurable that you’ve improved.

Embracing these principles in training squeezes the trigger of the greatest weapon in the arsenal of the human brain – adaptability. Every training session should be viewed as a challenge to refine and improve.

Deliberate Practice

“The most effective (improvement) method of all: deliberate practice. It is the gold standard, the ideal to which anyone learning a skill should aspire.” – Anders Ericsson

Deliberate practice encompasses the principles of purposeful practice, with a couple of additional elements:

1.     The field must be well established, and elite performers easily identified.

2.     A coach or teacher guides training.

A good coach provides constant individualised feedback and designs training activities that target specific areas. They hold the ‘roadmap’ that guides the student through an evolving training regime that hones skills in a specific order. Certain skills can only be taught and practiced once others have been mastered.  This calculated and heavily supervised approach to training always leads to elite performance when the student is motivated. It is tried and tested.

A useful analogy is to think of purposeful practice as trekking through the desert to a specific destination that is out of sight. You know the general direction you need to go, but in order to reach the destination you must walk in a completely straight line – notoriously difficult in the desert. A good strategy would be to use landmarks up ahead such as trees and sand dunes to aim at, so as to avoid walking round in circles. You are progressing with a purpose, but there is minimal guidance.

In this context, deliberate practice can be thought of as that same journey, but instead there is a path marking the route you need to walk, with signposting along the way, and even a camel guide to get you back on track if you veer off the route.

Mental representations

Engaging in purposeful/deliberate practice modifies the structure of our brains. Specific neural circuitry, which fires action potentials when training a skill, get reinforced and increasingly complex. This serves to strengthen the ‘mental representations’ one has of the skill in question.

The human brain is a blank canvas, and learning a new skill is like painting a picture on that canvas – the picture being a mental representation of that skill. With effective training, and as one improves at performing the skill, a discernible image starts to take shape. As the years of effective practice roll on, the picture becomes increasingly detailed and animated, and eventually it correlates with performing the skill at an expert level.

The expert performer, via their mental representations, is acutely aware of how best to perform. By comparing what they are doing in the moment with the perfect picture in their head, they can modify their performance appropriately – self-policing. The quality and quantity of mental representations is what sets expert performers apart from everyone else.

“In pretty much every area, a hallmark of expert performance is the ability to see patterns in a collection of things that would seem random or confusing to people with less developed mental representations. In other words, experts see the forest when everyone else sees only trees” – Anders Ericsson

The perfect example of elite performance correlating with highly sophisticated mental representations is George Koltanowski, a chess Grandmaster who set the world record for simultaneous games of blindfolded chess – 34 games (he won 24 and lost 10)!  His mental image was so strong that he could animate each game in his mind without looking at a single chess piece. It turns out simultaneous-game blindfold chess has been a pursuit of Grandmasters for centuries.

Furthermore, in studies of elite footballers and basketball players, it has been shown that when visual stimulus is suddenly removed, they can accurately pinpoint the position of all their teammates and opposition, and even predict how the game evolves in the seconds that follow. Again, this is facilitated by their mental representations – highly detailed images that come to life in the brain of the performer.

Fascinatingly, if you asked a grandmaster to recall the positions of randomly placed chess pieces on a chess board, or asked a footballer to recall the positions of 22 randomly placed men on a football pitch (i.e. not in position as a result of a game), they would fail because their mental representations are specific for the respective activities. If the arrangement of pieces or players is random, it ceases to be meaningful, in much the same way a set of jumbled up words is meaningless in comparison to a sentence.

The ‘deliberate practice mindset’

To truly reap the benefits of purposeful/deliberate practice, one must reject three prevailing myths:

1.     Your abilities are limited by genetics.

2.     If you do something for long enough you’ll get better.

3.     All it takes to improve is to increase your effort levels.

Once this is done, you are set free; the world is your oyster. However, the road to expertise is long and gruelling, and patience is crucial. The four underlying principles of purposeful practice must be kept in mind at all times, and failure should always be viewed as a precious opportunity to reflect and refine one’s mental representations.

If no coach or teacher is available (i.e. deliberate practice not strictly possible), identify somebody who is at a level that you want to reach (i.e. a mentor), try and understand how they got there, and proceed to purposefully practice.

Intense periods of focus, constant repetitions, and hovering at the edge of one’s comfort zone in training will get pretty miserable and frustrating at times. However, it should be appreciated that when quantifiable improvements start to occur, striving for further gains will become more enjoyable… even exciting.

Remember that a crucial aspect of deliberate practice is that it focuses solely on performance (i.e. how to do it) – it is a skill-based practice, and this must be embraced. By effectively practicing components of the skill and building stronger mental representations, knowledge will build naturally alongside. New concepts will seem less abstract as they are absorbed whilst applying skills (NB: This is in contrast to the traditional approach to medical training which has placed more emphasis on knowledge acquisition than skill development, largely because it is more convenient and less labour-intensive to teach).

In medicine?

An unfortunate reality of most medical specialties is that once a practitioner is fully qualified (i.e. a consultant or attending physician) there are few opportunities for immediate feedback on his/her clinical practice. There are no longer regular mandatory appraisals, and too often, little feedback from the patients themselves (e.g. a radiologist might not be made aware of the outcome of a patient where a cancer was missed on CT scan).

Furthermore, as seniors are no longer being actively trained, it is very unusual for them to be pushed out of their comfort zones, and they will usually deem their own performance level to be ‘acceptable’. You might say that they are particularly guilty of naive practice. This is a recipe for stagnation, and an overall decline in performance. An interesting passage in the book is where Ericsson discusses research into senior radiologists looking at mammograms, and experienced GPs listening to heart murmurs. It turns out their diagnostic accuracy is no better (and in some cases worse) than their junior colleagues, who will have received more recent active education.

As an emergency medicine trainee, much of my daily work will embrace the principles of deliberate practice, but it is variable, and often depends on the boss I happen to be on shift with. Taking ownership is key. It’s up to me to be cognisant of what elements of practice will make me a better doctor, and anchor my training appropriately. Awareness of these principles has also given me a greater appreciation of the utility of simulation training – ‘off-the-job-training’ which focuses on closely supervised skill development rather than knowledge acquisition.

It will be far more of a paradigm shift for senior doctors (i.e. finished all training) to adopt deliberate practice, but the implications for patient outcomes, and indeed medicine’s overall trajectory, will be enormously positive if they do.

I highly recommend Peak to anyone interested in improving at what they do. Doctors, of all grades, should be aware of, and striving to incorporate, the lessons from Anders Ericsson’s masterpiece.

Robert Lloyd
@PonderingEM

*This blog first appeared on the Pondering EM blog

Primary Survey January 2017

1 Jan, 17 | by scarley

Highlights from this issue

Simon Carley, Associate Editor

Another fabulous year in Emergency starts with a new world order and new challenges for EM and prehospital care wherever you are in the world. This month our contributors tackle systems, cases, prognosis, analgesia, urine collection and more. Here’s the highlights.

Graphic

Scoring systems and nurses intuition

I’ve always been told to trust the nurses judgment, and in truth it’s got me out of trouble many times, but this intuition, gestalt, judgment is difficult to define. Allan Cameron looked at this whilst comparing nursing views on need for admission against a structured score (the Glasgow admission prediction tool). The bottom line is that nurses don’t do as well overall at predicting the need for admission, but if they are sure about their opinion then you’d be courageous (aka foolish) to ignore it. It’s good to see more work on how we make decisions in the ED as after that’s what can make huge differences to patient outcome.

Critically ill children and medication timings

Kenneth Michelson and colleagues at the Boston Children’s hospital have looked at how the presence of really sick patients impacts the care of others. I suppose this is intuitive as we know that the seriously ill or injured suck up the finite resources of the ED, and this study tries to quantify this in terms of medication timings. In essence they have shown that small but significant differences in time to crucial medications (such as antibiotics or steroids) occur if a patient is exposed to the presence of another critically ill child in the ED. It’s another lesson that EM requires a team, and that team has a finite capacity.

A wee wait for a wee wee

How I wish this trial was Scottish so that they could have used that title. Alas no, this paper on urine collection is from Adelaide, Australia. If you work in paediatric emergency medicine then you will know that waiting for urine is a common reason for patient delays. Jonathan Kaufman and colleagues looked at a method to augment this by placing a saline soaked gauze in the supra-pubic area in kids aged 1 month – 2 years. They managed a 30% success within 5 minutes, which is impressive although there was no control group and smallish numbers. The effect of temperature is unclear, but they are looking at this and we may learn more in the future.

Predicting exit block

Winter pressures are already being felt in the UK with many departments feeling the pressure of patient numbers and poor flow through the ED. Sue Mason and colleagues have produced a rapid evidence review that may be very helpful in the next few months. Amazingly, despite the huge impact on our departments there is a paucity of data out there on effective interventions and very few from the UK. This paper sets out the evidence base as it exists and we should all familiarize ourselves with it. As for solutions? Then this paper won’t deliver that but it is a call for further work (and let’s face it we’re not short of situations to study here in the UK).

Lis Franc fractures review

Simon Lau and colleagues bring us an update and review on Lis-Franc fractures. This is an injury I’ve seen missed several times during my career, some of which have resulted in poor patient outcomes. Even with digital radiology and rapid reporting a few seem to slip through the net and so this is a welcome paper. There are some top tips in here, especially for those injuries with limited radiological signs. Well worth a read and a basis of a good teaching session in your department.

Stopping resuscitation in pre-hospital traumatic arrest

When I started training the resuscitation of traumatic cardiac arrest was considered to be akin to resurrection but times have changed and a much more aggressive approach has led to many survivors from blunt and traumatic injury. Deciding on futility is tricky and this month we publish a paper from Taiwan that uses a database of cardiac arrest outcomes to determine a rule for terminatint resuscitation efforts. In brief the presence of blunt trauma plus asystole is considered futile. However, we don’t know if that is a self fulfilling prophecy. If no efforts are made then a poor outcome is inevitable and a circular argument ensues. Retrospective studies always struggle with this conundrum so have a read and form your own view.

Long term outcome from traumatic cardiac arrest

More on what happens to patients following a traumatic cardiac arrest from our French colleagues. Francois-Xaview Duchateau and fellow researchers examined the Traumabase dataset to look at the neurological outcomes amongst survivors. Overall the results are encouraging and support the aggressive approach to managing these patients. Of note 90% were victims of blunt trauma which makes this month’s paper from Taiwan as many of the survivors were in asystole when the EMS teams arrived (which might apparently deem them un-survivable by their proposed tool). Clearly we need to read these two papers in tandem and carefully consider the discussion in this French paper. The bottom line appears to be that we still don’t quite understand traumatic cardiac arrest, but that it is not a lost cause. Another superb month in the EMJ.

Don’t forget to keep in touch between paper editions with the EMJ Blog and Podcast accessible through the journal website at http://emj.bmj.com

Primary Survey December 2016

30 Dec, 16 | by scarley

Highlights from this issue

  1. Ian Maconochie, Deputy Editor

Weekend working

This is a controversial area in the setting of UK healthcare practice. Claims have been made about patient safety being affected disproportionately during the weekend in comparison with the rest of the week. This paper looks at ED working and has an important commentary to accompany it. The editor has also made a podcast which is definitely worth listening to! https://soundcloud.com/bmjpodcasts/that-old-weekend-effect

Temperature management in an adult ED: Oral, TM and Temporal artery v rectal temperature

Temperature regulation is maintained in the pre-optic anterior nucleus of the hypothalamus, the ‘gold standard value’ in physiological animal models being recorded at the arch of the aorta. However, in ED, this is a little difficult to obtain!

Temperature is one of the ‘vital signs’, and remains part of the routine assessment of most patients. Surprisingly, temperature measurement is still undergoing scientific investigation albeit that the first use of thermometers in humans (by Santorio Santorio) was in 1612.

This paper takes as a gold standard, the rectal temperature and compares it in 3 other sites, namely the tympanic membrane (TM), oral and the temporal artery (TA) temperatures, looking at patients who have fever. TM is most accurate at picking up rectal temperatures above 37.5°C, that TA and TM are about the same in their ability to pick up rectal temperatures of 38°C. The mean differences and standard deviations for Oral, TM and TA were –0.5 (0.6), –0.3 (0.4) and 0 (0.6) degrees centigrade from the recorded rectal temperature. Heat loss from the body occurs by conduction, radiation and convection, and it is not uniform over the body, i.e. there is regional variation, e.g. sweat glands are most numerous in the fingers and lowest on the upper lip, 530 glands per cm2 as compared with 13 glands per cm2. So the differences in rectal, oral, TM and TA temperatures are not unexpected. Overall trend is generally of more value to clinicians.

Appendicitis

This vestigial organ still causes a lot of trouble, especially in the paediatric population. The search for definitive measures are still elusive-in this issue, there are 2 papers that look at ways to assist clinicians by means of tests and/or in combination with scoring systems.

The first shows that, although there is neuroectodermal tissue in the appendix, which should increase the secretion of its 5HAA in response to inflammation, its measurement does not help at all in differentiating patients without appendicitis from those with it.

The second by Versic et al combines white cell count, C-reactive protein and calpropectin (an intracellular calcium binding protein) making an aggregated figure. A low figure was deemed to enable clinicians to rule out the appendicitis owing to its high sensitivity. The utility of this figure is questionable in very early phases. The Alvarado score (AS), comprising signs, symptoms and laboratory values including white cell count was also tested with the figure, and improved the diagnostic accuracy in low risk patients as determined by AS system.

Writing in the ED

Two articles look at very practical aspects of ED management, that of discharge summaries and if they declined in quality owing to shorter ED patient stays being introduced, and the question ‘is it cost effective to have a medical scribe on the shop floor?’.

The first had 10 components of a discharge summary that needed to be present for it to be adequate, namely:

Patient information, discharge date/time, discharge diagnosis, treatment information, treatment complications information, procedure information, procedure complications information, investigation results information, ongoing care for primary care provider, ongoing care information for patient, discharge medication information and next medical review. Summaries before and after the introduction of 6 hour target in New Zealand (in 2009) were studied. There was no difference in discharge documentation quality, with a trend towards an improvement in their quality. Medical scribes are used in the USA and may have improved clinician productivity by 13–20%, but the cost of any training scheme to make a competent scribe has not been determined until now in this paper from Australia.

Ten scribes underwent a one month course, followed by pre-work training sessions and clinical shifts for 2–4 months (one shift per week), being trained by ED clinicians. The duration of training ranged from 68–118 hours after the classroom based teaching. There was an estimated 4% increase in clinician productivity. The overall cost for teaching to make a competent scribe was USD $6371.

Community based perceptions of emergency care in Zambian communities lacking formalized emergency medicine systems

This qualitative work focuses on the health needs of communities in Zambia, identifying barriers and obtaining community generated solutions. The key messages are that low cost steps such as educational initiatives in the community, enhancing prehospital care, having triage systems in place in the ED and training healthcare providers in emergency care would have significant impact. The authors should be congratulated for producing this important paper that allows the voice of healthcare users to be heard, with the hope that it can influence the development of healthcare services in Zambia.

Nuances of Neurogenic Shock

4 Nov, 16 | by rlloyd

nuances-of-neurogenic-shock

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

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

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

What is neurogenic shock?

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

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

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

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

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

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

Recent EMJ paper – Taylor et al, October 2016

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

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

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

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

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

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

Take-home message 

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

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

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

Robert Lloyd
@PonderingEM

The weekend effect: Part 2 – a traumatic time!

29 Oct, 16 | by cgray

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

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

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

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

metcalfeabstract

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

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

Who was studied?

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

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

What did they find?

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

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

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

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

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

What conclusions can we draw?

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

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

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

vb

Chris
@cgraydoc

 

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

How Junior Doctors Think: A Guide for Reflective Practice

19 Oct, 16 | by rlloyd

how-do-junior-doctors-thinkl_

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

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

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

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

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

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

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

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

Key findings from the paper:

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

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

Phase 1: Case Framing

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

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

Phase 2: Evolving Reasoning

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

1) Diagnosis instantly recognised (T1 predominant)

Usually from a single cue in the assessment.

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

These reflex diagnoses are then interrogated for error via:

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

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

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

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

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

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

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

Phase 3: Ongoing Uncertainty

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

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

Three points I’ve taken from the paper…

1) Inexperience can lead to ‘misframing’

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

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

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

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

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

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

2) Diagnostic time-outs should be encouraged

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

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

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

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

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

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

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

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

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

Final Thoughts

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

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

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

The Paper

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

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

Robert Lloyd
@PonderingEM

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