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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

The 4-hour standard. Why can’t you get it right?

10 Jan, 17 | by scarley

please-get-it-right

If you were hoping for a solution to flow in the ED then this is not the post for you. Rather it’s an appeal and a cry of pain from all UK clinicians who work in emergency departments for politicians and journalists to understand what the 4-hour target is.

It is the percentage of patients seen and DISCHARGED OR ADMITTED within 4 hours.

Journalists regularly mistake this as the time that people wait to be seen in the ED which of course is entirely different. Yesterday Jeremy Hunt was questioned in the commons about the current crisis in the ED and even the opposition front bench mistook the 4 hour standard as wait to be seen and not the time it takes for us to completely sort patients out and either get them home or into a hospital bed.

Even Wikipedia is unclear on the matter, and so it’s perhaps not surprising that everyone is confused. The King’s fund does much better and has some excellent research in the area.

Does this matter? Well I would argue that it does. From a public perception if we are failing to even assess people within 4 hours that does indeed sound awful. The idea that we have to complete the ED journey within 4 hours must surely be understood as a more challenging task. If it were just a wait to be seen then in all honesty we’d be running at well over 100% already (if you include triage which you should).

So. An appeal that perhaps no journalist or politician will read. Please get it right and stop emergency clinicians shouting at the TV or radio every time you get it wrong. We’re under enough stress as it is.

vb

S

@EMManchester

https://twitter.com/deanoburns/status/818745470281465856

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.

How to write off your paperwork. EMJ Blog.

29 Dec, 16 | by cgray

how-to-write-off-your-paperwork

Emergency medicine is one of those specialities where physicians of all grades have to make their own notes, even the consultants. Medical and surgical bosses have juniors to scribe at the ward round, secretaries to type up dictated clinic letters, assistants to type op notes (most of the time). EM consultants, like their junior colleagues, still need to put their own pens to paper, or fingers to keyboard.

There are two general ways to make notes in the ED. You can do it whilst talking to the patient, which creates the most contemporaneous notes, allows you to use the patient’s own words, and means you can easily recant the story back to them to confirm details, though can sometimes create the impression that you aren’t giving the patient your full attention. I am a big fan of this approach, writing quickly means I can document almost as fast as I can talk. In my opinion, I forget fewer questions, meaning I can carry on with other tasks without having to return to the patient when I remember later on. It’s an approach that works well for me and my very short attention span, though only really works when I’m in a department with paper documentation. Alternatively notes can be completed after seeing the patient, when you can rearrange everything you have learnt into a sensible and concise narrative. However, writing at the desk puts you in the line of fire of technicians asking you to check ECGs, or other colleagues asking your opinion on their patients, to name a few examples. These interruptions have the potential to cause confusion in the history and examination you are trying to commit to paper, and details can be missed or altered.

I would miss doing my own paperwork in the emergency department – I write small and fast, (and reasonably legible) and my note taking helps to put my thoughts in order to make differentials and come to conclusions. However, I’m sure many of you have wondered how much quicker and efficiently you could work if you had someone to write notes for you. Maybe you even have a scribe – I know of people that do, and it seems to be reasonably popular in the US.

Scribes can help those who adopt either approach, and whether electronic or paper. They allow contemporaneous note taking, so that the clinician can focus on the patient, listening to their answers carefully rather than just planning the next question. It can be easy to miss cues from the patient when you are documenting at the same time. They also mean that time isn’t spent documenting at the nurses station, allowing a better focus on other tasks – not missing that subtle MI on the ECG you’ve been shown because you’re still trying to remember how to spell “Sjögren’s”. However, as I’ve already mentioned, sometimes you need to write the notes yourself, for those more complicated patients where writing it out helps with problem solving.

In this month’s EMJ, Katherine Walker and team from Melbourne have put together an observational study and cost analysis to determine the feasibility of training medical scribes in the ED. They took 10 trainees, put them through a 1 month pre-work course followed by 2-4 months of training and clinical sessions facilitated by emergency physicians. Only 5 trainees became competent, and required 68-118 hours of clinical work to do so. They found training scribes to be a feasible exercise, and crucially did not find any loss of productivity in the physicians who trained them. Medical students became competent more quickly than pre-med or non-medical students, and only medical/pre-medical students made it through the whole programme. There is little information on how scribes were selected to go forward to each part of the scheme, and also what the criteria were for applicants to be offered an interview. There was an overall loss in money from the programme, which had not been recuperated by the end of the study. Longer periods of observation would be needed to identify how long it would take for training costs to be outweighed by productivity savings, if at all.

As always we’d recommend you read the paper yourself to get the full results and to be able to draw your own conclusions. A reply from a senior scribe, Nicholas Rich, also provides a useful commentary and some further reading.

It’s an interesting concept, one that doesn’t appeal to me personally, but maybe it does to you. Have you got a scribe? Do they improve your productivity and patient interaction? We’d love to know.

vb

Chris
@cgraydoc

#FOAMed, credentials and a view from the college (sort of).

10 Dec, 16 | by scarley

156r09lpI found an amazing tweet on my timeline today that taught me many things. Firstly, I was not aware that students were publishing their own theses online and as an open access resource (this is fantastic), and secondly the topic in question is of great interest to me and everyone here, that is the development of #FOAMed.

Chris Walsh is a super chap who is head of e-learning at the Royal College of Emergency Medicine. He is an extremely intelligent man with a strong academic track record, initially in the humanities, and now also in the field of medical and digitial education.

He has now published his MSc thesis online looking at the development, current state and future direction of e-learning resources for the RCEM.

Click here to read the thesis online.

I am very interested in the view from a senior member of the college as my relationship with the college over e-learning has been difficult at times. As an advocate of #FOAMed I’ve always struggled with the requirements to meet the limitiations and restrictions of an overarching organisation whilst maintating the freedom, speed and open discussion that #FOAMed creates. This is a theme in the thesis and I found Chris’s analysis of #FOAMed as a dialogic process fascinating. This work also aludes to the changing relationships between organisations, traditions, curricula, members, technology and delivery. It’s complex and fascinating.Chris has used a mixed methods technique to look at the impact and future direction of e-learning for the College and for #FOAMed. The perspective is clearly from his position, and thus the influence of the College perspective is very clear, but there are many interesting elements for any producer or consumer of #FOAMed.So what are the main themes? Obviously this is my interpretation and you really should read the whole document.

    #FOAMed is here to stay.#FOAMed engages and invigorates elements of the EM community but some are not engaged.There is a desire amongst some for credentialing of activity related to #FOAMed (though the strength There is some confusion between e-learning and #FOAMed type activities and credentialing.The RCEM is developing a system to credential #FOAMed learning.There is a belief and understanding that #FOAMed will be incorporated into formalised learning and continuous professional development.

There are many other questions too of course. This study is based on small samples and almost all the interviews were conducted with those involved in college work. The survey data was sought through social media spaces which is good as they are #FOAMed consumers, but also limits the findings to those who are already engaged in this style of learning. The perspective is thus largely one of the college establishment and as a result may be a self-fulfilling one. However, I’m not sure that matters that much as the project is really aimed at those groups as opposed to those who are not currently engaged with College resources. It does therefore study a specific, but relevant

So. Follow the link above to read the thesis (or at least read the abstract), follow Chris Walsh on his twitter account, and if you feel inclined I’m sure he would be delighted to hear your thoughts.

My final question is in regard to the proposed credentialing of #FOAMed activity into an online CPD portfolio.

The question is whether users will be able to record activity from non RCEM #FOAMed sites, or will it be limited and paywalled by the college. As a #FOAMed advocate I’m clearly keen to support learners to be able to record #FOAMed CPD from any blog or podcast.

That may not be a decision that Chris will personally make, but I’d love to know the answer (and hope it’s the right one).

The bottom line is that this is a great piece of work that takes our understanding of College based learning further and deeper than we have previously seen.

vb

S

 

What do Emergency Medicine and Donald J. Trump have in common?

7 Dec, 16 | by rlloyd

trump-01

Illustration by A3 Studios

*Caution: Emotionally-charged post, pinch of salt required… personal feelings only and not the editorial view of the EMJ/BMJ.

On the morning of the 9th November 2016, I woke up to the earth-shattering news that Donald Trump had been elected President Elect of the United States. It’s a moment I’ll never forget.

Rain pounded menacingly against my bedroom window, all my social media outlets exploded with sentiment of anger and sadness, and my American fiancé lay next to me in floods of tears.

I, like many (urm… all) of my friends and family, and seemingly the majority of the #FOAMed community, am horrified by the Trump phenomenon. His hateful, divisive rhetoric is unlike anything I’ve previously encountered in a public figure, let alone the new leader of the free world. Appropriately, and frighteningly, he has drawn comparisons with some of modern history’s ugliest dictators, such as Hitler and Mussolini. Mind-bendingly hideous stuff.

Throughout his campaign, Trump would verbally decapitate anyone who dared to undermine him. Cutting personal insults and sinister threats (‘I’ll throw her in jail when I’m in the White House!’) were par for the course, and reflective of an insecure man with astonishingly thin skin. Of course most of the time it was his rival Hillary Clinton in the firing line, but even fellow Republicans took some damage if they decided to be critical.

If his foul-mouthed tirades were a shrewd strategic move for diverting attention from his lack of political acumen and poor grasp of the Presidential job description, then arguably, the man’s a genius. Decipherable policy specifics were sparse, but unashamed fascism seemed to be a common theme, exemplified by absurd proposals to build a wall on the US-Mexico border and ban all Muslims from entering the US.

I’ve lost count of how many times I felt convinced of his self-destruction. Whether it was accusing all Mexican immigrants of being ‘rapists’, jokingly inviting a Clinton assassination attempt, or the release of a video where he openly boasted of sexual assault, he somehow kept on surviving. And then he won the keys to the White House. Ugh.

I am no journalist. Nor am I a political analyst. I’m a blogtastic British junior doctor training to be an Emergency Physician, and therefore pretty far removed from the whole debacle (*wipes sweat off brow*). Having said that, witnessing Trump’s ascendancy has triggered an important work-related reflection that I feel the urge to share.

Where is our basic human decency?

The Trump campaign suffered from a disease which stripped it of basic human decency. Depressingly, this reminded me of the alarming regularity that I witness unnecessary rudeness and outright bullying in the ED environment. Unpleasant, heated exchanges are a daily occurrence (certainly where I work anyway). Where does the hostility come from?

We’re bloody busy

The influence of workload cannot be emphasised enough. The ED is inevitably the busiest department in every reasonably-sized hospital, and it remains so 24 hour-a-day, 7 days-a-week (despite what our Health Secretary might have the tabloid newspapers believe).

When you consider that in 2015-16 there were 22.9 million visits to the 136 existing EDs in the UK, I think it’s fair to say overburdened is an understatement (by developed world standards of course) (1). Stress levels can reach fever pitch at the sight of a an overflowing waiting room, a seemingly never-ending list of ‘unclicked-on’ patients on a computer screen, or a growing congregation of paramedics indicating that pregnant ambulances are queuing up.

All of these are inevitable features of working in a UK ED, and with the added pressure to have patients ‘sorted’ in under four hours (i.e. discharged or warded), it’s understandable that some might become irritable and combative. It doesn’t matter if you are a native ED doctor, nurse or visiting specialist, the feeling is contagious; it’s a pressure-cooker workplace, and too often I see people releasing their personal pressure-valves by taking out frustrations on colleagues.

Of course, all of the emotional demands of working in such an over-stretched environment are heightened when dealing with particularly sick and unpredictable patients. As such, the resuscitation room tends to be the arena where I am most stunned by the way colleagues address each other.

False inferiority complex

There is no department where tribalism is more evident than the ED. It’s a bubbling cauldron of inter-specialty and multidisciplinary interaction.

As emergency medicine practitioners, we’re arguably the only nominal generalists in the hospital setting. This means that in the eyes of some of our specialty colleagues, we’re ‘second best’ at managing many of the pathologies we see. We can commence management of acute coronary syndrome, but we’re not cardiologists; we can intubate, but we’re not anaesthetists; we can even crack chests, but we’re not cardiothoracic surgeons.

This, of course, is a total fallacy. Emergency physicians might seem like generalists at surface-level, but the reality is that they ‘specialise’ in appropriately differentiating the undifferentiated. Where neighbouring specialties anchor towards diagnosing familiar pathologies (e.g. the cardiologist quickly labelling a patient’s chest pain as myocardial ischaemia), emergency physicians won’t jump to premature and potentially dangerous false conclusions, and remain open to multiple possibilities until firm evidence presents itself. In the initial phase of managing patients fresh from the community, across the spectrum of acuity, the emergency physician possesses the safest, and most expert pair of hands.

Unfortunately this isn’t always recognised by our specialty colleagues, who can overlook the inherent challenges of the emergency medicine landscape, and occasionally be quick to patronise, condescend, and even ridicule when being referred to, particularly when by a junior person.

In the more vulnerable amongst us ED folk, this can breed a false inferiority complex and erode confidence. Seniors are more likely to react with verbal pugilism if they feel disrespected.

Conflict is further cultivated by the unfortunate reality that much of our job involves giving someone else more work to do, which naturally fosters resentment on their part.

Of course, the outcome of inter-specialty collisions in the ED don’t always end in tears, and I appreciate that I might be painting a overly grim picture. However, in my experience the referral process can turn ugly very quickly, particularly when other stressors are in play (e.g. being particularly busy).

Blame culture

Doctors aren’t supposed to make mistakes. However, it’s undeniable that healthcare (especially the ED) is highly error-prone. It’s an unpredictable, dynamic environment with an extraordinary amount of moving parts.

The hallmark of a good system is a strong culture of learning from failure. The ultimate example is the peerless aviation industry, whose safety model has become the stuff of legend – they jump up and down with excitement when a plane crashes because it represents an opportunity for precious learning (2).

In stark contrast, it’s no secret that the healthcare industry hasn’t exactly covered itself in glory when it comes to promoting patient safety. From the Mid-Staffordshire Enquiry to the Harold Shipman scandal, our history is littered with examples of system failures that should have been thwarted earlier through a healthier culture of incident reporting and institutional change management.

I’m not saying we’ve had no success stories, I’m merely suggesting that there’s an awful lot of room for improvement. There’s the tragic case of Elaine Bromiley, whose death in the anaesthetic room prior to a routine sinus operation prompted an independent investigation which led to a global revolution in patient safety measures around airway management (3). It’s worth noting that the investigation was driven by Elaine’s inspirational husband Martin – a commercial airline pilot.

There are plenty of historical and structural reasons for our suboptimal safety culture, but arguably the most important factor is that society puts doctors on a pedestal, and assumes invincibility. Error is heavily stigmatised in our workplace because the public expects perfection. So when the inevitable mistakes do occur and we fear being implicated, a strategy for deflecting attention is to turn on each other. Even when there is no risk of being implicated, we still can’t resist the urge to point the finger of blame (or gossip about the incident behind the back of the guilty party) because somehow it soothes open wounds from previous public humiliations.

When it comes to mistakes, our institutional focus is on who did it, and not what can be learnt from it. Opportunities for progression usually descend into fruitless professional witch-hunts. And this culture is ingrained in us all from medical school.

The ‘patients lives are on the line’ card

Trump exonerated himself from his revolting campaign narrative by playing the ‘political correctness’ card. He fooled the electorate, and branches of the media, into thinking his verbal excrement was acceptable (even attractive) because he wasn’t a career politician and therefore didn’t ‘play by the rules’. No other presidential candidate in US history would have got away with some of the things he’s said, but he was ‘sticking it to the establishment’, so it was OK.

In a similar vein, I believe that it’s become acceptable for collegiality and decency to be left at the door of the ED because the ‘patients lives are on the line’ card gets played. The stakes are far too high for us to care about the way we treat each other.

This attitude is helped along by our very rigid, arguably militaristic hierarchical structure.

There is no doubt that a hierarchy is crucial for ultimate decision-making accountability, but it gets abused too often in my opinion. Of course some are more guilty than others, but if a senior person is feeling particularly under pressure (or, dare I say it, out of their depth), it’s all too easy for them to take out their frustrations on a defenceless junior staff member – riding the authority gradient. And it’s totally acceptable to do so, because it’s a patient’s life at stake of course.

I’m not just talking about consultants and senior nurses, it spans the entire spectrum of ED staff. I’ve witnessed a rookie doctor rotating through the ED viciously bark at student nurses for taking ‘too long!’ to attach the monitoring to a perfectly stable patient in majors – unacceptable, and an abuse of authority even at the most junior level.

Misplaced self-importance anaesthetises basic manners. We weaponise the inherent moral high ground of doctoring in much the same way that Trump weaponised being ‘un-PC’. We’re getting away with behaviour that we shouldn’t.

The irony of playing this ‘card’ (so to speak) is that our patients ultimately suffer because our multidisciplinary teammates are less willing to go the extra mile for someone they don’t like. Truly toxic stuff. Are we that self-righteous? Are we that arrogant?

Why are we not holding ourselves to a higher standard?

I am not proclaiming to be mightier than thou. I have fallen foul of high stress, surfed the authority gradient and hidden behind the fallacy that I’m making regular life and death decisions as much as the next junior emergency medicine trainee. I can recall multiple times where I’ve been unacceptably rude to colleagues, and even remember an occasion where I made a nurse cry and run out of resus. I was remorseful about those moments, but only transiently. There was always something ‘terribly important’ I could distract myself with, ridding me of the shame I felt for being a b*****d to a colleague for no valid reason.

However, those I verbally abused will not have recovered so quickly, and are now more likely to treat their future juniors as I did them on those occasions. This is the vicious cycle of bullying that I’m sure every doctor reading this post will relate to on some level, whether they can admit to it or not.

Why are we not holding ourselves to a higher standard? As front row spectators to the fragility and preciousness of human existence, surely we of all people should have more respect for each other.

We musn’t be fooled into thinking that just because we have different skillsets or seniority that we aren’t singing from the same hymn sheet. No matter what it says on your hospital name badge, we all have the same job description: help make people better.

We deal in the currency of human life, which in my opinion is the greatest professional privilege that there is. No matter how bad our day seemingly is, or how much pressure we feel under, you can bet your bottom dollar that you need to look no further than the frightened, desperate person staring back at you from the trolley to find someone worse off. That dose of perspective is a gift, and it alone should do the job of warding off Trump-like demonstrations of contempt for our colleagues.

Of course, Americans voted for Trump in their droves (in much the same way that Brits voted for ghastly Brexit). Why? That’s not for me to say; I’ll leave that to the politicos. What I can say with some certainty is that a massive proportion of the Western world feels a potent combination of embarrassment, sorrow and anger that we’ve allowed such a harmful situation to escalate.

Is this not the very same cocktail of emotions that we feel after a hostile exchange in the ED? We must strive to be better at checking ourselves before forgetting our basic human decency and engaging in needless workplace warfare.

We’re better than this.

Do the right thing

As medical professionals, our knowledge-base and skillset give us almost supernatural status in the eyes of the public. Being a doctor is more than a job, it’s a title. But that’s not why they’ll allow us to slice into their bodies, poison them with medications, and have access to their most hidden secrets. They allow us these privileges because we’re supposed to be fundamentally good people who’ll always act in their best interests no matter what the cost. We, more so than anyone else in wider society, are deemed to be the custodians of doing the right thing.

That should be something we carry with us at all times in our workplace, regardless of who we are speaking to, or the nature of the scenario. There is no place for Trumpism in the ED.

Robert Lloyd
@PonderingEM

NB: I appreciate that the content of this post is emotionally-driven, opinion-based, and potentially controversial. Please feel free to commentate/agree/criticise in the comments, it would be great to generate some discussion around the topics brought up.

References

  1. Accident and Emergency Statistics: Demand, Performance and …
  2. Black Box Thinking. By Matthew Syed.
  3. What can we learn from fatal mistakes in surgery. By Kevin Fong, BBC News.

Many thanks A3 Studios for the amazing accompanying graphic.

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

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.

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