You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

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

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.

The weekend effect. Part 1.

28 Oct, 16 | by scarley

the-weekend-effect

Chris Moulton VP of the Royal College of Emergency Medicine and Ellen Weber discuss the weekend effect. This is well worth a listen to get behind the headlines and politics of a controversial meme in healthcare.

What is it? Is there an effect and what can we do about it?

Click on this link to read more about the paper on Chris Gray’s blog.

 

vb

S

 

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

Dispatching stress in the EOC #IAM999

5 Sep, 16 | by cgray

ou're never making just one decision_(1)

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

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

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

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

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

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

vb

Chris

@cgraydoc

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

22 Aug, 16 | by rlloyd

musings

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

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

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

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

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

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

Stevenson et al, 2007 (2)

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

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

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

Kerslake et al, 2015 (3)

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

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

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

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

National Audit Project 4, 2011 (4)

nap4

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

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

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

Analysis of the ED-based events included mention of:

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

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

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

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

Opportunity for EM to take a leading role

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

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

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

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

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

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

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

Final thoughts

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

Robert Lloyd
@PonderingEM

Worth Reading/Listening

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

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

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

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

 

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

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

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

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

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

 

References

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

Diagnosing Small Bowel Obstruction in the ED: A Role for Ultrasound?

23 May, 16 | by rlloyd

real
Diagnosing small bowel obstruction (SBO) is bread-and-butter work for the emergency physician. It accounts for 2% of patients presenting to the ED with abdominal pain, and 20% of all surgical admissions[1]. In the developing world the majority of SBO patients have had previous intra-abdominal surgeries causing adhesions… But I won’t delve into aetiology, let’s talk diagnostics.

The May 2016 EMJ issue’s ‘Image Challenge’ is a classic case[2]. An adult male with significant surgical history (caecal adenocarcinoma with subsequent right hemicolectomy) presents to the ED complaining of abdominal pain and vomiting. His abdomen is distended and diffusely tender. Slam dunk.

How would I manage this patient in the ED? Having made them nil by mouth, started IV fluids, and given adequate analgesia, I’ll request the routine plain x-rays (abdominal and erect chest) that almost all of my acute abdomen patients get. A positive AXR for SBO (centrally distributed dilated loops with valvulae conniventes/air fluid levels) will prompt me to insert a nasogastric tube, and call the surgeons with a view to CT/a trip to theatre. I imagine that’s fairly common practice up and down the UK.

The image provided for the discussed case is an ultrasound image showing dilated, fluid-filled loops of bowel – suggestive of SBO. It turns out AXR is pretty useless at detecting SBO, particularly when you consider how much we rely on it traditionally, with a sensitivity of 50-60%[3]. Ultrasound is a quick, cheap, radiation-free option available to us in the ED. And guess what? It’s more reliable than AXR for detecting SBO. Some evidence was published in the EMJ back in 2013 – let’s take a look. 

Jang et al prospectively enrolled 76 adults in the ED who were suspected to have SBO, and going for a CT[4]. All patients had an ultrasound exam performed by an EM resident, along with an AXR interpreted by a radiologist. The reference standard for SBO diagnosis was the CT result.

Each EM resident already had a basic understanding and experience of point-of-care scanning, having all undergone a prior introductory course. They were given only a 10 minute (!!) practical tutorial in SBO ultrasonography, and then 5 practice scans prior to being let loose on the study patients. A 10 minute tutorial is fairly minimal prep I think most would agree.

A positive ultrasound was defined as either:

  1. Dilated loops (>2.5cm) of fluid-filled dilated bowel proximal to normal/collapsed bowel
  2. Reduced peristalsis – back-and-forth movement of spot echoes inside fluid-filled bowel

Participants were taught to scan in the paracolic gutters bilaterally, epigastric and suprapubic regions. This is the standard approach to SBO ultrasound – see this video for a great tutorial on how to perform the scan. Interestingly, in this study the phased array probe was used instead of the curvilinear – the usual option for transabdominal scanning.

Ultrasonography comfortably outperformed plain radiography in detecting SBO. A sensitivity of 93.9% and specificity of 81.4% left AXR trailing behind with a sensitivity of 46% and specificity of 67%. Dilated loops on ultrasound proved to be far more sensitive than reduced peristalsis – probably because reduced peristalsis is generally considered to be a late finding in SBO, often seen with strangulation[5].

Of course there are limitations with this small study. There was a disproportionately high prevalence of SBO in the study population (33 out of 76 patients – 43%), bringing into question its external validity. The doctors performing the US exams volunteered themselves, indicating they were enthusiasts – potentially introducing what the authors describe as ‘ultrasound-interest’ bias. And of course, the participants knew they were being compared to a standard, bringing the Hawthorne Effect into play. Nonetheless, pretty convincing stuff.

And there’s more. Here is some further reading:

Unluer, E.E., et al., Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction. Eur J Emerg Med, 2010. 17(5): p. 260-4.

Schmutz, G.R., et al., Small bowel obstruction: role and contribution of sonography. Eur Radiol, 1997. 7(7): p. 1054-8.

Something else to consider, is that additional information can be picked up when performing a bedside scan on a patient in whom there is a concern for SBO – free fluid between bowel loops, no peristalsis, or >3mm bowel wall thickening suggests bowel wall ischaemia[6]. Gallstones in the presence of dilated loops? Think gallstone ileus. A lurking AAA might even be picked up.

I’m not suggesting that plain radiography no longer has a role in the suspected SBO patient. Surely though, adding bedside ultrasound to our list of investigative options is an opportunity to improve patient care. A negative scan would provide added reassurance when ruling the diagnosis out in less concerning patients; and we can expedite initial/definitive management in the high-risk patients who have an equivocal AXR.

Ultrasound will always be operator-dependent, but Jang et al have demonstrated that scanning for SBO is a relatively easy skill to acquire. Encouraging stuff.

What is your approach? Does ultrasound have a role in these patients? We would love to hear your thoughts in the comments.

Robert Lloyd

Some more online resources

A video with some more discussion on the Jang paper – the Ultrasound Podcast

Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool

Ultrasound for Small Bowel Obstruction – emDocs blog

References

  1. Delabrousse, E., et al., CT of small bowel obstruction in adults. Abdom Imaging, 2003. 28(2): p. 257-66.
  2. John Eicken, S.E.F., Image challenge: Adult male with abdominal pain and vomiting. Emerg Med J 2016;33:5 337 doi:10.1136/emermed-2015-205181.
  3. Dr Henry Knipe, D.J.J., Small Bowel Obstruction, in Radiopaedia.org.
  4. Jang, T.B., D. Schindler, and A.H. Kaji, Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J, 2011. 28(8): p. 676-8.
  5. Guttman, J., et al., Point-of-care ultrasonography for the diagnosis of small bowel obstruction in the emergency department. CJEM, 2015. 17(2): p. 206-9.
  6. Alice Chao, M.a.L.G., MD, FACEP, Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? Emergency Ultrasound Section Newsletter – October 2014.

UK emergency department performance: Failure or Success.

14 May, 16 | by scarley

GEY

Recent figures suggest that UK emergency systems are failing to meet the 4-hour standard (aka the 4 hour target). At first glance this is true the data shows that 88.7% of patients are seen and discharged/admitted within 4 hours as compared to the target (I’m going to stick with target) of 95%.

This has been described as ‘worst ever month’ and if we look at simple percentages that’s true.

Sadly, comments such as failure and worst are demoralising for the teams who are working really hard to deliver emergency care in an overworked and stressed system. The key here is in the percentages, they underestimate the number of patients actually seen in a system that is seeing more patients every year.

It is perhaps worthy to note that in the last quarter figures there were 5,867,323 attendances at UK emergency departments. Of these 711,201 waited more than 4 hours.

In other words we managed 5.15 Million patients within the 4 hour target.

Well done all. This is not a failure, it’s an incredible achievement considering the current staffing, political and financial climate. Times are tough, the target may not be met, but let’s keep some perspective.

This is a huge achievement.

vb

S

Further reading

BBC on worst ever results for UK Emergency care

RCEM response to figures

King’s fund response to latest statistics.

NHS emergency care statistics

Why do Emergency Medicine?

21 Dec, 15 | by scarley

Great work from colleagues in Edinburgh.

Why would you do EM? Learn more by visiting their website at http://www.edinburghemergencymedicine.com/ and join the #EDvolution.

vb

S

EMJ blog homepage

Emergency Medicine Journal blog

Analytical approach to the developments and changes in the field of Emergency Medicine Visit site



Creative Comms logo

Latest from Emergency Medicine Journal

Latest from EMJ