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Primary Survey March 2017

23 Feb, 17 | by scarley

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

Under pressure: does cricoid improve laryngoscopy?

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

Statistics made much easier!

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

Who calls ambulances and doesn’t wait?

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

A new device to help metrics for ED weighting

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

The trajectory of an academic emergency physician

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

Can doctors measure pain in children?

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

vb

Rick Body

PDF

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

Are nurses always right?

15 Feb, 17 | by cgray

Are nurses always right?

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

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

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

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

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

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

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

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

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

vb

C
@cgraydoc

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

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

Primary Survey: November 2016.

22 Oct, 16 | by scarley

primary

Richard Body, Associate Editor

The Manchester derby for paediatric early warning scores

There is clearly a need for a validated physiological early warning score for specific use in the paediatric emergency department (PED). In this issue, Cotterill et al compare two paediatric early warning scores developed in Manchester: the Royal Manchester Children’s Hospital Early Warning System (ManCHEWS) and a modified version, the Pennine Acute Trust Paediatric Observation Priority Score (PAT-POPS). The modified score incorporates the original physiological scoring system but also takes account of the nurse’s judgement and specific elements of a patient’s background. This Manchester derby was a close call: but will the marginally superior accuracy of PAT-POPS for predicting hospital admission ultimately win over the simplicity of ManCHEWS?

Future emergency care: the (citizen’s) jury has spoken

In Queensland, Australia, Scuffham et al took an extremely interesting approach to patient and public involvement. They convened a citizen’s jury to deliberate on matters relating to the delivery of emergency care. The jury’s verdict is intriguing and highly relevant to the future of Emergency Medicine. The participants were clearly amenable to alternative models of emergency healthcare delivery including care provided by allied health professionals and decisions not to transport patients to hospital from the pre-hospital environment.

What is ‘productivity’?

If you sometimes feel that measuring productivity in the Emergency Department has the potential to create a dehumanized production line (and even if you don’t), this month’s paper by Moffatt et al is a ‘must read’. In a series of semi-structured interviews with healthcare practitioners working in an Emergency Department, this team explores their feelings about the notion of ‘productivity’. The findings are heartening and are sure to kindle a warm feeling in the heart of any emergency physician. Hopefully this important work will lead to greater recognition of the need to retain compassion in our practice, promote an appropriate balance between ‘care’ and ‘efficiency’ and avoid the “sausage factory” mentality, to quote one of the participants.

A SuPAR new biomarker of serious illness?

In Emergency Medicine we are becoming accustomed to the use of biomarkers that may lack specificity for any one particular condition, but that provide important prognostic information. Lactate could be considered one such biomarker, and its interpretation has become an important skill for emergency physicians. This may suggest that we are at the dawn of a new era for biomarkers. Our traditional ‘binary thinking’ about diagnostics, whereby tests can simply tell us whether a patient does or does not have a particular disease, is beginning to seem crude and outdated. In this issue, Rasmussen et al measured SuPAR at the time of admission to an Acute Medical Unit in a cohort of over 4,000 patients. SuPAR was shown to predict mortality and the need for hospital re-admission even after adjustment for confounders. The findings are impressive, and this work must lead on to further research to identify how this interesting non-specific biomarker can be used to guide real life healthcare decisions.

Health inequality and the global importance of emergency care

We know surprisingly little about the relationship between emergency care provision and the impact of emergent conditions on health, internationally. Of course, emergency physicians might expect that failure to provide adequate emergency care would lead to greater mortality and morbidity from such conditions. In this issue, Chang et al quantify this problem. In an analysis from 40 countries, they found that all fifteen of the major global causes of mortality and morbidity can present emergently, and identified that insufficient access to emergency care is clearly associated with higher mortality and morbidity. This makes sobering reading as a demonstration of global health inequality, and highlights the pressing need to develop Emergency Medicine internationally.

vb

Rick Body

@richardbody

Lessons from Camels. EMJ Blog.

8 Oct, 16 | by scarley

EMJ Blog

Life long learning and developing is vital for the good ED practitioner,  treatments change, pathologies change and even opinions change over months and years, and we on the front line must continually adapt and change with them.

To highlight the importance of this I would like to tell you a story. It is a story about a camel.

In 2006 palaeontologist Natalia Rybczynski was tramping through the artic wastes in the far North of Canada (as you do) as she came across some unusual grey rocks. Now personally I would have stubbed my toe on these rocks, cursed and wandered off in search of a hot chocolate, but being a shrewd and observant palaeontologist Natalia saw that these were fossils of a type she had not encountered before. She collected these, and returned over the next few years, managing to find around 30 fragments of what appeared to be a fossilised tibia(1).

Subsequent super clever collagen fingerprinting techniques revealed that these remains amazingly were from a hitherto undiscovered giant camel. Now this raised some interesting questions.  Camels are sublimely adapted to the hot and dry desserts, with their large spoon-like feet for walking on sand, and large fat filled hump meaning they can survive for longer without food. The function of having all your fat reserve in a single hump also means that you can do without the surrounding layer of adipose tissue, allowing these animals to dissipate heat easily in their hot climates.

So how could these hot weather specialists have survived in the arctic, where temperatures often plummet deep into the negative figures. (I promise I am getting to the medicine!)

To get the answer we need to re-examine what we think we know about camel’s adaptations, and take them out of the context we always find them in (the desert). For example, those wide flat feet could easily be adapted to snow, as well as sand, in fact it is likely they initial evolved to walk in soft snow and then subsequently were found to be of an advantage in the desert sands. That hump with the fat reserves would be vital when trying to survive in a place were for 6 months of the year there is darkness and nothing grows.

We have thought of camels as hot weather beasts for hundreds of years, and then all of a sudden someone finds a few lumps of rock in the arctic that causes us to completely reconsider what we think we know, and to have to think in new ways to explain things we thought we had sorted.

The recent example from the field of medicine is the FEAST trial (2) We have believed for many years that fluids were the mainstay in the treatment of severe sepsis and septic shock, and then someone comes along with a brilliant study that casts doubt on this assumption and causes us to have to rethink what we thought we knew. The FEAST trial shows us that we do not understand pathophysiology of septic shock as well as we think we do. As good clinicians we should accept this and try to explain the apparent paradoxical findings. The authors to their credit, offer the explanation that fluid boluses may cause damage through reperfusion injury, effecting pulmonary compliance or myocardial function. The FISH (Fluid In SHock) trial is currently running in hospitals across the UK to follow-up FEAST and see if we should be changing our practice.

As clinicians we have a duty to continually question what we think we know, and to search for better and more efficient ways of treating our patients. The doctor who clings to dogma and does things a certain way, because they have always been done that way is doing his patients a disservice and indeed could be putting them in harms way.

We will never know everything, and what we believe we know now will change over the course of our careers and even our lives, so I would urge everyone to learn the lessons of the giant camels, and never stop questioning what we think we know, to enable us to always do the best possible for our patients.

Thanks
Chris Arrowsmith

ST4 Emergency Medicine
Current Paediatric Intensive Care and Acute Retrieval Clinical Fellow, Bristol

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References

1. Rybczynski N, et al. 2013. Mid-Pliocene warm-period depostis in the High Arctic yield insight into camel evolution. Nature Communications, 4:1550

2. Maitland K, et al and the FEAST Trial Group. Mortality after Fluid Bolus in African Children with Severe Infection. N Engl J Med. 2011 May 26.

Primary Survey September 2016: EMJ

24 Aug, 16 | by scarley

This month’s primary survey from the EMJ.

Emergency Triage and Treatment Course in primary care health centres in Guatamala

Emergency triage Assessment and treatment (ETAT) course was developed by WHO in 1999 as part of its Integrated Management of Childhood Illnesses program for improving outcomes for children. It has been devised as a hospital based system for health services of limited resource settings.

This study took ETAT and introduced into the primary care setting, making it a self-sustaining locally led course in a district within Guatamala. The course comprised 5 modules that cover Triage, Airway/breathing, Circulation, Coma/convulsions and Dehydration which took 16 hours in total. Two courses were delivered in October 2012, and subsequently candidates were asked to undergo a written test and a survey about their confidence prior to the course and immediately thereafter, and then again at 3 months, 6 months and 12 months after the course. They were asked to take part also in a clinical skills assessment. During this time, a quality improvement program was established to identify and remedy problems that were found to be significant for candidate performance and learning.

There was an improvement in knowledge, from the pre-course to post course tests that was sustained in all subsequent tests. The clinical skills retention, assessed at 3, 6 and 12 months, all scored highly.

There was a boost in confidence before and after the course although this did start to reduce over time (but not to statistically significant standards). The level of confidence remained than that determine in the pre-course assessment.

This paper highlights that ETAT which has been shown to improve care for children in the resource limited care setting and shows that with planning and the use of QI programs, clinical skills knowledge and even confidence in a range of health care practitioners can be enhanced.

Point of care lung ultrasound in young children

This study had a ‘novice’ ultrasound operator look at the lungs of children triaged as having a respiratory problem such as wheeze or respiratory tract infection. The images were captured before any treatment was given to the children; these images were evaluated by an expert in ultrasound to determine if there were any of the following:

  • 3 or more B lines per intercostal space, consolidation+/− pleural abnormalities

  • Any of these features being present counted as a positive ultrasound.

None of the children with asthma had a positive ultrasound, whereas in pneumonia, all were positive. In children with asthma and pneumonia about half of he cases were positive as was the case in children with bronchiolitis. However, caution must be applied about just using ultrasound as the numbers in the study are small and more validation studies are required.

On a roll!

Why do log rolls in the unconscious adult patient? This retrospective study over 2 years looking at GSC 9 or less +/− intubated patients from the Alfred Trauma registry with major trauma (ISS >12) and compared the log roll findings with the CT/MRI reports on the presence or absence of thoracolumbar injury. Out of the 403 patients, about 85% did not have any abnormal findings on log roll. Out of the patients who had a thoracolumbar fracture(s), 72.5% had a normal log roll. Lesions seen included abrasions, bruising, haematoma, open wounds, foreign bodies and burns which were important in some instances for acute patient management. Using palpation in this group of patients to find any abnormalities is questionable. For determining thoracolumbar fractures, palpation has a specificity of 98.8% but a sensitivity of 8.5%. The authors therefore recommend that visual inspection is important but that palpation may not be as helpful, especially when patients may go onto have CT/MRI imaging to rule in or out thoracolumbar fractures. It should be noted that this idea needs further prospective studies to confirm or repute the proposal!

Sawbones? A potential life-saving intervention

Fortunately pre-hospital limb amputation is not common but when needed, it can be life-saving. The study used cadaver limbs, donated for medical research purposes, to see which was the most effective tool/technique to perform an amputation. Four devices were examined for the time from knife to full amputation, the number of attempts required, and perceived risk to the rescuer or “patient” during the procedure.

After the procedure, an assessment was made of the damage to the soft tissue, skin and bone, by 6 independent clinical rates according to a 5 point scale, with 5 being the most favourable result.

Ninety one seconds was the longest time taken to effect amputation, and all 4 techniques/tools had their advantages and disadvantages—a really important topic to improve patient care in difficult situations, showing practical aspects about a life-saving procedure.

Good communication makes for less ‘traumatised’ patients

Good interpersonal skill can reduce patient worry as seen in this study of acute coronary syndrome patients. The incidence of subsequent posttraumatic stress reactions decreases according to patient perception of communication with their clinician. It is important to think about how we conduct ourselves as this impacts greatly on how much better our patients can become!

“Delayed discharges and boarders”….

An ebb and flow of patients would be ideal, but as this paper shows that delay in the discharge of patients backs up patients in ED. The authors show this in their setting, in a busy hospital in Dublin and, in the discussion, show that this is a commonplace problem in many different countries throughout the world. How social and community care can improve their ‘joined-upness’ with hospital based care is essential for delivering optimum patient care.

Ian K Maconochie

Click here to go to the journal site.

What’s the future of medical journals?

10 Jul, 16 | by scarley

The future of medical publishing

I had the pleasure of joining a panel discussion at the recent SMACC conference on the future of medical journals. I was delighted to share the stage with some real big hitters such as Richard Smith (ex editor of the BMJ) and Jeff Drazen (current editor in chief of the NEJM), together with some amazing researchers such as Sara Bassin Flavia Machado, Kathy Rowan, John Myburgh, Simon Finfer and Kath Maitland.

As with all panel discussions there was a degree of entertainment generated by our host Simon Finfer, but this is a significant matter. Journals and the publishing process have a huge role and influence on the conduct, funding and dissemination of science. The panel was assembled with deliberately discordant views to challenge the status quo and to look to what may be a fabulous, or perhaps a more dystopian future.

Richard Smith is a vociferous proponent of a post journal world and you can read his thoughts here. It’s really worth a read as a challenge to how we deliver knowledge from primary research out to those that actually need it and then out to practice, and more importantly to those that will benefit from it i.e. our patients.

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I found myself at one end of the on stage sofas with Rob MacSweeney who many of you will know from the Critical Care Reviews website, and with whom I share many views. I think we played our role as challengers to the status quo pretty well. Rob in particular is a fantastic exponent of getting research to the bedside in an ethical and fair way. If you’re not following his blog, and getting his newsletter at critical care reviews then follow the link and think about joining in.

There was too much on the day to summarise here, but I’d ask you to have a think about some of the ideas raised on the day. Right or wrong the panel were challenged on the following.

  1. Publishing in high impact journals is a key to academic promotion. Should it be?
  2. Universities are using a proxy measure (impact factors) to determine promotions. That’s outsourcing a really important measure to a system that has huge flaws.
  3. Similarly, funding organisations measure success in terms of publications in high impact journals. Journals thus have a huge influence on research funding priorities and success. Is this right?
  4. Peer review has been repeatedly shown to have huge flaws, fails to detect fraud, fails to detect poor quality and is prone to interpersonal bias and politics. Can we find a better way?
  5. Social media has the potential to produce post publication review, but is it any good, and can we collate it?
  6. Should we have open publishing, followed by widespread open peer review and then publication, and would this be better at detecting fraud, bias and error?
  7. Some journals make their papers open access after a period of time (e.g NEJM) and this is a good thing, but it would be better if it was sooner. Should all funding agencies demand open access (as many now do)?
  8. The relationship between researchers seeking publication, impact factors, promotion and future funding is complex and arguably at risk of a ‘mutualism’ relationship that does not directly benefit patients. How do we break that relationship (and do we need to)?
  9. Many journals believe that they are providing a service by filtering the poor quality out and only presenting research that is worthy of attention. The question was raised as to whether we need ‘other people’ to do this for us. Do we really need journal editors to be our filters and guides or can we do it for ourselves?
  10. Patients enter trials on the understanding that they will benefit healthcare in the future. Is it therefore unethical that that information is behind a paywall and not widely distributed?

We covered many more topics and I’d recommend a listen when it is eventually released from the SMACC website. For me, straddling the traditional world of journals as an EMJ editor, and also as proponent the new world of #FOAMed it was fascinating. I think it’s increasingly difficult to see how journals can survive in their current format with the rise of easy e-publishing and the ability to engage with a much broader audience across the internet. However, thinking that journals will remain as they are and not adapt to a changing world would be similarly naive. Journals will have to adapt and change and I’m sure they will.

My thoughts are that the role of journals as sole publishers of original research will diminsh, taken over by an open publication, hive-mind reviewed, open multi peer review process (I can dream). This will not mean that journals will die. Arguably there will be an increasing need for the  collation and interpretation of science, and arguably this will be a more effective and useful service for readers. The signs of such a change are already here. For example the BMJ has changed format over the years and now serves original research in a more summary style within the paper version. The detail is available, but not in the paper copy. It seems that accessibility, engagement and interpretation are increasingly valued, and that’s no bad thing. Here at the EMJ the primary survey and the podcasts serve a similar purpose and they are popular.

What then is the future of medical publishing? I’m not sure but I’m fairly confident that the status quo will not continue. What do you think?

vb

S

EMJ Editor and Editor at St.Emlyn’s virtual hospital, blog and podcast.

PS. The debate was fuelled by some rather fabulous on stage drinks. The 25 year old Bushmills as recommended by Rob was truly stunning.

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

The Alteplase Controversy Goes Prime Time

19 Sep, 15 | by rradecki

Alteplase & Stroke

Just a few months ago, alteplase for acute ischemic stroke was assaulted in the pages of the BMJ. Academic debate on this subject is hardly novel, as the controversy within the ivory tower has dragged on almost since thrombolytics for stroke received therapeutic approval.

However, as the use of alteplase grows, the number of patients harmed by its use has correspondingly increased. Regardless of the perceived benefits of the treatment, the resulting harms have accumulated into a full public outcry, with family members of those harmed petitioning the government for increased oversight. There are now two ongoing reviews in the United Kingdom – the Medicines and Healthcare products Regulatory Agency review has been joined by the Academy of Medical Sciences. A full 38 minute segment on BBC Radio 4 details several personal stories, and contains snippets of interviews with the renowned David Newman, among others.

In the same vein, the American College of Emergency Physicians has finally released their revision to the highly-conflicted 2012 policy statement regarding treatment of acute ischemic stroke. Substantially altered from the 2012 version, ACEP has dramatically weakened the prior recommendations to reflect the paucity of randomized trial evidence. While two pivotal trials demonstrated significant absolute benefit, such trials enroll simply a few hundred patients in the setting of vastly heterogenous presentations and prognoses for acute stroke.

The new policy statement issues two recommendations for offering alteplase to qualifying patients, both under the “Level B” classification – representing “recommendations” for patient care subject to “moderate clinical certainty”. This is a change from the previous guideline, which provided concise recommendations favoring treatment within three hours as Class A. The new recommendations:

      With a goal to improve functional outcomes, IV tPA should be offered and may be given to selected patients with acute ischemic stroke within 3 hours after symptom onset at institutions where systems are in place to safely administer the medication. The increased risk of sICH should be considered when deciding whether to administer IV tPA to patients with acute ischemic stroke.

Despite the known risk of sICH and the variability in the degree of benefit functional outcomes, IV tPA may be offered and may be given to carefully selected patients with acute ischemic stroke within 3 to 4.5 hours after symptom onset at institutions where systems are in place to safely administer the medication.

It remains to be seen whether these recommendations substantially alter clinical practice or encourage additional investigation. Beyond 3 hours – the timeframe most critiqued by Alpers et al – alteplase remains unapproved for use by the FDA, and by these guidelines need not be offered to patients.

As always, the hope is these developments will spur further, prospective, independent evaluation. We need thousands, not hundreds, of patients in well-designed trials devoid of conflict-of-interest. Otherwise, we continue to place patients at risk, both from the harms of alteplase or the harms of potentially not receiving a truly beneficial therapy.

 

vb

Ryan

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