Ep 139 - May 2019 Round Up

St. Emlyn's Podcast: Key Insights from May in Emergency Medicine

As we transition into the warmer months, it's an opportune time to reflect on recent discussions and developments within the field of emergency medicine, particularly those highlighted in the latest episode of the St. Emlyn's podcast. This episode covered a wide range of topics, from workplace safety to advancements in pediatric care and innovative approaches in patient management. Below is a comprehensive summary of the key points discussed.

Workplace Safety: A Pressing Concern

The podcast began with a reflection on a recent violent incident at Newham Emergency Department (ED), which served as a stark reminder of the dangers healthcare professionals face daily. Emergency departments, by their very nature, are open and accessible, making them vulnerable to violent incidents. This recent attack has prompted a nationwide reassessment of safety measures, with many EDs enhancing their protocols to protect staff.

The conversation emphasized that violence in the workplace should never be normalized. It’s crucial that healthcare professionals feel safe and supported in their working environment. Leadership within departments plays a critical role in this, not only by implementing robust safety protocols but also by fostering a culture of solidarity and mutual support among staff. The incident at Newham underscores the need for constant vigilance and proactive measures to ensure the safety of everyone working in emergency medicine.

Leadership in Education: Simon Carley’s New Role

In more positive news, Simon Carley’s recent appointment as the CPD (Continuing Professional Development) lead for the college was discussed. This role is a significant milestone, not just for Simon but also for the integration of modern educational approaches within formal medical education. Simon’s involvement with St. Emlyn's has long been focused on innovative, social media-driven education, and this new role offers an opportunity to bring these methods into a broader educational framework.

The appointment highlights the value of combining traditional education with the dynamic, accessible formats offered by the #FOAMed (Free Open Access Meducation) community. It’s a recognition that medical education can benefit from new perspectives and that the integration of these ideas can enhance the learning experiences for healthcare professionals.

Pediatric Status Epilepticus: Evaluating Second-Line Agents

The discussion moved to a detailed analysis of pediatric status epilepticus, focusing on the findings from two key trials: the Eclipse trial and the ConSEPT trial. These studies compared the efficacy of levetiracetam (Keppra) and phenytoin as second-line agents for stopping seizures in children.

The trials found no significant difference between the two drugs in terms of their effectiveness, which has led to debate within the medical community about whether to switch from phenytoin to levetiracetam. While levetiracetam is perceived as easier to administer and safer, the lack of a clear superiority has left the decision somewhat open. However, the ease of use and safety profile of levetiracetam make it an appealing option, and some institutions are considering making the switch.

For clinicians, the takeaway is that while both drugs are viable options, the choice may ultimately come down to individual preferences and institutional protocols. The trials underscore the importance of continuous evaluation of treatment options, particularly in complex cases like pediatric seizures.

Understanding Clinical Trials: The Importance of Statistical Literacy

Simon Carley also highlighted the importance of understanding the statistical nuances in clinical trials, particularly the difference between demonstrating a difference between treatments and establishing their equivalence. This distinction is crucial for accurately interpreting research findings and making informed clinical decisions.

The discussion emphasized that clinicians must be cautious in how they interpret trial results, particularly when it comes to determining whether treatments are genuinely equivalent or if the lack of a significant difference merely reflects the study’s design. This level of critical appraisal is essential for ensuring that new research is applied correctly in clinical practice.

Prolonged Field Care in the ED: Learning from Military Medicine

Another topic discussed was prolonged field care, a concept borrowed from military medicine that is becoming increasingly relevant in emergency departments due to overcrowding and delays. Rich Carden introduced the HITMAN mnemonic—Hygiene and Hydration, Infection, Tubes, Medication, Analgesia, and Nutrition—as a framework for managing patients who are stuck in the ED for extended periods.

The HITMAN approach ensures that patients' fundamental needs are met even when resources are stretched. This method helps prevent complications and improves patient outcomes, even in less-than-ideal conditions. The approach is particularly relevant in today’s healthcare environment, where EDs are often overwhelmed and patients may wait longer than usual for admission or transfer.

Atrial Fibrillation: Reassessing Cardioversion Strategies

Atrial fibrillation (AF) management was another key topic. A recent study in the New England Journal of Medicine compared immediate cardioversion with a wait-and-see approach in patients with new-onset AF. The study found that a wait-and-see approach was non-inferior to immediate cardioversion, with 69% of patients in the wait-and-see group spontaneously cardioverting within 48 hours.

This finding challenges the traditional approach of immediate cardioversion and suggests that in many cases, a more conservative approach may be just as effective. However, the decision should be made through shared decision-making with the patient, taking into account their preferences and the specific circumstances of their condition. This patient-centered approach ensures that treatment decisions are made collaboratively and with the patient’s best interests in mind.

Traumatic Cardiac Arrest: Reevaluating Chest Compressions

The podcast also touched on the evolving management of traumatic cardiac arrest, particularly the role of chest compressions. Recent studies, including one involving porcine models, suggest that in cases of hypovolemic traumatic cardiac arrest, chest compressions may not be beneficial and could even be harmful. Instead, the focus should be on addressing the underlying cause, such as restoring circulating volume.

This shift in practice highlights the importance of understanding the specific etiology of cardiac arrest and tailoring resuscitation efforts accordingly. Communicating these changes to the entire resuscitation team is crucial, as there may be resistance to deviating from traditional protocols. Ensuring that everyone is on the same page and understands the rationale behind the approach is key to successful implementation.

Virtual Reality in Pain Management: An Emerging Tool

Virtual reality (VR) is emerging as a promising tool in pain management, particularly in pediatric patients undergoing painful procedures. A recent study discussed in the podcast found that children who used VR experienced less distress during procedures compared to those who received standard care.

VR offers an innovative, accessible method for managing pain and anxiety, and its use is likely to expand in the coming years. The ability to create immersive environments that distract patients during procedures has the potential to improve patient experiences and outcomes, not just in children but potentially in adults as well.

The Power of Peer Review: Enhancing Clinical Practice

Finally, Simon Carley discussed the importance of peer review in clinical practice. Peer review is a valuable tool for continuous improvement, allowing clinicians to receive feedback from colleagues on their performance. While it can be challenging to create a culture where feedback is welcomed and constructive, the benefits are significant.

Peer review helps clinicians avoid complacency, stay up-to-date with best practices, and continually refine their skills. It’s a simple, cost-effective way to ensure that healthcare professionals are delivering the highest standard of care. Creating a supportive environment where feedback is seen as an opportunity for growth rather than criticism is essential for the success of peer review initiatives.

Conclusion

The discussions in this month’s St. Emlyn's podcast highlight the complexities and challenges of working in emergency medicine, from ensuring workplace safety to staying current with evolving practices. By engaging with new research, embracing innovative tools like virtual reality, and fostering a culture of continuous improvement through peer review, we can continue to advance the field and improve patient care. As always, the St. Emlyn's blog and podcast remain valuable resources for staying informed and connected with the latest developments in emergency medicine.