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A UK based Emergency Medicine podcast for anyone who works in emergency care. The St Emlyn ’s team are all passionate educators and clinicians who strive to bring you the best evidence based education. Our four pillars of learning are evidence-based medicine, clinical excellence, personal development and the philosophical overview of emergency care. We have a strong academic faculty and reputation for high quality education presented through multimedia platforms and articles. St Emlyn’s is a name given to a fictionalised emergency care system. This online clinical space is designed to allow clinical care to be discussed without compromising the safety or confidentiality of patients or clinicians.
Episodes
Sunday Sep 27, 2015
Sunday Sep 27, 2015
Mastering the Art of Clinical Referrals: A Guide for Emergency Physicians
Introduction
Effective communication is crucial in the emergency department (ED), particularly when referring patients to inpatient teams. It not only ensures optimal patient care but also enhances professional relationships and personal job satisfaction. In this post, inspired by the St. Emlyns podcast, we'll explore a practical framework for making clinical referrals, emphasizing the importance of clear, structured communication. We'll discuss the SBAR (Situation, Background, Assessment, Recommendation) format, the concept of the "James Bond opening," and strategies for handling difficult conversations, all tailored to the fast-paced environment of emergency medicine.
Why Effective Referrals Matter
Referrals are an integral part of patient management in the ED. Every referral is made with the patient's best interest in mind, whether they need further investigations, specialized treatment, or simply continuity of care. Ensuring that the receiving team understands the urgency and context of the referral is vital. Good communication can influence how the inpatient team perceives the referring physician and can enhance collaborative relationships, leading to better patient outcomes and professional fulfillment.
Setting the Stage: The James Bond Opening
When initiating a referral, it’s essential to grab the attention of the receiving team quickly and effectively. This is where the "James Bond opening" comes in—start with a high-impact statement that summarizes the critical aspect of the patient's condition. For example, instead of saying, "I have a patient with abdominal pain," begin with, "I have a 25-year-old male who likely has appendicitis." This approach not only captures attention but also sets the stage for a focused and efficient conversation.
The SBAR Framework: Structuring Your Referral
The SBAR model provides a structured approach to communication, ensuring all essential information is conveyed succinctly. Here’s how to implement it:
Situation
Begin with a brief description of the patient's current condition. This is where the "James Bond opening" fits perfectly. Clearly state the key clinical concern that necessitates the referral.
Background
Provide context for the situation. This includes relevant medical history, the reason for the current ED visit, and any pertinent findings. For instance, you might say, "The patient has had two days of right iliac fossa pain and a history suggestive of appendicitis."
Assessment
Share your clinical judgment about the patient's condition. This not only demonstrates your understanding but also signals the expected pathway of care. In our example, "Based on the examination and symptoms, I believe the patient has appendicitis."
Recommendation
Conclude with a clear, direct request. Specify what you need from the inpatient team, such as a physical assessment, further diagnostic testing, or specific interventions. For instance, "I'd appreciate it if the surgical team could evaluate the patient for potential appendicitis and consider admission for further management."
Enhancing the Referral Process: Tips and Tricks
Introduce Yourself Clearly
Always start the conversation by introducing yourself with your name and role. For example, "Hi, I'm Ian, one of the ED doctors." This personal touch helps build rapport and sets a friendly tone. If the receiving team introduces themselves by title only, politely ask for their name, fostering a more personable interaction.
Predict and Prepare for Questions
Anticipate the questions the receiving team might ask and prepare your responses. For example, if referring a potential appendicitis case, be ready to discuss symptoms, lab results, and physical findings. This not only streamlines the conversation but also demonstrates your preparedness and competence.
Use the Illusion of Choice
To smooth the referral process, offer options that guide the receiving team towards a decision that benefits the patient. For instance, "Would you prefer to see the patient in the ED or on the ward?" This technique, known as the illusion of choice, empowers the receiver while subtly directing the conversation towards the desired outcome.
Navigating Difficult Conversations
Not all referral conversations go smoothly. Sometimes, the receiving team may be uncooperative or dismissive. Here are strategies to handle such situations:
Stay Calm and Professional
If the conversation becomes contentious, avoid escalating the situation. Remain calm and professional, focusing on patient care rather than engaging in arguments. A useful tactic is to suggest pausing the conversation: "Let me discuss this further with my senior and get back to you."
Seek Support from Senior Staff
If you encounter resistance, consult a senior colleague or consultant. They can provide additional insights or take over the conversation, ensuring the patient receives the necessary care.
Empathize with the Receiving Team
Understand that the receiving team might be under significant pressure, dealing with their own caseloads and challenges. Acknowledging their situation can defuse tension and facilitate a more constructive dialogue.
Conclusion: Practice Makes Perfect
Effective referrals are a skill that, like any other medical procedure, requires practice and reflection. Using the SBAR framework, starting with a strong "James Bond opening," and preparing for potential questions can significantly improve the quality of your referrals. Remember, every interaction is an opportunity to enhance patient care and build professional relationships.
For more insights and discussions on emergency medicine, communication skills, and more, visit the St. Emlyns blog and podcast series. Let's continue to improve our skills and ensure the best outcomes for our patients.
Saturday Sep 05, 2015
Sunday Jul 26, 2015
Sunday Jul 26, 2015
Iain and Simon discuss the core skills that all EM clinicians need to manage pain in the ED.
These are the basics, but don't be put off. The basics are more important than the fancy stuff that we will discuss in a later podcast.
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Thursday Jul 16, 2015
Thursday Jul 16, 2015
A podcast mini to round up and look forward to the next few months on the podcast.
We also have a special recording of Danny Boy from the Irish Youth Choir and conducted by Greg Beardsell. This performance was dedicated to Dr John Hinds in Dublin following his untimely death in a motorcycle accident.
Please listen and take a moment to remember him and all that he has done to inspire everyone involved in the care of the injured.
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Sunday Jul 12, 2015
Sunday Jul 12, 2015
Day 2 and 3 at #smaccUS. Iain and Simon round up the highlights and look forward to #smaccDUB.
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Tuesday Jul 07, 2015
Tuesday Jul 07, 2015
Navigating Grief: Lessons from the St Emlyns Podcast with Liz Crow
In a compelling episode of the St Emlyns podcast, host Ian Bidsel engages in a profound discussion with pediatric social worker Liz Crow about the intricacies of grief, especially within the healthcare sector. This episode was prompted by the tragic loss of John Hines, a respected member of the SMACC community known for his work as a motorcycle doctor. Liz shares her insights into the unique challenges faced by healthcare professionals when dealing with grief, both personally and professionally.
The Unique Nature of Grief
Grief is a deeply personal experience that varies significantly from person to person. Liz Crow emphasizes that there is no "normal" way to grieve; each individual's response is shaped by various factors, including age, personality, and prior experiences with loss. The podcast challenges the traditional Kubler-Ross model, which suggests a linear progression through five stages of grief. Liz argues that grief is a fluid process without a set path, characterized by an unpredictable mix of emotions.
Grieving in the Healthcare Profession
Healthcare professionals often encounter death and suffering, which can complicate their grieving process. The sudden death of John Hines highlighted the vulnerabilities even within a community accustomed to dealing with trauma. Liz and Ian discuss the common practice of compartmentalization among healthcare workers, where emotions are set aside to focus on the task at hand. While this can be a necessary coping mechanism, Liz warns against prolonged avoidance of emotions, as it can lead to long-term psychological issues.
The conversation underscores the importance of self-awareness and self-care. Healthcare professionals are encouraged to acknowledge their grief and seek support when necessary. This may involve adjusting work responsibilities or taking time off to process emotions. Liz stresses that compartmentalization should be temporary and that healthcare workers need to find safe spaces to express and process their grief.
Coping Strategies and Community Support
Liz explores various coping strategies that can help individuals navigate their grief. These include journaling, physical activity, creative expression, and talking with trusted friends or professionals. The key is to find what works best for each person. The SMACC and FOAMed communities provide a supportive network, especially through social media, which has facilitated shared experiences and mutual support. However, Liz notes that online interactions can sometimes lack the depth needed for processing complex emotions.
The podcast also addresses the public aspect of grieving, particularly when the person lost is a public figure like John Hines. For those who admired him, his death serves as a stark reminder of life's fragility. Liz and Ian discuss the discomfort of confronting mortality, especially when it involves someone perceived as larger than life. This public grieving can add another layer of complexity to personal mourning.
The Importance of Open Conversations About Grief
A significant theme in the podcast is the need for open dialogue about grief. Liz encourages listeners to communicate their feelings and to be open about their vulnerabilities. She highlights the cultural stigma against showing emotion, particularly among men, and calls for a shift in how we perceive emotional expression. The healthcare community, often valuing emotional resilience, may need to rethink its attitudes toward vulnerability.
Ian shares his personal experiences of feeling isolated in his grief, particularly in professional settings where the expectation is to maintain a façade of normalcy. Liz acknowledges this common experience and emphasizes the importance of finding supportive communities and being open about one's struggles.
Integrating Grief into Life
Liz suggests that instead of viewing grief as something to "move through," it should be seen as an experience to integrate into one's life. She uses the metaphor of grief as a wound that eventually becomes a scar—while the initial pain may subside, the impact of the loss remains. This perspective encourages compassion for oneself and others, recognizing that grief is an ongoing process rather than a problem to be solved.
For those struggling to cope, Liz recommends seeking professional help, particularly if grief begins to manifest as clinical depression. She distinguishes between the natural process of grief and the symptoms of depression, advising individuals to seek support if they find themselves unable to manage their emotions.
The Role of Professional Support and Self-Care
The podcast highlights the critical role of professional support and self-care for healthcare workers. Liz discusses the importance of accessing supervision and counseling, especially during personal crises. Self-care is not a luxury but a necessity, particularly for those in caregiving roles who may prioritize others' needs over their own. This can include taking time off, engaging in hobbies, or simply allowing oneself to grieve.
Moving Forward with the Community
As the SMACC and FOAMed communities continue to process John Hines' loss, this podcast serves as a reminder of the collective nature of grief and the importance of community support. The conversation provides valuable insights into the complexities of grieving, the significance of open dialogue, and the power of mutual support.
In conclusion, Liz and Ian emphasize that grief is a natural part of life, much like happiness. They encourage listeners to approach their grief with gentleness and understanding, acknowledging that there is no right or wrong way to grieve. Whether through professional support, personal coping strategies, or community connections, the journey through grief is unique to each individual. The key takeaway is to be patient with oneself and others, recognizing that healing is a gradual and ongoing process.
This episode of the St Emlyns podcast offers a deep exploration of grief, providing practical advice and emotional support for those navigating this challenging experience. The conversation encourages healthcare professionals and the wider community to engage openly with their emotions and to support one another through the journey of grief.
Thursday Jun 25, 2015
Thursday Jun 25, 2015
The first day of #smacc15 was amazing. An incredible introduction and an amazing program.
Wednesday Jun 24, 2015
Wednesday Jun 24, 2015
Iain and Simon discuss Iain's SMACC talk and how we deal with difficult cases in the ED.
Wednesday Jun 24, 2015
Wednesday Jun 24, 2015
SMACC Chicago: Insights, Learning, and Community at St Emlyn's
The SMACC (Social Media and Critical Care) Conference in Chicago brought together healthcare professionals and thought leaders from around the world. The St Emlyn's team, comprising Iain Beardsell, Simon Carley, Rick Boddy, and Natalie May, participated in various workshops and sessions, sharing their experiences and insights. This blog post captures the essence of the conference, highlighting key learning outcomes and the vibrant community spirit.
Evidence-Based Medicine: From Theory to Practice
Simon Carley kicked off the day with a workshop titled "Gambling with the Evidence," focusing on practical applications of evidence-based medicine (EBM). Unlike traditional EBM sessions that often dwell on statistics and literature reviews, this workshop emphasized how to translate evidence into clinical practice. Simon, alongside Rick Boddy, Rob McSweeney, Ken Milne, and Rory Spiegel, explored how healthcare professionals manage the overwhelming volume of evidence and integrate it into their practice.
Key takeaways included strategies for storing and accessing evidence efficiently, influencing colleagues with evidence-based practices, and the importance of critical skepticism. The workshop stressed the responsibility of individuals to thoroughly understand the evidence before implementing changes in clinical settings. This session underscored the necessity of a balanced approach to adopting new practices, ensuring they are rooted in a comprehensive understanding of available evidence.
FOAM: Creating and Sharing Educational Content
Natalie May joined other prominent figures in the FOAM (Free Open Access Meducation) community for the "Brew Your Own FOAM" session. Alongside Salim Rezé, Rob Rogers, Haney Malamarts, and others, Natalie discussed the creation of blogs, podcasts, and other educational resources. The session, likened to an Apple bar, provided an informal yet informative platform for attendees to engage with experienced content creators.
Participants gained insights into the technical and creative aspects of producing FOAM content. The session encouraged the sharing of knowledge and resources, emphasizing that a diverse range of voices and perspectives enriches the medical community. Natalie highlighted the importance of FOAM in democratizing medical education, making high-quality information accessible to a global audience.
Exploring Chest Pain and Cardiology Pathways
Rick Boddy delved into the nuances of chest pain management and cardiology in his workshops. The morning session on evidence-based medicine included discussions on the values and outcomes in clinical trials, particularly concerning stroke and thrombolysis. Rick emphasized the varying perspectives of patients, doctors, and policymakers, stressing the importance of considering these viewpoints when evaluating clinical outcomes.
The afternoon's emergency cardiology workshop, featuring experts like Steve Smith and Louise Cullen, focused on chest pain pathways. The session covered a range of topics, from ECG interpretation to chest pain algorithms. Rick noted the growing interest in high-sensitivity troponins and the need for tailored chest pain pathways that cater to specific local populations. The discussion also addressed the challenges of implementing standardized pathways and the importance of trusting the evidence.
Getting Creative: Enhancing Communication Skills
Simon Carley also participated in a workshop titled "Getting Creative," which explored creative communication methods in the medical field. The workshop featured three sessions: Michelle Johnson on writing, Grace Slyo on visual presentations, and Rob Rogers on podcasting. Michelle Johnson, a skilled writer, guided participants through the art of crafting compelling narratives, particularly for blog posts. She emphasized the power of language and the importance of clear, concise communication.
Grace Slyo's session focused on improving visual communication, offering tips on graphic design and effective presentation techniques. She provided valuable resources and exercises to help participants enhance their visual storytelling skills. Rob Rogers concluded the workshop with practical advice on creating engaging podcasts, covering everything from content creation to technical aspects. Simon found the workshop incredibly valuable, noting that these skills are essential for effective knowledge dissemination in the medical community.
Pediatric Critical Care: Lessons and Strategies
Natalie May attended the SMACC mini session on pediatric critical care, where experts discussed managing critically ill children in emergency and intensive care settings. The session opened with Fran Lockey and Phil Hyde addressing pediatric airway and breathing management. They emphasized the importance of simple airway maneuvers and two-handed bag-valve-mask ventilation, debunking the myth that intubation is always necessary.
Lisa McQueen provided a poignant presentation on children in shock, referencing the case of Rory Staunton, a child who tragically died from sepsis after being discharged from the emergency department. The session highlighted the critical role of thorough reassessment and face-to-face evaluations in pediatric care. The importance of vigilance in monitoring children's progress before discharge was a key message.
Pre-Hospital Care: Excellence in Action
Iain Beardsell shared his experience from the pre-hospital care workshop, led by Carol Harbig from Greater Sydney Hems. The workshop featured a range of topics and speakers, providing an in-depth look at pre-hospital emergency medicine. The highlight of the day was a presentation by Ashley Leibig, who delivered a powerful talk on the emotional challenges faced by pre-hospital care providers and the importance of peer support.
Iain emphasized the value of visualization and mental rehearsal in preparing for high-stress situations. The workshop underscored the importance of practicing difficult scenarios mentally to ensure readiness when faced with real-life emergencies. This approach helps clinicians develop a clear action plan, reducing the likelihood of hesitation or error during critical moments.
The SMACC Community: Beyond Clinical Knowledge
One of the standout features of the SMACC Conference is its holistic approach to medical education. The conference not only covers clinical and technical topics but also addresses the emotional and psychological aspects of healthcare. Ashley Leibig's talk, reminiscent of Liz Crowe's impactful presentations, reminded attendees of the need for compassion and self-care in a field often dominated by high-stakes decision-making.
The conference provided ample opportunities for networking and community building. The St Emlyn's team noted the importance of connecting with peers, sharing experiences, and learning from each other. The collaborative spirit of the FOAM community was palpable, with participants eager to exchange ideas and support one another in their educational endeavors.
Preparing for the Big Stage: Final Thoughts
As the day drew to a close, the St Emlyn's team prepared for their presentations at the conference. The anticipation and nerves were palpable, reflecting the high regard in which the opportunity to speak at SMACC is held. The team emphasized the importance of thorough preparation, including practicing presentations and ensuring all details are in order.
The St Emlyn's team encouraged attendees and followers to engage with them, highlighting the value of these interactions in enriching the conference experience. They looked forward to meeting new people and deepening connections within the medical community.
Conclusion
The SMACC Conference in Chicago provided a rich and varied learning experience for the St Emlyn's team. From evidence-based medicine to pediatric critical care and pre-hospital medicine, the workshops offered valuable insights and practical knowledge. The conference also underscored the importance of creative communication, emotional resilience, and community support in the medical field.
For those unable to attend, the St Emlyn's team hopes this blog post offers a glimpse into the vibrant and dynamic environment of SMACC. The team is committed to sharing the knowledge and experiences gained at the conference, contributing to the broader medical community's growth and development.
As always, the St Emlyn's team encourages feedback and engagement from their readers. Whether you're interested in evidence-based medicine, FOAM, pediatric care, or any other topic, there's something for everyone in the rich tapestry of SMACC. Stay tuned for more updates and insights as the conference continues to unfold.
Thursday Jun 04, 2015
Thursday Jun 04, 2015
Managing Back Pain in the Emergency Department: A Comprehensive Overview
In the emergency department (ED), back pain, particularly lower back pain without a traumatic cause, is a common and complex presentation. This condition can range from benign to life-threatening, requiring a thorough and systematic approach to ensure accurate diagnosis and effective management.
The Challenge of Back Pain in Emergency Medicine
Back pain patients often come with preconceived notions, especially when they seek pain relief. However, it's crucial to avoid jumping to conclusions, as back pain can result from various underlying issues, including serious conditions like ruptured abdominal aortic aneurysms (AAA) or infections. Therefore, clinicians should avoid hastily labeling cases as "musculoskeletal" without thorough evaluation.
Key Diagnostic Considerations
1. Broad Differential Diagnosis:
The differential diagnosis should begin with more severe and potentially life-threatening conditions. For example, an AAA can present with subtle back pain, particularly in the elderly, and missing this diagnosis can be catastrophic. Hence, abdominal examinations and bedside ultrasounds are essential tools for detection.
2. Pain Chronology and Characteristics:
Understanding the pain's duration and nature is vital. Chronic pain may suggest long-standing issues, while acute pain can indicate new, potentially severe conditions. Atypical symptoms like pain that worsens at night or at rest, as opposed to musculoskeletal pain that improves with rest, could signal neoplastic or infectious processes.
3. Multi-System Evaluation:
A comprehensive assessment, including vital signs and a review of systems, is critical. For instance, signs like tachycardia, fever, or hypotension can indicate systemic issues such as sepsis. Conditions like pyelonephritis, especially in immunocompromised patients, can manifest as back pain, necessitating a thorough evaluation.
Specific Conditions and Red Flags
Ruptured Abdominal Aortic Aneurysm (AAA):
In elderly patients, AAA must always be considered, especially with sudden onset back pain. This condition can be rapidly fatal, and quick diagnosis via ultrasound is crucial.
Neoplastic Disease:
Symptoms such as unexplained weight loss, persistent night pain, or a history of cancer necessitate evaluation for metastatic disease. Cancers known to metastasize to bone, like breast or lung cancer, may present with back pain, requiring thorough imaging and lab work.
Infectious Causes:
Spinal infections, such as osteomyelitis or epidural abscess, are serious conditions often presenting with back pain. Risk factors include intravenous drug use or immunocompromised states. High suspicion is necessary in patients with concurrent systemic symptoms.
Cauda Equina Syndrome (CES):
CES is a neurosurgical emergency, presenting with symptoms like severe lower back pain, saddle anesthesia, and bowel or bladder dysfunction. A meticulous neurological examination, focusing on lower limb function and perineal sensation, is necessary. MRI is the preferred diagnostic tool, providing detailed images of the spinal cord and nerve roots.
Imaging and Laboratory Tests
Imaging:
Imaging choices should be guided by clinical suspicion. MRI is preferred for evaluating soft tissues, especially in suspected CES cases. For older adults, plain X-rays can reveal fractures but are limited in detecting soft tissue issues. CT scans are useful for complex cases like suspected tumors or infections, while nuclear medicine imaging may detect metastatic lesions or stress fractures.
Laboratory Tests:
Blood tests are essential in cases where red flags suggest systemic involvement. Tests like a full blood count (FBC), inflammatory markers, and bone profiles can provide critical diagnostic information. Elevated inflammatory markers may indicate infection or inflammation, while abnormal calcium levels could suggest a paraneoplastic syndrome.
Management of Non-Specific Back Pain
Once serious conditions are ruled out, management focuses on non-specific, likely musculoskeletal back pain. This involves patient education, mobilization, and appropriate pain management.
Patient Education and Mobilization:
Patients should be informed about the importance of staying active to prevent muscle stiffness and worsening pain. The role of muscle spasm in pain should be explained, and patients encouraged to maintain activity despite discomfort.
Pain Management:
The WHO pain ladder guides pain management, starting with simple analgesics like paracetamol and NSAIDs. For more severe pain, moderate opioids like codeine may be considered. The goal is to provide sufficient pain relief to facilitate mobilization and prevent the development of chronic pain.
Controversial Treatments:
The use of benzodiazepines is controversial. They are not true muscle relaxants but can reduce anxiety and distress, potentially aiding pain management. However, they should be used sparingly and for short periods. The use of gabapentin for acute back pain is also debated, as it is primarily indicated for neuropathic pain.
Chronic Pain Management
For chronic pain patients, management focuses on a multidisciplinary approach, involving pain specialists, physiotherapists, and primary care providers. The goal is to manage the physical, psychological, and social aspects of chronic pain.
Collaborative Care:
Close collaboration with primary care providers ensures consistent messaging and management plans. Pain specialists can offer additional support, especially in complex cases requiring advanced pain management techniques.
Non-Pharmacological Interventions:
Non-pharmacological interventions, such as physical therapy and cognitive-behavioral therapy (CBT), are crucial. These therapies help strengthen muscles, improve posture, and manage the psychological impacts of chronic pain.
Conclusion
In conclusion, managing back pain in the ED requires a comprehensive, systematic approach. Clinicians must prioritize ruling out serious conditions, use appropriate diagnostic tools, and provide effective pain management and patient education. Collaboration with primary care and pain specialists is essential for managing chronic pain, ensuring a holistic approach to patient care. By following these guidelines, healthcare professionals can provide compassionate, evidence-based care, leading to better patient outcomes and a more efficient emergency department.
Red flag symptoms and analgesia advice below.
Friday May 22, 2015
Friday May 22, 2015
Barbra Backus joins Rick Body to discuss the origin, development and future of risk scores for ED patients with possible acute coronary syndromes. Two researchers at the top of their game, and authors of the HEART and MACS scores.
Wednesday May 06, 2015
Monday Apr 27, 2015
Monday Apr 27, 2015
A first podcast with Simon Laing from the RCEMFOAMed team. We look back at influential trauma related papers from 2014-2015.
Saturday Apr 18, 2015
Saturday Apr 18, 2015
Iain interviews the wonderful Tim Draycott on the management of the Obstetric patient with trauma.Tim is a consultant Obstetrician from Bristol and is a great speaker on this rather terrifying topic!
Thursday Mar 26, 2015
Thursday Mar 26, 2015
A short podcast updating the UK Advanced Paediatric Life Support (APLS) course guidelines for the management of trauma in children.
Don't forget to read the blog post here. APLS Updates: New kids on the block,
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Sunday Mar 22, 2015
Sunday Mar 15, 2015
Sunday Mar 15, 2015
High-Performance in Trauma Care: Lessons from Elite Sports Coaching
Welcome to the St Emlyns blog! Today, we're diving into an insightful discussion from the recent London Trauma Conference, where Dr. Tom Evans shared his unique experiences and lessons learned from working with the British rowing team as a coach. Dr. Evans, a post-CCT doctor in emergency medicine and former Sydney HEMS doctor, offers a fascinating perspective on high-performance culture in trauma care, drawing parallels with elite sports coaching.
The Challenge of High Performance in Trauma Care
In trauma care, the term "world-class" is often used to describe top-tier performance. However, as Dr. Evans points out, this concept can be misleading. Unlike athletes who prepare for specific, well-defined events, emergency medicine professionals face an unpredictable array of cases daily. Thus, instead of striving to be "world-class," a more practical and applicable goal is to focus on achieving "high performance."
High performance is not an end result but a continuous process. It involves creating a culture where every team member is committed to doing even the smallest tasks as well as possible. This mindset shift from an outcome-based to a process-oriented approach is crucial for trauma teams, as it emphasizes excellence in everyday practice rather than sporadic peak performances.
High-Performance Culture: Key Components
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Shared Mental Models: One of the key aspects of high-performance teams, both in sports and healthcare, is the creation of shared mental models. In coaching, athletes need a clear understanding of what their performance should look like. This clarity helps them execute their skills effectively under pressure. Similarly, in trauma care, standard operating procedures (SOPs) help create a shared understanding among team members. This reduces cognitive load and allows team members to anticipate actions and outcomes, leading to better coordinated and more effective care.
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Simulation and Visualization: Dr. Evans emphasizes the importance of simulation and visualization in preparing for high-stress situations. Just as athletes use these techniques to mentally rehearse their performances, healthcare professionals can use simulation training to test and refine their responses to various scenarios. High-pressure simulations are particularly valuable as they help teams assess their readiness and make necessary adjustments to their mental models.
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Marginal Gains and the Basics: The concept of marginal gains—small incremental improvements—is widely recognized in elite sports. However, Dr. Evans cautions against focusing solely on these gains without first mastering the basics. In trauma care, the foundational elements such as knowledge, systems, and debriefing must be solid. Marginal gains can only be beneficial when the team operates consistently at a high level. Therefore, trauma teams should prioritize getting the basics right before seeking minor improvements.
Training vs. Coaching: A Crucial Distinction
A critical insight from Dr. Evans is the difference between training and coaching. In medical education, training often focuses on imparting knowledge and passing exams. However, coaching is about enhancing performance and preparing individuals for real-world challenges. Coaches are invested in their athletes' performance outcomes and see success as tied directly to their athletes' achievements. This personalized and performance-driven approach contrasts with the often fragmented nature of medical training, where trainees rotate through multiple trainers and institutions.
Dr. Evans argues for a coaching approach in medical training. This would involve more personalized guidance and a focus on developing the skills and mindset needed for long-term success in the field. Such an approach could better prepare trainees for the unpredictable and high-stakes nature of trauma care.
Implementing High-Performance Strategies in Trauma Teams
To implement a high-performance culture in trauma care, several strategies can be adopted:
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Institutional Support and Investment: High-performance training requires time and resources. Hospitals and healthcare institutions must prioritize training and development, even if it means adjusting schedules or reducing clinical productivity temporarily. This investment is crucial for cultivating a culture of continuous improvement and excellence.
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Team-Based Training and Debriefing: Multi-specialty training and team-based exercises can help build a cohesive unit capable of high performance. Regular debriefing sessions after simulations and real cases are also essential. They provide opportunities for reflection, learning, and refinement of processes.
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Focus on Human Factors: Understanding and optimizing human factors—such as communication, teamwork, and decision-making under pressure—is vital. Incorporating these elements into training and everyday practice can significantly enhance team performance.
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Continuous Learning and Adaptation: The landscape of trauma care is constantly evolving, with new technologies and methodologies emerging. A high-performance team must be committed to continuous learning and adaptation, staying abreast of the latest developments and integrating them into practice.
Conclusion: A Call to Action for Trauma Teams
Dr. Tom Evans' insights offer a valuable perspective on achieving high performance in trauma care. By adopting strategies from elite sports coaching, trauma teams can cultivate a culture of excellence that prioritizes process, preparation, and continuous improvement. The shift from an outcome-focused to a process-oriented mindset, coupled with robust training and support, can lead to significant advancements in patient care and team effectiveness.
At St Emlyn's, we are committed to exploring innovative approaches to medical education and practice. We encourage our readers to consider how these high-performance principles can be integrated into their teams and institutions. Let's strive for excellence not just in the big moments but in every aspect of our work.
For more insights and discussions on trauma care, emergency medicine, and high-performance culture, stay tuned to the St Emlyns blog. Your feedback and experiences are always welcome, so feel free to share your thoughts in the comments below.
Friday Feb 27, 2015
Friday Feb 27, 2015
Managing Opiate Overdoses: Key Insights from St Emlyns
Opiate overdoses are a common and critical issue faced in emergency departments, especially in urban areas with prevalent drug use. This guide, based on insights from Dr. Simon Carley and Dr. Iain Beardsell, provides an in-depth look at recognizing, treating, and managing opiate overdoses, including potential complications and best practices for patient care.
Recognizing Opiate Overdoses
Patients present with opiate overdoses either accidentally or intentionally, including drug addicts, elderly patients overdosing on prescriptions, and those attempting self-harm. Recognizing an overdose involves identifying key symptoms:
- Depressed Level of Consciousness: Patients may appear lethargic or unresponsive.
- Respiratory Depression: A significantly reduced breathing rate.
- Myosis: Pinpoint pupils that are unresponsive to light.
- Cardiovascular Effects: In severe cases, patients may exhibit hypotension or bradycardia.
Initial Assessment and ABC Protocol
In cases of suspected opiate overdose, the initial assessment should follow the ABC (Airway, Breathing, Circulation) protocol:
- Airway: Ensure the airway is open and clear.
- Breathing: Assess and support breathing and ventilation as necessary.
- Circulation: Check for adequate blood pressure and oxygen saturation. Establish IV access for medication administration.
Administering Naloxone
Naloxone, an opiate antagonist, is the primary antidote for opiate overdoses. However, its administration must be cautious and titrated to avoid complications like acute withdrawal or revealing underlying conditions, such as stimulant overdoses.
Methods of Administration
- Intravenous (IV): Offers rapid onset, but should be administered in small aliquots (e.g., 100 micrograms) to prevent abrupt awakening and associated risks.
- Intramuscular (IM): Useful when IV access is challenging, though it has variable absorption rates.
- Intranasal (IN): Effective, especially in patients with adequate spontaneous respiration.
- Nebulized Naloxone: Useful for patients who are breathing but not fully responsive, allowing gradual titration.
Managing Long-Acting Opiates
Patients who have ingested long-acting opiates, such as methadone, require careful monitoring. Continuous naloxone infusion may be necessary to prevent re-sedation. The infusion rate should typically be two-thirds of the total dose needed to achieve the initial response.
Importance of Monitoring
Patients should be placed in a setting where continuous monitoring of ventilation can be performed. Suitable locations include:
- High Dependency Unit (HDU): For intensive monitoring.
- Acute Medical Unit (AMU): For stable patients needing continuous observation.
Advanced Monitoring Techniques
End-tidal CO2 monitoring can provide a continuous assessment of respiratory status, especially when high-flow oxygen is used, which can mask hypoventilation.
Addressing Concurrent Conditions
Opiate overdoses often coexist with other medical or substance-related conditions. Be vigilant for:
- Rhabdomyolysis: Caused by prolonged immobility, leading to muscle breakdown.
- Compartment Syndrome: Particularly in patients found unconscious for extended periods.
- Mixed Overdoses: Patients may also have ingested other substances like stimulants or tricyclic antidepressants, complicating treatment.
Psychosocial Considerations and Follow-Up
Patients presenting with opiate overdoses often have complex psychosocial needs. It is crucial to address these issues, including:
- Mental Health Assessment: Evaluate for deliberate self-harm and provide psychiatric support.
- Drug and Alcohol Services: Connect patients with support services for addiction.
- Homelessness Support: Involve homeless outreach teams as necessary.
Handling Recurrent Overdoses
It's not uncommon for patients to return with repeated overdoses, reflecting the chronic nature of addiction. While frustrating, healthcare providers must consistently offer support and care, recognizing that patients have autonomy in their choices.
Controversies and Emerging Practices
Recent case reports suggest potential benefits in ventilating hypercapnic, acidotic patients before administering naloxone to avoid complications like flash pulmonary edema or dysrhythmias. However, this practice remains controversial and requires careful risk-benefit analysis.
Case Study Insight
A notable case involved a pregnant patient with an opiate overdose who also had ingested cocaine and tricyclic antidepressants. Administering a high dose of naloxone precipitated severe withdrawal and unmasked the effects of other substances, leading to a critical situation. This highlights the importance of a controlled and gradual approach to naloxone administration.
Conclusion
Effective management of opiate overdoses in the emergency department requires a nuanced approach. This includes recognizing the signs, following the ABC protocol, and carefully administering naloxone. Continuous monitoring, addressing underlying conditions, and providing psychosocial support are crucial for comprehensive care. Stay informed on emerging practices and best practices to enhance patient outcomes. For more detailed guidelines and updates, follow the St Emlyns blog and join our discussions on emergency medicine best practices.
Sunday Feb 22, 2015
Sunday Feb 22, 2015
At the recent London Trauma Conference, Iain Beardsell from the St Emlyn's podcast interviewed Professor Tim Harris, an expert in Emergency Medicine at Bart's Health, who provided critical insights into the concept of shock. This discussion challenged traditional notions and emphasized the importance of understanding shock beyond simple metrics like blood pressure.
Redefining Shock: Beyond Blood Pressure
Professor Harris argued that shock should not be narrowly defined as a state of low blood pressure but rather as a condition of inadequate oxygen delivery to meet the body's needs. Traditional medical training often emphasizes measurable parameters such as pulse, blood pressure, and respiratory rate. However, these indicators do not fully capture a patient's physiological state, particularly the crucial aspect of cardiac output—the volume of blood the heart pumps per minute. Cardiac output is difficult to measure directly, especially in emergency settings, yet it is a vital determinant of whether a patient is experiencing shock.
Relying solely on blood pressure can be misleading. For instance, young, healthy individuals might maintain a systolic pressure of 80-90 mmHg while adequately perfusing their organs, whereas older patients with normally high blood pressure may experience organ dysfunction even with moderate drops in pressure. Therefore, a comprehensive assessment of shock must consider more than just blood pressure readings.
The Importance of Cardiac Output and Oxygen Delivery
A significant portion of the interview focused on the role of cardiac output and oxygen delivery. The body's oxygen needs vary based on physiological stressors such as physical activity or trauma. In trauma situations, patients often face substantial physiological stress, akin to "running for the bus," which increases their oxygen requirements. However, emergency assessments frequently emphasize visible signs like pulse and blood pressure, neglecting the more critical issue of oxygen delivery.
The traditional approach, which targets a specific blood pressure (often 90 mmHg systolic) as the threshold for shock, fails to account for individual differences in physiological response. For example, hypertensive patients with a baseline blood pressure of 200 mmHg may enter shock if their pressure drops to 120 mmHg. Conversely, young and fit individuals may tolerate much lower pressures without exhibiting shock symptoms.
Practical Implications for Trauma Care
In clinical practice, especially in trauma care, these insights necessitate a broader approach to patient assessment and management. Professor Harris emphasized the need to consider the mechanism of injury and other contextual factors in addition to traditional clinical signs. Understanding the energy transfer involved in an incident, such as a motorbike accident, can provide crucial information about potential internal injuries and blood loss.
Professor Harris advocates for a comprehensive approach that includes assessing the mechanism of injury, physiological responses, and potential complications. This method helps in making informed decisions about subsequent actions, such as whether a patient should go for a CT scan or directly to surgery. One key concept he highlighted was hemostatic resuscitation. In cases of major trauma, the priority may not always be to restore normal organ perfusion immediately but to maintain sufficient blood volume and prevent further deterioration. This approach often involves the use of blood products like fresh frozen plasma (FFP) and packed red cells, guided by a massive transfusion protocol.
Challenges and Considerations in Clinical Practice
Professor Harris also discussed the challenges of strictly adhering to guidelines. While guidelines provide valuable frameworks, they may not always apply perfectly to individual patient scenarios. The Advanced Trauma Life Support (ATLS) classification of shock into stages based on blood loss and physiological parameters often does not reflect real-world patient presentations. Factors such as medications, past medical history, pain, and anxiety can significantly alter a patient's physiological response to trauma.
This discrepancy underscores the importance of clinical judgment and experience in trauma care. Professor Harris emphasized that guidelines should be seen as tools to aid decision-making rather than rigid rules. Medical professionals must adapt these guidelines to the specific circumstances of each patient, taking into account their age, comorbidities, and overall clinical picture.
The Art and Science of Medicine
The conversation concluded with a reflection on the balance between the art and science of medicine. While evidence-based guidelines are essential, the true skill lies in applying these principles to individual patients. This requires a deep understanding of human physiology, extensive clinical experience, and the ability to think critically in high-pressure situations.
Professor Harris stressed the importance of continuous learning and professional development in mastering the complexities of trauma care. The more we learn about shock and trauma, the more we understand that simplistic models are insufficient. A holistic approach, considering the entire patient and their context, is crucial for effective care.
Key Takeaways
- Redefining Shock: Shock should be viewed as inadequate oxygen delivery rather than just low blood pressure.
- Cardiac Output and Oxygen Delivery: These are critical components of assessing shock, yet challenging to measure in real-time.
- Beyond Blood Pressure: Clinicians must consider the whole patient, including the mechanism of injury and physiological responses, rather than relying solely on blood pressure.
- Hemostatic Resuscitation: In major trauma, the focus may shift to maintaining blood volume and managing coagulopathy.
- Guidelines as Aids: While guidelines are useful, they should be adapted based on clinical judgment and the specific patient scenario.
- The Art of Medicine: The practice of medicine involves applying scientific knowledge with a nuanced understanding of each unique clinical situation.
Professor Tim Harris's insights challenge traditional approaches to shock and highlight the importance of a comprehensive, patient-centered approach in trauma care. This nuanced understanding of shock and trauma management is essential for improving patient outcomes and advancing the field of emergency medicine.
Tuesday Feb 10, 2015
Tuesday Feb 10, 2015
Rick and Kirstin delve deeper into the world of Novel Oral Anti Coagulants.
Monday Feb 02, 2015
Monday Feb 02, 2015
Saturday Jan 24, 2015
Saturday Jan 24, 2015
Revolutionizing Emergency Medical Response: An Inside Look at the GoodSAM App
Welcome to the St Emlyns blog! Today, we dive deep into an innovation that's poised to transform emergency medical care: the GoodSAM app. I had the privilege of sitting down with Mark Wilson, a consultant neurosurgeon, pre-hospital care practitioner, and the driving force behind this groundbreaking technology. Our conversation took place at the London Trauma Conference, where Mark shared insights into the motivation, development, and future of GoodSAM.
The Birth of GoodSAM: Addressing a Critical Need
Mark Wilson's journey with GoodSAM began through his work with London's Air Ambulance. During his time there, he observed a significant number of patients with head injuries experiencing periods of apnea before medical professionals could arrive. Often, these patients would suffer from hypoxic brain injuries rather than direct trauma to the brain. This observation sparked an idea: what if there was a way to reduce secondary brain injuries by ensuring that airways were kept open during the critical moments before emergency services could reach the patient?
The problem was clear—there simply weren’t enough trained individuals present at the scene of these emergencies to maintain open airways. Inspired by the thought that "you’re never more than five meters away from a spider," Mark and his team theorized that, especially in urban areas like London, you’re likely never more than a few hundred meters away from a trained medical professional.
Developing GoodSAM: From Concept to Reality
Turning this idea into a functioning application required technical expertise and collaboration. Enter Ali Gorgony, a tech developer from Imperial College, who played a crucial role in bringing GoodSAM to life. Together, they conceptualized and built the app, creating a platform that connects individuals in need of immediate medical assistance with nearby responders.
GoodSAM features two primary versions: the Alert app and the Responder app. The Alert app is designed for the general public, while the Responder app is for medical professionals such as doctors, nurses, and paramedics. Once a responder downloads and registers on the app, they are ready to assist in emergencies. The app uses advanced technology to triangulate the responder's location via beacons rather than GPS, ensuring minimal battery drain.
How GoodSAM Works: Saving Lives One Alert at a Time
When someone in distress uses the Alert app, it automatically dials 999 (or the local emergency number in other countries) and simultaneously notifies the three nearest responders. The responder’s phone emits a distinct siren sound, alerting them to the emergency. If they are available to help, they can quickly respond; if not, the next closest responder is notified. This system ensures that someone capable of providing immediate assistance, such as maintaining an open airway or performing CPR, can reach the patient as quickly as possible.
A standout feature of GoodSAM is its defibrillator registry, which currently includes over 12,000 defibrillators. Users can upload pictures of fixed defibrillators in public places, adding to a comprehensive map that responders can access during emergencies.
Ensuring Safety and Reliability: Governance and Verification
The integrity of GoodSAM's responder network is paramount. To ensure that only qualified individuals are registered, responders must upload identification and, if applicable, their GMC number. This information is verified before they are approved to respond to alerts. Additionally, institutions like London’s Air Ambulance and various ambulance services in the UK and Australia can register, allowing their staff to be verified under the institution’s approval.
GoodSAM's governance model is designed to maintain high standards and trust within the community. By verifying the identities and qualifications of responders, the app mitigates the risk of unqualified individuals responding to emergencies.
The Bigger Picture: Integrating with Emergency Services
Mark envisions a future where GoodSAM is fully integrated with emergency services' computer-aided dispatch (CAD) systems. This integration would enable automatic alerts to responders based on 999 calls, even if the GoodSAM Alert app hasn’t been used. This seamless connectivity would ensure even faster response times and potentially save more lives.
Addressing Legal Concerns: The Good Samaritan Act
One of the key concerns for medical professionals considering using the GoodSAM app is indemnity. Mark emphasizes that responding through GoodSAM is akin to performing a Good Samaritan Act. The UK does not currently have a formal Good Samaritan law, unlike parts of the US and Australia, but such legislation is expected to be introduced soon. This law will further protect responders, making it even more challenging for legal action to be taken against them for providing assistance in emergencies.
Sustainability and Social Enterprise: A Model for Good
GoodSAM operates as a not-for-profit social enterprise. Everything discussed so far is free for users—alerting, responding, and usage by ambulance services. The only potential costs arise from integrating with CAD systems, which require development on the part of ambulance services. The altruistic nature of GoodSAM ensures that its primary goal remains to save lives and improve emergency response times.
Spreading the Word: How You Can Help
Mark's call to action is clear: the more people who download and use the GoodSAM app, the greater its impact. He encourages everyone, medical professionals and laypersons alike, to download their respective versions of the app. For responders, having the app on their phone means they can provide critical assistance during emergencies. For the general public, the Alert app can quickly connect them to nearby help, potentially saving lives.
Conclusion: A Community Effort for Better Emergency Care
The development and success of GoodSAM are a testament to the power of community and collaboration. From Mark Wilson's initial observations and ideas to the technical expertise of developers and the support of medical institutions, GoodSAM represents a collective effort to improve emergency medical care. By leveraging technology and crowdsourcing, this innovative app has the potential to make a significant difference in response times and patient outcomes.
If you're inspired by the story of GoodSAM, I urge you to download the app, encourage your friends and family to do the same, and become part of a community dedicated to saving lives. Only good can come from this—literally.
Sunday Jan 18, 2015
Sunday Jan 18, 2015
Rick Body and Kerstin de Wit discuss the role of NOACs in clinical management. Part 1 addresses the basics, stuff you should know if you are prescribing these drugs.
Part 1 tells us the good stuff, don't forget to listen to 2 and 3 in the next few weeks as not everything is perfect ;-)
Check out the BLOG POST HERE
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Wednesday Jan 14, 2015
Wednesday Jan 14, 2015
Managing Early Pregnancy Problems in the Emergency Department
Welcome to the St. Emelene's induction podcast. I'm Iain Beardsell, and I'm Natalie May. Today, we're discussing the management of early pregnancy problems in female patients presenting to the emergency department (ED). Some of you may rarely encounter these cases, while others may see them frequently. This podcast aims to provide a detailed guide on how to manage these patients effectively, optimizing our approach for better patient outcomes.
Understanding Early Pregnancy Problems
Early pregnancy problems can range from minor concerns to life-threatening emergencies. As emergency physicians, our primary goal is to identify and manage the worst-case scenarios promptly. In this post, we'll cover the following topics:
- Worst-case scenarios and initial steps
- History and physical examination
- Risk factors for ectopic pregnancy
- Diagnostic testing: urine vs. serum HCG
- Per vaginal (PV) examination: when to perform
- Management of threatened miscarriage
- Patient communication and support
Worst-case Scenarios and Initial Steps
In emergency medicine, we often think about the worst-case scenarios first. For early pregnancy problems, the most critical concern is an ectopic pregnancy. Ectopic pregnancies occur in about 1 in 100 pregnancies in the UK and can be life-threatening if not identified and treated promptly.
Initial Steps
When a young female patient presents with lower abdominal pain or spotting and is potentially pregnant, our first steps should include:
- Confirming pregnancy status: Use a urine pregnancy test initially.
- Assessing vital signs: Look for signs of hemodynamic instability, such as hypotension or tachycardia, which could indicate a ruptured ectopic pregnancy.
- Taking a detailed history: Understand the patient's symptoms, last menstrual period, and any previous gynecological issues.
History and Physical Examination
A thorough history and physical examination are crucial in managing early pregnancy problems. Here's what you need to focus on:
History
- Last Menstrual Period (LMP): Helps estimate the gestational age.
- Symptoms: Type and location of pain, nature of bleeding, and presence of other symptoms like dizziness or shoulder pain.
- Previous Pregnancies: Gravida (number of pregnancies) and Para (number of completed pregnancies).
- Risk Factors: Previous ectopic pregnancy, pelvic inflammatory disease, and any surgeries or procedures involving the reproductive organs.
Physical Examination
- Abdominal Examination: Look for tenderness, guarding, or rebound tenderness.
- Vital Signs: Monitor for signs of shock or hemodynamic instability.
- Pelvic Examination: In specific cases, to assess for cervical motion tenderness, adnexal tenderness, or masses.
Risk Factors for Ectopic Pregnancy
Understanding the risk factors for ectopic pregnancy can help identify patients who need urgent evaluation. Risk factors include:
- History of pelvic inflammatory disease (PID)
- Previous pelvic or abdominal surgery
- Use of intrauterine devices (IUDs)
- Previous ectopic pregnancy
- Assisted reproductive techniques like IVF
- Anatomical abnormalities of the fallopian tubes or uterus
- Endometriosis
- Use of the progesterone-only pill
Diagnostic Testing: Urine vs. Serum HCG
Determining the pregnancy status and ruling out ectopic pregnancy requires accurate diagnostic testing. Here's a comparison between urine and serum HCG tests:
Urine HCG Test
- Sensitivity: About 96%, particularly when HCG levels are above 100.
- Specificity: High, meaning a positive result is reliable.
- Limitations: May give false negatives if HCG levels are very low, as seen in some ectopic pregnancies.
Serum HCG Test
- Sensitivity and Specificity: Both close to 100%, making it the preferred test for confirming pregnancy and assessing HCG levels.
- Usage: Particularly useful when urine tests are negative but clinical suspicion remains high.
When to Perform a Per Vaginal (PV) Examination
The necessity of PV examinations in the ED can be debated. However, they are essential in specific situations:
- Retained Foreign Bodies: Such as condoms or tampons.
- Significant Vaginal Bleeding: Particularly in cases of suspected cervical shock due to retained products of conception.
For other scenarios, PV examinations are best left to gynecology specialists who have the expertise and appropriate setting to perform these exams with the required sensitivity and specificity.
Management of Threatened Miscarriage
A threatened miscarriage involves vaginal bleeding in a pregnancy less than 24 weeks, with a closed cervical os. It is a common issue that can cause significant anxiety for patients. Here's how to manage these cases:
Terminology
- Threatened Miscarriage: Vaginal bleeding with a closed cervical os.
- Inevitable Miscarriage: Open cervical os, indicating that miscarriage is likely to proceed.
- Complete Miscarriage: All products of conception have passed.
- Incomplete Miscarriage: Some products remain, requiring further management.
Approach
- Assess Bleeding: Light bleeding can often be managed on an outpatient basis. Heavy bleeding requires immediate gynecological consultation.
- Provide Reassurance: Explain that early pregnancy bleeding is common and not necessarily indicative of a miscarriage.
- Pain Management: Offer analgesia, such as paracetamol or cocodamol, to manage discomfort.
- Follow-up: Arrange for follow-up with an early pregnancy assessment unit (EPAU) within 48 hours.
Patient Communication and Support
Dealing with early pregnancy problems can be distressing for patients. Effective communication and support are crucial.
Tips for Communication
- Be Empathetic: Understand that this might be a significant and emotionally charged situation for the patient.
- Explain Clearly: Provide information about what is happening and what the next steps are.
- Avoid Definitive Statements: Unless certain, avoid saying that the patient has definitely miscarried.
- Offer Reassurance: Reiterate that early pregnancy complications are common and often not due to anything the patient did wrong.
Psychological Support
- Acknowledge Emotions: Recognize the patient's feelings and provide support.
- Encourage Support Systems: Suggest involving family or friends for emotional support.
- Professional Help: Refer to counseling services if needed.
Conclusion
Managing early pregnancy problems in the ED requires a systematic approach, starting with identifying worst-case scenarios and performing appropriate diagnostic tests. Understanding the risk factors for ectopic pregnancy and knowing when to perform a PV examination are crucial. Providing compassionate care and clear communication can help support patients through what can be a distressing time.
By optimizing our approach, we can ensure better outcomes for our patients and provide the best possible care in these challenging situations. Always consult senior colleagues when in doubt and follow local guidelines to ensure consistency and quality of care.
Tuesday Jan 06, 2015
Tuesday Jan 06, 2015
Understanding Impact Brain Apnea: A Revolutionary Insight into Trauma Care
Today, we delve into a fascinating and crucial topic in trauma care: impact brain apnoea. We recently had the privilege of attending the London Trauma Conference and caught up with Dr. Gareth Davis, a leading figure in trauma care and pre-hospital emergency medicine in the UK. Dr. Davis shared his insights into impact brain apnoea, a phenomenon that, while not widely recognized, has significant implications for patient outcomes.
The Unseen Danger: What is Impact Brain Apnoea?
Impact brain apnoea refers to a sudden cessation of breathing due to a blow to the head. This phenomenon, although not commonly discussed, has been a subject of intrigue for trauma professionals for many years. Dr. Davis explained that this condition occurs when an impact to the brain stem interrupts normal breathing, potentially leading to severe consequences if not promptly addressed.
This condition's significance lies in its subtlety and the challenges it poses in pre-hospital care. Many trauma incidents involve high-impact forces, such as car accidents, where a patient may suffer head injuries. Understanding the mechanics behind impact brain apnea can be the key to differentiating between minor and severe trauma cases, potentially saving lives.
The Historical Context and Research Challenges
The concept of impact brain apnoea isn't new, but it has been challenging to prove and widely accept due to a lack of concrete evidence. Gareth emphasized that the inconsistency in patient outcomes—where one individual might suffer severe consequences while another escapes with minor injuries—sparked curiosity among trauma specialists. Over time, through a combination of clinical observations and literature reviews, the medical community has started to piece together a more comprehensive understanding of this condition.
A significant barrier in researching impact brain apnoea is the timing of medical intervention. Most pre-hospital care teams arrive at the scene minutes after an incident, often too late to observe the initial apnea phase. This delay makes it challenging to gather real-time data, leaving a gap in understanding the immediate physiological responses post-trauma.
Physiological Mechanisms: The Dual Threat
Dr. Davis highlighted two critical physiological responses following a head injury that contributes to the complexity of treating impact brain apnea: the immediate cessation of breathing and a subsequent catecholamine surge.
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Apnea and Hypoxia: The primary response is an apnea caused by the impact on the medulla oblongata, the brain's breathing control centre. This apnea leads to hypoxia (low oxygen levels) and hypercarbia (increased carbon dioxide levels), which can quickly deteriorate the patient's condition.
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Catecholamine Surge: Following the initial apnea, the body releases a significant amount of catecholamines—hormones like adrenaline—that flood the system. This response, while a natural reaction to stress, can be detrimental, especially when the heart is already struggling due to hypoxia. The combination of these factors can lead to traumatic cardiac arrest, a situation where the heart fails due to trauma-induced physiological stress rather than direct injury.
Understanding these mechanisms is crucial for emergency responders. Recognizing the signs of impact brain apnea and addressing them promptly can be the difference between life and death.
The Clinical Conundrum: Diagnosing and Treating Impact Brain Apnea
One of the most challenging aspects of dealing with impact brain apnea is the clinical presentation. Patients may not exhibit obvious signs of severe trauma, such as external bleeding or visible injuries, making it difficult to diagnose based solely on physical examination. Gareth discussed the importance of thorough history-taking and observing indirect signs—akin to observing the "echo" of a particle, like in the Higgs boson analogy.
The lack of direct evidence means clinicians often rely on a combination of observational data, patient history, and situational awareness. For example, if a patient presents with persistent hypotension without a clear source of bleeding, clinicians might consider central shock—a term used to describe shock due to central nervous system dysfunction rather than volume loss.
The Role of Public Education and Pre-Hospital Care
Gareth emphasized the crucial role of public education and pre-hospital care in managing impact brain apnoea. The public's ability to provide immediate aid, such as opening an airway and administering ventilatory support, can significantly affect outcomes. He pointed out that while there is a global trend to focus on chest compressions in cases of cardiac arrest, for patients with traumatic injuries, addressing airway and breathing is paramount.
In London, initiatives like the GoodSAM app are helping bridge the gap by connecting trained responders with emergencies in real-time. This app allows people with medical training to provide critical first aid before professional services arrive, potentially mitigating the effects of impact brain apnea by ensuring the patient's airway is open and they are breathing adequately.
Navigating the Future: Research and Education
The conversation with Dr. Davis also highlighted the future directions for research and education. The medical community needs to invest more in understanding and validating the concept of impact brain apnea. This investment includes funding for clinical studies and fostering an environment where healthcare professionals can share their observations and experiences.
Podcasts, blogs, and medical conferences are valuable platforms for disseminating information about new medical phenomena like impact brain apnea. Dr. Davis encouraged medical professionals to remain curious, continue their education, and be open to emerging concepts that may not yet have robust evidence but have practical significance in clinical settings.
Key Takeaways and Clinical Pearls
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Recognition and Belief: Clinicians need to recognize and believe in the concept of impact brain apnea. Even if direct evidence is scarce, understanding the physiological mechanisms and potential clinical presentations can guide effective treatment.
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Focus on Airway and Breathing: In cases of traumatic injury, especially with suspected head trauma, the immediate focus should be on ensuring the airway is clear and the patient is breathing. This intervention can prevent the cascade of negative physiological responses that lead to traumatic cardiac arrest.
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Role of Bystanders and First Responders: Public education and the involvement of trained responders are critical. Tools like the GoodSAM app can play a significant role in ensuring timely intervention.
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Continuous Learning and Adaptation: The medical field must remain adaptive, incorporating new research findings and adjusting treatment protocols as more is understood about conditions like impact brain apnea.
Conclusion
Impact brain apnoea is a critical yet under-recognized phenomenon in trauma care. Through continued research, education, and public awareness, we can improve patient outcomes and provide better care in pre-hospital and clinical settings.
Tuesday Dec 23, 2014
Tuesday Dec 23, 2014
Year in Review: Highlights in Emergency Medicine and Critical Care
As we close out the year, St Emlyn's takes a moment to reflect on the significant events and advancements in the field of emergency medicine, critical care, and FOAMed (Free Open Access Medical Education). The past year has seen remarkable progress in research, education, and community engagement, with key studies reshaping our understanding and practices. Here's a look back at the highlights and what we can look forward to in the coming year.
Key Research and Trials
This year has been notable for the publication of several high-impact studies in emergency medicine and critical care. While some findings may have appeared negative at first glance, they have ultimately underscored the strengths of current practices. For example, trials on mechanical CPR devices, such as the Lucas device, showed no significant improvement in outcomes for out-of-hospital cardiac arrest patients. Similarly, research on starch solutions in sepsis concluded that these substances could be harmful, advocating for their discontinuation despite continued use in some clinical settings.
The ARISE and ProCESS trials were particularly influential, examining the effectiveness of early goal-directed therapy in sepsis management. Although these studies did not demonstrate a significant advantage over standard care, they highlighted the high quality of usual treatment protocols, which have improved considerably over the past decade. The ANZICS trial also reported a significant decrease in sepsis mortality, further emphasizing the advancements in patient care.
Additionally, the Targeted Temperature Management trial found no difference in outcomes between maintaining post-cardiac arrest patients at 33°C versus 36°C. This finding suggests that more aggressive temperature control may not be necessary, streamlining care protocols.
The Role of FOAMed
The FOAMed movement has revolutionized access to medical education, allowing healthcare professionals to stay updated with the latest research and discussions. Within hours of publication, new studies are analyzed and debated on various platforms, enhancing knowledge dissemination and critical appraisal.
St Emlyn's, along with other prominent FOAMed resources like Life in the Fast Lane, has played a crucial role in this educational revolution. The emergence of new platforms, such as The Bottom Line, has provided additional avenues for high-quality content. The Bottom Line, in particular, offers concise, critical appraisals of literature from a British perspective, catering to a broad audience interested in emergency medicine and critical care.
Noteworthy Blogs and Podcasts
The past year has seen an increase in the quality and quantity of blogs and podcasts in the FOAMed community. Established sites like Resus.Me, EM Lyceum, and the SGM continue to provide valuable insights, while newer entries such as Broom Docs have brought fresh perspectives. Broom Docs, led by Casey Parker, is particularly noted for its thoughtful discussions on diagnostic tests and clinical judgment.
Podcasts have also become an essential part of the FOAMed landscape. St Emlyn's own podcast has grown significantly, offering interviews with experts and discussions on a wide range of topics. Other notable podcasts include Foamcast, which presents a polished and well-structured approach to emergency medicine education, and the Rage podcast, known for its informal yet informative style.
Conferences and the Evolution of Medical Education
Conferences remain a cornerstone of professional development in emergency medicine and critical care. This year, St Emlyn's team members attended several notable conferences, including the EMS Gathering in Ireland, which featured innovative learning approaches like the "Puss Bus" for sepsis education and Pecha Kucha-style presentations. These events provided valuable opportunities for networking, knowledge exchange, and exploring new educational formats.
A significant trend in conferences is the shift towards "Medutainment," which blends medical education with entertainment. This approach, inspired by platforms like TED Talks, emphasizes engaging and visually appealing presentations over traditional lecture formats. The move towards more dynamic and interactive sessions reflects the growing demand for high-quality, engaging content in medical education.
Looking Forward to 2015
The upcoming year promises to be equally exciting for emergency medicine and critical care. The SMACC Chicago conference in June is highly anticipated, featuring a lineup of world-class speakers and sessions. Additionally, the College of Emergency Medicine's conference in Manchester is expected to be a major event, with an impressive list of speakers and topics.
At St Emlyn's, we plan to continue expanding our content offerings. Our goal is to provide comprehensive coverage of key presenting complaints in the College of Emergency Medicine curriculum through our blog and podcast. We aim to deliver high-quality educational resources that not only inform but also inspire and engage our audience.
Acknowledgements
We would like to extend our heartfelt thanks to everyone who has supported St Emlyn's and the broader FOAMed community. Special thanks go to Mike Cadogan, whose behind-the-scenes work has been instrumental in maintaining many FOAMed platforms. We also appreciate the contributions of our guest writers and the entire Life in the Fast Lane team for their invaluable support.
Conclusion
The past year has been marked by significant advancements and enriching experiences in emergency medicine and critical care. The growth of FOAMed has democratized access to knowledge, allowing healthcare professionals to stay current with the latest research and best practices. As we look forward to 2015, we are excited about the opportunities for further growth and learning. We remain committed to providing high-quality, accessible education and fostering a supportive, informed community.
We wish all our readers and listeners a happy and healthy holiday season. Whether you're spending time with family or working through the festive period, we hope you find joy and fulfillment in your work and life. Thank you for being part of our journey, and we look forward to another year of learning and growth together.
Thursday Dec 11, 2014
Wednesday Dec 10, 2014
Wednesday Dec 10, 2014
London Trauma Conference Day 2: Comprehensive Summary
Welcome back to the St. Emlyn’s blog. I'm Iain Beardsell, joined by Natalie May, here to recap the second day of the London Trauma Conference at the Royal Geographical Society in Kensington. The day was filled with insightful talks and valuable teaching points, which we’re eager to share with you.
Elderly Trauma: Addressing Under-Triage
The day began with Marius Reigns focusing on the challenges of elderly trauma. Reigns highlighted the growing number of elderly patients in emergency departments and the critical issue of under-triage. Studies indicate that almost 50% of elderly trauma cases are under-triaged, compared to about 20% in younger patients. This leads to missed opportunities to reduce morbidity and mortality. Reigns emphasized the need to recognize the unique factors in elderly trauma, including multiple medical conditions, medication use, and systemic disadvantages in trauma management.
Pediatric Trauma: A Unique Approach
Ross Fischer, a favorite at St. Emlyn’s, delivered an outstanding presentation on pediatric trauma. He stressed the importance of not managing pediatric trauma with the same principles as adult trauma. Children have different injury mechanisms and often require different management strategies. For example, splenic injuries in children are less likely to need surgical intervention compared to adults. Fischer called for more research in pediatric trauma, emphasizing the rarity of these cases and the need for collaborative efforts to determine best practices. He also highlighted the importance of simulation in maintaining skills, noting that emergency physicians might only see one or two cases of pediatric trauma annually.
Obstetric Trauma: Critical Four-Minute Window
Tim Draikot followed with a humorous yet insightful talk on obstetric trauma. He reiterated the critical four-minute window for resuscitation in traumatic maternal cardiac arrest, after which a paramortum C-section should be performed. Draikot emphasized that this procedure is vital for the survival of both mother and child. He stressed the importance of this cognitive protocol—looking at the clock and acting decisively. Draikot’s engaging style made this crucial message resonate, reminding us that swift action can save lives.
Coaching Principles in Emergency Medicine
Tom Evans, a pre-hospital physician and rowing coach, shared fascinating insights on applying coaching principles to emergency medicine. He discussed the importance of clear mental models, focused teamwork, and having a defined endpoint. Evans drew parallels between coaching an elite athlete and managing a trauma team, emphasizing the need to strive for excellence. He posed the thought-provoking question: "What is our Olympics?" Evans’ talk encouraged us to find our own goals and work towards giving 100% in our practice.
The Future of ATLS: Evolving Beyond the Basics
Matt Walsh challenged the current status of Advanced Trauma Life Support (ATLS) in his talk. He argued that ATLS should now be considered a basic rather than an advanced course. Walsh proposed the idea of creating local trauma courses tailored to specific systems and teams, incorporating the latest evidence from conferences and social media. This approach aims to improve patient care by adapting training to local needs and continuously updating it with current best practices.
Afternoon Highlights: Forensic Pathology and Quick Hits
The afternoon session featured the Peter Baskett Memorial Lecture by forensic pathologist Stephen Lead-Beater. Lead-Beater provided a unique perspective on trauma through post-mortem examinations, offering insights that can inform and improve clinical practice. His lecture was both enjoyable and enlightening, adding a valuable dimension to the conference.
In the quick hits session, several key points were discussed:
- Cooling in Isolated Head Injuries: Currently, there's insufficient evidence to support this practice, but further research is anticipated.
- Calcium in Shocked Trauma Patients: It's advisable to consider calcium administration in hypovolemic patients, particularly those with calcium levels below 0.9 mmol/L. For massive transfusion protocols, administering 10 ml of 10% calcium chloride for every four units of blood is recommended.
- IO Access: While intraosseous (IO) access remains a vital option, especially for rapid sequence intubation (RSI), it's not the ultimate solution. The debate continues on whether IO can effectively deliver blood due to potential hemolysis issues.
- FAST Scanning: The role of FAST (Focused Assessment with Sonography for Trauma) scanning in stable patients is diminishing. Operator dependence and declining performance outside research centers are concerns. However, ultrasound's evolving role in assessing general shock remains significant.
- Social Media in Trauma Care: Connor Deasy highlighted the importance of social media in trauma care, with St. Emlyn’s receiving notable mentions for its contributions.
Conclusion and Looking Ahead
The second day of the London Trauma Conference has been immensely rewarding, offering a wealth of knowledge and practical insights. From the challenges of elderly and pediatric trauma to the critical timelines in obstetric emergencies, the talks have reinforced the need for continuous learning and adaptation in emergency medicine.
As we look forward to day three, focusing on air ambulance work and pre-hospital care, we hope you’ve found these recaps useful. Follow the discussions on Twitter for real-time updates and join us again tomorrow for more highlights.
Thank you for reading, and stay tuned for our next update from the London Trauma Conference. Take care and keep striving for excellence in your practice.
Tuesday Dec 09, 2014
Tuesday Dec 09, 2014
London Trauma Conference 2024: Day One Highlights
Welcome to the St Emlyn's blog! I'm Iain Beardsell, and I'm Natalie May. We’re excited to share insights from the London Trauma Conference 2024, held in the glamorous heart of Kensington, London. This year’s conference has brought together national and international experts, offering a wealth of knowledge on trauma care. Here, we’ll take you through some of the key highlights from day one, hoping to give you a feel for the event and perhaps persuade you to join us for the remaining days.
Karen Bray’s Dynamic Talk on Trauma Dissection
One of the standout sessions was Karen Bray's talk on trauma dissection. Her dynamic presentation, complemented by stunning slides, provided numerous take-home messages. For those following us on Twitter, you might have seen some key points and visuals already.
Karen’s discussion was particularly poignant given the recent tragic events in Australia involving Phil Hughes. Her ability to weave current events into her presentation added a layer of immediacy and relevance. We’ll delve deeper into her insights in a separate podcast, but suffice it to say, her talk was both enlightening and thought-provoking.
Pediatric Trauma and Research Challenges
Ian McConaughey addressed the perennial issue of pediatric trauma, emphasizing the inconsistencies in pre-hospital assessments. He pointed out the challenges due to the lower incidence of pediatric trauma compared to adults, which hampers research efforts. Ross Fisher from Sheffield built on this, discussing potential pathways to overcome these barriers in pediatric trauma research.
In line with these discussions, Ian Bailey from Southampton raised critical points about the evolution of trauma surgery in the UK. He highlighted the need to attract young doctors to general and trauma surgery, questioning why this isn’t currently a structured career path. His candid approach to addressing these “elephants in the room” was refreshing and necessary for future improvements in trauma care.
The Helmet Debate: To Mandate or Not?
One of the liveliest sessions featured a debate between Mark Wilson and Karim Brohi on the use of cycling helmets. This debate sparked significant discussion on Twitter. The crux of the debate was whether making helmets mandatory would reduce cycling participation and thereby negate the overall health benefits. Ultimately, Karim won with the argument that helmets should remain a choice rather than a mandate, but the conversation is far from over.
Impact Brain Apnea: A New Mechanism
We also had a compelling discussion with Gareth Davies on impact brain apnea—a newly recognized mechanism where a head injury can temporarily stop breathing. This simple yet critical understanding could reshape how we manage head trauma in the initial stages. Stay tuned for an upcoming podcast where we’ll explore this topic further.
Chris Moran on the Future of Trauma Care
Professor Chris Moran, a leading figure in trauma care in England, provided an insightful talk on the progress of major trauma centers over recent years. He also addressed the contentious issue of whether the focus should shift from in-hospital care to pre-hospital phases or rehabilitation. Surprisingly, he advocated for greater emphasis on rehabilitation, sparking a gut reaction among many attendees. However, upon reflection, the audience began to see the merit in his argument. Rehabilitation, though less glamorous than pre-hospital interventions, plays a crucial role in patient recovery and long-term outcomes.
Practical Insights on Chest Trauma and Rib Fractures
Doug West, a cardiothoracic surgeon from Bristol, delivered a practical talk on chest trauma, particularly the management of rib fractures. He highlighted the disparity in practices across centers, with some performing rib fixation regularly and others not at all. This variation underscores the need for standardized protocols and further research.
Tim Moll on Trauma in Motorsport
Tim Moll gave an entertaining and informative presentation on trauma in motorsport, a field with a historically high injury rate. He focused on the unique challenges of managing injuries in this sport, emphasizing the importance of understanding the specialized gear and protocols involved. This talk was enhanced by the presence of John Hinds, a veteran motorsport doctor, who added his invaluable perspective.
The Complex Relationship Between Shock and Blood Pressure
Tim Harris’s session on shock was another highlight. He challenged the traditional view that blood pressure is a direct surrogate for shock, emphasizing instead that shock is defined by inadequate oxygen delivery to tissues. This nuanced understanding is critical for trauma team leaders in managing hypotensive patients more effectively.
Looking Ahead: Day Two at the London Trauma Conference
As we wrap up day one, we’re looking forward to another full day of insightful sessions. Tomorrow’s program includes talks focused on patients requiring special consideration—such as the elderly, pediatric trauma cases, and trauma during pregnancy. These sessions promise to provide valuable knowledge for tailoring trauma care to these vulnerable populations.
Additionally, there will be master classes and breakaway sessions on remote critical care and core topics in trauma, as well as a full day dedicated to motorsport medicine. If you’re in the area, it’s not too late to join us. Turn up at the door, and you might find a space available.
Engage with Us
We’re the slightly tired but enthusiastic team running around Kensington, usually attached to our mobile phones or computers. If you see us, please say hello! We’d love to meet our listeners and readers. If you have any questions for the speakers, reach out to us, and we’ll try to include them in a special follow-up podcast.
From the beautiful, Christmassy setting of Kensington, the St Emlyn’s team at the London Trauma Conference wishes you a good evening. We’ll be back with more updates tomorrow. Thank you for listening and following along.
Wednesday Dec 03, 2014
Wednesday Dec 03, 2014
Exciting Collaboration Between St Emlyns and the London Trauma Conference
Welcome to the latest St Emlyns podcast! I'm Iain Beardsell, and alongside Natalie Mace, we are thrilled to announce an exciting new collaboration between the St Emlyns team and the London Trauma Conference. This esteemed conference will take place in London next week, and we've been honored with the opportunity to attend as members of the press. We will be interviewing some of the prominent speakers participating in the event, marking a significant first for our team at St Emlyns.
The London Trauma Conference: Dates and Highlights
The London Trauma Conference is scheduled from Tuesday, December 9th to Thursday, December 11th. This three-day event promises a stellar lineup of speakers from the Trauma World, including sessions on Trauma Surgery, Trauma Nursing, and a dedicated day for trainees. There’s even a special Thoracotomy day planned. This comprehensive program ensures there’s something for everyone in the field of trauma care.
Why Attend the London Trauma Conference?
We are not just attending to listen; our goal is to bring you the inside stories and insights from the speakers after their sessions. We aim to ask the questions you want answers to, making this conference more interactive and engaging for all of us. Whether you are a seasoned professional or a trainee, this conference offers invaluable knowledge and networking opportunities.
If you’re considering attending, we highly encourage it. You can find all the details and register at www.londontraumaconference.com. There are still places available, so don’t miss out on this exceptional event.
Engaging with the Conference Online
For those who can't make it to London, there are still plenty of ways to stay involved. Follow along on Twitter using the hashtag #ltc2014. We will be tweeting live updates from the sessions, and you can tweet your questions to us. We’ll do our best to catch up with the speakers and get your questions answered.
Getting Ready for Trauma Week
To get in the mood for the upcoming trauma week, we recommend listening to "The Fight for Life," a program by Kevin Fong on BBC Radio 4. This enlightening show traces the origins of trauma care and brings it up to the modern day. Kevin speaks with James K. Steiner, the American orthopedic surgeon who designed the ATLS course after his family was involved in a tragic air accident. The program is both moving and inspiring, highlighting the importance of coordinated trauma care.
Meet the Speakers: Friends of St Emlyns
We are excited to reconnect with many friends of St Emlyns at the conference. Among the notable speakers are Mark Wilson, a renowned neurosurgeon from London, and Karen Brodie, a respected vascular and trauma surgeon. Ross Fisher, a pediatric surgeon from Sheffield, will be discussing pediatric trauma. Additionally, our colleagues from Sydney Hems, including Cliff Reed and Brian Burns, will also be presenting. The lineup reads like a who's who of UK and international trauma medicine, ensuring a wealth of knowledge and experience will be shared.
Our Mission at St Emlyns
At St Emlyns, we are dedicated to spreading trauma care education as widely as possible. None of our team members have any financial interest in the conference; our goal is purely educational. We hope to learn and share valuable insights with you, our community, to enhance our collective understanding and capabilities in trauma care.
Welcoming New Doctors to Emergency Medicine
This week is particularly special as it marks the arrival of new doctors in our emergency departments across the UK. This transition happens four or five times a year, bringing fresh faces, enthusiasm, and, understandably, a bit of nervousness. We urge everyone to extend kindness and support to these junior doctors. Our emergency departments thrive on a culture of learning and collaboration, and it’s essential to make our new colleagues feel welcome and valued.
If you are one of these new doctors, make sure to check out our induction blog posts and podcasts. They are available on the St Emlyns blog at stemlynsblog.org and on our iTunes podcast feed. These resources are designed to help you navigate the initial challenges and embrace the exciting journey ahead in emergency medicine.
The Importance of Continued Learning in Emergency Medicine
As we see from the current news, it’s a challenging time for UK emergency medicine. However, at St Emlyns, we are committed to bringing you the best resources, insights, and inspiration to help you continue delivering exceptional care to your patients. Our collaboration with the London Trauma Conference is just one example of our efforts to enhance the education and support available to all healthcare professionals in our community.
Conclusion
We are incredibly excited about this new venture and look forward to sharing our experiences and learnings from the London Trauma Conference with you. Whether you join us in person or follow along online, we hope this event will be as enlightening and inspiring for you as it promises to be for us.
Thank you for being a part of the St Emlyns community. Please continue enjoying your work in emergency medicine, and we’ll be back with more updates and insights very soon. Take care and thanks for listening!
Saturday Nov 29, 2014
Saturday Nov 29, 2014
Top Five Diagnoses to Rule Out in Patients with Chest Pain
In emergency medicine, our primary objective is to rule out life-threatening conditions first. This principle guides our approach to patients with chest pain. Here are the top five diagnoses to consider:
- Acute Coronary Syndrome (ACS)
- Pulmonary Embolism (PE)
- Pneumothorax
- Pneumonia
- Aortic Dissection
These conditions can have overlapping symptoms but differ significantly in their management and prognosis. Let’s explore these further.
Acute Coronary Syndrome (ACS)
When a patient presents with chest pain, ACS is often the first concern. Key symptoms include central crushing chest pain, which may radiate to the arm or neck. While classic presentations are familiar to most, not all patients exhibit textbook symptoms. Factors like age, gender, and comorbidities can alter the clinical picture.
Initial Assessment and ECG Interpretation
Every patient with chest pain should receive an ECG as part of the initial workup. Interpreting ECGs requires a high level of expertise, as subtle changes can indicate significant pathology. In our department, only senior emergency physicians are tasked with reading initial ECGs to minimize the risk of missing critical findings. It's important to assess each ECG independently, even if previous records are available, as baseline abnormalities can obscure new, acute changes.
Troponin Testing
For patients where myocardial ischemia is suspected, a troponin test, particularly high-sensitivity troponin, is essential. This biomarker helps identify myocardial injury, even in cases where the ECG does not show definitive changes. Given the serious implications of missing an ACS diagnosis, a low threshold for testing is prudent. Approximately 10% of patients with a normal ECG may still have significant disease, highlighting the importance of comprehensive evaluation.
Pulmonary Embolism (PE)
Pulmonary embolism is another critical condition to consider, especially in patients presenting with pleuritic chest pain, shortness of breath, or risk factors such as recent immobilization, malignancy, or surgery. The clinical presentation of PE can vary, complicating diagnosis.
Clinical Decision Tools
The Wells score and PERC (Pulmonary Embolism Rule-out Criteria) are valuable tools in assessing the likelihood of PE. For low-risk patients, D-dimer testing can be used to rule out the condition, reducing the need for further imaging. However, for patients deemed at higher risk, CT pulmonary angiography (CTPA) is the gold standard for diagnosis. The decision to pursue imaging should be guided by clinical judgment and, where necessary, discussed with senior colleagues to avoid unnecessary radiation exposure and follow-up testing.
Pneumothorax
Pneumothorax should be considered in both young, otherwise healthy individuals and older patients with underlying lung disease. The hallmark symptom is sudden onset pleuritic chest pain, often accompanied by shortness of breath.
Diagnostic Approach
A chest x-ray is typically sufficient to diagnose pneumothorax. Given the low radiation dose and high diagnostic yield, x-rays should be performed for most patients with suspected pneumothorax. The imaging will not only confirm the presence of air in the pleural space but also help assess the severity and guide management decisions.
Pneumonia
Pneumonia is a common cause of chest pain, often accompanied by fever, cough, and sputum production. It is more common in patients with a history of respiratory disease or immunosuppression.
Identifying Pneumonia
A chest x-ray remains the cornerstone of pneumonia diagnosis. Clinical symptoms, such as productive cough and fever, along with imaging findings of consolidation, help differentiate pneumonia from other causes of chest pain. While not immediately life-threatening in most cases, timely recognition and treatment are crucial to prevent complications.
Aortic Dissection
Aortic dissection is a less common but highly dangerous cause of chest pain. Classic symptoms include severe, tearing pain radiating to the back. It is critical to maintain a high index of suspicion for aortic dissection, especially in patients with risk factors such as hypertension, connective tissue disorders, or a family history of the condition.
Confirmatory Testing
The definitive diagnostic test for aortic dissection is a CTA aortogram. While a chest x-ray can sometimes reveal mediastinal widening, it is not sufficiently sensitive to rule out dissection. Early consultation with cardiothoracic surgery and rapid imaging are key to managing suspected cases.
Communicating with Patients
Once life-threatening causes have been ruled out, patients often seek answers about their symptoms. When the etiology remains unclear, it’s important to communicate transparently with the patient. Possible benign causes include musculoskeletal pain or gastroesophageal reflux disease (GERD). While it’s reassuring to exclude serious conditions, acknowledging the limitations of our diagnostic tools and advising patients to return if symptoms change is crucial.
Patient Reassurance and Follow-up
Patients should be advised to follow up with their primary care physician for further evaluation and management of non-urgent conditions. Clear communication, including documenting your diagnostic reasoning and plan, is vital for medico-legal protection and patient safety.
Conclusion: Mastering Chest Pain in the ED
Chest pain remains a complex and multifaceted challenge in the emergency department. The ability to swiftly differentiate between benign and life-threatening causes is a critical skill for emergency physicians. Our approach should be guided by a thorough history, physical examination, and appropriate use of diagnostic tools. Remember, the primary goal is to exclude serious conditions, ensuring patient safety while avoiding unnecessary investigations.
As you continue your journey in emergency medicine, refine your skills in evaluating chest pain. Be diligent in your assessments, stay updated with the latest guidelines, and always communicate clearly with your patients and colleagues. This comprehensive approach will not only improve patient outcomes but also enhance your clinical practice.
Read the blog post here
Monday Nov 24, 2014
Monday Nov 24, 2014
Managing Shortness of Breath in Pediatric Patients: A Comprehensive Guide
Welcome to the St. Emlins blog. I’m Iain Beardsell, and I’m joined by our resident pediatric expert, Natalie May. Today, we’re discussing a challenging but crucial topic for those in Emergency Medicine: managing pediatric patients with shortness of breath.
Understanding Pediatric Shortness of Breath
Shortness of breath in children is a frequent and often intimidating presentation in the emergency department, especially during winter. This guide aims to provide a systematic approach to assess and manage these young patients effectively.
Initial Assessment: Stay Calm and Structured
When managing a child with shortness of breath, it's essential to stay calm and use a structured approach:
- Level of Consciousness: Determine if the child is alert or needs immediate resuscitation.
- Breathing Effort: Look for signs of respiratory distress such as the use of accessory muscles, intercostal and subcostal recession, tracheal tug, or head bobbing in infants.
- Breathing Efficacy: Listen for extra sounds like wheezes or stridor to identify the underlying pathology.
- Oxygen Delivery: Check the child's oxygen saturation, level of consciousness, and heart rate to evaluate breathing effectiveness.
Oxygen Administration: A Safe First Step
Administering oxygen is a safe and effective initial treatment for children with shortness of breath. It is unlikely to cause harm and can be crucial for stabilizing the patient while further assessments are made.
Detailed History and Physical Examination
Gathering a detailed history from the parents is essential:
- Chronology of Events: Determine how long the child has been short of breath.
- Pre-existing Conditions: Ask about any previous lung problems.
- Additional Symptoms: Note any associated symptoms like fever or cough.
- Inhaled Foreign Body: Consider this, especially if the onset of symptoms was sudden.
This information helps in deciding the appropriate therapy and whether the child needs hospital admission.
Common Causes of Pediatric Shortness of Breath
1. Bronchiolitis and Viral Wheeze
Bronchiolitis is a common winter illness in children under two, often caused by respiratory syncytial virus (RSV). Key signs include:
- Respiratory distress with significant use of accessory muscles.
- Wheezing and low oxygen saturation.
- History of recent cold symptoms in the family.
Viral Wheeze often presents similarly but occurs in slightly older children. Differentiating between bronchiolitis and viral wheeze involves assessing the severity and duration of symptoms.
Management:
- Oxygen: Provide supplemental oxygen if saturation levels are low.
- Bronchodilators: Trial with salbutamol through a spacer or nebulizer can be beneficial.
- Steroids: Generally avoided in children under five unless there is a formal asthma diagnosis or previous steroid-responsive episodes.
Admission Criteria:
- Severe respiratory distress.
- Persistent low oxygen saturation.
- Poor feeding and hydration status.
- History of prematurity or chronic lung disease.
2. Croup
Croup is another common viral illness presenting with a characteristic seal-like barky cough and inspiratory stridor. It often worsens at night, causing significant distress to both the child and the parents.
Management:
- Dexamethasone: A single oral dose (0.15-0.6 mg/kg) is effective in reducing airway inflammation and improving symptoms.
- Observation: Monitor the child for 2 hours post-treatment to ensure improvement.
- Calm Environment: Minimize distress and avoid unnecessary interventions that might exacerbate symptoms.
Safety Netting:
- Provide parents with clear instructions on when to return to the hospital, especially if symptoms worsen during the night.
3. Bacterial Infections: Pneumonia
Though less common than viral infections, bacterial pneumonia should be considered, particularly if the child presents with:
- Fever.
- Persistent cough.
- Decreased oxygen saturation.
- Subtle respiratory distress.
Management:
- Chest X-ray: Useful for diagnosis if bacterial infection is suspected.
- Antibiotics: Initiated based on clinical judgment and X-ray findings.
- Admission: Necessary for children with significant respiratory compromise or those unable to maintain adequate oxygen levels.
Special Considerations
Feeding and Hydration
Children with respiratory distress often have poor oral intake, leading to dehydration. Assess feeding history and urine output:
- Supportive Feeding: Nasogastric or intravenous fluids may be required.
- Monitor Hydration: Ensure adequate fluid intake and monitor for signs of dehydration.
Obligate Nasal Breathers
Infants are obligate nasal breathers, and nasal congestion can severely impact their breathing. Simple measures such as nasal saline drops can alleviate congestion and improve breathing.
Inhaled Foreign Bodies
Always consider the possibility of an inhaled foreign body, especially if the presentation is sudden and there is no clear viral cause. A chest X-ray or bronchoscopy may be required for diagnosis and management.
Conclusion: A Structured Approach for Success
Managing pediatric shortness of breath requires a calm, structured approach, leveraging skills from adult practice and adapting them for pediatric patients. Key steps include:
- Initial Assessment: Stay calm and systematic.
- Oxygen Administration: A safe first step.
- Detailed History and Physical Examination: Crucial for diagnosis.
- Management of Common Conditions: Bronchiolitis, viral wheeze, croup, and bacterial pneumonia.
Remember, there is always senior support available, whether from a senior emergency physician or a pediatric colleague. By staying cool and methodical, you can effectively manage these challenging cases and provide excellent care for your young patients.
Stay tuned to the St. Emlins blog for more in-depth discussions on pediatric emergencies and other critical topics in emergency medicine. Stay calm, stay curious, and keep learning.
Wednesday Nov 12, 2014
Wednesday Nov 12, 2014
The Challenge and Value of Research in Emergency Medicine: at DGINA 2014
Rick Body's talk from DGINA on the need for research in EM.
Check out the associated blog post at http://stemlynsblog.org
Friday Oct 31, 2014
Friday Oct 31, 2014
Exciting Updates from St. Emlyn's: Highlights, Conferences, and Upcoming Events
Welcome to the St. Emlyn's Podcast Recap
Greetings, St. Emlyn's community! We are delighted to bring you the latest updates and highlights from our podcast and blogosphere. Let's dive into our recent achievements, exciting conferences, and what's on the horizon for our team.
Highlights from the Past Few Months
The past few months have been phenomenal for St. Emlyn's. Our blog has seen a surge in readership, and we’ve received fantastic feedback on various posts and podcast episodes. One standout topic has been the work on high-sensitive troponin, thanks to Rick's invaluable insights. Even those of us working with troponin in our department found new learnings through the podcast.
Another high point was Natalie May's episode on button battery ingestion in children. This critical topic resonated with many of our listeners and highlighted the dangers and necessary precautions surrounding this issue. Additionally, having Alan Grayson critique NICE guidelines on heart failure provided us with fresh perspectives and sparked meaningful discussions within our virtual hospital.
Conferences and Collaborations
Our team has been active on the conference circuit, sharing knowledge and gaining new insights. The European Society of Emergency Medicine (EUSEM) conference in Amsterdam was a significant event, offering a plethora of information and networking opportunities. Natalie is even planning to produce a book and podcast to summarize the key takeaways from the conference.
Down in Exeter, the Chem conference exceeded expectations. Adam Ruben’s podcast recap provided a comprehensive overview of the event, and we had the pleasure of paddleboarding with Cliff Reed, adding a bit of fun to the professional gathering.
The Evolution of Emergency Medical Conferences
Emergency medical conferences have evolved remarkably over the past decade. The variety and depth of content offered now are impressive. Our team is already gearing up for the Chem conference in Manchester next September, and the recently released program for SMACC Chicago has everyone buzzing with excitement.
SMACC Chicago: A Preview
The SMACC conferences are renowned for their exceptional quality and dynamic content, and SMACC Chicago is no exception. The program is packed with sessions from leading experts in emergency medicine, making it challenging to choose which talks to attend. Simon Carley will be presenting alongside luminaries like Scott Weingart, Pat Cross-Kerry, Ashley Shree, and Stephen Mayer, promising a wealth of knowledge and inspiration.
The release of the SMACC Chicago program has us eagerly anticipating the event. With five streams of information, choosing which sessions to attend will be a delightful dilemma. Highlights include sessions with Karim Brohee, Paul Marik, Rick Body, and Louise Cullen. Simon is excited to be part of such an esteemed lineup, despite the stiff competition.
Workshops and Debates
Before the main conference kicks off, a series of workshops will provide hands-on learning experiences. Simon will join Scott from the Medical Evidence Blog, Ken Milne from SGEM, Rob McSweeney, Rick Body, and David Newman from Smart EM to discuss evidence-based emergency medicine. It’s an incredible opportunity to learn from and with the best in the field.
One of the anticipated sessions is the SMACC Chicago forum on Thursday afternoon, featuring debates and discussions on topics that matter deeply to the emergency medicine community. The session titled “Seeking the Truth” promises to be a highlight, with speakers like Paul Young and Simon Finfer discussing randomized controlled trials (RCTs).
Networking and Building Connections
Conferences like SMACC are not just about attending sessions—they’re about building connections and forming lasting relationships with peers and mentors. Meeting the greats of emergency medicine, such as Dave Newman, and discussing both cutting-edge topics and the human side of medicine, makes these conferences invaluable.
The Value of Investing in Education
While attending conferences can be a significant financial investment, the benefits far outweigh the costs. The opportunity to learn from leading experts, network with peers, and stay updated on the latest advancements in emergency medicine makes these events a crucial part of professional development. For those considering attending SMACC Chicago, registration opens on the 5th of November. Early registration for trainees, nurses, and paramedics offers a more affordable way to join this transformative event.
What's Next for St. Emlyn's?
Looking ahead, we have a robust lineup of podcasts and blog posts planned. Our induction series continues to provide valuable insights for new doctors entering emergency medicine departments across the UK. We’re also exploring topics like Gestalt and clinical thinking to deepen our understanding and improve patient care.
Join the Conversation: Get Involved with St. Emlyn's
We want to hear from you! Your feedback helps us tailor our content to meet your needs. Connect with us on Facebook, rate us on iTunes, and share your thoughts and ideas. We’re always looking for guest writers to contribute to our blog. If you have a topic you’re passionate about, reach out to us and join the St. Emlyn's community.
A Special Thanks
A special thanks to Sarah Payne for her timely articles on Ebola, which have been incredibly well-received. Her contributions have enriched our blog, providing vital information and sparking meaningful discussions.
Enjoy Your Emergency Medicine Journey
At St. Emlyn's, our mission is to make your emergency medicine journey more enjoyable and fulfilling. We’re committed to enhancing your professional development and patient care through engaging content and insightful discussions.
Stay tuned for more podcasts, blog posts, and exciting updates. Don’t forget to register for SMACC Chicago and join us for an unforgettable experience.
Thank you for being part of the St. Emlyn's community. Enjoy your emergency medicine journey, have fun, and go forth and heal the sick. We’ll be back soon with more exciting content and updates.
Friday Oct 31, 2014
Friday Oct 31, 2014
The Danger of Button Batteries: Essential Information for Emergency Physicians
Introduction
Hello and welcome to the St Emlyn's blog. I'm Simon Carley, and alongside me is Natalie May. This post addresses a frequent and potentially serious issue in emergency departments: the ingestion of button batteries. With Halloween and Christmas approaching, these small but hazardous objects become more prevalent in households with small children. Here, we provide critical insights for emergency physicians on identifying, managing, and preventing complications related to button battery ingestion.
Understanding Button Battery Ingestion
Button batteries, or disc batteries, are small, round batteries found in devices like watches, musical badges, and holiday decorations. Their size and shiny appearance make them attractive to children, who may ingest them or insert them into their noses or ears. While they appear harmless, button batteries can cause significant harm if they become lodged in mucosal surfaces.
The Risks of Button Battery Ingestion
When a button battery becomes wedged against a mucosal surface, it generates a small electrical current. This current can cause chemical burns and tissue damage within as little as two hours. If not promptly removed, the battery can lead to severe complications, including death.
Common Scenarios and Symptoms
Children often ingest various objects, but button batteries pose a unique risk due to their electrical properties. Here are common scenarios and symptoms to watch for:
- Ingestion: Symptoms range from mild (drooling, difficulty swallowing) to severe (vomiting, abdominal pain, gastrointestinal bleeding).
- Nasal Insertion: Batteries in the nose can cause nasal discharge, pain, and significant tissue damage if unnoticed.
- Ear Insertion: Batteries in the ear can lead to pain, discharge, and hearing loss if not promptly addressed.
Radiological Identification
Button batteries are radiopaque, making them visible on X-rays. They can be distinguished from coins by their characteristic double shoulder appearance. This feature is crucial for accurate diagnosis and timely intervention.
Management Strategies
Immediate Steps for Suspected Ingestion
- High Index of Suspicion: Be vigilant for signs of button battery ingestion, especially if parents report missing batteries from devices.
- Radiological Examination: Perform an X-ray to locate the battery and determine its position.
Removal from Ears and Noses
- ENT Referral: Button batteries in the nose or ears should be removed promptly by an ear, nose, and throat specialist. These areas are less moist than the esophagus but can still suffer chemical burns and tissue damage.
Esophageal Ingestion
- Surgical Emergency: Batteries lodged in the esophagus must be removed immediately. This task is typically handled by general surgeons or gastroenterologists. Delaying removal can lead to severe complications, including perforation, erosion into blood vessels, and catastrophic bleeding.
Post-Removal Care and Follow-Up
Even after successful removal, children must be monitored for complications. Discharge instructions should include warning signs such as gastrointestinal bleeding, severe abdominal pain, vomiting, respiratory distress, and refusal to eat. Follow-up appointments and possibly additional X-rays are essential to ensure no further damage has occurred.
Prevention Tips for Parents
Educating parents about the dangers of button batteries is crucial. Here are some tips to share with them:
- Secure Storage: Keep button batteries out of reach of children.
- Device Safety: Ensure battery compartments in devices are secure and childproof.
- Immediate Action: If a battery is missing and a child shows symptoms of ingestion, seek medical attention immediately.
Case Studies and Real-Life Examples
Case 1: Nasal Insertion
A child was brought to the emergency department with a suspected nasal insertion of a button battery. Despite a thorough examination, no battery was visible. However, an X-ray revealed a large button battery lodged in the posterior nose. Prompt referral to ENT and removal prevented further complications.
Case 2: Esophageal Lodgment
A child swallowed a button battery that became lodged in the esophagus. The battery was removed within two hours, but the child was monitored closely for weeks due to the risk of delayed complications. Despite initial removal, the child developed severe symptoms days later, highlighting the importance of vigilant post-removal care.
Conclusion
Button batteries pose a significant risk to children, particularly during festive seasons when they are more prevalent in households. Emergency physicians must maintain a high index of suspicion, utilize radiological tools effectively, and act swiftly to manage cases of ingestion or insertion. Educating parents about the dangers and prevention strategies is equally important. Stay vigilant, stay informed, and ensure the safety of our youngest patients.
Additional Resources
For more information on button battery ingestion and other pediatric emergencies, visit the St Emlyn's blog. Follow us on Facebook and join our community of emergency medicine professionals dedicated to providing the best care for our patients.
Tuesday Oct 28, 2014
Tuesday Oct 28, 2014
The Crucial Role of Accurate Coding in Emergency Medicine: Insights from St Emlyns
Welcome to the St Emlyns blog! Today, we dive into a topic often overlooked but crucial to the functioning and financial health of emergency departments (ED): coding. This subject might not have the drama of resuscitations or surgical interventions, but it significantly impacts how we are perceived and funded. In this post, we explore how coding works in the context of emergency medicine in England, why it matters, and how we can improve our practices for better outcomes.
Understanding Coding in Emergency Departments
What is Coding?
In the simplest terms, coding is the process of translating medical activities into standardized codes that determine how much a hospital gets paid for the services provided. This is done through systems like the HRG-4 (Health-Related Grouping) codes, which classify the treatments and investigations performed on patients.
Why is Coding Important?
Accurate coding is essential because it directly affects the revenue of an emergency department. The details recorded in discharge summaries play a significant role in determining the funds a hospital receives. For instance, different procedures and investigations, like CT scans or blood tests, have specific codes that contribute to the total amount of money paid to the hospital.
The Financial Implications of Coding
Top Earning Codes in Emergency Medicine
The highest amount an ED can earn for a single patient episode is £237, applicable in cases involving resuscitation, thrombolysis, or laser eye surgery. However, if no tests or treatments are performed, the hospital only earns £58 for that patient. This stark difference underscores the importance of detailed and accurate coding.
Common Investigations and Their Codes
- MRI/CT Scans: High-value procedures that significantly boost the hospital's revenue.
- Ultrasound Scans: Similarly valued to MRI/CT scans, contributing substantial amounts to the hospital's income.
- Vital Signs Recording: Even basic procedures like recording vital signs can elevate the payment from the lowest tariff.
Challenges in Implementing Accurate Coding
Perception vs. Reality
Many healthcare professionals, including doctors and nurses, often view coding as an administrative burden rather than a critical part of patient care. This perception needs to change, as the quality of coding affects not only financial outcomes but also how the department's efficiency and effectiveness are perceived by external bodies like the CCG (Clinical Commissioning Groups).
The Role of IT Systems
Modern IT systems have made the coding process more streamlined, though they are not without their challenges. Integrating coding tasks into daily routines, such as through discharge summaries and GP letters, can help ensure that all activities are recorded accurately.
Improving Coding Practices
Education and Awareness
Educating staff about the importance of coding and its impact on both departmental funding and patient care is crucial. Junior doctors and new consultants should be made aware of how their input affects the overall picture.
Dedicated Coding Staff
Some hospitals have experimented with employing dedicated coding staff who review and correct coding entries, leading to significant increases in revenue. This approach can alleviate the burden on clinicians and ensure more consistent and accurate coding.
Streamlining Processes
Integrating coding into clinical workflows can make it less of a chore. For example, requesting an X-ray through the hospital's system should automatically record it in the patient's coding data. Such improvements can simplify the process and reduce the likelihood of missed entries.
The Impact of Coding on Departmental Perception
Meeting Standards and Avoiding Fines
In England, EDs are required to meet specific standards, such as the four-hour wait time target. Failing to meet these standards can result in fines, which further strain departmental resources. Accurate coding helps present a true picture of the department's workload and efficiency, potentially mitigating some of these financial penalties.
Communicating with Commissioners
Accurate coding ensures that commissioners have a clear understanding of the services provided by the ED. Misrepresentations can lead to misconceptions about the department's performance and the appropriateness of patient attendances, affecting future funding and policy decisions.
Case Study: VB11Z Code
The VB11Z code, which indicates that no investigations or treatments were performed, often misrepresents the actual work done in the ED. For example, patients admitted under the care of other specialists but using ED resources might be incorrectly coded, leading to a loss of revenue. By addressing such coding inaccuracies, departments can better reflect their true workload and resource needs.
Practical Tips for Better Coding
Record Everything
Ensure that all procedures, tests, and treatments are recorded, no matter how minor they might seem. This includes vital signs, which can elevate the payment bracket significantly.
Integrate Coding with Patient Care
Make coding part of the routine patient care process. For example, use discharge summaries to not only inform GPs but also to ensure all activities are coded.
Leverage Technology
Utilize the full capabilities of IT systems to automate and streamline coding tasks. This can reduce the manual burden and improve accuracy.
Continuous Training
Regularly update staff on coding practices and the importance of accurate data entry. This helps maintain awareness and reduces the risk of complacency.
Conclusion
While coding might not be the most glamorous aspect of emergency medicine, it is undeniably one of the most crucial. Accurate coding not only ensures that departments are properly funded but also that they are accurately represented in terms of workload and efficiency. By integrating better coding practices into daily routines and educating staff on its importance, emergency departments can significantly improve their financial health and operational effectiveness.
For more detailed information, including specific codes and their values, visit our blog or contact us directly. Keep coding and keep improving patient care!
Thursday Oct 23, 2014
Thursday Oct 23, 2014
Rick and Iain explore how the latest guidance about the use of high sensitivity troponin was developed and how far we can be assured that it is evidence based.
The NICE guidance is available here. http://www.nice.org.uk/guidance/dg15
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Tuesday Sep 30, 2014
Tuesday Sep 23, 2014
Tuesday Sep 23, 2014
Mastering the Art of Presentation: Insights from St. Emlyns and Victoria Brasile
Welcome to the St. Emlyns blog! I'm Iain Beardsell, and today, we're diving into a recent enlightening session with the rest of the St. Emlyns team—Simon, Nat, and Rick—alongside the exceptional educator, Victoria Brasile. Victoria recently visited the UK and shared invaluable tips on delivering excellent presentations to the emergency medical community in Manchester. For those familiar with Victoria’s engaging talks at SMACC, either in person or online, you're in for a treat as we explore the key points from this memorable evening.
The Power of a Great Presentation
Victoria Brasile's visit was a golden opportunity for the emergency medicine community. Her session focused on how to deliver impactful presentations—an essential skill for any healthcare professional. Here are the core messages she shared:
- Connect with Your Audience: Establishing a strong connection with your audience is fundamental.
- Look and Sound Great: Presentation is not just about content but also about delivery.
- Keep It Simple: Simplicity ensures clarity and retention.
These principles form the bedrock of an excellent presentation, whether addressing a large lecture hall, a small group, or even a single patient.
Connecting with the Audience
Victoria emphasized the importance of making a genuine connection with your audience. She believes that regardless of the audience size, the ability to connect on a personal level is crucial. Here’s how you can achieve this:
- Engage Interactively: Encourage audience participation by asking questions or incorporating interactive elements.
- Use Relatable Stories: Share anecdotes that resonate with the audience’s experiences.
- Maintain Eye Contact: Establishing eye contact can make your audience feel involved and valued.
During the Manchester session, Victoria practiced what she preached by fostering interaction and creating an inclusive environment. Her approach demonstrated how effective communication can transform a presentation into an engaging dialogue.
The Importance of Presentation
Victoria highlighted that looking and sounding great goes beyond mere aesthetics; it’s about being confident and authentic. Here are her top tips:
- Dress Appropriately: Your attire should be professional but comfortable, ensuring you feel confident.
- Voice Modulation: Vary your tone to maintain interest and emphasize key points.
- Body Language: Use purposeful gestures to reinforce your message and avoid distracting habits.
In Manchester, Victoria’s presentation was a masterclass in these techniques. Her confident demeanor, combined with dynamic voice modulation and engaging body language, kept the audience captivated.
Simplicity is Key
The third cornerstone of a great presentation is simplicity. Victoria advised that a clear and straightforward message is more likely to be remembered and appreciated. Here’s how to keep it simple:
- Focus on Key Points: Identify and emphasize the main takeaways.
- Avoid Jargon: Use language that is easily understandable, avoiding technical terms unless necessary.
- Visual Aids: Use slides and visuals that are clear and directly related to your points.
Victoria’s own presentations are a testament to this principle. She distilled complex information into easily digestible parts, ensuring her audience could follow along and retain the key messages.
Lessons from the St. Emlyns Team
Our team also shared their reflections and learnings from Victoria’s session:
Rick Boddie: Managing Nerves
Rick found the session particularly insightful for managing presentation nerves. He realized that controlling nerves is essential not only for the speaker but also for the audience’s comfort. Rick’s takeaway included:
- Preparation and Practice: Regular practice to build confidence.
- Breathing Techniques: Simple breathing exercises to calm nerves.
- Audience Empathy: Recognizing that the audience might be just as nervous.
Natalie May: Planning for Interaction
Natalie focused on incorporating audience interaction into her presentations. She plans to use:
- Social Media and Technology: Integrating modern tools to engage the audience.
- Structured Interactivity: Planning specific moments for audience participation.
- Pacing: Slowing down her speech to ensure clarity and engagement.
Simon Carly: First Impressions
Simon highlighted the importance of making a strong first impression. His key points included:
- Immediate Engagement: Captivating the audience right from the start.
- Preparation: Ensuring thorough preparation before stepping onto the stage.
- Action-Packed Opening: Starting with a memorable and impactful opening, akin to a Bond movie.
Enhancing Audience Interactivity
Victoria’s innovative approach to audience interaction was a standout feature of her session. She shared how dedicating a few minutes for the audience to interact amongst themselves can enhance the overall experience. This strategy not only breaks the ice but also makes the audience feel more connected and engaged. During her SMACC Gold talk, Victoria’s use of theatre—changing the stage setup and creating a visually intriguing environment—demonstrated how a bit of drama can capture and hold the audience’s attention.
Conclusion: The Three Pillars of a Great Presentation
Victoria Brasile’s session at Manchester reinforced the three pillars of a great presentation: connecting with the audience, looking and sounding great, and keeping it simple. These principles are not just theoretical; they are actionable strategies that any speaker can implement to enhance their presentations. The St. Emlyns team’s reflections further underscore the importance of preparation, interaction, and first impressions.
As we continue to learn and grow in our professional journeys, let’s keep these valuable lessons in mind. Whether you’re presenting at a conference, teaching a class, or communicating with patients, these insights will help you deliver your message more effectively and confidently.
Stay tuned for more insights and tips from the St. Emlyns team. We hope you enjoyed this deep dive into the art of presentation. Until next time, embrace your emergency medicine practice with enthusiasm and excellence!
For more resources and links to Victoria Brasile’s talks, visit our blog site. If you have any questions or thoughts to share, please leave a comment below. We’d love to hear from you!
Friday Sep 12, 2014
Friday Aug 22, 2014
Friday Aug 22, 2014
Understanding Syncope: A Comprehensive Guide for Emergency Medicine
Introduction
Today, we are discussing syncope, a common yet complex condition involving a transient loss of consciousness due to a temporary reduction in blood flow to the brain. This comprehensive guide aims to provide insights into diagnosing and managing syncope in the emergency department.
The Challenge of Syncope Diagnosis
When patients present with collapse, it’s essential to differentiate between mechanical falls and syncope due to physiological reasons. The key to diagnosis lies in understanding whether the event was caused by a transient loss of consciousness or a mechanical fall. This distinction guides the diagnostic pathway and ensures the appropriate management of potential life-threatening conditions.
Physiology of Syncope
Syncope results from a temporary reduction in cerebral perfusion pressure, which can occur due to various physiological disruptions. Understanding the factors affecting cerebral perfusion, such as mean arterial pressure, cardiac output, and peripheral resistance, is crucial. Any significant deviation in these parameters can lead to syncope.
Cardiac Causes of Syncope
Rhythm Issues
Cardiac syncope often involves rhythm disturbances like bradycardia (abnormally slow heart rate) or tachycardia (abnormally fast heart rate). Bradycardia can reduce cardiac output, while tachycardia can decrease stroke volume. Identifying these rhythm issues is vital as they can be life-threatening.
Structural Issues
Structural heart diseases, such as aortic stenosis or hypertrophic cardiomyopathy, restrict blood flow, leading to syncope. Pulmonary embolism, although less common, can also cause syncope by obstructing pulmonary circulation.
Importance of ECG in Diagnosis
The electrocardiogram (ECG) is a critical tool for diagnosing cardiac causes of syncope. It helps identify arrhythmias, conduction abnormalities, and other cardiac issues. Continuous ECG monitoring, or Holter monitoring, can capture transient arrhythmias not seen on a standard ECG.
Neurological Causes of Syncope
Neurological conditions, such as seizures and transient ischemic attacks (TIAs), can present as syncope. Differentiating between these and true syncope is essential. Seizures often have specific signs like tongue biting, loss of bladder control, and post-ictal confusion. TIAs can cause temporary disruptions in blood flow to the brain, leading to syncope-like episodes.
Physiological Causes of Syncope
Vasovagal Syncope
Vasovagal syncope, triggered by stress, pain, or prolonged standing, involves a sudden drop in heart rate and blood pressure. It is a common and generally benign cause of syncope.
Orthostatic Hypotension
Orthostatic hypotension, a drop in blood pressure upon standing, can result from dehydration, medications, or autonomic dysfunction. It is a frequent cause of syncope, especially in elderly patients.
Diagnostic Approach
Patient History
A thorough patient history is crucial for identifying the cause of syncope. Key elements include the circumstances of the episode, prodromal symptoms, witness accounts, and medical history. This information helps distinguish between different causes of syncope.
Physical Examination
A comprehensive physical examination includes checking vital signs, cardiovascular examination, and neurological assessment. Identifying abnormalities during the physical exam can provide clues to the underlying cause of syncope.
Diagnostic Tests
- ECG: Identifies arrhythmias and conduction abnormalities.
- Holter Monitoring: Captures transient arrhythmias.
- Echocardiogram: Assesses structural heart diseases.
- Tilt-Table Test: Diagnoses vasovagal syncope or orthostatic hypotension.
- Blood Tests: Evaluate electrolyte levels, blood glucose, and cardiac biomarkers.
Management Strategies
Cardiac Syncope
Management of cardiac syncope focuses on stabilizing heart rhythm and function. Treatments may include pacemaker implantation for bradycardia, medications for tachycardia, and surgical interventions for structural heart diseases. Arrhythmias may require implantable cardioverter-defibrillators (ICDs).
Neurological Syncope
Managing neurological causes involves addressing the underlying condition. Antiepileptic medications control seizures, while immediate interventions restore blood flow in strokes or control bleeding. TIAs require medications and lifestyle changes to reduce recurrence risk.
Physiological Syncope
- Vasovagal Syncope: Management includes avoiding triggers, increasing fluid and salt intake, and using compression stockings. Severe cases may require medications.
- Orthostatic Hypotension: Gradual position changes, increased hydration, and reviewing medications. Medications like fludrocortisone may be necessary.
- Dehydration: Rehydration with oral or intravenous fluids.
- Medication Review: Adjusting or discontinuing medications contributing to syncope.
Safety Netting and Follow-Up
Safety netting ensures patients receive appropriate follow-up care and instructions. Key elements include providing clear discharge instructions, scheduling follow-up appointments, and educating patients about syncope causes and management.
Special Considerations
Reflex Anoxic Seizures
Reflex anoxic seizures, seen especially in children, involve shaking movements due to a drop in oxygenation. These can be misinterpreted as epileptic seizures but require different management.
Misdiagnosis Risks
Misdiagnosis of syncope as epilepsy or vice versa is common. Always consider both possibilities, especially when symptoms overlap.
Postural Hypotension and Specific Diagnoses
Postural hypotension requires careful evaluation. Special considerations include ruling out abdominal aortic aneurysm in older men and ectopic pregnancy in younger women.
Conclusion
Syncope is a multifaceted condition that demands careful evaluation and management in the emergency department. By understanding the underlying causes, utilizing appropriate diagnostic tools, and implementing effective management strategies, healthcare professionals can optimize patient outcomes and reduce the risk of recurrent episodes.
This guide aims to provide valuable insights into the diagnosis and management of syncope, helping healthcare providers deliver high-quality care. For further information, examples, and case studies, visit the St Emlyn's blog, where we continue to share knowledge and expertise in emergency medicine.
Remember, accurate diagnosis and timely intervention are key to managing syncope effectively. Stay vigilant, consult with senior colleagues when needed, and always prioritize patient safety.
Thank you for reading. If you have any questions or need further information, please get in touch. We look forward to continuing the conversation and improving patient care together.
Thursday Aug 07, 2014
Thursday Aug 07, 2014
Understanding High Sensitivity Troponins: A Guide for Emergency Physicians
Welcome to the St. Emlyn's podcast. I'm Ian Beardsell and I'm Rick Bodden. This is part two of our troponin special where we delve deeper into high sensitivity troponins (hs-Tn) and their significance in emergency medicine. Today, we'll explore the nuances of hs-Tn assays and how they can enhance our work in the emergency department (ED).
Introduction to High Sensitivity Troponins
High sensitivity troponins (hs-Tn) have transformed how we detect and manage myocardial infarctions (MI) in emergency settings. Unlike traditional assays, hs-Tn tests detect much lower concentrations of troponin, a protein released during myocardial injury, allowing for earlier and more accurate detection of cardiac events.
Analytical Sensitivity vs. Diagnostic Sensitivity
Understanding the difference between analytical and diagnostic sensitivity is crucial. Analytical sensitivity refers to the assay's ability to detect low concentrations of troponin, whereas diagnostic sensitivity relates to the test's performance in diagnosing acute myocardial infarctions (AMI).
Key Points on Analytical Sensitivity:
- Detection Threshold: High sensitivity troponin assays can detect troponin in over 50% of healthy individuals.
- Precision: These assays have a coefficient of variation (CV) of less than 10% at the diagnostic threshold, ensuring consistent results.
Diagnostic Sensitivity:
- Improved Detection: Studies show hs-Tn assays have a higher diagnostic sensitivity (90-92%) compared to older assays (80-85%).
- Early Rule-Outs: This makes hs-Tn particularly valuable for ruling out AMI in patients presenting with chest pain in the ED.
High Sensitivity Troponin Assays: A Closer Look
To illustrate, let's focus on the Roche troponin T high sensitivity assay:
- 99th Percentile Cutoff: 14 nanograms per liter.
- Detection Range: Can detect levels as low as 3 nanograms per liter.
- Higher Readings: It's common for hs-Tn assays to give higher readings than older assays for the same sample, which affects the diagnostic threshold.
The Balance Between Sensitivity and Specificity
While hs-Tn assays improve sensitivity, they may reduce specificity:
- More Positives: Lowering the diagnostic threshold results in more positive results, increasing diagnostic sensitivity but reducing specificity.
- Predictive Value: For example, a positive hs-Tn T result at patient arrival has a specificity around 70% and a positive predictive value of 50%.
Using High Sensitivity Troponins in the Emergency Department
Early Rule-Out Protocols: The most significant advantage of hs-Tn assays is their potential to expedite the rule-out process:
- Zero and Three-Hour Protocols: Studies suggest that hs-Tn assays can effectively rule out AMI with samples taken at 0 and 3 hours after arrival, instead of the traditional 6-hour wait.
- Efficiency: This protocol can significantly speed up patient throughput in the ED, reducing congestion and wait times.
Understanding Deltas: Delta refers to the change in troponin levels between tests:
- Absolute vs. Relative Deltas: Absolute changes (e.g., an increase of 10 nanograms per liter) are often more reliable than relative percentage changes.
- Clinical Context: It's crucial to interpret deltas in the context of the patient's overall clinical picture.
Practical Considerations for Emergency Physicians
Incidental Troponin Elevations: With increased testing at the front door, incidental findings are inevitable:
- Low Pre-Test Probability: In patients with a low pre-test probability of AMI (e.g., mechanical falls), a positive hs-Tn result often does not indicate AMI.
- Clinical Judgment: Consider repeating the test and evaluating the patient's history and clinical presentation before making a decision.
Patients with Comorbidities: Troponin levels can be elevated in patients with various comorbidities:
- Age and Chronic Conditions: Older patients and those with conditions like LV dysfunction may have higher baseline troponin levels.
- Reference Ranges: Use broader reference ranges for patients with comorbidities, as suggested by studies from Paul Collins and colleagues.
Future Directions and Guidelines
Ongoing Research: Research and guidelines on hs-Tn usage are continually evolving:
- NICE Guidelines: Recommendations on using hs-Tn in clinical practice are expected to be published, providing clearer protocols for emergency physicians.
- Early Adoption: As new evidence emerges, early adopters must balance innovation with patient safety.
Point-of-Care Testing: While hs-Tn assays currently require large analyzers, point-of-care testing remains a goal:
- Future Developments: Advances in technology may eventually make hs-Tn testing available at the bedside, further streamlining ED workflows.
Conclusion
High sensitivity troponins represent a significant advancement in the early detection and management of myocardial infarctions in the emergency department. By understanding the nuances of analytical and diagnostic sensitivity, utilizing early rule-out protocols, and interpreting results within the clinical context, emergency physicians can leverage these assays to improve patient care. As always, ongoing research and adherence to evolving guidelines will be essential in optimizing the use of hs-Tn in clinical practice.
We hope this podcast helps you better understand the complexities and advantages of high sensitivity troponins. For more insights and updates, stay tuned to the St. Emlyn's blog and feel free to reach out with your questions and experiences. Together, we can continue to advance emergency medicine for the benefit of our patients.
Wednesday Aug 06, 2014
Wednesday Aug 06, 2014
College of Emergency Medicine Conference 2024: Everything You Need to Know
Welcome to the St. Emlyne's blog, where we provide the latest updates and insights into the world of emergency medicine. Today, we're diving into the much-anticipated College of Emergency Medicine (CEM) Conference, set to take place in Exeter from September 9th to 11th. This conference is not only a hub for academic learning but also a celebration of the progress and future of emergency medicine.
Why Exeter?
Exeter, nestled in the scenic Southwest of England, offers an exciting venue for this year’s CEM Conference. The University of Exeter provides a fresh and dynamic backdrop, allowing attendees to experience a new environment. The choice of Exeter also aims to highlight the region's significant contributions to medical research and practice. Plus, the location promises better weather compared to other parts of the UK, making it a pleasant destination.
Key Highlights and Speakers
The conference is packed with sessions designed to engage and educate emergency medicine professionals. Here are some highlights to look forward to:
Inspirational Talks and Keynote Speakers
- Ann Marie Kelly from Australia will share her expertise on arterial and venous blood gases, offering critical insights for daily medical practice.
- James Robson, doctor to the Scottish rugby team and the British and Irish Lions, will discuss the pressures and challenges of pitchside medicine and his experiences over the past 15 to 20 years.
- Cliff Reed, a renowned figure in emergency medicine, will inspire attendees with his motivational presentations.
- Cliff Mann, the current college president, will discuss clinical topics, reflecting his deep involvement in frontline emergency medicine.
Engaging Sessions
The conference features a variety of sessions tailored to different interests within emergency medicine:
- Dragon's Den: Watch as grant applicants pitch their projects to a panel of emergency medicine experts, competing for a share of £1000 to fund their innovative ideas.
- Stroke Management: Jason Kendall will provide an in-depth look at stroke management and the latest research in this critical area.
Social and Networking Events
Balancing work with social activities is a key theme of the conference. Highlights include:
- Gala Dinner at Exeter Castle: An opportunity to unwind and network in a historic setting.
- Explore Devon Activities: From surfing at Bantham to paddleboarding on the River Exe, there are plenty of outdoor activities. Attendees can also enjoy kayaking, mountain biking, or exploring local museums.
Academic Excellence
The conference boasts a robust academic programme with four tracks running simultaneously on some days, ensuring there's something for everyone, whether you're a trainee, an established consultant, or involved in cutting-edge emergency medicine research.
Core Emergency Medicine Topics
Sessions focus on essential topics in emergency medicine, aiming to reconnect professionals with the fundamentals that make this field vital and rewarding. The goal is to address rising attendances and increasing pressures in emergency departments by reinforcing core knowledge and practices.
Cutting-Edge Research
Attendees will engage with the latest research and innovations in emergency medicine. The programme is designed to be both educational and academically stimulating, attracting participants with its high-quality content.
Why Attend?
The CEM Conference in Exeter offers numerous benefits:
- Professional Development: Enhance your knowledge and skills through sessions led by top experts in the field.
- Networking: Connect with colleagues from across the country and beyond, sharing experiences and best practices.
- Inspiration: Gain new perspectives and motivation from leading figures in emergency medicine.
- Fun and Relaxation: Enjoy the social events and explore the beautiful surroundings of Exeter and Devon.
Practical Information
Booking and Availability
If you haven't booked your place yet, it’s not too late! There are still a few spots available, but they are filling up fast. Visit the college website to secure your place and register for the explore Devon activities, which are also in high demand.
Staying Updated
For those who can’t attend in person, the conference will share video excerpts of key sessions. Follow the #CEMEXETER2014 hashtag on Twitter and check out the college's YouTube channel for updates and highlights.
Conclusion
The CEM Conference in Exeter is shaping up to be an unmissable event for anyone in the field of emergency medicine. With its combination of high-quality academic content, inspirational speakers, and engaging social activities, it promises to be both educational and enjoyable. Whether you're attending for the learning opportunities, the chance to network, or simply to enjoy the vibrant atmosphere, this conference has something to offer everyone.
Don't miss out on this fantastic opportunity to advance your career and connect with the emergency medicine community. Book your place today and join us in Exeter for an unforgettable experience!
Sunday Aug 03, 2014
Friday Aug 01, 2014
Sunday Jul 27, 2014
Monday Jul 21, 2014
Monday Jul 21, 2014
Starting Your Career in Emergency Medicine: Key Insights from St. Emlyn’s
Welcome to the world of emergency medicine! At St. Emlyn’s, we understand the challenges and excitement that come with starting your career in this fast-paced field. Whether you’re a new doctor stepping into the emergency department (ED) for the first time or a medical student gearing up for your rotation, we’ve got you covered. This post delves into the nuances of emergency medicine, sharing valuable insights from seasoned professionals, Iain Beardsell and Simon Carley, to help you navigate your journey effectively.
Understanding the Unique Nature of Emergency Medicine
Emergency medicine is distinct from other medical disciplines. Unlike the traditional approach taught in medical school, which involves extensive histories and comprehensive examinations, emergency medicine requires quick, focused thinking and decisive action. The goal is to identify and address life-threatening conditions promptly.
Time-Pressured Environment
In the ED, time is of the essence. Patients arrive needing immediate care, and as an emergency physician, you won’t have the luxury of lengthy deliberations. Your patients want answers quickly, and this urgency shapes the way you practice. You’ll learn to focus on the presenting problem and drill down into the most critical aspects of their condition.
Different Thinking Model
The thinking model in emergency medicine is primarily hyperthetico-deductive reasoning. This means you’ll form hypotheses based on initial information and then test these hypotheses through targeted questions and examinations. For instance, if a 55-year-old man presents with central crushing chest pain radiating down his left arm, your first thought should be an acute myocardial infarction (AMI).
Prioritizing Life-Threatening Conditions
One of the fundamental differences in emergency medicine is the approach to diagnosing and treating conditions. Instead of trying to confirm what a patient has, you’ll focus on ruling out what they don’t have, especially the most life-threatening possibilities. For example, with chest pain, you’ll consider AMI, pulmonary embolism (PE), and aortic dissection as top priorities.
The 10% Rule
Interestingly, about 10% of patients presenting with symptoms like chest pain or headache have significant pathology. Your job is to identify this 10% while efficiently managing the remaining 90%. This approach ensures that you don’t miss critical diagnoses while not overburdening yourself with unnecessary details.
Practical Steps for Your First Shift
As you prepare for your first shift in the ED, here are some practical steps and philosophies to keep in mind:
Resuscitation First
Your primary goal is to identify if a patient needs resuscitation. Are they critically unwell? Do they require urgent interventions to save their life? This is your top priority.
Pain Management
After ensuring resuscitation, your next focus should be pain management. A pain-free emergency department is a goal to strive for. Administer analgesia as needed to ensure patient comfort, even before completing a full history or examination.
Rule Out Life-Threatening Conditions
When a patient presents with a complaint, think about the worst-case scenarios related to their symptoms and aim to rule these out. For example, with chest pain, consider whether the patient might have an AMI, PE, or aortic dissection.
Focused History and Examination
Conduct a focused history and examination to gather information pertinent to the presenting complaint. Avoid getting bogged down with irrelevant past medical history unless it directly impacts the current situation.
Implementing the Four Big Hitters
Simon and Iain emphasize the importance of considering four key interventions for every patient:
- Oxygen: Determine if the patient needs oxygen or airway support.
- Analgesia: Ensure adequate pain relief is provided.
- Fluids: Assess if the patient would benefit from intravenous fluids.
- Antibiotics: Consider if antibiotics are necessary for their condition.
Learning and Growing in the ED
The ED is a dynamic learning environment. Here’s how you can maximize your growth and effectiveness:
Ask Questions
Don’t hesitate to ask questions. No question is too silly. Engaging with senior colleagues and seeking their advice will enhance your learning and patient care skills.
Continuous Learning
Emergency medicine is a field where continuous learning is crucial. Keep up with the latest practices, guidelines, and innovations. Attend workshops, conferences, and training sessions to stay updated.
Collaborative Approach
Remember that emergency medicine is a team effort. Collaborate with nurses, paramedics, and other healthcare professionals. Effective communication and teamwork are essential for providing the best patient care.
Reflect and Improve
After each shift, take time to reflect on your experiences. Identify what went well and areas for improvement. This self-assessment will help you grow as a clinician and enhance your skills over time.
The Importance of Confidence and Competence
Confidence in your abilities is vital, but it must be balanced with competence. Strive to be competent in your practice, and your confidence will naturally follow. Be aware of the balance between these two aspects to avoid the pitfalls of overconfidence.
Unconscious Incompetence
One of the dangers in any medical field is unconscious incompetence—being unaware of what you don’t know. Stay humble, keep learning, and seek feedback from peers and seniors to continuously improve your competence.
Embracing the ED Culture
The culture in the ED is unique. It’s a place where decisive actions and quick thinking are valued. Embrace this culture and the opportunities it presents for hands-on learning and making a real difference in patients’ lives.
A Little Less Conversation, A Little More Action
In the ED, the Elvis philosophy—“a little less conversation, a little more action”—applies. Focus on doing what’s necessary for the patient rather than getting caught up in lengthy discussions. This action-oriented approach is crucial for effective emergency care.
Conclusion: Your Journey Ahead
Starting your career in emergency medicine is both exciting and challenging. At St. Emlyn’s, we believe in providing you with the tools, knowledge, and support you need to succeed. Remember the key principles: prioritize life-threatening conditions, focus on critical interventions, continuously learn and ask questions, and embrace the dynamic culture of the ED.
We love our jobs and hope that you, too, will find the same passion and fulfillment in your career. Good luck, enjoy the journey, and know that we’ll be with you every step of the way through this podcast and our wider St. Emlyn’s community.
Welcome to the world of emergency medicine. Let’s make a difference together!
Thursday Jul 17, 2014
Thursday Jul 17, 2014
Navigating the Challenges and Benefits of Targets in Emergency Medicine: A Deep Dive from St. Emlyn's
Welcome back to the St. Emlyn's blog. Today, we're tackling a topic that's both crucial and controversial in the UK: the multitude of targets faced by emergency departments (EDs). As many of you know, our emergency services have become world leaders in setting and striving to meet various targets. This post explores the impact of these targets, drawing insights from a recent St. Emlyn's podcast discussion between Iain Beardsell and Simon Carley.
Understanding the Four-Hour Access Target
The four-hour access target is perhaps the most well-known and influential benchmark in UK emergency medicine. This target mandates that 95% of patients must be admitted, transferred, or discharged within four hours of arrival at the ED. Although some argue that this system forces a "clipboard mentality," there are substantial benefits.
Historical Context and Improvements
Before the introduction of the four-hour target, UK EDs often experienced chaotic conditions with patients waiting for days. The target has driven significant improvements by making timely patient management a priority across the entire healthcare system. It has led to increased staffing levels and has enhanced the efficiency of associated services, like radiology and laboratory testing, which are critical for patient care.
Benefits of the Four-Hour Target
- Improved Patient Flow: The four-hour target encourages EDs to streamline processes, reducing overcrowding and improving overall patient flow.
- Increased Staffing: The target has justified the hiring of more staff, including senior consultants, which enhances the quality of care.
- Enhanced Diagnostics and Protocols: The pressure to meet the target has fostered innovations in protocols and diagnostics, benefiting patient outcomes.
Challenges and Criticisms
However, the four-hour target is not without its drawbacks. One major issue is the pressure it places on clinicians, potentially leading to rushed or suboptimal decision-making, particularly during peak times when the ED is overwhelmed. This can sometimes result in junior doctors making hasty decisions under pressure.
Other Quality Indicators and Targets
Beyond the four-hour target, UK EDs face a plethora of additional quality indicators, including metrics for:
- The time it takes to see a senior decision-maker
- The recording of vital signs upon patient arrival
- The percentage of patients leaving before being seen
These targets aim to ensure comprehensive and timely care but also add to the administrative burden on clinicians.
Balancing Targets and Clinical Care
Achieving a balance between meeting targets and providing high-quality clinical care requires strong clinical leadership and effective management. It's crucial that the focus remains on patient care rather than merely ticking boxes. At St. Emlyn's, we advocate for using targets to enhance clinical processes rather than allowing them to dictate every action.
Financial Penalties and National Standards
In recent years, new targets linked to financial penalties have been introduced. For example, failing to complete VT risk assessments or properly signposting psychological services can result in financial consequences for hospitals. These measures, while well-intentioned, further complicate the landscape of clinical priorities and administrative tasks.
The Role of Clinical Leadership
Effective clinical leadership is vital in navigating these challenges. Leaders must prioritize direct patient care while managing the increasing number of bureaucratic processes. It's essential to prevent the overburdening of clinicians with administrative tasks, ensuring they can focus on what matters most: the patients.
Trauma Team Targets
Recently, trauma team targets have been established, such as the requirement for a consultant to see major trauma patients within five minutes of arrival and for these patients to reach CT within 30 minutes. While these targets aim to standardize care and improve outcomes, they can be challenging to meet consistently, especially for cases that do not follow the typical major trauma profile.
Real-World Implications
For instance, elderly patients who suffer injuries but present later with complications might not meet the consultant within the stipulated five minutes, potentially resulting in penalties despite receiving appropriate care. Additionally, the 30-minute CT target can push teams to rush procedures, which might compromise safety.
Learning from Experience
The UK healthcare system has learned valuable lessons from past experiences, such as the mid-staff inquiry, emphasizing the importance of clinical judgment over rigid adherence to targets. The goal is to use targets to support and improve patient care rather than let them drive clinical decisions.
Future Directions
Looking forward, increasing the number of consultants and ensuring they are actively involved in patient care decisions will be critical. This shift will help balance the need to meet targets with the imperative to provide high-quality, individualized patient care.
Conclusion: A Thought-Provoking Discussion
The discussion around targets in emergency medicine is complex and multifaceted. While they bring about improvements in efficiency and care standards, they also introduce significant challenges. At St. Emlyn's, we believe that with wise and flexible application, targets can be a powerful tool to enhance clinical care.
Your Thoughts?
We'd love to hear how targets impact your practice. Do they help you deliver better care, or do they create more hurdles than they're worth? Share your experiences with us, and let's continue this important conversation.
For more insights and discussions, keep following the St. Emlyn's blog. Your feedback is invaluable to us as we navigate the ever-evolving landscape of emergency medicine together.
Tuesday Jul 08, 2014
Tuesday Jul 08, 2014
Welcome to the St. Emlyn's podcast, where today we delve into the critical realm of trauma teams and trauma team leadership. Our focus is on optimizing efficiency and patient outcomes in the resuscitation room. Drawing from a hypothetical trauma case, we'll equip you with actionable knowledge to enhance your practice.
Understanding the Modern Trauma System
The UK has undergone significant reorganization in trauma services, emphasizing major trauma centres. These centres bypass local hospitals to ensure that patients with severe injuries receive specialized care. For instance, London has four major trauma centres, while Manchester has three. Along the South Coast, centres extend from Bristol to Brighton and down to Plymouth, ensuring a wide geographic spread.
The Importance of Trauma Team Leadership
Effective trauma team leadership is crucial for managing severe trauma cases. It's about making quick, informed decisions to optimize patient outcomes. One ambitious yet beneficial target is getting major trauma patients into a CT scanner within 30 minutes of arrival. Meeting this target can significantly improve patient outcomes.
Optimizing Team Dynamics
Efficient trauma team dynamics are key. Clear, structured communication is critical. Use first names to foster a collaborative environment and break down hierarchical barriers. For instance, instruct the anesthetist to manage both airway and analgesia, leveraging their skills in pain management.
Concurrent Activity and Task Allocation
In high-pressure environments, concurrent activity is vital. As the trauma team leader, ensure multiple tasks are performed simultaneously. For example, while one team member inserts a chest drain, another applies a pelvic binder, and a third prepares for intravenous access. This approach minimizes delays and streamlines patient management.
Packaging for Transport
Before transporting the patient to the CT scanner, ensure they are appropriately packaged. Use portable monitors and verify that all necessary equipment, such as oxygen and rescue medications, are in place. A pre-transport checklist can prevent any oversights and ensure a smooth transfer.
Collaborative Decision-Making
Trauma team leadership is not about making decisions in isolation. Engage with your team, including radiologists, surgeons, and nursing staff, to gather input and make informed decisions. For instance, if a radiologist identifies a pneumothorax via ultrasound, proceed with chest drain insertion without waiting for a chest x-ray.
Efficiency in the Resuscitation Room
Minimize unnecessary procedures to expedite patient care. Avoid routine lateral cervical spine x-rays, chest x-rays, and pelvic x-rays if ultrasonography provides sufficient information. Focus on interventions that directly impact patient outcomes and streamline the path to definitive diagnosis and treatment.
Effective Communication and Leadership
Effective communication is the backbone of trauma team leadership. Use structured handovers, clear task allocations, and constant updates to keep everyone informed. Avoid shouting; maintain a calm and controlled environment to foster teamwork and ensure the patient remains as comfortable as possible.
Adapting to New Protocols
Trauma care is continually evolving. The approach discussed here emphasizes minimizing time in the resuscitation room and prioritizing rapid transfer to the CT scanner. This shift requires a change in mindset, viewing the resuscitation room as an extension of the pre-hospital environment and the CT scanner as the definitive diagnostic tool.
Conclusion
Trauma team leadership is both an art and a science. It requires quick decision-making, efficient task allocation, and seamless communication. By adopting a structured approach, minimizing unnecessary interventions, and fostering a collaborative environment, we can improve patient outcomes and meet the challenging target of getting major trauma patients to the CT scanner within 30 minutes.
Whether you're in a major trauma centre or a smaller unit, the principles of effective trauma team leadership remain the same. Implementing these strategies will enhance your practice and ultimately save lives.
Good luck with your trauma team leadership efforts. We hope you find this podcast insightful and applicable to your practice. Stay tuned for more insights and updates from the St. Emlyn's team.
S
Sunday Jun 29, 2014
Sunday Jun 29, 2014
Understanding Relative Risk, Absolute Risk, and Number Needed to Treat: A Guide for Emergency Medicine
Welcome back to the St. Emlyn’s podcast. I’m Iain Beardsell and joining me is Simon Carley. Today, we’re delving into the complex yet critical concepts of relative risk, absolute risk, and the number needed to treat (NNT) in the context of emergency medicine. These metrics are essential for understanding the effectiveness of treatments and making informed decisions in clinical practice.
The Importance of Understanding Risk Metrics
In emergency medicine, it’s vital to comprehend how different treatments impact patient outcomes. This understanding not only helps in communicating with patients but also aids in making better clinical decisions. Two key terms frequently encountered are relative risk reduction and absolute risk reduction.
Relative Risk Reduction vs. Absolute Risk Reduction
Imagine we are conducting a trial on a new drug for myocardial infarction (AMI) patients. Typically, 10% of AMI patients die within a month. If our new treatment claims a 50% relative risk reduction, it sounds impressive. However, understanding what this actually means is crucial. A 50% relative risk reduction translates to reducing the death rate from 10% to 5%. While this is significant, it's essential to recognize the difference between relative and absolute risk reduction.
Calculating the Number Needed to Treat (NNT)
The NNT is a valuable metric for understanding how many patients need to receive a particular treatment to prevent one additional adverse outcome. It’s derived from the absolute risk reduction. For instance, if a treatment reduces mortality from 10% to 5%, the absolute risk reduction is 5%. To calculate the NNT, divide 100 by the absolute risk reduction percentage. In this case, 100 divided by 5 equals an NNT of 20. This means we need to treat 20 patients to save one life.
Examples of NNT in Practice
Let’s consider some real-world examples. Tranexamic acid in trauma has an NNT of around 50, meaning we need to treat 50 patients to save one life. For aspirin in treating myocardial infarction, the NNT is also around 50. These figures highlight the effectiveness of these treatments in clinical practice.
Balancing Benefits and Harms
Understanding NNT is crucial, but it’s equally important to consider the number needed to harm (NNH). This metric indicates how many patients need to receive a treatment before one adverse effect occurs. For example, in trials involving starch solutions for sepsis, the NNH was found to be around 10-16. This means for every 10 to 16 patients treated, one additional death occurred. Balancing the benefits and harms is essential for making informed clinical decisions.
Example: Stroke Thrombolysis
In stroke thrombolysis, the NNT is around 8, meaning one in eight patients benefits from the treatment. However, the NNH is about 16, indicating one in 16 patients might experience a harmful outcome, such as intracerebral hemorrhage. Communicating these risks and benefits to patients is crucial for informed consent and shared decision-making.
The Role of Natural Frequencies
Using natural frequencies, such as “one in 100 people” or “one in 50 people,” helps in explaining risks and benefits in a more understandable way. For instance, saying “one in 100 people in your neighborhood” or “one person in a packed football stadium” can make the statistics more relatable.
Misdiagnosis and Its Impact
A key takeaway is that not every missed diagnosis leads to adverse outcomes. Often, treatments may have minimal benefit, and in some cases, they could cause harm. For example, the rush to administer clopidogrel in acute myocardial infarction might not always be necessary, given its relatively high NNT.
Applying These Concepts in Clinical Practice
Understanding and applying these concepts can change how we approach patient care. It allows us to prioritize interventions that provide the most significant benefit while minimizing potential harm. It also highlights the importance of taking time to ensure the right diagnosis and treatment, rather than rushing into potentially harmful decisions.
The Number Needed to Educate (NNE)
A fun and thought-provoking concept introduced in our discussion is the Number Needed to Educate (NNE). How many blogs or articles do you need to read before it changes your clinical practice? This metric emphasizes the importance of continuous learning and staying updated with the latest evidence-based practices.
Conclusion
In emergency medicine, understanding relative risk, absolute risk, and NNT is vital for making informed treatment decisions. These metrics help in balancing the benefits and harms of treatments, leading to better patient outcomes. By effectively communicating these risks and benefits to patients, we can ensure shared decision-making and improve overall patient care.
Read more at St Emlyns and on the accompanying blogpost