Author Archives: Simon Carley

Croup: Riding the Dex Express

Sooooo….this paper turned up at JC last week (thanks to Nicola P) and whilst I’m not sure that it meets all three of our criteria for a top JC paper it is relevant as a week barely seems to go by without someone questioning the dose/route/brand/colour/size/ethnicity of medicine for croup.
Rule of thumb chaps and chapesses ‘The greater the dogma, the greater the ignorance’. Someone cleverer than I said that, but I’m happy to plagiarise ‘cos it’s true.
Anyway, Croup arrives as a question once again in the journal Emergency Medicine Australia, but this time the question relates to speed of onset in mild to moderate croup.

 STOP! If you are in exam mode at this point you should read the paper. See what you think about it and give it a mark out of 10.

We’ve talked about this paper and it’s a tricky one. The first question is why has this paper been done (which we cannot answer, but can surmise privately). The use of steroids in the management of croup is very well established and is something we led on here in Virchester many years ago. It was even one of the very first BETs back in 2004 (amazing to think that we are still talking about this 8 years later).
I’ve also seen the Cochrane review and even examined some CTRs for FCEM on the subject. So, it pretty much seems to me that the question of whether we give steroids for croup is well made. The research that remains is, I suppose, about refining and polishing what is surely a well established fact.

STEROIDS WORK IN CROUP Click the link and read the Cochrane review.

So, what about the paper this week? Is there anything we can draw from it and learn? Well, the authors have done an RCT (good) on mild/moderate croup patients. Interesting this as for the mild ones would you give steroids or just let nature take its course? (Ed – depends on how mild as croup score 1-3 is mild) I’m not sure so there maybe an element of over-treatment in comparison to other practices. Whatever, the authors tell us that there is an effect of giving steroids that they can define and detect at  30 minutes following administration of steroid and that this counteracts the information given through Cochrane about a delayed effect taking up to 6 hours.

I have major concerns with this paper and I just don’t see how this is going to make a significant difference to our practice in PEM.  I don’t think a paper like this would appear in an exam, but if it did I would be pulling holes in it along the following lines.

1. What is the clinically important question here? It seems that we are looking to see the speed of onset of steroid meds in mild/moderate croup. The clinical importance of this is perhaps unclear except in logistical (admission) terms. What defines a significant difference in this low acuity group? Mild croup is not admitted anyway so what is the issue we are addressing?

2. Sample size. OK. An interest of mine, and if you share that interest (you sad person) then hop over to the podcast to hear more about how to understand and interpret sample size calculations. In this paper they appear to be using tests for continuous data for data which is unlikely to be so. Honestly, it seems as though these are the wrong tests for this data, but there is insufficient information in the paper for us to tell. Where is the clue? Well, the Wesley croup score is a categorical score (at best ordinal). It’s not continuous and is unlikely to be normally distributed, so a t-test is rarely going to be the right test. So hmm, not enough information to know but questions are there to be asked. If you want to know more about stats for Critical Appraisal then click here and here. Apart from anything else, a study of just 70 patients would have to show a massive effect if it is be valid and I don’t see that here. Similarly the graph shows average scores only, and I’m not sure that I’m just interested in the change in average score amongst 35 patients. I want to see the distribution as well. This is a common problem in papers as the mean score reporting removes the depth and character of the data.

3. Right, so we are unsure of the validity of the question and also of the sample size what else? Well,  do applaud the authors for defining the numbers of patients that they ‘could’ have recruited and the difference between that number (828) and the number recruited (70) is huge. This suggests a degree of patient selection which may well affect the results. Now, I don’t want to put a massive downer on this as it is an inevitable problem with EM research, but this ratio really asks questions as to whether this is a representative sample, or whether the results will be heavily skewed because it is a sample of convenience.

So, it sounds as though we were pretty down on this paper from a methodological point of view. We gave it a 3/10 to be honest which is clearly not high, but just wait is there ANYTHING we can take away from this piece of work at all. Well, it’s tricky to be honest. It’s likely (but I’m finding it difficult to tell) that oral dex starts working fairly quickly, but that was never a clinical dilemma for me before I read this paper so I’m not going to change practice. However, it’s a useful to use this as a vehicle to discuss Croup (again), to review the relevant BETs and to talk about how to spot flaws in papers.

 bw

Simon C

PS. If you are still in exam mode try answering the following questions…

1. What is meant by the term ‘double-blinded’ and why is it important in a trial like this?

2. Four patients in the placebo group worsened during the initial phase of the trial and were then given steroids. They were analysed in the placebo group despite getting steroids. What is this type of analysis called and is it the right approach?

Journals are dead: Long live the Journal Club

“The report of my death was an exaggeration”

Mark Twain

Just a quicky and a link out to our guide on Emergency Medicine Journal Clubs. Despite the rumours of the imminent demise of all medical journals, we at @stemlyns strongly believe that this will not lead to the death of journal clubs. Even if paper publication wanes (and it probably will) it will be even more important for clinicians to have the skills and abilities to be wary of what ‘evidence’ is out there.

For example anyone can now set up a Blog (Er, not sure that’s the right message here – Ed) and say what they like. How do you know it’s fair comment and good enough to change practice?

You do need, and you will always need to be a sceptic with the skills to critically appraise and critique the evidence and we think that a Journal Club is a great way to learn.

Read more here on our top tips for making your Emergency Medicine Journal Club effective, productive and worthwhile.

Our Journal Club runs on a Friday lunchtime in the ED. We’ll review, debate and then blog on the papers we discuss. Watch the blog for the latest in EM Critical Appraisal.

vb

Simon C

PS: We’ll be keeping a log of papers reviewed in our Journal Club from now on. If it works then we should have a rolling program of the best, most current and most relevant papers for Emergency Medicine. If you’re coming up to an exam….it’s a good place to visit.

Kiddy pills, syrup, compliance and cost.

I was wandering through the Paeds journals looking for something relevant to EM recently (there wasn’t much) when I came across two articles in Archives of diease in childhood. The first by Baguley et al tells me that Kids are more likely to take medicines if they taste nice. Not exactly rocket science I agree, but what I did not know is that there is a scale of drugs which are known/not known to be taste nice, and interestingly Flucloxacillin, a drug widely used in emergency medicine is one of the least pleasant tasting. Augmentin on the other hand, for which the penalty for prescribing off protocol is crucifixion (not really but it feels like it) is apparently very tasty indeed. This may seem fairly benign and obvious but it’s really important for us as EPs as clearly there is no point in prescribing if the compliance is going to be poor.

Here’s a list from the paper ranking some of the more commonly prescribed antibiotics in Paeds ED practice from the paper.

  • ▶ Antibiotics children will normally swallow

    • ▶ Co-amoxiclav (×3/day) or Augmentin Duo (×2/day)

    • ▶ Cefaclor, cefalexin, Amoxil (branded) (all ×3/day)

    • ▶ Co-trimoxazole

  • Antibiotics children might swallow

    • ▶ Penicillin V (×4/day)

    • ▶ Amoxicillin (generic) (×3/day)

    • ▶ Clarythromycin (×2/day), azithromycin (×1/day)

  • Antibiotics children often spit out or grimace when taking

    • ▶ Erythromycin (×4/day)

    • ▶ Trimethoprim (×2/day)

  • ▶ Rarely tolerated with good adherence

    • ▶ Flucloxacillin (×4/day)

    • ▶ Clindamycin (×4/day)

So, is there a way round this rather than just continuing to prescribe and hope for the best? For patients there is some really good generic advice out there on loads of websites and your pharmacy may have advice as well, but what about us as EPs. Is this really a question for us at all or do we just prescribe and say get on with it. There are two suggestions in the journal that I thought were worth a ponder. One we can do right now and one for the future. In the same paper Baguley et al describe the concept of a ‘taste test’ to give the first dose of antibiotics before the child leaves to see if they will tolerate it. This seems perfectly sensible to me. We should probably do this for those drugs down the bottom end of the table, and arguably for all of them. I’m going to suggest and then wait for all the reasons why we can’t, and then I’ll suggest it again, and again…….

The future idea is another paper in Archives which challenges dogma, and I love a bit of dogma baiting! We all know that the only reason we are messing about with antibiotics in syrup form is because kids can’t take tablets. Or can they? Spomer et al have performed a rather nice (admittedly pilot) study looking at whether children aged 0.5-6 years can swallow tablets as compared to syrup….and the result is that they can. Not only that, but they can swallow tablets as well as they can take syrup, and, in children aged 6-12 months they do better with tablets. Ok, it’s a small paper, a pilot and we cannot infer from this that mini-pills are the future, but it does raise some interesting questions that I’d like to see answered over the next few years.

Compliance is a vital component of any successful theraputic intervention but one that we in Paeds EM perhaps do not take account of as much as we should. Better compliance has got to be better for patients, for countering microbiological resistance and ultimately for healthcare costs.

It’s certainly made me think about that next prescription for oral fluclox syrup. I wonder if it will get used in the way that I prescribe it?

Now, at this stage it would be great to tell you the results of my blind tasting of antibiotics in the department. This is of course unethical so I haven’t, but I’d love to hear from anyone who has. It does remind me of my time in Neonates (a long time ago when consultants could make juniors do this sort of thing) when the drug rep came round with all the different types of formula feeds designed from ultraprems right up to full term and beyond. It was possibly the weirdest, most unpleasant and arguably most bizarre taste test I’ve ever undertaken.

Simon C

The Olympics and the ED physician

It’s a great week to be British. Bradley Wiggins wins the tour and we are just a few short days away from the greatest show on Earth – the Olympics I mean.

(Ed – don’t mention the Cricket, & don’t send this to any South Africans)

So, Virchester is hosting some of the Olympic events and as a result the local EDs have been put on standby to receive athletes and their support teams as patients. We have some experience in this as a few years ago the Commonwealth games were held here and it was interesting to think back to that time and reflect on how it affected us in the ED. Virchester also hosts many elite sporting teams so we are used to famous and/or talented sportsmen and women turning up on our doorstep.

Teams form the large, wealthy countries invariably bring their own team of healthcare staff with them ranging from docs to physios. It’s likely that most problems will be dealt with by these people and therefore they won’t come to you that often. If they do then the athlete/support staff are usually accompanied by one of their physicians. These are usually fairly easy consults as a result.

Athletes and staff from the less well off nations present different problems. They may not have their own supporting staff and as a result it is possible that they may end up in your ED. Now, LOCOG and other major sporting organisations put on fantastic facilities and teams of staff to deal with this issue, but still they may slip through the net. In previous events we have had all sorts of things turning up in the ED, from acute trauma, right through to long term health problems presenting to the ED for treatment (for conditions where treatment might be tricky to get back home).

So, despite the best laid plans, if you are near an Olympic venue you might get Olympic participants through the door. So, what are you going to do about it and where are the dilemmas? These are not the thoughts of a sports physician and I know that many ED docs know more about sports medicine than I do, rather what should we be thinking about as non-sports medicine experts faced with the prospect of high profile, high maintenance, high risk athletes turning up in our EDs over the next few weeks.

  • 1. Who should they see? This is the age old chestnut of how to manage VIPs in the ED. Should anyone be prioritised in terms of time or in the seniority of clinician who sees them? Rightly or wrongly I would suggest ensuring that elite athletes are reviewed by a senior physician. These are high risk (legally and clinically) patients and it makes sense to get the best opinion possible.
  • 2. Costs? All participants in the Olympics are entitled to free health care so there are no concerns here. The NHS committed to “Provide free comprehensive healthcare to Olympic and Paralympic family members throughout their stay for the Games whilst still providing healthcare for our local residents”. Treat them as NHS patients and don’t worry about it.
  • 3. Clinical Vigilance? This is a tricky concept for me to explain, but it’s something along the lines of balancing between delivering normal care (which should be the best you can) with an appreciation that sports medicine is different. It’s different clinically as there are a host of conditions that are sports specific, but also the psychological elements around the relationship between athlete, coach and physician (team and you). Complex factors such as the injury being made public, desire to compete, potential risk etc. may all be at play in the consultation and you may find it difficult to understand everything that’s going on. So close to an Olympics such conflicts are likely to rear their heads. I have found this aspect of treating athletes the most complex and difficult.
  • 4. Expertise? You’re a great emergency physician I know, but don’t step outside your comfort zone. By all means diagnose the undisplaced metacarpal fracture in the water polo player, but think long and hard before you advise them on whether they can play with it strapped up in 5 days time. I have been asked all sorts of stuff about prognosis, therapy etc. Remember that time to healing to sit behind a desk is somewhat different to time to be able to compete at elite level. Similarly, you don’t want to say something is OK to compete on if it then results in more serious injury. If you are going to give advice beyond your competency phone your medical protection organisation soon (see note below).
  • 5. Drugs? This is not about you detecting  the performance enhancing kind, but rather that little stock of drugs in the cupboard that might result in an athlete testing positive. The WADA (World Anti Doping Association) lists can be found here. I guess analgesics and B2 agonists are the areas where the typical ED doc might make an error. That could be rather embarrassing so best avoided.
  • 6. Refer appropriately. LOCOG has a number of health centres specifically for athletes. If in doubt give them a call they probably know more than you (and me). London 2012 Olympic Games Healthcare Guide – December 2011-1

So, hopefully everything will go swimmingly well (the Ozzy swimmers are in Virchester this week), and we won’t see any athletes or staff at all……., but somehow I don’t think so.

vb

Simon Carley
NB. Sports medicine and EM. I actually think they make really great bedfellows as much of what we do is transferable to the sporting arena. I once attended a Cricket match at Old Trafford when a chap collapsed in front of us. Within minutes there were 2 ED consultants, an ICU consultant, a Cardiology consultant and a Rheumatology consultant in attendance. We sorted the chap out and handed him over to the site doctor…..an SHO in pathology who’s domain knowledge was thankfully not required.

NICE faces the sickle

New guidance out on sickle disease from NICE in the BMJ

I must admit to having a bit of an interest in sickle cell disease and the ED. There are two reasons for this.

Firstly, and most importantly, it is a really important disease to manage well. It’s a proper disease that we have learnt about since the very first weeks of med school, one for which the pathology, pathophysiology and treatment is well described and understood.

Secondly, I am constantly intrigued to see new docs arrive in the ED with preconceptions about the disease and it’s sufferers that I cannot understand or explain.
So, back to basics. Sickle cell anaemia is a ‘proper disease’, it can kill you, and shortens your life expectancy which is bad, very bad indeed. Living with sickle disease can be tough and patients suffer painful vaso-occlusive crises that may require them to come to our EDs for help. If you work in a multi-ethnic practice like Virchester then you will meet many patients with Sickle disease so it’s important that we understand how to help them. In our ED that means that we have a really good working relationship with our haematologists and in particular a specialist nurse in sickle disease who knows our local population really well and who has encouraged the development of personalised treatment plans. These are shared with the ED (the pink file), the patients, and with the haematology team. If not then we have a great pathway for the treatment of ‘unknown’ patients with sickle disease. It’s safe, evidence based and it works. Many of our local patients manage their disease very well at home and only come to see us when home management has failed. With few exceptions they only come to us when they really need help.

So, in Virchester everything is rosy. Except it’s not because I still occasionally come up against ideas which I find difficult to explain and understand, and this is almost always around the use of analgesia in vaso-occlusive crises.

So, let’s think about analgesia. In many ways I think that sickle disease is the poster boy for good analgesia management in the ED. Get this right and you probably have an ED that manages most pain well (there is a poster girl as well – but that’s for another day).

Why is it the poster boy? Well, because the management of sickle disease is one where analgesia is a cornerstone of management, where there are few physical signs, but where I see clinicians manage patients in very different ways. Such variation is not just an issue in my practice, but also in past studies and papers where the experiences of patients attending EDs is far from optimal. Take this quote from a 1999 paper in the BMJ

“The experiences of patients with sickle cell disease of hospital care are characterised by mistrust, stigmatisation, control, and neglect”

Now that was a long time ago (1999) and I like think we have made fantastic progress locally, but I am not convinced that this is the case everywhere because I still see suspicion and concern amongst some junior docs rotating in from St Elsewhere. Why is this I wonder? Where and how did they learn it? Why is it that we have a disease that causes pain, suffering, shortens lives but for which I sometimes see docs and nurses ‘not believe’ that the patient is genuinely in pain and as a result their analgesic management is suboptimal.

Why then? Is it the disease itself? Well perhaps as there are often few physical signs in sickle disease that ‘justify’ the pain to the physician. There is no bleeding, deformity and often few physiological signs. I hear odd comments such as ‘nobody in that much pain has a pulse less than 110’……! Really, do you want me to demonstrate whilst I take your pulse….? Until we have a pain-ometer that can quantify pain then we have to presume that the patient is telling the truth unless we know otherwise. In law we are innocent until proven guilty and the same should apply here. Similarly, on a general approach to pain then we must decide whether analgesia is something that we should freely offer, or should it be something that is earned? What do I mean by this? Well, its that I believe that analgesia is one of the most important things that we can do to improve the patient experience of illness and injury. We should be seeking out pain and treating it, not waiting for our patients to beg for it to be taken away.

This cannot be right and we cannot accept it, but how can we make it better.

I would suggest the following.

  • 1. Speak to your local haematologists and devise a protocol for the management of sickle pain. Why not use something like that advised by NICE and abstracted in this weeks BMJ
  • 2. Use sickle as a teaching tool for analgesia. Ask your colleagues about their attitudes towards sickle disease and the patients. Challenge, argue and question any attitudes that trouble you.
  • 3. Role model the care of sickle patients in the ED. As a senior these are great cases to see with a junior doc. Great for the patient as they get great care. Great for you as it tells you a lot about their attitude towards the disease and analgesia in general. Ask them how they ‘measure pain’, you might be surprised at the results…
  • 4. Talk to your local haematologists. Establish a mechanism for them to tell you about difficult or complex patients.
  • 5. Train the whole team. Analgesia is something often prescribed by docs but prioritised by the nurses. If you only train one of the tribes then you will fail.
  • 6. Listen to Dr Gentile.

When the patient is comfortable ask them what they felt about their experiences in your ED. It’s highly unlikely that this will be their first attendance at the ED. Ask them how you did, ask them about good and bad experiences in the past. In general they will tell you.

Lastly, another plug for the unbelievably fantastic podcast from Dr Gentile on pain management in the ED. Whilst not strictly about sickle disease you just know that if you did have sickle disease (or anything else painful) you would want Dr Gentile to look after you.

I am told that my posts might be too thought provoking where some people just want the answers. I think not. I’d rather write about things that we all find challenging. Where there are answers we can give them, but so much of our practice is dependent not just on the evidence but also on ourselves. We should never stop questioning the evidence, we should never stop questioning ourselves.

vb

Simon C

PS. This is our current management protocol for ‘unknown’ sickle patients. Time for a review I think, but even so this works pretty well at the moment. Advice on changes welcome.

EDP_2003-22_Sickle_Cell_Crisis

Giving bad feedback or giving feedback badly?

I find myself in an educators dilemma regarding feedback in the ED. I’ll try to explain why and please do give me your thoughts.

The first thing I have to say is that I agree with Greg Henry at ICEM2012 in that the amount of positive feedback given to colleagues should exceed the criticism. Greg suggested a 10:1 as a ratio, but as a more  reserved Englishman without the gregarious nature of some of my American colleagues I’m running at about 3:1, any more than that and you get put on antipsychotics on this side of the pond. Anyway,  to be honest the offering of positive feedback is fine. It makes me feel good, it makes the trainee feel good, and I usually try to do it in public so that everyone know about it. Great, fine, let’s park the positive stuff.

My dilemma comes with the negative feedback, how to feedback when things have not gone well and lessons are there to be learned. How do we go about this and where are the challenges that we need to identify and manage.

Perhaps an example will help.

One of your radiologists calls you to alert you to an X-ray that they think was missed as it looks as though the patient was discharged. The X-ray clearly shows a fracture of the talus so you pull the notes and indeed it was. The patient presented in an intoxicated state having fallen off a kerb and was complaining of an ankle injury. X-rays were taken, reported as normal on the day by the attending doctor and the patient was discharged with crtuches and ankle sprain advice. It looks as though they left the ED that night (5 days ago). So, you do the usual stuff, recall the patient, apologise, refer etc. The patient gets an operative repair and seems to do OK. So, I’m fine with the clinical care, but clearly an error has been made here and we need to do something about it. I guess three things could have happened.

  • The doc may not be able to spot a talus fracture due to simple incompetence.
  • They looked at the wrong X-ray.
  • They only looked at one part of the X-ray (the malleoli as that’s where they suspected the injury.

My question is how to handle the feedback to the doctor who saw the patient? I’ve seen many behaviours over the years in these situations. Interestingly I have seen some seniors not bother to tell the juniors that an error has been made. Usually this is to ‘protect’ the doctor from getting upset about making an error. Can this be right? Almost certainly not as it is important to learn from error, and also to understand how error takes place (which you cannot do unless you explore the circumstances). So how are you going to go about this in a way that promotes learning and development, and what do we want to happen during that feedback process.

I’m going to be controversial and contradictory here as I must admit that in my mind there are number of things that I want to achieve whilst giving the feedback.

  • 1. Discuss and understand what happened.
  • 2. Discuss what the consequences are.
  • 3. Potentially change future behaviour.
  • 4. Ensure that this makes them feel bad (really????).

I guess you were with me up until number 4?? Why would I want a colleague to feel bad with feedback? Well, it’s not that I ‘want’ them to feel bad, it’s because I want physicians to care, I want them to understand that our actions and decisions have consequences and that part of that consequence must be for us to be able to empathise and understand the effect of error with our patients. The doctor who does not care, dismisses the error on the basis of other’s failings, who moves on rapidly without pausing for thought worries me greatly…., but on the other hand the doctor who is devastated by hearing about an error, who loses confidence and changes behaviour in an abnormal way is similarly a failure of feedback, learning and development. The point is that there is an inevitability that a bad outcome for a patient will result in the doc involved feeling bad.

So, what are we to do  when faced with a question of giving bad news to a colleague. How do we balance the conversation and experience into one that ensures colleagues reflect and pause, without leading them to despair and a feeling of belittlement? I don’t want them to leave thinking that they have been told off, that’s not the point. It’s just that there is a difference between telling people off vs telling them that everything is fine, because everything is not fine and error is a fantastic learning tool. I think learning is most effective when the error matters to the physician. I’m not sure I have this right yet, but these are my top tips.

  • 1. Try and feedback near the start of a clinical shift. It is likely that confidence will be affected and it’s good to be able to observe this in the workplace where it can be dealt with. Keep an eye on your colleagues and make sure they are OK. They will probably be ruminating about what has happened and this can affect them in many ways.
  • 2. Recognise that the senior person who gives the feedback is unlikely to be the one that the junior will then come to for support immediately afterwards. They’ll usually find someone else first. If I feedback to a junior doc then the perceived power distance (on their part) often makes it feel more like criticism than development (whatever you say). Not sure how to avoid this apart from point 6 below.
  • 3. If you can, feedback with a colleague who will also be around on shift. If I’m feeding back to a junior doc I’ll do this with a middle grade doc as well, or at least tell them that an incident has occured prior to the shift. They are often then the person that the trainee turns to for support later that day.
  • 4. Follow up in a few days time to ask if they have any more thoughts on the events and even directly ask if it has changed their practice. You will be amazed how often it does, increased referrals, increased second opinions, inrcreased investigations are common after an error.
  • 5. Buy a box of tissues.
  • 6. Lastly, never underestimate the value of admitting and publicising your own errors amongst your colleagues. We all make mistakes but there is nothing worse than feeling that you are the only one. Build a culture that shares and learns from error and you’ll find feedback easier whichever side of the conversation you happen to be on.

Oh, and the Talus fracture in this case? Well the scenario was fake, it was me who missed it. A busy night when something went wrong, I think I looked at someone else’s X-ray whilst dealing with too many patients at the same time.  I got feedback from a colleague, I felt really bad about it (still do), I learned, I got better, I shared.

Simon Carley

 

1800 – tonight we have a short audio interview with one of my colleagues added to the post about getting yourself ready for feedback. Great stuff from Nat.Natalie May on tips to giving difficult feedback

Should POPs be mixed with Heparin?

We published an interesting BET in the EMJ earlier (open access version here) this year about the use of low molecular weight heparin for patients placed in below knee POPs in the ED. This is particularly pertinent to me as I have been unlucky enough to deal with several really nasty cases in the last few years.

Standby phone goes…….Young cardiac arrest on the way in…….as the doors to resus open you see the POP on the leg….and you know this is going to end badly.

Some of the conversations with the spouses and children of patients who have died young are memorable for all the wrong reasons.

So, there is no great surprise that the cause of death is inevitably massive PE, and this is where it gets interesting as we assume that this is a preventable death. If only they had been given prophylaxis then surely this would not have happened. Well, perhaps not as the event rate is low and heparin is not without it’s own complications, so what is the evidence?

Well, my colleagues Dan Horner and Cath Roberts found a pretty good systematic review on the subject that came to an interesting conclusion. The NNT for prevention of DVT is 14. Crikey, 14 people treated to prevent one DVT is a shocker to me as that reduction is a result of a big change on a very high event rate (>18% incidence of DVT in the placebo group)….but it’s one that I don’t see coming through the door of the ED. Considering the rate of POP applications in the fracture clinic next door if the rate was that high then why am I not swamped with fracture clinic patients with DVTs? A tricky question and I can only surmise, but arguably this is a different patient group to the spontaneous patients and as the BET states, the incidence of PE and fatality as a result of these rather common DVTs is low.

So, should we routinely treat? Do you routinely treat? Would this change your practice??

I must admit to having changed practice. I am much more likely to prescribe LMWH if there is even a sniff of a risk factor and no contra-indications and up until recently I’ve been using POPs much less frequently.

I’d also say that if I turn up in your ED with a broken leg that requires a POP I will be asking for the LMWH. I don’t think I want to risk a 1:5 – 1:6 chance of getting a DVT.

What about you? Would you, should you, could you, do you??

Simon Carley

New NICE guidance on Investigation of DVT in the ED

Is Venous Thrombo Embolism the most controversial area of EM practice at the moment? I think it might be as there is rarely a meeting or conference where the subject is not discussed and debated.

So is the National Institute for Clinical Excellent (NICE) here to rescue is from the controversies. Well yes, and of course no…..so basically no.

The new guidance looks to incorporate the Wells score together with d-dimers and USS scanning of the lower limbs to diagnose DVT and there is much to like in their approach. It has an element of pragmatism about it, stating that there are different approaches depending on what is available – I like that – I’ve seen too many guidelines that stipulate processes only available 9-5 Mon-Fri (when the people who wrote them work) and not enough that are similarly useful at 2am on a Saturday night.

So, what’s new. Well the two level Wells score is fine. Previous scores using high, moderate and low scores as originally described seem to confuse lots of people (why?) and in reality the important group to define is the low risk (or DVT unlikely group). The Wells amendment from 2003 seems to make sense and has already been adopted by other centres in the UK.

What else? Well the big difference to me is the early use of proximal scanning for DVT. Fine and dandy as a rule in test if available but above knee DVT scanning misses lots of calf clots. This means that we might get an early diagnosis of a proximal DVT without pursuing d-dimers, waits for blood tests and general delay. I like this if it is available and indeed it is a skill that emergency physicians can own, and it’s unlikely to cause problems.

However, I think it’s fair to say that there is some controversy about what to do about clots below the knee and as the guidance states the evidence out there is not great with just a handful of low quality studies to help us answer the question (see page 50 of the guidance). However,  my feeling is that if they are around then that’s useful to know. In the new NICE guideline scanning below the knee is not recommended in the algorithmn (though it is mentioned as an area for future research in the main text). If a patient is d-dimer positive but above knee DVT scan negative they go home and come back for another scan in 6-8 days to see if it has progressed.

Should we be worried about those 6-8 days without anticoagulation? Or is this a way of avoiding the potential risks associated with unnecessary anticoagulation? What would you do?

So what should we do in a centre such as ours with an excellent service that scans and diagnoses thrombolembolic disease throughout the lower limb venous system? My feeling is that we continue to investigate according to the best technology available. In my centre and several others this means that when we send a patient round for a scan we will be told whether or not they have a below knee DVT. I cannot then not know this information and I need to do something with it, it’s just really hard to ignore information once you have it and arguably very difficult to manage any future complaint or concern when there is an evidence trail back to you. So, I’d be really interested to know what others are doing with their below knee DVTs. Anticoagulate or not? If you do or you don’t who is driving that decision? You, your haematologists or your general physicians? My feeling having spoken to many EPs is that practice is really variable and that cannot be right for patients.

So, whilst the NICE guideline is good it is perhaps based on what is universally achievable rather than what is potentially excellent. Politically it is great when everyone is ‘equally excellent’ (whatever that means), but we all know that to not be the case. So for now I will aspire to be better than NICE and continue to take heed of clots in the calf…until some better evidence comes along at least (and I know a man who is doing just that as we speak @thegreathornero).

Simon Carley

EM as a career? Yeah, but no……

I have too many jobs!

Amongst other tasks I manage the foundation program for junior docs at my large university teaching hospital. I’m effectively responsible for getting them through the two years of their career with the hope that they will get signed off by the GMC and go on to greater things. I have great trainees, many are high achievers who will go far in whichever career they choose.

I’ve run the program for a few years now and unsurprisingly one of the things I have made everyone do is emergency medicine. All docs do at least 4 months of EM in my hospital. I think it’s good for them, it exposes them to a wide range of clinical problems and tests them to stand by their own decision about diagnosis, treatment and discharge.

So what’s this got to do with recruitment you might ask? Well, at the end of the two years I ask all the trainees which jobs they enjoyed, and as you would expect there are a variety of answers, but it’s perhaps surprising that about a third rate EM as their most interesting and rewarding placement.

So would they consider it is a career I ask?

The responses are consistent and worrying for those of us who are seeking to nurture the next generation of EPs in the UK. Despite their interest in the clinical work, hardly any trainee considers EM as a career choice, and it’s not because of the clinical practice. They love the team working, the unpredictability, the frequent and rapid patient contact. It’s the working conditions, the lifestyle and the career prospects that’s putting them off.

Why they ask should I do EM as opposed to something like medicine or general practice? Fewer weekends, fewer evenings, easier exams……, same pay.

Pay does seem to be a major motivator for todays young medics, but not in the way I originally thought. It’s not so much the amount but the fact that there are no differential pay recognition for those who work the hardest, and at the most socially disruptive times of the week. Why would you do our job for the same pay as your friend who only works every 10th weekend (whilst you do every 2nd). It’s not the absolute amount, rather its the fact that it does not matter which speciality you train in, and indeed practice as a consultant in, the pay and financial reward is the same. So how we find a way of valuing the extra effort and disruption that a trainee embarking on a career in EM takes on? I’m not sure that I can think of many that are not financially orientated. Perhaps time off? More holidays so that we can retain some of our excellent oversees trainees who struggle to find time on busy rotas to travel home to see their families? Ideas please.

But is this not the case with many there specialities? Are there others where personal sacrifice is required as a junior in order to get to the top? Of courses there are. Plastic surgery is a good example where competition is fierce and additional effort is expected with a long and challenging training program…but the rewards at the end are potentially enormous. Not so in EM, there is little or no private practice to rival that of the plastic surgeons nor the prospect of leisurely on calls as a consultant as increasingly EM consultants are moving towards the very same 24-hour rotas that is putting off the juniors.

We are already in a staffing crisis in EM. Consultant posts remain unfilled, Middle grade rotas have been decimated in many departments and trainees in our early training programs are leaving EM for the less onerous and disruptive specialities such as anaesthetics.

What then can we do? A starting point would be to recognise the additional disruption that training in EM causes to the individual and their family. The UK Government is consulting on the idea of differential pay depending on where you work. Perhaps the time is now for us to give additional reward to the hard working trainees in emergency medicine. Perhaps that might convert some of my enthusiastic and brilliant trainees to stay in a speciality where they love to work, and one in which they feel rewarded for doing so.

Simon Carley

Tranexamic acid needs a make over

I was listening to the EMCRIT podcast today. As usual it was absolutely excellent, but on this occasion it was especially superb as Scott Weingart was joined by the wonderful Prof. Tim Coates from Leicester. Tim is an inspiring EM researcher and speaker who also happens to be largely responsible for one of the largest RCTs in Emergency Medicine history; CRASH-2. Now, this is no time to go over CRASH-2 again. The bottom line is that tranexamic acid is both cheap and fabulous for the treatment of major trauma patients.

We should give it, we should pretty much always give it and neither he nor I know why clinicians have not adopted it as widely as it should. Actually, that’s not entirely true, I have a theory and that is that it’s just not ‘cool’ as a treatment.

?

What do I mean by ‘cool’? Well it’s just a feeling really based on practicing medicine for many years. When new treatments come into practice we clinicians (and especially EPs with our love of shiny things), love them to be exciting, difficult, even perhaps dangerous. Think of the excitement around stroke thrombolysis in previous posts that seems to based on little evidence. That requires CT scans, expert opinions, senior input, expensive therapies and in our neck of the woods transfer to another facility. It’s difficult, it’s expensive, it’s dangerous….it’s ‘cool’.

Tranexemic acid is not cool. It’s dirt cheap and can be given by any doc in our department.

Just as aspirin used to get missed in the rush for thrombolysis for MI (in the days before PCI) we are now missing TXA in the rush for Whole Body CT, Shock packs and advanced transfusion management. I see history and wonder what we can do to help.

So, how do we make TXA cool? I sometimes think that if I lock it in the controlled drugs cupboard next to the tPA and the Ketamine then tell everyone that it’s potentially fatal and scare them half to death it might get used more often. Perhaps if someone raised the price to £500 a shot we might think of it more often? Obviously that’s ludicrous but we need to do something.

TXA needs a make over, any ideas?

…….but what else? Where do we go next with TXA? If it works in major trauma then what about other bleeding disorders? What will CRASH-3 which will look at TXA in head trauma tell us?  Then what might CRASH-x tell us in the future? Who knows but I was quite surprised to see that there is already evidence out there for it’s potential use in GI Bleeding in this BestBet from the Royal London Hospital. Not convincing but promising enough for consideration in the future?

I think so.

Simon Carley