Author Archives: Simon Carley

The Critical Appraisal FCEM exam

If you are planning on being an emergency physician in the UK then you will probably be thinking about trying to get through the FCEM exam. At the current time that means that you are going to have to pass the critical appraisal component. This is a 90 minute written exam which you have to pass if you want to get those magical post nominals and your ticket to a consultant post. But…..

…….lots of people fail the critical appraisal exam. Why?

Well, because they don’t answer the questions obviously, but it’s perhaps a bit more complex than that as having seen some of the answers and having done loads of practice sessions over the last few years there are common errors that candidates make. So, here are a few tips on how to get through the exam, these are my thoughts alone and they do not represent anyone else (and especially not the College).

1. Read the online guide to the critical appraisal. Have a look at past questions and common errors. Notice how often the same errors seem to get made in each round of exams!

2. Practice, practice, practice. If you don’t read papers on a regular basis then start now. You really need to do this in a group so if you don’t have a journal club start one. There are loads of models out there, choose something that works for you. This link is our original model from 1998!!! which is still not a bad way to start.

3. Don’t try and be clever. Lots of people want to use big words and technical terms when the question doesn’t ask for it. If  you get asked to explain something e.g. blinding, then explain it. Don’t try and list 15 sorts of Bias that blinding hopes to avoid. Just answer the question in terms that you would use to a colleague (the examiners are your future colleagues so explain in those terms).

4. Look at the size of the area on the sheet given for the answer. If the answer area on the form is a small box the clue is that the examiners are looking for a short answer. If you find yourself writing outside of the allocated space you are either a – writing with a crayon or b – missing the point of the question.

5. A major part of the exam is writing an abstract which will have been blanked out. This can be tricky and it’s easy to get waylaid. My advice is to use the standard Objectives, Methods, Results, Conclusions format. Make sure these link up! Crazy people have an objective that does not match the results, which is a separate point to the conclusion. Don’t do that. Start with the Aim as stated by the authors. This will give you the objective AND tell you what you should be looking for in terms of the principal finding for the results, that then leads nicely into giving you a conclusion.

6. There will only be two sorts of papers. Theraputic (prob an RCT) or diagnosis. Focus your practice and learning on these types of papers.

7. Learn some basic stats terms that you can explain to a colleague. You don’t need to know hard stuff but the basics should be there. If you want a basic guide to stats for crit app then you can listen to a few old stats lectures we put together specifically for people aiming at getting through a critical appraisal test. Stats 1 ; Stats 2 They are bit old and were early attempts, but if you find them useful that’s great.

8. Don’t talk about stuff you don’t understand. Randomly inserting words that you think might be relevant without understanding them rarely helps.

9. Write clearly. Candidates in a VIVA can explain if something is unclear. In a written exam you have to be able to read and interpret what is on paper. Make sure it makes sense.

10. Write like a pharmacist, not like a doctor. If it cannot be read, it cannot be marked. Similarly one quote I do like from recent feedback is self explanatory

    • Many candidates wrote correct statements – but they were not relevant to the answer…..

So. It’s not a difficult exam if you already do critical appraisal as part of your practice and if you regularly read papers. It’s an easy exam to pass, but also easy to fail if you try and be too clever or technical.

 

 

Rabies management in the ED.

Interesting article in the Journal of the Royal Army Medical Corps on the management of Rabies. Now, we don’t get a lot of Rabies in Virchester, but the weather is so terrible here lots of our patients come back having been bitten by dogs in foreign climes.There was even a death recently in the UK from Rabies contracted abroad. Apparently the patient was sent home from the ED at one point which got the media excited (though the details were somewhat more complicated).

A few key points to pick up.

1. Don’t forget to treat the wound as a bite. Obvious, but you can get so caught up in the rabies question that you forget about the basics.

2. Get advice from the HPA or local communicable diseases experts. They know more than you do!

3. Know where you can access Rabies immunoglobulin and vaccine.

As an extra thought don’t forget that European Bat Lyssavirus does occur in the UK and you should think about this in people who handle bats and occasionally in fly fisherman who may catch a bat on the wing whilst fishing.

Simon Carley

The wise thirsts for questions, not answers!

The following post displays comments from tweets about speakers at the 14th ICEM in Dublin in June 2012.

Some reflect evidence-based medicine, some just personal practice supported by expert opinion only.

We post these in order to generate reflection and lateral thinking.

Remember: The wise thirsts for questions, not answers!

Ruben Strayer:

Cricoid pressure is futile during during RSI

Modified/delayed RSI in order to improve pre-oxygenation prior to paralysis: sub-naesthetic dose of ketamine in agitated patient to allow oxygenation

A failed cricothyroidotomy performed at the right time is defensible but a successful one perfomed too late is indefensible

Apneic oxygenation: leave the nasal cannula on the patient while you are intubating (oxygen diffusion)

Ron Walls:

Is it ethical to teach direct laryngoscopy on critically ill patients given the superiority of video devices?

Emanuel Rivers:

52% of septic patients are coming from EDs but the mortality is the lowest in this group when compared to those originating from somewhere else

What is important is not the amount of fluid you give but how quick you give it

10% of septic patients have a normal lactate

Lactate as a marker of severity is great but in conjunction with other markers of sepsis

EGDT better late than never!

Ian Stiell:

Today’s EPs are not interested in EBM unless in the format of an app or in less than 140 characters

Tim Harris:

Urgent thoracotomy is to be performed in witnessed traumatic cardiac arrest. If you cannot do one, you should not be receiving trauma

Major trauma is rare and it is therefore difficult to become an expert

Tim Coats:

Gelofusine impedes coagulation more than normal saline

Mattu:

Chest pains in the elderly is associated with belching in 47% of cases

Cameron: 

Victoria immobilizes 50,000 C-spines for 20 unstable fractures per year

Greg Henry:

Management is doing things right, leadership is knowing the right things to do

Cadogan:

The purpose of research is to induce change, not to get published!

Jones:

Epinephrine is the second agent of choice after norepinephrine in sepsis (or vasopressin)

Cantor:

Procedural sedation good quality indicator of an ED

Greg Henry:

Give good news in public, criticise in private. Compliment ten times more than you criticise

Unattributed:

Midline bony tenderness lacks sensitivity and specificity for cervical fractures (U/K)

CT scan sensitivity for spinal injury 98% vs x-rya 58% (data from trauma centres) (U/K)

Anaphylaxis in the patient on beta-blockers: add glucagon –it will activate cGMP directly (U/K)

Since the 2005 ALS guidelines, the survival of OHCA has risen from 27% to 50% (U/K)

One needs to read 17 articles/day to keep current in EBM (U/K)

Patients with high BP post-arrest do better: it improves cerebral micro-circulation (U/K)

Experimental evidence suggests that therapeuthic hypothermia best started within 5 hours of the arrest (U/K)

If you are an idiot offline, you will be an idiot online (U/K)

If you have no internet presence at all then anyone can control your internet presence (U/K)

The visual connection with the patient is essential. If the physician cannot see the patient, the patient stays longer in ED (U/K)

If you train exclusively in one country, you will not appreciate where EM is globally! (U/K)

There is pressure on EPs to give up some of their work because there is not enough of them. Does anyone else do it better? No! (U/K)

We agree that children are not just small adults. But older children do behave like adults in trauma! (U/K)

Traumatic cardiac arrest: no adrenaline, no CPR.  O2, ventilate cautiously, bilateral thoracotomy! (U/K)

Recognising ambulatory care sensitive cases: a solution to overcrowding? (U/K)

 

Tweets collected by Janos P Baombe

ON POST-EXPOSURE PROPHYLAXIS: a diet PEPSE served on ice

You are on a busy shift in ED when a young man in his twenties presents after having being triaged with a “personal problem” he would not disclose in triage. He has asked to see a senior doctor urgently.
When alone, he discloses unprotected oral intercourse two days ago in a local sauna for gay men. He was the recipient and there was no ejaculation involved. The details of the sexual practice itself baffle you and the patient is requesting PEPSE (post-exposure prophylaxis following sexual exposure).
You scratch your head, as the area you work in is known to have a low HIV prevalence and you are unsure if the described rather unusual sexual intercourse is in itself an indication to start PEPSE.

The British Association for Sexual Health and HIV (BASHH) in the UK have recently revised its guideline on who should receive PEPSE following sexual exposure.
The guideline is based upon a comprehensive review of the literature and the recommendations are based upon a combination of biological plausibility, cohort studies, data from PEP in other settings and expert opinion.

This is clearly a crucial decision for the patient presenting to ED at 2AM and potentially a difficult one for the EP if not aware of the guidelines or the local prevalence of HIV in his/her area of practice.

The risk of an individual acquiring HIV following an exposure is dependent upon the risk that the source is HIV- positive where unknown and the risk of infection following a specific exposure from an HIV-positive individual:
The risk of HIV transmission can therefore be calculated. Risk of transmission = risk that source is HIV-positive X risk of exposure
Knowledge of local HIV prevalence rates will clearly assist in calculating the risk of transmission and cumulative risk should be considered for repeated exposures.

It is worth mentioning that the probability of HIV transmission depends upon the exposure characteristics (anal, oral or other types of sexual practice), the infectivity of the source (viral load) and host susceptibility (immunosuppression). Some factors increase the risk of transmission like the presence of ejaculation, the presence of genital ulceration, the viral load, the absence of circumcision etc.

PEP is not 100% effective and individuals have acquired HIV despite commencing PEP following both occupational and sexual exposures. Delayed initiation of PEP, presence of resistant virus in the source, different penetration of drugs into tissue compartments, poor/non-adherence and further high- risk sexual exposures may explain some transmissions.

Adherence and completion rates to the recommended four weeks of PEP among health-care workers and individuals exposed non- occupationally have been historically poor for several reasons.

There have also been concerns that the availability of PEPSE will reduce commitment to primary prevention strategies (the use of condoms) and consequently result in more frequent high-risk behaviour.

It is essential that emergency physicians perform a risk versus benefit analysis for every individual presenting following an exposure and the decision to initiate PEP is made on a case-by-case basis.
This should consider both the risk of transmission according to exposure and the risk of the source being HIV-positive as well as the viral load in the source if known (this is clearly difficult to ascertain in most of the ED cases).

The writing committee recommends that PEPSE is indicated when the estimated transmission risk is 1 in 1000 or greater.
The same committee also feels that when the exposure is classified as ‘consider’, PEPSE should only be prescribed if there are additional factors that may increase the likelihood of transmission, i.e. following sexual assault, in the presence of an STI (i.e. where the source is known to have an STI or the exposed individual has symptoms or signs suggesting an STI) or where the source is suspected to have acute HIV infection. www.bashh.org/documents/4076

Given that, for optimal efficacy, PEPSE should be commenced as soon as possible after exposure, 24-hour access has now been made be available nationwide in the UK.

Emergency physicians therefore assume significant responsibility for provision of PEPSE, with the need for support and training from areas of local expertise.

It is recommended that individuals presenting for PEPSE should be referred and seen as early as possible by a clinician or team experienced in the management of PEPSE and with expertise in HIV testing and transmission – whether or not PEPSE is offered or accepted.

Take home message:
1. familiarise yourself with your national/local protocol for PEPSE (it is not difficult with 24h internet access)
2. know your local HIV prevalence (get yourself bleeped out of the consult room by your nurse and google it)
3. a systematic and professional approach in the often sensitive details of sexual practice is essential (who knows, you might come across something you could put into practice at home with your partner!)
4. ask for specialist help if in any doubt (pick up that phone and call a friend!)

Janos P Baombe

COWs

We’ve been running cases of the week for quite a while now, though there was a bit of a pause when the world got busy!

Anyway, the COWs are just snippets of interesting cases that have come through the ED and which have lessons that need to be shared. We often say that there is never a boring day in the ED. Somewhere, someone is dealing with a patient or problem that’s fascinating, original and exciting…..the problem is that the person involved may not be you, and that’s a problem. Although I advocate evidence in clinical practice there is no point in trying to practice EBM without patients, cases and clinical conundrums. We absolutely need patients, and in particular patient narratives to tell contextualise evidence and to make it real.

So, COWs are sort of like show and tell with a message. They are/will be something that we found interesting with a few learning point or questions. Some will be simple, some FCEM level, some stupidly bizarre.

Hope you enjoy them and feel free to share.

For starters give this a whirl.
http://www.stemlyns.org.uk/case/caseDetails.php?tabID=3181

Simon Carley

#ICEM2012

Following on from the amazing twitterfest at the International Conference of Emergency Medicine in Dublin I think there will be many emergency physicians updating, revising and expanding their online presence.

There is no doubt that social media can have a positive effect in medical education and research and I think that I may have been lucky enough to be present at the start of something big…..or maybe it’s always been there but I’ve never realised it before.

So, what can we do in Manchester?

Ideas are overflowing after meeting such fantastic people in Dublin, but rather than create something entirely new the way forward will be to find a way to distribute the incredible learning that takes place behind closed doors at StEmlyns (1,2), and of course to find ways of disseminating the evidence from BestBets out to a wider audience.

Time for some distributed thinking.

S

1. http://classroom.stemlyns.org.uk
2. http://www.bestbets.org
3. http://www.stemlyns.org