Category Archives: Med Ed

Medical education

The POP, the chief, his risk assessment and her thrombprophylaxis…

So, we’ve already talked about this. But changing times call for changing posts. And we want to know what you think…

A 30 year old comes in 10 days after being put in an equinus POP for an Achilles rupture. His leg hurts more now than ever. You split the pop – swollen to mid thigh. Whole leg CUS shows a popliteal thrombus. Oh dear. 3 months of warfarin for you, my boy.

The next one out of the box is a 29 year old mother of 2 with a similar injury. She is on the combined oral contraceptive pill but otherwise has no risk factors for VTE. You ask for an equinus cast. She is half way out the door.  But then you stop to think. And you scratch your chin. And you ponder…

Thromoboprophylaxis for ambulatory limb trauma is not a new idea. The French and Germans have been interested in this for ages. There are individual centres in the UK that have tried to tackle the problem head on (and also provide nice slides to say how – good FOAMed even prior to its inception!).  Both NICE and ACCP recognise the issue, but fall short of digging into it based on potential issues with the evidence (see below for the NICE effort). Some people even think it’s not a problem. But we keep seeing harsh lessons in both the media and medical literature. So we need to ask ourselves – how can we manage this issue in an evidence based way?

There is actually a lot of evidence for perusal, including several systematic reviews and a well conducted meta-analysis. As well as this, there are loads of studies from different countries looking at incidence and reiterating the issue: a certain proportion of ambulatory trauma patients discharged in POPs, wherever they are, whoever they are and whatever their injury, will develop VTE. As a global specialty, we should be on top of this.

One of the difficulties with the evidence is trying to segregate the data that applies directly to our patients from the mass of heterogeneous papers looking at post-op patients. I would suggest the evidence is already there to support extended prophylaxis in the majority of patients who have had orthopaedic surgery. What I want to know is: does the plaster on its own warrant prophylaxis?

I think it does. Along with some Virchester colleagues I have recently had the pleasure of reviewing all the evidence and attempting to provide a pragmatic appraisal and translate this into a workable guideline. The result is a 2 page clinical decision support tool (And a lot of additional light reading) recently endorsed  by the UK College of Emergency Medicine – it is front page news at the moment but will be easily found in the guidelines section when the buzz dies down.

Some people have worried about potential morbidity from use of prophylactic anticoagulation. I think the evidence suggests that low molecular weight heparin (LMWH) in prophylactic dose is actually fairly harmless to the majority of these punters, provided you use it properly. And I think any DVT (including distal/calf) is something to be avoided. The risks of untreated thrombi include propagation, embolization, post thrombotic syndrome, symptomatic progression and impaired fracture healing. I’ll take a few weeks of LMWH over that lot any day thank you very much.

Does everyone need it? – probably not. There is good evidence to suggest that low risk punters (those with minor injuries/no fracture/no POP/no additional risks for VTE) will probably have a low chance of subsequent VTE.  But the main thing we wanted to try and change with this guideline is the thought process. Think #/POP?  – think risk assessment for VTE. You’ll be amazed how many 25 year old women say yes to the COCP/Smoking/FH/Long haul travel next week if you take the time to ask them about it properly.

Where next? I know the Dutch are currently in the throes of evaluating Nadroparin in a large sample size for this very indication. I know people demand and expect a higher level of evidence prior to establishing as routine what may involve a significant cost and a degree (likely very small) of morbidity. I personally also think the new oral anticoagulants (NOACs) might have a role to play here. Anyone keen for an international multicentre trial should get in touch – we could knock that out in no time with the right support and funding.

But until this evidence comes, I think there is enough overall to warrant strong consideration on an individual basis. I personally don’t need to see a flawless systematic review to make me think a treatment may benefit my patient. I need to see face validity, a reasonable level of evidence of benefit and a reasonable level of evidence suggesting little harm from the intervention.

Have a read and see what you think. Very very interested to know your opinions and happy to field any queries anyone might have.

And remember – POP in the ED? Think VTE. Don’t let your patient end up RIP. Like the Notorious BIG. Or Eazy E. Or Heavy D. Or ODB.

But not Warren G.

Fo’ real.

Dan

You Snooze, You Ooze: Anticoagulation and Minor Head Injury

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We’re lucky to have NICE guidelines in the UK.  A couple of years ago, on a visit to the US, one of my collaborators from the US mentioned how jealous he was that we have them.  His practice was to get a CT scan for everyone with a head injury.  The NICE guidelines give us a framework for implementing evidence-based decision rules like the Canadian CT head and CHALICE rules on a widespread basis.  One area I think the NICE guideline for head injury can improve, however, is for anticoagulated patients with minor head injury.

 

The NICE guideline suggests that we scan head injured anticoagulated patients who have lost consciousness or have amnesia.  In the absence of other high risk features, however, the remainder of patients are potentially eligible for immediate discharge without even so much as an INR check.  This makes me worry. 

 

Unfortunately, the Canadian CT head rule can’t really help us out here because that study excluded patients with coagulopathy.  The New Orleans rule didn’t exclude coagulopathic patients but their analysis was, shall we say, somewhat underpowered as they only had 1 patient with coagulopathy in the study!  So what is the evidence behind managing head injury in anticoagulated patients?

 

Fortunately, we do have some evidence, although it’s relatively limited evidence if we’re honest. A case series of 144 patients demonstrated that the incidence of clinically important intracranial injury in warfarinised patients was 7%.  For me, that’s a sufficient risk to prevent me from ruling out a bleed in this group and to make me want to request a CT brain.  Roughly 7% of patients with chest pain who have a normal ECG are having an acute myocardial infarction.  But I wouldn’t dream of ruling out AMI just because the ECG is normal.  So neither should we consider ruling out intracranial haemorrhage at that level of risk.

 

What’s more, anticoagulated patients who develop an intracranial haemorrhage may not meet the NICE criteria for CT (which are based on the Canadian CT head rule, incidentally).  This means that they can bleed despite being relatively asymptomatic.  And a subtherapeutic INR doesn’t mean we can relax either, as shown in this great study from John Batchelor and Simon Rendell from my own institution.

 

OK, so we’re going to get a CT for these patients.  I’ve sold you that, right?  But if the CT’s normal, surely we can relax.  Right?

 

This great small study from Annals of Emergency Medicine sheds some light on that situation.  The authors implemented a protocol to immediately CT all warfarinised head injured patients, observe them for 24 hours, then re-scan them.  Of 97 patients, 87 agreed to stay in for observation and have a repeat scan.  5 (6%) of those patients had a late bleed, not detected on the initial scan.  OK, it was minimal in 2 patients.  But 1 required craniotomy.  What’s more, only 1 of those 5 patients had showed signs of neurological deterioration in the 24 hour period between scans.  2 further patients developed late bleeds even after a normal scan at 24 hours.   So, this study definitely tells us that there’s an important incidence of late bleeding in anticoagulated patients.  Not only do we need to strongly consider scanning these patients, but we also need to consider repeating the scan 24 hours later, even in the absence of neurological deterioration.  What’s more, the symptoms reported by the patient may not be a great predictor of intracranial bleeding.  Only 1 of the 6 who bled reported a severe headache, and only 1 was vomiting.  If we rely on our patient becoming symptomatic during the period of observation, we may still miss some late bleeds.

 

Of course, this is just one study.  Other studies do confirm that there’s an incidence of late bleeding in anticoagulated patients, although it may not be quite as high as 6%.  However, what’s clear is that these patients ooze, and they ooze slowly.  Of course, we don’t want to miss a bleed, if present, initially.  Given the prevalence of bleeding at the time of presentation, I suggest that we should still scan these patients at presentation.  But we should also be alert to the possibility of late bleeds.

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From discussions on Twitter, I know that people are doing this after 6 hours rather than 24.  There’s no evidence to definitively tell us which strategy is better.  In my practice, I’ll be strongly considering an initial scan, an INR scan, a period of observation and a repeat scan after 24 hours.  It’s not clear whether that’s the optimal strategy.  What is clear is that we must be extremely careful with these patients.  They bleed.  And they bleed late.

 

So, what about reversal of the anticoagulation?  Well, that’s a whole different debate – you’ll have to watch this space!…

 

Rick Body

You Snooze, You Ooze: Anticoagulation and Minor Head Injury

We’re lucky to have NICE guidelines in the UK.  A couple of years ago, on a visit to the US, one of my collaborators from the US mentioned how jealous he was that we have them.  His practice was to get a CT scan for everyone with a head injury.  The NICE guidelines give us a framework for implementing evidence-based decision rules like the Canadian CT head and CHALICE rules on a widespread basis.  One area I think the NICE guideline for head injury can improve, however, is for anticoagulated patients with minor head injury.

The NICE guideline suggests that we scan head injured anticoagulated patients who have lost consciousness or have amnesia.  In the absence of other high risk features, however, the remainder of patients are potentially eligible for immediate discharge without even so much as an INR check.  This makes me worry.

Unfortunately, the Canadian CT head rule can’t really help us out here because that study excluded patients with coagulopathy.  The New Orleans rule didn’t exclude coagulopathic patients but their analysis was, shall we say, somewhat underpowered as they only had 1 patient with coagulopathy in the study!  So what is the evidence behind managing head injury in anticoagulated patients?

Fortunately, we do have some evidence, although it’s relatively limited evidence if we’re honest. A case series of 144 patients demonstrated that the incidence of clinically important intracranial injury in warfarinised patients was 7%.  For me, that’s a sufficient risk to prevent me from ruling out a bleed in this group and to make me want to request a CT brain.  Roughly 7% of patients with chest pain who have a normal ECG are having an acute myocardial infarction.  But I wouldn’t dream of ruling out AMI just because the ECG is normal.  So neither should we consider ruling out intracranial haemorrhage at that level of risk.

What’s more, anticoagulated patients who develop an intracranial haemorrhage may not meet the NICE criteria for CT (which are based on the Canadian CT head rule, incidentally).  This means that they can bleed despite being relatively asymptomatic.  And a subtherapeutic INR doesn’t mean we can relax either, as shown in this great study from John Batchelor and Simon Rendell from my own institution.

OK, so we’re going to get a CT for these patients.  I’ve sold you that, right?  But if the CT’s normal, surely we can relax.  Right?

This great small study from Annals of Emergency Medicine sheds some light on that situation.  The authors implemented a protocol to immediately CT all warfarinised head injured patients, observe them for 24 hours, then re-scan them.  Of 97 patients, 87 agreed to stay in for observation and have a repeat scan.  5 (6%) of those patients had a late bleed, not detected on the initial scan.  OK, it was minimal in 2 patients.  But 1 required craniotomy.  What’s more, only 1 of those 5 patients had showed signs of neurological deterioration in the 24 hour period between scans.  2 further patients developed late bleeds even after a normal scan at 24 hours.   So, this study definitely tells us that there’s an important incidence of late bleeding in anticoagulated patients.  Not only do we need to strongly consider scanning these patients, but we also need to consider repeating the scan 24 hours later, even in the absence of neurological deterioration.  What’s more, the symptoms reported by the patient may not be a great predictor of intracranial bleeding.  Only 1 of the 6 who bled reported a severe headache, and only 1 was vomiting.  If we rely on our patient becoming symptomatic during the period of observation, we may still miss some late bleeds.

Of course, this is just one study.  Other studies do confirm that there’s an incidence of late bleeding in anticoagulated patients, although it may not be quite as high as 6%.  However, what’s clear is that these patients ooze, and they ooze slowly.  Of course, we don’t want to miss a bleed, if present, initially.  Given the prevalence of bleeding at the time of presentation, I suggest that we should still scan these patients at presentation.  But we should also be alert to the possibility of late bleeds.

From discussions on Twitter, I know that people are doing this after 6 hours rather than 24.  There’s no evidence to definitively tell us which strategy is better.  In my practice, I’ll be strongly considering an initial scan, an INR scan, a period of observation and a repeat scan after 24 hours.  It’s not clear whether that’s the optimal strategy.  What is clear is that we must be extremely careful with these patients.  They bleed.  And they bleed late.

So, what about reversal of the anticoagulation?  Well, that’s a whole different debate – you’ll have to watch this space!…

Rick Body

Are they laughing at me?

As the world becomes smaller and our populations more multicultural (Yes I am a “Lefty” Mr Burley)… so communication in our emergency departments becomes even more crucial.

Last week whilst working in the UK, I was involved in the care of a young refugee from Eastern Europe who had not a word of English at her disposal. I’m sure everyone has had a consultation where very little in the way of effective communication has taken place – you try charades, signing, talking loudly and clearly in English and smiles…. But in the end, all that time you put in to learning history taking skills at university  – useless.

Now, in the ED we are used to a lack of information…. (Indeed I think if I have more than 70% of information on which to base a decision I fall into a apoplexy of indecision)…and that is OK; if you know that’s all you’ve got. But it becomes incredibly frustrating when you want to do the best you can for a vulnerable patient and you know your missing vital information because you just can’t get the message through a language barrier.

Back to the patient…There are not many people who can effectively communicate in Baltic state languages in our department so I attempted (for the first time) using “Language Line”. For those that don’t know – this is a telephone service that allows you to contact a translator for any language in the world (except perhaps some dialects in the North-east of the UK!). Once you have you have your translator you then spend an incredibly long time passing the phone between yourself and the patient whilst the person on the other end translates ever more personal information (all in complete confidence – so we are told – and with patient consent).

This is great, a revolution. Instant understanding. Verbatim translation…..Except… those moments when – and you’ve no doubt know it – the patient and translator have an incredibly long conversation and perhaps share a laugh…… and you get a classic one word translation in response.

You wonder… What were they talking about? Were they laughing at me? Have I got some food left around my mouth? And you start to get a bit uncomfortable….

Probably more important you think –  have I missed something?

So, the translator and the patient have a rapport, they share a laugh (perhaps at my expense) but you get a history to write down and everyone’s happy…. Except the real history is often hidden in the nuance of communication – the way something is said, the unspoken words, the carefully selected words, the language.

And we do miss vital information….

A very interesting paper from South Africa by Penn et al. has attempted to characterise the information we miss in translation. But, hold onto your hats it’s Qualitative Research.

From the outset I will say that its not specific to the ED, but the findings are interesting and can be related to translation of all sorts.

What the authors did was record healthcare interviews performed “pas de trois” (their French term not mine), i.e. doctor-patient-translator. Using the interview transcripts they have then decided selected what they term “asides” – times when the translator and patient communicated between themselves and not involved the doctor. They have then taken these asides and classified them as “big talk” (topics like patient beliefs about illness, relationship issues, disclosure issues) or “small talk” (topics such as transport, weather, clarification requests).

Asides were rarely translated for the doctor (even when directly asked)…. And here’s the thing – these nuanced conversation pieces were judged to contained vital health related cues that were never triggered by the doctor in the rest of the consultation. For example, in one consultation a patient discloses information  regarding who has knowledge of her HIV status – and the fact that a partner might not know, which was never relayed to the doctor.

These were issues that gave insight into the patient’s true agenda but weren’t brought out in direct conversation only these non-interpreted “asides”. The treating doctor was left none-the-wiser. Being qualitative there are no hard outcome measures – just developing of these themes…however, this is all interesting stuff because it gives us 2 useful insights:

  1. That we must beware of the translated consultation – we are missing the point!!
  2. History taking (even in your mother tongue) is more than just about asking textbook questions – patients are constantly giving us social cues and clinically important information from each and every aside…. We had better be listen carefully.

So next time you’re in a translated consultation and the patient and translator laugh at you… They probably are laughing at you… But be sure to ask why…

@tombartram

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.

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.

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

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

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.

 

 

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