In our third Redthread special we talk to a Young Person helped by the charity. He takes us through his own teachable moment and the help that Redthread offered him. We also have David Bentley from Redthread and QMC ED Sister Janice Morgan both giving their perspective of how the Young Person was helped in an inspiring story.
In this second Redthread special we were joined by Hannah Yates, the Business Development Manager for Redthread and Imran Mohammed, Programme Manager for Redthread in the Midlands. In this episode they take us through:
The background of Redthread
The Public Health approach used by Redthread
How Redthread has spread nationally and the political interest it’s inspired
It was great when Freya, David and Richard from the Redthread team at the QMC Emergency Department came down to record the first of three podcasts with us.
Redthread is a charity working with young people to help them lead happy, healthy and safe lives. Key to this is the teachable moment, the moment a young person is in an Emergency Department and can be shown the way to turn their life around. Since starting in London over 20 years ago they have since expanded into Nottingham and now Birmingham too!
In this episode the team tell us about their own backgrounds, how they came to Redthread and how Redthread came up to Nottingham. They then take us through their day-to-day work and the help they can offer vulnerable young people. There's advice along the way as well as chat about Curlywurlies!
For more information visit the Redthread website
In this special episode Senior ACP James Pratt joined the podcast to talk about Advanced Clinical Practitioners in ED. This is a topic he's talked about before at various conferences and meetings. At EM2C 2018 he started his talk rather impressively:
James and Jamie talk about:
- What is an ACP and what their job role entails
- James' own career and the development of the ACP team at the QMC Nottingham
- What the Nottingham ACP course consists of and the course entry criteria
- Issues in the development of the ACP team and how these were approached
- Potential areas of future development
There's an emphasis on the education and time required to create the ACP service and how this is not a short term solution to staffing issues but rather a long term investment in our staff
For more information on the ACP course at the University of Nottingham you can visit the course page here
For more information on Advanced Clinical Practitioner Educators you can visit the Association of Advanced Clinical Practitioner Educators website here
We're looking make more podcasts on advanced practice in the future so please get in touch with any suggestions!
Here are the slides. As ever just click to scroll through them.
- Why bullet points are bad (irony)
- How to storyboard - spark points and lightning slides
- The science of presentations - cognitive overload, the three second rule, the rule of thirds and dual coding
- How to present data
Here is the Take Visually for this episode:
For more information on learning theories (and why it's wrong to think about 'types' of learners) check out Learning Scientists.
Good luck telling people of the amazing things you've seen.
In this podcast Dr. Harry Pick, Respiratory Registrar and Clinical Research Fellow at Nottingham University Hospitals NHS Trust came down to talk us through Chest X-ray Interpretation; a key skill in the Emergency Department!
Harry very kindly gave us a copy of the Powerpoint he uses when he teaches this topic; due to confidentiality reasons these slides don't have X-rays on them but great resources can be found at Radiology Masterclass. Click either side of the pictures to move through them.
Remember the step by step approach:
Right patient; day and time? - this is key for all investigations.
Is the film AP (anterior to posterior) or PA (posterior to anterior). This matters for two reasons. Firstly, an AP film tends to be an portable CXR and so tells you that the patient was sick when it was taken, this may be confirmed by the presence of chest leads, O2 tubes and central lines on the film. Secondly AP films exaggerate the size of the heart and so you cannot comment on cardiomegaly. You can on a PA film. In a healthy individual the heart should be no more than 50% of the thoracic width on a PA film. If the scapulae are not projected into the chest assume it is a PA film. It should always say if it is an AP film.
'RIPE' - Rotation (equal space between medial aspects of clavicles to spinous processes), Inspiration (>7 anterior and 9 posterior ribs, Picture (can you see everything you want to see?) and Exposure (can you see vertebral bodies behind the heart).
Then remember ABCDE - this varies - the Take Visually below follows Airway, Breathing, Circulation, Diaphragm and Everything else.
Harry's ABCDE covers the same things but in a different order - Apices, Behind the heart, Cardiophrenic and Costophrenic angles, Diaphragms - above and below and Everything else.
Don't forget to compare the chest x-ray with any previous ones (very easy on most programmes) - this is very useful to assess any acute changes. Older x-rays should also have been reported which will help your interpretation!
As you can see there's a subtle variation, make sure you find a method that works for you!
Here is the Take Visually for this podcast.
Geeky Medics have a great page on the subject as well.
In the third part of the day we focused on balloons, namely REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) - the Life in the Fast Lane post can be found here. The talk was by @emeddoc. This procedure is intended for cases of non-compressible traumatic haemorrhage. Before REBOA the best possible method to achieve haemostasis was through compressing the descending aorta via resuscitative thoracotomy (RT). Data from the American Association for the Surgery of Trauma (AAST) in 2014 shows that REBOA is at least non-inferior to RT. In trauma patients in LOST (ie not TCA yet) who required REBOA 92.6% survived their stay in ED and 22.2% survived to discharge. Increasingly work has shown REBOA to be feasible in the pre-hospital setting and has the best survival rates if performed pre-hospital.
However, a study from Japan showed that REBOA is associated with an increase of 16.5% in mortality. However, the median door to surgery time was 97 minutes and further research has shown in animal studies that lactate clearance is intact 45-60 minutes post REBOA but after that the ischaemia distal to the balloon may be irreparable hence the poor date from Japan. This raises the possible of future research into partial inflation to not completely cut off distal flow and have some permissive hypotension.
REBOA is not just for the pre-hospital medics to be concerned about; it requires clear handover to the hospital and theatre teams after it is used as it will alter physiology. It it there to buy time for the definitive surgery and it was emphasised several times that any unit wanting to implement REBOA will require widespread organisation and culture change.
Here is the Take Visually graphic for this podcast and blog:
It was a brilliant and interesting day; thank you to all the organisers. Antwerp is a lovely city and the Belgian people were very welcoming; if you can visit do!
In the second part of the Focused Trauma Conference we were treated to a focus on the role of ultrasound and clam shell thoracostomy.
Dr Jim Connolly (@jiconnoly) kicked off the second part by imagining a post-stethoscope world (Stethxit) and instead where we all have hand held ultrasound devices - a reality that's closer than we think - he believes once they crack a cost of <£1000 (i.e. the cost of the new iPhone) a unit we will all have one! POCUS will help identify the majority of causes in cardiac arrest (pretty much all of 4Hs and 4Ts apart from hypothermia or toxins). POCUS reduces the time to operation, the number of CT scans and even the length of stay in hospital. It is time critical, helps with Bayesian reasoning and with answering Yes/No answers. It is more sensitive than auscultation and x-ray in detecting pneumothorax and takes a quarter of the time that CXR does. However it is important to remember its limits:
- A FAST scan needs about 500ml blood in the abdomen to pick up - "you need blood to bleed" and so there may be false negatives
- It changes nothing in penetrating TCA
However in blunt TCA it is useful to pick up cardiac standstill (a very poor prognosis) and also to distinguish pseudo from real PEA.
It was then onto thoracostomy with Professor Lockey and then Dr Connolly again. The procedure was first performed in 1988 and provides better visualisation than the left lateral approach. Professor Lockey talked about the approach in 'street thoracostomy' often performed in cases of stabbings and even terrorism:
- Open the pericardium
- Seal the hole (ideally a single hole in the right ventricle) - occlude with a finger, stitch or staple it or use foley catheter
- Restart the heart - flick it, volume load, 2 handed massage, ventricular adrenaline, given bicarbonate (usually young people getting stabbed so should be fine) and calcium
- Clip the internal mammary arteries and clamp aorta and hilar
- If the patient wakes during anaesthetise with Midazolam 1mg and Ketamine 30mg
- Forensic awareness is also important in cases of stabbings
The whole procedure should take less than 2 minutes. It is not to be performed in cases of shootings/high energy transfer, if the heart is empty or if the TCA has been prolonged.
Dr Connolly reinforced many of these messages as well as emphasising that the biggest barrier to before the clamshell is the fear of being criticised. It is a procedure not an operation designed to achieve damage control and restore physiology NOT anatomy. It is to be performed in witnessed TCA or if there were very recent signs of life or if the systolic BP is <70mmHg despite fluid resuscitation. The wound most likely to survive is a wound to the right ventricle with a tamponade. When suturing a horizontal mattress suture is least likely to occlude the coronaries. He also emphasised the importance of training - at times of stress we revert to our lowest level of training. There are other considerations to have - once output is restored the patient needs to go straight to theatre and can have only vertical sliding not horizontal.
Here are the Take Visually graphics for this podcast:
It was great to attend the inaugural Focused Trauma Conference hosted at the University of Antwerp. Although run with a Belgian slant on things there were a number of British speakers and the whole event was in English which was useful for my dotard ears as one of the few uni-linguists in the audience. The venue was amazing.
Thanks to the breaks the day roughly broke up into three sections with different topics explored. So, like the aorta in REBOA, (more of that later) we will tackle the day in three parts.
In the first part Professor Nijs began by exploring major trauma in Belgium. Belgium has twice the mortality rate due to trauma of the UK and has no system of Quality Assurance. I was really proud to be part of the NHS as he highlighted the improvements seen in the UK since the MTC network was set up. Whilst he pointed out that all systems need a 5 year maturation period in the UK we had seen immediate improvements in outcomes which increased year on year. Major Trauma is an area of constantly changing paradigms: we no longer consider traumatic cardiac arrest a futile endeavour and there are ever improving methods of haemorrhage control such as REBOA. He feels Belgium should aspire to the UK model but they will need:
1. The resources
2. People who understand
3. People who have the skills
Dr Ed Barnard (@edbarn) then spoke about traumatic cardiac arrest (TCA). There is no universal definition of traumatic cardiac arrest which makes research difficult but this is predominately a disease of young people. Whilst initial papers gave low survival rates recent Trauma Audit and Research Network (TARN) data from 2009-2015 shows a 7.5% survival to hospital discharge rate as well a 2/3 moderate to good neurological outcome post TCA. He discussed methods of public engagement as well as distinguishing between low output states in trauma (LOST) and no output states in trauma (NOST). Whilst the standard methods of controlling bleeding and IV filling may work in LOST the future of resuscitation in NOST may involve methods of controlling and providing flow such as selective aortic arch perfusion.
In the final talk of part one discussed the European Resus Council (ERC) algorithm for TCA,
Universal cardiac arrest algorithms are not suitable for TCA as they can result in delays of nearly 10 minutes whilst looking for a reversible cause such as tension pneumothorax. The ERC algorithm places chest compressions at a lower priority in TCA than treating hypoxia, tension pneumothorax, tamponade and hypovolaemia. Dr Truhlar (@TruhlarA) openly admitted that the role of CPR is unknown.
The only nation to reject the ERC guidelines was the UK (insert Brexit reference) with the UK Resus Council producing its own guidelines as above which keeps thoracostomy and needle decompression as considerations not standard practice for all TCA.
Dr Monsieurs (@kmonsieurs) continued this debate of the role of chest compressions in TCA. He felt that maybe chest compressions provide little benefit in TCA and get in the way of other things which provide much more benefit. There was discussion about how hard it can be for a professional to stop CPR for other procedures once bystanders have been doing compressions after calling for help. Dr. Barnard made the interesting point that chest compressions whilst improving systolic BP cause diastolic BP to drop and so reduce coronary perfusion.
I think the role of chest compressions in TCA and the ERC and UK TCA algorithms will provide much more fuel for research in the years to come!
Here's the Take Visually for this podcast:
Take Aurally is once again on the move this time heading to the Belgian city of Antwerp to take in the refined air, culture and the Focused Trauma Conference on 14th October.
For those not going worry not as we shall podcast from the conference (or a cafe near by) as well as present a Take Visually or three. Remember to follow @takeaurally for all the goings on.
Here's the full running order:
Kunal Gohil, the ED Pharmacist at the QMC came down to discuss his role, the benefits, challenges and further developments.
We talked about:
- The training of a pharmacist in the UK
- Kunal's background and how he came to work in the Emergency Department
- His role and how it has developed
- A normal day in the life of an ED Pharmacist
- The benefits to the department and trust
- His work on time critical medication such as anti-Parkinson's
- Advice for other pharmacists and trusts interested in the role
Here is our Take Visually on the ED Pharmacist:
In these videos we'll show you how to put on a Polysling, a High Arm Sling and a Broad Arm Sling!
Not particularly educational but still important to remember to find time for humour! As a fan of the Amateur Transplants it was a real pleasure to see Suman Biswas at Das SMACC and here he is in action. Enjoy!
The other week I watched Jurassic Park being played in Wollaton Park (otherwise known as Bruce Wayne's house). Maybe it's a reflection of how sad I am but I couldn't help but think of Emergency Medicine and FOAMed as I watched this amazing masterpiece of a film. If you haven't watched it now is the chance to stop reading and watch it. You won't be disappointed.
In the scene featuring the Brachiosaurus (see above) the characters are open mouthed and in awe. It's easy to be in awe of Emergency Medicine, especially as you first start, perhaps even intimidated. But there are lessons from this film which can help us as we tackle this majestic speciality.
Embrace education and listen
In the film Lex is nearly eaten by a Tyrannosaurus Rex until Dr Alan Grant tells her to stay still as it won't be able to see her (rubbish but I never said this film was a documentary). She stays still and isn't eaten. Donald Gennaro and Ian Malcolm do move and one is eaten and the other is severely injured. The lesson: listen to your seniors and follow advice especially when faced by a T-Rex or the Triple-A-asaurus.
Educate, don't terrify
In the book by Michael Crichton (who also wrote E.R.) - again read the book if you haven't - Alan Grant loves kids (makes sense as kids love dinosaurs). In the film he hates kids at the beginning before going on a story arc where he loves them. In this early scene he decides to teach a child to respect dinosaurs by terrifying him. The result? One scared child who I'm sure didn't go on to love dinosaurs. We have to inspire as educators not terrify. Those who teach through fear are dinosaurs. Figuratively.
Don't let the little things take you down
The books 'Jurassic Park' and 'Lost World' and the film 'Lost World Jurassic Park' feature small dinosaurs (Procompsognathus in the books, Compsognathus in the film). Whilst little and innocent looking these dinosaurs work together to kill much larger humans. There's a lesson there that if we ignore the small things (not checking bloods, not doing our at work assessments) they can get together and take us down. Don't let them.
Just because you could doesn't mean you should
An important ethics lesson here for all doctors and researchers regardless of speciality. ''First do no harm'.'
Keep it simple...
In the film 'Jurassic World' Ingen decide that as the public are now bored of dinosaurs (as if) to make a new dinosaur the Indominus Rex by mixing the DNA of a T-Rex, Velociraptor, tree frog and, oddly, cuttlefish. The result is a terrifying problem of their own making with multiple traits including, strangely in a creature designed for public display, the ability to camouflage. It's easy in Emergency Medicine to create problems either in our decision making, attitude, human factors...the list goes on. Keep it simple.
...and get help
The Indominus Rex is ultimately only taken down by a tag team effort between Rexy and Blue the Velociraptor with the Mosasaur providing the coup de grâce. Make sure you work as a team. Work on your team work skills. We can then tackle even the biggest problem.
Importance of CPR
A vital skill we all should learn and encourage. No, his technique is not great but at least Dr Grant gives it a try and Tim lives. And it's still better than James Bond's effort in Casino Royale...
Life er finds a way
This classic line from Dr Ian Malcolm sums up everything really. But in the Emergency Department we have to accept there are some things out of our control. There will always be more patients to see. We can't save everyone. We see people at their worst everyday in an environment that shocks people who are new to it. Whilst we should always seek to improve we should also appreciate the sheer amazing job we already do. And accept that sometimes there are somethings we can't change.
There we have it. Lessons from Jurassic Park for the Emergency Department. I'm off to watch Jurassic Park again. Hopefully if we follow these lessons we too can make it on the helicopter home...
Just as with ECGs arterial blood gases (ABGs) are an essential part of Medicine and unavoidable. They're a vital part of assessing the unwell patient.
Unfortunately students are often quite blood gas-phobic and this needs to be overcome and hopefully with a stepwise approach we can all learn to love the blood gas! Once again I'll be enlisting the help of Albert Einstein and his chalkboard - the meme generator can be found here.
It's worth saying that ABGs are not nice to receive and so think if you really need to do one or if you could get away with a venous blood gas (VBG). A VBG will give you a reliable pH, bicarbonate, electrolytes, glucose and lactate as well as carbon dioxide if it's normal. ABGs are really good for determining the oxygen partial pressure however. Life in the Fast Lane has a brilliant blog on the subject of VBG vs ABG. This blog will mostly focus on ABGs.
So as ever make sure the gas in your hand is from the right person at the right day and time and look at how much oxygen the patient is on. This is the amount of inspired oxygen or fraction of inspired oxygen (FiO2) the patient is receiving. The delivery device being used by the patient will tell us their FiO2.
Room air at sea level has a FiO2 of 21%.
The next oxygen delivery is nasal cannulae which are only good at delivering 1-4L/m of oxygen - beyond that the patient won't have any benefit and have very turbulent air up their nose! The FiO2 of oxygen delivered by nasal cannula is as follows:
1 L/m = 24%
2 L/m = 28%
3 L/m = 32%
4 L/m = 36%
The next oxygen delivery system to look at are Venturi masks; these deliver a guaranteed FiO2 of oxygen and are brilliant at titrating oxygen to patients especially patients with COPD.
The Venturi come in different colours and will have the FiO2 written on their side as well as the l/min that are needed to provide that FiO2. Make sure they have the correct flow rate or they won't work. The range available will vary site to site but in the department I work at the Venturi available are 24%, 28% & 40%.
The next highest oxygen delivery system you'll commonly see are non-rebreather masks (NRM).
"15 litres through a non-breather mask" is a very common statement in an acute A-E station. It's less easy to predict the FiO2 here only that is is somewhere between 60-100%.
Make sure the FiO2 or oxygen delivery is documented on the gas.
pH: 7.35 – 7.45 (pH messages the amount of Hydrogen ions in a solution (in this case blood) the lower the pH the more acidic the blood, the higher it is the more alkalotic it is)
There are two main components contributing to the pH - the respiratory side (CO2) and metabolic (Bicarbonate). A problem with one can be compensated with the other - more of that later.
PaCO2: 4.7-6.0 kPa (Pa stands for Partial Pressure - the amount of pressure the gas in question contributes to the atmosphere measured in kilo Pascals. CO2 is acidic when dissolved in solution. Increasing respiration rate blows off CO2 while reducing respiration rate means we retain CO2. Normally PaCO2 is what drives our ventilation; this is not the case in chronic CO2 retention such as COPD where hypoxia then drives respiration)
PaO2: 11-13 kPa (if this is low then the patient is hypoxia - this is cause of cardiac arrest and so must be identified early)
HCO3-: 22-26 mEg/L (Bicarbonate is basic and so is used as a buffer against acid. Increasing the amount of bicarbonate however takes hours to days whereas it's almost instantaneous to alter respiration rate)
Base excess: -2 to +2 mmol/L (this is measure of the metabolic component of a problem with the pH. If the BE is below -2 then the patient has a base deficit and so has metabolic acidosis. If the BE is above +2 then the patient has a base excess and a metabolic alkalosis
Once you're happy with the ABG being for the right patient etc it's now time to first look at the pH - is it normal, high (alkalotic) or low (acidotic)?
Is the CO2 normal, high (hypercapnic) or low (hypocapnic)?
Is the O2 normal, high (hyperoxic) or low (hypoxic)?
At this point we need to remember the Alveolar-arterial (A-a) gradient. This is the gradient between the PaO2 of inspired air and that in the blood. In a healthy adult it should be about 5-10mmHg. That means the PaO2 on your ABG should be about ten less the FiO2, hence why in room air (FiO2 21%) the normal range of PaO2 is 11 - 13 kPa.
A-a gradient is accurate up until FiO2 of about 60% and over. Why is it important? Well, you could have a patient on a 28% Venturi with normal saturations but if their PaO2 is less than 18 kPa (say 12 kPa) then they have relative hypoxia and we should be more worried about them and make sure they are getting senior support.
If the patient is hypoxic check the PaCO2 again
If PaO2 is low and PaCO2 is low or normal then the patient has Type 1 Respiratory Failure - the lungs are failing in the function of taking O2 from the air to blood
If the PaO2 is low and PaCO2 is high then the patient has Type 2 Respiratory Failure - the lungs are failing in getting O2 from the air and removing CO2 from the blood. This may be acute, chronic or acute on chronic. The raised PaCO2 will lower pH acutely; the blood will respond by buffering this by increasing bicarbonate production in the kidneys. This process takes days to hours. Patients may walk around with a fully compensated Type 2 Respiratory Failure (such as COPD) but then decompensate and become acidotic again despite the raised bicarbonate - acute on chronic failure
Acute Type 2 Respiratory Failure (no compensation):
Pa O2 7
Chronic Type 2 Respiratory Failure (fully compensated):
Decompensated Chronic Type 2 Respiratory Failure (Acute on Chronic):
Causes of Type 2 Respiratory Failure can be pulmonary (such as COPD); peripheral (such chest wall deformities or peripheral nervous diseases such as Motor Neuron Disease) or central (such as overdose of opiates or benzodiazepines causing respiratory depression)
So now we know the values for pH, PaCO2, PaO2 and Bicarbonate it's now time to put it together and identify whether it is a Respiratory or Metabolic cause for pH disturbance
I use the mnemonic 'ROME'
The problem is Respiratory when the PaCO2 is Opposite to pH
The problem is Metabolic when the bicarbonate (HCO3-) is Equal to pH
I find this is a very quick way of identifying the cause, being aware of course that you can have mixed acidosis (due to combined high PaCO2 and low bicarbonate) and mixed alkalosis (low PaCO2 and high bicarbonate)
If the problem is respiratory then there will be metabolic compensation (compensating high PaCO2 with high bicarbonate and vice versa) - this takes a long time remember
If the problem is metabolic then there be respiratory compensation which is much quicker
Compensation can be none, partial (there is an attempt but pH remains deranged) or full (pH back within normal limits)
Remember that there are other bits of information on an ABG
Potassium - if deranged do not wait for serum U&Es before commencing treatment
Glucose - while BM machines will just say 'HI' once BM ~30 the ABG will measure up to about 50
Lactate - important measure of tissue perfusion
Haemoglobin - not entirely accurate but will give an idea of anaemia/bleeding
It is important not to miss this information as well!
There is a brilliant RCEM module on ABGs here.
Check out the brilliant Geeky Medics page on ABG interpretation here.
It's that time of year again; the medical new year where 5 years of medical school comes to fruition and students become F1 doctors. I've thought back to my time as an F1 and here's 50 tips. If you don't get the Sunscreen reference then I'm officially old...
- Medicine is a noble art dating back throughout humanity. We will outlive any government or Health Secretary. I've never not experienced anything other than respect from lay people when I've told them I'm a doctor. We get cynical in our bubble but what we do is amazing. Don't forget that.
- Make your intentions noble.
- Chocolate will always go down well with your new colleagues. Tea and coffee or at least the offer of them will go down well with your patients and relatives.
- Chest pain always needs an ECG. Regardless of description.
- Abdominal pain and trauma rarely present in a straightforward way in the elderly. Have a low threshold to CT scan and always discuss with a senior.
- Beware posterior STEMIs. If you see regional ST depression look for ST elevation in other leads. Make sure you check if any LBBB is old or new.
- Know your trust's PCI, Stroke and Upper GI Bleeding protocols early. Don't wait until it's 0300 and you're with a poorly patient to find out.
- Back pain + Collapse = AAA until proven otherwise.
- 'Nurse' is not a first name. Learn the names of your colleagues.
- All women are pregnant until you prove otherwise.
- Don't forget the aorta.
- If you think it's a PE it probably is.
- 'Senior Review' is not a plan.
- 'C?C' is not a diagnosis.
- 'Acopia' does not exist.
- It's never alcohol until you rule out everything else. If it is alcohol consider Chlordiazepoxide and Pabrinex.
- Gastritis is not an F1 diagnosis to make. I'd argue it's not an Emergency Department diagnosis to make. Rule out more serious causes first.
- Know the head injury guidelines.
- You can't always cure but you can always be nice.
- Be judicious with requesting D Dimers.
- Analgese often and early. Document it. If your patient declines then document that too.
- Always listen to your gut - whether it's telling you your patient is ill or that you're hungry.
- Your nursing colleagues won't kiss you backside but will certainly save it. Be kind to them.
- Monitor your urine output and urine colour and hydrate accordingly.
- Don't just write ''ECG nil acute'' in the notes. Write your findings even if it's just ''Normal Sinus Rhythm.'' Your colleagues later on will thank you.
- Remember to prescribe time critical medications - Anti-Epileptics, Anti-Parkinsons, Antibiotics and Insulin.
- Respiratory rate is often the first observation to go off.
- Remember mean arterial pressure. Your patients brain (GCS) and kidneys (U&E/Urine output) need monitoring.
- Remember that amazing 360 degree human being you were on your application to medical school? Who sang, played instruments, played sports, danced, had dreams and passions? Don't forget that person. Use your free time.
- Take annual leave. Travel.
- Not every patient is nice but they still deserve your best.
- Mental health and serious organic disease are not mutually exclusive. Don't be biased.
- Don't say 'unresponsive'. Use GCS.
- Migraine and epilepsy don't start in later life. Rule out sinister causes first for new headaches and seizures in the elderly.
- Don't wear suede to work.
- How to SBAR: 1). Say who you are and where you are calling from. 2). Say the reason you are calling. 3). Then start your SBAR.
- Don't judge others with different values that you judge yourself with.
- See the bigger picture. This is one of my favourite pictures taken from the edge of our solar system showing Earth. It reminds me to see the bigger picture, a very valuable lesson when there is a 10 hour bed wait or a 5 hour wait to be seen in the department. Always see the bigger picture. Remember the 18 year old you who was so excited to get into medical school.
39. It's not OK to not be OK. Talk to someone. 40. There is nothing more contagious in healthcare than emotions. Smile. Be positive and it will spread. 41. Doctors consistently are amongst the most respected professions. Never abuse that trust. 42. Remember #HelloMyNameIs. 43. Always get your sleep. 44. Coffee is your friend. 45. You should always get more out of alcohol then it gets out of you. If that changes get help. 46. Pain and Urinary retention are two important causes of agitation.
47. Be careful what you post on social media.
48. Not matter how hard breaking news is for you it is worse for the patient/family receiving it.
49. Chew your food. Especially watermelon - trust me on this.
50. Wear sunscreen.
ECGs are an essential part of Medicine and unavoidable as a student and junior doctor. I remember being bleeped as an F2 on call by an Orthopaedic surgeon to read the ECG of one of his patients as he had forgotten...ECGs are definitely a case of improving confidence and knowledge through repeated practice and exposure.
Once again I cannot recommend Life in the Fast Lane enough for incredible resources when it comes to ECG.
Here is our video on how to take an ECG:
In the latest Take Aurally podcast I discuss an approach to ECG interpretation and in this blog I've enlisted the help of Albert Einstein to help me through. You can find the tool for making this meme here.
Remember, it doesn't matter how the patient describes their chest pain as an ''ache'', ''twinge'', 'indigestion''...whatever chest pain is chest pain and needs an ECG.
This step is vital, is the ECG in your hands from the right patient, right day and time? Also, get an idea about the presentation behind the ECG, do they have pain, shortness of breath, collapse or palpitations?
Only in certain BBC television dramas (cough, Casualty, cough) does a flat line on an ECG mean death. In real life it means that the ECG lead in question is not connected properly and needs reattaching. Make sure you can see electrical activity in all 12 leads.
Most ECGs will tell you this anyway but it is important to be able to work this out for yourself. In a regular rhythm (equal distance between all R waves) you can count the number of large squares between each R wave and divide 300 by this number. Alternatively you can count the number of beats on the rhythm strip and times this by 6.
This is all about looking at the R-R distance for successive beats. This can be marked on a separate piece of paper and moved along to confirm.
If the rhythm is irregular you can then also see if it's regularly irregular or irregularly irregular
The QRS complex should be 3 small squares wide. This is important for two reasons. In tachycardia the duration of QRS points to the diagnosis and management as shown in the Resus Council flowchart below. In normal rates it also points to a bundle branch block.
P waves indicate sinus rhythm. PR interval should be 3-5 small squares.
First degree heart block: PR interval is prolonged and remains the same (occurs between SA and AV node)
Second degree heart block: Mobitz 1 - the PR interval gets longer and longer until there is a dropped QRS and the cycle starts again. (Occurs in the AV node) Mobtiz 2 - the PR interval is long, stays the same length but there is a dropped QRS in a ratio: 3-1, 4-1 etc (occurs after AV node in bundle of His/Purkinje fibres)
Third (complete) heart block: No relationship between P waves and QRS (occurs anywhere from AV node down)
PR interval could also be shortened as seen in WPW.
Axis is all about the general spread of electrical activity across the heart.
Here I look at leads I and II. Usually the R waves should both be positive as here:
In left axis deviation the R wave in II is now negative so they pointing away from each other or 'leaving'.
Leaving = Left Axis Deviation
This is a sign of ischaemia
Here the R wave is I is negative so they reaching for each other.
Reaching = Right axis deviation
RAD is a sign of RVH
This is important to notice ST elevation - STEMI (2mm or more in 2 or more chest leads or 1mm or more in 2 or more limb leads) or ST depression or T wave inversion - can be seen in NSTEMI
Be wary if you see regional ST depression - this could be reciprocal depression so make sure you look for ST elevation in other leads
Remember to look at the J point - the point where the S wave joins the ST segment - this can be raised in young, thin patients giving the appearance of ST elevation. This is caused benign early repolarisation or 'high take off'
T waves can also point to other conditions - the tall T waves in hyperkalaemia; biphasic T waves in hypokalaemia or ischaemia; or flattened in ischaemia or electrolyte imbalance.
U waves, small deflections after the T wave can be seen in a number of conditions; hypokalaemia, hypothermia or antiarrhythmic therapy like digoxin
It was an honour to be asked to present at the 4th annual Undergraduate Medical Education Conference (UMEC) at the University of Nottingham on 7th July. It's a great opportunity to see the great work being done to improve the teaching of our students.
I think we were all impressed by the work of WAMS (Widening Access to Medical School) a programme run by medical students in association with work by the university to widen access to students who might otherwise not go to medical school. I was very lucky with the support from home I received; many are not so lucky.
It was great to hear from my fellow podcaster Charley Peal on her work 'Nifty Fifty' giving clinical students a booklet of 50 challenges such as escorting a patient to X-ray to help them orientate and stay on the ward. Or as she and her fellow medical fellow Becca Noble put it ''avoid being a trip hazard''. Not saying I actually caused people to trip up when I was a medical student but I certainly had some near misses.
There was a good discussion about the difficulties of sharing educational resources. This is why I support FOAMed despite its detractors. No paywall; no firewall. The challenge is quality control of course but I've often thought that there's great work going on that just isn't celebrated enough. I've regularly been in conferences and felt it just seems like some institutions are better than others at getting their message out there. There must be reasons at the individual level to explain this but it must also be due to leadership and the culture of an institution.
We also discussed the conundrum at the heart of medical education I feel. Our students want to pass exams. We want them to be safe doctors. It's sad but understandable when in the past I've had to cancel sessions because they're near exams and whilst they'd help the students as doctors I know engagement would be poor if I put it on.
My DREEAM colleague Matt Govan kindly filmed me. It's actually hard to boil a subject down into 7 minutes and it took a lot of practice. Looking at it I hope it shows a progression with using the P3 approach to presentation. The last time I presented I was told I dance about a bit so here I'm routed to the spot by 'anchoring' against the podium.
In my last blog at Das SMACC I mentioned how SMACC has helped change the approach to conferences at this philosophy was evident at UMEC; short presentations, workshops dotted amongst the schedule with social media being used throughout. As someone who attends a lot of conferences it's a great development and one to be continued. Thanks to everyone at the UMEC organising committee.
And so Das SMACC ist fertig and I am sat in my office in Nottingham reflecting on an amazing three days. Thank you to all who made Das SMACC happen and thank you to my colleagues for accompanying me on the ride, tolerating me and allowing me to convert their voices into MP3 format.
So, Day Three. It's fair to say that I was not in the best of humours at the beginning of the day which may have had something to do with the Das SMACC party the night before. Maybe.
The morning however was worth the trek in. An inspiration panel of educationalists (new word for me) on the future of education in Critical Care. There is a Storify thread which you can follow here as otherwise my succinct points below won't do it justice.
- How do we train doctors now to deal with the future? - train the basics well and use these as the building blocks for the future, teach empathy and compassion as these will still be needed as automation increases
- Interprofessional education should be the norm and used throughout medical school, teach the fundamentals (anatomy, pathology) together and then subspecialise later - I completely agree with this and think this should be the way all universities function, if I come to power...
- We don't actually teach how to be a doctor at medical school, we teach students how to be a resident (F1) which is where they learn to be a doctor - Amen Walter!
- Don't focus on learning from simulation, rather simulate to learn from work
- The future will not be simulation centres but rather each hospital having a fluid, focused simulation team who will able to provide expertise to all departments within the hospital, we can't assume anyone can facilitate simulation, treat it as a skill like ECMO or REBOA
- Look at your coaching conversations, tailor your approach, ask your students what they would like you to look out for at the beginning of the session - YES! Definitely going for this approach in the future, I regularly find it hard to discuss everything in a debrief
- Always talk after simulation, whether good or bad or indifferent
- Also a big discussion on the best time to give feedback and Work Based Assessments - a recurring problem I have!
- We don't train people to give or receive feedback - another recurring problem
How to Fail - Kevin Fong
Another new man crush! Anaesthetist/Astronaut Kevin spoke about failure. The old saying is true; it's not an option. Failure will always happen. We have to adapt to accept this and approach our safety mechanisms and responses to failure appropriately. Hypercompetence is a myth. Hubris is wrong. We have to have 'graceful failure' otherwise human factors fails and we will let out patient down. I also liked his point that maybe the only reason medical science began to see the heart as a pump was because mechanics had invented a pump and we had a frame of reference. Makes me wonder what fundamental point we're currently missing because we don't have that frame today.
Helping Without Harming - Jenny Rudolph
An inventive and entertaining talk. Rather than being annoyed at someone and thinking WTF think another WTF (What's Their Frame?) The hashtag #WTF2WTF is alive and kicking on Twitter and it will be interesting to see how this goes. More about fundamental-attribution bias. Thought provoking, something I will try.
The Global Refugee Crisis: Why it’s Critical that we Care - Vera Sistenich
The only talk to get a standing ovation. I can't do it justice, watch it at the SMACC website. The more people who watch the better.
How to Fail… Part Two - Martin Bromiley
We all know his late wife's story. How he does it I don't know but another great talk. A man with much to be angry about who actually chose to understand and help. His thoughts were inspiring on human factors:
- "I would't do what they did" - not helpful, next time you catch yourself thinking that think instead "Why did it make sense at the time?"
- Confident humility - no one is too senior to seek feedback
- Look at our systems in place, do they make it hard to be right and easy to be wrong?
This isn't a cop out but I genuinely couldn't do the last session featuring Martin Bromiley and James Piercy justice so please check it out on the Das SMACC site. Amazing human beings and it was a privilege to hear them. I hope I don't have to go through what they did but I hope I could always be as kind.
So that was Das SMACC. Personally I love FOAMed and it was great to be with like minded people in an amazing city. Berlin is an amazing mixture of beauty and horror and needs to be seen. What about SMACC? It is a bit cultish if I'm honest. I can see the point of some of its detractors pointing out the swearing, the hashtags, how something is either great or sh*t. And it has made 'celebrities' of medics - yes I know the irony as someone who blogs and records his voice in his spare time - which is something that may create challenges in the future. But I loved it. SMACC has challenged the old school. Conferences where someone stands at the front and talks with no engagement are thankfully dying out. It's been great to see the smart conferences adapt with workshops, social media and an open minded approach. 'Punk movements' like SMACC are the vehicle of such changes. I hope I will always be so open minded. The focus on the next generation and innovation was a pleasure to see as well. Danke Berlin. Danke Das SMACC.
Typed in the shadow of the Tempodrom here are some of my highlights from the second day of Das SMACC; a lot discussed in the podcast which will also be out in a bit. Sorry if this reads a bit like a stream of consciousness poem.
A MEETING OF THE TRIBES: INTER-PROFESSIONAL ISSUES IN CRITICAL CARE
What tribe are you? As you increase complexity you can increase the tribalism shown. If there a rite of passage you go through after which you know you belong? The flat culture is celebrated until it falls apart under conflict. The microaggression - 'just a nurse' needs to be avoided.
A common enemy (such as ITU) can help unite it encourages more tribalism. The consultant sets the tone of the shift but so does everyone in the team. Be aware of fundamental attribution bias and distinguish between behaviour and intention. We often criticise others based on their behaviour but praised ourselves for our intentions regardless of outcome or behaviour. Vulnerability and intention build teams. Be aware of your emotional intelligence and think who you want to be. Don't wage time fixing what doesn't work build on what does work. Think about your team reflexibility and how tribalism may affect your education culture. Beware of emotional contagion - how we behave transmits to others. Positive feedback is often vague whilst critical feedback is specific and we often forget the positive feedback compared to negative so more positive is needed so the student/colleague remembers.
Making Complex Problems Simple: Chris Hicks
A brilliant talk breaking down the management of a very complicated trauma call. A large process doesn't mean complex. Keeping it simple needs strategy. We make our habits and then our habits make us. We don't want any wild variances at the simple level. Four stages: Habit, Emergency Theory, Factor down problem, Limit variables.
Emergence theory creates complexity (this is how swallows appear to be flying in sequence - swarm behaviour). Three factors at play much like a swarm: Alignment. Separation. Cohesion - break you team down into sub teams: those dealing with airway, those on chest, those on pelvis etc.
Factor down from surface complexity e.g. look at airway problem, circulatory problem rather than whole massive problem.
Limit variables - eliminate steps, reduce team numbers, practice sim and increase engagement
- Lean on habit, foster emergence (semi-autonomous sub teams)
- Factor down problem
- Limit variables
Dream Big Plan Simple
The Future of Out-Of-Hospital Cardiac Arrest: Maaret Castren
50% of sudden cardiac risk had symptoms in preceding 4 weeks yet there is no risk prediction tool. Recommended the European Resus Academy - 10 steps to improve cardiac arrest survival.
Learning from Sim Part II: Critical Moments in the Emergency Department: Chris Hicks
Discussed emotional valence in simulation: if you feel an emotion in simulation you will better remember it when you feel that emotion for real i.e. anger or fear. Must practice good psychological health in simulation.
Finding the Needle in the Haystack: Paediatric Cardiac Disease: Michele Domico
Cardiac disease presents every other way than chest pain, murmur, cyanosis and hypoxia are obvious but far more common and vague are fatigue, failure to thrive, sepsis.
Children should not be fatigued, think if it adds up. Infection may unmask. Quiet tachypnoea can mean easily missed poor perfusion. Small children should not be quiet when you examine. Normal BP and HR does not mean good CO. Might have multiple presentations and have been given another diagnosis. Beware cognitive bias. Think heart in cases of repeat presentations.
Guts or Gadgets?… Prayers or Protocol?… Training or Tricks? - MJ Slabbert
Discussed the process of naturalistic decision making as she brilliantly went through a case of penetrative chest injury peri-arrest in the community. Do you go with protocol and RSI there knowing the BP will plummet and you'll have to do a thorocotomy in the community or scoop and run 5 minutes to hospital? Which is best?
16 Bits of Anaphylaxis - Daniel Cabrera
An outstanding presentation invoking Space Invaders.
- We do a terrible job - 50% missed, only 50% who need adrenaline get it
- Highly preventable death - 1-2% pop, 1-2% die
- Know your enemy, no difference between anaphylaxis and anaphylactoid management, be vigilant and fast, sting to arrest 15 minutes, medicine allergy to arrest 5 minutes
- Cardiorespiratory collapse kills so does lack of education and access
- Know your weapon - adrenaline, IM, early use!
- Early diagnosis - Young, elderly, history of anaphylaxis, asthma, cardiopulmonary disease
- Don't be afraid, second dose IM, then infusion, 50% patients will need second dose, crystalloids, in respiratory distress O2 and nebs help, steroids and antihistamine control symptoms don't fix the problem
- Prepare for very difficult airways, swelling, increased pulmonary pressure
- No retreat, no surrender, best treatment for refractory anaphylaxis has limited evidence, more evidence behind increasing adrenaline infusion rate or using glucagon, there are very limited case reports of noradrenaline, vasopressin and methylene blue
- ECMO could be used in refractory hypotension, early and aggressive resuscitation, 1-20% have biphasic reactions, criteria for diagnosis varies in literature
- Education, adrenaline, action plan - make sure the patient knows they have an allergy, follow-up in clinic and an IM pen
Resuscitation for the Resuscitationist
Mass panel discussion here. No clear outcomes but some interesting areas of debate:
Vasoplegia e.g 130/7 - intravenous do not work
? Use of Methylene blue
Repositioning the pads
Additional machine with 2nd set of pads with synchronized defib
Esmolol for refractory VF worth a try
Ketamine for semi-conscious patients during CPR
Encourage awake arrested patient to cough
When enough is enough-- close to 40 min of good quality CPR
Post resus temp control aiming 32-34C
Paralysis for temp control
Right, off to get the podcast out and then get to the party! Enjoy!