All posts by janos baombe

My top 5 reasons to attend #SMACC this year…

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So I am back from an amazing few days in Chicago where the most amazing medical conference of the world just took place at McCormick place in Chicago (USA).

As a FOAM(ed) convert and avid Twitter user, I had been so far only a passive follower of this annual gathering of inspirational speakers but decided this year to attend the conference personally on the constant gentle nudging of a colleague and mentor of mine @EMManchester.

There is an argument that in the 21st century there is no need to physically attend medical conferences as most of them are relayed on social media via Twitter, YouTube, online material posts etc.  I will come back to that later.

I boarded the plane in Virchester for the windy city with a rather sceptical mindset but some degree of trepidation and landed at Chicago O’Hare airport having traveled back in time (time zone wise!) a few hours.

I was planning to have a couple of hours rest and visit the city before the academic event but my Twitter account kept buzzing of activity and I therefore found myself in a restaurant downtown with a burger washed down with some rather good american ale.

My trip had started a few hours ago only and I already managed to have a social catch up with the lovely @_NMay and some fellow emergency physicians and paramedics from Oz and the USA. Funnily enough, I had never physically met @docib who is integral part of our StEmlyns team at Virchester and an EMP in the UK so it was rather odd to finally meet him…across the pond.

The few days before the conference flew by rapidly filled in with some cultural programmes like a visit to the Art Gallery, a boat tour of the skylines of the city and food gatherings with amazing people from the four corners of the planet. It was amazing to finally physically meet face to face some of the leading figures of emergency and acute care.

The conference itself was attended by approximately 2,000 delegates and after an american style opening ceremony (jazz music, cheerleaders, confettis ), the real event unfolded with legendary  speakers like Scott Weingart, Cliff Reid, Rob Rogers, Liz Crowe  (to cite only a few!).

Themes for the talks ranged from cutting edge respiratory support to resilience for emergency physicians through our lost connection with the spiritual world.

As a conference which had truly embraced social media and  in the true spirit of FOAM(ed), real-time debates were taking place during and after sessions via the use of Twitter and questions to the speakers were also collected this way.

The tea and lunch breaks were another opportunity to catch up with the delegates and speakers who were very approachable and keen to meet with everyone. The attire of some delegates was somewhat…relaxed.

 

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The gala dinner at Chicago Navy Pier was a success on all levels! The  theme for this year was “festival chic” (open to a wide range interpretation as you can imagine) and the British Virchester team turned up in James Bond tux and bow tie attire (which resulted in a few selfies and congrats from the crowd).

You cannot take care of the sick if you do not pay attention to your own mental and/or physical health so a group of delegates had even organised group runs along the shores of the river Chicago and Lake Michigan. Quite a performance (from me)!

 

It would be difficult for me to go through the benefits of attending #SMACCUS through a single blog so I tried to summarise my top ones below:

1. the conference was a true cutting edge professional meeting presenting the latest progress in the fields of emergency, pre-hospital medicine and acute care

2. as mentioned earlier, I finally connected physically with some truly inspirational people whose name I knew only through social media or as authors of published articles

3. I reconnected with some old friends and colleagues I had not seen since my university or specialty training years

4. this event was a definite drive for me to make some things change for the better in my own organisation

5. I had the opportunity to attend some of the innovative pre-conference workshops

 

Attending such a huge professional event can be daunting for the beginner and I would suggest the following tips if you are a “SMACC virgin”:

1. Book early to benefit from discounted conference and hotel fees. Keep in mind that it is an investment worth your money in terms of education, development, networking.

2. Reduce hotel costs by sharing a room with a colleague or friend. Some of the StEmlyns authors teamed up and roomie tales are always a laugh!

3. Become acquainted with twitter prior the conference. You do not have to be a pro but there is loads going on online before, during and after the conference too. Of course nothing stops you from attending the conference without social media: SMACC is not a conference for the geeks (only).

4. Remember that a conference is also a social event so join the official gala dinner, impromptu bar gatherings, city sight-seeings etc. Some delegates attended a baseball match and a U2 concert this year!

5. Do not be shy: go over and say hello. Chances are you already know each other on social media and everyone is much engaging.

 

Having returned to the UK a few days ago and back to my daily clinical work, my head is still spinning with the fantastic social and professional meets with inspirational colleagues. I can feel on me the signs and symptoms of a mythical illness called #SMACCDown: lassitude mixed with inspiration,  sadness mixed with joy,

I however feel revitalised again thinking the next SMACC event that will take place at our doorsteps in Dublin in June 2016.

So, have you got any valid reason not to attend in order to celebrate our noble profession?

Janos

 

 

 

 

New NICE guidance on intravenous fluid therapy for adults in hospital: how is this relevant to EM?

 

fluid

The National Institute for Health and Care Excellence (NICE) has recently issued new guidance on the use of intravenous fluids in adult patients.

For those clinicians not familiar with it, NICE is the UK-based body that provides guidance by supporting healthcare professionals and others to make sure that the care they provide is of the best possible quality and offers the best value for moneyIts recommendations are based on systematic reviews, explicit consideration of cost effectiveness and where evidence is missing,  expert opinion.

“Why is there a need to issue guidance on this?” I first thought when I came across this. “After all, we are experts in prescribing and utilising IV fluids in acute setting. We have been doing it for so long!”.

I remember having the same thoughts when the British Thoracic Society issued its framework for the prescription and use of oxygen. Having read the document, I rapidly changed my mind at the time. I did the same with this one!

Despite the fact that fluid management is one of the commonest medical tasks, there has been emerging evidence that emergency and acute care physicians are failing on use of optimal volume, rate or choice of the type of fluid to be administered.  This article published in the New England Journal of Medicine looked at the paediatric population and suggests indeed that we had been well overgenerous with fluid volumes during resuscitative phases.

 

The size of the problem:

The National Confidential Enquiry into Perioperative Deaths (NCEPOD) suggested that as many as 1 in 5 patients receiving IV fluids in hospital suffered complications due to inappropriate administration. The same professional body demonstrated an increased risk of death within thirty days of having a surgical intervention following inappropriate fluid administration. The numbers are not small and seem to be linked to acute care and the guideline is therefore relevant to Emergency Medicine in many aspects.

 

What are the recommendations?

1. IV fluid therapy is to be provided only to those patients whose needs cannot be met by oral or enteral routes. This seems obvious but we have to acknowledge that we tend to be overzealous with fluid therapy in clinical situations where often a pint of fluid is enough.

2. Prescribing staff need to remember the five Rs: resuscitation, routine maintenance, replacement, redistribution and reassessment. This should be seen as a treatment continuum with each stage having its particularity on fluid type, volume, rate etc.

3. An algorithm is offered to facilitate administration of fluid therapy. Algorithm 1 and 2 are probably the most relevant to Emergency Medicine (assess needs and fluid resuscitation)

4. The guidance further stresses that the type of fluid and rate/volume is to be specified. Now, I am quite bad at this often just scribbling down NaCl STAT (instead of Normal Saline Solution 0.9% at 500ml/h).

5. IV fluid management is to review over the next 24 hours and on a daily basis. This again sounds obvious but there is a need to adjust type, volume and rate according to responsiveness and electrolytes.

6. Take into account all other sources of fluid and electrolytes intake including drugs, IV nutrition, blood and blood products. And yes, it does include that 250ml of Dextrose in which you had given vitamin B complex or the IV paracetamol. Again, I am bad at this!

7. Involve the patient whenever possible in decision making and discuss signs and symptoms to look out for if need is to adjust their balance. I guess, it is a medial intervention so it would be part of the GMC document Good Medical Practice.

 

What about fluid resuscitation?

1. For acute replacement, the document recommends the use of crystalloids that contain sodium in the range 130 – 154mmol/L with boluses of 500mL over less than 15 minutes. Again, note that the traditional teaching of 20ml/kg would overestimate the volume to be given.

2. Do not use tetrastarch for fluid resuscitation but consider rather human albumin solution 4 – 5% for patients in severe sepsis. This recommendation is based on results from large randomised clinical trials that have reported an increased risk of renal dysfunction and mortality in critically ill or septic patients who received hydroxyethyl starch (HES) compared with crystalloids. It was therefore deemed that the risks of HES products for plasma volume expansion outweigh the benefits in all patient groups and clinical settings and the MHRA recently suspended the licences for all HES products.

3. When using IV fluids containing chloride concentrations >120mml/L (such as our beloved “Normal” Saline solution), monitor serum chloride concentration daily to look out for hyperchloraemic acidosis. Who had not been caught up in this before?

 

What are the issues around fluid therapy?

Despite being a key area of patient care, it appears according to this document, that most of hospital staff have not received adequate training in assessing the needs and managing fluid and electrolyte therapy.

I think this is probably a fact and I cannot remember when was the last time I read up about the topic (probably around my exit exam period!). The guidance does suggest that hospitals should ensure regular training for staff in order to demonstrate competence in understanding basic physiology, assessing the needs and risks of patients, monitoring response and preventing/treating consequences of mismanaged IV fluid therapy.

As an emergency physician, I find documents like this interesting. Within healthcare systems they have tremendous power and authority, but in trying to cover a topic as vast as fluid replacement they lack the finesse and detail that I deliver on a daily basis in the resuscitation room. If we take a common EM condition such as sepsis then my practice is to make detailed fluid assessments according to physiological data and response to fluids. The NICE guidelines delivers a much more blunt tool, as an example the suggestion to deliver 2000mL of crystalloid for patients before seeking expert help is not the way we deliver critical care in the ED.

In summary, there is some good stuff in the document. The underlying principles are good but as with many national guidelines the tools to deliver lack the finesse and elegance required for the critically ill patient in resus. Emergency physicians will need to look beyond these guidelines if they are to consider themselves resuscitationists.

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Janos Baombe

 

JC: Milk for refractory migraines?

propofol iran propofol iran

Every day is a school day in Virchester!

When you thought you had heard everything about Propofol with recent media cover over the unfortunate event involving a pop star, a paper from Iran suggest that there would be a role for its use in refractory migraines!

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What was this paper about?

This study was set to evaluate the role and efficiency of intravenous Propofol in patients presenting to the ED with refractory migraines defined as headaches not resolved with usual analgesics (NSAIDs, triptans, dexamethasone, opioids etc.). It is believed its pharmacological effects are related to the active molecule binding to the gamma-aminobutyric acid (GABA) receptors that are downregulated in migraines.

Interesting concept indeed in theory but can we draw hard line clinical conclusions from a case series considering that they are at the bottom of the pyramid of evidence?

The authors recruited eight patients presenting to ED with refractory migraine headaches as defined above. A small number of patients indeed making this trial open to systematic errors (bias) and random errors (chance).

The crucial recruitment process is not clearly defined either: one could not work out if these patients had a formal diagnosis of migraine (and that is why they had taken triptans and opioids prior to ED presentation) or if they were diagnosed at point of presentation using the International Headache Society (IHS) criteria as suggested by the paper. A stringent selection of recruited patients is needed indeed in any trail as this will affect the generalisability of your findings and the recommended steps of identification of patients, assessment of eligibility, consent and recruitment/randomisation information is clearly missing here.

A Visual Analogue Scale (VAS) was recorded at the point of recruitment and after treatment that consisted of boluses of IV Propofol to alleviate the headache. If you are not familiar with the VAS then you can have a look here. It is a validated tool to record pain in subjects but such an assessment is highly subjective, when looking at change within individuals, and are of less value for comparing across a group of individuals at one time point.

They have been also valid point raised during the Twitter JC session about its reliability in acute severe pain and during the administration of a sedative.

 

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Furthermore the authors did not define what they considered therapeutic effect and it is difficult therefore to interpret their results.

The authors followed up all patients by phone for 72 h after discharge from the ED. Of eight patients being followed up during this time period, six were found to remain without symptoms. One case however experienced a headache at follow-up and another one also reported recurrence 36 h later. Both were relieved by NSAIDs.

The authors concluded after expanding pharmacology in the discussion, that Propofol is an effective, rapid-acting, safe drug and with few side effects for relieving refractory migraine headaches.

Take home message:

Can we draw conclusions from a simply descriptive study involving small numbers, with a dubious recruitment process and potentially unreliable measurements? Let us not be completely negative about this theoretically interesting concept as any large multi-centre trial usually starts with a pilot study like this one!

A dose finding study probably needs to be established to establish the efficacy of Propofol in this clinical context and a randomised controlled trial or a cross-over trial is probably needed before hard conclusions can be drawn for clinical practice…

 

 

NICE on headaches

 

What a headache today!
What a headache today!

Everyday is a school day!

 

NICE (the National Institute for Healthcare and Clinical Excellence) have recently issued their new recommendation on the management of headaches in young people and adults.

For those colleagues not working in the UK and not familiar with the funky term, NICE was set up over a decade ago to reduce variation in the quality of treatments and aims to help resolve uncertainty about which medicines, treatments, procedures and devices represent the best quality care for the National Health System (NHS). Sounds nice, doesn’t it?! They have put a lot of guidance out there some of which we have already covered on St.Emlyns (Sickle cell VTE guidance for example), so I like to keep a look out on what they are up to, and this particular recommendation caught my eye for several reasons.

First the title itself was somewhat unusual as NICE usually separates their recommendations into paediatric and “grown-ups”… I thought: “Really? A guideline, that applies to both children and adults? Less reading to do and worth a read then!”

Secondly, I remember as a junior trainee how much I dreaded seeing patients with a mysterious presentation of headaches, sometimes pitching up with symptoms for weeks accompanied by non-specific symptoms like dizziness, blurred vision etc. Diagnostic uncertainty from my end and zero patient satisfaction from the other were common occurences. This is a problem though as headaches are clearly debilitating for the individual, constitute a major health and social burdens they are a common reason for absenteeism from work and school (Ed – and of course let’s not forget that some of them are life-threatening). So, as a clinician you will come across it regardless of where you practice emergency medicine in the world.

As usual, NICE based their recommendation on systematic reviews and where none were available on what I like to call the “grey-haired clinician’s subjective opinion” (or authority-based medicine if you prefer). No ageism intended!

So what of the recommendations themselves? Some of the initial recommendations are “common sense” (though I believe in evidence-based practice rather than common sense medicine) and did not surprise me at all. It is what we teach the juniors to do everyday: investigate or refer headaches with fever or new neurological symptoms, those of a sudden onset or those accompanied by a loss of consciousness.

Some however, left me baffled! NICE suggest referring or further investigating headaches that get worse with Valsalva maneuver or with exercise. I do not know about you folks but when I get home after a hard day at work with a banging headache, it tends to get worse with a sneeze or if I get on the spinning bike! I therefore considered this clinical information to be a poor predictor of bad outcome and a poor diagnostic feature.

Let us not forget that most of our final diagnosis is actually based on clinical examination and interpretation of presenting features. A small table about features helping the diagnosis of primary headaches looked very much like a reminder from medical school but was very handy indeed.

I however always found that patients in Virchester look at me blankly and really struggle to describe their symptoms when I ask them the unavoidable question: “Would you be kind enough, Mrs X, to describe the nature of your headache?”. I often imagine myself in the patients’ shoes and think they find this question rather comical (well, they would if they were not in tears after a week of agonising pain) and futile (“Does it matter doc? Just sort it out now!”). Anyway, good table for the juniors and those preparing for exams.

“Be aware of medication overuse headaches” they go on to state. The British media covered this question for a couple of days not that long ago and there is no doubt that in a society of consumers where painkillers are available over the counter, we do abuse them easily and maybe stricter regulations are needed in the near future.

In the management section NICE recommend not performing imaging in patients where the clinicians have diagnosed a primary headache solely for reassurance. Reassurance of the clinician or that of the patient? Both equally important I would argue. Good communication skills are needed here to tackle patients’ disappointment when you will let them know they will not get a scan as recommended by their neighbour!

Parts of the proposed clinical management are discussion with the patient and re-assurance. Again, not a skill we were traditionally taught at medical school…

Acupuncture for tension-type headaches based on a single randomised trial? “You are having a laugh, doc?” reflects my personal opinion too but I guess it is a low risk intervention, worth a try. I do not know about the overall costs.

Same for Riboflavin or vitamin B2 in migraines, with or without aura. I guess the clinician could throw in the “five a day” here to convince the skeptical patient (and colleague): it will probably not harm.

We knew about the benefit of oxygen administration in cluster headaches and I have been using it in my clinical practice for years (with moderate results). Arrange ambulatory and home oxygen say NICE. I would struggle to arrange that in Virchester from my local ED I have to confess.

Overuse headaches are caused by… abuse of analgesics. Surprised? I was however genuinely surprised that NICE recommends stopping medications abruptly and not progressively! Only half of those who succeed in stopping will be given such a definite diagnosis. A new approach for addictive illness?

In summary, this guideline did not add anything new to my clinical practice but did come up with some interesting suggestions. It is a good aide-mémoire for the trainees and a trigger for future research.

The authors particularly suggested the followings as areas of future research:

 

  • Can a course of steroid treatment help people with medication overuse headaches withdraw from medication?
  • Can psychological interventions improve headache outcomes and quality of life?

 

Ok, it is almost tea time in the UK. I still drink mine with lemon. I think I am addicted to either the theophylline or the lemon. I hope it will not give me a headache…

 

Janos P Baombe

 

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JC: Gut feeling about serious paeds infections

So, I am back to rainy Northern England after my exotic travels to Cameroon and Gran Canaria (note: I still managed to join Twitter JC every Friday!) to find a paper on my desk for the weekly JC.

[tweet https://twitter.com/JC_StE/status/271964163780255744]

We have a long tradition for the weekly face-to-face JC in Virchester but we also run a Twitter -based JC started recently and which runs alongside it “to bring to the debate to the cyberspace” (as I like to say).

A paper from Belgium this week which is also open access (I just love that country…and its beers!).

So what’s this paper all about?

During my daily practice as an Emergency Physician, I have come to contact with children presenting to our ED with a variety of symptoms. Some of them will look very unwell (easy: treat and save!) but some of them will look well with very vague symptoms. Here is the clinical conundrum: how do you pick up the ones that are seriously ill (probably at the very early stage of a serious illness) and have very deceiving clinical symptoms?

It is clearly impractical (and financially impossible in any part of the world) to admit them all for a period of observation as a safety net. This means that we often have to rely on our intuitive analysis (“gut feeling” if you want to be simplistic) rather than our analytical one. You will no doubt have heard this from a colleague or a worried parent: “I do not know what is wrong exactly but this child is just not right!”. This is what the authors referred to as very nicely “finding a needle in the haystack” (very poetic).

Well, this paper embarked on to elucidate what this “gut feeling” provides in addition to clinical assessment for diagnosing serious infections in children and attempted to identify the associated features of the physician-patient encounter. This observational study set in Flanders recruited 3981 children aged 0-16 years who had presented with an acute illness for a maximum of five days.

You will stop me here and ask me about the arbitrary limitation of five days (I will say: you have to draw a line and it is often arbitrary) or the external validity/generabilisality of this as this kids were seen by primary care colleagues in a developed country (and I will say this could be a first step before validation in other settings).

So what did they look for?

For each child, a list of clinical features were recorded, including the physician’s clinical impression (subjective observation as the illness was serious recorded as present or absent) and their “gut feeling” (intuitive feeling that something was wrong recorded as present, absent or unsure).

You do not have to be a statistician to read a medical paper (and you might not like stats) but you will have picked up on the fact that during the multivariate logistic regression analysis the ‘gut feeling’ was coded as a dichotomy (present/unsure or absent). Again, it does not matter if you understand the intracacies of the method (and I am not sure I do myself!), but in essence the method allows the researcher to analyse a component (in this case gut feeling) as an individual element, adjusting  any raw effect in the data for other factors that might make a difference. The problem as readers is that it is often tricky to get a feel for the data when this sort of analysis has been undertaken and we are quite reliant on the authors.

Clearly it’s important that we are all talking about the same thing so it was resassuring that serious infections (sepsis, pneumonia, meningitis, pyelonephritis, cellulitis, osteomyelitis, bacterial gastroenteritis) were clearly defined by the authors. However, in this study sepsis equated to the finding of  pathogens in blood culture, but we could question whether this is an adequate gold standard. What about the contaminated sample (false positives) or the ones that grow nothing despite an illness (false negative). Furthermore, gastroenteritis equals bacterial pathogens in stool cultures but which pathogens, and might we have included the asymptomatic carriers (incidental finding during a febrile episode)? Again, these were unanswered questions when we read the paper.

The authors then undertook to characterise the diagnostic value of “gut feeling” constructing a 2×2 table. This is a very important point for those of you sitting exams. The CEM Fellowship exam will often ask you to work out sensitivity, specificity, NPV, PPV, etc. from  a similar table.

They then carried out a multivariable logistic regression analysis and used a goodness of fit model to test its strength.

What is this all about? It is much more important to understand these things rather than being able to define them precisely: we are not statisticians, but as medics we need to know enough to test whether a paper is valid. Basically, the first one is a statistical method that estimates the effects of several predictors on an outcome (think Wells score or Ottawa rules) and the second one tests if this works well in practice.

If you are a geek or a nerd, you will argue that the method assumes linearity of data and this does not work well here. I will ask you at this point to go and see someone more intelligent than me!

Moving on swiftly…

The dataset included 380 children, 21 of whom were admitted with a serious infection (12 pneumonia, 6 pyelonephritis, one each for sepsis or meningitis, cellulitis or lymphangitis), the mean age being 5.05 with a range 0.02 – 16.93.

Table 1. shows the overall diagnostic performance of gut feeling. Here is the time to revise your Spin and Snout if you are sitting exams folks!

From this table, the authors concluded that they had the potential to prevent two cases being missed at a cost of 44 false alarms. Interesting numbers, don’t you think so? The balance they give us is 44 admissions for 2 diagnoses to be picked up. We cannot say that it is two lives saved as the potential for intervention is not tested in this paper. Overall then the economic call is whether those admissions are worth it. We thought probably that they were in such a high risk group.

The “gut feeling” was more specific (rule-in value) than the clinical impression and this, irrespective of the seniority of the doctor, the age of the child or his/her diagnosis.

Table 2 shows features associated with gut feeling when the impression overall was of a non-serious illness.

I will let you have a look at the tables on the links and draw your own conclusions but the results were as to be expected really. Basically, you are very sick if you have had a convulsion, lost weight or if mummy was concerned. My grandmother could have told you that (no, she was not medically trained and I do not think she had heard of confidence intervals and the worry when they are as wide as in this table)!

So what is the “take home message”?

Reading this paper brought little to my clinical practice. It however was a great discussion at JC (both face-to-face and on the cyberspace) and I wondered where this would fit within the NICE guidelines we use in the UK (fair enough different population and setting).

It also prompted some brainstorming with colleagues and friends about the utility of intuitive versus analytical thinking (but this is another debate!) in our practice.

As a final note, I like to read papers and I like to critically appraise them. This is not about savage criticism, it is about having a cautiously open mind and trying to extract information form a jargonist manuscript. I said this before and I will repeat it: you do not need to know statistics as a geek to read a medical paper! You do not believe me? Listen to someone who has more experience than I do!

Agree/disagree with anything said? Please post a comment and/or join us at Twitter JC every friday at 13:00GMT (I will be there!) @JC_StE

 

Janos P Baombe

 

Before you go please don’t forget to…

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