GMEP media

Here at St. Emlyn’s we have been managing patients with pneumothoraces as out patients for many years. The approach in the UK has been ‘guided’ by the BritishThoracic Society guidelines.

BTS guidelines document

For many PNXs we simply aspirate, and if successful we discharge the patient back to community and follow them up in clinic with serial chest radiographs.

In recent years we have started to question this approach. We have gone over to using very small (8 and 10 French) chest drains for simple pneumothoraces which are far less invasive than the old ATLS methods of finger sweep insertions. Arguably the insertion of a small Seldinger guided chest drain is a relatively minor procedure, only slightly more uncomfortable than having a pleural aspiration -  but of course you then have to admit the patient as they have a chest drain in as they are connected to an underwater drain……or do you?

Arguably you don’t. There is an alternative and that is to place a Heimlich valve on the end of the chest drain to maintain a negative pressure seal. This is not something that appears in the BTS guidelines, but there are clearly people doing it.Could we then safely discharge patients with a small chest drain and a Heimlich valve in place? It’s a good question that Fraser Brims and Nick Maskell have tried to answer in Thorax.

http://www.worldtrippers.com

I would also like to thanks the Lee family who kindly gave permission for the use of this photo from their website. Not only is at a great photo but it’s also a very interesting story from a patient’s perspective about what it feels like to have a pneumothorax, a chest drain, hemlich valve, underwater seal and then surgery. Joss certainly went through the full gamut of procedures and I really think their experiences are worth a read (an amazing family).

Simon Carley

The post JC: Should we use Heimlich Valves for ambulatory pneumothorax management? St. Emlyn’s appeared first on St Emlyns.

Streamlining of prehospital stroke management: the golden hour.

If you have been happily playing with #FOAM for the last year or two then you must have come across the many excellent articles on the use of thrombolysis in stroke.

Ed – what do you mean you’ve missed the debate!!

Seriously? Well I suppose it’s possible that you may have missed the superb contributions that have exposed the questions and concerns about the efficacy and fair reporting of trials looking at stroke thrombolysis. If you’ve missed the debate then I would strongly recommend that you have a look at the following…

• Gareth Hardy’s Prezi on the trials: Adventures in Wonderland
• Domnhall Brannigan: IST-3 – is it another false dawn? The Underneaths of EM
• Andy Neill: the lytic trials
• The NNT.com: Thrombolytics for stroke
• Michelle Johnston still firmly feline & on top of the fence at LITFL: Schrödinger’s Fence

There are many more out there and if you want to hear a fantastic review of all this then keep your eyes out for Domnhall’s talk from SMACC2013 when it is released. That was a fantastic summary and I hope it will make an appearance soon.

So, why am I talking about this if there has already been many questions in the #FOAM community already? Well, the Lancet has released a new article in the online first section that makes claims and suggests therapies that I would love my esteemed colleagues to review. The paper looks at streamlining prehospital care to deliver patients with stroke to a centre available to deliver thrombolysis as quickly as possible. This is analogous to the changes we have seen around cardiac care to deliver patients to thrombolysis, and no PCI as quickly as possible. In this study the argument for rapid transfer is predicated on the assumptions that thrombolysis is ‘state of the art’ and that the NNT for a positive outcome is 4.5 if thrombolysis is administered within 1.5 hours (NNT of 9 if 1.5-3 hours post symptom onset).

Now, just to redress the balance a little then you might also want to whizz over to EMCrit and listen to Scott’s podcast on the optimisation of processes for the delivery of stroke thrombolysis in hospital. To be fair Scott does not personally endorse it, but does say that if your institution decides to do this then do it well, and this is a way of delivering a slick door to needle time.

• Reducing door to tPA time in ischaemic stroke

Does this matter? Well arguably yes. The proposals set out in the paper will require investment in time and money, and at a time of austerity we really do need to make sure that our health pounds are spent wisely.

So, if this area interests you then please do have a read, and if you feel the need it’s worth mentioning  that the Lancet has a quite vigorous correspondence section………

Simon Carley

The post JC: Time is brain…., calling #FOAMagitators. St.Emlyn’s appeared first on St Emlyns.

Here at St.Emlyn’s we like a bit of #dogmalysis. We like to challenge established thinking and perhaps to look again at what we all know to be true.

One such dogma is that ‘Children are not little adults’.

This is embedded into our training from undergraduate level, through postgraduate training and it’s one of the most common (and quite frankly the laziest) lines to appear at the beginning of any paediatric text.

Now, there is much to be said for paediatrics and paediatricians. I work with some absolutely amazing paediatricians on a regular basis and frequently use their skills, knowledge and experience for kids in the ED. In my current hospitals it’s a great symbiotic relationship that works well, but in my training and travels this has not always been the case. When we stop and think about sick kids, and I mean really sick kids we might perhaps need to think again about whether the expertise lies in a job title, or in a skills set. In terms of resuscitation should we ask ourselves a dogmalysis type question….

In the resus room are children really just little adults?

The following talk was delivered at SMACC 2013. A great conference that excelled at getting clinicians to think and challenge what we think we already know. My contribution is designed to be the antidote to the established dogma around children and as such I’ve designed the talk to be delivered as a challenge to established thinking.

I wanted to do this talk from the perspective of a general emergency physicians who deals with kids as I believe this to be the norm in the UK. Most sick kids will initially be seen by a general EP and whilst I think some paediatric specialists in the UK believe that this should change and that adult and child emergency medicine should split apart, that’s not my belief and for much of the country it will not be practically possible. So, for the foreseeable future we need to ensure that our EPs are mentally prepared to engage with paediatric resuscitation in the same way that they do for adults. That, I hope, will be the outcome of this talk.

All the cases are illustrative and not real cases. For confidentiality reasons I’ve made the main case up based on an amalgam of past events and experiences over many years. The docs mentioned are essentially hypothetical (see note on cases on St.Emlyn’s below). They are included to illustrate the principles discussed and show a chain of events that can take place through procrastination resulting from a fear of intervening in sick kids. I should also clarify that when I say (in the talk) that cases such as these are not uncommon – that refers to the delay in intervention. I don’t want to give the impression that children are dying on a regular basis! The vast majority of kids are treated well in the UK, but it is not infrequent to see delays manifested in the resuscitation process that we would not expect to see in adults.

The views are designed to promote debate and are based on my personal thoughts and experiences. They do not represent the opinions of my colleagues, my employer or students. In fact I may be the only person in the world who thinks this……but I don’t think so. We recently met Joe Lex here in Virchester and he attributed the following (I think) to Rosen (previously said Tintinalli – thanks to Chris Nickson for correction)  ‘the last thing a sick kid needs to see is a paediatrician’, and whilst that is a far more provocative statement than anything in my presentation there may be some truth in the statement. Let’s go for an amendment ‘a sick kid should not ONLY see a paediatrician’. Hopefully that statement will make more sense after listening to the podcast.

If you like this I would strongly recommend that you also listen to the talks given in the same session. Matt O’Meara doing a great job on the FEAST trial, the very impressive Mary McCaskill on neonatal nightmares, and Andrew Numa on futility in paediatric care.

Matt O’Meara on the FEAST trial.

Mary McCaskill on Neonatal nightmares

Andrew Numa on defining futility.

Finally, I have always worked in hospitals that see kids and I think it’s a really exciting and rewarding part of practice. Like everyone else I am not immune to errors and many of the lessons in this presentation are…., as Casey Parker might say Hard Learned.

The post Children are just little adults. SMACC2013. St.Emlyn’s appeared first on St Emlyns.

It was  a long day. After getting home from a late shift the night before, I was up at 4 to catch my 0530 train, and toddled off down to London. What, you may ask could be worth all that?

Simples:

I spent the day at the Essence of EM course, run by Cliff Reid, one of the most well known faces of #FOAMed and EM internationally. As if that wasn’t enough, the rest of the faculty were made up of highly experiences EM and ICM doctors, including Dr Louisa Chan (consultant ICM/EM), Phil Hyde (Consultant PICU), and Dr Mike Clancy, until recently president of the College of Emergency Medicine.

At #EssenceEM today. Look! It’s that chap off of t’internet!

June 5, 2013 8:32 am via Tweetbot for iOSReplyRetweetFavorite

@DrGDH

Gareth Hardy

Running Essence of Emergency Medicine course today in London with great faculty and some VIP delegates!! #EssenceEM

June 5, 2013 7:50 am via webReplyRetweetFavorite

@cliffreid

Cliff Reid

So what was on the agenda for the day? The latest EM literature? Some cutting edge new technique that has twitter all in a flap? No. While clearly a man of many talents, Cliff is best known in the #FOAMed world for speaking on the human factors that affect us every day in EM. These ideas and concepts are as vital as any clinical skills and knowledge, yet are notoriously difficult to teach and assess in today’s world of tick box assessments. Anyone who has heard Cliff speak will know how good he is at getting these ideas across, and will understand why I jumped at the chance to hear him talk  in person.

Story Time

Cliff and his colleagues told us their stories. Some were funny, some were inspiring, some tragic and deeply personal. These weren’t “see how awesome I am” stories. These were stories of the events that had inspired them, or mistakes they have made.

 

 

“How could I have done something so dumb?” - Cliff Reid

Hearing such experienced people discuss their mistakes openly and honestly prompted the candidates to open up about the events that have affected them. After all, we learn very little when we get things right. We learn when we screw up, or when a colleague leaves us for dust; that’s when we’re inspired to be better.

The theme of learning from errors and incidents ran through the day. Mike Clancy led a discussion on dealing with a colleague’s error. Presented as an opportunity for improvement, an error is the most valuable learning tool we have – provided we are committed to changing your practice, or the system, to ensure it doesn’t happen again.

ED group therapy - share and tell akin to extreme M&M, pure rolled gold!#EssenceEM

June 5, 2013 1:26 pm via Twitter for iPadReplyRetweetFavorite

@cherylemartin

cherylmartin

#EssenceEM when things go wrong, take it upon yourself to make the improvement and importantly sustain the change

June 5, 2013 9:43 am via Twitter for iPadReplyRetweetFavorite

@mrntv

mrn

What kind of Emergency Physician do you want to be?

This leads us on to the second theme running through the day. This question was asked of us right at the start. The phrase ‘taking responsibility’ once a constant refrain. Take responsibility for your patients! Do all you can for them, don’t just move them on to become someone else’s problem. If the system you work in is preventing you delivering the best care possible, then take responsibility, change that system. If the patient in front of you needs a lifesaving procedure –  then step up.

#EssenceEM - Have you run through the rare life, limb and sight saving procedures in your ultra high fidelity simulator (your brain)?

June 5, 2013 9:49 am via Tweetbot for iOSReplyRetweetFavorite

@mike_eddie1

Michael Eddie

Put your patients first, don’t abdicate responsibility to other specialities if you feel patient care will be compromised. Learn to communicate with your colleagues and advocate for your patient. Don’t abdicate responsibility to the bureaucracy; there may be a four hour wait in minors, but the unwell patient in front of you should be your priority.

To hear Cliff and his colleagues talk like this is music to the ears of UK EP’s currently struggling through a difficult time in the speciality. I think many of us feel that the pressures heaped upon us are compromising our ability to look after our patients, and that the high level, patient focused kind of care that Cliff promotes is not feasible in a world of breaches and under staffed rotas. I found it inspiring to here those eminent in our speciality discussing these concepts, and to see that the majority of attendees on the day were consultants who will take these ideas home to their department.

We all had a great day, and I can only thank Cliff for his time and dedication (plus I think I owe him a pint). Should you get the chance to attend this course in the future, I can not recommend it too highly.

Fantastic day at http://t.co/GPL8yG8eDI loads of ways to be a better ED doc. #EssenceEm

June 5, 2013 8:24 pm via Twitter for AndroidReplyRetweetFavorite

@Nmanville

Nick

Well earned drinks afterwards! Left to right: Mike Eddie, Duncan Roche, Louisa Chan, Cliff Reid, Reuben Griscti, Bijou Cherian, Richard Browne

Gareth Hardy of the drgdh blog fame

The post Review: The Essence of Emergency Medicine appeared first on St Emlyns.

I’m an APLS instructor & course director and have contributed various bits and bobs over the years and it’s a great course. I’d go further and say that it’s a really great course to get a grounding in Paeds resus that has made a real impact to paediatric care around the world. I love it, the organisers, the content and pretty much everything about it…., well almost everything. If you’ve done the course in the last few years you’ve no doubt seen that the APLS formulas have changed for weight calculation. We’ve gone from a nice and easy to remember (Age+4) x2 to a rather more complicated set of three formulae that require quite a lot more thought, memory and calculation.Maybe I’m getting old, but I find it tricky to recall this immediately and I have to look it up, or surreptitiously glance at the wall in resus for a quick aide memoire. Is it me, or is just a bit more tricky these days.

If you’ve missed the change in the 5th edition of APLS then they are shown below. I find this sort of thing interesting as we knew that the old formulae did not predict weight very well. A number of papers over the years have looked at different ways of getting a more accurate estimation of weight. Formulas based on age are fine, but there is a huge variability in size according to age (I just have to look at my daughters class at school to see how this might not work), so length based assessments have also been derived such as the Broselow tape. However, we can’t measure children before they arrive so it’s still sometimes useful to estimate a weight prior to a child’s arrival in order to prepare the resus room

_____________________________________

Old formula:

Weight = (Age+4)2

Under the age of 12 months APLS 4th edition estimates on a continuum of an average weight of 3.5Kg at birth to 10Kg at 12 months

New formula:

Weight 0 -1 = (Age/2)+4

Weight 1 -5 = (Age x2)+8

Weight 6 -12 = (Age x3)+7

_____________________________________

So, in the 5th edition APLS we have seen an increase in complexity, but does that lead to an increase in accuracy for us as emergency physicians?

A couple of years ago I helped three of my trainees to look at this in the UK, and despite valiant efforts to get it published we have failed  as we appear to have failed to get a message across about weight estimation in the resus room, but if you will permit us the vanity of self publication we’d like to share the findings here on the blog. This work is based on the fabulous efforts of Pete Hulme, Amar Javaid and Ken Anderson.

What about the analysis?

This is where we ran into a spot of bother with reviewers and journals. Many previous papers and many reviewers were keen to look at the overall accuracy of one score against another, that has typically been achieved by looking at the average weight as predicted by the formula vs the real weight. You can compare the performance of one score against the other by looking at how well the correlate overall. Correlation is one way of looking at agreement, but for many reasons it’s a bad way when looking at this sort of data. You usually get a good correlation simply because as true weight goes up, then so does the estimate (obviously). It’s not helpful and does not tell us as clinicians what is important. Correlation is too easy, too lazy and too likely to give a nice positive result. As clinicians we don’t need simple correlation we want to know if there is a clinically important difference between an estimated weight and the real weight.

So, what is a clinically important difference? Let’s say that you estimate a weight and it’s 5% different from the real weight. Would that be important clinically? Probably not, but what if it were 10%, 15% 20% or more. Arguably as the % difference between measured and actual weight increases the greater the clinical significance. In our opinion (and it is only an opinion) we felt that over 15% and certainly over 20% different could be important when considering resus drug doses and fluid requirements for paediatric resuscitation. That’s just our opinion, please feel free to disagree.

So that’s how we looked at the data. We looked to see  how often the estimated weight differs from the true weight as a percentage difference from the true weight.  We compared the two weights by plotting the actual weight against the percentage discrepancy between measured and calculated weights. We then calculated the discrepancy in weight estimations using cut offs at 10,15 and 20% body weight discrepancy with 95% confidence intervals assuming a normal distribution.

So what did we find?

Firstly, let’s have a look at the data as distributions.

Old Formula plot

New formula plot

I like looking at distributions as you can get a feel for what the data is before applying summative statistical tests. It’s something I learned a long time ago and it’s advocated by Bland and Altman, gurus of the med stats world. Anyway, at first look the new formula appears to be a better fit for the true weight of paediatric patients, but what about the number of patients who fall outside of the clinically important difference?

We can tabulate this looking at the numbers of patients who fall outside the 10,15 and 20% ranges across the three age groups linked to the new formula.

Difference as % of measured weight	Age range	Old formula (by age range)	New formula (by age range)	Overall Old formula (all ages)	Overall New formula (all ages)
>20%	0-1(163 patients)	7 under49 over	10 under31 over	42%	29.7%
	1-5(516 patients)	5 under151 over	5 under151 over
	5-12(323 patients)	3 under209 over	53 under77 over
>15%	0-1	7 under77 over	16 under47 over	56.6%	46.5%
	1-5	10 under229 over	10 under229 over
	5-12	6 under237 over	67 under96 over
>10%	0-1	12 under106 over	26 under72 over	72.2%	63.5%
	1-5	29 under301 over	29 under301 over
	5-12	10 under264 over	85 under122 over

The table supports our first assumption. The new formulas are indeed more accurate.

Simon Carley

The post APLS weight estimation – don’t do it (well almost never). St.Emlyn’s appeared first on St Emlyns.

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If I think back to my practice a few years ago (as I’m getting older) there is no doubt that the number of CT scans I’ve performed from the ED has increased. In both my adult and paediatric practice the indications for CT have increased, the ease of obtaining a scan has decreased and as a result I’ve almost certainly delivered many more mSieverts in the last year than say 5 years ago….., but does this matter?

On the one hand I’ve picked up a lot more pathology, and probably at an earlier point in the diagnostic process. In trauma we have seen the advantages of the Afghani-scan (full body CT) and early CT brain protocols has undoubtably led to earlier identification of surgically treatable bleeds. So, there are lots of positives, but there are also some negatives and one of these is the increase in the overall dose of ionising radiation to the population and the potential for the increase in cancers. Now, this is a difficult area to study as you need a lot of time and good record keeping, but it can be done.

In this week’s BMJ John Matthews and colleagues in Australia have performed a population study that incorporates 680000 children exposed to CT scans, and compares them to a population of 10,259,469 patients who did not receive a CT scan. These are pretty big numbers, and it’s an open access paper too

Simon Carley

The post JC: Do paediatric CT scans cause cancer? St.Emlyn’s appeared first on St Emlyns.

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A few years back I picked up a book at the airport by a chap called Malcolm Gladwell, a rather famous writer it turns out and one familiar to many EPs who has produced some excellent work. I like his books as they make me think, it’s work that challenges my past assumptions and in some cases raises questions that make me feel quite uncomfortable. I’ve read a few of his books now and all have their merits, but I think that the one I use in teaching the most is ‘Blink’. Blink looks at how we make rapid assessments and judgements in daily life and explores the positives and the negatives of this…., is this relevant for the emergency physician? Well of course it is. Our days are a constant stream of rapid assessment and decision making. It’s probably not a bad idea to stop and think about it once in a while.

Anyway, a small passion of mine is to try improve understanding around equality and diversity issues in Emergency Medicine. We’ve recently had IDAHO day and in Virchester we have recently had a whole week around Equality and Diversity training for all staff. In the ED our practice means that we see everyone regardless of who they are and where they come from. As one of my colleagues mentioned recently we ‘are’ diversity, with a really mixed population and staff, and we do some fantastic things to help our patients and staff support this. What about ‘you’ though, and ‘me’, and ‘your’ colleagues? Are we the sort of people who are truly free of any prejudice and judgement? Do we exercise prejudice in our work and do characteristics such as weight, age, race, skin colour, gender and sexual orientation influence how we deal with patients and colleagues?

I will take a guess and say that at this point most people reading this will say that it doesn’t. We would not describe ourselves as racist, sexist physicians (and all the other groups we can think of). We don’t consciously discriminate as that’s clearly contrary to the practice of being a good emergency physician, but are you sure? How would you know if you are the sort of clinician who links certain characteristics to certain group of people? How would you start to understand whether patient characteristics might affect you?

We might even ask if it matter at all if we treat patients the same? Is there evidence that race (as one example) influences us? Disturbingly there is. Just dip into Medline for a selection of the many papers around linked to the subject. We can go back to 2000 and Dr Knox Todd who showed that white patients received more pain relief in the ED, in 2006 data from the USA , more recently in 2010.….., I could go on. It looks as though we have an issue around pain relief and an association with race. That makes me think that this stuff really matters.

So, back to Malcolm Gladwell and Blink. It is here that I discovered  work around the concept of Implicit Association developed at Harvard University by Anthony Greenwald and Mahzarin Banaji. Implicit association suggests that we unconsciously associate certain characteristics with certain groups (e.g. skin colour) with the individual associating positive or negative influences against these characteristics. By assessing the degree of association the IAT builds a picture of how an individual associates certain characteristics as either a positive, neutral or negative trait. The literature behind it at the time, and since, is complex and beyond the scope of this post. You are welcome to read more including the many controversies around the methods and interpretation of results should you wish. My usage is much more basic. I think it’s a great way of challenging us to think about our own assumptions and the associations that we make about our patients.

What was fascinating in Blink, and borne out by the many colleagues who have taken this test is that nearly all of us have preferences for certain characteristics, and that they are not always in the direction and magnitude that we think. The great thing about the research is that the tests are available for free and online. You have to give some additional details to answer the question sets that cover a range of topics, but it’s worth the effort.

Of course, it’s not just the Harvard team that have identified associations between characteristics and preference. It’s even something that we can detect in children, with kids expressing less of a preference to overweight characters in story books.

So, I’ll ask the question. Do you have racist, sexist, gender, orientation, weight etc. preferences and association? I don’t think you know, but if you’d like to, then you know where to take the test. The public and free demo tests are available across a range of topics. If you want to be a better clinician I think you’ll find them useful.

The post Do Emergency Physicians judge patients on race, sex, sexual orientation, weight, etc.? St. Emlyn’s appeared first on St Emlyns.

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So what do we mean by a miss exactly? Is it always a terrible thing and why is it that if we constantly miss diagnoses (we do you know) we are not in court every week? Hopefuly if you have read parts 1 to 5 of risky business then you are now absolutely convinced that error is an integral part of the diagnostic  process, in fact it is so much a part of the diagnostic process that I don’t really consider it error any more it is an inevitability that some patients will slip through the diagnostic net when you see them. You will not diagnose them, they will appear to you to be free of disease and you will, no doubt, reassure themselves and yourself that all is fine and dandy. Both you and your patient will hopefully sleep well that night.

Just occasionally though, just once every so often, you will wake about 3am and wonder…., ‘I wonder if that patient was the one that slipped through the net?’, or ‘I wonder if I might call them tomorrow to check they are OK?’ I’ll give a pound to any emergency physician who has never woken with such thoughts, and I’m pretty certain that the pounds will stay in my pocket.

But a miss is a miss isn’t it?

Firstly we should get an idea of what a real miss looks like….., if you are Italian you will not enjoy this!

http://www.youtube.com/watch?v=voT5W9Doa-s

Now that was a miss with consequences. That miss by Baggio lost Italy the world cup, handing the win to Brazil and pushing Roberto Baggio into top place for world’s worst misses. So it’s a bad one, unlike Diana Ross who also committed one of the worst penalty shots of all time, but there were no consequences at all (except for the obvious humilation)

http://www.youtube.com/watch?v=WXjCKwBtG0I

What do these football analogies tell us as clinician in the ED?

If we don’t ‘make’ a diagnosis what are the potential outcomes for the patient who was missed? The natural assumption amongst most clinicians is that harm will then happen. A missed diagnosis surely means that we have lost the opportunity to make the patient better, but hand on a minute. In the last post we talked about how many therapies (such as thrombolysis) have an inhereny harm within them, so it’s not so clear cut as we might have thought.

So, let’s stop and think about what needs to happen for true patient harm to take place. Perhaps we can think of this as a series of steps. For serious harm to take place a number of things need to happen.

Step 1. The patient needs to get worse.

Pretty obvious if you think about it, but not intuitive. Many conditions that we see in the ED are self limiting, even potentially serious ones such as DVT/PE or even some acute coronary syndromes (depending on your definition) can resolve spontaneously with no long term sequelae. Infections such as pneumonia could go either way but a significant number of patients will get better spontaneously from a whole range of infectious diseases, cardiovascular conditions and trauma.

Step 2. The patient needs to not come back.

Most conditions get worse over a period of hours/days and the patient will develop new or worsening symptoms. Patients with infective disease are classic for this, even when they have significant disease. Almost all other conditions will ‘usually’ worsen, but sadly not all. There is a proportion of patients with conditions such as ACS, PE, SAH where sudden, rapid and fatal deterioration may take place. There is little that can be done in these circumstances, but believe me the incidence of this is rare in comparison to the number of patients we see. So basically, most ‘missed’ patients who get worse will come back.

Step 3. You need to miss it again.

Possible. It is possible to make the same mistake twice. Indeed there is something about our pride as physicians which is challenged by a patient returning with the same problem that we have already ‘ruled out’. Experience has taught me that pride is not a good feature for an emergency physician. Any returning patient should be considered a ‘red flag’. In general terms I teach our juniors that a returns patient is an admit/senior review until proven otherwise. Returns are high risk patients.

Step 4. You have no treatment on return

So, when they do come back for things to get really bad there has to be nothing that we can do to make it better. A patient with a missed MI might come back in cardiac arrest and not survive, which would be awful, but those cases are rare. More commonly a patient will return with a worsening of disease. A missed chest infection may turn to pneumonia, a wound infection to an abscess. Whilst it would have been better for your patient to have been treated at the first opportunity there are still therapeutic options and in the vast majority of cases they will get better.

In other words even if a patient comes to the ED and you do not identify their underlying condition (and if you have read the other posts in this series you will know that this HAS to happen) then it does not mean that disaster will ensue. Most of the time there are either no consequences at all, or, the patient will deteriorate and return within a time frame that gives you opportunity to intervene and treat the condition.

The odds then are very much in your favour, even with the necessity of accepting the fact that we miss diagnoses we can find some solace in the odds that such misses do not lead to disaster. Most patients will safely traverse a number of steps to safely reach the other side of their illness. Does this relax you? Does this make you complacent? Well perhaps. It makes me a little more relaxed about the whole uncertainty of the diagnostic process but I’m not sure that my patients see it that way. Thus far we’ve not really considered the patient, but they must surely feature somewhere and they do…..in Part 7.

vb

Simon Carley

This article is part of a series on understanding diagnostic tests in the ED. For other articles in the series click here.

The post Emergency Medicine: A risky business part 6. How many steps to disaster? appeared first on St Emlyns.

Many Emergency Physicians are deeply committed to education. Many will be also be instructors on life support courses. This will often be done in their own time and at not inconsiderable personal sacrifice….

In the current climate we are also facing some pressures in job plans and rosters to justify our efforts and activities beyond just seeing patients on the shop floor. Now obviously seeing patients is what we are all about, but in order to do that we need to develop ourselves, our staff and our departments. Education is key to this and I’m a fan of accrediting those efforts externally as ‘evidence’ for revalidation and appraisal.

So, I am delighted to announce that the Academy of Medical Educators (AoME) in the UK has approved the Generic Instructors Course (GIC) course as an equivalence route for membership of the Academy. In the past membership was obtained by completing an application form involving a fair bit of reflective writing and evidence. It was good, but it did take a bit of work and I think it put a lot of people off applying. The new automatic approval process means that if you have passed the GIC you will be automatically accepted as a member of the Academy.

(Bonzer as out Antipodean colleagues might say – Ed)

Bonzer indeed, though it is worth stopping and thinking about the benefits. There is a cost of course which is pretty high in my opinion. If you are part of an organisation with corporate partnership then you pay the reduced rate (ALSG is, as is my own trust). It’s also tax deductable, so if you are lucky enough to pay lots of tax then it’s considerably less again.

* lower rate applies for corporate partners & ALSG is one.

So, apart from the benefits of external validation and a signal to others that you are a ‘professional educator’ (Ed- really???) what else is in it for you? It’s worth having a look at the following document from the Academy itself to explain more, but in essence this is a move to professionalise and recognise education as a specific skill and role. If you are interested in education this may well prove valuable in the future.

Why you should join the Academy

If you have not done a GIC course,  then don’t worry you may well still be eligible for membership or even fellowship of the academy through the usual routes of application. A number of workshops on applications are planned by the academy around the country and you can attend one of those.

Ed – What if I did my GIC with the Resus council??

Good question. As I understand the situation at the current time this is a specific arrangement with ALSG. I don’t think the Resus council is a corporate partner, and I don’t think they have been through the approvals process. I would check with them directly if  you want to know more.

My own conflict of interest is perhaps that I am a Fellow of the Academy and was for a brief time a member of Council, though that ended last year. I’ve also facilitated some workshops on joining the AoME so feel free to take my comments with a pinch of salt. I’ve also done loads of work with ALSG including a little to do with getting this process approved. The major thanks must go to the fabulous Sue Wieteska of ALSG who has yet again done an amazing job in supporting the hard working instructors of ALSG. Thanks also to Mike Davies and Kevin Mackway-Jones & everyone else who has contributed.

Simon Carley

The post Good news – AoME + GIC = Membership. St.Emlyn’s appeared first on St Emlyns.

Thanks to Karim for a heads up on this one. Just a quick post this time, but another paper looking at the use of tranexamic acid in trauma and in this case the potential synergistic effect of cryoprecipitate together with TXA in trauma patients.

MATTERS-II : Potential synergistic effects of cryoprecipitate and TXA on mortality after trauma haemorrhage: http://t.co/SwH5YyzGa7

May 17, 2013 6:39 am via TweetDeckReplyRetweetFavorite

@karimbrohi

Karim Brohi

So, what of the paper? What can it tell us about the management of traumatic coagulopathy in the resus room? Well, for starters, read the abstract below and follow this link for the full paper (if you have journal access) which is now available on the JAMA network.

So, another trial is another from the same group that put the MATTERS trial together. The results are really interesting but the design and setting limit the applicability to my practice. Perhaps we need to keep thinking but wait a little longer to see how this works in the civilian population.  Back to you Karim….

If only someone was doing an RCT of cryoprecipitate in trauma haemorrhage... Oh wait - there's CRYOSTAT!! 8) http://t.co/rEZDjeBWUz

May 17, 2013 6:58 am via TweetDeckReplyRetweetFavorite

@karimbrohi

Karim Brohi

So, let’s look at this with interest, and wait to see what CRYOSTAT tells us. Looking at the protocol I think it will give us the answer we need, but I’m not yet sure when we might see the findings.

Simon Carley

The post JC Cryo + TXA for trauma apparently it also MATTERS. St.Emlyn’s appeared first on St Emlyns.