Not every conference has to be huge, multimedia and international, there is a lot to be said for local conferences. This week I attended the BASICS North West regional conference1. Here are some of my notes and highlights of the day. If you’re interested only in torso trauma then skip to the end, but beware of doing that, there is some cracking stuff before that.
Theo and Martin put on a great day and I really hope that theu do the same next year.
Bariaric problems in Pre-Hospital care wth Hannah Bawdon
Hannah is a Sydney HEMS alumnus who now works as a consultant anaesthetist and prehospital care doctor in the Midlands. It’s impossible to talk about the epidemiology of obesity without dodgy puns featuring, so pick your own, but it’s a ‘growing’ problem of epidemic proportions. Did you know that more than a quarter of the world’s population are overweight or obese adults? 2 billion! It’s more common globally than undernutrition, and getting worse (in all age groups). We are a society of extremes.
Hannah talked about the consequences of obesity for individual patients and for services. Obesity is a multisystemic disorder, with clinical consequences for us, e.g. respiratory (difficult airway and ventilatory management – don’t lie your patients flat!), cardiovascular (how do you assess volume status and fluid responsiveness when you can’t record an accurate BP or find anatomy on ultrasound?) and musculoskeletal systems (chronic pain complicates acute pain management, and there’s an increased risk of fractures from low-energy mechanisms). Mental health cannot be ignored; there is still a huge stigma in society about obesity, with an often downward spiral of social isolation, anxiety and depression from which it is so hard for patients to break free. Patients need our support and understanding, not our judgement.
In terms of the impact on services, bariatric patients require bigger kit and greater resources. Kit includes medical kit (e.g. BP monitoring cuffs, pelvic binders, IO needles, etc) and extrication / packaging equipment (scoops, stretchers, ambulances), often brought to scene by additional personnel; a ‘simple’ extrication can turn into a several hour multi-agency response, and the patient might require critical care throughout this whole period.
Trauma is an interesting one, because injury severity scores are actually lower in the bariatric population, with a different pattern of injury (e.g. more likely to injure chest, less likely to have significant abdominal or head injuries). Once injured though, bariatric patients do worse, with longer stays in hospital, longer stays on ICU and greater risk of complications, such as VAPs. Part of the problem is diagnostic difficulty (e.g. perinephric fat on ultrasound can resemble intraperitoneal free fluid), part of it is treatment difficulty (e.g. reaching the rib cage to do a thoracostomy or insert a chest drain; performing a surgical airway to aid weaning from a ventilator), part is the impact of their pre-existing comorbidities, the rest is unknown.
Hannah had plenty of learning points, but these stick out….
- RAMP your patient, wherever possible – makes such a difference to airway management and their ability to breathe
- A standard BP cuff on a forearm works well
- Think ahead: what extra resources do you need to manage the patient effectively for their extended pre-hospital journey? What extra resources do the hospital need time to organize to allow care to continue in the ED?
Sex drugs and Rock and Roll with Mark Buchanan.
Alcohol and drugs are rife in our region. Alcohol is still the biggest problem we see, but of late we’ve had incrasing problems with psychoactive substances such as SPICE and other novel psychoactive substances designed to increase adrenaline, dopamine and serotonin levels. Mark talked about how easy it is to obtain drugs online via sites that make purchase incredibly easy and which also have what Mark described as an Amazon style review system. Personally I thought the reviews were a bit more like trip advisor.
Current issues remain as alcohol, Mephedrone, synthetic cannabinoids, halluciingens, high dose exstacy, GHB, Xanax, Benzos, psychadelics, hallucinogens and more. Bottom line is that if you work in emergency care you really do need to understand what the drugs do and how to manage them.
Sepsis with Stuart Lee
Stuart used a quick Kahoot quiz to demonstate the impact of Sepsis on society and on prehospital care. In summary, the impact on patients, families and economically is huge (billions a year in the UK). It is an area where promot treatment and early recognition can make a real difference and that’s an area where prehospital teams can make a difference. It’s worth watching the trailer and film to STARFISH which highlights the impact of sepsis on families even when patients survive. Perhaps that’s something we forget. The impact of severe sepsis does not end when the patient leaves the ED, the ICU or even the hospital. The physical injuries may be permanent, and also the psychological effects are also profound. Stuart quoted a PTSD rate of 38% which is alarming. A recurrent theme in reviews of sepsis management is that early intervention is frequently missed.
Stuart highlights that in prehospital care it is an evidence light area. A recent systematic review suggests that little is proven2, but that cannot be an excuse for complacency and there is much work being done here in the NW. This includes early identification, pre-alerts, resuscitation and antibiotics. As yet we don’t know the impact but we hope it will be shown to make a difference.
At the moment we are probably doing too many pre-alerts, but this is under review and change. NEWS scores are currently in use, but that is not perfect3. NEWS2 is on the way which takes more account of dynamic change4. This is planned to be used in association with red flags and risk factors to focus attention on those with significant sepsis. As ever with all triage tools the challenge is to find something that is both specific and sensitive. As we know, that’s a huge challenge with any triage score5.
Stroke is still a major cause of morbidity and mortality in the UK. Early identification and response for these patients is clearly important. A lot of this work in the North West has been around the identification of patients who are suitable for thrombolysis and the systems are in place to do this (whether we believe it works or not). In the NW from a research persepctive there are three themes
- Reduction of harm from intracerebral stroke
- Reduction of secondary stroke
- Recognition of prehospital stroke
Lisa talked about how we need to consider both the quanitive outcomes and the qualitive outcomes for patients, familes, clinicians and services. Her focus is in the third theme in explore decision making amongest prehospital providers. The qualitive approach has led to a deeper understanding of the complexities of prehospital care of potential stroke patients, for instance around stroke mimics, and the lack of feedback on the decisions they make in the prehospital setting.
Who care for the carers with Den Langhor
I’ve hard Den speak before and she is excellent.speaker. I think I first heard this at the RCEM conference in Liverpool where Den described the experience of being a patient herself. This talk was about looking after yourself and looking after your colleagues. This is probably not the place to describe the details of her case but it involved the care of of a traumatically injured patient who provoked memories of the tragic death of her father. Den describes how she was well supported and how much of a difference that makes.
She also describes how it can be hard to support your colleagues and that the role of a clinical leader is sometimes really tough when some of your colleagues are going through significant life events. As clinicians we may also find ourselves put into the position where we are conflicted between our roles as a family member and also being a professional. Others will treat you differently and you will have expectations placed upon you by others (family, police, authority) and also by yourself.
It’s worth noting that in the NHS 1/3 of employees report work related stress and 60% come to work even though they are personally unwell. We are not great at looking after oursleves and we can do better. How would you repond to a colleague who is going through a major life event. Den’s advice can be summarised as to be kind, supportive but also to recognise that those offering support may also need to be supported themselves.
How being a doctor supercedes being a grieving relative in the eyes of authorities meaning that greater expectations are put onto grieving doctors, making it harder for them to find space to grieve.
— Dr Esther Murray #wearetheuniversity (@EM_HealthPsych) June 20, 2018
The Neuroscience behind moral injury with Esther Murray
Esther is a psychologist who has an interest in wellbeing, research methods, psychology (obvs) and who also works alongside neurosciencetists to understand responses to stress and their effects on wellbeing. Esther works in London with those involved in the management of trauma patients. Moral Injury occurs in those who have witnessed events which transgresses their moral code6. Although described in survivors of military operations it is arguably applicable to health care workers too. There is plenty of research out there that tells us of psychological impacts of working in health care, but also that there is a paucity of research on long term outcomes7.
In healthcare we are often required to focus intently on what we are doing at the time, and this makes it difficult to later process the event emotionally and thus we cannot resolve our throughts and feelings about traumatic and challenging events. Moral injury may occur when we cannot make sense of an event or events (e.g. terrorist attack against kids)8. Symptoms might be social withdrawal, emoptional numbing, lack of empathy, and notably shame. Shame is powerful in this context and may be one of the most difficult emotions to let go. It also prevents our ability to express empathy and to accept and receive support from others. This pattern can lead to burn out and substance abuse.
One way to look at this is to measure our response to hearing or seeing other persons traumatic events, a vicarious effect if you like. This has been looked at by one of Esther’s colleagues9. For most people it’s normal to feel empathy when you see others experiencing pain. However, in physicians watching people having needles inserted, the physicians had different emotions suggesting some adaptation10. The thing about the seeing needles inserted is that their neural responses were dampened, with more experienced physicians rating patient experiences as less painful. That does not really seem to reduce physician empathic distress, so although it’s adaptive for neural reaction to dampen, it probably isn’t adaptive to feel less distress and empathy. This is really complex.
— LondonPerformance (@PerformanceLDN) June 24, 2017
Debrief appears to be important, but there are personal and system wide barriers to engaging with this, even when the individual knows that there would be benefit to the conversation. Esther’s work suggests that an early debrief is different to a later one and that different people may offer alternative aspects of a personal, or emotional or technical debrief.
Some cases are more impactful than others, who witnesses events (e.g children), violence, sounds and sights can make certain events worse. The mechanism and reason behind events may influence and in some cases amplify the effects of the clinical event on the individual. All these can contribute to moral injury in the clinician.
So what can we do? Well at the moment we don’t really know. Work is ongoing to look at this and to identify what could moderate the potentially injurious experiences of emergency health workers. At the moment we don’t know what works, what is preventatve or what is needed at what stage of career. We also don’t know much about those who don’t suffer moral injury. What’s predictive of resilience in this area. There is clearly so much to look at, but in the first instance I would follow Esther and get in touch if you want to get (potentially) get involved in the research.
The RIGHT-2 trial update
This is an interesting piece of research looking at ways to improve the care of stroke patients. Now we are a little sceptical about thrombolysis here at St Emlyn’s but we should park that cynicism and agree that we need to work hard to research and improve our care of patients with this devastating disease. You can read more about the RIGHT-2 trial here11,12. It’s still recruiting so no significant results as yet. This is a randomised controlled trial to compare the use of GTN against placebo for patients who are FAST positive and hypertensive. There is a reasonably pathophysiological argument, but as always we need to see some hard data before we can decide.
The Forensic interface with Ben Sefton.
The day finished with a fascinating explanation of the role of a crime scene investigation team and how they interface with prehospital crews. In essence what we do at scene is a bit of a nightmare for the police as we tend to contaminate everything. They are fine with that so long as the patient is alive, but once dead we should be mindful of the need for future investigation and try to preserve what we can.
Ben told us that working with forensic crime scenes in Manchester for 30 years has been challenging, difficult but also incredibly interesting and rewarding at times. A bit like EM I thought and in truth our paths do cross on many cases.
One key pearl was that it was almost never required to turn the resus bay, or an ambulance into a crime scene just because someone died there. We’ve had that requested in the past – on one occasion I was asked to close resus (!) but Ben suggested that was usually an overenthusiastic response and that it’s perfectly reasonable to challenge it. On rare occasions it may happen, but if in doubt get hold of a senior officer and clarify with the CSI team.
Torso trauma with me
I spoke on updates to how we are managing torso trauma in the UK. In Manchester I work in the Paediatric and adult major centrres in Manchetser and we see a lot of penetrating and blunt torso trauma. Over half an hour we covered a lot of ground but these were my top tips.
1. Surgeons are geting smaller. What I mean by this is that a lot of blunt (and some penetrating) solid organ injury is being managed by interventional radiology (endovascular surgeons if you like). This remioves the need for a large and complex laparotomy and can improve recovery rates and reduce complications. If you’ve seen this done it’s magic. I remember a case with a severe kidney and splenic injury who a few short years ago would have certainly gone to theatre. After initial resuscitation and a CT scan that showed persistent bleeding we took the patient to IR and instead of them spending weeks recovering on ICU, probably ending up with a tracheostomy and associated complications they were out of ICU in 3 days and discharged shortly afterwards. I think interventional radiologists are amazing.
2. What can we do for broken ribs? Well in the past not a lot. These days were are doing more, especially for the patient with a flail chest. That intervention is to internally fix the ribs. The data is not perfect but it really does look like it can reduce complications, ventilator days, tracheostomy rates and survival. What we don’t quite have a feel for is which patients are going to most benefit. There is more work to be done on the evidence, but as a technique it seems here to stay. Read more here on our previous post looking at a past trial13. We also seem to be seeing more flail chests. I think this is for two reasons, an elderly population (who get more rib fractures from low falls and stair injuries, and the increased use of CT such that we now identify them when in the past they were missed.
3. Handlebar injuries are a real worry in kids. Basically be very concerned about this group of patients. They often have significant injury without that much in the way of clinical signs. Have a low threshold for imaging and observation. If in doubt get advice. The same for lap belt bruising, Ross FIsher regularly reminds us that this is pathognomic for significant injury and these children must be assessed and investigted by an expert.
4. In kids we mostly use non-operative management for abdominal trauma. Even significant splenic injury can be managed by replacing blood, and good intensive care management. The need for laparotomy is rare unless there is bowel or pancreatic injury. Oddly enough the use of interventional radiology is rare in kids, which I don’t really understand in the older kids (many of whom are bigger than me). Perhaps something magical happens at age 16.
5. Shock assessment is hard in torso trauma. We now know that the ATLS levels of shocj are basically rubbish and we should not try and pigeon hole patients. We also see some interesting physiological responses to penetrating trauma. Patients often do not get the tachycardia we expect to see and hypotension may be a late or early sign in pure blood liss. I surmise that this is because in many stabbings there is little tissue damage and cytokine release which affects the cardiovascular reponse. Similarly we know that brain injury affects CVS response.The bottom line is that assessment of shock is hard and the numbers are not absolute14.
6. The best resusciation fluid is blood…. but you don’t have it. This is a key point for many prehospital teams in the UK. In my part of the world there is no prehospital blood. So what do you do when you are faced with a peri-arrest patient form exsanguinating trauma? The answer is probably small amounts of fluid to maintain signs of flow. Flow is tricky, but probably means that the patient can talk to you and that you have a pulse. You can read more about the rationale here15.
7. Decompressing chests. Firstly we probably only need to do it when there are good signs of tension, secondly, in the spontaneously breathing patients do it in the anterior axillary line with a long needle (5cm)16, thirdly in the ventilated patient stop messing about and do a thoracostomy17.
8. One of the problems in the initial assessment and management of the torso trauma patient is that we don’t know exactly what is killing the patient. Yes we can support physiology but the interventions such as chest decompression are quite tricky to be certain about in the prehospital and ED environment. My belief, and increasingly in practice is that ultrasound can really let you know more about what’s going on and what you need to do about it. Increasingly there are services that are using ultrasound in the prehospital setting and that may be the future18.
9. Don’t forget the back! Spinal injury is the commonest torso injury, but we sometimes forget. Beware the elderly torso trauma hiding lots of spinal injuries
10. fFnally that we tend to see our part of the patient journey, but the patient goes from one group of clinicians to another. From a patient perspective we need to try and be as quick, safe and efficient in our segment of the patient journey. Constantly consider the following in time critical trauma patients.
- What is killing this patient
- What do I NEED to do now (and what can wait until later)
- What can be done in parallel as opposed to the ATLS way of thinking which is a serial approach.
Obviously there is so much more I could discuss, but amongst a group of experts it was fun to discuss areas of change, controversy and the future directions of investigation and therapy in torso trauma. You may also want to review the post on the management of chest injury, drains and thoracostomy here19. It has also been shown that the higher the cognitive load, the less the empathy, but this does not have the same effect in physicians. Physicians have a whole range of differing responses to empathy and pain as compared to the general public depending on issues such as how people become unwell (think AIDS or obesity), thus it seems that our empathy is partially a moral judgement.