Academic EM Blog 3 from Prof Smith

​Dear all,
I hope you are all looking after yourselves in these challenging times. If, like me, you signed up for the RCEM Wellbeing app to help, but then didn’t do anything else about it because you got distracted, you will be receiving weekly emails telling you that you’ve achieved 0 out of 7 domains of wellbeing. 
 
COVID-19 research
 
So, the big news this week is that we’ve found a cure for COVID-19 (if you believe the hype).. and I’m not talking about injecting disinfectant. Remdesivir is an anti-viral agent which has shown some early promise in laboratory studies, and is the subject of large randomised controlled clinical trials in China, the USA and the UK (as part of the RECOVERY trial previously mentioned). The study from China has now been reported in the Lancet, and the media coverage surrounding this has been considerable (a British understatement):
https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31022-9.pdf
However, when I read the paper, I thought I must be reading the wrong one. This is a negative study, that was stopped early, was underpowered, and showed no significant difference in time to clinical improvement or mortality. I try not to conflate my academic leanings with politics or money, and I will therefore avoid suggesting alternative reasons for the hype over this drug and the findings of this initial study, including US presidential endorsement, but they are not based on clinical evidence. I am very prepared to alter my opinion if new evidence is published, but based on what is out there at the moment, this is much ado about nothing. 
 
In general, if patients are sick, we know what to do; if patients are well, we also know what to do. But what about those who appear well at first, but who might deteriorate and make us look bad by coming back a lot worse a day or two down the line. We could all make use of a simple test to detect those patients who initially look ok but probably aren’t. If you have been monitoring the outputs from our Italian colleagues in particular, you may have heard of the 40 step test (or the Italian step test as the Italians have called it). This has been suggested as a useful discriminator for those patients who, if they desaturate on exertion, perhaps might be in a group that need a closer look, and potentially supplemental oxygen treatment. Older colleagues may remember a similar clinical test being employed to investigate those with pneumocystis pneumonia, common in the immunocompromised before effective treatment for HIV was available. 
Helpfully, our colleagues at the Centre for Evidence Based Medicine in Oxford have produced a short cut review on the efficacy and safety of rapid exercise tests for exertional desaturation: 
https://www.cebm.net/covid-19/what-is-the-efficacy-and-safety-of-rapid-exercise-tests-for-exertional-desaturation-in-covid-19/
They’ve looked at both the 40 step test and the 1 minute sit to stand test (which is validated in patients with other conditions such as interstitial lung disease), and found that although these tests have not been validated in patients with COVID-19, they may have a role in adding to the clinical judgement of such patients. We have certainly added it to our armoury in Plymouth.
 
Non-COVID evidence
 
I have my own views about giving pain relief to our emergency patients (in a nutshell, we can do better) but I’ve been keeping a watching brief on articles about chronic prescription opioid use in the USA; I often wonder why this is not more of a problem in the UK. Some try to blame emergency department prescribers for this crisis in the US, by linking emergency department opiate prescriptions to long term opioid use, but I have yet to see convincing evidence that this is the case, certainly in the UK. More evidence to put in the melting pot is published in this month’s issue of Annals of Emergency Medicine: 
https://www.annemergmed.com/article/S0196-0644(19)31134-5/fulltext
I suspect this is a complex area which has as much to do with socio-economic factors as it does with what your ED sends you home with after you’ve broken your ankle, but in general terms, it is up to all of us to rationalise our analgesia advice and prescribing to avoid harming patients in the longer term. 
 
Non-clinical 
 
Brigadier Tim Hodgetts is the head of the Army Medical Services and an emergency physician by background. He has published a BMJ blog outlining the elements of clinical leadership required to run a field hospital, with a summary of TEPID COIL (a military acronym outlining the key elements required for success) and how it might apply to a Nightingale facility. Well worth a look:
https://blogs.bmj.com/bmj/2020/05/01/transferable-lessons-for-clinical-leadership-of-a-field-hospital/
Brigadier Tim taught me a lesson about leadership and change management when I was a registrar at Frimley Park Hospital in the late 1990s. He was improving trauma care in the hospital at the time. He attended every trauma call, day or night, seven days a week to make it happen. 
 
Stay safe and sane,
Jason Smith on behalf of the academic team