Academic EM Blog 3 from Prof Smith
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.
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):
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:
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.
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:
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.
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:
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
Academic EM blog (2)
As I didn’t get any bottles thrown at me for my first academic update, I thought I might try a second. Do let me know if you have any suggestions for improvement or other topics that you think should be covered.
The papers are coming thick and fast, but still the quality of evidence is limited. I promised to keep an eye out for certain things; one of these is the coagulopathy and risk of thromboembolic disease associated with COVID-19, and specifically whether we should be targeting this with therapeutic rather than prophylactic anticoagulation. The short answer is that no-one yet knows – but there is a comprehensive 66-page review written by the international great and good in JACC if you want the long version:
The clinical bottom line is that if you are admitting someone to hospital with any significant illness, including COVID-19, they should be risk assessed and considered for weight-based prophylaxis to avoid the complications of thromboembolism. But then we knew that already..
What about potential treatment options for our patients with COVID-19? Self-proningis not a term I’d come across before this pandemic, but I have come across the concept while lying on a sun lounger beside a pool reading a book. I think the emergency medicine term for this is ‘lying on your front’. However, the idea really appeals to me because it’s free, almost anyone can do it, and if it helps our patients with COVID-19, then we are potentially onto a winner.
The majority of previous evidence related to proning is in intubated patients with ARDS in the ICU. This article, published a few days ago, is one of the first descriptions of proning in awake patients in the ED:
The rationale is clear, and in this series from New York a convenience sample of 50 hypoxic patients with suspected COVID-19 were recruited in the ED and underwent proning – which almost universally improved their oxygenation (the primary outcome). These were sick patients, 13 of whom ended up being intubated, but if there is a potential to avoid escalation in a group of our COVID-19 patients then we should be exploring this. Hopefully there will be more evidence to come on this topic, and in particular the potential risks associated with the technique, which haven’t been fully explored.
Exciting times for the research community involved in COVID-19 trials. The latest one that caught my eye is the proposed convalescent plasma study being coordinated by NHSBT – you may remember that in the dark days of the Ebola crisis a similar treatment was proposed and investigated. Further details can be found at:
Bottom line – if you have had COVID-19, we need your plasma to run this clinical trial.
If you are interested in academic emergency medicine and what the future holds, you might want to take a look at this editorial in the EMJ, which I hope persuades you that the future is bright, but we all have a part to play.
Another article that caught my eye in the EMJ was this paper encompassing a review and exploratory trial of methods of removing glue from the eyelids. It’s embarrassing when it happens but if you have an idea of how to manage it, then hopefully the angst around the situation can be reduced.
An interesting take on whether we as healthcare workers are more at risk of contracting COVID-19 than our neighbours is included in this episode of ‘More or Less’ from BBC Radio 4. It also includes an explanation of the infographic used to explain social isolation
Finally, given my academic role, I will always encourage you to read high quality research articles, and apply the principles of critical appraisal to what you read. In these strange times, however, I would urge you all to read a non-evidence based book, “The Boy, the Mole, the Fox and the Horse” by Charlie Mackesy; a fable for our times, equally relevant to young and old. In the words of the horse, “Everyone is a bit scared”, “But we are less scared together.”
Stay safe and sane,
Jason Smith on behalf of the academic team
The Derrifoam Blog
Welcome to the Derrifoam blog - interesting pictures, numbers, pitfalls and learning points from the last few weeks. Qualityish CPD made quick and easy.....