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For January we’ll look at patients with mental health or substance-related presentations. This was a patient presenting with overdose, being cared for in the ambulatory area of the department. This was the first live-streamed session. I hope shortly we will be able to do this with the majority of simulations so that the wider team can benefit.
The simulated case: A man in his 20s presenting after an overdose of mirtazapine and propranolol, tachycardic with some muscle ache but with normal blood pressure. What happened? The healthcare assistant recorded observations and recorded the patient’s history. The importance of safeguarding children was explained and the details of the patient’s children were recorded. TOXBASE was consulted for management guidelines. It was decided to move the patient to majors due to the tachycardia, with a view to move to CDU once medically fit for liaison psychiatry consultation. What did we think? In debrief we discussed: Safeguarding: We talked about how we explain to patients the need for information about children in their care. This can clearly be an emotive topic and one in which intentions can be misunderstood. The group consensus was for a focus on the identification and provision of support as an outcome. Remember that adults who present who do not have children may still care for parents or other vulnerable adults - ask about this. Ask about vulnerability factors: do they feel safe at home? Do they have a support network? Have a look at the SCARF acronym in the “to-do” section below. The specifics of these medications: We talked about some of the specific risks with propranolol (e.g. hypotension - potential to be prolonged especially if sustained release) and mirtazapine (serotonin syndrome) and importance of ECG (QTc), bloods (e.g. CK) and a good examination. Bedside manner: We sometimes see people repeatedly attend with overdose. So it’s really important that we do maintain empathy and don’t burn out. Men with EUPD may be more likely to experience aggression and attend via police custody so it’s important to maintain the same appreciation that they need our help and support. Referring to PLNs: Have a look at the recent referral guidance sent out by email 14/01/21: “In brief the main message is refer early - from START or immediately behind START. Referrals can be made by medical or nursing staff after initial assessment… Mental health assessment can be made in parallel with medical treatment and referral for such assessment should not be delayed”. Cannulation: Consider the likelihood of the cannula being used before putting one in “just in case”. One review has suggested a median of 32.4% cannulas inserted in ED are not subsequently used, and clearly there are well documented risks of them. To do: Have a read of the email on referrals from 14-01-21. It also contains links to the RCEM mental health toolkit [ ] Think about using “SCARF” to cover vulnerability factors with the patient, and ask about them directly: feeling Safe at home? Are there others with Control? Abuse? Relationships? Family/friends? [ ] If you took part in the sim or watched on the livestream, you can use this blog as a starter to reflect on your own experience of it [ ] Blog by: James Keitley ED sim fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author.
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For January we’ll look at patients with mental health or substance-related presentations. In this sim a man with alcohol withdrawal presented following a presumed seizure. We'll repeat this sim next week.
The simulated case:
A man in his 40s brought into ED after a presumed unwitnessed seizure having cut down on alcohol during COVID19 lockdown. He moved through START into majors but following another seizure he moved into resus. This self-terminated. What happened? Joint nurse and doctor assessment to establish history and examine the patient. Blood tests, Pabrinex and withdrawal treatment were started. It was decided that the patient needed to be admitted given that he had multiple seizures. What did we think? In debrief we discussed: Role of vitamin replacement: This patient received IV Pabrinex. In alcohol misuse thiamine (vitamin B1) deficiency is more likely, and Pabrinex is used to rapidly replace this vitamin in order to prevent or treat Wernicke’s encephalopathy. Without treatment Wernicke’s can be life-threatening. We talked about the same people may well have nutritional deficiencies that mean they are at risk of refeeding syndrome whilst in hospital. Alcohol liaison: Alcohol liaison specialists are available 08:30-17:00 Monday to Friday. You can find the number in the ‘daily email’ 30/11/20, and I have also added them to the Induction app under “alcohol liaison”. Remember not to presume they are already in contact with services, or presume based on previous presentations that they don’t want to be. The relevant organisations for us are: Plymouth patients - Harbour Cornwall patients - Addaction Devon patients - RISE recovery Raising the alarm: During COVID19 we’ve welcomed many new members of staff to the emergency department. We talked about differences between ED and areas of the hospital that staff have previously worked in, in terms of reasons to pull emergency buzzers. A seizure is a perfectly good reason to pull an emergency buzzer, as is any scenario where you need a greater number of people to be present immediately. To do: If you see a patient like this in-hours, speak to the alcohol liaison team and find out what additional help can be put in place for them [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] Blog by: James Keitley ED sim fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author. Continuing the surgical theme today we simulated a young patient with a perforated appendix. Next week's SimFridays is cancelled for Christmas. Hope everyone is able to relax and spend some time with family or friends - even if that might now be in virtual form. Next month the plan is for a mental health theme - if anyone has ideas of how best to approach simulation in this month please get in touch.
The simulated case: A 19 year old woman presented with abdominal pain during the night, and due to ED pressures she had been waiting to be assessed in majors at the time of morning handover. What happened? The ED team assessment in majors found her to be tachycardic and tachypnoeic, with uncontrolled pain. She had an A-E assessment followed by management of pain, fluid resuscitation and antibiotics - then the potential causes of this presentation were considered. What did we think? In debrief we discussed: Imaging: We talked about the considerations of using CT in this patient group. Generally, ultrasonography is preferred in young women due to the higher incidence of gynaecological cause and the radiation involved in CT. However, as discussed in the simulation, the timing of the imaging must also be considered - if there is going to be a long delay for USS then the preference might shift to CT. If there is a high suspicion of appendicitis with shock, then immediate appendicectomy may be performed however if there is diagnostic uncertainty then there is value in imaging, and the evidence suggests this does not cause additional delay in general. (ASGBI commissioning guide 2014, see p12-13).
Gynaecological vs general surgical causes:
This patient was shocked and had an empty bladder scan, therefore a urine pregnancy test had not been possible. We talked about while there is diagnostic uncertainty it may be reasonable to involve both teams. β-HCG can be added-on to blood already taken. Simultaneous treatments: In this case there were competing demands on our colleagues time and resources. There were paracetamol, antibiotics, fluid, and analgesia to give - and only one cannula - and there was also discussion to be had with ED seniors, radiology (+/- scan requesting), and the surgical team. Managing these priorities was a key part of the thinking in this scenario. What would be your strategy in this circumstance be? Overnight delays: We talked about how after the initial front-door assessment there can be delays in being seen definitively, and patients have the potential to worsen during this time. The expected benefit from having a greater number of nursing colleagues is a repeated theme from SimFridays feedback, and today this was also discussed as something that would benefit patients like these. Other feedback included having patients like this allocated to the more visible bays, or if in the corridor then under the care of an assigned nurse. In this simulated case the patient went on to have a CT abdomen which showed acute appendicitis with perforation, and they went to theatre. To do: The next time you have multiple tasks to complete, take a moment to think through your thought processes. You might instinctively know which tasks take highest priority - analyse why you know this to be the case, what would change your mind, when is this not the case etc [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] Blog by: James Keitley ED sim fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author. I have been reflecting on my workplace experiences over the last few months and how I think I am responding to our pressured and uncertain world and how that relates to my relationships with colleagues and what I observe in those beside me. From time to time I have noticed that my response to feedback will be defensive, and I suspect that others respond in a similar way. Whilst understandable it has consequences in my clinical practice, how the care is delivered by the team and how that is received by the patient. At first there may be blame and criticism leading to datix report and complaints. This leads to conflict, defensiveness and eventually to individual disengagement. I know this because I have experienced this and have disengaged from time to time; it is my way of coping, and I am conscious that others might be doing that too. I personally start to lose the sense of joy and the importance of the work that we do, the difference we make in such an important moment in a patient’s life.  We need to embrace a compassionate and grown up approach to sustain a high performing team. It’s important to create psychological safety and trust; to ask ourselves what would it be like if we could share difference and see it as enrichment of our clinical practice, counterviews are appreciated for what they are as different; and if there is concern about the safety and quality of that approach it is highlighted generously with the motivation to help and educate. From our own and colleagues’ experiences, it can be quite disheartening to face any kind of criticism from peers or managers. There is some kind of fear that one is being blamed for mistakes, which tends to happen more often in a high risk, pressured situation when our calmness and generosity is more in need. We are lucky to have a No Blame Policy at UHP but still why do we always feel guilty when we have taken action in the best interests of a patient at the time, then later, it is proven not to have been the right thing to do? Perhaps we need to adopt alternative ways to approach these incidents. Use them as a case study at meetings or handovers to avoid similar issues again… Human to human communication may reflect a much better outcome and resolve any misunderstandings amongst colleagues. No-one should be made to feel that they are being punished for having genuinely tried to act in the best interests of their patient, but there may be some learning that comes from this. I recently read this concept somewhere and perhaps if we can all use similar thoughts, we can have a better understanding and be supportive, caring and compassionate towards each other. This is not any different to us wanting to treat our patients the way we would like to be treated, only this time we are thinking about looking after us, after each other. By this we will clap for ourselves as we will be heroes for each other. Each time you have to challenge someone please remember the following: 1)This person has beliefs, perspectives, and opinions, just like me. 2)This person has hopes, anxieties, and vulnerabilities, just like me. 3)This person has friends, family, and perhaps children who love them, just like me. 4)This person wants to feel respected, appreciated, and competent, just like me. 5)This person wishes for peace, joy, and happiness, just like me. We are living in a very unprecedented and challenging world. Let’s care, be kind and be fair. We are the best team but we can now move towards perfection by “being the change we want to see in the Team”. AuthorWritten by Shadna Lallchand, ENP, Derriford ED December 2020 Today we looked at how we investigate older people with traumatic injury. The TARN report on major injury in older people (2017) showed differences in how these patients are looked after compared to younger trauma patients. A high number of injuries occur from falls from standing height in the home, and major injuries can be difficult to identify. In related news, over the next couple of months we will simulate some trauma calls to run through processes and identify any potential system errors when caring for trauma patients in the emergency department.
The simulated case: A 90 year old female who had been found on the floor of her lounge by carers. She has been unable to describe the day’s events but has pain in her hip.
What did we think? In debrief we discussed: Imaging: We talked about the chest examination involving a firm palpation around the sides and back of the chest if possible, to ensure we don’t miss injury around the sides of the patient. In this patient, with definite head and hip injuries on opposite sides of the body, with low saturations and pain around the side of the chest there are indications for a CT trauma scan to look for underlying injury. In other cases it may be entirely appropriate to have a CT head and a hip x-ray. Each case should be considered and discussed with someone experienced in seeing such patients.
We hear older patients say they have recurrent urinary infections - and this may of course still be the case - but consider whether there is something else that is being misdiagnosed based on positive urine dip/culture. Start afresh. This is only about leukocytes/nitrites and infection, so if you’re using the urine dip for another purpose this doesn't apply! Physiological considerations: We talked about how particularly in older people it needs to be considered whether their past medical history, frailty or medication history might be affecting the clinical picture and lead to error. For instance are they taking a medication to control heart rate that affects a tachycardic response to bleeding? By definition frailty is a reduced ability to keep homeostasis after insult, so normal observations may not be reassuring, and may represent a lack of response to injury where there should be a response. To do: RCEM learning on silver trauma [ ] Have a look at the GP guidance on UTI in those over 65 years of age [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] Blog by: James Keitley ED sim fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images not cited are copyright- and attribution-free in the public domain or taken by the author.
Today we were in resus for a run through of how we would assess, investigate and treat an adult patient presenting in SVT. We looked at the decision making that is required to safely and efficiently manage their care.
The simulated case:
A 66 year old male, who noticed a sudden onset of palpitations at home this morning, approximately 3 hours ago. He’s feeling subjectively unwell, though denies any pain. He’s never felt like this before. He has a background of hypertension - controlled with an ACE inhibitor - and smokes around 10 cigarettes per day. He arrived by ambulance, and as a result of his fast heart rate was directed straight to resus, where the sim team took over. What happened? Steven was only complaining of a pounding sensation in his chest and feeling “unwell”, though couldn’t elaborate much further. His 12 lead ECG showed narrow complex regular tachycardia with absent P waves, suggestive of an SVT.
What did we think?
In debrief we discussed: Treatment strategies: “Adverse features” that are essential to assess for are: Myocardial Ischaemia Shock Syncope Heart Failure These can indicate the need for DC cardioversion. An effective ABCDE assessment and primary survey of the acutely ill adult, coupled with effective history taking is therefore key to managing this case. As with all situations, the ground can shift and regular reassessment is essential. Non-technical skills: We discussed decision heuristics and non-technical skills in the context of a stressful and rapidly changing scenario. The effective use of mini-summaries really helped the team share the mental model and understand the direction the case was progressing in. Situations where decision making needs to be challenged were reviewed, and we talked about speaking up using the PACE format: Probe - “are you sure about…” Alert - “don’t you think this will cause…” Challenge - “I’m afraid this is going to harm the patient…” Emergency action - “STOP what you are doing! I will get help…” The guidelines: ALS Tachydysrhythmia Guidance: (See original quality version here) 
REVERT team discussing the Modified Valsalva Manoeuvre: (original link here)
To do: RCEM learning on SVT here [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] Blog by: Joey Giles, Senior Advanced Clinical Practitioner --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author. We were in ambulatory today thinking about the sort of patient that can slip under the radar. This was a patient with chest pain for whom aortic dissection was also a diagnostic possibility. The simulated case: A 66 year old man with hypertension, who has had sharp chest-through-to-back pain that started while out walking his dog. Think about cases where you have considered aortic dissection or seen it considered by other people - what are the aspects that raise it as a possibility?  What happened?
The patient had their blood taken in START, and was brought through into ambulatory for observations and an ECG. After a history and exam, aortic syndrome was considered more likely and they were transferred to majors while awaiting urgent CT angiogram. What did we think? In debrief we discussed: Threshold for considering the aorta: Aortic dissection can present in a variety of ways, and is often not the top diagnosis for the given presentation, so there needs to be a low threshold for considering it and looking for it. Although relatively uncommon, the high number of patients coming through ED means there could be around 1 per month in Derriford ED. Some resources refer to “chest pain plus one” where one looks for an additional feature alongside the chest pain that makes it atypical - e.g. back pain, abdominal pain, neurological changes. Mostly we are looking for:
There may be a pulse deficit or different BP in each arm, but these signs are not common and their absence does not exclude the diagnosis. In debrief we reviewed a chest x-ray with widened mediastinum, but again this is uncommon and a normal chest x-ray does not exclude aortic dissection. Logistics: The patient needed to move from ambulatory majors, for which the nurse in charge desk can be phoned to arrange. Patients would also need to move before they can have oxygen. They required an urgent CT angiogram, which also means a green cannula is needed. We thought about whether this patient might need an escort for the CT or not. Blood pressure management: The aortic dissection guideline on EDIS gives clear instructions regarding the management of blood pressure using labetalol. The target is a pulse of around 60 bpm and systolic BP under 110-120mmHg. If there is a discrepancy between arms the aim is to bring the higher result down, although one would need to be mindful not to drop the lower BP below the level required to perfuse. Closed loop communication: We talked about the use of closed-loop communication in this case to ensure tasks are being completed. The guidelines: The guideline is on EDIS under “adult medicine” and then “cardiology”. To do: Listen to “the aorta will #@&$! you up” (20 mins) online lecture here [ ] RCEM e-learning here [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] James Keitley - ED Sim Fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author. SimFridays sessions never seem to be on a Friday lately... so will be called "Sim ED" now instead! We did something a bit different and a bit scary in this one, and practised management of a patient with viral haemorrhagic fever (VHF). This tested our knowledge, team-working, and also the laboratory processes.
The simulated case: Tanya is a woman in her thirties presenting with bloody diarrhoea, fever and a petechial rash. She returned 5 days ago from volunteering in Sierra Leone. What are the possible causes of this? Which of these are most common? Which are most serious? How would you approach a patient like this to cover the serious ones without overlooking common causes?
What did we think? In debrief we discussed: Horses vs zebras: From the outset of this simulation there was consideration of which diseases are endemic in the country the patient had visited, and VHF was considered likely. As a result one clinician reviewed alone in PPE and there were long discussions about tests, who to contact etc. It was pointed out that still common things are common and tasks like taking observations, giving fluids and antibiotics should not be delayed. Diagnoses like infectious gastroenteritis, sepsis, and even malaria are comparatively common so we need to both be wary of the serious but rare diagnosis whilst also cracking on with management of the more common options. Don’t forget the basics to avoid missing the horses! A really good A-E with attention to all vital signs and a brief history will help you act on the important horses question: IS THIS SEPSIS?... And treat it expeditiously.
Explaining to the patient: Clearly coming to hospital in these circumstances would be very scary. I thought the patient explanations here were great and managed to explain the seriousness of the situation, gave clear instructions (“please do not leave the room”) whilst also being quite reassuring that the team had a good plan of what to do. Logistics of isolation and PPE: See the guidelines section below for what the SOP tells us about isolation for VHF. In this scenario the patient was isolated in a side room of majors. We discussed that a patient isolated like this must either have an en suite bathroom or at least a dedicated commode, and that this is very difficult to provide at present. We will be looking to source more. The patient’s blood sample labels were printed elsewhere by the runners and passed into the room to be applied to the samples. They were bagged once within the isolation room and dropped into a second bag held outside the room, before being put into a haze container and transported to the lab on foot. Clearly tasks like this require a good enough level of staffing to have people available nearby. The labs can send staff to collect the samples… don’t be afraid to ask for this when speaking to them.
Testing: The guidelines section below highlights specific requirements. In this scenario there were debate as to whether to delay taking blood until after the discussion with microbiology to ensure the correct samples were collected. Each time a sample is taken from a highly infectious patient there will be risk involved, so perhaps it is sensible if there is no immediate need, to confirm the tests first with the expert. We talked about how it has become automatic to process a venous blood gas for all patients. Because of splash risk it isn’t recommended in possible VHF cases, so perhaps one to think twice about how the results might change our management. Speaking to other teams: In the case of VHF there are many external people that need informing (see guidelines below). We talked about how long these discussions can take, and the importance of having concurrent tasks occurring that utilise different members of the team. Speaking up: We talked about team dynamics and the importance of speaking up and reminding the rest of the team of key actions. In this sort of rare presentation, it will be common to feel out of one’s depth and unsure, using your team to check any missed actions or specifically to read out the SOP is really helpful. As this blog has mentioned previously, closed loop communication (including use of first names) to confirm tasks, and graded assertiveness (see previous post on this) to remind others in the team, are both important. The guidelines: Probably the easiest place to find guidelines quickly for this patient is to go to the StaffNet homepage and use the search bar to find “viral fever” or “VHF”. The top option is an infection control page that talks about many diseases on different tabs, including VHF and Ebola. Alternatively there is a version inside the G drive under “Trust Documents”. I will highlight key parts here as a quick read. Please go to the source for the full info: Overview of VHF (info source Trust guidelines):
Triage assessment: If we know ahead that such a patient is coming, they should remain in the car park until cubicle 11 is ready for them to be transferred to directly. There is a VHF risk assessment flowchart on a single side of paper which you can easily follow to assess the likelihood of VHF. It also has brief but clear outcomes depending on the likelihood, and an overview of PPE required. This for me is the key part of the guidelines you must print for patients where it is being considered. There are negative-pressure isolation rooms in other departments, so ideally if VHF is considered likely from our flowchart the patient should be transferred to one of these via the bed manager or duty senior nurse, and then managed by the medical take team. Who to tell? Microbiology first. If thought to be likely VHF, switchboard can be asked to undertake the “critical internal incident call-out cascade” which will inform the necessary internal staff and open a major incident. The on-call director will then inform Public Health England and the other external agencies. Isolation and PPE: Side room with either en-suite bathroom or a dedicated commode. Ideally negative-pressure. The guidelines state exactly how to deal with laundry, spillages, waste etc.
If the VHF screen comes back as positive the patient should be transferred to a HLIU (Royal Free London) and the local health protection team will be involved.
Testing: Urgent malaria testing (EDTA tube), FBC, U+Es, LFTs, clotting, CRP, glucose, blood cultures. Must call the combined labs ahead to inform them of the potential case. If high risk, they will send a haze container for the samples to be put inside. Must ask for a named contact in the lab to hand the sample to and provide a number to contact us back on. Must not use the pod system. The consultant microbiologist will organise the VHF screen from their side. The test is done on 1 x EDTA and 1 x clotted serum tubes. So, overall likely to need 3 x purple EDTA tubes, 2 x yellow serum tubes, 1 x blue and blood cultures. It is recommended generally not to use point-of-care blood gas testing due to splash-risk (Shorten and Wilson-Davies 2017). Management of contacts: If a patient has a “high probability” of VHF, a register must be kept of all staff entering the patient’s room (there is one ready to print in the guideline appendix). There are tables for how to manage contacts on pages 20 and 21 of the guidelines. Generally it involves self-monitoring temperature and reporting if symptoms develop. Interestingly, even for the highest risk contact (e.g. mucosal splash, needlestick, sexual contact) there are no restrictions on work or movements if asymptomatic, but they must monitor temperature and report to the monitoring officer daily. To do: Consider the next time you know ‘red PPE’ will be required for a case whether the donning/doffing guides in the PPE cupboard will be helpful to have nearby [ ] Have a look at the single-page risk assessment for VHF on StaffNet [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] See you next time, James Keitley - ED Sim Fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author. Today we tried something different in a sim session… O&G Consultant Tim came down to ED with two of his registrars (Steph and Amy) and we rotated through two obstetric emergencies in ED stations… socially distanced of course but let me tell you, there is NOTHING socially distanced about the raw practice of delivering a baby! Amy and Steph talked us through a normal delivery:  Should present face down, deliver the head, then allow “Restitution” – where the baby rotates to fit the torso through the birth canal. On the next contraction – the anterior(upper) shoulder should deliver then posterior shoulder. Now breathe yourself…. And if the baby is breathing – there is no rush to cut cord, you can give the baby a quick dry and a rub and put it skin to skin with mum… job done! Then, we talked through and delivered a baby with the absolutely EMERGENCY finding of Shoulder dystocia… code very, very scary… This is where the baby’s shoulder is stuck behind mum’s symphysis pubis… Risk factors – obesity in mum, gestational DM – big baby Head may deliver slowly, ‘turtle necking’, undelivered chin. May not restitute fully No progression on second contraction This is completely Time critical– as a team we have only a few minutes to prevent a hypoxic brain injury/death… here is the SOP:
Be aware that you may cause fractures to humerus/clavicle, this is totally OK if you can baby out alive…. Super scary… let’s hope those 2222 bleep holders can run fast and have mini, super strong hands!! Give this a watch: https://www.youtube.com/watch?v=1HeXmlf_sp4 Our obstetric registrar friends also talked us through how to deliver a baby presenting as a Breech delivery… First thing: This May be very quick in multiparous women – be prepared to catch!  You will notice that buttocks are presenting. The baby is facing posteriorly (down)… Bring mum to the end of bed. This is a hands off situation. Minimal handling of the baby will avoid stimulation that will promote breathing (while head still inside)/increased metabolism/oxygen consumption. If handling is required - only to the bony pelvis/hips of the baby. Allow the buttocks to deliver – allow baby to hang down The hips will probably be flexed and knees extended, you can use your finger to ‘flick’ them out:  Allow delivery until the shoulder blades are seen The arms can be delivered by gentle rotation of baby at hips Or Sweeping the arms over the baby’s face with a finger  The neck/head needs to flex to allow narrowest cross section to pass through the birth canal.
 Again, have a watch of this: https://www.youtube.com/watch?v=EWjKswZ3Mm8 And that if that didn’t get our hearts racing fast enough, we also spent an hour chatting to Tim about resuscitating the pregnant patient in a peri-arrest or cardiac arrest situation, medications during pregnancy, post partum haemorrhage management and pre-eclampsia treatments… The harsh fact is maternal mortality is not falling, despite improvements in care because patients are becoming increasingly complex…  While we work at Derriford ED, we need to know a few things about obstetric emergencies: 30993 – Labour ward emergency phone – useful if putting out a 2222 – tell them what the problem is – so they know what to bring eg – shoulder dystocia (run very, very fast and get here yesterday) vs PPH (come quickly). As a refresher, we reminded ourselves of the physiological changes that occur in pregnancy, affecting every letter from A-E… check out the PROMPT course for more on that or read your ALS special circumstances chapter… Here area few pearls from Tim’s talk:
Resuscitation in pregnancy…also a scary subject… Same principles as any other resuscitation but do not forget:
Now the thorny subject of PE/VTE disease in pregnancy…. A negative D-dimer is probably useful in low pre-test probability patients but what about imaging?? V/Q vs CTPA
We had a great chat about managing Post-Partum Haemorrhage (PPH) Primary PPH occurs up to 48 hours of delivery vs Secondary PPH which occurs after 48hours (secondary is much more likely to be infective) Resuscitate – as for haemorrhagic shock – think blood products, rotem, calcium etc. Give antibiotics if suspected infection (so nearly all secondary PPH)… We all love the 4Hs and 4Ts of cardiac arrest causes… but in obstetrics, let’s not forget the 4 T’s of PPH: Tone– Most common, the uterus is exhausted after its big night out (push,push, push) and needs a hormone to increase uterine contraction – ergometrine/syntometrine/misoprostil. (caution if hypertensive). We keep ergometrine in our ED resus drug cupboard:  Tim also reminded us about using Bimanual compression in these ladies: put a fist into the vagina while also applying fundal pressure – it should be painful/tiring if effective (may need to change operator). Here is Tim showing us the desired effect on the tired atonic uterus….  On those 4Ts also think:
Trauma–a simple perineal tear possibly… – if arterial, can bleed quickly – fresh red blood is likely to be perineal: is it possible to put a quick suture in place and apply pressure? Tissue– Retained products? Check the placenta after eth delivery of the baby and placenta, is there a chunk missing or ragged membranes, suggesting some may remain in mum’s uterus? And finally: Thrombin– Are they forming clots? – A DIC picture represents fairly advanced bleeding… we need ROTEM to help us… along with the expertise of the obstetric team… resuscitate with blood products asap. Briefly, we considered another obstetric emergency presentation we may see in ED: Eclampsia Usually we will see a patient presenting with a headache and Hypertension and/ or proteinuria (can occur without either but very rare). This is pre-eclampsia… It is of unknown cause but may progress to seizures – give MgSO4 - 4g in 20mls saline over 20 mins (double the typical ED dose for asthma etc) Use labetalol for BP control…. And that was our multiprofessional interactive, hands on, socially distanced morning…. More soon, watch this space! With huge thanks to the obstetric team of Tim, Amy and Steph, to James Keitley for his unwavering enthusiasm for education and awesome administrative support today and to Neil Spencer for lending me his notes to Annetticise… For October the sim theme is “breathing”. This blog covers some of the learning points from 29/10/20. We will be aiming to run simulations weekly - mostly Fridays but not always - see the gmail calendar. November will be "cardiovascular" month.
The simulated case: Sam is a woman in her seventies presenting with increasing shortness of breath over the last 2 days. She is requiring >10L/min of oxygen by facemask to keep saturations >94%. At this point consider how wide the potential causes of breathlessness are. After treating the hypoxia, which tests or investigations might increase or decrease the likelihood of it being any of these potential diagnoses? What happened? We ran this short simulation with a nurse, HCA and trainee ACP in the resus area of ED. A history was taken, observations recorded and appropriate oxygen delivered. A range of causes were considered and appropriate investigations (bloods, ECG, chest x-ray) carried out. This simulated patient ultimately would have been found to have bilateral pulmonary emboli (they had increased risk due to metastatic cancer); however, in this short sim the intention was for the patient to be assessed, have emergency management and the right tests thought about. What did we think? In debrief we discussed: History taking: When asking rapid questions to narrow down the differential diagnosis, there is a risk with asking questions in the negative (e.g. “you don’t have chest pain at all?”) that the patient may passively reply “no” to questions, compared to “are you in any pain?” they may be more likely to explain that they do. Investigating and treating PE: We discussed the PERC score, Well’s score, ECG signs, and the treatment options for PE including anticoagulation, thrombolysis and interventional radiology - see guidelines section below. In terms of ECG signs, the most reliable is sinus tachycardia, however this article and its links cover well the signs of right heart strain to look for, and how to differentiate it from similar presentations. Decision making in ED: Breathlessness (or even hypoxia) has a wide list of potential causes. In the emergency department patients are being seen often at the early stages of illness where the disease is potentially less manifest and information is scarce. At this point there is a much higher uncertainty. Prof Carley has a recorded talk and a blog about making decisions amongst this uncertainty here. In cases I have seen during this period of high uncertainty it may be that the patient is treated for several potential causes of their symptoms. For example the patient with PE and secondary heart strain may have already had antibiotics for ?sepsis and dual antiplatelets for ?ACS. This can be okay, as long as the decisions were made with good intentions based on the information available at the time. In the case of those treatments, potentially the benefit from early treatment and the high risk of not treating them may outweigh the risk of giving treatment to someone who is later found not to have the disease. However there are other risks lying in this period of uncertainty. We discussed in the debrief the potential for anchoring bias, where the clinician “anchors” to one early piece of information and all subsequent information is either thought to fit that mental model or is discarded. This may mean that the patient with PE is actually only ever treated for pneumonia, and PE is never considered. Personally, I suspect this bias has greater power when a clinical handover happens - if you are handed over a patient “we’re treating them for X, and they’ve been referred to MAU” is there a risk you anchor to that diagnosis? If new information comes along (e.g. new blood results, their chest x-ray, a colleague reporting they don’t seem to be improving) it’s important to go back and reassess with an open mind. Anecdotally someone I know who suffered a PE explained to me their experience in ED felt like minds had been made up immediately and subsequent information didn’t seem to adjust that idea. Another similar bias we discussed was confirmation bias: believing the patient has a particular diagnosis and then unconsciously only retaining information that supports this, discounting that which refutes it. A technique to combat these biases is to actively seek out information which would change your diagnosis or plan. What other diagnoses would be really important not to miss, and what signs might lead to that diagnosis instead?
In our new layout of ED, with front-door senior assessments, patients often have a potential diagnostic label attached to them before they reach the more junior clinicians. This has clear logical benefits for patients. But we raised in debrief that there is the potential for the biases above to occur following this. More junior members of the team may feel difficulty in broaching alternative diagnoses. So we discussed in general how one might explore decision making with a colleague by framing it as a “teaching moment”. For example, “I wouldn’t have thought about X diagnosis for this person, do you mind helping me understand why it is X and not potentially Y?” or “I noticed X piece of information, from my lectures they used to say X was associated with Y, but here you’ve said it’s most likely Z - do you mind telling me about why it’s different here?”. We’ve talked before in this blog about graded assertiveness and the PACE model here.
For a gateway into the larger field of ‘thinking about how we think’ in emergency medicine, go to this blog by Dr Natalie May. And for a deep-dive, I recommend this ebook on how we make decisions in the ED. The guidelines: The EDIS guideline can be found under “adult medicine”, with other helpful resources being the British Thoracic Society guideline (note from 2003) and this LifeInTheFastLane article. These three have been used in the following sections. The PERC rule is a rule-out scoring system for low risk emergency department patients. A score of zero in a low risk patient means <2% risk of PE, which means the risks of investigating most of these patients further would outweigh benefits averaged over the population. It was not possible to use it in this case as it is only for use when the risk of PE is low (e.g. Wells <1). A Wells score is a very important step in the investigation of potential PE as it helps us determine how likely the diagnosis is as a baseline before any investigation (the pre-test probability). We then seek to use examination and tests to change this probability up or down. A patient’s Wells score helps us decide whether a d-dimer blood test will aid us in the diagnosis or not. Because of the test characteristics of d-dimer, where pre-test probability is low a negative d-dimer can help rule out PE, but where the pre-test probability is high a positive or negative d-dimer will not significantly alter the probability of it being PE. Please do look at our EDIS guideline which has a flowchart on when to use PERC, d-dimer and imaging. The patient in this scenario would have gone on to have a CT pulmonary angiogram. It’s worth noting that patients usually need a green (18 gauge) cannula for this. With the diagnosis confirmed there are different possible treatments. Thrombolysis is generally used when there is ‘massive PE’ i.e. with circulatory compromise, or in PE-associated cardiac arrest where a bolus of 50mg alteplase can be used. The patient in this scenario had normal blood pressure and had significant bleeding risks, so thrombolysis was not being considered initially. Interventional radiology can be used to remove clots. If sub-massive (inc heart strain) or massive PE has been detected, discuss with the ED senior or IR directly whether the patient is suitable. The EDIS guideline gives DOAC dosing or weight-based doses of enoxaparin if anticoagulation is being used. There is a separate guideline on the “outpatient pathway” that shows where someone can be safely discharged with treatment vs when admission is more appropriate. To do: Look at the EDIS PE guideline and the separate link for who can be treated with “the outpatient pathway” [ ] When looking after a patient in the next week try to think specifically about possible diagnostic biases and how you might acknowledge and avoid them based on the above [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] James Keitley - ED Sim Fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain. |
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Created by N Bothma
Last updated July 2020 |