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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
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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. For October the sim theme is “breathing”. This blog covers some of the learning points from 16/10/20. We will be aiming to run simulations weekly - mostly Fridays but not always - see the gmail calendar.
The simulated case: Adam is in his 70s and has presented with shortness of breath, fever and productive cough. He has been brought to the Plym (?COVID) area of the emergency department. What considerations are there in where and how we care for patients like this? What is helpful to prepare before the patient's arrival?
What did we think?
In debrief we discussed: Differences in the environment of Plym theatres to be aware of e.g. how to attach oxygen and how to access help. In particular we noted that the tannoy is different to the one for the rest of the department. To seek help one needs to use the white tannoy on the wall to tannoy to the “green desk” of Plym where they can relay the tannoy to the rest of the department if required. Reflecting on the sim perhaps walkie-talkies to facilitate two-way communications between those in resus and those in the green areas would be helpful, especially if the potential runner might be moving around and completing other tasks. It was noted that often the staffing level does not allow for an additional person to be a runner, so perhaps a walkie-talkie worn by a designated person would aid in making sure someone is available when needed. We discussed the difficulty of requesting a doctor to Plym if there is not someone already present. It is generally done through tannoying for “a doctor”. Perhaps if there was a named person each day that can be tannoyed they would be more likely to respond promptly. In terms of collecting samples like the throat swab or blood bottles, we talked about double bag techniques to pass the samples to the green runner. In this case resus was an amber area as was the nearby corridor so a VBG could have been taken directly to the machine still within amber, however blood tests would have needed ICM stickers applied within the area before they were bagged once, and dropped into a second bag held by someone in the green area. We reviewed the geography of Plym including where to don and doff. The guidelines: The choice of antibiotic in potential community acquired pneumonia can be found on our “RxGuidelines” mobile app. See last week’s blog post for the criteria that determine the need for a patient to go to Plym rather than the main ED. To do: Consider going to Plym and conducting a mental run-through of how you would act with a patient in Plym area if you needed to don PPE/collect samples/call specialties/doff without contaminating clean areas [ ] Have a look at the tannoys on the wall of Plym resus and make sure you know how you would access help from there if you needed it [ ] 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. For October the sim theme is “breathing”. This blog covers some of the learning points from 08/10/20. We will be aiming to run simulations weekly - mostly Fridays but not always - see the gmail calendar. We previous ran a simulation a few weeks ago of a paediatric asthma case - see the blog post - and this week have reviewed asthma in an adult case.
The simulated case: Laura is in her 20s and has presented short of breath. She has previously been admitted to ICU as a result of her asthma. What key questions are important here to work out the cause of breathlessness?
What did we think? In debrief we discussed: Choice of oxygen delivery: with sats almost normal could apply low flow, or initiate 15L/min non-rebreathe and titrate down with assessment. We talked about identification of whether Laura should be considered a possible COVID19 case, which could have implications for safety of those treating her and geographically where in the department she should be looked after in. The Pubic Health England case definition as of 28/09/20 is “new continuous cough or temperature ≥37.8°C or loss of, or change in, normal sense of smell (anosmia) or taste (ageusia)” (Public Health England 2020) however I will find out exactly which criteria we are working from in the Emergency Department and update this paragraph with that information shortly. [EDIT 14/10/20]: the criteria for moving to Plym ED as of 19/06/20 are: fever PLUS acute-onset respiratory symptoms (persistent cough, hoarseness, nasal congestion/discharge, shortness of breath, sore throat, wheezing, sneezing) OR clinical/radiological pneumonia OR anosmia. The patient in this sim had respiratory symptoms so no fever, so unless pneumonia was clinically expected/radiological found, they were appropriate to be outside of Plym. [end of edit]. We discussed the dose of salbutamol nebuliser. Anecdotally I have been told 5mg produces no additional benefit over 2.5mg with greater risk of side effects, although I admit I haven’t seen the evidence of this. A BestBET specific to COPD reviewed one double-blind RCT and found no difference in outcome between 2.5mg and 5mg (Kusre 2010) - note albuterol is the US name for salbutamol. Please do comment below if you have further experience or information about this choice. We talked through analysis of blood gas results for this patient. In particular the importance of noting pCO2 in an asthma exacerbation. We expect it to be lower than normal range. So if in the normal range on an arterial sample this is a worrying sign of impending exhaustion and failure - escalate these patients urgently. Note on the BTS/SIGN guideline, a normal pCO2 of 4.6–6.0 kPa is considered a sign of life-threatening exacerbation, and a raised pCO2 considered near-fatal. We discussed whether d-dimer would be tested in this scenario. We know that in d-dimer testing it is important to consider both the test characteristics, and the pre-test probability of PE. D-dimer has a good sensitivity for PE, but a specificity of around 41% (Perrier et al 1997), meaning that of people without PE, many will still have a positive test. So we need to consider the patient’s pre-test likelihood of PE, such as with Well’s scoring, to decide how a positive or negative test is going to influence that probability before we test it. In practice it may be that blood is being taken before this assessment has taken place, so if we are already performing coagulation tests on the “blue tube” we can consider after our assessment whether to add-on d-dimer or not. We noted in the scenario several times that communication techniques were used to good effect. In an SBAR handover, a key point of a pause followed by “I am concerned because X” with eye contact grabbed the attention of the listener to vital information. Between colleagues use of “are you happy with doing X while I do Y?” summarised tasks that needed to be done whilst ensuring the other person was trained and able to carry out that task, and allowed them the opportunity to “close the loop” in their response. Feedback from the participants noted that it can be difficult to find peak flow meters, and that it would be helpful to have had greater nursing staffing both in terms of caring for patients like this, but also in being able to attend simulation training. The guidelines: Our EDIS guideline on adult acute asthma is the same as page 17-18 of the BTS/SIGN quick reference guide. This gives an overview or both assessment and treatment. It was used in the scenario to categorise the attack as “acute severe” and not yet in the “life-threatening” or “near-fatal” categories. Choice of steroid: the BTS/SIGN guidelines 2019 (page 102) state: “steroid tablets are as effective as injected steroids, provided they can be swallowed and retained. Prednisolone 40–50 mg daily or parenteral hydrocortisone 400 mg daily (100 mg six hourly) are as effective as higher doses.” BTS/SIGN 2019. To do:
Review the quick overview guideline, which is via “ED browser” on EDIS, or page 17-18 here [ ] Reflect on how scary it would be to be admitted with an asthma attack such as this, and how we might consider helping this anxiety in patients we see [ ] If you need to, consider reading an overview of blood gas interpretation - there are many online, for example this one by Geeky Medics [ ] 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 simulation fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. We aim to run simulations every Friday at 11am, see the gmail calendar for the up-to-date schedule. The sim homepage is derriforded.com/sim where you can see our monthly theme and you can submit suggestions for what we should cover! In September we have covered (click to see the blog summary):
The DKA simulation below was carried out twice and the learning here is a summary of both sessions.
The simulated case: Tara is a 10 year old child brought in by a parent. They have been feeling unwell for a few weeks and today they have developed vomiting and pain in their abdomen. Do you already have key diagnoses in mind? What examinations and selective testing will help you rule options in or out?
What did we think? In debrief we discussed:
We discussed in debrief the latest shift in DKA management, from a previous intention to restrict fluid input due to concern of causing cerebral oedema, to a stance of greater fluid administration. The weight of evidence indicates that cerebral oedema develops out of the disease process itself rather than related to fluid-giving. The local guideline (see below) gives clear instruction of the fluid required in this case. We talked through the balance required in keeping the parent informed about what is happening whilst ensuring no delay with immediate care needs. We briefly touched upon the PACE model of assertiveness. This blog describes the challenges of speaking up and how PACE can be used to gradually but assertively escalate your concern to a colleague - you can scroll down to where the example of this is given. Here is a case study of it being used by a “junior” colleague to make suggestions to a “senior” during the resuscitation of a child. Feedback from the sim participants noted the difficulty for adult-trained nurses to be familiar with the paediatric area and equipment - we can aim to pair a paediatric and adult nurse during scenarios. It was suggested we should have more speech directly from the mannequin - we can aim to do this if a facilitator remains outside of the room in future. The guidelines: On the ED browser page you can find two paeds DKA links - the documentation and an appendix for further information. The documentation link is a complete booklet that allows you to write in your results as it guides you through the process and the calculations. You can take a look at the same document on the British Society for Endocrinology and Diabetes page here. It is a good idea to print this off early in the process so it can guide you. I am going to look into whether we can have a few full-colour versions available. This guideline was brought out in March 2020 and represents some significant changes on previous versions that are worth being aware of. As mentioned above, the fluid strategy is now more permissive rather than restrictive, with all patients receiving a fluid bolus of 10mL/kg 0.9% saline, with an extra 10mL/kg (i.e. 20mL/kg total) for those in shock (Tasker 2020). Inadequate fluid resuscitation is noted as one of the key contributors to death in DKA resulting from inadequate cerebral perfusion (BDPED). Have a look at page 5 (and a little at the top of page 7) of the appendix document, also to be found here. This gives a (virtually) single-page overview of what we need to achieve for these patients in the ED. However when you are looking after a patient with DKA you should use the full guideline above. Some more detail on this change in guidance, by Dr Tom Siese: The latest thinking is that rather than the cerebral injury in DKA being simply related to osmotic shifts due to over-rapid fluid treatment, there is increasing evidence which points towards a state of metabolic acidosis and dehydration which then paves the way for a “hyperinflammatory state”. The results from the recent randomised controlled PECARN DKA Fluid Trial (Kuppermann et al 2018) supports the return of permissive fluid boluses in paediatric DKA. At time of writing, the latest editorial in the Archives of Disease in Childhood (Tasker 2020) notes caution in treating cases with altered consciousness, as only 2% of study participants in the above trial had a GCS<14. Therefore the bottom line is don’t be afraid to rehydrate children with DKA, but all cases will still need discussing with a senior member of the paediatric team from an early stage. To do: If it’s been a while since you worked in the paeds area, ask someone who is regularly there to show you where key items are, and if you have supernumerary time you could spend some of it in paediatrics [ ] Have a look at the main guideline document either on our ED browser or via the link above, plus page 5-7 of the appendix document [ ] 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 On behalf of the faculty behind this sim Hana Bashir, Andy Robinson, Thomas Siese, Rachel Garlick References:
- British Society for Paediatric Endocrinology and Diabetes [BSPED]. 2020. Integrated care pathway for the management of children and young people with diabetic ketoacidosis. Available from: https://www.bsped.org.uk/media/1742/dka-icp-2020-v1_1.pdf. - British Society for Paediatric Endocrinology and Diabetes. 2020. BSPED Interim Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis. Available from: https://www.sort.nhs.uk/Media/Guidelines/BSPED-DKA-guideline-2020-update.pdf. - Kuppermann et al. 2018. Clinical Trial of fluid infusion rates for paediatric DKA. NEJM; 378:2275-2287. www.nejm.org/doi/full/10.1056/nejmoa1716816 - Nickson C. 2019. Speaking Up. LifeInTheFastLane blog. Available from: https://litfl.com/speaking-up/. - Tasker R C. 2020. Fluid Management during DKA in children: guidelines, consensus, recommendations and clinical judgement. ADC; 105: 917-918. pubmed.ncbi.nlm.nih.gov/32847796/ - Yianni L, Rodd IG236(P) Pace – ‘Probe, Alert, Challenge, Escalate’ Model of Graded Assertiveness Used in Paediatric ResuscitationArchives of Disease in Childhood 2017;102:A93. --------------- For clinical decisions please refer directly to the guidance. This blog will not be updated. |
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