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

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For clinical decisions please refer directly to the guidance. This blog may not be updated.

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:​

​What did we think? 
In debrief we discussed:

• Technical
  • The guideline and where to find it - see below. 
  • Neurological observations important in case of developing cerebral oedema.
  • VBGs: for efficiency it’s a good idea to take a capillary blood gas at the same time as the blood sugar level, in case there are delays with obtaining venous access.
• Non-technical
  • Maintaining communication lines by keeping the team leader at the end of the bed where possible. 
  • Remembering to start handovers with the “S” in SBAR. 

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.

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For clinical decisions please refer directly to the guidance. This blog will not be updated.

What happened?
The nurse assessed James and noted he’d been out drinking with older teenagers and had an injury to his head. They noted normal observations, GCS14 (E4V4M6), and no serious concerns at this point. 

The doctor’s assessment was interrupted by the arrival of James’ mother. She was unhappy and keen to remove James from the ED. The team attempted to engage with her on the importance of staying with James while he is assessed and treated. 

It was noted that James met the criteria for a CT of his head. 


What did we think? 
In debrief we discussed:

• Safeguarding: use the Salus referral but also if very concerned can phone too.
• Parent should stay, encourage but if they do insist on leaving include on Salus referral.
• Discussed the NICE CT pathway, but sometimes deviation needed -> speak to a senior.
• Consent in children: see “guideline” below. 

Feedback from the participants noted that greater staffing might make the care of patients like this easier. It was noted that this sim being in the Stewart room rather than in situ meant a reduction in realism. For the next sim we will ensure the room is better kitted out with the equipment necessary.

​
The guidelines:
Consent in children:

The mental capacity act doesn’t apply to children under 16. Children under 16 can give affirmative consent if they are deemed “Gillick competent” - see link.

If the parents disagree with treatment like they did in this sim:

For our first month of SimFridays we’re looking at paediatrics, and if you couldn’t join us for the first session (4th September) this blog covers some of the learning points. We will be aiming to run simulations every Friday at 11am - go to derriforded.com/sim particularly if you have suggestions of what we should cover!​

​What did we think? 
We talked through the scenario in debrief. Key points were: 

• Early oxygen and nebs
• If you’re an adult-trained nurse, to know where to find key equipment and drugs in the paediatrics area
• Know where the guideline is
• Early escalation
• Kids can improve rapidly, but keep treatment going after referral

We noted that in reality in our ED the tannoy system is used to request urgent reviews. This has the potential to be impersonal “can a doctor come to…” and there is some risk of bystander effect with it. Do we assume someone else will go? 

Very early on the question of whether to move to resus was raised. To arrange this, one would need to speak to the team in Majors - when is a good time to leave the patient if this is what is needed?

We discussed the usefulness of having a capillary blood gas if possible when discussing with the paediatric team. 

We discussed that the paediatric team may be far away, both in time and in space! So it’s important to highlight sick people to seniors within ED too, and keep treatment/monitoring going to make sure they’re still improving.

In the feedback for the session it was raised whether doctors should rotate through allocated paediatric ED days. It was also asked about how to access asthma action plans - see the “to do” section below for this. 


The guideline:
I can’t post the asthma guideline here but you can find it on the ED browser under children’s guidelines. It’s split into pdfs for each age range, and it’s a really straightforward single-page sheet. You can see how to grade the child’s observations into the severity of asthma attack, and there are clear treatment options. 

There is also an advice sheet for parents under the patient information leaflets section.

Here is the BTS/SIGN equivalent in how to grade moderate vs severe vs life-threatening attacks (BTS/SIGN 2019) - the full guideline is under the “to do” section below.
​

Key steps in child >5 years old: 

• Salbutamol 5mg via nebuliser, plus ipratropium 250 microgram if life-threatening or poor response
• Oxygen
• Ametop ready for access
• Capillary gas
• Oral prednisolone 30-40mg or IV hydrocortisone
• If dischargeable, a written asthma action plan: see “to do” below.

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   [  ]

The SIGN asthma guideline here  [  ]

Check out the asthma plans that can be downloaded from Asthma UK here   [  ]

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 at the next one!
James Keitley - ED sim fellow

--------------
References: 
British Thoracic Society and Scottish Intercollegiate Guidelines Network (2019). British guideline on the management of asthma: quick reference guide. Available from: https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-quick-reference-guide-2016. Viewed 09/09/20. 

Photos either taken by the author or copyright- and attribution-free in the public domain.

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For clinical decisions please refer directly to appropriate guidance. This blog will not be updated.

​I thought it prudent to give another academic update, given that there has been some big research news in terms of COVID-19 and other relevant emergency medicine studies in the last couple of weeks.  If you want a general update on the state of play nationally with regards to emergency medicine research, some of the challenges we’ve faced and how the future might look, check out this recent podcast which is available via the RCEM Learning site:
http://iz4.me/VO8s6zO8eBb1
 
COVID-19 research
 
I’ve mentioned the RECOVERY (Randomised Evaluation of COVid-19 thERapY) trial before. This is a large UK multicentre randomised controlled trial, led by researchers in Oxford, of possible treatments for patients admitted to hospital with COVID-19. Many of us have recruited patients to this study, which is still ongoing. As a reminder, the treatment arms are:
 

• Lopinavir-Ritonavir (commonly used to treat HIV)
• Low-dose Dexamethasone 
• Hydroxychloroquine (which has now been stopped due to lack of efficacy)
• Azithromycin 
• Tocilizumab (an anti-inflammatory treatment given by injection)
• Convalescent plasma (containing antibodies against the SARS-CoV-2 virus, collected from donors who have recovered from COVID-19)

 
It has an unusual and novel adaptive design – so it changes as time goes on, and tests multiple interventions, with the ability to stop or start different treatments as the trial progresses. It makes traditional methodologists twitch. Outcome is all cause mortality at 28 days. 
 
The first result published was hydroxychloroquine – which showed no benefit – and so that arm was discontinued. The second result, which resulted in a press release last week, was the dexamethasone arm. The pre-print of the full results paper is now available at:
https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1
They found that dexamethasone reduced deaths by one-third in patients receiving invasive mechanical ventilation (29.0% vs. 40.7%, RR 0.65 [95% CI 0.51 to 0.82]; p<0.001), and by one-fifth in patients receiving oxygen without invasive mechanical ventilation (21.5% vs. 25.0%, RR 0.80 [95% CI 0.70 to 0.92]; p=0.002). Impressive stuff from the UK medical research community, and a further illustration that academia is the new rock and roll.
 
Non-COVID evidence
 
More big news from an emergency medicine study that spanned half a decade in our emergency departments across the UK and indeed the world. Should we give TXA to patients with GI bleeds? 
 
The results of the HALT-IT study have now been published:
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30848-5/fulltext
The trial found that tranexamic acid does not reduce deaths from GI bleeding (mortality was 4% in both the intervention and control groups). Of note, it increased the risk of venous thromboembolic events (deep vein thrombosis or pulmonary embolism), although the absolute risk was low (0.8% versus 0.4%). Re-bleeding was similar in both groups. 
So, an intervention that had crept into routine practice in my hospital, certainly among the admitting physicians looking after these patients because it felt like the right thing to do, is torpedoed by robust clinical evidence from a randomised controlled trial. 
 
 
Stay safe and sane,
Jason Smith on behalf of the academic team

​I was recently supposed to have been facilitating a session on vaginal bleeding as part of ACCS teaching so here is my attempt at a little bit of online education. Not my favourite subject on either a personal or professional level and don’t expect me to start speaking like a gynaecologist.  
A little Covid humour to start:

​Here goes. Everything an EM doctor needs to know on the glamorous topic of PV bleeding.
Keep it simple, stupid:
Question 1:Is the woman bleeding so heavily that they are showing signs of haemodynamic compromise? (Are they pale, ashen, sweaty? Peripherally shut down with a tachycardia? Hypotensive?). This is generally not a good sign and might make you feel a bit sweaty too. Take a deep breath, ask for some help and get the patient moved into resus.

​Take another deep breath and start reciting the alphabet: A and B – pop some oxygen on, C – if you have always wanted to insert a MASSIVE cannula then now is your chance. Two would be even better. Be kind if time allows and use a little local anaesthetic. Take some bloods and send some for an urgent cross-match. If the patient is really unwell then consider activating the massive transfusion protocol and starting a balanced transfusion (PRBC, FFP, platelets).
Tranexamic acid is rarely a bad thing when people are bleeding a lot from any cause so think about it early.
If you are a bit handy with the ultrasound or can find someone who is then it is worth scanning the abdomen for free fluid (has the patient ruptured an ectopic?).

​A gynaecologist is going to want to know about this patient sooner rather than later so get on the phone early.
The most likely cause of shock due to vaginal bleeding is a ruptured ectopic pregnancy in a pre-menopausal woman and fibroids in a post-menopausal woman.
 
Learning Bite: If the woman presents with signs of shock but with a BRADYCARDIA then you need to think about CERVICAL SHOCK. The patient will feel faint, sick and generally awful with hypotension and bradycardia. In the ED this is usually due to a miscarriage. It occurs when the products of conception pass through the cervix and cause a profound vagal response.
The only treatment is to remove the products. This is a relatively simple procedure. The cervix is visualised with a speculum and the products are gently removed with sponge forceps (see below). It is very gratifying thing to do as the woman will literally improve before your eyes. One of our own registrars did this recently with good effect. It is important to think about it as a possibility and as always ask for help.

​Question 2: Is the woman pregnant? 
In Emergency medicine the dogma is that we should suspect pregnancy in any woman between the ages of 10 and 50. In reality most women know or recognise the possibility that they might be pregnant so do ask the question first. Establish when their last period was. Ask about symptoms of early pregnancy (e.g. breast tenderness, tiredness, urinary frequency). Try and get a urine sample as quickly as possible.
If the pregnancy test is positive then the woman has a RUPTURED ECTOPIC until proven otherwise. Classically a ruptured pregnancy will present 6-8/52 after the woman’s last period. Pain is often more of a feature than bleeding.

​If the patient is unstable then they will be managed as described above. If the patient is stable then the bottom line is that they need a trans-vaginal ultrasound as soon as possible. This can happen as an in-patient or an outpatient depending on degree of suspicion, extent of symptoms and confidence that the patient will adhere to safety netting precautions if they are allowed home. Please discuss this with a senior and then refer to the gynae team. Make sure they have had the relevant bloods sent first – don’t forget a group and save in case they deteriorate and a serum beta-HCG is helpful as a baseline for the gynae team (they may monitor this serially).
Clearly miscarriage is more common than an ectopic but is initially managed in the same way by us in the ED. 
PV bleeding in late pregnancy obviously has an entirely different differential including placental abruption, placenta previa, uterine rupture and labour. It is very rare to see such patients in our ED as they usually present to labour ward. If they do appear unexpectedly resuscitate as above and seek specialist help EARLY.

​Question 3: Is the woman pre or post-menopausal?
Any woman with post-menopausal bleeding has cancer until proven otherwise. At the time of writing we don’t have access to the 2WW pathways so the patient will need a letter or phone call to their GP to get this sorted.
We are now left with a pre-menopausal patient who isn’t haemodynamically compromised and isn’t pregnant. Breath. You now have time to take a bit more of a history!
Questions that will help you elucidate what is going on:

​

1. You need a description of the bleeding. Heavy bleeding means different things to different people so worth trying to ask some objective questions – how often do they need to change their pads/ tampons (2-3 hours is considered heavy)? Any clots? Any flooding? Double protection required? (pads and tampons)
2. Is the bleeding menstrual, inter-menstrual or post-coital? - this obviously helps to focus your diagnosis
3. Is there associated pain? (more likely with ovarian cyst pathology, fibroids, PID, endometriosis)
4. Are there any infective symptoms? Fever, systemic upset, vaginal discharge? Think about sexually transmitted infections and PID.
5. Has there been any genital trauma or sexual assault? (not always disclosed easily)
6. Any foreign body? (retained tampon?)
7. Is there any bleeding tendency? (anti-coagulants, hereditary bleeding disorder)
8. Could this be due to a more systemic problem? – any symptoms suggestive of hypothyroidism, liver disease etc

For this last group of patients (stable, non-pregnant, pre-menopausal) it probably doesn’t matter whether or not you make a definite diagnosis in the ED. Let’s be honest ED docs are not going to be the best at managing these conditions. We need to try and help the patient feel symptomatically better and decide if they need admission or referral back to the GP.
So, what can we do in ED? (assuming as always that the patient is not in need of resuscitation)

• Prescribe pain killers if needed
• Remove a retained tampon
• Check for trauma if indicated by the history
• Palpate the abdomen for any large masses
• Consider a PV and speculum exam (but this may very often not be appropriate in the ED).
• Get some swabs done and prescribe antibiotics if you suspect PID (this may very reasonably require referral to the gynae team if this isn’t in your skillset)
• A VBG will show if they are anaemic. This may be all you need. Routine clotting and TFTs are NOT indicated unless clinical suspicion is high
• Consider oral tranexamic acid as an option to reduce bleeding

What we shouldn’t do in the ED:

• I don’t think it is suitable for ED to prescribe hormones to try and reduce bleeding. These should be started in primary care with appropriate risk assessment and follow up. 

The flow chart here is a really good summary of everything discussed above:

References and Further Learning
1. NICE guidance on ectopic pregnancy and miscarriage:
https://www.nice.org.uk/guidance/ng126
 
2. RCOG guidance on diagnosis and management of ectopic pregnancy:
https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14189
 
3. NICE guidance on heavy PV bleeding:
https://www.nice.org.uk/guidance/ng88/resources/heavy-menstrual-bleeding-assessment-and-management-pdf-1837701412549
 
4. RCEM learning module on bleeding in pregnancy:
https://www.rcemlearning.co.uk/modules/bleeding-in-pregnancy/
​

​Dear all,
As summer appears to have landed, all thoughts of coughs and fevers are surely receding into the background as we queue for our takeaway fish and chips. However, I thought it might be time for an academic update, to remind you that the evidence base around COVID-19 is ever-increasing, and of course there is also a raft of other emergency medicine research worthy of a mention. 
 
COVID-19 research
 
“Truth: a fact or belief that is accepted as true.” 
There is a danger in COVID times that we forget our evidence-based principles and assume that tests that we do for COVID-19 will give us a true answer. More in hope than expectation perhaps. We all know how to assess the performance of a diagnostic test, but of course that depends on how it compares with the gold standard for that disease. This is obviously more difficult to achieve with a new disease, where we don’t have a gold standard, or where the new test forms part of the gold standard. A recent paper in the BMJ also reminds us that the performance of diagnostic tests depends on the population in which the test is applied, and importantly the pre-test probability:
https://www.bmj.com/content/369/bmj.m1808
This is well worth a read, and illustrates in clear terms the impact on those who may have false negative tests, and their ongoing probability of having the disease. 
In addition, for those interested in exploring in more detail how we might define a better gold standard for the diagnosis, those clever people in the centre for evidence-based medicine in Oxford, in collaboration with our own Rick Body from Manchester, have developed a composite reference standard:
https://www.cebm.net/covid-19/a-composite-reference-standard-for-covid-19-diagnostic-accuracy-studies-a-roadmap/
Hopefully this will be utilised as a standard in future clinical trials of diagnostic accuracy.
 
Non-COVID evidence
 
In amongst the flurry of COVID-19 activity, you may not have noticed that the LoDED (Level of Detection of troponin in the ED) study results have been published recently in the journal Heart.This may be the signal of a paradigm shift in the way we deal with patients with chest pain in UK emergency departments, and is well worth a read:
https://heart.bmj.com/content/early/2020/05/23/heartjnl-2020-316692
This was an emergency medicine-led multi-centre randomised controlled trial of the clinical effectiveness of an early rule out strategy for patients with low risk chest pain, involving early discharge after a single hs-cTn test when the result was below the limit of detection. The good news is that none of the patients who were discharged using this strategy had a major adverse cardiac event within 30 days. In the words of the authors, the LoDED strategy might facilitate safe early discharge in >40% of patients with chest pain. 
 
Given that there is a national initiative to get us to walk and cycle everywhere to avoid public transport, should we be cycling to work? Yes, is the answer, but don’t crash your bike: 
https://www.bmj.com/content/368/bmj.m336
In this UK population-based study, the authors tried to determine whether bicycle commuting is associated with increased risk of injury and whether the health benefits of commuting outweigh the risk with a follow up of 10 years. They compared active and non-active mode of transport in more than 230,000 commuters. 2.5% of the cohort reported cycling as their main form of commuter transport. The study results suggest that commuting by bike is associated with a 45% higher risk of admission to hospital and a 3.4-fold higher risk of a transport-related injury. 
However, if 1000 participants changed their commute to include cycling for 10 years and associations were causal, it would result in 23 more admissions to hospital (of less than a week) for first injury and three more admissions for a week or more. On the plus side, there would be 15 fewer first cancer diagnoses, four fewer cardiovascular events and three fewer deaths.
 
Stay safe and sane,
Jason Smith on behalf of the academic team

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