Incivility affects everyone.  How does it make you feel when someone is rude to you? Research shows that mild to moderate rudeness results in 60% reduction in cognitive ability (your bandwidth) following the event.  A fine example of this effect is the delayed reaction by your brain when you think about how you should have reacted in the moment when someone was rude to you about half an hour later.  And then you feel disappointed that you couldn’t think of this sharp reaction at the time!

Incivility also affects on-lookers. 20% of on-looking staff have a decrease in performance and 50% will have a reduction in willingness to help others. When patients and relatives in the area witness incivility between staff members, 75% will have less enthusiasm for the organisation and 65% will be anxious in dealing with the staff.

Our natural reaction as human beings are to react defensively, perhaps we think of it as protecting ourselves. So, next time when you are trying to refer a patient to another team and you have a rude response, think about your reaction. Before you are rude in return, think about the effect of incivility on the individual and on-lookers and ultimately on patient care and patient safety.  Rather than rising to the same level of rudeness, we should appreciate that there may be a reason for the other person’s behaviour and perhaps ask them “Are you OK? You don’t seem like yourself”. Perhaps offer them a cup of tea...

​We should not expect rudeness in our day to day professional interactions, and we should certainly not be rude to others. If you're rude, you automatically make your team perform worse.

Please go to the Civility Saves Lives website for more reading
https://www.civilitysaveslives.com/ 
http://www.bota.org.uk/hammer-it-out/

N Bothma

He managed to make it to the shore, get out of his wetsuit, and drive to the emergency department where described severe pain over the suprapubic area. His observations were all within normal range and with analgesia , he managed to mobilise and fully weight bear from wheelchair to bed , although with severe pain.

Examination showed tenderness over the symphysis pubis and the left side of the groin. The abdomen was soft otherwise and there were no other evident injuries. Lower limb examination was normal but range of movement of the left hip was restricted by pain in the left side of the groin. ​

​An X-ray of the pelvis showed evidence of pelvic diastasis, and the left sacroiliac joint was suspicious for a potential fracture. After discussing with the orthopaedic team, a CT pelvis was obtained which confirmed pelvic diastasis with no associated fractures. There was also a 10*6*11 cm pelvic haematoma anterior to and compressing the urinary bladder. Both sacroiliac joints appeared normal, with an incidental cystic lesion noted lateral to the left sacroiliac joint. 

​The patient was admitted under the orthopaedic team, where two days later, he underwent an open reduction and internal fixation of the pelvic diastasis with a left sacroiliac screw insertion.

This is the CXR if an elderly gentleman, 83 years, who presented in resus after a collapse.
​He was found to be SOB and had a CXR:

What do you think: does he need a drain?

On further inspection and manipulating the x-ray:

A guest post by Dr Clair Ashford, Diving and Hyperbaric Physician at the DDRC.
​

Decompression illness is technically described as a disease of compressed gas divers, aviators, astronauts and caisson workers where gas bubbles form in tissues and/or the blood during or after a decrease in environmental pressure. 
​
However, in ED the main reason you will see it is with divers. They have bubbles of nitrogen in places where they shouldn’t be. They need oxygen – to help the nitrogen clear from the system – and usually recompression as treatment. So, before we get to the technical stuff… please put them on high flow oxygen and call us ASAP.

It can present with pretty much any clinical picture (see below – How does DCI Manifest?). Call us if you are not sure. Diagnosis is clinical and we often speak to the diver to get a history of the dive as there aren’t many diving docs. 

We may ask you to do a very thorough neurological examination. Yes, this involves tendon hammers and neurotips, but we do appreciate that these are sparse in an ED. As we are nearby we can see stable patients easily at our unit or come into Derriford ED.

Do not give Entonox (50% nitrous oxide/50% oxygen) under any circumstances to anyone who has recently dived as the nitrous oxide is highly soluble and will increase the inert gas load, making the symptoms of DCI worse. It can also expand within the air filled spaces of the body and cause barotrauma to the lungs, ears, sinuses or gut.  Do not give pain killers unless you have a very long transfer to a chamber, and only after discussion with a diving doctor.

Lastly, we might send divers to you and ask for your help assessing whether they have a pneumothorax following a dive. We will ask for your help in deciding this with imaging as you see fit. If they do have a confirmed Ptx with significant DCI symptoms and need recompression, then we may ask for your assistance with a suitable chest drain before transfer.
​

​We are your local Hyperbaric Medical Centre and are very close by:

Most divers will come up bubbling. 
Please click here to hear some dopplers…

Last week saw the first POTTED session, on hydration assessment and paediatric fluids.
Aimed at all clinical staff, these will continue to run thoughout the autumn.

​Future dates:
26th Sept (Stewart room)
24th Oct (Stewart room)
14th Nov (Stewart room)
21st Nov (Paeds ED)
28th Nov (Stewart room)
5th Dec (Paeds ED)
12th Dec (Stewart room)

This is the presentation I gave at the ED Wellbeing day back in the summer. It is also available as a webinar on the Trauma Care website, and we discuss similar themes in this podcast. I have been inspired by several other people to produce this blog, and if you would like to know more I suggest you find them on Twitter, where you will find links to their FOAM resources: @emcrit, @DocTomEvens, @HumanFact0rz, @ResusPadawan, @EMSwami

Firstly I would like to emphasise that this blog is concerned with the ability to perform when faced with acute stress, not chronic stress or post-traumatic stress disorder.

The reason we, as humans, have a response to stress is the innate 'fight or flight' reflex which kept our ancestors alive. But the very design that gave us a survival advantage as cavemen, unfortunately has deleterious effects on our ability to perform under stress, when what we really want to do is run away!
​

In 1908, Robert Yerkes and John Dodson presented their ground-breaking research on the non-linear nature between arousal, based on task difficulty, and brain functioning. Focused/in-the-zone is a good thing. Performance improves when you are ‘a little bit activated’. But we need to be aware that this is not exponential – and recognise when performance tapers off.

There is a really interesting book on this subject by Lt. Col Dave Grossman, called 'On Combat'. It discusses the effect of stress on performance in the context of ‘deadly force encounters’ amongst military and armed police, and provides huge insight into the way in which stress could affect performance in medical staff too. Listen to this Emcrit podcast to hear more.

​Performance Deterioration as a Function of Heart Rate
From On Combat, by Lt. Col Dave Grossman – former US Army Ranger & paratrooper

• Condition black > 175 bpm
  
• Condition grey > 150 bpm (deteriorating complex motor skills, visual reaction time, cognitive reaction time)
  
• Condition red > 120 bpm
  
• Condition yellow > 90 bpm
  
• Likely optimal performance level is 115-145

The deleterious effects of stress on performance are profound and pervasive. The time taken to complete manual tasks is doubled under stress conditions.
In addition to the physiological consequences of increased heart rate, breathing rate and tremor, there is also an emotional and cognitive burden.

We feel fear, anxiety, frustration, and lose motivation.
We have a narrowed attention, decreased search behaviours, longer reaction time to peripheral cues, decreased vigilence, degraded problem solving, performance rigidity.
There are changes in social behaviour: loss of team perspective, decrease in pro-social behaviours such as helping, obliterate ability to share mental model.
Acute stress causes a doubly-whammy in terms of potential error, it erodes decision-making and situational awareness, and reduces team performance; so the individual is less receptive to suggestions from others, which would normally provide a safety-net.

A process occurs by which environmental demands (eg performing in front of others, taking an exam) evoke an appraisal process in which perceived demand exceeds resources, and results in undesirable physiological, psychological, behavioural or social outcomes.

If the individual determines that his or her resources are sufficient to meet the demands of the situation, the situation is appraised as a challenge and the potential for gain (i.e. elevated self-esteem, learning) is recognised. If the resources are not judged to be sufficient, the situation is appraised as a threat because of the significant potential for loss. Socio-evaluative stressors (when behaviour is potentially judged by others) and uncontrollable situations are more likely to be appraised as threats than challenges.

We need to move into a Challenge rather than a Threat mindset.
Think about how you can increase your resources:

• Ensure you are well rested, eat, go to the toilet! (Avoid HALT: hungry, angry, late tired)
• Be aware of your bandwidth and offload tasks to others before you feel overwhelmed
• Plan for WHEN, not IF, something happens, for example, front of neck access
• Be well trained, and well drilled as a team (that's what worked for me during the paediatric cardiac arrest)

​Stress inoculation training (SIT) is a three-phase cognitive behavioural training approach to limit the impact of acute stress on performance. SIT has been used to decrease the perception and influence of stress – or promote ‘stress resistance’ – across a variety of domains, from public speaking to combat aviation. Have a read of this blog/listen to the podcast for more information.

1. Conceptualisation-give a background of stress responses, why they happen, and what to expect.
2. Train and educate on the skills and tasks we want to see performed under stress. Then give the tools to deal with the expected stress.
3. Do a dry run to train in simulation without added stressors
4. Run the same training with stress inoculation

Your brain is the most powerful simulator you have.
Mental Practice is the mental rehearsal of activity in the absence of gross muscular movements; it has been demonstrated to enhance acquisition of technical and procedural skills. It has been shown to improve performance in basketball and piano players, to a standard equivalent to them having physically practiced performing the procedure, and there is evidence to support the same in the medicine.

Tactical breathing. Take a deep breath in for 4 seconds, hold it for 4 seconds, breath out for 4 seconds, hold for 4 seconds. Repeat. This combats the physiological affects of stress, and moves you down the combat stress performance graph.

Positive self-talk is used by athletes and any elite performance group.
Visualise yourself performing the task exactly how you want to see it done.

Your own perceptions are important:
Recognise your own stressors, beware of going into it with negative thoughts
Think about when you did it well, visualise success
Change your negative into positive thought (exude confidence, for both your patients and your trainees) 'Calm is contagious'  


Accept the fact, but reject the premise. Yes I was unsuccessful last time I performed this procedure but that doesn't mean I cannot be successful this time.

I suppose this is not surprising, and our Emergency Department is just as bad, if not worse, than an anaesthetic room: it is an alien environment, there is lots of frightening equipment stuff, and people rushing about! Children may be pushed beyond their capacity to cope.

Our job is to help children cope with anxiety and reframe it so that it does not become crippling. But how?

Advanced communication techniques fall into two groups

• Control attention: disrupt negative processes taking place, moving them from internal inaccessible state to external interactive state
• Coping strategies: help the child manage their anxiety

Not all techniques will work for all children, and as an individual you might prefer some to others. It is helpful to practice a few so you can try different approaches in different circumstances.

 
​Control attention
Overload
Example: "Hello James, come in. I love your shoes, reckon they'll fit me? I reckon they're too small but what's size between two friends? I'd probably bend them if I wore them, but not like Beckham though. He's a good player, better at United than Real, the real deal in red not white I think. Red devils are United, but they're heavenly players, making music on the pitch, perfect pitch but I'm tone deaf even though I love to sing in the shower. Not the rain shower, though Singing In the Rain is a great film, but water in the camera is bad news, it makes the colours run off the screen, right off track but listen to me I'm like a stuck record."

Accelerated rapport
Behaviour, non-verbal, verbal or tactile usually associated with having rapport where as yet that rapport does not exist.

Yes set

• Conversation intentionally structured such that the patient must respond with a 'yes', therefore obtaining a positive rather than a negative response.
• Momentum of the repetitive response to enable agreement without full consideration
• Experience dissonance if they break the yes pattern
• Example: Hello, you must be Charlotte? Are you're here with your mum? And you've hurt your arm? 

Bind of comparable alternatives
Free choice of two or more comparable alternatives, and whichever is chosen leads to behaviour in the chosen direction. Usually feel bound to accept one alternative.

• Would you like to go to sleep on the trolley or sitting in Mum's lap?
• Do you want me to examine your ear or nose first?
• Do you want me to measure your temperature or take your blood pressure first?
• Do you want four stitches or three really good ones?

Coping strategies
Humour
Use with caution and be inclusive and appropriate

• Hello Bob, can you tell me your name?
• Who is old, you or your Dad?
• Do your Mum and Dad have any children?
• Do you go to school? Oh really, what subject do you teach?

Successive approximation

• Now, George, I don't want you to get on the bed just yet, but could you just help me move it into position, and now help me put on the draw sheet
• Could you just hold the mask, while I tie up my shoelaces? Could you hold the mask up?
• Would you like to have a look around the ward before we go into the treatment room?

Distraction therapy
Methods to reduce anxiety and pain by focusing on something else

• Preparation: child and parents
• Choice: cuddles, bubbles, toys, books, music, games
• Allocate distraction to one person - avoid over distraction!!

Want to know more?
Please consider going on the course - see their website

ACCS teaching this week was on the topic of Vertigo & dizziness, we thought it would be useful to share some key points with a wider audience, and point you in the direction of some great resources, particularly the RCEM Learning module on the topic

​

​1 Vertigo an illusion of motion of either the subject or the environment
2 Presyncope a feeling of impending faint or loss of consciousness
3 Disequilibrium impaired balance and gait in the absence of abnormal head sensation dizziness of the feet
4 Light-headedness a non-specific description of symptoms that cannot be identified as one of the above types

3% of patients present to ED with dizziness/lightheadedness/imbalance, which equates to approximately 9 patients per day to our department, and the literature states that up to 28-59% of posterior strokes are missed in the ED.
​

Sensory inputs from the vestibular apparatus, visual system and proprioceptive stimuli from the neck and rest of the body. The vestibular apparatus consists of the membranous labyrinth contained within the bony labyrinth lying in the petrous temporal bone, which connects via the vestibulococclear nerve to the vestibular nuclei in the brainstem. These nuclei interconnect with neurones in the cerebellum, spinal cord and cerebral cortex.
 
The membranous labyrinth consists of the three semicircular canals and two chambers, the saccule and utricle. Flow of fluid (endolymph) in the canals stimulates cilia attached to a sensory organ located in the ampulla of each canal, the crista ampullaris. In the saccule and utricle, movement of calcified calcium carbonate crystals (statoconia or otoliths) stimulates cilia of another sensory organ, the macula. Therefore movement of the head in any plane modifies neural impulses transmitted via the vestibular nerve, connected to each of the sensory organs, to nuclei in the brain stem. Vertigo results from an imbalance of either the received signals or information processing in the brainstem.

Vascular supply is from anterior inferior cerebellar artery and posterior inferior cerebellar stray. These are branches of the basil artery and vertebral artery - the posterior circulation.

Establish that it is vertigo and not one of the other symptoms. A multitude of medical problems can cause lightheadedness/presyncope - these need to be explored and investigated differently (VBG/ECG/BP will be useful in this regard).

History
1. Onset: rapid vs insidious
2. Associated symptoms e.g. nausea/vomiting (more common in peripheral causes), tinnitus + deafness (both suggest Menieres)
3. Effect of head position on symptoms: exacerbated movements of head and then settles (suggests BPPV), exacerbated by movements of the head but persist (labyrinthitis, vestibular neuritis), not affected by movement of the head (central cause)
5. Recent local trauma (consider possibility of vertebral artery dissection if any preceding neck pain) or infection
6. PMHx: particularly for stroke risk factors
7. DHx: ACE inhibitors, amiodarone, aminoglycosides, beta blockers, cocaine, phenytoin, salicylates, sildenafil may all cause vertigo

​Examination
1. Ataxia (suggest central cause)
2. Nystagmus: Peripheral – horizontal, fatiguable, surpressed on visual fixation, unidirectional, fast phase beats away from pathology
3. Cranial nerves, including hearing assessment
4. Peripheral nervous system
5. Check for cerebellar signs (DANISH = Disdiadochokinesis, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia)
6. Ear examination
7. Consider undertaking a HiNTS examination - for more on this have a look at this St Emlyns blogpost, the paper it references: doi.org/10.1016/j.annemergmed.2017.10.012 and these YouTube videos

Central

• Cerebellar stroke/haemorrhage or TIA
• Space occupying lesion
• Infection
• Migraine

Peripheral

• Vestibular neuronitis - viral infection of the vestibulocochlear nerve thought to be herpes simplex.
  
• Labyrinthitis - with associated hearing loss - local spread of infection from middle ear.
  
• BPPV - caused by free otolith, symptoms brought on by movement and settle if keep head still
  
• Menieres - build up of endolymph, diagnosis of exclusion. Triad of symptoms: tinnitus , fluctuating hearing loss and peripheral nystagmus
  
  

Please have a listen to this podcast from the excellent people over at FOAMcast

This gent had a fall and then some knee pain.  His knee seemed pretty good on clinical exam and so very sensibly people asked questions about his hip too.  This was the view on his long femur Xray.  What do you think?

​There is something about scenarios like this which strike fear into even the experienced amongst us. It’s partly rational: we know that when kids start to decompensate and die from critical illness, they do so really quickly. We recognise that paediatric cases are less familiar and that there are difficulties: the idiosyncrasies of APLS, difficult dose calculations, tiny scaled- down versions of kit. Crucially, kids can’t tell us where it hurts or why they might be sick, so we feel like we’re rooting around in the dark, and then there’s some seriously scared parents to consider. 
There is also, perhaps, a less rational component. The fear related to dealing with very sick children maybe reflects innate evolutionary hardwiring: the tribe mentality that tells us ‘children shouldn’t die’. Our amygdala goes into overdrive: when confronted with a sick kid, it can be easy to panic and difficult to maintain objectivity. We reflect on how a paediatric resus case reminds us of our own parenting tribulations—sometimes we might even see the face of our own child in those who come into the department. And then there’s the fear of the consequences if it doesn’t go well, as it sometimes does. The stakes—professional, emotional, legal—always seem to be higher where children are concerned. Children up the ante.
I doubt many of us will ever find confronting very sick children truly fun, but it should be something we aspire to do well. And if done well, fixing sick kids has to be one of the most rewarding aspects of EM. If critical illness is detected promptly and treated appropriately, children ‘bounce back’ quickly. Parents are hugely grateful. A child with a good outcome might go on to live a healthy life for another fifty, sixty or seventy years. Done well, paediatric resuscitation demonstrates all that is good about being an ED clinician.
So how do we achieve greatness in paediatric resuscitation, especially when we don’t see that many really sick kids?
One way is to practice together. The department held an in-situ paediatric sim morning on the 22nd November. With participants from EM, Paediatrics, Anaesthetics and ITU, multi-disciplinary teams were put through their paces with three challenging scenarios based on real cases encountered in the ED. These included DKA, Sepsis progressing to PEA cardiac arrest, and near- fatal asthma requiring challenging ventilator strategies. Here’s some key lessons that resulted from the debrief:

We wouldn't dream of assessing a sick trauma patient without a team. Why is a very sick child any different? ​Just as with trauma, approach paediatric resuscitation as a team. Roles should be clearly allocated, a leader clearly identified, and a scribe should be allocated. There will likely be multiple decision makers present from EM, Anaesthesia and Paediatrics. Contributions from all team members should be welcomed, but it should always be easy to identify the team leader. 

​Need help now? The paediatric emergency team (PET) is the Hospital Trauma Call equivalent for sick kids. It compromises help from paediatrics, intensive care and also provides additional paediatric nursing support. It’s a great resource.
Standard activation criteria for the PET includes cardiac arrest, status epilepticus and reduced consciousness. The criteria are not definitive: as with trauma it is always safer to escalate if in doubt—the team can always stand down later. 
There’s also the red phone for paediatric anaesthetic support in Plym Theatres. This can be contacted by calling [30949]. Out of hours, the paediatric on call anaesthetist can be contacted through switchboard.

​As with so many things in EM, success in paediatric resus really does hinge on effective team communication. We talked a lot about our communication with each other and identified the following strategies as essential during the course of the morning:

1. Give an effective pre-brief. Delivering a formal briefing might feel awkward, but there’s a reason flight crews never get airbourne without one. A good briefing identifies the leader as credible and helps the team prepare, which is an incredibly powerful way of ensuring optimal performance. Here’s a structure I’ve adapted from the Victorian state trauma system:

• Find out everyone’s name
• Define levels of competence and experience
• Allocate individual roles and preparatory tasks to be completed by each member
• Create a shared mental model of the patient’s status (use ATMIST or SBAR) and identify issues that might occur early on (what if…?)
• Allow the team to ask questions and clarify issues

2. Take 10 for 10. At key points during the evolution of the resuscitation scenario, the team leader must ensure there is shared understanding amongst the team, and clearly outline the next steps. One way of doing this is to undertake a ’10 for 10’ summary—that is, spending 10 seconds or so to refocus the team maximise the effectiveness of the next 10 minutes. 

3. Task the team effectively. Paediatric resuscitation is not a garden party—there’s no place for the Royal ‘we’! Use names to grab the attention of team members and delegate directly, using closed loop communication for when a task has been completed. Recording names on the whiteboard as part of the briefing can really help.

4. Make a statement! Things change rapidly during resuscitation scenarios, but task focus means not everyone will notice at once. Lack of a shared mental model amongst the team is a common cause of mishaps and can spell disaster for the patient. Making a clear, assertive statement when something big changes gets everyone on the same page. Making explicit use of critical phrases and powerful language such as “this child is now in a PEA cardiac arrest”, makes it clear to the team that it’s time to up the game. 

​5. Make critical communication routine. The standardised communication strategies outlined above have been developed as a result of research looking at human factors, and are crucial to patient safety. It might be tempting to deviate, especially when working with friends and familiar colleagues. In an emergency with a very sick patient, this should be avoided.

​Situational awareness describes the ability of an individual and team to perceive, comprehend information to predict and respond to future events. Put simply, situational awareness is the ability to ‘see around the next corner’. Without situational awareness, crucial things get overlooked, missed or delayed which can have serious consequences for a very sick patient. We discussed a couple of points to optimise situational awareness:

• Lead from the end of the bed. By standing at the end of the bed, it is easier for the leader to maintain oversight of what is happening. Taking a hands off approach requires discipline and patience, but avoids the leader getting suckered in to psychomotor tasks and becoming task focussed themselves.
• Survey the landscape. It is important for the leader (and other team members) to continuously survey the entire situation before them. This means consciously switching gaze between the team, monitor and patient.

It was Stephen Senegal who asserted that ‘assumption is the mother of all fuck-ups’ in the 1995 film Under Siege. With an IMDB rating of only 5, this quote is probably the only message you need to take away. It’s highly relevant to EM though: think back to the last error you were involved in. I’d be surprised if false assumption did not feature somewhere. There are some ways to defend against assumption:

Checklists are a powerful defence against assumption. Key to the third sim case was use of the RSI checklist. Whilst maybe not yet perfectly refined, the checklist serves some vital functions:

• Empowers the leader to declare what is going to happen (RSI)
• Ensures all equipment is available and prepared
• Allocates roles
• (Crucially) defines the anticipated evolution of events by stating anticipated complications, a primary plan and alternatives

It can be really tempting to take shortcuts. Try to avoid this wherever possible—or where it’s absolutely necessary, make the rationale known. Time critical scenarios tend to be exactly the occasions when checklists are most likely to avert major errors, so try to stick to them whenever possible.
 
Drug Dose Checking. Paediatric drug doses are different to adults. It is possible that neither the clinician prescribing, preparing or administering a drug may have familiarity with it. We have recognised that this situation of the blind leading the blind is potentially dangerous and is presently being addressed with some great work. In the simulation scenarios, clear communication of the sequence of drugs and doses to be given during RSI is essential. Correct labelling of syringes with the drug AND dose provides an essential defence against error. 

​​The above is a largely personal reflection of what I gained from participation in a three-hour session. Looking back on it, the amount I learned (and which I will now endeavour to use the next time a sick kid comes into Resus 4) is huge: there is plenty besides which I haven’t touched on. For me, this is proof that multidisciplinary in-situ simulation provides an incredibly effective and high-yield way of learning. Crucially, by allowing teams to work through difficult scenarios in a safe environment simulation teaches us not only learn how to work together but to reframe, as a collective, some of the fear associated with difficult cases involving sick children.

Doing a good job is what motivates most of us to do our job,  but it’s easier said than done, and I’m aware of the fine and often fragile line that differentiates a good and bad outcome in so much of what we do. Knowledge is one thing, but success is so often dependent on the ‘softer’ stuff: leadership, communication, and team performance. And it is exactly these things that simulation addresses so effectively. I hope that we continue to embrace multidisciplinary simulation within the Department and our Trust: we’ll be all the better for it if we do and, crucially, so will our patients.