An Irish Emergency Physician in Australia

[Ed: Cian is a friend and recent graduate from EM training in Ireland and below are his reflections on his current gig in Geelong, Australia.]

This is my first attempt at writing a blog post. To borrow advice from Mark Twain, I’m going to write what I know and what I do everyday at work, so hopefully you will find it interesting.

I currently work as a Consultant Emergency Physician in Geelong Hospital in Victoria, Australia about 70km south of Melbourne*. I completed Emergency Medicine advanced training in Ireland in 2012 under the auspices of the College of Emergency Medicine in London. I relocated to Australia with my partner, Shirley, 12 months ago to experience a new healthcare system and the Australian lifestyle.

Geelong Hospital Emergency Department serves a catchment area of approximately 500,000 people throughout Victoria’s surf coast and regional Victoria. There are 64,500 new ED attendances each year consisting of undifferentiated pathologies of all acuities, including 20% paediatric cases. Outside Melbourne, Geelong is the fastest growing region in Victoria.

Geelong ED

 

Emergency Department, Geelong Hospital

* Since the time of writing this post in June 2014, the author has moved to work in Ireland

 

Key initiatives in our ED

While EDs across the British Isles are experiencing a severe workforce recruitment and retention crisis, the Australian staffing levels are the aspiration of the rest of the world. Working alongside me in Geelong, there are 14 full time equivalent EM consultants, 17 registrars, 12 residents/ interns, and 60 nurses in addition to physiotherapists, emergency nurse practitioners and administrative staff. Junior medical staff members are a mix of international medical graduates (many of them from Ireland and the UK) and Australian trainees.

Each weekday morning, 2 or 3 consultants are rostered to be present on the ED shop floor. The supervising consultant begins a ward round of all patients in the ED with the overnight staff. At 9am, another clinical consultant arrives to manage the short stay unit, all resus room cases for the day and the fast track area for minor injuries or illnesses. In addition to this each day, 3-4 registrars begin staggered shifts at 11am, 2.30pm and 4pm. There is a ward round at 4pm to handover all ED patients to the evening consultant who works until midnight and is on-call overnight.

Next Saturday evening, when I’m in charge, I will work alongside twoconsultants and five registrars until midnight. This makes the overall workload more manageable and less stressful since I can delegate registrars and consultants to manage sickest patients. The presence of several senior medical staff allows timely patient flow in the ED, direct supervision of cases and procedures for residents, registrars and interns and is necessary in a large, modern Australian ED.

Geelong ED also supports an eight-bedded short stay, Clinical Decision Unit. Stable patients are admitted to CDMU for observation, investigation and risk stratification of several common ED presentations. There are 2 consultant ward rounds each day and a supervised flow of patients from the main ED to this ward.

A prehospital patient notification system is in place to let us know in advance of all potentially serious cases arriving to the ED via ambulance. All local GP clinics telephone directly to the ED supervising consultant to notify us of patients that they are sending to the ED for further treatment and assessment. This way, it is possible to plan, prepare and allocate resources to these patients. Such initiatives are part of the reason that our department runs well on a day-to-day basis.

Fortunately, there is a strong emphasis on a ‘bias towards yes’ culture in our hospital fostering collegial and collaborative interactions between staff at all levels. People usually respond in a positive manner to ED requests and this helps achieve a common goal of safe, efficient and high-quality patient care.
Geelong 2

 

‘Working together’ – Baywalk bollards by local artist Jan Mitchell depicting surf lifeguards in Geelong

Geelong 3

Eastern Beach Reserve Geelong Waterfront

Geelong 4

‘The Place to Be’ – Victorian car registration plate

 

My shift in ED

Clinical shifts in our Emergency Department are dynamic, fast-paced and challenging. We are required to make many decisions about our patients in collaboration with inpatient specialist teams and the other hospital departments.

We manage on average 190 patients each day in Geelong ED with a seasonal variance, as Geelong is a popular tourist destination. The following cases are a selection of the patients I was involved with on a weekday shift recently. To put things in perspective, over this particular 24-hour period, there were 210 new ED attendances of which 73 were admitted (35%) and 137 reviewed, treated and discharged (65%). There were 3 trauma team calls, 3 stroke team calls and 1 code STEMI. There were 53 paediatric attendances. Our flight retrieval doctor was dispatched to regional Victoria to repatriate a critically unwell man to Melbourne.

First up in resus, my shift started with a young child with a small wound on his lip after a fall at home earlier that morning. Using intramuscular ketamine for procedural sedation the wound was closed nicely. He was recovered first in resus and then in the CDMU before Mom and Dad took him home in the afternoon. It was satisfying to manage this child safely in ED and avoid a hospital stay.

Our next case was a prehospital notification call from the Ambulance Victoria (AV) paramedics. An elderly lady had been involved in an MVA on the nearby Princes highway and had rolled over in her car. Our ED trauma team was quickly activated (trauma surgeon, anaesthetist and radiology department, operating theatre on standby) for this case. Following a normal bedside EFAST ultrasound, and CT imaging of her brain and cervical spine this patient was admitted to the trauma service for observation and a tertiary survey.

Another prehospital resus notification followed shortly afterwards. This time AV flight paramedics delivered us a patient with ongoing chest pain from a small peripheral medical centre. His initial ECG had been faxed to the ED and showed anterolateral ST elevation. A ‘code STEMI’ was activated and the cardiology team rushed him to the cath lab for emergency PCI reperfusion.

The Australian footy season is in full swing right now and shoulder dislocations are a common presentation and are considered bread and butter for most emergency physicians. The Cunningham technique is a no sedation approach to shoulder reduction. Using nothing more than kind words, gentle massage and positioning techniques, our next patient’s anterior shoulder injury was corrected and he was discharged in 45mins to follow up with the hospital orthopaedic service.

Next up, a young boy was brought to resus for ongoing respiratory distress and stridor. He had a choking episode the previous day while eating a chunk of apple at kindergarten. Mum was concerned when she noticed a high-pitched squeaking sound from her child, as were we! Reduced unilateral breath sounds and differential lung volumes on an expiratory chest x-ray clinched a diagnosis of inhaled foreign body in this child. Later that evening, the ENT team performed a rigid bronchoscopy to retrieve a piece of apple from the child’s left main bronchus.

After lunch, an elderly lady was wheeled in to the resus room. She had fallen in the bathroom overnight with a headstrike against the ceramic bath edge and a hyperextension injury of the cervical spine. In addition to a skull fracture and a C6 spinous process fracture she had bilateral upper limb weakness, parasthesiae and brisk upper limb reflexes. MRI confirmed a central cord syndrome and this lady was transferred to a neurosurgical unit in Melbourne for cord decompression.

Registrars in our department are well supervised especially for patient procedures. Considering the case of a lady with a proximal hip fracture, we talked about the benefits of a fascia iliaca compartment block for pain relief. I supervised one of our EM registrars, using an ultrasound-assisted technique, we successfully infiltrated the nerve compartment leaving this patient very comfortable while waiting for surgery later that evening.

Before finishing my day shift, an 18 month-old child was rushed into the resus room by concerned senior nursing staff at triage. She had been unwell for 2 days previously and now had severe respiratory distress with an increased work of breathing. Having initially stabilised using a high-flow humidified oxygen circuit in the ED, this child failed to improve further and was admitted to ICU for bronchiolitis and for ongoing airway support. So my day ended as it had begun with a sick child in our resuscitation room with a good outcome.

Every day at work in Geelong is exciting and stimulating. I’m surrounded by fantastic colleagues that I learn new skills from and hopefully impart some information in return. Australia has been a superb life experience thus far. I have found new enthusiasm to improve my clinical skills and re-discovered an appetite for knowledge.

At the end of my ED shift, I’m thoroughly tired but always happy.

 

geelong 6

‘Going places’ – Geelong V-Line train station

The post An Irish Emergency Physician in Australia appeared first on Emergency Medicine Ireland.

An Irish Emergency Physician in Australia

[Ed: Cian is a friend and recent graduate from EM training in Ireland and below are his reflections on his current gig in Geelong, Australia.]

This is my first attempt at writing a blog post. To borrow advice from Mark Twain, I’m going to write what I know and what I do everyday at work, so hopefully you will find it interesting.

I currently work as a Consultant Emergency Physician in Geelong Hospital in Victoria, Australia about 70km south of Melbourne*. I completed Emergency Medicine advanced training in Ireland in 2012 under the auspices of the College of Emergency Medicine in London. I relocated to Australia with my partner, Shirley, 12 months ago to experience a new healthcare system and the Australian lifestyle.

Geelong Hospital Emergency Department serves a catchment area of approximately 500,000 people throughout Victoria’s surf coast and regional Victoria. There are 64,500 new ED attendances each year consisting of undifferentiated pathologies of all acuities, including 20% paediatric cases. Outside Melbourne, Geelong is the fastest growing region in Victoria.

Geelong ED

 

Emergency Department, Geelong Hospital

* Since the time of writing this post in June 2014, the author has moved to work in Ireland

 

Key initiatives in our ED

While EDs across the British Isles are experiencing a severe workforce recruitment and retention crisis, the Australian staffing levels are the aspiration of the rest of the world. Working alongside me in Geelong, there are 14 full time equivalent EM consultants, 17 registrars, 12 residents/ interns, and 60 nurses in addition to physiotherapists, emergency nurse practitioners and administrative staff. Junior medical staff members are a mix of international medical graduates (many of them from Ireland and the UK) and Australian trainees.

Each weekday morning, 2 or 3 consultants are rostered to be present on the ED shop floor. The supervising consultant begins a ward round of all patients in the ED with the overnight staff. At 9am, another clinical consultant arrives to manage the short stay unit, all resus room cases for the day and the fast track area for minor injuries or illnesses. In addition to this each day, 3-4 registrars begin staggered shifts at 11am, 2.30pm and 4pm. There is a ward round at 4pm to handover all ED patients to the evening consultant who works until midnight and is on-call overnight.

Next Saturday evening, when I’m in charge, I will work alongside twoconsultants and five registrars until midnight. This makes the overall workload more manageable and less stressful since I can delegate registrars and consultants to manage sickest patients. The presence of several senior medical staff allows timely patient flow in the ED, direct supervision of cases and procedures for residents, registrars and interns and is necessary in a large, modern Australian ED.

Geelong ED also supports an eight-bedded short stay, Clinical Decision Unit. Stable patients are admitted to CDMU for observation, investigation and risk stratification of several common ED presentations. There are 2 consultant ward rounds each day and a supervised flow of patients from the main ED to this ward.

A prehospital patient notification system is in place to let us know in advance of all potentially serious cases arriving to the ED via ambulance. All local GP clinics telephone directly to the ED supervising consultant to notify us of patients that they are sending to the ED for further treatment and assessment. This way, it is possible to plan, prepare and allocate resources to these patients. Such initiatives are part of the reason that our department runs well on a day-to-day basis.

Fortunately, there is a strong emphasis on a ‘bias towards yes’ culture in our hospital fostering collegial and collaborative interactions between staff at all levels. People usually respond in a positive manner to ED requests and this helps achieve a common goal of safe, efficient and high-quality patient care.
Geelong 2

 

‘Working together’ – Baywalk bollards by local artist Jan Mitchell depicting surf lifeguards in Geelong

Geelong 3

Eastern Beach Reserve Geelong Waterfront

Geelong 4

‘The Place to Be’ – Victorian car registration plate

 

My shift in ED

Clinical shifts in our Emergency Department are dynamic, fast-paced and challenging. We are required to make many decisions about our patients in collaboration with inpatient specialist teams and the other hospital departments.

We manage on average 190 patients each day in Geelong ED with a seasonal variance, as Geelong is a popular tourist destination. The following cases are a selection of the patients I was involved with on a weekday shift recently. To put things in perspective, over this particular 24-hour period, there were 210 new ED attendances of which 73 were admitted (35%) and 137 reviewed, treated and discharged (65%). There were 3 trauma team calls, 3 stroke team calls and 1 code STEMI. There were 53 paediatric attendances. Our flight retrieval doctor was dispatched to regional Victoria to repatriate a critically unwell man to Melbourne.

First up in resus, my shift started with a young child with a small wound on his lip after a fall at home earlier that morning. Using intramuscular ketamine for procedural sedation the wound was closed nicely. He was recovered first in resus and then in the CDMU before Mom and Dad took him home in the afternoon. It was satisfying to manage this child safely in ED and avoid a hospital stay.

Our next case was a prehospital notification call from the Ambulance Victoria (AV) paramedics. An elderly lady had been involved in an MVA on the nearby Princes highway and had rolled over in her car. Our ED trauma team was quickly activated (trauma surgeon, anaesthetist and radiology department, operating theatre on standby) for this case. Following a normal bedside EFAST ultrasound, and CT imaging of her brain and cervical spine this patient was admitted to the trauma service for observation and a tertiary survey.

Another prehospital resus notification followed shortly afterwards. This time AV flight paramedics delivered us a patient with ongoing chest pain from a small peripheral medical centre. His initial ECG had been faxed to the ED and showed anterolateral ST elevation. A ‘code STEMI’ was activated and the cardiology team rushed him to the cath lab for emergency PCI reperfusion.

The Australian footy season is in full swing right now and shoulder dislocations are a common presentation and are considered bread and butter for most emergency physicians. The Cunningham technique is a no sedation approach to shoulder reduction. Using nothing more than kind words, gentle massage and positioning techniques, our next patient’s anterior shoulder injury was corrected and he was discharged in 45mins to follow up with the hospital orthopaedic service.

Next up, a young boy was brought to resus for ongoing respiratory distress and stridor. He had a choking episode the previous day while eating a chunk of apple at kindergarten. Mum was concerned when she noticed a high-pitched squeaking sound from her child, as were we! Reduced unilateral breath sounds and differential lung volumes on an expiratory chest x-ray clinched a diagnosis of inhaled foreign body in this child. Later that evening, the ENT team performed a rigid bronchoscopy to retrieve a piece of apple from the child’s left main bronchus.

After lunch, an elderly lady was wheeled in to the resus room. She had fallen in the bathroom overnight with a headstrike against the ceramic bath edge and a hyperextension injury of the cervical spine. In addition to a skull fracture and a C6 spinous process fracture she had bilateral upper limb weakness, parasthesiae and brisk upper limb reflexes. MRI confirmed a central cord syndrome and this lady was transferred to a neurosurgical unit in Melbourne for cord decompression.

Registrars in our department are well supervised especially for patient procedures. Considering the case of a lady with a proximal hip fracture, we talked about the benefits of a fascia iliaca compartment block for pain relief. I supervised one of our EM registrars, using an ultrasound-assisted technique, we successfully infiltrated the nerve compartment leaving this patient very comfortable while waiting for surgery later that evening.

Before finishing my day shift, an 18 month-old child was rushed into the resus room by concerned senior nursing staff at triage. She had been unwell for 2 days previously and now had severe respiratory distress with an increased work of breathing. Having initially stabilised using a high-flow humidified oxygen circuit in the ED, this child failed to improve further and was admitted to ICU for bronchiolitis and for ongoing airway support. So my day ended as it had begun with a sick child in our resuscitation room with a good outcome.

Every day at work in Geelong is exciting and stimulating. I’m surrounded by fantastic colleagues that I learn new skills from and hopefully impart some information in return. Australia has been a superb life experience thus far. I have found new enthusiasm to improve my clinical skills and re-discovered an appetite for knowledge.

At the end of my ED shift, I’m thoroughly tired but always happy.

 

geelong 6

‘Going places’ – Geelong V-Line train station

The post An Irish Emergency Physician in Australia appeared first on Emergency Medicine Ireland.

Recent controversies in sepsis

Below is a recent talk I prepared for a teaching meeting for the ICU and ED staff. Unfortunately I was still on my train when I was due to give it so here it is online instead.


References:

  • Annane D. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. JAMA. 2013 Nov 6;310(17):1809.
  • Brown SGA. Fluid resuscitation for people with sepsis. BMJ (Clinical research ed). BMJ Publishing Group Ltd; 2014 Jul 22;349(jul22 16):g4611–1.
  • SMACC Podcast: Myburgh: Fluid Resuscitation: Which, When and How Much?
  • EMCrit Podcast: Marik: Fluids in Sepsis
  • EMCrit Podcast: Angus on Process
  • Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008 Jul;134(1):172-8. doi: 10.1378/chest.07-2331. Review. PubMedPMID: 18628220.
  • Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368–77.
  • Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial. JAMA. 2010 Feb 24;303(8):739–46.
  • Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee2012. Crit Care Med.2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af. PubMed PMID: 23353941.
  • The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014 Mar 18;:140325070040003.
  • Kaukonen K-M, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012. JAMA. American Medical Association; 2014 Apr 2;311(13):1308–16.

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CEM FOAMed network

CFN Logo

The College of Emergency Medicine is the body responsible for training all the wonderful UK emergency medicine trainees and represents the speciality in the UK. The trainees in Ireland do the UK exams so the specialties in both countries have a fairly close relationship.

The college’s main online educational presence in recent years has been the ENLIGHTENme platform. There’s been some good stuff on there but it’s behind a log in and not immediately accessible in the way FOAMed resources have been.

With the rise of FOAMed and it’s influence on education of emergency physicians, it’s only natural that the college would want to embrace the idea.

Simon Laing (of the HEFT EM Podcast) is the college lead for this and he has been involved in recruiting people from the different regions of the UK and Ireland to provide FOAMed resources. Ultimately the goal is to ‘map’ the college curriculum. Somewhat similar to my own little anatomy project but on a much broader scale.

The UK exams for emergency medicine are a different beast to the Aus/NZ ones so it’s a natural that there’ll be a need for some more specifically directed resources.

The CEM FOAMed Network (rejoicing in the acronym CFN) is a project in development. The website is in the pipeline and the introductory podcast is now live on iTunes.

Please check it out and look out for more FOAMed resources in the near future.

Conflicts

  • I am the regional lead for Ireland for the project
  • The college was kind enough to provide me some small amount of funds for a microphone.

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Tasty Morsels of EM 041 – Acute Urinary Retention

[Featured Image: Frivadossi, Wikimedia Commons]

As always, this is from the ever expanding google doc on bits and bobs I read and learn from.

This time:

ED Management of acute urinary retention. EB Medicine

  • Causes
    • Men – think prostate
    • Women – bladder masses, gynae surgery and prolapse
    • Drugs: calcium channel blockers (i didn’t know this), anticholergics (i did know this one)
    • Spinal cord compression is probably the real emergent cause we need to think of
    • In a similar manner to other neuropathies, diabetics can get a diabetic cystopathy resulting in AUR.
  • The big take home should be this: you need to bloody well examine them. There is a real (and justifiable) desire to just slip in the catheter (or worse get someone else to do it) and get disposal nice and quickly. But as simple as most AUR is, you will miss important things (say spinal cord compression, or a penile tumour, especially in the patient with dementia or non-verbal patients) if you don’t physically get involved with the gorey details.
  • there’s some ‘himming’ and ‘haaing’ over whether to put a finger in the rectum. The main concern seems to be in prostatitis and seeding the blood with a prostate exam. They’re right to say that there’s no evidence of this causing harm. But that works both ways – there’s no evidence either way. There’s not a great deal of diagnostic value here I don’t think. The bigger issue is whether to put a catheter through an infected prostate. I figure if they’re in retention then I do it, and they get a nice chaser of gentamicin and an admission.
  • there’s some interesting stuff on urine samples for prostatitis. You can collect wee at lots of different points of the wee cycle and then massage the prostate a bit and get another few mls. There’s even a study looking at semen cultures for prostatitis. I imagine if I had prostatitis the last thing I might be able to do is provide a semen sample…
  • getting the patient to exhale when the tip is at the prostate seems to be of some use in relaxing the relevant sphincters
  • an episode of hypotension following bladder decompression is common due to a reflex response in reduced vascular resistance. Doesn’t mean the you don’t have to think about whether that patient’s severe abdo pain was actually a AAA rather than AUR…
  • they (sensibly) state that if it’s a simple catheter and no reason to think infection then antibiotics are not indicated. Very different from the raging, septic prostatitis
  • they quote the common figure of 2 in 3 patients requiring repeat catheterisation if the catheter is immediately pulled. They also note that those with a spontaneous AUR (which is likely prostatic hypertrophy in origin) is more likely to need a second catheter than those with a precipitated cause (eg infection or constipation).
  • they suggest that the 2 in 3 rate of recurrence mandates that the catheter is left in whereas I think that “hey, I have a 1 in 3 chance of not needing this – i’ll take those odds and come back if I can’t pee again”
  • catheters that get stuck and can’t be removed are usually due a ridge forming on the balloon during deflation and can be dealt with very slow reinflation and deinflation. The inflation channel can also be cut. Interestingly they say that filling the balloon with 10mls of mineral oil will dissolve the balloon in about 15 mins and allow removal. I have no idea if this applies to all makes.

The post Tasty Morsels of EM 041 – Acute Urinary Retention appeared first on Emergency Medicine Ireland.

IAEM 2014

The Irish Association for Emergency Medicine are hosting their annual scientific meeting this year in Dun Laoghaire. They’ve just launched the website for the event where you can find all the info you need. This year’s event is being hosted by one of former hospitals, St Vincent’s University Hosptial Dublin where both this site’s own David Menzies and our training program director, John Ryan are based.

It’s exciting to hear that FOAM’s own Scott Weingart is coming as our keynote speaker. Upstairs care, downstairs and all the way across the pond it seems!

It’s sure to be a great event and of course it’s open to those both north and south of the border and it would be a delight to see even a few of you over from the UK too.

As with most scientific conferences, there is the opportunity to submit posters and oral presentations and all the details are on the site.

See you there.

IAEM 2014 site

[Conflict of interest: I helped put together the website for the event for which I may or may not receive beer. Here's hoping...]

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