What do you believe? with Iain Beardsell.

SONY DSCA change is as good as a rest, or so the saying goes. Working in Emergency Departments we are constantly changing. Many of these changes are directed at the processes within the ED, continually striving to find the “golden bullet” solution to the “four hour question”.

Over the first six years of my consultant career the department I work in, like many others across the UK I’m sure, has been subject to constant change . These have come in different guises: “Lean”; Service Improvement; Perfect Week; the list goes on. Many of these are run by external agencies, at huge cost, all hoping to solve the dominant question in Emergency Medicine – How do we achieve the four hour target

Like, I suspect, many Emergency Physicians I have a very short attention span. This was part of the reason I chose the specialty that I love. Not unlike Martin Sheen’s President Bartlett of West Wing fame, the question on my lips most often is “What’s next?”. This serves me well when seeing patients, but not when I require the sustained interest required for successful change. We throw ourselves into projects, but over time this quickly wanes and the much vaunted developments are cast aside for the next new thing. The last few years in our ED are strewn with unsustained changes and I’d estimate that no more than one in ten ideas, no matter how promising or useful, have continued beyond six months after their inception.

Why is this? It can’t simply be that we lose interest. I recently watched a “TED” presentation that struck a chord.

In his talk Simon Sinek, an author best known for popularizing the concept of “the golden circle” describes a simple but powerful model for inspirational leadership all starting with the simple question “Why?”. As I watched, I realised that many of these changes over the years I had been happy to participate in, but I just didn’t believe in them. Apart from the temporal reasons with which we are obsessed I didn’t know why we were changing. We have keep doing new things, yet our “performance” hasn’t improved, in fact it has got worse.

As doctors and nurses in Emergency Departments we chose our career paths, I hope, because we believed in the best care for all, especially those with life threatening illness, at any time of day or night. This is our fundamental belief. Why is it, then, that we struggle to to adopt and maintain these changes that may help us towards that goal?

As Sinek discusses in his talk, it isn’t necessarily that the ideas we try to implement are bad, but because the premises on which they are based do not address our beliefs. There is a fundamental disconnect between the four hour target and what we think is best for our patients. Of course this is untrue – a faster, more efficient process for seeing people must be better for many, but with years of government scrutiny and management interference we have simply refuse to believe this anymore. We are, in general, a stubborn bunch and will not have others force their beliefs on us without the appropriate analysis

Change goes on apace in my department, as I am sure it does in yours, but it is my belief that it is time for us to pause and rethink what and why we are changing. Constant, rushed implementation of quick fixes that the clinical team do not believe in, but merely participate in, simply will not work. It is time for us to reappraise what we, as doctors and nurses, believe and then to proclaim these beliefs to others.

So I ask you all – what do you believe in? What does your department stand for? What is your vision? I asked this question of colleagues recently and was met with blank, rather guilty stares. We simply did not know. I’m sure you could come up with a few without any thought: to provide evidence based compassionate care to all, whenever they need it; to educate and encourage all staff so that work is not just a job, but a vocation; that no patient should be in pain; that we should aggressively resuscitate all those who require and desire it and tenderly and gently care for those who life is at its end. Articulating these visions and beliefs is easy – the real challenge is making them a part of your ED’s philosophy and daily life.

Of course, the irony is that none of these beliefs in anyway contradict the aims of the four hour standard. In fact they compliment it – evidence based care is efficient and limits unnecesssary testing and giving appropriate pain relief early facilitates discharge. And a happy clinical team, who work together will always, always be more effective and efficient.

We need a rest from the change. We need to look within ourselves and find what it is we believe in and then work towards these visions with passion and enduring commitment. We need to ask others, managerial and political, to trust us, to help us work towards achieving what we believe in and to join us on the journey. Given this opportunity we will provide the best emergency care we possibly can (including achieving government set targets). And that is my fundamental, unshakable belief.




The Role of IO in Trauma: A #FOAMed Debate

The Emergency Medicine Journal recently published a review of intraosseous access experience from the Royal Army Medical Corps. This review documents 1,014 IO devices and 5,124 infusions of blood products, medications, and fluids. There were no major complications, and the rate of minor complications was extraordinarily low – the most frequent being device failure, occurring approximately 1% of the time.

But, what is the role of intraosseous access in trauma?

Who is Dr. Brohi, you may ask? Just the head of the LondonTIER, Professor of Trauma Sciences in the Blizard Institute, Barts and the London School of Medicine & Dentistry, and Consultant Trauma & Vascular Surgeon at Barts Health NHS Trust. Someone whose opinion is worth a listen. If you have any doubts, watch him speak at SMACC GOLD.

To say his comment spurred a rivulet of FOAM would be an understatement. To see the entire thread of responses and branching conversations, start here and don’t stop scrolling. But, a few of the highlights:

What do you think?  Do you agree – the IO is, as used by the Royal Army Medical Corps (RAMC), a temporary tool prior to definitive access in a trauma center?  Or, do you find utility, even in the setting of a fully capable trauma resuscitation?

Highlights from the October issue of EMJ

EMJ_100x100Emerg Med J 2014;31:793 doi:10.1136/emermed-2014-204282

Highlights from this issue

  1. Ian K Maconochie, Deputy editor

Conducting emergency research when consent and consultation are a challenge (editor’s choice)

Studies in patients with emergency conditions that render them unable to give consent have been very difficult to conduct owing to ethical considerations. The guidance offered in the commentary by Gavin Perkins should bring significant benefit to this under researched population, an example of which is seen in this month’s editor’s choice: Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for pre-hospital traumatic pain randomised controlled trial. This is a follow up report on trauma patients who participated in a randomised trial of pain relief in the pre-hospital setting. The initial paper found that ketamine had significantly better analgesic effects than morphine; however regardless of treatment, persistent pain is still a big problem for many patients at 6 months, affecting quality of life.

Comparison of intubation modalities in a simulated cardiac arrest

Advances in intubation techniques include video assisted devices (VAD). This study looked at how long the procedure takes with 2 different modes of intubation, either direct laryngoscopy (DL) or using VAD, with and without bougie.

Twenty emergency physicians with prior training in these modes of intubation intubated a mannequin with a difficult airway on a hospital bed whilst continuous CPR was delivered.

Did the VAD improve time to intubation, and when a bougie was used, was this quicker than DL?

VAD was quicker than DL (median 20.6 seconds, IQR 17.7–27.1 as compared with 27 seconds, IQR 20.3–35.4.) However, using a bougie with the VAD added considerable time: 60.1 seconds (IQR 39.1–99). This important result leaves some questions: is a bougie really useful in this situation? Is its use deleterious? Maybe a future study looking at bougie use in the difficult airway in adults and children should be planned.

The effect of elevated serum alcohol on the outcome of severely injured patients

This retrospective cohort study looked at 184 criteria-selected patients admitted to Trauma Unit at the University Hospital between October 2008–December 2009 with injury severity scores above 17. Patients were stratified into 2 groups: blood alcohol level positive (BAL+) with >5% level of alcohol, and those with lower/no blood alcohol level (BAL–).

Injury severity scores were similar in the groups, but there was more traumatic brain injury in the BAL+ patients.

There was no significant difference in mortality between the 2 groups, the causes being similar in both. Nor were there significant differences in length of stay in hospital and ICU, or duration of ventilation.

Does this mean that alcohol has no effect? The jury is still out. Similar studies are needed from multiple centres with aggregated data to address this question.

The sad truth about the SADPERSONS Scale: an evaluation of its clinical utility in self-harm (reader’s choice)

This SADPERSONS score, devised in the US in 1983 for medical education, is supposed to help identify individuals at risk following a suicide attempt. Despite prior studies showing a lacklustre performance, the score continues to be used in EDs. The study in this issue followed 126 consecutive individuals of all ages presenting to a large UK general hospital with self-harm (including poisoning), to see if they re-presented to the ED within 6 months. All patients were also assessed by the specialist self-harm team. Using the previously recommended cut-off score of ≥7, SADPERSONS failed to identify 80% of subsequent self-harm and 50% of those who needed further secondary management. The authors conclude that use of the score by itself is insufficient to ensure that optimal care can be delivered.

A population based study on the night-time effect in trauma care

This retrospective study reviewed 1940 cases in the Emilia-Romagna area of Italy (with 4.5 million inhabitants), which has had a centralised trauma system since 2006 Out-of-hours and in-hours mortality of trauma patients was examined including, unusually, patients transferred from to the major trauma centre from the 84 satellite hospitals in this region.

There were fewer secondary night–time transfers but with an increased risk of mortality in this group. Another interesting finding is that only 40% of patients with severe trauma came to the major centre, a figure which the authors say, is paralleled in other health systems in the world.

The night-time effect on mortality is attributed to the ‘lack of homogenous transfer protocols and of a standard level of pre-hospital care around the clock’. It would be interesting to see what the impact of addressing these issues might be and to hear from other health systems if similar problems are found in trauma care networks.

Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study

Does a triage system plus a co-located GP unit reduce costs in delivering care? The answer appears that it does. In this study from Switzerland, the cost reduction overall was a staggering 417 000 Euros. Can you show cost reduction if you have a similar system in place?

Randomised trial comparing the recording ability of a novel, electronic documentation system with the AHA paper cardiac arrest record

Sixteen anaesthetists were asked to view pre-recorded PEA or VF arrests and document what happened using paper and electronic systems. There were fewer missed events, less irrelevant information noted and fewer mistakes made in documenting those events using the electronic system. It seems the quality and meaning of the data is enhanced by an electronic recording system.

An evaluation of the referral process in the emergency department

This is an area fraught with misunderstanding and potential upset if things go wrong! Miscommunication is frequently cited in serious events, but is commonplace in delivering healthcare. This study looked at how ED and non-ED clinicians felt about referring patients and offers some solutions to this key area of patient care.

And still more…

In addition to the other articles and features in the October issue, EMJ will be publishing an on-line issue with free, full-text access to all articles for the next three months. Find it from September 30th here http://emj.bmj.com/content/current

Support EM in Africa

Screenshot 2014-10-09 09.16.06Emergency Medicine is an emerging specialty the world over and we at St Emlyns and the EMJ are alwayts keen to promote innovation and learning wherever it takes place. In the past we have wholeheartedly supported the fantastic “Developing EM Conference” and its aims. Teaching and learning collaboratively across geographical borders is a challenge; teaching and learning across huge resource disparity is an even bigger one.

This month we have the opportunity to support another intervention for worldwide EM.
The African Federation of Emergency Medicine relies on financial support to assist delegates to attend its meetings. The second AFCEM conference is not far off but donations have been hit heavily in the wake of Ebola.

If you’ve ever been to a medical conference you know how amazing it feels to meet like-minded clinicians, to share knowledge and experience, build friendships and partnerships and to problem-solve together. African EM clinicians need your help in order to be able to attend the AFCEM 2014 AFCEM meeting in Addis Ababa next month.

Please support an African delegate – any financial contribution will help. You can AFCEM Support a Delegate Support a Delegate here.

You can read more about how this can make a difference in Help African EM Now! – LITFL this great piece by  Katrin Hruska on Twitter  over at Life in the Fast Lane.

Support an African delegate – together we can build EM the world over.

UPDATE – As of this today we have managed to assist 6 delegates to the conderence – let’s make it many many more




Natalie May

Consultant in Emergency Medicine

Royal Manchester Children’s Hospital


This post first appeared at St.Emlyn’s

This month’s primary survey from EMJ

EMJ_100x100Highlights from this month’s issue

  1. Steve Goodacre , Deputy Editor
  2. Ellen J Weber,  Editor in Chief


Restart a Heart

What do you have planned for October 16? Perhaps it’s a shift, or a few meetings, or a day of walking? All important, but perhaps you can spare a few minutes that day to encourage someone you know to take a CPR class? Or you can call the school your children go to and ask when they are going to start teaching CPR (and volunteer to help!). October 16 is European Restart a Heart Day, and in anticipation, we’ve included four articles in this issue—commentary and research—from international authors highlighting failures and opportunities to improve on bystander involvement in emergencies. Professor Tzi Bun Ng discusses the tragedy of a middle-aged woman who collapsed in a busy Chinese subway station but neither bystanders nor station employees came to her aid. The study by Vaillancourt, and. a systematic review by Zhimin He et al provide data on teaching first aid and resuscitation to the oldest and youngest among us. Andrew Lockey provides a commentary making a very good case for teaching CPR in schools.

Predicting ambulance journey times

Reconfiguration of emergency services is a topic that regularly attracts a lot of attention in EMJ. The potential benefit to patients from centralising specialist care needs to be balanced against the potential harm caused by increasing ambulance journey times. This means that before services are reorganised we need to estimate the impact of reorganisation upon ambulance journey times. An obvious way of doing this is to use commercially available Geographic Information Systems (GIS) software to estimate journey times, but do these estimates provide an accurate reflection of emergency ambulance journey times? McMeekin and colleagues compared GIS predictions to recorded times for 10 156 emergency ambulance journeys and found that the mean prediction discrepancy between actual and predicted journey times was an under prediction of 1.6 min. This difference is unlikely to be clinically significant and suggests it is reasonable to estimate journey times for service planning using generic GIS software. However, if you are thinking of using GIS software to predict the journey time of a specific patient to your hospital, then it might be worth bearing in mind that an average may not reflect substantial variation in the individual data.

Laryngeal mask airway or endotracheal intubation?

Endotracheal intubation may be seen as the gold standard for securing and protecting the airway but high failure rates and the risk of complications have led to concerns about use in the pre-hospital setting. As a consequence the laryngeal mask airway has been suggested as an alternative. Bosch and colleagues evaluated the use of a laryngeal mask airway in 50 patients in the Dutch ambulance service and report a 100% success rate with 98% success at the first attempt. This suggests potential for the laryngeal mask airway to provide better airway control than endotracheal intubation but randomised data are clearly required to determine comparative effectiveness. The scene is set for a trial of pre-hospital airway management—is anyone bold enough to take on the challenge?

Point of care testing—is it worth the cost?

Point of care devices can provide quicker availability of results and shorten emergency department length of stay but usually incur increased costs compared to laboratory testing. It is tempting to assume that a point of care test that provides results an hour earlier than the laboratory will reduce length of stay by an equivalent amount. However, randomised comparison is required to test this assumption. Asha and colleagues randomised 811 patients to receive either point of care or laboratory testing and found that point of care testing was associated with mean reductions of 26 minutes in time to disposition decision and 20 minutes in emergency department length of stay. Mean pathology costs were $12 higher in the point of care group, so $113 was being paid per hour saved in time to disposition. This adds up to a lot of dollars but also a lot of potential time saved across an emergency department population. Careful consideration is required to decide whether such expenditure is worthwhile.

Diuretic administration in acutely decompensated heart failure

Intravenous diuretics are often used in acute heart failure. The intense urine output achieved after administration is often viewed with satisfaction by the clinician, if not the patient. Llorens et al aimed to determine the effect of different administration strategies upon diuresis and a number of secondary outcomes in a randomised controlled trial of 109 patients with acutely decompensated heart failure. They found that continuous infusion produced a greater 24 hour diuresis than bolus administration but was more likely to result in hypokalaemia. There were no significant differences in improvements in clinical symptoms or signs between the three groups. This raises the question of whether there is any causal association between producing a substantial diuresis and improving relevant outcomes in acutely decompensated heart failure.

Lumbar puncture for suspected subarachnoid haemorrhage

This is another topic that engenders strong debate, often between those with contrasting perspectives of the problem. Emergency physicians see a large unselected group of patients often indiscriminately investigated with CT and doubt whether all those with negative CT really need lumbar puncture. Neurologists and neurosurgeons see the highly selected group with positive tests, including those with negative CT but positive lumbar puncture, and conclude that failure to perform lumbar puncture is unthinkable. Stewart and colleagues add some more data to inform the debate. In a cohort of 244 patients investigated for suspected subarachnoid haemorrhage they found that the sensitivity of CT for subarachnoid haemorrhage was 93.8%, rising to 95% if limited to scan performed within 12 hours of ictus. This suggests that CT alone is inadequate to rule out subarachnoid haemorrhage when it is suspected. The question remains though—when should we suspect subarachnoid haemorrhage? The prevalence of subarachnoid haemorrhage in the study cohort was 29%. If clinicians were able to select such a high prevalence cohort for investigation the debate about lumbar puncture would become largely irrelevant.