Emergency Trauma Management Course

Are you a GP, maybe a locum who spends time moonlighting in ED?  Do you work in an area that has no dedicated trauma service – hence you may be it one day?

Or are you a trainee – a young doctor wanting to go bush or into Emergency training?

Have you done the EMST or ATLS course?

If you have answered “Yes” to any of the above questions – then I have a piece of advice for you…..

Check out the ETM Course!    EMERGENCY TRAUMA MANAGEMENT

What is it? Well the mane say it really – it is a trauma course, but not another ABC course.  You are a smart doctor – you know all about the ABCs and can recite the various mnemonics for trauma management – but can you “run a trauma”?

Can you control a team of fellow resusciteers and make stuff happen?  Have you been trained in high-fidelity Sim with emphasis on communication and crew resource management?  Are you up to date with modern imaging pathways, decision-making and life-saving procedures?  Are you able to interpret trauma imaging confidently?

The traditional courses that we have all prepped and passed represent the basic standard of care that one might be able to deliver on a roadside with the usual kit.  However, the ETM course goes to the ceiling – this is about the real-world management of severely injured people in the ED.  Ticking the ABC boxes is not enough – you need to be able to provide first-class care in your ED.

To bring your knowledge up to this level Andy and his team have pulled al the educational strings – online learning, social media, electronic course book with greta video, even some ultrasound Mad Skillz

You can get a free peak or sign up to see the course materials.  However – the best way to make yourself a trauma badass is to sign up and immerse yourself in the full experience.

So check it out.  Give Andy a buzz and tell him “Casey sent you”.

DISCLAIMER:  I do not receive anything from the ETM course, I do as a matter of routine insist that new Docs coming to Broome complete this course as I feel it is the best way to prepare for the reality of small hospital ED trauma care.

I have been involved in creating some of the educational content on the course and think it is pretty good!

OK – end of advertorial.  Go on – check it out.  Worst case you spend a rainy weekend in Melbourne and your better half gets to spend a fun time on the cafe strips ;-)

Surviving Sedation 2015

It has been a busy month behind the scenes here at Broome Docs – lots of big projects and plans going on…  wait and see what we are have in the offing.

One project that I have been working on with a group of great clinicians from all over Australia.  It is called SURVIVING SEDATION 2015. Yes – that is a deliberate pun on the “Surviving Sepsis Guidelines” – and we want to install the idea that this is a high stakes situation, with lots of potential morbidity and unfortunate track record of mortality for these patients.  The goal is to use early, goal-directed sedation to maintain a safe environment for staff and allow patients to be cared for in a standardised, safe fashion.

We have been sharing ideas, data and experience around the acute sedation of patients with psychosis or other behavioural disturbance.  If you have been following the blog from the outset – then you will know that this is something that I am passionate about.  There have been a lot of changes to the way I practice when it comes to sedating Psychiatric patients.  This set of guidelines represents the vest available evidence, interpreted by front-line clinicians and presented in as simple, usable possible format.

Our lead “author” is Dr Minh le Cong – @ketaminh – the foremost Aussie researcher in Psychiatric retrieval.  Also on the panel were Dr Tim Leeuwenburg @Kangaroobeach , Dr Andy Buck @edexam and Dr George Douros.

Pre-publication peer review was also done by Dr Amit Maini @sithlord2004, Dr Peter Fritz @pzfritz & Dr Michael Downes @ToxTalks.

It is really difficult to write a set of guidelines that can be applied to all scenarios – our panel practice everywhere from major tertiary EDs to tiny remote clinics with near-zero resources for this scenario.  There is also a lot of variation in practice depending on your location. Many practitioners are working in locations that need to transfer Mental Health clients by air to a secure facility. Others work in hospitals that can provide this care immediately [though often not…]   However, as a panel we have tried to come up with a basic toolkit of medications, a strategy and logistical considerations that may be applied in any setting.

For the full detail of the rationale – pop over to Minh’s blog on the PHARM to read his thoughts.

The actual short version (2 pages – front and back) is designed to be laminated for reference in the clinic / ED / ward etc.

You can see it HERE SURVIVING SEDATION 2015

I am going to leave it up on the blog here in the permanent top menu under clinical resources.

SO – what is new in this set of guidelines?  Nothing too controversial.  The main changes are to the way we plan the sedation.

  1. Treat any Psych sedation as a “procedural sedation” – where the procedure is the safety of the patient +/- transfer to an appropriate centre.
  2. Pharmacological minimalism – using less agents in a titrated fashion
  3. There is a specific objective sedation score (SAT) – with goals of therapy clearly laid out.
  4. Ketamine is used in several potential situations: as a 2nd line IV / IMI agent in severe agitation and also as an infusion for transfer by air.
  5. There is emphasis placed on making a pre-sedation assessment of the airway / Anaesthetic / medical risk of sedation for a given patient.
  6. We have deliberately recommended that appropriate airway equipment and personnel be present.  No more dark, back room sedation supervised by the grad nurse up the far end of the ward.
  7. You will notice that midazolam does NOT feature in the mix.  This is the result of several papers showing it can be dangerous.  Diazepam is the chosen benzo – although this was largely due to its wide availability and clinical familiarity.  [Personally I will be using long-acting benzos such as clonazepam or lorazepam in my ED.]

Now it is your turn – I know that there are a lot of experts out there – and I want to hear your thoughts on this project.  So please have a read of the guidelines and the rationale on the PHARM site. Let us know what you like, don’t like or disagree with.  If you have any evidence that you feel might be incorporated – then send me the link.

Thanks

Safe sedating team

Casey

Clinical Case 114: Skull and Crackedbones

This case is inspired by a recent Twitter discussion with fellow Pads ED enthusiasts – Tessa Davis [ @TessaRDavis ] , Andrew Tagg [ @andrewjtagg ] , Rachael Rowlands [ @rachrwlnds ] and whoever else was reading.

As a background – you probably should read my previous ramblings about Paediatric head injury assessments here: Kids Coconuts and CTs

I think that the PECARN decision tool [MdCalc clickable version HERE ] is probably the most useful and robust data out there for making the call on children with minor head injuries in the ED.  In the past we have often taught or been taught to observe kids for hours and hours, or CT them.  The PECARN data set certainly has changed my practice in the last 5 years.

I now use it to identify children whom are at extremely low risk and feel confident to discharge them with follow-up instructions of course , one needs to be assured that the parents / carers are comfortable with this and able to access appropriate follow-up if required.  The PECARN study also gives us a basis for discussing the risks of observation, imaging and non-investigation in kids who are not in the low-risk group.

Now take a look at this part of the PECARN Algorithm – this is the section for kids aged under 2 years of age.

Screen Shot 2015-03-21 at 10.16.20 pm

The majority of kids that I see in this group are little ones who have walked / run / fallen head first into something solid.  They usually have a frontal “egg” or laceration over the forehead.

So lets walk through the algorithm.  If this kid has a large frontal haematoma then it is going to be tough to say that they do not have a skull fracture, or at least you may think you can feel something.  Let’s face it – pushing on a fresh, boggy swelling over a kids head is just plain cruel!

If you think that you can palpate a fracture – then they immediatley jump into the ‘high risk’ group i.e. the group that is recommended to CT early.  This was about 1 in 8 of the kids in this age group.

However, if there is no fracture palpable then you are very likely heading down the pathway to simple observation, or possibly into the super low-risk group.

Hence the question of the presence or absence of a skull fracture seems to be a big hinge-point when it comes to making this decision.  And here is what I suspect:  we are terrible at picking these!  OK, I understand that the PECARN trial is a pragmatic set-up.  It was a simple clinical call – was the clinician able to palpate a fracture.  However, in reality this does seem very subjective and prone to bias.

Enter our friend – the Ultrasound.  Is there nothing we cannot do with the probe?

Ultrasound is useful in picking fractures elsewhere in the body – particularly in superficial bones.  So can we detect skull fractures with any accuracy?

Well there are a few smallish trials looking gat this question in the literature:

One form New York, Jim Tsung and co. in Paediatrics, June 2013 - “Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children”

Another from Riera et al in Paediatric Emergency Care, May 2012 – “Ultrasound Evaluation of Skull Fractures in Children: A Feasibility Study”  This one had more small kids in it – i.e.. mean age 2 years

These are small trials – 115 patients combined.  19 had a fracture on CT – so the incidence was ~ 16%.  Like many POCUS papers they show the usual characteristics of bedside ultrasound techniques – very specific and reasonably sensitive – so if you see a fracture – there almost certainly is a fracture, but you will miss 15 – 20 % potentially based on the numbers here.  In the Tsung paper – only one fracture was missed – that was a fracture that was adjacent to the hematoma – rather than directly beneath it.  So you could improve this with a more thorough scan field.  In terms of likelihood ratios: bedside US give a +LR of 27 (excellent!) and a -LR of 0.13 (pretty good!).  As always – we need more data to validate this and make it more generally applicable.

So how would a bedside skull US fit into the PECARN pie?

Hard to say what our “Sensitivity and specificity” is for clinical palpation of skull fractures – I would guess we are 50% sensitive and 75% specific.

So using that as a comparison – we should be able rule in a few more kids who should probably get an early CT.

So will this mean we do more CTs?  I think not – as there are a lot of kids who have a nasty looking egg on the head – and we are often biased by the external picture into believing that we can feel a ‘step’ as we are worried and want to rule out badness.  So if we scan the kids with the ugly looking hematoma and find no fracture on US – then this would probably be a group where it is safe to push them into the “observe, wait ‘n see” strategy.  Although US is not super sensitive – it surely must be better than a subjective prod over a boggy lump.

[Note: if you use a stand-off pad or lots of gel – you can do this US without inflicting much pain at all.  No pressure needs to be applied.  So I think this is a more humane approach to the kids with a large, boggy swelling of the noggin.]

So overall I think that US would allow us to separate the goats from the sheep – allow us to create a bit of diagnostic daylight between these 2 groups:

(1) Those who definitely have a fracture and may need early imaging of the brain

(2) Those at lower risk of fracture who can be safely observed.

Bedside US probably doesn’t add too much to the kids whom can be classified as very low risk by the PECARN algorithm.

My practice is to promptly discharge kids who meet the “extremely low risk” criteria.  I give the parents reassurance and information for what to look out for.  But… this is my new pet peeve…  forcing a kid / family to sit in the ED for 4 – 6 hours to have “Neuro obs” completed seems like a really antisocial and low-yielding exercise in this group.  So if I am satisfied that the parents understand the risk and what to do if… happens, and there is no NAI question – I will send them home from triage.

Love to hear how you manage this common problem in your ED.

 

Casey

Suicide: Sailing on Uncertain Seas

Hi All

Last week I was lucky enough to be able to present this talk to the SWEETS Emergency Medicine Conference in Stockholm.

Thanks to Dr. Katrin Hruska for the invitation.

This is a video of my lecture and slides as presented by myself and local Broome Psych resident Dr Nick Gilbert.

The first 15 minutes is my discussion of suicide risk assessment, then 5 minutes from Nick on the biochemistry, future and therapy for suicidal patients.

Summary take home messages:

  1. Suicide is tough to predict
  2. You have to ask about suicide in your daily practice
  3. Formal risk assessment tools are sensitive, but very non-specific
  4. Predicting behaviour and making a “risk assessment” are not the same thing.
  5. To make the best call you need to delve deep into the cognitive processes that your patient is experiencing
  6. Empathy is key – you need to be able to understand their perspective
  7. Imagine that you and your patient are sailing together over some rough seas – do you have all the data, resources and share a common goal?

OK, if that makes no sense then listen to the podcast and hit me on the comments below:

DIRECT DOWNLOAD HERE 

Casey

 

PODCAST: Shared decision making

Shared decision making.

This is one of the hot concepts in healthcare right now.  It is not new – but it is being embraced in many fields as a part of the trend towards more evidence-based practice and the changing culture of medicine where “doctor knows best” is no longer an acceptable platitude.

If you read or listen to a lot of the FOAMed resources – then you will hear a lot of discussion about engaging our patients in a shared decision making process.  Whether that be to help us decide on the right investigation, treatment or indeed to make the decision to not investigate or treat a given problem.

Here is the ideal model as taught in most EBM courses:

Evidence_Based_Medicine_Graphic_web

Now that is a nice diagram – and it certainly sounds like a good idea.  Out with paternalism, in with patient choice, add a sprinkling of evidence and voila – we can all go home happy.

But….. and there are a few here… how does it all actually work on the ED floor, in the busy GP clinic or specialist suite?

Have a listen to the latest Broome Docs podcast – and hear my dissection of how it could, should and might work in everyday practice.

DIRECT DOWNLOAD HERE

PODCAST: Shared decision making

Shared decision making.

This is one of the hot concepts in healthcare right now.  It is not new – but it is being embraced in many fields as a part of the trend towards more evidence-based practice and the changing culture of medicine where “doctor knows best” is no longer an acceptable platitude.

If you read or listen to a lot of the FOAMed resources – then you will hear a lot of discussion about engaging our patients in a shared decision making process.  Whether that be to help us decide on the right investigation, treatment or indeed to make the decision to not investigate or treat a given problem.

Here is the ideal model as taught in most EBM courses:

Evidence_Based_Medicine_Graphic_web

Now that is a nice diagram – and it certainly sounds like a good idea.  Out with paternalism, in with patient choice, add a sprinkling of evidence and voila – we can all go home happy.

But….. and there are a few here… how does it all actually work on the ED floor, in the busy GP clinic or specialist suite?

Have a listen to the latest Broome Docs podcast – and hear my dissection of how it could, should and might work in everyday practice.

DIRECT DOWNLOAD HERE