I had the pleasure of running a couple of very brief social media workshops at respond 2014 a few days ago. This was the first national conference for community first responders and got off to a great start with more than 300 people.
Community first response was an alien idea to me until a fee months ago. I expected a rather amateurish bunch of enthusiastic civilians but was pleasantly surprised to find a highly motivated and enthusiastic group of volunteers who were well trained under a national structure. The main aim is of course to provide high quality CPR and early defibrillation as soon as possible in the event of cardiac arrest. Given the often rural nature of Ireland the concept of first responders is valuable.
If you’re in Ireland and interested in more about CFR then check out the conference web page, the hashtag and a few of the local groups.
If you’re here because of the social media workshop looking for more tips then I suggest you check out this video (aimed at prehospital professionals) and this post.
Are you an emigrated Irish doc in training in Oz or NZ and fancy coming home for 6 months as part of your training? Are you a kiwi or Aussie and fancy some time in Europe as part of your training?* Then these might be the jobs for you. These aren’t just the standard queue busting, service provision jobs but an opportunity to gain some new skills. If you’re working in Ireland and fancy a career development opportunity in one of the big Dublin hospitals then read on.
[* the Mater is accredited for training in Ireland through the college of emergency medicine which is the specialist college for emergency medicine in the UK and Ireland. From communication with the Australasian College in Emergency Medicine (ACEM) we have been told that any trainee wishing to undertake training overseas and have that time accredited toward their ACEM training should apply to the college prior to beginning the post and obtain prior approval to have the training added toward their ACEM training.so as far as we know it should be approved for training by ACEM too]
The Mater Misericordiae University Hospital (The Mater) in north Dublin is one of the main tertiary centres in the country. It has the national spinal injuries centre and all major specialities apart from neurosurgery and as far as I’m aware it’s the only place doing ECMO in the country. The hospital recently moved to brand new facilities including a new Emergency Dept, theatres and ICU.
The ED encompasses a large ‘acute floor’ model with acute medicine working out of the same department. There is a 5 bed resus with CT scanning within the resus bay. There is a dedicated ED ultrasound machine.
The hospital serves one of the more deprived areas of Dublin with the obvious result that it sees a fascinating range of pathology from stab wounds, pedestrian trauma to complications of alcohol and intravenous drug use and all the interesting infectious disease complications that come with it. One of the emergency medicine trainees is a lead for an international HIV screening project in the department.
The ED has created several new posts at registrar level to attract new staff and facilitate career development. All posts have protected non clinical time to pursue the appropriate sub specialty. Clinical work will be on the registrar rota in the ED.
Clinical Fellow (Registrar level) in Emergency Medicine/Emergency Imaging – 2 positions available – These posts are designed to provide the successful candidate with specialised training in emergency medicine and imaging in one of the busiest emergency floors (including a dedicated emergency imaging department) in the country. Fellows will be exposed to all aspects of emergency care (adult) and a broad spectrum of emergency imaging, and will co-ordinate monthly Emergency Medicine/Radiology teachng meetings. Depending on the existing level of ultrasound experience, Fellows will be expected to achieve Level 1 competency in Emergency Ultrasound (ultrasound experience preferred but not necessary) or gain competency in at least 3 of 10 level 2 modalities (for a candidate already signed of at level 1). There will also be teaching and scope for education and research in all aspects of emergency imaging including CT/plain films/nuclear medicine and MRI. Successful candidates will be allocated protected weekly training time in the relevant imaging areas including ICU, ECHO, Vascular and Diagnostic imaging departments (approx. 30% of WTE). The remainder of the clinical commitment is to the emergency floor. [Worth noting that the Mater has a fellowship trained emergency radiologist who you will be working with - Ed]
EM Education post
Emergency Medicine Education Fellow (Registrar level) 1 position available a unique opportunity to engage in a quality improvement program (in keeping with new developments in career progression in Emergency Medicine) in the Mater Hospital involving protected time per week developing departmental teaching including the online SHO induction/education website, online guidelines for the department and the hospital, in addition to a clinical registrar commitment. (Approx 30% WTE in educational training).
Trauma clinical fellow
Clinical Fellow (Registrar level) in Emergency Trauma – 1 position available – the successful candidate will have protected weekly teaching in trauma/plastic surgery clinics and will have responsibility for co-ordinating trauma team organisation, audit and research, with opportunities for training in emergency trauma and musculoskeletal radiology in addition to a clinical registrar commitment (Approx. 30% WTE dedicated to Trauma training).
Emergency Medicine/Critical Care Registrar comprising 9 months Registrar in Emergency Department plus 3 months in ICU, involving collaboration with Critical Care department for joint educational meetings and protocol guideline development offering opportunities for inter/intradepartmental quality improvement programs in keeping with new developments in career progression in Emergency Medicine.
Salaries are on the registrar scale which can be found in the appendix of this document.
Feel free to send me an email at emergencymedicineireland (@) gmail.com and I can write or Skype you with more info. If you’re at SMACC then I’d love to chat to you about it there.
Conflicts of interest
I work in the Mater and really quite enjoy it and it’d be lovely to have some more FOAMites to work with However my opinions are my own and do not necessarily represent that of the hospital.
In my current practise environment, a LOT of my patients are on long term methadone replacement. Indeed such is the unique nature of our local population that there’s quite a lot of research into intravenous drug use and even HIV. In a few years if my smart colleague gets all the data together, we’ll hopefully be able to tell you exactly what proportion of people are on methadone attending the ED.
It’s so ubiquitous amongst our patients that most don’t even consider it a medication. When you ask someone one if they take any regular medication, people will frequently not mention the fact that they take the OCP. The same goes for methadone, and even LMWH which a lot of our patients receive daily for their IDU (injecting drug use) associated VTE (venous thromboembolism).
Methadone is a fascinating little drug, both in regular use and in overdose so here’s a summary:
developed in Germany during world war II as a synthetic alternative to morphine as morphine was hard to obtain
used for opioid treatment programs, chronic pain, and palliative care.
Use in opioid treatment programs
usually provided as a directly observed medication in a pharmacy or drug clinic. In our part of the world it’s green like fairy liquid. The concentration can be altered so that even when receiving the same volume a bigger does is given.
The aim is usually long term rather than a short term detox. To come off methadone is normally a process that is meant to take months-years.
There is good evidence of effect on reduced relapse and possibly even mortality
mu opioid receptor agonist
NMDA receptor antagonist. The NMDA part is thought to attenuate opioid tolerance
Volume of distrubution 4 L/kg. This is realatively large and all you need to know is that is widely distributed in the tissues. This is one of the reasons for its long half life as it leaks back into the circulation from the tissues over time.
Elimination: mainly by oxidative biotransformation – which means it’s coverted into lots of metabolites, some active, some inactive. The metabolites and indeed methadone itself mainly leave in the wee wee.
of note there are, as usual, some problems with the urine testing. Some urine tox kits will test methadone separately from other metabolites. This is obviously a good way to monitor abstinence from illicit opioids. But like all urine testing – you need to know your test characteristics.
Half-life ranges from 5-130 hrs (which is a massive range) though the mean is around 30 hrs. There are a lot of issues with dosing in the early stages and can lead to significant accumulation and it has been noted in several papers that numerous death have occurred in the first week of methadone therapy.
CYP3A4 inducers will increase methadone metabolism and reduced clinical effect
eg carbamazepine, phenytoin and some anti-virals
CYP3A4 inhibitors will reduce metabolism and increase clinical effect (where the real harm happens, either from resp depression or prolonged QT)
these include fluconazole, a bunch of HIV drugs and erythromycin
Chronic Side Effects
a lot of people on methadone will have a prolonged QT. Like a lot of long QTs we find it’s likely meaningless. The risk probably comes with interactions with other drugs. If someone is on methadone and we add a drug that is also know to prolong the QT then there might be problems. Personally I doubt there’s an epidemic of torsades happening out there related to methadone and prolonged QT but it’s worth thinking about. [UPDATE ToxTalk thinks the QTc prolongation might be a real and important thing]
the mechanism is related to hERG K+ channel. I know – that’s just changed your whole world right there hasn’t it?…
as always with toxicology studies, it’s a mish mash of autopsy, animals and chart reviews. Not exactly the highest standard of evidence
Methadone is commonly found in fatal ingestions and is most commonly found with benzos. Bottom line – benzos and methadone in an OD are a bad combo.
Onset appears to usually be within the first few hours and one chart review found that everyone who got sick did so within the first 24 hrs
as a result it has been frequently recommended to me that methadone ingestions warrant admission for at least 24 hr observation (ToxBase recommend this for all symptomatic patients) unlike standard heroin toxicity, where people are normally fit for discharge fairly quickly.
the other recommendation is not to be too reassured by response to naloxone. Naloxone will indeed reverse some of the opioid effects, maybe just enough to allow them to abscond from the department just in time for the naloxone to wear off and the methadone to kick back in and they collapse and die in a corner. This happens. In general the best way to titrate your naloxone is breathing but still mainly unconscious.
just like heroin, non-cardiogenic pulmonary oedema can occur
Moody, David E. “Metabolic and Toxicological Considerations of the Opioid Replacement Therapy and Analgesic Drugs: Methadone and Buprenorphine.” Expert Opinion on Drug Metabolism & Toxicology 9, no. 6 (June 2013): 675–697. doi:10.1517/17425255.2013.783567. PMID 23537174 [WARNING - lots of complicated chemical structures and biochem in this one]
LoVecchio, Frank, Anthony Pizon, Brad Riley, Azadeh Sami, and Carmella D’Incognito. “Onset of Symptoms After Methadone Overdose.” The American Journal of Emergency Medicine 25, no. 1 (January 2007): 57–59. doi:10.1016/j.ajem.2006.07.006. PMID 17157684
Gruber, Valerie A, and Elinore F McCance-Katz. “Methadone, Buprenorphine, and Street Drug Interactions with Antiretroviral Medications..” Current HIV/AIDS Reports 7, no. 3 (August 2010): 152–160. doi:10.1007/s11904-010-0048-2. PMCID 2892618 [Open Access]
This is the post I created for the guys who attended the Social Media workshop at the Severn Deanery meeting in January 2014. It is based loosely on material from the Irish EMS gathering that I took part in last year Hopefully something from the 2 hrs stuck in your brains so that you’re not seeing all this as entirely new material. Hopefully I’ve included all the services and apps mentioned during the workshops.
For more info on the day itself check out the EMJ Blog that has an article outlining the day.
Firstly we got everyone to join Twitter. Or at least we tried to until the Hotel wifi started playing silly buggers. There was some kind provision of personal hotspots that enabled access. You access twitter via the website or via an app on your computer or phone. For interest sake I use TweetDeck through Chrome on my computer and use Twittelator Pro on my iPhone. There are lots of different apps available that allow you to access twitter so feel free to experiment a little.
I suggested that when you join twitter you should put a little of biographical information about yourself. People are more likely to interact with you if they know something about you. There are a lot of fake, spam Twitter accounts and having some info on someone helps people to trust you. I think it’s worth describing whether you’re a trainee or a fully trained physician on here too.
Simon suggest having a profile picture as well rather than the default, anonymous egg.
For example here’s mine:
When you get started I suggest you follow a few key people to start with. Here’s 5 to get you started:
The more interact, post and reply to people, the better your twitter experience will be. We don’t bite honestly, we loved being asked questions on Twitter.
You can also follow lists, either other peoples or your own that you create. This is a good way to ensure that you’re spending your time well on Twitter. If you make a list of people who consistently tweet high value info then you’ll not be bored by dross about people’s dinner…
Hashtags [words beginning with the '#' symbol] are good ways to join conversations together. My favourite hashtag is #FOAMed, this is a consistent conversation about FOAM resources. You can type #FOAMed into the twitter website or onto your twitter app to find it.
Of note there is also a #FOAMcc stream for more critical care topics and #FOAMped stream for kiddies. Or rather it’s about paeds EM, it’s not really for kids to read…. that would be just silly.
NB, on a mac the # symbol is produced by pressing the ‘option/alt’ key and ’3′ together.
I think the key is to get your podcasts on your smartphone. That way wherever you are yo can listen to them. It’s much more important to have them on your phone your computer in that sense. I suggest turing off podcast sync between itunes on your computer and your phone. You’ll only really use them on your phone anyhow.
The basic ‘podcasts‘ app from apple on the iphone is a reasonable place to start. Downcast is a great alternative.
Once downloaded, start the app and click the ‘store’ button.
Once you’re in the store, search for whatever it is you’re interested in.
Once you find a podcast you want to subscribe too, just click on the subscribe button. Every time a new podcast is released it should download automatically to your phone.
Most of the FOAM websites produce new material on a regular basis. To save you having to visit the site to check if new amterial has been released, you can use something called a feed reader that will collect all the new material from all your favourite websites in one place. I used to recommend Google Reader but it’s shutting down in July 2013 and I’m now suggesting feedly as a good alternative.
Once you’ve added feedly to your internet browser (usually as an ‘extension’) or downloaded the app to your phone or tablet then you can add the websites you’re interested by either clicking on the RSS symbol on the website
or copying and pasting the website URL into the search box
The mobile app is kept in sync with your computer and is set out in a similar easy to use way.
If you’re looking for one place to look for all the best in FOAM then check out Kane Guthrie’s LITFL review or the list on the Severn website.
So say you’re keen to start putting out your own FOAM material, then starting a blog is a good way to start. Here’s the website we set up at the workshop in 15 minutes.
This is what the ‘dashboard’; the construction site of the website looks like.
This is all free and easy to do via wordpress. I would strongly encourage you to get a wordpress account and fiddle around with it.
We only mentioned this briefly but I said I thought it was a brilliant platform for FOAMed but unfortunately under utilised. Its best features are probable communities [check outECG+ and the EMCrit community] and the google hangouts. Here’s a nice example of google hangouts being used to stream a conference live.
Or here as a conversation between experts discussing some medical papers. Saves all the hassle (but not quite as much fun) of actually meeting up.
Google plus does the cool thing of recording these video calls for you and storing them as a (private) YouTube video that you can then post on whatever website you want.
There is also the rather nifty community feature on google plus that can function in the same way as the #FOAMed hashtag but allows much more substantial conversation and response rather than the 140 characters of twitter. Here’s two examples
Due to technical issues we couldn’t quite pull this off live at the workshop but a screencast is typically a recording of what’s on your screen with a voice over. It’s a great way to share a lecture you’ve prepared with lots of other people. Once the video file is made you can upload it to YouTube, Vimeo or even better GMEP for other people to see.
Screenr.com let you record screencasts without having to download a separate app but I do a fair bit of this so I use one called screenflow. If you have a mac you can do this very easily by using quicktime on your mac. It comes free bundled with the operating software.
To do this:
1) Open QuickTime Player
2) Start a new screen recording [File>New Screen Recording]
3) Choose Mic and Quality
4) Make your screen selection or if recording a screen presentation, just start recording full screen then make your presentation full screen
At the end just press stop (there’ll be a stop symbol at the top of your screen) and then you’ll have a nice little video file of your screencast. Upload this to YouTube, put the link on Twitter and Robert is indeed your Mother’s Brother.
As an example here’s a screencast of a talk similar to the one I gave at the severn conference. The audio from the Severn Conference is available here.
[If anyone wants the slides for the talk they're available as a keynote presentation.]
Lastly the app I used for displaying my iPhone screen was one called Reflector which is $12 but a really, really well put together app that lots of people recommended but I first found via Haney Mallemat and my brother the software developer.
Title says it all. And it’s all been said before. David Newman is unsurprisingly involved in this paper and the SMART EM on this is well worth your time.
What they did:
prospective data on their chest pain unit with some chart review (with good but not fully described methods)
their routine was a 6 hour rule out then EST if possible or nuclear testing (which we don’t seem to do much of over here)
What they found:
mainly young patients (50) and mainly female and lots of hypertensives
about 80% were considered intermediate risk. Which is interesting in itself seeing as so many ended up discharged with negative tests
of the 4000 with stress tests ,470 had positive tests
ultimately about 130 got angios and only half of them had obstructive disease
only 28 got appropriate intervention as defined by cardiology guidelines. Lots of other people got stents but probably shouldn’t have.
Their discussion includes this phrase
While AHA guidelines suggest that provocative testing risk stratifies patients to a potentially near-zero short-term adverse event rate, there is increasing recognition that a negative result on serial bio-marker evaluation (typically a prerequisite for provocative testing) may also achieve this goal, making further risk stratification attempts redundant or inherently difficult.
Hermann, Luke K, David H Newman, W Andrew Pleasant, Dhanadol Rojanasarntikul, Daniel Lakoff, Scott A Goldberg, W Lane Duvall, and Milena J Henzlova. “Yield of Routine Provocative Cardiac Testing Among Patients in an Emergency Department-Based Chest Pain Unit: Yield of Stress Testing in Emergency Department Observation Units..” JAMA Internal Medicine (May 20, 2013): 1–6. PMID 23689690
I read this a few months back and forgot to post something on it. It’s not headline data the way IST 3 was but it’s worth knowing it’s out there. This is the long term (by which they mean 18 month) follow up on IST 3. The original trial has been written about and discussed fairly extensively on the FOAMed sites.
they got around 2000 or so because only certain countries did follow up.
for those available they managed to follow up on the vast majority
the follow up was mainly phone and postal so not that great.
30% knew which drug they got which they try to play down but given that the supposed benefit is so small then any recall may cause the difference
they do find about a 3.6% difference in alive and independent at 18 months favouring tPA (as pointed out by Brandon in the comments)
there’s a great Kaplan Meier curve showing early harm from TPA and then completely flat with placebo from then on. It’s behind the pay wall unfortunately but worth looking at
there was no difference in alive and independent at 18 months
“the unadjusted absolute difference in the number of patients alive and independent at 18 months was not significant”
So just to summarise that. A third of the patients knew which group they were in (nothing versus the fancy new drug) and ultimately there was no difference at 18 months.
“Effect of Thrombolysis with Alteplase Within 6 H of Acute Ischaemic Stroke on Long-Term Outcomes (the Third International Stroke Trial [IST-3]): 18-Month Follow-Up of a Randomised Controlled Trial.” The Lancet Neurology (June 2013). PMID 23791822