Take home points from an HMIMMS course

Before christmas I finally got another one of the alphabet courses under my belt – The Hospital Major Incident Medical Management & Support course. Or HMIMMS for short.

To be perfectly frank major incidents weren’t exactly on my radar – I like to describe emergency medicine in Ireland as one long protracted major incident so there’s a little bit of incredulity involved in actually planning for some major disaster when we can’t even manage the day to day.

Having done the course I now see why it’s considered as mandatory for training in emergency medicine. Emergency physicians will always be front and central in such scenarios, and the more senior you are the more important the management bits will be. The clinical stuff is easy but making sure your patients and staff get to where they need to be is a whole different story.

The table top exercises are some kind of cross between Monopoly and Settlers of Catan so it allows to unleash your inner geek a bit too.

Below are a few scribbled notes I took during the course and from reading the manual (which of course @EMManchester is an author of… that guy gets everywhere…)

Major incident

  • events that owing to the number, severity, type or location of live casualties require special arrangements to be made by the health services.
  • can also be put as “major incidents occur when the resources available are unable to cope with the workload from the incident”
  • A major incident can remain “uncompensated” when still unable to manage despite mobilisation of additional resources

7 main principles (abbreviated as the fairly unpronounceable CSCATTT)

  1. command
  2. safety
  3. communication
  4. assessment
  5. triage
  6. treatment
  7. transport

Phases of a major incident

  • pre hospital
  • reception
  • definitive care
  • recovery

The Collapsible Heirarchy

  • still not sure if i like the term
  • refers to the system used to delegate staff
  • roles can be coloured red yellow green in order of importance
  • some folk may fill multiple roles until further help arrives
    • for example at 2am the only surgical doctor in the hospital may be the poor surgical SHO who will assume the role of “senior surgeon” (in charge of entire surgical response) until someone more senior arrives and the SHO can go and change his underwear, or perhaps even his career.

Essential clinical roles that need filled ASAP

  • medical coordinator
  • senior EP
  • senior MLSO(lab)
  • senior surgeon
  • senior physician (often overlooked as we assume all major incidents are traumatic when they’re not – they can be toxicological or environmental


  • the most important thing is that the expectant cases are low down the list. A resuscitative thoracotomy may not be appropriate when your resources are over stretched
  • start with a triage sieve, so simple you don’t need to be clinical to use it. For example if you can walk then you’re immediately a lower priority.
  • a triage sort is a bit more detailed that involves some physiologic variables (GCS, HR, RR) to determine your level of priority (which is essentially which physical space you are assigned to in the ED).

There are some specific Irish documents available online looking at this in the Irish context. Your hospital will of course have it’s own major incident plan. it is no doubt dusty and out of date somewhere…

[Featured Image: Nuclear Explosion – Wikimedia Commons, CC License]

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Tasty Morsels of EM 044 – Thyrotoxicosis Factitia

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

This was something I wasn’t even aware existed but worth considering.

Classic symptoms of hyperthyroidism

  • tachycardia
    • usually sinus
    • a fib common too
  • sweating/feeling warm
  • poor sleep
  • weight loss
  • possible fine tremor
  • eye signs (Graves only)

Causes of these symptoms

  • usually Graves disease in the west
  • toxic multinodular goitre in areas of iodine deficiency
  • thyroiditis
  • the odd tumour here and there
  • the odd drug here and there (amiodarone and lithium being the big ones)
  • exogenous thyroid hormone use (rejoicing in the name thyrotoxicosis factitia)

The (very) basic physiology

  • Thyroid Stimulating Hormone (TSH) causes thyroid to produce more thyroid hormones
    • controlled by the axis of evil, hypothalamic-pituitary-thyroid axis
  • The hormones are:
    • T3 (triiodo- thyronine)
    • T4 (thyroxine)
  • Most T3 comes from conversion of T4 to T3 peripherally (liver and muscle mainly)
  • T3 is more biologically active
  • In most hospitals I’ve worked T3 isn’t measured routinely

Thyroid hormones can be taken surreptitiously in a few situations

  • reported outbreaks of hamburger thyrotoxicosis from ground beef from the neck of the animal
  • ingestion of various weight loss products that can contain either T3 or T4
    • note if it’s T3 causing the symptoms then T4 may be normal but the TSH should be suppressed. If your lab doesn’t normally measure T3 then it’s worth thinking about (a very smart biochemist had to explain all this to me)

The differentiating feature is probably the eye signs. Graves is the commonest cause of thyrotoxicosis in the west so if you see someone with classic hyperthyroidism and no eye signs then it’s always worth asking them about various supplements they may be taking.


  • Rosens 8th Chap 128
  • UpToDate: Exogenous hyperthyroidism
    • An outbreak of thyrotoxicosis caused by the consumption of bovine thyroid gland in ground beef. Hedberg CW, N Engl J Med. 1987;316(16):993.




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Location based decision making

This is something that I’ve noticed happening to me for as long as I’ve been doing emergency medicine (coming up on 10 years now) – that the physical part of the department that you see the patient in has a significant impact on my decision making process. 

A patient with chest pain arrives in resus, the staffing ratio is much higher here. The expected rate of pathology for all staff working in the area is much higher. Before the doctor sees the patient it is likely that the patient will be on a trolley, on a monitor, often an IV cannula is inserted and lab tests are flying through the chute to the lab before anyone has even further assessed the patient. Often the patient is changed to a gown and an ECG will be done.

A second patient with chest pain arrives and is brought to the minors area. There are no cubicles so they sit in a chair awaiting a doctor’s assessment. No further testing or assessment is done. As there are still no cubicles available to assess the patient the doctor apologetically walks the patient to the psychiatry interview room as it is the only free space in the ED with a door that can close to give the patient even the slightest bit of dignity.

I find when I am the doctor in both those situations I make rather different decisions, or at the very least, I feel inclined to make different decisions even if I ultimately don’t do so. The assumption of course is that if the patient is in the minors area then it’s not possible for the patient to have serious pathology and indeed vice versa – if they’re in resus then it’s not possible for them to have minor pathology.

I suspect everyone working in emergency medicine as noticed this to some degree. Hopefully those who are thorough enough will be able to make appropriate and safe decisions (sometimes involving waiting until a cubicle is free and properly exposing and monitoring the patient) no matter what the environment.

However it is a useful reminder, once again, on how overcrowding in the ED is a threat to safe and effective medical care. Ireland has had its own crisis this week – which of course only means that we got in the papers; the ongoing major incident that is the result of the decision to locate all crowding in the ED has been going on for much longer… While people often view ED attendances as simply punters seen by nurses and doctors, there is rarely reflection on the on the fact that working in an overcrowded environment with the compromises it requires exposes patients to the harm of cognitive biases and poor decision making.

[featured image via wikimedia commons]

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Anatomy for Emergency Medicine 030: CFN Eye Anatomy Part 1

This is the first of a series of podcasts I’m doing on basic eye anatomy for the CEM FOAMed Network. This is a developing resource which aims to provide a fully mapped college curriculum with FOAMed resources. Be sure and check it out and get the podcast. This podcast went out a while ago on the CFN and I’m just providing it for everyone else who hasn’t got it already.

The single most important resource you need is Ophthobook.com

[Direct Download] [8omb]

AFEM Podcast

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IAEM Position Paper on Trauma

Major trauma care in Ireland lags behind a lot of its western contemporaries (think UK, Aus/NZ and the US). We have 28 hospitals receiving major trauma (for a population of 4.5 million). We do not have a trauma system. We compare fairly poorly to our contemporaries who do have trauma systems. Not wanting to make hysterical and headline grabbing claims here but it seems a perfectly reasonable thing to say that people are dying in Ireland due to a lack of a trauma system, never mind the increased long term disability that comes from poor trauma care.

Trauma in Ireland is finally beginning to get a little bit of attention. We have joined TARN and the major overhaul in trauma care across the water in the UK has got us shifting rather nervously in our seats as to what might happen here.

The Irish Association for Emergency Medicine (for whom I have no formal position, apart from being a member) has just published its position paper on trauma care in Ireland and it’s well worth a read. It says a lot of very sensible things about the political hot potato of reconfiguration and the steps needed to produce a significant trauma system. There is of course a phenomenal amount of work ahead of us and this is only a started, if we want to develop advanced trauma care in Ireland. From an EM point of view there seems to be lots of interest (especially amongst the trainees and the recent consultants) but of course we have about 1/3 of the EM consultants here than they do say in Victoria, Australia so we can be as interested and as enthusiastic as we want we can’t fix it alone.  There appears to be (though please correct me if I’m wrong) little interest in the surgical community. I recently met one of the advanced surgical trainees whose passion is trauma surgery. He couldn’t identify a single colleague in training who shared his interest.

Have a read at the paper and see what you think, discussion is always welcome.

[featured image – wikipedia, CC]

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Tasty Morsels of EM 043 – Vibrio

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

At risk of this becoming an “Andy reviews EM:RAP” section here’s another one from the Dec 2014 program, again from the bounce back section. And once again it’s infectious disease.

As with the last one it falls into the category of pushing your diagnostic skills one step beyond. Most of us are happy to pick up the cellulitis that is sicker than normal but the step further is to track down the right bug and know why it matters.

Vibrio Vulnificans

If there was one take home point then it’s this:

  • Water born infections

Risk Factors

  • older male
  • liver problems (mainly alcohol, cirrhosis, haemochromatosis)
  • DM

Two types of Major Presentations

  1. Wound infections (stood on coral, cut getting off a boat, any cut sustained in the water). This can look like a necrotising infection but can be a simple cellulitis early
  2. Primary Septicaemia (classically from ingesting oysters). severe septic shock and usually with bullae formation on the skin


  • Doxycycline and Ceftazidime were suggested on EM:RAP
  • UpToDate suggested Doxy and Cefotaxime or Ceftriaxone
  • If you’ve got someone with a mild wound cellulitis and water exposure and you want to just treat with orals then you could add doxycycline to your usual meds.


  • EM:RAP Dec 2014
  • UpToDate
  • Rosens 8th pg 1856 has a great table [137-2] for all the unusual skin infections and what to treat them with

Featured image from CDC public health image library via wikipedia

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