Primary Survey October 2017.

Happy Birthday

Let us start by wishing the Royal College of Emergency Medicine a very happy 50th birthday. Thanks to everyone who has got us this far and thanks to those who will take EM in the  UK and across the globe even further in the next 50 years.

As for the journal, then another great month of papers and articles, plus links to the posters and abstracts from the RCEM conference in Liverpool this week.

Inconsistent practice and incidentalomas: time to ban the pan scan in trauma?

In this issue of the Emergency Medicine Journal we have two papers relating to the use of whole body computed tomography (WBCT) scanning in trauma. First, Sammy et al report on the extent of variation in practice across the United Kingdom. Even among Major Trauma Centres and after adjustment for potential confounders, there was a 13-fold difference in the proportion of patients undergoing WBCT. This important work should clearly lead us to ask why there is such variation, and to determine which approach is optimal for patient outcomes.

On the same topic of WBCT in trauma, Kroczek et al report on the proportion of patients that have incidental findings. All emergency physicians who care for patients with suspected major trauma must be familiar with this issue: the WBCT is intended to detect serious injuries but ultimately reveals an incidental finding that may require further investigation. Indeed, this work demonstrates that the phenomenon is very common. Three quarters of all patients undergoing WBCT had at least one incidental finding. While we may consider that such findings are likely to have dubious clinical importance, this work also suggests that many of the incidental findings are highly clinically significant and require urgent attention. Almost one tenth of patients undergoing WBCT had incidental findings that required urgent attention. You should also read the editorial on WBCT from our very own Caroline Leech.

Extreme emergency medicine

In this issue, we also take a detour from the ‘routine’ of day to day practice within the confines of an Emergency Department (ED). Laskowski-Jones et al provide a structured overview of the considerations for providing healthcare at extreme events in remote settings. Such events, which are gaining in popularity, include ‘obstacle’, ‘adventure’ and ‘endurance’ competitions with examples ranging from mountain biking to immersion in icy water and ultra-endurance foot races for up to 100 miles over 7 days. It is totally clear that providing healthcare for such events will require specific skills, and the excellent overview provided by Lawowski-Jones et al will clearly help to prepare emergency physicians who have an interest in this area.

In addition, we are proud to publish the results of a fascinating randomised controlled trial evaluating the impact of non-steroidal anti-inflammatory drugs (NSAIDs) on the incidence of acute kidney injury (AKI) in ultra-endurance runners. The findings reported by Lipman et al are intriguing for several reasons. First, the overall incidence of AKI in ultra-endurance runners was found to be incredibly high in this study, at 44%. Second, and importantly, the use of NSAIDs was found to significantly increase the incidence of AKI with a number needed to harm of just 5.5. The paper is clearly a must read for anyone with an interest in this area.

Sex, race and serious cardiopulmonary diagnoses

Proving that it’s never too late to publish good data, Allaban et al report a secondary analysis from a cohort of over 4000 patients with chest pain recruited between 1999 and 2008. They evaluated the differential value of individual symptoms for predicting serious cardiopulmonary diagnoses. There were some important differences. While in white men, the ‘typical’ symptoms for an acute coronary syndrome were predictive (pressure/tightness, substernal location and pain radiation to the left arm), there were no predictive symptoms in white women and only diaphoresis predicted serious cardiopulmonary diagnoses in black men. These findings suggest that sex and race do have an impact on a patient’s symptoms in this context, supporting the notion that women and black patients are more likely to present with ‘atypical’ symptoms.

How to make co-location of primary care a success

The Royal College of Emergency Medicine and the Patients Association both support the co-location of primary care services with EDs. In doing so, those patients who present to the ED with a complaint that could most appropriately be cared for in a primary care environment can be immediately re-directed to the co-located service, rather than adding to the problem of ED crowding. In this issue, Ablard et al use qualitative methodology to explore the factors that may help to make such initiatives a success, based on experience in the Yorkshire and Humber region of the United Kingdom. This is therefore important reading for anyone involved in service configuration.

Rick

The Ugly Side of Exercise #RSMFrontline

Last week I attended ‘Frontline resuscitation’, a one-day conference hosted on by the Military Medicine Section of the Royal Society of Medicine (#RSMFrontline). Its aim was to ‘showcase cutting edge developments in resuscitation medicine and provide understanding of how these can be translated to military medicine’. I was one several civilian attendees keen to benefit from some military-style elite education.

A wide range of blockbuster topics were covered including sports cardiology, latest research in trauma resuscitation (including SAAP – wow), performance psychology, and ECMO in cardiac arrest. Educational pearls and inspiring stories came thick and fast. I was impressed with the quality of presentation design, and enthused by the shared optimism for the future of resuscitation medicine amongst the speakers and audience. The day had an exciting, bouncy vibe.

I’m going to zoom in on three talks that I found particularly interesting. This blog tackles the first:

‘Sudden cardiac death in athletes: What can the military learn?’
Dr. Sanjay Sharma, Professor of Cardiology and London Marathon Medical Director

The phenomenon of sudden cardiac death (SCD) in athletes has huge crossover relevance to the very exercise-heavy business of being a soldier. Professor Sharma delivered a compelling argument for devoting more NHS resources to screening for/treating these patients despite their rarity, as it amounts to a considerable number of ‘life-years’ lost. This point was re-enforced by a distressing video showing a world-beating young basketballer collapsing and dying in the arms of his team-mates.

Professor Sharma frontloaded his talk with some eye-catching statistics:

  • 1 in 50,000 young athletes suffer SCD
  • 90% are male
  • 90% occur during/immediately after exercise
  • 80% have no warning symptoms (SCD is first presentation – frightening)
  • 40% occur in under-18s
  • 6 times more likely in Afro-Caribbeans
  • 1 in 300 Olympians/soldiers harbour a potentially lethal cardiac condition

Of course aetiologies vary, but they can be broadly categorized into ‘structural’ and ‘electrical’. The important structural pathologies are hereditary diseases of the cardiac muscle – hypertrophic cardiomyopathy (HOCM) and arrythmogenic right ventricular cardiomyopathy (ARVC is the most common cause of SCD in Italian athletes), or vasculature – anomalous coronary artery origin.

Prior to hearing the talk, I had erroneously believed that HOCM was the most common cause of SCD, but in fact electrical abnormalities like Congenital Long QT Syndrome, Wolff-Parkinson White Syndrome and Brugada Syndrome account for far more. Unlike structural pathologies, these conditions are impossible to pick up at autopsy, and so get labelled ‘unascertained cause of death’. It’s a guarantee, therefore, that we grossly underestimate the burden of these ticking time-bombs.

Clear take-home message: do not underestimate the importance of the humble 12-lead ECG. Alongside enquiring about exertional symptoms (chest tightness, disproportionate shortness of breath, palpitations, syncope, dizziness) and any family history of SCD, the ECG is the crucial component of screening. It reliably detects electrical pathologies, and raises suspicion for structural abnormalities – in HOCM approximately 95% will have an abnormal ECG.

Of course, there will be false positives (13% of black athletes have a grossly ischaemic looking ECG with ST elevation followed by T wave inversion in leads V1-V4 – distance running legend Mo Farah’s 12-lead was used as an example) and false negatives, but where screening programmes have been introduced, they have proven a major success in reducing SCD. In Italy, they have a state-sponsored general population screening programme which has reduced SCD in sport by more than 90% over the last 30 years.

IMG_3057

Routine general population screening is not on the NHS unfortunately. Screening is performed by charitable organisations like CRY, or by high performance sports institutions such as the Football Association, English Institute of Sport, Rugby Football Union, and Lawn Tennis Association. Most SCD sufferers are recreational sportspeople, and therefore miss out on being routinely screened. 

In the ED, we see countless children and young adults coming in from sport-related injuries and other non-cardiac presentations. We’re arguably more exposed to the population vulnerable to SCD than GPs and cardiologists (i.e. under 35s who take regular exercise). Perhaps we should be taking the opportunity to perform ECGs even though it might not be relevant to the presenting complaint. All EDs have the equipment and expertise readily available, and so effectively could act as a quasi-screening clinic for SCD pathologies, with minimal drain on resources. Perhaps there is potential for a local/regional quality improvement project here – an added string to the EM bow.

A point of discussion during the Q&A was the feasibility of introducing a military screening programme. It would be a massive (and therefore expensive) undertaking considering there are approximately 160,000 total regular forces. There is also the potential for removing healthy, highly trained soldiers from active duty because of a ‘borderline abnormal’ ECGs (red herrings). If genuine pathology is identified, is it the responsibility of the military to arrange appropriate treatment and follow-up? Further cost implications.

As Medical Director for the London Marathon, Professor Sanjay explained they don’t screen all runners because their limited staff would be drowning in ECGs if they did. The same obstacle would lie in the way of a military screening programme. One potential solution, which I wish I’d volunteered at the conference, would be to introduce machine learning technology for ECG interpretation. Huge efficiency gains, cost savings, and (dare I say it) avoidance of human error, could be on the cards. Of course, the utility of artificial intelligence in healthcare is a far from proven. More concrete evidence of its efficacy is required, a governance system needs to be introduced, and most medical professionals will require a considerable attitude adjustment before handing over any of their professional responsibilities to a machine. However, if and when the technology starts to gain traction in healthcare (which, in my opinion, is just around the corner), large scale ECG interpretation seems like low hanging fruit.

Robert Lloyd
@PonderingEM

Safety Newsflash! Retained Guidewires.

guidewires

If you’re a member of the Royal College of Emergency Medicine in the UK, you may have noticed an email pop up in your inbox recently, a safety newsflash on retained guidewires. RCEM put these out every few months, containing helpful and brief information in the crusade against events that should never happen, as well as some things to look out for when seeing patients. Examples of previous newsflashes include a reminder to think about AAA in patients with abdominal pain, and to remember that some oral dentures don’t show up on X-ray.

In this most recent installment, RCEM look at retained guidewires, which comes under number three on the NHS England list of never events – “retained foreign object post-procedure”. You might not think it’s common, and you’d be right – this has only happened eight times in emergency departments across the UK in the last two years, but that’s still eight too many. It makes up half of the reported never events in EDs.

With more and more emergency physicians utilising advanced skills to insert lines and chest drains in the resus room, it becomes so important to make sure we’re not causing patients harm through additional procedures to remove wires we’ve left behind.

So how do we do this?

RCEM’s advice follows that of the National Reporting and Learning System (NRLS), a branch of the National Patient Safety Agency. The aim is to make line insertion a standardised two-person task. Generally you can just put a line or drain in on your own, but having a second person as an observer, to witness and document guidewire removal, creates redundancy, with the aim of improving safety and focus on the task at hand

The NRLS advocate three measures to stop guidewires being left behind. The first is a standardised process where both the operator and observer see the guidewire removed, say it’s been removed, and document its removal. This may just be done in the notes, but I have seen in a trust I’ve worked in a sticker that comes pre-packaged in all arterial and central line kits with tickboxes and space to sign to standardise the documentation as well. It works very well, and putting it in the line packs makes it easy to remember to get an observer and complete the sticker to insert into the notes. This documentation is also audited.

The second measure is to emphasis guidewire control through training and education. We need to embed this as a mandatory step in all our lines or drains, just as we always clean the skin, or apply a dressing. It’s an important step, and should be emphasised not only to trainees being signed off to insert lines, but also to more senior doctors who have been putting them in for years.

Lastly, the NRLS is working with manufacturers to develop new ways to prevent guidewire retention.

RCEM has taken this and advocated a standardised procedural checklist for all invasive procedures. You can see this below.

 

invasive procedure checklist

 

Guidewire control is crucial, and if you’re not inserting these on a regular basis it can be all too easy to lose that control and lose your guidewire. Make sure you take steps to avoid this never event. Get an observer. Use the RCEM checklist, or your own trust one. Be safe for your patients.

vb

Chris

 

Don’t forget to check out the other safety newsflashes on the RCEM website.