RCEM Leeds Day 3

[Direct Download Podcast MP3]

Welcome to the RCEM CPD event in Leeds.

We’re here to give you updates and some pearls that we’ve gleaned from the conference.

The final day at #RCEMCPD16 opened with a very entertaining talk on interesting cases from Francis Morris (yes, he is on twitter.. as of today).

His knowledge nuggets are so difficult to do justice to on a blog, but luckily we managed to get a short video where he demonstrates his 20-second ankle examination technique.

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Tony Shannon followed with a lecture on health informatics, His notes on how to “work smarter not harder” is something I, personally only discovered over the last few years but can go a long way to keeping burnout at bay. (It rhymes as well!) There’s lots online if you haven’t tuned into it yet, (our references do not do justice to what google can find) but the trick is to pick and choose what will work for you.

Ahmed Hankir followed, with an insightful and entertaining performance (honestly, it was a lot like watching a drama play – this man can perform) on mental health in medical staff. The take homes from that are that mental ill-health is prevalent in medical staff, and there is a rather lot of stigma attached to it. So keep your ears to the ground, and be kind, as everyone you meet may be fighting a hard battle. (with apologies to Plato).

After a coffee break, we had a Schwartz round which brought clinicians into a “workgroup” style meetings to discuss emotional aspects of work. Two consultants very bravely shared negative clinical experiences and how they learned and moved on from them.

These conversations are intrinsically difficult, but they are so important to make us better clinicians, and be it a Schwartz round or another methods (like those outlined by Simon and Natalie in this podcast), it is really important that departments integrate this into their regular practice at work.

Moving on from these difficult conversations, Dyfrig Hughes spoke about why things go wrong in the ED. Making quite a few comments about healthcare and aviation, which if you’re into FOAMed, you’re likely to have heard of before, but he also spoke about why we make decisions, and why an experienced clinician’s decision making is quicker and different from that of novice junior physicians. Guess and gestalt is not a new concept, but don’t get too comfortable with the way you come to conclusions, as pattern recognition is itself an easy process, and although our overloaded brains choose this route, it is fraught with bias, so sometimes it is worth enforcing strategies to eliminate this.

Moving on with the concept of error, Peter Cutting has a BlogSpot on actual medical errors, with learning bites on how to improve on them.

It’s all a bit negative, but we are in it to get better, and the final talk of the day, and the conference, was by Simon Carley and ended on a high note with his talk about self-actualization, mastery and the EM midlife crisis. Confused? I don’t blame you. That’s why we caught him for a separate podcast which will be on the site soon. St. Emlyn’s also have 3 #RCEMCPD16 blogs on their site about the presentation, which you should check out.

It’s been an entertaining and inspirational 3 days for us at RCEM Leeds. We hope we have managed to spread this feeling with you.

Before we part, here are some of our favourite quotes, ciao for now!

 

If a pilot makes a mistakehe dies too

Guidelines Guide...

If I don't know something,i google it....but don't show it

Carpe

qSOFA

Unexpectedkindness is themost powerful,least costly, andmost underratedagent of humanchange

Thanks for listening

Nikki Abela

Craig Davidson

Charlotte Davies

 

Further Reading:

  1. Inc. 5 Scientifically Proven Ways to Work Smarter, Not Harder
  2. I am Chris Nickson, co-creator of LITFL: How I work Smarter
  3. Quote Investigator: Be Kind; Everyone you meet is fighting a hard battle
  4. Point of Care Foundation: Schwartz Round
  5. St. Emlyn’s: When things go wrong – the difficult conversation
  6. SMACC: Guess or Gestalt by Carley
  7. Emergency Medicine – Risk, Error and Learning
  8. St. Emlyn’s blog #RCEMCPD16

 

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Bored into a Nosebleed – Review.

A 19 year-old patient presents to your ED with a nosebleed. His friend states they were in the bleacher seats of an anime convention when he became so aroused that his nose just started gushing blood. He’s been bleeding for about 30 minutes despite holding pressure on his nose. Vitals are normal. When you try to examine his nose and remove the tissues, blood starts oozing from his nostrils.

teen-again-nosebleed-tampon

What is the most likely source of his bleeding, and how should you treat this type of nosebleed?

90% of nosebleeds are anterior, arising from Keisselbach’s plexus. Caused by: digital trauma (yeah that’s you, nosepicker!), rhino-sinusitis/dry mucosa/ excessive nose-blowing, uncontrolled hypertension, coagulopathy, etc.

Treatment:

1. Direct pressure, inspection for a site of bleeding. If seen, try to apply topical vasoconstrictors such as phenylephrine or oxymetozalone. If you see the exact site of bleeding and vasoconstrictors have not worked, consider chemical cautery with topical silver nitrate- however this is only advised if you have direct visualization and a relatively bloodless field. Never attempt chemical cautery in both nares.

2. If the above does not work, time to go for gold with tampons, aka anterior nasal packing. Nasal tampons like the RhinoRocket are available in our ED.  Nothing will make this 19 year-old kid feel more cool and special than shoving a tampon up his nose.

 

You try to control his bleeding with nasal packing, but blood continues to ooze down his pharynx. Where might the blood be coming from now? How are your going to control it and treat him?

Posterior bleeding! Usually arising from the sphenopalatine artery. This is much more difficult to control. Now you should involve ENT. Posterior packing involves a 12-14 Fr foley- first use local anesthetic, lubrication with bacitracin, and then insert and inflate with 5cc, retract until gently lodged in place, then inflated with another 5-10cc.  ENT uses more advanced and definitive methods like EMA embolization, endoscopic cautery, or surgery to stop the bleed.

 

What is your dispo for a patient with anterior nasal packing?

Your board answer: discharge with antibiotics to protect against staph infection and toxic shock syndrome (amox-clav is the first choice). HOWEVER, in practice, evidence does not support the routine use of antibiotics for anterior nasal packing. Regardless, patients with anterior packing must follow up with an ENT specialist in 2-3 days, and many ENT docs still prescribe antibiotics despite evidence lacking support.  

 

What is your dispo for a posterior bleed? What are the complications and what must you closely monitor for?

Admission. Posterior packing can lead to pressure necrosis, infections, dyspnea or hypoxia, and cardiac dysrhythmias so they need to get admitted to a cardiac tele-monitored bed. These patients definitely need antibiotics during admission.

 

Trivia time! What does having a nosebleed imply in Japanese culture?

Sexual arousement. Yup, nothing shows your more hot and aroused than…. a nosebleed?! Typically portrayed in manga or anime as a guy who sees an attractive girl and has an explosive nosebleed. Wanna see for yourself?

 

 

References
Summers SM, Bey T. Chapter 239. Epistaxis, Nasal Fractures, and Rhinosinusitis. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.

EM Lyceum. “Epistaxis, Answers” Post from Oct 12, 2013. http://emlyceum.com/2013/10/12/epistaxis-answers/

Huge thanks to Dr. deSouza.

Remember, the boards and in-service exam are not alway evidence-based. What we do in practice may not always be the right answer on your test. Frustrating, I know! Keep your chins up. Unless you have a nosebleed…

 

The post Bored into a Nosebleed – Review. appeared first on The Original Kings of County.

Transport is TRICI

The recent SEMS 2016 conference in Singapore was well received by attendees and its myriad of workshops/courses and talks continues to grow. This year, Changi General Hospital added a one day workshop to highlight the troubles in transporting critically ill patients. It involved lectures, simulation, quizzes and demos and lots of food.
"Shoutout" goes to Changi Simulation Institute for once again hosting and moulaging our sims.

TRANSPORT In the Critically Ill 
(aka TRICI)

What its all about - TRICI

Demonstrating practically our retrieval bag and contents

Dr Joanne Ang debriefing after a multi-stage simulation

No gain without pain
The actual quiz - learning without the stress of marks

Dr Charles Chan-Johnson (centre) & SSN Himmah (extreme left) giving a synopsis of actual ambulance transport

Ambulance ride along with mannequin


Teaching faculty of Dr Naleen and SSN Irene "treating" a critical patient

A/Prof Loh Lik Eng giving a paediatric transport primer
Feedback was encouraging and we plan to have more of the above. If you would like to join/participate/know more do send us an email.

Pressors

drips

The use of vasopressors and inotropes to treat hypotension is common in the emergency department.  It is now standard to start off with norepinephrine as your 1st line agent to treat shock in the ED.  But is norepi always that best choice?   What if you need a second agent?

 

Treatment of hypotension should be based on the etiology of shock.  The following are simple recommendations for which inotropes and pressors are best to use based on different types of shock.  The following assumes blood and fluids have been given where appropriate.

 

Septic Shock: Everyone knows norepinephrine is the 1st line agent.  Dopamine may have a small indication for use over norepi in  a highly select population but this is more advanced and not necessary for the average EM physician.  This article is an excellent demonstration of multiple previous studies which have shown a higher mortality and higher incidence of arrhythmic events when dopamine is used.  Most clinicians will reach for either epinephrine or vasopressin as the preferred second line agent.  I think it is ideal to perform a bedside echo prior to starting your second agent to assess cardiac function.  If evidence of dysfunction, epinephrine may be preferable for the additional inotropic support.  If cardiac function seems appropriate, vasopressin at a fixed dose may be appropriate to achieve the desired MAP and decrease norepinephrine concentrations.  This is the algorithmic approach from emcrit.

 

Cardiogenic Shock: The hypotensive patient in cardiogenic shock can be terrifying.  These patients have high mortality.  Although many will benefit from pci or mechanical support, we need to medically support them in the emergency department until such interventions are available.  The primary problem is cardiac output failure, therefore inotropy is crucial for these patient.  Your best options for inotropy are either epinephrine or dobutamine.  Dobutamine generally will cause some hypotension and typically will be paired with norepinephrine (a weak inotrope).  It is tempting to use a single agent, epi, in these patients but you shouldn’t.  Studies (study 1, study 2) seem to show worse outcomes with epinephrine alone compared to norepi and dobutamine.

 

Anaphylactic Shock: Epi, Epi and Epi are first line.

 

Hemorrhagic Shock: NO PRESSORS – blood as quickly as you can in a 1:1:1 fashion